ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00911.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

A 52‐year‐old white male presented for evaluation of moderate azotemia (blood urea nitrogen [BUN] 52 mg/dl and creatinine 5.4 mg/dl). Renal history was positive for hypertension (156/100), nocturia, and polyuria. There was a 10‐year history of an idiopathic seizure disorder. Medications were phenytoin 100 po tid and diltiazem 240 mg sustained release bid. An S4 and 1+peripheral edema were the only positive physical findings. Postural blood pressure changes were absent.Laboratory findings included a urinalysis with2+protein, finely granular casts, and 5–10 WBCs/ HPF. Twenty‐four hour urine protein was 1.1 g/24 h. Renal ultrasound: 9.2 cm left, 8.9 cm right kidney, and left renal biopsy demonstrated chronic interstitial nephritis. Other potential causes for interstitial injury were ruled out and phenytoin was discontinued. Prevention of seizures was obtained with phenobarbital.A few months later, the patient complained of excruciating nocturnal cramps in both gastrocnemius, occurring four to five times per night and necessitating hot baths and passive stretching of the calf muscles for temporary relief. Muscle exam was normal; neurologic exam revealed symmetric sensory and motor neuropathy consistent with renal failure. Thyroid function, magnesium, sodium, and calcium concentrations were normal. The patient was treated with vitamin E 400 IU/day with a decreased frequency and severity of cramps. Azotemia progressed to dialysis dependence (continuous ambulatory peritoneal dialysis [CAPD]). His cramp frequency and intensity on CAPD has waxed and waned. His dry weight has been frequently reassessed and increased as necessary. He has continued vitamin E with periodic use of verapamil or quinine, in addition, for cra

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00912.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

A29‐year‐old male frequently misses dialysis treatments. He abuses fluids and gains 5–7 kg between treatments. He demonstrates volume‐sensitive hypertension with predialysis seated blood pressures about 180/105 mmHg, occasional intradialytic hypotension, and postdialysis blood pressures of 160/90mmHg. His 3‐hr treatments are often complicated by leg cramps during the last hour. He periodically demands to quit dialysis early because of cramps, which may persist intermittently for hours after

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00913.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

A 72‐year‐old white female with end‐stage renal disease (ESRD) secondary to chronic glomerulonephritis has been on chronic hemodialysis for the past one and a half years. She has a history of congestive heart failure which has not been symptomatic since she began dialysis. She weighs 47 kg (103.4 lbs) and receives 3 hr of “conventional” hemodialysis with a blood flow rate of 350 ml/min which is well tolerated. Treatments are provided using a left upper arm polytetraflourethylene (PTFE) graft. Monthly percentage reduction in urea (PRU) values have been approximately 65%. However, her most recent PRU was 57% (predialysis blood urea nitrogen (BUN) 82 mg/dl, postdialysis BUN 35 mg/dl). Since her treatment parameters had not been changed, recirculation studies were obtained. The BUN values were: peripheral vein (P)—58 mg/dl, arterial line (A)—48 mg/dl, venous line (V)—23 mg/dl. Calculated recirculation was 29% ([P ‐ A]/[P ‐ V], 158 ‐ 48]/[58 ‐ 23]). The high level of recirculation prompted radiologic evaluation of the access. A fistulogram, including views of arterial inflow and central veins, showed no stenotic lesions. Needle placement was reviewed and found to be satisfactory. Repeat recirculation studies

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00914.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

A 43‐year‐old white, single man, who lives with his parents and has been diabetic since the age of 14, has been on center hemodialysis since January, 1990. He worked as an electrician, but because of medical complications connected with his diabetes, he has been permanently disabled since 1986. He failed self‐care dialysis due to major errors in judgment which could potentially have been life‐threatening to him. On center dialysis, he skips treatments on occasion and has interdialytic weight gains averaging 4–8 kg. About once a week he cuts treatment short because of leg cramping and/or arguments with nurses. He demands Xanax while being treated and, if the nurses are reluctant to give him this medication, he cuts the treatment short. On two occasions, he has received emergency dialysis because he skipped three consecutive dialyses.In the past three months the situation has deteriorated further. His weight gains have increased and he cuts dialysis short more frequently. For the past two months, when he comes to dialysis, he takes out a knife and places it on his bedside stand. He has never threatened anyone, but the nurses feel a bit compromised by it.His family has kept themselves very separate from the treatment. He speaks highly of his parents, who, although elderly, are apparently in good health. They are rarely in contact with the dialysis staff. When the social worker has attempted to contact them, they have communicated a lack of interest in being involved with the “problems of the dialysis unit.” Needless to say, the staff finds the patient's behavior and the attitude of his parents a major problem. He is very impulse‐ridden, has little ability to tolerate frustration, and, worst of all, denies any responsibility for his actions or inactions. He complains of an unsatisfactory dialysis schedule and of the nurses being angry with him. He denies suicidal thoughts, but admits to being depressed and f

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00915.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

R. T. was a 52‐year‐old divorced Caucasian male with end‐stage renal disease (ESRD) due to polycystic kidney disease. He was on thrice weekly hemodialysis for over 15 years until he succumbed to metastatic pulmonary cancer. His average dry weight was 285 pounds. His dialysis course was complicated by late onset diabetes mellitus, severe peripheral neuropathy, and renal bone disease. He had a history of noncompliance, even prior to initiating dialysis, with poor adherence to his prescribed antihypertensive regimen in spite of severe hypertension.During his years of dialysis, he exhibited both episodic and chronic noncompliance to much of his medical regimen, including: excess interdialytic weight gains of 10–25 pounds. This was a regular chronic noncompliance problem. He constantly drank large amounts of carbonated beverages because, he said, he was thirsty and craved these drinks; frequent high serum potassium predialysis because he refused to follow appropriate dietary regimens; irregular compliance with taking his phosphate‐binders, complaining of severe constipation and often not taking other prescribed medications; occasionally skipping dialysis, offering that he forgot what time it was or that he overslept; factitious dermatitis. Although regularly advised to desist, he picked and scratched on small skin lesions, often producing larger ulcers and abrasions. In fact, this likely led to his early demise. One lesion on his fistula arm was initially thought to be merely a factitious ulcer. However, it failed to heal and enlarged. He was advised to see a surgeon, but repeatedly canceled his appointments. Finally, when biopsied. it was squamous‐cell carcinoma. Despite wide excision and radiation treatments, the lesion metastasized to his lungs and he succumbed fifteen months later.The staff and his physician held repeated conferences in efforts to improve this patient's compliance. Interventions included: admonishment about the risks that could befall him; praise when he did well; frequent counseling by his physician and the staff members he liked; minor rewards such as dialysis time changes or shortening dialysis when Compliance improved; denying his manipulatory behavior and eliciting family support (which was not strong) when appropriate. At times, these interventions were helpful, and he displayed better compliance for short periods. It was noted that he was often depressed and exhibited personality problems. He complained that certain members of the staff didn't like him, and the staff felt antagonized by his noncompliant behavior. His greatest rapport was with his personal nephrologist to whom he responded from time to time with episodic

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00916.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

This 18‐year‐old male first presented to the University Hospital with end‐stage renal disease secondary to chronic glomerulonephritis. There was no pertinent past medical history. The patient had a 7th grade education and had never been employed. He received income in the form of Social Security Disability benefits and as such was qualified for both Medicare and Medicaid. He had been taken into custody at least 40 times in his life for shoplifting, petty larceny, drug possession, and traffic violations. He had been incarcerated several times in juvenile detention facilities. Shortly after the initiation of dialysis, it became apparent that this individual was not willing to accept the minimal constraints placed upon him by his kidney condition and the hemodialysis regimen. It was elected to offer him a kidney transplant which was initially quite successful. The transplant was rejected in six months because he neglected to take the medications that were placed in his possession. The patient returned to hemodialysis and a second transplant was undertaken with a similar fate. After returning to hemodialysis from the second kidney transplant, the patient continued to ignore his dietary restrictions. He consumed large amounts of fluid necessitating frequent unscheduled hemodialysis for pulmonary edema. Occasionally, emergency dialysis had to be performed on this patient two or more times over a single weekend. The patient was then placed on peritoneal dialysis but this was discontinued after only three months due to repeated episodes of peritonitis and overt uremia requiring several hospitalizations to treat peritonitis and to provide adequate dialysis. Once again, the patient was returned to hemodialysis. He frequently turned out to be the principal victim of his failure to take medications and follow the prescribed dietary regimen. In addition to his self‐inflicted injury, his behavior often victimized the staff and the other patients on dialysis. He was frequently late for his dialysis appointments and would occasionally miss dialysis completely. This resulted in major disruptions of the dialysis schedule. His behavior not only interrupted his care plan, but the care plans of other patients as well. He would appear without an appointment in overt pulmonary edema with loud and obnoxious behavior that was disruptive to staff and patients. The patient stated that if he came to the hospital at anytime in critical condition the facility would be required to provide him emergency treatment. He frequently bragged to other patients that he could force the staff to treat him whenever he wanted to.On several occasions, the patient threatened to kill the physician in charge. He also threatened to shoot the hospital administrator. These threats were unheeded until a family member informed the physician that the patient did own a pistol, and he did practice shooting. He kicked a surgeon during local access surgery so all surgery had to be performed under general anesthesia. He also pinched a nurse on the breast. He threatened many people with physical violence, although none was ever administered.Seven years after he began dialysis at the Medical Center, he disappeared without notice. Several months later, it was discovered that he was receiving dialysis treatment approximately 360 miles away. According to the new physician who was treating him, the patient continued to behave obnoxiously causing this facility to refuse to treat him. The Chancery Court in that county issued an order that compelled the physician to continue to treat the patient, but the patient had to submit to being bound and gagged during treatment. The patient became heavily involved in drug use and developed pancreatitis which required multiple surgeries. On several occasions, the patient reappeared at the University Hospital unannounced. Since he was established on dialysis at another facility, he was refused treatment. He returned to his treating hospital 360 males away by ambulance. Responsibility for his return trip fell upon the staff of the kidney unit.Eighteen months afier leaving the University, he returned to live with his family and requested a transfer for dialysis treatment to the Medical Center. He was refused. Under Mississippi law, the Medicaid Commission was required to furnish transportation to a facility 360 miles away thrice weekly and pay the cost of this transportation. The patient similarly was refused treatment by three other dialysis facilities in the area close to the University Hospital. A patient advocacy agency then filed suit on behalf of the patient against the physician at the Medical Center, a private dialysis clinic, and the University Hospital. The Court heard evidence on a motion for a preliminary injunction, and the Court refused to issue an order requiring the defendants to treat the patient. The Court did order ihe Division of Medicaid to continue to furnish transportation for the patient to the remote dialysis facility under a temporary restraining order. This decision was appealed and approximately three months later the Fifth Circuit Court in New Orleans issued a temporary restraining order requiring the defendants to treat the patient in Jackson until the issues in the case could be tried on the merits. The patient then was treated regularly at the University Hospital under an order from the Fifth Circuit Court of

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00917.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

Mr. X is a 49‐year‐old black male with end‐stage renal disease (ESRD) secondary to long‐standing insulin‐dependent diabetes and hypertension. He currently is on hemodialysis three times per week via a left forearm prosthetic A‐V graft, and is on the renal transplant waiting list. He is on insulin as well as the standard regimen of vitamins, antacids, erythrogenic agents and antihypertensives.Mr. X has noted a slow progressive loss in his ability to attain an erection over the past four to five years and, even after attaining an erection, he notes that he can only maintain it for a few moments. On occasion his erection is firm enough for vaginal intercourse, but he loses it soon after penetration. In most instances, his erection is not firm enough for vaginal penetration, and he achieves vaginal penetration by “stuffing” the penis into the vagina. At peak, he was having intercourse three times per week, but now it is only once a month. He masturbates only on occasion. He is able to ejaculate, and reaches orgasm with seminal expulsion, but the ejaculate volume is markedly diminished compared to that seen in his youth. Occasionally, he gets a morning erection, which is “five” on a scale of one to 10, with 10 the maximal erection he achieved during his peak years. With masturbation or with sexual stimulation he describes his erection as a “four of 10.” He denies trauma to the erect or flaccid penis. He claims to have had a gradual change in his penile sensitivity over the past three years.He denies radiation to his pelvic area, recreational drug use, and does not use alcohol. He has no drug allergies. His surgical history is noncontributory. He denies neurologic disease, hypercholesterolemia, heart disehse, and claudication, and had smoked 2 packs of cigarettes per day for 20 years, quitting seven years ago.Mr. X is currently separated from his wife; however, the same erectile dysfunction occurs, even with his new sexual partner.Physical examination was unremarkable. The penis was circumcised with no lesions or plaques. The testes were descended and normal. There were no hernias. The bulbocavernosus reflex was absent. The penile‐brachial index was 0.40 on the left and 0.52 on the right. Penile biothesiometry was abnormal on the penile shaft as well as the glans. The hormonal profile, including prolactin and testosterone were normal. The patient underwent a nocturnal penile tumescence (NPT) evaluation which confirmed the organicity of his disease. It demonstrated three short‐lived REM‐associated erections of poor quality.He opted for penile seif‐injection therapy, which he uses only on nondialysis days, combined with prophylactic oral antibiotics. This therapy, along with psychologic counseling has worked well, with return of a full rigid erection of 1/2 hr in duration. He is now quite satisfied, and has vaginal intercourse with his

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00918.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

In January of 1992, a 61‐year‐old white male chronic hemodialysis patient complained of impotence. He described a decrease in the rigidity and the length of time he could maintain an erection, as well as a decrease in the frequency of erections. He had been on maintenance hemodialysis since April, 1989 when he presented with end‐stage renal disease (ESRD) of unknown etiology. He had a remote history of renal calculi and pyelonephritis. Prior to starting dialysis, he had been treated for hypertension with clonidine and later enalapril. His noninsulin‐dependent diabetes mellitus was diet controlled for four years prior to his being seen at this institution. He had smoked less than five pack years in the remote past.Since starting dialysis he had required no medication for diabetes or hypertension. Subcutaneously administered erythropoietin was used to maintain his hematocrit at 33%‐35%. Other routine medications included vitamins and phosphate binders. He occasionally used ibuprofen for capsulitis of the right shoulder, concurrently with ranitidine for ulcer prophylaxis. He declined renal transplantation. His only problem on dialysis had been interdialytic weight gains of 3–6 kg. Benign gynecomastia noted after the initiation of dialysis therapy resolved spontaneously, prior to the development of impotence. His dialysis dosage was considered reasonable, with multiple evaluations yielding an average deliveredKt/Vof 1.4.Psychological evaluation found him to be well adjusted to dialysis and to have a stable family life. He had no prior history of sexual problems and the onset of his problem was described as gradual. His sexual dysfunction began more than two years after starting dialysis and affected erectile function rather than libido.Physical examination revealed a robust appearing, normotensive 61‐year‐old man weighing 102 kg, with a height of 1.8 meters. Cardiopulmonary examination was within normal limits. Abdominal examination was free of bruits and hepatosplenomegaly. Pulses were full and equal in the extremities. Rectal examination was unremarkable, with a normal prostate and rectal sphincter tone. Testes were normal in size and free of masses. Phallus was normal in appearance and no plaques of Peyronie's disease were detected. Gait was normal and there was no evidence of peripheral neuropathy.After discussion of the various treatment options, empiric therapy was started at the patient's request with testosterone enanthate 200 mg IM every two weeks. Although the patient reported a slight improvement shortly after the dose was given and requested a dosage increase, the overall response to six months of therapy was unsatisfactory. An endocrinologic evaluation was performed to determine the adequacy of the prescribed dose. This revealed a testosterone level of 351 ng/dl (normal 300–890 ng/dl). Follicle‐stimulating hormone (FSH) and luteinizing hormone (LH) levels were both found to be appropriately suppressed at<0.3 mIU/ml (normal LH 0.9–10.6 mIU/ml and FSH 2.4–19.9 mIU/ ml). A serum prolactin level drawn simultaneously was mildly elevated at 22.9 ng/ml (normal 0.1–18.1 ng/ml). Thyroid function tests were normal. Intact parathyroid hormone levels during this time period ranged from 13–66 pcg/ml (normal 10–75 pcg/ml) and aluminum levels were 10 μg/ml (normal 1–39 μg/ml). No increase in dose of testosterone was given. Of note is that elevations of serum triglycerides occurring during the testosterone therapy required the addition of gemfibrozil for treatment.Urologic consultation was obtained and the patient initially considered the purchase of a vacuum‐constrictor device. However, this proved to be too costly and he therefore agreed to learn to perform self‐injection of intracavernosal papaverine, and to b

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00919.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

A 56‐year‐old white male had longstanding insulin‐requiring diabetes mellitus and diffuse vascular disease. At age 50, he underwent coronary artery bypass grafting and placement of a permanent cardiac pacemaker. Four years later, he required bilateral above‐knee amputations for severe peripheral arterial disease. Over the next two years, he was hospitalized fifteen times for angina pectoris and congestive heart failure (CHF).In September 1990, six years following his cardiac surgery, Swan‐Ganz catheter data confirmed low cardiac performance. He required dopamine, dobutamine, angiotensin‐converting enzyme inhibitors, and high dose parenteral diuretics. Blood urea nitrogen (BUN) was 30 mg/dl, serum creatinine was 1.8 mg/dl, serum albumin was 3.9 g/dl and total serum protein was 7.1 g/dl. Fractional urinary sodium excretion was 0.36. Endogenous creatinine clearance was 20 ml/min. Urine protein excretion was 640 mg/day. Anasarca was attributed to CHF, and renal insufficiency was felt to be due to a combination of nephrosclerosis and low renal perfusion. Conservative management proved futile with development of worsening edema, progressive azotemia, and hyponatremia. At the time of nephrologic consultation, BUN was 159 mg/dl, serum creatinine was 4.5 mg/dl and serum sodium was 114 mEq/l. Pulmonary capillary wedge pressure was 22 mmHg and chest X ray confirmed the presence of large bilateral pleural effusions. Blood pressure had remained surprisingly normal at 126/70 mmHg.A Tenckhoff peritoneal dialysis catheter was placed and peritoneal dialysis begun using 1 l volume exchanges. Over the next several days, dialysis fluid volume was increased to 2 l, with dwell time and dextrose concentration being adjusted to allow for gradual fluid loss. Dialysis was continued on a daily basis for two weeks with a 40 pound weight loss and total resolution of CHF. He was discharged home, but required intermittent peritoneal dialysis over the next six weeks.He was trained to perform peritoneal dialysis using the technique of continuous ambulatory peritoneal dialysis (CAPD). His regimen consisted of 4 two‐liter exchanges daily with variable use of 1.5% and 4.25% dextrose‐containing solutions and intraperitoneal insulin. Over the ensuing months he required only 24 days of hospitalization. He regained use of his lower extremity prostheses and was able to drive his truck. He had no episodes of peritonitis, but required short‐term oral antibiotics for peritoneal catheter exit‐site infection. He expired of acute myocardial infarction afte

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00920.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY