Journal of the American Society of Nephrology : JASN
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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.
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J. Am. Soc. Nephrol. · Nov 1995
Randomized Controlled Trial Multicenter Study Clinical TrialLife-sustaining treatment preferences of hemodialysis patients: implications for advance directives.
The purpose of this study was to describe the life-sustaining treatment preferences of dialysis patients and to compare the acceptability of two generic and a disease-specific advance directive (AD). Of 532 potentially eligible hemodialysis patients, 95 (17.9%) participated in the study. These patients completed two generic (the Centre for Bioethics Living Will and the Medical Directive) and one disease-specific (the Dialysis Living Will) AD in a randomized cross-over trial. ⋯ Health states and illness severity, far more than treatment descriptions, influence preferences. Dialysis patients should be offered a generic AD, and some generic AD are more acceptable than others. Only a minority of dialysis patients will complete any AD, but the completion of written AD forms is only one element in the process of advance care planning.
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Continuous hemofiltration (CH) is being used in increasing numbers of pediatric intensive care unit patients. Experience with 114 CH treatments in 98 critically ill children from March 1988 to March 1993 is presented in this study. Ages ranged from 1 day to 23 yr (mean +/- SE = 7.1 +/- 0.7 yr), and 54% of patients were male. ⋯ Survival to hospital discharge was better in patients who did not receive pressors (P < 0.005) and in patients treated with combined ultrafiltration and dialysis (CAVH-D, CVVH-D) compared with ultrafiltration alone (CAVH, CVVH) (P < 0.005), but was not notably affected by patient age, sex, use of anticoagulation, filter life span, blood pump-assisted versus spontaneous CH, or duration of therapy. Filter life span was not affected by use of anticoagulation, but was remarkably longer in patients with arteriovenous versus venovenous CH (P < 0.004). It was concluded that: (1) empirical anticoagulation of patients treated with CH is not necessary; (2) children with a minority of underlying diseases and those requiring pressor support at initiation of CH appear to have relatively poor survival rates despite the technically effective use of CH; and (3) the addition of countercurrent dialysis to routine CH may enhance patient survival to hospital discharge.
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J. Am. Soc. Nephrol. · May 1995
Review Case ReportsCatastrophic secondary antiphospholipid syndrome with concomitant antithrombin III deficiency.
The association between thrombotic events and primary or secondary antiphospholipid/anticardiolipin syndrome is now well recognized. A spectrum of renal involvement ranging from glomerular thrombosis to renal infarction has been described. ⋯ The patient had an acquired antithrombin III deficiency, and the combination of secondary antiphospholipid syndrome with accompanying antithrombin III deficiency predisposed to thrombosis. Several mechanisms by which antiphospholipid/anticardiolipin antibodies cause thrombosis have been proposed and are briefly reviewed.
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Clearance data are customarily indexed to body surface area of 1.73 m2. This study examined whether this standard procedure gives correct values for renal perfusion in obese subjects. In 215 subjects who varied in age, gender, height, weight, obesity, and mean arterial blood pressure, RPF was determined by measuring the clearance of (131I)para-aminohippuric acid. ⋯ A separate repetition of the whole analysis for both normotensive (N = 55) and hypertensive subjects (N = 160) revealed a result similar to that found for the whole group. Thus, our results show that obesity was not a determinant of RPF, and when related to body surface area, inappropriately low values of RPF were calculated for obese patients. It was concluded that RPF values correlate with height and not with surface area in obese subjects.