How I Healed my Kidney Problems

Kidney Function Restoration Program

The All Natural Kidney Health & Kidney Function Restoration Program is a compilation of the best and most effective natural treatments for kidney disease from around the world. The system is meant to complement your usual medication and not to replace it. This easy to understand kidney disease program can help you make better-informed decisions about what is the right thing to do to support your kidney and return it to its former healthy state. The techniques shared in this program will help cure and retain your kidney back to its natural wellness. You may even be able to postpone or entirely avoid dialysis or a kidney transplant forever. The All Natural Kidney Health and Kidney Function Restoration Program contain zero filler and is fully backed by modern-day scientific research. Everything contained in this program is safe, natural, and with good safety profiles, proven case studies and doctor recommended. Many of the products including the diet, herbs, and supplements have been used safely in other countries for many years and in several hospitals in the United States. More here...

Kidney Function Restoration Program Summary


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What is hepatorenal syndrome How does it differ from acute renal failure in patients with endstage liver disease

Both types of renal failure occur in patients with cirrhosis and are characterized by oliguria and increases in serum creatinine. The etiology in both cases is renal hypoperfusion. Differentiation is important because treatment and prognosis vary. Hepatorenal syndrome (HRS) occurs in cirrhotic patients with portal hypertension and ascites. HRS is defined as a plasma creatinine of 1.5 mg dl and a urine sodium

Treatment of patients with terminal kidney failure

Hemoperfusion in terminal kidney failure patients results in the improvements of patients' well-being and uremic symptoms (Chang et al., 1971a, 1972g, 1974). It efficiently removes uremic wastes and toxins including the larger middle molecules (Chang, 1972e Chang, and Migchelsen, 1973 Chang and Lister, 1980 1981). Middle molecule is a term used by nephrologists to denote molecules in the molecular weight range of 300 to 15,000. However, hemoperfusion does not remove electrolytes, water or urea. Thus, it has been used in series with hemodialyzers as hemodialyzers were, at that time not effective in removing the larger middle molecules that were thought to be uremic toxins. 1980 Stefoni et al., 1980). Since then, the quality of hemodialysis membranes has improved and the present high flux membranes are superior to the standard dialysis membrane in removing the larger middle molecules. Even then, the clearance is still much less than compared to the better hemoperfusion devices....

Hemoperfusion in Terminal Renal Failure Patients

Hemodialysis machines are effective in the treatment of chronic renal failure patients. However, at that time there were not enough machines furthermore, it was extremely expensive. Only a small number of patients could afford treatment in a few countries. In most other countries, the high cost and unavailability of machines posed a barrier to their use in terminal renal failure patients. Since hemoperfusion is efficient in removing toxin or unwanted waste from the blood, we carried out studies into its possible use in uremic patients. This author has carried out 55 hemoperfusion procedures in 14 patients (Table 7). Initially, only one hemoperfusion procedure was carried out on each of four terminal renal failure patients. Having shown the safety of this procedure, two hemoperfusions were carried out on the 5th patient and three procedures were then carried out on each of the next three patients. After this, a 72-year-old female, who could not be managed by peritoneal dialysis or...

Acute renal failure related to pregnancy

133 Renal failure 301 septic abortion and massive haemorrhage (traditionally caused by placental abruption, although any cause of hypovolaemia may be followed by renal failure). Other important causes include pyelonephritis, drug reactions (especially non-steroid anti-inflammatory drugs NSAIDs ), acute fatty liver and incompatible blood transfusion. In most cases, ARF is caused by acute tubular necrosis, although cortical necrosis has been seen after abruption and pre-eclampsia. Problems are those of ARF generally, especially related to fluid balance and the apparently increased susceptibility of pregnant women to developing pulmonary oedema.

Effects of kidney disease on associations of adiposity with cardiovascular risk factors and cardiovascular disease

In contrast with the data for the general population, dialysis patients with higher body mass index have lower mortality compared with dialysis patients with normal BMI (41,42). Strikingly, these data have been consistent in several studies (43-45). Thus, it has been suggested that obesity is protective in dialysis patients (41). In other words, as the associations of body size with mortality appear to vary depending on the presence or absence of advanced kidney failure, it can be said that kidney disease is an effect modifier of this association. However, there are three problems with the suggestion that adiposity is protective in dialysis patients. First, the real paradox of the BMI paradox in dialysis patients is the possible association of high BMI with inflammation, yet with decreased mortality. Adipocytes are rich sources of proinflammatory cytokines such as IL-6 and TNF-a, which in turn stimulate the production of C-reactive protein (CRP) in the liver (46). It was shown in a...

Continuous Ambulatory Peritoneal Dialysis Catheters

Peritoneal dialysis catheters are placed into the abdomen most often for continuous ambulatory peritoneal dialysis (CAPD), as well as for acute dialysis and for drainage of malignant ascites. Continuous ambulatory peritoneal dialysis offers several advantages over hemodialysis including the ability to perform dialysis without the need for vascular access, systemic heparinization, or the hemodynamic changes associated with the volume shifts of hemodialysis. In addition, the quality of life of those on CAPD may be preferred as this process can be safely completed at a patient's home, work or play, saving multiple weekly trips to a dialysis unit.

Conjoint Hemoperfusion Hemodialysis

Conjoint Nerve Root

For the above reasons, clinical investigators around the world started to carry out clinical trials using hemoperfusion in series with hemodialysis for patients with dialysis resistant uremic symptoms and also to reduce the time needed for treatment. (Chang et al, 1975 Hemoperfusion in Poisoning, Kidney Failure, Liver Failure, and Immunology 285 Table 9. Effects of Hemoperfusion in Uremic Patients Since then, the quality of hemodialysis membranes has improved so that the present high flux membranes are better than the standard dialysis membrane in removing the larger middle molecules. Even then, the clearance is still much less compared to the better hemoperfusion devices. Hemoperfusion devices are usually manufactured by manufacturers of hemodialysis machines and membrane. In those countries with strong hemodialysis companies, the hemoperfusion devices are extremely expensive. On the other hand, in these countries with no large dialysis industries, hemoperfusion devices are not...

Assessment of Kidney Function in the Elderly

Kidney function commonly declines with age, although not universally (6-9). Approximately one-third of elderly adults do not exhibit an age-related decline in kidney function (6). This has led to the suggestion that a decline in GFR is not a normal accompaniment of aging, but rather due at least in part to concomitant hypertension, cardiovascular disease, and diabetes mellitus. By the age of 80 years, mean GFR, depending on how it is measured or estimated, is approximately 50-80 mL min, compared to 120 mL min or greater in subjects in their 20s-40s. The prevalence of CKD in 65-74 year olds and individuals 75 years and greater is increasingly steadily, and there are more patients 70 years or older starting dialysis each year than any other age group (10). Despite this reduced level of GFR with advanced age, serum creatinine levels tend to remain relatively unchanged or increase only modestly over time in the absence of other conditions, a reflection of the reduced muscle mass that...

Mechanisms of Kidney Damage in Adiposity

There are several biological mechanisms through which adiposity could lead to kidney damage (Table 1). Pathophysiology of increased microalbuminuria and proteinuria may include glomerular hyperfiltration, increased renal venous pressure, glomerular hypertrophy (due to mesangial cell hypertrophy and matrix production), and increased synthesis of vasoactive and fibrogenic substances (including angiotensin II, insulin, Mechanisms of Kidney Damage Reduction of renal mass contributes to retention of proinflammatory adipokines, leading to adipokine imbalance (28), and augments the inflammatory state in end-stage renal disease (ESRD). Leptin is a proinflammatory adipokine. Leptin is cleared by the kidney (29-31), and its concentration increases in renal impairment. In glomerular endothelial cells, leptin stimulates cellular proliferation, TGF- 1 synthesis, and type IV collagen production (32). In mesangial cells, leptin upregulates synthesis of TGF- 2 receptor (32) and type I collagen...


Anaphylaxis and anaphylactoid reactions during hemodialysis have been attributed to a number of different factors. Ethylene oxide used for sterilization can produce an IgE-mediated event. Other reactions have been related to the procedure used in processing the hemodialyzer. The type of hemodialysis membrane can be important. Severe reactions have been reported with the use of hollow-fiber membranes made of cuprammonium cellulose. The use of angiotensin-converting enzyme(ACE) inhibitors during dialysis seems to predispose to anaphylactoid events. When a patient experiences anaphylaxis during hemodialysis, the type of membrane should be changed, no reprocessed membrane should be used, and ACE inhibitors and p-blockers should be discontinued if possible.

Kidney Failure

During acute renal failure, the kidneys may suddenly lose their ability to remove wastes, concentrate urine, and conserve water and essential nutrients. Urine production decreases or stops completely. Often there is blood in the urine. Protein waste products quickly accumulate in the blood, damaging tissues and reducing organ function throughout the body. This condition, known as uremia, can be fatal if kidney function is not restored promptly and if the blood is not filtered and cleansed. Symptoms of this toxic reaction include drowsiness, confusion, loss of appetite, nausea and vomiting, and seizures. The onset of symptoms is rapid, often occurring within days, but the condition can be reversed if diagnosed and treated quickly. Disorders of the kidney itself also can lead to acute renal failure. These disorders include direct injury to the kidney, a urinary tract infection such as acute pyelonephritis (see page 286), kidney stones (see page 289), renal cell cancer (see Kidney...


With kidney failure, when the kidneys can no longer remove waste and excess water and acid from the blood and maintain the body's chemical balance, a person must undergo kidney dialysis. In this procedure, blood from an artery in the person's arm or leg flows through a tube and into a machine called a dialysis unit that works as an artificial kidney. The blood is filtered and cleansed in the dialysis unit and returned through another tube inserted into a vein in the same arm or leg. Usually dialysis is performed at a dialysis center (although it can be done at home) three times per week. The person can sleep, read, write, talk, or watch television during the 3 to 4 hours of each treatment. In another type of dialysis (called peritoneal dialysis), a cleansing fluid (called dialysate) is placed in the abdomen through a permanently implanted catheter (tube) to filter and cleanse the blood. To begin treatment, the person attaches a bag containing dialysate to the catheter and allows the...


Lipid peroxidation is increased during haemodialysis, because ofROS generation 188-190 , Paradoxically, total antioxidant capacity increases in patients undergoing dialysis due to high serum urate levels, although this decreases after dialysis, as does serum ATC 189 , Increased ROS generation has also been reported to increase apoptosis in leukocytes 191 . Potentially, this offers the interesting possibility of using either treatment of dialysis membranes with ATC

Connective Tissue Disorders And Aneurysmal Formation

Evidence suggests that certain inherited diseases, specifically diseases that might cause an inherent weakness in all vessel walls, including cerebral vessels, predispose individuals to aneurysmal formation. The disease most strongly linked to aneurysmal formation is autosomal dominant (adult) polycystic kidney disease (APKD), a common hereditary disorder that affects 1 in every 400 to 1000 live births. This systemic disease leads to formation of cysts in ductal organs, such as the kidney and liver (36). The two most common genes associated with this disorder are PKD1 and PKD2. PKD1, located on chromosome 16p13.3, encodes the polycystin 1 protein (37) and accounts for approximately 85 of cases (38). This protein has a large extracellular region and might participate in cell-cell and cell-matrix interactions. PKD2, located on chromosome 4q13-23, encodes the polycystin 2 protein and is present in approximately 10 of affected families. Polycystin 2 might interact with polycystin 1 to...

Cortical Spreading Depression

Leao's observations were made in rabbits under barbiturate anaesthesia, and the stimulus to the cortex was bipolar electrical current delivered from an induction coil, but several other stimuli are also effective. Dialysis through an implanted microcatheter or superfusion of the exposed cortex with potassium chloride (KCl) at 130 mM or more is effective in the rat brain 8 , as is local application of KCl with a wick. Neurosurgeons should

Geneticallyengineered cells

Potential applications in amyotrophic lateral sclerosis, dwarfism, pain treatment, IgG1 plasmacytosis, hemophilia B, Parkinsonism and axotomized septal cholinergic neurons, tumor suppression and other areas (Basic etal., 1996 Tan etal., 1996 Al-Hendy etal., 1996 Okada et al., 1997 Dalle et al., 1999 Saitoh etal., 1995 Hagihara et al., 1997 Winn etal., 1994 Aebischer et al., 1996 Bloch et al., 2004 Bachoud-Levi et al., 2000 Xu et al., 2002 Cirone et al., 2002). To avoid the need for implantation, we studied the oral use of artificial cells containing genetically-engineered nonpathogenic E. coli DH5 cells to lower systemic urea in renal failure rats (Prakash and Chang, 1996 Chang, 1997).

Artificial Cells Containing Bioadsorbents

The most common routine application of this approach is the use of microscopic polymeric artificial cells encapsulating activated charcoal (Chang, 1969, 1973a,b, 1975g) (Fig. 2.6). Its use solves the major problems of release of embolizing particles and damage to blood cells when bioadsorbents are used without the artificial cell membranes (Fig. 8). The first successful application was in suicidal overdose patients (Chang etal., 1973a,b). Since then, this has become a routine treatment worldwide for acute poisoning in adults and children, especially in cases of suicidal overdose (Chang, 1975b, 1975c Winchester, 1988 Singh etal., 2004 Lin etal., 2004 Peng etal., 2004 Lopez etal., 2002 Kawasahi etal., 2000 Lin etal., 2002 Tominaga, 1997). The treatment is particularly useful in places where dialysis machines are not readily available. The approach is also effective in removing toxic products in kidney failure patients (uremia), resulting in the relief of uremic symptoms (Chang etal.,...

Australian infectious bronchitis virus A

Strain of avian infectious bronchitis virus originally isolated by Cumming in 1962 from poultry in Australia suffering from a kidney disease known as uremia. Infectious bronchitis viruses isolated in Australia before 1980 induced nephritis with high mortality, whereas viruses isolated in the USA and elsewhere outside Australia showed little evidence of nephropathogenicity. Since 1980, most viruses isolated from Australia appear to be less nephrotropic, and no longer cause high mortality.

Antibiotics for Animals and Crops Lead to Resistance for People

The membrane surrounding the brain and spinal cord) in newborns, especially the premature infants. It also is a common cause of diarrhea, especially that disease of travelers we call la tourista. More rarely, certain strains cause a very severe diarrhea sometimes associated with kidney failure - the famous E. coli OH157 of undercooked burger fame. It tends to remain rather susceptible to antibiotics globally. But, about 60 of isolates causing infections in patients in the US are resistant to tetracycline. Of course, tetracycline is still used in humans as well as animals and for crops. But surprisingly, around 20 of strains were also resistant to streptomycin even though this drug is hardly ever used for treatment of people anymore. There is good reason to believe that part of this is due to streptomycin use for crops.

Amantadine An M2 Channel Blocker Of Influenza A Virus

Recommendations from a WHO expert group are that the anti-influenza compounds should be used prophylactically where epidemiological investigations show the presence of influenza A in the community. Prophylactic use should continue daily for up to 4-5 weeks until the epidemic has passed. Chemoprophylaxis is recommended for 'special-risk' groups, such as over-65s, some diabetics, and persons with chronic heart or chest diseases who have either not been immunized or who wish to receive additional protection to that of immunization, or those being potentially exposed to virus infection before vaccination has become effective (2-3 weeks). These members of the community are at much higher risk of serious complications and death following influenza than others. Clinicians now appreciate that amantadine dosage must be carefully adjusted for elderly and frail individuals and particularly those with kidney disease or urinary retention, in whom the drug could accumulate. A reduced dose of 100 mg...

Baby hamster kidney cells See BHK21 cells

Balkan nephropathy virus Virus particles morphologically resembling coron-aviruses seen in sections of kidney tissue from human cases of a slowly progressive kidney disease. This disease occurs only in the Balkans, mainly Bulgaria, and is rare in Muslims. Virus antigen in tissue sections reacts with patients' serum, but does not react with pig or bird coron-avirus antiserum.

Induction Of Aox Enzymes

Investigators have reported an association between plasma or serum TBA-reactive substances (TBARS) or diene conjugates and diabetic complications, whereas others have not (67-70). However, TBARS and diene conjugation assays should be interpreted with caution (53). MacRury et al. (70) compared different methods (conjugated dienes, TBARS, and chemiluminescence) of assessing free radical activities in diabetic subjects. In each case, diabetes was associated with elevated levels of different indirect measurements of lipid peroxidation. However, they did not find a relationship between diabetic complications and plasma measures of oxidative stress. More convincingly, elevated levels of plasma 8-epi PGF2a have been reported in diabetics, although its association with disease progression was not discussed (71). Another study, using the ferrous oxidation with xylenol orange (FOX) assay to measure lipid peroxides, found higher lipid-standardized peroxides in plasma from diabetic patients...

Use in industrial production

Ultrafiltrators did not cause complement activation. Without this test, some batches could result in adverse effects of unknown causes in humans. Chromatography, ultrafiltrators, dialysis membranes and other separation systems are used extensively in the preparation of different types of blood substitutes. It is, therefore, important to screen for the possibility of trace contaminants that could cause complement activation. In the same way, different chemical agents and different reactants used in industrial production could be similarly tested (Table 3.5).

Definitions Used In Antimicrobial Surveillance

The usage density rate used in the SA surveillance programme is defined as the number of DDDs used per 1,000 occupied bed-days (OBDs). This rate has been widely used as an appropriate measurement of usage in the non-ambulatory setting, and has been adopted by a number of international programmes (DANMAP, 2003 Fridkin et al., 1999), although to ensure comparability of data with other centres, the WHO DDD values should always be used. Antimicrobial usage data for outpatient areas, including hospital-in-the-home, day treatment centres, day surgery, and dialysis clinics are excluded from the SA programme to ensure that the denominator corresponds to that used by the concomitant multiresistant organism surveillance programmes conducted by the Infection Control Service.

Bloodstream Infections Including Endocarditis

Complicated S. aureus bacteremia requires 4 to 6 weeks of antimicrobial therapy, and should be considered in patients with positive blood cultures after 48 hr of treatment (despite removal of catheter, if suspected source), persistent fever after 72 hr, skin examination suggestive of acute systemic infection, community-acquired infection, and the presence of an orthopedic or other prosthetic device (15). Those with an unknown focus of bacteremia or endocarditis also require 4 to 6 weeks of treatment (Tables 3 and 4). In addition, patients who are quantitatively (i.e., primary hematology) or qualitative (i.e., diabetes and renal failure) immunodeficient require special attention, and 4 to 6 weeks of treatment should be considered.

Which Patients Are At High Risk For Developing Stressrelated Bleeding

Few patients who enter the modern ICU will develop life-threatening stress-related bleeding (see above). Patients who do develop stress-related hemorrhage, however, may experience significant morbidity and mortality. It is therefore important to identify the subgroups of ICU patients who would benefit most from prophylaxis. Stress-related lesions have been described in a wide range of clinical settings including severe respiratory insufficiency, hypotension, sepsis, major burns, severe trauma, central nervous system injury, acute renal failure, acute hepatic failure, and coagulopathy. Most of these clinical situations are associated with alterations in the gastric microcirculation, which may lead to local hypoxia and ischemia, increased vascular permeability, critical tissue acidity, and reperfusion injury (1) (Fig. 1).

Describe propofol infusion syndrome

Periods of time (higher than 4 mg kg hr for longer than 48 hours). Critically ill children are at the highest risk. Risk is increased with the administration of exogenous steroids and catecholamines and inadequate carbohydrate intake. Manifestations include cardiac failure, rhabdomyolysis, severe metabolic acidosis, hyperlipidemia, renal failure, and sometimes death. Currently propofol is not approved for use for pediatric intensive care unit sedation. Although the morbidity and mortality are currently very high for those with recognized propofol infusion syndrome and treatment options are limited, best outcomes have been achieved with supportive care such as hemodialysis and cardiorespiratory support.

Medical Therapy For Stress Ulcer Prophylaxis When And With What

ICU patients with fewer than two risk factors commonly associated with stress-related bleeding (Table 1), or with low risk scores for severity of disease total risk score 10 (30), APACHE II score less than 15 are at low risk for stress-related hemorrhage. In the absence of individual factors that may increase their risk substantially (prolonged mechanical ventilation, coagulopathy), prophylaxis is not indicated in these patients. Patients with at least two risk factors or multiorgan failure involving at least two organ systems (acute renal failure, acute hepatic failure, acute respiratory failure, hypotension, septic shock) should, on the other hand, receive prophylaxis.

Are there any illnesses or medical conditions that are associated with osteoporosis

End Stage Renal Disease Individuals with chronic kidney disease usually have high levels of phosphorus in the blood. High blood levels of phosphorus put them at increased risk for osteoporosis. They must take a special medication Dialysis called Renagel (sevelamer) that binds the extra phosphorus and allows the body to excrete the surplus through the intestines. Those who are on dialysis often have their blood checked weekly for phosphorus levels and their Renagel dosage adjusted accordingly. I have been on hemodialysis for kidney disease for well over a year. I have to be very careful about eating foods that are too high in phosphorus because my kidneys are not able to process the phosphorus correctly. My nephrologist does not want my phosphorus levels to get too high because calcium will be taken from my bones, making them weaker. Also, the phosphorus makes my skin itch. Although I take Renagel to keep the phosphorus levels down, the dialysis also removes phosphorus from my blood....

Quinupristin Dalfopristin

Of acute and chronic comorbidities including diabetes, oncologic conditions, chronic liver disease, dialysis, mechanical ventilation, and prior organ transplantation. Q D was administered at 7.5mg kg intravenously every 8hr to patients with documented VRE bacteremia or nonbacteremic VRE infection, with the duration of treatment determined by the primary treating physicians. The overall success rate, defined as both clinical success and bacteriologic eradication, was 65.8 in the initial study and 65.6 in the follow-up study. There have been several reports of clinical cure combining Q D with doxycycline or high dose-ampicillin in endocarditis however, no larger scale experience has been performed (75-77).

How may btype natriuretic peptide aid in the management of endstage congestive heart failure

Although large, prospective randomized trials have not been conducted to date with nesiritide (p-type natriuretic peptide), some initial data seem to indicate that it may be beneficial for the management of precardiac transplant patients with increased pulmonary vascular resistance and renal failure. Indeed, p-type natriuretic peptide improves the hemodynamic profile, increases renal sodium excretion, and suppresses the renin-angiotensin-aldosterone system, improving clinical symptomatology.

Factors Affecting the Measurement of Cardiac Troponins

Renal Failure Among patients with end stage renal failure (ESRF), cardiac disease is the single, most common cause of mortality, accounting for nearly 50 of all deaths 210 . It has been well established that the traditional markers of myocardial necrosis, such as CK, CK-MB, and myoglobin, as well as the cardiac troponins are commonly increased in renal failure even in the absence of clinically suspected myocardial infarction 26, 211, 212 . The significance of this observation has been the subject of recent debates regarding the universal acceptance of cardiac troponins as specific markers of myocardial infarctions. Furthermore, studies have shown the importance of troponin elevation in risk stratification, prognosis, and therapeutic interventions 102, 103, 116 . However, it is important to point out that most of these studies excluded patients with renal failure. Recently, two landmark studies have shown that even mild renal disease, as assessed by the estimation of the...

Arterial Stiffness and Extracellular Matrix

The growing prevalence and associated risk of arterial stiffness provide a major challenge to better understand the underlying causes and the resultant physiological impact of this condition. Structural components within the arterial wall, mainly collagen and elastin, are considered to be major determinants of arterial stiffness. Thus, quantitative and qualitative alterations of collagen and elastin fibers are involved in arterial stiffening that is associated with the aging process and disease states such as hypertension, diabetes, atherosclerosis, and chronic renal failure. Elucidation of mechanisms leading to the above alterations will aid in more specifically targeted therapeutic interventions because currently available cardiovascular medications fall short at reducing the stiffness of the large arteries. Reduction of arterial stiffness will likely have a significant impact on morbidity and mortality of older adults, as well as subjects suffering from cardiovascular and renal...

Serological Diagnosis of CD

Serological diagnosis is based on estimation of antibodies against gliadin and of autoantibodies directed against tTG. Gliadin antibodies have been known for more than 40 years 91 . However, their diagnostic sensitivity and specificity for CD is low. The immunoglobulin A (IgA) class has a somewhat higher specificity than the immunoglobulin G (IgG) class 88 . Increased concentrations of gliadin antibodies can also be found in a variety of other conditions not related to CD, for example inflammatory bowel disease 92 , IgA nephropathy 93 , HIV infection 94 , rheumatoid arthritis 95 , as well as in some apparently normal individuals. Furthermore, gliadin antibodies were also described in neurological disorders 96, 97 . The most frequently published neurological syndromes associated with gliadin antibodies are cerebel-lar ataxia (gluten ataxia) and peripheral neuropathy (celiac neuropathy). However, the association between gliadin antibodies and neurological diseases is, for the most part,...

Miscellaneous Diseases Associated with Increased Levels of MMPs and TIMPs

Ebihara et al. (E2) reported that plasma MMP-9 measurements made over a 4-year period in non insulin-dependent diabetics were highly predictive of the development of diabetic nephropathy. Compared with patients with 7.4. Polycystic Kidney Disease Elevated levels of serum MMP-1, TIMP-1, and plasma levels of MMP-9 have been reported in patients with autosomal dominant polycystic kidney disease as compared to healthy controls (N6).

What is the difference between a DXA and a pDXA

Evaluate your hip and spine. pDXA testing is not considered appropriate for monitoring bone density in patients undergoing treatments for osteoporosis because response to treatments is not as evident in the bones of your hands, arms, and feet. pDXA testing on your forearm, usually your nondominant arm (for example, your left forearm if you are right handed), is not recommended if your forearm has been previously fractured, if it has a dialysis graft site, if it has been subject to prolonged immobilization, or if there is severe weakness or paralysis of that arm.

Atrial Natriuretic Peptide

Angiotensin-aldosterone system, indicating that ANP may play an important role in regulating fluid balance (73,74). Elevated plasma concentrations of ANP have been reported In a variety of diseases including hypertension, congestive heart failure (CHF) and renal failure (75-77). In addition, a correlation has been reported between decreases in ejection fraction in patients with heart failure and increases in plasma ANP (75).

Complications And Other Issues

Patients with portal hypertensive bleeding are at risk for several systemic complications. Respiratory complications such as aspiration pneumonia and respiratory failure can occur. Infections, worsening hepatic function, and renal failure from either acute tubular necrosis or hepatorenal syndrome are other possible sequelae.

Cobalamin Vitamin B12 Deficiency

As shown in Fig. 3.4, according to the study of Andres et al. (10), the definition of cobalamin deficiency is a serum cobalamin level 0.4 mol mL in the absence of renal failure or folate and B6 deficiency. However, as pointed out by Solomon, there is considerable uncertainty about the diagnostic criteria and probably no one single laboratory value is sufficient (11). The causes of B12 deficiency in the elderly (and the approximate frequency with which they occur) are shown in Table 3.6 (from 10). * Serum cobalamin level 150 pmol L AND total serum homocysteine level 13 nmol L OR methymalonic acid 0.4 nmol L (in the absence of renal failure and folate and vitamin Bh deficiencies)

Studies In Healthy Volunteers

The occurrence of late complications is still very high. Waldhausl (1986) reported a prevalence of 41 diabetic retinopathy, 25 neuropathy and 15 diabetic nephropathy. Normal HBA, levels were only seen in 20.7 of metropolitan and in only 4.1 of rural Type-I diabetic patients. Although definitive proof is lacking, it is now generally accepted that the microangiopathy of diabetes is related to the level of glycaemia, and near-normoglycaemia should be the outstanding aim of treatment (Tchoubroutsky, 1978). The failure of conventional insulin treatment to maintain consistently normal blood glucose was felt to be a consequence of not considering the physiological pattern of insulin release. The kinetics of plasma free insulin during a conventional regimen with one or two daily subcutaneous injections of intermediate-acting insulin is unphysiological, and appropriate meal-related plasma insulin peaks cannot be achieved. The new intensified methods of insulin delivery, multiple daily...

Conclusion from Results of Basic Study Using the Acatalasemic Mice Model

However, at that time, enzymes for the most common genetic enzyme defect, phenylketonuria, could only be extracted from the liver. These liver enzymes are very complex and unstable and not suitable for use in artificial cells for enzyme therapy. With the later availability of simple and stable enzymes from microorganisms, enzyme therapy becomes much more feasible and practical. However, the major barrier is that enzymes are not stable at body temperature and thus can only function in the body after injection for a few days. In congenital enzyme defects, the duration of treatment is for the life of the patients. Repeated injection of enzyme artificial cells over the many years of treatment would result in the accumulation of much foreign material in the body. To solve this problem, catalase artificial cells retained in small chambers outside the body and perfused by body fluid can also remove perborate. However, a more convenient route of administration would be better for pediatric...

Vascular Malformations

Clear that vascular malformations can cause bleeding in any location left colon, stomach, or small bowel. Multiple lesions are present in 3075 of patients. Vascular malformations are probably best considered as a degenerative disease of aging, because they are most common in patients older than 60 years. The exact prevalence in the general population is unknown because many patients are asymptomatic, with lesions discovered only incidentally during bowel resection for another indication or during autopsy. Based on these data, their prevalence in the general population is estimated to be approximately 3 (16). Aortic stenosis and chronic renal failure have been reported to be associated with vascular malformations, although a recent review of the literature shows no clear association between aortic stenosis and vascular malformations (17). A recent study indicated that most patients with bleeding angiodysplasia or telangiectasia have a deficiency of the largest

Drug Selection And Dosing

After the correct drug is selected, dosing needs to be optimized using the same pharmacodynamic principles. The susceptibility breakpoints for gentamicin are 4 pg mL or greater for susceptible pathogens and 8 pg mL for intermediate pathogens (27). Current recommendations for high-dose extended-interval dosing target maximum concentrations of 14 to 20 pg mL. A pathogen could be reported susceptible to gentamicin, whereas maximum doses would achieve a Cmax MIC ratio of only 3.5 to 5 and AUC MIC of 13 to 19. Optimal pharmacodynamics is believed to be associated with a Cmax MIC ratio of 10 or greater and AUC MIC of 70 or greater (24,28). Use of gentamicin in this setting would be acceptable only in combination with a primary antibacterial agent that would achieve more optimal pharmacodynamic end points. Although a drug-free period is generally desirable with aminoglycosides, this is difficult to achieve among patients with markedly impaired renal function. One also must guard against...

Medication Errors And Adverse Drug Events

Medication errors are errors that result in preventable (actual or potential) ADEs. These errors are usually considered by the stage during which they occurred prescription, transcription, dispensation, or administration. Examples of prescription medication errors leading to an adverse event would include using an aminoglycoside in a patient with moderate renal impairment or other concomitant nephrotoxic drugs leading to worsening renal failure. The error component would enter the situation if gentamicin therapy could not be justified. Another example involves administration of a penicillin derivative to a patient with a known history of immediate hypersensitivity reaction. A medication error includes use of a drug without considering a contraindication or special risk applicable to an individual case. If the clinician is aware of the contraindication or special

Infections And Their Management

It is important to remember that the major drive against viral infection remains defensive, based on the use of sound infection control principles and vaccination. Rigorous infection control policies have had significant impact in many situations, such as the transmission of hepatitis B virus (HBV) in renal dialysis units (UK Department of Health, 2002) and the spread of norovirus, the cause of winter vomiting disease, during outbreaks on hospital wards (Chadwick et al., 2000 McCall and Smithson, 2002). The eradication of smallpox and the elimination of poliovirus from large parts of the globe are two of the most striking examples of vaccine preventable disease, but there are many more, including the prevention of influenza virus infection (Nichol, 2003) and vaccination against HBV (Bonanni and Bonaccorsi, 2001).

Methicillin Resistant Staphylococcus aureus

Resistant to antimicrobial agents continues to increase both in the hospital setting, particularly in the ICU, and in the community.84 In 1991, MRSA accounted for 35 of isolates in the United States, but that incidence has increased and now many hospitals are reporting MRSA rates as high as 50 to 70 .89,90 In 2000, more than 50 of S. aureus isolates causing infections in ICUs were resistant to MRSA.89-91 Methicillin resistance rates are highest in the nations of southern Europe (e.g., Italy, Greece, Portugal, and Turkey).92 Being a resident of large tertiary-care hospitals, acute care or nursing homes, and proximity to other patients with MRSA are well known risk factors for MRSA infections as well as burns, surgical wounds, dialysis, indwelling intravenous catheters, prolonged hospital-ization, advanced age, immunocompromise, and prior antibiotic administra-tion.58,93 Two recent meta-analyses demonstrated that bacteremia caused by MRSA was associated with significant mortality rates...

Oxidized Lipoproteins

Oxidation of LDL by Endothelial Cells - In 1981 it was shown that incubation of LDL with endothelial cells (EC) led to a modified form of LDL which was recognized by the receptor for ac-LDL on macrophages (25). A free-radical oxidation (e.g. lipid peroxidation) was later shown to be involved in the alteration of LDL by EC (26-28). The oxidation of LDL was accompanied by a nonenzymatic cleavage of the peptide bonds of apo B (29) the solubilized fractions of apo B of delipidated ox-LDL were demonstrated to be recognized by the ac-LDL receptor (30). EC lipoxygenase might play an important role in the EC-mediated LDL modification since inhibitors of this enzyme markedly reduced LDL oxidation, whereas superoxide dismutase showed only weak inhibition (31). Prior to this however, an EC line, which generated superoxide anion inefficiently, was shown to be unable to modify LDL oxidatively (32). Since LDL, which was added to the EC in a dialysis bag, did not undergo oxidative modification, a...

Key Points Aortoocclusive Disease

Coexisting diseases are extremely common and include coronary artery disease, hypertension, COPD, chronic renal disease, and diabetes mellitus. These comorbidities have a very important impact on outcome. 3. The most common cause of perioperative mortality is cardiac disease. Postoperative renal failure also has an important impact on outcome.

Monitoring and fluid therapy

All pre-eclamptic women should have a urinary catheter inserted and an accurate hourly fluid balance recorded. Fluid management is controversial. The risks of volume overload and iatrogenic pulmonary oedema must be balanced against the risk of hypotension if vasodilators are given without concomitant volume replacement. In general, the emphasis has shifted away from liberal use of fluids in order to encourage urine output, towards careful restriction, since long-term problems from renal failure are rare whereas deaths from pulmonary oedema are well reported.

Arterial Stiffness and Coronary Artery Calcification

Coronary calcification is thought to represent primarily calcification of atheroma 2, 3 . Evidence of an association between arterial stiffness and coronary calcification has been mixed. Haydar et al. 20 have shown that among 55 men and women with ESRD, cfPWV was positively associated with coronary calcification after adjusting for age, sex, duration of dialysis, CRP, and diastolic BP.

Oxidative Stress In Patients With Diabetes Mellitus

Age and may precede microalbuminuria in development of diabetic nephropathy (46). Free radicals produced by the system myeloperoxidase hydrogen peroxide halogen derivatives activate proteinases, which break down collagen and other components of the extracellular matrix present in the basal membrane of the glomeruli and in the mesangium. It has been shown that hydroxyl radicals may depolarize glomerular heparan sulfate in vitro and in experimental nephrotic syndrome, leading to loss of glomerular basement membrane integrity and albuminuria (47). Thus, oxygen radicals and proteinases can cause and amplify glomerular damage.

Hypothesis Of Advanced Glycation End Products And Its Receptor

AGE formation proceeds slowly under normal glycemic conditions but is enhanced in the presence of hyperglycemia, oxidative stress, and or conditions in which protein and lipid turnover are prolonged. For example, V-epsilon-(carboxymethyl)lysine (CML), one of the various AGE structures postulated to date, has been found to be a product of both glycoxidation (combined non-enzymatic glycation and oxidation) and lipid peroxidation reactions (53). CML and pentosidine have been shown to accumulate in diabetic kidneys in colocal-ization with a marker of lipid peroxidation (MDA), suggesting an association of local oxidative stress with the etiology of diabetic glomerular lesions (54). Evidence for an age-dependent increase in CML accumulation in distinct localizations and acceleration of this process in diabetes has been provided by immunolocalization of CML in skin, lung, heart, kidney, intestine, intervertebral discs, and particularly in arteries (55). In diabetic kidneys, AGEs were...

Inhibition Of Diabetic Complications By Antioxidant Treatment

One of the earliest events in atherogenesis is the adhesion of monocytes to the endothelium and its migration into the arterial intima. Endothelin-l, which is increased in diabetes and is believed to be relevant for the progression of nephropathy (113), has been shown to increase monocyte chemotaxis in a dose-dependent manner (97). a-Lipoic acid inhibits migration (114). a-Lipoic acid has also been shown to be an effective inhibitor of aldose reductase (115). Aldose reductase inhibitors have been suggested to prevent or reduce the different components of vascular dysfunction, cataract, neuropathy, and nephropathy in animal models of diabetes.

Epidemiology of Diabetes

The complications of diabetes, which include limb amputations, blindness, nerve damage, kidney failure requiring hemodialysis, and cardiovascular disease (CVD), pose the threat of enormous human and economic costs. A prospective study of more than 15,000 persons followed for 25 years confirms that the risk of cardiovascular death in patients with diabetes without previous coronary heart disease (CHD) is equal to that of patients with CHD without diabetes, with the risk in women being higher 3 . Direct healthcare expenditures and the costs of lost productivity attributable to diabetes in the USA were estimated at USD 132 billion in 2002 4 .

Malnutrition vs cachexia

Malnutrition, in conditions such as kwashiorkor and pyloric stenosis, results from inadequate intake of nutrients despite a good appetite, and manifests as weight loss associated with protective metabolic responses such as decreased basic metabolic rate and preservation of lean body mass at the expense of fat mass. Cachexia differs from malnutrition in several key ways. First, despite the fact that the cachexic person is starving, he or she is anorexic. Second, in normal starvation the metabolic rate decreases as a protective mechanism. This protective reduction in metabolic rate is not observed in cachexia. Resting energy expenditure is high in patients with cachexia from renal failure (9,10). Third, in simple starvation fats are preferentially lost and there is preservation of lean body mass. In cachexia, lean tissues are wasted and fat stores are relatively underutilized (11). Finally, the abnormalities in malnutrition can usually be overcome simply by supplying more food or...

Anorexia and cachexia

The etiology of anorexia in cachexic states is not well understood. CKD patients with anorexia regain appetite soon after starting dialysis treatment, presumably because of removal of one or more toxic factors that suppress appetite. Fractions in the middle molecular weight range isolated from normal urine and uremic plasma ultrafiltrate inhibited ingestive behavior in the rat. To investigate their site of action and specificity, rats were injected intraperitoneally, intravenously, or intracerebroventricularly with concentrated fractions of uremic plasma ultrafiltrate or normal urine and tested for ingestive and sexual behavior. An intraperitoneal injection of a urine fraction or a uremic plasma ultrafiltrate fraction inhibited carbohydrate intake by 76.3 and 45.9 , respectively, but an intravenous injection had no effect. An intracerebroventricular injection of urine middle molecular fraction or uremic plasma ultrafiltrate inhibited carbohydrate intake similarly. Injections of the...

Describe volume assessment and fluid management in patients with hepatorenal syndrome

Optimization of renal blood flow by correction of hypovolemia may prevent further renal injury during surgery in these patients. Volume assessment may be difficult since central venous pressures are often elevated despite relative hypovolemia from increased back pressure in the inferior vena cava from hepatic enlargement or scarring. A trial of volume expansion should be undertaken as the initial treatment of oliguria. Although immediate improvement occurs in more than one third of patients treated, HRS leads to progressive renal failure unless hepatic function improves.

Key Points Renal Function And Anesthesia y

Blood is drawn from the patient and flows toward a semipermeable membrane, the area of which is about 1 to 1.8 m2. Across the membrane is a dialysate with normal electrolyte concentrations. Electrolytes and waste products move down their concentration gradients. In addition, alkali within the dialysate moves into the patient. Negative pressure within the dialysate results in excess fluid removal. The duration of hemodialysis (HD) depends on flow rates and usually lasts from 4 to 6 hours. High flow rates are associated with rapid changes in electrolytes and volume status that are poorly tolerated by the patient. Usually these patients have dialysis three times weekly. The mortality associated with intermittent dialysis is 5 annually.

Eother motor diseases

Hypermetabolism of skeletal muscle leads to hydrolysis of adenosine triphosphate, glycolysis, glycogenolysis, uncoupled oxidative phosphorylation, increase in oxygen consumption, and heat production. The earliest symptom is often unexplained tachycardia. The sine qua non of MH is an unexplained rise in end-tidal CO2. Patients may demonstrate peculiar rigidity, even after nondepolarizing relaxants have been administered. If untreated, the patient develops numerous metabolic abnormalities, including metabolic acidosis, respiratory acidosis, hypoxemia, hyperthermia, rhabdomyolysis, hyperkalemia, hypercalcemia, hyperphosphatemia, elevations in creatine kinase, myoglobinuria, acute renal failure, cardiac dysrhythmias, and disseminated intravascular coagulation. Death is common if the problem is unrecognized and untreated. Data from the North American Malignant Hyperthermia Registry (NAMHR) have determined a rate of cardiac arrest of 2.7 and of death 1.4 . Interestingy, although the malady...

Leptin and ghrelin in cachexia

Leptin is cleared from the circulation primarily by the kidneys (50). Leptin levels are significantly increased in dialysis patients, even after correction for body mass index. The percentage of body fat was strongly correlated with leptin levels in these patients. However, the ratio of leptin levels to body fat is significantly greater for dialysis patients than for control subjects. Increased leptin levels are associated with markers of poor nutritional status, such as low serum albumin and high protein catabolic rate in dialysis patients. In children with CKD, leptin levels increase with declining renal function, presumably by reduced renal clearance. Leptin levels are inappropriately elevated in these children in relation to the percentage of body fat and inversely correlate with dietary nutrient intake. Thus leptin may be an important factor in the pathogenesis of anorexia and cachexia in CKD (51). Furthermore, serum leptin concentrations correlate with plasma insulin...

Signs and Symptoms of Other Organ Specific Reactions

Type II immune reactions (see Table 2) to drugs such as p-lactam antibiotics may result in a hemolytic anemia, usually 7 d after beginning therapy. Quinine, quinidine, and heparin have been involved in immune thrombocytopenic-type reactions. Hepatitis has been shown to occur with several drugs, including sulfonamides, phenytoin, and halothane. Methicillin as well as sulfonamides have been involved in producing interstitial nephritis in rare patients. Phenytoin and gold have been involved in reactions characterized by systemic eosinophilia and pneumonitis. The Churg-Strauss syndrome, a systemic eosinophilic granulomatosis and vasculitic process involving asthmatics, has been reported in increasing numbers of patients receiving leukotriene antagonists, glucocorticosteroids, and macrolide antibiotics, although there may be no causal relationship.

Complications of Hypothermia

The clinical use of induced hypothermia must be undertaken with its potential adverse effects in mind. Although no single complication was reported to be statistically significant over controls in the two trials, the potential risk of harm remains real. The HACA study defined complications to be any of the following bleeding of any severity, pneumonia, sepsis, pancreatitis, renal failure, pulmonary edema, seizures, arrhythmias, and pressure sores (8). The proportion of patients reported with complications in the HACA study is provided in Figure 1. Although numerous patients were reported to have complications from therapy, the proportion of patients did not differ significantly between the two groups, with 93 of 132 patients in the normothermia group (70 ) and 98 of 135 in the hypothermia group (73 p 0.70). The total number of complications was not significantly higher in the hypothermia group than in the normothermia group (p 0.09).

How is renal function affected

Renal blood flow and glomerular filtration diminish immediately, activating the renin-angiotensin-aldosterone system. Antidiuretic hormone is released, resulting in retention of sodium and water and loss of potassium, calcium, and magnesium. The incidence of acute renal failure in burned patients varies from 0.5 to 38 , depending primarily on the severity of the burn. The associated mortality rate is very high (77 to 100 ). Hemoglobinuria secondary to hemolysis and myoglobinuria secondary to muscle necrosis can lead to acute tubular necrosis and acute renal failure.

Mechanisms Linking Stiffness and Cholesterol

Systemic and local inflammation may lead to arterial stiffening by a variety of different mechanisms. Cytokines lead to increased expression of a number of inducible enzymes that may damage the structural components of the arterial wall. One enzyme of particular interest is matrix metalloproteinase-9 (MMP-9), which is a gelatinase capable of digesting arterial elastin - the main 'elastic element' of the large arteries. We have recently demonstrated a positive relationship between serum MMP-9 levels and aortic pulse wave velocity in a large cohort of apparently healthy subjects 41 . A pro-inflammatory environment also leads to an influx of inflammatory cells into the arterial wall. This in itself may lead to arterial stiffening possibly due to changes in the ground substance, secretion of destructive enzymes such as MMP-9 and remodelling of the wall. An interesting novel hypothesis is that inflammation, and inflammatory lipids in particular, may promote deposition of calcium within the...

Cytokine Measurements in Disease

Measurement of sIL-2R may be a more sensitive indicator of impending rejection than IL-2, although recent publications suggest that the predictive value of isolated results does not exceed that of creatinine. Levels are increased in chronic renal failure, bacterial and viral infection, and treatment with ATT or OKT3 cells (Yll). Malcus et al. (M6) found that serum creatinine and sIL-2R rose over the course of 5 days prior to a rejection episode. Increased sIL-2R in plasma had a sensitivity of 73 and a specificity of 87 for acute rejection, whereas creatinine showed a sensitivity of 70 and a specificity of 84 . A number of authors (D22, Nil, S52) have found that it is possible to distinguish viral infection and cyclo-

Artificial kidney machine

Kolff (1944) invented the artificial kidney, hemodialyzer, that has for many years supported the lives of thousands of kidney failure patients and also saved many lives from fatal accidental or suicidal poisoning. Unfortunately, only a small fraction of the world's patients can benefit from this treatment due to the high costs of the machine and treatment. In accidental or suicidal poisoning, in addition to the costs of the machine there are additional factors preventing its more common uses. For example, in many centers, especially the smaller ones, a hemodialyzer is not readily available. Furthermore, there are problems related to the length of treatment required, the possible fluctuation in extracorporeal blood volume and the specialized personnel required.

Vascular Blood Flow

Abnormalities in hemodynamics have been clearly documented to precede diabetic nephropathy (51,52). Elevated renal glomerular filtration rate (GFR) and modest increases in renal blood flow are characteristic findings in insulin-dependent diabetes mellitus (IDDM) patients (51,52) and experimental diabetic animals (53). Diabetic glomerular hyperfiltration is likely to be the result of hyperglycemia-induced decreases in arteriolar resistance, especially at the level of afferent arterioles (54,55), resulting in an elevation of glomerular filtration pressure. Multiple mechanisms have been proposed to explain the increases in GFR and glomerular filtration pressure, including an enhanced activity of angiotensin (56) and culturation in prostinoid productions (57-59). It is possible that the activation of DAG-PKC may also play a role in the enhancement of angiotensin actions because angiotensin mediates some of its activity by the activation of the DAG-PKC pathway (57). In addition, increases...

Vascular Permeability and Neovascularization

In the kidney, the expression of transforming growth factor-P (TGF-P) has been shown to be increased in the glomeruli of diabetic patients and experimental animals. Similar increases of TGF-p have also been reported in cultured mesangial cells exposed to high glucose levels (9). Because TGF-P can directly cause the overexpression of extracellular matrix, PKC inhibitors have been shown both to inhibit TGF-P expression by hyperglycemia and to prevent the mesangial expansion observed in diabetic nephropathy (7,9,11).

Permeability and transport characteristics

An artificial cell membrane has an ultrathin membrane of less than 0.05 micron as compared to the 2.0 micron thickness of the dialysis membrane. Furthermore, the small size of artificial cells means that 30 ml of artificial cells can have a total surface membrane area of 2 m2 as compared to the 1 to 2 m2 of a whole dialysis machine (Table 1, Fig. 10.1). This means that 30ml of artificial cells can have a theoretical mass transfer that is 100 to 200 times that of a whole artificial kidney machine (Chang, 1966, 1972a) (Table 1).

Experimental analysis

An experimental study of typical artificial cells has shown that the equivalent pore radius is 18 A (Chang, 1965, 1972a). This means that the membrane would be permeable not only to the smaller waste metabolites but also to the middle molecules in the 100025,000 molecular weight range. A detailed analysis of the rate of movement of different molecules has also been carried out (Chang and Poznansky, 1968a) (Table 2). These results show that metabolites normally present in the body can equilibrate very rapidly across the artificial cell membranes. This being the case, 30 ml of artificial cells retained in a shunt perfused by circulating blood will have a mass transfer equivalent to that of a whole artificial kidney machine (Chang, 1966) (Figs. 10.1 and 10.2). However, in the case of the artificial kidney machine, once solutes cross the membrane they are washed away by 100-200 liters of dialysis fluid. For artificial cells with a total internal volume of 30 ml, within a very short time,...

Selective PKCJ Isoform Inhibition

Recently, we reported that increases in albuminuria and abnormal retinal and renal hemodynamics in diabetic rats can be ameliorated by an orally available PKCP isoform selective inhibitor, LY333531. These physiological changes are concomitant with the inhibition of diabetes-induced PKC activation in retina and renal glomeruli (19). LY333531 prevented the overexpression of TGF-p, al(IV) collagen, and fibronectin in renal glomeruli of diabetic rats (33). These results suggested that activation of PKCp isoforms are involved in the development of some of the early abnormalities of diabetic vascular complications. PKC inhibitors could also mediate their effect by the inhibition of angiotensin actions. Angiotensin action appears to be increased because angiotensin-converting enzyme inhibitors have been shown to delay the progression of nephropathy (107). However, long-term studies are needed to clarify the usefulness of LY333531 to prevent the chronic pathological changes of diabetic...

APL and Transplantation

The greatest risk is found in the first 6 months after transplantation. For some patients, however, the hypercoagulable state persists throughout life, and thrombotic loss of the transplanted organ can occur years after transplantation surgery. Peritoneal dialysis in patients awaiting renal transplantation appears to be at utmost risk.

Why do some patients with MS become unable to urinate when they have to urinate all day and night

Treatment of bladder dysfunction is usually directed at relieving symptoms and reducing the risk of infection. Ditropan and other anticholinergic drugs are the mainstay of the treatment of urinary frequency and urgency. Unfortunately, these drugs tend to produce dryness of the mouth. Often, patients prefer to use the drugs only at night to reduce wakening and risk of incontinence. These drugs can be useful when patients with urinary frequency and urgency have to leave their homes. Urinary catheterization is sometimes necessary to achieve bladder emptying and can help prevent recurrent bladder infections and complicating kidney damage. If catheterization is recommended, it should

Incidence and Clinical Signs

A progressive and symptomless rise in WBC counts is frequently seen with ATRA treatment, but our group 26, 33 reported in some cases a rapid rise of WBC counts associated with cardiopulmonary and renal failure. Frankel et al. (1992) 34 then precisely described clinical symptoms of this ATRA syndrome, and several large series of cases of this syndrome have been published 44, 108 . Clinical signs of ATRA syndrome combine fever, respiratory distress, weight gain, lower extremity edema, pleural or pericardial effusions, hypotension, and sometimes renal failure. These signs are preceded by increasing WBC counts in the majority of case, but some patients develop symptoms at normal WBC counts 69 . Of note is that some cases of ATRA syndromecan occuruponrecoveryfromaplasia in patients whohavereceived early CT and are still receiving ATRA 44 .

Complications Of Aortic Surgery

Acute renal failure complicating aortic aneurysm repair is associated with a greater than 50 mortality. Two principal causes are nephrotoxic agents (such as radiographic contrast agents or perioperative antibiotics) and ischemic injury. The latter is more common, and is typically characterized by oliguria, a rapid rise in the creatinine level, and electrolyte imbalance. Etiologies of ischemic injury include hypovolemia, prolonged renal artery clamp time, and atheroembolization (typically from injudicious use of the aortic clamp on a diseased aorta, with subsequent extrusion of atheromatous debris into the renal orifices). In rare instances, and particularly in surgery for large iliac artery aneurysms and redo aortic surgery, ureteral injury may occur, because of its location anterior to the iliac vessels (6).

Clinical Manifestations

As previously discussed, bacteremia may indicate the presence of a focus of disease, such as intravascular infection, pneumonia, or liver abscess, or it may merely represent transient release of bacteria into the bloodstream. Septicemia or sepsis indicates a situation in which bacteria or their products (toxins) are causing harm to the host. Unfortunately, clinicians often use the terms bacteremia and septicemia interchangeably. Signs and symptoms of septicemia may include fever or hypothermia (low body temperature), chills, hyperventilation (abnormally increased breathing that leads to excess loss of carbon dioxide from the body) and subsequent respiratory alkalosis (condition caused by the loss of acid leading to an increase in pH), skin lesions, change in mental status, and diarrhea. More serious manifestations include hypotension or shock, DIC, and major organ system failure. The syndrome, known as septic shock, characterized by fever, acute respiratory distress, shock, renal...

Pathological Changes In The Pharmacokinetics

The elimination of biguanides is correlated with renal function, hence the elimination of metformin follows creatinine clearance. For buformin, the elimination in mild renal failure is unchanged (Held et al., 1970). The elimination half-life of metformin increases with renal failure at a creatinine clearance of 20-48 ml min-1 it is increased to about 5 h because of a decrease in metformin clearance from 450 ml min-1 to only 88 ml min-1 (Sirtori et al., 1978). Hydroxylation of phenformin is influenced by the genetic polymorphism of the mono-oxygenase. With high circulating amounts of phenformin its metabolism is reduced (Bosisio et al., 1981). Both pathological effects on liver and kidney account for an accumulation of the drug and a related risk of lactacidosis. Acute poisoning with metformin calls for intensive supportive therapy. Lactacidosis may require treatment with sodium bicarbonate or furosemide, a combination of insulin and glucose or peritoneal dialysis or haemodialysis...

The Common Cold and the

The flu is a viral infection of the nose, throat, and lungs. It is usually mild in young and middle-aged adults but can be life-threatening in older people and people who have a chronic illness such as heart disease, emphysema, asthma, bronchitis, kidney disease, or diabetes. The flu also can lead to more serious, potentially life-threatening infections such as pneumonia (see page 250). Because pneumonia is one of the five leading causes of death among older people, it is important for older people to take steps to prevent the flu. The best preventive measure is a flu shot (see page 93), given each fall at the beginning of the flu season. A pneumonia shot (see page 252) is another preventive measure available for older people and people who have a chronic illness the pneumonia shot is given only once.

Bloodstream Infections Endocarditis

Pathogens associated with this disease, primarily S. aureus and enterococci, antibiotic regimens of short duration are still possible for selected patients with susceptible isolates. Adjunctive diagnostic aids such as transesophageal echocar-diography often permit earlier diagnosis of endocarditis, thereby increasing the possibility that short-course antibiotic therapy may be applied successfully. Two studies in viridans group streptococcal endocarditis demonstrated that, in selected patients, a 2-week regimen of either penicillin or ceftriaxone combined with an aminoglycoside yielded cure rates comparable to those seen when penicillin or ceftriaxone is given for 4 weeks (108,109). Additional studies of viridans strepto-coccal endocarditis showed that 2 weeks of therapy with once-daily ceftriaxone combined with either netilmicin or gentamicin given once daily was equivalent to 2 weeks of penicillin given with an aminoglycoside in divided doses (109,110). This 2-week regimen is...

Miniaturized Artificial Kidney Based on Hemoperfusion Ultrafiltration

A third approach is to construct a truly miniaturized artificial kidney based on hemoperfusion in series with small ultrafiltrator (Chang etal., 1975, 1979a, 1977b, Chang, 1976c) (Fig. 10.9). In clinical studies, a small Amicon ultratiltrator was used (Fig. 10.11). Hydrostatic pressure from the blood pump alone gave effective ultrafiltration. Dialysis fluid is not required, the ultrafiltrate flowing directly into a measuring cylinder.

How do changes in renal function affect anesthetic management

Decreases in GFR and renal blood flow lead to an increased risk for intraoperative fluid and electrolyte disturbances and an increased risk of acute renal failure. Intravascular volume must be replaced to maintain urine output at 0.5 ml kg hr or more. Moreover, many medications used intraoperatively and their metabolites that depend on renal clearance have prolonged elimination half-lives and longer durations of action. An example of these would be morphine and its metabolites, which, if not used with renal function in mind, can result in prolonged respiratory depression.

Management options Preexisting disease

Standard anaesthetic and analgesic techniques are suitable, given the above considerations. Renal function and blood pressure should be closely monitored during pregnancy. Discussion with the renal physicians and obstetricians is required regarding the timing of dialysis and method of delivery. Any arteriovenous shunt should be noted and steps taken to protect it during labour and or delivery. Drugs excreted renally should be used with caution, and those known to impair renal blood flow or function (especially NSAIDs) should be avoided.

Besides anaphylaxis what is a major risk with regard to contrast media

Renal failure is a well-documented, severe reaction long associated with soluble contrast media, particularly in patients with disorders predisposing them to renal failure such as renal disease, diabetes, jaundice, multiple myeloma, hypovolemia and diminished renal blood flow from severe cardiac or vascular disease. Adequate hydration is absolutely necessary to decrease the impact on the patient. Furthermore, the necessity of the contrast study should always be considered. Particular caution must be used in patients taking metformin since renal failure in these patients can lead to severe, life-threatening lactic acidosis. For this reason it is recommended that metformin be held for 48 hours before performing any radiologic study in which contrast media are to be used.

Recovery of PEG and Salt

Aqueous two-phase systems composed of PEG and a salt such as phosphate have been applied in large scale. Therefore, the recovery of the phase components can be of economical interest. Possible ways to recover the salt and PEG from bottom and top phase, respectively, of a PEG-phosphate system are presented below. The phosphate is recovered from the bottom phase by crystallization at low temperature. The top phase is desalted by dialysis or ultrafiltration and the resulting PEG solution is then, if necessary, concentrated by evaporation. 4. Place the upper phase in a dialysis bag with a capacity of at least 150 mL. Put the bag in 5 L of water which is slowly stirred. After 4 h change to fresh water and continue the dialysis for another 4 h (see Note 15). 5. Concentrate the PEG solution by letting the dialysis bag hang free in a strong air steam, e.g., in a well-ventilated fume hood, for 2 h or until the volume does not decrease any longer.

Factors in Opioid Selection

Pharmacokinetic studies of meperidine, pentazocine and propoxyphene have revealed that liver disease may decrease the clearance and increase the bioavailability and half-lives of these drugs. These changes may eventuate in plasma concentrations higher than normal. Although mild or moderate hepatic impairment has only minor impact on morphine clearance, advanced disease may be associated with reduced elimination. Patients with renal impairment may accumulate the active metabolites of propoxyphene (norpropoxyphene), meperidine (normeperidine) and morphine (morphine-6-glucuronide). In the setting of renal failure or unstable renal function, titration of these drugs requires caution and close monitoring. If adverse effects appear, a switch to an alternative opioid is often recommended.

Symptoms And Signs

In HFRS acute fever over a period of 3-6 days is followed by a hypotensive phase which can develop into classical shock symptoms. An oliguric phase, when extensive haemorrhaging may occur, is then followed by a diuretic phase. Depending on the supportive therapy, mortality ranges from 5 to 20 . In the milder forms of the disease such as NE acute high fever, often with headache and malaise, is followed by abdominal lumbar pain and renal involvement. Elevated levels of liver enzymes and increased SR and CRP are often observed. There is less tendency for haemorrhages, but in the more serious cases renal failure can develop that may require dialysis. The mortality is 50 . Differential diagnosis. The symptoms of HPS may resemble influenza, legionella, pneumonia or respiratory syncytial virus infections in young children. HFRS symptoms can resemble leptospirosis, rickettsiosis or dengue fever. NE is often tentatively diagnosed as acute poststreptococcal glomerular nephritis,...

Interventions Directed At Dros

The importance of good practice and consistent application of evidence-based guidelines, as discussed above, cannot be overemphasized when discussing the prevention and control of DROs. In 2003, the CDC launched its Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. General principles were presented in the form of a twelve step program to prevent infections and diminish opportunities for development of resistance in the hospitalized adult population (Fig. 5). This ambitious program includes guidance and resources for preventing resistance in dialysis patients, long-term care residents, hospitalized children, and surgical patients.

Risk Assessment for MRSA at Hospital Admission

According to Friedman and co-workers (2002), the health care-associated infected patient was defined as a subject who fulfilled any of the following criteria intravenous therapy within 30 days specialized nursing at home attendance to a hospital or outpatient clinic for dialysis previous hospitalization for at least 2 days within 90 days residency in a nursing home or long term care facility. This separate category of infection, differentiated from the community- and nosocomial-acquired infections, was justified since these infections were similar to nosocomial infections in terms of frequency of various comorbidity, source of infection, pathogens, susceptibility patterns, and mortality rate. A significant impact for physicians of this new categorization of infections would be on the choice of empirical therapy for infections diagnosed at hospital admission and for infection-control policies. In a case-control study including 108 patients with true CoNS bacteremia diagnosed within 48...

Risk Assessment for MRSA During Hospitalization

A systematic review of the English language literature was performed to determine the overall benefit of mupirocin therapy in reducing the rate of S. aureus infection among high-risk patients requiring chronic hemodialysis (HD) or peritoneal dialysis (PD) (Tacconelli et al. 2003a). A total of 10 clinical studies were evaluated with 1212 patients in the treatment group and 1233 in the control group. Overall, mupirocin therapy reduced the risk of developing an S. aureus infection by 68 among all dialysis patients (Figure 14.2). In a subgroup analysis of different dialysis modalities, the risk reduction was 80 for HD and 63 for PD patients, respectively. Analysis of different types of S. aureus infections, including exit-site infection, peritonitis, and bacteremia, demonstrated significant reductions among patients receiving mupirocin therapy. Figure 14.2. Risk ratio and 95 CI of S. aureus infections versus placebo or no prophylaxis in clinical trials for prevention of S. aureus...

Algorithm For Treatment Of Lower Intestinal Bleeding

Our current approach to lower GI hemorrhage is outlined in Fig. 1. Patients undergo initial assessments of fluid status and comorbidities for surgery. They undergo resuscitation with fluids and blood transfusions, as required, and are prepared for surgical therapy should this become necessary. Hemoglobin and hematocrit, electrolytes, coagulation profile, liver function tests, and kidney function tests are performed. Adequate resuscitation and correction of fluid and electrolyte balance are important not only for future surgical intervention, but also for diagnostic tests, which may require intravenous contrast and or sedation.

Functions of Aldose Reductase

The participation of aldose reductase in the development of diabetic complications is assumed to be based on a triad of tissue effects sorbitol accumulation, myo-inositol depletion and decreased activity of Na K-ATPase. These alterations, first described in the ocular lens, also occur in other tissues like the renal glomerulus, peripheral nerves and the retina. The enhanced activity of aldose reductase may therefore be involved in the development of diabetic neuropathy, diabetic retinopathy and diabetic nephropathy, although it may not be the sole factor underlying these complications.

Preservation Strategies

The sudden arrival of clinical kidney transplantation in 1962-1963 was so unexpected that little collateral research or other formal preparation had been made to preserve organs.77 Although kidneys were successfully transplanted in the pioneer identical twin cases despite protracted periods of warm ischemia, the maturation of clinical transplantation could not proceed without effective organ conservation.77 This conservation was at first accomplished by total body hypothermia of living volunteer kidney donors,78 using methods developed by cardiac surgeons for open heart operations.79 In the experimental laboratory, Lillehei et al. simply immersed the excised intestine in iced saline before its autotransplantation,80 a method also used by Shumway when developing experimental and clinical heart and heart-lung transplantation.81-83 Thus the principle of hypothermia was understood at an early time, although not efficiently applied. The first major innovation in hypothermia was in the...

And Bonnie ChingHa Kwan

The prevalence of chronic kidney disease is growing worldwide. Epidemiological data suggest there is a causal relationship with adiposity. There are also laboratory research and clinical studies showing that adiposity is involved in the development and the progression of kidney disease itself. Mechanisms include adaptation to increased body mass, activation of sympathetic nervous and renin-angiotensin systems, effects of insulin resistance, lipid overload, and release of adipokines. Kidney disease may also affect the association of adiposity with cardiovascular outcomes. In this chapter, the interactions of adiposity and kidney disease and their effects on clinical outcomes are examined. Key Words Adipose tissue obesity kidney disease insulin resistance cardiovascular outcomes.

Action of Aldose Reductase Inhibitors

The presence of aldose reductase in glomerular epithelial and mesangial cells (Corder et al., 1977) and its increased activity in hyperglycaemia (Kikkawa et al., 1987) suggest participation of the polyol cycle in the development of diabetic nephropathy. This is supported by the fact that the above-mentioned

Tissue binding approaches

Demonstration that tissue partitioning can be determined in vitro was made by comparing tissue plasma ratios generated using equilibrium dialysis to ex vivo tissue partitioning data in rats 24 . However, it was noted that this method tended to underestimate partitioning of bases into tissues that are rich in lyso-somes, such as lung. Using rabbit muscle homogenates, Schuhmann et al. 25 demonstrated a strong correlation between free VD and total free ratios in muscle homogenate for 9-11 drugs spanning a range of chemical properties. Muscle homogenate binding was determined using ultrafiltration, and the selection of this tissue type rather than others was made on the basis that muscle mass comprises the vast majority of body mass. There are some practical challenges in measuring binding to tissue homogenates including the fact that data need to be gathered in dilutions of homogenates followed by extrapolation to binding values that would be observed in undiluted material....

Definition and Mechanisms of Oxidative Stress

Oxidative stress has been defined as the steady state level of reactive oxygen or oxygen free radicals in a biologic system , or a shift in the pro-oxidant - antioxidant balance in the pro-oxidant direction. It is implicated in diabetes, atherosclerosis, renal failure (which is often associated with diabetes), and many other disease processes, as well as normal aging.39,40 Exposure to oxidative stress is an unavoidable part of life. Reactive oxygen species (ROS) (such as in Table 7.3), normal byproducts of many enzyme reactions, are always being formed in vivo, and play a vital role in host defense, such as in the phagocytosis of foreign organisms and substances, and in modulation of hormones, growth factors, and cytokine

Toxic and Side Effects

The absence of side effects in a 1-year clinical trial with ponalrestat was reported by Ziegler et al. (1991), but in this study no therapeutic efficacy was seen A 6-month study with ponalrestat to elucidate the effects on kidney function was also free from side effects (Pedersen et al., 1991). Dizziness, possibly based on a blood pressure-lowering effect, was reported for tolrestat. In addition, hepatocyte lesion accompanied by changes in hepatic parameters within the first 3-6 months of treatment was seen (Ryder et al., 1987). For sorbinil, significant hypersensitivity reactions have been reported (Sarges, 1989).

Surveillance Cultures

Most routine environmental cultures in the hospital are now considered to be of little use and should not be performed unless there are specific epidemiologic reasons. The decision to perform these cultures should be determined by the microbiologist, infection control practitioner, and hospital epidemiologist. However, certain surveillance cultures are still performed as a method of limiting outbreaks. These include culturing cooling towers or hot water sources for Legionella spp., culture of water and dialysis fluids for hemodialysis as well as endotoxin testing, culture of blood bank products, especially platelets, and surveillance cultures for vancomycin-resistant enterococci, methidllin (or oxacillin)-resistant S. aureus and vancomycin-resistant S. aureus using rectal and oropharyngeal swabs. Physical rehabilitation centers often culture hydrotherapy equipment (whirlpools) quarterly to verify that cleaning methods are adequate some centers culture more frequentiy.

Shunt Placement Open vs Percutaneous

Peritoneal dialysis catheters can be placed via an open or percutaneous method. General contraindications to catheter placement include abdominal wall hernias or infections, active inflammatory bowel disease, diffuse intraabdominal adhesions, respiratory insufficiency, and gastrointestinal stomas (11). The Tenkhoff catheter, which is made of Silastic and equipped with two Dacron cuffs, is the most commonly used PD catheter. Placement by the open method is done in the operating room under general or local anesthesia. A small infraumbilical midline incision is used to better allow the catheter to reach into the dependent pelvis. (A supraumbilical incision can be utilized in patients with previous lower abdominal surgery to avoid adhesions.) The abdominal wall fascia is opened, a purse-string suture placed into the peritoneum, and a catheter guide used to direct the catheter toward the pelvis. The purse-string suture is tied down, securing the catheter in position with a watertight seal...

Is Oxidative Stress per se Increased in Diabetes and Vascular Damage

Glycation of LDL27,86,87 correlates with other measures of glycemia and increases matrix binding in vitro97,98 such that it may be more likely to be retained in the arterial subendothelial space in vivo, where it is susceptible to further modification, such as oxidation. It is controversial as to whether LDL glycation increases susceptibility to oxidation. Relative to healthy controls, Tsai et al. demonstrated increased susceptibility of LDL from Type 1 diabetic patients with poor glycemic control to in vitro (copper-induced) oxidation.99 However, we did not find any difference in susceptibility to copper oxidation of LDL from healthy controls and complication-free Type 1 diabetic subjects in moderate glycemic control.100 Nor did we find greater susceptibility to copper oxidation of in vivo glycated LDL fractions from Type 1 diabetic subjects than their relatively non-glycated LDL fractions, nor were there significant differences in the lipid soluble antioxidant content, CML,...

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