SUMMARY Depressive symptoms may be associated with fluid and dietary non adherence which could lead to poorer outcomes. The purpose of this study was to examine the relationship between depressive symptoms and fluid and dietary adherence in 100 patients with end‐stage renal disease (ESRD) receiving haemodialysis. A descriptive, cross‐sectional design with a convenience sample of 100 patients with ESRD receiving maintenance haemodialysis completed instruments that measured self‐reported depressive symptoms and perceived fluid and dietary adherence. Demographic and clinical data and objective indicators of fluid and diet adherence were extracted from medical records. As many as two‐third of these subjects exhibited depressive symptoms and half were non adherent to fluid and diet prescriptions. After controlling for known covariates, patients determined to have moderate to severe depressive symptoms were more likely to report non adherence to fluid and diet restrictions. Depressive symptoms in patients with ESRD are common and may contribute to dietary and fluid non adherence. Early identification and appropriate interventions may potentially lead to improvement in adherence of these patients.
Acute occlusions of arteries such as those of the cerebral and peripheral circulation are usually due to thrombotic or embolic events. Emboli have not been previously reported to cause arteriovenous (AV) dialysis access malfunction. We describe in this report three patients with end-stage renal disease (ESRD) and atrial fibrillation (Afib) who developed acute ischemia of an arteriovenous access-bearing extremity due to embolization. The clinical manifestations mimicked thrombotic events, but the presence of symptoms and signs of limb ischemia distinguished these cases clinically. A timely diagnosis followed by an appropriate intervention can lead to limb and access salvage.
<b><i>Background:</i></b> In dialysis and renal transplant patients with secondary and tertiary hyperparathyroidism (HPT), the value of intraoperative parathyroid hormone (ioPTH) during parathyroidectomy (PTX) and its association with long-term PTH levels are unknown. The present study aims at evaluating the relationship of ioPTH with long-term PTH levels post-PTX in dialysis and renal transplant patients in a single-center study. <b><i>Methods:</i></b> The ioPTH was measured in 57 dialysis patients (33 females and 24 males) and 18 renal transplant recipients (12 males and 6 females) who underwent PTX from 2005 to 2015 for refractory HPT. Near-total PTX was performed in 56 patients and total PTX with autotransplantation in 20 patients. The PTH monitoring included 3 samples: pre-intubation, 10- and 20-min (pre-ioPTH, 10-ioPTH, and 20-ioPTH) post parathyroid gland excision. Patients were followed up for up to 5 years. <b><i>Results:</i></b> In the dialysis group, the median (25th–75th percentile) pre-, 10-, and 20-ioPTH levels were 1,447 pg/mL (938–2,176), 143 pg/mL (78–244) and 112 pg/mL (59–153) respectively. In the renal transplant group, pre-, 10-, and 20-ioPTH levels were 273 pg/mL (180–403), 42 pg/mL (25–72), and 34 pg/mL (23–45) respectively. All patients in the transplant group had a functional kidney transplant at the time of PTX with a median serum creatinine of 1.3 mg/dL (1.2–1.7) and estimated glomerular filtration rate of 55 mL/min (40–60). The median time between renal transplant and PTX surgeries was 22 months (7–81). The last median follow-up PTH level was 66 pg/mL (15–201) in the dialysis group and 54 pg/mL (17–72) in the transplant group (<i>p</i> = 0.438). The mean time for last PTH post-PTX was 2.3 ± 2.0 years. In both groups, there was no significant difference between 20-ioPTH and any-time post-PTX PTH levels (<i>p</i> = 0.6 and <i>p</i> = 0.9). Nineteen patients (25%) were readmitted within 90 days because of hypocalcemia. One patient in the dialysis group was readmitted for post-PTX hematoma evacuation. No patient required repeat PTX because of recurrent HPT that was refractory to medical therapy. Only one dialysis patient required repeat PTX because the first procedure failed. <b><i>Conclusions:</i></b> The 20-ioPTH is a good indicator of long-term PTH levels in dialysis and renal transplant patients. Hypocalcemia is a common complication, particularly in dialysis patients, and it is the main reason for readmission after PTX. Hypoparathyroidism is a potential concern after PTX in dialysis patients.
<b><i>Background:</i></b> In adults, membranous nephropathy (MN) is a major cause of nephrotic syndrome. While a majority of cases of MN are idiopathic, secondary forms can be seen in the setting of autoimmune disease, neoplasia, infection, and after being exposed to certain therapeutic agents. Both human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections could cause MN. However, the effect of coexisting HIV and HCV infection on the spectrum and progression of kidney disease as well as the effect of MN treatment on HIV and HCV infection are not well known. <b><i>Methods:</i></b> In this study, we describe a patient with hemophilia A and acquired HIV and HCV infections, a patient who developed severe nephrotic syndrome and for whom renal biopsy showed MN. <b><i>Results:</i></b> Patient responded well to adrenocorticotropic hormone gel without adversely affecting HIV or HCV infections. <b><i>Conclusion:</i></b> Adrenocorticotropic hormone gel might be useful in the management of complex cases of idiopathic MN.
Studies suggest a J-shaped association between blood pressure and cardiovascular events in the setting of intensive systolic blood pressure control; whether there is a similar association with stroke remains less well established. The Secondary Prevention of Small Subcortical Strokes was a randomized trial to evaluate higher (130-149 mm Hg) versus lower (<130 mm Hg) systolic blood pressure targets in participants with recent lacunar infarcts. We evaluated the association of mean achieved blood pressure, 6 months after randomization, and recurrent stroke, major vascular events, and all-cause mortality. After a mean follow up of 3.7 years, there was a J-shaped association between achieved blood pressure and outcomes; the lowest risk was at ≈124 and 67 mm Hg systolic and diastolic blood pressure, respectively. For example, above a systolic blood pressure of 124 mm Hg, 1 standard deviation higher (11.1 mm Hg) was associated with increased mortality (adjusted hazard ratio: 1.9; 95% confidence interval: 1.4, 2.7), whereas below this level, this relationship was inverted (0.29; 0.10, 0.79), P<0.001 for interaction. Above a diastolic blood pressure of 67 mm Hg, a 1 standard deviation higher (8.2 mm Hg) was associated with an increased risk of stroke (2.2; 1.4, 3.6), whereas below this level, the association was in the opposite direction (0.34; 0.13, 0.89), P=0.02 for interaction. The lowest risk of all events occurred at a nadir of ≈120 to 128 mm Hg systolic blood pressure and 65 to 70 mm Hg diastolic blood pressure. Future studies should evaluate the impact of excessive blood pressure reduction, especially in older populations with preexisting vascular disease.URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059306.
Inflammation is commonly associated with malnutrition and cardiovascular disease in end-stage renal failure patients. Anti-inflammatory properties of the isoflavones, a micronutrient component of soy, have been reported in several experimental models and disease conditions, but never in renal failure. We hypothesized that dietary soy isoflavones correct laboratory evidence of systemic inflammation in haemodialysis (HD) patients with underlying high blood levels of C-reactive protein (CRP).End-stage renal disease patients on chronic HD, with elevated CRP (>10.0 mg/l) were enrolled in this pilot study. The subjects were double-blind randomly distributed with 2 : 1 ratio to receive isoflavone-containing soy-based nutritional supplements (soy group) or isoflavone-free milk protein (control group) for 8 weeks. Serum isoflavone, inflammatory markers and nutrition markers were assessed at baseline and at the end of the treatment.Thirty-two subjects were enrolled. Fifteen subjects in the soy group and 10 in the control group completed the study; five dropouts were due to acute illness and two due to food intolerance. After intervention, blood isoflavone levels were 5- to 10-fold higher in the soy group than in the control group [e.g. median genistein (25-75th percentile): 337.9 (175.5-1007) nM in the soy group vs 41.4 (22.9-100.4) nM in the control group; P < 0.001]. However, the isoflavone levels ranged widely in the soy group (e.g. genistein: 33-1868 nM) and, depending on the individual compound, four to seven subjects had end-of-treatment levels that were not different from baseline. Variation from baseline of the individual serum isoflavone levels (Delta-isoflavone) and CRP displayed a strong inverse correlation in the soy group (R = -0.599, P < 0.02). In addition, Delta-isoflavone correlated positively with the variation of albumin (R = 0.522, P = 0.05) and insulin-like growth factor-1 (R = 0.518, P < 0.05). Group levels of CRP were not statistically different after intervention although a trend towards lower levels was noted in the soy group [18.2 (12.7-29.1) mg/l at baseline vs 9.7 (5.2-20.7) mg/l at week 8; NS] but not in the control group [20.6 (9.2-38.5) vs 17.6 (9.1-40.7) mg/l].These data suggest the possibility of beneficial effects of isoflavone-rich soy foods on the inflammatory and nutritional status of HD patients with underlying systemic inflammation.
Since January 2017, patients with acute kidney injury requiring dialysis (AKI-D) can be discharged to outpatient dialysis centers for continued hemodialysis (HD) support. We aimed to examine the rate of kidney recovery, time to recovery, and hospitalization-related clinical parameters associated with kidney recovery in patients with AKI-D.Single-center prospective cohort study.111 adult patients who were admitted to the University of Kentucky Hospital, experienced AKI-D, and were discharged with need of outpatient HD.Hospitalization-related clinical parameters were evaluated.Kidney recovery as a composite of being alive and no longer requiring HD or other form of kidney replacement therapy.Discrete-time survival analysis and logistic regression were used to determine adjusted probabilities of kidney recovery at prespecified time points and to evaluate clinical parameters associated with recovery.45 (41%) patients recovered kidney function, 25 (55.5%) within the first 30 days following discharge, 16 (35.5%) within 30 to 60 days, and 4 (9%) within 60 to 90 days. Adjusted probabilities of recovery were 36.7%, 27.4%, and 6.3%, respectively. Of the remaining patients, 49 (44%) developed kidney failure requiring chronic kidney replacement therapy and 17 (15%) died or went to hospice. Patients who did not recover kidney function were older, had more comorbid conditions, had lower estimated glomerular filtration rates at baseline, and received more blood transfusions during hospitalization when compared with those who recovered kidney function.Selection bias given that patients included in the study were all eligible for AKI management with outpatient HD as part of Medicare/Medicaid services.At least one-third of AKI-D survivors discharged from an acute care hospital dependent on HD recovered kidney function within the first 90 days of discharge, more commonly in the first 30 days postdischarge. Future studies should elucidate clinical parameters that can inform risk classification and interventions to promote kidney recovery in this vulnerable and growing population.
Acid-Base and Electrolyte Disorders: A Companion to Brenner & Rector's The Kidney Authors: Thomas D. DuBose, Jr., MD; L. Lee Hamm, MD Bibliographic Data: W.B. Saunders Company, 2002. ISBN: 0-7216-8956-6, 547 pp, hard cover, $100.00. Reviewer's Expert Opinion: Description: This companion to the classic textbook, Brenner & Rector's The Kidney, 6th edition (W.B. Saunders, 2000), is specifically written to address practical approaches to the clinical disorders of acid-base and electrolyte abnormalities. Purpose: The purpose is to provide a concise and practical approach to the diagnosis and management of patients with acid-base and electrolyte abnormalities. Emphasis is placed on the logical linking of the pathophysiology to the diagnosis and therapy. Although there are numerous books addressing this particular subject, the editors and authors have diligently attempted to make this book rather unique by providing a practical resource for students and practicing clinicians. Specifically, unique chapters relevant to the critical care setting are presented and specific therapeutic recommendations are provided. In addition, recent advances in genetic and molecular understanding of various disorders are reviewed. The authors/editors have succeeded in achieving their goals. Audience: This book is primarily written for medical students and trainees in various specialties, including nephrology. It would also be quite useful to a busy clinician dealing with acid-base and electrolyte abnormalities. A panel of over 50 internationally distinguished experts have contributed. Features: The book is divided into five sections: acid-base disorders, disorders of water metabolism, sodium, potassium, and divalent ions. It contains numerous figures and tables that are of high quality and very easy to follow. The style of writing is focused, condensed yet simplified. A noticeable effort was made to use current material and incorporate the new with the old. Assessment: This is a quality book that can be used by physicians at all levels of their training. The content is concise and clinically relevant. References are relatively recent and well chosen. The authors have succeeded in diligently linking the understanding of the pathophysiologic mechanisms of acid-base and electrolyte abnormalities to the proposed diagnostic and therapeutic approaches. This is not an easy task given the complexity of these disorders. I particularly recommend this book to trainees in nephrology and critical care medicine.
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