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A prospective search for episodes of silent myocardial ischaemia (SMI) was carried out during sessions of haemodialysis in 62 patients with chronic renal failure and was positive in 37.1% of the cases. The occurrence of SMI is correlated with the number of cardiovascular risk factors (p = 0.008) and particularly with diabetes (p = 0.012), smoking (p = 0.007) and age (p = 0.02), as well as with the type of nephropathy that had caused the renal failure (p = 0.02). During a 6-month follow-up two patients died; both had silent myocardial ischaemia on Holter recordings. In these anaemic patients, haemodialysis might sensitize the detection of ischaemia by the concomitant occurrence of hypotensive, hypovolaemic or hypoxic episodes, thus playing a aggravating role. The existence of such episodes characterizes a subgroup of patients at high cardiovascular risk for whom the prognosis and the best therapeutic approach remain to be determined.
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PMID:[Silent myocardial ischemia during hemodialysis in patients with chronic renal insufficiency]. 185 93

If ACE-inhibitors are considered for therapy in patients with heart failure, the actual renal function has to be taken into account. In patients with reduced intravascular volume, e.g. during therapy with diuretics, the renin-angiotensin system is activated. In this situation, the renin-angiotensin-system contributes to the maintenance of arterial blood pressure and glomerular filtration rate by angiotensin II mediated vasoconstriction in vas efferens and systemic circulation. A sudden complete inhibition of the renin-angiotensin system therefore may cause a pronounced decrease in blood pressure and a reduction in glomerular filtration rate (impaired renal excretory function). In patients with heart failure concomitant chronic renal failure, the use of ACE-inhibitors is without major risk; however, the clinical efficacy may be limited. This does not apply to patients with diabetes, where the risk for impairment of renal function is increased. The potential advantage of short acting ACE-inhibitors such as captopril may clinically be relevant only in patients with very advanced severe heart failure and low arterial pressure. In any case, it is recommended to start ACE-inhibitors with a low dose and withdraw diuretics one or two days before in order to restore the intravascular volume.
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PMID:[ACE inhibition in heart failure and compromised kidney function]. 186 34

Studies addressing the epidemiological issues of end-stage renal disease (ESRD) and the implications for health resource allocations are valuable, especially because the Medicare ESRD program is expected to continue growing during the next decade. Studies on trends in the causes of renal failure have benefited from Medicare's extensive data files on ESRD patients. However, no studies have been published that validate the cause of renal failure field in the Medicare files. The primary disease causing renal failure for over 10,000 New York State patients in the Medicare ESRD program was compared with their hospital discharge diagnoses. Of these patients, 8,730 (83%) had a known cause of renal failure in the Health Care Financing Administration (HCFA) data files. Eighty-nine percent of these patients' primary cause of renal failure was matched with the same major hospital diagnostic code. Patients with diabetes and glomerulonephritis had the highest overall match rates (96% to 97%). Patients with polycystic kidney disease and causes of renal failure other than the four major causes had the lowest match rates (75% to 76%), but these match rates increased to 84% to 87% for patients hospitalized more than five times. Some differences in match rate by age and race were found. These findings suggest that HCFA data on the causes of renal failure of ESRD patients are reasonably accurate and can be used successfully to study a variety of issues related to the diseases leading to chronic renal failure.
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PMID:Validation of the cause of renal failure of patients in the Medicare end-stage renal disease program. 188 30

Reflex sympathetic dystrophy syndrome (RSDS), a complex clinical syndrome characterized by pain and swelling of an affected extremity, is most commonly seen after trauma. We report the case of a woman with diabetes mellitus and chronic renal failure who presented with RSDS 5 months after placement of an arteriovenous (AV) graft for hemodialysis. The temporal relationship between RSDS and the vascular surgery suggests AV graft placement as the precipitating event for the development of RSDS. Treatment with systemic corticosteroids successfully relieved the patient's symptoms. We believe that RSDS should be included in the differential diagnosis of unexplained limb pain and swelling after AV graft placement.
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PMID:Reflex sympathetic dystrophy syndrome of the hand after placement of an arteriovenous graft for hemodialysis. 188 37

The prevalence of diabetes in Alaska from 1984 to 1986 was determined through medical records review. Cases were identified from hospital and physician discharge forms and from financial abstracts. As of December 1986, 3,719 Alaskans met the criteria for physician diagnosis of diabetes. The overall age-adjusted prevalence of diagnosed diabetes mellitus, 1,357/100,000, was lower than the U.S. rate of 2,470/100,000. The overall age-adjusted prevalence rates of specific complications and pregnancy among Alaskans with diabetes were retinopathy--167.5/1,000; blindness--24.3/1,000; amputations--19.4/1,000; end stage renal disease--9.7/1,000; pregnancy--50.7/1,000. Limitations in available data sources such as death certificates, hospital records, and subspecialists' medical records provided serious problems in identifying persons with diabetes, especially those in the 30- to 69-year age group who have not yet developed complications requiring hospitalization or subspecialty care. This population perhaps is most in need of services to prevent future complications of diabetes.
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PMID:Diabetes prevalence in Alaska, 1984-1986. 188 17

The summary fibrinolytic activity of the urine (SFAU) was studied in 39 patients with diabetic glomerulosclerosis (DGS), 12 patients with diabetes mellitus (DM) without renal involvement, 8 patients with reduced glucose tolerance and 20 healthy subjects. The level of plasmin, plasminogen activators, plasminogen activation inhibitors and antiplasmins in the concentrated urine were also determined. Diabetic patients without clinical manifestations of DGS revealed a significant reduction of SFAU, plasmin activity and plasminogen activators. A significant reduction of the fibrinolytic activity of the urine was found in DGS without chronic renal failure and especially in DGS with chronic renal failure. It is concluded that reduced levels of urinary plasminogen activators may be used as an index of preclinical stages of renal involvement.
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PMID:[Fibrinolytic activity of the urine in patients with diabetic glomerulosclerosis]. 189 54

Diabetic nephropathy is the most frequent cause of chronic renal insufficiency in adults. Its early stage, characterized by increased albuminuria, develops in susceptible subjects already manifestation of diabetes. This stage can be treated by inhibitors of the angiotensin-converting enzyme which reduce the pathologically elevated intraglomerular pressure even in normotonic subjects. Enalapril was administered for a period of 12 weeks to eight children and adolescents with a normal blood pressure and albuminuria of 30-300 mg/24 hours during repeated assessments. During treatment there was not only a significant decline of albuminuria (from 104.6 +/- 42.7 mg/24 hours to 47.2 +/- 15.4, p = 0.003) but also a drop of the pathological glomerular hyperfiltration (from 3.38 +/- 1.87 ml/s to 1.48 +/- 0.54 ml/s within six weeks - p = 0.02 and to 2.05 +/- 0.80 ml/s resp. within 12 weeks, n.s.). The favourable effect persisted also for some time after discontinuation of treatment. Treatment was relatively well tolerated by the patients. The problem remains whether it is possible to retard or prevent in this way the development of further stages of diabetic nephropathy, include chronic renal failure.
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PMID:[The effect of enalapril on the development of diabetic nephropathy in children and adolescents]. 189 36

It is projected that the proportion of black Americans, American Indians, Asian Americans, and Hispanic Americans entering the ESRD program will continue to increase. Despite the increase in the average age of the ESRD population, the minorities entering the ESRD program are much younger. The major risk factors of ESRD--hypertension, diabetes, and glomerulonephritis--are affecting these minorities at a higher rate and in varying combinations. High prevalence and severity of hypertension followed by diabetes mellitus are the major risk factors in blacks, especially black women. Heroin and HIV nephropathies, tied to the epidemic of illicit drug abuse, have a major impact on young black men. The high prevalence of diabetes and the epidemic of glomerulonephritis in certain tribes are the major risk factors in American Indians. Hypertension and diabetes are the risk factors for the rapidly increasing Asian American population, especially for the elderly segment of this population. Diabetes predominates as the risk factor for the rapidly growing Hispanic American population, a group that needs to be identified separately within the ESRD program. Diabetes and hypertension are treatable, and adequate control can prevent progression of renal failure. However, with minority groups, it is difficult to fully implement the measures necessary to achieve this control. Outreach programs are necessary not only to provide medical treatment but to include instruction in socioeconomic and educational strategies. Programs that will seek out these patients and treat them should also educate them about their diet, about the detrimental effects of alcohol and smoking, and about the danger of substance abuse. Ultimately, these programs may be much cheaper than supporting a rapidly increasing ESRD program.
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PMID:End stage renal disease in minorities. 192 May 1

We evaluated a total of 13 cases of Freiberg's disease in patients aged 47-77 years collected over an 8-year period. Seven were associated with diabetes mellitus and one with chronic renal failure; the remainder had no underlying disease. Atrophy of intrinsic small foot muscles secondary to neuropathy, which is prevalent in diabetes mellitus, may play a part in the development of Freiberg's infraction.
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PMID:Freiberg's disease in diabetes mellitus. 192 74

To study the present status of TB in a general hospital, we reviewed the records of 186 patients with TB at the Saga Medical School Hospital. Ninety-two patients (49.5%) had extrapulmonary tuberculosis and 59 patients (31.7%) had complicated severe diseases. The variety of TB lesions and underlying diseases often caused diagnostic delay and misdiagnosis. In fact, 16 cases were not identified to be TB until after death. The TB prevalence was significantly high in malignant disease, diabetes mellitus, collagen disease and chronic renal failure among the total number of patients discharged. Twenty-one patients developed TB while on an intensive therapy for underlying diseases. Unfortunately, 22 patients with TB died in our hospital. These findings suggest that special care must be taken to prevent TB in a general hospital. We emphasize that early diagnosis of TB depends on the suspicion of this infection on the part of the physician.
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PMID:The present status of active tuberculosis in a general hospital; a study of 186 cases. 194 40


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