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1.
BMC Nephrol ; 21(1): 8, 2020 Jan 13.
Artigo em Inglês | MEDLINE | ID: mdl-31928529

RESUMO

BACKGROUND: Transfer from a pediatric to an adult medical setting is associated with many barriers. Additionally, there are little data on patients' assessment of the transition process itself. 3 years ago at Lurie Children's Hospital of Chicago, we established a kidney transition program with the help of an adult nephrologist, physician assistant (PA) and social worker (LCSW). After 18 months, we evaluated the patients' perception of the program as part of a continuous quality initiative process. METHODS: Patients who had transitioned from pediatric care and were seen at least once in the adult nephrology clinic were anonymized and asked to take an established 5-point Likert scale survey. Survey questions addressed readiness to transition, the transition process itself, and the perception of adult care. Surveys were followed with semi-structured interviews. 3 readers rated each response as either "negative," "neutral," or "positive." Average, standard deviation and reader reliability were calculated. The readers also selected a word that best depicted each response and those most-common words were counted by question and overall. RESULTS: 17 out of 42 patients (40%) completed the survey. Average age at transition (mean + SD) was 20 + 2 years; the majority of patients (82%) felt ready to transfer to adult care but only 59% felt they were consulted on the timing. 88% of patients felt having a transition appointment and meeting the adult care providers in the pediatric setting to be valuable. Although 94% of patients ultimately felt comfortable in the adult care environment, 18% experienced noticeable differences in treatment recommendations. 13 semi-structured interviews were conducted. Overall, the patients responded positively (3 + 0, 100% reader reliability) to the transition. But, when asked what could have improved the transition, the word the patients used most was, "earlier." CONCLUSION: Young adults (YA) transitioning to adult care often feel ready to transition earlier than their transfer of care date. They subjectively benefit from a transition program that outlines the process of transferring their care. Many YA patients would benefit from a transition program that bolsters patient independence during early adult care visits.

2.
Am J Kidney Dis ; 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31585683

RESUMO

Infection is a major cause of morbidity and mortality in patients with chronic kidney disease (CKD), including those receiving maintenance dialysis or with a kidney transplant. Although responses to vaccines are impaired in these populations, immunizations remain an important component of preventative care due to their favorable safety profiles and the high rate of infection in these patients. Most guidelines for patients with CKD focus on the importance of the hepatitis B, influenza, and pneumococcal vaccines in addition to age-appropriate immunizations. More data are needed to determine the clinical efficacy of these immunizations and others in this population and define optimal dosing and timing for administration. Studies have suggested that there may be a benefit to immunization before the onset of dialysis or transplantation because patients with early-stage CKD generally have higher rates of seroconversion. Because nephrologists often serve as primary care physicians for patients with CKD, it is important to understand the role of vaccinations in the preventive care of this patient population.

3.
Arthritis Rheumatol ; 71(6): 964-971, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30614663

RESUMO

OBJECTIVE: To generate a core set of items to develop classification criteria for scleroderma renal crisis (SRC) using consensus methodology. METHODS: An international, multidisciplinary panel of experts was invited to participate in a 3-round Delphi exercise developed using a survey based on items identified by a scoping review. In round 1, participants were asked to identify omissions and clarify ambiguities regarding the items in the survey. In round 2, participants were asked to rate the validity and feasibility of the items using Likert-type scales ranging from 1 to 9 (where 1 = very invalid/unfeasible, 5 = uncertain, and 9 = very valid/feasible). In round 3, participants reviewed the results and comments from round 2 and were asked to provide final ratings. Items rated as highly valid and feasible (median scores ≥7 for each) in round 3 were selected as the provisional core set of items. A consensus meeting using a nominal group technique was conducted to further reduce the core set of items. RESULTS: Ninety-nine experts from 16 countries participated in the Delphi exercise. Of the 31 items in the survey, consensus was achieved on 13, in the categories hypertension, renal insufficiency, proteinuria, and hemolysis. Eleven experts took part in the nominal group technique discussion, where consensus was achieved in 5 domains: blood pressure, acute kidney injury, microangiopathic hemolytic anemia, target organ dysfunction, and renal histopathology. CONCLUSION: A core set of items that characterize SRC was identified using consensus methodology. This core set will be used in future data-driven phases of this project to develop classification criteria for SRC.


Assuntos
Lesão Renal Aguda/classificação , Hipertensão Maligna/classificação , Rim/patologia , Escleroderma Sistêmico/complicações , Lesão Renal Aguda/etiologia , Anemia Hemolítica/classificação , Anemia Hemolítica/etiologia , Pressão Sanguínea , Técnica Delfos , Humanos , Hipertensão/classificação , Hipertensão/etiologia , Hipertensão Maligna/etiologia , Proteinúria/classificação , Proteinúria/etiologia , Índice de Gravidade de Doença
4.
J Infect Chemother ; 23(5): 326-332, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28109741

RESUMO

Vancomycin is one of the most commonly utilized antibiotics in US hospitals. It remains the drug of choice for the treatment of serious infections caused by methicillin-resistant Staphylococcus aureus. For many of these deep-seated infections, guidelines recommend achieving troughs of 15-20 mg/L for treatment efficacy. At our institution we observed a number of cases of presumed vancomycin-induced acute tubular necrosis clinically diagnosed by the nephrology service. We report eight cases of presumed vancomycin-induced acute tubular necrosis, three of which required hemodialysis before resolution of nephrotoxicity. Only three of the eight patients received nephrotoxins prior to development of nephrotoxicity. All eight patients ultimately recovered renal function following discontinuation.


Assuntos
Lesão Renal Aguda/induzido quimicamente , Antibacterianos/efeitos adversos , Vancomicina/efeitos adversos , Adulto , Antibacterianos/uso terapêutico , Relação Dose-Resposta a Droga , Feminino , Humanos , Masculino , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Pessoa de Meia-Idade , Infecções Estafilocócicas/tratamento farmacológico , Vancomicina/uso terapêutico , Adulto Jovem
5.
Mol Immunol ; 77: 89-96, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27490940

RESUMO

C3 glomerulopathy (C3G) is an ultra-rare complement-mediated renal disease characterized histologically by the predominance of C3 deposition within in the glomerulus. Familial cases of C3G are extremely uncommon and offer unique insight into the genetic drivers of complement dysregulation. In this report, we describe a patient who presented with C3G. Because a relative carried the same diagnosis, we sought an underlying genetic commonality to explain the phenotype. As part of a comprehension genetic screen, we completed multiplex ligation-dependent probe amplification across the complement factor H related region and identified amplification alterations consistent with a genomic rearrangement. Using comparative genomic hybridization, we narrowed and then cloned the rearrangement breakpoints thereby defining a novel fusion gene that is translated into a serum protein comprised of factor H related-5 (short consensus repeats 1 and 2) and factor H-related-2 (short consensus repeats 1-4). These data highlight the role of factor H related proteins in the control of complement activity and illustrate how perturbation of that control leads to C3G.


Assuntos
Proteínas Inativadoras do Complemento C3b/genética , Proteínas do Sistema Complemento/genética , Glomerulonefrite Membranoproliferativa/genética , Adulto , Western Blotting , Hibridização Genômica Comparativa , Feminino , Humanos , Masculino , Reação em Cadeia da Polimerase Multiplex , Linhagem
6.
Curr Rheumatol Rep ; 18(1): 5, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-26711696

RESUMO

Scleroderma renal crisis (SRC) is an uncommon complication of systemic sclerosis. Despite the advent of angiotensin-converting inhibitor therapy, SRC remains a life-threatening complication. Recent studies have contributed to a better understanding of SRC, but much remains unknown regarding its pathophysiology, risk factors, and optimal management. Genetic studies provide evidence that immune dysregulation might be a contributing factor, providing hope that further research in this direction might illuminate pathogenesis and provide novel predictors for this complication.


Assuntos
Lesão Renal Aguda/etiologia , Escleroderma Sistêmico/complicações , Lesão Renal Aguda/patologia , Lesão Renal Aguda/fisiopatologia , Lesão Renal Aguda/terapia , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Humanos , Transplante de Rim , Prognóstico , Fatores de Risco , Escleroderma Sistêmico/diagnóstico , Escleroderma Sistêmico/tratamento farmacológico , Escleroderma Sistêmico/fisiopatologia
7.
Clin J Am Soc Nephrol ; 9(9): 1620-6, 2014 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-24970869

RESUMO

BACKGROUND AND OBJECTIVES: Calcitriol is used to treat secondary hyperparathyroidism in patients with CKD. Paricalcitol is less calcemic and phosphatemic in preclinical studies and in some trials in dialysis patients, but head-to-head comparisons in nondialysis patients are lacking. A large meta-analysis of trials concluded that these agents did not consistently reduce parathyroid hormone (PTH) and increased the risk of hypercalcemia and hyperphosphatemia. Therefore, the objective of this multicenter trial was to compare the rate of hypercalcemia between calcitriol and paricalcitol, while suppressing PTH 40%-60%. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patients with stages 3-4 CKD (n=110) with a PTH level >120 pg/ml were recruited and randomized to 0.25 µg/d of calcitriol or 1 µg/d of paricalcitol between April 2009 and July 2011. Subsequent dose adjustments were by protocol to achieve 40%-60% PTH suppression below baseline. The primary endpoint was the rate of confirmed hypercalcemia of >10.5 mg/dl between groups. RESULTS: Forty-five patients in each group completed the 24 weeks of treatment. Both agents suppressed PTH effectively (-52% with paricalcitol and -46% with calcitriol; P=0.17), although the paricalcitol group reached a 40% reduction in PTH sooner at a median 8 weeks (interquartile range [IQR], 4, 12) versus 12 weeks (IQR, 8, 18; P=0.02) and had a lower pill burden of 240 (IQR, 180, 298) versus 292 (IQR, 231, 405; P=0.01). Confirmed hypercalcemia was very low in both groups (three with paricalcitol and one with calcitriol) and was not significantly different (P=0.36). Both groups had small increases in calcium and phosphorus levels (0.3-0.4 mg/dl in each electrolyte) and significant decreases in alkaline phosphatase, a marker of high bone turnover, with no significant differences between groups. CONCLUSIONS: These results show that both calcitriol and paricalcitol achieved sustained PTH and alkaline phosphatase suppression in stages 3-4 CKD, with small effects on serum calcium and phosphorus and a low incidence of hypercalcemia.


Assuntos
Calcitriol/uso terapêutico , Ergocalciferóis/uso terapêutico , Hiperparatireoidismo Secundário/tratamento farmacológico , Idoso , Humanos , Hipercalcemia/induzido quimicamente , Hipercalcemia/epidemiologia , Hiperparatireoidismo Secundário/etiologia , Incidência , Falência Renal Crônica/complicações , Pessoa de Meia-Idade
8.
Am J Health Syst Pharm ; 70(23): 2105-9, 2013 Dec 01.
Artigo em Inglês | MEDLINE | ID: mdl-24249760

RESUMO

PURPOSE: The management of digoxin therapy using pharmacokinetics in a patient undergoing continuous venovenous hemofiltration (CVVH) is reported. SUMMARY: A 46-year-old African-American woman with New York Heart Association class IV, American College of Cardiology- American Heart Association stage D heart failure arrived from an outside facility with complaints of dyspnea after minimal exertion, orthopnea, and lower-extremity edema. A transthoracic echocardiogram revealed an estimated left ventricular ejection fraction of 15%. The patient subsequently required left ventricular assist device placement on hospital day 5 as a potential bridge to transplantation. A total digoxin loading dose of 500 µg i.v. (8.2 µg/kg) was given in two divided doses six hours apart. The next morning, the serum digoxin concentration was 1.9 ng/mL, and the patient was started on a maintenance digoxin dosage of 125 µg i.v. daily. On postoperative day (POD) 20, the patient developed acute kidney injury, and CVVH was initiated. The sieving coefficient (Sc), transmembrane clearance (CLtm), digoxin concentration in ultrafiltration fluid (Cuf), and need for supplemental digoxin were determined to account for CVVH- associated digoxin loss. After 14 days of CVVH, the patient's clinical condition improved, and CVVH was transitioned to intermittent hemodialysis. On POD 66, the patient was discharged to an extended-care facility without adverse reactions related to digoxin therapy. CONCLUSION: Analysis of serum digoxin concentration and digoxin Cuf values suggested that digoxin was cleared by CVVH, allowed calculation of Sc and CLtm values, and facilitated determination of digoxin requirements in a critically ill patient requiring CVVH.


Assuntos
Cardiotônicos/uso terapêutico , Digoxina/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológico , Hemofiltração/métodos , Lesão Renal Aguda/terapia , Cardiotônicos/administração & dosagem , Cardiotônicos/farmacocinética , Estado Terminal , Digoxina/administração & dosagem , Digoxina/farmacocinética , Relação Dose-Resposta a Droga , Ecocardiografia , Feminino , Insuficiência Cardíaca/cirurgia , Coração Auxiliar , Humanos , Pessoa de Meia-Idade
9.
Antimicrob Agents Chemother ; 57(12): 5854-9, 2013 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-24018264

RESUMO

Ceftazidime is a broad-spectrum cephalosporin with high-level activity against a variety of Gram-negative pathogens, including Pseudomonas aeruginosa. Improved outcomes are associated with cumulative percentages of a 24-h period that the drug concentration exceeds the MIC under steady-state pharmacokinetic conditions (%TMIC) of >45 to 70% of the dosing interval. Optimal dosing to achieve a 90% probability of target attainment (PTA) in patients receiving high-flux hemodialysis (HFHD) is unknown. We used existing data from six anephric adults receiving hemodialysis to construct a population model with the Pmetrics package for R. From the final model's joint probability density, we simulated the PTA for various ceftazidime dosing regimens, HFHD schedules, and organism MICs. For HFHD every 48 h and 1 g of ceftazidime given posthemodialysis, the PTA exceeds 90% for all isolates with MICs of ≤8 µg/ml, assuming a goal of 70%TMIC. For 72-h dialysis intervals, postdialysis dosing of 1 g is adequate for achievement of the 70%TMIC goal only for organisms with MICs of ≤4 µg/ml, while 2 g is adequate for organisms with MICs of ≤8 µg/ml. A dose of 500 mg once daily, regardless of HFHD schedule, has a 90% PTA for organisms with MICs of ≤16 µg/ml, while 1 g once daily may achieve 100% PTA even for resistant organisms with a MIC of 32 µg/ml. Therefore, to ensure maximal ceftazidime activity, once-daily dosing of 500 mg to 1 g ceftazidime in patients receiving HFHD may be preferable for critically ill patients when MIC data are unavailable and for more resistant organisms with ceftazidime MICs of 16 to 32 µg/ml.


Assuntos
Antibacterianos/farmacocinética , Ceftazidima/farmacocinética , Modelos Estatísticos , Pseudomonas aeruginosa/efeitos dos fármacos , Diálise Renal/métodos , Antibacterianos/farmacologia , Ceftazidima/farmacologia , Contagem de Colônia Microbiana , Simulação por Computador , Esquema de Medicação , Cálculos da Dosagem de Medicamento , Humanos , Infusões Intravenosas , Testes de Sensibilidade Microbiana , Infecções por Pseudomonas/tratamento farmacológico , Infecções por Pseudomonas/microbiologia , Pseudomonas aeruginosa/crescimento & desenvolvimento , Insuficiência Renal Crônica/microbiologia , Insuficiência Renal Crônica/terapia
10.
Ann Pharmacother ; 45(12): e64, 2011 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-22116989

RESUMO

OBJECTIVE: To report a sieving coefficient for peramivir in a patient receiving continuous venovenous hemofiltration (CVVH). CASE SUMMARY: An 18-year-old male presented with chills, myalgias, and dyspnea and was hospitalized. Nasal secretions were positive for influenza by rapid antigen test at an outside facility and oseltamivir was commenced. Oral absorption was predicted to be unreliable, and intravenous peramivir was accessed as an emergency investigational new drug applicaiton (eIND). CVVH was initiated after the development of acute renal failure, with blood samples collected to determine peramivir concentrations. DISCUSSION: Peramivir, an intravenous investigational neuraminidase inhibitor with activity against influenza viruses, has limited data for dosing in the setting of CVVH. A single patient received 600 mg of peramivir intravenously and had blood and ultrafiltrate concentrations measured serially. A sieving coefficient of approximately 0.9 was identified. CONCLUSIONS: Peramivir is well cleared by CVVH, and drug exposure is potentially predictable based on flow rates. Further study is necessary.


Assuntos
Lesão Renal Aguda/metabolismo , Lesão Renal Aguda/terapia , Ciclopentanos/farmacocinética , Guanidinas/farmacocinética , Hemofiltração , Influenza Humana/tratamento farmacológico , Influenza Humana/metabolismo , Lesão Renal Aguda/virologia , Adolescente , Ciclopentanos/uso terapêutico , Guanidinas/uso terapêutico , Humanos , Vírus da Influenza A Subtipo H1N1/isolamento & purificação , Influenza Humana/virologia , Masculino , Oseltamivir/uso terapêutico
11.
Int J Nephrol ; 2011: 436856, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21716699

RESUMO

Vancomycin (VAN) has been associated with acute kidney injury (AKI) since it has been put into clinical use in the 1950's. Early reports of AKI were likely linked to the impurities of the VAN preparation. With the advent of the more purified forms of VAN, the incidence of AKI related to VAN were limited to acute interstitial nephritis (AIN) or as a potentiating agent to other nephrotoxins such as Aminoglycosides. VAN as the sole etiologic factor for nephrotoxic acute tubular necrosis (ATN) has not been described. Here, we report a case of biopsy-proven ATN resulting from VAN.

12.
Heart Rhythm ; 8(4): 592-8, 2011 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21126602

RESUMO

BACKGROUND: Chronic hemodialysis (HD) patients have an elevated risk of sudden cardiac death (SCD), particularly in the 24 hours before the first HD of the week. Temporal changes in cardiac autonomic dysfunction, as characterized by abnormalities in heart rate variability (HRV) and heart rate turbulence (HRT), along with T-wave alternans (TWA), may contribute to this dispersion of risk. OBJECTIVE: This study sought to determine the prevalence of abnormal HRV, HRT, and TWA in HD patients and to compare their temporal distribution among periods of variable SCD risk. METHODS: HRV, HRT, and TWA were analyzed from 72-hour Holter monitors in HD patients, and results were compared among the 24-hour high-risk period before the first dialysis session of the week, the 24-hour intermediate-risk period beginning with the weeks' first dialysis, and the low-risk period the day after the first dialysis. Positive cut points were standard deviation of all normal R-R intervals ≤70 ms for HRV, onset ≥0% and/or slope ≤2.5 ms/R-R for HRT, and ≥53 µV for TWA. RESULTS: Of 41 enrollees, 28 (46% male, age 55 ± 12, ejection fraction 57% ± 11%) had sufficient data for analysis. Abnormalities were prevalent with 82%, 75%, and 96% of patients reaching threshold for HRV, HRT, and TWA in at least one 24-hour period, respectively. There was no significant difference in the prevalence of abnormal measures among dialytic intervals nor in the intraindividual distribution of abnormal measures (P >.05 for all). CONCLUSION: Abnormal HRV, HRT, and TWA are prevalent in HD patients and may indicate heightened SCD risk. No significant correlation was observed among these measures and recognized periods of variable risk.


Assuntos
Arritmias Cardíacas/epidemiologia , Sistema Nervoso Autônomo/fisiopatologia , Morte Súbita Cardíaca/epidemiologia , Sistema de Condução Cardíaco/fisiopatologia , Frequência Cardíaca/fisiologia , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Arritmias Cardíacas/etiologia , Arritmias Cardíacas/fisiopatologia , Morte Súbita Cardíaca/etiologia , Eletrocardiografia Ambulatorial , Feminino , Seguimentos , Humanos , Falência Renal Crônica/complicações , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Estudos Prospectivos , Fatores de Risco
13.
Prog Transplant ; 20(3): 216-20, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20929105

RESUMO

BACKGROUND: Despite the known benefits of preemptive kidney transplantation, its rate of use remains low. OBJECTIVE: To determine whether focused, comprehensive education provided at a clinic for patients with chronic kidney disease would improve the rate of preemptive transplantation and transplant wait times. METHODS: A retrospective cohort study design was used. The rate of preemptive transplantation and transplant wait times were compared between patients with end-stage renal disease who had been followed in a chronic kidney disease clinic for more than 3 months and patients with end-stage kidney disease who had not been followed for chronic kidney disease care during the same period. RESULTS: More African Americans than others had initiated dialysis without having had previous care for chronic kidney disease. The rate of preemptive transplantation was 24% for patients followed in the clinic. For those patients without living donor options, mean transplant referral time was significantly different between patients followed at the clinic and patients who were not: 234 (SD, 392) days before dialysis was started versus 161 (SD, 525) days after dialysis was started (P = .01). CONCLUSION: A chronic kidney disease clinic can influence rates of preemptive kidney transplantation and transplantation referral times.


Assuntos
Assistência Ambulatorial/organização & administração , Falência Renal Crônica/terapia , Transplante de Rim/estatística & dados numéricos , Educação de Pacientes como Assunto/organização & administração , Listas de Espera , Afro-Americanos/estatística & dados numéricos , Análise de Variância , Distribuição de Qui-Quadrado , Estudos de Coortes , Currículo , Feminino , Humanos , Illinois/epidemiologia , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/etiologia , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente/organização & administração , Avaliação de Programas e Projetos de Saúde , Encaminhamento e Consulta/organização & administração , Estudos Retrospectivos , Gestão da Qualidade Total/organização & administração
15.
Am J Kidney Dis ; 49(5): 656-63, 2007 May.
Artigo em Inglês | MEDLINE | ID: mdl-17472848

RESUMO

BACKGROUND: Patients with end-stage renal disease (ESRD) have a high incidence of sudden cardiac death and may benefit from implantable cardioverter defibrillators (ICDs). However, ESRD also may predispose patients to device-related complications, potentially offsetting some of the benefits of prophylactic ICD placement. The purpose of this study is to compare the incidence of complications after cardiac rhythm management device (CRMD) implantation in patients with and without ESRD. METHODS: An observational study was performed on 41 patients with ESRD and 123 controls without ESRD who had a CRMD (permanent pacemaker or ICD) implanted at a single institution from 1998 to 2005. Controls were matched for age, sex, type of device, and calendar year of device implantation. Primary and secondary end points were any complication and complications requiring intervention, respectively. RESULTS: 23 complications occurred in 16 of 41 patients with ESRD (39%) versus 13 complications in 13 of 123 matched controls (11%; P < 0.001). Major complications occurred in 29% of patients with ESRD versus 5% of controls (P < 0.001), whereas minor complications occurred in 17% and 6%, respectively (P < 0.03). Hematoma, thrombosis, and device-related complications, including elevated defibrillation thresholds, were more common in patients with ESRD (P < 0.05 for all), and there also was a nonsignificant trend toward greater infection risk (P = 0.1). There were no fatal complications in either group. CONCLUSIONS: Patients with ESRD had greater complication rates after CRMD implantation compared with matched controls, but these complications did not result in death. These results should be considered when evaluating patients with ESRD for prophylactic CRMD implantation, but do not support withholding such therapy.


Assuntos
Desfibriladores Implantáveis/efeitos adversos , Frequência Cardíaca , Falência Renal Crônica/terapia , Idoso , Morte Súbita Cardíaca/epidemiologia , Morte Súbita Cardíaca/etiologia , Gerenciamento Clínico , Falha de Equipamento , Feminino , Frequência Cardíaca/fisiologia , Humanos , Falência Renal Crônica/epidemiologia , Falência Renal Crônica/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
16.
Adv Chronic Kidney Dis ; 14(1): 105-12, 2007 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-17200050

RESUMO

This study examines whether stabilization of the glomerular filtration rate (GFR) is possible in patients with advanced chronic kidney disease (CKD), managed in a CKD clinic. A cohort of 82 patients with stages 4 and 5 CKD was followed for a period of 2 years after initiation of erythropoietin for anemia to determine the GFR and the frequency of primary outcomes (dialysis, transplantation, or death). GFR, calculated by the abbreviated Modification of Diet in Renal Disease formula, was determined every 3 months. After 24 months, 35 subjects (43%) developed a primary outcome. Controlled for other risk factors, the risk of having a primary outcome increased 19.7% for every unit that the GFR decreased (95% confidence interval [CI], 11.9%-26.8%, P < .001) and decreased 21.7% for every unit that the hemoglobin increased (95% CI, 0.5%-38.4%, P < .001). Blacks had a 3.1 times higher risk (95% CI, 1.4-6.9, P = .006) of developing a primary outcome than other ethnicities. In subjects who did not develop primary outcomes (n = 47 or 57%), GFR remained unchanged (19.5 +/- 9.1 at the end of the study v 20.8 +/- 5.3 mL/min/1.73 m(2) at baseline, P = .16). The standardized mortality rate was 4.75 and 9.77 per 100 person-year for stages 4 and 5, respectively. We conclude that stabilization of GFR over a 2-year period can be achieved in many patients with advanced CKD treated with erythropoietin in a CKD clinic. Although the precise reason for the stabilization of GFR cannot be elucidated from this study, our data are "proof of concept" that CKD outcomes can be improved in a CKD clinic setting.


Assuntos
Taxa de Filtração Glomerular , Nefropatias/terapia , Diálise Renal , Adulto , Idoso , Idoso de 80 Anos ou mais , Doença Crônica , Estudos de Coortes , Feminino , Humanos , Nefropatias/fisiopatologia , Falência Renal Crônica/patologia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
17.
J Ren Nutr ; 15(3): 345-55, 2005 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-16007564

RESUMO

BACKGROUND: Malnutrition-inflammation complex syndrome and anorexia, common conditions in maintenance dialysis patients, are strongly associated with higher mortality and hospitalization and lower quality of life (QoL) in this population. Megestrol acetate, 800 mg/day, has been shown to increase appetite and food intake and to mitigate inflammation in cachectic AIDS and cancer patients, leading to weight gain, but it is also associated with side effects at this dose. METHODS: We evaluated the efficacy of the oral solution of megestrol acetate in half of its conventional dose in improving the nutritional state and inflammation in 10 hypoalbuminemic dialysis patients (albumin < 3.7 g/dL). Six women and 4 men, ages 60.2 years, took 400 mg of megestrol acetate solution daily for 16 weeks. Anthropometry, dual energy x-ray absorptiometry, 24-hour diet recalls, and biochemical measurements of nutrition and inflammation, including serum C-reactive protein and leptin, were performed. RESULTS: At the end of the 16 weeks of intervention, weight and body mass index increased by 9%, body fat proportion by 31%, and triceps skinfold by 40% (P < .01). Serum albumin increased from 3.0 to 3.3 g/dL and continued to increase significantly to 3.6 g/dL after 3 months postintervention (P = .03). Serum leptin increased from 5.2 to 10.7 ng/mL (P = .09). Daily protein and energy intake increased progressively up to 27% to 42% by the end of the trial (P < or = .01). In 8 patients without acute infection, serum C-reactive protein declined from 1.24 to 0.78 mg/L (P = .06). QoL and appetite were reported to be improved. No major side effects were observed, and all 10 patients completed the 16 weeks of daily intake of megestrol acetate without interruption. CONCLUSIONS: Megestrol acetate oral solution in half of its conventional dose is safe and improves the nutritional state, inflammation, and anorexia in maintenance dialysis patients. Larger-scale placebo-controlled randomized studies are needed to confirm the beneficial effects of 400 mg/day of megestrol acetate in dialysis patients.


Assuntos
Inflamação/tratamento farmacológico , Acetato de Megestrol/administração & dosagem , Desnutrição Proteico-Calórica/tratamento farmacológico , Diálise Renal , Adulto , Idoso , Idoso de 80 Anos ou mais , Anorexia/complicações , Anorexia/tratamento farmacológico , Antropometria , Composição Corporal , Índice de Massa Corporal , Peso Corporal , Proteína C-Reativa/análise , Proteínas na Dieta/administração & dosagem , Ingestão de Energia , Feminino , Humanos , Hipoalbuminemia/complicações , Inflamação/complicações , Falência Renal Crônica/complicações , Falência Renal Crônica/terapia , Leptina/sangue , Masculino , Acetato de Megestrol/efeitos adversos , Pessoa de Meia-Idade , Estado Nutricional , Estudos Prospectivos , Desnutrição Proteico-Calórica/complicações , Albumina Sérica/análise , Síndrome , Resultado do Tratamento
18.
Adv Chronic Kidney Dis ; 11(4): 398-403, 2004 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-15492978

RESUMO

Physicians utilize the measurement of the urea reduction ratio (URR) and Kt/V as surrogates for the adequacy of hemodialysis, as well as to follow the course of patients longitudinally. These measurements are affected by the duration of a dialysis treatment, the type and size of the dialyzer membrane used during the treatment, the blood flow rate during the treatment, and the adequacy of vascular access. We, and others, have noted that eating during dialysis can be associated with decreases in URR and Kt/V. However, there have been no previous studies that have examined the effects of eating before dialysis on these variables. This study examined the effects of eating one-third of a daily diet 2 hours before dialysis as opposed to fasting for a minimum of 3 hours before dialysis on the measured URR and Kt/V as obtained routinely in our dialysis unit. Sixty seven patients gave informed consent for the study, and 42 completed the protocol. No differences were found in URR or Kt/V when dialysis was performed 2 hours after eating compared with performing dialysis after at least a 3-hour fast in the group as a whole or in subgroup analyses of men, women, patients with diabetes, patients in different age groups, or patients who dialyzed on different shifts. Unlike intradialytic food ingestion, moderate predialysis food intake does not affect the measurement of dialysis adequacy as determined by URR and Kt/V.


Assuntos
Ingestão de Alimentos , Diálise Renal , Ureia/urina , Idoso , Jejum , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Período Pós-Prandial , Fatores de Tempo
19.
J Nephrol ; 17(1): 125-9, 2004.
Artigo em Inglês | MEDLINE | ID: mdl-15151269

RESUMO

Patients with end-stage liver disease are prone to hemodynamic and immunologic renal injury, the latter at times manifesting as glomerulonephritis. Elevated serum immunoglobulin A (IgA) levels and mesangial IgG-IgA deposits are common in these patients, but are often clinically silent. We report a patient with autoimmune hepatitis and secondary IgA nephropathy (IgAN) who presented with nephrotic syndrome, acute renal failure (ARF), with 30% of the renal glomeruli having undergone crescentic change, and with IgA2 deposits in the glomerular mesangium. This article discusses secondary IgAN pathogenesis and its therapeutic management.


Assuntos
Lesão Renal Aguda/etiologia , Glomerulonefrite por IGA/etiologia , Hepatite Autoimune/complicações , Glomérulos Renais/patologia , Síndrome Nefrótica/etiologia , Lesão Renal Aguda/patologia , Adulto , Feminino , Glomerulonefrite por IGA/diagnóstico , Glomerulonefrite por IGA/patologia , Hepatite Autoimune/terapia , Humanos , Síndrome Nefrótica/diagnóstico , Síndrome Nefrótica/patologia
20.
Semin Nephrol ; 22(6): 526-32, 2002 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-12430097

RESUMO

In this article, we maintain that the management of patients with chronic kidney disease (CKD) is best provided in a clinic setting that integrates nephrologic expertise, patient education, and comprehensive supportive services. Our experience with a CKD clinic in an urban academic setting is described. As a way to assess and quantify the impact of our clinic on clinical outcomes, we have analyzed our results in terms of 2 variables: presence of permanent access at the time of dialysis initiation and impact on renal function as assessed by calculated glomerular filtration rate (GFR). The number of clinic visits was taken as an index of comprehensive renal care before dialysis initiation. Individuals who started dialysis with a functioning permanent access had been seen in our clinic more frequently than those seen less frequently (20 +/- 3.5 and 4.4 +/- 2.1 visits, respectively, P <.005). The impact on renal function was analyzed in a group of 80 unselected patients stratified into 3 stages based on the recently published National Kidney Foundation Disease Outcomes Quality Initiative (K/DOQI) guidelines: stage III (mean GFR 39 +/- 1.5 mL/min, n = 21), stage IV (mean GFR 21 +/- 0.6 mL/min, n = 46), and stage V (mean GFR 12 +/-.76 mL/min, n = 13). Provision of comprehensive renal care in conjunction with anemia management using weekly injections of erythropoietin subcutaneously resulted in stabilization of GFR in patients with stages IV and V over a period of 15 months of follow-up evaluation. In patients with stage III CKD, GFR decreased over the initial period of follow-up evaluation (first few months), and to a lesser extent by the end of follow-up evaluation (15 mo). Further studies are underway to discern the factor(s) underlying the overall clinic effect versus a beneficial effect of anemia correction on GFR. Our data suggests that stabilization of GFR is a goal that can be accomplished with comprehensive renal care provided in an organized clinic setting.


Assuntos
Instituições de Assistência Ambulatorial/normas , Falência Renal Crônica/terapia , Garantia da Qualidade dos Cuidados de Saúde , Diálise Renal , Anemia/etiologia , Anemia/terapia , Chicago , Assistência Integral à Saúde , Taxa de Filtração Glomerular , Humanos , Falência Renal Crônica/complicações , Apoio Nutricional , Guias de Prática Clínica como Assunto , Encaminhamento e Consulta
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