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Biomedical subjects

R Gokal

Publications and source records attributed to R Gokal.

At least 55 records · Page 3Linked to original sources
PubMed1996

Gustatory sweating in diabetes mellitus.

Gustatory sweating has been only rarely reported in diabetes mellitus and is thought to be due to axonal regeneration within the autonomic nervous system. We investigated the relationship of gustatory sweating to other diabetic complications. 196 patients in four groups (diabetic nephropathy, diabetic neuropathy, diabetic controls, and non-diabetic renal failure) were questioned about gustatory sweating. Somatic and autonomic neuropathy were assessed by clinical signs, vibration perception threshold, and heart rate variability. Sixty-nine percent of patients with nephropathy and 36% of those with neuropathy reported gustatory sweating, whereas less than 5% reported it in the other two groups. Five subjects reported that gustatory sweating either disappeared or significantly improved immediately after renal transplantation. Analysis of the nephropathy and neuropathy groups separately showed a strong correlation between gustatory sweating and degree of neuropathy (p < 0.01). This study shows that gustatory sweating is much more common than previously believed and demonstrates that it is often very closely linked with diabetic nephropathy.

Analysis of Variance↗
PubMed1996

The influence of small solute clearance on dietary protein intake in continuous ambulatory peritoneal dialysis patients: a methodologic analysis based on cross-sectional and prospective studies.

The statistical relationship between solute clearance (expressed as Kt/V) and dietary protein intake (DPI; estimated from the normalized protein catabolic rate [NPCR]) has led to the assumption that dialysis dose is one of the most important determinants of DPI in continuous ambulatory peritoneal dialysis patients. However, there is increasing concern about the clinical value of such a correlation between variables that contain common components. We have investigated the statistical nature of the cross-sectional correlation between Kt/V and NPCR using mathematical modelling. In addition, in a prospective study, the impact of increasing Kt/V on protein intake estimated from the NPCR and from 3-day food diaries (DPI) was evaluated in 59 patients over a 1-year period. Two thousand sets of random numbers were generated for the components, from which Kt/V and NPCR were calculated. The subsequent cross-sectional correlation between the randomly generated Kt/V and NPCR was highly significant (r = 0.64 to 0.74). In contrast, there was a much weaker cross-sectional correlation between relatively independent measures of dialysis dose (urea clearance) and protein intake measured from food diaries (r = 0.36). Analysis of the prospective relationship revealed a significant correlation with a decrease in urea clearance (due to loss of renal function) accompanied by a decrease in both PCR (r = -0.80) and DPI (r = -0.51). In contrast, when Kt/V was increased (by larger volume exchanges) there was no significant increase in protein intake. This study has demonstrated that the strength of the cross-sectional relationship between Kt/V and NPCR is due to mathematical coupling of "like with like," and this correlation cannot be used to substantiate a link between dialysis dose and nutrition. Prospective analysis does show a dependence of protein intake on urea clearance. However, this dependence is only seen in those patients undergoing a reduction in clearance due to loss of renal function. Increasing exchange volume to offset such losses was not accompanied by improvements in protein intake.

Adult↗
PubMed1996

Dialysis fluid cytotoxicity and inhibition of host defence in cultured human mesothelial cells are neutralized rapidly with incubation in the peritoneum.

BACKGROUND: A recent survey puts the global dialysis population at 535100; of those on peritoneal dialysis, 85% are on continuous ambulatory peritoneal dialysis. Current hyperosmolar dialysis fluids are toxic to peritoneal cells and inhibit certain host-defence functions. An alternative preparation, glucose polymer, has recently been developed. METHODS: Mesothelial cell viability, interleukin-6 and prostacyclin synthesis, after exposure to 7.5% glucose polymer, 1.36% glucose or 3.86% glucose peritoneal dialysis effluent solution was assessed. RESULTS: In its neat form, at an original pH of 5.4, glucose polymer was as toxic as hyperosmolar solutions (P < 0.01). Synthesis of interleukin-6 and prostacyclin were significantly inhibited by neat dialysis fluid, (P < 0.01). However, after an in vivo intraperitoneal incubation of only 15 min the toxicity of all solutions tested in vitro was lost. CONCLUSIONS: Despite rapid in situ neutralization of dialysis fluid toxicity, mesothelial injury and inhibition of host-defence function, early in the dialysis cycle, may affect peritoneal physiology given the complex network of pathways to which these cells contribute. Although recent trials indicate improved ultrafiltration is achievable with glucose polymer, it is not a biocompatible dialysis fluid in its current manufactured form.

6-Ketoprostaglandin F1 alpha↗
PubMed1996

Measuring the adequacy of peritoneal dialysis: is there a link with nutrition and outcome?

Adequacy of peritoneal dialysis is predictive of outcome but the absolute evidence for setting optimal levels or targets is still lacking. The link between adequacy and nutrition is also tenuous and appears to be based on a mathematical relationship. The ability of standard continuous ambulatory peritoneal dialysis regimes to provide adequate dialysis may be limited in anuria and in large individuals.

Humans↗
PubMed1996

Hypercalcaemia, hypermagnesaemia, hyperphosphataemia and hyperaluminaemia in CAPD: improvement in serum biochemistry by reduction in dialysate calcium and magnesium concentrations.

Phosphate binders are necessary to control hyperphosphataemia in the majority of dialysis patients. Whilst aluminium salts are efficient phosphate binders, their use is associated with toxic side effects. Calcium salts are a widely used alternative, but hypercalcaemia is a common side effect, limiting their use and raising concern about metastatic calcification. Reduction of the dialysis fluid calcium concentration has been shown to reduce hypercalcaemia in haemodialysis patients, with an associated decrease in serum PTH. We analysed the effect of reduced calcium/magnesium (1.25/0.25 mmol/l), 40 mmol/l lactate, PD fluid (PD4) on 11 CAPD patients with uncontrollable hypercalcaemia (> 2.65 mmol/l) and hyperphosphataemia (> 1.80 mmol/l). Only 1 patient remained hypercalcaemic, while phosphate fell in 6 patients (2.23 +/- 0.16 on no binder, to 1.68 +/- 0.08 mmol/l at 6 months (p < 0.05), but was unchanged in 5 (2.10 +/- 0.15 to 2.48 +/- 0.14 mmol/l [p = NS]). Overall mean calcium x phosphate product changed little. However, in a subgroup it fell significantly (p < 0.05). Geometric mean iPTH rose, but not significantly. The subgroup of patients whose calcium x phosphate product fell, exhibited a much smaller rise in iPTH than the others (57.3-73.2 vs. 52.8-167.1 pg/ml). 1.25-Dihydroxyvitamin D3 was subnormal in all patients. Mean serum magnesium fell from 1.24 +/- 0.06 to 0.89 +/- 0.04 mmol/l (p < 0.001), whilst mean serum bicarbonate rose significantly (25.2 +/- 0.4 to 28.9 +/- 1.2 mmol/l; p < 0.01). Withdrawal of aluminium-containing phosphate binders resulted in mean serum aluminium falling significantly from 31.1 +/- 5.7 at start of PD4 to 15.4 +/- 2.7 mu g/l at 6 months (p < 0.05). In summary, in around 50% of CAPD patients with persistent hypercalcaemia and hyperphosphataemia, reduction in PD fluid calcium can produce significant improvement in phosphate, reduction of calcium x phosphate product, and enable avoidance of aluminium-containing phosphate binders. Patients whose calcium and phosphate control remains poor, still benefit from the reduction, or cessation, of oral aluminium intake.

Adult↗
PubMed1996

Is peritoneal permeability an adverse risk factor for malnutrition in CAPD patients?

In light of the correlation between the dialysate to plasma ratio of creatinine (D/P Cr), peritoneal (PD) protein loss and hypoalbuminaemia, peritoneal permeability has been implicated as a risk factor for malnutrition in CAPD patients. However, serum albumin is also affected by hydration which is itself influenced by peritoneal permeability. In a cross-sectional study of 147 CAPD patients we investigated the relationship between peritoneal permeability, PD protein loss and nutritional state. Stepwise regression analysis revealed D/P Cr to be the only significant predictor of serum albumin independent of PD protein loss. No significant relationship was demonstrated between D/P Cr, body fat, lean muscle mass and dietary protein intake. Increased peritoneal permeability does not cause hypoalbuminaemia as a consequence of increased PD protein loss, and does not adversely affect somatic fat and protein status.

Analysis of Variance↗
PubMed1996

CAPD overview.

Explore the source record for details and available documents.

Cross-Cultural Comparison↗
PubMed1996

Optimal use of glucose polymer (icodextrin) in peritoneal dialysis.

The osmotic effectiveness of glucose polymer is now well established. The relative inertness of this macromolecular compound has been the key factor in its success as the first "colloid" osmotic agent in clinical use. In its present form, it produces sustained ultrafiltration for up to 12 hours, and a daily overnight use would obviate the need for hypertonic exchanges, especially 3.86% glucose. In addition, it could be used in automated peritoneal dialysis regimes to enhance ultrafiltration and solute clearance during the daytime. Preliminary reports also indicate that it is beneficial in diabetic patients and in some patients who have lost ultrafiltration. The new "bimodal" formulations look promising, with the potential to replace all the currently used hyperosmolar exchanges with physiological solutions. Although systemic accumulation of glucose polymer breakdown products occurs, it reaches steady-state levels quickly (within two weeks) and remains stable throughout the duration of polymer use. In the long-term study, these levels of maltose and oligosaccharides over three-and-a-half years represent the longest exposure of these substances in uremic patients without any clinical or metabolic adverse effects and provide an important evidence of safety. Future work based on studies that are ongoing suggest that a family of physiological solutions ("bimodal" preparations in iso-osmolar combination) could be available, and the individual's dialysis prescription could be tailored to take into account the ultrafiltration, metabolic needs, as well as the long-term viability of the membrane. Glucose polymer will be a key component of such solutions.

Dextrins↗
PubMed1996

The impact of peritoneal permeability and residual renal function on PD prescription.

Our objective was to evaluate the impact of peritoneal transport characteristics and residual renal function on peritoneal clearance and to determine the dialysis volume required to achieve targets for KT/V and weekly creatinine clearance (WCC) in patients with differing weights, renal function, and transport status. Retrospective analysis and mathematical model simulation of urea and creatinine clearance were used. This review demonstrates the important contribution of both residual renal function and peritoneal transport in attaining target values for KT/V and WCC. The limitations of a standard 4 x 2 L dialysis prescription are highlighted in anuric patients and those with low peritoneal transport. In addition, the limitations of short dwell, rapid exchange dialysis modalities are emphasized, especially in patients with low and low average peritoneal transport where daily clearance is demonstrated to be considerably less than conventional continuous ambulatory peritoneal dialysis (CAPD). Attainment of proposed targets for KT/V (1.7) and WCC (50 L) is greatly dependent on residual renal function. In CAPD, peritoneal transport characteristics determine urea clearance through an effect on ultrafiltrate. Thus low transporters of identical weight will have greater values for peritoneal dialysis KT/V. Creatinine clearance is considerably influenced by transport status. The majority of low and low average groups will need some degree of renal function to achieve currently proposed targets. In these patients, conversion to high volume, short dwell modalities will further compromise small solute clearance unless daytime long dwells or tidal dialysis is instigated.

Blood Urea Nitrogen↗
PubMed1996

Management of foot problems in diabetes.

Many diabetic foot complications are preventable. This requires a team approach, aiming to identify the high-risk patient and provide appropriate education and foot care. An established ulcer needs careful management with the emphasis on pressure relief and establishing a good blood supply.

Combined Modality Therapy↗