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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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...

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...

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...

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...

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...

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.

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

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.

Hemodialysis

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...

Nephropathy

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...

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.

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.

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...

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.

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-)

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...

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...

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.

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...

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

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.

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.

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...

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...

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.

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.

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

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...

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.

Globalization of the food supply and the influence of economic factors on the contamination of food with pathogens

Demand-side factors that support the increased globalization of the world's food supply include increases in income levels and urbanization. These factors are important in that they affect the mix of food purchased and consumed domestically and the composition of global food trade. Different foods have a different mix of potential microbial foodborne illness hazards to consumers and also vary in the risk of contamination. In turn, hazards in the different foods vary in the likelihood and severity of acute illness and chronic complications (e.g. mild illness from Salmonella in cantaloupe, kidney failure from E. coli 0157 H7 in ground beef). Additionally, wealthier nations tend to demand safer food.

Early and late mortality

Defined as occurring within 30 days of surgery or prior to discharge from the hospital, whichever comes second) occurs in 8-16 , depending on the preoperative clinical severity of the cohort.28,69,77,89 Risk factors for early operative mortality include older age, S. aureus infection, perivalvular abscess with fistulization, worse preoperative heart failure, and preoperative renal failure.28,69,77,92

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).

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.

Institutional Ethics Committees

Ethics committees have played clinically relevant roles in U.S. healthcare contexts since the 1960s. At that time, some hospitals established committees to approve requests for abortion and sterilization and to allocate scarce dialysis machines. Universities and hospitals created human subjects committees to scrutinize research protocols and consent forms in the 1970s, these committees became federally mandated institutional review boards (IRBs).

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.

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.

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

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