Alternative Cures for Kidney Disease

Beat Kidney Disease

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! More here...

The Kidney Disease Solution Overview


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The author has done a thorough research even about the obscure and minor details related to the subject area. And also facts weren’t just dumped, but presented in an interesting manner.

When compared to other e-books and paper publications I have read, I consider this to be the bible for this topic. Get this and you will never regret the decision.

Relationship of Chronic Kidney Disease and ESRD with Clinical Outcomes

Kaplan-Meier event-free survival for major adverse cardiovascular events, including repeat revascularization, in patients with chronic kidney disease including end-stage renal disease (Renal) versus matched control patients undergoing percutaneous coronary intervention. (From Rubenstein MH, Harrell LC, Sheynberg BV, et al Are patients with renal failure good candidates for percutaneous coronary revascularization in the new device era Circulation 2000 102 2966.) Patients with CKD often have existing comorbidities that may complicate their procedure and postproce-dure management. As always, developing a systematic approach that incorporates the patient's history, physical examination, and laboratory studies is critical. As described earlier, the clinician needs to pay particular attention to accurate assessment of the degree of CKD at baseline, as well as several clinical risk factors that have been consistently associated with poor outcomes in patients with CKD (e.g.,...

Kidney Disease Urinary Disease and Diseases of the Reproductive Organs

Clinically, the main symptom of nephropathy is swelling thus, the water-swelling diseases of the ancient texts probably included symptoms due to disorders of the cardiovascular system as well as kidney diseases. Kidney disease might be found in the ancient texts under the headings of swelling, water disease, or water-cancer disease (ascites). Water-swelling diseases associated with irregular pulse probably indicated disorders due to heart disease, rather than kidney disorders. The section on water-swelling disease in the Hyangyak chipsong pang lists ten different forms.

Indications for Dialysis

Planning for dialysis should begin when GFR falls less than 30 mL min 1.73 m2 (stage 4 CKD),1 when progression to ESKD is inevitable, to allow time to educate the patient and family on the treatment modalities and establish the appropriate access for the modality of choice. Ideally, initiation of dialysis should be done at a point when the patient is ready to undergo treatment, rather than when the patient is in emergent need of dialysis. Initiation of dialysis is dependent on the patient's clinical status. Symptoms that may indicate the need for dialysis include persistent anorexia, nausea, vomiting, fatigue, and pruritus. Other criteria that indicate the need for dialysis include declining nutritional status, declining serum albumin levels, uncontrolled hypertension, and volume overload, which may manifest as chronic heart failure, and electrolyte abnormalities, particularly hyperkalemia. Blood urea nitrogen (BUN) and SCr levels may be used as a guide for the initiation of dialysis,...

The location and number of renal cysts

Location and Number of Renal Cysts The location of the renal cyst(s) is perhaps the most important factor in determining the surgical approach. The transperitoneal approach is best utilized for management of simple renal cysts located along the anterior surface of the kidney and peripelvic cysts. A mechanical bowel preparation is recommended prior to cyst ablation in patients with autosomal dominant polycystic kidney disease to help decompress the bowels and optimize the already limited working space secondary to the large kidneys. Cysts located along the posterolateral surface of the kidney can be managed by the transperitoneal approach, but may be more efficiently approached by retroperitoneal access. For patients with multiple renal cysts (e.g., autosomal dominant polycystic kidney disease), exposure of the entire renal surface may be necessary and therefore the transperitoneal approach is preferred. In patients with a history of prior abdominal surgery, dense, complex adhesions...

Technical Modifications for the Management of Complex Renal Cysts

The laparoscopic approach to ablating simple renal cysts is relatively straightforward however for complex renal cystic lesions, there are technical modifications worthy of mention. Peripelvic Renal Cysts The branches of the renal vasculature and collecting system are often distorted and splayed by the peripelvic cysts, making them difficult to identify and differentiate from the cyst itself. Prior attempts at percutaneous drainage can also result in inflammation and scarring, making the tissue planes between the peripelvic cyst and hilar structures even less distinct. Placement of a ureteral catheter with retrograde injection of indigo carmine-or methylene blue-stained saline is useful in identifying the course of the splayed collecting system and for identification of collecting system injuries. Precise identification of renal vascular braches can be aided by the use of laparoscopic ultrasound with Doppler if available. Unlike with simple peripheral renal cysts, excision of the...

Peripelvic Renal Cysts

The results of laparoscopic management of peripelvic cysts are somewhat lower than that reported with simple peripheral renal cysts (Table 5). Roberts et al. reported on 11 patients with peripelvic cysts and found that operative time (233 minutes vs. 164 minutes, p 0.003) and blood loss (182 mL vs. 98 mL, p 0.04) were statistically greater than a concurrent group of 21 patients with peripheral renal cysts (10). There were no transfusions, open conversions, or radiographic recurrences in this series. TABLE5 Results of Laparoscopic Ablation of Symptomatic Peripelvic Renal Cysts TABLE5 Results of Laparoscopic Ablation of Symptomatic Peripelvic Renal Cysts TABLE 6 Results of Laparoscopic Ablation of Symptomatic Autosomal Dominant Polycystic Kidney Disease TABLE 6 Results of Laparoscopic Ablation of Symptomatic Autosomal Dominant Polycystic Kidney Disease

Chronic Peritoneal Dialysis Catheter

Chronic peritoneal dialysis catheter are designed to be used on a long-term basis, are made from biocompatible material such as silicone or polyurethane, and usually contain numerous 1-mm diameter side holes however, at least one type of chronic peritoneal catheter that has linear grooves or slots rather than side holes is available on the market. All of the chronic peritoneal dialysis catheters have one or two extraperitoneal Dacron cuffs that promote local inflammatory response and cause a fibrous plug to fix the catheter in position, which prevents fluid leakage and inhibits organism migration from outside the peritoneal cavity. There are four common types of peritoneal dialysis catheters The cuff of continuous ambulatory peritoneal dialysis catheters also has many designs single cuff, double cuffs, and disc-bell deep cuffs. The material used to manufacture chronic peritoneal catheters are soft, such as silicone rubber or polyurethane. The polyurethane catheters form a weak bond...

Complications Of Laparoscopic Placement Of Chronic Peritoneal Dialysis Catheter

Continuous ambulatory peritoneal dialysis is now an established technique for renal dialysis. In chronic peritoneal dialysis, operative laparoscopy is minimally invasive and is associated with the low morbidity and rapid return to normal activity. Reported series have shown feasibility and safety of the laparoscopic technique, which is also more effective than the open procedure or blind technique (61,70-72) however, the laparoscopic placement of the chronic peritoneal dialysis catheter can still have complications, both acute and chronic.

Peritoneal Dialysis Catheter Removal

Peritoneal dialysis catheter removal can also be safely performed without significant discomfort under local anesthesia. Here too, an operating room is not needed because the procedure can be performed in a procedure room using standard precautions for infection control. Briefly, the local anesthetic is infiltrated at the site of the primary incision and the subcutaneous tissue. Dissection is then carried down to the subcutaneous tissue and the subcutaneous tunnel harboring the catheter is identified. Using blunt dissection, a portion of the tunnel is separated from the surrounding tissue. The tunnel is then lifted by applying a hemostat under it. Using toothed forceps and Metzenbaum scissors, the tunnel layers are cut in a longitudinal direction and the catheter is exposed (Fig. 7). The catheter is clamped with hemostats and a nylon suture is applied through the catheter just outside the hemostats as a tag. At this point, the catheter is cut just outside the hemostat (remaining...

Glomerulonephritis Brights Disease

Glomerulonephritis, an immunologic disease of the kidneys, affects the glomerulus, a cluster of capillaries that is the filter in the functioning unit of the kidney, the nephron. Inflammation, initiated by immune complexes, injures the glomerulus. Often the disease is acute, but it may be completely undetected until signs of kidney failure appear. This silent disease may prove fatal.

Arteriovenous Dialysis Studies

An initial study at Emory University in 1994 to treat patients who had failed PTA of arteriovenous dialysis grafts using the MicroSelectron HDR afterloader reported 40 patency rate at 44 weeks,55 but the long-term results of this study were similar to standalone PTA without irradiation. Similar disappointing results were reported by Parikh and colleagues56 from a pilot study using external radiation doses of 12 and 18 Gy for AV dialysis shunts in 10 patients. At 6 months, target lesion revascularization (TLR) was 40 , but at 18 months, all grafts failed and required intervention. Cohen and associates57 randomized 31

Postoperative Renal Failure

Surgery which involves large blood loss, in surgery following trauma and in most septic patients, avoidance of renal failure involves close monitoring of the cardiovascular state, including CVP and urinary output, avoidance of hypoxaemia and hypotension, and adequate fluid and blood replacement. In many instances, e.g. in patients with pre-existing renal dysfunction, shock, sepsis or liver disease, a pulmonary artery catheter is required to optimize cardiac output and oxygen delivery, and to guide vasoactive drug therapy. Low-dose (2-5 pg kg l min l) dopamine is frequently recommended to prevent renal failure in such situations, but its efficacy is unproven and its use may confuse the situation by inducing diuresis through stimulation of dopaminergic receptors in the renal tubules. The only proven therapy in the prevention and early treatment of acute renal failure is adequate fluid resuscitation titrated against CVP or PAOP, and maintenance of an adequate cardiac output and mean...

Diabetic Nephropathy Diabetic Glomerulopathy Renal Interstitial Syndromes

Before the DCCT, a patient with type 1 diabetes had a 30 to 40 likelihood of developing macroproteinuria (> 300 mg day), which would quickly progress to renal insufficiency and the need for renal dialysis. This process begins with pro-teinuria and increasing BP as early as 10-15 years after diagnosis of type 1 diabetes. In the early 1970s, when repeated studies showed that lowering of BP reduced cardiovascular events, diabetologists began to observe that good BP control, including use of diuretics, prolonged the interval from the onset of proteinuria to renal failure. The first studies of the angiotension-converting enzyme (ACE) inhibitor capto-pril suggested that treatment reduced macroproteinuria in patients with moderate renal insufficiency. Subsequent work in the 1990s indicated that reduced proteinuria impaired nephron loss and preserved renal function. The protein leak into the glomerular space may contribute to the mesangial proliferative reaction, starting a process that may...

Cerebral Microdialysis

One of the available cerebral perfusion techniques, cerebral microdialysis (CM), can be used to perform an in vivo study of the brain neurochemical processes. In this system a very thin dialysis tube (less than 0.3 mm external diameter) is inserted under stereotactic guidance into the region of interest this allows the passive transfer of substances flowing inside the capillary under the concentration gradient between the perfusion liquid and the extracellular liquid. The liquid collected by the probe electrode is subjected to standard chemical analysis, such as high-pressure liquid chromatography (HPLC), in order to assay the transmitter substances of specific interest.

Chronic Kidney Disease

Renal disease is a significant public health burden, with almost 20 million persons in the United States having chronic kidney disease (Coresh et al., 2003). In 2002 the National Kidney Foundation issued guidelines on the evaluation and management of CKD. The centerpiece of this new approach is defining CKD as kidney damage or decreased kidney function for 3 months or longer (Levey et al., 2003). Proteinuria is a clinical sign of kidney disease. Patients with proteinuria should be approached as described earlier. Patients with abnormal urinary protein values (e.g., UPr UCr) or other markers of kidney damage should be assessed for CKD (Johnson et al., 2004). The primary measure of kidney function is the glomerular filtration rate (GFR), and the stages of CKD are based on GFR (calculated by Cockcroft-Gault or MDRD equation) (Table 40-5). The modification of diet in renal disease (MDRD) equation performs as well or better than measured creatinine clearance (Levey et al., 1999). However,...

Anemia of endstage renal failure

The anemia of end-stage renal failure has multiple contributory factors including EPO deficiency, toxic inhibitors of EPO action, androgen deficiency, micronutrient deficiency (iron, folate, pyridoxine), blood loss and hemolysis (Neff et al. 1985). The effect of androgen therapy on hemoglobin involves both increased circulating EPO concentration (Buchwald etal. 1977) and augmentation of EPO action (Ballal etal. 1991). EPO deficiency is a major factor (Winearls 1995) and androgen therapy probably acts mainly by increasing EPO, since androgen therapy has no effect on hemoglobin after bilateral nephrectomy (von Hartitzsch and Kerr 1976) when the major source of endogenous EPO is removed. Androgen therapy has consistent effects on EPO secretion and hemoglobin concentrations (Navarro and Mora 2001), although circulating EPO is not consistently related to resultant increases in hemoglobin (Teruel et al. 1995). Endogenous testosterone is an important physiological determinant of red cell...

Burying The Peritoneal Dialysis Catheter

Traditional surgical implantation of Tenckhoff catheters involves immediate exteri-orization of the external segment through the skin, so that the catheter can be used for supportive peritoneal dialysis or for intermittent infusions during the break-in period. To prevent blockage and to confirm function, the catheter is flushed weekly with saline or dialysate each exchange carries the same risk of peritonitis as in continuous ambulatory peritoneal dialysis therapy to avoid bacterial contamination of the exit site. The catheter must also be bandaged and the skin exit site must be kept clean in the weeks after placement. The patient must, therefore, be trained in some techniques of catheter care. It has always been difficult to decide when to place a peritoneal dialysis catheter in a patient with chronic renal insufficiency. If the catheter is placed too early, the patient may spend weeks to months caring for a catheter that is not used for dialysis. If the catheter is placed after the...

Autosomal Dominant Polycystic Kidney Disease

Autosomal dominant polycystic kidney disease, an inherited form of polycystic disease with nearly 100 penetrance, ultimately leads to renal failure requiring dialysis. The identified genes for polycystic kidney disease (PKD1) reside on the short arm of chromosome 16, which accounts for 85 to 90 of cases (17), and for PKD2 on chromosome 4, which accounts for 5 to 10 of cases (18). Patients also have increased incidence of intracranial hemorrhages and hepatic and pancreatic cysts. Patients may develop hypertension, back and flank pain, infection, intracystic hemorrhage, and malignancy. Laparoscopic cyst decortication has been shown to improve pain and hypertension with no compromise of renal function (19). Simple nephrectomy may provide dramatic relief to symptomatic patients with preexisting end-stage renal disease. These patients generally have giant kidneys, which add unique challenges to the minimally invasive surgeon. Outcomes in 11 such patients undergoing laparoscopic nephrectomy...

Contraindications To Peritoneal Dialysis Catheter Placement

There are relatively few contraindications to the placement of peritoneal dialysis catheters. The most important consideration is whether or not the abdominal cavity has previously been violated. Previous pelvic surgery that may lead to adhesions, colostomy, ileostomy, or urinary diversion would be a relative contraindication. Absolute contraindications include aortic vascular graft within three months, presence of ventriculoperitoneal shunt, ascites, and peritonitis. Previous retroperitoneal extraperitoneal surgical procedures such as hysterectomy, caesarean section, and nephrectomy (retroperitoneally) are not considered contraindications.

The Indication For Dialysis

There are two modalities of dialysis hemodialysis and peritoneal dialysis. The indication for dialysis includes end-stage renal disease, acute renal failure, drug and chemical poisoning, acute hyperkalemia, metabolic disorder, and volume overload from congestive heart failure or lung diseases. In the case of renal failure, dialysis therapy is initiated when approximately 90 of normal renal function has been lost. The absolute contraindications for all forms of dialysis are irreversible dementia or coma, hepatorenal syndrome, and advance malignancy. Both forms of dialysis are effective with proper patient selection. hemodialysis has the advantage of rapid clearance. It is useful in hyperkalemia, volume overload, and drug overdose. Continuous ambulatory peritoneal dialysis has been utilized during the last five years with increasing frequency in the treatment of patients with chronic renal failure. Peritoneal dialysis is preferred in patients who cannot tolerate the hypotensive state or...

Acute Renal Failure

Despite the well-documented oliguria associated with laparoscopy, acute renal failure following laparoscopy, in the absence of another obvious etiology, is rare. However, in one 67-year-old man with chronic renal insufficiency, renal tubular acidosis, and hypertension, renal failure lasted for two weeks following laparoscopy (175). The effect of laparoscopy on kidney function is transient, with renal indices returning almost to baseline within two hours of the release of pneumoperitoneum (68). This has been shown to be the case even in a high-risk renal insufficiency model (176). The adverse effects of nephrotoxic agents such as aminoglycosides are not worsened by laparoscopy (177). If acute renal failure does occur after laparoscopy, other etiologies should be evaluated before ascribing this adverse event to the pneumoperitoneum.

Simple Renal Cysts

As listed in Table 4, numerous series of laparoscopic ablation of symptomatic simple renal cysts can be found in the literature performed via both the transperitoneal and the retroperitoneal route (9-16,22,27,28). Most series, however, are limited due to a small number of patients with short follow-up. In those series with 10 or more patients, the mean operative time was 111 minutes (range, 75-164 minutes) and mean length of hospital stay was 3 days (range, 1.9-5.4) (9,10,12,14-16). A complication rate of 0 to 20 and a 0 mortality rate in these series compares favorably with a historical series of open renal cyst ablation reporting a complication rate of 37 and mortality rate of 1.6 (4). In a multi-institutional review of 139 laparoscopic renal cyst ablation cases, Fahlenkamp et al. found a total complication rate of 3.5 (28). Postoperative pain following laparoscopic renal cyst ablation is low with Rubenstein et al. finding that 67 of patients required no parenteral narcotics and 89...

Renal Cysts

Simple renal cysts are common in the older adult population and should not disqualify a donor. Complex cysts should be approached with caution, because some of these may, in fact, harbor a malignancy. Simple renal cysts are common in the older adult population and should not disqualify a donor. Complex cysts should be approached with caution, because some of these may, in fact, harbor a malignancy. With the fine-cut computed tomography scans currently in use, many patients are now being diagnosed with too small to characterize lesions. These are likely to represent simple cysts and should not disqualify the donor. In general, we advocate removing the kidney with the renal cyst. However, we tend to remove the left kidney if the cyst is a too small to characterize lesion on the right kidney. Patients with simple small bilateral cysts are not disqualified and the kidney with the largest cyst is chosen.

Renal Failure

ARF or CRF. 150 The fact that dialysis can rapidly clear UE suggests that the responsible molecules causing UE are water soluble and small to moderate in size. However, Cooper and associates studied the brains of 10 patients who had died of uremia and noted the brain content to be normal for K, Cl, and Mg slightly decreased for Na and approximately doubled for Ca. In experimental uremia, increased brain Ca levels have been associated with an increase in the PTH level. y In addition, the increase coincided with the onset of EEG abnormalities, with both appearing about 2 days after onset of the RF. In a study of 20 dialysis patients with EEG slowing, a direct correlation was noted between the plasma concentration of the N-terminal fragment of PTH and the degree of EEG slowing. y , yj Administration of PTH to normal dogs produces EEG changes similar to those seen in uremic animals. The EEG abnormalities, as well as the increased brain Ca, can be prevented by performing a...

Kidney Failure

Acute renal failure (ARF) as complication of the systemic inflammatory response is a clinical entity characterized by an abrupt decline in the glomerular filtration rate (GFR), resulting in oliguria and azotemia, all of which have been detected in the CLP-induced MODS rats, but not in those with blockade of C5a (19) (Figure 3C). Though the presence of C5aR has been described on human glomerular mesangial cells and more recently on renal tubular cells, the linkage between C5a and development of ARF during MODS is obscure. There are suggestions that infusion of C5a leads to a significant fall in renal blood flow by increasing the vascular resistance in the afferent and efferent arterioles (50). Proteinuria was observed in CLP-induced MODS, reflective of the presence in urine of proteins larger than the glomerular filtration barrier of 60 kDa. In CLP rats there were morphological changes in podocytes, including fusion of their foot processes and flattening of their cell surfaces, and...

Renal Cyst Surgery

Although percutaneous aspiration of renal cyst is diagnostic and may be therapeutic, unfortunately cysts typically recur. Laparoscopic decortication of the rare renal cyst that is symptomatically an effective minimally invasive alternative to percutaneous aspiration or open surgery. Laparoscopic ultrasonography may be helpful for laparoscopic localization and drainage of difficult renal cysts (36-39). Brown et al. employed laparoscopic ultrasonography in 21 patients with symptomatic renal cysts, allowing intraoperative identification of previously undetectable renal cysts (37). Elashry et al. reported their experience in two patients who underwent five laparoscopic ultrasonography-guided cyst marsupializations, suggesting that 10 MHz Color Doppler imaging contributed to discrimination of peripelvic cyst anatomic vasculature, permitting safe decortication of cysts adjacent to hilar vessels (38). This technique may also be helpful in patients with polycystic kidneys. Lee et al., in...


During hemodialysis, there may be an initial lowering of the plasma drug concentration, followed by a rebound after dialysis. Most psychotropic medications are highly protein bound and not significantly cleared by dialysis. In contrast, lithium, gabapentin, and topiramate are completely removed by dialysis, with the common practice being to administer these medications after dialysis (Levy 1990). Drugs with a narrow therapeutic index should be avoided wherever possible in dialysis patients. In addition, patients on dialysis often have significant fluid shifts and are at risk of dehydration, with neuroleptic malignant syndrome being more likely in these situations (Kunishima et al. 2000). Another common issue is that of orthostatic hypotension that occurs particularly following dialysis.

Diabetic Nephropathy

Renal failure is a major independent predictor of cardiovascular events. Diabetes is the leading cause of renal failure in Western countries. In 2002 in the United States, diabetic nephropathy accounted for more than 40 of the new cases of renal failure, and 44,000 diabetic patients began treatment for endstage renal disease.2 The condition underlying diabetic nephropathy is microvascular disease. Even in the absence of renal failure, albuminuria is a frequent finding in diabetes. Any degree of albuminuria has been found to be a risk factor for CV events, regardless of the presence or absence of diabetes.137 In addition, diabetic nephropathy with or without renal failure is a key determinant of risk after both PCI and CABG. A single-center analysis involving 1575 diabetic patients undergoing PCI showed that patients with renal failure had significantly more in-hospital complications than those with normal renal function, including mortality (2.6 versus 0.5 , respectively), neurologic...

End Stage Liver Disease

Like kidney disease, the only treatment to prolong life in advanced liver disease is transplant. Patients with end-stage liver disease typically present with ascites, jaundice, pruritus, or encephalopathy and frequently with all four symptoms. Additionally, bleeding disorders are common and associated esophageal or gastric varices bleeds are the cause of death in about one-third of those who die from liver disease. Palliative care in these patients focuses on the symptom management of end-stage liver disease complications.

TABLE 227 Sources of Na Loss

Kidney disease or external influences on renal function Renal diseases CKD, nonoliguric AKI, the diuretic phase of AKI, and salt wasting nephropathy. Salt wasting nephropathy occurs with interstitial nephritis, medullary cystic or polycystic kidney disease, and postobstruction. Patients with salt wasting nephropathy have reduced GFR (Stage 3-5 CKD) Abbreviations GI, gastrointestinal CKD, chronic kidney disease

Heart Failure and Diabetic Cardiomyopathy

At a cellular level, structural changes identified in the myocardium of animal models of diabetes include increases in the extracellular space, extracellular fibrosis, myocyte atrophy, and apoptosis.34 These changes have been related to an increased vascular permeability caused by microvascular disease. Analogies have been identified between myocardial changes and the involvement of renal glomeruli in diabetic nephropathy, including increased thickness of the basement membrane, reduction of capillary density, and increased permeability with consequent increases of extracellular volume.34 Clinical and pathologic consequences include myocardial hypertrophy, impaired contraction, diastolic dysfunction, and impaired exercise capacity.33 The relation between glycemic control and diabetic myocardial abnormalities has been variable and contradictory. Although epidemiologic, clinical, and laboratory evidence supports the notion of diabetic cardiomyopathy, this concept is not universally...

Treatment Desired Outcomes

Hypertension management by nonpharmacologic and pharmacologic therapies has proven useful in reducing the risk of heart attack, heart failure, stroke, and kidney disease morbidity and mortality. For every 20 mm Hg systolic or 10 mm Hg diastolic increase in BP, there is a doubling of mortality for both ischemic heart disease and stroke.21 The goal of BP management is to reduce the risk of CVD and target organ damage. Targeting a specific BP is actually a surrogate goal that has been associated with reductions in CVD and target organ damage.

Angiotensin Receptor Blockers

Have demonstrated their usefulness as effective antihypertensives in these special populations. Studies (the Irbesartan Diabetic Nephropathy Trial IDNT and Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan RENAAL NIDDM refers to noninsulin-dependent diabetes mellitus ) have demonstrated superiority of delaying progression toward renal dysfunction for ARBs relative to alternat-

Phosphodiesterase inhibitors

They are indicated for acute refractory cardiac failure, e.g. cardiogenic shock, or pre- or post-cardiac surgery. However, long-term treatment with oral PDE III inhibitors is associated with increased mortality in patients with congestive cardiac failure. All PDE III inhibitors may cause hypotension, and tachyarrhythmias may occur. Other adverse effects include nausea, vomiting and fever. Amrinone may cause thrombocytopenia and is available only as a parenteral preparation. The half-life of all PDE III inhibitors is prolonged several-fold in patients with cardiac or renal failure and they are commonly administered as an i.v. loading dose over 5 min with or without a subsequent i.v. infusion. Amrinone and milrinone are derived from bipyridines, whereas enoximone is an imidazole derivative. Enoximone undergoes substantial first pass metabolism, and is rapidly metabolized to a sulfoxide compound, which is excreted via the kidneys. The elimination tj 2 of enoximone is 1-2 h in healthy...

Multifactorial Intervention

The Steno-2 study compared the efficacy of a targeted, intensified, multifactorial intervention with that of conventional treatment on modifiable risk factors for CV disease in 160 patients with diabetes and microalbuminuria.140 The primary end point was a composite of CV death, nonfatal MI, stroke, revas-cularization, and amputation. Intensive treatment was characterized by a stepwise implementation of behavior modification and pharmacologic therapy that targeted hyperglycemia, hypertension, dyslipid-emia, and microalbuminuria, along with secondary CV prevention with aspirin. Conventional treatment was in accordance with national guidelines. After a mean follow-up of 8 years, patients receiving intensive therapy had a significantly lower risk of CVD (HR 0.47), nephropathy (HR 0.39), retinopathy (HR 0.42), and autonomic neuropathy (HR 0.37). The authors concluded that a target-driven, long-term, intensified intervention aimed at multiple risk

Summary and Prospects

The future of medical genetics is very bright indeed. Systematic screening of the human genome has revealed hundreds of inherited DNA sequence variants, or RFLPs (Willard et al. 1985 O'Brien 1987). Exploitation of these markers has made it possible to establish genetic linkage and chromosome map locations for a large number of hereditary human illnesses including Duchenne muscular dystrophy (Davies et al. 1983 31020), Huntington's disease (Gusella et al. 1983 14310), cystic fibrosis (Tsui et al. 1985 21970), adult polycystic kidney disease (Reed-ers etal. 1985 17390), retinoblastoma (Cavenee et al. 1985 18020), familial polyposis (Bodmer et al. 1987 17510), manic-depressive or bipolar illness (Egeland et al. 1987 30920), and neurofibromatosis (Barker et al. 1987 16220). Moreover, the genes themselves have been cloned for retinoblastoma (Friend et al. 1986) and Duchenne muscular dystrophy (Monaco et al. 1986), as well as for chronic granulomatosus disease (Royer-Pokora et al. 1986...

Clinical Examples Of The Anatomic Paradigm In Practice

Dard therapy that render trials outdated. The results of a randomized trial do not necessarily apply to populations that were systematically excluded from that trial. Because most trials, especially procedural trials, exclude patients with complex and high-risk conditions, their results provide the most guidance for the simplest decisions. Almost all CABG trials have systematically excluded patients within 7 to 30 days of an acute MI, patients with LVEF less than .35, hemodynamically unstable patients, patients with anatomy deemed unfavorable for CABG (no anatomic contraindication is harder to define than diffuse disease), patients older than 70 years of age, patients with one or more prior heart surgeries, and patients with severe comorbidities, including but not limited to chronic obstructive pulmonary disease, pulmonary hypertension, prior stroke, cancer, severe liver disease, and severe renal failure.

Clinical applications of ACE inhibition

ACE inhibitors are established in the treatment of hypertension they decrease morbidity and mortality in congestive cardiac failure, and improve left ventricular dysfunction after myocardial infarction. They delay the progression of diabetic nephropathy and have a protective effect in non-diabetic chronic renal failure, although they are associated with proteinuria in approximately 1 of patients. ACE inhibitors improve vascular endothelial function by their effects on A-II and bradykinin the clinical importance of this in patients with vascular disease is unknown. the elderly or those receiving NSAIDs, and renal function should be checked before starting ACE inhibitor therapy, and monitored subsequently. Hyperkalaemia (plasma K+ concentration usually increases by 0.1-0.2 mmol L 1 because of decreased aldosterone concentrations) may be more marked in those with impaired renal function or in patients taking potassium supplements or potassium-sparing diuretics. The mechanism of cough is...

Pathophysiology Of Renal Dysfunction

The most common reason for renal dysfunction after cardiac catheterization and PCI is related to the use of intravascular contrast agents. Despite their widespread use in imaging studies, the exact mechanisms responsible for the development of contrast-related nephropathy remain unknown.1 Most studies suggest that both direct toxic injury to the renal tubules and ischemic injury to the renal medulla from vasomotor changes and decreased perfusion are responsible. The latter appears to be mediated partly by the development of reactive oxygen species such as superoxide and has important implications for treatment with scavenging agents.2 Diabetes mellitus and heart failure also may exacerbate contrast-related nephropathy, specifically through impairment of vasodilatory responses in the renal vasculature.3 Finally, additional factors may exacerbate the development of renal dysfunction after cardiac cath-eterization and PCI. Many medications may directly contribute to renal toxicity or...

Renal Dysfunction Risk Factors And Prognosis

The most commonly used definition of renal dysfunction after cardiac catheterization and PCI in the literature (which refers primarily to contrast-related nephropathy) is a rise in serum creatinine levels of 0.5 mg dL or a 25 increase from baseline. Although its reported incidence ranges from 8 to 15 in the general population,8 the clinical importance of this change in most cases is uncertain given its transitory nature. In only a few of these patients (< 1 ) will this abnormality extend beyond a few weeks and require the need for renal replacement therapy with either hemodialysis or peritoneal dialysis. In most cases with long-term complications, patients have preexisting evidence of advanced CKD. Over the last several years, several risk-prediction models have been developed to predict a patient's risk of developing renal dysfunction (and specifically contrast-related nephropathy) after cardiac catheter-ization and PCI. A recent model by Mehran and colleagues, developed in 8357...

End Stage Renal Disease

Stages of Chronic Kidney Disease (CKD), Action Recommendations, and Prevalence Kidney damage with normal or > 90 Kidney damage with mild decrease in 60-89 Kidney failure < 15 or dialysis Adapted from National Kidney Foundation K DOQI clinical practice guidelines for chronic kidney disease Evaluation, classification, and stratification. Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 2002 39 S1-S266. Adapted from National Kidney Foundation K DOQI clinical practice guidelines for chronic kidney disease Evaluation, classification, and stratification. Kidney Disease Outcome Quality Initiative. Am J Kidney Dis 2002 39 S1-S266. Figure 5-4. Cardiovascular mortality in the general population (GP, data from the National Center for Health Statistics) compared with patients with end-stage renal disease treated by dialysis (data from United States Renal Data System, 1994-1996). (From Sarnak MJ, Levey AS, Schoolwerth AC, et al Kidney disease as a risk factor for development of...

Clinical Pharmacology

Both the carboxylate form and the lactone form of topotecan may undergo further metabolism into an UGT-mediated glucuronide product (i.e., topotecan-O-glucuronide and N-desmethyl topotecan-O-glucuronide) (160). This is a reversible transformation because beta-glucuronidase is able to reform topotecan and N-desmethyl topotecan. Because topotecan is metabolized in the liver only to a minor extent, it is not surprising that the pharmacokinetics in patients with impaired liver function did not significantly differ from those in patients with normal hepatic function (161). In contrast, patients with moderately impaired renal function had significantly reduced plasma clearance (162). As a clinical practical consequence, dose modifications are recommended for patients with impaired renal function and are not required for patients with liver dysfunction (161,162). As mentioned earlier, in patients with impaired renal function the clearance of total topotecan is reduced, i.e., a 33 decrease in...

Minimizing The Risk Of Renal Dysfunction

Normal saline infusions at a rate of 1 mL kg hour for 6 to 12 hours before the procedure and continuing after the procedure.53 Data from a large trial suggested that the substitution of isotonic saline for 0.45 normal saline may modestly reduce the incidence of contrast-related nephropathy, particularly among patients with diabetes mellitus and those receiving large doses of contrast agents.54 In a small clinical trial of 36 patients with serum creatinine levels at baseline equal to or greater than 1.4 mg dL, it was demonstrated that 1 L orally followed by 6 hours of intravenous hydration starting at the time of contrast agent exposure was equivalent to prepro-cedural intravenous hydration.55 This approach may be more realistic for outpatients who come in the day of their procedure. Recently, there has been great interest in the use of sodium bicarbonate infusions to hydrate patients with CKD during the periprocedural period. Sodium bicarbonate may relieve oxidative stress, which is a...

What questions should be considered before ordering a CTmyelogram study of the spine

Does the patient have any history of adverse reaction to iodinated contrast media or any conditions that increase the risk of an adverse reaction to these agents Some factors considered to increase the risk of a reaction to iodinated contrast include renal insufficiency, diabetic nephropathy, significant cardiac or pulmonary disease, asthma, multiple allergies, and patients at the extremes of age.

Risks of Preoperative PCI

Decision analyses have suggested that coronary angi-ography and intervention before vascular surgery should be carried out only if the risk of the vascular surgery is relatively high (> 5 mortality risk) and the anticipated risk of angiography and revascular-ization is relatively low (< 3 mortality risk). However, many studies have demonstrated that the short- and long-term risks of performing PCI are substantially increased among patients with comorbidities requiring noncardiac surgery, especially if PCI is performed in individuals with concomitant peripheral vascular disease. Among 2340 patients enrolled in the BARI trial or registry, the presence of peripheral vascular disease was associated with a 50 relative increase in major in-hospital cardiovascular events after PCI (11.7 vs. 7.8 ) and an almost twofold increased likelihood of adverse events after CABG. Similarly, within another large registry of 25,114 patients who underwent PCI between 1997 and 2001, the presence of...

High Blood Pressure Hypertension

High blood pressure (hypertension) is dangerous. If blood pressure is high, the heart has to work harder to pump the same amount of blood, which puts a great stress on the cardiovascular system. Patients with high blood pressure are more prone to heart attacks, heart failure, kidney failure, and strokes. Fortunately, blood pressure can be controlled with appropriate medications and lifestyle modifications, greatly reducing the risk of complications.

Neurodynamic Aspects Of Consciousness

Hebb's visionary notion in 1949 of reverberating cell assemblies was an important beginning point for a neurodynamic emphasis. Neurodynamics is thus a relatively new discipline, addressing how brain activation changes over time. The neurodynamic perspective is complementary to traditional perspectives that emphasize structures, connectivities, and neuromodulators in that it seeks to understand the time-dependent changes that occur in neuronal populations (neural network models, by comparison, do not reference time). The behavior of these time-sensitive populations are typically measured by EEG, single unit recordings (inso far as these indirectly imply population behaviors), or magnetoencephalography (MEG) and also in dynamic neurochemical measures, such as in vivo dialysis. Neurodynamics attempts to correlate these signatures from various measurement modalities with behavioral and subjective measurements, focusing on the challenge of modeling context-dependent and sequential...

Genetics In Tuberous Sclerosis Complex

A wide variety of mutations of this gene have been reported these are deletion, rearrangement, or missense mutation and mutations leading to premature truncation of proteins. The TSC2 gene is located very close to PKD1 (polycystic kidney disease) gene. In a few patients with TSC associated with infantile polycystic kidney disease, a contiguous genetic deletion affecting both TSC2 and PKD1 genes has been demonstrated.13 The TSC2 gene has a 5.5 kb transcript that encodes a protein, called tuberin, that contains 1807 amino acids and has a molecular weight of 200 kDa.18 Fifty-eight amino acids near its C terminal show homology to part of guanosine 5'-triphosphate (GTP)-ase activating protein (GAP).18

Enhanced elimination techniques

Extracorporeal techniques Haemoperfusion, haemofiltration, and haemodialysis may be useful for eliminating a small number of substances. These techniques require specialized equipment and are usually only available on critical care units (haemofiltration) or renal units (haemoperfusion and dialysis). Filtration and dialysis may also be used to support failing kidneys.

Clinical Evidence for Bivalirudin

(0.75 mg kg and 1.75 mg kg hr IV) and provisional abciximab or eptifibatide versus the planned use of these GP IIb IIIa inhibitors and heparin (65 mg kg IV), conducted in a double-blind, double-dummy manner.47 The commonly used triple ischemic end point of death, MI or urgent revascularization by 30 days was assessed with a noninferiority design. The major exclusions to this study were patients presenting with STEMI undergoing PCI for reperfusion, patients at significant risk for bleeding, or those requiring dialysis. As a result, approximately 50 of patients underwent PCI for an ACS, multivessel intervention was undertaken in about 15 of cases, and saphenous vein graft intervention occurred in 6 of patients. Provisional use of a GP IIb IIIa inhibitor was permitted for coronary dissection, thrombus formation, unplanned stenting, slow flow, distal embolization, and ongoing clinical instability in the bivalirudin arm, whereas provisional placebo was used in the arm of patients already...

Un nouveau debut A New Beginning

Julia Child passed away a few days shy of her 92nd birthday, due to complications of kidney failure. In the year before her death she endured knee surgeries, kidney failure, and suffered a stroke. She opted not to receive treatment when her doctor informed her of an infection that would require hospitalization, remaining the conductor of her own symphony to the last.

General Considerations

The appearance of the head and face, their contours and texture, often provides the first insight into the nature of illness. Sunken cheeks, wasting of the temporal muscles, and flushing of the face are important visible clues of systemic illness. Some facial appearances are pathognomonic of disease. The pale, puffy face of nephritis, the startled expression of hyperthyroidism, and the immobile stare of parkinsonism are examples of classic facies.

Blood Urea Nitrogen and Creatinine

Creatinine is a product of muscle metabolism, and production is related to muscle mass, age, gender, and race, and dietary meat intake. Creatinine is filtered by the glomerulus and secreted by the proximal tubule. Creatinine levels increase as renal function is reduced. At normal renal function, most of the urinary creatinine excretion is from glomerular filtration, with about 5 to 10 from tubular secretion. As the glomerular filtration rate (GFR) declines, a larger proportion of creatinine excretion comes from secretion therefore, direct measurements of creatinine clearance overestimate GFR with progressive reductions in renal function. Some drugs, including cimetidine, trimethoprim, fenofibrate, salicylates, and pyrimethamine, can block the secretion of creatinine and falsely elevate creatinine levels, particularly in the setting of a low GFR. Although serum creatinine has long been used to estimate renal function, current guidelines from the National Kidney Foundation recommend...

Cobalamin Vitamin B12 and Folic Acid Deficiency

The hematologic picture is identical for both folate and vitamin B12 deficiency. Megaloblasts are enlarged blastic cells (precursors to the erythroid and myeloid cell lines) found in the bone marrow and caused by aberrant DNA synthesis. The peripheral blood smear typically shows the presence of oval macrocytes, hypersegmented neutrophils (> 5 neutrophils with 5 lobes or any neutrophil with 6 lobes). Anisocytosis (size variation) and poikilocytosis (shape variation) of the red blood cells (RBCs) are often present, so the RBC distribution width (RDW) is increased. The reticulocyte count is usually decreased. Thrombocytopenia is present in 12 and leukope-nia in 9 of cases occasionally, B12 or folate deficiency will present with pancytopenia. Coexisting disease such as iron deficiency, inflammatory process, renal failure, or thalassemia trait also may normalize the mean corpuscular volume (MCV) value in the patient with vitamin B12 or folate deficiency.

Why Are the Elderly Susceptible to These Mental Status Changes

The answer is not known with certainty, but there are several likely reasons. Age-related decline in liver and kidney function results in a decreased ability to metabolize and eliminate drugs, which results in significantly slower elimination and clearance of these drugs from the bloodstream with increased effects and side effects. The

Natriuretic Peptides BNP and Nterminal proBNP

Blood levels of natriuretic peptides are used in the evaluation of heart failure. Cardiac cells release natriuretic peptides, in response to stretch and wall tension. Ventricular myocytes release a pro-B-type natriuretic peptide (pro-BNP), which is cleaved into the active B-type natriuretic peptide (BNP) and the inactive N-terminal pro-BNP (NT-pro-BNP). Levels of both BNP and NT-pro-BNP increase with age and in renal insufficiency and are reduced in women and obese patients. Some medications, including spironolactone, ACE inhibitors, and angiotensin receptor blockers, lower BNP NT-pro-BNP levels. Other conditions that increase natriuretic peptides include myocardial ischemia, atrial fibrillation, pulmonary embolus, pulmonary hypertension, chronic kidney disease, and sepsis.

Risk of Anesthesia and Surgery and the Importance of Location

The location where you have your surgery does matter. The facility where surgery is performed is extremely important when it comes to high-risk patients and complex or highly specialized surgery. Mortality and complication rates have been shown to vary widely from institution to institution on such major cases as cardiac surgery and major vascular surgery.8 The evidence suggests that mortality rates for certain complex surgical procedures (e.g., open-heart surgery, major vascular surgery, and total hip replacements) are significantly reduced when the number of cases being performed exceeds a certain minimum number of cases.9 The same principle holds true for other invasive and complex surgeries. For example, if you are having a liver transplant or a kidney transplant, it may be worth the extra distance to go to the surgeon and a facility that does this procedure on a regular basis in large numbers.

Angiotensin Receptor Blockers in Heart Failure

Primary end points in the Irbesartan Diabetic Nephropathy Trial (IDNT) (A) and Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) study (B). (A, from Lewis EJ, Hunsicker LG, Clarke WR, et al Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med 2001 345 851-860 B, from Brenner BM, Cooper ME, de Zeeuw D, et al Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001 345 861-869.) Figure 12-4. Major clinical outcome trials using angiotension-converting enzyme (ACE) inhibitors. CAD, coronary artery disease CVA, cerebrovascular accident DM, diabetes mellitus HBP, high blood pressure HF, heart failure MI, myocardial infarction. (Data from Lewis EJ, Hunsicker, LG, Clarke WR, et al, for the Collaborative Study Group Renoprotective effect of the angiotensin-receptor antagonist irbesartan in...

Clinical Presentation And Diagnosis

Creatic enzymes can cause cardiovascular shock. Acute renal failure may result from hypovolemia.8 Patients at greatest risk for mortality from acute pancreatitis are those who have multiorgan failure (e.g., hypotension, respiratory failure, or renal failure), pancreatic necrosis, obesity, volume depletion, above 70 years of age, and an elevated Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score.9-10

Antiatherosclerotic and Vascular Injury

Rary therapy with the addition of either placebo or the ACE inhibitor trandolapril.100 Neither the primary outcome of cardiovascular death, nonfatal MI, or coronary revascularization procedure or the major secondary end point of cardiovascular death or nonfatal MI was reduced in the ACE inhibitor group (see Fig. 12-9C). As the most contemporary of the three trials, PEACE had the lowest comorbidity as manifested by lower baseline blood pressure, cholesterol, and prevalence of diabetes. These important demographic features were translated into a better prognosis, because the clinical event rates in the placebo group of PEACE were lower than observed in even the ACE inhibitor arms of HOPE or EUROPA. Although appropriate questions have been raised regarding this apparent discrepancy of results, including the lower-risk population and the specific ACE inhibitor tested, other secondary end points, such as development of congestive heart failure and incidence of new diabetes, were reduced in...

Computed Tomography

With the increase in cross-sectional imaging studies, computed tomography has become a more reliable modality for diagnosing renal cysts and differentiating them from other renal lesions such as a solid neoplasm. FIGURE 1 Renal ultrasound of a patient with multiple simple renal cysts. Note the sonolucent nature of cysts displaying through transmission with thin walls, absence of nodules, septations, or calcifications. The advantage of laparoscopic decortication of symptomatic renal cysts. Include the ability to address multiple, peripelvic, and bilateral renal cysts in a single operation, while minimizing incisional morbidity. FIGURE 1 Renal ultrasound of a patient with multiple simple renal cysts. Note the sonolucent nature of cysts displaying through transmission with thin walls, absence of nodules, septations, or calcifications. FIGURE 2 Contrast enhanced computed tomographic image of a patient with left peripheral renal cyst and right peripelvic renal cysts. Note The peripelvic...

Magnetic Resonance Imaging

Enhancement of a renal lesion following the administration of gadolinium suggests the likelihood of a solid neoplasm, whereas a simple renal cyst does not enhance and appears homogeneous with low signal on T1-weighted images and high signal on T2-weighted images (Fig. 3). TABLE 1 Bosniak Criteria for Classification of Renal Cysts Based on Computed Tomographic Findings TABLE 1 Bosniak Criteria for Classification of Renal Cysts Based on Computed Tomographic Findings FIGURE 3 T2-weighted magnetic resonance image of a patient with autosomal dominant polycystic kidney disease. Note The cysts appear homogeneous and bright, consistent with fluid density similar to the cerebral spinal fluid. Note that virtually the entire renal parenchyma of both kidneys is replaced by numerous cysts of varying sizes. No enhancement was noted within these cysts after gadolinium administration. FIGURE 3 T2-weighted magnetic resonance image of a patient with autosomal dominant polycystic kidney disease. Note...

Consequences Of Ckd And Eskd Impaired Sodium and Water Homeostasis

Sodium and water balance can be maintained despite wide variations in intake with normal kidney function. The fractional excretion of sodium (FENa) is approximately 1 to 3 with normal kidney function, allowing sodium balance to be maintained with a sodium intake of 120 to 150 mEq (120-150 mmol) per day. Urine osmolality can range from 50-1,200 mOsm L (50 to 1,200 mmol L) with normal kidney function, allowing for water balance to be maintained with a wide range of fluid intake. As the number of functioning nephrons decreases, the remaining nephrons increase sodium

Personnel and Equipment Configuration

In addition to the operating surgeon, laparoscopic renal cyst ablation requires the following personnel a surgical assistant, scrub technician, circulating nurse, and anesthesia team. During the transperitoneal approach, both the operating surgeon and the assistant stand on the abdominal side of the patient, contralateral to the targeted kidney. A typical operating room configuration for a left transperitoneal laparoscopic renal cyst ablation is shown in Figure 5. The scrub nurse and equipment table are situated near the surgical team at the foot of the table. The operating table must be adjustable and allow for lateral rotation. Two towers or cabinets equipped with a color video monitor mounted at eye level, light source, and carbon dioxide gas insufflator are placed on either side near the head of the table to allow the operating surgeon, assistant, and scrub technician to view and continuously monitor the surgical procedure. A video camera is attached to the laparoscope and its...

Right Transperitoneal Laparoscopic Technique

For a right-sided transperitoneal laparoscopic renal cyst ablation, trocar configuration is the mirror image of that used for a left-sided technique (i.e., the second 10 12-mm trocar is placed lateral to the right rectus muscle with all other trocars remaining the same). The ascending colon is reflected medially and for cysts located near the hilum, reflection of the duodenum may be required. A combination of blunt and sharp dissection of the attachments between the duodenum and kidney (Kocher maneuver) is performed with avoidance of electrocautery. For cysts located along the superior pole of the kidney, sharp release of the coronary ligament of the liver allows for anterior retraction of the right lobe of the liver for exposure to the upper pole of the kidney. A 3-mm or 5-mm additional trocar may be placed two to three fingerbreadths superior to the existing 5-mm trocar to allow for insertion of a laparoscopic instrument or grasper for liver retraction. The subsequent steps follow...

Collecting System Injury

Injury to the collecting system can occur during aggressive biopsy and fulguration of the base of the cyst wall or during attempts at cyst wall excision of a peripelvic or autosomal dominant polycystic kidney disease cysts. When biopsy of the cyst base is indicated, only superficial samples should be taken especially in the case of peripelvic cysts or cysts located close to the collecting system. Reference to preoperative radiologic films may be helpful in assessing the depth of the cyst and its proximity to the collecting system. Direct coagulation of the collecting system should be avoided. As mentioned previously, placement of an open-ended ureteral stent at the start of the operation especially in the treatment of peripelvic or autosomal dominant polycystic kidney disease cysts can help identify the precise location of a collecting system injury and facilitate its repair.

Adjacent Organ Injury

Use of a preoperative bowel preparation especially in more challenging cases such as autosomal dominant polycystic kidney disease can decompress the bowel, improve visualization, and reduce the chance of iatrogenic injury from laparoscopic instrumentation. During mobilization of the colon and small bowel, the use of elec-trocautery should be minimized to avoid accidental cautery injury to the bowel and subsequent delayed bowel perforation. During a right-sided procedure, great care must be taken during the dissection of the duodenum. Use of electrocautery or careless sharp dissection around the duodenum can result in duodenal injury and catastrophic consequences. Complications such as ileus, fever, urinary tract infection, urinary retention, atelectasis, pneumonia, cellulitis, renal insufficiency, neuromuscular injury, incisional hernia, transfusion, recurrence of cyst, persistence of pain, deep venous thrombosis, and pulmonary embolism can occur following laparoscopic renal cyst...

Postoperative Complications

Complications such as ileus, fever, urinary tract infection, urinary retention, atelectasis, pneumonia, cellulitis, renal insufficiency, neuromuscular injury, incisional hernia, transfusion, recurrence of cyst, persistence of pain, deep venous thrombosis, and pulmonary embolism can occur following laparoscopic renal cyst ablation. Two postoperative complications that are worthy of special mention are perinephric hematoma and urinoma. To reduce the occurrence of postoperative bleeding and hematoma, meticulous hemostasis should be confirmed at the conclusion of renal cyst ablation. As high carbon dioxide insufflation pressures can mask ongoing bleeding, the intra-abdominal carbon dioxide pressures should be reduced to 8 to 10 mmHg when assessing for bleeding points. To avoid the occurrence of urinoma, every attempt should be made to avoid inadvertent entry into the collecting system when performing renal cyst ablation and to repair overt injuries if they occur. Recurrence of a renal...

Calcium and phosphorus

Osteoporosis (thinning bones) similar to that which occurs in older people is not common in dogs. Most fractures in dogs are due to trauma and are not age-related. Many people think that, because older people are recommended to take additional calcium to help prevent thinning of the bones, the same must be true for dogs. In fact there is no special need for extra calcium or vitamin D3 in older dogs provided a balanced diet is fed. However, because of possibly decreased kidney function and the high chance of kidney disease, older dogs should be fed a food containing a low level of phosphorus (around 0.5 Table 10.8).

Nfor potassium 1 rmEq 1 rmrriol

Cretion results from acute renal failure, chronic renal failure, or Addison's disease. Excess potassium release from cells results from tissue breakdown (surgery, trauma, hemolysis, or rhabdomyolysis), blood transfusions, and metabolic acidosis. It is critically important to recognize that the treatments of hyperkalemia discussed thus far are transient, temporizing measures. They are intended to provide time to institute definitive therapy aimed at removing excess potassium from the body. Agents that increase potassium excretion from the body include sodium polystyrene sulfon-ate, loop diuretics, and hemodialysis or hemofiltration (used only in patients with renal failure). Sodium polystyrene sulfonate (Kayexalate, various manufacturers) can be given orally, via NG tube, or as a rectal retention enema and is dosed at 15 to 60 g in four divided doses per day.

Stent Thrombosis Risk and Management

Several large-scale studies of the carefully selected patients from randomized trials or more general practice36,37 have attempted to assess the incidence, timing, and risk factors for DES-associated stent thrombosis. Intravascular ultrasound (IVUS) and autopsy studies suggest a correlation with stent under-expansion, dissection, plaque prolapse, and stenting adjacent to vulnerable plaque.38 The 30-day risk appears to be 0.6 to 1.4 , which is not dissimilar to that with bare metal stents. From 6 months to 2 years, however, some studies suggest numerically small but significant excess risk with DESs. Simoli-mus- and paclitaxel-eluting stents appear to have similar risks.30 Consistent findings among the studies are the relation of cessation of clopidogrel therapy, renal failure, and bifurcation lesions to risk of thrombosis, often increasing the risk by more than five times.36,37 Other studies have found that the thrombosis risk also was related to stent length, in-stent

Pleural Effusion Fluid in the Chest

There are many causes of pleural effusions. They could develop as a result of heart failure, liver failure, or kidney failure or be related to a tumor in the chest. Sometimes, fluid can accumulate in the chest cavity for other reasons, such as an infection. In this case, the material may be pus. Sometimes the fluid is bloody, and when related to trauma, the fluid may actually be blood.

Functional Considerations

The elderly are more likely to present with left ventricular dysfunction, multivessel CAD, and associated comorbidities such as diabetes and chronic kidney disease, placing them at higher risk for PCI and often making CABG a more desirable option. Previous studies have demonstrated an increased risk of adverse cardiovascular events in the elderly after PCI. In a prospective registry (Routine versus Selective Exercise Treadmill Testing after Angioplasty ROSETTA Registry) designed to evaluate the use of functional testing after PCI, patients 75 years or older were compared with those younger than 75 years old. The older cohort was found to have a higher incidence of death, cardiac death, unstable angina, MI, and the composite end point of all of these outcomes at 6 months after successful PCI. Prior CABG correlated with a higher incidence of events. These elderly patients had a much higher incidence of comorbidities at baseline, which might have explained the differences found.45 With...

Pilot studies of the NASG

Based on the successes of the case series in Pakistan, the authors and their in-country colleagues are conducting NASG pilot studies in comprehensive emergency obstetric care facilities in Nigeria (Dr Dosu Ojengbede, University of Ibadan), teaching facilities in Egypt (John Snow International), and in primary and secondary health facilities in Mexico (Population Council and IMSS-Opportunidades). These studies compare use of a standardized protocol of shock and hemorrhage care in the pre-intervention period with the same standardized protocol plus the NASG in the postintervention phase. The primary outcome was volume of measured blood loss after initiation of treatment with or without the NASG. To obtain a relatively objective measure of blood loss, maternal bleeding after admission to the study is measured using a specially designed, closed-end, calibrated plastic blood collection drape. Prior studies of this drape indicate that it is more accurate than visual assessment in measuring...

Pharmacologic Therapy

Mechanistically, APAP is believed to inhibit prostaglandin synthesis in the CNS and block pain impulses in the periphery. APAP is well tolerated at usual doses and has few clinically significant drug interactions except causing increased hypoprothrombinemic response to warfarin in patients receiving APAP doses of more than 2,000 mg per day. The maximum recommended dose for patients with normal renal and hepatic function is 4,000 mg per day. Hepatotoxicity has been reported with excessive use and overdose, and the risk of this adverse effect increases in those with hepatitis or chronic alcohol use, as well as those who binge drink or are in a fasting state. Regular chronic use of APAP has been associated with chronic renal failure, but reports are conflicting. For these reasons, the maximum dose should be reduced by 50 to 75 in patients with renal dysfunction or hepatic disease and in those who engage in excessive alcohol use.

Experience of the French Multicenter Registry

Lefevre presented the French data comparing coronary intervention (n 193), bypass surgery (n 233), and medical treatment (n 57) for LMCA stenoses at the Complex Catheter Technique meeting in Japan in 2002.61 Eleven centers in France enrolled 483 patients from May 2001 to June 2002 in this study. Thirty-two percent of patients constituted a high-risk group of patients older than 75 years, with pulmonary failure, renal failure, severe peripheral disease, previous bypass graft surgery, previous stroke, and left ventricular ejection fraction less than 30 . Coronary intervention, bypass surgery, or medical therapy was selected for 40 , 48 , and 12 of the cases, respectively, at the operator's or the patient's discretion. High-risk patients were more common in the coronary intervention group than in the bypass surgery group (45 versus 14 ), although triple-vessel disease was more common in the surgery group than in the angioplasty group (52 versus 28 ). The rates of distal LMCA involvement...

What damage can BPHcause

Enlargement of the prostate, BPH, increases the resistance to the flow of urine out of the bladder. Thus the bladder needs to work harder to push urine beyond the resistance. In order to accomplish this, the bladder pressures must increase. As a result of this need for increased force there is hypertrophy of the bladder muscle. The increased work that the bladder muscle needs to do to empty the bladder may lead to the development of overactive bladder (Questions 41 and 42). This increased pressure that the bladder needs to generate can be transmitted backwards from the bladder to the kidneys, and in some individuals it may impair the drainage of the kidneys, causing swelling of the kidneys hydronephrosis and a decrease in kidney function. If the bladder cannot create enough pressure and or cannot maintain the elevated pressure, then the bladder may not

When does BPH need to be treated

The need to initiate treatment for BPH is divided into absolute and relative indications. Absolute indications refer to objective medical reasons to intervene. These include impaired renal function because of prostatic obstruction, hydronephrosis or dilation of the ureters and kidneys, recurrent urinary tract infections, bladder stones, and inability to void (urinary retention). Impaired renal function

Laterality of Nephrectomy

Historically, the percentage of right kidney donors in the open experience ranges from 26 to 37 (78). Common indications for right-sided donor nephrectomy include multiple left renal arteries or veins, right renal cysts, smaller right kidney, or possibly solitary right-sided nephrolithiasis (79-81).

Traumatic gas gangrene

May be detected by soft tissue radiographs, computerized tomography (CT) scan, or magnetic resonance imaging however, none of these radiographic procedures are more specific or sensitive than physical examination revealing crepitus in soft tissue.5 However, radiographic procedures are particularly helpful to demonstrate gas in deeper tissue such as the uterus. Rapidly-developing signs of systemic toxicity include tachycardia, low-grade fever, and diaphoresis, followed by shock and multiorgan failure. In one study shock was present in 50 of patients presenting and of those who developed shock at some point in their hospitalization, 40 died, compared with 20 in the group as a whole.6 Bacteremia occurs in 15 of patients and may be associated with brisk hemolysis. One patient has been described wth a decrease in the hematocrit from 37 to 0 over a 24-h period.7 Subsequently, despite transfusion with 10 units of packed red blood cells over a 4-h period, the hematocrit never exceeded 7.2 .7...

Current Status Of Laparoscopic Approach

Laparoscopic donor grafts have been shown over the short term to function as well as open donor grafts (10,115). Many centers have demonstrated good short-term follow-up of graft survival in kidneys procured with the laparoscopic techniques. Montgomery and coworkers report 94 graft function at five years (115). The jury is still out as regards how long these grafts will function. Living donation is a personal sacrifice for the donor. Therefore, every effort should be made to maximize long-term graft survival. In a large series of living donors from the University of Minnesota, risk factors for worse long-term recipient graft survival included pretransplant smoking, pretrans-plant peripheral vascular disease, pretransplant dialysis for more than one year, acute rejection episodes, and donor age over than 50 (116). Out of respect to the donor, detrimental factors in the recipient should be modified as much as possible.

Expansion of Laparoscopic Approach

It is evident that the laparoscopic approach, while not perfect, has done well enough to be considered the first-choice approach for a majority of donors. However, laparoscopic donor nephrectomy is more expensive than open donor nephrectomy, as shown by Mullins et al. (119) in a study evaluating the actual Medicare expenditures, which found that all transplantations were less expensive than dialysis in the long term. Cadaveric transplantation reaches a break-even point in costs over dialysis at 18 months posttransplant. Laparoscopic living donation reaches the break-even point at 14 months posttransplant. Open donor nephrectomy was most efficient costwise, reaching a break-even point at only 10 months posttransplant compared to dialysis. So, there is a dollar cost to the benefits of laparoscopy for the donors.

Patient Selection Indications And Contraindications

Clinically significant lymphoceles present in several different manners depending on their precipitating cause. The most common occurence is after a pelvic lymph node dissection, In these cases, patients will present with lower abdominal discomfort or swelling, fever, ipsilateral lower extremity swelling, deep venous thrombosis, scro-tal swelling, lymphocutaneous fistula, or incidentally on computed tomography for adjuvant radiotherapy to treat prostate cancer. Presentation following pelvic renal transplantation is similar, with the addition of perinephric fluid collections, renal failure, or suspected graft rejection.

Laparoscopic Technique

If needed, hemostasis can be achieved through the use of electrocautery or the application of titanium clips. The patency of the peritoneal window can be maintained by the placement of a pedicle flap of omentum into the cavity. The pedicle flap should be secured with titanium clips to prevent closure of the window and also bowel herni-ation through the peritoneal opening. A permanent peritoneal dialysis catheter can be placed in lieu of omentum in recurrent lymphoceles, those with limited peritoneal openings or those that are anatomically difficult to access. Similar to omentoplasty, peritoneal dialysis catheters must be fixed to the lymphocele wall to prevent migration. They are, however, contraindicated in those lymphoceles that are infected (20) As with any laparoscopic procedure, careful inspection for hemostasis is critical.

Animal Models Of Disease

Unlike humans, in the mouse there are two Daf genes, Daf1 and Daf2. The Daf1 gene, like the human DAF gene, encodes GPI-anchored DAF that is ubiquitously expressed, while the Daf2 gene encodes transmembrane anchored DAF that is restricted in its distribution to the testes and spleen (Lin et al., 2001). Consequently for an animal model, the Daf1 gene was targeted. Daf1 knock-out mice (Lin et al., 2001 Miwa, 2001) provide a resource for studying several experimental animal models of disease including experimental autoimmune myasthenia gravis (EAMG), a murine model of systemic lupus erythrematosus (SLE) in MRL lpr mice, acute nephrotoxic serum (NTS)-induced nephritis, and dextran sodium sulfate (DSS)-induced colitis. In EAMG, the binding of anti-acetylcholine receptor (AChR) antibodies to the post-synaptic junction activates the classical pathway, ultimately leading to endplate damage (De Baets et al., 2003). Following anti-AChR mAb administration, as compared with Dafl* + littermates...

Diagnosis of coronary heart disease in stroke patients

When caring for stroke patients in the acute or rehabilitation phase, it is necessary to be aware of clinical symptoms of myocardial ischemia such as chest pain or exertional dyspnea, or electrocardio-graphic abnormalities such as ST-depression, T-wave abnormalities or newly developing Q-waves 20 . The detection of myocardial injury can be improved by measuring serum levels of troponin T or troponin I, biomarkers which are found to be highly specific for myocardial necrosis 24 . Elevated troponin levels in stroke patients with signs or symptoms of myocardial ischemia should entail rhythm monitoring and cardi-ological consultation regarding further therapeutic and diagnostic measures, including coronary angio-graphy and percutaneous coronary intervention. Stroke patients with normal troponin levels but signs and symptoms suggestive of myocardial ischemia should also be referred to the cardiologist, because stress testing might be indicated. In acute stroke patients without a history or...

Action on bone marrow

Testosterone has been demonstrated to stimulate erythroid colony formation dose-dependently in vitro. Hence, androgens might have a promoting effect on erythroid colony forming units in bone marrow (Moriyama and Fisher 1975a). As trials in rabbits demonstrated, testosterone may directly act on these colony forming units to enhance their differentiation into EPO-responsive cells, causing an increase of nucleated erythroid cell numbers. Thus, EPO is required to further increase the maturation ofthese cells (Moriyama and Fisher 1975b). There is also some evidence that, determined by the direct action of androgens on the cellular cycle of bone marrow stem cells, a prevailing differentiation towards the erythroid series and a resulting decrease of differentiation into leucocytes is caused by testosterone (Kozlov etal. 1979). This seems to be a pivotal and initial step of androgen action in erythropoiesis as has been demonstrated by bone marrow biopsies in some patients with renal failure...

Nuclear Factor Kappa B

The NF-kB DNA aptamer was also studied in a murine model of nephritis, where the aptamer but not the scrambled-oligonucleotide control abolished glomerular inflammation and gene expression of inflammatory markers IL-1a, IL-1 , IL-6, ICAM-2, and VCAM-1 (Tomita et al., 2000).

Feline polycystic kidney disorder

In PKD a large number of fluid-filled cysts form within the kidneys (Feline Advisory Bureau 2004). The cysts are present from birth but increase in size until they damage the surrounding kidney tissue and cause kidney failure (Fig. 16.10). The cat will eventually die, despite supportive treatment. The disease is peculiar to Persian cats and any breed of cat where Persian genes have been included, such as the Tiffany.

Influence Of Renal Disease On Pharmacokinetics

Renal disease may affect drug pharmacokinetics through several mechanisms. Acidic drugs bind mainly to albumin. In renal failure, a decrease in serum albumin, an increase in serum urea, and the competition of endogenous substrates and drug metabolites for plasma protein binding sites lead to a decrease in the plasma protein binding of drugs. Highly protein-bound drugs have an increased unbound, active, free fraction. Under these circumstances, there may be an increase in the volume of distribution. Drugs are metabolized in the liver to water-soluble, inactive metabolites. Although uraemia has an effect on the intermediary metabolism of the liver, it does not seem to affect hepatic drug metabolism in humans.

Influence Of Drugs On Renal Function

Sevoflurane undergoes approximately 5 metabolism and one of the primary metabolites is fluoride. There were initial concerns that sevoflurane may be similar to methoxyflurane and impair the ability of the kidneys to concentrate urine. However, after sevoflurane administration is stopped, there is a rapid decrease in plasma fluoride concentration because of its insolubility and rapid pulmonary elimination. The intrarenal metabolic production of fluoride is also much less with sevoflurane than with methoxyflurane. Although after extensive use it would appear that sevoflurane renal toxicity is not a problem in clinical practice, its prolonged use is not recommended in patients with significantly impaired renal function.

Calcium Channel Blockers

Calcium antagonists may cause hypotension and thereby decrease renal perfusion. Therefore their use is not really justified in most cases of post-ischaemic acute renal failure. The effects of the depolarizing and non-depolarizing neuromuscular blocking agents might be enhanced by the calcium antagonists. Caution should always be exercised when this combination is used in patients with renal dysfunction.

Physiology of the Peritoneum

The peritoneal circulation plays a major role in the exchange of fluid and solutes draining peritoneal dialysis. The parietal peritoneum is supplied by the vessels from the abdominal wall and the visceral peritoneum. The splanchnic vascu-lature contains about one-third of total blood volume and a blood flow rate that exceeds 1200 mL min, with mesenteric blood flow representing about 10 of cardiac output. There are many factors that influence the peritoneal circulation, such as age, cardiac output, exercise, and hormonal substances (such as angiotensin and epinephrine) (6,7).

Osmotic Diuretics Mannitol

Mannitol is often used prophylactically to protect the kidneys against an ischaemic incident (e.g. cardiopulmonary bypass, aortic cross-clamping or hypotensive episodes) and subsequent acute renal failure. It has been suggested that decreasing the oxygen demand in the proximal tubular cells preserves oxygen balance. By increasing tubular flow, it might also provide a flushing effect to remove necrotic cellular debris from the renal tubules after ischaemic injury. The hyperosmotic and oxygen radical scavenging effects of this drug might also reduce tubular endothelial cell swelling. However, although mannitol has been shown to be effective in animal experiments, studies have failed to show a renal protective effect in clinical practice. There is also litde evidence that conversion from an oliguric to a non-oliguric renal failure decreases the mortality rate in critically ill patients. Nevertheless, mannitol is used regularly during renal transplantation to help 'preserve' the donor...

Blind or Seldinger Technique

In the blind or modified Seldinger technique, a needle is inserted into the abdomen, a guidewire placed, a tract dilated, and the catheter inserted through a split-sheath all maneuvers are performed without visualization of the peritoneal cavity (11). The deep cuff usually remains outside the outer rectus sheath after implantation. The blind technique is not widely used in the United States. The bedside blind insertion technique is associated with a significant risk of visceral damage and high rate (31 ) of subsequent migration leading to failed dialysis (12). The other disadvantage is that final catheter placement cannot be controlled, and it is not suitable for the placement of complex catheters.

Amiloride and triamterene

Amiloride acts directly on the distal tubule and collecting duct. It causes potassium retention and an increase in sodium loss. After oral intake, up to 25 is absorbed, onset of its peak effect is within 6 h, and it is then excreted unchanged in the urine. Amiloride is almost always used in combination with thiazide or loop diuretics. It then has a synergistic action in terms of diuresis, although it opposes the potassium loss. Amiloride has few side-effects. Hyperkalaemia and acidosis may occur, and it is therefore con-traindicated in patients with renal failure.

Hereditary C4 Deficiency

Absence of both C4B genes is associated with increased risk of IgA nephropathy and glomerulonephritis (43). Absence of at least one C4B gene, which leads to low levels of plasma C4, has been associated with dermatological diseases, specifically discoid lupus erythematosus, angioedema, and urticaria (44). C4 deficiencies have also been shown to be associated with anti-SS-A antibodies and with anti-cardiolipin antibodies in blacks (45-46).

Parathyroid Calcium Sensor Proteins

Cloning of the calcium sensor recognized by the antibodies revealed a 500-kd glycoprotein with a single membrane-spanning domain this protein belongs structurally to the low-density lipoprotein (LDL) receptor superfamily.52 Particular homology was demonstrated with the rat Heymann's nephritis antigen, which constitutes a large glycoprotein of the proximal kidney tubule and possibly serves as an autoantigen of experimental nephritis. The calcium-binding motifs of the calcium sensor are probably composed of repetitive epidermal growth factor (EGF)-like modules, and calcium sensitivities of the LDL superfamily of proteins are in the range of the extracellular concentration of ionized plasma calcium. Kinetic studies of these proteins indicate the presence of positive cooperativity for the interaction of calcium, whereby multiple binding sites can efficiently alter protein signaling. Under these circumstances, cells equipped with the sensor are allowed to respond efficiently to the narrow...

Transradial versus Transfemoral Approaches for Percutaneous Coronary Intervention

Many advantages make the transradial approach the method of choice for outpatient PCI, which has been reported to be highly feasible and safe.6,7 The transradial approach is also of particular interest for patients at high risk for bleeding, such as elderly patients, women, those with renal failure, obese patients, or those on multiple antithrombotic agents, especially glycoprotein (GP) IIb IIIa inhibitors. For example, the transradial approach has been associated with fewer vascular complications in obese patients (multivariate OR 0.12 95 CI 0.02 to 0.94 P .043) in a retrospective series of 5234 diagnostic or interventional (56.6 ) procedures,8 as well as in the elderly (1.6 versus 6.5 , P .03).9 Other patients may be better served by the radial rather than femoral approach, including those with severe or proximal peripheral arterial disease, patients with bilateral aor-tofemoral bypass grafts, those with aortic aneurysms, and patients with a history of femoral complications

Combined Hereditary Complement Deficiencies

A family with four children has been identified in which three of the children are homozygous deficient for factor H and two of the three children are heterozygous deficient for C2. One of the two children with both C2 and factor H deficiency had classic SLE with nephritis. Two patients have been identified with combined homozygous C7 and C4B deficiency one of the patients was normal and one had SLE (73). The patient with SLE had a sister who was asymptomatic but was also homozygous C7 deficient. Additional patients have been identified with combined properdin and C2 deficiency, and DAF and C9 deficiency, but rheumatic disease was not reported for any of them.

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