Objective Peritoneal catheters often become dislocated, and this may lead to malfunction. Since it is not usually possible to bring them back into their correct position, they must be replaced. With the aim of preventing this complication, we designed a new catheter. Design The new catheter has the same form as the Tenckhoff catheter except for a small increase in external diameter of the last 2 cm, made possible by the high specific weight of a small12-g tungsten cylinder incorporated in the Silasticat the abdominal end. The new catheter may be inserted by a percutaneous technique. Setting University hospitals of Sienaand Perugia, Italy. Patients In the last three years, 32 of these catheters have been implanted for a total experience of 468 patientmonths. Their position was checked on insertion and every two months thereafter by radiography; 26 Tenckhoff catheters (415 patient-months) were studied at the same time. Insertion was performed surgically and by a percutaneous method. The frequency of cuff extrusion, exit-site infections, leakage, and peritoneal infection were noted, together with peritoneal function, which was evaluated by KTN and weekly creatinine clearance one month after catheter insertion; the tests were repeated when dislocation occurred and at the end of the trial. Results No dislocations occurred with the self-locating catheters, whereas nine dislocations occurred in control patients (p = 0.0003). There were no significant differences with respect to controls for cuff extrusion, exit-site infections, leakage, peritoneal infection, and peritoneal function. Conclusions The presence of a small weight at the catheter tip prevents displacement completely, keeping the intraperitoneal part of the catheter in place.
The morphometric and morphological changes in the mesothelial cell population were studied in rabbits in peritoneal dialysis with lactate and bicarbonate buffer solution. During dialysis the mesothelial population underwent radical changes in morphology and morphometric analysis showed a significant increase in cell size. Light microscope examination showed two types of changes: hyperplasia of the mesothelial cell with diameters of up to 80 μm, nucleus proportional to the cytoplasm, a large nucleole giving an owl’s eye appearance and cytoplasm rich in granular material. The second change was multiple nuclei and arrest of cell division. Nuclear division occurred, but no separation of the cytoplasm. The cells became larger than 200 μm, packed with nuclei and relatively little cytoplasm. Electron microscopy confirmed that the hyperplastic cells had perfect structure whereas the polynucleate cells contained vacuoles and little cytoplasmic reticulum. Immunohistochemistry using monoclonal antibodies SK2-27 and SK 60-61 specific to cytokeratins 14, 16, 17 and 8, 18, respectively, identified the cells as mesothelial. The changes were related to the glucose content of the peritoneal dialysis solution. Glucose is therefore the bioincompatible agent that modifies the mesothelium during peritoneal dialysis, causing it to become hyperplastic or blocking replication.
Objective To determine the biocompatibility of a peritoneal dialysis (PD) solution containing amino acids compared to PD solutions containing glucose. Design The biocompatibility of three dialysis solutions containing 1.1% amino acids, 1.36% glucose, and 3.86% glucose, respectively, was evaluated in vivo in rabbits. Methods After 60 days of PD, peritoneal histological changes in rabbits were investigated by light and transmission electron microscopy. The parameters investigated were: (1) mesothelial damage; (2) submesothelial edema; (3) submesothelial cell infiltration; (4) submesothelial fibrosis; and (5) vascular alterations. Semiquantitative evaluations were performed for all the above alterations; quantitative morphometric evaluation was performed for mesothelial damage (cubic transformation of the mesothelium, areas devoid of mesothelium, submesothelial edema) and thickness of peritoneal arteriole walls. Results (1) Mesothelial damage was practically nonexistent in rabbits dialyzed with the solution containing amino acids, and intermediate and severe with low glucose and high-glucose solutions, respectively. Both controls and rabbits dialyzed with amino acid solution showed flat continuous mesothelium; rabbits dialyzed with low-glucose solution showed cubic continuous mesothelium; and rabbits dialyzed with high-glucose solution showed cubic discontinuous mesothelium. Cytopathic mesothelial effects were slight with the solution containing amino acids and severe with both the low and high-glucose solutions. Duplication and thickening of mesothelial basement membrane were never observed. (2) Submesothelial edema showed a worsening trend from controls to rabbits dialyzed with solution containing amino acids, low glucose, and high glucose. (3) No difference in submesothelial infiltration was found between groups. (4) Submesothelial fibrosis was never observed. (5) Vascular alterations were never observed. Conclusion These results are evidence that PD solution with amino acids is more biocompatible than high and also low-glucose solutions.
We have investigated the clinical utility of a new quantitative two-site radioimmunometric assay specific for bone alkaline phosphatase (B-ALP) in 219 healthy control subjects and in 264 patients with various metabolic bone diseases. B-ALP was compared with total alkaline phosphatase (T-ALP) and with osteocalcin (BGP). B-ALP increased linearly with age in both sexes. In postmenopausal normal women B-ALP increased by 82% compared with premenopausal normal women, whereas the differences between pre- and postmenopausal women for T-ALP and BGP were 18% and 30% respectively. As assessed by Z-score, the highest values of B-ALP were found in patients with Paget's disease of bone, bone metastases or hyperparathyroidism and in patients on maintenance haemodialysis. In osteoporotic patients, B-ALP< but not T-ALP, showed a slight but significant (P < 0.05) difference compared with normal women. On the basis of bone turnover, osteoporotic patients were divided into two groups: high turnover and low turnover; B-ALP, like BGP, was significantly (P < 0.01) higher in patients with high turnover. In conclusion, B-ALP, measured by this new method, can be considered a sensitive marker of bone turnover and could be especially useful in identifying women at risk of developing osteoporosis.
Few studies have dealt with assaying aluminium levels in different tissues of uremic patients; so far a comparison has never been made between its accumulation in the various tissues of uremic patients and controls. Aluminium levels were determined in the following biological samples: 1)111 serum samples from hemodialysis patients and 55 serum samples from normal subjects; 2) 47 urine samples from the same dialysis patients and 45 from the controls; autopsy tissue specimens (blood, bile, brain, rib, cartilage, cranium, lung, spleen, kidney, aorta, vena cava, liver, muscle) from 12 deceased dialysis patients undergoing post-mortem diagnosis and 10 autopsy cases in which death was not associated with uremia. In living subjects, both serum and urinary levels of aluminium are significantly higher in hemodialysis patients than in controls; a significant positive correlation was found between serum and urinary levels of aluminium. In autopsy specimens, aluminium levels were higher in the dialysis group than controls for all tissues; the differences were statistically significant except in heart and urine. Tissue concentrations of aluminium in the two groups were then analysed separately both in uremic patients and controls. The highest values found in dialysis cases were in the bile, followed by blood, urine and lung; levels in the other tissues were considerably lower. In controls, the distribution was somewhat different, due to much lower levels in the liver and bile with respect to dialysis cases. Again we found surprisingly high levels in the lung. The results show that aluminium storage in uremic patients occurs in all organs and tissues, albeit to different degrees.
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