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Biomedical subjects

E J Will

Publications and source records attributed to E J Will.

At least 55 records · Page 3Linked to original sources
PubMed1993

Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure.

OBJECTIVE: To determine whether continuous modes of renal replacement therapy result in improved cardiovascular stability compared with standard daily intermittent treatment in critically ill patients. DESIGN: Prospective, randomized controlled trial. SETTING: Intensive care unit in a quaternary referral center for liver failure/transplantation. PATIENTS: Thirty-two consecutive, critically ill, mechanically ventilated patients with combined acute hepatic and renal failure. INTERVENTIONS: Patients were randomized to treatment with either intermittent machine hemofiltration or continuous modes of renal replacement therapy; continuous arteriovenous hemofiltration (CAVH) or arteriovenous hemofiltration with dialysis (CAVHD), provided intracranial pressure was controlled. MEASUREMENTS AND MAIN RESULTS: Cardiac output, tissue oxygen delivery (DO2), and uptake were assessed during 32 treatments with intermittent machine hemofiltration (4 hrs) and during the first 5 hrs of 25 continuous treatments (CAVH and CAVHD). During the first hour of treatment, there was a reduction in cardiac index of 15 +/- 2% during intermittent machine hemofiltration compared with no significant change during the continuous modes of treatment (CAVH/CAVHD) (3 +/- 3%; p < .05). This reduction in cardiac output during intermittent machine hemofiltration was associated with a maximum reduction in mean arterial pressure from 82 +/- 2 to 66 +/- 2 mm Hg (p < .001), a reduction in pulmonary artery occlusion pressure of 27 +/- 4%, tissue DO2 of 15 +/- 3%, and tissue oxygen uptake of 12 +/- 5%, with no significant change in systemic vascular resistance and an increase in pulmonary vascular resistance of 50 +/- 12%. In addition, there was a maximum increase in intracranial pressure of 45 +/- 5% during the first hour of intermittent machine hemofiltration. There were no significant changes during the same time period during the continuous modes of renal replacement therapy. CONCLUSIONS: In critically ill patients, in whom DO2 is impaired, the use of continuous forms of renal replacement therapy is preferred for its improved cardiovascular tolerance compared with daily intermittent machine treatments.

Acute Kidney Injury↗
PubMed1993

Anticoagulation with low molecular weight heparin (Fragmin) during continuous hemodialysis in the intensive care unit.

A preparation of low molecular weight heparin (Fragmin) was administered to patients with multiorgan failure receiving continuous venovenous hemodialysis. Three patients received a high-dose regimen (35 IU/kg bolus followed by 13 IU/kg infusion), and 7 received a low-dose regimen (8 and 5 IU/kg, respectively) for 36 h. High-dose Fragmin was associated with minimal clotting in the extracorporeal circuit. Plasma fibrinopeptide A levels declined, and mean anti-Xa activity was in the range 0.47-0.79 IU/ml. The urea equilibration coefficient (UEC) (100% at initiation) remained above 90% throughout. All 3 patients had mild bleeding episodes, which led to discontinuation of Fragmin in 1. During all low-dose treatments, marked thrombus formation occurred in the extracorporeal circuit, and in 2, the circuit clotted within the study period. Fibrinopeptide A levels further increased in 4 patients, and mean anti-Xa activity was in the range 0.27-0.53 IU/ml. UEC declined appreciably in 3 treatments (including the 2 in which early circuit clotting occurred). One patient experienced a mild bleeding episode. The low-dose Fragmin regimen produced safer anticoagulation in patients at risk from bleeding and is suitable for prolonged renal support although the tendency to thrombosis may necessitate more frequent circuit changes.

Acute Kidney Injury↗
PubMed1993

The effect of treatment with recombinant human erythropoietin on the histological appearance and glycogen content of skeletal muscle in patients with chronic renal failure treated by regular hospital haemodialysis.

The effect of treatment with recombinant human erythropoietin on the histological appearance and glycogen content of the anterior tibialis muscle was studied in 10 patients with chronic renal failure treated by regular haemodialysis. Repeat muscle biopsies taken when the target haemoglobin concentration of 11 g/dl was achieved showed an increase in median glycogen content from 35 mg/g fat-free dry muscle to 51 mg/g (p < 0.05). The histological appearance showed a marked improvement in muscle fibre diameters, in particular for the type I fibres and a reduction in cytoarchitectural abnormalities. These changes would be expected to produce an increase in both muscle strength and performance and are most probably a consequence of an increase in muscle oxygen delivery.

Adult↗
PubMed1993

Membrane biocompatibility: effects on cardiovascular stability in patients on hemofiltration.

We investigated the effect of membrane bio-incompatibility on cardiovascular stability in 10 patients with combined acute hepatic and renal failure during 44 isovolemic intermittent machine hemofiltration treatments, using a polyamide membrane in 24 and a polyacrylonitrile membrane in 20. Cardiac output decreased by 14 +/- 2% during polyamide treatment compared to 8 +/- 3% during polyacrylonitrile (P < 0.05). Pulmonary artery occlusion pressure decreased by 20% or more in 65% of the polyamide treatments compared to 38% of the polyacrylonitrile (P < 0.05). Tissue oxygen delivery decreased by 16 +/- 2% during polyamide treatment compared to 6 +/- 3% during polyacrylonitrile treatment (P < 0.05). Mean arterial blood pressure declined from 80 +/- 3 mm Hg to 70 +/- 2 mm Hg during polyamide treatment (P < 0.001), whereas there was no significant change during polyacrylonitrile treatment. Thus, in this group of critically ill patients, the use of two different membranes was associated with greater cardiovascular stability with polyacrylonitrile treatment compared to polyamide, with respect to maintenance of tissue perfusion and perfusion pressure. This suggests that extracorporeal membrane bio-incompatibility may have a role in determining cardiovascular stability during treatment with extracorporeal circuits.

Acute Kidney Injury↗
PubMed1993

Effect of renal replacement therapy on patients with combined acute renal and fulminant hepatic failure.

The mortality of patients with combined acute hepatic and renal failure remains high. Previous studies have reported both patient morbidity and mortality directly attributable to the use of extracorporeal circuits used to treat renal failure. We investigated the effect of various modes of renal replacement therapy in 30 consecutive patients referred with both fulminant hepatic and acute renal failure. Cardiac output decreased during the first hour of 30 intermittent machine haemofiltration treatments, by 15 +/- 3%, as did tissue oxygen delivery, 16 +/- 3% and tissue oxygen uptake, 13 +/- 4%, whereas there was no significant change during 30 continuous hemofiltration and/or dialysis treatments. Intracranial pressure remained stable during the continuous modes but increased from 9 +/- 2 mm Hg to 17 +/- 2 mm Hg, P < 0.01, during intermittent machine hemofiltration, with the greatest increase of 55 +/- 9% within the first hour. Mean arterial blood pressure was stable during treatment with the continuous modes, but decreased by 20 +/- 3% during the first hour of intermittent machine hemofiltration, resulting in a maximum reduction in cerebral perfusion pressure of 35 +/- 8%. In this group of critically ill patients continuous modes of renal replacement therapy resulted in superior cardiac and intracranial stability compared to standard intermittent modes of treatment.

Acute Kidney Injury↗
PubMed1993

Aluminium mobilization following renal allograft transplantation may have an immunomodulatory role by reducing the incidence of graft rejection.

Urinary aluminium excretion was prospectively monitored during the first year following first cadaver renal allograft transplantation in 79 consecutive patients. Plasma and urinary aluminium concentrations steadily declined with time. Thirty-five patients had 0-1 episodes of acute graft rejection compared to 44 with two or more rejections; more of the former group had been prescribed aluminium-containing phosphate binders (74% versus 56%, P < 0.02), and following transplantation this group had a persistently greater urinary aluminium excretion, suggesting a greater aluminium body burden. There were no significant differences in terms of gender distribution, blood transfusion, or HLA matching between the groups, thus suggesting that either the subsequent mobilization of aluminium body stores following transplantation and/or the accumulation of aluminium in the reticulo-endothelial system prior to transplantation may have had an immunomodulatory effect in reducing the incidence of renal allograft rejection.

Adolescent↗
PubMed1992

Blood lactate is reduced following successful treatment of anaemia in haemodialysis patients with recombinant human erythropoietin both at rest and after maximal exertion.

The effect of increasing haemoglobin by erythropoietin therapy on exercise capacity was investigated in 11 regular haemodialysis patients, previously transfusion dependent. Exercise work load increased from a median of 100 W (95% confidence limit, 25-135) to 120 (45-180; p < 0.05) following erythropoietin, and the duration of the exercise test from 13 (3.5-20) to 15.5 min (4-22; p < 0.05). Resting blood lactate concentration decreased from 0.8 (0.6-1.6) to 0.3 mmol/l (0.3-0.4), p < 0.05, following treatment with erythropoietin, as did blood lactate concentration at maximal exertion from 2.0 (1.0-4.1) to 1.8 mmol/l (0.5-2.8; p < 0.05). In association with the increase in haemoglobin from a median of 6 (5.1-6.8) to 11.1 g/dl (11-11.9) following erythropoietin therapy, patients were able to achieve greater exercise capacity both in terms of maximum work load and duration of exercise in association with a reduced resting arterial lactate and a similar exercise-induced lactate production. This suggests that treatment had improved muscle function in terms of lactate production and/or utilisation. This was probably due to the increase in tissue oxygen delivery, as there was an increase in the median arterial oxygen content from 79 (65-85) to 150 ml O2 (144-157) following erythropoietin treatment.

Adult↗
PubMed1992

Use of the urinary protein creatinine index to assess proteinuria in renal transplant patients.

The use of 24-h urine protein collections for the assessment of proteinuria in renal transplant patients has been compared with the protein creatinine index (PCI) obtained from spot urine samples. Paired data from 148 patients showed a correlation of 0.77 (P less than 0.001) between 24-h protein excretion and the PCI. A PCI of 750 identified proteinuria of greater than 1.0 g/24 h with a sensitivity of 89% and a specificity of 93%. The predictive value of a positive test was 81% and that of a negative test 96%. Similar performance was observed for the detection of proteinuria of differing severities ranging from 0.5 g/24 h to 2.0 g/24 h. The use of spot testing was popular with both patients and staff, and reduced the sample handling cost to 15% of that of 24-h urine collection. We recommend that PCI be adopted as the standard outpatient test for the assessment of proteinuria following renal transplantation.

Adolescent↗
PubMed1991

Tumour necrosis factor does not increase during routine cuprophane haemodialysis in healthy well-nourished patients.

Serum tumour necrosis factor (TNF) was measured by both bioassay and immunoassay (ELISA) during routine cuprophane acetate haemodialysis in 17 asymptomatic patients. In 14 (82%) there was no change in the serum values during haemodialysis. TNF was found to increase, using both assays, in three patients, the responders. These patients differed from the others in terms of body mass index, mean index 16.8 kg/m2 (range 14.8-18.2), compared to the non-responders, mean 24.1 kg/m2 (range 19.6-33.1), P less than 0.05, and had an increased serum calcium, mean 2.9 mmol/l (range 2.6-3.2) compared to the non-responders, mean 2.4 mmol/l (range 1.7-2.8), P less than 0.05. Two of the TNF responders subsequently died of cachexia and respiratory infection. The third underwent a successful parathyroidectomy, and when retested after an increase in body-weight with a normal serum calcium concentration no longer showed an increase in TNF during haemodialysis.

Adult↗
PubMed1991

Adverse effects on cerebral perfusion of prostacyclin administered directly into patients with fulminant hepatic failure and acute renal failure.

Prior to commencing renal replacement therapy, 8 patients with fulminant hepatic failure and acute renal failure were treated with an infusion of prostacyclin, 5 ng/kg/min, for 30 min, administered directly into the femoral vein. During this period, several adverse effects were noted. There was a reduction in mean arterial blood pressure from a median of 82 (range 65-93) to 67 mm Hg (55-80), p less than 0.01; and an increase in intracranial pressure from a median of 14 (6-33) to 17 mm Hg (6-42), p less than 0.05; with a consequent reduction in cerebral perfusion pressure from a median of 63 (43-77) to 43 mm Hg (15-74), p less than 0.05. There was a reduction in arterial oxygen tension from a median of 19 (13-28) to 16 kPa (12-27), p less than 0.05; and no change in cardiac output, from a median of 6.7 (4.9-11.2) to 6.5 l/min/m2 (3.8-11.0), p greater than 0.05). The administration of prostacyclin into this group of critically ill patients, at risk of death due to cerebral oedema/hypoxia, produced both a reduction in cerebral perfusion pressure and a reduction in total cerebral oxygen delivery.

Acute Kidney Injury↗
PubMed1991

Hyperlactataemia and metabolic acidosis during haemofiltration using lactate-buffered fluids.

We have investigated the effect of an exogenous lactate load given during machine haemofiltration treatment in 22 patients with acute renal failure and 12 patients with chronic renal failure, without any overt evidence of liver disease. Hyperlactataemia occurred in all patients, but the expected changes in acid base status, an increase in bicarbonate and a reduction in arterial hydrogen ions were observed in less than 40% of the treatments in the acute renal failure group. Ultrafiltrate losses of lactate and bicarbonate could not alone explain the changes in acid-base status. There was a positive correlation between the increase in arterial lactate and hydrogen ion concentrations, r = 0.52, p less than 0.01. Lactate accumulation in patients at, or close to, their threshold for lactate utilisation may result in further depression of cardiac function and peripheral lactate utilisation. Hyperlactataemia due to use of lactate-based dialysis/haemofiltration solutions in critically ill patients may result in a worsening of the acid-base status, and arterial pH should be monitored so that bicarbonate solutions can be substituted if the changes are progressive.

Acidosis, Lactic↗
PubMed1991

Prevalence of Helicobacter pylori in patients with end-stage renal failure and renal transplant recipients.

The prevalence of Helicobacter pylori was determined using an ELISA technique for IgG antibodies to H. pylori in 76 patients with end-stage renal failure who were receiving regular haemodialysis and 202 patients with functioning renal transplants. Twenty-seven (34%) of the haemodialysis group and 58 (29%) of the transplant group were positive for H. pylori IgG antibodies, and the prevalence did not differ significantly from that in 247 age-matched healthy controls. In the haemodialysis group, patients positive for H. pylori were older, median age 60 years (range 22-73), compared to those patients without H. pylori antibodies, median age 52 years (range 22-75), p less than 0.05, more suffered from dyspeptic symptoms, 35 vs. 10% (p less than 0.01), yet fewer had been prescribed aluminium-containing antacids, 38 vs. 78% (p less than 0.01). In the transplanted group, those positive for H. pylori were more symptomatic for dyspepsia, 30 vs. 11% (p less than 0.01), and had lower serum creatinine values, 136 +/- 10 mumol/l (mean +/- SEM) vs. 172 +/- 12 mumol/l (p less than 0.05), compared to those without H. pylori antibodies. Almost all the transplant patients with H. pylori antibodies were taking steroids (98%) compared to 84% of those without antibodies (p less than 0.05). The prevalence of antibodies to H. pylori in this study was increased in symptomatic dyspeptic subjects and reduced in those patients prescribed aluminium-containing phosphate binders.

Adult↗
PubMed1991

The prognostic use of a lactate infusion in patients with severe hepatorenal failure.

We have used machine hemofiltration (MHF) with lactate-buffered hemofiltration replacement solution in the management of four patients with severe hepatorenal failure. Hyperlactatemia developed in all four patients. However, consecutive treatments were associated with increasing blood lactate values postfiltration in the two patients who died and with a fall in the lactates in the two patients who survived. The survivors had lower postfiltration blood lactates 3.2 +/- 0.2 mmol/L (mean +/- SEM) compared to the nonsurvivors, 5.3 +/- 0.5 mmol/L (p less than 0.01). This suggests that the measurement of blood lactate following a lactate challenge may be of prognostic significance in patients with severe hepatorenal failure.

Adult↗
PubMed1991

Volumetric control of continuous haemodialysis in multiorgan failure.

The authors have developed a system for volumetric control of continuous haemodialysis. The article describes this system and reports its successful use in providing renal support in the intensive care unit to 10 patients with multiorgan failure. In addition to providing effective treatment of uraemia, it permits the precise control of fluid balance in a prospective manner ("dial-up" fluid balance) while reducing nursing workload.

Acute Kidney Injury↗
PubMed1991

The effect of prostacyclin on intracranial pressure in patients with acute hepatic and renal failure.

Prostacyclin was administered on 20 occasions to 12 patients with fulminant hepatic failure complicated by acute renal failure prior to commencing dialysis at a dose of 5 ng/kg.min. Intracranial pressure was noted to increase during the infusion from a median of 12 mmHg (95% confidence limits 9-14) to 17 mmHg (12-25), p less than 0.01, at the same time the mean arterial blood pressure declined from 79 mmHg (65-82) to 64 (56-70), p less than 0.01, and the cerebral perfusion pressure from 62 mmHg (53-67) to 44 mmHg (41-55), p less than 0.01. The changes were greater for those patients who subsequently died from cerebral edema. Patients with fulminant hepatic and acute renal failure are at risk of dying from cerebral edema. The direct administration of prostacyclin, used for extracorporeal anticoagulation, may cause a further increase in intracranial pressure and reduce cerebral perfusion, thus resulting in patient morbidity and mortality.

Acute Kidney Injury↗
PubMed1991

Aluminium mobilization following renal transplantation and the possible effect on susceptibility to bacterial sepsis.

We monitored urinary aluminium excretion in 60 renal allograft recipients for the first 6 months following transplantation. Plasma and urinary aluminium values steadily decreased during the study period. Patients who suffered two or more bacterial infections during this period excreted more urinary aluminium than those with only one or no infections. Twenty patients experienced a two-fold or greater sudden unexpected increase in urinary aluminium excretion: 14 of these patients (60 per cent) had evidence of infection (10 bacterial and four viral), at this time. Both urinary aluminium and fractional aluminium excretion were greater in the 10 patients with bacterial infection than in the other 10 patients. Thus, patients who suffered bacterial infections had higher base-line urinary aluminium excretion, suggesting a higher body burden of aluminium. In addition, bacterial sepsis was associated with aluminium release from tissue stores with an associated increase in urinary aluminium excretion. This implies that patients with an increased body burden of aluminium are more prone to bacterial sepsis, and that aluminium excretion is increased during sepsis.

Adult↗