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Biomedical subjects

N W Levin

Publications and source records attributed to N W Levin.

At least 91 records · Page 5Linked to original sources
PubMed1994

Adequacy of dialysis.

Adequate dialysis is not easily defined. The concept that there is a relationship between dialysis dose and survival is gradually gaining acceptance. Nutritional status and possibly the type of dialyzer membrane used also influence survival in hemodialysis patients. The roles of physicians, patient care staff, technicians, nutritionists, and social workers in assuring adequacy can be clearly delineated in practice. Until recently, health status and quality of life evaluations have received less attention than clinical and laboratory parameters of adequacy. Instruments used to assess quality of life must be further developed and integrated with survival and morbidity data to improve the level of care provided for dialysis patients. The tools are available to enhance adequacy; they need to be utilized.

Humans↗
PubMed1993

National Cooperative rHu Erythropoietin Study in patients with chronic renal failure--an interim report. The National Cooperative rHu Erythropoietin Study Group.

This second interim report of the National Cooperative rHu Erythropoietin Study presents data from 324 patients new to recombinant human erythropoietin (Epoetin alfa) who completed at least 12 months of study participation. Mean hematocrit levels increased to approximately 30% by month 3 in patients on hemodialysis (n = 293) and stabilized for the remainder of the study whether Epoetin alfa was administered by the intravenous (n = 250) or subcutaneous (n = 42) route. The intravenous dosage level ranged between 106.9 and 121.6 U/kg/wk; subcutaneous dosing ranged between 87.4 and 108.0 U/kg/wk; dosing levels in patients on peritoneal dialysis (n = 31) were similar, although there was a trend towards slightly higher hematocrit levels. Throughout the 12 months of the study, there was no relationship between blood pressure and either hematocrit level or Epoetin alfa dose. Approximately two thirds of the patients were receiving iron supplementation at any given time, and there was a trend towards the increased use of oral iron supplements. The incidence of adverse events in this cohort of patients was low throughout the study, and there was no relationship between the incidence of adverse events and either hematocrit level or Epoetin alfa dose. Based on an analysis of data from baseline to first follow-up, Epoetin alfa therapy resulted in improvement in several quality-of-life factors, most notable of which was vitality. Improvement occurred in all patient subgroups with some variability in the level and intensity of effect. Overall, these data demonstrate that Epoetin alfa therapy is safe and effective when used in a broad cross-section of patients on dialysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1993

Relationship between dialyser type and signs and symptoms.

A crossover study to compare the effects of seven different dialysers on intradialytic symptoms in 37 patients during dialysis with acetate-containing dialysate was performed at five centres in four countries. The same manufacturing lot of each dialyser and of blood line sets were used by all centres. The same clinical data (duration of dialysis, blood pressure, weights, temperature, drugs, symptoms, and treatments) and technical data (blood flow, dialyser clearance, and ultrafiltration rate) were collected. Kt/V for urea was used to determine dialysis prescribed. Intradialytic symptoms and signs were measured hourly or when observed by staff using the haemodialysis treatment form (see Introduction). After each week of treatment with a particular dialyser, patients completed a questionnaire relating to the presence and severity of symptoms. (Only presence or absence of symptoms are presented.) Wide differences in dialysis duration and blood flow between centres were noted. These may have contributed to the differences between centres in relationship to staff reported responses to different dialyser: Dialysers with the lowest incidence of both signs and symptoms and of chest pain, back pain, and itching (arbitrarily designated bioincompatibility symptoms) were the Duo-Flux and Filtral, with the G120 M, the CD 4000, and the T 150 having the highest incidence. By patient questionnaire the most biocompatible dialysers were the T 150, F 60, and the Filtral, with the most symptom producing being the G120 M and the G10-3N. Perceptions of symptoms between patients and staff differed substantially overall and between centres. Hypersensitivity reactions were noted in two patients, both occurring with cuprammonium cellulose hollow-fibre dialysis, despite adherence to manufacturers' instructions concerning saline priming and removal. Both patients showed antibody titres greater than 1:160 against ethylene oxide-HSA. Ethylene oxide was not detected (limit of detection 1 part per million) in dialysers, blood line sets, or fistula needles. The study suggests that dialysis symptom reporting is complicated by individual perceptions, staff reactions, and the efficiency of recording. In this study ethnic and cultural differences must be added to the haemodynamic differences and other prescription-related elements in influencing symptoms. Despite these problems a hierarchy of dialyser-related symptoms and signs could be discerned which largely paralleled laboratory findings of biocompatibility. Future comparative studies relating symptomatology to membrane and dialyser structure should consider the variables identified as influencing symptoms and their reporting.

Biocompatible Materials↗
PubMed1993

Behaviour of white blood cells and the complement system.

Seven different types of dialysers were investigated in five dialysis centres in four countries with respect to behaviour of white blood cells and the complement system. The results of this controlled crossover study demonstrated significant differences in the dialysers. Those containing cuprammonium cellulose (G10-3N and G120 M) showed the greatest changes in white blood cell count, including monocytes and neutrophils, as well as the greatest complement activation. With regard to lymphocytes the subpopulation of low-mobility cells, which were predominantly the B-cells, showed the greatest mobility with dialysers containing cuprammonium cellulose. The PAN copolymer- and PMMA-containing dialysers Filtral and T 150 clearly caused the least changes in white blood cells and complement factors. Dialysers containing cellulose acetate and polysulphone membranes (Duo-Flux Artificial Kidney, CD 4000, and F 60) produced only a moderate decrease of WBC, monocyte, neutrophil, and lymphocyte counts, and this result corresponded to a relatively small change in complement factors.

Acrylic Resins↗
PubMed1993

Improvement of plasma lipoprotein profiles during high-flux dialysis.

Patients undergoing maintenance hemodialysis therapy have increased mortality due to cardiovascular disease. One possible etiologic factor for this increased mortality is the lipid abnormalities associated with chronic renal failure. These include elevated triglyceride (TG) and decreased high-density lipoprotein (HDL) concentrations. Lipoprotein profiles of patients undergoing chronic hemodialysis with either saponified cellulose ester (CE) (N = 9) or polysulfone (PS) high-flux dialysis membranes (N = 10) were compared. Patients in each group received similar amounts of heparin during the dialysis. CE-dialyzed patients showed no alteration in serum TG, HDL, low-density lipoprotein, or total cholesterol when predialysis and postdialysis values were compared. PS patients, on the other hand, had a significant decrease in TG concentrations (P < 0.01) as well as a significant rise in HDL (P < 0.01). These changes might signify activation of lipoprotein lipase (LPL) during dialysis. LPL activity in PS sera was significantly greater than LPL in CE sera. Moreover, sera from PS patients inhibited LPL much less than did sera from CE patients. These findings suggest that a circulating substance not dialyzable with cellulosic membranes inhibits LPL in uremic subjects and is removed during dialysis with a PS membrane. Alternatively, the greater biocompatibility of PS may produce less LPL inhibitory cytokines during dialysis. The improvement of lipoprotein profiles in patients receiving dialysis with PS membranes may, in the long term, lead to less morbidity and mortality from atherosclerotic disease.

Adult↗
PubMed1992

Clinical experience with short-time hemodialysis.

After at least 6 months on conventional hemodialysis (cellulosic dialyzers, acetate dialysate, and a 3- to 4-hour treatment time), 56 patients were changed to short-time hemodialysis (less than 180 minutes) using polysulfone dialyzers and bicarbonate-containing dialysate. Treatment time decreased (191 +/- 5 v 147 +/- 5 min; P = 0.001), while Kt/V (1.22 +/- 0.04 v 1.29 +/- 0.06; P = NS) and normalized protein catabolic rate (pcr) (1.10 +/- 0.05 v 1.10 +/- 0.07 g/kg/d; P = NS) remained constant. When compared with the conventional period, 30 months of short-time hemodialysis resulted in no changes in predialysis blood pressure (BP) (151 +/- 2/84 +/- 1 v 151 +/- 2/86 +/- 1 mm Hg), postdialysis BP (144 +/- 2/81 +/- 1 v 143 +/- 3/84 +/- 1 mm Hg), interdialytic weight gain (2.4 +/- 0.1 v 2.7 +/- 0.2 kg), or blood urea nitrogen (BUN) (26.1 +/- 0.71 v 25.3 +/- 1.07 mmol/L [73 +/- 2 v 71 +/- 3 mg/dL]). Shorter treatment times were not associated with an increase in intradialytic complications. Actually, the frequency (%) of dialysis treatments associated with nausea (5.94 +/- 1.33 v 2.21 +/- 0.52), vomiting (3.12 +/- 0.87 v 0.54 +/- 0.14; P less than 0.05), headaches (5.60 +/- 1.13 v 2.03 +/- 0.52; P less than 0.05), and back pain (0.91 +/- 0.25 v 0.05 +/- 0.05; P less than 0.05) was decreased.(ABSTRACT TRUNCATED AT 250 WORDS)

Acetates↗
PubMed1992

Quality of life and hematocrit level.

As the anemia that accompanies chronic renal failure (CRF) is successfully treated with recombinant human erythropoietin (epoetin), striking improvements in overall quality of life have been noted in several clinical studies of patients receiving chronic hemodialysis. A review of available clinical data has shown that, following epoetin therapy, peak oxygen consumption, a principal indicator of exercise ability, increased by approximately 50% as the hematocrit level increased. Following epoetin therapy in pediatric patients with end-stage renal disease (ESRD), the ventilatory anaerobic threshold (VAT) increased significantly and correlated well with increases in hemoglobin concentrations. Increased exercise capacity associated with the reversal of anemia appeared to positively effect many quality-of-life parameters. Analysis of questionnaires incorporating both subjective and objective quality-of-life indicators showed significant improvements between baseline and follow-up periods. Many patients experienced relief from some of the debilitating symptoms of anemia and many had significantly improved functional ability. Higher activity and energy levels were reflected in enhanced emotional and social well-being, with improvements noted in appetite, sleeping behavior, and sexual function. There was no change in the employment status of most patients. The extent of improvement in overall quality of life may be a function of the baseline level of impairment and the potential for reversal. However, baseline capabilities at rest may not be appropriate for physiologic studies.

Anemia↗
PubMed1991

Mortality and duration of hemodialysis treatment.

Decrease in the average duration of hemodialysis treatment time is a continuing phenomenon. We investigated the relationship of 3-year mortality to duration of dialysis in a 1984-1985 national random sample of 600 hemodialysis patients from 36 dialysis units. Mortality was negatively associated with duration of dialysis treatments, as shown by the Cox model, adjusted for other patient and dialysis unit covariates. With adjustment for other covariates, patients receiving an average dialysis treatment duration of less than 3.5 hours had relative mortality risks of 1.17 to 2.18 compared with those with treatments longer than 3.5 hours (mortality risk of 1.0). Reverse causation (the possibility that more seriously ill patients received dialysis for a shorter time) appears unlikely. We conclude that duration of the dialysis procedure is an important element in determining patient mortality as one of the factors determining the adequacy of dialysis.

Adult↗
PubMed1991

Filtration of dialysate using an on-line dialysate filter.

UNLABELLED: Increased concerns about pyrogenic contamination of dialysate have led to the development of an on-line dialysate filtration system. Bacteriological testing of the system was performed (n = 6) by introducing bicarbonate concentrate contaminated with E. coli 026:B 6 (3 x 10(9) cfu/ml) into a dialysis machine equipped with a two-stage polysulfone filtration system. The bacterial concentration of the dialysate entering the filtration system was maintained above 10(6) cfu/ml and endotoxin levels ranged from 30-300 ng/ml during the 3-hour test period. Bacterial and endotoxin levels on the input side of the first-stage filter reached minimum concentrations of 5.4 x 10(9) cfu/ml and 30,000 ng/ml respectively. All output samples of filtered dialysate showed no bacterial growth and endotoxin levels were below the sensitivity (0.003 ng/ml) of the LAL assay. A dialysis machine (QD = 500), equipped with a single stage filtration system, was used for 18 months of clinical testing. In order to evaluate the system's reliability with regard to membrane failures and reduced dialysate flow, filter membrane integrity was verified weekly using a pressure holding test and dialysate flow was measured under routine clinical conditions. No membrane failures occurred, and dialysate flow was maintained at 511 +/- 17 ml/min (n = 70) during the test period. IN CONCLUSION: dialysate filtration is an effective and practical method for prevention of pyrogenic reactions due to high levels of bacteria and endotoxins.

Bacterial Infections↗
PubMed1988

Glomerular uracil nucleotide synthesis.

The biosynthesis of basement membrane material requires the sugar derivatives of uridine 5'-triphosphate (UTP) for protein glycosylation. Uridine and orotate utilization for the biosynthesis of uracil ribonucleotides was studied in isolated rat glomeruli incubated in vitro. At a 1 microM concentration total orotate utilization was 9.6 +/- 1.8 pmol.min-1.mg DNA-1 (1 mg DNA approximately 0.175 X 10(6) glomeruli), 51% of the total amount metabolized was used in ribonucleotide formation, and there was a significant UTP accretion. Except at a high initial concentration (50 microM), exogenous uridine failed to increase the UTP pool due to rapid uridine breakdown by a cytosolic phosphorylase. Inhibition of this enzyme with benzylacyclouridine resulted in increased biosynthesis and accretion of UTP, and in a 17-fold higher concentration of uridine, primarily produced from performed sources of nucleosides. Continuous addition of exogenous uridine to maintain its concentration at 1 microM resulted in a total uridine utilization of 550 +/- 30 pmol.min-1.mg DNA-1. Uridine salvage for ribonucleotide biosynthesis was only 3% of the total metabolized. In contrast to uridine, and presumably due to UTP pool compartmentation, orotate incorporation into uridine 5'-diphosphosugars was prominent. The metabolism of exogenous orotate was not decreased by the presence of large amounts of uridine and by an expanded UTP pool. It is concluded that when exogenous orotate is present, it is an important precursor for glomerular uracil ribonucleotide biosynthesis. Due to its rapid rate of catabolism, uridine cannot maintain ribonucleotide biosynthesis at a rate sufficient to result in UTP accretion unless it is provided continuously in substantial quantities.

Animals↗
PubMed1988

Glomerular uracil nucleotide synthesis: effects of diabetes and protein intake.

The biosynthesis of uridine 5'-triphosphate (UTP), uridine 5'-diphosphohexoses, and 5'-diphosphohexosamines (UDP-sugars) was studied in isolated rat glomeruli 48 h after streptozotocin-induced diabetes. Compared with control, diabetic glomeruli demonstrated an increase in the following: exogenous orotate utilization, orotate incorporation into UTP and UDP-sugars, UTP accretion rate, and UDP-sugar pool size. Since these phenomena were not associated with enhanced biosynthesis of orotate de novo, the increased glomerular UDP-sugar bioavailability in diabetes is due to enhanced utilization of exogenous orotate. Plasma concentrations of orotate and uridine were measured in control, sham operated, and unilaterally nephrectomized rats receiving 5, 20, or 60% protein diets. The concentration of pyrimidine precursors correlated directly with protein intake, with doubling at the 60% dietary protein level. In conclusion, glomerular uracil ribonucleotide biosynthesis may be modulated by the quantity of dietary protein. Because UDP-sugars are necessary for basement membrane material formation, an increase in their bioavailability may be part of the metabolic change responsible for diabetic glomerulosclerosis. Diets with high protein content could augment this metabolic alteration.

Animals↗
PubMed1987

Effective long-term immunosuppression maintained by low cyclosporine levels in primary cadaveric renal transplant recipients.

Nephrotoxicity and cost are the major problems in the use of cyclosporine (CsA) in renal transplantation. Thus, maintenance of CsA levels at the lower limits of the therapeutic range is desirable. The lowest CsA level effective in preventing rejection while avoiding nephrotoxicity has not been defined. We report on 44 primary cadaveric renal transplant recipients treated with a protocol that involved a progressive reduction in the trough CsA levels. CsA was initiated at an oral dose of 15 mg/kg, and this dose was adjusted to achieve serum trough levels, as measured by radioimmunoassay, of 150-200 ng/ml during the first month, 100-150 ng/ml during the second month, 75-100 ng/ml during the third month, and 50-75 ng/ml thereafter. Patient and graft survival at 18 months were 94% and 83.6%, respectively. The mean daily CsA doses were 6.7 +/- 3.1 mg/kg at 6 months, 5.5 +/- 3.2 mg/kg at 12 months, and 4.7 +/- 2.4 mg/kg at 18 months. Corresponding trough serum CsA levels were 94 +/- 59 ng/ml, 64 +/- 22 ng/ml, and 44 +/- 21 ng/ml at 6, 12, and 18 months, respectively. Mean serum creatinine concentrations were 1.8 +/- 0.6 mg/dl at 6 months, 1.7 +/- 0.5 mg/dl at 12 months, and 1.6 +/- 0.5 mg/dl at 18 months. The mean serum creatinine concentration at 18 months was not significantly different from that of 18 conventionally treated primary cadaveric renal transplant recipients (1.6 +/- 0.5 vs. 1.4 +/- 0.4 mg/dl, P = .31). A total of 67% of patients did not have any rejection episodes under this protocol, while 71% of patients never developed CsA nephrotoxicity. No patient was taken off CsA for progressive nephrotoxicity. We conclude that trough serum CsA levels of 50-75 ng/ml, as measured by radioimmunoassay, are sufficient to maintain effective immunosuppression in the long-term management of primary cadaveric renal transplant recipients. These values are much lower than previously recommended, and this approach ameliorates chronic CsA nephrotoxicity.

Adult↗
PubMed1987

Effect of dialyzer reprocessing methods on complement activation and hemodialyzer-related symptoms.

The effects of different dialyzer processing methods and of reuse on complement activation and dialyzer-related symptoms were studied in 96 maintenance hemodialysis patients. New dialyzers were either unprocessed (Group 1) or machine-washed with bleach and stored in formaldehyde (Group 2). Reused dialyzers were manually cleansed using the combination of bleach and formaldehyde (Group 3), or machine-washed in formaldehyde (Group 4) or peracetic acid (Group 5). Prewashed new dialyzers (Group 2) were associated with greater complement activation during dialysis when compared with unprocessed, new dialyzers (Group 1) (p less than 0.05). Reused, unbleached but formaldehyde-treated or peracetic acid-treated dialyzers (Groups 4 and 5) were associated with reduced complement activation (p less than 0.05). Complement activation was not reduced when bleach was used for reprocessing (Group 3). The percentage of patients without symptoms during dialysis was significantly greater with reused dialyzers than with new dialyzers (Groups 3 through 5 versus Groups 1 and 2; 39 versus 25%; p = 0.035). The severity of total symptoms correlated significantly (p = 0.0004) with complement activation. Our results suggest that total symptoms during dialysis are correlated with the degree of complement activation. However, trends in the data pertaining to chest pain suggest that factors other than complement activation may be important in the pathogenesis of some dialyzer-related symptoms.

Chest Pain↗
PubMed1987

Effect on renal function of change from high to moderate protein intake in type I diabetic patients.

The effects on renal function of moderate restriction in protein intake were studied in 14- to 20-yr-old type I diabetic patients who had no clinical renal disease or hypertension; matched normal subjects served as controls. After assessment of protein intake and renal function, studies were conducted at the completion of each of two consecutive dietary periods of 1 wk. Diets containing 3.5 and 1.5 g X kg-1 X day-1 protein were provided during the first and second periods, respectively. Baseline protein intakes were substantial in both controls (1.86 g X kg-1 X day-1) and diabetics (2.17 g X kg-1 X day-1). Baseline creatinine clearance was increased in diabetics (P = .043). At the end of the high-protein intake period, both diabetics and controls showed similar high values of glomerular filtration rate (GFR) and renal plasma flow (RPF). GFR and RPF decreased markedly (P less than .001) and to a similar degree in both groups after normal protein intake. GFR and RPF in diabetics were not higher than in controls at this point, but filtration fraction was increased in diabetics. Albumin excretion rates were similar in both groups and not influenced by renal function changes. GFR and RPF values correlated significantly with the quantity of protein intake, as estimated from the urea nitrogen appearance rate in both groups. The results suggest that the functional response to variations in protein intake is not altered in the diabetic kidney. In addition, increased renal function in diabetics may be related partly to the excessive protein content in commonly prescribed diabetic diets.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗