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Background: Patients with chronic kidney disease (CKD) often have uncontrolled hypertension despite polypharmacy. Pharmacogenomic drug-gene interactions (DGIs) may impact the metabolism or efficacy of antihypertensive agents. We report... more
Background: Patients with chronic kidney disease (CKD) often have uncontrolled hypertension despite polypharmacy. Pharmacogenomic drug-gene interactions (DGIs) may impact the metabolism or efficacy of antihypertensive agents. We report changes in hypertension control after providing a panel of 11 pharmacogenomic predictors of antihypertensive response. Methods: A prospective cohort with CKD and hypertension was followed to assess feasibility of pharmacogenomic testing implementation, self-reported provider utilization, and blood pressure control. The analysis population included 382 hypertensive subjects genotyped for cross-sectional assessment of DGIs and 335 subjects followed for 1 year to assess systolic (SBP) and diastolic blood pressure (DBP). Results: Most participants (58.2%) with uncontrolled hypertension had a DGI reducing the efficacy of > 1 antihypertensive agent. Subjects with a DGI had 1.85-fold (95% CI 1.2-2.8) higher odds of uncontrolled hypertension as compared to...
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Long, frequent hemodialysis (HD) was thought to be a sound treatment because of improved clearance of uremic toxins and control of extracellular fluid volume. After all, no solute or volume control is tantamount to no dialysis, and... more
Long, frequent hemodialysis (HD) was thought to be a sound treatment because of improved clearance of uremic toxins and control of extracellular fluid volume. After all, no solute or volume control is tantamount to no dialysis, and whatever its shortcomings, dialysis does keep people alive. The
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Background/Aim: Home hemodialysis (HHD) has been associated with improved clinical outcomes vs. in-center HD (ICHD). The prevalence of HHD in the United States is still very low at 1.8%. This critical review compares HHD and ICHD outcomes... more
Background/Aim: Home hemodialysis (HHD) has been associated with improved clinical outcomes vs. in-center HD (ICHD). The prevalence of HHD in the United States is still very low at 1.8%. This critical review compares HHD and ICHD outcomes for survival, hospitalization, cardiovascular (CV), nutrition, and quality of life (QoL). Methods: Of 545 publications identified, 44 were not selected after applying exclusion criteria. A systematic review of the identified publications was conducted to compare HHD to ICHD outcomes for survival, hospitalization, CV outcomes, nutrition, and QoL. Results: Regarding mortality, 10 of 13 trials reported 13–52% reduction; three trials found no differences. According to 6 studies, blood pressure and left ventricular size measurements were generally lower in HHD patients compared to similar measurements in ICHD patients. Regarding nutritional status, conflicting results were reported (8 studies); some found improved muscle mass, total protein, and body ma...
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More frequent hemodialysis sessions and longer session lengths may offer improved phosphorus control. We analyzed data from the Frequent Hemodialysis Network Daily and Nocturnal Trials to examine the effects of treatment assignment on... more
More frequent hemodialysis sessions and longer session lengths may offer improved phosphorus control. We analyzed data from the Frequent Hemodialysis Network Daily and Nocturnal Trials to examine the effects of treatment assignment on predialysis serum ...
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Purpose: Exercise participation in hemodialysis centers remains low despite the opportunity, equipment, and proven benefits. The purpose of this study was to measure the perceived benefits and perceived barriers to exercise participation.... more
Purpose: Exercise participation in hemodialysis centers remains low despite the opportunity, equipment, and proven benefits. The purpose of this study was to measure the perceived benefits and perceived barriers to exercise participation. Methods: A questionnaire using the Exercise Benefits/Barriers Scale was administered to 150 in-center, chronic hemodialysis patients at a free standing dialysis center with an ongoing exercise program for three years. This survey was adapted to show the patients’ perceived benefits and barriers of exercise in the dialysis unit. Results: The overall score of the unit (n = 150) was 92.0 ± 12.2 with a possible range from 31 to 124. Exercisers (n = 32) had a mean of 98.1 ± 12.3 on the scale; non-exercisers (n = 118) had a mean on 90.4 ± 11.7 (p < .05). Answers to 12 of the 31 questions were significant (p < .05). Seven questions were perceived benefits; five questions were perceived barriers. All (n = 150) Non Exercisers (n = 118) Exercisers (n = 32) Mean Mean Mean Exercise Benefits/Barriers Scale 92 ± 12.2 90.4 ± 11.7 98.1 ± 12.3 Benefits 62.1 ± 10.2 61.2 ± 9.8 65.3 ± 11.0 Barriers 29.6 ± 4.6 28.8 ± 4.6 32.9 ± 3.2 Questions with p < .05 Enjoy exercise 3.0 ± 0.7 2.7 ± 0.9 3.4 ± 0.6 Prevent heart attacks 3.3 ± 0.6 2.9 ± 0.8 3.4 ± 0.6 Improve cardiovascular system 3.1 ± 0.7 3.1 ± 0.7 3.4 ± 0.6 Difficult due to vision 3.3 ± 0.8 3.3 ± 0.8 3.7 ± 0.5 Difficult due to arthritis 2.9 ± 1.0 2.8 ± 1.0 3.6 ± 0.6 Takes too much time 3.0 ± 0.7 2.9 ± 0.7 3.3 ± 0.6 Boring 3.3 ± 0.6 3.0 ± 0.8 3.3 ± 0.7 Increase physical fitness 3.2 ± 0.6 3.0 ± 0.6 3.3 ± 0.6 Increase stamina 3.2 ± 0.6 3.1 ± 0.5 3.4 ± 0.7 Family does not encourage 2.7 ± 0.9 2.7 ± 0.9 3.1 ± 0.8 Carry out activities without tiring 3.0 ± 0.7 2.9 ± 0.7 3.2 ± 0.7 Improve body function 2.9 ± 0.7 2.8 ± 0.7 3.1 ± 0.7 Conclusion: Physical improvement was the main reason to exercise. Lack of desire and health problems were the chief reasons named for not exercising. Addressing the benefits and barriers may improve exercise participation among chronic hemodialysis patients.
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Cyclooxygenase-2 (COX-2) is constitutively expressed in restricted subpopulations of kidney cells, where it presumably acts as an antiapoptotic factor. In conditions that are characterized by inflammation, COX-2 expression also has been... more
Cyclooxygenase-2 (COX-2) is constitutively expressed in restricted subpopulations of kidney cells, where it presumably acts as an antiapoptotic factor. In conditions that are characterized by inflammation, COX-2 expression also has been described in glomerular mesangial ...
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The parathyroid oxyphil cell content increases in patients with chronic kidney disease (CKD), and even more in patients treated with the calcimimetic cinacalcet and/or calcitriol for hyperparathyroidism. Oxyphil cells have significantly... more
The parathyroid oxyphil cell content increases in patients with chronic kidney disease (CKD), and even more in patients treated with the calcimimetic cinacalcet and/or calcitriol for hyperparathyroidism. Oxyphil cells have significantly more calcium-sensing receptors than chief cells, suggesting that the calcium-sensing receptor and calcimimetics are involved in the transdifferentiation of a chief cell to an oxyphil cell type. Here, we compared the effect of the vitamin D analog paricalcitol (a less calcemic analog of calcitriol) and/or cinacalcet on the oxyphil cell content in patients with CKD to further investigate the genesis of these cells. Parathyroid tissue from four normal individuals and 27 patients with CKD who underwent parathyroidectomy for secondary hyperparathyroidism were analyzed. Prior to parathyroidectomy, patients had received the following treatment: seven with no treatment, seven with cinacalcet only, eight with paricalcitol only, or cinacalcet plus paricalcitol...
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Diabetic glomerulopathy is a well-recognized consequence of both type I and type II diabetes. Occasionally, pathologic diagnosis may be challenging for the pathologist. These circumstances include atypical light microscopy or diabetic... more
Diabetic glomerulopathy is a well-recognized consequence of both type I and type II diabetes. Occasionally, pathologic diagnosis may be challenging for the pathologist. These circumstances include atypical light microscopy or diabetic change with a second superimposed glomerulopathy (dual disease). We have compiled a selection of 12 renal biopsies from diabetic patients that show either an unusual pattern of nephropathy or &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;dual disease,&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; as well as 2 cases in which the patient had no history of diabetes but had renal biopsies exhibiting changes consistent with diabetic nephropathy. The salient diagnostic features are discussed. To accurately assess these biopsies, immunofluorescence and electron microscopy become essential, and a broadened differential diagnosis must be considered.
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De novo thrombotic microangiopathy (TMA) after renal transplant is rare. Cytomegalovirus (CMV)-related post-transplant TMA has only been reported in 6 cases. We report an unusual case of a 75-year-old woman who developed de novo TMA in... more
De novo thrombotic microangiopathy (TMA) after renal transplant is rare. Cytomegalovirus (CMV)-related post-transplant TMA has only been reported in 6 cases. We report an unusual case of a 75-year-old woman who developed de novo TMA in association with CMV viremia. The recurrence of TMA with CMV viremia, the resolution with treatment for CMV, and the lack of correlation with a calcineurin inhibitor (CNI) in our case support CMV as the cause of the TMA. What is unique is that the use of eculizumab without plasmapheresis led to prompt improvement in renal function. After a failure to identify a genetic cause for TMA and the clear association with CMV, eculizumab was discontinued. This case provides insight into the pathogenesis and novel treatment of de novo TMA, highlights the beneficial effects of complement inhibitors in this disease, and shows that they can be safely discontinued once the inciting etiology is addressed.
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Diabetic glomerulopathy is a well-recognized consequence of both type I and type II diabetes. Occasionally, pathologic diagnosis may be challenging for the pathologist. These circumstances include atypical light microscopy or diabetic... more
Diabetic glomerulopathy is a well-recognized consequence of both type I and type II diabetes. Occasionally, pathologic diagnosis may be challenging for the pathologist. These circumstances include atypical light microscopy or diabetic change with a second superimposed glomerulopathy (dual disease). We have compiled a selection of 12 renal biopsies from diabetic patients that show either an unusual pattern of nephropathy or "dual disease," as well as 2 cases in which the patient had no history of diabetes but had renal biopsies exhibiting changes consistent with diabetic nephropathy. The salient diagnostic features are discussed. To accurately assess these biopsies, immunofluorescence and electron microscopy become essential, and a broadened differential diagnosis must be considered.
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A successful 38-week pregnancy is reported following renal transplantation approximately 1 week after conception. The patient was treated with quadruple sequential induction therapy, maintenance immunosuppression, and routine... more
A successful 38-week pregnancy is reported following renal transplantation approximately 1 week after conception. The patient was treated with quadruple sequential induction therapy, maintenance immunosuppression, and routine posttransplantation care, including ganciclovir treatment for a symptomatic cytomegalovirus infection during the pregnancy and 3 months after delivery. No decline in renal function was noted. The mother and child remain healthy at 18 months. This case demonstrates the ability of renal transplant patients to maintain renal function throughout pregnancy and the lack of deleterious effects upon the child during gestation and at up to 18 months after birth, despite significant immunosuppression, including antithymocyte globulin induction therapy, and infectious complications of the mother's renal transplantation.
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The optimal dose and duration of rabbit antithymocyte globulin (rATG) induction has not been defined.Methods. We compared the safety and efficacy of 2 dosing strategies, rATG 1.5 mg/kg for 4 days (n=59) versus 2 mg/kg for 3 days (n=59),... more
The optimal dose and duration of rabbit antithymocyte globulin (rATG) induction has not been defined.Methods. We compared the safety and efficacy of 2 dosing strategies, rATG 1.5 mg/kg for 4 days (n=59) versus 2 mg/kg for 3 days (n=59), in a retrospective, cohort study.Results. Two-year rejection-free survival was 95% in each group (P=.983). Renal function and infection rates were similar. The incidence of leucopenia was similar, although the 2 mg/kg group was more likely to be thrombocytopenic on day 2 (4% versus 28%,P=.04). Length of stay tended to be longer for the 1.5 mg/kg group (6.0±3.7versus5.1±1.9daysP=.104). A cost savings of $920 per patient for rATG were seen in the 2 mg/kg group (P=.122).Conclusions. Shorter, more intense dosing of rATG is safe and effective. The 3-day dose strategy resulted in a clinically shorter length of stay and may result in cost savings.
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The relative benefit versus safety of induction therapy in live-donor renal transplant recipients is controversial. This paper presents observational data of live-donor recipients who received Thymoglobulin induction and standard... more
The relative benefit versus safety of induction therapy in live-donor renal transplant recipients is controversial. This paper presents observational data of live-donor recipients who received Thymoglobulin induction and standard maintenance immunosuppressive therapy. Review and analysis of clinic records and electronic databases of live-donor renal transplants that received Thymoglobulin induction from May 1996 through 2003. Data analysis included 214 live-donor recipients (146 related, 68 unrelated) with a mean follow-up of 3.0+/-1.9 years. The average age of recipients was 44+/-13 years, with a majority being Caucasian (86%) and male (64%). Nineteen (9%) received previous transplants. No patients experienced delayed graft function and 10 (5%) developed acute rejection. Overall, predicted five-year patient survival was 96% and graft survival was 82%. The rates of CMV infection (5%), malignancy (3%), and lymphoproliferative disorder (0.5%) were low. When compared to live-donor kidney transplant recipients nationwide, the center cohort demonstrated improved five year patient (96% center versus 90% national, P=0.0326) and graft survival (82% center versus 79% national, P=0.0901), and a lower one-year acute rejection rate (2% center versus 21 % national, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). In this analysis, the use of Thymoglobulin in live-donor renal transplantation was associated with an absence of delayed graft function, low acute rejection rates, and high patient and graft survival without increasing the risk of infection or lymphoproliferative disorder.
Research Interests: Family, Kidney transplantation, Survival Analysis, Treatment Outcome, Transplantation, and 15 moreRenal transplantation, Humans, Female, Male, Follow-up studies, Middle Aged, Adult, Retrospective Studies, Graft Rejection, Thyroglobulin, Antiviral Agents, Postoperative Complications, Cause of death, Treatment Failure, and Medical and Health Sciences
The aim of this study was to demonstrate that 3-days of induction immunosuppression with thymoglobulin was as effective and safe as a 7-day course and reduced initial hospitalization after transplantation. This was a prospective,... more
The aim of this study was to demonstrate that 3-days of induction immunosuppression with thymoglobulin was as effective and safe as a 7-day course and reduced initial hospitalization after transplantation. This was a prospective, nonrandomized trial of 40 consecutive patients receiving thymoglobulin induction for 3 days and followed for 1 year. An historical group of 48 patients that received 7 days of thymoglobulin served as controls. At 1 year, acute rejection (5 vs. 4%), graft survival (95 vs. 98%) and patient survival were similar; a composite end point of freedom from death, rejection, or graft loss, the event-free graft survival, was similar as was the safety profile. In the 3-day group, lymphocyte depletion was more sustained and initial hospitalization was significantly shorter (6 vs. 8 days). Three-day induction with thymoglobulin is as effective and safe as seven days, decreases initial hospitalization and causes more sustained lymphocyte depletion.
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One-year results of a randomized, double-blinded trial of Thymoglobulin versus Atgam for induction therapy in renal transplantation revealed that Thymoglobulin was associated with higher event-free survival (94% vs. 63%), less acute... more
One-year results of a randomized, double-blinded trial of Thymoglobulin versus Atgam for induction therapy in renal transplantation revealed that Thymoglobulin was associated with higher event-free survival (94% vs. 63%), less acute rejection (4% vs. 25%), and better graft survival. This article compares the safety and efficacy of Thymoglobulin versus Atgam induction through 5 years. Review and analysis of clinic records and electronic databases. At 5 years, event-free survival (73% vs. 33%, P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001), graft survival (77% vs. 55%, P=0.047), and freedom from rejection (92% vs. 66%, P=0.007) were higher with Thymoglobulin versus Atgam. No additional cytomegalovirus (CMV) disease occurred after the first year with Thymoglobulin or Atgam (13% vs. 33%, P=0.056). There were two cases of posttransplant lymphoproliferative disorder (PTLD) with the Atgam arm and none with Thymoglobulin. Thymoglobulin was associated with profound lymphopenia at 2 years after transplantation. Thymoglobulin was associated with higher event-free survival, graft survival, and freedom from rejection without increased PTLD or CMV disease at 5 years compared with Atgam. The prolonged and profound lymphopenia may contribute to the long-term results associated with Thymoglobulin.
Research Interests: Surgery, Treatment, Kidney transplantation, Treatment Outcome, Comparative Study, and 15 moreTransplantation, Renal transplantation, Humans, Female, Male, Cytomegalovirus, Incidence, T lymphocytes, Middle Aged, Adult, First Year, Neoplasms, Graft Rejection, Acute rejection, and Medical and Health Sciences
Long-term follow-up of heart, liver, and lung transplantation has led to an increased recognition of secondary end-stage renal failure (ESRF) in transplant recipients. This study examines our center&#39;s experience with renal... more
Long-term follow-up of heart, liver, and lung transplantation has led to an increased recognition of secondary end-stage renal failure (ESRF) in transplant recipients. This study examines our center&#39;s experience with renal transplantation following previous solid organ transplantation. From January 1, 1992, to September 30, 1999, our center performed 18 renal transplants in previous solid organ recipients. During the same period, 815 total renal transplants were performed. One- and 3-year graft and patient survival, recipient demographics, donor type, and reason for transplantation were compared between these groups. Of the 18 recipients, 7 had prior heart transplants, 4 had prior liver transplants, and 7 had prior lung transplants. Cyclosporine toxicity contributed to renal failure in 17 (94.4%) of the patients-either as a sole factor (11 patients) or in combination with hypertension, renal artery stenosis, or tacrolimus toxicity (6 patients). Kaplan-Meier 1- and 3-year patient survival was 82.9% and 73.7%, compared with 95.5% and 90.7% in all renal transplant recipients. No surviving patient has suffered renal allograft loss. Mean current creatinine level is 1.4 mg/dL. Renal transplantation is an excellent therapy for ESRF following prior solid organ transplantation. One and 3-year patient and graft survival demonstrate the utility of renal transplantation in this patient population.
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Targeting 2-hr postdose cyclosporine (C2) levels to 1,000 to 1,700 mg/dL during the first 6 months after renal transplantation is recommended for triple immunosuppressive regimens. This trial determines whether lower C2 levels could be... more
Targeting 2-hr postdose cyclosporine (C2) levels to 1,000 to 1,700 mg/dL during the first 6 months after renal transplantation is recommended for triple immunosuppressive regimens. This trial determines whether lower C2 levels could be targeted safely in de novo kidney transplant recipients under a quadruple regimen compared with a similar cohort monitored with trough (C0) levels. This single-center, sequential, cohort-designed trial included patients who received Thymoglobulin, corticosteroids, an antimetabolite, and cyclosporine monitored by C2 (n=50) or C0 (n=50). Cyclosporine was tapered to maintain the C2 between 1,000 and 1,200 ng/mL months 0 to 3 and between 600 and 1,000 ng/mL thereafter and C0 between 250 and 350 ng/mL months 0 to 3 and between 100 and 250 ng/mL thereafter. Baseline patient and donor characteristics were similar. There were no differences in graft survival (100% C2 vs. 100% C0), acute rejection (4% C2 vs. 6% C0), allograft function, or adverse events at 6 months. C2 levels were lower than the suggested guidelines throughout the study (33% lower at 1 month and 48% lower at 6 months). Lower cyclosporine doses were achieved in the C2 arm compared with the C0 arm by 1 month and were sustained throughout the trial, which translated into an average cyclosporine cost savings of USD $773 in the C2 arm during the 6-month period (P&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;0.001). With a quadruple immunosuppressive regimen and lower C2 targets than recommended for triple therapy, safe and effective cyclosporine minimization was achieved. Lower cyclosporine doses were achieved in C2-monitored patients compared with C0-monitored patients, translating into lower immunosuppressive costs.
Research Interests: Surgery, Treatment, Kidney transplantation, Concentration, Transplantation, and 15 moreProspective studies, Humans, Female, Male, Cyclosporine, Reduction, Middle Aged, Adult, Cost Reduction, Drug Costs, Cost Control, Cohort Studies, Immunosuppressive Agents, Adrenal cortex hormones, and Medical and Health Sciences
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The aim of this study was to compare the efficacy and safety of Thymoglobulin (a rabbit-derived polyclonal antibody) to Atgam (a horse-derived polyclonal antibody) for induction in adult renal transplant recipients. Transplant recipients... more
The aim of this study was to compare the efficacy and safety of Thymoglobulin (a rabbit-derived polyclonal antibody) to Atgam (a horse-derived polyclonal antibody) for induction in adult renal transplant recipients. Transplant recipients (n=72) were randomized 2:1 in a double-blinded fashion to receive Thymoglobulin (n=48) at 1.5 mg/kg intravenously or Atgam (n=24) at 15 mg/kg intravenously, intraoperatively, then daily for at least 6 days. Recipients were observed for at least 1 year of follow-up. By 1 year after transplantation, 4% of Thymoglobulin-treated patients experienced acute rejection compared with 25% of Atgam-treated patients (P=0.014). The rate of acute rejection was lower with Thymoglobulin than Atgam (relative risk=0.09; P=0.009). Rejection was less severe with Thymoglobulin than Atgam (P=0.02). No recurrent rejection occurred with Thymoglobulin compared with 33% with Atgam (P=NS). Patient survival was not different, but the composite end point of freedom from death, graft loss, or rejection, the &quot;event-free survival,&quot; was superior with Thymoglobulin (94%) compared with Atgam (63%; P=0.0005). Fewer adverse events occurred with Thymoglobulin (P=0.013). Leukopenia was more common with Thymoglobulin than Atgam (56% vs. 4%; P&lt;0.0001) during induction. The mean absolute lymphocyte count remained below baseline with Thymoglobulin throughout the study (P&lt;0.007), but with Atgam, significant lymphocyte reductions occurred only at day 7. The incidence of cytomegalovirus disease was less with Thymoglobulin than Atgam at 6 months (10% vs. 33%; P=0.025). Brief (7-day) induction with Thymoglobulin resulted in less frequent and less severe rejection, a better event-free survival, less cytomegalovirus disease, fewer serious adverse events, but more frequent early leukopenia than induction with Atgam. These results may in fact be explained by a more profound and durable beneficial lymphopenia.
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Acute rejection of renal allografts is mediated by infiltrating alloreactive T cells. The goals of this study were to correlate T cell proliferation with rejection and to determine whether T cell proliferation in the absence of rejection... more
Acute rejection of renal allografts is mediated by infiltrating alloreactive T cells. The goals of this study were to correlate T cell proliferation with rejection and to determine whether T cell proliferation in the absence of rejection would predict future rejection episodes. Toward this, kidney biopsies (n=100) were cultured in the presence of interleukin-2. Cultures were examined at 4, 24, and 48 hr for T cell proliferation. A strong correlation was observed between T cell proliferation at any time point and rejection. There was not a significant correlation between T cell proliferation in biopsies with no rejection and the occurrence of a rejection episode within 2 months. However, T cell proliferation after 4 hr was a better predictor of the occurrence of rejection within 2 months compared with observations after 24 and 48 hr. Therefore, a subgroup of patients with unremarkable biopsies but T cell proliferation may be at risk for rejection and warrant closer observation and possible tailoring of immunosuppression.
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Long-term follow-up of heart, liver, and lung transplantation has led to an increased recognition of secondary end-stage renal failure (ESRF) in transplant recipients. This study examines our center&#39;s experience with renal... more
Long-term follow-up of heart, liver, and lung transplantation has led to an increased recognition of secondary end-stage renal failure (ESRF) in transplant recipients. This study examines our center&#39;s experience with renal transplantation following previous solid organ transplantation. From January 1, 1992, to September 30, 1999, our center performed 18 renal transplants in previous solid organ recipients. During the same period, 815 total renal transplants were performed. One- and 3-year graft and patient survival, recipient demographics, donor type, and reason for transplantation were compared between these groups. Of the 18 recipients, 7 had prior heart transplants, 4 had prior liver transplants, and 7 had prior lung transplants. Cyclosporine toxicity contributed to renal failure in 17 (94.4%) of the patients-either as a sole factor (11 patients) or in combination with hypertension, renal artery stenosis, or tacrolimus toxicity (6 patients). Kaplan-Meier 1- and 3-year patient survival was 82.9% and 73.7%, compared with 95.5% and 90.7% in all renal transplant recipients. No surviving patient has suffered renal allograft loss. Mean current creatinine level is 1.4 mg/dL. Renal transplantation is an excellent therapy for ESRF following prior solid organ transplantation. One and 3-year patient and graft survival demonstrate the utility of renal transplantation in this patient population.
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We estimated the survival and hospitalization among frequent hemodialysis users in comparison to those patients undergoing thrice-weekly conventional hemodialysis. All patients had similar characteristics and medical histories. In this... more
We estimated the survival and hospitalization among frequent hemodialysis users in comparison to those patients undergoing thrice-weekly conventional hemodialysis. All patients had similar characteristics and medical histories. In this cohort study of frequent hemodialysis users and propensity score-matched controls, the collaborating clinicians identified 94 patients who used nocturnal hermodialysis (NHD) and 43 patients who used short-duration daily hemodialysis (SDHD) for a minimum of 60 days. Ten propensity score-matched control patients for each NHD and SDHD patient were identified from the United States Renal Data System database. Primary outcomes were risk for all-cause mortality and risk for the composite outcome of mortality or major morbid event (acute myocardial infarction or stroke) estimated using Cox proportional hazards models. Risks for all-cause, cardiovascular-related, infection-related, and vascular access-related hospital admissions were also studied. Nocturnal hemodialysis was associated with significant reductions in mortality risk and risk for mortality or major morbid event when compared to conventional hemodialysis. There was a reduced but non-significant risk of death for patients using SDHD compared to controls. All-cause and specific hospitalizations did not differ significantly between NHD and SDHD patients and their matched control cohorts. Our study suggests that NHD may improve patient survival.
Research Interests: Kidney diseases, Dialysis, Comparative Study, Medical History, Humans, and 15 moreKidney, Hospitalization, Female, Hemodialysis, Male, Cohort Study, Acute Myocardial Infarction, Clinical Sciences, Aged, Middle Aged, Adult, Mortality Risk, Case Control Studies, Databases as topic, and Hospital Admission
Cyst proliferation in patients with autosomal dominant polycystic kidney disease is associated with renal failure, hypertension and pain. We examined the long-term impact of laparoscopic cyst decortication on renal function, hypertension... more
Cyst proliferation in patients with autosomal dominant polycystic kidney disease is associated with renal failure, hypertension and pain. We examined the long-term impact of laparoscopic cyst decortication on renal function, hypertension and pain control in patients with adult dominant polycystic kidney disease presenting with refractory pain. Between 1994 and 2003, 37 patients with adult dominant polycystic kidney disease underwent laparoscopic cyst decortication at Barnes-Jewish Hospital. A total of 19 patients (4 male, 15 female) with at least 3-year followup were included in the study. Renal function was evaluated using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) estimated glomerular filtration rate formula. End stage renal disease was defined as progression to transplant, dialysis or stage 5 chronic kidney disease. Hypertension was evaluated using the antihypertensive therapeutic index. Pain assessment was based primarily on a telephone questionnaire. At a mean followup of 10.9 years (range 6.4 to 16.9), 67% of evaluable patients reported more than 50% improvement in pain. Ten patients had progression to end stage renal disease--3 dialysis, 6 transplant, and 1 chronic kidney disease stage 5. Two patients had stage 5 chronic kidney disease at initial presentation. A comparison of preoperative estimated glomerular filtration rate between patients with and those without end stage renal disease revealed a lower preoperative estimated glomerular filtration rate in the former group (43.4 vs 75.4 ml/minute/1.73 m(2), p = 0.01). Of the patients 53% had an improved or stable antihypertensive therapeutic index at last followup, although no improvement in mean overall antihypertensive therapeutic index was noted (4.7 pre-laparoscopic cyst decortications vs 7.0 post-laparoscopic cyst decortications, p = 0.28). Durable pain relief but not hypertension control was seen at 10-year followup. Preoperative estimated glomerular filtration rate is a strong predictor of post-laparoscopic cyst decortication progression to end stage renal disease. A cautious approach with laparoscopic cyst decortication should be taken in patients with poor preoperative renal function.
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Context: Parathyroid oxyphil cells, whose function is unknown, are thought to be derived from chief cells. Oxyphil cells increase in number in parathyroid glands of patients with chronic kidney disease (CKD) and are even more abundant in... more
Context: Parathyroid oxyphil cells, whose function is unknown, are thought to be derived from chief cells. Oxyphil cells increase in number in parathyroid glands of patients with chronic kidney disease (CKD) and are even more abundant in patients receiving treatment for hyperparathyroidism with calcitriol and/or the calcimimetic cinacalcet. Objective: We examined oxyphil and chief cells of parathyroid glands of CKD patients for differential expression of genes important to parathyroid function. Design/Setting/Participants: Parathyroid tissue from CKD patients with refractory hyperparathyroidism was immunostained for gene expression studies. Main Outcome Measure: Immunostaining for PTH, PTHrP, calcium-sensing receptor, glial cells missing 2, vitamin D receptor, 25-hydroxyvitamin D-1α-hydroxylase, and cytochrome c was quantified and expression reported for oxyphil and chief cells. Results: Expression of all proteins analyzed, except for the vitamin D receptor, was higher in oxyphil ce...
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To compare the effects of paravertebral analgesia with levobupivacaine or bupivacaine on intra- and postoperative pain for thoracic surgery. A prospective, randomized, and double-blinded study. A university hospital. Forty patients... more
To compare the effects of paravertebral analgesia with levobupivacaine or bupivacaine on intra- and postoperative pain for thoracic surgery. A prospective, randomized, and double-blinded study. A university hospital. Forty patients undergoing thoracic surgery. Patients received paravertebral catheterization and a bolus (14-20 mL) of 0.5% bupivacaine (n = 20) or 0.5% levobupivacaine (n = 20) with morphine, 60 μg/kg, before the induction of general anesthesia that consisted of a propofol infusion. A paravertebral continuous infusion (0.05 mL/kg/h) of 0.25% bupivacaine or 0.25% levobupivacaine, 100 mL, with added morphine, 10 mg, and clonidine, 0.15 mg, was started at the end of surgery for 72 hours postoperatively. Postoperative rescue diclofenac analgesia was available if required. The primary outcome was intraoperative fentanyl consumption. Static and dynamic pain scores measured by a visual analog scale were assessed regularly. Intraoperative fentanyl consumption was significantly lower in the levobupivacaine group compared with the bupivacaine group (p = 0.001). On all 3 postoperative days, static pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). Dynamic pain scores were significantly lower in the levobupivacaine group compared with the bupivacaine group during the 2 postoperative days (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). A smaller proportion of patients in the levobupivacaine group used rescue analgesia (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.005). Paravertebral analgesia with levobupivacaine resulted in less intraoperative fentanyl consumption, lower static (3 days) and dynamic (2 days) pain scores, and less rescue analgesia than analgesia with bupivacaine.
Research Interests: Male Circumcision, Cataract surgery, Humans, Child, Female, and 15 moreClinical, Male, Infant, Clinical Sciences, Aged, Middle Aged, Amides, Nerve Block, Ambulatory Surgical Procedures, Pain Measurement, Analgesics, Clinical Anesthesia, Motor activity, Bupivacaine, and Cardiovascular medicine and haematology
Hyperammonemia, post-orthotopic lung transplantation, is a rare but mostly fatal complication. Various therapies, including those to decrease ammonia generation, increase nitrogen excretion, and several dialytic methods for removing... more
Hyperammonemia, post-orthotopic lung transplantation, is a rare but mostly fatal complication. Various therapies, including those to decrease ammonia generation, increase nitrogen excretion, and several dialytic methods for removing ammonia have been tried. We describe three lung transplant recipients who developed acute hyperammonemia early after transplantation. Two of the three patients survived after a multidisciplinary approach including discontinuation of drugs, which impair urea cycle, aggressive ammonia reduction with prolonged daily intermittent hemodialysis (HD), and overnight slow low-efficiency dialysis in conjunction with early weaning of steroids and other therapeutic measures. Our experience suggests that early initiation of dialysis, high dialysis dose, increased frequency, and HD preferably to less efficient modalities increases survival in these patients.
Research Interests:
In this randomized clinical trial, we aimed to determine whether increasing the frequency of in-center hemodialysis would result in beneficial changes in left ventricular mass, self-reported physical health, and other intermediate... more
In this randomized clinical trial, we aimed to determine whether increasing the frequency of in-center hemodialysis would result in beneficial changes in left ventricular mass, self-reported physical health, and other intermediate outcomes among patients undergoing maintenance hemodialysis.
Research Interests:
Prior small studies have shown multiple benefits of frequent nocturnal hemodialysis compared to conventional three times per week treatments. To study this further, we randomized 87 patients to three times per week conventional... more
Prior small studies have shown multiple benefits of frequent nocturnal hemodialysis compared to conventional three times per week treatments. To study this further, we randomized 87 patients to three times per week conventional hemodialysis or to nocturnal hemodialysis six times per week, all with single-use high-flux dialyzers. The 45 patients in the frequent nocturnal arm had a 1.82-fold higher mean weekly stdKt/V(urea), a 1.74-fold higher average number of treatments per week, and a 2.45-fold higher average weekly treatment time than the 42 patients in the conventional arm. We did not find a significant effect of nocturnal hemodialysis for either of the two coprimary outcomes (death or left ventricular mass (measured by MRI) with a hazard ratio of 0.68, or of death or RAND Physical Health Composite with a hazard ratio of 0.91). Possible explanations for the left ventricular mass result include limited sample size and patient characteristics. Secondary outcomes included cognitive ...
Research Interests: Magnetic Resonance Imaging, Humans, Kidney, Hypertension, Blood Pressure, and 15 morePhysical Health, Female, Hemodialysis, Male, Patient Compliance, Cognitive Performance, Clinical Sciences, North America, Aged, Middle Aged, Adult, Left ventricular hypertrophy, Chronic Kidney Failure, Equipment Design, and hyperphosphatemia
Research Interests:
Research Interests:
Research Interests:
Research Interests:
Research Interests: Exercise Physiology, Exercise therapy, Humans, Hypertension, Blood Pressure, and 15 moreFemale, Hemodialysis, Male, American, Clinical Sciences, Chronic Renal Failure, Middle Aged, Cycle Time, Adverse Event, Cost Saving, Physical Exercise, Control Group, Aerobic Exercise, Costs and Cost Analysis, and Antihypertensive agents
Goals of maintenance hemodialysis therapy include not only the preservation of an individual... more
Goals of maintenance hemodialysis therapy include not only the preservation of an individual patient&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s life in the presence of kidney failure, but also restoration of optimal quality of life. Although many conceptual and method problems are associated with the definition and assessment of quality of life in the chronically ill, there is broad agreement that patient quality of life is related to physical function and well-being. Evidence exists that despite advances in dialysis therapy, a high percentage of patients on maintenance dialysis therapy report chronic psychological symptoms, impaired activities of daily living and social function, and incomplete occupational rehabilitation that impair their functionality. This article reviews the impact of L-carnitine therapy on several dimensions of functionality in maintenance hemodialysis patients.