Kidney Problems Diet

Kidney Function Restoration Program

You'll Learn: This Delicious Super Food Straight From Your Fridge is Loaded With Special Compounds that reverse free radical kidney cell damage. This food (freely available from a grocery store near you) has tremendous antioxidant activity. Antioxidants soak up and destroy free radicals. Free radicals are what cause much of the damage in inflammatory, degenerative and kidney diseases. The Popular Test Used By Korean Doctors which is barely used in America to check for potent kidney destroying toxins. Ridding your kidneys of these toxins is very easy but you first have to discover if you have them. The Essential Fatty Acid has shown in hundreds of people through multiple studies to put out inflammation and correct heart complications seen in kidney disease. This Miracle Nutrient Featured in the prestigious medical Journals of Nephron, Clinical and Experimental Nephrology, Renal Physiology and other double blind studies to produce significant results in reversing kidney problems, lowering blood pressure and study participants reported a boost in energy and focus. This Naturally Occurring Amino Acid Discovered by Russian scientists in the 1920s and published in over 100 studies worldwide has shown to slow down and possible stop kidney disease, improve your red blood cells (which are malfunctioning in renal disease), and increase mood and decrease fatigue. The National kidney Disease Foundation recommends suffers of renal disease get tested and supplement their diet with this nutrient. But very few medical professionals are actually doing this. The Delicious Tropical Fruit that is cultivated in the Caribbean, South America, Asia, Australia and parts of Africa that is toxic and poisonous to an injured kidney. If you have any decrease in kidney function you must stay far away from this fruit that is abundant in the spring and summer seasons. Read more here...

Kidney Function Restoration Program Summary


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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...

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

Meningioma Cell Line Picture

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...

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.

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...

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...

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...

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...

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.

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...

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.

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...

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...

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...

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...

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.

Renal Failure

Blood pressure and renal function are intrinsically related. Hypertension may cause acute renal failure or exacerbate chronic renal failure, whereas renal disease may result in hypertension. In patients with renal disease, the control of hypertension can delay the progression of further injury. Worsening renal function in the setting of elevated pressure, with elevation of BUN and creatinine levels, proteinuria, or the presence of red cells and red cell casts in the urine, is considered a hypertensive emergency that requires immediate reduction of blood pressure. Nitroprusside is the preferred agent in these cases. Patients who have known renal failure and are dialysis dependent and have volume overload may require emergent dialysis if they present with uncontrolled hypertension with other evidence of end-organ dysfunction.

Acute Renal Failure

If there is doubt about the cause of the renal failure, central venous pressure and pulmonary capillary wedge pressure measurements can be helpful. The presence of postobstructive uropathy above the urinary bladder can be confirmed using abdominal ultrasound. When no prerenal or postrenal cause can be identified, there is likely to be an intrinsic cause of ARF.


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...


Diabetic nephropathy is one of the leading causes of end-stage renal disease. Approximately one-third of new cases of renal failure each year are due to diabetic nephropathy. Incidence approaches 40 percent lifetime in type 1 diabetes and 4 to 20 percent in type 2 diabetes. Since the overwhelming majority of diabetics are type 2, most patients with nephropathy will have this form of the disease. Hyperglycemia leads to glomerular hypertension and hyperfiltration, which in turn lead to deposition of protein in the mesangium. These protein deposits ultimately lead to sclerosis of the glomerulus and to renal failure. Intensive insulin therapy as practiced in the DCCT reduced by 60 percent the frequency of microalbuminuria, the clinical herald of diabetic nephropathy. In addition to being a marker for nephropathy, albuminuria has also been shown to correlate with high risk for coronary ischemic events. Angiotensin-converting enzyme (ACE) inhibitors have been shown to delay both the onset...

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...

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...

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...

Etiology Pathogenesis

There is compelling in vitro (14) and animal model (15,16) experimental data showing that ANCA IgG causes glomerulonephritis and vasculitis, probably by direct interaction with neutrophils (and possibly monocytes) resulting in activation with release of lytic enzymes and reactive oxygen radicals that cause the inflammatory injury to glomeruli and vessels. Strong clinical support is provided by the observation that a neonate developed pulmonary hemorrhage and nephritis following transplacental transfer of maternal MPO-ANCA IgG (17).

Why Study Echinoderms

Sea urchin sperm homologues of polycystin-1 and polycystin-2, the proteins mutated in autosomal-dominant polycystic kidney disease, have been sequenced (Mengerink et al. 2002 Neill et al. 2004). Both proteins have been shown to co-localise exclusively to the plasma membrane over the sperm acrosomal vesicle, where they may function as a cation channel mediating the sperm acrosome reaction. These data provide the first suggestion for the role of a polycystin-1 protein in a specific cellular process (Mengerink et al. 2002).

Intraoperative angiography

If the patient is suspected to have renal failure, the amount of contrast used is kept at a minimum. Angled projections can be obtained without moving the C-arm by rotating the patient's foot. The use of contrast in the Fogarty catheter balloon during fluoroscopy allows the calf vessel into which the catheter slides to be identified. The technique for intraoperative angiography is also a prerequisite for interoperative use of endo-vascular treatment options such as angioplasty (Fig. 10.4).

Fluid requirements in illness

Certain patients are at increased risk of pulmonary oedema. Patients with heart failure, renal failure and the elderly are the most common examples. Patients with capillary leak, for example, in severe sepsis, are also at risk of interstitial oedema, yet can require large amounts of intravenous fluid as they are volume depleted. Monitoring and management in these cases is more complex (see Chapter 7).

Introduction Clinical Setting

Classical Alport's syndrome is an X-linked disease and is the most common form of Alport's syndrome (90 of patients), with an overall incidence of Alport's syndrome in the United States of 1 5000 to 1 10,000 (1-4). Patients show hematuria in childhood with progressive hearing loss in one third, and ocular defects and progression to renal failure in 30 to 40 by early adulthood. Anterior lenticonus is the most common eye defect.

The Goodpasture antibodies and the antigenantibody reaction

The detailed characterization of the autoantibodies present in patients with renal-pulmonary syndromes is important since treatment and prognosis vary greatly depending upon antibody specificities. The poor prognosis associated with the presence of circulating GP antibodies justifies the 'toxic' quality by which they are known. The GP antigen is especially immunopathogenic and the specific way in which GP antibodies bind is critical in determining the severity of the resulting nephritis. This is supported by the fact that the development of experimental GP syndrome requires the administration of dimeric

Renal Transport Of Cationic Diuretics

In summary, secretion of diuretics into the lumen of the proximal tubule is an essential step for the action of these agents. It is this event that allows loop diuretics to maintain potency in the setting of reductions in glomerular filtration rate. Competitive inhibition for transport between diuretics and other endogenous and exogenous compounds is an important component of diuretic resistance in a number of circumstances, especially in chronic renal failure. For diuretics with a high affinity for the transporters, increasing the diuretic dose may improve tubule secretion and efficacy.

Concurrent Medical Evaluations

Before any required therapeutic procedures, all patients should undergo a preoperative medical examination by colleagues in primary care medicine and or anesthesiology. Patients with renal failure should also be evaluated by nephrology. In relatively rare instances, a patient's overall medical condition may require optimization before proceeding with the required therapeutic interventions. In rare instances, this may include the use of hemodialysis before proceeding with relief of upper urinary obstruction. Acutely ill patients should be appropriately monitored in the hospital setting. In fact, those patients deemed too unstable for therapeutic intervention should have their clinical situation optimized in the intensive care unit setting.

Human Health Effects

It has been suggested for several decades that excessive exposure to OA plays a substantive role in the development of BEN. BEN is a bilateral, noninflammatory, chronic nephropathy in which the kidneys are extremely reduced in size and weight and show diffuse cortical fibrosis. Functional impairments are characterized by progressive hypercreatininemia, hyperuremia, and hypochromic anemia. In an endemic area of Croatia, an extremely high incidence of urinary tract tumors in the endemic areas for BEN, particularly urothelial tumors of the pelvis and ureter, has been reported. In Bulgaria, 16 cases of urinary tract tumors were reported among 33 autop-sied patients with BEN. A causal relationship between exposure to OA and these human diseases is suggested by (i) similarities in the morphological and functional renal impairments induced by OA in animals and those observed in BEN and (ii) the finding that foods from the endemic areas are more heavily contaminated with OA than foods from...

Acute Urologic Management

The acute treatment of upper urinary tract obstruction is to re-establish urinary drainage. The timing (immediate vs delayed), approach (endoscopic, percutaneous, open, laparoscopic), and goals of treatment (temporizing vs definitive) depend heavily on the diagnostic workup. When safe and possible, an effort should be made to provide definitive treatment at the same time as urinary drainage is established. In cases of renal failure, concurrent infection, or complete obstruction, however, the only goal of treatment should be urgent decompression of the blocked upper tract.

Clinicopathologic Correlations

Much more benign course, with less than 10 mortality even when only symptomatic treatment was given. Improved survival in the last 10 years is associated with use of a combination of antiplatelet agents and plasmapheresis (21). In some series, plasma exchange has resulted in better prognosis than plasma infusion, but the results are not clear-cut. New molecular insights (see above) suggest that plasmapheresis could be useful when acquired inhibitors of ADAMTS13 are present, whereas plasma replacement theoretically could be indicated in patients with deficiency of this protease or factor H mutation, with normal plasma presumably correcting the deficiency (19). ADAMTS13 testing has been advocated as a means to distinguish between HUS and TTP, with TTP proposed to result from ADAMTS13 mutation and resulting deficiency (7). However, there may be overlap both clinically and at a molecular level. Hemolytic uremic syndrome accounts for about half of cases of acute renal failure in HIV...

Type II hypersensitivity

In this condition it is the rhesus (Rh) antigen system on the red cell surface which is responsible for die reaction causing fetal-maternal incompatibility. The name has derived from a similar antigen recognized by the serum of rabbits immunized with rhesus monkey red cells. The human Rh(D) antigen is encoded by a dominant gene which is present in approximately 80 of the population. There are therefore Rh and Rh individuals. The disease follows the gradual sensitization of a Rh mother to the blood group Rh' antigen of fetal red cells bearing the paternal Rh ' antigen. This happens at the time of first delivery when the mixing of maternal newborn blood occurs. As a consequence, Rh'-specific IgG is made in the postpartum period. With subsequent pregnancies, these antibodies cross the placenta into the fetal circulation and react with fetal red cells, destroying them. Therefore the disease mainly occurs with the second or subsequent Rh ' -incompatible children. The symptoms are...

The Physiological Roles Of The Bcl2 Family Proteins In Development And Homeostasis

Bcl-2 family proteins play a critical role in programmed cell death. The term programmed cell death (PCD), initially defined by developmental biologists, describes the temporally and spatially controlled death of cells during development (101). The genetic pathway of PCD was first systemi-cally characterized in the nematode C. elegans by Horvitz and colleagues (102). The antideath molecule CED-9 is essential to the normal development of the worm, so that the loss of function mutation of this molecule causes normally surviving cells to die, which results in embryonic lethality (103). This essential role of antideath molecules has also been observed in mammals. Inactivation of some mammalian anti-apoptosis genes, bcl-xL or mcl-1, leads to embryonic lethality. Whereas bcl-xL seems to be important for the development of the neuronal and hematopoietic systems (104), mcl-1 is critical to the development of trophectoderm, important for the implantation of embryos to the uterus (105)....

TABLE 1422 Characteristics of Malaria Causing Plasmodium Species

Hemolysis can be high with P. falciparum infection, since parasitemia can be overwhelming and erythrocytes of all ages are susceptible. Parasitized erythrocytes lose flexibility and are removed in the microcirculation, with resultant obstruction and tissue anoxia of the lungs, kidneys, brain, and other vital organs. Noncardiac pulmonary edema, renal failure, and cerebral malaria may result. Sequestration accounts for the paucity of observed mature parasites in the peripheral smear of patients infected with P. falciparum.

H 1231 Pathophysiology

Another type of ischemic complication is mul-tifactorial and follows aortic surgery, usually after emergency operations in which hypovolemic shock is common. Arterial clamping, poor perfusion due to hypovolemia, and hypotension may cause renal failure and ischemic colitis of the sig-moid colon. Reperfusion injury after declamping makes the ischemic consequences worse. Renal insufficiency evolves within 1 week of the operation, but a decrease in urine production is seen immediately after the procedure. Intestinal ischemia usually has an early onset because of postoperative hemodynamic problems but might also be delayed. As soon as the intestinal perfusion is below the critical limit damage will occur.

Atpase Chromatinremodeling Complexes

The diversity of chromatin-remodeling complexes is likely to be even greater than is currently realized. Numerous SWI2 SNF2-related genes have been identified by reduced stringency hybridization or genome sequencing projects, and some of these genes probably encode orphan catalytic sub-units of complexes that await identification and purification. Some of these putative catalytic subunits have interesting properties, such as the ability to regulate DNA methylation. A targeted mutation of Lsh (lymphoid specific helicase) results in a 50 to 70 reduction in cytosine methylation throughout the genome. Homozygotes die shortly after birth, possibly because of renal failure. (The gene is lymphoid-specific in adults but widely expressed in embryos.) Interestingly, expression and activity of de novo and maintenance DNA methyltransferases are unaffected. Instead, Lshl is expressed during S phase and may facilitate localization of Dnmtl to hemimethylated DNA following replication or protect...

Use of Diuretics for the Treatment of Heart Failure

The congestive states are those disorders which create steady-state expansion of blood and extracellular fluid volume. They include congestive heart failure due to primary and secondary cardiac disorders of multiple etiologies. Heart failure may be defined as an inability of the heart, at normal filling pressures, to pump the quantity of blood necessary to meet the body's metabolic demands. This definition encompasses various forms of myocardial dysfunction, mechanical abnormalities which restrict the flow of blood into or out of the heart, cardiac arrhythmias, and mechanical or metabolic abnormalities which increase cardiac demands. Congestion and cardiac failure can be due to non-cardiac disorders such as severe anemia, thyrotoxicosis, primary salt overload, and beriberi which expand plasma volume and increase cardiac demands beyond the normal heart's capacity to respond. Salt overload secondary to acute or chronic renal disease can also produce congestion. Table 1 lists the major...

Surgical outcomes and effect on left ventricular function

Operative mortality for elective aortic valve replacement in chronic aortic regurgitation is 4-10 with five year survival rates of 70-85 in recent series, and is similar in women and men. Most patients experience a decrease in cardiac symptoms and an improved functional capacity postoperatively. Predictors of operative mortality include severe symptoms, renal failure, and atrial fibrillation.

Structural changes and binding sites localisation

In addition to structural changes also provided by CD and FT-IR, fluorescence could provide an estimation of binding of aroma to food proteins (Damodaran and Kinsella 1980b, 1981b, Dufour and Haertle 1990b, Dufour et al. 1992, Frapin et al. 1993, Liu et al. 2004, Yang et al. 2003), but comparison with equilibrium dialysis often showed an overestimation of the binding constant (Guichard 2002, Muresan et al. 2001).

Hemolyticuremic Syndrome Postdiarrheal

In the laboratory, both of the following findings will be present (1) anemia of acute onset with microangiopathic changes (schistocytes, burr cells, or helmet cells on smear) and (2) acute renal failure with hematuria, proteinuria, or increased creatinine levels (50 percent over the patient's baseline values, or greater than 1.0 mg dL for a child under 13 years of age, or greater than 1.5 mg dL for persons over 13 years of age with previously normal renal function).

Centrifugation Steps. You Proceed With The Purification Using The Supernatant Fraction That Contains Mostlyintact

(d) You solubilize the ammonium sulfate pellet containing the mitochondrial proteins and dialyze it overnight against large volumes of buffered (pH 7.2) solution. Why isn't ammonium sulfate included in the dialysis buffer Why do you use the buffer solution instead of water

Major immune activation

Immune activation, particularly with progressive renal failure, may be another cause for a patient failing to improve despite antibiotic treatment. In these patients blood cultures may have been negative (even if there has been no previous antibiotic treatment) and negative serology and microbiology will have excluded infection by cell dependent organisms. There may be doubt about the diagnosis but flamboyant vegetations are usually seen on echocardio-graphy and the patient may have had emboli. Changing the antibiotics fails to help. In these rare patients deterioration will continue until removal and replacement of the valve. No organisms may be grown from it or stain microscopically, but the rapid improvement that follows surgical intervention clearly shows that the bacterial antigen had persisted in the valve. There is a danger of such patients being falsely diagnosed as having Libmann-Sacks (in association with systemic lupus erythematosus) or marantic endocarditis but, unlike...

Combination with or NH3 leads to generation of Renal Regulation of PH in Acid Base Balance Disturbances

Acid base disturbances can be divided into disturbances of respiratory origin (respiratory acidosis and alkalosis) and non respiratory origin (metabolic acidosis and alkalosis). 'Metabolic' refers to acid base disturbances that affect the bicarbonate buffer system by a means other than an alteration of PCO2. Metabolic acidosis is by far the most common metabolic disturbance, and is often associated with pathological conditions involving the excess production of acid. Examples of these are diabetic ketoacidosis or septicaemia. Alternatively failure to excrete acid as in renal failure can also lead to a metabolic acidosis. hence, reduces renal re-absorption and regeneration. The exception to this is renal failure, where the kidneys' failure to excrete H+ is the cause of metabolic acidosis.

General principles of membrane processing

There are several related separation processes incorporating membranes. Diafiltration is an extension of UF or MF and is discussed on pages 267-8. Electrodialysis is a combination of membrane and ion-exchange separation which can be used for demineralisation of food materials, reviewed by Grandison (1996b). Dialysis is a concentration-driven membrane separation, which has medical and biochemical applications, but is unlikely to contribute to food preservation. Similarly, pervaporation is the separation of liquid mixtures with a permselective membrane, but is unlikely to have food applications.

General Emergency Department Care

Whole-bowel irrigation is unlikely to be of any clinical benefit. Hemodialysis, hemoperfusion, and peritoneal dialysis have no established role in the treatment of MAOI poisoning. Urinary acidification is not recommended because it is ineffective at enhancing MAOI elimination and predisposes to acute renal failure secondary to myoglobin precipitation within renal tubules.

How to Perform and Interpret a Virtual Colonoscopic Examination

Colonography Air Adequate Topogram

There are two main bowel preparations available cathartics such as magnesium citrate and oral phospho soda, and lavage solutions such as polyethylene glycol. In our experience, both magnesium citrate and phospho soda provide an acceptable bowel preparation. Radiologists should emphasize the need for bowel preparation and be familiar with the instructions that are provided with these commercial kits to better answer patient's questions. Magnesium citrate should not be used in patients with renal failure and phospho soda should not be used in patients with renal, cardiac, or hepatic insufficiency. We have found that the polyethylene glycol prepa-ration frequently leaves a large amount of residual fluid (Macari et al. 2001). While this preparation is adequate for colonoscopy, large amounts of residual fluid could obscure masses during CTC (whereas at conventional colonoscopy residual fluid can be aspirated out of the colon). Unlike a barium enema examination, in which different...

Pathologic Findings

On gross examination, kidneys with AIN are enlarged with a pale cortex and a distinct corticomedullary junction. Histologically there is diffuse interstitial edema with an interstitial infiltrate of lymphocytes, monocyte-macrophages, and plasma cells to varying degrees (Fig. 13.1). Eosinophils may comprise from 0 to 10 of the infiltrate, depending on the etiology of the AIN. When there are many eosinophils, they may be focally concentrated. The inflammatory cells are often prominent at the corticome-dullary junction, and are generally confined to the cortex. Neutrophils and basophils are infrequent large numbers of neutrophils suggest a diagnosis of acute infectious interstitial nephritis. In some cases granulomas may be found in the interstitium or around ruptured tubules. Glomeruli and vessels are usually uninvolved. The inflammation extends into the walls and lumina of tubules (tubulitis), with distal tubules more often affected than

Cardiovascular Complications

HYPERTENSION Hypertension occurs in 80 to 90 percent of patients starting dialysis. Hypertension represents a significant risk factor for coronary artery disease, cerebrovascular accidents, and heart failure. Hemodynamic profiles of hypertensive ESRD patients show that maintenance of hypertension is dependent on increases in total peripheral resistance. The etiology of the increase in total peripheral resistance appears to be multifactorial. Increases in blood volume, the vasopressor effects of native kidneys, the renin-angiotensin system, and the sympathetic nervous system all have been shown to play a role in ESRD hypertension. Management of hypertension in ESRD patients should begin with the control of blood volume. If that is unsuccessful, most patients' hypertension can be controlled with adrenergic-blocking agents, angiotensin-converting enzyme (ACE) inhibitors, or vasodilating agents, such as hydralazine or minoxidil. Bilateral nephrectomy is rarely necessary for blood pressure...

Why Pythagoras Wouldnt Eat Falafel Glucose 6Phosphate Dehydrogenase Deficiency

Fava beans, an ingredient of falafel, have been an important food source in the Mediterranean and Middle East since antiquity. The Greek philosopher and mathematician Pythagoras prohibited his followers from dining on fava beans, perhaps because they make many people sick with a condition called favism, which can be fatal. In favism, erythrocytes begin to lyse 24 to 48 hours after ingestion of the beans, releasing free hemoglobin into the blood. Jaundice and sometimes kidney failure can result. Similar symptoms can occur with ingestion of the antimalarial drug primaquine or of sulfa antibiotics or following exposure to certain herbicides. These symptoms have a genetic basis glucose 6-phosphate dehydrogenase (G6PD) deficiency, which affects about 400 million people. Most G6PD-deficient individuals are asymptomatic only the combination of G6PD deficiency and certain environmental factors produces the clinical manifestations.

The Role Of Genetic Manipulation In Bioseparations

The recombinant product can take various forms in the host organism and this can influence the downstream purification process. Many are synthesised in a soluble form in the cell cytoplasm. The crude cell extract which contains these products will also contain all the normal cell components in a complex mixture. As stated above, the purification problems can be minimised if the desired product is the major component in the mixture. In some cases, particularly when proteins are cloned into foreign hosts, or are expressed in high levels, the recombinant product forms an intracellular insoluble aggregate (inclusion bodies) (Kane & Hartley, 1988). This is due to the specific association of partially folded recombinant peptide chains produced during the folding process (Mitraki & King 1989). Inclusion bodies differ from other insoluble cell components in size and density and can therefore be isolated relatively easily by differential centrifugation (Taylor et al 1986). However, the...

Decontamination and Enhanced Elimination

Gastric decontamination should be initiated in all patients with suspected NSAID overdoses. Activated charcoal with the cathartic sorbitol should be given orally or through a nasogastric tube. Repeated doses of activated charcoal without sorbitol are indicated in symptomatic patients. Dialysis and charcoal hemoperfusion are not effective in enhancing elimination, because NSAIDs are highly protein bound. Manipulation of serum and urine pH through alkalinization is not helpful in enhancing elimination.

Chapter References

Kharasch MS, Johnson KM, Strange GR Cardiac arrest secondary to indomethacin-induced renal failure A case report. J Emerg Med 8 51, 1990. 9. Kleinknecht D Interstitial nephritis, the nephrotic syndrome, and chronic renal failure secondary to nonsteroidal anti-inflammatory drugs. Semin Nephrol 15 228, 1995.

Vitamins and Minerals

The standard oral and intravenous vitamin intake and what is currently being given at Harbor-UCLA Medical Center and UCLA Medical Center are listed in Table 4. Also included are the few exceptions to the routine intravenous amounts for both Tables 4 and 5. The mineral and trace element requirements are listed in Table 5. These vitamin, mineral, and trace mineral recommendations are for hospitalized cancer patients and noncancer patients who are hospitalized. They should not have oliguric renal failure or cholastatic liver disease. In acute oliguric renal failure, vitamins A and D should be reduced or eliminated from the enteral or parenteral solutions. Potassium, phosphorus, magnesium, zinc, and selenium should be reduced or eliminated. Iron and chromium are known to accumulate in renal failure and should be removed from the par-enteral or enteral formulations. In cholastatic liver disease, the trace elements copper and manganese are excreted via the biliary tree in the bile and...

TABLE 16B1 Clinical Presentation of Digitalis Toxicity

Chronic toxicity occurs most typically in the elderly cardiac patient taking digoxin and diuretics. Signs and symptoms may mimic more common illnesses such as influenza and gastroenteritis. An altered mental status or psychiatric symptoms may not be recognized as signs of digitalis toxicity. Almost any cardiac dysrhythmia may be seen, but ventricular dysrhythmias occur more frequently in chronic than in acute poisonings.6 The serum digoxin level is not an accurate predictor of toxicity, and the serum potassium is usually decreased, normal, or may even be elevated in the setting of renal failure.

H.lundolm Psychological

Lusvarghi et al., Natural History of Nutrition in Chronic Renal Failure, Nephrol Dial Transplant ll(Suppl 9), 75-84 (1996). 72. W. E. Mitch, Robert H. Herman Memorial Award in Clinical Nutrition Lecture, 1997 Mechanisms Causing Loss of Lean Body Mass in Kidney Disease, Am. J. Clin. Nutr. 67, 359366 (1998). 74. J. S. Park et al., Protein Intake and the Nutritional Status in Patients With Predialysis Chronic Renal Failure on Unrestricted Diet, Korean J. Intern. Med. 12, 115-121 (1997). 75. M. J. Blumenkrantz et al., Metabolic Balance Studies and Dietary Protein Requirements in Patients Undergoing Ambulatory Peritoneal Dialysis, Kidney Int. 21, 849-861 (1982). 77. B. Schneeweiss et al., Energy Metabolism in Acute and Chronic Renal Failure (see comments), Am. J. Clin. Nutr. 52, 596-601 (1990). 78. J. D. Kopple, McCollum Award Lecture, 1996 Protein-Energy Malnutrition in Maintenance Dialysis Patients, Am. J. Clin. Nutr. 65, 1544-1557 (1997). 81. J. Kelleher et al., Vitamin A and Its...

TABLE 1683 Calculating Digoxin Specific Fab Fragment Dosage

The serum digoxin level has no correlation with clinical toxicity following Fab administration because most laboratories use assays that measure both bound and unbound digoxin, although there are some laboratories that measure only free digoxin levels. Minutes after Fab fragment administration, the free digoxin level falls to zero, but the total serum digoxin level (bound to Fab fragments) increases 10- to 20-fold. 12 The Fab-digoxin complex is eliminated by renal excretion.1B In the case of renal failure, the complex may persist in the circulation for prolonged periods. Recurrent toxicity can occur up to 10 days after Fab fragment administration in patients with renal failure. Hemodialysis does not enhance the elimination of the digoxin-Fab complex. 1B

Potassium Sparing Diuretics

Potassium retention while inducing sodium and water excretion. Triamterene has direct effects on the renal tubule to inhibit sodium exchange for potassium and hydrogen. Amiloride's mechanism of action, also independent of aldosterone, is to promote potassium retention in exchange of sodium and water. Volume depletion, hyperkalemia, hyponatremia, and hypochloremia are common manifestations of toxicity for this class of medication. Treatment for potassium-sparing diuretic toxicity is directed at maintaining intravascular volume, repleting sodium, and reversing the hyperkalemia. Hypotension is best initially treated with intravenous fluids, usually normal saline. If hypotension is persistent, a vasopressor such as dopamine is warranted. The most serious manifestations of hyperkalemia include neurologic and cardiovascular dysfunction. Treatment of hyperkalemia should remain a priority, and can be serious enough to warrant dialysis.

TABLE 452 Conditions Associated with Elevated CKMB Levels

Myoglobin is a small (17,500-Da), heme-containing protein found in striated (skeletal) and cardiac muscle cells. When disrupted, these cells rapidly release myoglobin into the serum. Myoglobin serum levels increase rapidly after significant muscle damage and return to baseline values relatively quickly in the presence of normal kidney function. This property makes myoglobin potentially valuable as a serum marker for myocardial necrosis. After MI, serum myoglobin levels begin to rise within

Randomized clinical trials

The most persuasive evidence for the beneficial effect of long-term ACE inhibitor therapy in high-risk patients without heart failure and or low left ventricular ejection fraction and with or without hypertension, has been provided by the Heart Outcomes Prevention Evaluation (HOPE) trial.45 This trial enrolled 9297 patients aged 55 years or older with coronary artery disease, peripheral arterial disease or prior stroke, or diabetes with additional risk factors. Treatment with the ACE inhibitor ramipril titrated up to 10 mg daily resulted in a highly significant 22 reduction in the composite primary end point of myocardial infarction, stroke or death from cardiovascular causes (Table 18.3 Figure 18.1). In addition, the risk of stroke, myocardial infarction, need for revasculariza-tion procedures, heart failure and the development of diabetes were significantly decreased. In the 3577 patients with diabetes, ramipril significantly reduced the risk of the composite primary outcome by 25...

Pathophysiology and biologic rationale

More recently, the modest elevation in plasma homocys-teine levels has been evaluated as a potential CV risk factor. Such modest elevations in plasma homocysteine can be related to genetic, physiologic, pathologic, and nutritional factors, including MTHFR mutations (for example, thermo-labile MTHFR), older age, male gender, postmenopausal status in women, smoking, sedentary lifestyle, dietary factors including increased intake of animal proteins which have a higher methionine content and low intake of folate, vitamins B6, and B12, renal failure, transplantation, and medications such as corticosteroids and cyclosporin which have been associated with hyperhomocysteinemia.49

Renal and Metabolic Toxicity

Solvent abuse and occupational exposure to hydrocarbons may result in renal dysfunction. Exposure to hepatotoxic halogenated hydrocarbons, such as carbon tetrachloride and trichloroethylene, has caused acute renal failure as well as centrilobular hepatic necrosis. 15 Occupational hydrocarbon exposures have been associated with a variety of glomerulonephritides including Goodpasture's syndrome. I8

Secondarytertiary hyperparathyroidism

Secondary hyperparathyroidism is a physiological response from the parathyroid glands to a chronically low calcium state, which in the UK is most commonly due to chronic renal failure. Surgical treatment depends on whether the patient is on a waiting list for renal transplantation. In that case, some residual parathyroid tissue should be preserved. Either a sub-total parathyroidectomy can be performed excising 3M glands leaving approximately 30 mg of parathyroid tissue at a site carefully marked, or alternatively total parathy-roidectomy and muscle implantation of 15-20 X 1mm3 cubes of parathyroid tissue. The usual site for implantation is the brachioradialis of the forearm not being used for haemo dialysis. If a successful renal transplant is not performed, approximately 20 of patients will develop hyper-function of the remaining piece of tissue requiring further surgery to this. Patients who are not for renal transplant should have a total parathyroidectomy performed. With either...

The Effect of Reimbursement

Reimbursement has affected both dialysis techniques and quality of care provided to dialysis patients. In the 1980s cost was the federal policymakers' primary concern about the ESRD program, and federal reimbursement rates for dialysis were reduced twice. By 1989, the average reimbursement rate adjusted for inflation for freestanding dialysis units was 61 percent lower than it had been when the program began (Rettig and Levinsky). When the U.S. Congress established the Medicare ESRD program, the highest estimate for cost of the program by 1977 was 250 million the actual cost was approximately 1 billion (Fox and Swazey). At least two major reasons were held to be responsible for the higher cost the increasing number of patients being started on dialysis, some of whom would have been unthinkable dialysis candidates ten years earlier, and the growth of in-center dialysis while the use of less costly home dialysis declined. Despite inflation and increases in the costs of salaries,...

Chronic Diuretic Therapy for Heart Failure [3033

Bowel wall edema may impair the gastrointestinal absorption of diuretics and some diuretic resistance which occurs in patients with heart failure has been attributed to this mechanism. More recent studies have shown that patients with congestive heart failure and severe peripheral edema who presumably also have GI edema, absorb normal quantities of orally administered loop diuretics. However, the time course of absorption is altered 27 . Heart failure delays and reduces peak blood levels, although the area under the plasma drug concentration vs time curve (representing the total quantity of absorbed diuretic) is not reduced i.e., the drug is absorbed more slowly. This may affect the efficacy of loop diuretics when they are used to treat patients with advanced renal failure as well as CHF and high peak blood levels are required for adequate secretion.

International Perspective

Economics plays the leading role in determining the availability of dialysis in countries throughout the world. The countries with the largest numbers of patients on dialysis are among the richest the United States, Japan, and Germany. The number of patients per million population treated with dialysis correlates highly with the gross national product per capita. Countries with a per capita gross national product of less than 3,000 per year treat a negligible number of patients with dialysis and transplantation. Approximately three-quarters of the world's population live in these poorer countries. In parts of the world where dialysis technology and money for healthcare are limited, dialysis is severely rationed. Two sets of criteria have been used to select patients for dialysis. In India, China, Egypt, Libya, Tunisia, Algeria, Morocco, Kenya, and South Africa, money and political influence play an important role in deciding which patients will have access to dialysis and...

Effect of iron excess on immunity

Iron excess has been associated with increased susceptibility to infections and abnormal neutrophil and lymphocyte function. Patients with iron overload undergoing dialysis showed decreased phagocytosis and bactericidal capacity of blood neutrophils. Hemochromatosis patients with elevated levels of storage iron were reported to have elevated numbers of CD8 T cells and impaired ability of peripheral blood mononuclear cells to respond to mitogens. Increased transferrin saturation in cancer patients receiving chemotherapy has been associated with increased in vitro growth of Escherichia coli and Staphylococcus aureus. NK cell cytotoxicity against K562 target cells was decreased in patients with (3-thalassemia major who are iron overloaded as a consequence of chronic transfusion therapy. In patients with (3-thalassemia intermedia, decreased opsonization and granulocyte phagocytosis, decreased serum immunoglobulin levels, and changes in B and T cell numbers and function have

Preparation of ISCOMantigen complexes

Ing Quillaja saponins, cholesterol and phospholipid at a molar ratio of about 1 1 1. The assembly of ISCOM is facilitated by hydrophobic interaction between these components and the antigen. The ISCOM antigen may be an envelope protein of a native virus, a cellular membrane protein, or peptides containing hydrophobic domains or any antigen with a hydrophobic domain. In the case of virus, the envelope is disintegrated by a detergent, preferably nonionic, to release a protein-detergent complex (Figure 1). Upon the removal of the detergent (e.g. by dialysis or density gradient centrifugation) in the presence of Quillaja saponins, cholesterol and additional lipid, ISCOM assembly takes place. Primarily nonamphipathic proteins (e.g. gpl20 of human immunodeficiency virus (HIV) may also be integrated into ISCOM by refolding the protein to expose certain hydrophobic sequences, which are then available to form hydrophobic interactions. By efficient coupling methods, peptides may be conjugated...

Approaches and Clinical Studies

Six-month follow-up, all evaluated cases had negative findings on MRI and needle biopsy. However, in the further results one case was reported with a local recurrence. Postoperative renal function at 24 h was unchanged in this study. There was no evidence of urine leakage. One patient was noted to have a perirenal hematoma. Rukstalis et al. treated 29 patients with an open procedure 21 . At a mean follow-up of 16 months, 91.3 of patients had a complete response according to MRI, and there was one biopsy-proved local recurrence. There were more complications in the open group, including ensuing renal failure in three patients, one conversion to nephrectomy, and one persistent RCC on short-term postprocedural imaging. Shingleton and Sewell reported a percutaneous series under general anesthesia 12 . At a mean follow-up of 9.1 months, there was no evidence of tumor recurrence, although one patient required retreatment due to continuing residual enhancement in the treated area. A wound...

Neuroregenerative Mechanism Of Neuroimmunophilin Ligands

Corresponds to the mouse protein LN1, which could be involved in the progress of lupus nephritis.'' The results showed that ''PAHX has the physical capacity to interact with the FKBP12-like domain of FKBP52, but not with FKBP12 Also, '' the specific association of PAHX and FKBP52 is maintained in the presence of FK506. Although the function of PAHX FKBP52 complex is still unclear, this observation suggests that PAHX is a serous candidate for studying the cellular signaling pathway(s) involving FKBP52 in the presence of immunosuppressants.

Oxygen Carrying Resuscitation Fluids

Blood remains, from a physiologic perspective, the ideal resuscitation agent, but there are substantial practical limitations to its routine use. Although the potential for disease transmission has been significantly reduced by modern donor screening techniques, it has not been completely eliminated. 17 Other concerns include the limited availability of blood products the cost of collection, storage and transfusion a limited shelf-life and the existence of religious prohibitions against the transfusion of blood products. These issues have led researchers to search for alternative agents that can safely and effectively deliver oxygen to the cells. 18 To date the use of stoma-free hemoglobin as well as (PHP) conjugate represent examples of hemoglobin-based substitutes under investigation. Hemoglobin solutions became of interest during World War II owing to practical difficulties of blood storage and compatibility testing on the battlefield. Their use was ultimately rejected due to their...

Surgical reintervention

If PVE is complicated, it has to be decided whether medical treatment should be continued or urgent surgical intervention is required. The indications for surgery in PVE are similar to those in NVE large (> 10 mm), mobile vegetations, thromboembolic events with vegetations still demonstrable, sepsis persisting for more than 48 hours despite effective antibiotic treatment (guided by blood cultures and MICs), and acute renal failure. A cerebral embolic event is not a contraindication for open heart surgery provided that there is no cerebral haemorrhage and the time between embolic event and surgery is short (preferably < 72 hours) so that the blood-brain barrier can be expected not to be significantly disturbed (fig 12.2).15 Periprosthetic dehiscence with or without myocardial failure has a poor prognosis. If congestion is not promptly removed by

Measuring Renal Function

Finally, in order to develop early intervention strategies, it is necessary to be able to identify individuals born with a low nephron endowment who may be predisposed to later renal disease. In an important study, birth weight in humans was found to be significantly correlated with nephron number with a predictive increase of250,000 nephrons for each 1kg increase in birth weight.105 Thus, should low birth weight individuals be considered a high risk for developing early renal failure If so what can be measured or examined to detect this Lack of agreement on the most appropriate tests to be done to test kidney function in children has led to guidelines being developed by the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative. The two most critical recommendations were the measurement of protein to creatinine ratios in spot urines and estimation of glomerular filtration rate (GFR) from serum creatinine using predictive equations which take into account the...

Internal Injuries Owing to Electrocution Table

Hand Grenade Damage

Muscle damage is caused by heat, electrical current, ischemia, and trauma (145). High-voltage current causes considerable muscle, vessel, and nerve damage (38,150, 152). The extent of cutaneous burns in a low-voltage electrocution does not predict the amount of muscle necrosis Muscle compartment syndromes develop secondary to edema and vascular ischemia (139,141,147,152). Myoglobinuria leads to renal failure (see Chapter 8, Section 13. and refs. 38, 141, 142, 144, 145, 147, 152, 157, and 158). There is no significant correlation

Pathophysiology Of Salt Retention And Edema The Underfill Vs Overflow Hypotheses

Edema Mechanism

Some disorders which cause the nephrotic syndrome also produce overt structural renal derangements which reduce renal perfusion and glomerular filtration. In such cases, these renal abnormalities may be the principal cause of salt and water retention. This is the obvious explanation for the salt retention which occurs when a proliferative glomerulonephritis produces both the nephrotic syndrome and renal insufficiency. However, in many patients no other apparent functional or structural renal derangements exist. For example, when nephrotic syndrome is due to minimal change disease, this can be considered a pure form of nephrosis. In this group underfill pathophysiology is most likely. However, even in many of these pure nephrotic patients, some studies suggest that the salt-retaining signals originate within the kidney itself. If this is correct, an alternative hypothesis to explain the salt retention of nephrosis becomes necessary.

TABLE 1153 Differential Diagnosis of Congestive Heart Failure Based on Age of Presentation

PERICARDITIS Usually, this presents as cardiomegaly that is discovered incidentally on chest radiograph. Clinical signs such as chest pain, muffled heart sounds, and a friction rub may be present. In older patients and adolescents, classic pleuritic or positional chest pain, abdominal pain, and tachycardia may be seen. An echocardiogram is performed on an urgent basis to distinguish a pericardial effusion from dilated or hypertrophic myocarditis. The most common etiology is in association with coxsackie viral myocarditis. Bacterial pericarditis from Haemophilus influenzae is rare today and was uncommon even before the availability of H. influenzae type B conjugated vaccines. Typically, most cases of bacterial pericarditis present with profound toxicity and muffled heart sounds and jugular venous distention. If not appropriately drained in addition to antibiotic treatment, constrictive pericarditis will result in tamponade. Pericarditis that accompanies rheumatic fever, lupus...

Ischemic Acute Tubular Necrosis Light Microscopy

Mature and immature forms, and granulocyte precursors. These cells are in greater concentrations in the vasa recta than in other renal vascular beds. The glomerular capillary tufts are usually unaltered. However, there are several reasonably common abnormalities there may be some degree of capillary collapse and dilatation of Bowman's space. Additionally, tubular metaplasia (tubularization) of parietal epithelial cells may be evident in recovery. Solez and colleagues (5) assessed these morphologic changes as to their frequency in active renal failure, recovery phase, and normal controls. In their landmark study, they noted that the following were more common in biopsies from patients with renal failure vasa recta leukocyte accumulation, tubular cell necrosis, regeneration (mitotic figures), dilatation of Bowman's spaces, loss of brush border staining, tubular casts, and interstitial edema and inflammation. However, only cellular necrosis and loss of brush border staining distinguished...

TABLE 562 Cyclosporine Drug Interactions

Commonly encountered side effects of cyclosporine are listed in Table 56 3. Hypertension occurs in the majority of patients and frequently requires combination therapy to achieve adequate control. Renal insufficiency is also quite common and is mediated at least in part by the vasoconstrictive effects of cyclosporine on the proximal renal tubule. Management of cyclosporine-induced renal insufficiency requires careful monitoring, because worsening renal insufficiency results in elevated cyclosporine levels, leading to more renal dysfunction, thus creating a vicious cycle. Although early renal insufficiency is frequently reversible, some patients have developed end-stage renal disease requiring dialysis or renal transplantation.

Esophageal Motility Disorders in Systemic Diseases Scleroderma

Esophageal involvement is found in more than half of patients with systemic sclerosing diseases. Peristalsis and LES tonus are markedly diminished, allowing reflux of corrosive gastric juice. Other causes of impaired esophageal motility are diabetes mellitus, renal failure, neuropathies, and myopathies.

Assessment of Mg Status

The parenteral loading test is probably the best available marker for the diagnosis of Mg deficiency. The Mg retention after parenteral administration of Mg seems to reflect the general intracel-lular Mg content, and a Mg retention more than 20 of the administered Mg suggests Mg deficiency. However, this test is not valid in the case of abnormal urinary Mg excretion and is contraindicated in renal failure.

Clinical Features

Systemic toxicity characterizes stage 3 of iron toxicity. During this stage, intracellular iron disrupts cellular metabolism with resultant shock and (lactic) acidosis. Iron-induced coagulopathy may worsen bleeding and hypovolemia. Hepatic dysfunction, renal failure, and cardiomyopathy may also occur.

TABLE 1942 Parkland Formula

Electrical injuries, incineration burns, and associated crush injuries may produce rhabdomyolysis and myoglobinuria, leading to renal failure. See Chap.,,2,71 for further discussion. Two additions or modifications to isotonic crystalloid resuscitation have been studied adjuvant colloid and hypertonic saline. However, neither improves patient outcome. Adjuvant colloid given along with isotonic crystalloid resuscitation has not proven beneficial and is associated with increased accumulation of water in the lungs and decreased glomerular filtration rate.12 Hypertonic saline has produced an increased rate of renal failure and death. 13

Immunocompromised Patients and Health CareAssociated Endocarditis Epidemiology

While rates of infection due to viridans group streptococci decreased (p 0.007). Hemo-dialysis was independently associated with S. aureus infection (odds ratio, 3.1 95 confidence interval, 1.6-5.9). Patients with S. aureus endocarditis had a higher one-year mortality rate (43.9 vs. 32.5 P 0.04) that persisted after adjustment for other illness severity characteristics (hazard ratio, 1.5 95 confidence interval, 1.03-2.3). In a recent international study initiated by the International Collaboration for Endocarditis (ICE), healthcare-associated infection was the most common form of S. aureus infective endocarditis. Most patients with health-care-associated S aureus endocarditis (131 patients, 60.1 ) acquired the infection outside of the hospital. Persistent bac-teremia was independently associated with MRSA infective endocarditis (OR 6.2 95 CI 2.9-13.2). Patients in the United States were most likely to be hemodialysis dependent, to have diabetes, to have a presumed intravascular device...

H 10542 Reperfusion Syndrome

For patients with suspected reperfusion syndrome - urine acidosis and high serum myoglobin levels - alkalinization of the urine is often recommended in order to avoid renal failure despite weak support in the literature. If the urine is red, the urine pH < 7.0, and serum myoglobin > 10,000 mg ml, 100 ml sodium bicarbonate is given IV. The dose is repeated until the pH is normalized.

TABLE 2311 Drugs that Can Cause Hypocalcemia

Renal Failure Hypocalcemia is a frequent finding in renal failure. This may be partially due to the resulting hyperphosphatemia, but there is also decreased production of 1a,25-(OH)2-vitamin D in the kidney, which, in turn, causes decreased intestinal absorption of calcium. Secondary hyperparathyroidism with increased PTH levels often results from the chronic hypocalcemia. If PTH levels remain elevated and hypercalcemia develops in spite of cure of the renal failure by renal transplantation, the patient is said to have tertiary hyperparathyroidism. Hypomagnesemia Hypomagnesemia in association with hypocalcemia may be seen in alcoholism, diuretic use, epilepsy, and renal failure. Neonatal hypomagnesemia leads to low PTH secretion, decreased responsiveness of bone cells to PTH, and decreased calcium mobilization from bone.

The Mthfr Gene Product MTHFR

Some of the clinical implications of MTHFR 677C T are summarized in Chapter 2. The implications of MTHFR 677C T and MTHFR 1298A C in cardiovascular disease, cerebrovascular disease, venous thrombosis, longevity, neural tube defects, pregnancy, congenital abnormalities, preclampsia, diabetes, cancer, psychiatry, and renal failure are reviewed in refs. 19 and 20.

Class I Antidysrhythmic Agents

Dosing and Administration In the past, the recommendation for intravenous loading of procainamide for treating ventricular dysrhythmias was as a bolus injection. However, a continuous infusion has been shown to be safer (fewer adverse effects) than a bolus injection until the dysrhythmia is controlled, hypotension develops, the QRS complex widens more than 50 percent, prolongation of the QT interval develops, or a total of 17 mg kg (1.2 g for a 70-kg patient) has been given. The recommended infusion rate is 20 mg min in urgent situations, however, 30 mg min may be given cautiously. Blood pressure and QRS complex must be monitored during intravenous administration. If procainamide suppresses the VT, initiate a continuous infusion at 1 to 4 mg min to maintain the suppression. Lower doses are generally necessary for patients with CHF, hypotensive states, and hepatic or renal failure. Measurement of daily serum levels of procainamide or NAPA should be considered in patients with risk...

Anti Diuretic Hormone ADH

Painful stimulation and haemorrhage, as associated with surgery, are potent triggers for evoking the release of ADH. The resulting increase in ADH promotes water re-absorption from the distal renal tubules and collecting ducts in the renal medulla. This tends to reduce plasma osmolality and expand the volume of extracellular fluid, due to water retention. The resultant urine produced is of low volume and concentrated. ADH activity is also affected by the metabolites of volatile anaesthetic agents. Fluoride ions produced from the metabolism of methoxyflurane, and to a lesser extent, enflurane, interfere with the normal receptor response to ADH resulting in the potential for high output renal failure. ADH also increases peripheral resistance through arteriolar constriction, which helps to maintain arterial pressure.

Deficient Secretion

Deficient vitamin D activity may be a result of reduced dietary intake (or malabsorption) in associated with low levels of UV exposure. Failure of vitamin D activation may also be a problem in patients with chronic renal failure. The most obvious effects are de- mineralization of bone leading to osteomalacia in adults and rickets in children.

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