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Abstract
This study of drug-protein binding in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) measured the serum and dialysate binding of cefamandole -an acidic, cephalosporin antibiotic. Ten CAPD patients, five with and five without peritonitis received a 1.0 g intraperitoneal dose of cefamandole; serum and dialysate was sampled at 4, 10, and 24 h after drug administration. Binding also was studied in serum obtained from five chronic hemodialysis patients and five normal volunteers. Equilibrium dialysis was used to determine protein binding and high performance liquid chromatography to measure cefamandole. Mean fraction unbound (fu) serum values for CAPD patients were 0.35 ± 0.04 (noninfected) and 0.37 ± 0.14 (peritonitis). In comparison, the fu values in hemodialysis patients were 0.41 ± 0.19 and 0.15 ± 0.02 in normal volunteers. Greater than 90% of cefamandole in dialysate was unbound suggesting that antibiotics, which cross the peritoneal membrane, are present in the free, microbiologically active form.
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2
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Abstract
Two patients developed Fournier's syndrome while on continuous ambulatory peritoneal dialysis. In both cases, massive scrotal edema appears to have been the precipitating cause of the polymicrobial genital infection. Early recognition and prompt treatment of this syndrome is essential if one is to avoid the high morbidity and mortality associated with this disease. Fournier's syndrome, first described in 1883, is a fulminant necrotising subcutaneous infection of the male external genitalia (I). Although initially thought to be idiopathic, recent evidence suggests that an underlying condition can usually be identified as the precipitating cause of this rare but serious infection (2, 3). Herein, we describe two patients who developed massive scrotal edema while on continuous ambulatory peritoneal dialysis (CAPO). Subsequently, both patients suffered polymicrobial infections of the scrotum with necrosis. We discuss the possible role of CAPO and scrotal edema in leading to the development of Fournier's syndrome.
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An assessment of the long-term health outcome of renal transplant recipients in Ireland. Ir J Med Sci 2011; 178:407-12. [PMID: 19495831 DOI: 10.1007/s11845-009-0363-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2009] [Accepted: 05/05/2009] [Indexed: 01/14/2023]
Abstract
BACKGROUND Renal transplantation remains the preferred method of renal replacement therapy in terms of patient survival, quality of life and cost. However, patients have a high risk of complications ranging from rejection episodes, infection and cancer, amongst others. AIMS AND METHODS In this study, we sought to determine the long-term health outcomes and preventive health measures undertaken for the 1,536 living renal transplant patients in Ireland using a self-reported questionnaire. Outcomes were divided into categories, namely, general health information, allograft-related information, immunosuppression-related complications and preventive health measures. RESULTS The results demonstrate a high rate of cardiovascular, neoplastic and infectious complications in our transplant patients. Moreover, preventive health measures are often not undertaken by patients and lifestyle choices can be poor. CONCLUSIONS This study highlights the work needed by the transplantation community to improve patient education, adjust immunosuppression where necessary and aggressively manage patient risk factors.
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Abstract
AIM Encapsulating peritoneal sclerosis (EPS) is arguably the most serious complication of chronic peritoneal dialysis (PD) therapy with extremely high mortality rates. We aimed to establish the rates of EPS and factors associated with its development in a single center. METHODS We retrospectively reviewed the records of all our PD patients from 1 January 1989 until 31 December 2008. All suspected cases were confirmed at laparotomy. Multifactorial models adjusted for potentially confounding variables such as age and sex. RESULTS Eleven cases of EPS were identified giving a prevalence rate of 1.98%. Median duration on PD was substantially longer in affected versus unaffected patients (42.5 months versus 13.8 months; p = 0.0002). EPS patients had experienced a mean of 3.54 previous cases of peritonitis (1 infection per year versus 0.71 per year in unaffected patients; p = 0.075). Six patients died (54.5%) due to intra-abdominal sepsis including all five who presented with small bowel obstruction. Three patients had an omentectomy and adhesiolysis performed with a successful outcome. CONCLUSION Our study reinforces the link between duration on PD and EPS. While mortality was high in our cohort, emerging surgical techniques demonstrate a favorable outcome that can be achieved even in severely affected cases.
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Favorable Graft Survival in Renal Transplant Recipients with Polycystic Kidney Disease. Ren Fail 2009. [DOI: 10.1081/jdi-56606] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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A Longitudinal Study of the Yield and Clinical Utility of a Specifically Designed Secondary Hypertension Investigation Protocol. Ren Fail 2009; 25:709-17. [PMID: 14575279 DOI: 10.1081/jdi-120024286] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE It has become common practice to use a day-case based approach to identify from the population of hypertensive patients those with an identifiable cause. We aimed to prospectively identify 96 consecutive hypertensive patients undergoing an algorithmic investigation protocol based around two day case hospital attendances. METHODS The overall diagnostic yield and associated costs were recorded and the patients were observed for a mean of 2.5 years with ambulatory blood pressure (BP) monitoring every three months. RESULTS A secondary cause of hypertension was identified in 18.1% of patients, three quarters of whom had renovascular disease. There was a fall in blood pressure with time (157/97 vs. 140/85) but this was associated with an increase in the amount of medication required (mean medication score 5.99 vs. 7.65). Improvement in BP occurred irrespective of whether or not a secondary cause was identified. Only 3.2% of patients were cured of their hypertension as a result of enrollment in the protocol. The cost of identifying each case of secondary hypertension was Euro 10, 196. CONCLUSIONS A comprehensive protocol aimed at identifying secondary hypertension had a low yield, the majority of whom had renovascular disease. In light of recent data illustrating the lack of improvement in BP following dilatation or bypass of atherosclerotic renovascular disease, it is debatable whether searching for it is justifiable.
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Disseminated lymphoma presenting as acute thigh pain and renal failure. Ren Fail 2009; 31:246-7. [PMID: 19288331 DOI: 10.1080/08860220802669909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
A 66-year-old diabetic man presented with severe right thigh swelling and pain together with acute renal failure. At autopsy, this was found to be due to disseminated high grade B cell lymphoma invading the psoas muscle and multiple organs, including the kidneys. The unique presentation of this case emphasizes the need for increased awareness of the variety of ways in which lymphoma can manifest itself.
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8
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Abstract
It is recognized that cytomegalovirus (CMV) infection in transplant recipients may lead to graft loss. Prophylaxis with acyclovir has therefore gained widespread acceptance, but the debate on whether this intervention improves long term graft survival continues. All patients who received renal grafts at the National Renal Transplant Centre, Dublin, between January 1992 and December 1999 were retrospectively analyzed. During this time period, patients who were CMV positive and/or had received grafts from CMV-positive donors were administered prophylactic oral acyclovir 800 mg thrice daily, adjusted for calculated creatinine clearance, from the first day post-transplantation. This treatment was continued for three months unless the graft failed or the patient developed CMV disease or died. Graft and patient outcomes were compared in recipients who received acyclovir with those who did not. Over the study period, 935 patients received renal transplants in our center, of whom 487 were administered acyclovir. The incidence of CMV disease was 3.3 cases per 100 patients per annum in those who required prophylaxis. Despite prophylaxis, graft outcomes were found to be significantly worse (p value < 0.001) in the group that qualified for acyclovir. We conclude that acyclovir provides incomplete protection from the negative impact of CMV on graft survival.
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9
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Abstract
In April 2005, a case of reactivation of hepatitis B virus (HBV) infection occurred in a patient undergoing haemodialysis in an Irish hospital. This incident potentially affected patients attending hospitals throughout the country, so a national incident team was set up coordinate the response to the incident. A total of 306 dialysis patients, attending 17 different dialysis centres (14 in Ireland), were identified as having been potentially exposed to HBV as a result of this incident. A programme of HBV serological testing and HBV vaccination was instituted. There was no evidence that any patient acquired HBV infection as a result of cross-infection from the index patient, although 11 patients (3.6%) had evidence of past infection (anti-HBc positive, HBsAg negative). The majority of patients in this cohort were of unknown HBV vaccination status (62.7%), 13.4% were fully vaccinated, 4.6% partially vaccinated and 15.7% unvaccinated. Of 239 tested for anti-HBs, 183 (76.6%) had a titre <10 mIU/ml. Local incidents in dialysis units can have national implications due to the frequent patient transfer between units. This incident highlighted serious deficiencies in current structures and practices, and a lack of appropriate guidelines. However, there were positive outcomes from this incident. The majority of Irish dialysis patients have now been vaccinated against HBV, and lessons learned have been used to develop national guidelines on HBV vaccination and testing and on the management of incidents of blood-borne viral infections in dialysis units.
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Severity of primary MPGN, rather than MPGN type, determines renal survival and post-transplantation recurrence risk. Kidney Int 2006; 69:504-11. [PMID: 16395262 DOI: 10.1038/sj.ki.5000084] [Citation(s) in RCA: 96] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Previous studies suggested that membranoproliferative glomerulonephritis (MPGN) type II has a worse renal survival and an unacceptable risk of recurrence post transplantation. We hypothesised that other factors may determine this risk. We analysed all cases (n=70) of MPGN diagnosed by renal biopsy in Ireland from 1972 to 1995. We used Cox regression analysis to determine factors that were independently predictive of renal failure. MPGN II had more crescent formation and mesangial proliferation (P<0.05). Mean follow-up duration was 13.8 years, during which time 41 (58.6%) developed end-stage renal failure (ESRF). The median time to ESRF was 8.3 years (95% confidence interval 5.7-10.9) and 5-, 10-, and 20-year probabilities of ESRF were 32, 54, and 70%, respectively. Multivariate analysis revealed that severity of interstitial fibrosis (P<0.05), crescent formation (P<0. 01) and mesangial proliferation (P<0.05) were independently associated with ESRF. Decade of diagnosis, age, MPGN type, and creatinine or complement level at baseline did not predict renal survival in this model. In 21 (49%) of the 43 renal transplants, MPGN recurred. Younger age at initial diagnosis (P<0.01) and the presence of crescents on the original biopsy (P<0.005) were independently associated with recurrence on multivariate analysis. MPGN type was not associated with recurrence in this model. Contrary to previous reports, after controlling for crescent formation, MPGN II was not associated with more ESRF or recurrence in the allograft. It is therefore the more aggressive glomerular changes associated with MPGN II, rather than the disease type per se, that determine outcome.
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Reduced graft function (with or without dialysis) vs immediate graft function--a comparison of long-term renal allograft survival. Nephrol Dial Transplant 2006; 21:2270-4. [PMID: 16720598 DOI: 10.1093/ndt/gfl103] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delayed graft function (DGF) is a common complication in cadaveric kidney transplants affecting graft outcome. However, the incidence of DGF differs widely between centres as its definition is very variable. The purpose of this study was to define a parameter for DGF and immediate graft function (IGF) and to compare the graft outcome between these groups at our centre. METHODS The renal allograft function of 972 first cadaveric transplants performed between 1990 and 2001 in the Republic of Ireland was examined. The DGF and IGF were defined by a creatinine reduction ratio (CRR) between time 0 of transplantation and day 7 post-transplantation of <70 and >70%, respectively. Recipients with reduced graft function (DGF) not requiring dialysis were defined as slow graft function (SGF) patients. The serum creatinine at 3 months, 6 months, 1, 2 and 5 years after transplantation was compared between these groups of recipients. The graft survival rates at 1, 3 and 5 years and the graft half-life for DGF, SGF and IGF recipients were also assessed. RESULTS Of the 972 renal transplant recipients, DGF was seen in 102 (10.5%) patients, SGF in 202 (20.8%) recipients and IGF in 668 (68.7%) patients. Serum creatinine levels were significantly different between the three groups at 3 and 6 months, 1, 2 and 5 years. Graft survival at 5 years for the DGF patients was 48.5%, 60.5% for SGF recipients and 75% for IGF patients with graft half-life of 4.9, 8.7 and 10.5 years, respectively. CONCLUSION This study has shown that the CRR at day 7 correlates with renal function up to 5 years post-transplantation and with long-term graft survival. We have also demonstrated that amongst patients with reduced graft function after transplantation, two groups with significantly different outcomes exist.
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Favorable Graft Survival in Renal Transplant Recipients with Polycystic Kidney Disease. Ren Fail 2005. [DOI: 10.1081/jdi-200056606] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Abstract
BACKGROUND The aim of this paper was to evaluate patient and kidney graft survival rates in renal transplant recipients and compare the outcomes between the different patient age groups. METHODS A retrospective review of all adult renal transplants performed at Beaumont Hospital between the years 1986-2001 was carried out. Patients were defined as 'elderly' if they were 65 years of age or older and 'younger' if less than 65 years at the time of transplantation. Patient and transplant graft survival rates were analysed for each age group. RESULTS Data were analysed on 1462 'younger' patients and 105 'elderly' renal transplant recipients. Estimated patient survival at 1, 5 and 10 years were 96%, 87% and 74% in the younger patient group compared to 85%, 59% and 33% in the elderly group. The adjusted graft survival rates (adjusted for death due to other causes and with a functioning graft in situ) for the younger group were 89%, 77% and 64% at one, five and ten years respectively, while for the elderly group, adjusted one, five and ten year survival rates were 89%, 83% and 70% respectively. CONCLUSIONS Although the elderly have a shorter life expectancy than the younger population they do benefit from renal transplantation similar to the younger recipients.
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Abstract
BACKGROUND Since the introduction of renal transplantation in the Republic of Ireland in 1964, the number of transplants performed annually has increased from single figures in the 1960s to the current rate of approximately 130 renal transplants per year. Improvements in graft and patient outcomes have been associated with the introduction of the immunosuppressive agent Cyclosporin (CSA) in the mid 1980s. AIMS The aim of this study was to examine trends in outcomes and factors that influence outcomes for adult kidney transplantation from 1986 to 2001. METHODS All adult cadaveric kidney transplantations carried out between 1986 and 2001 were included. We separated the transplanted grafts and patients into four time periods; 1986-1989, 1990-1993, 1994-1997, 1998-2001. Graft and patient survival outcomes were compared for the different periods. RESULTS The one-year kidney graft survival rate increased from 82% during 1986-1989 to 86% during 1998-2001. Patient survival over the four time periods studied has remained stable at approximately 95% at one year. CONCLUSION We report a significant improvement in kidney graft outcomes over the past 16 years. Patient survival has remained relatively stable during this period.
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Impaired renal allograft, but not patient survival, in patients with antibodies to hepatitis C virus. Ir J Med Sci 2005; 173:82-4. [PMID: 15540708 DOI: 10.1007/bf02914562] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The impact of hepatitis C virus (HCV) infection in renal transplant patients is controversial and there are no data on the outcome of renal transplantation in this sub-group of Irish patients. AIM To examine the outcome of renal transplantation in patients with hepatitis C. METHODS We examined the outcome of first grafts from renal transplant patients with hepatitis C antibody positive and compared them to a control group. During this period, 24 HCV positive patients received 33 grafts. All were treated with standard immunosuppression. RESULTS Graft survival rate was less in the HCV positive cases (p=0.0087). Graft survival at 1 year was 75% in the HCV positive group versus 85% in the HCV negative group, 40% versus 62% at 5 years and 14% compared with 40% at 10 years. Patient survival was similar in both groups (p=0.78). Patient survival at 1 year was 96% versus 94%, 87% versus 80% at 5 years and 70% in both groups at 10 years. CONCLUSION In the Irish renal transplant population, the presence of hepatitis C antibodies, before or after transplantation is associated with worse long-term graft, but not patient survival.
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Favorable graft survival in renal transplant recipients with polycystic kidney disease. Ren Fail 2005; 27:309-14. [PMID: 15957548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
Graft survival in the autosomal dominant polycystic kidney disease (ADPKD) transplant population at our center was compared to other end stage renal disease (ESRD) transplant recipients (excluding diabetics). There were 1512 adult cadaveric renal transplants carried out at our center between 1989 and 2002. After exclusions, 1372 renal grafts were included in the study. Using Kaplan-Meier methods, patient and graft survival were determined and compared between the two groups. Mean age at transplant was significantly older for the ADPKD group of patients. The age adjusted graft survival at 5 years was 79% for ADPKD patients compared to 68% in the controls. Patient survival for ADPKD patients improved from 89% at 5 years to 95% when age adjusted. Using the Cox proportional hazards models to compare ADPKD with other causes of ESRD (including recipient age and other variables) in a multifactorial model, ADPKD was significant at the 5% level (p=0.036). This study demonstrates a graft and patient survival advantage in ADPKD patients when age-matched compared to other ESRD patients.
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Improved patient survival in recipients of simultaneous pancreas-kidney transplant compared with kidney transplant alone in patients with type 1 diabetes mellitus and end-stage renal disease. Br J Surg 2003; 90:1137-41. [PMID: 12945083 DOI: 10.1002/bjs.4208] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND There are emerging data that simultaneous pancreas-kidney transplant (SPK) prolongs life compared with kidney transplant alone (KTA) in type 1 diabetics with end-stage renal disease. This study was a retrospective comparison of SPK with KTA in patients with type 1 diabetes. METHODS Between 1 January 1992 and 30 April 2002, 101 patients with type 1 diabetes were transplanted. Fifty-one of these patients received a KTA and 50 had a SPK. All patients underwent coronary angiography with surgical correction of any coronary artery disease before being listed. All patients who underwent SPK received quadruple immunosuppressive therapy consisting of antilymphocyte globulin, calcineurin inhibitor (tacrolimus or cyclosporin), azathioprine and steroids. Those who underwent KTA received calcineurin inhibitor (tacrolimus or cyclosporin), azathioprine and steroids. RESULTS Patient survival at 1, 3, 5 and 8 years was 96, 93, 89 and 77 per cent respectively after SPK, and 93, 75, 57 and 47 per cent respectively after KTA (P = 0.018 at 8 years). CONCLUSION The addition of pancreatic transplantation prolongs life in type 1 diabetic patients with renal failure compared with renal transplantation alone.
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Pathogenesis of acute renal failure associated with the HELLP syndrome: a case report and review of the literature. Eur J Obstet Gynecol Reprod Biol 2003; 108:99-102. [PMID: 12694980 DOI: 10.1016/s0301-2115(02)00352-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute renal failure is a rare but serious complication of pregnancy. We describe a 31-year-old woman with haemolytic anemia, elevated liver enzymes, low platelets (HELLP syndrome) who developed acute peripartum renal failure. Renal biopsy performed 2 weeks later because of persistent oliguria revealed thrombotic microangiopathy and acute tubular necrosis. This case highlights the probable pathogenesis of acute renal failure in HELLP patients and explains why it resolves in the majority of cases. A review of the literature that describes renal histology in HELLP patients is presented.
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Recurrence of familial interstitial nephritis following renal transplantation. Nephrol Dial Transplant 2002; 17:1695-7. [PMID: 12198227 DOI: 10.1093/ndt/17.9.1695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cutaneous squamous carcinoma leading to acute abdomen after renal transplantation. J Nephrol 2002; 15:589-92. [PMID: 12455728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2002] [Revised: 05/13/2002] [Accepted: 05/28/2002] [Indexed: 02/27/2023]
Abstract
Skin carcinoma is the commonest malignant complication of renal transplantation. We report the first case of a renal transplant recipient who presented with ileal obstruction as a consequence of squamous cell carcinoma metastases to the small intestine. This complication highlights the unusual presentation of malignancies associated with prolonged exposure to immunosuppression and the need for extra vigilance in such cases.
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The relation between maternal work, ambulatory blood pressure, and pregnancy hypertension. J Epidemiol Community Health 2002; 56:389-93. [PMID: 11964438 PMCID: PMC1732156 DOI: 10.1136/jech.56.5.389] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
STUDY OBJECTIVE The purpose of the study was to determine the relations between maternal work, ambulatory blood pressure in mid-pregnancy, and subsequent pregnancy outcome. DESIGN Data were studied on 933 healthy normotensive primigravidas who had been enrolled into a study on the predictive value of ambulatory blood pressure measurement performed between 18 and 24 weeks gestation. They were classified into three groups depending on whether they were at work (working group, n=245), not working (not working group, n=289), or normally employed but chose not to work (ENK group, n=399), on the day monitoring was performed. SETTING The Rotunda Hospital (a large maternity hospital), Dublin, Ireland. MAIN RESULTS Adjusted for age, body mass index, smoking, drinking, and marital status, women at work had higher mean daytime systolic (p<0.01) and diastolic (p<0.01) and 24 hour systolic pressures (p=0.03) compared with those not working. The rate of subsequent development of pre-eclampsia was significantly higher (odds ratio 4.1, 95% CI 1.1 to 15.2, p=0.03) among those at work compared with those not working. The association between pre-eclampsia and maternal work remained significant (odds ratio 5.5, 95% CI 1.1 to 27.8, p=0.04) even after allowing for the confounding factors of age, smoking, body mass index, and marital status. When daytime systolic and diastolic blood pressure were added to the regression analysis the risk ratios for pre-eclampsia remained high but did not quite reach statistical significance (odds ratio 4.7, 0.90 to 24.8, p=0.066). Birth weight and placental weight were not predicted by work status or blood pressure. CONCLUSIONS A significant independent relation was found between maternal work and ambulatory blood pressure levels in mid-pregnancy. In addition, it was found that maternal work was significantly associated with the subsequent development of pre-eclampsia
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A longitudinal study of the repeated use of alteplase as therapy for tunneled hemodialysis catheter dysfunction. Am J Kidney Dis 2002; 39:86-91. [PMID: 11774106 DOI: 10.1053/ajkd.2002.29885] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
When hemodialysis catheters allow only poor or no blood flow, it has become established practice in many centers to instill a thrombolytic agent in an attempt to clear the catheter. The catheter survival advantage gained by repeated use of such treatment is not known. In a prospective study, we analyzed all uses of alteplase in the setting of inadequate catheter blood flow in a cohort of 570 catheters over a 2(1/2)-year period. The time from alteplase instillation to the next episode in which it was required or catheter removal for nonfunction or thrombosis was recorded. Survival analysis was used to estimate the additional catheter survival afforded by each treatment. After censoring for elective catheter removal, the overall catheter half-life was 10.2 months. Catheter malfunction or thrombosis was the most common indication for catheter removal (36.3% of all catheters removed). Alteplase instillation was necessary in 2.77% of dialysis sessions. The median time from the first to second treatment or catheter removal for nonfunction or thrombosis was 27 days (95% confidence interval, 15.7 to 32.3). Additional median survival advantage gained from each subsequent treatment ranged from 10 to 18 days. Treatment of recurrent catheter malfunction with alteplase allows for a median of only five to seven additional dialysis sessions before the treatment must be repeated or the catheter must be exchanged. Although associated with minimal disruption to the dialysis schedule, the ultimate clinical benefit and cost-effectiveness of such treatment is doubtful.
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Abstract
BACKGROUND Peritonitis resulting from peritoneal dialysis (PD) remains a serious cause of morbidity and even mortality among dialysis patients. AIM To highlight the danger of antibiotic resistance in patients on dialysis who have received multiple courses of antibiotics. METHODS Two cases are reported in which the patients developed peritonitis resistant to vancomycin. CONCLUSIONS Multi-drug resistance is a growing danger. It is imperative to use the most appropriate antibiotics in the proper dosage. If infections persist, early removal of the catheters is essential. The use of antibiotics in PD patients needs to be limited. Sensitivity patterns of the cultured organisms must be monitored regularly as the lack of vigilance may help accelerate the development of the so-called 'super bug' resistant to all antibiotics.
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A prospective study of complications associated with cuffed, tunnelled haemodialysis catheters. Nephrol Dial Transplant 2001; 16:2194-200. [PMID: 11682667 DOI: 10.1093/ndt/16.11.2194] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Despite the US Dialysis Outcome Quality Initiative )DOQI( guidelines, for various reasons, increasing numbers of end-stage renal disease patients are becoming dependent on cuffed haemodialysis catheters (HCs) for chronic haemodialysis access. Their use is complicated by frequent failure due to thrombosis and catheter-related sepsis. In our unit, all HCs are put in place by the radiology department. METHODS In a prospective study we looked at the outcome of all HCs over a three-year period, during which time 573 consecutive HCs were placed in 336 patients. Each line was followed individually until it was removed or until the end of the study. RESULTS In a survival analysis of those HCs removed following HC failure, HC half-life was 312 days and one-year HC survival was 47.5%. The most frequent indications for HC removal were non-function (36.6%), clinical suspicion of line sepsis (16.4%) and patient death (14.4%). Using a Cox proportional hazards model, catheter number in a given patient and the presence of diabetes mellitus were found to be independent predictors of HC failure. The total incidence of HC-related sepsis was 1.3 episodes/1000 catheter days. The probability of developing bacteraemic HC-related sepsis was 27.5% at one year. CONCLUSIONS Less than half of the HCs were removed electively because of availability of a more permanent mode of renal replacement, thereby illustrating the level of dependence that has developed on them as permanent access. Consequently, their limitations (infection and malfunction) are placing an ever increasing burden on the healthcare services.
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Abstract
OBJECTIVE We undertook this study to evaluate the incidence and outcome of HELLP in Irish patients. In addition, duration and trends of the abnormal laboratory results were studied. STUDY DESIGN This prospective observational study screened 12068 pregnant women between January 1995 and March 1997. Any pregnant woman with hypertension, proteinuria, thrombocytopenia or anemia was monitored for hemolysis and elevated liver transaminases, from the time of recruitment till six weeks postpartum or resolution. RESULTS Thirteen of 12068 pregnant women (0.11%) developed HELLP. All had hypertension and 84.6% had proteinuria. Delivery was the only factor found to terminate the syndrome. Acute renal dysfunction was noted in 53.8% but none required dialysis. Laboratory parameters stabilized by the sixth postpartum day. Fetal mortality was 1 out of 14. There were no maternal deaths. CONCLUSIONS HELLP syndrome is a rare but potentially serious complication of pregnancy. Correlation with laboratory data and early intervention are vital in achieving a favorable outcome for both mother and fetus.
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Successful transplantation of kidneys from a donor with HELLP syndrome-related death. Transpl Int 2001; 14:108-10. [PMID: 11370163 DOI: 10.1007/s001470050856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We report on the successful use of kidneys procured from a donor with HELLP syndrome. The use of organs from a donor with HELLP syndrome has not been reported previously, perhaps because of the renal complications associated with it. Both recipients have been doing well since renal transplantation, with immediate graft function and acceptable graft function at 2 years of follow-up. In view of the continuing shortage of cadaveric kidneys for transplantation, this report highlights how organs from "marginal" donors should not be discarded without worthy consideration.
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Abstract
Hemolytic-uremic syndrome (HUS) is a well-recognized complication of cyclosporine (CyA) therapy. Transplant recipients with this complication are frequently switched to tacrolimus, although this drug has also been implicated. We report a case of a renal transplant recipient who developed severe graft dysfunction due to biopsy-proven HUS after receiving CyA. Renal function and hemolytic parameters improved with discontinuation of the drug, but they deteriorated again after commencement of tacrolimus 15 days later. A second transplant biopsy demonstrated fresh lesions diagnostic of HUS. Hemolytic parameters resolved with discontinuation of tacrolimus. This is the first report of metachronous HUS being caused in a renal transplant by both CyA and tacrolimus. We therefore believe that caution should be exercised when using tacrolimus as rescue therapy in patients with CyA-induced HUS.
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Mesangioproliferative glomerulonephritis with IgM deposition: clinical characteristics and outcome. Ren Fail 2001; 22:445-57. [PMID: 10901182 DOI: 10.1081/jdi-100100886] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The significance of IgM on immunofluorescence in renal biopsy specimens remains unclear. This retrospective case study was conducted to define the clinical features, response to therapy and outcome of patients with Mesangioproliferative Glomerulonephritis (MGN) with diffuse IgM deposition. Of 1919 native renal biopsies performed over a ten-year period, 139 (7.2%) had light microscopic features of MGN and manifested IgM as the dominant immunoglobulin. When exclusion criteria (more than a trace of IgA or IgG, segmental IgM, evidence of SLE, vasculitis, FSGS or Alport's syndrome and pregnant patients) were applied, 60 patients (3.1%) remained. Follow-up data were available for 54 cases with a mean age of 26.5 years (range 1.7-63). Mean follow-up period was 7.4 years (range 4.7-22.2). Forty-one per cent presented with nephrotic syndrome (NS), 26% with asymptomatic proteinuria (>250mg/24hr), 18% with macroscopic hematuria and 15% with isolated microscopic hematuria. Twenty-one percent of patients were hypertensive at presentation. Creatinine was initially <120 (mol/L in all but one patient. Only four patients (7.4%), all nephrotic, suffered a decline in renal function despite treatment; all 4 developed ESRF after a mean of 5.6 years (range 2-8.3). Two of these were subsequently re-biopsied and found to have FSGS. No patients with isolated microscopic / macroscopic hematuria or asymptomatic proteinuria suffered a decline in renal function. Protein excretion rate fell into the normal range in 63% of those receiving steroids, with 82% becoming steroid dependent. Of those treated with cyclosporine (48%) or cyclophosphamide (52%) only 9.5% and 14.5% respectively remained in prolonged remission after discontinuing treatment. It is concluded that MGN with IgM deposition carries a very favorable prognosis except in patients with NS who develop FSGS. However there is a high incidence of steroid dependence and resistance in the proteinuric group.
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Access recirculation in temporary hemodialysis catheters as measured by the saline dilution technique. Am J Kidney Dis 2000; 36:1135-9. [PMID: 11096037 DOI: 10.1053/ajkd.2000.19821] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Ultrasound dilution technology is emerging as the standard for measuring access recirculation and blood flow in hemodialysis patients. In temporary dialysis catheters, studies using the traditional two-needle urea method have suggested that short femoral catheters are associated with an unacceptably high degree of recirculation. This problem has never been assessed using ultrasound dilution technology. We performed a prospective observational study of consecutive patients undergoing dialysis through a temporary catheter. Measurements were made on 49 catheters; 10 catheters were excluded because poor flow necessitated reversal of the dialysis ports. Thirty-nine catheters in 33 patients were included in this analysis, of which 26 catheters were located in the femoral vein, and 13 catheters, in the internal jugular vein. Dialyzer blood flow was adjusted to give an ultrasonic flow rate of 250 mL/min (actual mean blood flow, 234.3 mL/min; 95% confidence interval [CI], 228 to 241). Overall mean recirculation rate was 8.9% (95% CI, 4.8 to 13.0). Multivariate analysis showed catheter location and length to be independent predictors of recirculation. Blood flow (within the range tested), duration into dialysis, time since catheter insertion, cardiac rhythm, and catheter type had no significant effect on recirculation rates. Recirculation in femoral catheters (13.1%) was significantly greater than that in internal jugular catheters (0.4%; P: < 0.001). Femoral catheters shorter than 20 cm had significantly greater recirculation (26.3%) than those longer than 20 cm (8.3%; P: = 0.007). We conclude that temporary femoral catheters shorter than 20 cm are associated with increased recirculation rates. In addition, when dialysis dose delivery is a priority, locating the temporary catheter in the internal jugular vein is an advantage.
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Renal thrombotic microangiopathy associated with interferon-alpha treatment of chronic myeloid leukemia. Am J Kidney Dis 2000; 36:E5. [PMID: 10873904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Recent reports have documented the development of renal thrombotic microangiopathy in patients with chronic myeloid leukemia (CML) who have undergone treatment with interferon-alpha. The pathogenesis of the renal lesion in such cases remains unclear. We report the case of a patient with chronic myeloid leukemia who developed renal failure and nephrotic syndrome while being treated with hydroxyurea and interferon-alpha. The renal biopsy showed features of chronic thrombotic microangiopathy. The patient had serologic and functional evidence of anti-phospholipid antibody. Interferon-alpha is known to cause induction of multiple autoantibodies. We propose that in the context of CML, interferon-alpha treatment can induce pathogenic anti-phospholipid antibodies that result in renal thrombotic microangiopathy. This has important implications for patients with CML receiving immune-stimulating therapy because it suggests that prospective monitoring of such patients for anti-phospholipid antibody might identify those at risk of developing thrombotic microangiopathy. Furthermore, patients with established anti-phospholipid antibody syndrome in this context might benefit from intervention such as early anticoagulation.
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A novel presentation of cryptococcal infection in a renal allograft recipient. IRISH MEDICAL JOURNAL 2000; 93:82-4. [PMID: 10967854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
The population of immunosuppressed patients is growing rapidly because of the HIV epidemic and the rapid expansion in transplant medicine. These patients may present to a variety of clinical specialties with seemingly innocuous infections. We present here the first Irish case of primary cryptococcal cellulitis. The patient was a 62-year old renal transplant recipient and was immunosuppressed with Cyclosporine, Azathioprine and Prednisolone. He presented with an apparent bacterial cellulitis on the dorsum of the hand that had failed to respond to a 3-week course of oral antibiotics. There was no clinical evidence of systemic infection. There was tissue necrosis present and the area was debrided surgically. Histological examination of debrided tissue revealed necrotic granulomata and budding yeast-like organisms. Cryptococcus neoformans was cultured from this specimen. The patient was treated with oral fluconazole 400 mg daily for 6 weeks with complete healing of the infected area and no evidence of recurrence after 12 months of follow up. This case emphasises the need for a high index of suspicion for atypical infection in the immunocompromised patient.
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Abstract
BACKGROUND Intravenous urography (IVU) is considered an integral imaging component of the nephro-urological work-up in a wide array of clinical settings. At our institution there is an open-access policy with regard to requesting IVU studies. METHODS In a prospective, blinded observational study we undertook to assess the diagnostic yield of IVU with respect to the source of referral (i.e. Urology, Nephrology, GP, A & E, other speciality) and the presenting features, such as renal colic, haematuria, bladder outflow obstruction, recurrent urinary tract infection (UTI) etc. Two hundred consecutive patients were evaluated. RESULTS Overall, 23% of tests were positive. There was a highly significant difference in diagnostic yield between the groups (P<0.001 for both referral source and test indication). A positive result was most likely after referral by a kidney specialist (37.1%) and when the test indication was renal colic (42%) or haematuria (32%). The yield was <15% in all other circumstances, with 94.9% and 92.1% of GP- and other hospital speciality-initiated IVUs being negative. When investigating recurrent UTI, 91.7% of tests were negative and 86.2% were negative when the indication was bladder outflow obstruction. CONCLUSIONS It is suggested that an open access policy for IVU is not justified, especially when cost and the risk associated with contrast media and radiation exposure are taken into account. Our study supports the abandonment of routine IVU in the investigation of UTI and bladder outflow obstruction.
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Abstract
BACKGROUND The effect of renal transplantation on pregnancy in Irish women not receiving CyA has been reported previously. AIM To examine all pregnancies occurring in Irish female renal transplant recipients since the introduction of CyA. METHODS Using a community based approach, we identified 29 pregnancies in 19 women, aged between 16 and 45, mean age 30.3 years. RESULTS These pregnancies ended in four miscarriages (13%), two intra-uterine deaths (6.9%) and 23 live births (79.3%). Of these live births, 73.9% were premature (< or = 36 weeks) and 65.2% were of low birth weight (< 2500 g). Admission to the neonatal intensive care was necessary in 61%, and two babies (8.7%) died in the neonatal period. Mean gestational age was 34 weeks, and mean birth weight was 2190 g. There was no change in graft function during pregnancy, with a small rise in serum creatinine post-partum (+9.64 mumol/L). The renal graft failed in three women (15.8%) by the end of the follow-up period. Compared with the precyclosporine era, the live birth rate was higher (79.3% versus 58%) with a trend towards lower birth weight and shorter gestation. CONCLUSION Renal transplantation with CyA use is not a contraindication to pregnancy, but it is associated with increased risk, especially when the serum creatinine is > 175 mumol/L.
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Outcome analysis of patients with vasculitis associated with antineutrophil cytoplasmic antibodies. Clin Nephrol 1999; 52:344-51. [PMID: 10604641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND Objective scoring systems of disease activity and disease-associated damage have proven useful in the management of patients with systemic vasculitis. PATIENTS AND METHODS We used the recently designed Birmingham vasculitis activity score (BVAS; maximum score 63) and vasculitis damage index (VDI; maximum score 59) to assess initial activity and long-term damage, respectively, in ANCA positive patients from one center over a 3-year period. Thirty-two patients with ANCA vasculitis were identified and analyzed as an historic cohort. The median BVAS for all vasculitis patients at first presentation was 19 (range 6 - 36). Patients with Wegener's granulomatosis had a significantly higher total score and respiratory BVAS score compared to the 15 with microscopic polyangiitis. The majority of patients received standard cyclophosphamide/steroid treatment. RESULTS At the end of follow-up (mean 24.9 months), 4 patients had died; all patients had evidence of permanent organ damage. The median total VDI score at last follow-up was 4.0 (range 0-11), with no differences between patients with Wegener's granulomatosis and microscopic polyangiitis. The VDI was not associated with the number of relapses. A high initial BVAS was found to correlate with a later high vasculitis damage index (r = 0.56). Initial renal or respiratory involvement was also associated with longterm damage in the same organ system. CONCLUSION Although mortality from ANCA-associated vasculitis has decreased, morbidity remains a common problem. High early-disease activity may identify patients at high risk of long-term organ damage, allowing more effective individualized therapy. This hypothesis requires validation in a prospective, controlled study.
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Abstract
OBJECTIVE Altered production of nitric oxide by the vascular endothelium may influence the pathogenesis of preeclampsia. The aim of this study was to measure circulating levels of nitric oxide metabolites (nitrites) in the uteroplacental, fetoplacental, and peripheral circulation of preeclamptic pregnancies compared with normotensive controls. METHODS Fifteen women with preeclampsia were compared with 16 women with normotensive pregnancies. At cesarean, blood samples were taken from the uterine vein draining the placental site, the umbilical vein, and the antecubital vein after delivery of the baby but before delivery of the placenta. Plasma nitrites were measured using the Greiss reaction after conversion of plasma nitrates to nitrites using nitrate reductase. RESULTS Nitric oxide metabolites were higher in the uteroplacental (P < .01), fetoplacental (P < .001), and peripheral (P < .02) circulations in samples from preeclamptic pregnancies compared with control pregnancies. In samples from the fetoplacental circulation only, nitric oxide metabolite levels were negatively correlated with gestational age (r = -.489, P < .01) and birth weight (r = -.544, P < .004). Nitric oxide metabolite levels were not significantly correlated with blood pressure, placental weight, or maternal age. CONCLUSION In established preeclampsia, production of nitric oxide was higher in the uteroplacental, fetoplacental, and peripheral circulation than in normotensive pregnancies. This increase may be part of a compensatory mechanism to offset the pathologic effects of preeclampsia.
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Hyponatraemia, seizures and stupor associated with ecstasy ingestion in a female. IRISH MEDICAL JOURNAL 1998; 91:178. [PMID: 9973755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
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Sensitization to human leukocyte antigen before and after the introduction of erythropoietin. Nephrol Dial Transplant 1998; 13:2027-32. [PMID: 9719159 DOI: 10.1093/ndt/13.8.2027] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Antibodies directed against human leukocyte antigens (HLAs) impact adversely on renal transplantation. Measures aimed at preventing such antibody formation are thus important. The introduction of recombinant human erythropoietin (rHuEpo) has permitted the reduction of blood transfusion in patients with chronic renal failure. The impact of rHuEpo on the incidence of sensitization in patients awaiting transplantation was therefore studied. METHODS A retrospective analysis of the patients awaiting transplantation before (group A) and 4 years after (group B) the introduction of rHuEpo was performed in order to ascertain changing patterns in the use of blood transfusion and causes of sensitization. RESULTS The total number of transfusions administered to haemodialysis patients decreased by 34% during the study period. This was accompanied by a significant reduction in the ratio of blood transfusion to haemodialysis treatment episodes (0.095 in group A to 0.06 in group B, P = 0.001). The number of patients sensitized as a consequence of blood transfusion decreased from 63% in group A to 28% in group B (P = 0.0004). The overall incidence of sensitization decreased from 50% in group A to 36.5% in group B (P = 0.008). This decrement was associated with a significant reduction in the mean waiting time for transplantation (42.1 +/- 1.1 vs 15.4 +/- 2.4 months, P < 0.0001). The incidence of sensitization due to previous transplantation increased during the study period from 41% in group A to 77% in group B, (P = 0.0004). There was no change in the number of patients sensitized due to pregnancy. CONCLUSION The introduction of rHuEpo has resulted in a significant decrease in the requirements for blood transfusion among patients awaiting transplantation and is associated with a significant reduction in transfusion-related sensitization and mean waiting time for transplantation.
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Circulating vascular cell adhesion molecule-1 in pre-eclampsia, gestational hypertension, and normal pregnancy: evidence of selective dysregulation of vascular cell adhesion molecule-1 homeostasis in pre-eclampsia. Am J Obstet Gynecol 1998; 179:464-9. [PMID: 9731854 DOI: 10.1016/s0002-9378(98)70380-1] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Our purpose was to investigate circulating levels of vascular cell adhesion molecule-1 in the peripheral and uteroplacental circulations during normotensive and hypertensive pregnancies. STUDY DESIGN This prospective observational study involved 2 patient groups. Group 1 consisted of 22 women with pre-eclampsia and 30 normotensive women followed up longitudinally through pregnancy and post partum. There were an additional 13 women with established gestational hypertension. Group 2 consisted of 20 women with established pre-eclampsia and 19 normotensive control subjects undergoing cesarean delivery. Plasma levels of vascular cell adhesion molecule-1 were measured in blood drawn from the antecubital vein (group 1) and from both the antecubital and uterine veins (group 2). Data were analyzed by analysis of variance. RESULTS In group 1 vascular cell adhesion molecule-1 levels did not change significantly throughout normal pregnancy and post partum. Women with established pre-eclampsia had increased vascular cell adhesion molecule-1 levels compared with the normotensive pregnancy group (P = .01). Vascular cell adhesion molecule-1 levels were not elevated in women with established gestational hypertension. In group 2 significantly higher levels of vascular cell adhesion molecule-1 were detected in the uteroplacental (P < .0001) and peripheral (P < .0001) circulations of pre-eclamptic women by comparison with normotensive women. In the pre-eclamptic group there was a tendency toward higher vascular cell adhesion molecule-1 levels in the peripheral circulation than in the uteroplacental circulation (P = .06). In contrast to vascular cell adhesion molecule-1, circulating levels of E-selectin and intercellular adhesion molecule-1, other major leukocyte adhesion molecules expressed by the endothelium, were not different in pre-eclamptic and normotensive pregnancies. CONCLUSION Established pre-eclampsia is characterized by selective dysregulation of vascular cell adhesion molecule-1 homeostasis. This event is not an early preclinical feature of pre-eclampsia, does not persist post partum, is not a feature of nonproteinuric gestational hypertension, and is not observed with other major leukocyte adhesion molecules. Induction of vascular cell adhesion molecule-1 expression in pre-eclampsia may contribute to leukocyte-mediated tissue injury in this condition or may reflect perturbation of other, previously unrecognized, functions of this molecule in pregnancy.
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Hemostasis in the uteroplacental and peripheral circulations in normotensive and pre-eclamptic pregnancies. Am J Obstet Gynecol 1998; 179:520-6. [PMID: 9731863 DOI: 10.1016/s0002-9378(98)70389-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Our purpose was to determine the hemostatic changes in the uteroplacental and peripheral circulations in normotensive and pre-eclamptic pregnancies. STUDY DESIGN This prospective, observational study involved 2 patient groups. Group 1 consisted of 30 normotensive women and 22 women with pre-eclampsia who were followed up longitudinally through pregnancy and post partum. Group 2 consisted of 20 women with established pre-eclampsia and 19 normotensive control subjects, all undergoing cesarean section. Plasma levels of thrombin-antithrombin III complex, soluble fibrin, plasmin-alpha2-antiplasmin complex, and fibrin-degradation product (D-dimer) were measured in blood drawn from the antecubital vein (group 1) and from both the antecubital and uterine veins (group 2). Data were analyzed by analysis of variance. RESULTS In group 1 levels of thrombin-antithrombin III complex, soluble fibrin, and fibrin-degradation product were significantly higher during normal pregnancy than at 6 weeks post partum. Plasmin-alpha2-antiplasmin complex levels did not change. No differences between the pre-eclamptic and normotensive pregnancy groups were found for any of the hemostatic markers. In group 2 normotensive women undergoing cesarean section, thrombin-antithrombin III complex and soluble fibrin levels were significantly higher in the uterine vein than in the antecubital vein. In group 2 women with pre-eclampsia, thrombin-antithrombin III complex and fibrin-degradation product levels were significantly higher in the uterine vein than in the antecubital vein. In addition, plasmin-alpha2-antiplasmin complex and fibrin-degradation product levels were higher and soluble fibrin levels were lower in the uterine vein in the pre-eclamptic group than in the normotensive group. CONCLUSION Both the coagulation and fibrinolytic systems are activated during normal pregnancy. Activation of these systems is more marked in the uteroplacental circulation than in the systemic circulation in both normotensive and pre-eclamptic pregnancies. An abnormal pattern of hemostasis occurs in the uteroplacental circulation in pre-eclampsia.
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Abstract
Renal involvement remains a major complication of multiple myeloma, particularly in advanced disease. A retrospective analysis was performed of the modes of presentation, treatment and outcome of all patients with multiple myeloma treated in our renal unit between 1987 and 1996. Thirty-four patients were identified: in 26 (76%) the diagnosis of myeloma was made only after referral. Light chains were the most common paraprotein in both serum and urine. Twenty-one (62%) patients underwent renal biopsy: myeloma cast nephropathy was the predominant histological finding in 16 cases. Thirty-one (91%) patients had severe renal failure (GFR < 20 mL/min), with 28 (82%) requiring dialysis within 2 weeks of admission. Despite treatment of presumed precipitaing causes of acute deterioration in renal function, only 1 of these 28 patients subsequently became independent of dialysis. Most had advanced stage myeloma: 29 (85%) were Durie-Salmon stage II or III. Hypercalcemia, sepsis and pathological fractures were the principal complications. Median survival overall was 5 months. The main causes of death were withdrawal of renal replacement therapy (overwhelming myeloma, severe debilitation) and sepsis. Nineteen (56%) patients received long-term (> 1 month) renal replacement therapy with a median survival of 8 months. However, five of these (26%) have survived for more than 12 months on dialysis and report a good quality of life.
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Renal transplantation performed across a positive crossmatch: a single centre experience. Ir J Med Sci 1997; 166:245-8. [PMID: 9394076 DOI: 10.1007/bf02944244] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
UNLABELLED The importance of certain positive crossmatches (CM+) in kidney transplantation remains controversial. Fifty consecutive kidney transplants were performed across a CM+ between Jan. 1990-April 1994. In 19 cases there was an isolated B-cell CM+ (Group I), in 24 an historic T-cell IgM CM+ (Group II) and in 7 an historic T-cell IgG CM+ (Group III). Comparing groups I:II:III: early acute rejection affected 32%, 42%, 57% of grafts; mean serum creatinine at 3 months was 166, 150, 229 umol/l (p < 0.05); 1 yr graft survival was 95 per cent, 96 per cent, 71 per cent (p = 0.09). In group III both graft losses were in the setting of an additional current B-cell CM+. CONCLUSIONS Transplantation performed in either the presence of an isolated B-cell CM+ or in the presence of an historic T-cell IgM CM+ was associated with acceptable outcomes at 1 yr. An historic T-cell IgG CM+ was confirmed as a contraindication to transplantation in most circumstances, especially when coupled with a current B-cell CM+.
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Liver function tests in pre-eclampsia: importance of comparison with a reference range derived for normal pregnancy. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1997; 104:1215. [PMID: 9333006 DOI: 10.1111/j.1471-0528.1997.tb10952.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Abstract
Familial Mediterranean fever (fMf) is an inherited condition characterized by polyserositis and is sometimes complicated by AA renal amyloidosis leading to nephrotic syndrome and renal failure. We present a case of a man with fMf who presented with rapidly progressive renal failure caused by light chain deposition disease. This disease association has not previously been described in the medical literature.
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Renal artery stenosis complicating Cogan's syndrome. Clin Nephrol 1997; 47:407-8. [PMID: 9202874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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Can 24-hour ambulatory blood pressure measurement predict the development of hypertension in primigravidae? BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1997; 104:356-62. [PMID: 9091016 DOI: 10.1111/j.1471-0528.1997.tb11468.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE To assess the role of 24-hour ambulatory blood pressure measurement in the mid-second trimester as a predictive test for the development of hypertension in pregnancy. DESIGN Prospective intervention. SETTING The Rotunda Hospital, Dublin. PARTICIPANTS One thousand one hundred and two healthy primigravid women. INTERVENTION 24-hour ambulatory blood pressure measurement at 18 to 24 weeks of gestation. MAIN OUTCOME MEASURES The development of pre-eclampsia or gestational hypertension. RESULTS A total of 1048 women had sufficient readings to be included in the final analysis. Of these, 23 (2.2%) developed pre-eclampsia, 64 (6.1%) developed gestational hypertension and 961 (91.7%) remained normotensive. Significantly higher ambulatory blood pressures were recorded in both the pre-eclamptic and gestational hypertensive group compared with the normotensive group. In addition, the gestational hypertensive group had significantly higher clinically measured blood pressure compared with the normotensive group. There were no differences between the pre-eclamptic and the gestational hypertensive group for any of the blood pressure parameters analysed. The best overall predictor for pre-eclampsia was 24-hour mean diastolic pressure which using a cutoff level of 71 mmHg gave a test with a sensitivity of only 22% and a positive predictive value of 15%. CONCLUSION Because the absolute differences are small and the overlap between the hypertensive and normotensive groups large, ambulatory blood pressure measurement, in a healthy primigravid population, between 18 and 24 weeks of gestation is not a useful predictor of hypertension.
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Predialysis systolic blood pressure correlates strongly with mean 24-hour systolic blood pressure and left ventricular mass in stable hemodialysis patients. J Am Soc Nephrol 1996; 7:2658-63. [PMID: 8989745 DOI: 10.1681/asn.v7122658] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
This study used a 24-h ambulatory blood pressure (ABP) monitor to study the relationship between dialysis room-measured blood pressures (BP) and mean 24-h systolic and diastolic ambulatory BP (SABP and DABP) with left ventricular mass (LV) in a group of 35 stable hemodialysis patients. Predialysis and postdialysis systolic and diastolic blood pressure data were collected for the 12 dialysis treatments before the wearing of the ABP device, and the means of these values are reported. All patients were maintained on the same antihypertensive medications for 3 months before the study and had a stable hematocrit value of 30 +/- 3% during this time period. There was no difference detected between daytime and nighttime ABP. SABP was a mean of 4.7 mm Hg below predialysis systolic BP (P = 0.004) and DABP was a mean of 3.7 mm Hg below predialysis diastolic BP. There was a strong correlation between SABP and predialysis systolic BP (r = 0.67, P = 0.0001); however, postdialysis diastolic BP correlated better with DABP than did predialysis diastolic BP. In addition, LV mass correlated with SABP (r = 0.35, P = 0.03) and predialysis systolic BP (r = 0.35, P = 0.03). There was no apparent correlation between either pre- or postdialysis diastolic BP with LV mass. It was concluded that predialysis systolic BP and postdialysis diastolic BP correlates strongly with SABP and DABP. Furthermore, predialysis systolic BP correlates with LV mass in hemodialysis patients. If the deleterious effects of hypertension in this patient population are to be avoided, it is the predialysis systolic BP that needs to be controlled: It is insufficient to be satisfied with good postdialysis BP control, if patients are hypertensive before beginning dialysis.
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Abstract
Three cases of HELLP syndrome are presented which illustrate its varied clinical presentation, the difficulty in making a diagnosis and the management problems. The cases varied in severity; all showed thrombocytopenia and abnormal liver function tests, but in one case the blood pressure remained within "normal limits" whereas another patient suffered grand mal seizures due to hypertensive encephalopathy.
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Long-term successful management of refractory congestive cardiac failure by intermittent ambulatory peritoneal ultrafiltration. QJM 1996; 89:681-3. [PMID: 8917742 DOI: 10.1093/qjmed/89.9.681] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Despite advances in the pharmacological management of cardiac failure, some patients remain refractory to this therapy. However, improved understanding of the physiology and technique of peritoneal dialysis has recently allowed ambulatory peritoneal ultrafiltration to be applied to the treatment of patients with intractable heart failure. We report the management of three such patients with New York Heart Association (NYHA) class IV cardiac failure, each with a left ventricular ejection fraction < 20%. They had become unresponsive to maximum pharmacological management with inotropes, diuretics and ACE inhibitors. All patients had biochemical evidence of pre-renal azotemia. Initially, patients received aggressive ultrafiltration by continuous veno-venous haemofiltration (CVVH) or one- to two-hourly peritoneal dialysis exchanges until they achieved an optimal dry body weight. Once stabilized, they were converted to an intermittent ambulatory peritoneal ultrafiltration (IAPU) regimen of one to three exchanges per 24 h according to their individual needs. During an 18 +/- 10-month follow-up, their duration of hospital confinement was reduced by 85% and all three patients improved from class IV to class II cardiac failure. IAPU may have a useful role in the long-term management of intractable heart failure in a selected group of patients.
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