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At least 793 records · Page 44Linked to original sources
PubMed1998

Overfeeding macronutrients to critically ill adults: metabolic complications.

Metabolic complications from overfeeding critically ill patients are serious and sometimes fatal. Nutrition care is best provided through repeated evaluation of patients' responses to feeding. Nutrition support may need to be modified over time to maintain metabolic stability and promote recovery. This article describes the etiology of 10 metabolic complications of overfeeding. Guidelines for recommending macronutrients are discussed, as are factors that could increase the risk of overfeeding. Patients who are very small, very large, or very old are particularly vulnerable to overfeeding. Overfeeding protein has led to azotemia, hypertonic dehydration, and metabolic acidosis. Excessive carbohydrate infusion has resulted in hyperglycemia, hypertriglyceridemia, and hepatic steatosis. High-fat infusions have caused hypertriglyceridemia and fat-overload syndrome. Hypercapnia and refeeding syndrome have also been caused by aggressive overfeeding. Dietitians can prevent or curtail the metabolic complications of overfeeding by identifying patients at risk, providing adequate assessment, coordinating interdisciplinary care plans, and delivering timely and appropriate monitoring and intervention. Dietitians need to document complications, interventions, and the outcomes of their clinical care to evaluate the appropriateness of existing nutrition guidelines.

Acidosis↗
PubMed1996

Poloxamer-188 as an adjunct to primary percutaneous transluminal coronary angioplasty for acute myocardial infarction.

Poloxamer-188 is a surfactant polymer with antithrombotic and hemorheologic properties that make it potentially useful as an adjunct to acute reperfusion strategies. Animal studies and early human studies have documented poloxamer-188 to be effective at improving myocardial salvage when used as an adjunct to intravenous thrombolytic therapy for acute myocardial infarction. The current trial was a prospective pilot study involving 150 patients who were randomized in a 2:1 fashion to a poloxamer-188 infusion for 48-hours versus placebo. The poloxamer-188 infusion was well tolerated subjectively. The only clinically significant laboratory abnormality noted was an elevation in the serum creatinine above 2.0 g/dl in 12% (n = 12) of the 98 poloxamer-188 treated patients versus 1 of the 52 (2%) of the placebo treated patients (p = 0.048). Clinical end points including reinfarction (1% vs 4%), cardiogenic shock (7% vs 6%), and death (9% vs 4%) were statistically similar in the poloxamer-188 and placebo groups, respectively (p = NS). Using quantitative nuclear techniques, final infarct size and myocardial salvage were statistically similar in the poloxamer-188 and placebo groups. Mean left ventricular ejection fractions 1 week post after infarction were 51% +/- 12% in the poloxamer-188 group and 52% +/- 13% in the placebo group (p = NS). Final infarct size, was not altered by the poloxamer- 188 infusion; however, it was significantly correlated with normal perfusion (Thrombolysis in Myocardial Infarction grade 3 flow) in the infarct vessel after angioplasty. This study documented poloxamer-188 to be ineffective as an adjunct to primary angioplasty for acute myocardial infarction and resulted in azotemia in 12% of the patients.

Aged↗
PubMed1984

Enalapril worldwide experience.

Overall, the worldwide experience on enalapril to date is very encouraging. The drug produces good to excellent responses in 54 to 66 percent of patients with essential hypertension and is at least as effective as either diuretics or beta blockers. The effects of enalapril compared with those of diuretics confirm that patients more dependent upon the renin-angiotensin system respond better. When hydrochlorothiazide is administered concomitantly with enalapril, almost all patients respond, with good long-term maintenance. In patients with severe hypertension, Blocadren or Aldomet may be added in addition to hydrochlorothiazide and will produce additional benefit. Enalapril attenuates the adverse metabolic effects of hydrochlorothiazide, particularly hypokalemia. Overall, although the efficacy of enalapril and that of captopril are similar, enalapril is better tolerated and does not appear to be associated with any significant occurrence of captopril-type side effects, particularly the skin rash and loss of taste. As expected, enalapril and other converting inhibitors may be associated with azotemia in patients with bilateral renovascular hypertension.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1989

Risk factors for nosocomial candidemia: a case-control study in adults without leukemia.

PURPOSE: The purpose of this study was to define risk factors for nosocomial candidemia in adult patients without leukemia at a tertiary care medical center. PATIENTS AND METHODS: All patients with nosocomial candidemia between August 1, 1981, and October 31, 1984, were included if they met strict selection criteria and did not have acute or chronic leukemia. For each case, one control was selected from among patients admitted during the same month/year and matched for hospital service and duration of hospitalization up to the first blood culture that grew Candida species. Logistic regression was used to obtain estimates of risk after simultaneously controlling for other variables. RESULTS: Candida albicans caused 24 of the 48 fungemias studied. The risk factors identified included the presence of a central line (odds ratio, 26.4; 95% confidence interval, 1.5 to 451.1); bladder catheter (13.0 1.3 to 131.4); two or more antibiotics (25.1, 2.1 to 318); azotemia (22.1, 2.2 to 223.2); transfer from another hospital (21.3, 1.7 to 274.5); diarrhea (10.2, 1.03 to 101.4); and candiduria (27.0, 1.7 to 423.5). A prior surgical procedure was associated with lowered risk (0.1, 0.01 to 0.9), suggesting perhaps that medical service patients are at higher risk than those on surgical services. Because total parenteral nutrition was always administered by means of a central line, it could not be shown to increase the risk over that conferred by a central line alone. CONCLUSIONS: This study has defined seven major risk factors for nosocomial candidemia. These findings should facilitate development of rational approaches to preventing infection and may assist clinicians in identifying those patients in whom this life-threatening complication is likely to occur.

Adolescent↗
PubMed1989

Pre-arrest morbidity and other correlates of survival after in-hospital cardiopulmonary arrest.

PURPOSE: Recent reports on the use of in-hospital cardiopulmonary resuscitation (CPR) have failed to provide an applicable method to identify patients who have little chance of surviving CPR. We prospectively evaluated the clinical characteristics and outcome of 140 consecutive hospitalized patients who had cardiopulmonary arrest and received CPR, and we propose a method for predicting survival in this setting. PATIENTS AND METHODS: The study period was July 1 through December 31, 1985, and the patient population consisted of 91 men and 49 women (age range, 18 to 92 years). We devised a multifactorial scoring system, the Pre-Arrest Morbidity (PAM) Index, to evaluate pre-arrest morbidity in individual patients. RESULTS: Seventy-seven (55%) of these patients were successfully resuscitated, 34 (24.3%) were discharged from the hospital alive, and 29 (20.7%) were long-term survivors (alive three months after discharge). Multivariate analysis of pre-arrest clinical variables demonstrated a significant association with mortality for hypotension, azotemia, and age 65 years or older, although none of these factors was absolutely predictive of a fatal outcome. The PAM Index was found to correlate inversely with the frequency of successful resuscitation, and the probability of short-term and long-term survival after CPR. Patients with PAM scores of 7 or greater had an extremely low likelihood of long-term survival (less than 15%), and no patient with a score of more than 8 survived to discharge. When the PAM score was considered in multivariate analysis of pre-arrest variables, it became the only significant independent predictor of mortality. CONCLUSION: The PAM Index may be useful in identifying patients in whom CPR may be ineffective.

Adult↗
PubMed1997

Bone mass, vitamin D deficiency, and hyperparathyroidism in congestive heart failure.

PURPOSE: In contrast to renal and hepatic failure, congestive heart failure (CHF) has not been associated with a defined metabolic bone disorder. However, low bone mass has been reported in patients with CHF who receive a cardiac transplant. Both the pathophysiology and therapy of CHF may influence bone and mineral homeostasis and evidence that calciotropic hormones may affect cardiovascular function is accumulating. Therefore, we evaluated patients with severe CHF to determine the prevalence of osteoporosis and to characterize relationships between mineral homeostasis, bone turnover, bone mass, and severity of CHF. PATIENTS AND METHODS: One hundred one patients (79 men and 22 women, aged 25 to 70 years) with severe CHF (New York Heart Association functional class III or IV) referred for consideration for cardiac transplantation were evaluated with measurements of serum 25-hydroxyvitamin D (25-OHD), 1,25 dihydroxyvitamin D [1,25(OH)2D], intact parathyroid hormone (PTH), markers of bone turnover (serum osteocalcin, urinary hydroxyproline, and pyridinium crosslinks); bone mineral density (BMD) by dual energy x-ray absorptiometry was measured in 91 patients. Left ventricular ejection fraction (LVEF) and resting cardiac output (CO) were determined in 88 and maximal treadmill exercise testing and peak oxygen consumption were performed in 45 patients. RESULTS: Osteoporosis (T score < or = -2.5) was present in 7% at the lumbar spine, 6% at the total hip, and 19% at the femoral neck. Osteopenia (T scores between -1.0 and -2.5) was present in 43% at the lumbar spine, 47% at the total hip, and 42% at the femoral neck. Women were more severely affected (P = 0.007). Frankly low serum 25-OHD (< or = 9 pg/mL) and 1,25(OH)2D (< or = 15 pg/mL) levels were found in 17% and 26% of the patients, respectively, and elevated serum PTH (> or = 65 pg/mL) in 30%. Both low serum 1,25(OH)2D and increased serum PTH were associated with prerenal azotemia. Low serum vitamin D metabolites were associated with biochemical evidence of increased bone turnover, but BMD did not differ by vitamin D or PTH status. Patients with more severe CHF had significantly lower vitamin D metabolites and higher bone turnover, whereas elevated PTH was associated with better LVEF (21 +/- 1 versus 18 +/- 1%; P = 0.05) and correlated positively with resting CO (R = 0.220; P = 0.04). CONCLUSIONS: Osteopenia or osteoporosis were observed in approximately half of these patients with severe CHF. Abnormal calciotropic hormone concentrations, also common, were associated with evidence of increased bone resorption but were not related to BMD in this cross-sectional study. Abnormal concentrations of calciotropic hormones were related to the severity of cardiovascular compromise. Because both low BMD and low serum concentrations of 25-OHD in patients with CHF are associated with higher rates of bone loss and fracture after cardiac transplantation, patients should be evaluated for and receive appropriate therapy for these disorders.

Absorptiometry, Photon↗
PubMed1999

Diuretic treatment and diuretic resistance in heart failure.

Diuretic therapy decreases capillary wedge pressure and improves New York Heart Association (NYHA) functional class both in acute and chronic heart failure. In advanced symptomatic heart failure, loop diuretics are generally necessary to improve symptoms of congestion. Diuretic resistance in the edematous patient has been defined as a clinical state in which diuretic response is diminished or lost before the therapeutic goal of relief from edema has been reached. The major causes of diuretic resistance are functional renal failure (prerenal azotemia), hyponatremia, altered diuretic pharmacokinetics, and sodium retention caused by counterregulatory mechanisms intended to reestablish the effective arterial blood volume. Therapeutic approaches to combat diuretic resistance include restriction of fluid and sodium intake, use of angiotensin-converting-enzyme (ACE) inhibitors, changes in route (oral, intravenous) and timing (single dose, multiple doses, continuous infusion) of diuretic therapy, and use of diuretic combinations.

Diuretics↗
PubMed1984

Serial nephelometric urine IgG measurement and the management of pregnancy-induced hypertension.

Serial IgG analysis was performed on the urine and serum of 16 patients with pregnancy-induced hypertension. Significant immunoglobulinuria developed prior to the development of azotemia, significantly decreased creatinine clearance, significant proteinuria (greater than or equal to 3+ dipstick or greater than or equal to 5 gm per 24-hour urine collection), or oliguria. Nephelometric measurement of urine IgG concentrations appears to be a rapid and accurate method for confirming the severity of clinical disease, the degree of renal involvement, the benefit of treatment modalities on renal function, and the likelihood of postpartum maternal morbidity.

Adolescent↗
PubMed1987

Pregnancy in Henoch-Schönlein purpura.

A 22-year-old white woman with Henoch-Schönlein purpura was treated with frequent plasmapheresis for increased severity of the disease activity during pregnancy. Hypertension, azotemia, and placental dysfunction were not observed. A healthy infant was delivered by cesarean section, and evidence of vasculitis was not detected in the placenta.

Adult↗
PubMed2003

Acute tubular injury causes dysregulation of cellular cholesterol transport proteins.

Acute renal injury causes accumulation of free and esterified cholesterol (FC, CE) in proximal tubules, mediated, at least in part, by increased cholesterol synthesis. Normally, this would trigger compensatory mechanisms such as increased efflux and decreased influx to limit or reverse the cholesterol overload state. This study sought to determine the integrity of these compensatory pathways following acute renal damage. Rhabdomyolysis-induced acute renal failure was induced in mice by glycerol injection. Normal mice served as controls. After 18 hours, BUN levels and renal cortical FC/CE content were determined. Expression of ABCA-1 and SR-B1 (cholesterol efflux proteins) were assessed by Western blot. Renal cortical LDL receptor (LDL-R; a cholesterol importer) regulation was gauged by quantifying its mRNA. To obtain proximal tubule cell-specific data, the impact of oxidant (Fe) stress on cultured HK-2 cell LDL-R, SR-B1, and ABCA-1 proteins and their mRNAs (versus controls) was assessed. Glycerol evoked marked azotemia and striking FC/CE increments (44%, 384%, respectively). Paradoxically, renal cortical SR-B1 and ABCA-1 protein reductions and LDL-R mRNA increments resulted. Fe-induced injury suppressed HK-2 cell SR-B1, ABCA-1, and their mRNAs. LDL-R protein rose with the in vitro Fe challenge. Renal tubular cell injury causes dysregulation of SR-B1, ABCA-1, and LDL-R protein expression, changes which should contribute to a cholesterol overload state. Reductions in HK-2 cell SR-B1 and ABCA-1 mRNAs and increases in renal cortical LDL-R mRNA imply that this dysregulation reflects, at least in part, altered genomic/transcriptional events.

ATP Binding Cassette Transporter 1↗
PubMed1999

Calcitriol directly sensitizes renal tubular cells to ATP-depletion- and iron-mediated attack.

Vitamin Ds have been reported to have diverse effects on cell homeostasis, leading to suggestions that they have therapeutic applications extending beyond their traditional actions on the Ca2+/parathyroid/bone axis. As some of these potential indications carry an inherent risk of acute renal failure (ARF; eg, cancer chemotherapy and organ transplantation), the goal of this study was to assess whether vitamin Ds directly affect renal tubule injury responses. Cultured human proximal tubular (HK-2) cells were exposed to physiological or pharmacological doses of either calcitriol (D3) or a synthetic vitamin D2 analogue (19-nor) for 3 to 48 hours. Their impact on cell integrity (percent lactate dehydrogenase (LDH) release and tetrazolium dye MTT uptake) under basal conditions and during superimposed injuries (ATP depletion/Ca2+ ionophore or iron-mediated oxidant stress) were determined. As vitamin Ds can be anti-proliferative, cell outgrowth ([3H]thymidine uptake and crystal violet staining) was also tested. Finally, the action of D3 on in vivo ARF (glycerol-induced myoglobinuria) and isolated proximal tubule injury responses were assessed. D3 induced a rapid, dose-dependent increase in HK-2 susceptibility to both ATP-depletion/Ca2+-ionophore- and Fe-mediated attack without independently affecting cell integrity or proliferative responses. In contrast, D2 negatively affected only Fe toxicity and only after relatively prolonged exposure (48 hours). D3 dramatically potentiated in vivo ARF (two- to threefold increase in azotemia), suggesting potential in vivo relevance of the above HK-2 cell results. Proximal tubules, isolated from these glycerol-exposed mice, suggested that D3 can worsen tubule injury despite a parodoxic suppression of H2O2 production. In contrast, D3 had a mild negative impact on cellular energetics (depressed ATP/ADP ratios), and it accentuated plasma membrane phospholipid breakdown. The latter was observed in both glycerol-treated and control tubules, suggesting a primary role in the injury- potentiation effect of D3. Vitamins D(s) may directly, and differentially, increase proximal tubule cell susceptibility to superimposed attack. This property should be considered as new uses for these agents are defined.

Acute Kidney Injury↗
PubMed1990

Liver transplantation for severe Amanita phalloides mushroom poisoning.

Amanita phalloides mushroom poisoning is an increasingly common and potentially lethal problem for which liver transplantation offers definitive therapy in selected patients. When significant liver dysfunction appears, early transfer to a liver transplant center is important to identify appropriate candidates and to begin the search for a donor organ. The clinical course of five severely poisoned patients, four of whom underwent liver transplantation, is reviewed. Indications for transplantation included primarily a markedly prolonged prothrombin time that was only partially correctable and a constellation of findings including metabolic acidosis, hypoglycemia, hypofibrinogenemia, and increased serum ammonia, following a marked elevation in serum aminotransferase levels. Unlike viral fulminant hepatic failure, grade III or IV hepatic encephalopathy, marked elevation of the serum bilirubin level, and azotemia were not indications for transplantation. Resected livers demonstrated hepatocyte viability of 0% to 30%. Manifestations of Amanita poisoning complicating preoperative and/or postoperative care included severe diarrhea, gastrointestinal hemorrhage, hypophosphatemia, bowel edema, and marrow suppression with lymphopenia, thrombocytopenia, and neutropenia. All five patients are well 1 year later. This largest experience with liver transplantation for Amanita poisoning further defines the early clinical and laboratory indications for, and the unique complicating features of, transplantation in this setting.

Acute Disease↗
PubMed1979

Ascites: its correction by peritoneovenous shunting.

Patients with refractory ascites and HRS should be considered to present an urgent indication for peritoneovenous shunting. The shunt offers a method of continuous reinfusion of ascitic fluid which corrects avid sodium retention, oliguria and azotemia. Severe encephalopathy, jaundice or peritoneal sepsis--common complications of cirrhosis--contraindicate installation of the shunt before improvement occurs. Associated cardiac disease does not contraindicate the use of the shunt provided that ascitic fluid is removed at the time of operation and large amounts of diuretics are used. This operation has also proved useful in ascites attributed to causes other than cirrhosis. The main complications include disseminated intravascular coagulopathy, hepatic coma and sepsis in a few patients. Results of a randomized prospective study indicate that the shunt should probably be considered in patients with diet-resistant massive ascites even before they prove to be refractory to diuretic therapy.

Aged↗
PubMed1998

Principles of diuretic therapy.

This section discusses the reasons different diuretic agents inhibit salt reabsorption at specific sites within the renal tubule. It also includes a brief review of how diuretics reach their target site of action along the nephron, together with a discussion of how disease states may affect the delivery of diuretics to those sites. When diuretics are administered to edematous patients, the natriuretic response is often blunted. In addition, increased renal tubular salt avidity is observed after administration of loop diuretics. The elements required to successfully achieve adequate natriuresis under such conditions are analyzed. Because achieving diuresis may result in significant hypokalemia, hyponatremia, metabolic alkalosis, and worsening prerenal azotemia, the prevention and management of these complications of diuretic therapy are also reviewed. A description of successful use of diuretics in specific edematous states, such as congestive heart failure, chronic renal failure, nephrotic syndrome, and liver disease, is followed by a brief discussion of the management of resistant edema and the use of diuretics in nonedematous states, including essential hypertension and other conditions.

Diuretics↗
PubMed1999

Total peroral intraoperative enteroscopy for obscure GI bleeding using a dedicated push enteroscope: diagnostic yield and patient outcome.

BACKGROUND: Intraoperative enteroscopy is an effective diagnostic and therapeutic method in selected patients with obscure gastrointestinal (GI) bleeding. The passage of a colonoscope orally and then rectally or the use of multiple enterotomies, has been used to completely inspect the small bowel. However, the development of dedicated enteroscopes allows complete inspection using the peroral route. AIM: The aim of the study was to assess the diagnostic yield, patient outcome, and success in reaching the terminal ileum using a video enteroscope passed orally during intraoperative enteroscopy. METHODS: The hospital charts of 12 patients who underwent intraoperative enteroscopy for GI bleeding of obscure origin and 2 patients with a known source (angioectasias) who underwent evaluation to determine extent were retrospectively analyzed. RESULTS: The terminal ileum was reached in 13 of 14 patients (jejunal stricture in 1 patient). Of the patients with bleeding of obscure origin (n = 12) a source was identified in 7 (angioectasias 4, lymphoma 1, carcinoid 1, nevuslike lesion 1). Surgical therapy was performed in these 7 patients and resulted in no further bleeding in 5. Bleeding recurred in 4 of the 5 patients who had no source identified during intraoperative enteroscopy. Of the 2 patients undergoing intraoperative enteroscopy to evaluate extent of angioectasias, additional angioectasias were found in 1 patient; both patients underwent surgical resection, and 1 patient had recurrent bleeding. Complications included serosal tears, 3 (2 requiring resection); avulsion of superior mesenteric vein, 1; postoperative congestive heart failure, 2; azotemia, 1; and prolonged ileus, 1. There were no deaths. CONCLUSIONS: The terminal ileum was reached 93% of the time with intraoperative enteroscopy. For patients with GI bleeding of obscure origin the diagnostic yield of intraoperative enteroscopy was 58%. Major operative morbidity occurred in 4 patients.

Aged↗
PubMed1982

Urinary extravasation in the newborn male with posterior urethral valves.

Neonatal urinary extravasation is a rare condition frequently associated with posterior urethral valves in males. At the Babies Hospital, Columbia Presbyterian Medical Center during a 16-yr period, 5 neonates with urinary extravasation and valves presented--of all valve patients. Presentation was characterized by abdominal distention and varying degrees of azotemia. Treatment consisted of upper tract drainage in two cases and lower tract decompression in three. The mortality of this series was zero. At follow-up all five patients had completely normal serum renal function studies; four out of five had essentially normal radiographic studies. Extravasation appeared to protect the upper tracts from significant damage. Successful management of this condition should be tailored to the individual patient.

Ascites↗
PubMed1987

Experience with renal failure during extracorporeal membrane oxygenation: treatment with continuous hemofiltration.

We use extracorporeal membrane oxygenation (ECMO) to treat respiratory and cardiac failure in children who are unresponsive to standard ventilator and pharmacologic management. All patients have cardiac and abdominal ultrasonography prior to ECMO to identify major structural anomalies and anatomically normal kidneys. Despite this, oliguric renal failure is seen in a number of patients. Acute renal failure (ARF) developed in two of the first 20 patients we placed on ECMO and both of these patients died. Six of the last 27 patients (22%) also developed ARF and were treated with continuous hemofiltration (CH) placed in-line with the extracorporeal circuit. The technique of CH removes plasma water and dissolved solutes while retaining proteins and cellular components of the intravascular space. The duration of CH ranged from 9 to 112 hours (mean 57.5 hours). Indications for CH were hypervolemia, hyperkalemia, and azotemia. The mean serum potassium prior to CH was 5.6 (range 4.3 to 7.0) compared with 4.5 after filtration. We filtered 5 to 10 mL/kg/h and replaced it with crystalloid chosen on the basis of serum and filtrate electrolytes. These six patients had a 33% mean weight gain prior to CH. We were able to remove as much as 2,200 g in the most edematous patient with significant improvement in cardiopulmonary status. Four of the patients on CH died of their primary pulmonary or cardiac disease without specific problems related to ARF. The other two patients were successfully weaned from ECMO, extubated, and have not needed further therapy for renal failure. We conclude that CH is useful in managing the complications of oliguric renal failure during ECMO.

Acute Kidney Injury↗
PubMed1978

A distinct human variant of hypoxanthine-guanine phosphoribosyl transferase.

A variant form of hypoxanthine-guanine phosphoribosyl transferase has been found in a neurologically normal pediatric patient who presented with hematuria an episodes of oliguria and azotemia. The level of erythrocyte enzyme activity was 3% of normal. Electrophoretic mobility was more rapid than normal. The Km for hypoxanthine was approximately ten times normal. Immunochemical analysis indicated that the variant enzyme cross reacted with antibody to normal HPRT. A system is described for the systematic characterization of a variant HPRT.

Antibodies↗