Dialysis & Transplantation最新文献

Treatment of chronic kidney disease (CKD) and its complications remains largely unresolved. Currently applied measures include blood pressure control and the use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers (ACEIs/ARBs), which can slow down progression of CKD, but are unable to halt or reverse it, nor can they oppose uremic toxicity. There is hence an unmet need to find additional therapies for CKD and progressive uremia.

An additional treatment measure to slow the progression of CKD and mitigate azotemia is dietary protein restriction. The putative mechanisms of action responsible for its therapeutic effects include beneficial hemodynamic effects (lowering intraglomerular pressure similar to ACEIs/ARBs)1 and the limitation of absorbable protein breakdown products, which could lead to the accumulation of uremic waste and consequent various deleterious effects. The down side of protein restriction is of course that it could also involve limiting the intake of useful or even essential nutrients and thus lead to protein-energy wasting, which in itself is associated with poor outcomes.2 Hence the proper application of protein restriction needs concerted efforts both from a well-trained team of professionals and from highly dedicated patients.

An alternative dietary approach is to selectively prevent the gastrointestinal absorption of only certain components that are responsible for dietary protein-related harmful effects in patients with CKD. Several such components have been suggested, with various mechanisms of action responsible for their deleterious effect. Phosphorus has numerous adverse effects including direct vascular toxicity and an association with increased mortality and progression of CKD. Disappointingly, even though phosphorus is a plausible uremic toxin and treatment regimens have been established to treat its elevated levels, the mortality and morbidity benefits of lowering phosphorus have not yet been tested in clinical trials.

Potassium is also introduced through intestinal absorption, and the abnormally high or low levels that are common in patients with CKD have been linked to increased mortality. Similar to phosphorus, there are also no clinical trials proving the benefits of strategies to normalize serum potassium levels. Other potential uremic toxins linked directly or indirectly to intestinal absorption are advanced glycation end products, indoles and phenols, which have been linked to deleterious processes such as increased oxidative stress,3 inflammation,4 vascular5 and renal6 toxicity, and increased mortality.5

Of the various uremic toxins resulting from intestinal absorption and/or abnormal metabolism and excretion, indoxyl sulfate (IS) is one of the most frequently studied; the consequences of its elevated levels have been examined in a variety of in vitro, in vivo animal,

Christian Longo murdered his wife, MaryJane, and three children 10 years ago in Waldport, Oregon. The police finally caught up with him in Cancun, Mexico, where Longo was living undercover with a young woman who thought he was a journalist named Michael Finkel, on assignment to write about Mayan ruins.1, 2 Even after being convicted and sentenced to death in 2003, Longo continued to maintain his innocence. However, he's since dropped that charade and has owned up to his crimes. Since 2009, Christian Longo has a new mission: He wants to be an organ donor. As he wrote in a New York Times op-ed piece in March, “There is no way to atone for my crimes, but I believe that a profound benefit to society can come from my circumstances. I have asked to end my remaining appeals, and then donate my organs after my execution to those who need them. But my request has been rejected by the prison authorities.”3

At first glance, the question of whether or not prisoners should be permitted to become organ donors appears straightforward. If the prisoner is healthy, and it can be ascertained that no coercion was involved, why not allow him to atone for his misdeeds by prolonging someone else's life? No law specifically prohibits prisoners from becoming organ donors but, as Longo discovered, no state in the union currently allows it among deathrow inmates. It turns out that the issue of prisoner organ donation, particularly when that prisoner faces a death sentence, is fraught with troubling ethical and logistical questions for which there are no easy answers.

Some of the controversy surrounding the issue of inmate organ donors concerns the nature of their crimes and their sentences. For example, people not on death row can ask that their organs be harvested should they die while in prison. However, it is illegal to offer a potential donor any kind of valuable incentive, monetary or otherwise, in exchange for their organ. That has not stopped people from suggesting that sentences be reduced somewhat for prisoners to become live kidney donors, and there are indeed cases on record of people being released from jail early so that they can give an organ to a family member. Perhaps the most recent, and prominent, was the decision by Governor Haley Barbour of Mississippi to release two sisters, Gladys and Jaime Scott, who were serving life sentences for a 1994 robbery that netted them $11.00, with the understanding that Gladys would give a kidney to Jaime, whose dialysiswas costing the state $200,000 a year (it turns out that neither woman was healthy enough to undergo the surgery).4

Governor Barbour's actions were controversial: Some observers praised him for being compassionate, while others thought he was simply trying to save the state some money, perhaps while garnering some good publicity. Whatever the governor's motivation might have been, his decision was illegal. “In this case, the right str

Prebiotics, probiotics, and synbiotics are now used more commonly in medicine, and they are generally considered to be dietary supplements and not drugs. They are not meant to be used for the treatment of disease, although recent interest has grown in the area of disease treatment. Not all of the research is in support of the benefit provided by these supplements, and it is important to be aware of the associated risks and benefi ts. In nephrology, these supplements show potential benefi ts in treating kidney stones, uremia, and urinary tract infections. This paper reviews the current literature with an emphasis on the risks and benefi ts of these supplements in the treatment of these renal disorders.

Veno-occlusive disease (VOD) of the liver is an extremely rare complication of azathioprine (AZT) use in patients with kidney transplants (KTs). Although VOD is frequently seen in bone marrow transplant patients, so far only 24 cases have been reported in KT patients. Our case adds to the available data on the disease, and we also reviewed the published data on this entity to establish the characteristics of VOD in the setting of KT. Our case highlights the importance of this potentially life-threatening complication and provides an overview of VOD in KT patients.

Even though many positive changes were ushered in by the KDOQI guidelines and the Fistula First Breakthrough Initiative, tunneled hemodialysis catheters remain an essential piece of the dialysis access puzzle. Their use is, however, attended by a multitude of complications and morbidity of which the general nephrologist must be aware. The purpose of this article is to review for the general nephrologist the infectious and non-infectious problems that often complicate the use of hemodialysis catheters.

The gram-negative marine bacterium Shewanella putrefaciens is an uncommon human pathogen. Five cases of S. putrefacians peritonitis during peritoneal dialysis (one acute and four chronic) have been reported previously. We report a case of S. putrefaciens peritonitis in a patient undergoing continuous cycler peritoneal dialysis. Our case is the first to be reported in a patient from the United States, with recurrence after initial treatment, and with acquired antibiotic resistance. Dial. Transplant.