Geriatric nephrology and urology最新文献

This study investigated the effects of 16-weeks of endurance exercise training (EET) on ambulatory blood pressure in older adults. Twenty-one men and women, 68.5 +/- 4.7 (mean +/- SD) years of age were randomly assigned to an exercise group (EG, n = 11) or to a control group (CG, n = 10). Subjects were normotensive (mean resting BP 132.0 +/- 8.6/80.1 +/- 6.6 mm Hg), free from overt cardiovascular or renal diseases, and were taking no vasoactive or diuretic medications. Maximal oxygen uptake (VO2max), body composition, resting BP, and 24-hr ambulatory systolic (ASBP) and diastolic (ADBP) blood pressures were measured in all subjects before and after the study period. The EG completed 16 weeks (3, 1-hour bouts/wk) of EET, progressing in intensity from 50% to 85% of maximal workload. The CG did not exercise. In the EG, although body composition and resting BP did not change (p > 0.05), VO2max increased by 14% (p = 0.001), mean 24-hr ASBP decreased 7.9 mm Hg (p = 0.0001), and mean 24-hr ADBP decreased 3.6 mm Hg (p = 0.002). In the CG, there were no significant changes in these variables (p > 0.05). These data suggest that EET can improve both aerobic fitness and "real-life" blood pressures in healthy older adults and may help inhibit increases in blood pressure associated with normal aging.

This brief review of glomerular disease in the elderly contains several lessons for the Geriatric Nephrologist. Remember the atypical presentation of acute nephritis in older individuals. Remember the common causes of nephrotic syndrome in the elderly; namely, membranous glomerulonephritis, minimal change disease, proliferative glomerulonephritis and amyloidosis. Remember the special risks of cytotoxic drug therapy of glomerular disease. Remember the importance of pauci-immune crescentic glomerulonephritis and polyangiitis associated with antineutrophil cytoplasmic antibody in the aging population. Remember the value of and use of urinary erythrocyte dysmorphism in the differential diagnosis of hematuria in the elderly.

The evidence of the benefit of lowering cholesterol levels in seniors from epidemiologic studies and RCTs is conflicting. Epidemiologic studies suggest that elevated cholesterol levels in elderly people may be a marker of good health. In some cases, lowering cholesterol in seniors may even prove harmful. Conversely, RCTs of lipid-lowering therapy have shown clear benefits in reducing coronary events in younger and middle-aged adults with or without pre-existing CAD. Both the epidemiologic studies and the RCTs we evaluated have methodologic concerns that make generalization to all seniors difficult. One epidemiologic study, in fact, found that there may be a physiologic decline in cholesterol levels as people age into their 70s and beyond [16]. We still do not appear to have a clear insight into the precise role cholesterol plays in seniors, especially those over the age of 75. In the future, as more data becomes available from RCTs and meta-analyses evaluating seniors in the older age group [15], we hope to have a better understanding of how to treat hypercholesterolaemia in this population. Until further studies are published, treatment plans need to be individualized, and the risks and benefits of treatment on various outcomes must be weighed according to the best evidence we have available.

A sixty-year-old previously healthy male patient presented with anuric renal failure of sudden onset. He was detected to have Aspergillus fumigatus fungal balls in the renal pelvis, ureters and bladder which were removed and his renal function improved. He was treated with itraconazole and sent home. Three weeks later he again presented with anuria and renal failure. He had recurrence of the obstruction with the same fungus. The fungal ball was removed, a double 'J' stenting was performed and he was treated with amphotericin B and itraconazole. Hence we report a previously healthy patient with no evidence of immunosuppression presenting an obstructive anuric renal failure due to isolated renal aspergillosis.

Reports on the success of permanent vascular access in elderly HD patients vary considerably. We reviewed the records of 149 patients [62F and 87M] aged 20-89 years old (median 59) who were on hemodialysis for 6-242 (49 median) months, and had undergone 202 vascular access procedures (177 Cimmino-Brescia fistulae and 25 PTFE grafts). Patients were divided into two groups according to the age they started HD. Group A: 48 patients, over 60 years old (range 60-83; median 70) on HD for 43.5, (6-140) months. Group B: 101 patients, under 60 years old, range (15-59) median 46, on HD for 54 (6-242) months. There were no differences between the two groups in terms of gender, primary renal disease, (except polycystic kidney disease), Hct and EPO administration. The initial choice of vascular access, the complications and the technique survival were examined in both groups. Cimmino-Brescia fistulae were used as the first choice of vascular access in all patients except one in group B. PTFE-grafts were the second or third choice in 7/48 (group A) and 15/101 (group B) (p: NS). The only reason for technique failure was vascular thrombosis in both groups (11/48 group A and 31/101 group B p: NS). Other complications were: aneurysms (10/48 and 14/101, p: NS), infections (0/48 and 2/101 p: NS) and edema (0/48 and 6/101, p: NS). Five-year technique survival of the first AV fistula in the two groups was 35% and 45% respectively (log-rank test, p: NS). These findings suggest that: a) A.V. fistula is the first choice of vascular access in aged HD patients; b) There is no difference in vascular access complications across age groups; c) Survival of the first A.V. fistula is independent of age.

Bladder suspension for urinary incontinence secondary to bladder neck hypermobility is highly successful. Of those who fail, however, a subset will develop new onset or markedly worsened irritative voiding symptoms. A series of such patients were identified to study the associated urodynamic abnormalities of this symptom complex. The charts of female patients presenting for incontinence from 1992-94 were reviewed. Forty-six patients with a mean age of 59.4 (range 28-79) fulfilled the inclusion criteria of developing new onset or markedly worsened post-operative frequency, urgency and urge incontinence within two years of undergoing bladder suspension. All had been evaluated with thorough history, physical examination, and urodynamic testing. Seventeen patients were found to have recurrent hypermobility. Eighteen had a diagnosis of intrinsic sphincter deficiency (ISD), including six that also had another diagnosis. Four patients were diagnosed with detrusor overactivity and seven with other miscellaneous diagnoses. Patients presenting with this symptom complex should be evaluated so that treatment can be tailored appropriately.

A gradual increase in blood pressure (BP), often attaining hypertensive levels, is common during aging--"age-related hypertension." Therefore, means to prevent or ameliorate this elevated BP safely are important. Although oral B-nicotinamide adenine dinucleotide (NADH), a natural coenzyme, is used principally to treat various neurologic disorders, we wished to investigate whether this agent had the same potential to lower BP and benefit the cardiovascular system as does coenzyme Q10, a similar-type agent. As a first approximation, spontaneously hypertensive rats (SHR) were used to determine effects of oral NADH. In a blinded, placebo-controlled study, ten rats received placebo; and ten, NADH for ten weeks. Systolic BP was measured by tail plethysmography. Blood was collected terminally, and chemistries were performed by routine methodologies. Thiobarbituric acid reactive species (TBARS) (an estimate of lipid peroxidation/free radical formation) was measured in renal and hepatic tissues. The following was noted: water and food intake were comparable, and the steady weight gain of young SHR were similar in the placebo and NADH groups. Although systolic BP did not differ between the two groups over the first month, it decreased and stayed markedly lower for the remainder of study in SHR receiving oral NADH. At the end of 60 days, SBP in NADH-treated SHR was 184 mm Hg +/- 2.8 (SEM) compared to 201 mm Hg +/- 2.1 (SEM) in control SHR (p < 0.001). No significant differences were seen in blood levels of glucose, insulin, triglyceride, and HDL levels but NADH intake lowered total cholesterol (p < 0.002) and LDL (p < 0.02). Renal TBARS were also significantly lower in SHR receiving NADH (P < 0.001). Accordingly, supplementation with the natural coenzyme NADH theoretically could prove to be useful in preventing age-related increases in BP and, thus, various cardiovascular maladies.