1/44. Pharmacist monitoring of drug therapy in patients with abnormal serum creatinine levels.Because of possibly drug-related adverse events that occurred in renal patients, a program was developed to routinely monitor renal patients to ensure that all prescribed drugs and dosages conformed to standard clearance-adjusted regimens. Summary laboratory reports were surveyed daily, patients with abnormally elevated serum creatinine values were noted, and reviews of patients' medication profiles and orders were performed at least daily. The pharmacist was made responsible for judging if renally-eliminated drugs were used appropriately. If the pharmacist deemed that a change was needed, the prescribing physician was contacted by telephone or in person. From January 1990 through December 1992, a total of 627 patients with renal impairment were monitored. Among these patients, 233 changes in drug therapy were implemented as a direct result of pharmacist assessment and subsequent physician contact. The most common changes were dosage decreases. Medications requiring changes most often were antimicrobial agents, accounting for 55% of all interventions. A retrospective assessment of interventional efficacy, performed through focused evaluation of 20 randomly selected cases, revealed no direct evidence of either therapeutic failure or drug toxicity in patients for whom pharmacist-directed changes were made. Pharmacist monitoring can have a beneficial influence on the care of renal patients.- - - - - - - - - - ranking = 1keywords = physician (Clic here for more details about this article) |
2/44. kidney disease and silicosis.AIM: To determine the prevalence of kidney disease in a cohort of individuals with silicosis. methods: review of medical records and questionnaires from patients reported to a state surveillance system for silicosis. Reporting of individuals with silicosis is required by state law. All individuals with silicosis reported as required by law to the State of michigan. Individuals included in this article were reported from 1987 to 1995. Cases were reported by hospitals, physicians, the state workers' compensation bureau, or from death certificates. Only individuals who met the criteria for silicosis developed by the National Institute for Occupational safety and health (NIOSH) were included. RESULTS: medical records were reviewed of 583 individuals with confirmed silicosis. This was mainly a population of elderly men. Ten percent of the 583 silicotics were found to have some mention of chronic kidney disease, and 33% of the 283 silicotics who we had laboratory tests on had a serum creatinine level >1.5 mg/dl. An association between kidney disease and age and between kidney disease and race was found among this cohort of 583 silicotics. Individuals with silicosis were more likely to have a serum creatinine level >1.5 mg/dl than age- and race-matched controls. However, no relationship between duration of exposure to silica or profusion of scarring on chest X-ray and prevalence of kidney disease or elevated creatinine levels was found. CONCLUSIONS: This study confirms previous case reports and epidemiologic studies of end-stage renal disease that found an association between kidney disease and exposure to silica. The epidemiologic data are conflicting on the mechanism by which silica causes kidney disease and are compatible with silica being able to cause kidney disease by both an autoimmune and direct nephrotoxic effect. Chronic kidney disease should be considered as a complication of silicosis.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
3/44. Electrocardiographic manifestations of hyperkalemia.hyperkalemia is one of the more common acute life-threatening metabolic emergencies seen in the emergency department. early diagnosis and empiric treatment of hyperkalemia is dependent in many cases on the emergency physician's ability to recognize the electrocardiographic manifestations of hyperkalemia. The electrocardiographic manifestations commonly include peaked T-waves, widening of the QRS-complex, and other abnormalities of altered cardiac conduction. Peaked T-waves in the precordial leads are among the most common and the most frequently recognized findings on the electrocardiogram. Other "classic" electrocardiographic findings in patients with hyperkalemia include prolongation of the PR interval, flattening or absence of the P-wave, widening of the QRS complex, and a "sine-wave" appearance at severely elevated levels. A thorough knowledge of these findings is imperative for rapid diagnosis and treatment of hyperkalemia.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
4/44. Fulminant pneumonia due to aeromonas hydrophila in a man with chronic renal failure and liver cirrhosis.A 40-year-old man on hemodialysis was admitted due to dyspnea and chest pain and was diagnosed with pneumonia and pericarditis. ampicillin was administered, but thereafter severe septic shock developed. The fulminant type of pneumonia progressed rapidly, and he died only 48 hours after the onset of symptoms. The autopsy and sputa culture revealed pneumonia due to aeromonas hydrophila. The source of this infection remained unkown. Interestingly, there were two types of A. hydrophila found during such a short period. The physician should suspect this disease by questioning the patient's history. Early treatment with adequate antibiotics is the only means of saving such a patient's life.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
5/44. Chronic illnesses and the end of life.Great progress has been made in controlling the symptom distress of dying patients. This article reviews some of these methods and examines some triggering events that should cause physicians to re-examine patients' goals and care.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
6/44. Important causes of hypoglycaemia in patients with diabetes on peritoneal dialysis.AIM: Diabetes is now the commonest cause of end-stage renal failure, so there are many diabetic patients receiving dialysis therapy. There are several important ways in which dialysis practice can impinge unfavourably on glucose control. This study focuses on the interaction between maltose-derived metabolites in a new peritoneal dialysis fluid and blood glucose measurements using reagent sticks that depend on the glucose dehydrogenase method. CASE REPORT: We report the cases of three patients, with insulin-treated diabetes and end-stage renal disease treated with peritoneal dialysis, who experienced symptomatic hypoglycaemia with inaccurate glucose readings on reagent strips when converted to icodextrin. CONCLUSION: Careful teamwork between diabetes and renal physicians and specialist nurses is highly desirable to achieve good glucose control in a group of patients at particular risk of microvascular and macrovascular complications.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
7/44. Severe prolonged tacrolimus overdose with minimal consequences.A 59-year-old man inadvertently received a 10-fold increase in his twice-daily oral dose of tacrolimus 1 mg that resulted in trough blood levels above 90 ng/ml for over a week. The patient had end-stage renal disease secondary to diabetes mellitus and had received a kidney transplant from his daughter 3 months earlier. Despite the numerous adverse effects commonly reported with tacrolimus, such as mild nephrotoxicity, nausea, tremors, and elevated liver enzyme levels, our patient's acute but prolonged overdose resulted in minimal signs and symptoms of toxicity. Nevertheless, education regarding the importance of accurate dosing, close monitoring, potential drug interactions, and the various capsule colors should be provided to all patients who receive tacrolimus, as well as their physicians, nurses, and pharmacists, in order to prevent as many errors as possible.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
8/44. Reluctance to accept life-saving treatment.The patient is a twenty-three-year-old man with end-stage kidney disease who has major conflicts about receiving maintenance hemodialytic treatment. These conflicts stem in part from the patient's hospitalization at the age of seven and the witnessing of heroic medical procedures used in an attempt to treat his father's eventually successful suicide. His unconscious doubts of his manliness result in a pseudoindependent behavior and a pose of hypermasculinity which induce a rejection of passivity and the dependent position necessitated by being a patient on hemodialysis. Rejection of hemodialysis may be a conscious or unconscious suicide attempt. In this patient, it may be a consequence of guilt in relation to his father's death and of other psycho-social factors. Effective treatment for this patient should include allowing him to exercise his independence in as many ways as is possible. Home dialysis and renal transplantation lend themselves to greater feelings of independence and may be preferable to center hemodialysis in this patient. The feelings surrounding the death of his father should be explored with a liaison physician or psychiatrist.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
9/44. colchicine neuromyopathy: a report of six cases.colchicine has been in use for therapeutic purposes for many years. It can, however, cause subacute onset muscle and peripheral nerve toxicity in patients with chronic renal failure. In this report we describe 6 patients who developed neuromyopathy after the administration of colchicine. All patients presented with proximal muscle weakness, elevated serum creatine kinase (CK) levels, and neuropathy and/or myopathy on electromyography (EMG). The diagnosis of colchicine toxicity was confirmed in all cases by the normalization of CK levels and EMG after discontinuation of the drug. Toxicity developed in 4 renal failure patients on therapeutic doses of the drug, while one patient took a massive dose for suicidal reasons, and the other was on high-dose therapy. patients using colchicine--especially those with renal failure--should be warned about the side effects of the drug and physicians should be careful in the administration of the drug.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
10/44. Diagnostic and interventional nephrology.The fragmented care of nephrology patients that results from referral to a radiologist for renal ultrasound (US) and biopsy, a surgeon for dialysis access placement, and an interventional radiologist for dialysis catheter placement and vascular access procedures often leads to delays in the treatment of these patients. Many specialists perform and interpret sonograms particular to their specialty rather than relying on technicians for performance and radiologists for interpretation, and nephrologists recently have begun to embrace this technology as an aid in the diagnosis and treatment of their patients. By combining an understanding of the pathophysiology of renal disease with the ability to perform clinical correlation and apply the laboratory data, the nephrologist is ideally suited to perform and interpret renal US and US guidance for percutaneous renal biopsies. Additionally, patients requiring peritoneal dialysis (PD) access have traditionally been referred to a general surgeon for catheter placement, which incurs additional delay in therapy and loss of decision-making control by the referring nephrologist. Recent data has emphasized that the peritoneal dialysis access procedure can be performed safely and effectively by a nephrologist trained in PD access procedures. Nephrologists also successfully perform tunneled hemodialysis catheter placement and vascular access procedures on an outpatient basis. The medical needs of patients with renal disease can be safely and efficiently delivered by a nephrologist trained in interventional nephrology (IN). This growing area of expertise will minimize delays, reduce cost, and allow physicians with training in the management of end-stage renal disease (ESRD) patients to be involved in the procedural aspects of their patients' care. An aggressive approach to the development of IN training programs at academic centers is warranted.- - - - - - - - - - ranking = 0.5keywords = physician (Clic here for more details about this article) |
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