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At least 919 records · Page 51Linked to original sources

PubMed1997

[Perioperative management of uremia and fluid balance in patients with compromised renal function undergoing open heart surgery].

Five patients with renal dysfunction underwent coronary artery bypass grafting (CABG). Three patients were in cardiogenic shock with acute myocardial infarction for whom CABG was carried out on emergent basis. Immediate preoperatively these patients were in almost anuria which was derived from sustained renal dysfunction plus decreased renal perfusion due to low cardiac output. The other two patients were operated on electively, and hemodynamic instability and artificial perfusion (cardiopulmonary bypass) affected their chronic renal disease (polycystic kidney and nephrosclerosis, respectively) so unfavorably that intraoperative anuria took place. In all patients intraoperative control of fluid balance and prevention of azotemia were accomplished by intraoperative hemofiltration (HF), in which 10 litters of body fluid was filtered out through a hemofiliter incorporated into the cardiopulmonary bypass circuit, and replaced with saline solution. In emergent cases (three patients) complete anuria was sustained and continuous hemodialysis/hemofilitration (CHDF) was successively performed to control water balance and to prevent exacerbation of uremia. Although they all were in profound low cardiac output state necessitating intraaortic balloon counterpulsation (IABP) and infusion of considerable amount of catecholamines, there was no hemodynamic instability occurred throughout the period of CHDF. In four cases renal function recovered significantly along with the recover from their cardiogenic shock so that they could wean from the hemodialysis therapy. In the remaining case intermittent hemodialysis was necessary in chronic phase. There were no hospital death nor late mortality. From this experience we might conclude that the combined use of intraoperative HF and successive postoperative CHDF is an effective method for controlling fluid balance and preventing uremia in cardiac surgical patients with severe renal dysfunction along with considerable hemodynamic instability.

Aged↗

PubMedDate not supplied

[Arterial hypertension in patients on chronic hemodialysis].

Arterial hypertension is frequent among chronically dialyzed patients. The kidney obviously plays a major role in arterial blood pressure control. There is a large number of experimental data emphasizing different factors (in addition to renin important in renal hypertension prognosis) such as: sodium balance, angiotensin, etc [1-8]. Sympathetic activity disorders or lack of vasodilatory prostaglandins and quinine may also play a certain role. In uremic patients peripheral arteriolar resistance is increased, unlike normotensive uremic patients or those who prove to be normotensive upon clinical examinations [8, 11-15]. Hypertension occurs in approximately 80% of patients with chronic renal failure, producing a number of complications primarily affecting the CNS and systemic circulation [5-8, 10, 11, 13]. The study concerned patients on chronic dialysis, with a male to female ratio of 69.9%:32.1%. In most of them the underlying disease, which caused chronic renal failure, was glomerulonephritis (60.0%), then pyelonephritis (17.0%) and nephrosclerosis, nephrolithiasis, polycystic kidney and, finally, renal tumours. The effect of permanent haemodialysis during the first year of treatment, was efficacious on hypertension in 1704 (65.1%) patients; in 672 (25.7%) patients therapeutical effects were achieved by dialysis and antihypertensive drugs, while in 240 (9.2%) subjects there was no improvement. General observations suggest that two types of arterial hypertension persisted in patients with chronic renal failure: volume-dependent arterial hypertension which is more frequent (90-95%) among haemodialyzed patients and renin-dependent hypertension. Such findings are of utmost importance indicating that hypervolaemia is one of the major factors in the development of arterial hypertension in patients with chronic renal failure, with renin playing the secondary role. Salt-free diet should be used in the treatment of arterial hypertension for years, a well conducted haemodialysis is highly effective in the control of arterial hypertension among these patients. In our series of patients dialysed three times a week; normalization of blood pressure was faster with lower incidence of hypertensive crises during haemodialysis and with few complications. Water and sodium excess was reduced by frequent haemodialyses and sudden changes in electrolyte, hydrostatic and other metabolic effects were minimized. Increased values of plasma renin activity were observed in a small number of patients. Ultrafiltration is insufficient for normalization of blood pressure. Hypertensive crises were frequent in these patients. Their response to medicaments such as methyldopa, beta-adrenergic blockers or other antihypertensive drugs, was good. Severe changes in blood vessels, especially in fundus oculi blood vessels were frequent in these patients. The life of hypertensive glomerulonephritis patients was especially endangered (graphs 1-6). In addition to the mentioned factors arterial hypertension during haemodialysis may also be of cardiac origin, including increase in cardiac output due to arteriovenous anastomosis, disequilibrium syndrome, changes in osmotic gradient of both extra- and intracellular spaces with resultant arteriolar wall oedema, erythrocyte amount, hypoxia, composition of dialysis fluid (sodium concentration), plasma osmotic pressure, metabolic acidosis and other factors. More recently, natriuretic hormone has also been indentified as a cause of vascular refraction. Peripherial arteriolar resistance as a cause of arterial hypertension among uremic patients must not be forgotten, because the genesis of arterial hypertension in patients with chronic renal failure is multifactorial. The highest percentage refers to volume-dependent arterial hypertension, whereas the percentage of other aetiologic factors is lower. Haemodialysis enables the normalization of blood pressure in most of hypertensive patients.

Adolescent↗

PubMed1997

Urinary stone disease: a practical guide to metabolic evaluation.

Urolithiasis is the third most common affliction of the urinary tract, after infections and diseases of the prostate. Approximately 10% of the North American population will have at least one urinary calculus by age 70. A thorough history and physical examination will usually confirm the diagnosis of urinary stone disease. A simplified laboratory evaluation may be performed for patients with a single stone episode. A more extensive evaluation is required for patients with recurrent, metabolically active stones and patients at high risk (ie, cystine stone formers and those who develop bladder dysfunction or nephrosclerosis). Intravenous pyelography with tomography remains the gold standard for imaging of the urinary tract to confirm the diagnosis and formulate a treatment plan.

Colic↗

PubMed1997

Characteristics of long-term peritoneal dialysis patients.

The records of 734 peritoneal dialysis (PD) patients trained at our center between January 1983 and December 1991 were reviewed, and those who had been on PD more than 5 years were selected to study the characteristics common to long-term survivors. We obtained the following results: 22 patients (3%) remained on PD for more than 5 years and 6 patients for more than 8 years (0.8%). Of these, 59.1% were males and 55% white with a mean age of 41.3 +/- 15.1 years and weight 71.1 +/- 14.7 kg. The causes of end-stage renal disease (ESRD) were: diabetes 31.8%, glomerulonephritis 36.4%, and nephrosclerosis 22.7%. The average peritonitis rate was 0.46 episodes/year and hospitalization 4.13 +/- 3.70 days/ year. After 3 years of PD all patients were essentially anuric. The mean 4-hour D/Purea = 0.94 +/- 0.01 and D/Pcreatinine = 0.68 +/- 0.03. Weekly Kpt/Vurea improved from 1.61 to 1.82, Kcreatinine from 40 to 45 L/1.73 m2, and dialysate volume from 11.6 to 14.1 L/day. The normalized catabolic protein rate (NPCR) remained stable at 0.7 g/kg/day. Serum albumin concentrations (SACs) averaged 3.5 g/dL and did not show a trend with time. Weights revealed marked variation with a mean group gain of 3.4 +/- 0.85 kg. Social support was excellent in 19 patients, and 20 were very compliant. Thirteen patients remain on PD, 4 expired, 1 received a transplant, and 4 transferred to hemodialysis. In conclusion, PD can maintain life for prolonged periods of time in the absence of renal function. Longterm survivors are typically of average size, enjoy stable and average peritoneal transport, good social support, remain compliant with therapy, and experience infrequent peritonitis. New PD modalities capable of delivering higher doses and adjustment of prescription based on residual renal function, peritoneal transport, and metabolic needs should increase the proportion of long-term survivors.

Aged↗

PubMed1997

[35 years of experience in reconstructive operations in surgery of vasorenal hypertension].

Reconstructive surgery was performed in 1148 patients with renal hypertension in the period from 1961 to 1996. Extracorporeal microsurgical correction with subsequent kidney autotransplantation was used in case of the lesions of the renal arteries branches. In 161 (14%) of the patients the result was unsatisfactory. The reasons of unsatisfactory results were the following: uncorrected stenosis of the contralateral renal artery (43%), nephrosclerosis of the contralateral kidney (26%), unknown reasons (31%). The long-term results have been followed up in 769 (67%) of the patients in the period for 135 +/- 4 months after the surgery. In 546 (71%) of the patients positive results persisted. The average time of symptomatic recurrence was 74 +/- 6 months after the surgery. Restenosis was the reason of recurrence in 61 (57%) of the patients. Based on these results the following recommendations are postulated: in atherosclerosis--the transaortic endarterectomy from the opening of the renal artery; in fibromuscular displasia--renal artery resection with end-to-end anastomosis; in nonspecific aorcic arteritis--bypass operations.

Adult↗

PubMed1997

Diabetic nephropathy as a model for the use of renal structural endpoints in clinical trials.

Slowly developing renal diseases (SDRD) such as diabetic nephropathy (DN) and hypertensive nephrosclerosis constitute the large majority of disorders leading to end-stage renal disease (ESRD). These disorders are characterized by years to decades without renal functional abnormalities during which renal structural changes are developing. The earliest renal functional abnormalities [such as microalbuminuria in patients with insulin dependent diabetes mellitus (IDDM)] are often associated with already well established renal lesions that may progress independent of the initiating cause. Since the clinical manifestations of these disorders are dependent upon established structural changes, prevention of the early lesions seems a logical goal and thus a useful endpoint for clinical trials. Functional endpoints are impractical at these early stages as they would take too long to manifest. Diabetic nephropathy in IDDM patients is a useful model for such study design, since there is sufficient knowledge of the natural history of the disorder and of the important structural endpoints to allow for the statistical power calculations crucial for study design. More information regarding natural history and structural-functional relationships is needed in non-insulin dependent diabetes, hypertension, and other SDRD before intervention trials using renal structural endpoints can be developed for these important causes of ESRD.

Animals↗

PubMed1997

[Etiologic aspects of nephrotic syndrome in Black African adults in a hospital setting in Abidjan].

We studied nephrotic patients hospitalised in internal medicine service at Treichville Teaching hospital from September 1986 to February 1993 for precising the aetiological aspects of black adult patients and their evolutive biological, clinical and epidemiological profile. Secondary Nephrotic syndrome represented 18% of the whole patients with Nephrotic syndrome hospitalised during the same period. In aetiological field it was about: diabetic nephropathy 11 cases (33%); lupus nephritis 7 cases (21%); renal amyloidosis 5 cases (15%); HIV nephropathy 5 cases (15%); schistosomiasis nephrotic syndrome 1 case (3%); pregnancy nephrotic syndrome 1 case (3%); cryoglobulinemia 1 case (3%); malignancy nephrotic syndrome 1 case (3%); nephrosclerosis 1 case (3%).

Acquired Immunodeficiency Syndrome↗

PubMed1998

Antiproteinuric efficacy of fosinopril after renal transplantation is determined by the extent of vascular and tubulointerstitial damage.

BACKGROUND: Angiotensin converting enzyme (ACE) inhibitors have been successfully used for treatment of proteinuria after renal transplantation (RTx). Factors possibly responsible for the great inter-patient variance of the antiproteinuric effect (APE) have not yet been investigated in renal-transplanted patients. METHODS: 28 patients after RTx with a persistent proteinuria of more than 1.25 g/d were treated prospectively with does of fosinopril (10-15 mg/d) which were not effective on systemic arterial blood pressure. Prior to initiation of fosinopril, renal graft biopsy was performed in all patients and renal graft artery stenosis was excluded by duplex ultrasound. Serum creatinine and proteinuria were measured prior to, as well as 3 and 8 months after initiation of ACE inhibition, mean arterial pressure was controlled via 24-h measurement and repeated spot measurements. Reduction of proteinuria was correlated with renal histology, serum creatinine, creatinine clearance, mean arterial blood pressure, sodium excretion before therapy and the relative changes of these parameters during therapy respectively. RESULTS: Therapy had to be stopped in 8/28 patients due to side effects including rise of serum creatinine (n = 4). Three patients were excluded due to non-compliance. In the remaining patients (n = 17) proteinuria was reduced from 2.94 +/- 1.66 to 1.82 +/- 1.39 and 2.48 +/- 3.05 g/d after 3 and 8 months respectively, in the mean +/- SD. There was a significant inverse correlation between the APE and the extent of benign nephrosclerosis, interstitial fibrosis and tubular atrophy. No correlation of the APE to any of the other parameters could be demonstrated. CONCLUSIONS: Fosinopril can be administered effectively in a subgroup of proteinuric renal transplant recipients. However, because of a high proportion of patients developing side effects, careful monitoring is obligatory. Our results show that the lesser the degree of chronic morphological injury, the greater is the antiproteinuric effect. Thus, the degree of pre-existing histologically proven damage of the graft may serve as an indicator for the antiproteinuric efficacy of ACE inhibitor therapy after RTx.

Angiotensin-Converting Enzyme Inhibitors↗

PubMed1998

Excessive expression of the tumor necrosis factor-alpha gene in the kidneys of patients with membranous glomerulonephritis.

BACKGROUND: The implication of cytokines in the pathogenesis of membranous glomerulonephritis (MGN) and minimal change disease (MCD) is not well known. To delineate the pathogenic roles of cytokines in MGN and MCD, renal tissue from patients with a variety of glomerulonephritides was studied for cytokine mRNA expression. METHODS: The renal tissue from patients with MGN, MCD, focal segmental glomerulosclerosis, acute tubulointerstitial nephritis, diabetic nephropathy, immunoglobulin (Ig) A nephropathy, hypertensive nephrosclerosis, IgM nephropathy, amyloidosis and glomerulosclerosis were studied for the expression of cytokines (tumor necrosis factor, [TNF]-alpha, interleukin [IL]-1 beta, IL-2, IL-4, IL-8 and IL-10) by reverse transcriptase polymerase chain reaction. RESULTS: The frequency for renal expression of TNF-alpha was significantly higher in patients with MGN than in patients with other diseases (p = 0.0295, as analyzed by Fisher's exact test). Its expression in MCD was also more frequent than in the controls, although not significant (p = 0.0794). IL-4 transcript was demonstrated in cultured lymphocytes stimulated with or without pokeweed mitogen in two patients with MCD. CONCLUSIONS: TNF-alpha, which is mainly produced by macrophages and neutrophils, is excessively expressed in the kidneys of patients with active MGN and MCD. IL-4, on the other hand, is expressed in the lymphocytes of patients with MCD. These results suggest that TNF-alpha and IL-4 may be involved directly or indirectly in the pathogenesis of these two diseases.

Cells, Cultured↗

PubMed1996

Intraglomerular fibronectin and laminin turn-over in chronically rejected kidney allografts in humans.

Chronic rejection is primarily responsible for the late loss of allografted organs and remains an important clinical problem. Chronic rejection in the kidney is characterised by arteriolosclerosis and nephrosclerosis, glomerulonephritis and interstitial fibrosis. Recently, a large number of studies have indicated that proteolytic enzymes play important roles as mediators of glomerular injury. The aim of the study was to assess intraglomerular fibronectin and laminin contents as well as cysteine proteinases in activity chronically rejected human kidneys. We investigated kidney tissue from graftectomy specimens obtained from 11 patients with end-stage renal disease following chronic rejection. A group of 9 patients undergoing nephrectomy because of cancer served as a control group, but only not involved parts of the kidneys were used. When intraglomerular laminin contents were related to DNA content, significant accumulation in chronically rejected allografts was found in comparison to controls (382 +/- 171 micrograms per microgram DNA and 190 +/- 82 micrograms per microgram DNA, respectively, p < 0.01. The accumulation of fibronectin was higher than in controls, however the difference was not significant. When proteinase activity was related to intraglomerular DNA content, significantly enhanced cathepsin B and L activity was found in rejected kidney allografts (57 +/- 16 nmol AMC/min per mg DNA) in comparison to controls (15 +/- 2 nmol AMC/min per mg DNA). Summarizing, we observed accumulation of fibronectin and laminin in glomeruli and simultaneously an excess of proteolytic activity in human chronically rejected kidneys. The above phenomenon indicates that a very active metabolic process takes place in glomeruli during rejection.

Adult↗

PubMed1963