ISSN:1062-4821    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewThis review examines the results of the ADEMEX (Adequacy of Peritoneal Dialysis in Mexico) study in the context of other recent advances in peritoneal dialysis, and assesses the implication of this new knowledge for the optimal peritoneal dialysis prescription.Recent findingsThe prospective randomized controlled ADEMEX study demonstrated no survival advantage of an increased dose of peritoneal small molecule clearance delivered by chronic ambulatory peritoneal dialysis. Coincident with this finding, there has been increasing awareness that many peritoneal dialysis patients are volume expanded, and that there are adverse cardiovascular consequences to this chronic overhydration. As a result there has been a shift away from interest in peritoneal small solute clearance with renewed interest in peritoneal removal of salt and water. There is also increasing evidence of the importance of residual renal function in maintaining euvolemia and as a prognostic indicator for survival.SummaryThe ADEMEX study and subsequent investigations have changed the way we perceive the optimal peritoneal dialysis prescription. This has resulted in de-emphasis of peritoneal small molecule clearance and increased emphasis on clinical assessment of dialysis adequacy, preservation of residual renal function, and optimization of salt and water removal.

ISSN:1062-4821    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewThe HEMO study is a randomized clinical trial using a 2×2 factorial design to assign patients to a standard or high dose of dialysis and to a low flux or a high flux dialyzer. This study is the largest, most comprehensive, randomized clinical trial ever performed in the maintenance hemodialysis population. This review analyzes the results of the study and discusses how the HEMO study results affect efforts to lower morbidity and mortality in the hemodialysis population.Recent findingsThe primary outcome of the HEMO study was death from any cause. This outcome was not significantly influenced by treatment assignment for the dose of dialysis or for the flux of the dialysis membranes used. The main secondary outcomes also did not differ significantly in either the dose groups or the flux groups.SummaryThe results of the HEMO study support current clinical practice guidelines for the delivery of thrice-weekly dialysis, but the results do not support conventional attempts to lower the high morbidity and mortality in hemodialysis patients. Current efforts are being focused on increasing dialysis time and/or frequency, improving phosphate control, and lowering traditional and nontraditional risk factors for adverse cardiovascular events in this patient population.

ISSN:1062-4821    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewOxidative stress has been described as ‘a disturbance in the prooxidant-antioxidant balance in favor of the former, leading to potential damage. In uremic patients, an increase in oxidative stress may occur because of the loss of residual renal function, and may be exacerbated by dialysis. This review will focus on the emerging biochemical evidence of an increase in oxidative stress in uremic patients, the relationship with renal replacement therapy, and the potential linkages to acute-phase inflammation, malnutrition, and adverse cardiovascular outcomes in uremic patients.Recent findingsMany studies from multiple research laboratories around the world have recently utilized in-vivo biomarkers to describe increased oxidative stress in uremic patients. An emerging literature suggests that there are links between an increase in oxidative stress, endothelial dysfunction, an increase in acute-phase inflammation, and an accelerated risk of cardiovascular complications in dialysis patients. Additional uremia-associated metabolic abnormalities, including hyperhomocysteinemia, intravenous iron exposure, and biocompatibility changes related to dialysis, may contribute to an increase in oxidative stress. Finally, two well-conducted pilot clinical randomized trials have suggested that antioxidant therapy may have efficacy in reducing cardiovascular events in uremic patients.SummaryThe implications of the findings of a generalized increase in oxidative stress associated with uremia have led to the suggestion that antioxidative therapy may be efficacious in reducing cardiovascular complications. Pilot studies have suggested potential efficacy for this approach. However, further large-scale randomized clinical trials will be required to establish a compelling, evidence-based approach to the use of antioxidants in patients with uremia.

ISSN:1062-4821    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewViral nephropathies, particularly those caused by polyomaviruses of the BK-virus strain, are serious complications following renal transplantation. The review will highlight the morphological, pathophysiological and clinical aspects of BK-virus nephropathy. New patient management strategies are discussed.Recent findingsImmunosuppression with tacrolimus and mycophenolate-mofetil promotes the activation of latent BK-virus in the urinary tract and increases the odds ratio for developing BK-virus nephropathy significantly. A productive infection with BK-viruses shows viral replication in tubular epithelial cells and acute tubular injury. BK-virus nephropathy can be further complicated by concurrent acute rejection episodes contributing to graft demise. Risk assessment after transplantation and patient management during ongoing viral nephropathy have undergone revision by the introduction of real time quantitative polymerase chain reaction techniques measuring BK-virus genome load fluctuations in the serum. Treatment strategies for BK-virus nephropathy include not only low-dose immunosuppression but also drugs with antiviral effects: cidofovir and leflunomide. Transient anti-rejection therapy, including anti-lymphocytic preparations, is a therapeutic option in cases of BK-virus nephropathy and concurrent acute rejection. Recent advances in patient management strategies have resulted in markedly improved graft survival. In cases of graft loss due to BK-virus nephropathy, re-transplantation should be considered.SummaryBK-virus nephropathy is a significant complication following renal transplantation. Recent advances have improved our understanding of the morphological changes, potential risk factors and patient management strategies would be optimized. The availability of quantitative viral load measurements now offers the opportunity for a more accurate and timely clinical intervention.

ISSN:1062-4821    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewThe immunosuppressants are potent and toxic drugs with narrow therapeutic ranges. The pharmacokinetic variability of these drugs has made establishing appropriate dosing difficult. Currently, therapeutic drug monitoring is an important adjunct to achieving the precarious balance between efficacy and toxicity. However, pharmacogenomic analysis has the potential to improve dosing strategies. Several of the drugs in this category are metabolized through complex pathways, which have the potential to be affected by genetic traits. The current literature has addressed several genes and polymorphisms in relation to these drugs.Recent findingsPolymorphisms related to the coding of P-glycoprotein (coded by theMDR-1gene) and cytochrome P450 3A enzymes have been the main focus of research. These gene products are involved in regulating the absorption and metabolism of the principal immunosuppessants. Two polymorphisms (C3435T and G2677[A/T]) of theMDR-1gene have been shown to influence the bioavailability and toxicity of tacrolimus and cyclosporin. Phase I metabolism of these drugs has been shown to be affected by two polymorphisms (CYP3A5*1 and CYP3AP1*1), related to cytochrome P450 3A5 expression, rather than cytochrome P450 3A4.SummaryThe current literature has shown disparity as to which are the most important polymorphisms affecting the metabolism of immunosuppressants. Although pharmacogenomics has the potential to allow improvements in devising optimal dosing regimes, it has not yet offered any definitive solutions to the problems of dosing, because the process of elucidating the complex influence of genetics on drug metabolism is only starting to be unravelled.

ISSN:1062-4821    

出版商:OVID    

年代:2003

数据来源: OVID

ISSN:1062-4821    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewThe presence of a wide variety of autoantibodies is a characteristic finding in systemic lupus erythematosus. Autoantibodies against nuclear proteins, such as anti-nuclear and anti-double-stranded DNA antibodies, are used as diagnostic markers in systemic lupus erythematosus. Renal involvement is frequently found in systemic lupus erythematosus and is an important risk factor for death. Therefore, markers for the diagnosis and follow-up of nephritis are very important. Anti-C1q autoantibodies are strongly associated with renal involvement in systemic lupus erythematosus. This study will review recent findings on the pathogenic role and clinical importance of anti-C1q antibodies in lupus nephritis.Recent findingsRecent clinical studies have clearly emphasized the diagnostic relevance of anti-C1q autoantibody levels in patients with lupus nephritis. With a possible negative predictive value of 100%, anti-C1q autoantibodies are the only exclusive antibodies associated with the involvement of a single organ in systemic lupus erythematosus. Next to the clinical findings, the pathogenic significance of anti-C1q antibodies has been shown in an animal model. The deposition of autologous C1q in healthy glomeruli of mice after the infusion of anti-C1q antibodies induces moderate tissue damage.SummaryThe latest insight into the pathogenesis of anti-C1q autoantibodies in the development of lupus nephritis and the recently demonstrated clinical importance of anti-C1q autoantibodies for the diagnosis of lupus nephritis support the value of further investigations. New diagnostic methods for the detection of anti-C1q and an accurate follow-up of antibody levels might be of use in clinical practice.

ISSN:1062-4821    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewThe examination of urine sediment is a diagnostic test which is frequently neglected by nephrologists. With this review the authors wanted to demonstrate that it can provide useful and relevant information in a wide spectrum of clinical situations.Recent findingsThe authors reviewed the main contributions dealing with urine sediment examination, published in international journals in the period from January 2002 to April 2003. After a section on methodological aspects, they described the importance of urine sediment examination in various diseases of the urinary tract. These included bladder B-lymphoma, systemic histoplasmosis, urate nephropathy, Fabry disease, myeloma cast nephropathy, giant cell arteritis, and lupus nephritis. The significance of ‘decoy cells’ in the urine as a marker of polyomavirus BK reactivation was also discussed, both in renal transplantation and other conditions such as solitary pancreas transplantation, chronic lymphatic leukaemia, and HIV infection. In the section devoted to urine sediment changes caused by drugs the authors dealt with leukocyturia induced by indinavir, and crystalluria, which can follow amoxycillin and acyclovir administration. Finally, they reported on the utility and limits of flow cytometry for the automated analysis of urine sediments.SummaryThe review of the recent literature on urine sediment examination shows that this test has important clinical implications in a large spectrum of diseases. Therefore, it should be more widely used by nephrologists.

ISSN:1062-4821    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Purpose of reviewOnline monitoring of haemodialysis provides more detailed and more immediate measurement of parameters currently assessed during haemodialysis. It can also assess novel variables that are not routinely measured and could intensively monitor the haemodynamic response to dialysis. In an era of expanding numbers of increasingly dependent patients on dialysis, the ability to provide intensive and extensive monitoring of haemodialysis is a boon. The technology available to do this is rapidly becoming more sophisticated, more widely available and more diverse than ever before.Recent findingsAdequacy of urea removal is of crucial importance to mortality on haemodialysis, and online monitoring of urea removal is now achievable using a number of different methods. Some of these methods also measure sodium flux, allowing precise monitoring of sodium balance. Haemodynamic disturbance can be assessed using relative blood volume monitoring equipment, or more directly with non-invasive pulse-wave analysis giving a continuous blood pressure reading. The attributes of each of the separate technologies involved are examined.SummaryOnline monitoring of a variety of pertinent parameters during haemodialysis provides an array of tools that are steadily being incorporated into routine clinical practice. Research is also benefiting from novel insights into the process of haemodialysis provided by this technology.

ISSN:1062-4821    

出版商:OVID    

年代:2003

数据来源: OVID