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Highlights for Nephrology Nurses from the Updated NKF-K/DOQI Guidelines. Nephrology Nursing Journal. 28(1): 45-50. February 2001.

This article reviews for nephrology nurses the updated National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF DOQI), published in January 2001. The updated guidelines (renamed the K DOQI) have been expanded in coverage from a focus on dialysis to a focus on kidney disease in all its stages, including those that occur well before dialysis becomes necessary. Nephrology nurses were active members of the groups that updated the K DOQI; in this article, nephrology nurses from the four content area work groups provide highlights of the revisions. Regarding hemodialysis adequacy, the new guidelines emphasize that institutions should make sure that the dialysis dose is measured consistently, that Kt per V is calculated using blood urea nitrogen (BUN) measurements taken at defined pre and postdialysis blood draws, and that patient comfort is considered, particularly in its effect on adherence (compliance with recommended dialysis amounts). Recommendations for improving peritoneal dialysis include lowering the creatinine clearance requirements for patients with low transport status, considering early initiation of dialysis in patients with poor nutritional status, and making preservation of residual renal function a goal. Recommendations for improving vascular access outcomes include using native arteriovenous (AV) fistulas where possible, considering use of bridge devices while AV fistulas mature, improving monitoring programs to prevent access complications (such as thrombosis), and referring patients for fistulograms to diagnose low flow rate problems. Recommendations for improving anemia management include using hemoglobin rather than hematocrit as anemia endpoint, considering the use of sodium ferric gluconate complex in sucrose injection, waiting 1 week (rather than 2) after the last dose of intravenous iron to measure iron indices, administering erythropoietin subcutaneously when possible, and watching for the effect of ACE inhibitors and C reactive protein on erythropoietin responsiveness. 4 tables. 49 references.

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Kidney Transplantation in Young Children: Should There be a Minimum Age?. Pediatric Nephrology. 16(12): 941-945. December 2001.

The optimal age in transplantation in children with end stage renal disease (ESRD) remains controversial. Many centers have adopted a policy of waiting until such children reach a certain minimum age or weight, maintaining them on chronic dialysis until then. However, the authors of this article note that with proper donor selection and recipient care, comparable results can be achieved in very young age groups. This article presents results with kidney transplantation in children less than 1 year old. Between January 1984 and December 1999, the authors performed 321 kidney transplants at the University of Minnesota in children younger than 13 years old. The authors analyzed results in three age groups: less than 1 year (n = 30), 1 through 4 years (n = 122), and 5 through 13 years (n = 169). The authors found no significant differences in patient or graft survival rates between the three groups. Almost all infant (less than 1 year) recipients underwent primary transplants from living donors (LDs). However, even when comparing the results only of primary LD transplants between the three groups, there were no significant differences. To date, all the infant recipients are alive and well, 24 (80 percent) with a functioning original graft. Causes of the 6 graft losses were chronic rejection (n = 3), vascular thrombosis (n = 2), and recurrent disease (n = 1). Infants had significantly lower incidences of acute and chronic rejection compared with older recipients, but a tendency to higher incidences of delayed graft function and vascular thrombosis (clotting). The authors conclude that kidney transplant results in very young children can be comparable to those in older children. The timing of the transplant should not be based on age or size alone. 4 figures. 2 tables. 14 references.

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Liver Transplantation. In: Okuda, K., ed.,et al. Hepatobiliary Diseases: Pathophysiology and Imaging. Malden, MA: Blackwell Science, Inc. 2001. p. 599-612.

Liver transplantation is the treatment of choice for patients with irreversible liver failure. This chapter on liver transplantation is from a textbook that familiarizes the reader with various imaging modalities, the information they provide, and the merits of each, in order to facilitate the combined use of different imaging techniques in the diagnosis and management of hepatobiliary (liver and bile tract) diseases. The authors stresses that successful liver transplantation is dependent on accurate radiological imaging. As a member of the transplantation team, the radiologist must be familiar with the surgical anatomy of liver transplantation and the complex imaging of liver transplant patients. The radiological assessment includes the preoperative evaluation of patients with liver failure, accurate hepatic imaging of living donors, and rapid and accurate diagnosis of postoperative complications. The author discusses preoperative imaging, anatomy and normal postoperative findings, and post transplantation complications, including vascular complications, biliary complications, fluid collections, rejection, and post transplant malignancy (cancer). The preoperative assessment includes both technical aspects such as liver volume determination, and accurate diagnosis of conditions affecting transplantation, such as vessel thrombosis and liver cancer. The postoperative evaluation centers of rapid and accurate detection of complications. The author concludes that in many instances, accurate and prompt radiological assessment can play an important role in implementing treatments that prevent graft failure. 26 figures. 44 references.

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Open Donor, Laparoscopic Donor and Hand Assisted Laparoscopic Donor Nephrectomy: A Comparison of Outcomes. Journal of Urology. 166(4): 1270-1274. October 2001.

In experienced hands, laparoscopic surgery has been shown to be safe for procuring kidneys for transplantation that function identically to open nephrectomy (surgical removal of a kidney) controls. This article reports on a study of allograft function in patients (n = 48) with greater than 1 year followup who underwent open donor, classic laparoscopic, and hand assisted laparoscopic nephrectomy. Of these patients, 34 underwent consecutive laparoscopic live donor nephrectomy and 14 underwent open donor nephrectomy. Mean patient age was 36.5 years (plus or minus 8.4 years) for donors and 29 years (plus or minus 17 years) for recipients at transplantation (range of 13 months to 69 years). In the laparoscopic group, 11 patients underwent the transperitoneal technique, and 23 underwent hand assisted laparoscopic nephrectomy. Total operating time was significantly reduced with the hand assisted laparoscopic technique, as was the time from skin incision to kidney removal and warm ischemic (without blood flow) time. No blood transfusions were necessary. Complications included adrenal vein injury in 1 patient, small bowel obstruction in 2 patients, abdominal hernia at the trocar site in 1 patient, and deep venous thrombosis in 1 patient. The authors conclude that both classic laparoscopic donor and hand assisted laparoscopic donor nephrectomies appear to be safe procedures for harvesting kidneys. The recipient graft function is similar in the laparosocpic and open surgery groups. An editorial comment is appended to the article. 2 figures. 3 tables. 14 references.

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Platelet Dysfunction in Type 2 Diabetes. Diabetes Care. 24(8): 1476-1485. August 2001.

This review article examines the hypothesis that platelet and neurovascular dysfunction are integral parts of the metabolic syndrome and coexist with features of the syndrome. Platelets are essential for hemostasis, and knowledge of their function is basic to understanding the pathophysiology of vascular disease in diabetes. Intact healthy vascular endothelium is central to the normal functioning of smooth muscle contractility as well as its normal interaction with platelets. What is not clear is the role of hyperglycemia in the functional and organic microvascular deficiencies and platelet hyperactivity in people with diabetes. The entire coagulation cascade is dysfunctional in diabetes. Increased levels of fibrinogen and plasminogen activator inhibitor 1 favor both thrombosis and defective dissolution of clots once formed. Platelets in people with type 2 diabetes adhere to vascular endothelium and aggregate more readily than those in healthy people. Loss of sensitivity to the normal restraints exercised by prostocyclin (PGI2) and nitric oxide (NO) generated by the vascular endothelium presents as the major defect in platelet function. Insulin is a natural antagonist of platelet hyperactivity. It sensitizes the platelet to PGI2 and enhances endothelial generation of PGI2 and NO. Thus, the defects in insulin action in diabetes create a milieu of disordered platelet activity conducive to macrovascular and microvascular events. 3 figures. 1 table. 108 references. (AA-M).

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Refractory Pancreatitis Secondary to Ruptured Hepatocellular Carcinoma into the Common Bile Duct. Digestive Diseases and Sciences. 46(5): 1029-1033. May 2001.

Hepatocellular carcinoma (HCC, liver cancer) is a common disease worldwide and continues to be the leading cause of death of males in Taiwan (from where this article originates). Jaundice is present in 19 to 44 percent of cases of HCC at the time of diagnosis and is usually attributed to the preexisting liver cirrhosis (scarring) or extensive hepatic parenchymal (the liver body) destruction by tumor. Icteric hepatoma (a type of liver tumor) is characterized by intermittent obstructive jaundice with associated complications, such as cholangitis (inflammation of the bile ducts) and hemobilia. In this article, the authors report the first case of icteric hepatoma that initially presented as pancreatitis in addition to obstructive jaundice. The 59 year old man was admitted with a 2 week history of tea colored urine, intermittent tarry stool, vomiting, and postprandial epigastralgia (pain in the stomach after meals) with radiation to his back. He denied alcohol abuse and drugs consumption and he had never experienced pancreatitis. After 8 days of hospital treatment, the patient was released and able to eat a normal diet at an outpatient visit one month later. However, he was rehospitalized 8 weeks later with another episode of pain; surgical treatment was implemented. The patient died of multisystem organ failure on the 32nd postoperative day. For this case, the treatment was focused on two goals. First, the consequences of the biliary obstruction including the pancreatitis should be resolved by nonoperative methods, if available. Second, the origin of the migrating tumor should be eradicated either by transarterial chemoembolization or hepatic (liver) resection. The present case was not suitable for hepatic resection or hepatic artery ligation because of intrahepatic metastasis of both lobes and portal vein thrombosis (clotting) seen at exploration. Although palliation could be satisfactorily given, the prognosis continues to be dismal. 4 figures. 11 references.

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Systemic Vasculitis: A Difficult Diagnosis in the Elderly. Physician Assistant. 25(1): 37-38, 47-53. January 2001.

Illnesses in geriatric (aging) patients are often difficult to diagnose because the patients may not present with the typical pattern for many common diseases. This article reviews the diagnosis of systemic vasculitis in the elderly. Vasculitis is a group of heterogeneous disorders characterized by inflammation of blood vessels. The inflammation may cause narrowing, thrombosis (clotting), or occlusion (blockage) and necrosis (death) of the vessels. Vasculitis can also cause aneurysm or rupture, which will result in an inadequate blood supply and damage to the tissues of the differing organ systems involved. The author notes that the atypical presentation in the elderly, compounded by the fact that vasculitides present with vague symptomatology, have nonspecific diagnostic testing, and are difficult to differentiate because of their overlapping presentations, makes the diagnosis of systemic vasculitis difficult for the clinician. Additionally, geriatric patients often delay seeing the physician because they attribute their symptoms to the aging process. This article provides the clinician with tools to enhance the diagnosis of systemic vasculitis in a more timely and systematic fashion in the geriatric patient. Specific subtypes discussed include giant cell arteritis, polyarteritis nodosa, microscopic polyangiitis, and Wegener's granulomatosis. Nonspecific constitutional complaints, combined with those from multiple organ systems in the geriatric patient, should bring the suspicion of vasculitis. Once vasculitis is suspected, the clinician must move quickly to rule out the mimics of this systemic illness, including malignancies and infections. The diagnosis of a specific vascular syndrome is based on clinical symptoms, angiography, biopsy results, ANCA (antineutrophil cytoplasmic autoantibodies), and viral testing. Appropriate treatment with corticosteroids, cytotoxic agents, and antiviral therapy should begin as soon as possible to improve the patient's prognosis. 3 tables. 17 references.

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Toxic Megacolon: Role of CT in Evaluation and Detection of Complications. Journal of Clinical Imaging. 25(5): 349-354. September-October 2001.

This study was undertaken to determine the role of computed tomography (CT) in the evaluation of patients with toxic megacolon (including the detection of complications). A retrospective analysis of CT findings of 18 consecutive patients with toxic megacolon was performed. Underlying etiology included 12 patients with pseudomembranous colitis (PC), four patients with ulcerative colitis (UC), and two patients with cytomegalovirus colitis. Eleven patients were HIV positive. CT features, correlation with severity of disease, and development of complications were analyzed. Colonic dilatation with intraluminal and or fluid with a distorted colonic contour or an ahaustral pattern was seen in all patients. In four patients (22 percent), CT depicted complications: two colonic perforations and two septic thrombosis (clots) of the portal system (the vascular system of the liver). Six patients died (33 percent), three of whom had the above complications. The presence and degree of submucosal edema (fluid accumulation), wall thickening, degree of dilatation, nodular contour, and ascites did not correlate with clinical outcome. Two thirds of patients with toxic megacolon had PC as the underlying etiology. CT was helpful in depicting diffuse colitis, and it was instrumental in detecting life-threatening abdominal complications, contributing to the management of these patients. The authors conclude that CT abnormalities cannot be used to predict the clinical outcome unless complications develop. 4 figures. 25 references.

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Complications of Dialysis in Diabetic Patients. In: Lameire, N. and Mehta, R.L., eds. Complications of Dialysis. New York, NY: Marcel Dekker, Inc. 2000. p. 697-704.

Dialysis patients with diabetes mellitus comprise the largest subgroup of patients in end stage renal disease (ESRD) treatment programs in developed countries. This patient population is unfortunately also subject to greater morbidity and mortality when compared to nondiabetic dialysis patients. This chapter on the complications of dialysis in patients with diabetes is from a book that offers a comprehensive, multidisciplinary resource for the nephrologist and caregiver providing dialysis, covering all aspects of dialysis therapies and their complications. The authors of this chapter note that older age at the time of dialysis initiation and the presence of often advanced microvascular and macrovascular disease account for this excess rate of complications and death on dialysis. The management of dialysis patients with diabetes requires an aggressive, preemptive, multidisciplinary, and patient education oriented approach, which must often be led by the nephrologist (kidney specialist) who has the most frequent contact with the patient. Peripheral vascular, cardiovascular, and cerebrovascular disease, retinopathy (eye disease), gastropathy, and dialysis associated complications are the major contributors to co-morbidity in diabetic dialysis patients. Hemodialysis related complications include hypotension (low blood pressure), hypertension (high blood pressure), high interdialytic weight gain, vascular access problems, access thrombosis (clotting), ischemic monomelic neuropathy, and venous hypertension. Other problems discussed include bone disease, diabetic retinopathy, undernutrition, and hyperglycemia (high blood sugar levels). The complications of peritoneal dialysis in patients with diabetes including peritonitis, underdialysis, undernutrition, and hyperglycemia. The authors conclude by noting that the increasing prevalence of type 2 diabetes will require that nephrologists target the problems prevalent in this population in order to reduce morbidity (illness) and mortality (death). 2 tables. 46 references.

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Complications of Vascular Access. In: Lameire, N. and Mehta, R.L., eds. Complications of Dialysis. New York, NY: Marcel Dekker, Inc. 2000. p. 1-27.

This chapter on the complications of vascular access is from a book that offers a comprehensive, multidisciplinary resource for the nephrologist and caregiver providing dialysis, covering all aspects of dialysis therapies and their complications. Vascular access is essential for hemodialysis; without effective access, dialysis can not take place. However, access also accounts for many of the complications seen in hemodialysis patients. The author discusses the three types of vascular access and the complications associated with each type: tunneled cuffed catheters (TCC), prosthetic bridge grafts (PBG), and autologous native fistulas (AVF). Topics include complications of initial placement, catheter thrombosis, infection, venous stenosis (narrowing), graft thrombosis, graft infection, pseudoaneurysm formation, PBG related ischemia, and inadequate development of the AVF. The author concludes that the hemodialysis community has a great need for a better solution for the management of vascular access and for an organized strategy to decrease the incidence of complications and to handle them appropriately when they occur. At a minimum, this strategy must include a plan to maximize the use of native fistulae, a policy for appropriate use of dialysis catheters, a quality assurance program to detect the access at risk, implementation of procedures to increase access longevity, and a system to manage graft thrombosis effectively and efficiently. 5 figures. 9 tables. 191 references.

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