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INTRODUCTION: Medical students should be familiar with the end of life ethical issues and its considerations. For teaching end of life care to medical students, literature is a source of excellent narratives of patients with experiences of terminally ill condition in their journey through suffering and one of the most favourite bioethics literature readings has been the death of Ivan Ilych by Tolstoy. We used this novel to show medical students end of life events and suffering and asked them to write a reflective essay on it. We aimed to find what students think about terminally ill patients and their journey to death. METHODS: In an inductive qualitative content analysis model, 350 essays, collected by homogenous sampling, were analyzed. The fourth year medical students were provided with the Death of Ivan Ilych novel to read. They were asked to write a reflection essay based on the reflective stages defined by Sandars. These essays served as the unit of analysis, each being read several times and a coding model was formed according to main topics. The related concepts in each unit were named as themes and each theme was abstracted to a code and the related codes were compared and developed as categories. RESULTS: Qualitative content analysis of 350 essays of fourth year medical students revealed three major categories in students' reflection on reading Death of Ivan Ilych as an end of life human body. These included: 1) Emotional experience, 2) Empathy and effective communication, 3) Spirituality and dignity. Analysis of essays showed that this reflection activity may help medical students have a deeper idea of the end of life situation and feelings. CONCLUSION: This project suggests that literature can be used as an example to introduce new ethical concepts to less experienced medical trainees. The students acquired the concept of the story and reflected the major aspects of the suffering of a human being in their essays. Having used and evaluated the effect of literature on facilitating ethical insight in the teaching end of life care, we strongly recommend this method and specially the novella, Death of Ivan Ilych.
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INTRODUCTION: Uremic pruritus is one of the most common disabling symptoms in patients with end-stage renal disease. We aimed to study the effect of montelukast sodium for the treatment of uremic pruritus lasting more than 3 months in patients undergoing hemodialysis and compare it with placebo. METHODS AND MATERIALS: Eighty patients undergoing hemodialysis at 3 centers in Shiraz, Iran, were recruited to a randomized double-blinded controlled trial to receive 10 mg of montelukast or placebo, daily for 30 days. To assess the severity of pruritus, a visual analogue scale and the Detailed Pruritus Score, based on a combined score of severity and distribution of pruritus and sleep disturbance, were used. Sleep disturbance, severity, and distribution scores were added up to calculate the patients' final score at the start and the end of the study. RESULTS: The mean reduction of visual analogue scale score was significantly greater in the montelukast group (2.73 ± 2.03) compared to that in the placebo group (5.47 ± 2.37, P < .001). Mean reduction in Detailed Pruritus Score was also greater in the montelukast group (3.24 ± 2.2 versus 6.44 ± 3.25, respectively, P < .001). The mean high-sensitivity C-reactive protein in the montelukast group decreased from 5.48 ± 3.86 µg/mL to 3.86 ± 3.58 µg/mL, while it increased in the placebo group from 6.69 ± 4.49 µg/mL to 8.14 ± 5.20 µg/mL. CONCLUSIONS: Montelukast can be an add-on therapy in uremic pruritus, especially when pruritus is refractive to other treatments.
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Acetatos , Fallo Renal Crónico/complicaciones , Prurito , Quinolinas , Diálisis Renal , Uremia , Acetatos/administración & dosificación , Acetatos/efectos adversos , Adulto , Proteína C-Reactiva/análisis , Ciclopropanos , Monitoreo de Drogas , Femenino , Humanos , Fallo Renal Crónico/terapia , Antagonistas de Leucotrieno/administración & dosificación , Antagonistas de Leucotrieno/efectos adversos , Masculino , Persona de Mediana Edad , Prurito/diagnóstico , Prurito/tratamiento farmacológico , Prurito/etiología , Quinolinas/administración & dosificación , Quinolinas/efectos adversos , Diálisis Renal/efectos adversos , Diálisis Renal/métodos , Sulfuros , Resultado del Tratamiento , Uremia/diagnóstico , Uremia/etiologíaRESUMEN
BACKGROUND: This study aimed to assess the psychometric properties of the Persian version of the Ferrans and Powers 3.0 quality of life index (dialysis type) in patients receiving hemodialysis (HD) in order to describe their health-related quality of life (HRQOL). METHODS: The sample (n = 150) consisted of adult HD patients receiving HD for at least 6 months from the establishment of the study. A total of 88 men and 62 women, with an average age of 50.47, from Shiraz, southern Iran, were enrolled in this study. The questionnaire was translated into Persian language using back translation and bilingual techniques. Convergent, discriminant, and construct validity of the Ferrans and Powers 3.0 dialysis version was evaluated. To check the internal consistency of the data, Cronbach's alpha, which indicates the reliability of the data, was used for the entire questionnaire and for the subscales. RESULTS: The convergent and discriminant validity and success scaling rate for both sexes were 100 %. Cronbach's alpha was 0.95 overall, which was greater than 0.7 for all the subscales except for the family subscale. Our results suggest that HD patients in southern Iran have higher HRQOL scores when compared with those in other countries. Despite the higher mean HRQOL score for men compared with women, men had significantly higher HRQOL scores only in the health and functioning subscale. There was no significant correlation between HD patients' HRQOL and educational level. CONCLUSION: The Persian version of Ferrans and Powers 3.0 has sufficient reliability and validity for measuring the quality of life of Persian-speaking HD patients. Female HD patients need more support and attention from family and society.
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Fallo Renal Crónico/terapia , Calidad de Vida , Diálisis Renal , Encuestas y Cuestionarios , Adulto , Anciano , Escolaridad , Femenino , Humanos , Irán , Fallo Renal Crónico/psicología , Masculino , Persona de Mediana Edad , Psicometría , Diálisis Renal/psicología , Reproducibilidad de los Resultados , Factores Sexuales , TraduccionesRESUMEN
Cytokines are important factors determining the outcome of transplantation since host ability in cytokine production may be affected by cytokine gene polymorphisms. The aim of the present study was to investigate the effect of IL-17, IL-23R and IL-21 gene polymorphisms in the outcome of kidney transplantation. A total of 250 kidney transplant recipients were included in this study. Overall 70 recipients (28%) experienced an acute rejection. IL-17 197 A/G, IL-21+1472 G/T, IL-21 5250 C/T, and IL-23R C/T gene polymorphisms were evaluated by PCR-RFLP or ARMS-PCR methods. The serum levels of IL-17 and IL-21 were also checked by ELISA. IL-17 GG carriers and G allele were significantly more frequent in patients with acute rejection as compared to patients without any sign of rejection (P=0.045 and P=0.032, respectively). In addition after gender classification, IL-23R AA carriers and A allele were significantly more frequent in male patients who experienced an acute rejection as compared to non-rejected patients (P=0.03, P=0.011, respectively). The IL-17 serum levels have also shown significant differences between rejected and non-rejected groups (24.37±32.94 for AR and 8.6±9.9 for non-AR groups, respectively; P=0.035). The mentioned results indicate that IL-17GG genotype, G allele and its serum level have predictive values for acute rejection. GG genotype and G allele of IL-17 is a genetic risk factor for development of acute rejection. Also, AA genotype and A allele of IL-23R is a sex dependent genetic risk factor for the development of acute rejection, but this subject needs to be studied in a different population.
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Citocinas/metabolismo , Rechazo de Injerto/diagnóstico , Rechazo de Injerto/inmunología , Trasplante de Riñón , Receptores de Interleucina/genética , Enfermedad Aguda , Adolescente , Adulto , Anciano , Aloinjertos/inmunología , Niño , Citocinas/genética , Femenino , Regulación de la Expresión Génica , Frecuencia de los Genes , Predisposición Genética a la Enfermedad , Genotipo , Rechazo de Injerto/genética , Humanos , Masculino , Persona de Mediana Edad , Polimorfismo Genético , Pronóstico , Factores de Riesgo , Factores Sexuales , Resultado del Tratamiento , Adulto JovenRESUMEN
INTRODUCTION: Metabolic complications are common after kidney transplantation and can cause considerable morbidity and even threaten graft function. This study aimed to investigate the prevalence of hyperlipidemia and its impact on graft function in 10 years of follow-up of patients undergoing kidney transplantation. MATERIALS AND METHODS: This prospective study was conducted on 73 patients who underwent kidney transplantation between April 1996 and April 1998 to evaluate their lipid profile and graft function as well as the effect of hyperlipidemia in long-term kidney allograft function. Kidney allograft dysfunction was defined as a serum creatinine level greater than 1.8 mg/dL. RESULTS: The mean serum triglyceride level was higher at 1, 3, 5, and 10 years, but not 7 years, among patients with graft dysfunction in comparison with patients with normal graft function. However, these differences were not significant. The mean serum total cholesterol level was significantly higher in patients with graft dysfunction at 1 year (P = .03). Of the patients with graft dysfunction, 94.7% developed hypercholesterolemia at the first year visit, as compared to 70.4% of patients with normal graft function (P = .03). The frequency of hypercholesterolemia was higher among those with a serum creatinine greater than 1.8 mg/dL at all other visits, but without significant difference. CONCLUSIONS: Hyperlipidemia is common after kidney transplantation, especially in the first year after transplantation. Higher serum total cholesterol levels might be related to graft dysfunction.
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Colesterol/sangre , Creatinina/sangre , Hiperlipidemias/complicaciones , Enfermedades Renales/fisiopatología , Trasplante de Riñón/efectos adversos , Riñón/fisiopatología , Triglicéridos/sangre , Adolescente , Adulto , Anticolesterolemiantes/uso terapéutico , Femenino , Estudios de Seguimiento , Humanos , Hipercolesterolemia/sangre , Hipercolesterolemia/complicaciones , Hiperlipidemias/sangre , Hiperlipidemias/tratamiento farmacológico , Hipolipemiantes/uso terapéutico , Enfermedades Renales/sangre , Enfermedades Renales/etiología , Trasplante de Riñón/fisiología , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Adulto JovenRESUMEN
INTRODUCTION. This study aimed to compare outcomes of kidney transplantation in patients with systemic lupus erythematosus (SLE) and a matched control group of non-SLE kidney recipients. MATERIALS AND METHODS. In a case-control study, 33 patients with kidney transplantation due to end-stage renal disease caused by SLE were matched to a control group consisted of 33 non-SLE patients who had been transplanted during the same period of time in our center. The clinical characteristics, complications, and patient and graft survival were compared between the two groups. RESULTS. In each group, 12 patients (36.4%) received a kidney from a deceased donor, 15 (45.4%) from a living unrelated donor, and 6 (18.2%) from a living related donor. There was no significant difference between the outcome in SLE patients and duration of dialysis before transplantation. The mean duration of hospital stay was 23.4 ± 18.1 days in the SLE group, while it was 13.0 ± 7.3 days in the controls (P = .006). One-year graft survival was 79.0% in patients with SLE and 90.9% in non-SLE patients (P = .17). One-year patient survival was 93.9% in patients with SLE versus 81.8% in the controls (P = .26). Nine patients in the SLE group versus 11 patients in the control group developed posttransplant complications (P = .59). CONCLUSIONS. Although hospital stay after transplantation was longer in the SLE kidney recipients than controls, safety of kidney transplantation was comparable. Graft failure in the SLE patients was not significantly different between patients with different sources of kidneys.
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Fallo Renal Crónico/etiología , Fallo Renal Crónico/cirugía , Trasplante de Riñón , Lupus Eritematoso Sistémico/complicaciones , Adulto , Estudios de Casos y Controles , Femenino , Supervivencia de Injerto , Humanos , Tiempo de Internación/estadística & datos numéricos , Masculino , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
We present an unusual case of a chronic hemodialysis patient with moderate diffuse acrocyanosis and prominent unilateral clubbing of his right hand fingers, with classic physical features of hypertrophic osteoarthropathy. The patient's left hand, which had a functioning arteriovenous fistula, did not show any evidence of clubbing. We briefly discuss the different theories in regards to the pathogenesis of clubbing, and the potential role of arteriovenous fistula in preventing its occurrence.
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Dedos/patología , Fallo Renal Crónico/complicaciones , Osteoartropatía Hipertrófica Secundaria/etiología , Diálisis Renal/efectos adversos , Adulto , Cianosis/etiología , Cianosis/patología , Humanos , Fallo Renal Crónico/sangre , Fallo Renal Crónico/terapia , Masculino , Osteoartropatía Hipertrófica Secundaria/sangre , Osteoartropatía Hipertrófica Secundaria/patología , Resultado del TratamientoRESUMEN
BACKGROUND: Generalized pruritus is a significant complication in end-stage renal disease patients. The mechanism is unknown and most treatments are ineffective. This study is the first clinical trial designed to evaluate the effect of cromolyn sodium (CS) on renal itch. METHODS: Sixty-two haemodialysis (HD) patients with pruritus were enrolled into the study and were randomly assigned to receive CS or placebo (135 mg three times daily) for 8 weeks. Patients were asked to record the severity of their pruritus on each dialysis session on a visual analogue scale (VAS) during the 8 weeks of treatment and 4 weeks following discontinuation of treatment. Serum tryptase levels were determined at baseline, after 8 weeks of treatment and 4 weeks after discontinuation of treatment. RESULTS: Data were analysed in 21 patients in the CS group and 19 patients in the placebo group that completed the study. A significant difference was seen in the severity of pruritus between the two groups during the period of study. Level of pruritus decreased from 8.48 +/- 2.2 to 0.9 +/- 1.8 after 8 weeks of treatment with CS. Geometric mean of serum tryptase at baseline and 8 weeks after treatment were 21.3 and 19.5 ng/ml for the CS group and 18.03 and 18.2 ng/ml for the placebo group, respectively. Although the geometric mean of tryptase had decreased in the CS group, this decrease was not statistically significant (P = 0.214). CONCLUSION: CS can significantly reduce the severity of pruritus in HD patients, but this effect is not due to a decrease in serum tryptase level.
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Cromolin Sódico/uso terapéutico , Enfermedades Renales/complicaciones , Prurito/tratamiento farmacológico , Triptasas/sangre , Administración Oral , Adulto , Anciano , Enfermedad Crónica , Cromolin Sódico/administración & dosificación , Método Doble Ciego , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prurito/sangreRESUMEN
BACKGROUND: Pancreas transplantation is the treatment of choice for selected patients with type 1 diabetes mellitus. We reviewed our first 40 patients who underwent pancreas transplantation in Shiraz Organ Transplant Center. METHODS: Between April 2006 and April 2008, we performed pancreas transplantation on 40 recipients. The operation included portal venous drainage and exocrine enteric drainage. Immunosuppressive therapy included prednisolone, tacrolimus, and mycophenolate mofetil. Ganciclovir was administered as prophylaxis for cytomegalovirus. Peri-operative and regular follow up data on survival and complication were gathered and analyzed. RESULTS: The mean follow-up was 10.1+/-6.5 months (range: 1 - 24 months). Mean age of donors and recipients was 23.6+/-8.2 and 32.30+/-8.9 years, respectively. The mean pretransplant insulin consumption was 43.75+/-17.4 IU. Fasting blood glucose before transplantation was 275.5+/-72.3 mg/dL that decreased to 95.6+/-7.01 at six months follow-up (P<0.001). Complications were as follows: re-exploration (n=9), gastrointestinal complications (n=10), acute rejection episodes (n=12), and chronic rejection (n=4). We lost one patient due to diffuse cytomegalovirus and aspergillus infection three months after the operation with a functioning graft. Overall graft survival was 84.9% and patient survival 97.5%. CONCLUSION: Good patient and graft survival in these series encouraged us to continue the program with all its difficulties.
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Diabetes Mellitus Tipo 1/cirugía , Trasplante de Páncreas/efectos adversos , Adolescente , Adulto , Femenino , Supervivencia de Injerto , Humanos , Inmunosupresores/uso terapéutico , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Adulto JovenRESUMEN
Data regarding the socioeconomic status in Iranian kidney transplant (KT) recipients is lacking. In this cross sectional descriptive study we evaluated the socio-economic status of 100 KT recipients in Shiraz organ transplantation center. In a cross-sectional design, we randomly selected and interviewed 100 RT recipients (50 males and 50 females). Data regarding age, gender, martial status, occupation, level of education, number of children, type of insurance, monthly household income, place of residence, ownership of a personal transportation device, duration and frequency of pre-transplant dialysis, family history of CRF (Chronic renal failure), and etiology of renal disease were obtained. There were 50 (50%) patients aged between 16 and 35 years, 55 had a family history of CRF, 60 had been on dialysis for more than a year, 61 were married, 47 did not have any children, 41 had more than 3 children, and 65 were unemployed due to physical and emotional impairment as a result of their disease. The majority (73%) did not have a high school diploma, 15% were illiterate, 85% were below the poverty line, 52% were from rural areas, and 98% were covered by insurance. We conclude that patients with CKD in our study had acquired this condition possibly due to negligence and lack of basic health care in the lower socioeconomic class. In addition, KT is an available therapeutic modality to lower socio-economic level in Iran.
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Trasplante de Riñón/estadística & datos numéricos , Clase Social , Factores Socioeconómicos , Adolescente , Adulto , Estudios Transversales , Femenino , Humanos , Técnicas In Vitro , Entrevistas como Asunto , Irán , Fallo Renal Crónico/cirugía , Persona de Mediana EdadRESUMEN
Autosomal dominant polycystic kidney disease (ADPKD) is a common cause of end-stage renal disease and a common indication for renal transplantation. Patients with ADPKD show some differences in graft outcome and complications following renal transplantation. This study was undertaken to evaluate the demographics, outcome and complications of renal transplantation in patients with ADPKD. In a retrospective case-control design, 51 patients with ADPKD were recognized amongst a total of 1200 renal transplant patients. For each case, a matched control based on sex, age (+/- 5 years) and type of kidney donor, was selected. All relevant data were gathered using patients' records and PNOT software. There were 34 males (66.7%) and 17 females (33.3%) with ADPKD. Mean age at transplantation was 42.6 +/- 14.3 years and source of donor organ was predominantly live unrelated (72.5%). Forty patients (78.4%) had extra-renal manifestations of ADPKD, the most common of which were cardiac valvular disease (24 cases, 47.1%), and liver cysts (10 cases, 19.6%). Rejection occurred in 12 patients in the case-group (23.5%) in comparison to nine patients (17.6%) in the control group (p > 0.05). Twenty-nine cases (56.9%) did not develop any complications. The common complications noted after transplantation included infections (15.7% in cases vs 19.6% in controls), and cerebrovascular accidents (13.7% in cases vs 16.6% in controls). Patient outcome after short- and long-term follow-up was slightly better in the ADPKD population than the control group; however, it was not statistically significant. Also, no complication was found to occur more frequently in ADPKD patients.
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Trasplante de Riñón/fisiología , Riñón Poliquístico Autosómico Dominante/cirugía , Adulto , Anciano , Femenino , Humanos , Trasplante de Riñón/mortalidad , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Análisis de Supervivencia , Sobrevivientes , Resultado del TratamientoRESUMEN
With increasing long-term graft survival and life-long immunosuppression, cardiovascular disease and infectious complications are major causes of morbidity and mortality. We retrospectively evaluated 1200 consecutive kidney transplant patients at Shiraz Organ Transplant Center from December 1988 to December 2003. Data on demographic profile, donor source, blood pressure, rejection episodes, cause of death, and hematological and biochemical serum profiles were collected to compare alive and dead recipients. One hundred fifty six patients (13%) died in the post transplant period. Patient death was more prominent during the first years after transplantation. Most common causes of death were cardiovascular (28.3%), graft loss (20.7%), and infection (19.6%). Post transplant systolic and diastolic blood pressures, BUN, creatinine, fasting blood sugar, and total cholesterol were higher, and serum HDL lower in the dead recipients than those who remained alive (P< 0.05). No significant difference was found in LDL, hemoglobin, and triglyceride values between the two groups. The one- and three-year patient survival rates were 94% and 91.5%, respectively. We conclude that the patients who died after transplantation had more risk factors than stable patients who remain alive. A multidisciplinary approach to control the co-morbid factors could be beneficial to decrease the mortality of patients after renal transplantation.