We studied all new patients accepted for renal replacement therapy (RRT) in one unit from 1/1/96 to 31/12/97 (n = 198), to establish time from nephrology referral to RRT, evidence of renal disease prior to referral and the adequacy of renal management prior to referral. Sixty four (32.3%, late referral group) required RRT within 12 weeks of referral. Fifty-nine (29.8%) had recognizable signs of chronic renal failure > 26 weeks prior to referral. Patients starting RRT soon after referral were hospitalized for significantly longer on starting RRT (RRT within 12 weeks of referral, median hospitalization 25.0 days (n = 64); RRT > 12 weeks after referral, median 9.7 days (n = 126), (p < 0.001)). Observed survival at 1 year was 68.3% overall, with 1-year survival of the late referral and early referral groups being 60.5% and 72.5%, respectively (p = NS). Hypertension was found in 159 patients (80.3%): 46 (28.9%) were started on antihypertensive medication following referral, while a further 28 (17.6%) were started on additional antihypertensives. Of the diabetic population (n = 78), only 26 (33.3%) were on an angiotensin-converting-enzyme inhibitor (ACEI) at referral. Many patients are referred late for dialysis despite early signs of renal failure, and the pre-referral management of many of the patients, as evidenced by the treatment of hypertension and use of ACEI in diabetics, is less than optimal. (+info)
Ex vivo evaluation of a Taylor-Couette flow, immobilized heparinase I device for clinical application.
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Efficient and safe heparin anticoagulation has remained a problem for continuous renal replacement therapies and intermittent hemodialysis for patients with acute renal failure. To make heparin therapy safer for the patient with acute renal failure at high risk of bleeding, we have proposed regional heparinization of the circuit via an immobilized heparinase I filter. This study tested a device based on Taylor-Couette flow and simultaneous separation/reaction for efficacy and safety of heparin removal in a sheep model. Heparinase I was immobilized onto agarose beads via cyanogen bromide activation. The device, referred to as a vortex flow plasmapheretic reactor, consisted of two concentric cylinders, a priming volume of 45 ml, a microporous membrane for plasma separation, and an outer compartment where the immobilized heparinase I was fluidized separately from the blood cells. Manual white cell and platelet counts, hematocrit, total protein, and fibrinogen assays were performed. Heparin levels were indirectly measured via whole-blood recalcification times (WBRTs). The vortex flow plasmapheretic reactor maintained significantly higher heparin levels in the extracorporeal circuit than in the sheep (device inlet WBRTs were 1. 5 times the device outlet WBRTs) with no hemolysis. The reactor treatment did not effect any physiologically significant changes in complete blood cell counts, platelets, and protein levels for up to 2 hr of operation. Furthermore, gross necropsy and histopathology did not show any significant abnormalities in the kidney, liver, heart, brain, and spleen. (+info)
Incidence of analgesic nephropathy in Berlin since 1983.
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BACKGROUND: Phenacetin was removed from the German market in 1986 and was replaced mainly in analgesic compounds by acetaminophen. Our objective was to examine the effect of this measure on the incidence of analgesic nephropathy in light of the changes in other end-stage renal diseases. METHODS: We therefore compared the proportion of renal diseases in all patients starting dialysis treatment during three 18-month periods: 4/1982-9/1983 (n=57); 1/1991-6/1992 (n=81); and 10/1995-3/1997 (n=76). RESULTS: On the one hand, the proportion of end-stage analgesic nephropathy decreased significantly from 30% in 1981-1982 to 21% in 1991-1992 and 12% in 1995-1997 (P=0.01). On the other hand, type II diabetes increased significantly from 7% to 22% (P=0.01) and 29%, (P=0.001). Using the chi2 distribution test to analyze the frequencies of seven diseases at three different time intervals, however, showed that the changes in renal-disease proportions between 1982-1983, 1991-1992 and 1995-1997 were not significantly independent. There was a significant median age increase from 52 years (CI0.95 44-58) in 1982-1983 to 63 (CI0.95 55-67) in 1991-1992 and 63 (CI0.95 60-66) in 1995-1997 (P=0.003) for all patients starting dialysis but not for those with analgesic nephropathy [59 (55-71) vs 64 (53-67) and 61 (50-72); n.s.]. CONCLUSION: The decrease of end-stage analgesic nephropathy since 1983 may be partially due to the removal of phenacetin from the German market in 1986. However, considering the general increase in numbers of dialysis patients, their higher age and the increased incidence of type II diabetes, the decrease in analgesic nephropathy is not a statistically significant independent variable. Altered admittance policies for dialysis treatment have yielded a new pattern of renal-disease proportion which interferes with changes in the incidence of analgesic nephropathy. (+info)
La roca magica: uses of natural zeolites in agriculture and industry.
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For nearly 200 years since their discovery in 1756, geologists considered the zeolite minerals to occur as fairly large crystals in the vugs and cavities of basalts and other traprock formations. Here, they were prized by mineral collectors, but their small abundance and polymineralic nature defied commercial exploitation. As the synthetic zeolite (molecular sieve) business began to take hold in the late 1950s, huge beds of zeolite-rich sediments, formed by the alteration of volcanic ash (glass) in lake and marine waters, were discovered in the western United States and elsewhere in the world. These beds were found to contain as much as 95% of a single zeolite; they were generally flat-lying and easily mined by surface methods. The properties of these low-cost natural materials mimicked those of many of their synthetic counterparts, and considerable effort has made since that time to develop applications for them based on their unique adsorption, cation-exchange, dehydration-rehydration, and catalytic properties. Natural zeolites (i.e., those found in volcanogenic sedimentary rocks) have been and are being used as building stone, as lightweight aggregate and pozzolans in cements and concretes, as filler in paper, in the take-up of Cs and Sr from nuclear waste and fallout, as soil amendments in agronomy and horticulture, in the removal of ammonia from municipal, industrial, and agricultural waste and drinking waters, as energy exchangers in solar refrigerators, as dietary supplements in animal diets, as consumer deodorizers, in pet litters, in taking up ammonia from animal manures, and as ammonia filters in kidney-dialysis units. From their use in construction during Roman times, to their role as hydroponic (zeoponic) substrate for growing plants on space missions, to their recent success in the healing of cuts and wounds, natural zeolites are now considered to be full-fledged mineral commodities, the use of which promise to expand even more in the future. (+info)
Diagnosis and treatment of chronic renal failure in children.
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This activity is designed for primary care and specialist physicians. GOAL: To provide an overview of the unique features and treatment of chronic renal failure in children. OBJECTIVES: 1. Describe the diagnosis of chronic renal failure in children. 2. Discuss the medical treatment of chronic renal failure in children. 3. Understand the treatment of end-stage renal disease in children. 4. Discuss the financial impact of caring for a child with chronic renal failure. (+info)
Annual Report of the German Renal Registry 1998. QuaSi-Niere Task Group for Quality Assurance in Renal Replacement Therapy.
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During the past 3 years, the basis of a German Renal Registry has been established. An agreement between end-stage renal disease (ESRD) therapy providers, insurance companies and the government has been reached to fund and support the registry office and its electronic data base. An overall acceptable compliance has been achieved to provide data voluntarily, although in the future the data submission will have to be mandatory to achieve complete data sampling within an acceptable time frame. In Germany, 713 patients per million population (p.m.p.) are on renal replacement therapy (RRT). The incidence of new patients commencing RRT is 156 p.m.p. These numbers are comparable with those reported from other European countries such as France, Italy and Spain, but significantly lower than those reported from the US or Japan. More than 92% of all dialysis patients are treated by haemodialysis and only a limited number with peritoneal dialysis. Approximately 25% of the patients have a functioning kidney graft. The transplantation rate of 25 p.m.p. is far from sufficient if compared with Spain, Austria or the US. Although an increasing number of diabetic patients commenced RRT, the percentage, i.e. approximately 30%, is less than in the US or Japan. The annual growth of the population on renal replacement cannot currently be given precisely because the database is still limited, but it seems to be approximately 3-4%. (+info)
End-stage renal disease in Canada: prevalence projections to 2005.
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BACKGROUND: The incidence and prevalence of end-stage renal disease (ESRD) have increased greatly in Canada over the last 2 decades. Because of the high cost of therapy, predicting numbers of patients who will require dialysis and transplantation is necessary for nephrologists and health care planners. METHODS: The authors projected ESRD incidence rates and therapy-specific prevalence by province to the year 2005 using 1981-1996 data obtained from the Canadian Organ Replacement Register. The model incorporated Poisson regression to project incidence rates, and a Markov model for patient follow-up. RESULTS: Continued large increases in ESRD incidence and prevalence were projected, particularly among people with diabetes mellitus. As of Dec. 31, 1996, there were 17,807 patients receiving renal replacement therapy in Canada. This number was projected to climb to 32,952 by the end of 2005, for a relative increase of 85% and a mean annual increase of 5.8%. The increased prevalence was projected to be greatest for peritoneal dialysis (6.0% annually), followed by hemodialysis (5.9%) and functioning kidney transplant (5.7%). The projected annual increases in prevalence by province ranged from 4.4%, in Saskatchewan, to 7.5%, in Alberta. INTERPRETATION: The projected increases are plausible when one considers that the incidence of ESRD per million population in the United States and other countries far exceeds that in Canada. The authors predict a continued and increasing short-fall in resources to accommodate the expected increased in ESRD prevalence. (+info)
Long-term outcome of dialysis patients in the United States with coronary revascularization procedures.
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BACKGROUND: The optimal method of coronary revascularization in dialysis patients is controversial, as previous small retrospective studies have reported increased cardiac events after percutaneous transluminal coronary angioplasty (PTCA) compared with coronary artery bypass (CAB) surgery. The purpose of this study was to compare the long-term survival of chronic dialysis patients in the United States following PTCA or CAB surgery. METHODS: Dialysis patients hospitalized from 1978 to 1995 for first coronary revascularization procedure after initiation of renal replacement therapy were retrospectively identified from the United States Renal Data System database. Survival for the endpoints of all-cause death, cardiac death, myocardial infarction, and cardiac death or myocardial infarction was estimated by the life-table method and was compared by the log-rank test. The impact of independent predictors on survival was examined in a Cox regression model with comorbidity adjustment. RESULTS: The in-hospital mortality was 5.4% for 6887 PTCA patients and 12.5% for 7419 CAB patients. The two-year event-free survival (+/-SE) of PTCA patients was 52.9 +/- 0.7% for all-cause death, 72.5 +/- 0.7% for cardiac death, and 62.0 +/- 0.7% for cardiac death or myocardial infarction. In CAB patients, the comparable survivals were 56.9 +/- 0.6, 75.8 +/- 0.6, and 71.3 +/- 0. 6%, respectively (P < 0.02 for PTCA vs. CAB surgery for all endpoints). After comorbidity adjustment, the relative risk of CAB surgery (vs. PTCA) performed 1990 to 1995 for all-cause death was 0. 91 (95% CI, 0.86 to 0.97); cardiac death, 0.85 (95% CI, 0.78 to 0. 92); myocardial infarction, 0.37 (95% CI, 0.32 to 0.43); and cardiac death or myocardial infarction 0.69 (95% CI, 0.64 to 0.74). CONCLUSIONS: In this retrospective study, dialysis patients in the United States had better survival after CAB surgery compared with PTCA, but our study does not exclude the possibility of more unfavorable coronary anatomy in the PTCA patients at baseline. Our data support the need for prospective trials of newer percutaneous coronary revascularization procedures in dialysis patients. (+info)