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OBJECTIVE: To determine the prevalence of vitamin C (ascorbic acid [AA]) deficiency in patients with end-stage renal disease, the effect of supplemental AA on plasma AA concentrations, and the extrinsic and intrinsic factors that affect plasma AA concentrations in this patient population. DESIGN: In study 1, we compared the effect of hemodialysis (HD) on plasma AA concentrations between patients with low and high pre-HD AA concentrations. In study 2, we analyzed kinetic and nonkinetic factors for their association with increased plasma AA concentrations in patients on maintenance HD. Study 1 was performed in a single outpatient HD clinic in Cherry Hill, New Jersey. Study 2 was performed in 4 outpatient HD clinics in Southern New Jersey. SUBJECTS AND INTERVENTION: In study 1, we collected plasma samples from 8 adult patients on maintenance HD at various time points around their HD treatment and assayed them for AA concentration. In study 2, we enrolled 203 adult patients and measured pre-HD plasma AA concentrations. We ascertained supplemental AA use and assessed dietary AA intake. MAIN OUTCOME MEASURE: In study 1, plasma AA concentrations were compared during the intradialytic and interdialytic period. In study 2, pre-HD plasma AA concentrations were correlated with supplement use and demographic factors. RESULTS: Study 1 showed that over the course of a single HD treatment, the plasma AA concentration decreased by a mean (±standard deviation) of 60% (±6.6). In study 2, the median pre-HD plasma AA concentration was 15.7 µM (interquartile range, 8.7-66.8) in patients who did not take a supplement and 50.6 µM (interquartile range, 25.1-88.8) in patients who did take a supplement (P < .001). Supplement use, increasing age, and diabetes mellitus were associated with a pre-HD plasma AA concentration ≥30 µM. CONCLUSION: HD depletes plasma AA concentrations, and AA supplementation allows patients to achieve higher plasma AA concentrations.
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Deficiencia de Ácido Ascórbico/epidemiología , Ácido Ascórbico/sangre , Fallo Renal Crónico/sangre , Fallo Renal Crónico/terapia , Diálisis Renal , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Ácido Ascórbico/administración & dosificación , Deficiencia de Ácido Ascórbico/complicaciones , Complicaciones de la Diabetes , Dieta , Suplementos Dietéticos , Femenino , Humanos , Fallo Renal Crónico/complicaciones , Masculino , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
Hematuria is a common clinical manifestation of diseases affecting the urinary system. Sometimes it may not represent any underlying disease and is of no clinical significance, especially when it is transient in young adult patients. However, it may represent underlying intrinsic kidney disease or malignancy in patients, even if transient. Therefore, detection of hematuria in the appropriate clinical setting and further investigation based on the individual clinical scenario helps establish correct diagnosis and guide further management. This article discusses the etiologies and workup of hematuria.
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Hematuria/diagnóstico , Hematuria/etiología , Células Sanguíneas , Células Epiteliales , Humanos , Enfermedades Renales/diagnóstico , Enfermedades Renales/etiología , Atención Primaria de Salud , Factores de Riesgo , Toma de Muestras de OrinaRESUMEN
Immunoglobulin M (IgM) nephropathy is an uncommon glomerular disease characterized by IgM deposits in the mesangium. This case report describes a 52-year-old woman with a 10-year history of underlying systemic lupus erythematosus with minimal proteinuria who developed sudden onset of nephrotic syndrome. Renal biopsy revealed IgM nephropathy, with no clear evidence of lupus nephritis. Complements and dsDNA serologies were negative. The nephrotic syndrome resolved with prednisone therapy. Four months later, while receiving a maintenance dose of prednisone, the proteinuria relapsed. Remission was achieved after a repeat course of steroid therapy. Low-dose prednisone therapy was maintained thereafter for long-standing steroid-dependent lupus.
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Antiinflamatorios/uso terapéutico , Mesangio Glomerular/patología , Glomerulonefritis/diagnóstico , Síndrome Nefrótico/diagnóstico , Prednisona/uso terapéutico , Análisis Químico de la Sangre , Diagnóstico Diferencial , Femenino , Mesangio Glomerular/inmunología , Glomerulonefritis/tratamiento farmacológico , Glomerulonefritis/etiología , Humanos , Inmunoglobulina M/metabolismo , Riñón/patología , Lupus Eritematoso Sistémico/complicaciones , Lupus Eritematoso Sistémico/diagnóstico , Lupus Eritematoso Sistémico/tratamiento farmacológico , Persona de Mediana Edad , Síndrome Nefrótico/tratamiento farmacológico , Síndrome Nefrótico/etiología , Proteinuria/complicaciones , Proteinuria/tratamiento farmacológico , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
Background. Erythropoietin deficiency and anemia occur in Chronic Kidney Disease (CKD) and may be treated with Erythropoietin Stimulating Agents (ESAs). The optimal hemoglobin, in non-End Stage Renal Disease CKD, is controversial. Methods. We review three recent randomized trials in anemia in CKD: CHOIR, CREATE, and TREAT. Results. CHOIR (N = 1432) was terminated early with more frequent death and cardiovascular outcomes in the higher Hb group (HR 1.34: 95% C.I. 1.03-1.74, P = .03). CREATE (N = 603) showed no difference in primary cardiovascular endpoints. Stroke was more common in the higher Hb group (HR 1.92; 95% C.I. 1.38-2.68; P < .001) in TREAT (N = 4038). Conclusions. There is no benefit to an Hb outside the 10-12 g/dL range in this population. To avoid transfusions and improve Quality of Life, ESAs should be used cautiously, especially in patients with Diabetes, CKD, risk factors for stroke, and ESA resistance.
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AIM: To determine the efficacy and effects of the oral administration of ascorbic acid on anemia management in ESRD patients with hyperferritinemia. METHODS: Twenty-one anemic hemodialysis patients with ferritin levels greater than 350 ng/mL had received oral daily ascorbic acid at a dose of 500 mg/day and were retrospectively studied. Hemoglobin, hematocrit, EPO dose, ferritin, and transferrin saturation were recorded at baseline and after three months of treatment. EPO dose/hematocrit was calculated. Serum oxalate levels were also measured. RESULTS: Hb increased 9% from 11.4 to 12.2 gm/dL (p = 0.05), HCT increased 10% from 33.3 to 36.7% (p = 0.05), but EPO dose requirement decreased 33% from 26,229 to 17,559 U/week (p = 0.03). Ferritin levels decreased 21% from 873 to 691 ng/mL (p = 0.004). Mean oxalate level during therapy was 87 micromol/L (normal <27). Patients with oxalate levels >27 micromol/L were instructed to stop ascorbic acid treatment, and mean levels decreased from 107 to 19 micromol/L (p = 0.01) over a mean time of 71 days. CONCLUSION: In this study, daily oral ascorbic therapy decreased ferritin levels and EPO dose requirements while raising hemoglobin and hematocrit level. This beneficial profile of effects of ascorbic acid therapy is consistent with improvement of EPO resistance and cost savings in this population.
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Anemia/tratamiento farmacológico , Ácido Ascórbico/uso terapéutico , Trastornos del Metabolismo del Hierro/complicaciones , Fallo Renal Crónico/complicaciones , Vitaminas/uso terapéutico , Administración Oral , Anciano , Anciano de 80 o más Años , Anemia/sangre , Anemia/complicaciones , Estudios de Cohortes , Esquema de Medicación , Femenino , Ferritinas/sangre , Humanos , Trastornos del Metabolismo del Hierro/sangre , Trastornos del Metabolismo del Hierro/terapia , Fallo Renal Crónico/sangre , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Diálisis Renal , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
BACKGROUND AND OBJECTIVES: Although epoetin alfa is commonly initiated weekly (QW) in anemic chronic kidney disease (CKD) patients, recent evidence indicates that it can be initiated every 2 wk (Q2W) and used in maintenance therapy every 4 wk (Q4W). This study examined the feasibility of initiating epoetin alfa Q4W in anemic CKD patients not receiving dialysis. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This open-label study randomized subjects (1:2:2:2) to treatment with epoetin alfa 10,000 IU QW, 20,000 IU Q2W, 20,000 IU Q4W, or 40,000 IU Q4W for 16 wk. Subjects were > or =18 yr, had hemoglobin <11 g/dl, a glomerular filtration rate of 15 to 90 ml/min per 1.73 m(2), and had not received erythropoietic therapy within 8 wk. The primary analysis was a noninferiority comparison of the 40,000 IU Q4W to the 20,000 IU Q2W group in the per-protocol population with respect to hemoglobin change from baseline to the end of study. RESULTS: Of 262 subjects randomized, 229 comprised the per-protocol population. Mean hemoglobin change from baseline for the 40,000 IU Q4W group (1.24 g/dl) was not inferior to the 20,000 IU Q2W group (1.11 g/dl) with the lower limit of 95% CI, -0.21 g/dl. In the QW, 20,000 IU Q2W, 20,000 IU Q4W, and 40,000 IU Q4W groups, 90%, 87%, 75%, and 86% of subjects, respectively, achieved a hemoglobin increase > or =1 g/dl. Serious adverse events were similar across all groups. CONCLUSIONS: Epoetin alfa can be initiated Q4W in anemic CKD subjects.
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Anemia/tratamiento farmacológico , Eritropoyetina/administración & dosificación , Hematínicos/administración & dosificación , Enfermedades Renales/complicaciones , Anciano , Anciano de 80 o más Años , Anemia/sangre , Anemia/etiología , Enfermedad Crónica , Esquema de Medicación , Epoetina alfa , Transfusión de Eritrocitos , Eritropoyetina/efectos adversos , Estudios de Factibilidad , Femenino , Ferritinas/sangre , Hematínicos/efectos adversos , Hemoglobinas/metabolismo , Humanos , Inyecciones Subcutáneas , Compuestos de Hierro/administración & dosificación , Enfermedades Renales/sangre , Enfermedades Renales/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Proteínas Recombinantes , Transferrina/metabolismo , Resultado del Tratamiento , Estados UnidosRESUMEN
There are limited data suggesting that initiation of epoetin alfa at extended dosing intervals of every 2, 3, or 4 wk may be efficacious for treating anemia in patients who have chronic kidney disease and are not on dialysis (CKD-NOD). This open-label, multicenter, single-arm study investigated the efficacy of administration of 20,000 IU of epoetin alfa once every 2 wk as initiation therapy in these patients. Adults with CKD-NOD were eligible when they had hemoglobin (Hb) <11 g/dl, GFR of 10 to 60 ml/min per 1.73 m2, and stable serum creatinine for the past 6 mo. Patients received 20,000 IU of epoetin alfa subcutaneously every 2 wk for up to 27 wk, with dosage adjustments permitted after 4 wk of treatment. The primary efficacy end point was the proportion of patients with Hb response, defined as achievement of the target Hb range of 11 to 12 g/dl for at least two consecutive visits. Sixty-seven patients were enrolled; >88% (59 of 67) of patients achieved an Hb response. Mean Hb increased to the targeted range by week 6 and remained in the range through week 28. Hb increases of 1 and 2 g/dl were observed in 91 and 78% of patients, respectively. Epoetin Alfa was well tolerated; most adverse events were mild or moderate in nature and typical of the CKD patient population. In this study, results demonstrated that epoetin alfa can be initiated safely and effectively at an extended dosing interval of 20,000 IU every 2 wk in patients with CKD-NOD.
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Anemia/tratamiento farmacológico , Anemia/etiología , Eritropoyetina/administración & dosificación , Hematínicos/administración & dosificación , Enfermedades Renales/complicaciones , Anciano , Enfermedad Crónica , Esquema de Medicación , Epoetina alfa , Femenino , Humanos , Masculino , Proteínas RecombinantesRESUMEN
Nocardia otitidiscaviarum is an uncommon human pathogen and a rare cause of pulmonary infection and bacteremia. We report a case of N. otitidiscaviarum bacteremia and pulmonary infection in a patient with end-stage renal disease (chronic kidney disease, stage 5) and sickle cell anemia. The epidemiology, pathogenesis, and treatment of Nocardia infections are discussed.
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Anemia de Células Falciformes , Fallo Renal Crónico , Enfermedades Pulmonares , Nocardiosis , Nocardia , Anemia de Células Falciformes/complicaciones , Animales , Antibacterianos/uso terapéutico , Comorbilidad , Femenino , Humanos , Fallo Renal Crónico/complicaciones , Enfermedades Pulmonares/diagnóstico , Enfermedades Pulmonares/microbiología , Enfermedades Pulmonares/terapia , Nocardiosis/diagnóstico , Nocardiosis/microbiología , Nocardiosis/terapiaRESUMEN
BACKGROUND: The timing of medical therapies has been shown to influence the outcomes and side effects of treatments for disease. This report examines the extent to which hemodialysis treatment time of day was associated with cardiovascular mortality and morbidity and all-cause mortality in a secondary analysis of the Hemodialysis Study. METHODS: Dialysis start time defined dialysis shift: morning beginning between 0400 and 0930 hours (n = 822); midday, between 0930 and 1530 hours (n = 851); and evening, between 1530 and 2200 hours (n = 172). Outcome measures included all-cause mortality, cardiac death, composite end point of all-cause mortality or first cardiac hospitalization, and composite end point of first cardiac hospitalization or cardiac death. RESULTS: Morning hemodialysis was associated with a lower likelihood of cardiovascular events compared with the evening shift in all-cause mortality or first cardiac hospitalization (evening versus morning, relative risk [RR], 1.29; 95% confidence interval [CI], 1.01 to 1.65; P = 0.043), as well as first cardiac hospitalization or cardiac death (evening versus morning, RR, 1.44; 95% CI, 1.11 to 1.89; P = 0.007). No differences were noted in the other 2 outcomes, and there was no statistically significant difference between the morning and midday shifts. Although crude mortality rates were greater in the midday compared with morning (RR, 1.21; 95% CI, 1.05 to 1.39; P = 0.008), this association was attenuated after adjustment (RR, 1.04; 95% CI, 0.89 to 1.22; P = 0.64). CONCLUSION: Making extensive adjustment for patient characteristics, this report does not support the association of lower all-cause mortality with morning hemodialysis or a particular benefit for older patients.
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Enfermedades Cardiovasculares/epidemiología , Diálisis Renal , Enfermedades Cardiovasculares/etiología , Ritmo Circadiano , Femenino , Estudios de Seguimiento , Humanos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Estudios Multicéntricos como Asunto , Ensayos Clínicos Controlados Aleatorios como Asunto , Tasa de Supervivencia , Factores de TiempoRESUMEN
A sensitive and reproducible method to determine the in vitro infectious potency of a pentavalent reassortant rotavirus vaccine (RotaTeq) has been developed as an alternative to classical potency assays. Potency was determined based on cell-based viral replication followed by quantitative reverse-transcription polymerase chain reaction (RT-QPCR) analysis. In the assay, confluent Vero cell monolayers in 96-well plates were inoculated with serial dilutions of test samples, a pentavalent reassortant rotavirus reference standard and assay controls, followed by incubation for 24h. The cells were lysed with a Triton X-100 solution and the lysates assayed by RT-QPCR to quantitate viral nucleic acid produced during replication. The RT-QPCR utilizes primer/probe sets specific to each virus reassortant and the potencies of each sample were determined relative to the reference standard. This assay, hereafter referred to as the Multivalent QPCR-Based Potency Assay (M-QPA), permits the specific quantitation of each individual reassortant virus in the presence of the other four reassortant viruses. In addition, the assay was demonstrated to be concordant with a traditional method (plaque assay) for the quantitation of infectious virus particles. It is anticipated that assays of this type will become a valuable tool in the assignment of potency values and in the monitoring of stability of live virus vaccines.
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ARN Viral/análisis , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa/métodos , Vacunas contra Rotavirus , Rotavirus , Vacunas Atenuadas , Animales , Chlorocebus aethiops , Rotavirus/genética , Rotavirus/fisiología , Vacunas contra Rotavirus/genética , Vacunas Atenuadas/genética , Células Vero , Ensayo de Placa Viral , Replicación ViralRESUMEN
BACKGROUND: It has been widely supposed that high dose and high flux hemodialysis would affect the quality as well as the length of life of patients treated by maintenance hemodialysis. The HEMO Study examined changes in health-related quality of life as a secondary study outcome. Specific hypotheses were that study interventions would affect physical functioning, vitality, Short Form-36 Health Survey (SF-36) physical and mental component summary scores, symptoms and problems associated with kidney disease, and sleep quality. METHODS: At baseline and annually, subjects responded to both the Index of Well-Being and the Kidney Disease Quality of Life-Long Form questionnaires. The interventions were assessed on the basis of their average effects over 3 years. RESULTS: At baseline, the SF-36 physical component summary score was lower than in healthy populations, but the mental component score was nearly normal. Over 3-year follow-up, physical health continued to decline; mental health and kidney disease-targeted scores remained relatively stable. The high dose hemodialysis intervention was associated with significantly less pain (4.49 points, P < 0.001) and higher physical component scores (1.23 points P= 0.007), but these effects were small compared to the natural variability in scores. High flux membranes were not associated with statistically significant differences in health-related quality of life. CONCLUSION: The HEMO Study results demonstrate the marked burden of chronic kidney failure and hemodialysis treatment on daily life. In this trial among patients undergoing maintenance three times a week hemodialysis, the SF-36 physical component summary score and pain scale showed significant but very small clinical effects favoring the higher dialysis dose. No clinically meaningful benefits or either the dose or flux interventions were observed for other indices of health-related quality of life.
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Difusión , Estado de Salud , Fallo Renal Crónico/terapia , Membranas Artificiales , Calidad de Vida , Diálisis Renal , Anciano , Femenino , Humanos , Fallo Renal Crónico/fisiopatología , Fallo Renal Crónico/psicología , Masculino , Salud Mental , Persona de Mediana Edad , Dolor/etiología , Dolor/fisiopatología , Diálisis Renal/efectos adversos , Diálisis Renal/instrumentación , Encuestas y Cuestionarios , Análisis de SupervivenciaRESUMEN
UNLABELLED: BACKGROUND; Despite technical progress in therapy, hemodialysis patients continue to report health-related quality of life (HRQOL) substantially lower than that of the general population. While African Americans with end-stage renal disease (ESRD) survive longer than members of other races, few studies have compared the HRQOL of African Americans with that of non-African Americans. METHODS: We examined differences in sociodemographic, clinical, and HRQOL variables by race. A multiple regression model assessed the extent to which race was associated with differences in HRQOL scores after adjustment for sociodemographic and clinical variables. Racial differences in the relationship between comorbid disease severity and HRQOL were explored. RESULTS; In adjusted models, African Americans had higher scores in the Index of Well-Being and burden of kidney disease, but lower scores in cognitive function (all P < 0.05). For scales reflecting symptoms and effects of kidney disease, sleep quality, and the Physical Component Summary, the fall in HRQOL with increasing comorbidity was significantly greater in non-African Americans (all P < 0.05). After adjustment, there were no racial differences in scores on the Mental Component Summary, social support, dialysis staff encouragement, or patient satisfaction. CONCLUSION: To our knowledge, ESRD is the only chronic illness for which African Americans report significantly better psychologic well being and a lower burden of disease than non-African Americans. Further research is needed to understand whether these experiences affect health care utilization, medical decision making, and patient survival. Clarification of the reasons for race differences may suggest measures to improve HRQOL for all patients with ESRD.
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Negro o Afroamericano , Estado de Salud , Fallo Renal Crónico/etnología , Fallo Renal Crónico/terapia , Calidad de Vida , Diálisis Renal , Adulto , Anciano , Cognición , Comorbilidad , Costo de Enfermedad , Femenino , Humanos , Fallo Renal Crónico/fisiopatología , Fallo Renal Crónico/psicología , Masculino , Persona de Mediana Edad , SueñoRESUMEN
ABSTRACT. Examined is the relationship of patient-reported health-related quality of life (HRQOL) to the mode of survey administration in the Hemodialysis Study. In addition to self-administered surveys to assess HRQOL, interviewer-administered surveys were made available to include patients with poor vision, decreased manual dexterity, or strong preference. For examining the predictors of participation by self-administration of the survey, multiple logistic regression was performed. For examining the relationship of HRQOL results to mode of survey administration, adjusted differences between the self-administered and interviewer-administered groups were obtained from multiple linear regression models accounting for sociodemographic and case-mix factors. A total of 978 of the first 1000 subjects in the Hemodialysis Study completed the survey by interview (n = 427) or by self-administration (n = 551). The interviewer-administered group was older, was more likely black, had longer duration of ESRD, had a higher prevalence of diabetes, and had more severe comorbidity (all P < 0.01). After adjustment for these differences, patients in the interviewer-administered group had higher scores on scales that measured Role-Physical, Role-Emotional, and Effects of Kidney Disease (all P < 0.001). Dialysis studies that restrict HRQOL measurement to patients who are able to complete surveys without assistance will not accurately represent the health of the overall hemodialysis population. Clinical studies and clinical practices using HRQOL as an outcome should include interviewer administration or risk a selection bias against subjects with older age, minority status, and higher level of comorbidity. Future investigation should include research of survey modalities with a low response burden such as telephone interview, computer-assisted interview, and proxy administration.
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Diálisis Renal/psicología , Adolescente , Adulto , Anciano , Femenino , Humanos , Enfermedades Renales/diagnóstico , Enfermedades Renales/patología , Modelos Lineales , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Calidad de Vida , Distribución Aleatoria , Factores de TiempoRESUMEN
BACKGROUND: Neurons in the dorsal spinal cord play important roles in nociception and pain. These neurons receive input from peripheral sensory neurons and then transmit the signals to the brain, as well as receive and integrate descending control signals from the brain. Many molecules important for pain transmission have been demonstrated to be localized to the dorsal horn of the spinal cord. Further understanding of the molecular interactions and signaling pathways in the dorsal horn neurons will require a better knowledge of the molecular neuroanatomy in the dorsal spinal cord. RESULTS: A large scale screening was conducted for genes with enriched expression in the dorsal spinal cord using DNA microarray and quantitative real-time PCR. In addition to genes known to be specifically expressed in the dorsal spinal cord, other neuropeptides, receptors, ion channels, and signaling molecules were also found enriched in the dorsal spinal cord. In situ hybridization and immunohistochemistry revealed the cellular expression of a subset of these genes. The regulation of a subset of the genes was also studied in the spinal nerve ligation (SNL) neuropathic pain model. In general, we found that the genes that are enriched in the dorsal spinal cord were not among those found to be up-regulated in the spinal nerve ligation model of neuropathic pain. This study also provides a level of validation of the use of DNA microarrays in conjunction with our novel analysis algorithm (SAFER) for the identification of differences in gene expression. CONCLUSION: This study identified molecules that are enriched in the dorsal horn of the spinal cord and provided a molecular neuroanatomy in the spinal cord, which will aid in the understanding of the molecular mechanisms important in nociception and pain.