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Biomedical subjects

K D Nolph

Publications and source records attributed to K D Nolph.

At least 37 records · Page 2Linked to original sources
PubMed1998

Renal failure and deafness: branchio-oto-renal syndrome.

Branchio-oto-renal (BOR) syndrome is a rare autosomal dominant condition that may present with hearing loss, branchial cysts, and renal failure. The characteristic phenotypic expression of the full syndrome may be partial or complete, and a whole range of renal abnormalities may be present. Its similarity to Alport's syndrome may lead to misdiagnosis. We report here a case of adult-onset renal failure in a 44-year-old white man previously believed to have Alport's syndrome and a review the relevant literature.

Adult↗
PubMed1998

Rationale for early incremental dialysis with continuous ambulatory peritoneal dialysis.

There are good reasons to suspect that if a weekly Kt/V urea of <2.0 is inadequate for CAPD then it is also inadequate for CRF without dialysis. Spontaneous protein intakes tend to fall below 0.7-0.8 g/kg at these levels in both CAPD and CRF. Low protein intakes can be associated with deterioration in nutritional status and a falling serum albumin. Low serum albumin concentrations at the start of dialysis are associated with increased risk of death during dialysis. Some nutritional problems which develop during conservative management prior to dialysis initiation may not be completely reversible. Since both renal function and CAPD offer nearly continuous urea clearances, it makes sense that targets for adequacy in CAPD should also be targets for initiation of chronic dialysis. At this time, it seems that a weekly Kt/V urea of 2.0 is a reasonable value. There may be reasons why chronic peritoneal dialysis is more suitable than intermittent HD for the initiation of early incremental dialysis. These advantages have to do with the ease of providing small incremental dialysis doses as needed to maintain the Kt/V urea at a level of 2.0 for the kidney and dialysis combined. Early CAPD may be less threatening to residual renal function than HD. Daily CAPD allows early control of sodium and water balance. It also delays the use of blood access sites until larger dialysis doses achieved with HD are absolutely necessary. There may be cost advantages as well. We should abandon the philosophy of initiating dialysis after patients have already suffered the ravages of uraemia and related malnutrition.

Humans↗
PubMed1998

Increased peritoneal membrane transport is associated with decreased patient and technique survival for continuous peritoneal dialysis patients. The Canada-USA (CANUSA) Peritoneal Dialysis Study Group.

The objective of this study was to evaluate the association of peritoneal membrane transport with technique and patient survival. In the Canada-USA prospective cohort study of adequacy of continuous ambulatory peritoneal dialysis (CAPD), a peritoneal equilibrium test (PET) was performed approximately 1 mo after initiation of dialysis; patients were defined as high (H), high average (HA), low average (LA), and low (L) transporters. The Cox proportional hazards method evaluated the association of technique and patient survival with independent variables (demographic and clinical variables, nutrition, adequacy, and transport status). Among 606 patients evaluated by PET, there were 41 L, 192 LA, 280 HA, and 93 H. The 2-yr technique survival probabilities were 94, 76, 72, and 68% for L, LA, HA, and H, respectively (P = 0.04). The 2-yr patient survival probabilities were 91, 80, 72, and 71% for L, LA, HA, and H, respectively (P = 0.11). The 2-yr probabilities of both patient and technique survival were 86, 61, 52, and 48% for L, LA, HA, and H, respectively (P = 0.006). The relative risk of either technique failure or death, compared to L, was 2.54 for LA, 3.39 for HA, and 4.00 for H. The mean drain volumes (liters) in the PET were 2.53, 2.45, 2.33, and 2.16 for L, LA, HA, and H, respectively (P < 0.001). After 1 mo CAPD treatment, the mean 24-h drain volumes (liters) were 9.38, 8.93, 8.59, and 8.22 for L, LA, HA, and H, respectively (P < 0.001); the mean 24-h peritoneal albumin losses (g) were 3.1, 3.9, 4.3, and 5.6 for L, LA, HA, and H, respectively (P < 0.001). The mean serum albumin values (g/L) were 37.8, 36.2, 33.8, and 32.8 for L, LA, HA, and H, respectively (P < 0.001). Among CAPD patients, higher peritoneal transport is associated with increased risk of either technique failure or death. The decreased drain volume, increased albumin loss, and decreased serum albumin concentration suggest volume overload and malnutrition as mechanisms. Use of nocturnal cycling peritoneal dialysis should be considered in H and HA transporters.

Adult↗
PubMed1998

Hemodialysis and CAPD--are they comparable?

I have made comparisons of thrice weekly HD (not daily HD) and PD (mainly CAPD). In terms of patient survivals, there is no proven modality advantage. In terms of cost and quality of life, PD probably has advantages in many patients. With a tendency towards earlier initiation of dialysis and incremental prescriptions to achieve a targeted amount of small-solute clearances, PD probably has cost and technical advantages.

Health Care Costs↗
PubMed1997

Hypokalemic metabolic alkalosis with hypomagnesuric hypermagnesemia and severe hypocalciuria: a new syndrome?

Bartter's and Gitelman's syndromes are characterized by hypokalemia, urinary potassium wasting, elevated plasma renin activity and aldosterone levels, normotension, and prostaglandinuria. They differ in that hypomagnesemia and hypocalciuria are universal in Gitelman's syndrome; 20% of cases of Bartter's syndrome have hypomagnesemia and hypercalciuria. We present a 44-year-old white man referred for hypokalemia. Clinical evaluation was unremarkable. He had hypokalemia (P(K), 2.8 to 3.0 mEq/L), hypochloremic metabolic alkalosis, mild azotemia (serum creatinine, 1.4 to 1.8 mg/dL; creatinine clearance, 59 mL/min), normocalcemia, marked persistent hypocalciuria (FE(Ca), 0.08% to 0.09%), and normal intact parathyroid hormone levels (51 pg/mL) and glucosuria. He had persistent hypermagnesemia (P(Mg), 2.1 to 2.8 mEq/L) with relative hypomagnesuria (FE(Mg), 3.2% to 5.2%) given the level of renal impairment and hypermagnesemia. Supine plasma renin activity and aldosterone levels were high (11 ng/mL/hr and 43 ng/dL, respectively). An excessive dietary intake of magnesium, including medications, was excluded. Studies were performed after withdrawing all medications for 8 days. A maximum water diuresis was established (an oral load of 20 mL/kg; stable Uosm, 120 mOsm/kg), and free water and solute clearances were studied at baseline and after sequential intravenous injections of 125 mg chlorothiazide and 40 mg furosemide. The patient had moderate renal impairment (technetium diethylene triamine pentacetic acid [DTPA] clearance, 35.4 mL/min/1.73 m2) and, in contradistinction to Bartter's and Gitelman's syndromes, sodium and water handling in the thick ascending limb of the loop of Henle and the distal tubule (fractional distal solute reabsorption) was normal, but there was evidence of a defect in the proximal tubule reabsorption (glucosuria, supranormal C(H2O) and high distal delivery). Hypomagnesuria and hypocalciuria appeared to be secondary to an increase in their absorption in the loop of Henle (increased excretion following furosemide). In conclusion, this combination of metabolic abnormalities has never been described. We postulate a proximal tubular defect in the absorption of NaCl leading to hypocalciuria, hypomagnesuria, and potassium wasting. Whether the tubular defect is primary or secondary to a renal parenchymal disease is, however, unclear.

Acute Disease↗
PubMed1996

Four-year experience with swan neck presternal peritoneal dialysis catheter.

The swan neck presternal catheter is composed of two flexible (silicon rubber) tubes joined by a titanium connector at the time of implantation. The exit site is located in the presternal or parasternal area. The catheter located on the chest was designed to reduce the incidence of exit site infections compared with peritoneal dialysis catheters with abdominal exit sites. From August 1991 to May 1995, 24 swan neck presternal catheters have been implanted in 24 patients for the following reasons: obesity nine patients, ostomies three patients, a suprapubic catheter one patient, previous problems with abdominal catheters two patients, desire to use a bathtub five patients, need to use a whirlpool one patient, need to wear sweatpants with an elastic waistband one patient, and body image two patients. In the same period, 47 abdominal swan neck catheters were implanted in 44 patients who preferred catheters with the exit on the abdomen. Presternal catheters tended to perform better regarding exit and tunnel infections, even though they were implanted in several patients in whom regular catheters with the exit on the abdomen would be difficult or impossible to implant. Two-year survival probability of presternal catheters was 0.88 +/- 0.14 (+/- SE). Recurrent/refractory peritonitis was the only reason of catheter failure. The differences in results between presternal and abdominal catheters were statistically insignificant; only the use of antibiotics to treat exit site infection was significantly higher with abdominal catheters. Patient acceptance of the exit position was good; at least seven patients preferred presternal catheter for psychological or body image reasons. We conclude that the swan neck presternal catheters provide excellent results comparable to those achieved with swan neck abdominal catheters. The catheter seems suitable for any patient commencing peritoneal dialysis and is particularly useful in extremely obese patients (body mass index > 40 kg/m2) and those with ostomies. The catheter exit location in the chest may be preferred by some patients, both men and women, for psychological or body image reasons. No specific contraindications to the presternal catheter implantation have been identified.

Abdomen↗
PubMed1996

Choosing the right dialysis option for your critically ill patient. What's right for a hyperkalemic patient may be wrong for one with shock.

Critically ill patients frequently require dialysis. Options include intermittent hemodialysis, peritoneal dialysis, and various forms of continuous extracorporeal therapy. Intermittent hemodialysis is useful for hemodynamically stable patients who can tolerate rapid solute and fluid removal. Peritoneal dialysis, which is underused in the ICU, offers two distinct advantages: It does not require vascular access and systemic anticoagulation is not necessary. Continuous extracorporeal therapies are better tolerated by hemodynamically unstable patients, since these techniques can remove large amounts of fluid over an extended period. Base your choice of therapy on the patient's condition and needs, the options available at your institution, and the experience of you and your staff.

Anticoagulants↗
PubMed1996

Effects of bicarbonate dialysis solution on peritoneal transport in rats.

We studied the effects of bicarbonate dialysis solution (TB 1.36) on the peritoneum in our rat model of dialysis. Twenty-four male Sprague-Dawley rats were divided into two groups (n = 12 each). One group was dialyzed with standard 1.36% Dianeal PD-2 (L-group); the other group was dialyzed with TB 1.36 (B-group). After break-in dialysis after catheter insertion, the animals were dialyzed twice daily with 30 mL of the designated dialysis solution for four weeks. White blood cell count with differentials and microbiological culture of the dialysate were examined once a week to detect peritonitis. A peritoneal equilibration test (PET) was performed on the eighth and thirty-sixth days. The dialysate was obtained at 0, 2, and 4 hours; a blood sample was taken at 0 hour. Peritoneal tissue specimens were obtained after the second PET. Histological score was calculated based on the degree of thickening of the peritoneum. Five rats in L-group and three rats in B-group suffered from peritonitis. Two other rats in B-group had complications and did not complete the experiment. Therefore, seven rats from each group finished the experiment, and the PET data was analyzed. The peritoneal transport property of B-group did not change over time, while, in L-group it became less permeable on the thirty-sixth day. Fibrotic thickening of the peritoneum was observed in both groups, however, the histological score was slightly lower in B-group. These results suggest that the bicarbonate dialysis solution may be less harmful to the peritoneum.

Animals↗
PubMed1996

The effect of peritonitis on the peritoneal membrane transport properties in patients on CAPD.

Peritonitis is known to acutely affect the transport characteristics of the peritoneal membrane, however, the long-term effects are not known. We studied the effect of peritoneal inflammation on mean dialysate-to-plasma creatinine concentration ratio (D/P), dialysate protein losses (DPL, g/week), and dialysate albumin losses (DAL, g/week), done at six weeks or more postepisode, in 152 patients [102 (67%) males, mean age 57 years (range 21-91)]. These patients were on continuous ambulatory peritoneal dialysis for a mean of twelve months (range 1-97). A total of 94 distinct peritonitis episodes were managed in 47 patients (31%). The number of patients with 0, 1, 2, 3, 4, and 5 episodes of peritonitis were 105, 29, 3, 6, 4, and 5. These episodes were treated with a standard protocol. There were no statistically significant differences between the D/P, DPL, or DAL between the groups. The parameters did not show any correlation to time on dialysis. Thus, in conclusion, peritonitis, if promptly treated, does not cause any permanent change in D/P, DAL, or DPL.

Adult↗
PubMed1996

Protein catabolic rate in CAPD patients: comparison of different techniques.

Protein intakes of patients on continuous ambulatory peritoneal dialysis (CAPD) are estimated by protein catabolic rate (PCR) or dietary protein intake assessments (DPI). In this study we compared two approaches suggested by Randerson et al. for calculating PCR. One method incorporates urea generation rate (UG) and estimated dialysate protein losses (PCR), while the other includes UG and measured dialysate protein losses (PCR). We feel that calculating PCR2 is more convenient in practice. We studied 95 patients on CAPD, 49 men and 46 women, with a mean age of 56.5 years (range 26.6-84.5 years) and lean body mass of 41 kg (range 19-71 kg). Mean +/- SEM of PCR1, PCR2, and DPI were: 0.89 +/- 0.02, 0.86 +/- 0.02, and 0.90 +/- 0.04 g/kg standard weight (std wt)/day, respectively. PCR1 and PCR2 were highly and significantly correlated (r = 0.94, p = 0.0001). The difference of PCR1-PCR2 is plotted against dialysate protein loss, which reveals that PCR2 often underestimates PCR1 if dialysate protein loss is > 10 g/day, but this difference is minimum (< 0.1 g/kg standard weight/day) when the dialysate protein loss is < 15 g/day. We conclude that PCR2 is an easy and effective method to monitor nutritional status in the majority of CAPD patients as very few will have dialysate protein losses > 15 g/day.

Adult↗
PubMed1995

A proposed glossary for dialysis kinetics.

Quantification of the dialysis dose and assessment of nutritional status and response to nutritional therapy have become standard parts of the management of the chronic dialysis patient. Although advances in these areas have led to a more rational basis for therapy, certain misconceptions and points of confusion appear to have occurred. Recognizing the importance of a standard nomenclature to the development of concepts and the communication of research findings, we have attempted to compile a list of terms that are commonly used in the field of dialysis. New terms have been proposed for current ones that do not seem adequate. In addition, we have discussed potential methodologies for obtaining more accurate data for dialysis kinetics and for precise monitoring of nutritional intake and status. It is hoped that this glossary will stimulate discussion that will lead to refinements in terminology and concepts that will, in turn, improve research and practice in nephrology. It is anticipated that many of these definitions and recommendations will be modified or superseded as the management of patients with renal failure continues to advance.

Adolescent↗