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Biomedical subjects

C L Manske

Publications and source records attributed to C L Manske.

At least 19 recordsLinked to original sources
PubMed1999

Risks and benefits of kidney and pancreas transplantation for diabetic patients.

Type 1 diabetic patients with end-stage renal disease can choose dialysis or transplantation for renal replacement therapy. For patients choosing transplantation, a kidney from a living related donor is associated with longer allograft and patient survival. When a living donor is not available, then a combined cadaveric kidney and pancreas transplant can be considered. The addition of a pancreas transplant incurs greater morbidity and may require higher levels of immunosuppression. However, there may be substantial benefits, including improvement in quality of life and stabilization of neuropathy. Patients with type 1 diabetes younger than 45 years with little or no atherosclerotic vascular disease are ideal candidates for a combined kidney and pancreas transplant. Patients who do not meet these criteria but who have life-threatening hypoglycemia may also wish to consider pancreas transplantation, but have an increased risk of serious complications. The risks and benefits of combined kidney and pancreas transplantation are outlined in this review and should be carefully considered by potential transplant recipients and their physicians.

Diabetes Mellitus↗
PubMed1998

Outcome of coronary artery bypass surgery in diabetic transplant candidates.

Insulin-dependent diabetic (IDDM) patients with end-stage renal disease and coronary artery stenoses > or = 75% have a poor prognosis. However, information is lacking on the morbidity and mortality of the coronary artery bypass operation in this group. We studied 30 consecutive IDDM transplant candidates undergoing a bypass operation to determine the incidence of complications and long-term outcome. Perioperative mortality was 3% and the complication rate was 60%. During follow-up, five patients experienced six myocardial infarctions, the majority within six months of operation. Twenty-one patients underwent successful kidney transplantation after the bypass operation. Overall patient survival was 80%, 73%, and 66% at 1, 2 and 4 yr. In summary, the coronary artery bypass procedure in IDDM transplant candidates has a high morbidity, but the long-term outcome is good. Appropriately counseled IDDM transplant candidates with coronary artery disease should be considered for coronary revascularization and subsequent transplantation.

Coronary Artery Bypass↗
PubMed1997

Atherosclerotic vascular complications in diabetic transplant candidates.

Serious vascular complications limit the success of renal transplantation in diabetic patients. Nearly half of diabetic transplant recipients die within 3 years after transplantation from a vascular complication. However, it has been difficult to determine before transplantation which patients are likely to do poorly. Because atherosclerosis is a systemic disease, we hypothesized that diabetic transplant candidates with pretransplant coronary artery disease would be at high risk for vascular complications even if asymptomatic at the time of pretransplant evaluation. Our hypothesis was that insulin-dependent (IDDM) transplant candidates with coronary artery disease identified with pretransplant coronary angiography would have an increased number of vascular events (amputation, cerebral vascular accident [CVA], or myocardial infarction [MI]) within 3 years of follow-up. We prospectively studied 198 consecutive diabetic transplant candidates grouped on the basis of coronary artery disease. Group 1 patients had no stenosis that was 50% or greater, group 2 patients had one or more stenoses between 50% and 74%, and group 3 patients had one or more stenoses of 75% or greater. During median follow-up of 41 months, 64 patients experienced 98 amputations, 28 MIs, and seven CVAs. At 36 months of follow-up, 55% of group 3 patients, 30% of group 2 patients, and 11% of group 1 patients had experienced a vascular event (P < 0.001). Cox regression confirmed the association of coronary artery disease with subsequent vascular events. Patients with coronary artery disease had a sevenfold increased risk of amputation and a fourfold increased risk of myocardial infarction. Six of seven CVAs occurred in patients with coronary artery disease. We conclude that coronary artery disease identified at pretransplant evaluation is associated with an increased risk of noncoronary vascular complications within 3 years after evaluation.

Adult↗
PubMed1993

Screening diabetic transplant candidates for coronary artery disease: identification of a low risk subgroup.

Coronary artery disease is the major cause of death in diabetic renal transplant recipients. Because one-third of diabetic transplant candidates have clinically silent coronary artery disease, many transplant centers recommend coronary angiography prior to transplantation. However, angiography is expensive and may precipitate acute renal failure. Therefore, we developed a noninvasive screening algorithm to identify patients at low risk for coronary artery disease (CAD), defined as one or more coronary stenoses > or = 50% diameter. We performed coronary angiography in 141 consecutive asymptomatic Caucasian type I diabetic renal transplant candidates. Fourteen of 16 patients age 45 or older had CAD. One hundred and twenty-five patients under age 45 were randomly divided into two groups. Ninety patients were used to identify clinical factors significantly associated with CAD which included smoking for five or more pack years, nonspecific ST-T wave changes on electrocardiogram, and diabetes duration 25 years or longer. The screening algorithm, "CAD is predicted in diabetic transplant candidates under age 45 with any of the above risk factors," was then tested in the remaining 35 patients and in 35 additional patients. In these 70 patients, the algorithm had a sensitivity of 97% and a negative predictive accuracy of 96%. We conclude that coronary angiography should be recommended to Caucasian type I diabetic renal transplant candidates age 45 or older because of the high probability of disease. In patients younger than 45 without a smoking history, ST-T wave changes on EKG, or diabetes longer than 25 years, the likelihood of CAD is low and angiography can be avoided.

Adult↗
PubMed1993

Coronary artery disease in diabetic patients with nephropathy.

Patients with juvenile-onset, insulin-dependent diabetes mellitus (IDDM) are at high risk of premature coronary artery disease. The risk is concentrated in diabetic patients who develop nephropathy. Synergy in atherogenesis is likely to be present between hyperglycemia and the metabolic alterations of diabetic nephropathy, which include hypertension, hypercholesterolemia, and high lipoprotein (a) levels. The accumulation of advanced glycation end-products in blood vessel walls and on lipoproteins may result in increased vascular permeability and uptake of cholesterol, particularly in the setting of hypertension and hypercholesterolemia. The net result may be acceleration of atherogenesis.

Coronary Disease↗
PubMed1992

Coronary revascularisation in insulin-dependent diabetic patients with chronic renal failure.

Insulin-dependent diabetic patients found to have substantial coronary artery disease at the time of assessment for renal transplantation have 2-year survival of less than 50%. Because most of these patients have no angina symptoms their management is controversial. We tried to find out whether coronary artery revascularisation in such patients might decrease the combined incidence of unstable angina, myocardial infarction, and cardiac death. 151 consecutive insulin-dependent diabetic candidates for renal transplantation underwent coronary angiography. 31 had stenoses greater than 75% in one or more coronary arteries, atypical chest pain or no chest pain, and a left ventricular ejection fraction greater than 0.35. Of these, 26 agreed to be randomly assigned medical treatment (a calcium-channel-blocking drug plus aspirin) or revascularisation (angioplasty or coronary bypass surgery). 10 of 13 medically managed and 2 of 13 revascularised patients had a cardiovascular endpoint within a median of 8.4 months of coronary angiography (p < 0.01). 4 medically managed patients died of myocardial infarction during follow-up. Thus, revascularisation decreased the frequency of cardiac events in insulin-dependent diabetic patients with chronic renal failure and symptomless coronary artery stenoses. These findings suggest that diabetic renal transplant candidates should be screened for silent coronary artery disease, because revascularisation may decrease cardiac morbidity and mortality in this population.

Adult↗
PubMed1992

Henoch-Schönlein vasculitis as a manifestation of IgA-associated disease in cirrhosis.

Cirrhosis has been associated with a variety of glomerular lesions that generally include deposits of IgA in the mesangium. However, loss of renal function secondary to IgA deposition in cirrhotics is infrequent. An unusual patient who developed rapidly progressive glomerulonephritis followed by leukocytoclastic vasculitis with IgA deposition on skin biopsy is presented. We postulate that this is an example of Henoch-Schönlein purpura occurring secondary to altered IgA processing in cirrhosis.

Female↗
PubMed1992

Prevalence of, and risk factors for, angiographically determined coronary artery disease in type I-diabetic patients with nephropathy.

BACKGROUND--Thirty-five percent of type I-diabetic patients are dead of coronary artery disease by age 55 years, and the risk of death is increased eightfold to 15-fold in patients with nephropathy. However, the prevalence of coronary artery disease with respect to age is unknown and few risk factors have been identified. METHODS--One hundred ten insulin-dependent diabetic patients underwent routine pretransplant coronary angiography and cardiac risk factor assessment. Angiograms were evaluated by two angiographers for presence or absence of coronary artery disease (CAD, defined as one or more coronary artery stenoses of 50% or greater in diameter, and no CAD, defined as no stenosis of 25% or greater in diameter, respectively). Prevalence of CAD by age was determined, and associated risk factors were defined. RESULTS--Fifty-two of 110 patients had CAD. Coronary artery disease prevalence increased significantly with age; 13 of 16 patients older than 45 years of age had CAD. For patients 35 years of age or younger, associated risk factors included a family history of premature myocardial infarction, higher hemoglobin A1c level, hypertension for more than 5 years, lower high-density lipoprotein level, and smoking for more than 5 pack-years. For patients between 35 and 45 years of age, associated risk factors included number of years of diabetes, higher hemoglobin A1c levels, and smoking more than 5 pack-years. CONCLUSIONS--In type I-diabetic patients with nephropathy, CAD prevalence increased significantly with age and was found in the majority of patients older than 45 years of age. Coronary artery disease risk factors operative in the general population were significantly associated with CAD in this high-risk group. In addition, a role for hyperglycemia in accelerated atherogenesis was supported by the association of both higher hemoglobin A1c levels and number of years of diabetes with CAD.

Adult↗
PubMed1990

Contrast nephropathy in azotemic diabetic patients undergoing coronary angiography.

PURPOSE: To evaluate the incidence of, risk factors for, and outcome of contrast nephropathy in azotemic diabetic patients undergoing coronary angiography. PATIENTS AND METHODS: Fifty-nine insulin-dependent diabetics with a mean serum creatinine level of 522 mumol/L (5.9 mg/dL) underwent coronary angiography as part of a pretransplant evaluation. Twenty-four azotemic diabetics undergoing inpatient evaluation not including angiography for transplantation formed the control group. Serum creatinine measurements obtained at baseline and after radiocontrast exposure were compared in patients and control subjects. Risk factors for contrast nephropathy were evaluated in patients with a 25% or greater increase in serum creatinine. RESULTS: Serum creatinine was significantly elevated 24 hours after radiocontrast exposure in patients (557 +/- 141 mumol/L versus 522 +/- 141 mumol/L, mean +/- SD; p less than 0.001) but not in controls. Seven patients required dialysis within 6 days of coronary angiography and two additional patients required dialysis within 14 days. Contrast nephropathy, defined as a serum creatinine increase of greater than 25% when measured 48 hours after radiocontrast exposure, occurred in 50% of patients and no controls. Univariate analysis of risk factors for contrast nephropathy revealed a significant association with dye quantity (p = 0.002), mean arterial pressure less than 100 mm Hg (p = 0.02), and ejection fraction less than 50% (p = 0.04). Stepwise logistic regression verified the independence of dye quantity and low mean arterial pressure but not low ejection fraction as risk factors for contrast nephropathy. Follow-up serum creatinine values were not significantly different in patients and control subjects. CONCLUSIONS: Azotemic patients with diabetes are at high risk of developing contrast nephropathy even when less than 100 mL of radiocontrast agent is used. The acute renal failure is reversible but precipitates the need for short-term dialysis in some patients. Radiocontrast quantity is an important risk factor not previously noted. The incidence of contrast nephropathy can be minimized by using less than 30 mL of radiocontrast agent.

Acute Kidney Injury↗
PubMed1989

Genetic variation and microevolution of dengue 2 virus in Southeast Asia.

Dengue 2 (DEN 2) virus strains collected from dengue hemorrhagic fever (DHF) patients and Aedes aegypti mosquitoes in Thailand, Burma, and Vietnam over a 25-year period have been analyzed by computer assisted T1-RNase-resistant oligonucleotide fingerprinting. Fifty-seven DEN 2 virus strains of the Thailand topotype were separated into four major clusters by phylogenetic analysis of 97 unique oligonucleotides identified in a common well-resolved region of the fingerprints. Similarities in the 57 fingerprints indicated that DEN 2 virus of a single, continually evolving genetic population has been involved in endemic transmission of the disease. Virus isolates from DHF cases and mosquitoes are genetically very similar, indicating that different genetic topotypes are not selectively the cause of severe DEN disease in Thailand. Microevolution of the DEN 2 virus genome from 1962-1986 was gradual with detectable changes in the pattern of oligonucleotides through time. Segregation of the DEN 2 virus fingerprints into the three decades (1960s, 1970s, and 1980s) revealed the rate of genetic change to be one consensus oligonucleotide per year. Based on average association coefficient (Sab) values between the consensus fingerprints for each decade, the similarity between the consensus fingerprints decreased by 1.4% per year. Genetic variation during each of the three decades was found to be essentially the same (0.866 +/- 0.053). Constancy in the microevolutionary rate and genetic variability suggests that a balance of genetic drift and natural selection acting on the viral population did not significantly change throughout the 25-year period.

Aedes↗
PubMed1987

Nonuniformity of nucleotide substitution rates in molecular evolution: computer simulation and analysis of 5S ribosomal RNA sequences.

The effects of temporal (among different branches of a phylogeny) and spatial (among different nucleotide sites within a gene) nonuniformities of nucleotide substitution rates on the construction of phylogenetic trees from nucleotide sequences are addressed. Spatial nonuniformity may be estimated by using Shannon's (1948) entropy formula to measure the Relative Nucleotide Variability (RNV) at each nucleotide site in an aligned set of sequences; this is demonstrated by a comparative analysis of 5S rRNAs. New methods of constructing phylogenetic trees are proposed that augment the Unweighted Pair-Group Using Arithmetic Averages (UPGMA) algorithm by estimating and compensating for both spatial and temporal nonuniformity in substitution rates. These methods are evaluated by computer simulations of 5S rRNA evolution that include both kinds of nonuniformities. It was found that the proposed Reference Ratio Method improved both the ability to reconstruct the correct topology of a tree and also the estimation of branch lengths as compared to UPGMA. A previous method (Farris et al. 1970; Klotz et al. 1979; Li 1981) was found to be less successful in reconstructing topologies when there is high probability of multiple mutations at some sites. Phylogenetic analyses of 5S rRNA sequences support the endosymbiotic origins of both chloroplasts and mitochondria, even though the latter exhibit an accelerated rate of nucleotide substitution. Phylogenetic trees also reveal an adaptive radiation within the eubacteria and another within the eukaryotes for the origins of most major phyla within each group during the Precambrian era.

Animals↗
PubMed1983

Esophageal candidiasis: treatment with ketoconazole.

Three patients with esophageal candidiasis were treated with a new orally administered antifungal agent, ketoconazole. Favorable results were obtained in two patients; in the remaining patient other foci of candidal infection developed while the patient was receiving ketoconazole.

Administration, Oral↗