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Biomedical subjects

M M Avram

Publications and source records attributed to M M Avram.

At least 37 records · Page 2Linked to original sources
PubMed1994

Pervasive failed rehabilitation in center-based maintenance hemodialysis patients.

At its inception in 1972, the end-stage renal disease (ESRD) program was conceived with a set of assumptions about cost, rate of growth, and treatment outcomes in its client population. Despite the potential to correct anemia with recombinant erythropoietin (EPO) introduced in 1987 and improved survival, the level of physical activity among some segments of the hemodialysis population remains suboptimal. This study was undertaken, among other reasons, to identify correlates of poor functional status as measured by a modified Karnofsky scale. Using a modified Karnofsky scale, we measured the functional status of 430 patients who had been treated by hemodialysis for at least 1 year and some of whom were also receiving concomitant treatment with EPO. Patients studied were randomly selected from eight dialysis units in urban New York and suburban New Jersey. A Karnofsky score of less than 70 indicated frank disability--the subject was unable to perform routine living chores without assistance. In addition, current vocational activity was ascertained, and comorbid conditions were quantified. The necessity for wheelchair dependence was noted for each patient. The mean age (+/- SD) of the study population was 56 +/- 14 years (range, 21 to 92 years). Subjects had been on maintenance hemodialysis for 4.09 +/- 3.8 years (range, 1 to 23 years). The study group included 215 men and 215 women, of whom 65% were black, 27% white, 6% Hispanic, and 2% Asian; 36.5% had diabetes mellitus. Although 376 members (87%) of the study group were under treatment with EPO, the mean hematocrit of the study population was only 29% +/- 4.5%.(ABSTRACT TRUNCATED AT 250 WORDS)

Activities of Daily Living↗
PubMed1994

Serum ferritin, hematocrit and mean corpuscular volume in hemodialysis.

Prior to beginning to administration erythropoietin (EPO) in 1989, we examined the relationships of hematocrit (HCT), mean corpuscular volume (MCV), and serum ferritin (FER) in one group of hemodialysis patients (group A, n = 117) and replicated the findings in a second group (group B, n = 73). The groups had similar mean (+/- SD) HCT (A: 25.7 +/- 5.3%; B: 25.2 +/- 5.1%), MCV (A: 83.3 +/- 6.5 fl; B: 83.5 +/- 7.5 fl) and FER (A: 607 +/- 1446 micrograms/l; B: 374 +/- 601 micrograms/l). For group A, iron stores [log (FER)] correlated inversely with HCT (r = -0.44, p < 10(-4)) and directly with MCV (r = 0.32, p < 10(-3)). After dividing group A into octiles by the FER level, the lowest octile (mean FER 17.8 +/- 6.2 micrograms/l) had the highest mean HCT (29.5 +/- 6.4%) and lowest mean MCV (80.8 +/- 7.1 fl), while the highest octile (mean FER 3,312 +/- 3,005 micrograms/l) had the lowest mean HCT (21.9 +/- 2.8%) and the second-highest mean MCV (86.4 +/- 4.9 fl). The trends were similar in group B. We conclude that increased erythropoiesis appeared to cause or, at least, unmask iron deficiency in HD patients even prior to the advent of EPO therapy. Variations in the level of erythropoiesis among these patients (presumably due to variation in EPO levels, chronic inflammation) strongly influenced the determinants of iron stores (i.e., marrow utilization of iron, transfusion need); iron stores, in turn, influenced MCV.

Adult↗
PubMed1993

Low-density lipoprotein immunofluorescence at the site of renal injury in glomerulosclerosis: a potential pathogenetic role for lipids in renal disease.

The role of lipids in the genesis of renal disease has received increased attention. We describe the presence of anti-low-density lipoprotein immunofluorescence at the site of renal injury found by light microscopy. This may offer immunohistologic evidence for a potential role of this atherogenic lipid in the genesis of renal disease and glomerulosclerosis. Furthermore, we describe the contribution of cholesterol in early renal disease and markers for malnutrition in the dialytic management of end-stage renal disease. Interventional strategies, including vasoactive agents present and future, are presented.

Glomerulosclerosis, Focal Segmental↗
PubMed1993

Prealbumin and lipoprotein(a) in hemodialysis: relationships with patient and vascular access survival.

The high morbidity and mortality of hemodialysis patients has led to a search for early markers of risk. Because cardiovascular and nutritional risk are prevalent in this population, we examined the prognostic value of the serum levels of two markers of risk in the general population: (1) lipoprotein(a) [Lp(a)], a low-density lipoprotein-like particle linked to myocardial infarction and coronary bypass stenosis, and (2) prealbumin, a marker of visceral protein status, with a shorter half-life than that of serum albumin. Baseline demographics, clinical information, dialysis prescription, and serum biochemistry measurements of 125 hemodialysis patients followed for up to 14 months were recorded on enrollment. Vascular access events and deaths were recorded prospectively. The hypotheses tested were that increased serum Lp(a) levels would predict cardiovascular mortality and vascular access stenosis and thrombosis, and that reduced serum prealbumin levels would predict mortality risk independently of established risk predictors. Cross-sectional analysis of serum Lp(a) demonstrated a skewed distribution with a median value of 38.3 mg/dL (upper tertile, > or = 57 mg/dL). Lipoprotein(a) was significantly higher in black patients (P < 0.001) and was significantly correlated (P < 0.005) with total cholesterol and apoprotein B (apoB), but not with a history of prior coronary disease. Serum prealbumin was strongly correlated with serum albumin (r = 0.49, P < 0.001). However, prealbumin correlated (P < 0.001) more strongly with other serum nutrition markers (total cholesterol, apoB, creatinine, urea) than did serum albumin. Fourteen-month cumulative survival was 80%. Age, diabetes, and serum levels of albumin, prealbumin, creatinine, total cholesterol and apoB, but not Lp(a), were correlated with survival in univariate analysis. Using the Cox proportional hazards model, independent predictors of mortality risk were prealbumin less than 15 mg/dL versus higher values (relative risk [RR] = 4.48, P < 0.01), apoB (RR = 0.97 per 1 mg/dL increase, P < 0.02), creatinine less than 10 mg/dL versus higher values (RR = 3.51, P = 0.04), and age (RR = 1.04 per year, P = 0.10). Thirty-eight patients experienced at least one vascular access thrombosis (n = 33) or stenosis (n = 5) during the study. Patients with Lp(a) > or = 57 mg/dL had decreased vascular access event-free survival compared with patients with Lp(a) less than 57 mg/dL (56% v 73%, P < 0.06). This trend was increased in magnitude and statistically significant for white and Hispanic patients (31% v 79%, P < 0.01).(ABSTRACT TRUNCATED AT 400 WORDS)

Aged↗
PubMed1993

Predictors of mortality in hemodialysis patients.

Serum biochemical measures suggestive of undernutrition have been reported to correlate with 1-yr mortality risk in prevalent groups of hemodialysis patients. The predictive power of these variables has not been reported in newly diagnosed patients or in patients whose dialysis prescription is guided by urea kinetics. The relationship of these predictors to mortality over periods of longer than 1 yr is also unreported. Therefore, the survival of 184 hemodialysis patients was examined for up to 44 months (1987 to 1991) with the Cox proportional hazards model. Baseline demographic, clinical, and biochemical parameters were used as independent variables. To adjust for bias in patient selection, the survival of patients with 12 months or less of prior dialysis at the time of enrollment ("new cases") was analyzed separately from that of patients with more than 1 yr of prior treatment ("long-standing cases"). Serum albumin was less than 3.5 g/dL in 31% of new cases and in 12% of long-standing cases. Adjusting for the other variables, low serum albumin was the strongest mortality risk predictor in both new and long-standing cases. Low serum cholesterol was an independent risk predictor in both groups. Diabetes and race were not significant predictors. Mean age at enrollment was nearly a decade higher for nonsurvivors than for survivors, in both new and long-standing groups. Yet, age was not an independent risk predictor in the Cox model for the new group because of an unexpectedly high death rate among young black men. Female gender, which was confounded by increased age, took the place of age in the model for the new group. For each model, there was good agreement between observed and predicted mortality for up to 24 months. To assess the influence of dialysis treatment time and dose (measured as pre-to-post treatment urea ratio) on risk, survival was examined in a subset of 139 patients monitored for up to 22 months, from 1989 to 1991, a period when the urea ratio was used routinely. Adjusting for the other variables, low serum albumin and cholesterol again independently increased risk. The urea ratio was also a significant independent predictor. The pattern of mortality by urea ratio was U shaped, with minimum risk for values between 2.5 and 3.4 Treatment time did not influence risk. It was concluded that baseline serum values of albumin and cholesterol strongly influence survival for up to 2 yr in new and long-standing hemodialysis patients.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1992

The uremic dyslipidemia: a cross-sectional and longitudinal study.

Patients on maintenance hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) exhibit numerous disturbances of serum lipids and apoproteins that may contribute to their high cardiovascular mortality. Cross-sectional studies have found that lipid levels are inversely related to time on dialysis. However, it is not known whether this association is the result of the attrition of hyperlipidemic patients or a decrease in lipid levels over time in all patients. Additionally, few studies have investigated the effect of dialysis modality on the lipoprotein disturbances of uremia adjusting for the confounding influences of demographics, or nutritional and endocrine status. To address these issues, we undertook a cross-sectional and longitudinal study of lipids, apoproteins, and atherogenic risk ratios in patients maintained on HD and CAPD. Patients were enrolled in annual cohorts from 1987 to 1990 and monitored until 1991. A total of 196 HD and 77 CAPD patients were studied. Total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), apoprotein (apo) A-I, and apo B were measured on enrollment and remeasured annually in survivors through 1990. Using multivariate methods, we examined the relationship of the lipids, apoproteins, their respective ratios, and their changes over time, to a broad range of clinical factors and to mortality. Compared with HD patients, CAPD patients had significantly higher TC, apo A-I, and apo B, and a significantly lower apo A-I/apo B ratio. Serum albumin correlated directly with TC and apo B and inversely with apo A-I/apo B. For patients with normal serum albumin (> or = 3.5 g/dL [35 g/L]), CAPD patients had a significantly higher TC/HDL-C than HD patients; otherwise the ratios were similar for CAPD and HD. Independent influences on lipoprotein levels in HD and CAPD patients were also demonstrated for race, gender, and diabetes, but not for parathyroid hormone (PTH) levels. For both dialysis modalities, patients who died had significantly lower TC and apo B, and significantly higher apo A-I/apo B throughout their entire courses compared with survivors. In the subset of patients followed longitudinally for 2 or more years, apo B tended to decrease with time, but TC, HDL-C, and apo A-I were stable. The longitudinal changes in lipoproteins did not correlate with outcome or other factors. In conclusion, CAPD patients have more atherogenic lipoprotein profiles than HD patients. Improved visceral protein nutritional status, as defined by serum albumin level, is associated with hyperlipidemia and, especially vor CAPD, worsened atherogenic risk ratios.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1992

Peritonitis and the patient with human immunodeficiency virus (HIV).

The prevalence of HIV positive patients (HIV pts) with ESRD is likely to increase and many will be going on CAPD. There are, however, factors which cause one to be concerned about a possible increased risk of peritonitis in these patients. These include not only their impaired immune and nutritional status, but often their mental status. We examined the incidence and type of peritonitis among the 184 patients who have been in our program since December 1983 for a total of 4,017 patient months (pt mo). During this time we treated 9 known HIV pts (4 drug users and 5 homosexuals) for a total of 114 pt mos. We also looked at albumin, cholesterol, and creatinine as possible risk markers. We found a greater than two fold incidence of peritonitis in the HIV positive patients and that low albumin was a significant risk factor in the HIV negative patients, but not in the HIV positive patients.

HIV Seropositivity↗
PubMed1991

Successful treatment of tuberculous peritonitis while maintaining patient on CAPD.

Although conventional wisdom advises removal of the Tenckhoff catheter as part of the therapy for tuberculous peritonitis, there are a few recent reports of cases successfully treated while maintaining the patients on CAPD. We wish to report three cases treated without interrupting CAPD. In two of the patients, cultures were positive for Mycobacterium tuberculosis and in the third case, although the cultures were negative, the patient improved on anti-Tb medications. Smear for AFB was positive in one patient; and two had a positive PPD. All had predominance of lymphocytes and monocytes in effluent. The total WBC count was 160-300 and two patients had fever. All had abdominal pain. One patient was treated with INH and ethambutol; one with INH and rifampin and one (who was suspected of being HIV+) also received pyrazinamide (PZA) until culture was available. Cultures grew in 4-6 weeks. All were started on therapy prior to having the culture results, and all showed clinical improvement within two weeks. One patient had his catheter replaced two months later because of pseudomonas peritonitis, continued on CAPD for an additional five months, then changed to HD because of recurrent bacterial peritonitis. One patient died of complications of diabetic vascular disease three months later with no evidence of peritonitis. One patient has remained on anti-Tb treatment for seven months and is doing well on CAPD.

Adult↗
PubMed1991

Lipid abnormalities in black renal patients.

Racial differences in lipoprotein (LP) and cardiovascular (CV) abnormalities have been noted in the general population and in the population of patients on dialysis. Few studies have investigated the interaction of race and LP and CV disturbances in other renal disease groups. We studied lipid profiles and risk ratios (total cholesterol (TC)/high density lipoprotein-cholesterol) (HDL-C) and apolipoprotein (apo) A-I/apo B (A-I/B)) and the influence of race across a spectrum of renal disease groups (normal renal function (NRD), nephrotic range proteinuria (NS), hemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD), post-transplant (TR), renal insufficiency (RI)). We also performed a longitudinal study of lipid profiles in patients with end stage renal disease (ESRD) and the relationship of these profiles to race and other variables. There was a general tendency towards a better CV risk profile for blacks than whites in all the groups. Blacks tended to have lower TC, higher HDL-C, lower TC/HDL-C, higher apo A-I, lower apo B, and higher A-I/B. We analyzed four yearly cross-sections of the HD and CAPD populations using ANOVA with adjustment for appropriate covariates. Whites had lower HDL-C and a higher TC/HDL-C risk ratio than blacks. HD patients had lower TC, TC/HDL-C, apo A-I, and apo B than CAPD patients, and women had higher TC than men. When lipid profiles were studied longitudinally by yearly intervals, no consistent significant changes were seen, but over two years, levels of apo B fell and A-I/B rose. Race had no significant effect on any of the longitudinal data.(ABSTRACT TRUNCATED AT 250 WORDS)

Black People↗
PubMed1990

Hemodialysis and the elderly patient: potential advantages as to quality of life, urea generation, serum creatinine, and less interdialytic weight gain.

A total of 204 patients treated by maintenance hemodialysis or continuous ambulatory peritoneal dialysis (CAPD) were studied to ascertain how advancing age influences adaptation to uremia therapy. No difference in Karnofsky score was noted among patients over 70 years of age and two groups of patients, 16 to 59, and 60 to 69 years of age, respectively. In a subset of 33 hemodialysis patients studied midweek, it was noted that increasing age is associated with a lower serum creatinine concentration, lower interdialytic weight gain, and a lower urea generation rate. These three findings contribute to a relative ease in treating older uremia patients with hemodialysis or CAPD, as they tend to be stable and compliant relative to younger patients.

Adolescent↗
PubMed1990

Urinary red cell size: diagnostic value and determinants.

Urinary red blood cells (RBC) are usually small and morphologically abnormal in glomerular (GN) hematuria, and slightly enlarged and morphologically normal in nonglomerular (NG) hematuria. This study was performed to evaluate the diagnostic value of urinary red cell size and morphology and to investigate the mechanism of the alteration in cell size. In 34 consecutive patients with hematuria we examined the urinary RBC size distribution and mean corpuscular volume (MCV) by electronic sizing of suspensions of RBC in an isotonic medium and, in 28 cases, compared it with the presence of 50% or greater dysmorphia. In 15 consecutive cases, we correlated MCV values with urine chemistries. In two GN cases we recorded the urine MCV serially during a furosemide-induced diuresis. In vitro incubations of peripheral or urinary RBC in various electrolyte solutions prior to sizing were also performed. The MCVs were significantly lower in GN (p less than 10(-6)) and probable GN (p less than 10(-4)) than NG hematuria. A cutoff of 72 fl completely separated GN and probable GN from NG cases. Fifty percent or more 'dysmorphic' RBC were seen in 12 of 13 GN, 3 of 4 probable GN but in no NG sediments. In patients with NG hematuria, the ratio of urinary to peripheral MCV tended to be greater than unity and correlated strongly with pH (r = -0.97; p less than 0.002). The effect of pH was confirmed in vitro. Furosemide diuresis induced a partial correction of the microcytosis of GN RBC, which correlated with the changes in urine composition. Furosemide had no effect on GN cells in vitro.(ABSTRACT TRUNCATED AT 250 WORDS)

Diuresis↗
PubMed1990

The impact of CAPD treatment on lipid metabolism and cardiovascular risk.

The metabolism of lipids in CAPD has not been fully elucidated. To further clarify the behavior of dyslipidemia in this setting we followed the values of total cholesterol (TC), HDL-cholesterol (HDL-C) and apolipoprotein (apo) parameters over time (12-24 months) in 40 patients and correlated these values and their ratios with clinical (age, gender, race, weight, diabetes, etc.) and biochemical (multiphastic screen) information. Mean HDL-C was lower in men (p less than 0.04), in whites, (p less than 0.03) and in diabetic patients (p less than 0.05), but there were no group differences for mean total cholesterol, mean apolipoprotein values, the atherogenic risk ratio TC/HDL-C, or the anti-atherogenic ratio apo A-I/apo B. Total months on CAPD was found to correlate positively with TC/HDL-C (p less than 0.05), an atherogenic risk factor, and to correlate negatively with HDL-C (p less than 0.02), an anti-atherogenic index. There was also a negative correlation with another anti-atherogenic index, apo A-I/apo B, which did not reach statistical significance (r = -0.41, p = NS). Counterbalancing this apparently increased atherogenic risk is the stability of individual parameters for each patient over time in this study. In fact, the good news appears to be that TC, HDL-C, apolipoproteins and the risk ratios TC/HDL-C and apo A-I/apo B all remained stable over 12-24 months (p = NS by paired t-test for all). Thus, we find no evidence for worsening of the uremic dyslipidemia over time with CAPD treatment.

Apolipoproteins↗
PubMed1989

Renal size and function in diabetic nephropathy.

The purpose of this investigation was to study in a group of diabetics with varying degrees of renal failure, the relationship of renal size to the degree of renal function. A literature search of the past 25 years has failed to document a precise relationship between structure and function in this setting. Patients were admitted, and sex, age, race, serum creatinine levels, renal size and mean blood pressure were ascertained. Patients with polycystic kidney disease were, obviously, excluded. The group consisted of 26 diabetics, divided into two groups based on previous (prior to onset of uremia) insulin and ketone status. Interestingly, there was no significant difference between groups with insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) as regards mean blood pressure (106.5 +/- 15.3 mm Hg vs. 108.9 +/- 17.64 mm Hg; t = 0.3607892, p = 0.9). Mean kidney length was inversely related to serum creatinine level (r = 0.3980, n = 26, p less than 0.05). There was no correlation between mean renal length and mean blood pressure (r = 0.189, p greater than 0.05). However, there was a significantly higher proportion of larger kidneys (11 cm or more) in the IDDM group than in the NIDDM group (Fischer's exact test; p less than 0.0001) which was related neither to age nor blood pressure. In this paper, we show an inverse correlation between kidney length and serum creatinine.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1989

Similarities between glomerular sclerosis and atherosclerosis in human renal biopsy specimens: a role for lipoprotein glomerulopathy.

Much recent work has focused on the progressive nature of renal injury, and hemodynamic alterations have been implicated in the pathogenesis of the predominant lesion, focal glomerulosclerosis. Despite the well-documented atherogenic toxicity of lipids in cardiovascular morbidity, little is known about lipid-associated renal injury. However, lipids are toxic to endothelium, and the glomerulus is a vascular bundle. Several authors participating in this symposium have presented evidence for an association between hyperlipidemia and glomerulosclerosis in animal models. This association is particularly significant given the expanded therapeutic armamentarium now available to treat hyperlipidemia. In fact, glomerular injury may be moderated by pharmacologic treatment of hyperlipidemia in a rat renal ablation model. Very little evidence exists, however, for a similar association in human renal disease. We have, in the course of clinical practice, made certain observations in renal biopsy specimens that may for the first time link atherogenesis and lipid deposition to human glomerular injury.

Arteriosclerosis↗
PubMed1989

Cholesterol and lipid disturbances in renal disease: the natural history of uremic dyslipidemia and the impact of hemodialysis and continuous ambulatory peritoneal dialysis.

Lipid abnormalities have been postulated to contribute to renal insufficiency by a mechanism that is analogous to atherogenesis. The majority of patients treated for chronic renal failure die of cardiovascular complications. Lipid abnormalities in this group are thought to contribute to this high mortality. Proving a causal association between dyslipidemia and accelerated atherosclerosis in the end-stage renal disease population has been confounded by the presence of other pro-atherogenic conditions in this population. The current study compiles the lipid data we have accumulated from our renal population for the years 1987 to 1989. The report is divided into three main parts: The first is a survey of lipid levels and atherogenicity indicators in groups with different types of renal disease or modalities of treatment. The second is a multivariate analysis of the relationship of clinical and biochemical variables (and their interactions) to the serum lipid and apolipoprotein levels and their ratios and their change over time in a large dialysis population. In the third study, we quantitate the peritoneal clearances of apolipoproteins A-I and B in patients undergoing continuous ambulatory peritoneal dialysis and assess the relationship of these clearances to serum lipid and lipoprotein levels and risk ratios.

Apolipoproteins A↗