Beth Piraino - Academia.edu (original) (raw)
Papers by Beth Piraino
CAPD related infections and catheter loss continue to be the major problems facing the peritoneal... more CAPD related infections and catheter loss continue to be the major problems facing the peritoneal dialysis patient. Few risk factors for infections and catheter loss have been identified. We hypothesized that overweight and underweight patients may be at increased risk for infections and catheter related problems. We examined the effect of the patient's weight at the start of peritoneal dialysis on the subsequent peritonitis and catheter infection rates, as well as catheter loss. Weight was expressed as a percentage of ideal body weight (IBW). Those patients who were more than 110% of IBW were considered to be overweight, 90 to 110% of IBW normal and less than 90%, underweight. An equivalent percentage of patients were overweight and underweight at the initiation of peritoneal dialysis (55/228, 24% for both groups). Overweight, normal, and underweight patients had peritonitis rates of 1.0, 0.9, and 0.8 episodes/y and catheter infection rates of 1.1,1.2, and 0.8 episodes/y, respectively. Despite these similar rates, catheter loss due to infectious complications was greatest in the overweight group and least in the underweight group (p<0.05). No obvious explanation for the difference in catheter loss rate was found. Neither S. aureus nor P. aeruginosa infections occurred more frequently in the overweight patients. However, S. aureus infections more often led to catheter loss in the overweight patients. Catheter loss due to catheter leaks and failure to drain was similar in the three groups of patients. We conclude that deviation from ideal body weight at the initiation of dialysis is not a risk factor for CAPD related infections. However, for unclear reasons, increasing weight is associated with increasing risk of catheter loss secondary to infections. Further research in this area is warranted.
Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis
Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis, 1991
Gentamicin is well known to be a cause of vestibular toxicity. Despite this, gentamicin is often ... more Gentamicin is well known to be a cause of vestibular toxicity. Despite this, gentamicin is often used to treat peritonitis and exit-site infections in peritoneal dialysis patients because of the ease of intraperitoneal administration and the broad coverage of aerobic Gram-negative bacilli, including Pseudomonas aeruginosa. We report 4 cases of severe vestibular toxicity occurring in peritoneal dialysis patients treated with gentamicin. They were all treated as outpatients for peritonitis or an exit-site infection while on continuous ambulatory peritoneal dialysis (CAPD) or continuous cyclic peritoneal dialysis (CCPD). The drug was administered to 3 patients in each peritoneal exchange (5 mg/L) after a loading dose. A fourth patient was given 1 mg/kg of intraperitoneal gentamicin every other day. The mean length of treatment was 21 days. Levels were not used to adjust the doses. All developed severe vertigo from which there was incomplete or no recovery. We suggest that gentamicin an...
Nature clinical practice. Nephrology, 2006
Methods to prevent peritonitis are an essential component of any successful peritoneal dialysis (... more Methods to prevent peritonitis are an essential component of any successful peritoneal dialysis (PD) program. Careful attention to training of the parents and child on the proper technique of PD and avoidance of manual spiking by using an assist device for the cycler, or use of the double-bag system for continuous ambulatory PD, should decrease risk of peritonitis from touch contamination. Secondly, reduction of peritonitis can be achieved through reduction of exit site infections by use of mupirocin antibiotic cream at the exit site of the PD catheter as part of routine care. If an exit site infection develops and is refractory to therapy, then the PD catheter can be successfully replaced as a single procedure, to reduce the risk of peritonitis. The third step in reducing the risk of peritonitis is to avoid repetitive episodes with the same organism. This may again involve replacing the catheter; as long as the effluent can be cleared, this again can be performed as a single procedure, thus allowing the child to avoid the trauma of hemodialysis. The focus in pediatric PD programs must always be on preserving the peritoneal membrane, and not on preservation of the catheter. With careful attention, peritonitis can become an uncommon event. Fig. 1 Percentage of children within each range of peritonitis rates. Data from reference [1]
Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis
Peritoneal dialysis (PD) patients are at risk for 25(OH) vitamin D deficiency due to effluent los... more Peritoneal dialysis (PD) patients are at risk for 25(OH) vitamin D deficiency due to effluent loss in addition to traditional risk factors. To measure 25(OH) vitamin D deficiency in prevalent PD patients, to evaluate a replacement dose, and to determine the effects of correction. 25(OH) vitamin D levels were drawn on prevalent PD patients. Patients deficientin 25(OH) vitamin D were given ergocalciferol, 50000 IU orally once per week for 4 weeks. Patients scored muscle weakness, bone pain, and fatigue on a scale of 0 (none) to 5 (severe). Serum calcium, phosphate, parathyroid hormone (PTH), and 25(OH) vitamin D, and 1,25(OH)2 vitamin D levels were obtained before and after treatment. 25(OH) vitamin D levels were measured in 29 PD patients. Deficiency (<15 ng/mL) was found in 28/29 (97%); 25/29 (86%) had undetectable levels (<7 ng/mL). One course of ergocalciferol corrected the deficiency in all but 1 patient, who required a second course. Scores for muscle weakness and bone pai...
American Journal of Kidney Diseases, 1996
We reviewed all episodes of peritonitis associated with exit site and/or tunnel infection (n = 87... more We reviewed all episodes of peritonitis associated with exit site and/or tunnel infection (n = 87; rate, 0.1/yr; 13% of all peritonitis episodes) occurring from 1979 to 1995. The exit site or tunnel infection was diagnosed at the time or shortly after the patient presented with peritonitis in 66% of the episodes. In the other one third the exit site
We reviewed methods of preventing peritonitis in children. A considerable body of evidence indica... more We reviewed methods of preventing peritonitis in children. A considerable body of evidence indicates that peritonitis rates are lowest with the use of a double-cuffed catheter, with a downward directed tunnel, placed by an experienced surgeon. Evidence in adults, but lacking in children, suggests that exit-site mupirocin will lower Staphylococcus aureus exit-site infections and thus peritonitis rates. The risk of peritonitis due to contamination can be diminished by the avoidance of spiking and by the provision of a long training period. Catheter removal and replacement for catheter-related peritonitis may be done simultaneously in certain circumstances and is useful in decreasing the risk of recurrent peritonitis. Antibiotic prophylaxis at the time of catheter insertion, for contamination, during dialysate leaks, and for invasive procedures appears to be useful in diminishing peritonitis risk.
Seminars in Dialysis, 2007
Infection Control and Hospital Epidemiology, 2010
We examined the Clostridium difficile infection rate and risk factors in an outpatient dialysis c... more We examined the Clostridium difficile infection rate and risk factors in an outpatient dialysis cohort. The Cox proportional hazard for developing C. difficile infection was significantly higher with high comorbidity index and low serum albumin level. Conversely, it was lower for patients who had frequent bloodstream and dialysis access-related infections.
Topics in Clinical Nutrition, 2011
Purpose-Describe the nutritional quality of foods consumed by hemodialysis patients and variation... more Purpose-Describe the nutritional quality of foods consumed by hemodialysis patients and variation by day of the week.
American Journal of Kidney Diseases, 2010
Blood Purification - BLOOD PURIFICAT, 2000
S. aureus is the major cause of access infections in both hemodialysis and peritoneal dialysis pa... more S. aureus is the major cause of access infections in both hemodialysis and peritoneal dialysis patients. It is also a common cause of bacteremia, the risk dependent on the type of access used (fig. 1). Rates of bacteremia are low with permanent arteriovenous access or a peritoneal dialysis catheter, higher with tunnelled catheters, and highest with acute HD catheters [1-9]. Hoen et al. [1]determined in a French study of 988 adult patients on chronic HD for 6 months that the risk of bacteremia (assigning a relative risk of one to patients with a fistula) was 1.29 for a graft or shunt and 7.64 for a catheter. Clearly, the best approach to reduce bacteremia in the HD patient is to use permanent access as opposed to a catheter for HD [10]. However, in the United States a high proportion of patients on HD use catheters, at least in part due to late referral of the patient with chronic renal failure to the nephrologist.
Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis
Peritoneal catheter infections are a cause of peritonitis, catheter loss, and permanent transfer ... more Peritoneal catheter infections are a cause of peritonitis, catheter loss, and permanent transfer of continuous ambulatory peritoneal dialysis (CAPO) patients to hemodialysis. Risk factors for catheter infections have not been delineated. We investigated the location of the peritoneal exit-site location as a risk factor for catheter infection and loss. There was no relationship between catheter infection rates and exit location. Catheters exiting on the beltline had a median infection rate of 0.5 episodeslyear, as opposed to 1.2 episodes/year for catheters exiting above the beltline and 0.9 episodes/ year for catheters exiting below the beltline (ns). The percentage of catheters that became infected and required removal was the same for catheters exiting above, below, or on the beltline. Although we recommend avoiding the beltline for patient comfort, exit-site location is not an important determinant of infection rates or catheter outcome.
Nephrology news & issues, 2007
Research in Nursing & Health, 2009
This randomized controlled trial tested an intervention, Sharing Patients' Illness Representation... more This randomized controlled trial tested an intervention, Sharing Patients' Illness Representations to Increase Trust (SPIRIT), designed to enhance communication regarding end-of-life care between African Americans with end-stage renal disease (ESRD) and their chosen surrogate decision makers (N = 58 dyads). We used surveys and semi-structured interviews to determine the feasibility, acceptability, and preliminary effects of SPIRIT on patient and surrogate outcomes at 1 week and 3 months post-intervention. We also evaluated patients' deaths and surrogates' end-oflife decision making to assess surrogates' perceptions of benefits and limitations of the SPIRIT while facing end-of-life decisions. We found that SPIRIT promoted communication between patients and their surrogates and was effective and well received by the participants.
Peritoneal Dialysis International, 2013
We compared a group of 60 insulin-dependent diabetics maintained on CAPO with 60 nondiabetic matc... more We compared a group of 60 insulin-dependent diabetics maintained on CAPO with 60 nondiabetic matched controls to determine if the diabetic patients were at increased risk for catheter-related infections. Although catheter infection rates were 17% higher in the diabetics (1.4/year versus 1.2/year in nondiabetics), time to first catheter infection was not different between the groups (p=0.6). Rates of peritonitis, peritonitis associated with catheter infection, multiple catheter infection, and catheter removal were also similar among the diabetics and controls. S. aureus caused 52% (42/81) of the catheter infections in the diabetics and 60% (35/58) in the controls. More catheter infections in the nondiabetics versus the diabetics lacked drainage or resulted in sterile cultures (17/75 versus 7/88 respectively, p≤0.01 ), but the significance of this finding is uncertain. In conclusion, we did not find insulin-dependent diabetes mellitus to be a statistically significant risk factor for catheter-related infections.
CAPD related infections and catheter loss continue to be the major problems facing the peritoneal... more CAPD related infections and catheter loss continue to be the major problems facing the peritoneal dialysis patient. Few risk factors for infections and catheter loss have been identified. We hypothesized that overweight and underweight patients may be at increased risk for infections and catheter related problems. We examined the effect of the patient's weight at the start of peritoneal dialysis on the subsequent peritonitis and catheter infection rates, as well as catheter loss. Weight was expressed as a percentage of ideal body weight (IBW). Those patients who were more than 110% of IBW were considered to be overweight, 90 to 110% of IBW normal and less than 90%, underweight. An equivalent percentage of patients were overweight and underweight at the initiation of peritoneal dialysis (55/228, 24% for both groups). Overweight, normal, and underweight patients had peritonitis rates of 1.0, 0.9, and 0.8 episodes/y and catheter infection rates of 1.1,1.2, and 0.8 episodes/y, respectively. Despite these similar rates, catheter loss due to infectious complications was greatest in the overweight group and least in the underweight group (p<0.05). No obvious explanation for the difference in catheter loss rate was found. Neither S. aureus nor P. aeruginosa infections occurred more frequently in the overweight patients. However, S. aureus infections more often led to catheter loss in the overweight patients. Catheter loss due to catheter leaks and failure to drain was similar in the three groups of patients. We conclude that deviation from ideal body weight at the initiation of dialysis is not a risk factor for CAPD related infections. However, for unclear reasons, increasing weight is associated with increasing risk of catheter loss secondary to infections. Further research in this area is warranted.
Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis
Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis, 1991
Gentamicin is well known to be a cause of vestibular toxicity. Despite this, gentamicin is often ... more Gentamicin is well known to be a cause of vestibular toxicity. Despite this, gentamicin is often used to treat peritonitis and exit-site infections in peritoneal dialysis patients because of the ease of intraperitoneal administration and the broad coverage of aerobic Gram-negative bacilli, including Pseudomonas aeruginosa. We report 4 cases of severe vestibular toxicity occurring in peritoneal dialysis patients treated with gentamicin. They were all treated as outpatients for peritonitis or an exit-site infection while on continuous ambulatory peritoneal dialysis (CAPD) or continuous cyclic peritoneal dialysis (CCPD). The drug was administered to 3 patients in each peritoneal exchange (5 mg/L) after a loading dose. A fourth patient was given 1 mg/kg of intraperitoneal gentamicin every other day. The mean length of treatment was 21 days. Levels were not used to adjust the doses. All developed severe vertigo from which there was incomplete or no recovery. We suggest that gentamicin an...
Nature clinical practice. Nephrology, 2006
Methods to prevent peritonitis are an essential component of any successful peritoneal dialysis (... more Methods to prevent peritonitis are an essential component of any successful peritoneal dialysis (PD) program. Careful attention to training of the parents and child on the proper technique of PD and avoidance of manual spiking by using an assist device for the cycler, or use of the double-bag system for continuous ambulatory PD, should decrease risk of peritonitis from touch contamination. Secondly, reduction of peritonitis can be achieved through reduction of exit site infections by use of mupirocin antibiotic cream at the exit site of the PD catheter as part of routine care. If an exit site infection develops and is refractory to therapy, then the PD catheter can be successfully replaced as a single procedure, to reduce the risk of peritonitis. The third step in reducing the risk of peritonitis is to avoid repetitive episodes with the same organism. This may again involve replacing the catheter; as long as the effluent can be cleared, this again can be performed as a single procedure, thus allowing the child to avoid the trauma of hemodialysis. The focus in pediatric PD programs must always be on preserving the peritoneal membrane, and not on preservation of the catheter. With careful attention, peritonitis can become an uncommon event. Fig. 1 Percentage of children within each range of peritonitis rates. Data from reference [1]
Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis
Peritoneal dialysis (PD) patients are at risk for 25(OH) vitamin D deficiency due to effluent los... more Peritoneal dialysis (PD) patients are at risk for 25(OH) vitamin D deficiency due to effluent loss in addition to traditional risk factors. To measure 25(OH) vitamin D deficiency in prevalent PD patients, to evaluate a replacement dose, and to determine the effects of correction. 25(OH) vitamin D levels were drawn on prevalent PD patients. Patients deficientin 25(OH) vitamin D were given ergocalciferol, 50000 IU orally once per week for 4 weeks. Patients scored muscle weakness, bone pain, and fatigue on a scale of 0 (none) to 5 (severe). Serum calcium, phosphate, parathyroid hormone (PTH), and 25(OH) vitamin D, and 1,25(OH)2 vitamin D levels were obtained before and after treatment. 25(OH) vitamin D levels were measured in 29 PD patients. Deficiency (<15 ng/mL) was found in 28/29 (97%); 25/29 (86%) had undetectable levels (<7 ng/mL). One course of ergocalciferol corrected the deficiency in all but 1 patient, who required a second course. Scores for muscle weakness and bone pai...
American Journal of Kidney Diseases, 1996
We reviewed all episodes of peritonitis associated with exit site and/or tunnel infection (n = 87... more We reviewed all episodes of peritonitis associated with exit site and/or tunnel infection (n = 87; rate, 0.1/yr; 13% of all peritonitis episodes) occurring from 1979 to 1995. The exit site or tunnel infection was diagnosed at the time or shortly after the patient presented with peritonitis in 66% of the episodes. In the other one third the exit site
We reviewed methods of preventing peritonitis in children. A considerable body of evidence indica... more We reviewed methods of preventing peritonitis in children. A considerable body of evidence indicates that peritonitis rates are lowest with the use of a double-cuffed catheter, with a downward directed tunnel, placed by an experienced surgeon. Evidence in adults, but lacking in children, suggests that exit-site mupirocin will lower Staphylococcus aureus exit-site infections and thus peritonitis rates. The risk of peritonitis due to contamination can be diminished by the avoidance of spiking and by the provision of a long training period. Catheter removal and replacement for catheter-related peritonitis may be done simultaneously in certain circumstances and is useful in decreasing the risk of recurrent peritonitis. Antibiotic prophylaxis at the time of catheter insertion, for contamination, during dialysate leaks, and for invasive procedures appears to be useful in diminishing peritonitis risk.
Seminars in Dialysis, 2007
Infection Control and Hospital Epidemiology, 2010
We examined the Clostridium difficile infection rate and risk factors in an outpatient dialysis c... more We examined the Clostridium difficile infection rate and risk factors in an outpatient dialysis cohort. The Cox proportional hazard for developing C. difficile infection was significantly higher with high comorbidity index and low serum albumin level. Conversely, it was lower for patients who had frequent bloodstream and dialysis access-related infections.
Topics in Clinical Nutrition, 2011
Purpose-Describe the nutritional quality of foods consumed by hemodialysis patients and variation... more Purpose-Describe the nutritional quality of foods consumed by hemodialysis patients and variation by day of the week.
American Journal of Kidney Diseases, 2010
Blood Purification - BLOOD PURIFICAT, 2000
S. aureus is the major cause of access infections in both hemodialysis and peritoneal dialysis pa... more S. aureus is the major cause of access infections in both hemodialysis and peritoneal dialysis patients. It is also a common cause of bacteremia, the risk dependent on the type of access used (fig. 1). Rates of bacteremia are low with permanent arteriovenous access or a peritoneal dialysis catheter, higher with tunnelled catheters, and highest with acute HD catheters [1-9]. Hoen et al. [1]determined in a French study of 988 adult patients on chronic HD for 6 months that the risk of bacteremia (assigning a relative risk of one to patients with a fistula) was 1.29 for a graft or shunt and 7.64 for a catheter. Clearly, the best approach to reduce bacteremia in the HD patient is to use permanent access as opposed to a catheter for HD [10]. However, in the United States a high proportion of patients on HD use catheters, at least in part due to late referral of the patient with chronic renal failure to the nephrologist.
Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis
Peritoneal catheter infections are a cause of peritonitis, catheter loss, and permanent transfer ... more Peritoneal catheter infections are a cause of peritonitis, catheter loss, and permanent transfer of continuous ambulatory peritoneal dialysis (CAPO) patients to hemodialysis. Risk factors for catheter infections have not been delineated. We investigated the location of the peritoneal exit-site location as a risk factor for catheter infection and loss. There was no relationship between catheter infection rates and exit location. Catheters exiting on the beltline had a median infection rate of 0.5 episodeslyear, as opposed to 1.2 episodes/year for catheters exiting above the beltline and 0.9 episodes/ year for catheters exiting below the beltline (ns). The percentage of catheters that became infected and required removal was the same for catheters exiting above, below, or on the beltline. Although we recommend avoiding the beltline for patient comfort, exit-site location is not an important determinant of infection rates or catheter outcome.
Nephrology news & issues, 2007
Research in Nursing & Health, 2009
This randomized controlled trial tested an intervention, Sharing Patients' Illness Representation... more This randomized controlled trial tested an intervention, Sharing Patients' Illness Representations to Increase Trust (SPIRIT), designed to enhance communication regarding end-of-life care between African Americans with end-stage renal disease (ESRD) and their chosen surrogate decision makers (N = 58 dyads). We used surveys and semi-structured interviews to determine the feasibility, acceptability, and preliminary effects of SPIRIT on patient and surrogate outcomes at 1 week and 3 months post-intervention. We also evaluated patients' deaths and surrogates' end-oflife decision making to assess surrogates' perceptions of benefits and limitations of the SPIRIT while facing end-of-life decisions. We found that SPIRIT promoted communication between patients and their surrogates and was effective and well received by the participants.
Peritoneal Dialysis International, 2013
We compared a group of 60 insulin-dependent diabetics maintained on CAPO with 60 nondiabetic matc... more We compared a group of 60 insulin-dependent diabetics maintained on CAPO with 60 nondiabetic matched controls to determine if the diabetic patients were at increased risk for catheter-related infections. Although catheter infection rates were 17% higher in the diabetics (1.4/year versus 1.2/year in nondiabetics), time to first catheter infection was not different between the groups (p=0.6). Rates of peritonitis, peritonitis associated with catheter infection, multiple catheter infection, and catheter removal were also similar among the diabetics and controls. S. aureus caused 52% (42/81) of the catheter infections in the diabetics and 60% (35/58) in the controls. More catheter infections in the nondiabetics versus the diabetics lacked drainage or resulted in sterile cultures (17/75 versus 7/88 respectively, p≤0.01 ), but the significance of this finding is uncertain. In conclusion, we did not find insulin-dependent diabetes mellitus to be a statistically significant risk factor for catheter-related infections.