Foods you can eat with Kidney Problems

The Kidney Disease Solution

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

The Kidney Disease Solution Overview

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HIV and Kidney Disease

Kidney disease related to AIDS was described as early as 1984 in reports from New York and Florida. Since then, a wide spectrum of acute and chronic renal syndromes has been reported. HIV-associated kidney disease was initially thought to occur late in the course of the infection, but it is now known that the kidneys may be involved in all the stages of HIV disease including acute infection. Renal glomerular and tubular epithelial cells may be directly infected by HIV. Effective therapies for HIV infection and the associated OIs have led to improved patient survival, which in turn has resulted in an increased number of HIV-infected individuals who require renal replacement therapy. Antiretroviral treatment has also resulted in increased reports of drug-related nephrotoxicities. IRIS may also involve the kidneys. Mortality rates for kidney diseases in HIV-infected individuals are increasing, and there is evidence that HAART may slow or prevent pro-gression.Appropriate screening for...

Extra Corporeal Dialysis

Other than Peritoneal Dialysis, electrolytic chloroxidizer is used as well in extra-corporeal dialysis. Because of the fact that the dialytic circuit is considered an extension of the blood circuit of the patient, it is imperative to adopt universal precautions in order to avoid potential transmission of infections. In chemical disinfection, the requirements for dialysis monitors disinfections are being easily recognizable for positive presence or for residual presence before any single use of the dialysis monitor It seems to us that the electrolytic chloroxidizer, better that any other agent, positively answer to these requirements (in particular if used after a descaling agent such as citric acid, oxalic acid or acetic acid). Furthermore, the other advantages described earlier are not satisfied by other industrial hypochlorites. In fact, because of the 1998 European new regulations concerning all medical devices, a disinfectant for dialysis apparatus must be 'CE marked'. All other...

Monitoring Kidney Function

Screening for kidney disease is very important because there are treatments that prevent the kidney disease from getting worse (see Chapter 3). The screening usually starts five years after diagnosis in people with type 1 diabetes, and at diagnosis in people with type 2 diabetes. The ADA recommends that people with diabetes be screened annually for kidney disease by measuring blood creatinine levels and urine albumin level in the first morning urine. It is not necessary to do a twenty-four-hour or an overnight urine collection the spot urine first thing in the morning is just as good. Your doctor will give you a small urine cup, and you will collect the first morning urine and take it to the lab. A urine albumin of less than 30 (milligrams per gram creatinine) is normal, 30 to 300 indicates early diabetic kidney disease (microalbuminuria), and greater than 300 indicates more significant disease (macroalbuminuria).

Adult Dominant Polycystic Kidney Disease ADPKD

ADPKD is an entity with an incidence of 1 400 to 1 1000 (47). By definition, it is inherited in an autosomal dominant fashion caused by mutations in the PKD1 or PKD2 genes, which are responsible for proper encoding of Polycystin and other vital cellular membrane proteins (48). Patients with the disease develop multiple, bilateral renal cysts, which progressively enlarge and eventually destroy remaining areas of renal parenchyma (47). The cysts are thought to derive from an abnormal proliferation of renal tubular cells (48). Co-morbidities associated with ADPKD can be numerous. Up to 50 of patients with ADPKD develop end-stage renal disease that necessitates hemodialysis or renal transplantation by the age of 60 (49). In addition, hypertension can develop in up to 50-70 of patients (50,51). The pathogenesis of hypertension in ADPKD patients is complex, but is thought to be derived from progressive intrarenal ischemia through physical compression by enlarging cysts, thus activating the...

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...

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.

Internal Disinfection of the Dialysis Monitors

Disinfection of the monitors for dialysis, whichever method and agent used, is not a single operation but consists of a series of operations in succession which should comprise primarily a procedure of post-dialysis rinsing and pre-disinfection, then cleansing, descaling, thorough disinfection and a final post-disinfection rinse so that the machine is in perfect condition for the successive dialysis sessions. Post-Dialysis Pre-Disinfection Rinse This is done with the aim of removing all residue of the dialysis solution from the hydraulic circuit of the machine, and if correctly carried out for a sufficient time with adequate flux it makes a valid contribution to the removal of organic substances such as hematic traces coming from an intradialytic rupture of the filter. It is particularly important for the removal of glucose residue which, if not completely eliminated, 'caramelizes' when heat-disinfection is used and represents an ideal pabulum for germs. The aim is to act on the...

External Disinfection of Dialysis Monitors

Disinfection of the hydraulic circuits of the dialysis monitors is not the sole procedure capable of guaranteeing maximum security it is also necessary to carry out a thorough cleansing and disinfection of the external parts of the equipment before starting another dialysis session. A correct procedure includes the operators (clothing, maneuvers, instruments) and the environment (from the dialysis room to the furnishing). Having a correctly disinfected monitor in its internal components, but operating in a contaminated environment is paradoxical. Disinfection of connectors with Amuchine 25 for 10-15 min at the end of each dialysis treatment followed by a generous rinse could be very useful 64 (table 1). In table 1, we report a list of the most important incompatibilities and of the dangerous associations between chemical, disinfecting, descaling, detergent normally utilized in the dialysis centers ( 65 modified). We also report their characteristics and possible toxic effects 66-68 ....

Chronic Renal Failure

Chronic renal failure (CRF) lipoprotein abnormalities are characterized by hypertriglyceridemia and a reduced HDL. The LDL particles in CRF tend to be of the phenotype B variety and therefore are more atherogenic. Atherogenicity is further enhanced by elevated Lp(a) levels. Decreased activity of both LPL and hepatic lipase are presumed to induce decreased clearance of triglyceride-rich lipoproteins. Unfortunately, these abnormalities do not resolve with the institution of dialysis or transplantation (11).

Chronic Renal Failure Introduction

Chronic renal failure (CRF) is the progressive deterioration of kidney function that reaches 50 or more loss or a creatinine level of less than 2 mg dl. Causes include congenital kidney and urinary tract abnormalities in children less than 5 years of age, and glomerular and hereditary kidney disorders in children 5 to 15 years of age. The disease involves all body systems as abnormalities include water, Na+, Ca++ losses, K+, HPO2-4, Mg++ increases, and reduced Hgb and Hct that result in metabolic acidosis, anemia, growth retardation, hypertension, and bone demineralization. Eventually, if untreated, uremic syndrome develops as the kidneys are not able to maintain fluid and electrolyte balance. End stage renal disease (ESRD) is defined as loss of kidney function at 90 or greater. ESRD is the term applied when the kidneys are no longer able to clear wastes from the body. Eventually the disease terminates in death unless kidney transplantation or dialysis is performed.

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...

Microdialysis Equipment

Perfusion Ringer (PR) Dialysis fibers are perfused with isotonic solution, the composition of which should resemble as much as possible the composition of brain extracellular fluid. Because fluid composition in each specific brain area is unknown and subject to time variations, PR composition has been validated on the base of its capacity to cause minimal alteration of brain function in that specific brain area, being compatible with voltage-responsive and calcium-dependent neurotransmitter release. The composition of PR used in our most recent investigations is 147 mMNaCl, 2.2 mM CaCl2, 4 mMKCl. It can be pumped through the dialysis probe at a constant flow of 1 L min. The rationale of ionic composition of PR has been debated in several articles (5,6). The most critical ions in the PR composition are K+ and Ca2+. The former is critical because its presence in the PR may alter physiological depolarization of terminals, with a consequent change in neurotransmitter release. Experiments...

Various Applications in Dialysis

Ronco C, Mishkin GJ (eds) Disinfection by Sodium Hypochlorite Dialysis Applications. Contrib Nephrol. Basel, Karger, 2007, vol 154, pp 139-144 Amuchina 10 Solution, Safe Antiseptic for Preventing Infections of Exit-Site of Tenckhoff Catheters, in the Pediatric Population of a Dialysis Program

Biofilm and Disinfection in Dialysis

Disinfection enters the quality assurance program in dialysis and represents part of the various anti-inflammatory treatment strategies adopted to improve outcome in these patients. Fig. 1. Subsequent phases of biofilm formation with bacterial deposition (a), attachment (b), growing (c) up to a mature biofilm (d) onto a silicone tube from a dialysis monitor hydraulic circuit. Fig. 1. Subsequent phases of biofilm formation with bacterial deposition (a), attachment (b), growing (c) up to a mature biofilm (d) onto a silicone tube from a dialysis monitor hydraulic circuit. Fig. 2. Biofilm presence on a peritoneal dialysis catheter removed because of peritonitis caused by colonization. Fig. 2. Biofilm presence on a peritoneal dialysis catheter removed because of peritonitis caused by colonization. Today, as a matter of fact, disinfectants in dialysis are considered as class II devices and therefore regulated by FDA in the US and CE mark application directives in Europe. Therefore...

Ficolins and IgA Nephropathy IgAN

IgA nephropathy (IgAN) is a common renal disease that is characterized primarily by mesangial deposition of IgA (Floege and Feehally 2000 Donadio and Grande 2002). Earlier studies showed that IgA activates the alternative pathway of complement, whereas more recent data also indicate activation of the lectin pathway. Activation of the lectin pathway of complement is associated with more severe renal damage (Roos et al. 2006). It was also demonstrated that both MBL and ficolin were found to contribute to the progression of the to IgA nephropathy (IGAN) (Roos et al. 2006). All Glomerular deposition of MBL was positively associated with co-deposition of L-ficolin. Renal biopsies of patients with IgAN showed mesangial deposition of IgA1 but not IgA2. Circulating IgA1 from patients with IgAN was reported to have aberrant glycosylation of O-linked glycans, which potentially are involved in recognition by lectins. Precise identification of the ligand for MBL and L-ficolin in the mesangium,...

What the clinician needs to know about chronic renal disease

Women with normal or only mildly decreased prepreg-nancy renal function (Scr < 125 mol l) usually have a successful obstetric outcome, and pregnancy does not appear to adversely affect the course of their disease. There are exceptions with most strongly advising against pregnancy in women with scleroderma and periarteritis nodosa. A few express reservations when the underlying renal disorder is lupus nephropathy, membranoprolif-erative glomerulonephritis, and perhaps IgA and reflux nephropathies. Dialysis has been advocated prophylactically during pregnancy to increase the chances of successful outcome but 'buying time' for fetal maturation in this way is independent of the inexorable declines in renal function ultimately to endstage failure. As extreme prematurity and disturbing, life-threatening maternal problems are commonplace such additional health risks are difficult to justify. Perhaps the aim should be to preserve what little renal function remains and to achieve renal...

What the clinician needs to know about dialysis patients

Dialysis and the prospects for pregnancy and afterwards Despite reduced libido and relative infertility, women on dialysis can conceive and must therefore use contraception if they wish to avoid pregnancy. Although conception is not common (an incidence of 1 in 200 patients has been quoted), its true frequency is unknown because most pregnancies in dialysis patients probably end in early spontaneous abortion. The high therapeutic abortion rate in this group of patients, (although decreased from 40 in Women on dialysis, if they become pregnant, may present for care in advanced pregnancy because it was not suspected by either the patient or her doctors. Irregular menstruation is common in dialysis patients and missed periods are usually ignored. Urine pregnancy tests are unreliable (even if there is any urine available). Ultrasound evaluation is needed to confirm and date pregnancy. DIALYSIS POLICY Some patients have gestational GFR increments despite renal function being insufficient...

Disinfection of Disposable Dialysis Tubing

The rate of continuous cycler PD use in the hospital setting is increasing. Using a cycler frees up the nurse's time. Instead of performing 4-8 manual exchanges per day, the nurse can put up enough dialysate for a day with one connection to initiate the cycle and one disconnection to terminate the cycle. Infection rate decreases due to fewer connect disconnect procedures where touch contamination is possible. The patient can be disconnected for procedures and then reconnected to the same line. Despite these advantages, there is increased cost of continuous cycler PD. The costs are related to the cycler, cycler tubing sets, cycler drain line bag and dialysate solutions. The patient must be able to disconnect and reconnect to the cycler either in between or during PD treatments as needed either in dwell or at the end of drain. Thus the concept of disinfection of disposable dialysis tubes for multiple use 19 .

Adult Polycystic Kidney Disease

Laparoscopic cyst decortication has also been described for the management of symptomatic ADPKD. ADPKD is the most common renal cystic disease, accounting for 9-10 of patients on chronic dialysis (3). The disease typically presents in the third or fourth decade of life and is progressive in nature. Mutations in at least three genes thought to be responsible for the disease have been identified PKD-1, PKD-2, and PKD-3, with a mutation in the PKD-1 gene on the short arm of chromosome 16 Although the primary management goal of ADPKD is control of hypertension and delay in loss of renal function, many patients suffer debilitating pain associated with expansion of the renal cysts. Medical management with non-narcotic analgesics is the recommended initial therapy, although nonsteroidal anti-inflammatory drugs (NSAIDs) may potentially exacerbate renal failure. Surgical management is reserved for those patients who fail conservative therapy. Percutaneous cyst aspiration has been used with...

Diabetic Nephropathy

The prevalence of diabetic nephropathy has increased dramatically and is now the first cause of end-stage renal disease requiring renal replacement therapy worldwide (72). Although the genetic background is important in determining susceptibility to diabetic nephropathy, exposure to chronic hyperglycemia leading to the subsequent activation of multiple pathogenic pathways appears to be the main initiating factor (2,3,4-6,41). Diabetic nephropathy occurs in up to 30 -40 of diabetic patients. The initial abnormalities include glomerular hyperfiltration and hyperperfusion resulting in microalbu-minuria, increased glomerular basement membrane thickening, and mesangial ECM deposition. These processes are followed by mesangial hypertrophy, diffuse and nodular glomerulosclerosis, tubulointerstitial fibrosis, and eventually progressive renal failure (73). Immunohistochemical studies of kidneys from normal and diabetic rats show that glomerular basement membrane, mesangium, podocytes, and...

Simple Renal Cysts

Reports of laparoscopic cyst decortication for simple renal cysts using both the transperitoneal and retroperitoneal approaches abound in the literature (34,36,42-48). Among series with at least 10 patients, success rates of (77-100 ) have been reported, although follow-up is short (under 1 yr) in most series (Table 3). In most series, the indication for surgery was persistent pain requiring narcotic analgesics. Most investigators used cyst resolution as the primary outcome parameter and determinant of success however, resolution of pain was reported in greater than 75 of patients in most series (34,36,42,45,48). The need for transfusion was rare and most groups reported minimal blood loss, few complications, and only rare cases required open conversion. Indeed, Fahlenkamp reviewed 139 cases of laparoscopic cyst decortication at four centers and noted only five complications (47). Complications that have been

Biofilm and Dialysis

Several medical devices could be used. Intravascular or urinary catheters represent the most frequent cause of medical device related pathologies, but it is during the phase of chronic kidney replacement therapy that uremic patients are at higher risk. During chronic hemodialysis infections, with related inflammatory events activation, may take place not only from vascular access but also from dialysis apparatus 12 . Even in the absence of standardized collection methods, biofilm has been detected in the hydraulic circuits of hemodialysis machines particularly in low-flux sections, loops and ultrafilters. In this biofilm, the concentrations of bacteria and endotoxins can range from 1.0 X 103 to 1.0 X 106 cells cm2 and 1-10EU cm2, respectively. Several constituents of cell wall of viable or not viable microorganisms can be released into the dialysate, including high molecular weight substances (> 100,000 Da) as well as low molecular weight ones (< 1,000 Da) or DNA fragments 13 ....

Acute Renal Failure

Acute renal failure is characterized by the sudden deterioration of renal function with a rapid decline of GFR to near 5 ml min, often associated (in approximately 75 of cases) with oliguria (< 500 ml of urine day or < 20 ml hr). Acute renal failure may result from numerous causes that may be divided into prerenal, renal, and postrenal. Prerenal causes are generally associated with diminished renal perfusion caused by decreased cardiac output, hypovolemia, hypotension, or severe renal vasoconstriction. Postrenal causes involve conditions in which intrarenal or extrarenal urinary passages become obstructed. Our emphasis shall be on renal causes of acute renal failure, especially those resulting from severe and sustained renal hypoperfusion (such as cardiovascular surgery) or those resulting from noxious substances intrinsic nephrotoxins such as those released during hemolysis or rhabdomyolysis or extrinsic nephrotoxins such as certain antibiotics and radiocontrast agents.

Central Venous Catheters

Bedside thereby eliminating the need for expensive and often unavailable operating room time. CVCs are essential for those patients requiring emergency dialysis or patients who are described as access failure, having used up the vessels required to create a permanent access. These devices can serve as a bridge for new fistulae waiting maturation or as a backup to the fistulas that require ligation due to high output states or steal syndrome 4 . Not only are these catheters readily available, but the survival rates of the CVCs are reported to be 75 at 1 year and 50 at 2 years, thereby allowing them to become an alternate form of long-term access to the arterio-venous fistula and graft 5, 6 . CVCs are used as a permanent access in children, the elderly, morbidly obese, or in diabetic patients whose blood vessels are not suitable for the creation of a permanent, internal, arterio-venous fistula or graft.

Complications of Central Venous Catheters

Central vein stenosis with occlusion begins at the time of catheter insertion as a result of the trauma of passing a large dialysis catheter through the vein wall. A fibrin sheath forms at the site of insertion progressing down the length of the catheter to the tip. The fibrin is reported to transform into fibrous tissue which stimulates intimal hyperplasia creating the stenosis and possible occlusion. The incidence of central vein stenosis is reported to be between 5 and 17 9 . Symptoms include swelling of the ipsilateral extremity, edema involving the upper chest, head and neck, and the presence of engorged chest wall veins. If severe, the edema can cause decreased mobility and pain. Treatment is balloon angioplasty with or without stent placement.

Chronic Exit Site Care of Healed Exit Site

ESI Exit-site infection PD peritoneal dialysis TI tunnel infection. ESI Exit-site infection PD peritoneal dialysis TI tunnel infection. The mean age, months on PD, method of dialysis (CAPD CCPD), and number of diabetic and non-diabetic patients were not statistically different (table 1). ESI TI rates were lower in the Amuchina group (0.52 episode patient year) in comparison to the povidone group (0.60 episode patient year). No catheter was lost in the Amuchina group. Local irritation and scab formation were more common in the Amuchina group 21 . Piraino B, Bailie GR, Bernardini J, Boeschoten E, Gupta A, Holmes C, et al Peritoneal dialysis- Golper TA, Brier ME, Bunke M Risk factors for peritonitis in long-term peritoneal dialysis The Gadallah MF, Ramdeen G, Mignone J, Patel D, Mitchell L, Tatro S Role of preoperative antibiotic prophylaxis in preventing postoperative peritonitis in newly placed peritoneal dialysis catheters. Am J Kidney Dis 2000 36 1014-1019. Mupirocin Study Group...

Dedication

They were always convinced of the importance of the scientific research. During their tenure, more than 400 studies have been performed and collected. In the early years, the attention was reserved principally to the treatment of wounds and burns. Later, starting in the 70s, my father was pivotal in addressing Amuchina's attention to the developing world of dialysis. Gratefully, Disinfection by Sodium Hypochlorite Dialysis Applications is dedicated to his memory.

Abstract

All dialysis treatments include a certain risk of infection because of the decreased immune defenses of the patients and because of dialytic techniques that increase the potential of microbial contamination. Peritoneal dialysis, and in particular continuous ambulatory peritoneal dialysis (CAPD), has a higher risk of infections of the peritoneum, but even of the subcutaneous tunnel. These infections are caused by environmental microorganisms principally gram-positives (Staphylococcus epidermidis and Staphylococcus aureus). We tested three active ingredients, electrolytic chloroxidizer, iodine and chlorhexidine gluconate. It is evident that because of the large spectrum of activity, the good effectiveness even at the lowest concentration, coupled with good tolerability (and to the fact of not causing allergic reactions) the electrolytic chloroxidizer appears to be an ideal antiseptic in CAPD. All dialysis treatments include a certain risk of infection because of the decreased immune...

Infection

Chlorhexidine gluconate, a cationic bisbiguanide, was developed in England in the early 1950s and was introduced into the United States in the 1970s. It is a chlorophenol biguanide with a broad antimicrobial spectrum. It is thought that chlorhexidine produces enzymatic reactions within the cell that result in protein denaturation and inactivation of nucleic acids 16 . Chlorhexidine is active against many Gram-positive and to a slightly lesser degree Gram-negative bacteria. Chlorhexidine is supplied in various concentrations of 0.5 with 70 alcohol, 2 , and a 4 detergent. It has greater residual activity than alcohol alone and is not inactivated by the presence of blood or human protein 19, 38-40 . There is minimal absorption through the skin. Anaphylactic reactions with bronchospasms and generalized urticaria are very rare and are associated with use on mucous membranes. In a prospective, randomized trial by Fuchs et al. 41 , three different methods of catheter exit site care were...

Background

In the late 70s, the introduction of the system suggested by Oreopoulos et al. 1 , i.e. the 'wearable enrolled 2-l plastic bag system', made possible the wide practical clinical application of the new, more efficient, continuous ambulatory peritoneal dialysis (CAPD) schedule proposed by Popovich et al. 2 ,

Discussion

Our study shows that Amuchina is effective in the prevention of exit-site infection during the 14 months of the study, seventeen times more than pH neutral soap. With very similar groups, in age, and time on dialysis, when is compared the Amuchina group with the soap group, the OR 17, shows the safety of using the chloroxidizer, which is statistically significant (p 0.004). There are some items to be observed, such as all children took care of their own exit-sites. Somehow it is surprising that Pseudomonas was our dominant strain isolated,

Methods

This is a retrospective single-center study based on patients' records and data files. The Hospital Civil de Guadalajara is a large tertiary-care facility that offers dialysis to patients of low social strata and no medical insurance. Since 1989, we have kept an epidemiological surveillance of the episodes of peritonitis in our CAPD program. All patients who started CAPD between July 1st, 1989, and June 30th, 2003 were eligible for the study. From July 12, 1989 to May 12, 1999, both Dianeal (Baxter International, Inc.) and Solucion DPTM (Laboratorios Pisa, Mexico) spike systems were used (conventional group). In this period, the transfer sets were changed using povidone-iodine 10 solution. Also, a connection shield with a sponge soaked with this disinfectant was used at the transfer set's Luer-lock connector and at the spike-bag outlet port connection. From May 13, 1999, the double-bag system (BenYTM, Laboratorios Pisa, Mexico) was introduced in all patients (double-bag group), and...

Preface to the First Edition

The cause of diabetes mellitus is metabolic in origin. However, its major clinical manifestations, which result in most of the morbidity and mortality, are a result of its vascular pathology. In fact, the American Heart Association has recently stated that, from the point of view of cardiovascular medicine, it may be appropriate to say, diabetes is a cardiovascular disease (1). But diabetic vascular disease is not limited to just the macrovasculature. Diabetes mellitus also affects the microcirculation with devastating results, including nephropathy, neuropathy, and retinopathy. Diabetic nephropathy is the leading cause of end-stage renal disease in the United States, while diabetic retinopathy is the leading cause of new-onset blindness in working-age Americans. The 24 chapters of Diabetes and Cardiovascular Disease focus on either clinical or basic aspects of diabetes and cardiovascular disease. Part I, Pathophysiology, reviews the mechanisms and risk factors for diabetic...

Studies In Renal Disease

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

Genetic Considerations

Metabolic acidosis occurs primarily in patients with insulin-dependent diabetes mellitus (IDDM) and chronic renal failure, regardless of age. Metabolic acidosis from severe diarrhea can occur at any age, but children and the elderly are at greater risk because of associated fluid imbalances. Young women are at an increased risk of metabolic acidosis because of the popular fad diets of starvation. Ethnicity and race have no known effects on the risk for acid-base imbalance.

Discharge And Home Healthcare Guidelines

Allergic purpura is an allergic reaction that leads to acute or chronic inflammation of the vessels of the skin, joints, gastrointestinal (GI) tract, and genitourinary (GU) tract. It occurs as an acquired, abnormal immune response to a variety of agents that normally do not cause allergy, and it is manifested by bleeding into the tissues, organs, and joints, which leads to organ dysfunction, discomfort, and immobility. An acute attack of allergic purpura can last for several weeks, but usually episodes of the disease subside without treatment within 1 to 6 weeks. Patients with chronic allergic purpura can have a persistent and debilitating disease. The most severe complications are acute glomerulonephritis and renal failure. Hypertension often complicates the course, and if bleeding is excessive, the patient can develop a fluid volume deficit. On rare occasions, patients may be at risk for airway compromise from laryngeal edema.

Activation of the Polyol Pathway

Polyol pathway, could prevent the some pathological abnormalities in diabetic retinopathy, nephropathy, and neuropathy (59). However, these results are not supported by data obtained from clinical trials using inhibitors of aldose reductase. A 3-year follow up of diabetic patients treated with Sorbinil (250 mg per day) failed to discern difference in retinopathy (61), although another aldose reductase inhibitor Zenarestat has been shown to improve nerve conduction in diabetic peripheral polyneuropathy (62). Based on the largely negative clinical data, a significant role for the activation of the polyol pathway in the pathogenesis of diabetic vascular complications has not been fully established.

Diabetes And Circulatory Problems

Even though people with type 1 diabetes generally do not have high blood pressure and high cholesterol problems, they can develop heart disease after many years. This is especially likely to occur if they have diabetic kidney disease. Lower blood pressure. I have already discussed in the Diabetic Kidney Disease section earlier in this chapter the importance of controlling blood pressure. The treatment goal is to get the systolic blood pressure (top number) below 130 mm Hg and the diastolic blood pressure (bottom number) below 80. Take aspirin. Clinical studies show that aspirin reduces the risk of heart attacks and stroke. Aspirin works by making platelets (the cells in the blood that are responsible for blood clotting) less sticky. Recent studies indicate that lower doses are just as effective as higher doses, so low-dose aspirin therapy (a 75-81 mg dose once a day) is recommended if you already have heart disease or circulatory problems. If you cannot tolerate aspirin because of...

Clinical Implication Of Drug Transporters

Japanese and non-Ashkenzai Jews than in other ethnic groups. Patients with this disease have low serum urate levels. They have no renal or systemic diseases except for the development of nephrolithiasis or exercise-induced acute renal failure. Some patients with this disease have defects in URAT1.40-42 The most frequently found mutation W258Stop of URAT1 results in a premature truncated protein, which is devoid of the transporter function due to deficiency in targeting to cell membrane.i0 Several studies have demonstrated that the single i nucleotide polymorphisms (SNPs) or regulatory SNP ( rSNPs) sometimes could result in interindividual variation in mRNA expression of OATs and could potentially regulate the drug PKs in human tissues or animal models.43-45 However, some conflicting data on the effects of polymorphisms on the function of drug transporters such as OAT3 or OAT1 may highlight that some SNP might be substrate or race specific. Another example of the involvement of OATs in...

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)....

Circoviruses and Gyroviruses Induce Diseases

PCV1 and PCV2 seem to be restricted to pigs. PCV2 is the etiological agent of a new disease in swine, the so-called post-weaning multisystemic wasting syndrome (PMWS), and may be involved in several other porcine circoviral diseases (PCVDs) like porcine dermatitis and nephropathy syndrome (PDNS) or porcine respiratory disease complex. PMWS was first recognized in Canada in 1991. Since then it has been described as a major economic concern in virtually all pig-producing areas of the world. PMWS primarily occurs in pigs between 60 and 80 days old. Maternal antibodies confer titer-dependent protection against PCV2 infection - higher titers are generally protective, but low titers are not. PMWS is characterized by wasting, respiratory signs, enlargement of superficial inguinal lymph nodes, diarrhea, paleness of the skin or icterus, but the clinical signs are often variable. The most consistent feature of PMWS is a generalized depletion of lymphocytes. Secondary infections with...

Basement Membrane Thickening and Extracellular Matrix Expansion

Histologically, increases in type IV and VI collagen, fibronectin and laminin and decreases in proteoglycans are observed in the mesangium of diabetic patients with nephropathy and probably in the vascular endothelium in general (152,153). These effects can be replicated in mesangial cells incubated in increasing glucose levels that were prevented general PKC inhibitors (154-156). Additionally, increased expression of transforming growth factor (TGF)- P has been implicated in the development of mesangial expansion and basement membrane thickening in diabetes. Because PKC activation can increase the production of ECM and TGF-P, it is not surprising that several reports have shown that PKC inhibitors can also prevent hyperglycemia- or diabetes-induced increases in ECM and TGF-P in mesangial cells or renal glomeruli (98).

Primary Nursing Diagnosis

With an acute hemolytic reaction there are three conditions to consider renal failure, shock, and disseminated intravascular coagulation (DIC). To counteract shock and minimize renal failure, the physician prescribes aggressive normal saline or colloid intravenous infusion. Mannitol is often used to promote diuresis. Dopamine may be used if hypotension is a problem. Furosemide (Lasix) may be given to keep urine output at 50 to 100 mL hr. For pyretic reactions, after the possibility of a hemolytic reaction is ruled out, an antipyretic such as acetaminophen may be given and the transfusion may be restarted with caution. For severe reactions, see the table that follows.

Host Range Tissue Ttopism and Virus Propagation

Most coronaviruses cause epidemic disease in only one species, although limited replication, usually without disease, may result from experimental inoculation of other species. Coronaviruses typically cause respiratory or enteric diseases, although several can also cause hepatitis, infectious peritonitis, nephritis, myocarditis, sialodacryadenitis, or neurological, reproductive or immunological disorders. The viruses were named for their natural host and sometimes for the associated disease for example, avian infectious bronchitis virus (IBV) mouse hepatitis virus (MHV) sialodacryadenitis virus of rats (SDAV) bovine coronavirus (BCoV) porcine hemag-glutinating encephalomyelitis virus (HEV) turkey bluecomb coronavirus (TCoV) human respiratory coronaviruses (HCoV) transmissible gastroenteritis virus of swine (TGEV) porcine respiratory coronavirus (PRCV) canine coronavirus (CCoV) feline infectious peritonitis virus (FIPV) and feline enteric coronavirus (FeCoV) and rabbit coronavirus...

Phosphorylation of CFTR Protein by the Catalytic Subunit of Protein Kinase A PKA

After the quantity and purity of CFTR protein in the different fractions eluted from the column are determined (see Subheading 3.2.), best fractions are removed from the dialysis bag and combined into one tube. 3. Removal of PKA after the phosphorylation reaction is required to avoid interference of the kinase with the intrinsic ATPase activity of the pure CFTR protein (18). Thus, to remove PKA, all samples are dialyzed in a Spectra Por dialysis membrane (molecular weight cutoff 50 kDa) overnight at 4 C, against 4 L of buffer D. The next day, buffer D is changed to buffer C and the samples are further dialyzed at 4 C overnight.

Analysis of the Activity of Purified CFTR Protein

In the following paragraphs we discuss our current biochemical methods for the measurement of CFTR ATPase activity as these methods have undergone revisions since the original protocols were published (1,18,20). For example, one major change in the protocol is the requirement of the purified protein to be used fresh (i.e., immediately after the dialysis and without freezing). We observed that the catalytic activity of the purified and reconstituted CFTR protein markedly decreased after freezing and thawing cycles. Another revision of the previous protocol is the shorter time required for the ATPase assay, that is, 2 h rather than 4 h. On the other hand, our assays of CFTR channel have not been substantially revised since our description in Methods in Enzymology (18) and therefore will not be revisited in this chapter.

Exogenous Sources of Advanced Glycoxidation End Products

Animal studies have demonstrated the close relationship between increased dietary AGE intake and development and or progression of many diabetes-related complications. Nephropathy, postinjury restenosis, accelerated atherosclerosis, and delayed wound healing were significantly inhibited by lowering dietary AGE intake (27-30). Sebekova and associates demonstrated in the remnant-kidney rat model that feeding an AGE-rich diet for 6 weeks increases kidney weight and causes proteinuria, independent of changes in glomerular filtration rate, pointing to the detrimental effect of such diet on the kidney (31). Of particular interest are studies showing that a low-glycotoxin environment can prevent or delay significantly autoimmune diabetes in successive generations of nonobese diabetic (NOD) mice (32) and to improve the insulin-resistant state in db db (+ +) mice (33). Reduction in exposure to exogenous AGEs of db db (+ +) mice, lacking in leptin receptor and thus prone to insulin resistance...

Advanced glycoxidation endproducts metabolism

Other intracellular protective systems also help to limit the accumulation of reactive AGE intermediates. Methylglyoxal is first converted by glyoxalase-I to S-D-lacto-ylglutathione in the presence of reduced glutathione as an essential cofactor, and then converted to D-lactate by glyoxalase-II. The significance of such systems is supported by studies in which overexpression of glyoxalase-I prevented hyperglycemia-induced AGE formation and increased macromolecular endocytosis (47). These systems, however, could still be overwhelmed by high AGE conditions such as diabetes, renal failure, or sustained excess dietary AGE intake.

Physiological Changes

Genitourinary Potential for renal shutdown brought about by hypovolemia or acute renal failure exists. Massive diuresis from fluid returning to the vascular space marks the end of the emergent phase. Patients may develop hemomyoglobinuria because of massive full-thickness burns or electric injury. These injuries cause the release of muscle protein (myoglobin) and hemoglobin, which can clog the renal tubules and cause acute renal failure.

Pathology and Histopathology

Although most LDV infections are inapparent in mice, some histopathogenic changes are observed in infected animals. As described above, the serum levels of seven enzymes are chronically elevated in LDV-infected mice. Normally, an increase in serum levels of tissue enzymes is the result of tissue damage, but in LDV-infected animals little tissue damage is observed. Although there are five naturally occurring LDH isozymes in mouse plasma, only the level of isozyme LDVV is elevated in LDV-infected mice. Studies have indicated that the increase in enzyme levels is primarily the result of a decreased rate of enzyme clearance. A subpopulation of Kupffer cells involved in receptor-mediated endocytosis of LDH is severely diminished in mice by 24 h after LDV infection. It has been postulated that LDV replication in these cells causes their death and results in increased LDH serum levels. Splenomegaly, characterized by a greater than 30 increase in spleen weight, occurs in about 40 of the mice...

Individuals with chronic disease

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

Advanced glycoxidation endproducts interactions

The receptor for advanced glycation end-products (RAGE), a well-characterized multiligand member of the immunoglobulin superfamily, is viewed as an AGE-binding intracellular signal-transducing peptide, which mediates diverse cellular responses rather than as a receptor involved in AGE endocytosis and turnover. Several other distinct ligands have been described for RAGE including amyloid, amphoterin, and S100 calgranulins (5,41,59-62). RAGE is present at low levels in adult animals and humans, but is later upregulated regardless of diabetic vascular disease (62). RAGE expression is increased in sites of increased AGE accumulation such as vasculature, neurons, lymphocytes, and tissue-invading mononuclear phagocytes. In the kidney, RAGE is expressed in glomerular visceral epithelial cells (podocytes) but not in mesangium or glomerular endothelium (59). Diabetic RAGE-transgenic mice exhibit renal vascular changes characteristic of diabetic nephropathy (60). In contrast, brief infusion of...

Special Investigations

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

Effect of MnSOD over hiperglycemic memory

Results from Epidemiology of Diabetes Interventions and Complications Study indicate that hiperglycemic memory also occurs in human patients (34). It was demonstrated that the effects of conventional and intensive treatments over occurrence and severity of post-study diabetic retinopathy and nephropathy persist until 4 years after Diabetes Control and Complications Trial, in spite of almost identical glycosilated hemoglobin values during the 4-year follow-up period (34). It is interesting that obtaining normoglycemia through pancreatic transplantation is not effective yet in reducing diabetic retinopathy progression (34). Other studies demonstrate that previous glycemic exposure and glycemic level at first visit also have influence over diabetic retinopathy development (34). The lesson from those studies is that achieving the best glycemic control when diabetes is diagnosed seems to be of outstanding importance once HbAlc levels already during the first year of disease are related to...

Gender Ethnicracial And Life Span Considerations

Although a patient of any age can develop a cardiac tamponade, the very young and the elderly have fewer reserves available to cope with such a severe condition. Because trauma is the leading cause of death for individuals in the first 4 decades of life, traumatic tamponade is more common in that age group, whereas the older adult is more likely to have an iatrogenic tamponade. Males have higher rates of unintentional injury than do females in children, cardiac tamponade is more common in boys than in girls with a male-to-female ratio of 7 3. Cardiac tamponade related to human immunodeficiency virus infection is more common in young adults, whereas cardiac tamponade due to malignancy or renal failure is more often seen in elderly patients. Ethnicity and race have no known effect on the risk of cardiac tamponade.

Postoperative Management

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

Preoperative Assessment

The diagnosis of a renal cyst is made radiographically either as an incidental finding or during evaluation of symptoms such as flank or abdominal pain, early satiety, hematuria, hypertension, or urinary tract infection. Ultrasound or computed Fig. 1. Nonenhanced CT scan for patient with symptomatic right renal cyst. Fig. 1. Nonenhanced CT scan for patient with symptomatic right renal cyst. tomography (CT) provide the most reliable means of diagnosing renal cysts (Figs. 1 and 2). Intravenous urography (IVU) may suggest the presence of a cyst indirectly by demonstrating distortion of the collecting system, but in general IVU is not a reliable imaging modality for identification of renal cysts. A history of ADPKD, VHL, or tuberous sclerosis may prompt screening radiographic studies for monitoring the development or degeneration of renal cysts (Fig. 3). Likewise,

Prostaglandins Thromboxanes and Other Arachidonic Acid Metabolites

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

Kallikrein Kinin System

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

Management Algorithms Complex Cysts

An attempt to predict the malignant potential of renal cysts has resulted in a classification scheme based on radiographic appearance. The Bosniak classification relies on criteria to categorize cysts into low-, medium-, or high-risk groups (Table 1) (4). In a recent meta-analysis, Bosniak Class II, III, and IV cysts were found to have a risk of 24, 41, and 90 , respectively (5). If the suspicion of malignancy is high, percutaneous aspiration of the cyst fluid for cytological examination may be performed, although the risk of a false-negative cytology remains. A comprehensive meta-analysis by Wolf et al. found an overall sensitivity of cyst aspiration in diagnosing malignancy of 90 , a specificity of 92 , positive predictive value of 96 and negative predictive value of 80 (5). The risk of a false negative aspiration has been estimated at 20 , and the occurrence of tumor seeding along the needle tract has been reported (6-12). Consequently, definitive management of complex cysts has...

Symptomatic Simple Cysts

For symptomatic simple renal cysts, an initial attempt at conservative therapy with analgesics should be undertaken. If these measures fail, percutaneous aspiration or sclerosis or surgical decortication may be tried. Cyst aspiration for simple, peripheral cysts can be performed using CT or ultrasound guidance and enables sampling of the cyst fluid for cytology. Unfortunately, simple percutaneous drainage is associated with a high rate of fluid reaccumulation, resulting in the frequent addition of a sclerosing agent (13,14). Multiple compounds have been used as sclerosing agents, including alcohol (15-17), tetracycline (18), minocycline (13), and povodine-iodine (19), with success rates ranging from 75-97 and complication rates from 1.3-20 . As such, percutaneous sclerosis should be the preferred therapy for most simple cysts once the benign nature of the cyst is established. For patients who fail percutaneous cyst aspiration and or sclerotherapy or are unsuitable candidates,...

Vancomycinresistant E Faecium

The streptogramin, quinupristin dalfopristin is being used in multiple trials for treatment of gram-positive infections, including those caused by vancomycin-resistant E. faecium. Undoubtedly, this latter organism will prove a significant problem in immunocompromised patients. Two such cases of life-threatening infections in the setting of severe immunosuppression, one in a patient with chronic renal failure on peritoneal dialysis who developed vancomycin-resistant E. faecium peritonitis and the other in a severely neutropenic patient with lymphoma who was receiving chemotherapy were seen at the consulting service at Stanford.

Labeling Antibody With Longarmed Biotin

The following protocol is for conjugating either IgG or IgM antibodies alternative information appropriate for the two types of antibodies is indicated in certain steps. Conjugation of IgM antibodies using dialysis buffer at pH 7.5, rather than pH 8.4, provides consistently better labeling, perhaps due to overlabeling og the IgM at higher pH. (DMF) Dialysis tubing For discussion of dialysis and a detailed procedure, see Andrew and Titus (1991). 4. Remove unbound biotin by dialysis against final dialysis buffer at 4 C as in step 1.

Conjugation Of Texas Red To Rphycoerythrin To Produce An Energy Transfer Fluorochrome

Ammonium sulfate solution) R-PE dialysis buffer (prepared within 2 days of use see recipe) Conjugation buffers A and B (see recipes) Texas Red-sulfonyl chloride (Molecular Probes) N,N-Dimethylformamide (DMF) Glycine (ultrapure or ACS grade) Dialysis tubing 1. Dialyze 10 to 50 mg R-phycoerythrin (R-PE) against 500 ml R-PE dialysis buffer with two or three changes over 2 days at 4 C. Allow > 4 hr between buffer changes. Protect R-PE from light by covering containers with foil during dialysis and in all subsequent steps when practical. For discussion of dialysis and a detailed procedure, see Andrew and Titus (1991). 14. Pass the resulting solution over a Sephadex G-50 fine column equilibrated with R-PE dialysis buffer, using 25 ml resin per ml solution volume. From step 16 to this point takes 4 hours. The product may be stored up to 15 days at 4 C. To store longer, add sodium azide to 1 final concentration. The sodium azide will require removal by dialysis prior to conjugation.

Advanced Glycation Endproducts AGEs

AGEs and its receptor RAGE (receptor of AGEs) are known to exert a pivotal role in diabetic vascular complication such as retinopathy and nephropathy. Dysfunction of BRB in diabetic retinopathy is also caused by AGEs associated mechanism. First, dysfunction and apoptosis of pericyte, a key cellular component in the formation and maintenance of BRB are suggested as a mechanism of AGEs related BRB breakdown in diabetes. In streptozocin induced diabetic rats, significant deposition of AGEs and expression of RAGE were noted in pericytes of the capillary beds (Stitt et al., 1997). AGEs showed toxicity to pericyte in vitro and this toxic effect is mediated by AGE-RAGE interaction (Yamagishi et al., 1995). ROS generation through AGE-RAGE interaction results in oxidation of DNA, membrane lipid peroxidation and subsequent apoptotic pericyte death (Yamagishi et al., 2002b). In addition, AGEs regulate the expression of growth factors from pericyte which participate in the BRB function (Shimizu...

Possible therapeutic approach to diabetic retinopathy through BRB modulation

ACTION I A Clinical Trial In Overt Nephropathy of Type 1 Diabetics, AT1R angiotensin II type 1 receptor, DIRECT Diabetic Retinopathy Cardesartan Trials, ETDRS Early Treatment of Diabetic Retinopathy Study, DM diabetes mellitus, EUCLID EURODIAB Controlled Trial of Lisinopril in Insulin-Dependent Diabetes Mellitus, FIELD Fenofibrate Intervention and Event Lowering in Diabetes, FU follow-up, ME macular edema, MVL moderate visual loss, PKC-DRS PKC inhibitor diabetic retinopathy study, PKC-DMES PKC inhibitor diabetic macular edema study, sRAGE soluble form of RAGE.

Take Home Messages

The laparoscopic approach to complex renal cysts is controversial and patient candidates for laparoscopic exploration and or decortication require careful selection. For Bosniak II III cysts, aspirated cyst fluid should be sent for cytology and samples of the cyst wall and base should be sent for histopathologic evaluation.

Efficacy in Models of Ischemic Injury

94 , suggesting that the cell-signaling mechanisms described above are required for APC's observed efficacy. Murakami et al. 133 showed in a rat model that APC could attenuate endotoxin-induced pulmonary vascular injury by inhibiting activated leukocytes. Moreover, APC was shown to reduce ischemia or reperfusion-induced renal injury in rats by inhibiting leukocyte activation 134 . Overall, these effects on leukocyte function in vivo are consistent with the mechanistic data of EPCR-dependent signaling and suppression of cell adhesion molecules from endothelial studies (Figure 4.8) 69,70 . APC has also shown efficacy in cardiac ischemic injury models 135 . These data suggest that APC, in addition to its effectiveness in severe sepsis (as discussed below), may be effective in reducing ischemic tissue damage in disorders such as stroke, cardiogenic shock, and acute renal failure.

The Mthfr Gene Product MTHFR

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

Outcomes in Diabetic Patients

The Microalbuminuria, Cardiovascular, and Renal Outcomes (MICRO)-Heart Outcomes Prevention Evaluation (HOPE) study was a placebo-controlled trial designed to evaluate the effects of the ACE inhibitor ramipril and vitamin E on the development of diabetic nephropathy and CVD in diabetic patients (5). The ACE inhibitor component of the HOPE trial was discontinued early, after 4.5 years, because there was clear evidence of a beneficial effect on cardiovascular endpoints in the ramipril-treated group (96). Analysis of the composite outcome including MI, stroke, or cardiovascular-related death, revealed that the protective effects associated with ACE inhibition were similar in the absence or presence of diabetes (96). The beneficial effects of ACE inhibition occurred in both type 1 and type 2 diabetic patients and were irrespective of hypertension (5). Interestingly, the results from this study demonstrated that ACE inhibition reduced cardiovascular endpoints beyond that which would be...

Clinical Features and Infection

The major clinical manifestations observed in naturally infected cats are chronic oral diseases, chronic upper respiratory tract disease, chronic enteritis and chronic conjunctivitis. Anorexia, weight loss, lethargy, vomiting, fever of unspecified origin and recurrent cystitis were other signs observed in these cats. Abnormal behavioral problems, lymphosarcoma and myeloproliferative disease were also seen in a small proportion of affected cats. Abnormalities in kidney function and pathology have been reported both in naturally and experimentally infected cats. Glomerulosclerosis, fibrosis, tubular degenerative changes and diffuse interstitial infiltration by phagocytes and plasma cells have been observed in naturally infected cats, while glomerular mesangial cell proliferation has been seen in experimentally infected cats. Overall, natural FIV infection causes progressively degenerative immune disorder, neurologic disorders, wasting syndrome and a variety of persistent secondary...

Description Medical Diabetes

Long-term complications such as disease of the large and small blood vessels lead to cardiovascular disease (coronary artery disease, peripheral vascular disease, hypertension), retinopa-thy, and renal failure. Diabetic patients also have nerve damage (neuropathy) that can affect the peripheral nerves, resulting in numbness and pain of the hands or feet.

Health Insurance and Medicine in the 1980s

New medical technologies constituted a major factor in health care cost increases and became one driver of cost containment. A number of expensive new technologies had diffused rapidly before evaluation, including dialysis and kidney transplantation in the 1960s, computed tomography in the 1970s, and magnetic resonance imaging in the 1980s (Institute of Medicine 1985 Rettig 1991). This phenomenon drew the attention of health economists, who began to analyze the elements of increasing costs of health care. They concluded that roughly half of the annual increase in costs of health care could be attributed to the effects of new medical technologies (Newhouse 1992 Weisbrod 1991). Insurers were quite aware of these effects and the pressure they exerted on insurance premiums. Major corporations, as purchasers of health care, also became sensitive to new medical technologies as a source of increasing costs for employer-financed health insurance.

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.

Starvation And Immune Responses 41 Models of Starvation in Normal Mice

Starvation causes significant immune impairment (83). It has been shown that acute starvation in mice reduces the number of CD4+ T-cells and suppresses the development of T-cell-mediated immunity (84). Furthermore, starvation causes delayed repopulation of the lymphoid compartment following an insult, such as sublethal irradiation (85). The timing of the acute starvation appears to be crucial in terms of influencing immune responses. Starvation around the time of priming to an antigen has the greatest effect on reducing the subsequent T-cell immune response to that antigen. Starvation around the time of rechallenge also reduces the immune response, although by not to as great an extent (82). Food restriction can also impair immune responses such that it can prevent death from autoimmune nephritis in the NZB x NZW Fj model of murine lupus (86).

Use Of Diuretics In Nephrotic Syndrome

The subset of patients with chronic renal disease who have nephrotic syndrome provide an additional challenge to effective diuretic therapy. In patients with this condition blunted responses to diuretics are frequently observed early in the course of the disease when GFRs are normal or only modestly reduced. Both pharmacodynamic and pharmacokinetic mechanisms account for diuretic resistance in nephrotic syndrome. Most pharmacokinetic studies have focused on the effect of reductions in serum albumin on delivery of loop diuretic to the kidney. Because loop diuretics are so highly protein bound (> 90 ), reductions in serum albumin result in significant increases in the amount of free drug and the resultant increase in volume of drug distribution. Total plasma clearance of furosemide has also been reported to be increased in some studies but this may reflect the increase in nonrenal clearance of that agent reported with reduced renal function. Thus, as noted by Keller and associates,...

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.

Complications Of Albumin And Diuretic Combinations

Magnitude of the diuretic response nor the level of baseline renal function. Although serum creatinine concentrations fell from their peak value following discontinuation of albumin and diuretic therapy, serum creatinine concentrations did not return completely to baseline despite a follow-up of up to 7 weeks in some cases. Whether the increase in serum creatinine reflects a reduction in renal function or change in creatinine production is unclear. The underlying disease in the majority of patients who manifested this change was focal glomerulosclerosis. Finally metal contamination of albumin can occur during processing of albumin from plasma and there have been reports of accumulation of these metals, especially aluminum in patients during albumin replacement. Patients with impaired renal function are more susceptible to this problem. Data on complications of albumin and diuretic therapy in other hypoprotei-nemic conditions have not been specifically reported.

Public Patient Outcomes

Significantly advancing the care of patients (e.g., statins in hypercholesterolemia in the 1990s). More untreatable diseases are finding amelioration or improvement through product innovation over the past 20 years (e.g., HIV infections with new classes of antiviral drugs, anemia of kidney disease and cancer with epoietin alfa, and enzyme deficiency diseases such as Gaucher disease with enzyme replacement). A novel product choice has been created because of its unique mechanism of action different from existing products, altering a key newly identified pathophysiologic process for a disease (e.g., aromatase inhibitor Arimidex or oncogene inhibitor Herceptin for breast cancer), or a better side effect profile has been achieved (e.g., Nonsteroidal anti-inflammatory drugs for arthritis versus aspirin). The new product achieves patient care improvement with higher efficacy over prior therapy, becoming a clinically superior or even best-in-class product (e.g., Crestor as a statin for high...

Clinical manifestation

Occult malignancy-associated spontaneous gas gangrene no obvious preceding event gas gangrene presents with sudden onset of pain, with low-grade fever and apathetic mental status local swelling and serosan-guineous exudate appear soon after onset of pain skin turns to a bronze color, then progresses to a blue-black color with hem-orrhagic bullae entire region sometimes becomes markedly edematous within hours wound may be nonodorous or have a sweet mousy odor crepitus following gas production pain and tenderness to palpation disproportionate to wound appearance late signs hypotension, renal failure, and a paradoxical heightening of mental acuity

Bilateral Upper Urinary Tract Obstruction

The classic presentation of bilateral upper urinary tract obstruction often differs clinically when compared to unilateral obstruction. Bilateral upper urinary obstruction most commonly occurs on a more chronic basis, related to an extrinsic process that progresses slowly over time. In this scenario, signs and symptoms directly related to the extrinsic process often prompt the workup which ultimately leads to the diagnosis of bilateral obstruction. When bilateral chronic upper urinary tract obstruction progresses to the point of causing symptoms, manifestations of renal failure are also commonplace. A common presentation for acute bilateral upper urinary obstruction is related to bilateral obstructing ureteral or UPJ stones. The tip-off to this diagnosis can be the development of bilateral flank pain in the setting of anuria however, more commonly the bilateral stones will be only partially obstructing and the patient will maintain an adequate urine output. Urgent management of...

Endocrine Functions Of The Kidney

Erythropoietin is interesting because it is a growth factor (or cytokine) that behaves like a hormone. Erythropoietin is a 34-kDa glycoprotein that is secreted by interstitial cells in the kidney, and its synthesis and release is increased by a low hematocrit or a fall in blood oxygen carriage. Erythropoietin acts on erythroid progenitor cells in bone marrow as a colony-stimulating factor and increases the production of red blood cells. As might be expected, renal failure is accompanied by anemia as one of its many side effects. However, the fall in erythropoietin production is not the only reason for the anemia. Disseminated tissue hemorrhaging and a decrease in hemoglobin and red blood cell production accompany uremia. Nevertheless, the anemia of renal

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.

Effect of Supplementation on Vitamin E Metabolism and Excretion

Urinary excretion appears to be an important route for the CEHC metabolites 40 . Therefore, an impaired renal function model is likely to be a useful tool with which to investigate tocopherol metabolism. Confirming this, patients with kidney dysfunction have been shown to have an exponential increase in a- and y-CEHC concentrations compared with healthy subjects and haemodialysis appears to lead to only a short term correction of this response 37-39 . As expected in these patients, supplementation with a-tocopherol increases plasma a- and y-CEHC concentrations while y-tocopherol supplementation increases y-CEHC concentrations. These accumulations occur as a result of the decreased renal clearance, hence, highlighting the importance of urinary excretion in tocopherol metabolism.

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.

Water Reabsorption Driven By Solute Reabsorption

Perhaps the most frequently administered intravenous fluid is isotonic saline (0.9 0.9 g of NaCl dL). Isotonic saline is used as a replacement for extracellular salt and water that may be depleted by dehydration, or when a patient is not eating and drinking normally. Thus, unless there is reason to suspect that a patient is actually volume overloaded, which may occur with congestive heart failure or liver or kidney failure, ample isotonic saline is given as a means of maintaining normal extracellular fluid volume. If the kidneys are operating normally, it is difficult to expand the extracellular fluid volume significantly because the kidney increases its excretion of salt and water to match the increased input. Most of this adaptation occurs quickly and is due to decreased salt and water reabsorption in the proximal tubule.

Symmetrical Neuropathies

The natural history of chronic distal symmetrical neuropathy remains poorly understood. This is mainly because there is paucity of well conducted prospective studies that have sought to examine this (6). In addition, the inadequate knowledge regarding the pathogenesis of distal symmetrical neuropathy is also a contributory factor, although several mechanisms have been suggested (31-35), and the list of potential mechanisms is constantly growing. Unlike in diabetic retinopathy and nephropathy, the scarcity of simple, accurate, and readily reproduciable methods of measuring neuropathy further complicates the problem (15,16). One study (36) reported that neuropathic symptoms remain or get worse over a 5-year period in patients with chronic distal symmetrical neuropathy. A major drawback of this study was that it involved highly selected patients from a hospital base. A more recent study reported improvements in painful symptoms with worsening of quantitative measures of nerve function...

Genitourinary System Basic Care Plan Introduction

Urine descends through the ureters to the bladder, where it is stored until it is excreted via the urethra. Disease processes may cause inflammation, tissue damage, and scarring with resultant dysfunction of the organs or structures of the genitourinary system. Structural defects may be either congenital or acquired and can obstruct urine flow causing renal damage and possibly lead to kidney failure. The kidneys of infants and children are immature in regard to fluid and electrolyte balance because of their limited ability to concentrate urine. This creates increased risk for fluid and electrolyte fluctuations and the possibility of dehydration during illness. Renal function matures as the child grows.

DRG Category 134 Mean LOS 35 days Description Medical Hypertension

Untreated, hypertension can cause major complications. It contributes to the development of atherosclerosis and increases the workload of the heart, thereby reducing perfusion to major organs and possibly resulting in transient ischemic attacks (TIAs), strokes, myocardial infarction, left ventricular hypertrophy, congestive heart failure, and renal failure. Damage to small arteries in the eye can lead to blindness.

Ficolins Structure Function and Associated Diseases

Innate immunity relies upon the ability of a few pattern recognition molecules to sense molecular markers. Ficolins are humoral molecules of the innate immune systems which recognize carbohydrate molecules on pathogens, apoptotic and necrotic cells. Three ficolins have been identified in humans L-ficolin, H-ficolin and M-ficolin (also referred to as ficolin-2, -3 and -1, respectively). They are soluble oligomeric defence proteins with lectin-like activity and they are structurally similar to the human collectins, mannan-binding lectin (MBL) and surfactant protein A and D. Upon recognition of the infectious agent, the ficolins act through two distinct routes initiate the lectin pathway of complement activation through attached serine proteases (MASPs), and a primitive opsonophagocytosis thus limiting the infection and concurrently orchestrating the subsequent adaptive clonal immune response. Recently a lot of reports showed that dysfunction or abnormal expressions of ficolins...

Chronic Diuretic Therapy for Heart Failure [3033

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

Years of Life Gained per 100000 Persons Screened Thousands

The model performed by the Office of Technology Assessment of the Unites States Congress (49) studied the cost-effectiveness of FOBT, FS, DCBE and colonoscopy, both individually and in combination, for patients aged 50-85 yr (Fig. 9). Although it accounted for years of life lost as a result of detection and treatment of cancer, it did not account for imperfect compliance. The most striking finding of this study is that all strategies cost less than 20,000 per year of life saved. This is well within the commonly accepted range (< 40,000) of cost-effectiveness for US health care (dialysis costs approximately 35,000 per year of life saved).

Anticipatory Grieving

Related to (Specify perceived potential loss of child by parents perceived potential loss of physiopsychosocial well-being by child.) Defining Characteristics (Specify expression of distress of potential loss, inevitable kidney failure, kidney dialysis, premature death of child.) Goal Parents and child will begin to work through the grief process by (date and time to evaluate). Outcome Criteria

Epidemiology and Diagnosis

Acutely, patients presenting with AUR will typically complain of both an intense desire to void and a degree of suprapubic pain (Fitzpatrick and Kirby 2006). They may give a history of preceding LUTS, with a reduced urine flow rate and a sensation of incomplete bladder emptying correlating best with subsequent progression to AUR. Those with chronic retention will not typically have pain. Some may describe a feeling of fullness, and some may even notice a suprapubic swelling. Usually, however, they present simply with an inability to pass urine, often having not voided for over 24 h. Some of these patients will, however, present in extremis with acute renal failure. These patients are often uremic, and some may have life-threatening electrolyte imbalances including hyperkalemia. Typically, on catheterization, they will have very large residual volumes and subsequently may have a significant diuresis, which needs careful observation and management with appropriate fluid replacement. In...

Macrovascular Disease And Diabetic Neuropathy

The most direct evidence of a strict relationship between lower extremity atherosclerosis and diabetic neuropathy is derived from large vessel revascularization studies, which have shown an improvement in nerve conduction velocity in one but not another study (61,62). A longer-term follow-up of the latter study did however show that reversal of hypoxia slows the progression of peroneal nerve conduction velocity deterioration (63). The efficacy of a number of pharmacological treatments that can achieve a similar effect, in improving peripheral nerve function has also been tested. In a double-blind placebo-controlled clinical trial with a vasodilator, Trandalopril, for more than 12 months, peroneal motor nerve conduction velocity, M-wave amplitude F-wave latency, and sural nerve amplitude improved significantly (64). Recently, the appropriate blood pressure control in diabetes trial, aimed to assess the effects of intensive against moderate blood pressure control with either Nisoldipine...

Prevention and Control

Although neutralizing antibody titers in human convalescent sera can, if at all, only barely be detected in laboratory tests, there are anecdotal case reports suggesting the potential benefit of passive immunization against Ebola virus infection. Furthermore, recent reports from the 1995 outbreak in Zaire about effective treatment of acutely ill patients with whole blood transfusions from convalescent donors suggest that quantities of antibodies, predicted to be marginally effective in laboratory tests, may still be protective. There is experimental evidence that active immunization employing killed virus, recombinant expressed glycoprotein, and recombinant gene 4 (GP)-DNA (DNA vaccination) is partially successful in animals, suggesting that these may be feasible strategies to elicit protective immunity. At present, however, vaccines for human application are not available. A specific chemotherapeutic treatment is not available to date, but knowledge of the expected clinical course...

Clinical and Experimental Data

Reported that it was usually normal or increased 5 . These findings were consistent with overflow physiology. However, the results of subsequent similar studies were equivocal the blood volume of some nephrotic patients was reduced, in others it was normal, and in still others expanded 4 . Several factors may account for these conflicting results. First, as discussed, the hypovolemic underfill hypothesis is most likely to explain salt retention in patients with minimal change nephropathy. Many of the aforementioned studies included other forms of nephrotic syndrome. Intrinsic renal abnormalities which may cause renal salt retention are more likely when glomerulonephritis reduces renal perfusion and glomerular filtration. However, studies limited to patients with minimal change disease and normal glomerular filtration rates also often report normal or increased blood volumes. These results suggest that overflow pathophysiology may be operative in many nephrotic patients.

General and Salt Restriction

Treatment of nephrotic edema should be directed principally at the underlying glomerular process whenever possible. For example, the most effective treatment for the salt retention and edema produced by minimal change nephropathy is a glucocorticoid induced remission. Similarly, the best treatment for edema associated with a toxin or drug induced nephropathy, is elimination of the inciting agent. However, very often the glomerular process cannot be promptly or completely corrected. Weeks or months of treatment may be required to induce a clinical response. Many forms of nephrotic syndrome cannot be effectively treated. In some of these patients symptomatic treatment of the salt retention, ECF expansion, and edema may become necessary.

Diseases and Host Range

Probably all coronaviruses replicate in epithelial cells of the respiratory and or enteric tracts, though not necessarily producing clinical damage at those sites. Avian 1BV not only causes respiratory disease but can also damage gonads in both females and males, and causes serious kidney disease (dependent on the strain of virus, and to some extent on the breed of chicken). 1BV is able to

Nephrotic Syndrome Introduction

Nephrotic syndrome is an alteration of renal function caused by increased glomerular basement membrane permeability to plasma protein (albumin). Alterations to the glomerulus result in classic symptoms of gross proteinuria, hypoalbuminemia, generalized edema (anasarca), oliguria, and hyperlipidemia. Nephrotic syndrome is classified either by etiology or the histologic changes in the glomerulus. Nephrotic syndrome is also classified into 3 types primary minimal change nephrotic syndrome (MCNS), secondary nephrotic syndrome, and congenital nephrotic syndrome. The most common type of nephrotic syndrome is MCNS (idiopathic type) and it accounts for 80 of cases of nephrotic syndrome. MCNS can occur at any age but usually the age of onset is during the preschool years. MCNS is also seen more in male children than in female children. Secondary nephrotic syndrome is frequently associated with secondary renal involvement from systemic diseases. Congenital nephrotic syndrome (CNS) is caused by...

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