Variable pharmacokinetics of extended interval tobramycin or gentamicin among critically ill patients undergoing continuous venovenous hemofiltration.

BACKGROUND/AIMS: Aminoglycosides are a major weapon against serious Gram-negative rod infections, yet aminoglycoside usage is limited by the risk of nephrotoxicity. The risk of toxicity is reduced by extended-interval dosing of aminoglycosides, defined as 5 - 7 mg/kg given intravenously in intervals of 24 hours or greater based on serum drug concentrations. In critically ill patients undergoing continuous venovenous hemofiltration, there are few published reports of the pharmacokinetics of extended-interval dosing of aminoglycosides. METHODS: We evaluated the pharmacokinetics of extended-interval dosing of gentamicin and tobramycin in 9 critically ill patients on continuous venovenous hemofiltration at Dartmouth-Hitchcock Medical Center between April 2007 and September 2011. RESULTS: Aminoglycoside elimination half-life values were highly variable (median 7 hours, range 3 - 26 hours) and did not correlate with total body weight or estimated creatinine clearance derived from the dose of continuous venovenous hemofiltration. Five of 9 patients cleared infection, but only 4 patients survived to hospital discharge, 2 of whom were dialysis-dependent. CONCLUSION: Extended interval aminoglycoside dosing during continuous venovenous hemofiltration yields unpredictable half-lives and drug levels among high-risk critically ill patients. Close monitoring of serum aminoglycoside levels is required.

Stercoral ulcer as a cause of lower gastrointestinal (LGI) bleeding in chronic hemodialysis patients.

Gastrointestinal (GI) bleeding is more common in patients with chronic kidney disease and is associated with higher mortality than in the general population. Stercoral ulceration of the colon is rarely reported in the nephrology literature. We observed 2 cases of stercoral ulcer presenting as lower gastrointestinal (LGI) bleeding in patients on chronic hemodialysis. Both patients were elderly (81 and 75 years, respectively) with a history of constipation. Diagnosis of stercoral ulcer as the cause of lower GI bleeding was made using endoscopic procedures. Stercoral ulcer should be considered in cases of lower GI bleeding in chronic dialysis patients.

End-of-life care beliefs among Muslim physicians.

OBJECTIVE: Physicians' religiosity affects their approach to end-of-life care (EOLC) beliefs. Studies exist about end-of-life care beliefs among physicians of various religions. However, data on Muslim physicians are lacking. This study explores the beliefs centering on aspects of end-of-life care among Muslim physicians in the US and other countries. DESIGN: A 25 item, online survey was created and distributed via Survey Monkey®. The survey was targeted toward Muslim physicians in the US and other countries. RESULTS: A total 461 Muslim physicians responded to our survey. The primary end point was if the Muslim physicians thought that making a patient DO NOT RESUSCITATE (DNR) is allowed in Islam?. Nearly 66.8 % of the respondents replied yes as compared to 7.38 % of the respondents who said no. Country of origin, country of practice, and if physicians had talked about comfort care in the past had the most impact on the yes vs. no response (p=0.0399, p=0.0092 and 0.0023 respectively). CONCLUSION: Muslim physicians' beliefs on EOLC issues are affected more by the area of practice, country of origin and previous experience in talking about comfort care than the religious beliefs.

Blood Loss through AV Fistula: A Case Report and Literature Review.

Little has been written about acute blood loss from hemodialysis vascular access. We describe a 57-year-old Caucasian male with an approximately 7 gm/dL drop in hemoglobin due to bleeding from a ruptured aneurysm in his right brachiocephalic arteriovenous fistula (AVF). There was no evidence of fistula infection. The patient was successfully managed by blood transfusions and insertion of a tunneled dialysis catheter for dialysis access. Later, the fistula was ligated and a new fistula was constructed in the opposite arm. Aneurysm should be considered in cases of acute vascular access bleeding in chronic dialysis patients.

A review of risk factors for stroke in patients with chronic kidney disease.

BACKGROUND: Patients with chronic kidney disease (CKD) are at higher risk for stroke because of higher prevalence of traditional and non-traditional cardiovascular risk factors. METHODS: We performed an extensive literature review with pre-defined keywords. We summarized the results of the studies evaluating for risk factors predisposing to stroke in CKD patients. RESULTS: The incidence of stroke and stroke-related mortality is higher in CKD patients compared with the general population. Presence of anemia, hypoalbuminemia, malnutrition, uremia, and hyperhomocysteinemia in patients with CKD is associated with higher incidence of stroke. Hemodialysis and renal transplant patients are at higher risk of developing stroke compared with those who do not require renal replacement therapy. CONCLUSION: The early recognition of risk factors associated with stroke in CKD population is imperative. Early interventions may potentially decrease the incidence and associated mortality of stroke in CKD patients.