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Background Use of intermittent antibiotic dosing is increasing in the treatment of peritoneal dialysis (PD)-related peritonitis. We studied the pharmacokinetics of intravenous (IV) piperacillin in automated PD patients. Patients and Methods Eight patients (3 males, 5 females) were recruited and received a single IV dose of piperacillin (35 mg/kg actual body weight). Blood and dialysate samples were collected at the beginning, middle, and end of dwells 1 – 3 (on cycler), and end of dwells 4 – 5 (off cycler) for a 24-hour period. Baseline and 24-hour urine samples (nonanuric patients, n = 7) were collected. Pharmacokinetic parameters were calculated assuming a one-compartment model. Glomerular filtration rate (GFR) and piperacillin clearance (CL) values were normalized to 1.73 m2. Results The patients were 49.5 ± 10.1 years of age (mean ± SD) and had been receiving PD for a median of 3 months (range 2 – 66 months). Dwell times were 2.25 ± 0.06 hours on cycler and 7.26 ± 0.14 hours off cycler. Piperacillin half-life was not statistically different on or off the cycler (on cycler 1.99 ± 0.39 hr, off cycler 4.39 ± 5.4 hr; p = 0.12) and remained insignificant, even accounting for an outlier (on cycler 2.01 ± 0.41 hr, off cycler 2.54 ± 1.48 hr; p = 0.19). Piperacillin total CL (CLT) was 31.29 ± 6.02 mL/minute. Renal CL (CLR) and PD CL (CLPD) accounted for 8.8% and 16.8% of CLT; CLR correlated well with GFR (CLR = 0.86 GFR + 0.1; p < 0.000 03). Mean piperacillin serum and dialysate end-of-dwell concentrations were above minimum inhibitory concentration of susceptible organisms (8 μg/mL) for the three cycler exchanges only. Serum and dialysate concentrations predicted using a one-compartment model suggest that IV piperacillin 4000 mg would provide adequate concentrations for susceptible organisms over a 12-hour period. Conclusion The current IV piperacillin dosing recommendations of 4000 mg every 12 hours for PD-related peritonitis are appropriate for patients on automated PD. Intermittent intraperitoneal piperacillin is not recommended.

There is increasing use of intermittent dosing of antibiotics to treat peritoneal dialysis (PD)-related peritonitis. The disposition of intravenous cefazolin and tobramycin was studied in automated PD (APD) patients. Ten patients were recruited and received a single intravenous dose of cefazolin (15 mg/kg) and tobramycin (0.6 mg/kg). Blood and dialysate samples were collected at the beginning, middle, and end of dwells 1 to 3 (on cycler), and at the end of dwells 4 to 5 (off cycler) for a 24-h period. Baseline and 24-h urine samples were collected. Pharmacokinetic parameters were calculated using a monoexponential model. Cefazolin and tobramycin half-lives were markedly different on cycler than off cycler (cefazolin on cycler : 10.67 +/- 4.66 h; cefazolin off cycler : 23.09 +/- 5.6 h; P = 0.001; tobramycin on cycler : 14.27 +/- 4.53 h; tobramycin off cycler : 68. 5 +/- 26.47 h; P < 0.001). Mean serum and dialysate concentrations were above minimum inhibitory concentrations of susceptible organisms throughout the 24-h period for both drugs with intravenous administration. A model was developed to examine serum and dialysate concentrations after intermittent intraperitoneal administration of 15 mg/kg cefazolin and 0.6 mg/kg tobramycin. Model-predicted intraperitoneal cefazolin provides adequate serum and dialysate concentrations for 24 h. Intermittent intraperitoneal tobramycin doses must be 1.5 mg/kg for one exchange during the first day and then given as 0.5 mg/kg thereafter. It is concluded that the current empiric dosing recommendations for PD-related peritonitis may be adequate for cefazolin (15 to 20 mg/kg); however, tobramycin doses must be changed to 1.5 mg/kg intraperitoneally on day 1, then to 0.5 mg/kg intraperitoneally thereafter in APD patients.

For decades, salicylates have been recognised as one of the leading causes of drug overdoses. Deaths attributable to salicylates alone can be as high as 20.6% per year of analgesic drug deaths.[1] The incidence of salicylate poisonings, especially those with a chronic component, is difficult to ascertain because of the under-reporting of such cases and the poor correlation with serum levels. However, it is perceived to be low and usually occurs in patients with chronic pain.[2] Classic signs and symptoms in mild cases of acute salicylate toxicity include tachypnoea, lethargy, vomiting and hyperthermia without overt acidosis. In severe cases, symptoms worsen and, in addition, the patient may have metabolic acidosis and/or coma.[3] These symptoms correlate with the Done nomogram, which is used to assess the severity of acute salicylate poisoning.[4] Unfortunately, the severity of chronic salicylate overdoses is difficult to determine since serum concentrations do not accurately correlate with the Done nomogram.[5] Data illustrating the clinical ramifications of mixed acute and chronic intoxication of salicylates are scarce. Pulmonary injury has been well documented with chronic salicylate toxicity. Animal lung biopsy studies of salicylate poisoning have demonstrated increased permeability of alveoli.[6] To the best of our knowledge, these findings have not been confirmed in humans other than at autopsy.[7] This case illustrates the magnitude of diffuse pulmonary damage resulting in respiratory failure from long-term salicylate use as well as histological evidence in an otherwise healthy individual.

Hemoperfusion consists of the passage of anticoagulated blood through a column containing adsorbent particles. It was introduced in 1940 and refined from 1950 to 1970, and then introduced clinically for the treatment of acute intoxications between 1970 and 1980. Life-threatening valproic acid toxicity is an indication for coated charcoal hemoperfusion usually accomplished without complications, but we report a case of acute severe intravascular hemolysis during the time of hemoperfusion with coated charcoal column.

OBJECTIVE: To describe a case of toxicity secondary to chronic ingestion of 6–12 times the recommended daily allowance of over-the-counter (OTC) chromium picolinate. CASE SUMMARY: A 33-year-old white woman presented with weight loss, anemia, thrombocytopenia, hemolysis, liver dysfunction (aminotransferase enzymes 15–20 times normal, total bilirubin 3 times normal), and renal failure (serum creatinine 5.3 mg/dL; blood urea nitrogen 152 mg/dL). She had ingested chromium picolinate 1200–2400 μg/d for the previous 4–5 months to enhance weight loss. The patient had chromium plasma concentrations 2–3 times normal. Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome were ruled out by clinical findings, peripheral blood smears, and a bone marrow biopsy. The patient was managed with supportive measures and received blood product transfusions and hemodialysis. Hemolysis stabilized and liver function improved over 6 days. Liver function returned to normal prior to discharge. Renal function began to return on day 12 and her serum creatinine on discharge was 1.3 mg/dL. One year later, all laboratory values were within normal limits. DISCUSSION: Trivalent chromium is an essential trace element that is considered safe when ingested in normal quantities. Trivalent chromium compounds are used by patients to enhance weight loss, increase lean body mass, and/or improve glycemic control. Information regarding the toxicity of chromium picolinate is limited. CONCLUSIONS: Chromium supplements may cause serious renal impairment when ingested in excess. Medication histories should include attention to the use of OTC nutritional supplements often regarded as harmless by the public and lay media. OBJETIVO: Describir un caso de toxicidad producida por la ingestión crónica de picolinato de cromio, producto que no requiere prescripción médica, en cantidades de 6–12 veces mayores que las recomendadas. RESUMEN DEL CASO: Una mujer de 33 años presentaba pérdida de peso, anemia, trombocitopenia, hemólisis, disfunción hepática (aminotranferasas 15–20 veces el valor normal, bilirubina total tres veces el valor normal), y fallo renal (creatinina sérica = 5.3 mg/dL, nitrógeno ureíco sanguíneo = 152 mg/dL). Esta paciente había ingerido 1200–2400 μg diarios de picolinato de cromio durante los pasados 4–5 meses para bajar de peso. La paciente tenía una concentración de cromio en el plasma 2–3 veces lo normal. Se descartaron los síndromes de trombocitopenia púrpura trombótica y uremia hemolítica mediante hallazgos clínicos, cultivo de sangre, y biopsia de médula ósea. La paciente se manejó con medidas de apoyo, transfusiones con productos de sangre y hemodiálisis. La hemólisis se estabilizó y la función hepática mejoró a los 6 días de tratamiento. La función hepática regresó a los limites normales antes de ser dada de alta. La función renal comenzó a normalizarse el día 12 de la hospitalización y la creatinina sérica disminuyó a 1.3 mg/dL el día que la paciente fue dada de alta. Un año más tarde, todos los valores de laboratorio se encontraban dentro de los límites normales. DISCUSION: El cromio trivalente es un elemento traza esencial que se considera seguro cuando se ingiere en cantidades recomendadas. En la actualidad, los compuestos de cromio trivalente son utilizados para ayudar en la pérdida de peso, aumentar el peso magro y/o mejorar el control glucémico. La información disponible relacionada con la toxicidad del picolinato de cromio es aún muy limitada. CONCLUSIONES: Los suplementos de cromio pueden causar impedimentos renales serios cuando se ingieren en cantidades excesivas. Es importante que el historial médico incluya información sobre los suplementos nutricionales que pueda estar utilizando el paciente. Estos productos se adquieren sin prescripción médica y muchas veces el público y los medios de información no especializados los consideran inofensivos. OBJECTIF: Décrire un cas de toxicité associee à l'ingestion chronique d'un produit de comptoir, le picolinate de chromium, à une dose de 6–12 fois celle recommandée quotidiennement. RÉSUMÉ DU CAS: Une femme âgée de 33 ans se présente à l'urgence où on constate une perte de poids, une anémie, une thrombocytopénie, une hémolyse, un problème hépatique (le taux des aminotransférases est de 15–20 fois la normale, le taux de la bilirubine totale est de 3 fois la normale), et une insuffisance rénale (créatinine sérique = 5.3 mg/dL, azote uréique sanguine = 152 mg/dL). Elle a ingéré 1200–2400 μg par jour de picolinate de chromium pendant les 4–5 mois précédents pour stimuler une perte de poids. Les concentrations plasmatiques de chromium sont de 2–3 fois la normale. Un purpura thrombotique thrombocytopénique et un syndrome hémolytique urémique ont été éliminés à l'aide des données cliniques, des prélèvements sanguins et d'une biopsie de la moëlle épinière. Un traitement de support a été administré à la patiente; elle a reçu des transfusions sanguines et une hémodialyse a été réalisée. L'hémolyse s'est stabilisé et la fonction hépatique s'est améliorée en 6 jours. La fonction hépatique s'est normalisée avant le départ de la patiente. La fonction rénale a commencé à s'améliorer au jour 12 et la créatinine sérique était de 1.3 mg/dL à son départ. Un an plus tard, toutes les valeurs de laboratoire sont à l'intérieur de la limite de la normale. DISCUSSION: Le chromium trivalent est un oligo-élément essentiel considéré sécuritaire lorsqu'il est ingéré en quantité normale. Des produits à base de chromium trivalent sont utilisés couramment par les patients pour favoriser la perte de poids, pour augmenter la masse maigre et/ou pour améliorer le contrôle glycémique. Les données concernant la toxicité du picolinate de chromium sont limitées. CONCLUSIONS: Les suppléments de chromium peuvent causer une altération grave de la fonction rénale s'ils sont ingérés en quantité excessive. Lors des entrevues avec les patients, une attention particulière devrait être portee à l'utilisation des suppléments nutritionnels disponibles sans ordonnance et considérés sans danger par le public et la presse.

Acute poisoning from excessive dapsone (4,4-diaminodiphenylsulfone) intake in uncommon in the United States; no cases were reported during 1992. However, with the increasing use of dapsone for diseases other than leprosy and dermatitis herpetiformis, such as acne vulgaris, psoriasis, and Pneumocystis carinii pneumonia infection in acquired immunodeficiency syndrome, clinicians should be aware of potential toxicities. This report describes a case of accidental dapsone intoxication resulting in severe cyanosis with a modest elevation in methemoglobin concentration.

In the present study we examined the relationships among hemodialysis patients' perceptions of control over their health, attributions of causality, and staff ratings of coping and compliance. Patient responses to questions posed during a semi-structured interview were predictors entered into multiple regression analyses with coping and compliance ratings as criterion variables. Results indicate that having tried to prevent kidney failure and not succeeding predicts poor compliance and poor coping. Perceived control is associated with positive coping but is unrelated to compliance. Finally, patients who wondered, "Why me?" but had not arrived at an answer received the poorest coping and compliance ratings from staff. Results are discussed in light of current theory regarding the beneficial effects of perceived contingency between actions and outcomes, and the need to find a meaning for one's illness.

Excerpt Renal failure may precipitate or exacerbate hepatic encephalopathy in patients with liver disease (1, 2). One postulated mechanism is the excessive production of ammonia by the bacterial fl...