ABSTRACT
Post-dilution on-line hemodiafiltration (OL-HDF) is the most efficient infusion mode to obtain maximum clearances of uremic toxins, with a recommended manual infusion flow (Qi) of 25% of the blood flow with the main limitation that causes alarms by hemoconcentration throughout the session. Recent technical advances allow automatic prescription of Qi if hematocrit and total protein (TP) values are specified. As these analytical results are not possible to obtain in each dialysis session, a practical way to prescribe Qi is to make an automatic prescription adjusting the hematocrit and total protein values at the beginning of the session to obtain the manual prescription required and we will call it automatic-manual prescription. The aim of this study was to compare manual Qi with automatic-manual Qi in postdilution OL-HDF. 30 patients (16 men and 14 women), 59.9 +/- 15 years old, in hemodialysis program for 50.1 +/- 67 months were included. Every patient underwent four OL-HDF sessions, two with manual Qi (4008-S and 5008 monitors) and two with automatic-manual Qi (A-M), one with the same Qi and one with manual Qi +20 (A-M+20). The same usual dialysis parameters were maintained: helixone dialyzer, dialysis time of 266 +/- 39 minutes, blood flow of 420 +/- 36. Recirculation, Kt and intradialysis alarms were measured at each session. No significant differences in the fistula recirculation or dialysis dose measured using Kt. Total infusion volume was 24.9 +/- 4 (4008 S), 23.4 +/- 4 L (5008) with manual Qi, 23.6 +/- 4 L (A-M) Qi (NS) and 25.8 +/- 5 L (A-M+20). Only 14% of patients had no incidents. The number of alarms was significantly higher with manual prescription 55 alarms with 4008 and 40 with 5008 vs. AM (11) p < 0.01) and A-M+20 (16 alarms) We concluded that automatic-manual Qi is a practical way for post-dilutional OL-HDF prescription where the same efficiency and total reinfusion volume with an important reduction of intradialysis alarms are obtained, allowing to rise Qi by 20% without increasing intradialysis alarms.
Subject(s)
Hemodiafiltration/methods , Kidney Failure, Chronic/therapy , Prescriptions , Adult , Aged , Algorithms , Automation , Blood Proteins/analysis , Clinical Alarms , Female , Hematocrit , Hemodiafiltration/instrumentation , Humans , Male , Middle Aged , Online Systems , Pressure , Rheology , Urea/analysisABSTRACT
The Airway Division of the Catalan Society of Anaesthesiology, Intensive Care and Pain Management (SCARTD) presents its latest guidelines for the evaluation and management of the difficult airway. This update includes the technical advances and changes observed in clinical practice since publication of the first edition of the guidelines in 2008. The recommendations were defined by a consensus of experts from the 19 participating hospitals, and were adapted from 5 recently published international guidelines following an in-depth analysis and systematic comparison of their recommendations. The final document was sent to the members of SCARTD for evaluation, and was reviewed by 11 independent experts. The recommendations, therefore, are supported by the latest scientific evidence and endorsed by professionals in the field. This edition develops the definition of the difficult airway, including all airway management techniques, and places emphasis on evaluating and classifying the airway into 3 categories according to the anticipated degree of difficulty and additional safety considerations in order to plan the management strategy. Pre-management planning, in terms of preparing patients and resources and optimising communication and interaction between all professionals involved, plays a pivotal role in all the scenarios addressed. The guidelines reflect the increased presence of video laryngoscopes and second-generation devices in our setting, and promotes their routine use in intubation and their prompt use in cases of unanticipated difficult airway. They also address the increased use of ultrasound imaging as an aid to evaluation and decision-making. New scenarios have also been included, such as the risk of bronchoaspiration and difficult extubation Finally, the document outlines the training and continuing professional development programmes required to guarantee effective and safe implementation of the guidelines.
Subject(s)
Airway Management/standards , Airway Management/methods , Anesthesia , Critical Care , Decision Trees , Humans , Pain ManagementABSTRACT
Renal tumors can be associated with a thrombus that affects the renal vein and even the inferior vena cava. Radical surgery may require a 2-phase approach involving different anesthetic techniques: an abdominal approach for removal of the kidney and a thoracic approach for extraction of the thrombus, with extracorporeal circulation and in some cases cessation of blood circulation. We present 2 cases in which nephrectomy and thrombectomy were carried out with the support of extracorporeal circulation. The thrombus was in the renal vein and the inferior vena cava, extending to the outlet to the right atrium in both cases. In 1 case a portion reached the bifurcation of the pulmonary artery. The operation was performed under hypothermia to reduce circulation and did not require aortic clamping, cardioplegia, or cessation of blood flow.
Subject(s)
Anesthesia, Inhalation/methods , Carcinoma, Renal Cell/surgery , Hypothermia, Induced , Kidney Neoplasms/surgery , Nephrectomy/methods , Renal Veins/surgery , Thrombectomy/methods , Thrombosis/surgery , Vena Cava, Inferior/surgery , Wilms Tumor/surgery , Adult , Antineoplastic Combined Chemotherapy Protocols/therapeutic use , Blood Loss, Surgical , Carcinoma, Renal Cell/pathology , Combined Modality Therapy , Dactinomycin/administration & dosage , Doxorubicin/administration & dosage , Extracorporeal Circulation , Fatal Outcome , Female , Hemostatic Techniques , Humans , Kidney Neoplasms/drug therapy , Kidney Neoplasms/pathology , Male , Middle Aged , Multiple Organ Failure/etiology , Neoplasm Invasiveness , Postoperative Hemorrhage/drug therapy , Pulmonary Embolism/etiology , Renal Veins/pathology , Thrombosis/etiology , Vena Cava, Inferior/pathology , Vincristine/administration & dosage , Wilms Tumor/drug therapy , Wilms Tumor/pathologyABSTRACT
On the basis of previously described X-ray studies of an enzyme/aza-dipeptide complex,8 aza-dipeptide analogues carrying N-(bis-aryl-methyl) substituents on the (hydroxethyl)hydrazine moiety have been designed and synthesized as HIV-1 protease inhibitors. By using either equally (12) or orthogonally (13) protected dipeptide isosteres, symmetrically and asymmetrically acylated aza-dipeptides can be synthesized. This approach led to the discovery of very potent inhibitors with antiviral activities (ED50) in the subnanomolar range. Acylation of the (hydroxethyl)hydrazine dipeptide isostere with the L-tert-leucine derivative 29 increased the oral bioavailability significantly when compared to the corresponding L-valine or L-isoleucine derivatives. The bis(L-tert-leucine) derivatives CGP 75355, CGP 73547, CGP 75136, and CGP 75176 combine excellent antiviral activity with high blood concentration after oral administration. Furthermore, they show no cross-resistance with saquinavir-resistant strains and maintain activity against indinavir-resistant ones. Consequently they qualify for further profiling as potential clinical candidates.
Subject(s)
Anti-HIV Agents , Aza Compounds , Dipeptides , HIV Protease Inhibitors , HIV Protease/metabolism , Administration, Oral , Animals , Anti-HIV Agents/administration & dosage , Anti-HIV Agents/chemical synthesis , Anti-HIV Agents/pharmacology , Aza Compounds/administration & dosage , Aza Compounds/chemical synthesis , Aza Compounds/pharmacology , Biological Availability , Dipeptides/administration & dosage , Dipeptides/chemical synthesis , Dipeptides/pharmacology , Drug Evaluation, Preclinical , Drug Resistance, Microbial , Female , HIV Protease Inhibitors/administration & dosage , HIV Protease Inhibitors/chemical synthesis , HIV Protease Inhibitors/pharmacology , HIV-1/drug effects , HIV-1/enzymology , HIV-1/physiology , Indinavir/pharmacology , Mice , Mice, Inbred BALB C , Saquinavir/pharmacology , Structure-Activity Relationship , Virus Replication/drug effectsABSTRACT
The sprouting of new blood vessels, or angiogenesis, is necessary for any solid tumor to grow large enough to cause life-threatening disease. Vascular endothelial growth factor (VEGF) is one of the key promoters of tumor induced angiogenesis. VEGF receptors, the tyrosine kinases Flt-1 and KDR, are expressed on vascular endothelial cells and initiate angiogenesis upon activation by VEGF. 1-Anilino-(4-pyridylmethyl)-phthalazines, such as CGP 79787D (or PTK787 / ZK222584), reversibly inhibit Flt-1 and KDR with IC(50) values < 0.1 microM. CGP 79787D also blocks the VEGF-induced receptor autophosphorylation in CHO cells ectopically expressing the KDR receptor (ED(50) = 34 nM). Modification of the 1-anilino moiety afforded derivatives with higher selectivity for the VEGF receptor tyrosine kinases Flt-1 and KDR compared to the related receptor tyrosine kinases PDGF-R and c-Kit. Since these 1-anilino-(4-pyridylmethyl)phthalazines are orally well absorbed, these compounds qualify for further profiling and as candidates for clinical evaluation.
Subject(s)
Angiogenesis Inhibitors/chemical synthesis , Aniline Compounds/chemical synthesis , Enzyme Inhibitors/chemical synthesis , Phthalazines/chemical synthesis , Pyridines , Receptor Protein-Tyrosine Kinases/antagonists & inhibitors , Receptors, Growth Factor/antagonists & inhibitors , Administration, Oral , Angiogenesis Inhibitors/chemistry , Angiogenesis Inhibitors/pharmacokinetics , Angiogenesis Inhibitors/pharmacology , Aniline Compounds/chemistry , Aniline Compounds/pharmacokinetics , Aniline Compounds/pharmacology , Animals , Biological Availability , CHO Cells , Cell Line , Cricetinae , Enzyme Inhibitors/chemistry , Enzyme Inhibitors/pharmacokinetics , Enzyme Inhibitors/pharmacology , Humans , Mice , Models, Molecular , Neoplasms/blood supply , Neovascularization, Pathologic , Phosphorylation , Phthalazines/chemistry , Phthalazines/pharmacokinetics , Phthalazines/pharmacology , Proto-Oncogene Proteins/antagonists & inhibitors , Receptor Protein-Tyrosine Kinases/genetics , Receptors, Growth Factor/genetics , Receptors, Vascular Endothelial Growth Factor , Structure-Activity Relationship , Transfection , Vascular Endothelial Growth Factor Receptor-1Subject(s)
Airway Obstruction/prevention & control , Anesthesiology/trends , Intraoperative Complications/prevention & control , Respiration, Artificial/methods , Aged , Airway Obstruction/epidemiology , Anesthesiology/methods , Contraindications , Equipment Design , Female , Fiber Optic Technology , Humans , Intubation, Intratracheal/instrumentation , Intubation, Intratracheal/methods , Laryngeal Masks , Laryngoscopy , Male , Middle Aged , Respiration, Artificial/instrumentation , Risk Factors , Societies, Medical , Video RecordingABSTRACT
Kidney involvement associated to lymphoma is a known phenomenon but frequently not characterized due to the low frequency with which biopsies are realized in these patients. Several histological patterns can co-exist and happen unnoticed without a biopsy. Parenchyma infiltration in kidney for lymphoma has been found in 34% (post-mortem) and 14% (pre-mortem) and have low incident of clinical manifestations. Other patterns of renal injury are associated to lymphoma and minimal changes disease is especially related with Hodgkin's lymphoma. Renal lesions associated to paraprotein in lymphoplasmacytic lymphoma are an exceptional association, in spite of in 20% of them, appear cryoglobulinemia. There are a few cases reported in the literature with different histological patterns: light-chain disease, amyloidosis, and immunotactoid glomerulopathy related with kidney injury in patients with lymphoma. A 39-year-old male presented an association among paraproteinemia, membrano-proliferative glomerulonephritis no hepatitis C virus related and lymphoplasmacytic lymphoma with renal infiltration. This case emphasized the variety of renal lesions that lymphomas could trigger and the value of the nephropathology in the diagnosis and outcome of the hematologic diseases with paraproteinemia.
Subject(s)
Cryoglobulinemia/etiology , Glomerulonephritis, Membranoproliferative/complications , Kidney/pathology , Waldenstrom Macroglobulinemia/complications , Adult , Antibodies, Monoclonal, Murine-Derived/therapeutic use , Biopsy , Disease Progression , Edema/etiology , Glomerulonephritis, Membranoproliferative/blood , Glomerulonephritis, Membranoproliferative/pathology , Hepatitis C , Humans , Male , Nephrotic Syndrome/etiology , Plasma Exchange , Proteinuria/etiology , Purpura/etiology , Rituximab , Vasculitis/etiology , Waldenstrom Macroglobulinemia/blood , Waldenstrom Macroglobulinemia/diagnosis , Waldenstrom Macroglobulinemia/drug therapy , Waldenstrom Macroglobulinemia/pathology , Waldenstrom Macroglobulinemia/therapyABSTRACT
INTRODUCTION: The aim of this study was to evaluate the experience of a renal transplantation unit in the management of human immunodeficiency virus (HIV)-infected patients with end-stage renal disease (ESRD). METHODS: A prospective study was performed between 2005 and 2010 among 23 patients with ESRD. RESULTS: In this study 83% of HIV-infected patients with ESRD were included on the waiting list for renal transplantation with 4 patients in a clinical evaluation phase. During the follow-up, 52% of waiting list patients (n = 11) received a renal transplant, and 1 patient underwent a simultaneous kidney-pancreas transplantation. Among the waiting list group we observed a significant later exclusion (43%; n = 3). Among the transplanted group there was a high but clinically inconsequential prevalence of acute tubular necrosis (36%; n = 4) and acute rejection episodes (36%; n = 4). The renal function showed a serum creatinine of 1.1 mg/dL at a follow-up of 24 + 12 months. All patients on the waiting list and after the transplantation are prescribed combined antiretroviral treatment (cART) with a low viral load <50 with CD4 >200. CONCLUSIONS: HIV-infected patients with ESRD should be considered to be candidates for renal transplantation if they meet the HIV inclusion criteria. Renal transplantation in adequately selected HIV-infected patients is a safe procedure with acceptable patient and graft survivals.
Subject(s)
HIV Infections/complications , Kidney Failure, Chronic/surgery , Kidney Transplantation , Waiting Lists , Adult , Anti-HIV Agents/therapeutic use , Biomarkers/blood , Creatinine/blood , Female , Graft Rejection/blood , Graft Rejection/immunology , Graft Survival , HIV Infections/diagnosis , HIV Infections/drug therapy , HIV Infections/mortality , Humans , Kidney Failure, Chronic/complications , Kidney Transplantation/adverse effects , Kidney Transplantation/immunology , Kidney Transplantation/mortality , Kidney Tubular Necrosis, Acute/etiology , Male , Middle Aged , Patient Selection , Prospective Studies , Spain , Survival Analysis , Survival Rate , Time Factors , Treatment Outcome , Waiting Lists/mortalitySubject(s)
Acute Kidney Injury/etiology , Calcium Oxalate/metabolism , Hyperoxaluria/etiology , Short Bowel Syndrome/complications , Aged , Bile Duct Neoplasms/surgery , Bile Ducts, Intrahepatic , Biliary Fistula/etiology , Calcium Oxalate/pharmacokinetics , Cardiac Output, High/etiology , Cholangiocarcinoma/surgery , Crystallization , Dietary Fats/pharmacokinetics , Drainage/adverse effects , Humans , Intestinal Absorption , Ischemia/etiology , Liver/blood supply , Male , Postoperative Complications , Proteinuria/etiology , Short Bowel Syndrome/metabolism , Surgical Wound Infection/etiology , Surgical Wound Infection/surgeryABSTRACT
BACKGROUND: Maintenance of airway patency and oxygenation are the main objectives of face-mask ventilation. Because the incidence of difficult mask ventilation (DMV) and the factors associated with it are not well known, we undertook this prospective study. METHODS: Difficult mask ventilation was defined as the inability of an unassisted anesthesiologist to maintain the measured oxygen saturation as measured by pulse oximetry > 92% or to prevent or reverse signs of inadequate ventilation during positive-pressure mask ventilation under general anesthesia. A univariate analysis was performed to identify potential factors predicting DMV, followed by a multivariate analysis, and odds ratio and 95% confidence interval were calculated. RESULTS: A total of 1,502 patients were prospectively included. DMV was reported in 75 patients (5%; 95% confidence interval, 3.9-6.1%), with one case of impossible ventilation. DMV was anticipated by the anesthesiologist in only 13 patients (17% of the DMV cases). Body mass index, age, macroglossia, beard, lack of teeth, history of snoring, increased Mallampati grade, and lower thyromental distance were identified in the univariate analysis as potential DMV risk factors. Using a multivariate analysis, five criteria were recognized as independent factors for a DMV (age older than 55 yr, body mass index > 26 kg/m2, beard, lack of teeth, history of snoring), the presence of two indicating high likelihood of DMV (sensitivity, 0.72; specificity, 0.73). CONCLUSION: In a general adult population, DMV was reported in 5% of the patients. A simple DMV risk score was established. Being able to more accurately predict DMV may improve the safety of airway management.
Subject(s)
Anesthesia, General/methods , Anesthesiology/methods , Intubation, Intratracheal , Laryngeal Masks , Adult , Body Mass Index , Female , Humans , Intraoperative Complications , Male , Middle Aged , Monitoring, Intraoperative , Multivariate Analysis , Positive-Pressure Respiration , Predictive Value of Tests , Prospective Studies , Risk FactorsABSTRACT
The ostracod species Eucypris virens exhibits geographical parthenogenesis, with rare sexual populations in southern Europe and widespread asexual populations elsewhere. DNA sequence data from the nuclear ITS1 and mitochondrial COI regions have been used to estimate genetic variabilities and reconstruct phylogenies. The observed divergence was exceptionally high, with intraspecific maxima of 10.3% (ITS1) and 20.9% (COI) among European lineages, levels reported for interspecific comparisons of other taxa. Phylogenetic reconstructions reveal multiple origins of asexual clones from sexual populations. However, we argue that such data can only provide a lower limit on the number of origins of asexual reproduction, and an upper limit on the age of asexual lineages. Congruence between gene trees for different loci can provide support for the inference of long-term apomictic reproduction. Nuclear and mitochondrial data differ in their placement of some asexual clones, possibly indicating that genetic exchange has taken place between sexual and asexual lineages. Such intraspecific hybridization is one route to combine the benefits of both reproductive modes, and it might explain how asexuality managed to persist in E. virens even in long, evolutionary terms.