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Biomedical subjects

R M Raja

Publications and source records attributed to R M Raja.

At least 19 recordsLinked to original sources
PubMed2001

Acid-base balance and nutrition in peritoneal dialysis.

Acidosis has been implicated in increased protein catabolism and malnutrition of dialysis. The present study examines the effect of acid-base balance on the nutrition status of peritoneal dialysis (PD) patients. We followed 43 PD patients for one year. Blood chemistries were measured monthly. Patients were divided on the basis of subjective global assessment (SGA) into well-nourished (A), mildly-to-moderately malnourished (B), and severely malnourished (C) groups. Mean serum bicarbonate and albumin concentrations were, for group A (n = 16), 23.5 mmol/L and 3.96 g/dL respectively; for group B (n = 17), 27.2 mmol/L and 3.50 g/dL respectively; and for group C (n = 10), 25.9 mmol/L and 2.9 g/dL respectively. In group A, mean serum bicarbonate was significantly lower, and albumin concentration significantly higher as compared with the other groups. Interestingly, of 9 patients with serum HCO3 < 22 mmol/L, 6 were in group A and 2 were in group B. Of 6 patients with serum HCO3 > 29 mmol/L, 5 were in group B and 4 were in group C. The data suggest that well-nourished PD patients tend to be more acidotic. Malnutrition in alkalotic PD patients may be due to low protein intake resulting in decreased acid production; however, an effect of alkalosis on protein metabolism cannot be excluded.

Acid-Base Equilibrium↗
PubMed1997

Long-term pancreas allograft outcome in simultaneous pancreas-kidney transplantation: a comparison of enteric and bladder drainage.

BACKGROUND: The optimal pancreatic exocrine drainage method remains controversial. Bladder drainage (BD) is widely used, but associated with a high incidence of urological complications (acidosis, dehydration, pancreatitis, and urinary tract infection). Enteric drainage (ED) avoids this morbidity, but may be associated with inferior graft survival. METHODS: We conducted a retrospective study comparing BD and ED in 71 simultaneous pancreas-kidney transplant recipients (37 BD; 34 ED) transplanted between February 1988 and June 1996. RESULTS: Five BD and five ED patients experienced early pancreas loss within 3 months after transplantation. The mean follow-up of the remaining 61 patients has been 45.7+/-3.9 and 76.0+/-3.3 months for ED and BD patients, respectively (P<0.005). Both groups had similar pretransplant demographics, co-morbidity, and nutritional and immunological status. The incidence of volume depletion (3.4% vs. 34.3%), acidosis (0% vs. 41.0%), pancreatitis (3.4% vs. 39.7%) and urinary tract infection (26.7% vs. 71%) was lower in ED patients (P<0.005 vs. BD). Of the BD group, 18.7% required conversion to ED for intractable complications. Initial length of stay was equivalent (17.7+/-9 days vs. 18.4+/-10 days) between groups. However, the number of admissions (0.79+/-0.18 vs. 1.38+/-0.14) and in-hospital days/patient/year (6.26+/-1.16 vs. 11.46+/-2.12) was less in ED patients (P<0.05 vs. BD). Actuarial patient and pancreas allograft survival up to 4 years after transplant was similar between groups. CONCLUSIONS: Compared with BD, (a) perioperative morbidity is not increased by ED, (b) ED is associated with fewer complications and hospitalizations, and (c) ED is not associated with increased long-term pancreas graft failure. These data suggest that ED is superior to BD and should be considered as the preferred technique for simultaneous pancreas-kidney transplants.

Acute Disease↗
PubMed1997

Importance of iron saturation for erythropoietin responsiveness in chronic peritoneal dialysis.

There is a great variation in erythropoietin (rHuEPO) requirements in peritoneal dialysis (PD) patients. Although some studies show the importance of higher iron saturation (FeS, > 20%) in hemodialysis patients for a maximal rHuEPO response, data on PD patients are scarce. We followed 38 stable PD patients for 5 months to evaluate the factors that may be responsible for variability in rHuEPO response. All patients received oral iron supplement and erythropoietin subcutaneously twice a week and were divided into three groups according to weekly rHuEPO dose (U/kg): Group I, < 50; Group II, 50-100; Group III, > 100. Hematocrit was maintained at a currently accepted level of 30%-36%. Iron saturation levels were 30.4 +/- 2%, 27.7 +/- 2.5%, and 21.7 +/- 2.5%, and rHuEPO doses were 37.3 +/- 2.4, 71.2 +/- 2.3, and 141.5 +/- 9.7 in Groups I, II, and III, respectively. There were no significant differences in age, sex, etiology of renal failure, parathyroid hormone, serum albumin, blood urea nitrogen (BUN), and creatinine between various groups. These data suggest that rHuEPO requirements are lower in PD patients with higher FeS. FeS may be a good indicator of rHuEPO requirement and responsiveness in PD patients. Achieving higher FeS than the currently accepted 20% may further decrease rHuEPO requirements in PD patients and have significant cost implications.

Administration, Oral↗
PubMed1996

Sodium profiling in elderly haemodialysis patients.

Intradialytic vascular instability continues to be one of the most frequent complications in elderly haemodialysis patients. Signs of impending hypotension such as sweating, apprehension, tachycardia, nausea, or vomiting may be infrequent in the geriatric population. The onset of hypotension in the elderly may be sudden and profound and may lead to serious consequences such as myocardial infarction, stroke, or aspiration if not treated promptly. Prevention of vascular instability is extremely important in the elderly. Avoiding rapid ultrafiltration sedatives, or antihypertensive medications and food intake may be beneficial. Optimal dialysate composition (dialysate sodium, bicarbonate, and calcium concentration) is important. Dialysate sodium profiling may be useful in the elderly to reduce intradialytic hypotension. Step sodium profiles result in better plasma volume refilling in early dialysis, while linear dialysate sodium profiles have greater plasma volume in late dialysis, suggesting that dialysate sodium profiles may need to be individualized for optimal response. Sodium profiling could also result in sodium retention, and long-term studies are needed in the elderly before their widespread use is recommended. Use of newer modalities such as continuous monitoring of plasma volume with Crit Line, and determination and monitoring of body-fluid compartments with bioimpedance may further improve vascular stability in the elderly.

Aged↗
PubMed1996

Home ascites drainage using a permanent Tenckhoff catheter.

Management of refractory ascites (RA) can be accomplished in many ways. Rapid recurrence will be a problem even with repeated paracentesis. We studied the use of a permanent Tenckhoff catheter (PTC) for drainage of RA in 10 patients. The cause of RA was cardiomyopathy in 7 patients, malignancy with liver metastasis in 2, and end-stage liver disease in 1 patient. The volume of ascites drained (AD) ranged from 0.5-7.0 L, with a mean of 2.6 L. Mean blood pressure pre-AD was 112/68 mm Hg, and post-AD was 109/66 mm Hg (p > 0.05). Heart rate pre- and post-AD was 80 bpm and 81 bpm, respectively (p > 0.05). The number of ADs ranged from two to 63 (mean: 16). There was no fluid replacement during or post-AD. There were no complications or infections from AD. The mean interval between ADs was 7.8 days. Mean duration of survival was six months. All patients eventually expired. In conclusion, PTC can be a useful and safe alternative for draining RA at home in terminally ill patients. Complications of repeated paracentesis are minimized, and the need for hospitalization is avoided. AD with PTC may be preferred to repeated paracentesis in RA.

Adult↗
PubMed1994

Transhepatic PermCath for hemodialysis.

The establishment and maintenance of a reliable vascular access continues to be a problem in hemodialysis. We report a patient with end-stage lupus nephritis who had no alternative for vascular access and failed peritoneal dialysis. A vascular access device (PermCath, Quinton Instrument Co, Bothell, WA) was inserted using a transhepatic approach. There were no bleeding or thrombotic complications. The catheter was replaced once through the same track due to poor blood flow and reinserted once after 5 days due to infection. The patient has been doing well and receiving adequate dialytic therapy for over 1 year with this form of vascular access.

Adult↗
PubMed1990

Dilutional acidosis.

Rapid, extreme expansion of the extracellular fluid with solutions devoid of acid or alkali theoretically can produce a metabolic acidosis, due to buffer dilution. This phenomenon has previously been demonstrated only in experimental animal studies. We have reported what we believe to be the first documented case of hypobicarbonatemia and metabolic acidosis consequent to massive saline infusion, other causes having been excluded.

Acidosis↗
PubMed1989

Variable efficacy of calcium carbonate tablets.

Orally administered calcium carbonate tablets are commonly prescribed as a calcium supplement and for their phosphate-binding effects in renal failure patients. Two cases are reported in which a commercially available brand of calcium carbonate tablets appeared to be ineffective. Formal investigation of the bioavailability of this product revealed it to have impaired disintegration and dissolution and a lack of clinical efficacy. Recommendations that will enable physicians to avoid prescribing and pharmacists to avoid dispensing ineffective calcium carbonate tablets are proposed.

Adult↗
PubMed1987

Thrombotic complications of indwelling central catheters used for chronic hemodialysis.

A new double-lumen silicone-rubber dialysis catheter, designed to be placed surgically in central veins, is now available. There is little published data concerning the long-term use of this catheter for hemodialysis, but a review of the literature suggests that pericatheter thrombus formation with or without occlusion of major veins has been a complication of chronic central venous catheterization with a variety of catheters, in both dialysis and nondialysis settings. We had this catheter placed in four diabetic patients who had severe problems related to maintenance of adequate vascular access. Two of the four patients underwent venography within 3 months of catheter placement because of impaired catheter function and were found to have thrombi on the outside of their catheters. These thrombi could not be dissolved with fibrinolytic agents, and the catheters were removed surgically without incident. The other two patients have no radiologic evidence of thrombus formation 4 and 7 months, respectively, after catheter placement. We suggest that proper selection of patients for this type of vascular access should be the subject of future studies and that patients with malfunctioning catheters undergo venography to rule out the presence of significant catheter related thrombosis.

Adult↗
PubMed1987

Heparin free dialysis: comparative data and results in high risk patients.

Heparin free hemodialysis was compared to systemic heparinization, intermittent saline flushes and constant saline infusions in eight, stable chronic patients dialyzing on hollow-fiber artificial kidneys (HFAK) at blood flows of 250 to 300 ml/min. No significant differences in small molecule clearance, fluid removal or dialyzer clotting were noted. Since this data showed that heparin free hemodialysis without supplemental saline was feasible in a group of stable, chronic dialysis patients, we then prospectively studied twenty-nine patients judged to be at increased risk of hemorrhage from heparinization during 100 heparin-free dialyses. The incidences of severe and moderate dialyzer clotting were 7% and 20%, respectively. Seventeen of 27 treatments in which moderate or severe clotting occurred had identifiable factors thought to predispose to dialyzer clotting such as low blood flows, poor vascular-access function, severe hypotension and intradialytic blood transfusions. Although higher hematocrit values were associated with greater degrees of dialyser clotting, stepwise discriminant analysis employing blood flow, blood pressure, hematocrit and transfusion administration could not develop an accurate predictor or combination of predictors of clotting. No patient experienced de novo or increased bleeding and problems with inadequate dialysis were not observed. Since this method of heparin free dialysis is as safe and effective as previously reported strategies and requires no specialized equipment or procedures, it is a reasonable initial strategy for dialyzing high risk patients.

Acute Kidney Injury↗
PubMed1986

Comparison of coaxial and side-by-side double lumen subclavian catheters with the single lumen catheter.

Subclavian catheters are increasingly being used for vascular access. Many double lumen catheters (DLCs) have been designed to alleviate the need for a single-needle machine. Clinical studies comparing the safety of various DLCs with single lumen catheters (SLCs) are scarce. This study compares our experience with Sh-SLCs (Single-Shiley), Vas-DLCs (Coaxial-Vascath), and Qu-DLCs (Side-by-Side, Quinton). Similar aseptic insertion and handling techniques were used. The catheters were filled with heparin at the end of dialysis (HD) and no interdialytic infusions were given. Fifty-two Sh-SLCs were inserted in 46 patients for 253 HDs, 71 Vas-DLCs in 47 patients for 185 HDs, and 51 Qu-DLCs in 38 patients for 215 HDs. HDs/catheter were 4.9, 2.6, and 4.2, the percent incidence of septicemia was 2%, 7%, and 0%, and the catheter failure was 11%, 48%, and 16% for Sh-SLCs, Vas-DLCs, and Qu-DLCs, respectively (P less than 0.05 Vas-DLC v Sh-SLC and Qu-DLC). The poor flow problems were more frequent on the left side with Vas-DLCs (16/31) and Qu-DLCs (7/17), but not with Sh-SLCs (2/25). Other major complications were not noted. These results suggest that infections and mechanical problems may be more frequent with Vas-DLCs than Sh-SLCs and Qu-DLCs. Use of Qu-DLCs is a safe and may be preferred since a single-needle machine is not required. Insertion of a DLC on the right side may be preferred due to higher mechanical problems on the left side.

Catheters, Indwelling↗
PubMed1986

Lethal accumulation of procainamide metabolite in severe renal insufficiency.

Four patients, 64-80 years of age, with severe renal dysfunction and heart disease received conventional doses of procainamide as treatment for cardiac arrhythmias. Serum procainamide concentrations at these times ranged from 6.2 to 13.3 micrograms/ml and were within the recently expanded therapeutic range for resistant ventricular arrhythmias. All 4 patients demonstrated marked and delayed accumulation of the active metabolite N-acetylprocainamide, with highest observed serum concentrations ranging from 42.0 to 59.4 micrograms/ml. Cardiotoxicity associated with these levels included progressive widening of the QRS and corrected Q-T intervals, induction of polymorphic non-sustained ventricular tachycardia (torsades de pointes), and severe depression of left ventricular function which appeared to be important factors in the deaths of these patients. The use of lower procainamide doses and careful anticipatory monitoring of serum concentrations of procainamide and N-acetylprocainamide are essential in this high-risk group.

Acecainide↗
PubMed1986

Resin hemoperfusion for drug intoxication--an update.

Hemoperfusion through Amberlite XAD-4 resin column has been shown to effectively remove sedative-hypnotics, analgesics and other drugs causing acute intoxication. There is no appreciable clinical toxicity and dramatic shortening of coma time and possible decrease in mortality may be achieved. Thrombocytopenia and clotting may be diminished by pre-perfusion coating with 2.5% albumin. Albumin coating may facilitate the repeated use of hemoperfusion without any complications. More recently, resin hemoperfusion has been used for procainamide, N-acetylprocainamide and theophylline intoxication achieving exceptionally high clearance rates.

Acecainide↗