Nephrology

This is the second part of a document describing a voluntary certification process based on Joint Commission International (JCI) criteria developed by the Italian Society of Nephrology (SIN) and JCI representatives. In the first part we discussed standards for clinical care delivery and performance measurements related to chronic kidney disease care. Herein (Part II), we complete the description of Performace measurements and CKD care by describing issues related the management and clinical information management.

Summary: Dialysate based assessment of the delivered dose of dialysis offers several advantages over blood sampling methods as it remains accurate in the face of fistula recirculation, urea rebound, variable blood flow and incorrect treatment time. Kr/V is calculated from the slope of the decline in urea concentration in the dialysate over the course of the treatment. By equilibrating dialysate with blood at the initiation of the treatment an estimate of pre-dialysis blood urea and the volume of distribution for urea (V) can be obtained. We performed Kt/V assessments on 20 in-centre haemodialysis patients using the Baxter Biostat 1000® dialysate urea monitor and compared the results with urea reduction ratios and Kt/V calculated by the formula of Basile. In addition, in 11 of these patients, V and pre-dialysis urea was derived and compared to total body water estimates using D2O. the mean Kt/V by Biostat was 1.11 ± 0.23 and by formula was 1.23 ± 0.16 (P < 0.005, Student's paired t-test). the lab pre-dialysis urea was 24.4 ± 6.2 mmol/L compared to the Biostat result of 23.9 ± 5.9 (when corrected for plasma water), with the mean difference of the techniques being −0.53 mmol/L. (95% CI −0.36–1.42). For V, the D2O result was 36.7 ± 9.7 litres, compared to the Biostat result of 37.9 ± 9.6. the mean difference of the techniques by Bland and Altman analysis (or bias of the Biostat) was 1.2 L (95% CI −0.9–3.3) and the limits of agreement were −5.2–7.6L. Thus the Biostat provides easy access to dialysis adequacy data and gives a reasonable assessment of V, tending to overestimate this value.

OBJECTIVETo report our experience with over 300 patients treated with percutaneous nephrolithotomy (PNL), for although PNL was established as a treatment in the 1970s, its use diminished with the introduction of extracorporeal shockwave lithotripsy (ESWL); clinical experience with ESWL showed its limitations, and the role of PNL for treating urolithiasis was redefined, which with improvements in instruments and lithotripsy technology has expanded the capability of percutaneous stone disintegration.To report our experience with over 300 patients treated with percutaneous nephrolithotomy (PNL), for although PNL was established as a treatment in the 1970s, its use diminished with the introduction of extracorporeal shockwave lithotripsy (ESWL); clinical experience with ESWL showed its limitations, and the role of PNL for treating urolithiasis was redefined, which with improvements in instruments and lithotripsy technology has expanded the capability of percutaneous stone disintegration.PATIENTS AND METHODSThe study included 315 patients (156 males, 159 females, aged 13–85 years) treated with PNL in our department between 1987 and 2002. The mean (range) stone diameter was 27 (7–52) mm. The kidney was punctured under ultrasonography guidance via a lower-pole calyx whenever possible. The working channel was dilated using an Alken dilator under X-ray control. If necessary, a flexible renoscope was used. Ultrasonic, pneumatic and laser probes were used for lithotripsy.The study included 315 patients (156 males, 159 females, aged 13–85 years) treated with PNL in our department between 1987 and 2002. The mean (range) stone diameter was 27 (7–52) mm. The kidney was punctured under ultrasonography guidance via a lower-pole calyx whenever possible. The working channel was dilated using an Alken dilator under X-ray control. If necessary, a flexible renoscope was used. Ultrasonic, pneumatic and laser probes were used for lithotripsy.RESULTSFour weeks after treatment the total stone-free rate was 96.5%; 45.7% of all patients were primarily stone-free, 21.3% had clinically insignificant residual stones that passed spontaneously within 4 weeks after PNL, and 33% of the patients needed auxiliary measures (a second PNL, ESWL, ureterorenoscopy). Overall, the early complication rate was 50.8%, the most common complications being transient fever (27.6%), clinically insignificant bleeding (7.6%) or both (3.2%); 3.5% of the patients developed urinary tract infections (with no signs of urosepsis), 3.2% had renal colic and 2.9% upper urinary tract obstruction. One patient (0.3%) developed acute pancreatitis after PNL; one died from urosepsis and one needed selective angiographic embolization of the punctured kidney due to bleeding. No patient required transfusions and there were no injuries to neighbouring organs.Four weeks after treatment the total stone-free rate was 96.5%; 45.7% of all patients were primarily stone-free, 21.3% had clinically insignificant residual stones that passed spontaneously within 4 weeks after PNL, and 33% of the patients needed auxiliary measures (a second PNL, ESWL, ureterorenoscopy). Overall, the early complication rate was 50.8%, the most common complications being transient fever (27.6%), clinically insignificant bleeding (7.6%) or both (3.2%); 3.5% of the patients developed urinary tract infections (with no signs of urosepsis), 3.2% had renal colic and 2.9% upper urinary tract obstruction. One patient (0.3%) developed acute pancreatitis after PNL; one died from urosepsis and one needed selective angiographic embolization of the punctured kidney due to bleeding. No patient required transfusions and there were no injuries to neighbouring organs.CONCLUSIONSThese results show that PNL causes no significant blood loss or major complications in almost all patients. Two aspects may especially reduce the potential complications: ultrasonography-guided renal puncture and using PNL in an experienced centre. PNL is a highly efficient procedure that provides fast and safe stone removal.These results show that PNL causes no significant blood loss or major complications in almost all patients. Two aspects may especially reduce the potential complications: ultrasonography-guided renal puncture and using PNL in an experienced centre. PNL is a highly efficient procedure that provides fast and safe stone removal.

The overall probability of forming stones differs in various parts of the world: 1-5% in Asia, 5-9% in Europe, 13% in North America, 20% in Saudi Arabia. The composition of stones and their location in the urinary tract, bladder or kidneys may also significantly differ in different countries. Moreover, in the same region, the clinical and metabolic patterns of stone disease can change over time. We examined some epidemiological evidence about the main risk factors for stone formation, both individual and environmental. A slightly higher rate of renal stone disease emerged in males than in females, and in white Caucasians than in Blacks. Stones in the upper urinary tract appear to be related to the life-style, being more frequent among affluent people, living in developed countries, with high animal protein consumption. Bladder stones are nowadays mainly seen in the Third World, on account of very poor socio-economic conditions. A high frequency of stone formation among hypertensive ...

Kidney disease alters the pharmacokinetic disposition of many medications, requiring dosage adjustment to maintain therapeutic serum concentrations. The Cockcroft-Gault (CG) equation is used for pharmacokinetic studies and drug dosage adjustments, but the Modification of Diet in Renal Disease (MDRD) Study equation is more accurate and more often reported by clinical laboratories than the CG equation.Diagnostic test study.Pooled data set for 5,504 participants from 6 research studies and 4 clinical populations with measured glomerular filtration rate (GFR).Estimated kidney function using the MDRD Study and CG equations incorporating actual (CG) or ideal body weight (CGIBW) and standardized serum creatinine concentrations.Measured GFR assessed by using iodine-125–iothalamate urinary clearance.Concordance of assigned kidney function categories designated by the Food and Drug Administration (FDA) Guidance for Industry for pharmacokinetic studies and recommended dosages of 15 medications cleared by the kidneys.Concordance of kidney function estimates with measured GFR for FDA-assigned kidney function categories was 78% for the MDRD Study equation compared with 73% for the CG equation (P < 0.001) and 66% for the CGIBW equation (P < 0.001). Concordance between the MDRD Study equation and CG and CGIBW equations was 78% and 75%, respectively (P < 0.001). Concordance of kidney function estimates with measured GFR for recommended drug dosages was 88% for MDRD Study equation compared with 85% for the CG equation (P < 0.001) and 82% for the CGIBW equation (P < 0.001), with lower concordance when dosing recommendations for drugs included narrow GFR ranges. Concordance rates between the CG and CGIBW equations and MDRD Study equation were 89% and 88%, respectively (P < 0.05).Results based on simulation rather than pharmacokinetic studies. Outcome was drug dosage recommendations, rather than observed drug efficacy and safety.The MDRD Study equation can also be used for pharmacokinetic studies and drug dosage adjustments. As more accurate GFR-estimating equations are developed, they should be used for these purposes.

У навчальному посібнику висвітлено сучасну інформацію про методи діагностики в клініці внутрішньої медицини з урахуванням рекомендацій провідних світових та європейських наукових товариств. Детально розглянуто питання фізикального, лабораторного та інструментального дослідження основних систем організму (серцево-судинної, дихальної, травної, опорно-рухової, сечовидільної, кровотвірної) та при алергійних захворюваннях.
Для лікарів-практиків терапевтичного профілю (лікарів загальної практики — сімейної медицини, терапевтів, кардіологів, пульмонологів, гастроентерологів, ревматологів, нефрологів, гематологів, алергологів), аспірантів, лікарів-інтернів, резидентів і студентів медичних закладів вищої освіти.

Background: Morbidity related to vascular access is the leading cause of hospitalization for chronic hemodialysis patients and is associated with high cost. Since data on vascular access complications are scarce, this study was designed to focus on vascular access complications in hemodialysis patients. Methods: 119 patients with End Stage Renal Disease (ESRD) on regular hemodialysis were recruited for the study, They were subjected to the following Laboratory blood tests: Kidney function tests, CBC, KT/V, serum albumin, fasting blood sugar, swab culture and sensitivity from the skin over the vascular access and blood culture and sensitivity from both central and peripheral samples, In addition, radiological Doppler ultrasound was done for all patients to evaluate the vas-cular access. Results: 27 out of 119 patients (22%) have positive blood culture, 64 (53.7%) patients have positive swab culture, 68 (57%) patients have stenosis, 25 patients (21%) have athermanous plaques and 44 (36.9%) patients have aneurysmal dilatation. There was a significant low Kt/V in patients with stenosis and aneurysmal dilatation (p < 0.001). Low Kt/V, low serum albumin level and low BMI were significant in patients with central blood infection (p < 0.008, <0.008 and <0.001 respectively). There was significant increase in the risk of infection in male patients, patients with low BMI, increased BUN and increased duration of HD session (p < 0.046, <0.008, <0.002 and <0.009 respectively). Stenosis was the most common risk factor for vascular failure as it occurred in (29%) of patients. Diabetes was the second common risk factor for vascular failure as it occurred in (17%) of patients. Conclusion: Stenosis and infection are the most common complications of the vascular access. DM is an important risk factor for the incidence of infection. Other risk factors for dialysis CRBSI include older age, low serum albumin, high BUN and decreasing the duration of dialysis.

Despite the high costs of treatment of people with kidney disease and associated comorbid conditions, the amount of reliable information available to guide the care of such patients is very limited. Some treatments have been assessed in randomized trials, but most such trials have been too small to detect treatment effects of a magnitude that would be realistic to achieve with a single intervention. Therefore, KDIGO convened an international, multidisciplinary controversies conference titled &quot; Challenges in the Conduct of Clinical Trials in Nephrology &quot; to identify the key barriers to conducting trials in patients with kidney disease. The conference began with plenary talks focusing on the key areas of discussion that included appropriate trial design (covering identification and evaluation of kidney and nonkidney disease outcomes) and sensible trial execution (with particular emphasis on streamlining both design and conduct). Break out group discussions followed in which ...

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