Kidney Problems Diet

The Kidney Disease Solution

The ebook teaches you how to beat kidney disease in a way that no big pharm company wants you to know. The biggest companies make their money when people like you, with kidney disease come in and wonder if there is any way that they can be cured. The medical industry profits off of these sorts of people, because most people do not know that there is a way around the mass-produced medical industry. With the information in this ebook guide you will be able to restore your help without using drugs that end up hurting your kidneys even more. You will be able to avoid surgery, or having to use dialysis just to survive. You can also improve your quality of life if you are already on dialysis or end stage renal failure. This book was born of years of research from Duncan Capicchiano, ND. All of his research, findings, and suggestions are available to you! Read more here...

The Kidney Disease Solution Overview


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Morbidity Mortality from Acute Renal Failure

Reported mortality rates for ARF have remained the same from before to after the advent of dialysis 40 to 90 percent.1314 This statistic reflects a changing epidemiology and etiology of ARF. Before the availability of effective dialysis, many young patients died directly of complications specific to ARF. Now that dialysis effectively treats life-threatening complications of ARF, the patient's age and underlying diseases determine mortality from ARF. ARF has become an index of the severity of patients' other disease processes. With the advent of dialysis, the most common causes of death with aRf are sepsis, cardiac, and pulmonary failure. This is not to imply that ARF is a benign disease even in those patients not requiring dialysis, mortality was 31 percent in patients with ARF compared with only 8 percent in matched patients without ARF.15 Even after adjusting for comorbidity, the odds ratio for dying in patients with ARF was 4.9 compared with patients without ARF. drug-induced...

TABLE 893 Key Historical Elements for Hemodialysis Patients

Dialysis patients are often quite knowledgeable concerning their dry weights and baseline laboratory test results. If the patient is not forthcoming with this data, the emergency physician can contact the HD center and ask about the dry weight, average interdialysis weight gains, and any recent HD complications. In addition, the dialysis nurses and technicians are very devoted to their patients can provide a great deal of soft data concerning the patient. Query the patient in detail concerning uremic symptoms as markers of inadequate HD. Finally, ask patients whether they retain their native kidneys, which can be continued sources of hypertension, infection, and nephrolithiasis.

Dialysis Disequilibrium

Fluid shifts related to a rapid decrease in blood urea nitrogen, the specific cause of this osmotic edema remains controversial. A reverse urea effect theorizes that the BBB prevents urea concentrations in the brain from decreasing with serum levels during and immediately following dialysis. A relative hyperosmolar state within the brain encourages the formation of osmotic edema. This fluid shift depends on the rate of dialysis and may be reversed by increasing serum osmolarity. The reverse urea effect hypothesis has been disputed and recent attention has focused on the role of idiogenic osmoles, which has been suggested because urea levels do not fully explain changes in CSF and serum osmolarity measurements. The generation of these organic acids as a protective mechanism against dehydration has been speculated to account for postdialysis decreases in intracellular pH. The clinical manifestations are usually transient and may be avoided or minimized by employing slower rates of...

As An Adjunct To Dialysis

Loop diuretics have also been administered to patients with end-stage renal disease on maintenance dialysis in an attempt to reduce interdialytic weight gains, prevent heart failure or pulmonary congestion, and control blood pressure without unpalatable limitations in fluid or sodium intake. It has also been suggested that this strategy could reduce the number of hypotensive episodes which occurred during hemodialysis during removal of excess fluid. The ma jority of these studies have been performed in patients on chronic hemodialysis. Most individuals on dialysis who have residual renal function respond to loop diuretics, although very large doses are frequently required. However, the effect of diuretics on weight gain and blood pressure in this population have been inconsistent. In a double blind study of hemodialysis patients with residual creatinine clearances of less than 4 ml min, 200 mg per day of torasemide or 250 mg of furosemide increased fractional sodium excretion compared...

Chronic Renal Disease

Maternal risks associated with renal disease are linked to the degree of renal compromise. As renal function diminishes, fertility decreases. Pregnancy rarely occurs in women who have a preconception serum creatine of > 3 mg dL. Preterm delivery and superimposed preeclampsia frequently complicate pregnancies of patients with underlying renal disease. Patients with chronic pyelonephritis may have an increased number of recurrences due to bacteriuria, increased glucosuria, and mechanical compression of the ureter in the third trimester pregnancy. Those with a history of reflux nephropathy are at increased risk of sudden escalating hypertension and worsening renal function. Urolithiasis is associated with more frequent urinary tract infections. Patients with lupus nephropathy are at greatly increased risk for exacerbations of the disease and superimposed preeclampsia, particularly if their disease was not in remission for at least 6 months prior to conception.

Acute Renal Failure From Diuretic And Nsaid Administration

Acute renal failure has been reported in two healthy volunteers taking indomethacin and triamterene as part of a drug study, in one patient taking this combination, and recently in a man with mild hypertension taking ibuprofen and the combination of hydrochlorothiazide and triamterene who had been strenuously exercising. The latter individual underwent a renal biopsy which showed acute tubular necrosis (ATN). All patients subsequently recovered renal function in a time course consistent with ATN. Why these individuals developed ATN is unclear, but an idiosyncratic reaction to this combination of drugs or potentiation of physiologic reductions in renal blood flow induced by exercise has been proposed. Clinicians and patients should be aware of the potential risks from this drug combination.

Relationship between the glucose level and retinopathy nephropathy and peripheral neuropathy

In patients with diabetes, the risk of retinopathy, nephropathy, and neuropathy is highly correlated with various measures of glycemia including fasting plasma glucose, 2 hour postprandial plasma glucose (after a 75 g oral glucose load), and glycated hemoglobin level.10'16'17 For example, the risk of retinal and renal disease is very low below a fasting and 2 hour plasma glucose of 7-0mmol l or 11-1 mmol l respectively, and increases as these measures increase within the diabetic range. Therefore, the plasma glucose level is a continuous risk factor for these complications in patients with diabetes. It is also a modifiable risk factor. The Diabetes Control and Complications Trial16 clearly showed that for patients with type 1 diabetes, dramatic reductions of the risk of retinopathy (63 risk reduction RR ), laser therapy (51 RR), microalbuminuria (39 RR), clinical proteinuria (54 RR), and neuropathy (60 RR) can be achieved by tight glucose control. Tight glucose control also led to...

Salt Retention with Severe Renal Failure andor Acute Glomerulonephritis

Patients with markedly reduced glomerular filtration rates will filter much less salt than normal. Renal tubule salt reabsorption decreases, but if a large quantity of salt is ingested progressive positive salt balance and overload will develop. When salt intake exceeds output, ECF, interstitial and vascular volume all expand. The pattern of distribution of retained salt and water which occurs in patients with severe renal failure is more symmetrical than that which develops in most patients with nephrotic syndrome. All the subcompartments of the ECF expand to produce hypertension, pulmonary congestion, cardiomegaly, and generalized edema. The different salt distribution patterns in nephrotic patients and in patients with renal failure may be due to their different plasma albumin concentrations in these conditions. Hypoalbuminemia favors an accumulation of retained salt and water in the interstitial space. However, some nephrotic patients develop massive edema, without vascular...

Hepatic and Renal Failure

Considering the importance of the liver and kidney in the maintenance of blood glucose levels hypogly-cemia is remarkably rare in both liver and kidney disease. In liver disease hypoglycemia is virtually confined to patients with acute toxic hepatic necrosis, whether due to overwhelming viral infection or specific hepatotoxins such as poisonous mushrooms, unripe akee fruit, and paracetamol in excess. Its appearance always portends an extremely poor prognosis. The association of hypoglycemia with primary cancer of the liver is comparatively common and due to overexpression and secretion of aberrant, or big IGF-II, and is not, as was once supposed, due to nonspecific destruction of hepatic tissue. Hypoglycemia is very rarely due to hepatic secondaries except from IGF-II secreting tumors. Kidney failure is one of the commoner causes of hypoglycemia in nondiabetic hospital inpatients and does not carry as grave a prognostic significance as in patients with liver disease. It generally...

TABLE 8811 Diagnostic Sequence for Acute Renal Failure ARF

Large postvoid residuals after catheterization suggest obstruction below the bladder, and catheter drainage should be maintained until the obstruction is relieved. To prevent hypotension and hematuria, the traditional recommendation is for intermittent clamping of the catheter during drainage of a distended bladder, but experimental and clinical evidence provides no support for this tradition. 31 Hematuria upon catheter drainage of a distended bladder is related to the degree of bladder wall damage before relief obstruction and not correlated with the rate of emptying. Urine should be completely and rapidly drained from an obstructed bladder, because prolonged urine stasis only predisposes the patient to urinary tract infection, urosepsis, and renal failure. Urine output is a generally poor method of gauging blood volume.35 Oliguria requires differentiating prerenal from intrinsic renal etiologies. Low urine output in prerenal syndromes is the result of normal renal concentrating...

Chronic Renal Failure

The common denominator in chronic renal failure, irrespective of its cause, is reduced renal blood flow and glomerular filtration rate. To maintain the proper milieu interieur the kidney, responding to hemodynamic, neural, and humoral signals, undergoes some very significant alterations in its reabsorptive and secretory functions. In order to continue excretion of the ingested sodium in the diet, the diseased kidney with a reduced number of functioning nephrons, reabsorbs less of the filtered sodium in each of the remaining functioning nephrons. To illustrate, an individual with a GFR of 100 ml min and a serum Na+ of 150 mEq liter (of plasma water) who excretes 150 mEq of Na+ day reabsorbs all but 0.69 of the filtered sodium (99.31 ) filtered Na+ 150 mEq liter X 100 ml min X 1440 min day 21,600 mEq day fractional excretion of Na+ (150 mEq day -h 21,600 mEq day) X 100 0.69 , A patient excreting 150 mEq of Na+ day with a GFR of 10 ml min excretes as much as 6.9 of the filtered sodium...

Preventing renal failure

Acute renal failure is defined as acute oliguria (< 400 ml per day) or a rapid (hours to weeks) decline in glomerular filtration rate manifested by a rise in urea and creatinine. The rise in creatinine is often slow. In fact, if all renal function is lost, the serum creatinine rises by only 80-160 imol litre-1 (1-2 mg dl-1) per day. Oliguria is defined as the production of 100-400 ml urine per day. Anuria is defined as the production of < 100 ml per day, whilst absolute anuria is no urine output. Absolute anuria reflects urinary tract obstruction until proven otherwise. It is generally believed that a urine output of < 0 5 ml kg-1 per hour for greater than two hours is an important marker of renal hypoperfusion and should trigger remedial action. However, 50-60 of acute renal failure is non-oliguric. Hypotension, dehydration, and sepsis are the commonest causes of acute tubular necrosis. Prerenal causes of acute renal failure are the most common in both hospital and the...

Pathophysiology of acute renal failure

The pathophysiology behind acute renal failure (ARF) is complex and only partly understood. Many data come from animal models where acute tubular necrosis is induced by transiently clamping a renal artery. Real patients are more complex, where renal failure is often part of a developing multisystem illness. The outer medulla is relatively hypoxic and prone to injury. When there is an ischaemic or septic insult, inflammatory mediators damage the endothelium. It is not as simple as damaged tubular cells sloughing and blocking the collecting ducts there is a complex response Involving programmed cell death (apoptosis) and damage to the actin cytoskeleton, which facilitates cell-to-cell adhesion and forms the barrier between blood and filtrate. Genetic factors also play a role. Knockout mice without the gene for a cell adhesion molecule ICAM-1 (which helps leukocytes bind to the endothelium) do not develop ARF after an ischaemic insult. Ischaemic or nephrotoxic acute tubular necrosis...

Minitutorial low dose dopamine in acute renal failure

Using low dose dopamine at 0-2-2-5 micrograms kg-1 per minute (renal dose) for both the prevention and treatment of acute renal failure is common. Yet randomised trials have shown it is of no benefit either as prevention in high risk postoperative patients or as treatment in established acute renal failure. The effects of a dopamine infusion are complicated because it acts on a number of different receptors that have opposing actions. The action of dopamine is not constant throughout its dose range (see a fuller description in Chapter 6). Stimulation of a receptors causes systemic vasoconstriction and the blood pressure rises pi receptors increase contractility of the heart, p2 receptors reduce afterload, and dopamine (DA) receptors cause renal and splanchnic vasodilatation. Dopamine acts on all these receptors. In addition, there are two major subgroups of DA receptor DA1 receptors are in the renal and mesenteric circulation DA2 receptors are in the autonomic ganglia and sympathetic...

Renal replacement therapy haemodialysis and haemoflltratlon

Indications for RRT in acute renal failure are as follows Haemodialysis removes solutes from blood by their passage across a semipermeable membrane. Heparinised blood flows in one direction and dialysis fluid flows in another at a faster rate. Dialysis fluid contains physiological levels of electrolytes except potassium, which is low, and molecules cross the membrane by simple diffusion along a concentration gradient. Smaller molecules move faster than larger ones. Urea and creatinine concentrations are zero in the dialysis fluid because they are to be removed as much as possible. A 3-4-hour treatment can reduce urea by 70 . Water can be removed by applying a pressure gradient across the membrane if needed.

H 1466 When Can the Patient be Given Dialysis

For all problems with dialysis accesses an important issue is the patient's need for dialysis. Inserting a temporary catheter in the neck or groin should be weighed against the possibility of a successful operation. A basic rule is that a revised dialysis access should be allowed at least a couple of days to heal after the procedure to avoid bleeding complications. Dialysis requires heparinization, which in combination with uremic patients' tendency for coagulopathy increases the risk for bleeding. During dialysis clots in the suture line are dissolved and bleeding is likely. Such bleeding is often difficult to treat. Moreover, interposed vein grafts have thin walls and are easy to damage during puncture. Vein grafts needs at least 10-14 days to be arterialized, and PTFE grafts should be incorporated in surrounding tissue to minimize the risk for bleeding. Accordingly, if the need for dialysis is urgent and the risk of surgical bleeding after revision is considered small, dialysis can...

Membranoproliferative Glomerulonephritis

Membranoproliferative Glomerulonephritis

Merulonephritis has also been used for MPGN type I. Increased mononuclear cells and occasional neutrophils may be present. The proliferation is typically uniform and diffuse in idiopathic MPGN, contrasting the irregular involvement most commonly seen in proliferative lupus nephritis (Fig. 3.1). In secondary forms of MPGN, the injury may be more irregular. Crescents may occur in both idiopathic and secondary forms. Deposits do not involve extraglomerular sites. Lesions progress with less cellularity and more pronounced matrix accumulation and sclerosis over time (6). Tubular and vascular fibrosis and sclerosis proportional to glomerular scarring are seen late in the course. Treatment so far has offered limited success. Type I MPGN has recurred in up to 30 of transplants in some series (17). However, the disease may have a more benign clinical course when it recurs. Interferon-a therapy decreases symptoms of renal involvement in hepatitis C-associated MPGN, but relapses are prompt as...

Postinfectious Glomerulonephritis

Acute postinfectious glomerulonephritis is a kidney disease that follows after an infection. The most common and best understood form of acute postinfectious glomerulonephritis is poststreptococcal glomerulonephritis. Less is known about the other forms of postinfectious glomerulonephritis. In addition, there are glomerulonephritides that occur during persistent bacterial infections such as bacterial endocarditis, deep abscesses, and infected atrioventricular shunts in hydrocephalus (1). A large number of bacterial, viral, and mycotic infections may be followed by acute glomerulonephritis. Especially after bacterial and viral infections, a proliferative form of glomerulonephritis occurs (2). In parasitic infections membranous or membranoproliferative forms are seen more often, with in general a worse prognosis. However, most cases of acute postinfectious glomerulonephritis are caused by group A streptococci and follow upper airway infections, such as pharyngitis or tonsillitis, by 14...

Bs Acute Renal Failure

Acute renal failure (ARF) is defined as a deterioration of renal function over hours or days that results in the accumulation of toxic wastes and the loss of internal homeostasis. Glomerular filtration rate (GFR) is commonly used as an index of renal function, and rapid declines in GFR are viewed synonymously with ARF. Although this concept of ARF is universally accepted, exact definitions of ARF vary in the medical literature. Laboratory scientists, who can directly measure GFR, define ARF as a 50 percent decline in GFR. Clinicians must rely on indirect measures of GFR to define ARF, such as a 50 percent decline in creatinine clearance or a 50 percent increase in serum creatinine from baseline. Finally, some physicians define only those patients requiring dialysis treatment as having ARF. ARF is very common and emergency physicians play a critical role in the early recognition of ARF and prevention of further iatrogenic injury. TABLE 88-1 Incidence of Acute Renal Failure (ARF) in...

Ultrafiltration and dialysis probes

Macromolecules (e.g., proteins and polysaccharides) in solution can be separated from low M.Wt. solutes (e.g., salts, amino acids) by dialysis which utilises a semipermeable membrane to retain macromolecules and allow small solute molecules to pass through (Fig. 12.8). An alternative way of separating macromolecules from low M.Wt. components is by ultrafiltration, in which pressure, vacuum or centrifugal force is used to filter the aqueous medium and low M.Wt. solutes through a semipermeable membrane, which retains the macromolecules (Fig. 12.9). Both of these techniques have been widely exploited in academic settings and by the food industry (e.g., preparation of low lactose milk and hypoallergenic foods). A biosensor probe integrating dialysis and enzyme-based potentiometric detection (Fig. 12.10), and an ultrafiltration probe (UF, Fig. 12.11) have been used in the medical research field for continuous in vivo isolation and detection Fig. 12.8 Example of a dialysis cell (disc...

Access to Dialysis and the Just Allocation of Scarce Resources

The numbers of dialysis patients steadily grew each year, resulting in an ever increasing cost of the Medicare ESRD program. In the 1980s the United States experienced record-breaking budget deficits, and questions began to be raised about continued federal funding for the ESRD program. Observers wondered if the money was well spent or if more good could be done with the same resources for other patients (Moskop). Critics of the ESRD program observed that it satisfied neither of the first principles of distributive justice equality and utility. On neither a macro- nor a microallocation level did the ESRD program provide equality of access. On the macroallocation level, observers asked, as a matter of fairness and equality, why the federal government should provide almost total support for one group of patients with end-stage disease those with ESRD and deny such support to those whose failing organs happened to be hearts, lungs, or livers (Moskop Rettig, 1991). On a microallocation...

TABLE 884 Differential Diagnosis of Intrinsic Renal Failure

Acute tubular necrosis (ATN) secondary to renal ischemia accounts for the majority of cases of intrinsic renal failure. Nephrotoxins are the second most common cause of ATN, accounting for approximately 25 percent. When the etiologies of ARF were reviewed in a multivariate analysis, a synergistic effect was noted for the combination of ischemic and nephrotoxic ATN.11

Withholding and Withdrawing Dialysis

After cardiovascular diseases and infections, withdrawal from dialysis is the third most common cause of dialysis-patient death. In one large study, dialysis withdrawal accounted for 22 percent of deaths (Neu and Kjellstrand). Older patients and those with diabetes have been found to be most likely to stop dialysis. Over time, as the percentage of diabetic and older patients (those sixty-five or over) on dialysis increased, withdrawal from dialysis became more common. According to surveys of dialysis units performed in the 1990s, most dialysis units had withdrawn one or more patients from dialysis in the preceding year with the mean being three. (Moss et al., 1993). Because of the increased frequency of decisions to withhold and withdraw dialysis in the 1980s and 1990s, the clinical practices of nephrologists in reaching these decisions with patients and families generated heightened interest. Discussions of the ethics and process of withholding or withdrawing dialysis became more...

Is Low Birth Weight a Risk for Kidney Disease

Much of the evidence for programming of adult disease comes from human epidemiological studies and animal models where the offspring is of low birth weight due to maternal undernutrition or placental insufficiency.3'4 Infants born of low birth weight, that is small for gestational age (SGA) are at increased risk of developing adult diseases particularly hypertension and noninsulin dependent diabetes mellitus (NIDDM). A link between low birth weight and renal disease is not as firmly established as for cardiovascular and metabolic disease, but this is probably due to more limited examination of renal function rather than no such association being present. Also, as hypertension and NIDDM are well defined risk factors for chronic renal disease, it is often difficult to ascertain whether renal disease occurs as a result of these diseases or is independendy a result of low birth weight. A recent literature review of renal disease identified low birth weight as a 'progression promoter' for...

Renal Failure

Renal disease covers a wide spectrum of clinical pictures from decreased renal reserve, through varying degrees of renal impairment to end stage renal failure. Up to 80 of excretory function may be lost before a rise in serum urea or creatinine is seen. The creatinine value gives a useful indication of the degree of renal failure. The corresponding urea value is more readily affected by dietary protein, tissue breakdown and hydration and is, therefore, less useful. The cause of renal impairment or failure is very relevant to anaesthesia because the underlying disease process may have other manifestations. Renal failure may be acute or chronic (Figure PR.16). The majority of renal patients presenting for anaesthesia will have chronic renal failure and most will be on a dialysis programme, involving either intermittent haemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD). At pre-operative assessment, the anaesthetist should establish the cause of renal failure and look...

Acute renal failure

Acute renal failure (ARF) is the sudden development of renal insufficiency resulting in the body's inability to excrete nitrogenous waste and maintain fluid and electrolyte balance. While a straightforward concept, defining renal failure in the clinical setting remains more challenging. Novis et al. reviewed 26 studies of post-operative renal failure and found no two studies utilized the same definition. That being said, commonly used definitions include an increase in serum creatinine by 20-50 over baseline, a creatinine clearance of less than < 50 , or the need for RRT.


The most common indication for kidney transplantation in the United States is renal failure secondary to diabetic nephropathy (types 1 and 2). Kidneys for transplant recipients were generally obtained from deceased donors however, the advent of the laparoscopic donor nephrectomy technique has resulted in living donors supplying greater than 50 percent of kidneys at many transplant centers. Following successful kidney transplantation, diabetics remain at risk for allograft loss due to recurrent diabetic nephropathy. For those type 1 diabetics with minimal medical comorbidities, pancreas transplantation has been performed successfully with excellent long-term results. Type 2 diabetic patients are not candidates for transplantation as their metabolic defect is due to insulin insensitivity as opposed to a complete absence of the hormone. The differentiation between types 1 and 2 is imperative prior to consideration for pancreas transplantation and may be accomplished by serum C-peptide...


TECHNICAL ASPECTS The nephron removes toxins and maintains internal homeostasis through an elegant combination of glomerular filtration followed by selective reabsorption and secretion of water and solutes. HD uses the brute force techniques of ultrafiltration and clearance to replace the functions of the nephron. HD substitutes a hemodialyzer filter for the glomerulus to produce a ultrafiltrate of plasma. Adjustment of the pressure gradient across the hemodialyzer filter during HD controls the amount of fluid removal (ultrafiltration). Solute removal (clearance) during HD is dependent on the filter pore size, the amount of ultrafiltration (solute drag), and the concentration gradient across the filter (diffusion). Solute diffusion down chemical gradients from the blood to the dialysis fluid (dialysate) determines their final blood concentration. Since hemodialyzer pore size prevents the filtration of proteins, dialysate consists only of electrolytes (Na +, K+, Cl-, HCO3-, Ca++, and...

Peritoneal Dialysis

Ganter accomplished the first PD in 1923. Practical long-term RRT with PD did not become available until 1976, when Popovich and Moncrief worked out the basic concepts of continuous ambulatory peritoneal dialysis (CAPD). Their work was significantly aided by the development of a practical silicon rubber catheter by Tenckhoff in 1968, which is still in use today. Because of its simplicity, PD is the most common form of RRT used outside the United States and Canada. TECHNICAL ASPECTS PD can be accomplished in either an acute setting or chronically via exchanges of solution throughout the day (CAPD) or through multiple exchanges at night while the patient sleeps continuous cyclic peritoneal dialysis (CCPD) . 1,15 EVALUATION OF PERITONEAL DIALYSIS PATIENTS When a PD patient arrives in the emergency department, certain historical elements are important (Table. 89-5). As with HD patients, the disease that caused the renal failure frequently persists. The type of PD and the person who...

Dialysis kidney

Two principal therapies exist for patients who develop irreversible kidney failure and require renal replacement therapy to survive kidney dialysis and kidney transplantation. The topic of kidney transplantation is addressed elsewhere in the Encyclopedia. This entry discusses kidney dialysis. The two main techniques for kidney dialysis are hemodialysis and peritoneal dialysis. In hemodialysis, blood is pumped from a patient's body by a dialysis machine to a dialyzer a filter composed of thousands of thin plastic membranes that uses diffusion to remove waste products and then returned to the body. The time a hemodialysis treatment takes varies with the patient's size and remaining kidney function most patients are treated for three and one-half to four and one-half hours three times a week in a dialysis unit staffed by nurses and technicians. In peritoneal dialysis, a fluid containing dextrose and electrolytes is infused into the abdominal cavity this fluid, working by osmosis and...

Cardiovascular Disease

The risk of heart disease increases with a rise in cholesterol levels especially when other risk factors are present (17-19). Plasma total cholesterol was accepted as a causal factor (among multiple factors) by the World Health Organization (WHO) expert committee in 1982 and by the U.S. National Institute of Health Consensus Development Conference in 1985 (17). Diet and its effects on plasma cholesterol levels are discussed in the next section. Plasma triglyceride levels have also been correlated with increased risk of heart disease (17) and are associated with increased low-density lipoprotein (LDL) cholesterol levels. High blood pressure increases the risk of a stroke, heart attack, kidney failure, and congestive heart failure. When obesity, smoking, high blood cholesterol levels, or diabetes are also present, high blood pressure increases the risk of a heart attack or stroke severalfold.

Tissue injury by neutrophils

Kill microorganisms ingested by the neutrophil. Occasionally, however, these injurious products may be released to the extracellular space and cause tissue damage, for example if the perceived foreign body is too large for ingestion. In addition, antiproteinases normally present in the interstitial fluids can be inactivated by neutrophil-derived oxygen radicals, thereby enhancing the damage inflicted by neutrophil proteinases such as elastase, gelatinase and col-lagenase. Experimental proof for neutrophil-inflicted tissue injury is found in models of immune complex-induced dysfunction of various organs such as the Arthus reaction and nephrotoxic nephritis, among others.

New Points of Emphasis

The third edition includes a wide array of new titles ranging from Bioterrorism, Holocaust, and Immigration, Ethical and Health Issues of, to Artificial Nutrition and Hydration, Cancer, Ethical Issues Related to Diagnosis and Treatment, Dementia, Dialysis, Kidney, DNR Do Not Resuscitate, and sets of articles under Cloning and Pediatrics. Topic areas such as Reproduction and Fertility, Organ and Tissue Transplantation, Death and Dying, Ethical Theory, Law and Bioethics, Mental Health, Genetics, Religion and Ethics, and alike have been thoroughly redesigned, and are essentially new. As mentioned in the Preface, half of the third edition is entirely new, while half consists of deeply revised and updated articles from the earlier edition. There isn't a single article that was not thoroughly updated, even if only at the level of bibliographies, unless it is designated as classic.

Studies In Renal Disease

The individual response to treatment with ACE inhibitors is highly variable. 20 Therefore, several studies have been conducted in which the efficacy of ACE inhibitor therapy was studied in relation to ACE genotype in patients with kidney diseases (Table 2). Yoshida et al. 21 studied the response to ACE inhibitor therapy in 21 Japanese patients with IgA-nephropathy, who were treated with lisinopril (10 mg day). After 4 years of therapy, only patients with DD genotype showed a significant reduction in proteinuria. These results were confirmed by Moriyama et al. 22 in patients with various renal diseases and by Ha et al. 23 in patients with diabetic nephropathy. Those results are also consistent with a study performed by Perna et al. 24 Proteinuria, change of glomerular filtration rate, and progression to end-stage renal disease were effectively reduced by treatment with ramipril in patients with the DD genotype. Interestingly, ethnic background may play a very important role as...

TABLE 54 Triage Categories

Victims who have been trapped by rubble for several hours or days should be watched very closely for signs and symptoms of crush syndrome, such as cardiac arrhythmias, hyperkalemia, and renal failure. 6 ,61 Fulminant pulmonary edema or pneumonia from dust inhalation may also be a delayed cause of death for victims of building collapse.

Neonatal Resuscitation

Chronic renal disease Anemia Normal newborns are equipped with physiologic, pharmacologic, and metabolic responses to enable them to survive the hypoxia that develops as a consequence of asphyxia. Generally, brain injury occurs only when the asphyxia is severe enough to impair cerebral blood flow. Initially the injury is reversible, and only longer periods of ischemia lead to permanent damage. The pattern of injury is strongly influenced by the distribution of blood flow. During asphyxia, blood flow is redirected to the heart, brain, and adrenals at the expense of other organs, such as the kidneys and the gastrointestinal tract. Within the brain, flow is directed to the brainstem at the expense of the high cerebral structures, such as the cortex. In the preterm neonate, the periventricular white matter is susceptible to injury. In the full-term or postterm neonate, the gray-matter regions, such as the overlying parasagittal watershed cortex, are more vulnerable to ischemic injury....

Aluminum Deposition in Tissues

Most metals are deposited to a much greater extent than average in a few organs liver, kidneys, and skeleton. However, the proportion of the total body burden deposited in these is variable and depends on many factors, including the chemical properties of the ion and the age, sex, and metabolic status of the individual. The major site of deposition of aluminum is the skeleton. Skeletal deposits of aluminum have been demonstrated in normal bone using chemical analysis and are easily detected in bone from renal failure patients using histochemical staining techniques. Subsequently, aluminum remains on bone surfaces until it back-exchanges into tissue fluids, the bone surface is removed by osteoclasts, or the bone surface is buried by the apposition of new bone. These processes will result in the gradual loss of bone aluminum and in a transfer of aluminum from bone surfaces to the volume of the bone matrix. Such volume deposits are clearly seen in stained biopsy sections from dialysis...

Toxicity of Systemic Aluminum

The toxicity of aluminum has been extensively reviewed both by WHO and by the US Department of Health and Human Services. Exposure to aluminum at environmental levels produces no known adverse effects in man. There is little evidence to suggest that aluminum may produce adverse effects under conditions of chronic, excess, occupational exposure. Under conditions of high medical exposure, resulting in large aluminum body burdens, the metal is toxic. Aluminum intoxication is characterized by aluminum-induced bone disease (AIBD), microcytic anemia, and encephalopathy. Most information concerning these has been obtained by the study of dialyzed renal failure patients. These patients had lost their ability to excrete aluminum and accumulated large body burdens of aluminum by transfer of the metal from contaminated dialy-zates (most commonly tap water) during hemodia-lysis. The amount of transfer, and resultant body burdens, depended on the duration of treatment and the concentration of...

Evidence for a Role in Alzheimers Disease

The etiology of nonfamilial, sporadic AD is unknown. However, cases have been attributed to head injury and environmental factors, including aluminum. Involvement of aluminum in AD has been suggested because (1) of the similar symp-tomologies of AD and dialysis dementia (2) the administration of aluminum to animals produces histological changes within the brain that are, in some respects, similar to those seen in the brains of AD patients (3) of some reports indicating the presence of aluminum within the cores of senile plaques (4) of the results of some epidemiological studies that have linked AD incidence either with aluminum levels in drinking water or with its consumption as medicines and (5) a disease similar to AD is prevalent in some Pacific islands (Guam), where the levels of aluminum in soils and water are high. However, (1) the pathologies of AD and dialysis dementia are different (2) the histomorphological changes seen in experimental animals differ, in important respects,...

Cardiac Resuscitation And Outcomes

A potentially poor response to resuscitation can be expected for patients with metastatic disease, acute cerebrovascular accident, sepsis, renal failure, or pneumonia. Failure to respond to prehospital ALS protocols leads to a survival rate of less than 2 percent. The age of the patient also affects predicted survival rate, with a 0 percent survival rate for unwitnessed arrests of elderly patients 2 and for long-term care patients.3 Overall survival of victims of cardiac arrests, to hospital discharge, has been estimated to be between 0 and 16 percent.

ALS as an immunosuppressive agent

Treatment of rejections, and to treat steroid-resistant rejection. The mechanism of action is not fully clarified, but depletion of circulating lymphocytes does occur. This may result from either cytotoxic mechanisms or opsonization. The widest experience with ALS is from kidney transplantation, but ALS has also been used in connection with transplantation of small bowel, heart, bone marrow, liver, pancreas (or islet cells), cornea and skin.

TABLE 2314 Symptoms and Signs of Hypercalcemia

TREATMENT Up to one-third of patients with hypercalcemia have hypokalemia, and in those with malignant disease, more than half the patients may have hypokalemia. Some patients also have hypomagnesemia. The tendency toward hypokalemia and hypomagnesemia will be aggravated by diuresis and should be monitored carefully. A number of modalities are available to treat hypercalcemia (Xakleii2.3.-.1 i5). Mithramycin, calcitonin, and hydrocortisone should be used in severe cases. Mithramycin is a cytotoxic drug that suppresses bone resorption and calcium release from bone. It is infused over 3 h. It is particularly useful in patients with metastatic bone disease. Calcitonin is also an osteoclast inhibitor but less toxic than mithramycin. When used in conjunction with corticosteroids, resistance to calcitonin may be delayed. Glucocorticoids are useful in patients with sarcoidosis, vitamin A or D intoxication, multiple myeloma, leukemia, or breast cancer. They work by inhibiting bone resorption...

Introduction Clinical Setting

Immunoglobulin A (IgA) nephropathy was first described by the pathologist Jean Berger (1,2) and thus is sometimes called Berger's disease. Immunoglobulin A nephropathy is defined by the presence of IgA-dominant or co-dominant mesangial immunoglobulin deposits (Fig. 6.l) (3). Lupus glomerulonephritis, which may have IgA dominant or co-dominant deposits, is excluded from this diagnostic category. Immunoglobulin A nephropathy occurs as a primary (idiopathic) disease, as a component of Henoch-Sch nlein purpura small-vessel vasculitis, secondary to liver disease (especially alcoholic cirrhosis), and associated with a variety of inflammatory diseases including ankylosing spondylitis, psoriasis, Reiter's disease, uveitis, enteritis (e.g., Yersinia enterocolitica infection), inflammatory bowel disease, celiac disease, dermatitis herpetiformis, and HIV infection (4-6).

TABLE 2318 Causes of Hypermagnesemia

DIAGNOSIS Serum magnesium levels are usually diagnostic. The possibility of hypermagnesemia should be considered in patients with hyperkalemia or hypercalcemia. Hypermagnesemia should also be suspected in patients with renal failure, particularly in those who are taking magnesium-containing antacids, such as Maalox (see Ta_bie 2.3 18). TREATMENT The only treatment available is the immediate cessation of Mg 2+ administration. If renal failure is not evident, dilution by IV fluids followed by furosemide (40 to 80 mg IV) may be helpful. In symptomatic patients, 1 ampule (10 mL of 10 ) calcium gluconate or 5 mL of 10 IV CaCl2 (given over 5 to 10 min is appropriate). Patients with renal failure may benefit from dialysis against a decreased Mg 2+ bath that lowers serum Mg2+ levels. CHLORIDE (Cl-)

Scrum Crdefcifl 20 of ihc kxly vch total body Vdefkit

The total body Cl - should be repleted by giving 25 percent of the calculated Cl- deficit as KCl and 75 percent as NaCl. In the setting of renal insufficiency or failure, treatment options are more complicated in that NaCl administration may lead to volume problems and KCl may lead to hyperkalemia. The replacement method of choice, amino acid hydrochlorides or 0.1 N HCl, will lead to a non-anion-gap acidosis, worsening the underlying wide-anion-gap acidosis associated with renal failure.

Immunofluorescence Microscopy

The sine qua non for a diagnosis of IgA nephropathy is immunohistologic detection of dominant or co-dominant staining for IgA in the glomerular mesangium (Fig. 6.1). A caveat to this is that the staining for IgA should at least be 1+ on a scale of 0 to 4 + or 0 to 3+. Trace amounts of IgA are not definitive evidence for IgA nephropathy. The IgA is predominantly IgA1 rather than IgA2. Capillary wall staining is observed in about a third of patients, and is more common in Henoch-Sch nlein purpura nephritis (10). The mesangial immune deposits of IgA nephropathy stop abruptly at the glomerular hilum and are not observed along tubular basement membranes. Rare patients have IgA nephropathy concurrent with membranous glomerulopathy, and thus their specimens show granular capillary wall IgG staining and mesangial IgA dominant staining (13). tive feature of IgA nephropathy compared to other immune complex diseases is the predominance of staining for lambda over kappa light chains in many...

Troubleshooting a Persistently Hypotensive Patient

Treatment of a persistently hypotensive patient after maximal therapy can be a harrowing experience in the ED. The patient who has obvious trauma with ongoing hemorrhage, the reason is usually apparent, and the outcome is dismal if uncorrected. In medical cases of shock or in cases without ongoing hemorrhage, potential pitfalls should be rapidly reviewed. Is the patient appropriately monitored Is there malfunctioning arterial blood pressure monitoring, such as dampening of the arterial line or disconnection from the transducer Is the patient adequately volume resuscitated The early use of vasopressor will falsely elevate CVP and disguise hypovolemia. Is the intravenous tubing into which the vasopressors are running connected appropriately Are the vasopressor infusion pumps working Are the vasopressors mixed adequately Does the patient have a pneumothorax after that CVP placement Has the patient been adequately assessed for an occult penetrating injury (a bullet hole or stab wound) Is...

Clinical Features

The patient with evolving cardiogenic shock often will exhibit a rapid progression of findings indicating poor perfusion. Clinical evaluation, diagnostic testing, and treatment are initiated simultaneously. History from the patient is often blunted by the severity of the patient's condition, so family, EMS personnel, and medical records should supplement the patient's history. Key information includes current medications, allergies, and past history of MI, CHF, diabetes mellitus, and renal failure. Although the patient may experience chest pain, ischemic equivalents include profound weakness, shortness of breath, or a feeling of impending doom.

Interactions between the NMTs Are Common

Many of the results of the behavioral studies cited previously are interpreted as though a single NMT system was affected by the experimental drug. These interpretations are true in an approximate sense only. Even if drugs bind tightly and selectivity to a single receptor (they frequently do not), more than one neuroactive substance may be affected through simple postsynaptic effects and reuptake mechanisms. For example, if NA is infused into cortical tissue-containing cells and axon terminals of DA neurons, micro-dialysis of that tissue records increases in both NA and DA. The NA increase is expected since it was added by the experimenter. However, what caused the increase in DA The increase cannot be caused by the action of NA on receptors on dopaminergic cell bodies because none are present. The answer is that both NA and DA are recycled into the presynaptic terminal of the DA neuron, which causes the synaptic release of DA to increase. Thus, drugs applied by the systemic route are...

Case presentation 1 continued

Outpatient setting.26,27 Brown et al. randomized 194 patients with moderate-to-severe cellulitis to 2 g intravenous cefazolin daily or 2 g intravenous ceftriaxone daily, while both groups received probenecid 1 g orally.26 Outcomes were similar, 91-8 versus 92-7 clinical cure, with cost savings associated with the cefazolin group. However, the majority of patients were intravenous drug users with injection site infections, follow up was not complete and patients were given a prescription for penicillin and cloxacillin upon enrolment.26 Grayson et al. randomized 116 patients who presented with moderate to severe cellulitis to 2 g intravenous cefazolin and 1 g probenecid orally or 1 g intravenous ceftriaxone and placebo.27 Clinical cure rates were similar 86 in the cefazolin arm versus 96 in the ceftriaxone arm (P 0-11) and remained equivalent up to 1 month follow up, 96 versus 91 (P 0-55).27 Both studies excluded patients with penicillin allergies, septic patients requiring...

In Vitro Bioavailability Technique

In that they are less expensive, rapid, and amenable to high throughput analyses. Often, experimental in vitro methods involve an initial 'digestion phase' where the food is treated with acid and digestive enzymes to simulate the initial steps of food breakdown. The digestion phase is then followed by a second phase wherein the goal is to estimate the potential relative availability of a nutrient. This usually involves the measurement of the concentration of the soluble nutrient of interest in a supernatant of the digested food following centrifugation or after dialysis of the digested food products across a semi-permeable membrane designed to select only low-molecular-weight complexes. Variations on this theme include the addition of radioactive isotopes following the digestion phase and the in vitro measurement of cellular uptake of the nutrient in a cell culture preparation or some appropriate index of nutrient uptake. In the case of iron, for example, cellular synthesis of...

Clinicopathologic Correlations

Immunoglobulin A nephropathy is said to be the most common form of glomerulonephritis in the world (4). The prevalence of IgA nephropathy varies among different racial groups, with the highest prevalence among Asians and Native Americans, intermediate prevalence among Caucasians, and lowest prevalence among individuals of African descent (4). Immunoglobulin A nephropathy and Henoch-Schonlein purpura nephritis are twice as common in males as females. On average, Henoch-Schonlein purpura nephritis occurs at an earlier age than IgA nephropathy (9). The onset and diagnosis of IgA nephropathy usually is in late childhood or early adulthood, whereas Henoch-Schonlein purpura usually occurs in children younger than 10 years of age. Immunoglobulin A nephropathy can manifest any of the signs and symptoms caused by glomerular disease. The most common initial manifestations are asymptomatic microscopic hematuria or intermittent gross hematuria or both. Approximately 10 of patients present with...

Circumstances Leading to Deficiency

Disease, sudden infant death syndrome, renal dialysis, gastrointestinal diseases, and alcoholism. Studies of biotin status during pregnancy and of biotin supplementation during pregnancy provide evidence that a marginal degree of biotin deficiency develops in at least one-third of women during normal pregnancy. Although the degree of biotin deficiency is not severe enough to produce overt manifestations of biotin deficiency, the deficiency is sufficiently severe to produce metabolic derangements. A similar marginal degree of biotin deficiency causes high rates of fetal malformations in some mammals. Moreover, data from a multivitamin supplementation study provide significant albeit indirect evidence that the marginal degree of biotin deficiency that occurs spontaneously in normal human gestation is teratogenic.

Organic Phenolchloroform Extraction

Organic extraction involves the serial addition of several chemicals. First sodium dodecylsulfate (SDS) and proteinase K are added to break open the cell walls and to break down the proteins that protect the DNA molecules while they are in chromosomes. Next a phenol chloroform mixture is added to separate the proteins from the DNA. The DNA is more soluble in the aqueous portion of the organic-aqueous mixture. When centrifuged, the unwanted proteins and cellular debris are separated away from the aqueous phase and double-stranded DNA molecules can be cleanly transferred for analysis. Some protocols involve a Centricon 100 (Millipore, Billerica, MA) dialysis and concentration step in place of the ethanol precipitation to remove heme inhibitors (Comey et al. 1994). While the organic extraction method works well for recovery of high molecular weight DNA, it is time-consuming, involves the use of hazardous chemicals, and requires the sample to be transferred between multiple tubes (a fact...

Membranous Glomerulopathy

Membranous Glomerulopathy

Membranous glomerulopathy is a major cause of the nephrotic syndrome in adults (1,2). Only in the past decades has it been surpassed by focal and segmental glomerulosclerosis as the main cause of the nephrotic syndrome (3-5). Membranous glomerulopathy develops mostly idiopathically, but can also be seen in relation with and possibly secondary to, among others, hepatitis B, Sjogren's syndrome, transplantation, lupus erythematosus, diabetes mellitus, sarcoidosis, syphilis, exposure to certain drugs and heavy metals (penicillamine, bucillamine, gold, mercuric chloride), and malignancies (10 ), including carcinomas, carcinoids, sarcomas, lymphoma's, and leukemias (2,6-10). The possibility of a malignancy must be considered especially in older patients with membranous glomerulopathy. In these patients it is also imperative to perform urinary immunoelectropho-resis routinely to rule out myeloma and renal primary amyloidosis (AL) (2). Finally, idiopathic membranous glomerulopathy, of which...

Clinical Use of Advance Directives

Although it is best to gain a consensus of all the interested parties, especially about forgoing life-sustaining treatment, ultimately a named proxy has the final decision. Healthcare providers who wish to override proxies based on a patient's written advance directive should be wary. It is not clear that all patients would want their proxy's or loved one's wishes overruled. Because people often write advance directives to relieve family members of the burden of decision making, the patient may not have wanted it followed if doing so would cause tremendous anguish. In a 1992 study, Ashwini Sehgal and colleagues found that over half of a group of dialysis patients thought their doctors or proxies should have at least some leeway to interpret their advance directive. Rather than taking unilateral actions against the wishes of proxies, healthcare providers might be best off consulting with the hospital ethics committee.

Central Venous Catheter

Common sense applies, and all treatment teams should cooperate in the care of patients with tenuous IV access. For example, a patient in chronic renal failure with an infected dialysis catheter should have hemodialysis prior to removing the line, and a plan in place to reinsert a new catheter prior to the next dialysis session.

Healthcare of Older People

The nature of illness in older people greatly influences the ethical issues in their healthcare. Older people have a higher burden of illness than younger people. On average, they are likely to have several chronic medical conditions, be on multiple medications, and have frequent encounters with the healthcare system, including more hospitalizations. Because older people are closer to the end of their life expectancy, they have a greater chance of being involved in situations where difficult healthcare decisions must be made. Decisions about the appropriate use of life-sustaining medical treatment for older patients are commonplace. These range from Do-Not-Resuscitate (DNR) orders, to decisions to discontinue dialysis, to decisions about withholding or withdrawing artificial nutrition and hydration. Many, if not most, deaths in healthcare institutions in the United States are preceded by explicit decisions to limit treatment. These treatment limitation decisions, more properly viewed...

Pathogenetic implications

Bence Jones proteins play a direct role in myeloma-associated kidney disease and their measurement is of important prognostic significance. They are also involved in visceral diseases featuring tissue deposition of LC-related material. Combined study of serum and urine by sensitive methods reveals evidence of BJP in almost all cases of AL (amyloid light chain) amyloidosis. In LC deposition disease, tissue deposits of monoclonal LC (and of monoclonal heavy chains in some patients) correlate with the presence of a monoclonal population of bone marrow plasma cells, whatever the clinical context. In some cases, the LC are normal-sized and present in urine but in about 60-70 of patients they display an abnormal (short or enlarged by glycosylation) size, polymerize and are undetectable in serum and urine. In both instances there are numerous mutations in the variable (V) regions of the LC, especially in the hypervariable regions (with probably a direct pathogenic role), together with an...

TABLE 474 Some Nonatherosclerotic Etiologies of Acute Myocardial Ischemia

Dyskinesis, the paradoxical expansion of infarcted tissue, occurs during systole. With increasing size of the infarcted myocardium, left ventricular pump function decreases. Left ventricular end-diastolic pressure increases and left ventricular end-systolic volume increases. Cardiac output, stroke volume, and blood pressure may decrease. When left atrial and pulmonary capillary wedge pressures increase, congestive heart failure may develop. Poor perfusion to the brain and kidneys can result in altered mental status and impaired renal function, respectively.

Thin Basement Membranes Introduction Clinical Setting

This basement membrane abnormality has also been described as benign familial hematuria, and shows autosomal dominant or recessive inheritance (12-14). The clinical manifestation is that of chronic hematuria, either macroscopic or microscopic, intermittent or continuous. This lesion is common, and is present in 20 to 25 of patients biopsied for persistent isolated hematuria in some series, and may occur in more than 1 of the general population (17). The lesion may also coexist with other glomerular disease, commonly diabetic nephropathy or IgA nephropathy (18,19). Occasionally patients with thin basement membranes have nephrotic range proteinuria, with five of eight such cases in one series showing additional focal segmental glomerulosclerosis (FSGS) lesions (20).

Individuals with chronic disease

Transplant surgery, like all major surgeries, leads to short periods of immune suppression during which the patient may be at increased risk for infection (Cryer, 2000). Graft survival rate has greatly improved since the introduction of cyclosporine. However, pharmacological suppression of the immune system can lead to infection, a leading cause of mortality in kidney transplant patients

The case of outcomes report cards

Some critics contend that the trend is confounded by two factors. More assiduous coding of risk factors would artefac-tually increase the overall expected mortality, and surgeons could generate better mortality profiles by selectively turning down high-risk patients, even though such patients may have most to gain from CABG. There has indeed been a striking increase in the prevalence of various reported risk factors in the New York database since its inception. For example, prevalence of congestive heart failure rose from 1-7 in 1989 to 7-6 in 1991 renal failure rose from 0-4 to 2-8 , chronic obstructive pulmonary disease (COPD) from 6-9 to 17-4 and unstable angina from 14-9 to 21-8 in the same period.105 As well, a survey106 of randomly selected cardiologists and cardiac surgeons in Pennsylvania found that about 60 of cardiologists reported greater difficulty in finding surgeons who would operate on high-risk patients a similar number of surgeons reported that they were less willing...

Laboratory and Radiologic Tests

After collecting the medical history and performing the physical examination, the next step will be to decide which blood work and radiologic tests would aid in diagnosis. When ordering blood work, one should begin to think about whether the patient may need to go to the operating room. If so, what laboratory and diagnostic tests should be done to prepare the patient for surgery General blood work should be ordered, including a CBC to allow for assessment of leukocytosis or blood loss. An electrolyte panel (i.e., Chem 7, OP7) will give information regarding potential electrolyte abnormalities especially in vomiting and dehydrated patients, or those with medical comorbidities such as renal failure. If there is a question of hepatic compromise, a liver panel should be added. Checking a coagulation panel in older patients will help assess whether the patient is at risk for bleeding intraoperatively and also give an idea of the patient's hepatic synthetic function. If the patient presents...

Renal Anatomy and Basic Concepts and Methods in Renal Pathology

Escape of THP from within the nephron into the interstitium and peritubular capillaries has been documented to occur with tubular wall disruption. There are four major mechanisms proposed for this finding (1) increased intranephron pressure (reflux, obstruction), which can cause rupture of the tubular wall and spillage of contents locally (2) destruction of tubular walls by infiltrating leukocytes (as in any acute interstitial nephritis) collagenases produced by infiltrating cells, especially monocytes, can dissolve basement membranes and concomitant epithelial cell damage can result in tubular wall defects (3) in acute tubular necrosis (especially of ischemic type) both cell death and basement membrane loss have been described interstitial and capillary and venous THP is uncommonly observed and (4) intrinsic defects of tubular basement membranes (as in juvenile nephronophthisis), which likely result in loss of compliance of tubular walls and, in addition to...

Diagnosis Of Valvular Heart Disease

DIAGNOSING A NEWLY DISCOVERED MURMUR The first step in diagnosing a newly discovered murmur is to consider it in the context of the patient's medical condition. Patients with normal cardiac anatomy may have murmurs associated with anemia, thyrotoxicosis, sepsis, fever, renal failure with volume overload, pregnancy, and other clinical conditions. A diastolic murmur or a new murmur associated with symptoms at rest should always be considered abnormal and warrants referral for a workup and possible echocardiographic study and admission. Figure, 50.-.1. presents an algorithm for the clinical assessment of a newly discovered systolic murmur. The algorithm, based on the work of Etchells and colleagues,8 presents a step-by-step method of assessment to uncover an abnormal murmur. Each murmur category lists characteristics or maneuvers that have been shown to predict the presence of the named abnormal murmurs. The studies referred to by Etchells and colleagues have used cardiologists as...

Renal Disease Applied Physiology

The kidneys excrete water, electrolytes, water-soluble drugs and water-soluble products of metabolism. Plasma electrolytes, urea and creatinine provide an indication of renal function. While the plasma urea also depends on liver function, the creatinine concentration also depends on the level of protein metabolism in the body. For the plasma creatinine to rise, renal function must be < 30 of normal. As renal function is reduced below this the creatinine and urea will rise, as will the plasma potassium concentration. Water is retained and the production of new red cells is depressed by reductions in erythropoietin secretion. Acidosis develops, compensated by respiratory alkalosis and cardiac output increases. In established chronic renal failure the haemoglobin may fall to 5-6 g dl with a creatinine concentration > 700 mmol 1 and potassium > 6 mmol l. In the early stages of the disease some improvement may be possible by correction of the precipitating cause and by careful...

Constrictive Pericarditis

PATHOPHYSIOLOGY Constrictive pericarditis is pathologically distinct from acute pericarditis. 18 Following pericardial injury and the resultant inflammatory and reparative process, fibrous thickening of the layers of the pericardium may occur. This fibrous reparative process is most commonly encountered after cardiac trauma with intrapericardial hemorrhage, after pericardiotomy (open-heart surgery, including coronary revascularization), in fungal or tuberculous pericarditis, and in chronic renal failure (uremic pericarditis). When the fibrous and or collagenous response prevents passive diastolic filling of the normally distensible cardiac chambers, constriction is said to be present. Intrapericardial fluid is not required to produce such a hemodynamic effect. By its nature, constrictive pericarditis is most commonly a clinically chronic process. However, clinical manifestations may occur early if fluid also accumulates within the thickened, noncompliant pericardial sac (so-called...

Etiology Pathogenesis

Numerous studies indicate that autosomal recessive Alport's syndrome and benign familial hematuria thin basement membrane disease may represent a spectrum of severe to mild or carrier forms, respectively, of varying molecular defects in the same genes. Linkage of hematuria to mutations in either a4 type IV or a3 type IV has been documented in about 40 of kindreds with apparent thin basement membrane nephropathy clinically (17,21-23). In remaining kindreds without apparent linkage, de novo mutations or incomplete penetrance of the hematuria phenotype is proposed to occur. In one study of patients with thin basement membranes, there was

Selection Of An Antihypertensive Agent

The following section outlines therapies for hypertensive emergency and urgency. For those patients in an ambulatory setting, Table53 2. summarizes guidelines for the selection of an antihypertensive agent for patients with various coexisting conditions. 14 Diuretics should be one of the agents of first choice in patients with renal disease and congestive heart failure who are judged to be volume overloaded. Because of their greater prevalence of stage 3 hypertension (systolic pressure of 180 mmHg or more, and diastolic pressure of 110 mmHg or more), African American patients may require multidrug therapy. For treatment of patients with angina pectoris or postmyocardial infarction, b blockers are indicated. They are also indicated for those patients with a history of migraines, atrial fibrillation with rapid ventricular response, paroxysmal supraventricular tachycardia, and senile tremor. The use of b blockers is safe in the latter part of pregnancy, but their use should be avoided in...

Sodium Nitroprusside Nipride

SIDE EFFECTS AND CONTRAINDICATIONS The most common complication is hypotension. Prolonged infusions may lead to the rare complications of cyanide toxicity, which may occur in patients with hepatic dysfunction, and thiocyanate toxicity, which is associated with renal failure. 15 This rarely occurs in the ED. Because nitroprusside inhibits hypoxia-induced vasoconstriction in the pulmonary vasculature, there may be increased perfusion to nonventilated areas of the lung. Myocardial ischemia may be worsened by a coronary steal syndrome because of dilation of coronary arteries or by the combination of nitroprusside and clonidine. Another consequence of the vasodilatory effect of nitroprusside is increased intracranial pressure.

Special Investigations

Computerized tomography (CT) is more sensitive in demonstrating subcutaneous and retroperitoneal gas and fluid collections, but the use of contrast should be avoided in patients with renal failure. Magnetic resonance (MR) is the most sensitive imaging modality for evaluating pathology in soft tissues, but is expensive and not readily available.

Where databases do not help

Good clinical judgement is essential for the appropriate use of databases. Consider a further scenario, using Laurence-Moon-Biedl (LMB) as an example. A patient has the following features mental retardation, post-axial polydactyly, obesity, retinal dystrophy, scoliosis and renal cysts. The patient appears to have the LMB syndrome but has, in addition, a severe scoliosis. If the user includes this feature in the search, as well as all the more usual features, the correct diagnosis cannot be made by the computer, because the feature list attached to the LMB syndrome does not contain scoliosis. Is this therefore LMB If most of the other cardinal features are present, yes but this is a matter for clinical judgement. When a patient has, for instance, two extra malformations not previously recorded, it becomes difficult to know whether or not one is dealing with a new syndrome.

Postoperative Management

The wound should be inspected daily, and the surgeon should have a low threshold for redebridement. A mean of 2.5 debridements per patient is reported in the literature (Baskin et al. 1990 Corman et al. 1999). Bacterial culture results should be checked to make sure that appropriate antibiotic therapy is given. If the patient is in renal failure, aminoglycosides should be avoided and a third- or fourth-generation cephalosporin should be given.

Prostaglandins Thromboxanes and Other Arachidonic Acid Metabolites

When renal function is under the influence of vasoconstrictor stimuli (catecholamines, renal nerve activation, and ANG II), production of endogenous prostaglandins is increased and these agents partially counteract the vasoconstrictor effects 1, 28 . In this manner, prostaglandins take on a greater regulatory role in pathophysiologic conditions that compromise renal hemodynamics. Prostaglandin production is enhanced under several conditions such as acute renal failure, following hypotensive incidents, treatment with diuretics and immunosuppressive agents, or during compromised circulatory function. In particular, during long-term diuretic treatment, renal hemodynamic function may become more dependent on vasodilatory prostaglandins. Under such conditions, the blockade of prostaglandin formation with nonsteroidal antiinflammatory drugs (NSAID) may leave unopposed the vasoconstrictor influences of coexisting elevated levels of ANG II and catecholamines, leading to reductions in...

Kallikrein Kinin System

Kallikreins are serine protease enzymes that act on kininogens (a2-glyco-proteins) to form bradykinin and kallidin, which have powerful vasodilator and natriuretic actions. Their vasodilator action is mediated, in part, by their effects on endothelial cells to stimulate NO formation and release. Infusion of bradykinin intravenously or into the renal artery increases RBF and sodium excretion with lesser effects on GFR. Renal kallikrein is produced by the distal nephron and released into the lumen and interstitium, where kinin formation occurs. The tubular lumen is a primary site of intrarenal kinin formation, suggesting that one major role of kinins is to regulate tubular transport function. Kinin degradation occurs through the action of kininase II, which is identical to ACE therefore, some of the effects of ACE inhibitors (increase in RBF, sodium excretion, and urine flow) may be due to kinin accumulation. The effects of kinin blockade on normal kidney function, however, are...

Clinical Presentation and Echocardiography Findings

In the study by Di Salvo 18 age was not found to be corelated to the echocardiographic presentation of endocarditis, nor was age related to the incidence and localization of embolic events regardless to the pathogen involved. Elderly patients were operated on as frequently as younger patients and their operative risk of dying and complications was similar to that of younger patients (11 , 3 and 5 in groups C, B and A, respectively). In two reports however, renal failure, as a complication of endocarditis was more common in the elderly patients compared to younger patients 21,22 . An additional report 23 documented decreased use of echocardiography in the aged despite the fact that perivalvular complications were more common in this age group.

Pharmacological management

The two single dose studies of diamorphine and dihydrocodeine respectively in patients with chronic heart failure suggest improvement in abnormal ventilatory patterns. The pilot study was a randomized placebo controlled cross-over study of 10 patients with NYHA III IV symptoms.43 Patients were recruited from a heart failure clinic and randomized to receive oral morphine or placebo. Patients were given 5mg of morphine four times a day in the active arm, or dose reduced to 2.5mg four times a day if the serum creatinine was greater than 200mcmol l. Patients with a peak flow less than 150l min or a serum creatinine greater than 300mcmol l were excluded. On morphine, median breathlessness score (Visual Analogue Score 0 - 100mm) fell by 23mm (p 0.022) by day 2, and this improvement was maintained. Sedation scores increased until day 3, reducing on day 4. Four patients reported constipation on morphine compared with one on placebo, but there were no other differences between the two arms in...

Treatment and Outcome

In a report by Netzer et al. 21 , 82 younger patients (17-59 years) were compared to 53 elderly patients (65-90 years). There were no significant differences between the two groups regarding co-morbidities or clinical presentation except that renal failure was more common in the elderly. Mortality was significantly higher in the elderly patients 13 (25 ) vs. 9 (11 ) respectively, P < 0.04 . average of 12 days longer compared to the younger patients. The occurrence of renal failure and cerebral embolism during an episode of infective endocarditis was associated with higher rates of death (odds ratios, 4.8 and 4.0, respectively). Age, however, was not a significant contributor to mortality. These results differ from the other authors' sited above. It is important to note that in this group of patients the rate of enterococcal endocarditis and S. bovis endocarditis were not significantly higher in the elderly and this peculiarity might explain the lack of difference in outcomes between...

Pulmonary Angiography

Pulmonary angiography remains the gold standard for accurately diagnosing PE. The disadvantages include patient discomfort, cost, and complications. Pulmonary angiography has excellent interobserver reliability the PIOPED study found that review of study angiograms by another radiologist reached the same diagnosis in 96 percent of cases.8 Complications of pulmonary angiography include (1) fatalities in 0.5 percent, (2) major nonfatal complications such as renal failure, significant hematoma, or respiratory distress in 17 percent, and (3) minor complications such as angina, urticaria, or bronchospasm in 5 percent. 8

Cardiac assist devices

Scientists and physicians in many countries have dreamed for centuries of curing fatal heart diseases by creating a mechanical substitute. Technological advances during the 1960s in engineering fields such as metallurgy, fluid dynamics, electronics, and computer modeling made some scientists think that it might be possible to actually construct such a device. The emergence of the kidney dialysis machine, which could mimic the functions of a human kidney, created a fundamental change in attitude in medicine about the feasibility of building an artificial heart. In the late twentieth century, the quest for the Totally Implantable Artificial Heart (TAH) was once again the catalyst for other technological advances except for the TAH, the success of the artificial heart program to date is still up for debate.

The Artificial Heart Goes Private

In 1976, Willem Kolff (a physician and the inventor of kidney dialysis and one of the first artificial hearts) and some of his Utah colleagues formed a private company, Kolff Medical Associates, to attract venture capital to support their research. In order to interest private investors, they had to create a marketing program for their mechanical heart. The decision to proceed with a private company constituted a first step into the emerging and often ethically controversial world of public-private partnerships intended to advance medical research.

Dehydration and Human Performance

Natives of desert regions have, over the years, habituated to being chronically dehydrated. A study of the desert inhabitants found that they had a curtailed thirst drive that was associated with excretion of low volumes of concentrated urine and a high incidence of kidney disease (kidney stones). When additional water intake (approximately twice normal) was ingested in a subsample of this population, they were able to exercise 10 longer in the desert environment, presumably due to improved thermoregulation. The results of this and other studies illustrate that humans probably do not adapt to dehydration but can become used to a mild chronic dehydration due to inadequate fluid intake. This is not a true physiological adaptation since there are negative health and performance effects associated with chronic dehydration.

Drug Usage in Peri Arrest Arrhythmias

Iatrogenic complications of CPR are relatively common and may pose post resuscitation problems. Rib and sternal fractures occur frequently. Other complications of chest compressions may include visceral trauma (usually liver) and cardiac trauma. Complications related to poor airway and ventilatory management are inhalation of gastric contents, inadvertent oesophageal intubation and rarely gastric rupture. Other post arrest problems (not necessarily caused by CPR) are pulmonary oedema, recurrent cardiac arrest, cardiogenic shock, renal failure and adverse neurological outcome. Figure RS.12 shows examples of ECG tracings.

Annotation of the Hupo Ppp core datasets

One of the aims of the HUPO initiatives, as noted in the Section, is to link organ-based proteomes (liver, brain) with detection of corresponding proteins in plasma, and with proteins that are mediators, or at least, biomarker candidates, ofinherited or acquired diseases. Using the Online Mendelian Inheritance in Man (OMIM), we found 338 of our 3020 IPI proteins that match EnsEMBL genes in OMIM, including RAG 2 for severe combined immunodeficiency (SCID) Omenn syndrome, polycystin 1 for polycystic kidney disease (PKD), and BRCA 1, BRCA 2, p53, and APC for inherited cancer syndromes.

Prevention of Dehydration

Simple methods, such as recording body weight before and after exercise to determine fluid loss and observing the color of urine or the turgidity of skin, can be useful for monitoring hydration status. The simplest insurance against dehydration is to consume fluids prior to and during physical activity or heat exposure to match water loss. The amount of fluid needed to maintain a favorable hydration status is variable between individuals but often necessitates drinking in the absence of thirst. Excess fluid consumption is rarely a problem. However, caution should be used to avoid dilutional hyponatraemia from overzealous hydration. Humans can acclimate to work in a hot environment and enhance their ability to thermo-regulate and conserve fluid, but they cannot adapt to dehydration. Acute dehydration can decrease physical performance and thermoregulation ability and increase the risk for heat illness. Chronic dehydration can reduce metabolic and thermore-gulatory efficiency and...

Renal replacement therapy

When the kidneys ultimately fail, RRT is needed. There are generally two forms of RRT utilized in the intensive care setting hemodialysis and hemofiltration. In hemodialysis, blood is pumped through a semi-permeable filter which is bathed in a dialysate fluid. Electrolytes and fluid move down a concentration gradient into the dialysate fluid and it is removed, carrying off potassium, phosphate, urea, water, etc. Hemodialysis utilizes rapid blood flow rates over a 2-4 h duration and is performed on a daily or every other day basis. As such, it is felt to be associated with hemodynamic instability and large fluid shifts, which may not be tolerated in an unstable patient. That being said, slower forms of dialysis (sustained low-efficiency dialysis, SLED), which occurs over a longer time period, up to 12 h, is now being utilized in some centers. Peritoneal dialysis is generally not utilized in the ICU. Hemofiltration was initially done by withdrawing blood from the arterial side and...

Materials and Methods Patients

The indications for RF ablation were conditions that rendered surgery highly risky because of pulmonary or cardiovascular diseases, absence of response to chemotherapy or immunotherapy, presence of a solitary kidney, or von Hippel-Lindau disease (VHL). The latter group of patients often present with RCCs at a young age and develop multiple and bilateral RCC tumors that result in multiple resections, total nephrectomy, and finally the need for dialysis 22 . Two board-certified interventional radiologists in collaboration with one experienced urologist evaluated all patients to determine their suitability for RF ablation. Thus, five patients with a solitary kidney and two patients with VHL were included in this study. In all patients, preoperative routine examination showed that the prothrombin time, partial thromboplastin time, and complete blood count were within normal limits.

Control of Blood Glucose Level

Irrefutable evidence exists that better control of blood glucose concentration reduces the risk of developing long-term complications from diabetes. This is especially true of microvascular complications such as retinopathy (eye disease), nephropathy (kidney disease), and nerve damage in both type 1 and type 2 diabetes. Control of blood glucose also reduces the risk of macrovascular disease (heart disease, stroke, and peripheral vascular disease), although the contribution of blood glucose to these complications is less strong.

Prevention or Control of Comorbidities

Morbidity and mortality among people with diabetes are rarely due to acute hyperglycemia or diabetic ketoacidosis. Rather, the long-term complications are either specific to diabetes (e.g., diabetic retinopathy or nephropathy) or accelerated by diabetes (e.g., atherosclerosis). Diabetes significantly increases the risk of coronary artery, cerebro-vascular, and peripheral vascular disease, with these cardiovascular complications accounting for approximately 80 of deaths in diabetes. Prudent dietary management of diabetes therefore requires consideration of what can be done to prevent or control the various comorbidities of this disease. For example, all people with diabetes should be on a diet that minimizes the risk of atherosclerosis. At the first clinical sign of hypertension, dietary methods should be implemented to lower blood pressure.

Methods 21 Pervaporation

Pervaporation is defined as a separation technique in which a liquid feed mixture is separated by partial vaporization through a nonporous permselective (selectively permeable) membrane (11). Transport phenomena in pervaporation are different when compared to any other membrane processes such as dialysis, reverse osmosis, and ultrafiltration because of multiple interactions

TABLE 827 Diagnosis and Treatment of Spontaneous Bacterial Peritonitis

Occasionally patients present with refractory and incapacitating ascites as a primary complaint. Associated symptoms include extreme fatigue, increased respiratory effort, and orthopnea. These individuals often have failed maximal diuretic therapy and have undergone high-volume paracentesis in the past. Before performing this procedure, it is useful to consult with the patient's primary care provider or hepatologist to review a protocol. As much as 6 to 8 L of ascitic fluid can be drained over a 60- to 90-min interval with the concomitant peripheral infusion of albumin (6-8 g L of ascites collected). Many practitioners believe the albumin infusion is unnecessary when peripheral edema is present because mobilization of edema fluid attenuates intravascular volume loss. Complications of the procedure are not infrequent and include hemorrhage, infection, acute renal failure, and hemodynamic compromise. Such patients may be ideal candidates for an observation unit or short-stay...

TABLE 833 Laboratory Utilization in Suspected Acute Pancreatitis

Amylase levels are expressed in either Somogyi units (SU) or international units, with the normal ranges generally reported as 60 to 160 SU 100 mL or 110 to 300 IU L, respectively.8 Amylase has a half-life of about 2 h and, although the elimination is incompletely understood, it is at least partially cleared by the kidneys, leading to elevated levels in renal failure. Lipase This enzyme, which catalyzes the breakdown of triglycerides into free fatty acids, is predominantly found in the pancreas, but lipase activity is present in the gastric and intestinal mucosa and in the liver. An elevated serum lipase level has been noted in a number of nonpancreatic diseases, most of which are intestinal or hepatobiliary disorders. 71 Heparin may cause a release of endothelial membrane-bound lipase into the serum, resulting in a measurable increase in lipase activity within minutes of heparin administration. Lipase is cleared by the kidneys and can be elevated to three times the upper limit of...

Pathological Characteristics

The pathogenesis of cerebral aneurysms is incompletely understood but is likely complex and multi-factorial involving a congenital predisposition and superimposed environmental factors. Evidence for a congenital component arises from observations of familial cases and the increased incidence ofaneurysms in disorders such as autosomal-dominant polycystic kidney disease, fibromuscular dysplasia, aortic coarc-tation, and connective tissue disorders such as Mar-fan's syndrome and Ehlers-Danlos syndrome. In support of an environmental component, data reveal a clear age-related component (increased incidence with increasing age and rarity of aneurysms in children) and the de novo development and or growth of aneurysms after unilateral carotid occlusion. Additionally, cigarette smoking has been consistently reported to confer predisposition to aneurysmal SAH in large series across different populations. Furthermore, injury to the vessel walls by various insults, such as infection, trauma,...

Hematologic Complications

ANEMIA Anemia in ESRD patients is of multifactorial origin, secondary to decreased erythropoietin, blood loss from dialysis, and decreased red blood cell survival times. In addition, wide fluctuations in plasma blood volume seen in dialysis patients often cause factitious anemia. Without treatment, the hematocrit in ESRD patients will usually stabilize at 15 to 20 percent, with normocytic and normochromic red blood cells. Bone marrow will show erythroid hypoplasia with little effect on leukopoiesis or megakaryocytopoiesis. Management of anemia is by the infusion of human recombinant erythropoietin on a regular basis. Erythropoietin replacement therapy has markedly improved the quality of life for ESRD patients by increasing exercise capacity and tolerance. An increase in blood pressure has been reported in approximately 30 to 35 percent of patients receiving erythropoietin. NEUTROPHIL DYSFUNCTION Immunologic deficiency in ESRD patients produces a high mortality rate from infectious...

Historical Background

An understanding of the emergence of bioethics will help to capture the panoramic breadth and complexity of the field. The 1960s is a pertinent point of departure, even though there were portents of the new field and issues in earlier decades. That decade brought into confluence two important developments, one scientific and the other cultural. In biomedicine, the 1960s was an era of extraordinary technological progress. It saw the advent of kidney dialysis, organ transplantation, medically safe abortions, the contraceptive pill, prenatal diagnosis, the widespread use of intensive-care units and artificial respirators, a dramatic shift from death at home to death in hospitals or other institutions, and the first glimmerings of genetic engineering. Here was a truly remarkable array of technological developments, the palpable outcome of the great surge in basic biomedical research and application that followed World War II. At the same time, stimulated by Rachel Carson's book Silent...

Chapter References

Hakim RM, Lazarus JM Initiation of dialysis. J Am Soc Nephol 6 1319, 1995. 7. Russo DB, Memoli B, Andreucci VE The place of loop diuretics in the treatment of acute and chronic renal failure. Clin Nephrol 38(suppl 1) S69, 1992. 8. Eiser AR, Lieber JJ, Neff MS Phlebotomy for pulmonary edema in dialysis patients. Clin Nephrol 47 47, 1997. 11. Pastan S, Bailey J Dialysis therapy. N Engl J Med 338 1428, 1998. 15. Viglino G, Cancarini G, Catizone L, et al Ten years of continuous ambulatory peritoneal dialysis Analysis of patient and technique survival. Perit Dial Int 13(suppl 2) S175, 1993. 17. Twardowski ZJ, Prowant BF Current approach to exit-site infections in patients on peritoneal dialysis. Nephrol Dial Transplant 12 1284, 1997.

The case of the Scottish academic nephrologist

In mid-1992, the major international company, Pfizer, decided to conduct a double blind placebo-controlled parallel group clinical trial assessing the safety and efficacy of a new medicine in patients with heart failure and impaired renal function, inadequately controlled on the treatment that they had been taking, unaltered, for at least eight weeks.13

Effectiveness Azathioprine

All of the immunosuppressants currently available carry potentially serious side-effects such as kidney damage (ciclosporin), bone marrow suppression (azathioprine), osteoporosis (systemic steroids) and skin cancer (photochemotherapy). These are described in more detail in the systematic review. It is difficult to make any statements about how useful these drugs are in comparison with one another because the impact of these adverse effects (for example azathioprine-induced bone marrow toxicity) can be predicted by tests beforehand and others (for example kidney damage with ciclosporine) can be identified at an early stage before any permanent damage has occurred. The relative efficacies of systemic immunosuppressants are therefore contingent upon the way they are used.

Complications Of Urologic Procedures

Urologic surgical procedures are being more commonly performed with outpatients or with inpatients who are discharged from the hospital earlier in their postoperative course. Ihus, patients often come to the emergency department with complications common to these urologic surgeries urinary tract infection (UII), acute renal failure (ARF), wound infection, urinary retention, pain, and fever. Whenever possible, the urologist who performed the original operation should be contacted when one of their patients comes to the emergency department with a complication from the procedure.

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