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Osteonecrosis has been increasingly associated with HIV disease throughout the 1990s, and the incidence appears to be rising. The hip is most commonly involved and often bilaterally. Although anecodotal reports suggest an association between osteonecrosis and highly active antiretroviral therapy, controlled epidemiologic studies do not support a direct link. Many patients with osteonecrosis have established risk factors, some of which may be related to HIV disease or its therapy, including corticosteroid use and hyperlipidemia. Alcoholism, hypercoagulability, megesterol acetate use, immune reconstitution, and other factors may also contribute. Plain radiographs and magnetic resonance imaging are the cornerstones of diagnosis. Management is dependent on the stage of bone disease and ranges from observation to total joint arthroplasty. Clinicians may help to prevent HIV-associated osteonecrosis by encouraging patients to limit their exposure to the established risk factors for the disease.
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PMID:Osteonecrosis in HIV disease: epidemiology, etiologies, and clinical management. 1247 64

It is estimated that there are greater than 100000 kidney transplant recipients with a functioning graft in the United States. Recent advances in immunosuppression have improved short-term graft survival rates and decreased early mortality by decreasing the incidence and therapy for acute rejection episodes. For those accepted on the waiting list, transplant prolongs patient survival compared with remaining on dialysis. During the 1990s, 3 new immunosuppressive drugs were introduced in clinical kidney transplantation. All were approved for use by the Food and Drug Administration after large, controlled, randomized trials. Mycophenolate mofetil (MMF), when combined with cyclosporine (CSA) and prednisone, lowered acute rejection rates by nearly 50% compared with control. Tacrolimus compared with CSA also significantly reduced acute rejection rates in kidney transplant recipients, but was associated with a significant increase in posttransplant diabetes mellitus (PTDM) in the early trials. When evaluated in combination with MMF, the incidence of PTDM was much lower. At the end of the decade, sirolimus was shown in several randomized trials to lower acute rejection rates and is believed to be less nephrotoxic compared with calcineurin inhibitors. All of the randomized trials were not statistically powered to assess long-term superiority. Registry analyses have been performed that appear to show some long-term benefit of immunosuppressive therapy with MMF. Other outcome assessments in kidney transplant recipients include risk factors for chronic allograft nephropathy, hypertension, hyperlipidemia, and bone disease. Although there are few randomized trials, understanding of the significance of these common complications has progressed and strategies for therapy and intervention have been developed. This article focuses on the randomized trials of immunosuppressive therapy and complications associated with use of these drugs. In addition, we review the current management and intervention for the comorbidities associated with the long-term clinical management of the kidney transplant recipient.
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PMID:Outcomes in kidney transplantation. 1283 99

Liver transplantation is a standardized therapy for end-stage liver disease. With current immunosuppressive protocols and patient care, ten-year patient survival rate has reached 60%. Several medical complications may develop during this period, including renal dysfunction, hypertension, diabetes mellitus, hyperlipidemia, and metabolic bone disease. The aim of this article is to analyze long-term results of several clinical trials reporting common medical dysfunctions after liver transplantation and to discuss their management.
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PMID:Medical problems occurring during the long-term follow-up after liver transplantation. 1460 27

Nephrotic syndrome is defined as the glomerular disease with massive proteinuria and hypoalbuminemia, and complications are numerous. Among these complications, saltwater retention, thromboembolism, hyperlipidemia, metabolic bone disease, infections are important for management of nephrotic syndrome. Recent advances in the understanding of alterations in the metabolism of circulating and somatic proteins associated with proteinuria and hypooncotic condition have led to new insights into the pathophysiologic processes associated with this syndrome. Therapeutic consideration should be paid not only for the treatment of primary diseases, but also for the prevention of these complications.
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PMID:[Prevention and management of complications in nephrotic syndrome]. 1550 Jan 36

Dialysis, in its routine 3 x week manifestation, undoubtedly is life saving. The therapy is limited by a number of factors that persist despite the development of safe machines and highly efficient dialyzers. The turnover of known, and very likely, many unknown uremic toxins, is rapid so that 3 x week dialysis is accompanied by relatively high levels of these substances. Only the lower part of the range of molecular weights of those putative uremic toxins, which are small proteins, are removed by current therapies. For substances such as phosphorus, long dialysis is successful in removing the excess retained dietary phosphorus, perhaps the only proven uremic toxin. The difficulty of achieving a normal extracellular volume is probably a major factor in the progression and poor outcomes of cardiovascular disease despite the potential improvement with management of hyperlipidemia, inflammation, potential arrhythmias, and cardiac failure due to other pathogenetic mechanisms. New developments in understanding of Vitamin D metabolism, Ca receptor inhibitor drugs, and control of hyperphosphatemia may reduce the problems of kidney bone disease and the adverse cardiovascular effect of calcium phosphorus disposition. Dialysis more frequent than 3 x week is already routinely, if only infrequently, used to deal with the very large volume or overhydrated patient. However, daily dialysis--whether short or long-is now beginning as a therapy with a large randomized NIH trial in the offing. Currently, the net growth of dialysis is approximately 4% a year, but it would not be surprising if there were a gradual increase in growth rates as CKD patients live longer due to control of cardiac disease. Eventually, the treatment of early kidney disease should reduce the dialysis population, particularly if diabetes can be better controlled or even prevented. The dialysis aspect of nephrology as a profession for physicians, nurses, and technicians appears to be on a long course with increasing demand and the need for applying what is already known, while awaiting new technical developments. Wearable artificial kidneys, involving the application of technology and use of new materials, are currently being investigated. The presence of nephrologists during the actual dialysis treatment is certainly not as evident as it was in the past. Reimbursement methodology has ensured at least a minimum of documented visits by nephrologists or nurse practitioners to the dialysis patient during treatment. It is controversial as to the value of this, but evidence has been presented that certain outcomes, such as use of appropriate dialysis dose and blood chemistries, are improved by more frequent visits. The present is over.
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PMID:Technology: kidneys--the present of dialysis. 1567 76

In the era of highly active antiretroviral therapy, long-term complications of HIV infection and antiretroviral therapy deserve heightened attention. Morphologic and metabolic complications seen during the course of HIV infection encompass a variety of entities that may share a common pathophysiologic pathway. This review article will discuss clinical syndromes such as wasting, lipoatrophy/lipohypertrophy, polymetabolic syndrome as well as hyperlipidemia, cardiovascular disease, lactic acidosis, and metabolic bone disease in HIV-infected patients.
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PMID:Metabolic and morphologic complications of HIV infection. 1708 1

Chronic kidney disease (CKD) is a complex disease affecting more than 20 million individuals in the United States. Progression of CKD is associated with a number of serious complications, including increased incidence of cardiovascular disease, hyperlipidemia, anemia, and metabolic bone disease. CKD patients should be assessed for the presence of these complications and receive optimal treatment to reduce their morbidity and mortality. A multidisciplinary approach is required to accomplish this goal.
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PMID:Chronic kidney disease and its complications. 1848 18

Successful kidney transplantation leads to restoration of renal function. Some metabolic disorders from chronic renal failure may persist and new metabolic abnormalities can develop (obesity, diabetes, hypertension, bone disease, and anemia). Additionally, influence of immunosuppressive drugs (corticosteroids, cyclosporine A, tacrolimus, and rapamycin) may aggravate the course of diabetes, hypertension, and dyslipidemia. Nutritional management of renal transplantation is divided into the pretransplant period, transplant surgery, and early and late posttransplant period. Patients in the pretransplant period in dialysis treatment may develop protein-energy malnutrition and negative nitrogen balance, with loss of lean body mass and fat deposits. Nutritional management in the early posttransplant period with a functioning kidney graft necessitates fluid and electrolyte balance control with protein intake of 1,2/kg BW/day and 30-35 kcal/kg BW/day. In a nonfunctioning kidney graft, dialysis treatment continues and the therapeutic dose of immunosuppressive drugs must be reduced. The principal objective in the late posttransplant period is the maintenance of optimal nutritional status. Nutrition is important in managing obesity, insulin resistance, diabetes, hyperlipidemia, and hypertension. Other posttransplant conditions for which diet and/or nutritional supplements may be beneficial include hypomagnesemia, hypophosphatemia, hyperuricemia, hyperkalemia, hyperhomocysteinemia, chronic renal allograft failure, renal anemia, and renal bone disease.
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PMID:Nutritional consequences of renal transplantation. 1912 81

As outcomes after liver transplant surgery continue to improve, management of the long-term consequences of the procedure and the associated immunosuppression become increasingly important. Liver allograft recipients have, compared with age and sex-matched controls, increased risk for cardiovascular and cerebrovascular events and death, for bone disease, and for some cancers. Early recognition and treatment of modifiable risk factors, especially of hypertension (present in up to 77% recipients), diabetes (in up to 22%), obesity (up to 40%), renal impairment (in up to 50%), and hyperlipidemia (in up to 66%) are necessary to maintain prolonged and healthy survival. Early recognition of de novo cancers (which occur in up to 26% recipients) indicates the need for additional monitoring for skin cancer and lymphoproliferative disorders, as well as cancers of the lung, colon, and upper gastrointestinal track. Early recognition of bone disease and appropriate intervention will allow introduction of strategies to reduce bone fracture. In this article, we review the evidence for the extent and treatment of these modifiable conditions in the allograft recipient.
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PMID:Long-term care of the liver allograft recipient. 1923 63

Biliary stasis can occur in many different diseases. Pruritus, metabolic bone disease, deficiencies of fat-soluble vitamins, steatorrhea, hyperlipidemia and fatigue represent the major extra-hepatic manifestations of cholestatic liver disease that considerably affect the patient's quality of life. The present article reviews pathogenetic and clinical aspects of and current therapeutic approaches to extra-hepatic manifestations of cholestatic liver disease.
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PMID:[Under-evaluated extrahepatic manifestations of cholestasis]. 1929 75


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