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Renal Insufficiency (renal + insufficiency)

Distribution by Scientific Domains

Medical Sciences	93%
Life Sciences	4%

Distribution within Medical Sciences

Transplantation	27%
Cardiovascular Disease	11%
Geriatric Medicine	8%
General & Internal Medicine	3%
Dermatology	2%
22 Other Subdomains	39%

Kinds of Renal Insufficiency

chronic renal insufficiency

moderate renal insufficiency

progressive renal insufficiency

severe renal insufficiency

Selected Abstracts

Estimation of Glomerular Filtration Rate in Older Patients with Chronic Renal Insufficiency: Is the Modification of Diet in Renal Disease Formula an Improvement?

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 7 2003
Edmund J. Lamb PhD
OBJECTIVES: To evaluate a new formula for glomerular filtration rate (GFR), derived from the Modification of Diet in Renal Disease (MDRD) study in older people. DESIGN: An observational study of the performance of the MDRD formula compared with other formulae and creatinine clearance (ClCr) as measures of the GFR. SETTING: Volunteers were recruited via outpatient clinics. PARTICIPANTS: Fifty-two patients (27 men, 25 women: mean age 80, range 69,92) with a variety of medical diagnoses. Mean GFR was 53.3 mL/min/1.73 m2 (range 15.9,100.2). Exclusion criteria included renal replacement therapy/renal transplantation and cognitive impairment. MEASUREMENTS:51Chromium ethylenediaminetetraacetic acid (51Cr EDTA) was used as the reference method against which the formulaic estimates of GFR were compared using bias plot and regression analyses. RESULTS: The MDRD and Cockcroft and Gault formulae (both coefficient of determination (R2) = 0.84) gave the best fit with GFR, followed by the Jelliffe formula (R2 = 0.81), ClCr (R2 = 0.73) and the Baracskay formula (R2 = 0.56). ClCr (,1.2%) demonstrated minimal bias compared with the MDRD (8.0%) and Cockcroft and Gault (,10.4%) formulae. However, imprecision compared with 51Cr EDTA was lowest for the Cockcroft and Gault formula, with 50% of estimates lying between ,9.5 and ,0.5 mL/min/1.73 m2 of measured 51Cr EDTA clearance. This compares with ,6.7 and 10.1 mL/min/1.73 m2 for ClCr and 0.0 and 12.7 mL/min/1.73 m2 for the MDRD formula. CONCLUSION: Calculated estimates of GFR are an improvement over ClCr estimation. On balance, the MDRD formula does not improve the estimate of GFR compared with the Cockcroft and Gault formula in older Caucasian patients with chronic renal insufficiency. [source]

Response to Cardiac Resynchronization Therapy in Patients with Heart Failure and Renal Insufficiency

PACING AND CLINICAL ELECTROPHYSIOLOGY, Issue 7 2010
EVAN C. ADELSTEIN M.D.
Background: Renal insufficiency (RI) adversely impacts prognosis in heart failure (HF) patients, partly because renal and cardiac dysfunction are intertwined, yet few cardiac resynchronization therapy (CRT) studies have examined patients with moderate-to-severe RI. Methods: We analyzed 787 CRT-defibrillator (CRT-D) recipients with a glomerular filtration rate (GFR) measured prior to implant. Patients were grouped by GFR (in mL/min/1.73 m2): ,60 (n = 376), 30,59 (n = 347), and <30 (n = 64). Overall survival, changes in left ventricular (LV) ejection fraction and LV end-systolic diameter, and GFR change at 3,6 months were compared among CRT-D groups and with a control cohort (n = 88), also stratified by GFR, in whom LV lead implant was unsuccessful and a standard defibrillator (SD) was placed. All patients met clinical criteria for CRT-D. Results: Among CRT-D recipients, overall survival improved incrementally with higher baseline GFR (for each 10 mL/min/1.73 m2 increase, corrected hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.13,1.30, P < 0.0001). Survival among SD and CRT-D patients within GFR < 30 and GFR , 60 groups was similar, whereas CRT-D recipients with GFR 30,59 had significantly better survival compared to SD counterparts (HR 2.23, 95% CI 1.34,3.70; P = 0.002). This survival benefit was associated with improved renal and cardiac function. CRT recipients with GFR , 60 derived significant echocardiographic benefit but experienced a GFR decline, whereas those with GFR < 30 had no echocardiographic benefit but did improve GFR. Conclusions: CRT may provide the largest survival benefit in HF patients with moderate RI, perhaps by improving GFR and LV function. Severe baseline RI predicts poor survival and limited echocardiographic improvement despite a modest GFR increase, such that CRT may not benefit those with GFR < 30 mL/min/1.73 m2. CRT recipients with normal renal function derive echocardiographic benefit but no overall survival advantage. (PACE 2010; 850,859) [source]

Weight restoration in a patient with anorexia nervosa on dialysis

INTERNATIONAL JOURNAL OF EATING DISORDERS, Issue 4 2005
D. Blake Woodside MD
Abstract Objective We report a case of weight restoration in a patient with anorexia nervosa, end-stage renal disease (ESRD) requiring dialysis, and cardiac insufficiency. Method The technical challenges and ethical issues involved in her clinical management are reviewed. Renal insufficiency is a common complication of more severe anorexia nervosa. Results Progression to renal failure, when it occurs, is most typically a terminal event. There are currently no published guidelines for monitoring the weight gain of patients undergoing dialysis. Conclusion We present a case of a patient who progressed from renal insufficiency to renal failure while in treatment for anorexia nervosa, and who was ultimately successfully weight restored while on renal dialysis. © 2005 by Wiley Periodicals, Inc. [source]

Nephrogenic systemic fibrosis in liver disease: A systematic review,

JOURNAL OF MAGNETIC RESONANCE IMAGING, Issue 6 2009
Sameer M. Mazhar MD
Abstract Nephrogenic systemic fibrosis (NSF) may develop in patients with liver disease, a fact highlighted by Food and Drug Administration (FDA) announcements cautioning against the use of gadolinium-based contrast agents (GBCAs) in select liver disease patients. The purpose of this systematic literature review is to characterize the risk of NSF in patients with liver disease. All published articles on NSF from September 2000 through August 2008, were identified via PubMed searches and examination of articles' reference lists. Two reviewers independently read each article and identified unique patients with biopsy-proven or suspected NSF. Data on demographics, liver status, renal status, and GBCA exposure were collected. A total of 324 articles were reviewed, with 108 articles containing case descriptions of 335 unique NSF patients. After excluding the 95/335 (28%) patients in whom the presence or absence of liver disease was uncertain, liver disease was confirmed present in 41/239 (17%) patients. Renal insufficiency could be assessed in 35 of the liver disease patients; severe renal insufficiency, defined as a glomerular filtration rate (GFR) or estimated GFR (eGFR) <30 mL/min/1.73 m2 or dialysis requirement, was present in 34/35 (97%) patients. The lone patient who developed NSF with mild/moderate renal insufficiency was atypical and received a total gadodiamide load of 0.76 mmol/kg over a 10-week period periliver transplantation. The published medical literature demonstrates that patients with liver disease who develop NSF also have severe renal insufficiency, suggesting that liver disease does not confer a risk for NSF beyond that of the underlying renal insufficiency. J. Magn. Reson. Imaging 2009;30:1313,1322. © 2009 Wiley-Liss, Inc. [source]

Red Maple (Acer rubrum) Leaf Toxicosis in Horses: A Retrospective Study of 32 Cases

JOURNAL OF VETERINARY INTERNAL MEDICINE, Issue 5 2006
Ashley Alward
Background:Ingestion of wilted red maple leaves by horses can result in severe hemolytic anemia and methemoglobinemia. Little is known about what factors influence the outcome of red maple leaf toxicosis in horses. Hypothesis:Our hypothesis was that physical examination findings, clinicopathologic variables or therapeutic modalities may predict outcome in horses with red maple leaf toxicity. Animals:Horses with red maple leaf toxicosis presented to referral hospitals in the southeast region of the United States. Methods:A multi-institutional retrospective study was designed to identify factors that predict mortality in horses with red maple toxicosis. Results:Thirty-two horses with red maple toxicosis were identified, 19 of which died. Twenty-nine horses presented with anemia and 24 had clinicopathologic evidence of systemic inflammation. Renal insufficiency was identified in 12/30 (41%) horses. Laminitis (9/28) and colic (13/30) also were identified in horses with red maple toxicosis, but development of these 2 conditions did not have a negative effect on short-term survival. Horses with red maple toxicosis that survived to discharge were likely to have developed pyrexia during hospitalization (P= .030). Horses that were treated with a corticosteroid had a significantly increased likelihood of death (P= .045). There was no significant relationship between initial serum hemoglobin concentration, methemoglobin concentration, or percentage methemoglobin and mortality in this horse series. Conclusions and Clinical Importance: This study suggests that information obtained on initial examination cannot be used to accurately predict survival in horses with red maple toxicosis, but horses that receive corticosteroids are unlikely to survive. [source]

Renal outcomes after liver transplantation in the model for end-stage liver disease era,

LIVER TRANSPLANTATION, Issue 9 2009
Pratima Sharma
The proportion of patients undergoing liver transplantation (LT) with renal insufficiency has significantly increased in the Model for End-Stage Liver Disease (MELD) era. This study was designed to determine the incidence and predictors of post-LT chronic renal failure (CRF) and its effect on patient survival in the MELD era. Outcomes of 221 adult LT recipients who had LT between February 2002 and February 2007 were reviewed retrospectively. Patients who were listed as status 1, were granted a MELD exception, or had living-donor, multiorgan LT were excluded. Renal insufficiency at LT was defined as none to mild [estimated glomerular filtration rate (GFR) , 60 mL/minute], moderate (30,59 mL/minute), or severe (<30 mL/minute). Post-LT CRF was defined as an estimated GFR < 30 mL/minute persisting for 3 months, initiation of renal replacement therapy, or listing for renal transplantation. The median age was 54 years, 66% were male, 89% were Caucasian, and 43% had hepatitis C. At LT, the median MELD score was 20, and 6.3% were on renal replacement therapy. After a median follow-up of 2.6 years (range, 0.01,5.99), 31 patients developed CRF with a 5-year cumulative incidence of 22%. GFR at LT was the only independent predictor of post-LT CRF (hazard ratio = 1.33, P < 0.001). The overall post-LT patient survival was 74% at 5 years. Patients with MELD , 20 at LT had a higher cumulative incidence of post-LT CRF in comparison with patients with MELD < 20 (P = 0.03). A decrease in post-LT GFR over time was the only independent predictor of survival. In conclusion, post-LT CRF is common in the MELD era with a 5-year cumulative incidence of 22%. Low GFR at LT was predictive of post-LT CRF, and a decrease in post-LT GFR over time was associated with decreased post-LT survival. Further studies of modifiable preoperative, perioperative, and postoperative factors influencing renal function are needed to improve outcomes following LT. Liver Transpl 15:1142,1148, 2009. © 2009 AASLD. [source]

Abdominal compartment syndrome after liver transplantation

LIVER TRANSPLANTATION, Issue 1 2005
Alexander E. Handschin
The abdominal compartment syndrome is a well-known complication after abdominal trauma and is increasingly recognized as a potential risk factor for renal failure and mortality after adult orthotopic liver transplantation (OLT). We present a case report of a young patient who presented with acute liver failure complicated by an acute pancreatitis. The patient developed an acute abdominal compartment syndrome after OLT. Transurethral measurement of intraabdominal pressure indicated an abdominal compartment syndrome associated with impaired abdominal vascular perfusion, including liver perfusion. Renal insufficiency was immediately reversed after decompressive bedside laparotomy. The abdominal compartment syndrome is a potential source of posttransplant renal insufficiency and liver necrosis in OLT. It remains, however, a rarely described complication after liver transplantation, despite the presence of significant factors that contribute to elevated intraabdominal pressure. (Liver Transpl 2005;11:98,100.) [source]

Response to Cardiac Resynchronization Therapy in Patients with Heart Failure and Renal Insufficiency

Evidence for a need to mandate kidney transplant living donor registries

CLINICAL TRANSPLANTATION, Issue 5 2008
Mahmoud Emara
Abstract:, Kidney disease is a global public health problem of growing proportions. Currently the best treatment for end-stage renal failure is transplantation. Living organ donation remains a complex ethical, moral and medical issue. It is based on a premise that kidney donation is associated with short-term minimal risks to harm the donor, and is outweighed by the definite advantages to the recipient. A growing number of patients with end-stage renal disease and shortage of kidney donors poses a pressing need to expand the criteria needed to accept kidney donors. The current donor registries are structured and are driven to expand donor pool. As living kidney donation is not without risks, more attention should be given to protect the donor health. After kidney donation, mild to moderate renal insufficiency may occur. Renal insufficiency, even mild, is associated with increased risks of hypertension, proteinuria and cardiovascular morbidity. We, therefore, foresee a need to mandate the establishment of renal transplant donor registries at all transplanting programs as a prerequisite to protect the long-term well being of kidney donors. These registries can collect the database necessary to develop standards of practice and guidelines for future kidney donation. [source]

Pharmacokinetics of dipeptidylpeptidase-4 inhibitors

DIABETES OBESITY & METABOLISM, Issue 8 2010
A. J. Scheen
Type 2 diabetes (T2DM) is a complex disease combining defects in insulin secretion and insulin action. New compounds have been developed for improving glucose-induced insulin secretion and glucose control, without inducing hypoglycaemia or weight gain. Dipeptidylpeptidase-4 (DPP-4) inhibitors are new oral glucose-lowering agents, so-called incretin enhancers, which may be used as monotherapy or in combination with other antidiabetic compounds. Sitagliptin, vildaglipin and saxagliptin are already on the market in many countries, either as single agents or in fixed-dose combined formulations with metformin. Other DPP-4 inhibitors, such as alogliptin and linagliptin, are currently in late phase of development. The present paper summarizes and compares the main pharmacokinetics (PK) properties, that is, absorption, distribution, metabolism and elimination, of these five DPP-4 inhibitors. Available data were obtained in clinical trials performed in healthy young male subjects, patients with T2DM, and patients with either renal insufficiency or hepatic impairment. PK characteristics were generally similar in young healthy subjects and in middle-aged overweight patients with diabetes. All together gliptins have a good oral bioavailability which is not significantly influenced by food intake. PK/pharmacodynamics characteristics, that is, sufficiently prolonged half-life and sustained DPP-4 enzyme inactivation, generally allow one single oral administration per day for the management of T2DM; the only exception is vildagliptin for which a twice-daily administration is recommended because of a shorter half-life. DPP-4 inhibitors are in general not substrates for cytochrome P450 (except saxagliptin that is metabolized via CYP 3A4/A5) and do not act as inducers or inhibitors of this system. Several metabolites have been documented but most of them are inactive; however, the main metabolite of saxagliptin also exerts a significant DPP-4 inhibition and is half as potent as the parent compound. Renal excretion is the most important elimination pathway, except for linagliptin whose metabolism in the liver appears to be predominant. PK properties of gliptins, combined with their good safety profile, explain why no dose adjustment is necessary in elderly patients or in patients with mild to moderate hepatic impairment. As far as patients with renal impairment are concerned, significant increases in drug exposure for sitagliptin and saxagliptin have been reported so that appropriate reductions in daily dosages are recommended according to estimated glomerular filtration rate. The PK characteristics of DPP-4 inhibitors suggest that these compounds are not exposed to a high risk of drug,drug interactions. However, the daily dose of saxagliptin should be reduced when coadministered with potent CYP 3A4 inhibitors. In conclusion, besides their pharmacodynamic properties leading to effective glucose-lowering effect without inducing hypoglycaemia or weight gain, DPP-4 inhibitors show favourable PK properties, which contribute to a good efficacy/safety ratio for the management of T2DM in clinical practice. [source]

Plasma anhydro- d -glucitol (1,5-AG) as an indicator of hyperglycaemic excursions in pregnant women with diabetes

DIABETIC MEDICINE, Issue 2 2006
M. Dworacka
Abstract Aims To evaluate the use of the plasma 1,5-anhydro- d -glucitol (1,5-AG) level as a possible marker for glucose excursions in pregnant women with diabetes. Methods The study group consisted of 55 pregnant women with diabetes (gestational diabetes mellitus,GDM, n = 28 or pre-gestational diabetes mellitus ,PGDM, n = 27), without hepatic or renal insufficiency, gestational age range 5,38 weeks. In each patient, 24-h glucose profile, glycated haemoglobin and 1,5-AG plasma levels were measured. Mean blood glucose (MBG) and M-value (by Schlichtkrull) were calculated. MBG, M-value and maximal daily glycaemia (MxG) were used as indexes of daily glycaemic excursions. Results A significant correlation was found between the 1,5-AG plasma level and MxG [r = (,0.3)] and between the 1,5-AG level and M-value [r = (,0.36)]. There was no association between the 1,5-AG level and gestational age. Multivariate regression analysis, with 24-h glucose profile, gestational age and MxG as independent variables, showed that MxG was the main parameter determining the 1,5-AG plasma level [, = (,0.68)]. The M-value, the coefficient of glucose fluctuations, also determined the 1,5-AG level but with lower statistical power [, = (0.41)]. No statistical differences were found in the group with HbA1c < 6% or > 6% for 1,5-AG and M-value, while MBG was higher in poorly controlled patients (HbA1c > 6%). Conclusions The plasma 1,5-AG level may be a useful marker of daily glucose excursion in pregnant women with diabetes, as an adjunct to HbA1c monitoring. [source]

Interactions between maternal subtotal nephrectomy and salt: effects on renal function and the composition of plasma in the late gestation sheep fetus

EXPERIMENTAL PHYSIOLOGY, Issue 2 2008
Amanda C. Boyce
Effects of altered maternal salt intake between 122 and 127 days gestation (term is 150 days) were studied in eight fetuses carried by ewes which had renal insufficiency caused by subtotal nephrectomy (STNxF) and seven fetuses carried by intact ewes (IntF). Plasma sodium and osmolality were increased in ewes with subtotal nephrectomy on a high-salt intake (0.17 m NaCl in place of drinking water for 5 days; P < 0.05). The STNxF had normal body weights. A high maternal salt intake did not affect fetal blood pressure or heart rate. Plasma osmolality was higher in STNxF (P < 0.001), and plasma sodium and osmolality were increased by high salt (P < 0.001 and P < 0.04, respectively). The STNxF had higher urinary osmolalities (P= 0.002), which were also increased by a high maternal salt intake (P= 0.03). Renal blood flow fell in STNxF in response to a high maternal salt intake, but increased in IntF (P= 0.003). In STNxF but not IntF, glomerular filtration rate and urinary protein excretion were positively related to fetal plasma renin levels (P, 0.01). It is concluded that the salt intake of pregnant ewes with renal insufficiency affects maternal and fetal osmolar balance, fetal plasma sodium and fetal renal function. Since STNxF also had altered renal haemodynamic responses to high maternal salt and evidence of renin-dependent glomerular filtration and protein excretion, we suggest that interactions between dietary salt and pre-existing maternal renal disease impair glomerular integrity and function in the fetus. [source]

Case Report: Atheroembolic renal disease in a 72-year-old patient through coronary intervention after myocardial infarction

HEMODIALYSIS INTERNATIONAL, Issue 4 2008
Anna Laura HERZOG
Abstract Cholesterol embolization or atheroembolic renal disease (AERD) is an often underdiagnosed issue in patients featuring a prevalent risk profile. It is a multisystemic disease with progressive renal insufficiency due to foreign body reaction of cholesterol crystals flushed into a small vessel system of the kidneys from the arteriosclerotic plaques. The most common setting in which it occurs is iatrogenic after vascular catheterization and less frequent spontaneously. Typical clinical symptoms are delayed impairment of renal function, cutaneous manifestations such as livedo reticularis or purple toes with persistingly palpable arterial pulse, myalgia, systemic symptoms such as weight loss and fever, and abdominal and neurological symptoms. Diagnosis is generally made by clinical appearance, risk profile, and interval of time from intervention; a definitive diagnosis can only be made by renal biopsy. Even though the exact incidence is not known because most patients do not undergo biopsy due to older age, comorbidity, and other explanations for loss of renal function, it is estimated to be 4% after vascular intervention. Patient and renal outcome is dependent on comorbidity, risk profile, and preexisting chronic kidney disease (CKD). About 30% of patients are estimated to require maintenance dialysis and these patients have a high risk of death within 24 months after the first renal replacement therapy. Prognosis is also influenced by severity. The case reported is a 72-year-old male patient with preexisting CKD stage 3 undergoing percutaneous coronary intervention after myocardial infarction and consecutive AERD with typical clinical appearance 6 weeks after the event. [source]

Correction of an anemia in patients with a terminal stage chronic renal insufficiency on haemodialysis

HEMODIALYSIS INTERNATIONAL, Issue 1 2005
R.Z. Ismagilov
One of the basic symptoms of a terminal stage chronic renal insufficiency is anemia. From everything, used methods of correction of an anemia, it is considered the most effective application of preparations recombinant human erythropoietin (r-Hu EPO). Since 1994 in the Scientific Centre of Surgery begins application r-Hu EPO. Application r-Hu EPO in patients with a terminal stage chronic renal insufficiency in 90,95% of cases had a positive effect, but 5,10% of patients have intolerance to erythropoietin, that has induced to search of new effective methods of correction of anemia. During research were determined quantity erythrocytes, hemoglobin, reticulocyte in peripheral blood and acid-alkaline condition of blood. All hematology parameters were defined at the beginning of treatment, over 5 day and for 15 day of stimulation of a bone marrow. For 15 days after stimulation of a bone marrow by the laser there was an authentic increase of quantity erythrocyte, hemoglobin, hematocrit. The initial contents erythrocytes made 2.22 ± 0.1 10 × 12, hemoglobin 67.7 ± 3.2 g/l and hematocrit 18.2 ± 1.2%. During treatment by the laser parameters erythrocytes have increased up to 2.9 ± 0.8 10 × 12, hemoglobin up to 89.6 ± 2.9 g/l and hematocrit up to 28.2 ± 1.3%(P < 0,005). Hematology parameters in blood of control group authentically have not changed. [source]

Analysis of serious non-AIDS events among HIV-infected adults at Latin American sites

HIV MEDICINE, Issue 9 2010
WH Belloso
Objective Acquired immune deficiency appears to be associated with serious non-AIDS (SNA)-defining conditions such as cardiovascular disease, liver and renal insufficiency and non-AIDS-related malignancies. We analysed the incidence of, and factors associated with, several SNA events in the LATINA retrospective cohort. Materials and methods Cases of SNA events were recorded among cohort patients. Three controls were selected for each case from cohort members at risk. Conditional logistic models were fitted to estimate the effect of traditional risk factors as well as HIV-associated factors on non-AIDS-defining conditions. Results Among 6007 patients in follow-up, 130 had an SNA event (0.86 events/100 person-years of follow-up) and were defined as cases (40 with cardiovascular events, 54 with serious liver failure, 35 with non-AIDS-defining malignancies and two with renal insufficiency). Risk factors such as diabetes, hepatitis B and C virus coinfections and alcohol abuse showed an association with events, as expected. The last recorded CD4 T-cell count prior to index date (P=0.0056, with an average difference of more than 100 cells/,L) and area under the CD4 cell curve in the year previous to index date (P=0.0081) were significantly lower in cases than in controls. CD4 cell count at index date was significantly associated with the outcome after adjusting for risk factors. Conclusions The incidence and type of SNA events found in this Latin American cohort are similar to those reported in other regions. We found a significant association between immune deficiency and the risk of SNA events, even in patients under antiretroviral treatment. [source]

Factors affecting outcome in liver resection

HPB, Issue 3 2005
CEDRIC S. F. LORENZO
Abstract Background. Studies demonstrate an inverse relationship between institution/surgeon procedural volumes and patient outcomes. Similar studies exist for liver resections, which recommend referral of patients for liver resections to ,high-volume' centers. These studies did not elucidate the factors that underlie such outcomes. We believe there exists a complex interaction of patient-related and perioperative factors that determine patient outcomes after liver resection. We sought to delineate these factors. Methods. Retrospective review of 114 liver resections by a single surgeon from 1993,2003: Records were reviewed for demographics; diagnosis; type/year of surgery; American Society of Anesthesiologists (ASA) score; preoperative albumin, creatinine, and bilirubin; operative time; intraoperative blood transfusions; epidural use; and intraoperative hypotension. Main outcome measurements were postoperative morbidities, mortalities and length of stay (LOS). Data were analyzed using a multivariate linear regression model (SPSS v10.1 statistical analysis program). Results. Primary indications for resections were hepatocellular carcinoma (HCC) (N=57), metastatic colorectal cancer (N=25), and benign disease (N=18). There were no intraoperative mortalities and 4 perioperative (30-day) mortalities (3.5%). Mortality occurred in patients with malignancies who were older than 50 years. Morbidity was higher in malignant (15.6%) versus benign (5.5%) disease. Complications included bile leak/stricture (N=6), liver insufficiency (N=3), postoperative bleeding (N=2), myocardial infarction (N=2), aspiration pneumonia (N=1), renal insufficiency (N=1), and cancer implantation into the wound (N=1). Average LOS for all resections was 8.6 days. Longer operative time (p=0.04), lower albumin (p<0.001), higher ASA score (p<0.001), no epidural use (p=0.04), and higher creatinine (p<0.001) all correlated positively with longer LOS. ASA score and creatinine were the strongest predictors of LOS. LOS was not affected by patient age, sex, diagnosis, presence of malignancy, intraoperative transfusion requirements, intraoperative hypotension, preoperative bilirubin, case volume per year or year of surgery. Conclusions. Liver resections can be performed with low mortality/morbidity and with acceptable LOS by an experienced liver surgeon. Outcome as measured by LOS is most influenced by patient comorbidities entering into surgery. Annual case volume did not influence LOS and had no impact on patient safety. Length of stay may not reflect surgeon/institution performance, as LOS is multifactorial and likely related to patient population, patient selection and increased high-risk cases with a surgeon's experience. [source]

Efficacy and safety of tacrolimus in refractory ulcerative colitis and Crohn's disease: A single-center experience

INFLAMMATORY BOWEL DISEASES, Issue 1 2008
Aaron Benson MD
Abstract Background: The published experience regarding the use of tacrolimus in Crohn's disease (CD) and ulcerative colitis (UC) refractory to more commonly used medical therapy has been fairly limited. Our objective was to describe our experience with its use in a cohort of patients which, to our knowledge, represents the largest North American cohort described to date. Methods: This was a retrospective, single-center chart analysis. Patients were identified by compiling all hospital discharges with principle diagnoses of ICD-9 codes for 555.0-555.9 (regional enteritis) and 556.0-556.9 (ulcerative colitis) from January 1, 2000, to October 31, 2005, and then cross-referencing the electronic charts for tacrolimus serum concentrations ordered during this time period. Additional patients were identified through verbal communication with participating clinicians. Information abstracted included proportion with clinical response and remission (using a modified disease activity index), ability to wean from steroids, need for surgery / time to surgery, and side-effect profile. Results: In all, 32 UC patients and 15 CD patients were identified. The mean disease duration was: UC 81 months (range, 1 month to 37 years), CD 100 months (range, 1 month to 35 years). The disease distribution for UC was: pancolitis 12 (37.5%), extensive colitis 6 (18.8%), left-sided 11 (34.4%), and proctitis 3(9.4%). For CD this was: TI 2 (13.3%), small bowel 2 (13.3%), colonic 3 (20.7%), ileocolonic 7(46.7%), and perianal 1 (6.7%). The duration of tacrolimus treatment for UC was mean, 29 weeks. For CD it was mean, 9.9 weeks. In all, 30/32 UC and 7/15 CD patients were on steroids; 4/30 UC and 0/7 CD patients were able to subsequently wean off steroids. In all, 12/32 UC patients proceeded to colectomy. Mean time to colectomy was 28 weeks and 6/15 CD patients proceeded to a resective surgery. The mean time to surgery was 22 weeks. In all, 22/32 UC patients achieved a clinical response; 3/32 achieved remission and 8/15 CD patients achieved a clinical response; 1/15 achieved remission. Adverse reactions were generally mild. In 6 patients the drug had to be discontinued because of an adverse reaction. There were no opportunistic infections identified, no cases of renal insufficiency related to drug administration, and no deaths while on the medicine. Conclusions: Our experience with tacrolimus in UC and CD indicates that it is safe and relatively well tolerated, although its clinical efficacy is quite variable. More prospective studies assessing its use are necessary. (Inflamm Bowel Dis 2007) [source]

Anaemia in heart failure: a common interaction with renal insufficiency called the cardio-renal anaemia syndrome

INTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 2 2008
A. Palazzuoli
Summary Background:, Although many studies have found a high prevalence of anaemia in patients with congestive heart failure (CHF), few have carefully examined the relationship between the CHF and the prevalence of anaemia and chronic renal insufficiency (CRI). Patients with advanced renal failure, significant anaemia, diffuse atherosclerosis, respiratory disease and more elderly patients have been systematically excluded from the great majority of the randomised clinical trials. Discussion:, Both anaemia and renal insufficiency are very common associated diseases associated with increased mortality, morbidity and rate of hospitalisation in CHF patients. Impaired renal function is associated with adverse outcomes because it represents a marker of coexistent disease and more diffuse atherosclerosis. In patients with CHF, progressive renal dysfunction leads to a decrease in erythropoietin (EPO) levels with reduced erythrocyte production from bone marrow. This may explain the common association between CHF, anaemia and CRI in clinical practice. The normalisation of haemoglobin concentration by EPO in patients with CHF and CRI results in improved exercise capacity by increasing oxygen delivery and improving cardiac function. Conclusion:, In this review, we describe the mechanisms linking anaemic status, CRI and CHF, the prognostic relevance of each disease, treatment implications, and potential benefit of EPO administration. [source]

Report: Cutaneous disorders in uremic patients on hemodialysis: an Egyptian case-controlled study

INTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 9 2010
Enas A. S. Attia MD
Summary Background, We studied the prevalence of mucocutaneous disorders in uremic adults and children on hemodialysis (HD) vs. controls, in Egypt. Methods, A total of 206 Egyptians with uremia (163 adults and 43 children) undergoing HD, and 199 healthy controls (161 adults and 38 children), were examined for mucocutaneous abnormalities. Results, Specific cutaneous diseases associated with renal insufficiency were found in five adults, including acquired perforating dermatosis and pseudo-porphyria. Non-specific abnormalities included xerosis (54%), pallor (42.2%), nail changes (34.9%), hair changes (34%), pruritus (32%), hyper-pigmentation (22.2%), coated tongue (14.1%), ecchymosis (1.5%), and gingival hypertrophy (1.5%). Disorders found significantly more often in uremics than controls included pallor, nail changes, hair changes, pruritus, hyper-pigmentation and coated tongue in adults (P < 0.05), and nail changes, hair changes, and hyper-pigmentation in children (P < 0.05). The prevalence of each mucocutaneous abnormality was similar in uremic adults and children except for pallor [more common in adults (P = 0.001)], and hyper-pigmentation [more common in children (P = 0.003)]. A greater number of hepatitis C virus-positive than -negative adult uremics had hyper-pigmentation (P < 0.05), and more diabetic uremics had pruritus than did non-diabetics (P < 0.05). Conclusion, Mucocutaneous disorders occur in adults and children with uremia, some of which are specific associations with the underlying renal disease. Occurrence of some of the non-specific abnormalities, such as xerosis, ecchymosis, and gingival hypertrophy, may be coincidental or associated with factors other than renal insufficiency. [source]

Weight restoration in a patient with anorexia nervosa on dialysis

High incidence of and risk factors for metachronous bilateral upper tract urothelial carcinoma in Taiwan

INTERNATIONAL JOURNAL OF UROLOGY, Issue 7 2006
PO-CHIEN HUANG
Aim:, Urothelial carcinoma (UC) can occur multifocally in the whole urothelium. A higher rate of bilateral metachronous upper tract (UT) UC was noted in Taiwan. The incidence and risk factors were largely unknown and hence were explored in the study. Methods:, From January 1977 through June 2003, 462 patients with unilateral UT-UC were studied retrospectively. The cumulative incidence of contralateral recurrence was analysed with the Kaplan,Meier analysis. Potential risk factors for contralateral recurrence including age, smoking, bladder cancer, renal function, diagnostic year etc. were evaluated with the log,rank test. Independent risk factors were identified by using the Cox regression analysis. Results:, The median follow-up time was 34 months (6,337). Among the 462 patients, 52 (11.3%) developed metachronous contralateral UC. The 2, 5, and 10-year contralateral disease-free survivals were 93.5%, 84.0%, and 75.7%, respectively. The median time to contralateral recurrence was 31.0 months. With the univariate analysis, only poor renal function (serum creatinine < or ,2.0 mg/dL, P < 0.001) and late diagnostic year (before or after 1990, P < 0.001) were risk factors for contralateral recurrence. In the multivariate analysis, poor renal function (hazard ratio: 2.98; 95% confidence interval: 1.67,5.33; P < 0.001) and late diagnostic year (hazard ratio: 4.27; 95% confidence interval: 1.71,10.65; P = 0.002) remained independent risk factors. Conclusions:, The incidence of metachronous UT-UC is high in Taiwan. Patients who had either chronic renal insufficiency or a disease diagnosed after 1990 had a higher risk of contralateral recurrence. [source]

High Oxidative Stress Is Correlated with Frailty in Elderly Chinese

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 9 2009
I-Chien Wu MD
OBJECTIVES: To evaluate the relationship between oxidative stress and frailty in elderly people. DESIGN: Cross-sectional study. SETTING: Community and hospital-based outpatient clinic. PARTICIPANTS: Ninety participants aged 65 and older. MEASUREMENTS: Frailty status was determined according to the presence of weak handgrip strength, weight loss, slow walking speed, exhaustion, and low activity level and was classified as frail (,3 criteria), prefrail (1 or 2 criteria), or robust (0 criteria). An oxidative stress marker (serum 8-hydroxy-2,-deoxyguanosine, 8-OHdG), metabolic markers (body mass index, waist,hip ratio, serum lipids, glucose, and albumin), an inflammatory marker (serum high-sensitivity C-reactive protein, hs-CRP), demographic information, and comorbidities (diabetes mellitus, hypertension, congestive heart failure, osteoarthritis, overweight or obesity, impaired fasting plasma glucose, renal insufficiency, and depression) were assessed. RESULTS: Of the 90 participants, 21 (23.3%) were frail, 56 (62.2%) were prefrail, and 13 (14.4%) were robust. Frail subjects had higher median (range) serum 8-OHdG (2.5 ng/mL (1.5,6.2 ng/mL) vs 2.3 ng/mL (0.5,8.1 ng/mL) and 1.0 ng/mL (0.5,5.3 ng/mL)) and serum hs-CRP (2.5 mg/L (0.3,32.1 mg/L) vs 1.8 mg/L (0.3,50.5 mg/L) and 1.7 mg/L (0.3,4.0 mg/L)) levels, lower mean±standard deviation serum albumin levels (4.1±0.4 g/dL vs 4.4±0.4 g/dL and 4.6±0.2 g/dL) and higher mean waist,hip ratios (0.96±0.11 vs 0.91±0.07 and 0.89±0.05)) than prefrail and robust subjects, respectively (P<.05 for all). In multivariable regression analysis, high serum 8-OHdG level was still significantly associated with frailty after adjusting for age, smoking status, comorbidities, waist,hip ratio, serum albumin level, and hs-CRP level. CONCLUSION: High oxidative stress, characterized by high serum 8-OHdG level, was independently associated with frailty in the selected sample of elderly Chinese. [source]

Distribution and Correlates of Lipoprotein-Associated Phospholipase A2 in an Elderly Cohort: The Cardiovascular Health Study

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2008
Curt D. Furberg MD
OBJECTIVES: To determine whether high levels of lipoprotein-associated phospholipase A2 (Lp-PLA2) are associated with prevalent cardiovascular disease (CVD) and to evaluate factors most influencing Lp-PLA2 levels in a community-based cohort of older adults. DESIGN: Cross-sectional. SETTING: The Cardiovascular Health Study (CHS), a population-based cohort study of men and women aged 65 and older. PARTICIPANTS: Five thousand five hundred thirty-one CHS participants. MEASUREMENTS: Levels of Lp-PLA2 activity were determined using stored blood samples from the baseline examination. RESULTS: Mean Lp-PLA2 was higher in participants with electrocardiographically determined ventricular conduction defect and major Q-wave abnormality and was positively correlated with left ventricular (LV) mass. It was high in those with echocardiographically determined abnormal LV ejection fraction, which persisted after adjustment. Mean Lp-PLA2 was also higher in participants with mild renal insufficiency and kidney disease. After multivariable adjustment, there was a modest but significant 27% greater risk of prevalent CHF per standard deviation increment of Lp-PLA2 and a modest but significant 12% greater risk of prevalent myocardial infarction. Lp-PLA2 was weakly but mainly most strongly correlated with cholesterol and lipoproteins, but those correlations were not especially strong. Lp-PLA2 was weakly positively correlated with soluble intercellular adhesion molecule-1 but not interleukin-6. In total, all factors considered could explain only 29% of Lp-PLA2 activity. CONCLUSION: Novel findings in the study are the associations, in those aged 65 and older, between Lp-PLA2 activity and LV dysfunction, CHF, and renal disease. CVD risk factors only minimally explain levels of Lp-PLA2. [source]

Estimation of Glomerular Filtration Rate in Older Patients with Chronic Renal Insufficiency: Is the Modification of Diet in Renal Disease Formula an Improvement?

Hypercalcemia and Overexpression of CYP27B1 in a Patient With Nephrogenic Systemic Fibrosis: Clinical Vignette and Literature Review,,

JOURNAL OF BONE AND MINERAL RESEARCH, Issue 6 2009
Vivian Y Pao
Abstract Nephrogenic systemic fibrosis (NSF) is a disease of thickened, hard, hyperpigmented skin lesions with or without systemic fibrosis occurring in patients with renal insufficiency and associated with the administration of gadolinium-containing contrast. The pathogenesis of this disease is unclear, and there is no definitive treatment. We describe a 71-yr-old patient with stable chronic lymphocytic leukemia (CLL), end-stage renal disease (ESRD), and NSF who presented with hypercalcemia in 2006. Before onset of renal insufficiency in 2002, serum calcium, phosphorus, and PTH levels were normal. In 2004, the patient began hemodialysis, and he was diagnosed with NSF in 2005, shortly after undergoing an MRI with gadolinium contrast administration. Over the next 6 mo, albumin-corrected serum total calcium levels rose from 9.9 to 13.1 mg/dl (normal range, 8.5,10.5 mg/dl) with normal serum phosphorus levels. On admission in September 2006, 1,25-dihydroxyvitamin D [1,25(OH)2D] levels were elevated at 130.7 pg/ml (normal range, 25.1,66.1 pg/ml). Biopsy of an NSF lesion showed increased 25-hydroxyvitamin D3,1-, hydroxylase (CYP27B1) immunostaining compared with the biopsy from a normal control. This is the first reported association of NSF with hypercalcemia caused by elevated 1,25(OH)2D levels. This metabolic disturbance should be sought in future cases to determine a connection between NSF, 1,25(OH)2D metabolism, and CYP27B1 activation in the skin, which may shed light on the pathogenesis of this unusual local and systemic fibrosing disorder. [source]

Paricalcitol [19-Nor-1,25-(OH)2D2] in the Treatment of Experimental Renal Bone Disease,

JOURNAL OF BONE AND MINERAL RESEARCH, Issue 5 2006
Jarkko Jokihaara
Abstract Paricalcitol is a less hypercalcemic vitamin D analog that has been shown to suppress secondary hyperparathyroidism and to prevent the associated histomorphometric changes in bone. In this study, we show that paricalcitol also ameliorates the renal insufficiency-induced loss of bone mineral and the mechanical competence of bone. Introduction: Renal bone disease is a common consequence of chronic renal insufficiency and the associated secondary hyperparathyroidism (SH). Paricalcitol [19-nor-1,25(OH)2D2] has been shown to ameliorate SH and prevent renal failure,induced histomorphometric changes in bone with minimal calcemic and phosphatemic activity. However, information about its efficacy on restoration of bone structural strength is lacking. In this study, we explored the effects of paricalcitol treatment on bone structure and strength in a model of advanced renal disease. Materials and Methods: Forty-five 8-week-old rats were randomly assigned to either surgical 5/6 nephrectomy (NTX) or Sham-operation. After a 15-week postoperative disease progression period, the NTX rats were further allocated to uremic control (NTX) and treatment (NTX + paricalcitol) groups, the latter of which received paricalcitol for the subsequent 12 weeks. After 27 weeks, the animals were killed, plasma samples were collected, and both femora were excised for comprehensive analysis of the femoral neck and midshaft (pQCT and biomechanical testing). Results: High mortality that exceeded 30% was observed in both NTX groups. NTX induced over a 13-fold increase in plasma PTH, whereas this increase was only 5-fold after paricalcitol treatment. At the femoral neck, NTX was associated with an 8.1% decrease (p < 0.05) in vBMD and a 16% decrease in breaking load (p < 0.05) compared with the Sham group, whereas paricalcitol treatment completely prevented these changes. At the femoral midshaft, the NTX resulted in a 6.6% decrease in cortical BMD (p < 0.01 versus Sham), and this change was also prevented by paricalcitol. Conclusions: Paricalcitol administration prevented renal insufficiency-associated decreases in BMD in the femoral neck and the femoral midshaft and restored bone strength in the femoral neck. Therefore, paricalcitol can efficiently ameliorate renal insufficiency-induced loss of bone mineral and mechanical competence of bone. [source]

Collagen Metabolism Is Markedly Altered in the Hypertrophic Cartilage of Growth Plates from Rats with Growth Impairment Secondary to Chronic Renal Failure

JOURNAL OF BONE AND MINERAL RESEARCH, Issue 3 2001
Jesús Álvarez
Abstract Skeletal growth depends on growth plate cartilage activity, in which matrix synthesis by chondrocytes is one of the major processes contributing to the final length of a bone. On this basis, the present work was undertaken to ascertain if growth impairment secondary to chronic renal insufficiency is associated with disturbances of the extracellular matrix (ECM) of the growth plate. By combining stereological and in situ hybridization techniques, we examined the expression patterns of types II and X collagens and collagenase-3 in tibial growth plates of rats made uremic by subtotal nephrectomy (NX) in comparison with those of sham-operated rats fed ad libitum (SAL) and sham-operated rats pair-fed with NX (SPF). NX rats were severely uremic, as shown by markedly elevated serum concentrations of urea nitrogen, and growth retarded, as shown by significantly decreased longitudinal bone growth rates. NX rats showed disturbances in the normal pattern of chondrocyte differentiation and in the rates and degree of substitution of hypertrophic cartilage with bone, which resulted in accumulation of cartilage at the hypertrophic zone. These changes were associated with an overall decrease in the expression of types II and X collagens, which was especially marked in the abnormally extended zone of the hypertrophic cartilage. Unlike collagen, the expression of collagenase-3 was not disturbed severely. Electron microscopic analysis proved that changes in gene expression were coupled to alterations in the mineralization as well as in the collagen fibril architecture at the hypertrophic cartilage. Because the composition and structure of the ECM have a critical role in regulating the behavior of the growth plate chondrocytes, results obtained are consistent with the hypothesis that alteration of collagen metabolism in these cells could be a key process underlying growth retardation in uremia. [source]

Coronary Artery Bypass Surgery in Patients with Malignancy: A Single-Center Study with Comparison to Patients Without Malignancy

JOURNAL OF CARDIAC SURGERY, Issue 2 2009
Nezihi Kucukarslan M.D.
In this study, we compared the outcome of coronary artery bypass graft (CABG) in such patients with those without malignancy. Methods: The patients were selected from those who had undergone coronary artery bypass surgery in the last decade. The study group (group I) included the patients with malignancy in remission. The control group comprised those patients who were selected randomly from those without any malignancy. The patients were retospectively examined with regard to preoperative, operative, and postoperative data from personal files, computerized recording system, and operation reports. Results: Group I included 48 patients (age 48 to 69; 29 male) while group II included 50 patients (age = 38 to 73; 35 male). In group I, comorbidity rates were: renal dysfunction in 12 (25%), obstructive lung disease 10 (21%), congestive failure in four (8%) patients. The malignancy rates were: lung in 15 (31%), breast in 10 (21%), stomach in five (10%), colon in four (8%), renal in one (2%), Hodgkin's lyphoma in three (6%), leukemia in two (4%), ovarian in three (6%), and prostate in five (10%) patients. In group II, the comorbidity rates were: diabetes mellitus 18 (36%), renal dysfunction in five (10%) and obstructive lung disease in 13 (26%) patients. In group I, chemotherapy and radiotherapy were performed in 38 and 34 patients, respectively. In groups I and II, the CABG was elective in 47 (98%) and in 45 patients (90%); the off-pump surgery was performed in 27 (56%) and 12 (24%) patients, respectively. The total duration of bypass was 37 ± 6 minutes and 44 ± 5 minutes; the duration of aortic clamp was 26 ± 4 and 29 ± 7 minutes, respectively, in groups I and II. Posoperative complication rates were: infection in 12 (25%), bleeding in eight (17%), acute renal insufficiency in eight (17%), prolonged air escape in five (10%), and prolonged entubation in 17 (35%) patients in group I and atrial fibrillation in 11 (22%) patients in group II. Mortality rates in both groups were two (4%). Conclusion: CABG in patients with comorbid malignancy is as safe as the other patients. In patients with full remission of malignancy, the surgeons should be encouraged about the safety of CABG. [source]

Two Different Therapeutic Strategies in ICD Lead Defects: Additional Combined LeadVersus Replacement of the Lead

JOURNAL OF CARDIOVASCULAR ELECTROPHYSIOLOGY, Issue 11 2007
CHRISTIAN G. WOLLMANN M.D.
Objectives: Implantation of an additional HV-P/S lead versus extraction of the defective HV-P/S lead and implantation of a new one is one possible therapeutic approach in cases of a defective high-voltage pace/sense lead (HV-P/S). No information is available on potential differences in clinical outcome in these different approaches. Methods: Between January 2000 and February 2006, 86 patients with HV-P/S lead defect received either an additional transvenous HV-P/S lead (n = 33, group 1) or the HV-P/S lead was replaced (n = 53, group 2). The duration of the initially implanted leads was significantly different in the two groups (7.4 ± 2.9; group 1 and 4.1 ± 3.4 years; group 2). The outcome of these two groups of patients was retrospectively analyzed. Results: Seventy-three patients [85%] survived until the end of follow-up of 29 ± 15 (group 1) and 33 ± 21 (group 2) months (P = ns), respectively. Thirteen patients died: six in group 1 and seven in group 2 (P = ns). Fourteen patients experienced perioperative complications (group 1: six; group 2: eight; P = ns). ICD system-related complications occurred in 22 patients (group 1: seven; group two: 15; P = ns). The event-free cumulative survival of patients with additional and replaced HV-P/S lead for postoperative events (including death) after 1, 2, and 3 years was 82%, 70%, 70%, and 86%, 81%, 66%, respectively (P = 0.93). Conclusions: Implantation of an additional HV-P/S lead or replacement of the HV-P/S lead in case of HV-P/S lead failure is statistically not different concerning mortality and morbidity. There are no predictors for further lead defects. Implantation of an additional HV-P/S lead should not be recommended in young patients or patients with greater likelihood of living many years. Predictors for death were an age over 70 years and renal insufficiency. [source]

The African American Study of Kidney Disease and Hypertension (AASK) Trial: What More Have We Learned?

JOURNAL OF CLINICAL HYPERTENSION, Issue 2 2003
Domenic A. Sica MD
The final results of the African American Study of Kidney Disease and Hypertension (AASK) have shown that the angiotensin-converting enzyme inhibitor ramipril was better than the , blocker metoprolol or the dihydropyridine calcium channel blocker amlodipine in slowing the rate of glomerular filtration rate decline in African American patients with mild to moderate renal insufficiency. Of note, there was no difference between the 92 mm Hg or less (lower group) and the 102,107 mm Hg (usual) mean arterial pressure groups as regards the secondary clinical composite end point. The secondary clinical composite end point in this study comprised a threshold drop of at least 50% or 25 mL/min in glomerular filtration rate, death, or reaching end-stage renal disease. The final results from this study would suggest that reduction in blood pressure to levels below those currently advocated for cardiovascular risk reduction, although a clearly attainable goal in this population, does not provide readily identifiable benefits to African Americans with hypertensive nephrosclerosis. Importantly, this study provides the basis for the primary use of angiotensin-converting enzyme inhibitors in an African American population with the characteristics of those studied in AASK. It remains to be determined if this represents a class effect for all angiotensin-converting enzyme inhibitors. [source]