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Biomedical subjects

J A Chazan

Publications and source records attributed to J A Chazan.

At least 19 recordsLinked to original sources
PubMed1992

The impact of diagnosis-related groups on the cost of hospitalization for end-stage renal disease patients at Rhode Island Hospital from 1987 to 1990.

The introduction of diagnosis-related groups (DRGs) for the reimbursement of hospital costs in the Medicare population made no provisions to identify end-stage renal disease (ESRD) patients. To assess the impact of the DRGs on ESRD patients, we prospectively evaluated all hospitalizations (901) at the Rhode Island Hospital from July 1987 through April 1990 among a chronic hemodialysis population of 587 patients. The complied data on length of hospital stay, cost per day, and total cost were compared with the accepted allowances as defined by the DRG codes assigned to the admissions. The mean values and comparisons were length of stay, 10.2 +/- 21 days (ESRD) versus 9.7 +/- 3.6 days (DRGs), P = 0.44; cost per day, $1,240 +/- $685 (ESRD) versus $671 +/- $897 (DRGs), P = 0.0001; and total cost, $9,660 +/- $17,170 (ESRD) versus $6,815 +/- $8,872 (DRGs), P = 0.0001, a difference of $2,275 per admission. The increase in daily, and thus total, costs was primarily due to the use of supplies, medications, laboratory procedures, and transfusion services. It appears from our data that the DRGs do not adequately reflect the cost of caring for ESRD patients with the same DRGs as non-ESRD patients because of increased demand for ancillary services. If these observations are confirmed, a reevaluation of the DRG process as it relates to ESRD patients is warranted.

Diagnosis-Related Groups↗
PubMed1992

Serum creatinine concentration at the onset of uremia: higher levels in black males.

We compared serum creatinine and blood urea nitrogen concentrations, estimated creatinine clearances and frequency of uremic symptoms at the start of chronic hemodialysis in all 20 black and 179 white males treated between 1969 and 1983. Serum creatinine concentrations were significantly higher in black males (16.5 +/- 5.9 mg/dl) than in white males (11.7 +/- 4.7 mg/dl; p = 0.016). There were no significant differences in blood urea nitrogen concentration, estimated creatinine clearance and frequency of uremic symptoms between the two groups. Blood urea nitrogen to serum creatinine ratios were lower in black males, (7.3 +/- 1.9) than in white males (11.4 +/- 3.8; p = 0.0001), and only one black male had a ratio greater than 10 compared to 60% of whites. We concluded that black males tend to have higher serum creatinine concentrations than white males at the onset of uremic symptoms, and that higher striated muscle creatinine production in black males and not lower renal function may be the cause.

Adult↗
PubMed1991

Increased serum aluminum. An independent risk factor for mortality in patients undergoing long-term hemodialysis.

The annual mortality rate among patients receiving long-term hemodialysis has been rising over the past decade. The prevalences of known risk factors such as older age, male sex, duration of dialysis, presence of diabetes, coronary artery disease, or hypertension do not seem to have changed during this time. However, evidence suggests that an increased body aluminum level may have an adverse effect on survival even in the absence of overt aluminum toxic reaction. Therefore, we evaluated the correlation between serum aluminum levels and mortality in 10 646 patients undergoing long-term hemodialysis. Mortalities were 18% higher for patients with serum aluminum levels between 1520 and 2220 nmol/L and progressively increased to 60% higher for patients with aluminum levels above 7410 nmol/L. Serum aluminum level was an important predictor of survival even after other known risk factors had been controlled. These data strongly suggest that patients undergoing long-term hemodialysis should have periodic surveillance of the serum aluminum levels, and in those patients who have plasma levels of 1520 to 2220 nmol/L or higher, one should seriously consider discontinuing aluminum salts and giving therapy to decrease body aluminum level if it is found to be increased.

Age Factors↗
PubMed1991

Fibrillary (immunotactoid) glomerulopathy. A possible role for kappa light chain in its etiology and/or pathogenesis.

The initial clinical manifestations, course, and immunopathologic findings of renal biopsies of nine patients with fibrillary glomerulopathy are reported. Their first symptoms and courses were variable, but proteinuria and renal failure were common. While some patients required hemodialysis soon after coming for treatment, others progressed to renal failure over several years. Three patients had monoclonal gammopathy; one of them had an isolated, transient, Bence-Jones proteinuria. The main pathologic features are glomerular enlargement, mesangial expansion, and mild hypercellularity. Congo red and thioflavin stains were negative. Kappa chain, either alone or with lambda chain and IgG, were the predominant immunoreactants. Ultrastructurally, the presence of coarse fibrils of 15-25 nm was characteristic, but there were also granular deposits in the capillary wall that occurred in a band-like pattern in the inner half of the glomerular basement membrane in a manner similar to the deposits seen in light chain deposit disease. The immunofluorescence and ultrastructural findings suggest that light chains (especially kappa) may be significant in the pathogenesis of fibrillary glomerulopathy and that there may be a relationship with light chain deposit disease.

Adult↗
PubMed1991

The clinical spectrum of renal osteodystrophy in 57 chronic hemodialysis patients: a correlation between biochemical parameters and bone pathology findings.

Fifty-nine chronic hemodialysis patients who had been on dialysis for an average of 77 months underwent bone biopsies and the pathologic findings were correlated with biochemical and demographic data. All but two had evidence of renal osteodystrophy, 23 with osteitis fibrosa (OF), 19 with osteomalacia and/or adynamic disease (OM/AD), and 15 with mixed osteodystrophy (MOD). Patients in each group were similar with regard to age, sex distribution, duration of dialysis, unstimulated serum aluminum, calcium and phosphorus. Patients with osteitis fibrosa (OF) had statistically higher DFO stimulated aluminum, alkaline phosphatase and PTHC levels than the other two groups although there was marked individual variation. The bone biopsies were also evaluated for the amount of aluminum deposited in the osteoid seam. All 23 of the patients with OF and 11 of the 15 patients with MOD had no, mild, or minimal aluminum deposition but 12 of the 19 patients with OM/AD had moderate to marked aluminum deposition. Patients with minimal to mild aluminum deposition were similar in age, duration of dialysis, sex distribution, unstimulated and DFO stimulated aluminum levels, calcium, phosphorus, alkaline phosphatase to those with moderate to marked deposition but had significantly higher parathormone levels. All patients had been treated in a similar fashion regarding diet, oral phosphate binders and vitamin D; therefore, the observed differences in bone pathology were not readily explicable. However, patients who were found to have osteitis fibrosa and those with minimal to mild aluminum deposition had significantly higher parathormone levels when compared with patients in the other groups at the inception of dialysis.

Adult↗
PubMed1990

Oral estrogens decrease bleeding time and improve clinical bleeding in patients with renal failure.

PURPOSE: A prolonged bleeding time is associated with platelet dysfunction and clinical bleeding in patients with renal failure. Parenteral estrogens have been shown to shorten the prolonged bleeding time in patients with chronic renal failure, although the mechanism of action is unknown. We conducted a study to evaluate the efficacy of oral conjugated estrogens in this setting. PATIENTS AND METHODS: Four patients with renal failure, prolonged bleeding time, and clinical bleeding were given 50 mg of conjugated estrogen (Premarin) daily. RESULTS: Bleeding time normalized in two cases and was reduced to less than 50% of the pretreatment value in one of the remaining two cases. Bleeding stopped in all patients within two days. Ten dialysis patients with prolonged bleeding time were randomized to a course of 50 mg of Premarin daily or placebo. The bleeding time in all five patients in the Premarin group normalized or decreased to below 50% of the pretreatment value after 7.0 +/- 4.2 days of therapy. The bleeding time did not normalize in the five patients treated with placebo. No side effects attributable to therapy were reported. CONCLUSION: We conclude that orally administered conjugated estrogens effectively improve the bleeding tendency in patients with chronic renal failure.

Administration, Oral↗
PubMed1990

Subclavian vein stenosis and thrombosis: a potential serious complication in chronic hemodialysis patients.

One hundred ninety patients, 61 with acute renal failure and 129 with chronic renal failure, underwent hemodialysis using a total of 302 subclavian vein catheters. Local hematomas and sepsis (seven events) were the only acute complications. Subclavian vein stenosis and/or thrombosis had occurred and were shown in five of 44 patients who had arteriovenous access created distal to the venous outlet obstruction, resulting in the loss of three of five of these accesses. In view of the fact that subclavian vein stenosis or occlusion is not associated with any clinical findings and we were unable to identify any predisposing factors associated with the use of the catheters, all patients who have had previous subclavian vein catheters probably should be evaluated to determine the patency of the subclavian vein before creation of a permanent access in that arm.

Aged↗
PubMed1990

Lymphocyte subpopulations in long-term dialysis patients: a case-controlled study of the effects of blood transfusion.

Lymphocyte subsets in a group of intensely transfused (greater than 10 units/year) patients on long-term hemodialysis were compared with those in a carefully controlled population of lightly transfused (1-10 units/year, no units during study period) long-term dialysis patients. The data confirm previous reports of lymphopenia and a symmetrical reduction of both T- and B-cell subpopulations in patients on long-term dialysis. Eleven (36.7%) of 30 intensely transfused dialysis (ITD) patients had a low T8 population when expressed as a percentage value, while 0 of 25 lightly transfused dialysis (LTD) control patients exhibited a low percentage of T8 cells. There were no significant absolute differences between the lymphocyte subsets in the ITD and LTD patients. These data contrast with previous reports of other groups of ITD patients in whom there was an observed increase in T8 cytotoxic suppressor cells. Our findings suggest that the immunologic effects of renal failure and long-term dialysis largely override the increase in T8 lymphocyte subsets observed in other groups of transfused patients. There is little difference between ITD and LTD patients, but both groups are significantly different from nontransfused controls. Further longitudinal studies are needed in completely untransfused patients to resolve the contribution of minimal transfusion therapy to the immunologic deficits observed in long-term dialysis patients.

Adolescent↗
PubMed1989

Plasma aluminum levels (unstimulated and stimulated): clinical and biochemical findings in 185 patients undergoing chronic hemodialysis for 4 to 95 months.

Plasma aluminum levels (unstimulated and stimulated by deferoxamine infusion), along with signs and symptoms associated with aluminum overload, were evaluated in 185 patients (97 men, 88 women; mean age, 58 +/- 8 years) who had been undergoing dialysis for 4 to 95 months and who were still receiving treatment in 1985 at a free-standing dialysis facility which has always used water purified by reverse osmosis. Monthly water aluminum levels never exceeded 15 micrograms/L; therefore, the major source of aluminum in these patients was oral phosphate binders. Unstimulated plasma aluminum levels ranged from 7 to 392 micrograms/L, averaged 81.5 +/- 56.4, and did not correlate with the duration of dialysis (r = 0.07; P greater than 0.31) or frequency of symptoms. Stimulated plasma aluminum levels increased in a linear fashion (r = 0.57; P less than 0.0001) with time on dialysis; however, there was no statistical association between the stimulated aluminum levels and a variety of nonspecific musculoskeletal or CNS symptoms, evidence of hyperparathyroidism, hematocrit, or calcium or phosphorus levels. These findings suggest that total body aluminum, as reflected in deferoxamine-stimulated serum aluminum levels, increases as a function of time undergoing dialysis.

Aluminum↗
PubMed1989

Renal parenchymal malakoplakia. Histologic spectrum and its relationship to megalocytic interstitial nephritis and xanthogranulomatous pyelonephritis.

We report five cases of renal parenchymal malakoplakia. They represent a histologic spectrum of this uncommon inflammatory process as it involves the renal parenchyma. Only one of these five cases presented the classical histologic picture of malakoplakia ("diagnostic stage"). Two cases--although with similar cellular infiltrate--had a marked paucity of Michaelis-Gutmann bodies and thus might have been classified as megalocytic interstitial nephritis were it not for the identification of such calcific intracellular inclusions under the electron microscope. The fourth case presented a pseudosarcomatous morphology and is similar to what has been described as a late or fibrous stage in malakoplakia of the urinary bladder. The last case had a destructive, frankly granulomatous histologic picture with a preponderance of foamy histiocytes reminiscent of xanthogranulomatous pyelonephritis, but with clusters of von Kossa-positive Michaelis-Gutmann bodies. The last two forms of the disease have not been previously reported to occur in the kidney. We believe that these cases represent various stages of development of the disease.

Adult↗