Improving blood transfusion practice by educational emphasis of the Blood Utilization Committee: experience of one hospital.

AIM: The aim of this study was to reduce crossmatch to transfusion ratio through development of a new Blood Utilization Committee. BACKGROUND: Blood utilization hinges on the cooperation between transfusion services, medical staff, nursing and administration. Transfusion committees have attempted to bring about better oversight and bridge the gap between departments but in our institution this did not work until we had a catalyst to drive the effort. The unabashed desire and enthusiasm of one of our cardiac surgeons for self-improvement led to the formation of a new Blood Utilization Committee in October of 2012. STUDY DESIGN AND METHODS: Crossmatch and transfusion data were gathered from our blood bank information system starting with the 4th quarter of 2011 through the 1st quarter of 2013. The crossmatch to transfusion ratio (C:T) was calculated and comparisons were made between the results from before and after the initiation of the committee. RESULTS: At the commencement of the committee the initial C:T for the cardiac team was 2.48. We calculated a decrease of the C:T to 1.5 four months after the November 2012 formation of the new committee. The P-value calculated (P<0.0005) proved that the decrease was statistically significant. CONCLUSION: The initial impulse generated by the cardiothoracic surgery team is now spreading to other DRG groups in our hospital and we are seeing a drop in their C:T as well. Better blood utilization is attainable when the physicians who perform most transfusions lead the charge.

Renal vasculature in potential renal transplant donors: comparison of MR imaging and digital subtraction angiography.

PURPOSE: To compare magnetic resonance (MR) angiography with a selective inversion-recovery sequence and digital subtraction angiography (DSA) in renal transplant donors. MATERIALS AND METHODS: Thirteen potential donors underwent MR imaging at 1.5 T and conventional angiography. Blinded evaluation of imaging findings was performed. A selective inversion-recovery sequence was used to obtain MR arteriograms. RESULTS: Eight accessory vessels were present; MR angiography showed 100% sensitivity in accessory vessel detection. Both studies depicted early arterial branching in two vessels, mild fibromuscular dysplasia in one patient, normal renal size in all patients, and prominent fetal lobulation in two kidneys. A small cyst was detected with MR imaging only. Minor venous anomalies were noted in three patients, though these were not surgically confirmed owing to contralateral surgery. CONCLUSION: Despite the small study population, MR angiography with this sequence appears to have potential value in pretransplantation evaluation of the kidney. Advantages include short examination time, noninvasiveness, avoidance of iodinated contrast media, no radiation, and lower cost than DSA.

Efficacy and safety of cilazapril, a new angiotensin-converting enzyme inhibitor.

Cilazapril (CIL), a new angiotensin-converting enzyme inhibitor, was evaluated for 16 weeks in 29 patients with mild to moderate essential hypertension (diastolic pressure 95 mm Hg to 115 mm Hg). Twenty-four patients (83%) normalized their blood pressure (BP) (diastolic pressure less than 90 mm Hg), 11 with low-dose CIL, six with high-dose CIL, one with high-dose CIL plus low-dose thiazide, and six with high-dose CIL and high-dose thiazide. Three withdrew because of side effects (fatigue, bloating, and polyuria). Statistically significant reductions in sitting and standing systolic and diastolic pressures occurred at 8 and 16 weeks on CIL. There was no change in standing or sitting heart rate, white blood cell count, creatinine clearance, urine protein levels. This is the first long-term data on this new converting enzyme inhibitor in human beings.

Endogenous digitalis-like factors in hypertension and chronic renal insufficiency.

Endogenous digitalis-like factors have been implicated in the adaptations that accompany renal insufficiency and in the pathogenesis of hypertension. We recently described several fractions of normal human plasma that inhibit NaK-ATPase and exhibit apparent digoxin-like immunoreactivity. To determine if hypertension and/or renal insufficiency affect plasma levels of these factors, we examined four patient groups: normotensive controls; hypertensive subjects with normal renal function; hypertensives with moderate renal insufficiency; and chronic dialysis patients. Plasma levels of digoxin-like immunoreactivity and NaK-ATPase inhibitory activity were significantly increased in hypertensive patients with mild renal failure (7.6 +/- 1.1 ouabain equivalents, mean +/- SEM, N = 21 vs 4.1 +/- 1.1 in normotensive controls, N = 20, P less than 0.05). NaK-ATPase inhibitory activity tended to be higher in patients with primary hypertension and normal renal function (5.5 +/- 0.7 ouabain equivalents, P less than 0.07); in dialysis patients, it was not different from controls. There was no correlation between NaK-ATPase inhibitory activity and blood pressure in any group. There was a significant rise in plasma NaK-ATPase inhibitory activity during dialysis (+ 1.8 +/- 0.7 ouabain equivalents, N = 22, P less than 0.03). As we have found that NaK-ATPase inhibitory activity in the plasma of normal humans can be separated into three distinct fractions, EI1, EI2, and EI3, we analyzed the plasma of 10 dialysis patients further. The increase in NaK-ATPase inhibitory activity could be attributed to fractions EI1 and EI3. These results suggest that plasma NaK-ATPase inhibitors increase with chronic renal insufficiency, but not hypertension alone. Although hemodialysis may acutely raise plasma levels, long-term dialysis returns them to the normal range.

Hypertension and proteinuria: long-term sequelae of uninephrectomy in humans.

Renal function and blood pressure were assessed in 52 renal allograft donors 10 years or more following uninephrectomy, and their current function compared to their pre-uninephrectomy function as well as to age- and sex-matched control subjects consisting of inpatient potential renal donors and a normal "outpatient" population. The results show no significant deterioration in renal function as determined by serum creatinine or creatinine clearance, as a function of years post-uninephrectomy or age at the time of donation. A higher incidence of proteinuria and hypertension was found in male donors as compared to their pre-uninephrectomy values and to age- and sex-matched, inpatient and outpatient control subjects. Female donors had increased proteinuria when compared to pre-uninephrectomy and to age-matched, inpatient potential donors. However, the extent of proteinuria and hypertension was not significantly different from outpatient age-matched females with two kidneys. In our population, uninephrectomy is associated with mild proteinuria and hypertension.

Focal segmental glomerulosclerosis.

Focal segmental glomerulosclerosis is an important cause of the nephrotic syndrome in children and adults. This paper reviews the pathogenesis, clinical manifestations, morphology, and treatment of focal glomerulosclerosis. In addition, it considers the recently described association of focal glomerulosclerosis with nonglomerular renal diseases and the possible role of this glomerular lesion in progressive renal failure.

Glomerulonephritis in a patient with sarcoidosis. Report of a case and review of the literature.

A 38-year-old woman who had severe impairment of renal function displayed crescentic glomerulonephritis on a renal biopsy specimen. Chest roentgenogram showed bilateral hilar adenopathy. A biopsy specimen of a hilar lymph nodes showed many noncaseating granulomas, consistent with sarcoidosis. Therapy with plasmapharesis, cyclophosphamide, and corticosteroids was associated with improvement of renal function and disappearance of hilar adenopathy. Based on this case and a review of the literature, sarcoidosis should be considered when studying crescentic glomerulonephritis.

Hyperkalemia associated with indomethacin.

Substantial hyperkalemia with ECG abnormalities developed in a patient. None of the common causes of hyperkalemia was found, eg, acidosis, hemolysis, rhabdomyolysis, renal failure, hypoadrenalism, leukocytosis, or thrombocytosis. The patient had been receiving indomethacin, a drug known to inhibit renin production, aldosterone excretion, and prostaglandin synthetase. The patient was rechallanged with indomethacin, and measurements of serum potassium and renin, urinary potassium, aldosterone, and creatinine levels were done. The study period clearly showed a hyporeninemic-hypoaldosterone states with diminished renal potassium excretion, leading to hyperkalemia associated with the indomethacin therapy. The development of hyperkalemia caused by indomethacin is probably unusual; however, we believe it is important to report this potentially serious pathophysiologic occurrence associated with a commonly used medication.

Survival with severe hypernatremia.

In a 74-year-old woman, excessive insensible water loss developed secondary to a period of hot, humid weather, associated with an underlying inability to obtain adequate water replacement. On admission to the hospital she was comatose, clinically dehydrated, and had laboratory values consistent with a water deficit of approximately 30% (9 L) of body water. Serum sodium concentration was 202 mEq/L. Serum osmolality was 430 mOsm/L. The patient remained comatose for seven days, during which time she was vigorously treated with fluids, and she gradually recovered. This case represents what we believe is a unique report in the literature of the severity of hypernatremia developing via this pathogenic mechanism and survival in an adult with this degree of disturbance of sodium and water homeostasis.