American journal of kidney diseases : the official journal of the National Kidney Foundation
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The medical care of end-stage renal disease (ESRD) patients includes not only dialysis-related medical care but preventive and general medical care as well as the care of minor acute illnesses. There is little information about nephrologists' interpretation of their potential role as a primary health care provider for the general medical needs of chronic dialysis patients. To characterize nephrologists' primary care practice patterns related to the care of chronic dialysis patients, we surveyed a randomly selected group of practicing nephrologists and asked questions about preventive medicine guidelines followed, treatment of minor acute illnesses, and management of chronic medical problems in ESRD patients. ⋯ Most nephrologists reported that they managed minor acute illnesses and comorbid conditions (diabetes mellitus, cardiac disease, and gastrointestinal disease) in their dialysis patients. Nephrology fellowship training programs and recertification programs may need to address issues of primary general health care of ESRD patients. Plans under development for health care programs and reimbursement criteria also need to recognize and consider the primary medical care role practiced by nephrologists caring for ESRD patients.
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Bardet-Biedl syndrome is a rare autosomal recessive disease characterized by dysphormic extremities, retinal dystrophy, obesity, hypogenitalism in males, and renal structural abnormalities. Because the clinical outcome of these patients is not well known, 21 families with Bardet-Biedl syndrome (BBS) were studied to determine the natural history of the disease. In a prospective cohort study, 38 patients with the syndrome and 58 unaffected siblings were identified. ⋯ Bardet-Biedl syndrome has an adverse prognosis, with early onset of blindness, obesity, hypertension, and diabetes mellitus. Renal impairment is frequent and an important cause of death. Survival is substantially reduced.
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Randomized Controlled Trial Comparative Study Clinical Trial
Regional hemodialysis anticoagulation: hypertonic tri-sodium citrate or anticoagulant citrate dextrose-A.
Regional citrate anticoagulation should be a simple process of substituting hypertonic (1.6 mol/L) citrate for heparin and adjusting the infusion to obtain an arterial activated clotting time of 150 to 200 seconds. Serious, documented complications of citrate anticoagulation involve citrate intoxication during isolated ultrafiltration; hyperaluminemia, hyperammonemia, and hypernatremia during sorbent dialysis; and profound alkalosis, paresthesias, arrhythmia, and cardiac arrest during bicarbonate dialysis. We suspected that some of these complications could be avoided by using anticoagulant citrate dextrose-A (ACD) rather than hypertonic tri-sodium citrate (TSC) as the anticoagulant. ⋯ During this evaluation isotonic and hypertonic citrate resulted in similar serum sodium changes, and standard dialysate effectively reversed the citrate/calcium interaction of both hypertonic and isotonic citrate infusions to restore homeostasis without a separate calcium infusion. The combination of TSC and bicarbonate dialysate does produce a profound metabolic alkalosis, which is lessened by using ACD. In general, regional citrate anticoagulation is simplified by using standard dialysate with a hypertonic rather than an isotonic citrate infusion, and dangerous complications are further evaded by adjusting the dialysate bicarbonate to 25 to 30 mmol/L or substituting a mixture of citric acid and TSC (ACD) for TSC.
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By examining the ethical features of dialysis withdrawal as well as tr transcultural differences in attitudes toward withdrawal, one can have a better understanding of the role of autonomy and community-based values on medical decision-making. Three distinctive patterns of withdrawal are described herein. The first concerns patients suffering from an advanced state of physical or mental decline. ⋯ In third pattern, the patient's decision to withdraw appears to be inappropriate to their potential for benefit from continued therapy. The nephrologist and patient are conflicted on what constitutes beneficence, with the former holding that continuation is morally superior. In such cases, the physician must mediate the situation in a beneficent fashion not solely dictated by a constraining view of patient autonomy.