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 15,891 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

Cardiovascular complications are a major cause of morbidity and the leading cause of mortality in renal transplant recipients. Multiple cardiovascular risk factors are often present before transplantation. Prior ischaemic heart disease, cerebrovascular disease and peripheral vascular disease predict post-transplantation mortality, as do older age, diabetes mellitus, smoking and length of time on dialysis. After transplantation, immunosuppressive agents and/or graft dysfunction may increase cardiovascular risk by causing hypertension, hyperlipidaemia and diabetes mellitus or glucose intolerance. Graft dysfunction may also contribute to cardiovascular risk by causing anaemia or hyperhomocysteinaemia. To assess the relative importance of potential cardiovascular risk factors in renal transplant recipients, a retrospective analysis has been performed on data from 911 patients at the Ospedale Maggiore, Milan, Italy. Preliminary findings confirm that cardiovascular complications are the leading cause of death in renal transplant recipients, accounting for 32% of all deaths. Other major factors predicting post-transplantation cardiovascular events include pre-transplant cardiovascular events, age, smoking, diabetes mellitus (often acquired after transplantation) and hypertension. Careful selection and adequate preparation of patients in addition to appropriate treatment of cardiovascular risk factors are needed before transplantation to reduce the risk of post-transplantation cardiovascular events. After transplantation, appropriate treatment of diabetes, hypertension and hyperlipidaemia, as well as avoidance of smoking, obesity and physical inactivity may reduce the risk of cardiovascular complications further.
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PMID:Role of anaemia in cardiovascular mortality and morbidity in transplant patients. 1181 11

Hyperlipidemia is one of the major modifiable risk factors for coronary heart disease in men and women. There is substantial epidemiological data showing the relationship between elevations in total and low-density lipoprotein cholesterol, triglycerides and low high-density lipoprotein cholesterol, and coronary heart disease in women. Yet hyperlipidemia is undertreated in women. This may be due to limited data to support intervention for the primary prevention of coronary heart disease, confusion in national guidelines, and inadequate counseling on diet and exercise in clinical practice. Lipid levels should be evaluated in women with established coronary heart disease, cerebrovascular disease, peripheral vascular disease, and diabetes. These women should be targeted for aggressive lipid lowering with diet, exercise, and medication. Women with multiple risk factors and early family history of coronary heart disease should also be evaluated. Asymptomatic young women with elevated or borderline lipids should be counseled with regard to lifestyle and behavioral interventions such as diet and exercise. (c) 2000 by CHF, Inc.
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PMID:Lipid lowering strategies in women. 1183 11

Ischemic renal disease (IRD) is a frequent cause of end-stage renal disease. Its prevalence is mainly known from autopsy or retrospective arteriographic studies. This prospective study was conducted in 115 subjects selected from 732 patients with advanced chronic renal failure (CRF). Only patients with clinical features suggestive of IRD were selected for this study. In addition to detailed clinical and laboratory evaluation, captopril renal scintigraphy was performed in selected cases. All subjects underwent renal arteriography and all were followed up for 18.4 +/- 11.4 months. Renovascular disease was seen in 15 patients and significant bilateral renal artery disease leading to IRD was observed in 13 (11.3%). Hence the prevalence of IRD in the advanced CRF patients was 1.7%. The majority of patients with IRD (8 [61%]) were above 46 years of age and there were more men than women (10:3). Atherosclerotic renovascular disease was the most common (10 [77%]), even though arthritis (1 [7.6%]), and fibromuscular dysplasia (2 [15.3%]) were also observed. Serum creatinine at time of presentation was significantly higher in patients with IRD (784 +/- 292, p = 0.043) compared to those who did not have IRD (359 +/- 126). Corrective procedures were performed in 5 patients. After treatment the improvement in serum creatinine in patients with IRD at 3 and 6 months (166 +/- 32 and 173 +/- 47, respectively) was significantly different (p < or = 0.05) compared to those who were not treated (610 +/- 194 and 645 +/- 220, respectively). Hyperlipidemia, coronary artery disease and peripheral vascular disease were more prevalent in patients who had IRD compared to those with renal failure. The incidence of diabetes mellitus were similar in both groups. This study denotes a lower prevalence of IRD in the advanced CRF population; they had more severe renal failure at presentation but specific corrective treatment delayed progression of renal disease significantly.
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PMID:Ischemic renal disease in Kuwait. 1186 39

Demographic, clinical and laboratory data were retrospectively collected from records of 146 cases of CT fluoroscopy-guided chemical lumbar sympathectomy for the palliation of inoperable peripheral vascular disease (PVD) between January 1997 and August 1999. Of these, 16% had claudication, 39% had rest pain and 44% had ischaemic ulcers or gangrene. Seventy-three percent of elective cases were outpatients. At 3 months, 27 cases were lost to follow up, leaving 119 cases. Within 3 months, improvement, defined as doubling of the walking distance, cessation of rest pain or healing of ulcers, occurred in 30.3% of cases. No change was observed in 45.4% of cases and 24.3% of cases deteriorated. Patients with ulcers or gangrene had significantly poorer results than those without any ischaemic lesions, as only 19% versus 39% of patients improved (P < 0.05). The presence of hypertension, diabetes mellitus, hyperlipidaemia and smoking had no value in predicting clinical outcome (P > 0.05). There were no major complications noted. CT fluoroscopy-guided chemical lumbar sympathectomy is safe and effective, with a complication rate of less than 1%, and efficacy of at least 30% measured within 3 months. It is a simple and minimally invasive procedure, easily performed on an outpatient basis. CT fluoroscopy-guided chemical lumbar sympathectomy should be considered for all patients in the early stages of inoperable PVD.
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PMID:Computed tomography fluoroscopy-guided chemical lumbar sympathectomy: simple, safe and effective. 1206 Jan 54

Bile acid synthesis plays a critical role in the maintenance of mammalian cholesterol homeostasis. The CYP7A1 gene encodes the enzyme cholesterol 7alpha-hydroxylase, which catalyzes the initial step in cholesterol catabolism and bile acid synthesis. We report here a new metabolic disorder presenting with hyperlipidemia caused by a homozygous deletion mutation in CYP7A1. The mutation leads to a frameshift (L413fsX414) that results in loss of the active site and enzyme function. High levels of LDL cholesterol were seen in three homozygous subjects. Analysis of a liver biopsy and stool from one of these subjects revealed double the normal hepatic cholesterol content, a markedly deficient rate of bile acid excretion, and evidence for upregulation of the alternative bile acid pathway. Two male subjects studied had hypertriglyceridemia and premature gallstone disease, and their LDL cholesterol levels were noticeably resistant to 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors. One subject also had premature coronary and peripheral vascular disease. Study of the kindred, which is of English and Celtic background, revealed that individuals heterozygous for the mutation are also hyperlipidemic, indicating that this is a codominant disorder.
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PMID:Human cholesterol 7alpha-hydroxylase (CYP7A1) deficiency has a hypercholesterolemic phenotype. 1209 84

The effect of lipemia on peripheral blood flow was studied in patients with and without peripheral vascular disease. Blood flow was measured by venous occlusion plethysmography in the calf and/or finger four to six hours after a fatty meal and after intravenous heparin. The abolition of postprandial lipemia by heparin was determined by measuring the plasma lactescence.Heparin resulted in no change in finger flow of either group or in calf flow in the control group. In nine out of 10 patients with occlusive vascular disease of the legs, it resulted in a small but significant increase of calf blood flow. No such alteration was found when heparin was given following a non-fatty meal.In 12 patients with intermittent claudication the clearing of postprandial lipemia by heparin caused prolongation of claudication time, as measured by the appearance of pain on treadmill exercise.It is concluded that, in some cases, postprandial lipemia is associated with a decrease in blood flow in a limb which is already the site of occlusive vascular disease.
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PMID:THE EFFECT OF LIPEMIA ON PERIPHERAL BLOOD FLOW. 1414 62

Cardiovascular disease post-transplant, particularly ischemic heart disease, is a significant problem for all transplant recipients. The major risk factors-smoking, obesity, diabetes, dyslipidemia and hypertension-are often more prevalent in heart transplant populations than in the general population. One of the main risk factors influencing graft loss and patient survival is cardiac allograft vasculopathy (CAV). Because CAV affects between 30% and 60% of cardiac transplant recipients within 5 years of surgery, prevention is a key focus for cardiac transplant teams today. CAV is caused by both immunologic mechanisms (e.g., acute rejection and anti-HLA antibodies) and non-immunologic mechanisms relating to the transplant itself or the recipient (e.g., donor age, hypertension, hyperlipidemia and pre-existing diabetes) or to the side effects often associated with immunosuppression with calcineurin inhibitors or corticosteroids (e.g., cytomegalovirus infection, nephrotoxicity and new-onset diabetes after transplantation). The calcineurin inhibitors, cyclosporine and tacrolimus, effectively prevent acute rejection, but do not prevent the development of CAV. CAV prevention will require a combined approach of new adjunct immunosuppressant agents (e.g., the proliferation signal inhibitors) and reduction in cardiovascular risk. Hypertension, hyperlipidemia and diabetes are also associated with the immunosuppression required to prevent organ rejection. Some studies have shown that hypertension is present more frequently in cyclosporine-treated patients than in tacrolimus-treated patients and that tacrolimus may be associated with a more favorable lipid profile. On the other hand, tacrolimus may be more diabetogenic than cyclosporine with current data suggesting a trend but no statistically significant supporting evidence. New-onset diabetes after transplantation is at times difficult to manage and may be an important determinant along with hypertension and hyperlipidemia of ischemic heart disease, cerebrovascular disease and peripheral vascular disease. The choice of calcineurin inhibitor for an immunosuppressive regimen in heart transplantation should consider the associated relative cardiovascular risks.
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PMID:Cardiac allograft vasculopathy after heart transplantation: risk factors and management. 1509 4

Aging is a major risk factor for cardiovascular disease. Chronological aging does not always parallel biological aging, but there is no reliable biomarker for the latter. In the present study, we tested the hypothesis that telomere attrition in white blood cells is related to endothelial dysfunction and the extent of atherosclerosis, and thus may serve as a useful marker for biological aging. We evaluated telomere lengths in white blood cells by measuring the mean telomere restriction fragment length (mTRFL), as well as endothelial function by flow mediated dilatation (FMD) in the brachial artery, in patients with various degrees of cardiovascular damage and in normal subjects. Cardiovascular damage was assessed by a cardiovascular damage (CVD) score, with 1 point being given for the presence of each cardiovascular risk factor (hypertension, hyperlipidemia and diabetes) and for each event (angina, myocardial infarction, cerebrovascular event and peripheral vascular disease). Subset analysis of CVD score groups revealed that mTRFL and FMD decreased in the rank order of CVD score. Although mTRFL was inversely correlated with age, telomere index, defined as the ratio of TRFL to TRFL predicted by age, also decreased with increase in CVD score. These results indicate that telomere attrition in white blood cells is more closely associated with endothelial damage and atherosclerosis than is chronological aging, supporting the hypothesis that mTRFL in white blood cells is a useful marker for biological aging of the cardiovascular system.
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PMID:Telomere attrition in white blood cell correlating with cardiovascular damage. 1519 78

In the environment of capitation for health care, physicians assume risks for the condition of their patients and, in essence, act as a type of insurance company. For example, in patients with diabetes, risks include retinopathy and cataracts, peripheral vascular disease and amputations, cardiovascular disease, hyperlipidemia, hypertension, high-risk pregnancies, and renal failure as well as its long-term consequences. Transplantation and million-dollar births are uncommon but extremely expensive events that may be best managed by a partnering arrangement that distributes the risk (and also shares in the potential profit). Health maintenance organizations manage risks by eliminating high-cost patients, decreasing length of stay, and reducing payments to physicians. In formulation of a proposal to assume care for a specific population, the characteristics of the patients and their history of utilization of health-care services should be well understood. With background information, projection of risks becomes more accurate. For management of a contract under capitation, the ability to track long-term outcomes will help to optimize the health care provided.
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PMID:Capitation and control of risk in managed care. 1525 8

Prediabetes is associated with a length-dependent polyneuropathy that typically is sensory predominant and painful. A diagnosis of prediabetes should be sought in patients with otherwise idiopathic sensory-predominant neuropathy by doing a 2-hour oral glucose tolerance test. Fasting plasma glucose of 100 to 125 mg/dL or 2-hour glucose 140 to 199 mg/dL (impaired glucose tolerance) constitutes prediabetes. Most patients with neuropathy associated with prediabetes (NAP) are obese and show metabolic manifestations of insulin resistance, including hyperlipidemia and hypertension. Appropriate treatment addresses hyperglycemia, insulin resistance, and neuropathic pain. Professionally administered individualized diet and exercise counseling (modeled on the Diabetes Prevention Program) has been shown to be more effective than glucose-lowering medications in preventing progression from impaired glucose tolerance to diabetes, and is the mainstay of treatment for all patients with NAP. The goals of this therapy should be a 5% to 7% reduction in weight and an increase to 30 minutes of moderate exercise five times weekly. Patients with prediabetes are at increased risk for myocardial infarction, stroke, and peripheral vascular disease. Therefore, risk reduction with control of hypertension and hyperlipidemia is essential. Neuropathic pain troubles nearly every patient with NAP, and often limits aerobic exercise. No trials have specifically addressed the patient population with NAP, and neuropathic pain treatment closely follows recommendations for diabetic neuropathy. Gabapentin, lamotrigine, and tricyclic antidepressants are well-validated first-line therapies. Adjunctive therapy with opioids, nonsteroidal anti-inflammatory drugs often are necessary. Diet and exercise seem to reduce neuropathic pain in patients with NAP.
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PMID:Polyneuropathy with Impaired Glucose Tolerance: Implications for Diagnosis and Therapy. 1561 Jul 5


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