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Biomedical subjects

C M Kjellstrand

Publications and source records attributed to C M Kjellstrand.

At least 19 recordsLinked to original sources
PubMed1991

Plasma concentrations of calcitonin gene-related peptide in fluid overload.

To investigate the hypothesis that calcitonin gene-related peptide (CGRP), a potent vasodilator, is an important physiological defence against fluid overload, plasma CGRP concentrations were measured in various degrees of fluid overload in 26 haemodialysis patients, for whom diuresis, mediated by atrial natriuretic peptide (ANP), is not a possible defence mechanism. Plasma CGRP concentrations were positively correlated with the degree of fluid excess (r = 0.815, p = 0.0001) and were significantly higher in 5 patients with severe fluid overload than in those less severely affected (143 [SE 14] vs 52 [11] pmol/l; p less than 0.001). CGRP may be an effective defence against complications of fluid overload since it can increase capitance by vasodilatation.

Atrial Natriuretic Factor↗
PubMed1991

Should intravenous immunoglobulin G be first-line treatment for acute thrombotic thrombocytopenic purpura? Case report and review of the literature.

Acute thrombotic thrombocytopenic purpura (TTP) is a rare and serious disease. Treatment with prednisone, anticoagulation, antiplatelet drugs, splenectomy, exchange transfusions, vincristine, and plasmapheresis may be effective in some patients, but the response to these therapies is inconsistent and all carry the potential for serious side effects. We, and others, have recently seen dramatic responses to intravenous (IV) immunoglobulin G (IgG) when other treatments have failed. Although IV IgG is expensive, its costs are low compared with those extended plasmapheresis regimens. Since the response to treatment can usually be evaluated within a few days and the side effects appear less than with other treatments, we believe a strong case can be made for the use of IV IgG as first-line therapy for acute TTP. Continued multicenter studies are necessary to finally solve the problem of competing and confusing treatment attempts and synergism of treatment in acute TTP.

Acute Disease↗
PubMed1991

Changing patient characteristics in chronic hemodialysis.

Patients accepted to chronic hemodialysis have changed. We analyzed these changes and survival, cause of death and other factors during 23 years at the Karolinska Hospital. Between 1965 and 1987, 274 patients were accepted: 60 are alive on dialysis, 75 died, 113 were transplanted, 25 sent to other units and one recovered renal function. The mean age increased from 44 to 55 years (p=0.001), the creatinine level at acceptance decreased from 1191 to 965 mumol/l (p = 0.001), the hemoglobin level rose from 70 to 85 g/l (p = 0.001) and the diastolic blood pressure decreased from 96 to 90 mmHg (p = 0.007). The number of co-morbid conditions increased from 1.2 to 1.4 (p less than 0.005). The diagnoses changed from over 90% primary renal disease to 20% systemic diseases such as nephrosclerosis and diabetes (p = 0.04). The chance of receiving a renal transplant decreased from 46 to 39% (p = 0.28). The transplanted patients were younger than the dialyzed patients 42 vs 47 years (p = 0.03) before 1980 and 49 vs. 56 years (p = 0.0001) after 1980. The cause of death changed. Withdrawal from dialysis increased from 5% of deaths before to 24% after 1980 (p = 0.047), cardiovascular deaths decreased from 85% to 55% (p = 0.01). Although the patients accepted for dialysis after 1980 had more serious renal disease and other degenerative diseases than those before, the mortality rate was reduced to only 1/4 to that before, in all age groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Hypertension profiling by total body water (TBW) determinations in patients on chronic hemodialysis.

Hypertension is an important risk factor in hemodialysis patients. Fluid overload and increased peripheral resistance are considered the two main causes. We studied the relation between volume state and blood pressure in 18 hemodialysis patients. Actual total body water (aTBW) was measured as tritium space and "ideal" total body water (iTBW) by an anthropometric method. The difference between aTBW and iTBW was considered a measure of fluid excess or deficit. Twelve patients were overhydrated, 5%-23%. Their predialysis blood pressure was significantly correlated to their degree of fluid excess; systolic BP:r = 0.71, p = 0.03, diastolic BP:r = 0.73, p = 0.02, mean arterial BP:r = 0.76, p = 0.03. Five of these patients had multiple antihypertensive drugs instead of adequate ultrafiltration. Five patients had a fluid deficit of -3 to -13% and hypertension due to vasoconstriction. Four of these were adequately treated with antihypertensive drugs but had exaggerated ultrafiltration. TBW determination with tritium is simple to perform and gives information on the volume state and thereby on the cause of hypertension in hemodialysis patients. Based on this, appropriate treatment can be chosen.

Blood Pressure↗
PubMed1990

Mortality on dialysis--on the influence of early start, patient characteristics, and transplantation and acceptance rates.

We compared changes from 1965 to 1987 in patients accepted to chronic dialysis, in a Swedish and a US dialysis center, by medical and clinical parameters at the start of dialysis and by duration of the dialysis. We also studied cause of death, outcome, and cumulative survival and tried to relate them to changes in patients and procedures. Finally, we studied how cumulative survival of dialysis patients was dependent on acceptance rates and transplant rates in five European regions and the United States. At both centers, the number of patients accepted grew, but since 1980, the only patient group that has increased has been older patients with many other diseases; these comorbid conditions have increased from approximately 1.2 to 1.4. In both centers, the number of patients with systemic disease, diabetes, and nephrosclerosis doubled. Cause of death showed a decrease in cardiovascular deaths and an increase in deaths due to stopping dialysis. The hemoglobin level increased from 70 to 90 g/L (7.0 to 9.0 g/dL) and the diastolic blood pressure decreased from 100 to 90 mmHg. The creatinine level decreased 30%, with an unchanged urea. Cumulative 3-year survival for patients without complications increased from 60% to approximately 90% and in patients with complications, it improved from 20% to 60% in Sweden and remained at approximately 60% in the US center. In the United States, many more patients were accepted to dialysis and the transplant rate was high. Cumulative survival on dialysis was inversely correlated both to the acceptance rates to dialysis and to the percent of patients transplanted. These factors explained over 90% of the differences in dialysis survival.

Aged↗
PubMed1989

Plasma concentrations of calcitonin gene-related peptide increase during haemodialysis: relation to blood pressure.

The authors measured the plasma levels of calcitonin gene-related peptide (CGRP), the most potent vasodilatator known, during sequential ultrafiltration and haemodialysis in 12 patients using a radio-immunoassay method. Mean plasma levels of CGRP were 70.3 +/- 16.5 (mean +/- SE) pmol l-1 at the start of treatment, it increased to 85.3 +/- 17.6 pmol l-1 during ultrafiltration and to 114.5 +/- 25.3 pmol l-1 during dialysis. Systolic blood pressure decreased during haemodialysis. Plasma levels of CGRP were negatively correlated to systolic blood pressure before and at the end of dialysis, and changes in plasma levels of CGRP were strongly correlated to changes in systolic blood pressure. The increase in CGRP levels was not correlated to the fluid removal, toxin removal or changes in osmolality. The increase in plasma levels of CGRP observed during dialysis may be an important cause of dialysis induced vasodilatation and fall in blood pressure.

Adult↗
PubMed1988

Role of hypervolemia and renin in the blood pressure control of patients with pyelonephritis renal scarring.

Patients with pyelonephritic renal scarring are at risk of developing renal failure and hypertension. We studied glomerular filtration rate (GFR), renal plasma flow (RPF), filtration fraction (FF), systolic (SBP) and diastolic (DBP) blood pressure, fractional sodium, potassium and phosphate excretion, peripheral renin activity (PRA), plasma aldosterone (p-Aldo), urinary albumin excretion (U-Alb) and urinary beta 2-microglobulin excretion (beta 2-M) in hydropenia and during transition to 3% volume expansion with isotonic saline infusion in 22 female patients with renal scarring due to pyelonephritis and 9 healthy controls. The patients had significantly lower GFR, higher SBP and higher PRA in hydropenia, but there was no significant difference in RPF, FF, DBP or p-Aldo. After volume expansion, SBP, DBP, PRA and p-Aldo were significantly higher in patients than in controls. Transition to 3% volume expansion was associated with a similar increase in SBP in both patients and controls, whereas DBP increased significantly more in the patients (p less than 0.01). Volume expansion resulted in a significant suppression of PRA and p-Aldo in both patients and controls. The patients with renal scarring had the same capacity to excrete sodium and water during transition to volume expansion as the healthy controls. The renin-aldosterone system seems abnormally activated and is probably more important than hypervolemia in the development of hypertension in this group of patients.

Adult↗
PubMed1988

Withdrawing life support--the survivors.

We studied the impact of withdrawal of life support on surviving relatives and families of patients who died when chronic dialysis was discontinued. Fifty-four (57%) relatives answered a written questionnaire. The relatives of 70% of home dialysis patients and 27% of center dialysis answered the questionnaire. The answering relative felt most angry and uncomfortable with the decision, ascribed the least anger and most comfort to the patient and an intermediate value to the rest of the family. Staff physician and resident ranked highest in involvement in making the decision, social workers and chaplains the lowest. Once the decision was made, social workers and nurses were most caring and helpful, residents and chaplains were rated the lowest. The relatives felt that they and the patients were the ones who most often brought up the decision to stop and also made the final decision. The relatives thought that the incompetent patients were most angry and uncomfortable but that they felt that decision to be right. The family and relatives were particularly angry and uncomfortable when the patient had discontinued dialysis for the stress of the procedure alone and not any medical complications. In these cases there was most family disagreement and the staff received startling low scores, both for involvement and caring and helpfulness. In answers to open-ended questions, the relatives expressed disappointment with physicians who were unwilling to talk to them, were overly optimistic and continued too long with treatment. They wished for more openness and truthfulness. No long-term psychological harm seems to have come to the relatives and families with one exception. Our finding suggests that more meetings with families and patients and openness about problems and complications during chronic dialysis and follow-up and counseling of families after the patients have died should be helpful.

Attitude to Death↗
PubMed1988

Inequalities in chronic dialysis and transplantation in Sweden.

We studied the chance of receiving dialysis and transplantation in Sweden and Stockholm based on age and sex. The number of patients accepted for chronic dialysis, divided into men and women or five age groups, were set in relation to the number of patients who died of ESRD (end-stage renal disease) in the same groups. The transplanted patients were likewise related to patients waiting on chronic dialysis. Although older patients were increasingly accepted for treatment, age is still strongly inversely correlated to acceptance. Thus in 1985, young patients aged 16-39 years had an 85% chance of being dialyzed, but patients over age 70 had only a 17% chance. Of potential male candidates, 44% received dialysis, but only 38% of women received it. Similar age, but less sex inequality, existed in the selection of patients for transplantation. In Sweden, age and sex influence the selection of patients for dialysis and transplantation.

Adolescent↗
PubMed1988

Withdrawing life support. Do families and physicians decide as patients do?

We studied whether families and physicians decided as patients do, in discontinuation of life-supporting treatment. We did so by comparing 66 competent patients, who themselves decided to stop dialysis to die, and 66 incompetent patients for whom families and physicians decided. We also compared comatose to demented patients and families' to physician's decision-making. There was no difference in sex, diagnosis, age, time period, decision maker (family or physician), site of residence, duration or type of dialysis, home or in-center dialysis or survival time after discontinuation. More competent than incompetent patients died at home (p less than 0.005). All incompetent patients had emerging complications, but such complications were present in only 40/60 competent patients (p less than 0.0005). In the early 1970s the physician initiated the termination of dialysis in all cases of incompetent patients; in the 1980s this had decreased to 48% (less than 0.001). No case was decided by court or hospital committee. There was no difference between comatose or demented incompetent patients, nor was there any important difference between family and physician decision-making. We believe our study indicates that substitute judgement is applied appropriately and that the decision can safely and best be left to families and physicians.

Aged↗