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Biomedical subjects

Jeffrey S Berns

Publications and source records attributed to Jeffrey S Berns.

At least 19 recordsLinked to original sources
PubMed2006

Spontaneous tumor lysis syndrome in acute myeloid leukemia: two cases and a review of the literature.

Spontaneous tumor lysis syndrome (TLS) is a constellation of electrolyte abnormalities and acute renal failure, which occurs in the setting of rapid cell turnover prior to the administration of cytotoxic chemotherapy. While spontaneous TLS is well described in patients with Burkitt's lymphoma, it is thought to occur less commonly in other hematologic malignancies. We present two cases of spontaneous TLS in patients with newly diagnosed acute myeloid leukemia (AML) followed by a review of the literature in this field.

Aged↗
PubMed2005

Variants in the Wilms' tumor gene are associated with focal segmental glomerulosclerosis in the African American population.

Wilms' tumor gene (WT1) is important for nephrogenesis and gonadal growth. WT1 mutations cause Denys-Drash and Frasier syndromes, which are characterized by glomerular scarring. To test whether genetic variations in WT1 and WIT1 (gene immediately 5' to WT1) associate with focal segmental glomerulosclerosis (FSGS), patients with biopsy-proven idiopathic and HIV-1-associated FSGS were enrolled in a multicenter study. We genotyped SNP rs6508 located in WIT1 exon 1, three SNPs (rs2301250, rs2301252, rs2301254) in the promoter shared by WT1 and WIT1, rs2234590 in exon 6, rs2234591 in intron 6, rs16754 in exon 7, and rs1799937 in intron 9 of WT1. Cases (n = 218) and controls (n = 281) were compared in the African American population. Stratification by HIV-1 infection status showed that SNPs rs6508, rs2301254, and rs1799937 were significantly associated with FSGS [rs6508 odds ratio (OR) 1.82, P = 0.006; rs2301254 OR 1.65, P = 0.049; rs1799937 OR 1.91, P = 0.005] in the non-HIV-1 group and rs2234591 (OR 0.234, P = 0.011) in the HIV-1 group. Haplotype analyses in the population revealed that seven SNPs were associated with FSGS; five SNPs had the highest contingency score [-log10(P value) = 13.57] in the HIV-1 group. This association could not be explained by population substructure. We conclude that SNPs in WT1 and WIT1 genes are significantly associated with FSGS, suggesting that variants in these genes may mediate pathogenesis by altering WT1 function. Furthermore, HIV-1 infection status interacts with genetic variations in both genes to influence this phenotype. We speculate that nephropathy liability alleles in WT1 pathway genes cause podocyte dysfunction and glomerular scarring.

Black or African American↗
PubMed2005

Single-center experience with the Arrow-Trerotola Percutaneous Thrombectomy Device in the management of thrombosed native dialysis fistulas.

PURPOSE: The present study sought to evaluate the performance of the Arrow-Trerotola Percutaneous Thrombolytic Device (PTD) in the treatment of native fistula thrombosis in a U. S. hemodialysis population. Specifically, the technical success, clinical success, complication rate and type, primary and secondary patency rates, effect of adjunctive thrombolytic therapy, and any variables that affected outcomes of procedures in which this device was used were analyzed. MATERIALS AND METHODS: Forty-two patients with 44 thrombosed native fistulas (17 radiocephalic, 10 brachiocephalic, 10 transposed or superficialized, five graft/fistula hybrids, and two leg fistulas) were treated with 62 mechanical thrombolysis procedures with use of the PTD. All patients had large clot burden. The device type was recorded in 43 procedures: standard (n = 21), over-the-wire (OTW; n = 19), or both (n = 3). No device was used in two cases because of inability to cross the anastomosis. Adjunctive therapies (n = 18) included the use of tissue plasminogen activator (tPA; n = 16) and deployment of the AngioJet device with (n = 1) or without tPA (n = 1). Stents were inserted in four procedures. Outcome variables included technical and clinical success, complications, and primary and secondary patency. Cox proportional-hazards regression and Kaplan-Meier analyses were performed. RESULTS: The technical success rate was 87% (54 of 62) and the clinical success rate was 79% (49 of 62). Percutaneous transluminal angioplasty was performed in all but two procedures. Complications occurred in 13% of procedures (n = 8); three resulted in technical failure. The primary patency rates were 38% at 6 months and 18% at 12 months; secondary patency rates were 74% and 69%, respectively. Outcomes were not affected by adjunctive techniques, fistula type, age of fistula, device type (ie, OTW vs standard), or patient sex. Secondary patency was superior when no residual clot or stenosis was present (P = .003). CONCLUSIONS: The PTD is effective for percutaneous treatment of thrombosed hemodialysis fistulas, with good short- and long-term outcomes in a U.S. population. Within the limitations of a retrospective study with a small sample size, use of an adjunctive thrombolytic agent did not appear to improve results compared with the use of the device alone.

Adult↗
PubMed2005

Pharmacologic adjuvants to epoetin in the treatment of anemia in patients on hemodialysis.

Anemia is a common complication of chronic kidney disease, particularly in patients who are on dialysis. The use of recombinant human erythropoietin has led to the eradication of severe anemia in the dialysis population. Correction of anemia in these patients has been associated with better quality of life and clinical outcomes. Some hemodialysis patients have anemia that either is relatively refractory to epoetin therapy or requires very high doses of epoetin (i.e., hyporesponsiveness), despite having adequate iron stores, and are thus unable to achieve or maintain target hemoglobin levels. Several pharmacologic agents have been studied for effects on improving response to epoetin, either to counter hyporesponsiveness or simply to reduce epoetin use for purely economic reasons. This review examines the available literature regarding the efficacy of these potential pharmacologic adjuvants to epoetin in the treatment of anemia in patients on maintenance hemodialysis, with special emphasis on androgens, vitamin C (ascorbic acid), and L-carnitine. A review of published guidelines and recommendations for use of these agents in hemodialysis patients is provided.

Adjuvants, Pharmaceutic↗
PubMed2005

The effect of a change in epoetin alfa reimbursement policy on anemia outcomes in hemodialysis patients.

In 1997, the Health Care Financing Administration Hematocrit Measurement Audit (HMA) program initiated use of a 3-month rolling average hematocrit (Hct) level for reimbursement of epoetin claims in hemodialysis patients, with denial of payment when this value exceeded 36.5%. This study evaluated the impact of the HMA program on anemia-related outcomes in hemodialysis patients. An observational, retrospective study of 987 hemodialysis patients from 11 dialysis centers in the United States was performed, collecting data between October 1996 and December 1997. Centers were selected from a pool of nearly all facilities in the United States, which during May 1997 satisfied one of two criteria: greater than 75% of patients at the facility had mean Hct level of > or =33% (Group A) or fewer than 50% of patients at the facility had mean Hct level of > or =33% (Group B). Each facility maintained its own anemia management practices without specific anemia management interventions as part of this study. Hct level, hemoglobin (Hb) level, and epoetin dose were analyzed to compare the pre-HMA period (October 1996 to May 1997) to the HMA period (June to December 1997) and/or for each of the five quarters of the study period. The primary study endpoint was the percentage of patients with Hct levels of > or =33% during each study quarter. The mean Hct level at baseline was 34% in Group A and 33.4% in Group B (p = 0.01). Hct levels, which were increasing before implementation of the HMA program, decreased during the HMA period (p < 0.001 and p = 0.013 in Groups A and B, respectively). The percentage of patients in Groups A and B with mean quarterly Hct levels of > or =33% decreased during the last quarter of the HMA implementation period compared to the quarter immediately preceding the start of the HMA program (p < 0.001 for both comparisons). Changes in Hb levels were similar to those seen in Hct levels. The mean epoetin dose administered decreased from 13,090 U/week at the start of the study to 11,884 U/week immediately before the HMA program took effect (p < 0.05). The HMA program adversely affected anemia treatment outcomes, regardless of whether dialysis units before HMA implementation had <50% of patients with a Hct level of > or =33% or had >75% of patients with a Hct level of > or =33%. The decline in mean weekly dose of epoetin was likely a result of withholding doses out of concern among providers about risk of reimbursement denial.

Adult↗
PubMed2005

Hemoglobin cycling in hemodialysis patients treated with recombinant human erythropoietin.

BACKGROUND: Treatment with recombinant human erythropoietin (rHuEPO) has been a major advance for the management of anemia in patients on hemodialysis. Therapy, however, is often observed to be associated with recurrent cyclic fluctuations in hemoglobin levels. The purpose of this analysis was to describe the phenomenology of hemoglobin cycling during rHuEPO treatment. METHODS: Data were analyzed for 281 hemodialysis patients treated at Winthrop-University Hospital Dialysis Centers between 1998 and 2003. Eligible patients' first full 1-year period with less than 10 hospital days was studied. Hemoglobin cycling (cycles with amplitude >1.5 g/dL and duration >8 weeks) and excursions (half of one full cycle) were analyzed. RESULTS: Greater than 90% of patients experienced hemoglobin cycling. The mean number of hemoglobin excursions was 3.1 +/- 1.1 per patient/year. The mean amplitude per hemoglobin excursion was 2.51 +/- 0.89 g/dL. The mean duration of hemoglobin excursions was 10.3 +/- 5.1 weeks. Factors associated with initiation of up excursions included increases in rHuEPO dose (84%), intravenous iron treatment initiation or increase in dose (27%), posthospital discharge (36%), factors associated with down excursions included rHuEPO dose hold (15%) or dose reduction (62%), infection (6%), discontinuation of intravenous iron therapy (5%), and hospitalization (14%). Patients with frequent hemoglobin cycling (>two full cycles per year) were characterized as being more responsive to rHuEPO [index of EPO responsiveness (ERI) 1036 +/- 659 compared to 1992 +/- 701 for other patients] (P = 0.02). CONCLUSION: Hemoglobin cycling is a common occurrence in rHuEPO-treated hemodialysis patients. It is most closely associated with frequent rHuEPO dose changes, hospitalization, and iron treatment practices.

Aged↗
PubMed2005

Anemia and mortality in hemodialysis patients: accounting for morbidity and treatment variables updated over time.

BACKGROUND: The objective of this study was to gain insight into the associations of anemia with mortality among maintenance hemodialysis (HD) patients and patient subgroups by an analysis that more comprehensively represents hemoglobin (Hb) level, morbidity, and treatment characteristics over time than was possible in prior observational studies. METHODS: A cohort study was conducted among 5517 subjects in the American arm of the Dialysis Outcomes and Practice Patterns Study Phase I. We used proportional hazard analysis to model all-cause mortality as a function of Hb level measured 1, 3, and 6 months previously. Forty-five potentially confounding patient-level characteristics were considered, including demographics, comorbidities, and time-updated levels of erythropoietin and parenteral iron dosing, medical events, and laboratory and dialysis measures. RESULTS: Compared to Hb 11 to <12 g/dL, subjects with Hb <11 g/dL had increased mortality [adjusted hazard ratios (95% confidence interval) in the 3-month-lagged model = 1.74 (1.24 to 2.43) for <9 g/dL, 1.25 (0.96 to 1.63) for 9 to <10 g/dL, and 1.22 (0.99 to 1.49) for 10 to <11 g/dL categories]. Mortality rates for subjects with Hb 12 to <13 g/dL and > or = 13 g/dL did not differ significantly from those with Hb 11 to <12 g/dL. The relationships between Hb and mortality varied modestly with changes in the time interval between Hb measurement and the time at risk for mortality, but did not vary according to ESRD vintage or health status indicators. CONCLUSION: Our findings confirm the associations of Hb levels > or =11 g/dL with longer survival among maintenance HD patients, but show no additional survival advantage for patients with Hb levels > or =12 g/dL. Further investigation of the relationships among anemia, treatment of anemia, and survival is warranted.

Adolescent↗
PubMed2004

Willingness of patients to switch from conventional to daily hemodialysis: looking before we leap.

PURPOSE: To evaluate the willingness of patients with end-stage renal disease to switch from conventional hemodialysis to short daily hemodialysis, and to determine what health benefits clinical trials of daily hemodialysis would have to document for patients to switch regimens. METHODS: We studied all patients receiving conventional hemodialysis (defined as three times per week) at three dialysis centers in Philadelphia during a 4-month period. Patients indicated their willingness to switch to daily hemodialysis (defined as six 2- to 3-hour in-center treatments per week) in each of 21 scenarios presented via an interactive computer display. We used conjoint analysis to determine how patients' decisions were influenced by four attributes of daily hemodialysis: predicted life expectancy, quality of life, number of annual hospitalizations, and weekly transportation time to and from the dialysis center. RESULTS: Of 126 patients interviewed, 55 (44%) would not choose daily hemodialysis regardless of its health benefits. The remaining 71 patients (56%) indicated that they would consider switching if daily hemodialysis was shown to yield certain health benefits. Patients were more willing to switch to daily hemodialysis as the associated life expectancy and average quality of life increased, and as the number of annual hospitalizations and weekly transportation time decreased (all P <0.001). CONCLUSION: Although daily hemodialysis has received broad support from nephrologists, funding agencies, and lawmakers as the emerging standard of care for patients with end-stage renal disease, upcoming clinical trials would have to document substantial health benefits in order for patients to switch to daily hemodialysis, and many patients may still decline this regimen regardless of the documented benefits.

Adult↗
PubMed2004

Predictors of amputation and survival following lower extremity revascularization in hemodialysis patients.

BACKGROUND: Peripheral vascular disease (PVD) has become increasingly common in end-stage renal disease (ESRD) patients, leading to an increase in the rate of revascularization and amputation. We studied the prognosis of ESRD patients undergoing their first revascularization procedure. METHODS: We conducted a longitudinal cohort study of hemodialysis patients enrolled in special studies of the United States Renal Data System. Cox proportional hazards analysis was used to assess the independent effect of type of initial revascularization procedure on lower extremity amputation and all-cause, cardiac, and infectious mortality over 3 years, after adjustment for sociodemographic, clinical, and biologic baseline characteristics. RESULTS: Eight hundred patients underwent an initial revascularization procedure by surgical bypass or angioplasty. The overall incidence of subsequent amputation was 16.3/100 person-years, 22.6 for bypass, and 5.7 for angioplasty. After adjustment for patient characteristics, the risk of amputation was higher for bypass versus angioplasty [relative hazard (RH) 4.00; 95% CI 2.46 to 6.57], for black versus white patients (RH 1.49; 95% CI 1.04 to 2.15), for uninsured or patients on Medicaid versus patients with private insurance or on Medicare (RH 1.65; 95% CI 1.12 to 2.72), and for patients with diabetes versus no diabetes (RH 2.51; 95% CI 1.67 to 3.76). Compared with patients who underwent angioplasty, the risk of all-cause (RH 1.37; 95% CI 1.10 to 1.70), cardiac (RH 1.50; 95% CI 1.08 to 2.09), and infectious (RH 2.17; 95% CI 1.10 to 4.29) mortality was greater among patients who underwent bypass. CONCLUSION: Risk of amputation following revascularization procedures was positively associated with type of procedure, black race, uninsured/Medicaid, and diabetes status. Risk of death was also higher following bypass. While this might reflect underlying severity of disease, patient education, screening, and optimal care of lower extremities should be emphasized to detect PVD at an early stage of the disease process.

Adult↗
PubMed2004

Willingness of dialysis patients to participate in a randomized controlled trial of daily dialysis.

BACKGROUND: The National Institutes of Health (NIH) has proposed conducting randomized controlled trials comparing short, daily, in-center hemodialysis with conventional hemodialysis. However, there is concern that difficulties recruiting patients may prevent the successful completion of such trials if patients believe the inconveniences of daily dialysis outweigh any potential health benefits. METHODS: To gauge willingness to participate in a daily dialysis trial, we described a hypothetical, randomized controlled trial comparing conventional to daily hemodialysis to 209 chronic hemodialysis patients, and assessed their motivations for and concerns about participating. RESULTS: We found that 85 patients (41%) of 209 patients who agreed to be interviewed expressed some willingness to participate in the hypothetical trial. Patients who expressed greater willingness to participate were younger (OR for participating = 0.96 per year, 95% CI = 0.94 to 0.98, P= 0.001), less likely to smoke (OR = 0.38, 95% CI = 0.17 to 0.84, P= 0.017), more likely to have been hospitalized during the last 12 months (OR = 2.8, 95% CI = 1.5 to 5.5, P= 0.002), less likely to have reactive airway disease (OR = 0.21, 95% CI = 0.06 to 0.69, P= 0.01) or coronary artery disease (OR = 0.20, 95% CI = 0.08 to 0.53, P= 0.001), and less likely to be on the waiting list for a kidney transplant (OR = 0.23, 95% CI = 0.10 to 0.50, P < 0.0001). CONCLUSION: The study suggests that less than half of eligible patients would be willing to participate in the randomized controlled trial. Differing willingness to participate across patient subgroups suggests that certain subgroups (i.e., older patients and those with coronary artery disease) will need to be targeted to ensure that results are generalizable to most hemodialysis patients.

Adult↗
PubMed2003

Clinical evaluation of heme iron polypeptide: sustaining a response to rHuEPO in hemodialysis patients.

BACKGROUND: Optimizing iron and recombinant human erythropoietin (rHuEPO) therapy is necessary to achieve target hemoglobin levels and minimize costs as the end-stage renal disease (ESRD) population expands. Oral iron products in patients with ESRD have been largely abandoned, and the safety of intravenous (IV) iron preparations has improved with the introduction of new-generation compounds that have little allergenicity. Recent work suggests oral heme iron may be an effective supplement for hemodialysis (HD) patients because it is absorbed by patients with high ferritin levels, has fewer side effects, and its absorption is stimulated by erythropoietin administration. METHODS: We performed an open, 6-month, prospective evaluation of heme iron in HD patients who had been on maintenance IV iron therapy. IV iron was discontinued and replaced with oral heme iron. Serum iron level, hematocrit (Hct), and erythropoietin and IV iron dose were monitored. RESULTS: During 6 months, 4 of 37 patients (11%) dropped out because of insufficient iron supplementation or intolerance and 5 patients (14%) were dropped because of unrelated complications or protocol violation. A slight reduction in average transferrin saturation (TSAT) was seen early, but reversed, and no significant changes were seen in TSAT or Hct. A significant reduction in average serum ferritin level was seen at months 4 through 6 (P < 0.01). CONCLUSION: During the 6-month study period, heme iron polypeptide successfully replaced IV iron therapy in a majority of HD patients and maintained target Hcts with no concomitant use of IV iron. This treatment was associated with a significant increase in rHuEPO efficiency (P = 0.04).

Administration, Oral↗
PubMed2003

Hemoglobin variability in epoetin-treated hemodialysis patients.

BACKGROUND: Understanding the clinical variability of hemoglobin measurements in epoetin-treated hemodialysis patients is important, particularly when this therapy is aimed at maintaining patient hemoglobin levels within a narrow range, such as the 11 to 12 g/dL range recommended in National Kidney Foundation Kidney Dialysis Outcomes Quality Initiative (NKF-K/DOQI) guidelines. This study examines hemoglobin variability under conditions of standard clinical practice in epoetin-treated hemodialysis patients. METHODS: We studied 987 hemodialysis patients participating in an observational retrospective study that evaluated anemia management practices from October 1, 1996 to December 31, 1997 at 11 United States dialysis centers that were randomly selected from a pool of nearly all United States dialysis facilities. Each participating facility maintained its own anemia management protocols without specific anemia management recommendations or interventions made as part of this study. Hemoglobin variability was determined by calculating the 1-month and 2- to 6-month rolling average hemoglobin for each patient. The range of mean hemoglobin values that included the middle 50% (25th to 75th percentile), 80% (10th to 90th percentile), and 90% (5th to 95th percentile) of values were determined. The hemoglobin ranges that included 1 standard deviation (SD) (67%) of the study values and 2 SD (95%) of the study values for each time period were calculated. RESULTS: The mean hemoglobin was between 10.9 and 11.2 g/dL throughout the study. The hemoglobin range encompassing 50%, 80%, and 90% of values from a single month was 1.7, 3.3, and 4.4 g/dL, respectively. A progressive narrowing in the range of hemoglobin values encompassed by each percentile grouping (i.e., hemoglobin variability) was observed as longer rolling intervals were averaged. The hemoglobin range within the 25th to 75th percentile was 1.7 g/dL using single-month hemoglobin values and 1.1 g/dL using a 6-month rolling average. The range of hemoglobin values that encompassed 90% of patients was 4.4 g/dL using single-month values, 3.7 g/dL using 3-month rolling averages, and 3.2 g/dL using 6-month rolling averages. Fewer than 50% of patients had hemoglobin values within the 1.0 g/dL NKF-K/DOQI recommended range, even when a 6-month rolling average was applied. When hemoglobin values were measured for 1 month, 1 SD was 1.4 g/dL; for the 3-month rolling average, 1 SD was 1.1 g/dL; and for the 4-, 5-, and 6-month rolling averages, 1 SD was 1.0 g/dL. Greater hemoglobin variability correlated with higher mean corpuscular hemoglobin (P = 0.003) and serum ferritin (P = 0.047), and inversely correlated with age (P = 0.006) and serum albumin (P = 0.0001). CONCLUSION: Substantial variability occurs in hemoglobin values in epoetin-treated hemodialysis patients. The NKF-K/DOQI recommended hemoglobin range appears to be too narrow in clinical practice. Expanding the target range and use of rolling average hemoglobin intervals of 3 to 6 months as a clinical and quality assurance measure avoids clinical variability inherent with the use of isolated hemoglobin values or single-month hemoglobin averages.

Aged↗
PubMed2002

Preventing bacterial infections and antimicrobial resistance in dialysis patients.

Antimicrobial use, in concert with patient-to-patient transmission of resistant strains, has caused a rapid increase in the prevalence of antimicrobial resistance in recent years. This increase is a particular threat to dialysis patients, who often have been in the forefront of the epidemic of resistance. In this report, which was written in collaboration between the American Society of Nephrology and the Centers for Disease Control and Prevention and has been endorsed by the Executive Council of the Infectious Diseases Society of America, we review and summarize existing clinical practice guidelines and recommendations concerning the prevention, diagnosis, and treatment of certain bacterial infections in dialysis patients and present four strategies to limit the spread of antimicrobial resistance in dialysis patients. First, preventing infection eliminates the need for antimicrobials, thereby reducing selection pressure for resistant strains. Efforts to prevent infection include avoidance of hemodialysis catheters, when possible, and meticulous care of hemodialysis and peritoneal catheters and other hemodialysis vascular access sites. Second, diagnosing and treating infections appropriately can facilitate the use of narrower spectrum agents, rapidly decrease the number of infecting organisms, and reduce the probability of resistance emerging. This entails the collection of indicated specimens for culture and avoidance of contamination of cultures with common skin microorganisms. Third, optimizing antimicrobial use helps protect the efficacy of such critical agents as vancomycin. Published guidelines for the use of vancomycin should be followed, and alternate agents should be used when infections with beta-lactam-resistant bacteria are unlikely or not documented. Fourth, preventing transmission in health care settings is important to limit the spread of resistant organisms. In this regard, such basic measures as glove use and hand hygiene are most important.

Drug Resistance, Bacterial↗
PubMedDate not supplied

Infection with antimicrobial-resistant microorganisms in dialysis patients.

The prevalence of antimicrobial-resistant microorganisms in various health care settings, including outpatient dialysis facilities, has increased dramatically in the last decade. Antimicrobial use and patient-to-patient transmission of resistant strains are the two main factors that have contributed to this rapid increase. Methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci are commonly isolated as a cause of hemodialysis (HD) catheter-related bacteremia and peritoneal dialysis (PD)-related catheter infection and peritonitis. The widespread use of vancomycin in dialysis patients is of concern because of an increase in the prevalence of vancomycin-resistant enterococci (VRE) in dialysis patients. Staphylococci with reduced sensitivity to vancomycin have also appeared in dialysis patients. A more recent problem is the appearance of S. aureus isolates with a high degree of resistance to the topical antimicrobial agent mupirocin. This has been seen in PD patients who have received prophylactic application of mupirocin at the peritoneal catheter exit site. Appropriate antimicrobial use will help protect the efficacy of currently used antibiotics, such as vancomycin. Published guidelines for use of vancomycin should be followed. New antimicrobials such as linezolid and quinupristin/dalfopristin have activity against VRE and MRSA, but resistance to these agents has already occurred. Preventing transmission of antimicrobial-resistant microorganisms in health care settings, including outpatient dialysis facilities, is important in limiting the spread of these resistant organisms.

Anti-Bacterial Agents↗
PubMedDate not supplied

Complications of percutaneous treatment of thrombosed hemodialysis access grafts.

Percutaneous catheter-based thrombolysis is commonly used in association with angioplasty to treat thrombosed hemodialysis arteriovenous grafts. Although major complications of these percutaneous procedures are relatively uncommon, they can result in several potentially serious complications, including pulmonary embolism, cerebral embolism, arterial embolism, bleeding with perigraft hematoma or hemorrhage, and vein rupture. This article reviews the epidemiology, clinical significance, and management of these complications.

Arteriovenous Shunt, Surgical↗
PubMedDate not supplied

Use of insulin and oral hypoglycemic medications in patients with diabetes mellitus and advanced kidney disease.

Diabetes mellitus is recognized as a leading cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) in the United States. There is a vast array of medications used to treat diabetes, including insulin and the sulfonylureas, as well as newer classes of drugs such as the thiazolidinediones and biguanides. In patients with reduced glomerular filtration rate (GFR), it is necessary to decrease the dosage of some of these drugs, while others are best avoided altogether. Accumulation of either the parent compound or its metabolites can result in symptomatic hypoglycemia, or in the case of metformin, significant lactic acidosis. In this article we will review the use of insulin and the various classes of oral medications used to treat type 2 diabetes mellitus, focusing on their pharmacokinetic properties and dosing in patients with advanced kidney disease.

Administration, Oral↗
PubMedDate not supplied

Use of low molecular weight heparins and glycoprotein IIb/IIIa inhibitors in patients with chronic kidney disease.

Despite aggressive intervention, cardiac causes of death, including acute coronary syndrome (ACS), continue to be a major source of mortality in patients with chronic kidney disease (CKD), including end-stage renal disease (ESRD). Multiple large prospective trials have demonstrated the clinical benefits of both low molecular weight heparin (LMWH) and glycoprotein (Gp) IIb/IIIa inhibitors in treating patients with ACS. Unfortunately patients with significant impairment of kidney function have generally been excluded from these major clinical trials. Consequently relatively little is known about the pharmacokinetics, appropriate dosing, efficacy, and safety of these medications in patients with CKD of various stages. This article examines the available literature regarding the pharmacokinetics, dosing, efficacy, and safety of LMWH and Gp IIb/IIIa inhibitors in patients with CKD.

Aged↗