A prospective study of the effect of noncompliance on small solute removal in continuous ambulatory peritoneal dialysis. Preliminary report

In nine patients on continuous ambulatory peritoneal dialysis (CAPD) who were in stable condition, the authors measured the effects of an extra daily exchange on small solute removals and clearances and the measured/predicted creatinine production (M/P). The goal was to evaluate the sensitivity of M/P to single exchange noncompliance. Daily collections of urine and dialysate were performed on the usual prescribed program and on the next day with an extra exchange of usual exchange volume. The average increase in drain volume of 26% was associated with an average increase in M/P of 6%. The maximum M/P increase was 15%; the percentage increase in M/P correlated inversely with renal creatinine clearance. Daily total urea clearance normalized to total body water by dialysis and renal function increased 12%. Extrapolating these findings suggests that an average patient with a baseline M/P near 1.0 and renal creatinine clearance of 5 ml/min would require more than 50% drain volume noncompliance to yield a M/P of 1.24 on the complaint day. A 50% noncompliance may not yield a M/P greater than 1.0 on the first compliant day if baseline M/P is less than 0.94. The authors suggest monitoring daily urine and dialysis creatinine output because M/P creatinine is relatively insensitive to noncompliance (particularly in patients with residual renal function) and because there are questions about the accuracy of predictions in patients with renal failure using formulae established in different populations. The authors recommend simply monitoring total daily creatinine output and establishing patients as their own controls. The authors provide a table for the interpretation of changes in creatinine output in conjunction with changes in other routinely monitored parameters.

Leukocyte kinetics in patients with peritonitis on long-term peritoneal dialysis

Dialysate and blood leukocyte counts were measured during 130 episodes of peritonitis in 91 hospitalized patients on long-term peritoneal dialysis (CPD). The authors found that the blood/dialysate leukocyte count can be less than 1.0, and this is usually the case when dialysate leukocyte count exceeds 20,000/mm3. Dialysate leukocyte removal in a single 2 L drain bag can approach the leukocyte number in the entire circulating blood volume. Daily drainage can remove leukocytes in amounts exceeding the blood leukocyte pool 2 to 3 fold. The observed blood leukocyte counts throughout a range of 2,700 to 10,000 at dialysate leukocyte counts greater than 20,000 per mm3 may reflect: 1) leukocyte removal approaching maximum bone marrow output of leukocytes, and/or 2) increasing microcirculatory margination of leukocytes in those episodes of peritonitis associated with very high dialysate leukocyte counts.

Rat model of peritoneal fibrosis: preliminary observations

The aim of this study was to establish a rat model of peritoneal fibrosis. After insertion of peritoneal catheters into 18 rats, the rats were divided into three groups. All animals were dialyzed twice a day with 4.25% Dianeal containing heparin. Group 1 rats (control) received antibiotics (vancomycin and gentamicin) in each exchange: group 2 rats were inoculated with Escherichia coli (5 x 10(6) in 5 mL of saline) at the beginning of the study; group 3 rats were treated with antibiotics after Escherichia coli inoculation; they also received a second inoculation of Escherichia coli after the second week of the study. By the end of the second week, group 2 rats were sacrificed because of catheter problems. Group 1 and 3 rats were sacrificed after 4 weeks of dialysis. A weekly peritoneal equilibration test (PET) was performed in each rat. The comparison of the PET results from the beginning and end of the study showed an increased permeability to glucose (p < 0.05) and total protein (p < 0.05) in group 3, which was not noted in group 1. In histology samples there was only delicate fibrosis with cellular infiltration in the peritoneum in group 1 rats. These changes were much more prominent in group 3 rats. This study suggests that E. coli peritonitis causes peritoneal fibrosis in rats, but to have a sclerosing encapsulating peritonitis (SEP) model this experiment must be carried out for a longer time.

Preliminary evaluation of silver-coated peritoneal catheters in rats

Silver is known to have powerful antibacterial properties against a variety of micro-organisms and has a low toxicity and a favorable biocompatibility profile. This study was designed to evaluate the effectiveness of silver-coated catheters in preventing early exit-site infection and to assess tunnel morphology. Seven male Sprague-Dawley rats underwent simultaneous implantation of two double-cuffed, silver-coated silicone rubber and standard silicone rubber catheters. Weekly observations and photographs documented exit-site characteristics. The animals were sacrificed and catheters removed and processed for histopathology of the external tunnel at 5 weeks. Exit sites of silver-coated catheters tended to have less inflammation and infection and healed better than those of uncoated catheters; however, these data did not achieve significance using the Wilcoxon signed-rank test. Sections of the external tunnel of well-healing exit sites showed an epithelialized tract with granulation tissue near the cuff and significant invasion of the external cuff by collagen with a mild neutrophilic inflammatory response. In contrast, the histology of the external tunnel of infected exists revealed exudate overlying inflammatory granulation tissue and a variable degree of fibrosis of the cuff. When the exit sites appeared similar, no significant histopathological differences in sinus tract and cuff morphology were noted with either silver or standard catheters. In conclusion, these findings suggest that silver coating of catheters may decrease the incidence of early exit-site infections and allow better ingrowth of the catheter.

Lithium carbonate decreases ultrafiltration rates in an experimental model of PD

Animal studies have shown increased fluid absorption from the peritoneal cavity following intraperitoneal (ip) vasopressin. Lithium is known to antagonize vasopressin effects on fluid absorption in kidney distal nephrons. The aim of the present study was to see whether lithium-containing exchanges increase the ultrafiltration rates (UF) during peritoneal dialysis (PD) in rats. PD was carried out in 6 Sprague-Dawley rats with 1.5% dextrose-containing PD solution using 15-ml volumes. Each exchange (ex) took 1 min for inflow, 4 mins for outflow and 25 mins for dwell. All rats underwent 9 consecutive half-hourly exs. During exs 4-6 lithium carbonate 2.5 mM was added to the PD solution. During lithium-containing exs significant increases in the glucose absorption rates (3.9 +/- 7.8 vs 37.5 +/- 8.1 mg/ex; p = 0.025) were associated with significant reductions in the UF (3.03 +/- 0.25 vs 1.78 +/- 0.12 ml/ex; p = 0.005). In conclusion, the isolated increase in glucose absorption without increases in the dialysate protein concentration with ip lithium, may suggest either a selective increase in size of the pores with a mean dimater near that of the glucose molecule or enhanced lymphatic absorption. ip lithium did not increase the UF in a rat model of PD.

Lean body mass estimation by creatinine kinetics

A new technique for estimating lean body mass (LBM) from creatinine kinetics has been developed. It is based on the principle that creatinine production is proportional to LBM and that, in the steady state, creatinine production is equal to the sum of creatinine excretion (urinary and dialytic) and metabolic degradation. This technique was applied to 17 normal subjects, 26 stable, chronic hemodialysis (HD) patients, and 71 stable, chronic peritoneal dialysis (PD) patients. In the HD group, LBM was also determined by bioimpedance in 11 patients and calculated from total body water, measured as the volume of urea distribution of a sterile urea infusion, in 15 patients. In normal subjects and in the PD group, LBM was assessed by creatinine kinetics as well as by bioimpedance, near infrared, and anthropometric techniques. In the HD patients, LBM by creatinine kinetics correlated significantly with LBM from total body water and the bioimpedance technique. There was no statistical difference between the total body water and creatinine kinetics techniques, but the bioimpedance values were systematically higher than those obtained by the kinetic technique. In the PD group and in normal volunteers, LBM values by creatinine kinetics correlated significantly with the other methods but were lower. Forty-seven percent of the HD patients and 66% of the PD patients had significantly lower LBM by creatinine kinetics than expected for their sex and age. Estimation of LBM by creatinine kinetics is proposed as a simple and convenient technique for the routine nutritional assessment of dialysis patients.

Comparison of different measurements of lean body mass in normal individuals and in chronic peritoneal dialysis patients

To evaluate different methods of measuring lean body mass (LBM) in chronic peritoneal dialysis (CPD) patients, we first made comparisons in seven normal subjects. Seven methods (total body potassium [TBK] counting, bioelectrical impedance with calculations according to Segal and Deurenberg, near-infrared interactance with and without exercise level included as a variable, anthropometric measurements, and creatinine kinetics) were compared with the standard method of underwater weighing (UW) for measuring LBM. Significant correlations with LBM measured by UW (r > 0.938) were found with LBM measured by all other methods. Compared with UW, the best result in normals was found with TBK as it had high r values, small y-intercepts, and slopes of regression lines close to unity in both measurements of LBM and %LBM; in addition, fat-free mass index by TBK best approximated that by UW and TBK had the lowest mean prediction error with UW. In 11 patients on CPD, LBM was measured by all the above methods except UW. Significant correlations of all methods with LBM measured by TBK used as the reference standard were noted (all r > 0.76) in the CPD population. The LBM measured by creatinine kinetics correlated best (by kilograms or percentage of body weight [%BW]) with LBM from TBK compared with the other methods in which values tended to be higher. The fat-free mass index by creatinine output was nearest to the fat-free mass index by TBK. The root mean square prediction error was lowest between LBM by creatinine output and that by TBK. The findings support the concept of measuring creatinine outputs in CPD patients for estimates of LBM as an index of nutritional status as well as for creatinine clearances as an index of adequacy. Total body potassium and creatinine output measurements of LBM reflect the LBM at normal body fluid volumes ("dry weight") and may be better indices of nutrition in dialysis patients than the other techniques, which include excess fluid in the LBM.

Changes in the peritoneal equilibration test in selected chronic peritoneal dialysis patients

Fifty-five patients on chronic peritoneal dialysis with two or more peritoneal equilibration tests (PET) performed between 1983 and 1992 with a mean interval of 21.9 +/- 22.7 months were studied retrospectively. Repeated PET were performed when transport changes were suspected rather than routinely. According to the initial PET, there were 16 high (HI), 17 high-average (HA), 15 low-average (LA), and 7 low (LO) transporters. There was a significant decrease in the mean creatinine dialysate to plasma ratio (D/P creatinine) in the HI transporters and an increase in the LA and LO transporters. The mean dialysate to instilled glucose ratio (D/Do) significantly increased in the HI transporters. The change in both the D/P creatinine and the D/Do of an individual strongly and inversely correlated to their respective initial values. The change in D/P creatinine and D/Do were significantly and inversely correlated to each other, indicating an actual transport change. No correlation was found between the change in transport with peritonitis episodes or frequencies. The centripetal [corrected] change of transport toward average described here may explain why low clearances or low ultrafiltration rates due to rapid transport are infrequent causes of peritoneal dialysis technique failure, and why patients who have been dialyzed for a long period are usually HA transporters.

Continuous ambulatory peritoneal dialysis with a high flux membrane

The standard peritoneal equilibration test (PET) was performed in 66 patients on CAPD. Patients were classified as low (n = 5), low average (n = 22), high average (n = 27), and high (n = 12) transporters based on the dialysate/plasma creatinine (D/P Cr) after 4 hour dwells. After an average time interval of 14 months on CAPD, indices of dialysis adequacy and nutrition were assessed. Based on monitoring of patient chemistries and drain volumes, peritoneal transport was considered stable during the interval. Instilled volumes and exchange tonicity were individualized in each patient to achieve combined renal and dialysis weekly creatinine clearance and KT/V urea that were not significantly different between groups. Overall, there were significant positive correlations of PET D/P Cr with dialysate albumin concentrations (r = 0.30, p < 0.02) and dialysate albumin losses (g/wk, r = 0.27, p < 0.04). There were significant inverse correlations with lean body mass (r = -0.26, p < 0.03), drain volumes (r = -0.025, p < 0.04), and KT urea by dialysis (L/wk, r = -0.24, p < 0.05). High transporters had significantly (p < 0.05) lower mean serum albumin, net protein catabolic rate (nPCR), lean body mass calculated from creatinine kinetics, and daily creatinine production (and presumably lower muscle mass) compared with one or more lower transport groups. In conclusion, we hypothesize that, in high transporters, use of more hypertonic exchanges with greater glucose absorption may inhibit appetite and nPCR; also, protein losses in drain volumes are increased. High transporters may require increased clearance and protein intake targets compared with other groups to maintain nutrition.(ABSTRACT TRUNCATED AT 250 WORDS)

Continuous ambulatory peritoneal dialysis with a high flux membrane. A preliminary report

The standard peritoneal equilibration test (PET) was performed in 66 patients on continuous ambulatory peritoneal dialysis (CAPD). Patients were classified as low (n = 5), low average (n = 22), high average (n = 27), and high (n = 12) transporters based on the dialysate/plasma creatinine (D/P Cr) after 4 hr dwells. After an average time interval of 14 months on CAPD, indices of dialysis adequacy and nutrition were assessed. Based on monitoring of patient chemistries and drain volumes, peritoneal transport was considered stable during the interval. Instilled volumes and exchange tonicity were individualized in each patient to achieve combined renal and dialysis weekly creatinine clearance and KT/V urea that were not significantly different between groups. High transporters had significantly (p < 0.05) lower mean serum albumin, net protein catabolic rate (nPCR), lean body mass calculated from creatinine kinetics, and daily creatinine production (and presumably lower muscle mass), and higher albumin clearances compared to one or more lower transport groups. In conclusion, we hypothesize that high transporters are prone to protein malnutrition related to increased dialysate protein losses, and perhaps suppression of appetite, with increased use of hypertonic exchanges. High transporters are candidates for protein supplementation on CAPD or transfer to nightly intermittent peritoneal dialysis where short cycles provide more ultrafiltration with less glucose absorption.

Peritoneal transfer during maximal hyperosmotic ultrafiltration in the rat

Peritoneal transfer parameters were estimated in rats (n = 24) while maximal net ultrafiltration rate (nUFR) was achieved with 15% dextrose dialysis solution (1,153 mOsm/kg) and compared with those obtained with 0.37% dextrose solution (301 mOsm/kg). Experiments were carried out with dialysis solutions of pH approximately 6.5 and approximately 7.6, respectively, for 15% dextrose dialysis solution and 0.37% dextrose solution. Increases in both convective and diffusive transfer resulted in more than 70% greater peritoneal clearances of urea, potassium, and phosphate with hyperosmotic solutions at both pH values. Protein removal was increased only with a hyperosmotic solution of pH approximately 6.5 compared with isosmotic conditions at the same pH. Results support the hypothesis that increased peritoneal transfer parameters under hyperosmotic conditions depend not only upon enhanced convection but also on factors promoting diffusive transfer.

Peritoneal transfer of carbon dioxide in the rat

In the authors' previous rat studies (Kidney Int 39: 608-617, 1991), peritoneal clearances (Cp) representing near exclusively diffusive CO2 transfer were evaluated: for isosmotic (0.37% dextrose) and hyperosmotic (15% dextrose) solutions with pH 7.2-7.3, Cp CO2 were 1.20 +/- 0.08 and 1.84 +/- 0.04 ml/min, respectively. In the present studies peritoneal transfer parameters (D/B, Cp) of CO2 gas, HCO3-, and total CO2 (tCO2) in anesthetized rats have been compared (n = 22) using solutions with dextrose contents as mentioned above but with a pH of 6.5 or 7.6; how much Cp CO2 measurements obtained with solutions at these pH values differ from Cp shown earlier with solutions of pH 7.2-7.3 has also been evaluated. When the pH was the same, transfer parameters of CO2 gas, HCO3-, and tCO2 were significantly higher under hyperosmotic conditions. The use of solutions with a pH different from 7.2-7.3 resulted in higher Cp of CO2 gas: with isosmotic solutions at pH 6.5 and 7.6, mean increases were 25 and 75%, respectively; with hyperosmotic solutions respective increases were 45 and 134%. The authors conclude that dialysis solution pH, especially under hyperosmotic conditions, significantly changes parameters of diffusive CO2 transfer in the rat. For evaluation of peritoneal blood flow from diffusive transfer parameters of CO2 gas, smaller overestimation can be expected when dialysis solution pH is slightly under than overadjusted compared to blood pH.

Cross-sectional assessment of weekly urea and creatinine clearances in patients on continuous ambulatory peritoneal dialysis

In 55 patients on continuous ambulatory peritoneal dialysis, the authors determined daily renal and dialysate clearances of urea nitrogen (CUN) and creatinine (CCr). Results are expressed as weekly CUN in liters (Kt) divided by liters of total body water determined from a nomogram (V). The authors calculated weekly CCr as the weekly dialysis clearance plus the average of renal CUN and CCr (to correct for creatinine secretion); they normalized total weekly CCr to 1.73 m2 body surface area. Mean weekly Kt/V and CCr were 2.1 and 65.2, respectively. Mean dietary protein intake by dietary survey was 0.85 g/kg body weight. Protein catabolic rate (PCR) calculated from urea kinetics was 0.94 g/kg standardized weight (V/0.58); PCR was significantly (p < 0.01) correlated with Kt/V (r = 0.53). The authors used linear regression to determine PCR, as follows: PCR = 0.80 [weekly Kt/V]/3 + 0.39. This slope is nearly 1.5 times that reported for the relationship of PCR to [weekly Kt/V]/3 in hemodialysis patients. Eighty-two percent of patients on continuous ambulatory peritoneal dialysis had more than the targeted minimum weekly Kt/V of 1.7, 71% had a weekly CCr more than the targeted minimum of 50, and 75% had a PCR > 0.8 g/kg/day. In support of the hypothesis that Kt/V requirements are related to peak concentration control rather than to time averaged blood urea nitrogen, patients on continuous ambulatory peritoneal dialysis have a higher PCR at given Kt/V values compared to hemodialysis patients. These patients are more likely to have a PCR > 0.8 if weekly Kt/V > 1.7.

Peritoneal clearances of carbon dioxide in the rat

In our previous rat studies (Kidney Int. 1991; 39: 608-617) we evaluated peritoneal clearances (Cp) representing near exclusively diffusive CO2 transfer: for isosmotic (0.37% dextrose) and hyperosmotic (15% dextrose) solutions with pH 7.2-7.3, CpCO2 were 1.20 +/- 0.08 and 1.84 +/- 0.04 ml/min, respectively. In the present studies we have compared Cp of CO2 gas and HCO3- in anesthetized rats (n = 22) using solutions with dextrose contents as mentioned above but with pH 6.5 or 7.6; we have also evaluated how much Cp CO2 measurements obtained with solutions at these pH values differ from Cp shown earlier with the solutions of pH 7.2-7.3. Cp of CO2 gas and HCO3- were significantly higher under hyperosmotic than isosmotic conditions. The use of solutions of pH different from 7.2-7.3 resulted in higher Cp of CO2 gas: with isosmotic solutions of pH 6.5 and 7.6 mean increases were 25 and 75%, respectively; with hyperosmotic solutions respective increases were 45 and 134%. We conclude that dialysis solution osmolality and pH significantly change Cp of CO2 gas and HCO3- in the rat. For evaluation of peritoneal blood flow from diffusive transfer parameters of CO2 gas, smaller overestimation can be expected when dialysis solution pH is slightly under-than overadjusted compared to blood pH.

Ultrafiltration and effective peritoneal blood flow during peritoneal dialysis in the rat

The dependence between maximum net ultrafiltration rate (nUFR) created by 15% dextrose dialysis solution and effective peritoneal capillary blood flow (EPBF) estimated by the diffusive mass transport coefficient (KBD) and peritoneal clearance (Cp) of CO2 gas was evaluated during 30 minute, 15 ml peritoneal dialysis exchanges in anesthetized rats (N = 18). The values of KBD for CO2 suggested a mean EPBF of 1.9 +/- 0.1 (SEM) ml/min for isosmotic exchanges and 2.7 +/- 0.2 ml/min for hyperosmotic ones with a mean maximum nUFR of 0.43 +/- 0.01 ml/min. Cp of CO2 measured after the first five minutes of dwell underestimated EPBF. In normally hydrated rats, maximum nUFR was achieved when the peritoneal filtration fraction was 32 +/- 2%. This value is similar to the glomerular filtration fraction in rats of 30%. Thus, our results indicate the following relationships: EPBF = (approximately 3 x maximum nUFR)/(1 - hematocrit). EPBF was about six times greater than maximum nUFR and exceeded about 57 times nUFR obtained under isosmotic conditions. These differences between EPBF and nUFR suggest normal EPBF is not a major limiting factor for maximum ultrafiltration achieved during peritoneal dialysis.

Maximum ultrafiltration rates during peritoneal dialysis in rats

It has been suggested that filtration pressure equilibrium could occur in peritoneal capillaries during peritoneal dialysis with very hypertonic exchanges. Rats were exposed to peritoneal dialysis solutions using 16 ml instillations, 30 minute cycles, and dextrose concentrations from 1.4 to 20 g%. There was a plateau in ultrafiltration per exchange at mean osmotic gradients above 360 mOsm/kg H2O near 12.5 ml/ex (0.42 ml/min). The findings are also compatible with filtration pressure equilibrium predictions at an effective capillary plasma flow of 0.84 ml/min and a filtration fraction near 50%. Studies with cardiovascular drugs (norepinephrine i.v., nitroprusside i.p., and dobutamine i.v.) showed no effects on the maximum ultrafiltration rates. This might indicate that flow is rather fixed because of known microcirculatory effects of solutions themselves.

Total creatine kinase and isoenzyme fractions in chronic dialysis patients

We measured total serum creatine kinase (CK) and serum creatine kinase MB fraction (CK-MB) in 53 patients on continuous ambulatory peritoneal dialysis (CAPD) and 52 patients on maintenance hemodialysis (HD), using Scalva UV methodology for CK and electrophoresis for CK-MB. Seven of the 53 CAPD patients (13%) had an elevated total CK, and only one of these 7 patients had an elevated CK-MB greater than 5%. In contrast 22 HD patients (42%) had increased total CK values, and 6 of these 22 HD patients (27%) showed elevated CK-MB isoenzyme greater than 5%. For each sex, blacks had higher mean CK values than whites. Twenty-one out of the 43 HD patients who received intramuscular injections had elevated total CK values and 6 of these 21 patients had elevated CK-MB isoenzyme independent of the timing of injection. The increased frequency of higher total CK values in HD patients appears to be related to race and androgen administration. The modest elevations in CK-MB fraction (5 to 8%) in these patients require careful interpretation.

Polycation as an alternative osmotic agent and phosphate binder in peritoneal dialysis

We have previously shown that polyanions can be utilized to achieve balanced removal of sodium and water during peritoneal dialysis. The excessive binding of potassium, calcium, and magnesium to anionic polymers proves undesirable. The present study was designed to demonstrate the reversibility of cation binding by using a polycation (polyethylenimine) as the osmotic agent, thus favoring the removal of undesirable excess phosphate anions via peritoneal dialysis. Polyethylenimine shows a measurable affinity for phosphorus when present as dialysate in an in vitro system simulating peritoneal dialysis. The polycation also stimulates ultrafiltration across the rat peritoneum when present in dialysate. The polymer is toxic to the rat and light microscopy reveals gross morphological tissue alterations of the visceral mesothelium and associated organs. We have demonstrated that a polycation can give ultrafiltration with enhanced removal of phosphate. Although the polymer we chose as a prototype is toxic to the rat, other polycations should be studied.

Polyanions and glucose as osmotic agents in simulated peritoneal dialysis

Peritoneal dialysis solutions contain glucose as an osmotic agent to obtain ultrafiltration. Due to rapid absorption, glucose does not sustain high ultrafiltration during long exchanges. Nonabsorbable polyanions might be effective as osmotic agents when suspended in electrolyte solution. Concentrations of freely diffusible ions should be in Gibbs-Donnan equilibrium with plasma electrolytes. The ideal proportion of diffusable to polymerbound cation concentrations is unknown. To obtain concentrations of free ions in equilibrium with plasma, it is assumed that the polymer solution dialyzed against a polyelectrolyte solution of the desired composition (with hydraulic pressure higher on the polymer side) will approach the same thermodynamic activity as the electrolyte solution. Subsequently, if transmembrane pressure is released, osmotic ultrafiltration will occur in proportion to the hydrostatic pressure applied during polymer solution preparation. Polyacrylate solution so prepared was compared with a commercial dextrose dialysis solution in an in vitro simulation of peritoneal dialysis. With dwell times up to 24 h, sustained ultrafiltration with polymer was observed, whereas, with dextrose, ultrafiltration ceased after 8 h. Concentrations of diffusible bivalent cations in polyacrylate were lower than intended due to avid polymer complexing; however, dextran sulfate solutions were developed to contain desired concentrations of diffusible electrolytes. The conclusion is that some polymer solutions might be useful in clinical settings when high sustained ultrafiltration is needed.

Preclinical toxicology studies with acyclovir: teratologic, reproductive and neonatal tests

Five studies were done to define the potential of Acyclovir (ACV), a new nucleoside analog for antiviral chemotherapy, to produce adverse effects on reproduction and development in laboratory animals. ACV produced no adverse effects when given by gavage to F0 generation mice at 50, 150 and 450 mg/kg/day in a two generation reproduction/fertility study. Some mice were evaluated for teratologic effects and others for postnatal development, including behavior, with negative results. ACV was not embryotoxic and did not increase the incidence of fetal malformations when given by subcutaneous injection to pregnant rats and rabbits at dose levels of 12, 25 and 50 mg/kg/day during the periods of major organogenesis. A comparative LD50 study revealed that 3-day-old rats were not more sensitive to acute toxic effects of ACV than more mature rats. Finally, in a comprehensive multidose toxicity study ACV was given subcutaneously to neonatal rats at 5, 20 and 80 mg/kg/day for 19 consecutive days. There was minimal effect on body weight gain in neonates treated at 20 mg/kg/day and a significant decrease in body weight gain at 80 mg/kg/day. Minimal renal lesions occurred at 80 mg/kg/day but no other signs of adverse effects on developing organ systems were observed. Except for decreased body weight gain in neonatal rats treated at 80 mg/kg/day, ACV did not produce adverse effects on mammalian development when tested in a variety of preclinical toxicology studies.

Acute changes in peritoneal morphology and transport properties with infectious peritonitis and mechanical injury

Peritoneal clearance studies were performed in rats undergoing acute peritoneal dialysis. Some of these animals were then exposed to laparotomy and mechanical drying of the peritoneum. Peritoneal clearance studies were repeated at intervals up to 11 days. Another group of rats was placed on daily peritoneal dialysis and allowed to spontaneously develop peritonitis which was not treated. These rats underwent peritoneal transport studies at differing durations of infection. In all groups, animals were sacrificed at the time of the last transport studies for morphological assessment of the peritoneum by light microscopy, scanning electron microscopy, and transmission electron microscopy. The results showed similar decreases in drainage volume and increases in glucose absorption and protein losses with both infection and drying. Both types of injury resulted in extensive mesothelial structural changes. While drying caused mainly denudation of the mesothelial surface, infectious peritonitis was associated with separation of mesothelial cells, and the appearance of numerous white blood cells between and on mesothelial cells. Exposure to peritoneal dialysis alone had no obvious effects on anatomy. Although changes in the peritoneal microcirculation and deeper structures cannot be excluded as contributing to peritoneal transport alterations, the findings suggest that alterations of mesothelium might explain some of the changes in peritoneal transport properties under the conditions of these studies.

Nature of insulin binding to plastic bags

The nature of insulin binding to plastic bags was evaluated to determine if it followed the physical laws of adsorption. To determine whether insulin is adsorbed on a liquid/air interface, the influence of foam in vials of radiolabeled insulin was evaluated. Using a bag-to-bag transfer method, the influence of regular insulin and detergent on radiotracer insulin binding was assessed. To evaluate the reversibility of the binding, bag pieces with bound radioactive insulin were washed with distilled water, detergent, and left to soak in detergent before measuring radioactivity. The radiolabeled insulin was adsorbed in the foam and then released into the bulk of the solution when the foam disappeared; hence, insulin can be entrapped in a liquid/air interface. The addition of regular insulin decreased the binding of the radiotracer insulin to the bag walls. The bound insulin could be removed by washing with water and detergent, but soaking in detergent did not remove a small residual quantity of the bound insulin, suggesting that minimal chemical binding or diffusion of the insulin into the plastic may occur. Insulin binding to plastic bags primarily follows the physical laws of adsorption.

Influence of temperature and time on insulin adsorption to plastic bags

The influence of temperature and time on insulin adsorption to plastic peritoneal dialysis bags was evaluated. A dialysis bag (1.5% dextrose, 2 liters) was injected with 25-microCi insulin I 125 and gently mixed. This bag was then attached to another empty bag of the same type. Following a bag-to-bag transfer method, the amount of insulin adsorbed on the plastic bags was measured at 24 degrees C and 37 degrees C, and after a 12-hour warming period at 37 degrees C. Regular insulin was added to the system in 40-unit increments up to 280 units. Radioactivity in all of the samples was measured in a gamma counter. As the amount of regular insulin increased, the percentage of insulin adsorbed decreased at both temperatures. More insulin was bound at 37 degrees C than at 24 degrees C for all levels of insulin. Data calculated according to the Langmuir isotherm equation showed that the maximum possible values of adsorption to the system at 24 degrees C and 37 degrees C were 17.8 and 18.4 units, respectively. The affinity constants at 24 degrees C and 37 degrees C were 0.0039 and 0.0065, respectively. The influence of prolonged warming at 37 degrees C was minimal. At the usual dosage of insulin (below 40 units) prescribed to the majority of dialysis patients, less than 9% (3.5 units) is adsorbed onto the dialysis bags.

Insulin binding to plastic bags: a methodologic study

A radiotracer method to assess insulin binding to commercially available plastic peritoneal dialysis solution containers was developed. A peritoneal dialysis bag (bag 2) was emptied and attached to another full bag (bag 1) of the same kind. In the syringe-to-bag method, bag 1 was symmetrically injected through the bag wall with four syringes containing dialysis solution and radioactive insulin, with or without regular insulin. The radioactivity in each syringe was measured with a gamma counter before injection, and all of the samples were counted afterwards directly in the syringes. Using a bag-to-bag transfer method, bag 1 was agitated, eight samples were taken from different parts through the wall, and then the contents were transferred to bag 2. Bag 2 was then agitated and eight samples were taken and counted. In the bag-pieces method, pieces of bag wall were cut and the radioactivity on the walls was measured to determine the amount of binding. The syringe-to-bag method gave negative results, severely underestimating the amount of insulin binding. The bag-to-bag transfer method yielded positive results in all instances. Increasing the amounts of regular insulin had no demonstrable impact on percent of binding. When the bag-to-bag method was compared with the bag-pieces method, it gave only slightly higher values; however, the bag-to-bag method was considered more reliable because the counting can be controlled more effectively. A 15-minute delay in sampling was not found to influence insulin binding. A reliable method of assessing insulin binding must be based on the following two principles: (1) The transfer of samples to intermediate containers should be avoided, and (2) radiotracer concentrations in the samples should be similar.