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Biomedical subjects

J C Fink

Publications and source records attributed to J C Fink.

27 records · Page 2Linked to original sources
PubMed1998

Colonization with vancomycin-resistant enterococci in chronic hemodialysis patients.

Vancomycin-resistant enterococcus (VRE) has been identified with increased frequency in dialysis populations, but the risk factors for VRE colonization are not well defined in hemodialysis patients. Patients from a university-affiliated outpatient dialysis center had surveillance stool or rectal cultures for VRE during April 1994 and January 1996. The combined cohort of 168 patients was followed-up for all-cause mortality, subsequent hospitalization, and VRE infection. Demographic and risk factor information, including age, gender, race, diabetes, coronary artery disease (CAD), and human immunodeficiency virus (HIV) infection, were collected on all patients. Sixteen patients had surveillance cultures grow vancomycin-resistant Enterococcus faecium or E faecalis (VREF), and nine additional patients had clinical cultures positive for VREF. The median follow-up time for patients with positive surveillance or clinical cultures for VREF was 421 days versus 423 days for those without VREF. Patients with positive surveillance cultures for VREF had less time on hemodialysis before screening (median = 207 days v 822 days; P < 0.01), and more hospitalization in the year before screening (median = 19 days v 3 days, P < 0.01) compared with those without VREF. Patients with VREF colonization were more likely to develop infection with VREF (25% v 1%, P < 0.01) than those without VREF colonization. However, adjusting for age, diabetes, coronary artery disease, and acquired immune deficiency syndrome (AIDS) using Cox-proportional hazards models, the presence of VREF on screening culture was not associated with increased risk of death (RR = 1.1, P = 0.86). Thus after adjusting for other comorbidities, VREF colonization was not associated with increased mortality. Patients with end-stage renal disease (ESRD) on hemodialysis who are hospitalized are more likely to have VREF, but longer duration on hemodialysis was not associated with presence of this organism. This suggests that VRE transmission occurs predominantly in the inpatient setting.

Adult↗
PubMed1997

A novel approach to the treatment of chronic allograft nephropathy.

BACKGROUND: Progressive deterioration of renal function in kidney transplant recipients is the leading cause of graft failure. Both nonimmunologic and immunologic mechanisms contribute to this deterioration. METHODS: Twenty-eight cyclosporine (CsA)-treated renal transplant recipients (21 cadaveric, 5 living, 2 simultaneous kidney-pancreas) with progressive deterioration of renal function were prospectively enrolled in a clinical trial and had their immunosuppressive regimen changed 24.3+/-7.7 months after transplant. All patients had their CsA dose reduced by 50%, azathioprine was discontinued, and mycophenolate mofetil was added to the medical regimen. The mean creatinine of the patients at the initiation of the change in immunosuppression was 3.5+/-1.2 mg/dl (range 1.9 to 6.2 mg/dl). RESULTS: Before the change in immunosuppression, the mean loss in renal function as indicated by the least-squares slope of the reciprocal of creatinine versus time was -0.006+/-0.002 (mg/dl)-1 per month. The change in immunosuppression significantly decreased the rate of loss in renal function for most patients when compared with their pretreatment values with a mean slope of 0.007+/-0.003 (mg/dl)-1 per month (P=0.003). Renal function improved in 21 of 28 patients. Only one patient had continued deterioration of renal function. In a multivariate analysis adjusting for CsA dose, mean arterial blood pressure, and baseline creatinine, the change in immunosuppression was significantly associated with improved renal function (P=0.02). There were no acute rejections after the immunosuppression change. CONCLUSIONS: We conclude that adding mycophenolate mofetil and reducing CsA in patients with chronic deterioration of graft function is well tolerated and results in a short-term improvement in renal function.

Adult↗
PubMed1995

Marked enzymuria after bone marrow transplantation: a correlate of veno-occlusive disease-induced "hepatorenal syndrome".

During the first month after bone marrow transplantation, approximately 15% of patients develop acute renal failure (ARF). This usually occurs in the setting of hepatic veno-occlusive disease (VOD). Prior clinical data have suggested that this form of ARF has a hemodynamic basis, analogous to the hepatorenal syndrome (HRS). If so, then proximal tubular injury would not be expected. To directly test this hypothesis, enzymuria (N-acetyl-beta-D-glucosaminidase [NAG]) was quantitated in the following groups of patients within the first 35 days after BMT: (1) VOD+ARF (serum creatinine level > 1.5 mg/dL; N = 10); (2) VOD with relatively normal renal function (serum creatinine level < 1.5 mg/dL; N = 11); and (3) patients without hepatic or renal complications (BMT controls; N = 12). For comparison, NAG was also quantitated in the following groups of non-BMT patients: (1) toxic/ischemic acute tubular necrosis (ATN) (N = 10); (2) jaundice without azotemia (N = 5); and (3) HRS (N = 6). Urine samples from eight healthy subjects established normal NAG concentrations (2.5 +/- 0.5 microU/mg urinary creatinine; mean +/- SE). All non-BMT patients with ATN had markedly elevated NAG levels (61 +/- 12; P < 0.001), validating the test as a marker of tubular damage. NAG concentrations were significantly elevated in all of the control BMT patients (24 +/- 3; P < 0.01), and the presence of VOD was associated with further striking increments (approximately 50 times normal). However, the degree of enzymuria was virtually identical for VOD patients with (125 +/- 27) and without (122 +/- 17) ARF. Jaundice in a non-BMT setting was associated with only mild NAG elevations (11 +/- 2). However, striking enzymuria was noted in all HRS patients (61 +/- 20), equaling the levels seen with ATN. The following conclusions were derived: (1) subclinical tubular injury, as defined by enzymuria, appears to be ubiquitous after BMT; (2) VOD dramatically increases the extent of enzymuria; (3) the degree of enzymuria in VOD patients is not correlated with renal dysfunction, implying that the associated ARF has a large hemodynamic component; and (4) HRS and ATN manifest comparable degrees of enzymuria, suggesting that substantial tubular damage exists in both of these forms of ARF.

Acetylglucosaminidase↗
PubMed1994

A decision aid for referring patients with systolic murmurs for echocardiography.

OBJECTIVE: To describe the practice pattern of a group of primary care providers in ordering echocardiography for healthy patients and to derive a decision aid to identify patients with systolic murmurs who have significant cardiac lesions. DESIGN: Retrospective case review of clinical variables, including the demographic, historical, and physical examination features obtained from chart review of the physician evaluation prior to referral for echocardiography and the echocardiographic results, with both univariate and multivariate regression analyses used to identify variables predictive of positive echocardiographic outcomes and to derive a regression model. SETTING: General internal medicine clinic in an urban major teaching hospital. PATIENTS/PARTICIPANTS: 169 patients between the ages of 18 and 55 years selected retrospectively from medical records. MEASUREMENTS AND MAIN RESULTS: Symptoms and auscultatory findings were not predictive of positive echocardiographic outcomes among the patients referred for the test. For the patients who had systolic murmurs, a logistic regression model had three significant predictors of positive echocardiographic results: additional year of age (odds ratio: 1.08, 95% CI: 1.02-1.13; p = 0.007); male gender (odds ratio: 5.87, 95% CI: 1.99-17.3; p = 0.002); and murmur grade > or = 3 (odds ratio: 4.99, 95% CI: 1.27-19.6; p = 0.02). The receiver-operating characteristic (ROC) curve area for this model was 0.741. If women aged 35 years and less with murmur grades < or = 2 had not been referred, 47% of the echocardiographies could have been avoided while retaining a sensitivity of 90%. CONCLUSIONS: The study suggested that healthy patients with systolic murmurs are least likely to have positive echocardiographic results when they are young and female and have murmur grades < or = 2. More careful screening of this group might make unnecessary almost half of the echocardiographies yielding negative results ordered for healthy patients with systolic murmurs.

Adolescent↗
PubMedDate not supplied

The inevitability of renal function loss in patients with hypercreatinemia.

UNLABELLED: Although it is anticipated that most patients with renal insufficiency will progress towards end-stage renal disease (ESRD) there have been few population-based studies to validate this assumption. We examined serial creatinines from 3,874 anonymous patients at an urban VA medical center who had a baseline creatinine of 1.4 mg/dl or greater to estimate the frequency of deterioration in renal function (DRF). DRF was defined as the first Cr (1stCr) value being lower than the last Cr (LCr) for each patient. The median follow-up was 48.3 +/- 0.5 months with 18 +/- 0.5 creatinine values per patient. The median 1stCr was 1.6 +/- 0.1 mg/dl with 32.2% of the patients having a 1stCr greater than or equal to 1.7 mg/dl. In the study group, 1,723 (44.4%) had DRF including 1,089 (41.4%) of those patients with a 1stCr of 1.4-1.7 mg/dl. However, 45 (36.6%) of those with a 1stCr value 3.0-5.0 mg/dl did not have DRF, the percent with stable creatinine in this group did not vary with length of follow-up. Over the study period, 299 (7.7%) of all the patients had a creatinine rise to 7.0 mg/dl, with 104 (4%) of those with a 1stCr of 1.4-1.7 mg/dl reaching this endpoint. CONCLUSION: A majority, but not all, patients with renal insufficiency lose renal function over time and those with even mild hypercreatinemia are at risk for deterioration in renal function. Hypercreatinemia, however, does not accurately discriminate between those renal insufficiency patients who are stable versus those at high risk for ESRD.

Analysis of Variance↗