Journal of the American Society of Nephrology : JASN
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J. Am. Soc. Nephrol. · Oct 1996
Review Case ReportsSevere hyperphosphatemia and hypocalcemia: a dilemma in patient management.
In the following report, a case of severe hyperphosphatemia and tetanic hypocalcemia resulting from the inadvertent oral ingestion of a phosphate enema is described. The physiology of serum phosphate regulation and the mechanism by which the elevation of serum phosphate is thought to induce hypocalcemia is discussed, and the treatment of hyperphosphatemia is reviewed. Finally, the potential consequences of the administration of calcium to treat tetany in a patient with severe hyperphosphatemia are considered.
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J. Am. Soc. Nephrol. · Oct 1996
Nocturnal blood pressure in treated hypertensive African Americans Compared to treated hypertensive European Americans.
Previous studies have shown that African Americans (blacks) tend to have higher nocturnal blood pressure than European Americans (whites). The study presented here was undertaken to determine whether treatment of hypertension influences nocturnal blood pressure differently in blacks than in whites. To answer this question, this study measured nocturnal blood pressure by ambulatory blood pressure monitoring (ABPM) in treated hypertensive blacks and whites whose daytime blood pressures were comparable. ⋯ The higher middle night blood pressure in blacks versus whites could not be explained by differences between the groups in daytime MAP, age, gender, body weight, serum creatinine level, proteinuria, diabetic status, or greater use of short-acting antihypertensive agents in blacks versus whites. It was concluded that when treated hypertensive blacks and whites are matched for the same daytime blood pressure, blacks tend to have significantly higher nocturnal blood pressure than whites. The magnitude of this difference suggests that it could contribute importantly to the greater target-organ damage that is seen in hypertensive blacks compared with hypertensive whites.
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J. Am. Soc. Nephrol. · Oct 1996
Why is it difficult for staff to discuss advance directives with chronic dialysis patients?
General experience and reported data show that a substantial number of patients, at least 10% in many surveys, eventually choose to withdraw from chronic dialysis. There are additional studies suggesting that discussing and completing advance directives (AD) can promote more acceptance and less acrimony for patients, families, and staff when patients die. Even so, surprisingly few AD are completed, and dialysis staff often shun discussion of AD with patients. ⋯ The results of this survey underscore important differences between individual professional disciplines that affect both the perceived barriers to, as well as the likelihood of, discussing AD with patients. It seems that emotional issues such as death and dying stress interdisciplinary team interaction and amplify discomfort. However, it may be possible to increase the level of comfort in talking to patients about AD for each professional discipline by addressing the findings from this study (role differences and barriers) through focused interventions and by facilitating mutual support among the distinct members of the dialysis staff.
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J. Am. Soc. Nephrol. · Aug 1996
Hypertension may be transplanted with the kidney in humans: a long-term historical prospective follow-up of recipients grafted with kidneys coming from donors with or without hypertension in their families.
In several genetic hypertensive rat strains, transplantation studies have established that the kidney carries at least a portion of the genetic message for hypertension. In man it has, of course, been more difficult to obtain clearcut results. This historical prospective observational study, double-blinded for knowledge of donors' and recipients' family history for hypertension, concerns 85 transplanted patients, not treated with cyclosporine and with stable renal function, followed up for an average of 8 yr. ⋯ More detailed analyses show that, in recipients without familial hypertension, the transplantation of a "hypertensive" kidney determines a tenfold larger increase in the requirement of antihypertensive therapy than the transplantation of a "normotensive" kidney, to obtain a similar blood pressure control (P = 0.003). This results is confirmed by the analysis of time-profile trends for antihypertensive therapy, adjusted for missing data, in the most clinically stable period (2nd to 10th yr after transplantation). The transmission of familial hypertension with the kidney is thus seen only in recipients coming from "normotensive" families, because a familial tendency for hypertension blunts the effect of receiving a "hypertensive" kidney.
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J. Am. Soc. Nephrol. · Jul 1996
Comparative StudyCardiac arrhythmias during central venous catheter procedures in acute renal failure: a prospective study.
To define the frequency and risk factors of cardiac arrhythmias during central venous catheter procedures in acute renal failure, continuous electrocardiographic monitoring with permanent recording was performed before and during 201 guidewire insertions in 171 patients requiring a central venous catheter for parenteral nutrition and/or dialysis access (121 procedures in 107 patients with acute renal failure; 39 procedures in 31 patients with normal renal function; 41 procedures in 33 patients with ESRD on chronic hemodialysis). No differences in cardiac arrhythmia frequencies were found during baseline recording. New arrhythmias were documented in 85 cases (85/201; 42%) during the catheter procedure. ⋯ All arrhythmias resolved spontaneously soon after partial guidewire withdrawal; nine episodes were symptomatic (in one case, ventricular tachycardia, followed by 10 s asystolia); no death directly related to the catheter procedure was observed. BUN and serum creatinine levels, as well as guidewire length remaining inside the patient, were significantly higher (P < 0.01) in patients with cardiac arrhythmias during central venous catheter procedures as compared with patients without arrhythmias; differences in other variables known as possible risk factors for arrhythmias (anatomical position, preexistent cardiac disease, utilization of proarrhythmogenic drugs, hypoxemia, acid-base status, and serum electrolytes, etc.) were not significant. Our study suggests that (1) patients with acute renal failure are at increased risk for cardiac arrhythmias during central venous catheter procedures; (2) an important risk factor is also represented by guidewire overinsertion, a technical error that should be avoided.