Features helpful in diagnosis and associated with death were evaluated In 26 episodes of peritonitis associated with intra-abdominal pathology (IAP) In continuous ambulatory peritoneal dialysis (CAPD) patients. Culture of multiple enteric pathogens, or of a single unusual enteric pathogen, from the dialysate was useful for diagnosis in 22/26 instances. Other diagnostic features (fecal material in dialysate, diarrhea containing dialysate, Increasing free air in the abdominal cavity) were infrequently found. A comparison of patients who died (n=11, 42%) and those who survived revealed that death was associated with bowel gangrene (5/6 died), recovery of bacteroides from the dialysate, more frequent and severe comorbid conditions (bacteremia, pneumonia, intra-abdominaland intracerebral bleeding, septic shock, hepatic failure), the development of severe malnutrition and thrombocytopenia during infection, and multiple surgical procedures until the diagnosis was established. Peritonitis associated with intra-abdominal pathology In CAPD patients is a severe infection with considerable diagnostic difficulty and high mortality. Early exploratory laparotomy upon suspicion of the nature of the peritonitis, usually raised by the recovery of enteric pathogens from the dialysate, may improve mortality.
The recovery of renal function following release of urinary tract obstruction with advanced azotemia determines both the need for emergency dialysis in the early post-obstructive period and the long-term planning for chronic kidney disease management. A man with prostatic cancer who presented with 16 days of anuria and a serum creatinine (Scr) of 42.7 mg/dl but had evidence suggesting residual renal function was managed conservatively and reached a steady-state Scr of 1.6 mg/dl within 84 h of urinary bladder catheterization. Modeling of the decrease in Scr taking into account the decline in the body creatinine pool that existed prior to the release of the obstruction and the accumulation in body fluids of creatinine produced after the release of the obstruction suggested that recovery of the value of glomerular filtration rate corresponding to the steady-state Scr occurred at the release of the urinary obstruction. The case illustrates both the clinical factors that may lead to the decision to postpone dialysis in a patient presenting with extreme obstructive azotemia and a novel method of modeling the recovery of renal function after release of the obstruction.
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