American journal of kidney diseases : the official journal of the National Kidney Foundation
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Chronic ambulatory peritoneal dialysis (CAPD) is a commonly used form of renal replacement therapy in patients with end-stage renal disease (ESRD) infected with the human immunodeficiency virus (HIV). An increased incidence of peritonitis, as well as an increased rate of infections with unusual and serious organisms, has been reported in these patients. ⋯ We suggest that the diagnosis of MAI peritonitis be suspected in HIV-infected patients with clinical CAPD peritonitis, negative cultures for bacteria or fungi, and a CD4 count less than 100 cells/microL. Therapy with a two-drug regimen for disseminated MAI infection without removal of the peritoneal dialysis (PD) catheter appears to provide symptomatic improvement while allowing ongoing PD.
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Patients with end-stage renal disease on hemodialysis have documented defects in their immune responses, and infections contribute significantly to their morbidity and mortality. This study prospectively detected and quantitated leukocyturia and bacteriuria in asymptomatic hemodialysis patients. ⋯ Pyuria was a good marker for significant bacteriuria in these patients. These results demonstrate that the urinary tract, even in ESRD patients on hemodialysis, may represent a significant reservoir for infection.
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A 15-year-old patient with severe bone disease (with bilateral fractures of hips and shoulders) due to primary hyperoxaluria type 1 (PH1) was treated with combined liver-kidney transplantation after a 4-year hemodialysis period. Normalization of excessive oxalate synthesis brought in by the liver graft combined with the slow excretion of skeletal oxalate stores by the renal graft led to progressive improvement of clinical, radiological, and histological evidence of oxalate osteopathy. This allowed bilateral hip replacement 3 years after transplantation, which led to complete physical rehabilitation of the crippled patient. Combined liver-kidney transplantation constitutes the treatment of choice for end-stage renal failure due to PH1, even in the face of severe oxalate bone disease.
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Resistant hypertension and paroxystic hemodynamic changes are common features in patients on regular hemodialysis. We describe a hemodialyzed patient who developed malignant hypertension. The finding of elevated plasma catecholamines suggested the diagnosis of pheochromocytoma, which was confirmed by surgical removal of the tumor.
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Septic shock, a distributive form of shock, is a common and lethal disease characterized by tachycardia, hypotension, normal or elevated cardiac index, and decreased systemic vascular resistance (SVR). For 2 to 4 days after onset of shock, the left ventricular ejection fraction (LVEF) is depressed; with adequate volume replacement, the left ventricle dilates and cardiac output (CO) is maintained or increased. In survivors, these abnormalities reverse to normal within 7 to 10 days. ⋯ Clinical and experimental evidence support the notion that myocardial depression, peripheral vascular abnormalities, and multiorgan dysfunction result from the combined effect of exogenous and endogenous mediators (eg, endotoxin, cytokines, and nitric oxide) released during septic shock. Although conventional therapy with fluids, vasopressors, and antibiotics is effective, the disease still has a high mortality rate. Studies investigating the effects of bacterial toxins and potentially harmful host mediators offer the greatest hope in finding new ways to eradicate this highly lethal disease.