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Mihara Y, Kado H, Matsumoto K, Kurose R, Tsujinaka E, Nakai K, Yamauchi A, Hatta T. Peritoneal Dialysis-associated Peritonitis Due to Streptococcus oralis Three Weeks after Peritoneal Dialysis Initiation. Intern Med 2024; 63:707-710. [PMID: 37438136 PMCID: PMC10982001 DOI: 10.2169/internalmedicine.2035-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/04/2023] [Indexed: 07/14/2023] Open
Abstract
A 60-year-old man with end-stage renal disease due to nephrosclerosis had a peritoneal dialysis catheter (PD) embedded with stepwise initiation of peritoneal dialysis using Moncrief and Popovich's technique three months ago. PD was initiated three weeks after creating an exit site. He presented with abdominal pain and fever a day before admission and was diagnosed with PD-associated peritonitis caused by Streptococcus oralis. Medical consultation after admission revealed a history of wisdom tooth extraction following PD catheter placement, resulting in delayed wound healing. Transient bacteremia can occur after tooth extraction, leading to PD-associated peritonitis. Contemplating the oral milieu in patients undergoing PD is pertinent.
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Affiliation(s)
- Yu Mihara
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Hiroshi Kado
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Kenji Matsumoto
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Ryo Kurose
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Erika Tsujinaka
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Kunihiro Nakai
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Asuka Yamauchi
- Department of Nephrology, Omihachiman Community Medical Center, Japan
| | - Tsuguru Hatta
- Department of Nephrology, Omihachiman Community Medical Center, Japan
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Chen Z, Deng H, Sun K, Huang Z, Wei S, Lin Y, Song Z, Liu Y. Prevalence of chronic periodontitis in patients undergoing peritoneal dialysis and its correlation with peritoneal dialysis-related complications. BMC Nephrol 2023; 24:71. [PMID: 36964507 PMCID: PMC10039550 DOI: 10.1186/s12882-023-03102-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 03/02/2023] [Indexed: 03/26/2023] Open
Abstract
OBJECTIVE The microinflammatory state can influence the occurrence of dialysis-related complications in dialysis patients. Chronic periodontitis (CP), in which plaque biofilm is considered to be the initiating factor, is a chronic infectious disease in the oral cavity. It is still uncertain whether CP affects the microinflammatory state in peritoneal dialysis (PD) and the occurrence of dialysis-related complications. The purpose of this study was to investigate the correlation between the periodontal index and clinical parameters in peritoneal dialysis patients with CP and dialysis-related complications, including peritoneal dialysis-associated peritonitis (PDAP) and cardiovascular and cerebrovascular events (CCEs). METHODS This was a retrospective cohort study, and 76 patients undergoing PD were enrolled. Clinical parameters, the occurrence of PD-related complications and periodontitis-related indicators, including the gingival index (GI), plaque index (PLI), probing depth (PPD) and clinical attachment loss (CAL), were collected. Correlation analysis was used to explore the correlation between periodontal or clinical parameters and the occurrence of PD-related complications. RESULTS All the patients had different degrees of periodontitis (mild 9.2%, moderate 72.4%, severe 18.4%); PPD was inversely related to serum albumin (r = - 0.235, p = 0.041); CAL has a positive correlation with serum C-reactive protein (rs = 0.242, p = 0.035); PLI was positively correlated with serum calcium (r = 0.314, p = 0.006). ANOVA, multivariate logistic regression analysis and Kaplan-Meier Survival curve suggested that CAL was a risk factor for the occurrence of PDAP. There was no correlation between periodontal parameters and CCEs or poor prognosis. CONCLUSION CP is universally present in PD patients, and the presentation of periodontitis influences the systemic inflammatory state in PD patients. CP is a risk factor for PDAP.
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Affiliation(s)
- Zhihao Chen
- Division of Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hai Deng
- Division of Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Kristine Sun
- Department of Periodontology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Zehui Huang
- Division of Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shan Wei
- Division of Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yunyao Lin
- Division of Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhongchen Song
- Department of Periodontology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Oral Diseases, Shanghai Key Laboratory of Stomatology & Shanghai Research Institute of Stomatology, Shanghai, China
| | - Yingli Liu
- Division of Nephrology, Shanghai Ninth People's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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3
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Purisinsith S, Kanjanabuch P, Phannajit J, Kanjanabuch T, Puapatanakul P, Johnson DW, Pongpirul K, Perl J, Robinson B, Tungsanga K. Oral Health-Related Quality of Life, A Proxy of Poor Outcomes in Patients on Peritoneal Dialysis. Kidney Int Rep 2022; 7:2207-2218. [PMID: 36217510 PMCID: PMC9546760 DOI: 10.1016/j.ekir.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 11/28/2022] Open
Abstract
Introduction We sought to evaluate the associations of poor oral health hygiene with clinical outcomes in patients receiving peritoneal dialysis (PD). Methods As part of the multinational Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), PD patients from 22 participating PD centers throughout Thailand were enrolled from May 2016 to December 2019. The data were obtained from questionnaires that formed part of the PDOPPS. Oral health-related quality of life (HRQoL) used in this study was the short form of the oral health impact profile (oral health impact profile [OHIP]-14, including 7 facets and 14 items). Patient outcomes were assessed by Kaplan-Meier analysis. Cox proportional hazards model regression was used to estimate associations between oral HRQoL and clinical outcomes. Results Of 5090 PD participants, 675 were randomly selected, provided informed consent, and completely responded to the OHIP-14 questionnaire. The median follow-up time of the study was 3.5 (interquartile range = 2.7–5.1 months) years. Poor oral health was associated with lower educational levels, diabetes, older age, marriage, and worse nutritional indicators (including lower time-averaged serum albumin and phosphate concentrations). After adjusting for age, sex, comorbidities, serum albumin, shared frailty by study sites, and PD vintage, poor oral health was associated with increased risks of peritonitis (adjusted hazard ratio [HR] = 1.45, 95% confidence interval [CI]: 1.06–2.00) and all-cause mortality (adjusted HR = 1.55, 95% CI: 1.04–2.32) but not hemodialysis (HD) transfer (adjusted HR = 1.89, 95% CI: 0.87–4.10) compared to participants with good oral health. Conclusion Poor oral health status was present in one-fourth of PD patients and was independently associated with a higher risk of peritonitis and death.
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Affiliation(s)
| | - Patnarin Kanjanabuch
- Department of Oral Medicine, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Jeerath Phannajit
- Division of Clinical Epidemiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Kidney Metabolic Disorders, Chulalongkorn University, Bangkok, Thailand
- Dialysis Policy & Practice Program, School of Global Health, Chulalongkorn University, Bangkok, Thailand
- Peritoneal Dialysis Excellent Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Correspondence: Talerngsak Kanjanabuch, Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand.
| | - Pongpratch Puapatanakul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Peritoneal Dialysis Excellent Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - David W. Johnson
- Department of Nephrology, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Krit Pongpirul
- Peritoneal Dialysis Excellent Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
- Department of International Health and Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Jeffrey Perl
- St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Bruce Robinson
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
| | - Kriang Tungsanga
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Fukumitsu K, Oka H, Iwamoto T, Kondo M, Hirashima Y, Kamimura T, Nakano T, Kitazono T. Repeated streptococcal peritoneal dialysis-related peritonitis following stomatitis and gingival bleeding: a case report. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-022-00414-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Identification of the pathogenesis of peritoneal dialysis (PD)-related peritonitis is important. However, identification of endogenous peritonitis, especially hematogenous infection, is difficult, and there are few reports of endogenous peritonitis via the bloodstream. We report a case of PD-related peritonitis presumed to be caused by hematogenous infection through the oral mucosa.
Case presentation
A 65-year-old woman commenced PD at the age of 52. Over the next 13 years, she developed two episodes of streptococcal peritonitis caused by Streptococcus salivarius, a commensal bacteria of the human oral mucosa, and all episodes occurred following stomatitis and gingival bleeding in the early summer. At the age of 65, she again suffered from stomatitis followed by gingival bleeding in early summer, and 2 weeks later, developed a third case of peritonitis caused by Streptococcus salivarius. The streptococcal peritonitis improved immediately following 2 weeks of antibiotic treatment. We surmise that the patient is subject to weakened immunity in the early summer, causing repeated oral problems with gingival bleeding, and subsequently leading to oral streptococcal peritonitis.
Conclusions
Our findings suggest that oral streptococcal peritonitis following oral problems such as stomatitis and gingival bleeding results from a hematogenous infection via the oral mucosa.
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Guía clínica de la Sociedad Española de Nefrología para la prevención y tratamiento de la infección peritoneal en diálisis peritoneal. Nefrologia 2022. [DOI: 10.1016/j.nefro.2021.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Hiramatsu T, Okumura S, Iguchi D, Kojima H. Higher dental care is positively associated with key prognosis factors in peritoneal dialysis patients: findings from a retrospective study. RENAL REPLACEMENT THERAPY 2022. [DOI: 10.1186/s41100-021-00389-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Oral disease may be increased in people with end-stage renal disease and associated with inflammation, cardiovascular disease, and mortality. Moreover, oral disease may be essential to decide the prognosis of peritoneal dialysis (PD) patients. However, only a few reports have explored the effects of dental care (DC) on cardiovascular diseases and mortality in PD patients. Thus, we aimed to investigate the association of DC with the prognosis of PD patients.
Methods
In this single-center, retrospective study, we enrolled 165 incident PD patients aged ≥ 20 years. We classified patients based on their dental care score, assessed using a self-reported questionnaire into the better dental care group (Group A, score ≥ 7) or the worse dental care group (Group B, score < 7). Demographic, clinical, hospitalization, hospital admission, comorbidities (including congestive heart failure, acute coronary syndrome, stroke, peripheral artery disease, and pneumonia), and mortality (including specific causes) data were extracted from the patient’s medical records. Data were analyzed using one-way ANOVA, Wilcoxon t-test, Kruskal–Wallis, Mann–Whitney U-test, chi-square test, Fisher’s exact test and multiple regression when appropriate. We compared the survival distributions among groups using the long-rank test.
Results
Of the 165 patients, 75 were allocated to group A and 90 to group B. PD patients with better dental care (group A) had significantly lower levels of C-reactive protein (CRP) and higher levels of serum albumin compared to PD patients with worse dental care (group B). Hospital admissions due to congestive heart failure, acute coronary syndrome, pneumonia, and peritonitis were also lower in group A than group B. Mortality rates due to congestive heart failure, acute coronary syndrome, pneumonia, and sepsis were lower in group A than in group B.
Conclusions
The study highlights the importance of good dental care, particularly for PD patients. Nephrologists and dental professions should design and implement oral health education strategies to improve PD patients’ dental care.
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Is there a relationship between oral hygiene and nutritional status in peritoneal dialysis patients? NUTR HOSP 2021; 39:355-364. [PMID: 34825569 DOI: 10.20960/nh.03786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Brackground: in the early stages of kidney disease, oral manifestations (gingivitis and periodontitis) may cause premature tooth loss and limit food intake. There is scarce evidence of the relationship between oral hygiene and nutritional status in patients on peritoneal dialysis (PD). OBJECTIVE we aimed to assess the relationship of oral hygiene with nutritional, clinical, and physical performance parameters in PD patients. METHODS this cross-sectional study included outpatients aged 34-69 years. Oral health questionnaire, nutritional, functional, and clinical assessment tools such as malnutrition inflammation score (MIS), subjective global assessment (SGA), handgrip strength, and gastrointestinal symptoms questionnaire (GSQ) were applied. Patients were divided according to debris, calculus, and simplified oral hygiene index (OHI-S) in two groups: "clean-slightly dirty" and "dirty-very dirty". RESULTS in total, 41 patients were included, those in the "dirty-very dirty" group had a worse nutritional status with higher scores on the MIS tool and worse nutritional diagnosis with SGA as compared to the "clean-slightly dirty" group. The handgrip strength was higher in patients in the best category of oral hygiene, and those with the worst hygiene presented greater severity of gastrointestinal symptoms. The risks of malnutrition in the three indices of oral hygiene with the worst category were statistically significant. CONCLUSION poor oral hygiene was associated with poorer nutritional status, lower handgrip, and worse GSQ. Poor oral hygiene might be related to persistent inflammation status and catabolism that favored protein-energy wasting.
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Chang Y, Lee JS, Woo HG, Ryu DR, Kim JW, Song TJ. Improved oral hygiene care and chronic kidney disease occurrence: A nationwide population-based retrospective cohort study. Medicine (Baltimore) 2021; 100:e27845. [PMID: 34964752 PMCID: PMC8615368 DOI: 10.1097/md.0000000000027845] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 10/11/2021] [Indexed: 01/05/2023] Open
Abstract
Oral diseases or poor oral hygiene have close connections with systemic inflammatory reaction, which is one of major mechanism in the development of chronic kidney disease (CKD). We conducted a research assuming that better oral hygiene care would be negatively related with the risk of developing new-onset CKD.From 2003 to 2004, a total of 158,495 participants from the Korean national health insurance data sharing service which provides health screening data including variables as age, sex, vascular risk factors, medication information, indicators regarding oral hygiene, and laboratory results. The diagnosis of CKD and vascular risk factors were defined according to the International Statistical Classification of Diseases and Related Health Problems codes-10th revision. The follow-up period for the study subject was until the occurrence of CKD, until death, or Dec 31, 2015.Approximately 13.3% of the participants suffered from periodontal disease, and 40.7% brushed their teeth at least three times a day. With a median of 11.6 (interquartile range 11.3-12.2) years' follow-up, the cohort included 3223 cases of incident CKD. The 10-year incidence rate for CKD was 1.80%. In multivariable analysis with adjustment for age, sex, demographics, vascular risk factors, blood pressure, and blood laboratory results, frequent tooth brushing (≥3 times a day) was negatively related to occurrence of CKD (hazard ratio: 0.90, 95% confidence interval [0.83-0.99], P = .043, P value for trend = .043).Participants with improved oral hygiene (≥3 times a day) have showed less risk of CKD. Additional interventional studies are in need to establish causative relationship between oral hygiene and risk of CKD.
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Affiliation(s)
- Yoonkyung Chang
- Department of Neurology, Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, College of Medicine, Ulsan University, Seoul, Korea
| | - Ho Geol Woo
- Department of Neurology, Kyung Hee University Hospital and College of Medicine, Seoul, Korea
| | - Dong-Ryeol Ryu
- Department of Internal Medicine, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jin-Woo Kim
- Department of Oral and Maxillofacial Surgery, Ewha Womans University, Seoul, Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
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Arenius I, Ruokonen H, Ortiz F, Furuholm J, Välimaa H, Bostanci N, Eskola M, Maria Heikkinen A, Meurman JH, Sorsa T, Nylund K. The relationship between oral diseases and infectious complications in patients under dialysis. Oral Dis 2020; 26:1045-1052. [PMID: 32026534 DOI: 10.1111/odi.13296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/08/2020] [Accepted: 01/30/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Association was investigated between oral health before dialysis and the incidence of systemic infections during dialysis. We hypothesized that low-grade systemic inflammation caused by poor oral health associates with infectious episodes in patients on dialysis, despite earlier eradication of oral infection foci. SUBJECTS AND METHODS A total of 117 patients (46 with peritoneal and 71 with hemodialysis) were examined and treated at predialysis stage and followed up during dialysis. Number of infection episodes and microorganisms cultured from blood and peritoneal fluid were analyzed. Number of teeth, periodontal inflammatory burden, and total dental index scores were assessed, and salivary matrix metalloproteinase 8, triggering receptor on myeloid cells 1, peptidoglycan recognition protein 1 (PGLYRP1), and interleukin-1β were measured. RESULTS In hemodialysis, 134 infection episodes were recorded, while peritoneal dialysis group had 77 peritonitis episodes. Culture-negative samples were 69% in hemodialysis and 23% in peritoneal dialysis group. Staphylococci were the most frequently associated microorganisms. Infections during dialysis did neither associate with oral health parameters nor associate with salivary inflammatory biomarkers, except for PGLYRP1, which associated with number of infection episodes during hemodialysis (p = .046). CONCLUSIONS A number of infection episodes during hemodialysis were associated with salivary PGLYRP1 but not the other salivary markers or oral infection markers.
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Affiliation(s)
- Ilona Arenius
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hellevi Ruokonen
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Fernanda Ortiz
- Division of Nephrology, Department of Medicine, Helsinki University Hospital, Helsinki, Finland.,Institute of Genetics, Folkhälsan Research Center, Helsinki, Finland
| | - Jussi Furuholm
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hannamari Välimaa
- Department of Virology, University of Helsinki, Helsinki, Finland.,Department of Oral and Maxillofacial Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Nagihan Bostanci
- Section of Periodontology and Dental Prevention, Division of Oral Diseases, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Maija Eskola
- Division of Nephrology, Department of Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Anna Maria Heikkinen
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jukka H Meurman
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Timo Sorsa
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.,Section of Periodontology and Dental Prevention, Division of Oral Diseases, Department of Dental Medicine, Karolinska Institutet, Huddinge, Sweden
| | - Karita Nylund
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Ogawa K, Kaneko K, Yokoo T. Denture Use Warning for Peritoneal Dialysis‐Related Peritonitis. Ther Apher Dial 2020; 24:96-97. [DOI: 10.1111/1744-9987.12860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 04/24/2019] [Accepted: 05/23/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Kyohei Ogawa
- Division of Nephrology, Department of Internal MedicineAshikaga Red Cross Hospital Tochigi Japan
| | - Kenji Kaneko
- Division of Nephrology, Department of Internal MedicineAshikaga Red Cross Hospital Tochigi Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal MedicineThe Jikei University School of Medicine Tokyo Japan
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