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Due to inadequate cadaveric and living related organ supply, many end-stage renal disease patients go to third-world countries for living unrelated (paid) kidney transplantation. Thirty-four patients who have had transplantations in two centres in India before coming to our centre for post-transplant care and follow-up are reported in this study. In the post-transplant phase at our centre, the mean follow-up period of the patients was 209.7 +/- 137.3 (range 6-450) days. Fourteen of them, having an uneventful course, were followed on an outpatient clinic basis. The rest of the patients were hospitalized because of the following surgical and/or medical complications, during admission: urinary fistula in two patients; lymphocele in three patients; urinary tract obstruction in two patients; decubitus ulcer in one patient; severe wound infection in one patient; subacute myocardial infarction in one patient; acute irreversible vascular rejection in two patients; urinary tract infection in two patients; pneumonia in two patients; congestive heart failure and severe electrolyte disturbance in two patients; post-transplant diabetes mellitus and ketoacidosis in one patient; cyclosporin nephrotoxicity in two patients; cyclosporin nephro-, hepato-, and neurotoxicity in one patient. Plasmodium falciparum malaria in three patients, generalized mucormycosis infection in one patient, and genitourinary aspergillosis in one patient were seen during the first month. Hepatitis B virus infection followed by chronic active hepatitis was diagnosed in two patients, 2 and 4 months after the operation; and Kaposi's sarcoma was noted in another two patients, 1 and 5 months after the operation.(ABSTRACT TRUNCATED AT 250 WORDS)
Nephrol Dial Transplant 1994
PMID:Living unrelated (paid) kidney transplantation in Third-World countries: high risk of complications besides the ethical problem. 808 44

Clinical features, diagnosis and outcomes of persistently positive dialysate culture (PPDC) after apparent cure of continuous ambulatory peritoneal dialysis (CAPD) peritonitis were investigated in 16 PPDC episodes observed in 16 elderly (age 62 +/- 8 years) men who had been on CAPD for 14 +/- 9 months. Seven patients (46.7%) were diabetic. Peritonitis was caused by S. aureus in 14 cases and S. epidermidis in 2 cases. Preexisting or simultaneous infectious foci were present in 15 cases, exit-site infection in 5, tunnel infection in 13, and intra-abdominal abscess in 2 cases. Indium scans were positive in 6/9 cases (67%). Two patients died with the peritoneal catheter in situ, one from intercurrent myocardial infarction and one from S. aureus sepsis with pneumonia. In another 14 cases the peritoneal catheters were removed because of either tunnel abscess (8 cases) or peritonitis recurrence (6 cases). PPDC following apparent cure of CAPD peritonitis is almost always associated with exit-site, tunnel, or intra-abdominal abscess and leads invariably to catheter loss. Associated mortality is substantial.
Adv Perit Dial 1993
PMID:Persistence of positive dialysate cultures after apparent cure of CAPD peritonitis. 810 23

Features helpful in diagnosis and associated with death were evaluated in 26 episodes of peritonitis associated with intra-abdominal pathology (IAP) in continuous ambulatory peritoneal dialysis (CAPD) patients. Culture of multiple enteric pathogens, or of a single unusual enteric pathogen, from the dialysate was useful for diagnosis in 22/26 instances. Other diagnostic features (fecal material in dialysate, diarrhea containing dialysate, increasing free air in the abdominal cavity) were infrequently found. A comparison of patients who died (n = 11, 42%) and those who survived revealed that death was associated with bowel gangrene (5/6 died), recovery of bacteroides from the dialysate, more frequent and severe comorbid conditions (bacteremia, pneumonia, intra-abdominal and intracerebral bleeding, septic shock, hepatic failure), the development of severe malnutrition and thrombocytopenia during infection, and multiple surgical procedures until the diagnosis was established. Peritonitis associated with intra-abdominal pathology in CAPD patients is a severe infection with considerable diagnostic difficulty and high mortality. Early exploratory laparotomy upon suspicion of the nature of the peritonitis, usually raised by the recovery of enteric pathogens from the dialysate, may improve mortality.
Perit Dial Int 1993
PMID:Peritonitis associated with intra-abdominal pathology in continuous ambulatory peritoneal dialysis patients. 839 3

Clinical data and outcomes of 18 patients, aged 80 or older, on continuous ambulatory peritoneal dialysis (CAPD) during the last five years were reviewed. There were 12 males and 6 females, with a mean age of 85 (range 82-91 years) and median duration on CAPD of 31.5 months (range 2-58 months). End-stage renal disease was caused by nephrosclerosis in 9, diabetes mellitus and light chain disease in 2 each, and chronic glomerulonephritis, membranous nephropathy, and IgA nephropathy in 1 each, with the cause unknown in yet another 2 patients. Hypertension and angina were the commonest comorbid conditions observed. Peritonitis episodes occurred one per 10.8 patient-months, and necessitated catheter removal in 7 patients and reinsertion in 6 of them. Fourteen episodes of exit-site infections were seen in 8 patients, 2 developed pericatheter leak, and 1 had tunnel infection. Nine patients are continuing CAPD successfully, with a median duration of 29 months (range 11-57 months). One patient was transferred to hemodialysis, and 8 died. The causes of death were peritonitis (3/8), cerebrovascular accident (2/8), pneumonia (1/8), and septicemia (1/8), with the cause not known in 1 patient. Our survival rate of 80% at three years is encouraging, and we advocate CAPD as a successful alternative treatment modality in octogenarians.
Adv Perit Dial 1996
PMID:Successful use of continuous ambulatory peritoneal dialysis in octogenarians. 886 86

We encountered two hemodialysis (HD) patients with recurrent infections and complete immunoglobulin A deficiency (IgAD). To survey the possibility of a similar occurrence in other populations, we conducted the present study. We used nephelometry to examine the levels of immunoglobulins G (IgG), A (IgA), and M (IgM) in 42 continuous ambulatory peritoneal dialysis (CAPD) patients, 246 HD patients, 56 chronic renal failure (CRF) patients, and 250 normal adults. Four CAPD patients (9.5%) and five HD patients (2.0%) were found to be completely IgA deficient (IgA < 6.67 mg/dL). Peritoneal dialysis patients therefore had a significantly higher prevalence of IgAD compared with HD and CRF patients. The underlying diseases leading to dialysis therapy in the IgAD patients varied. Their dialysis durations also varied. The occurrence rate of peritonitis in CAPD patients with IgAD was no higher than in patients without IgAD. The clinical significance of IgAD was focused on mucosal immunity, but the exact prevalence of infection was difficult to define. However, these patients' medical records did suggest more frequent respiratory tract infections and cellulitis events than did the records of patients without IgAD. Two PD patients with IgAD died of pneumonia. Immunodiffusion and indirect ELISA methods were used to detect the presence of auto-antibodies, successfully identifying them in three patients. Further research is needed to study other mechanisms of IgAD.
Adv Perit Dial 2000
PMID:High prevalence of selective immunoglobulin A deficiency in peritoneal dialysis patients. 1104 2

In December 2000, all U.S. dialysis centers were surveyed regarding selected patient care practices and dialysis-associated diseases. The results were compared with similar surveys conducted in previous years. During 1997-2000, the percentage of patients vaccinated against hepatitis B virus infection increased from 47% to 58% and the percentage of staff vaccinated increased from 87% to 88%. In 2000, an estimated 64% of patients were vaccinated for influenza and 27% for pneumococcal pneumonia. In 2000, routine testing for antibody to hepatitis C virus (anti-HCV) was performed on staff at 40% of centers and on patients at 58% of centers; anti-HCV was found in 1.7% of staff and 8.4% of patients. During 1995-2000, the percentage of patients who received dialysis through central catheters increased from 13% to 24%; this trend is worrisome because infections and antimicrobial use are higher in patients receiving dialysis through catheters. However, during the same period the percentage of patients receiving dialysis through fistulas increased from 22% to 28%. In 2000, 25% of catheters were used for new patients awaiting an implanted access, 28% for established patients with a failed access awaiting a new implanted access, 41% as an access of last resort, and 6% for other reasons, including patient preference. The percentage of centers reporting one or more patients infected or colonized with vancomycin-resistant enterococcus (VRE) increased from 11.5% in 1995 to 32.7% in 2000.
Semin Dial
PMID:National surveillance of dialysis-associated diseases in the United States, 2000. 1210 Apr 54

In December 2001, all U.S. chronic hemodialysis (HD) centers were surveyed regarding selected patient care practices and dialysis-associated diseases. The results were compared with similar surveys conducted in previous years. During 1997-2001, the percentage of patients vaccinated against hepatitis B virus (HBV) infection increased from 47% to 60% and the percentage of staff vaccinated increased from 87% to 89%. In 2001, an estimated 65% of patients had been vaccinated for influenza and 26% for pneumococcal pneumonia. In 2001, routine testing for antibody to hepatitis C virus (anti-HCV) was performed on staff at 42% of centers and on patients at 62% of centers; anti-HCV was found in 1.5% of staff and 8.6% of patients. In 2001, the incidence of HBV infection was higher among patients in centers where injectable medications were prepared at the dialysis station, and both HCV prevalence and incidence were higher among patients in centers where injectable medications were prepared at the dialysis station compared to a dedicated medication room. During 1995-2001, the percentage of patients who received dialysis through central catheters increased from 13% to 25%; this trend is worrisome, as infections and antimicrobial use are higher among patients receiving dialysis through catheters. However, during the same period, the percentage of patients receiving dialysis through fistulas increased from 22% to 30%. In 2001, 25% of catheters were used for new patients awaiting an arteriovenous (AV) access, 28% for established patients with a failed access awaiting new AV access, 40% as an access of last resort, and 6% for other reasons, including patient preference. The percentage of centers reporting one or more patients infected or colonized with vancomycin-resistant enterococcus (VRE) increased from 12% in 1995 to 31% in 2001.
Semin Dial
PMID:National surveillance of dialysis-associated diseases in the United States, 2001. 1525 Sep 25

Calcineurin inhibitors (CNIs) are associated with important side effects, such as nephrotoxicity, and thus there is an interest in developing CNI-sparing protocols using agents such as the proliferation signal inhibitor/mammalian target of rapamycin inhibitor everolimus. In a 3-month pilot study using an abrupt conversion protocol, ciclosporin (CsA) treatment was stopped after the morning dose and everolimus was started at 3.0 mg/day. Mycophenolic acid (MPA)-based therapy was continued, or prednisolone increased to 10 mg/day until target everolimus trough blood levels (3-8 ng/ml) were achieved. To date, seven patients have been enrolled, with three having completed at least 3 months of follow-up. Overall, conversion was effective and well-tolerated. Patients consistently achieved everolimus trough blood levels >3 ng/ml, and no episodes of acute rejection or proteinuria were reported after 3 months. In patients who completed the study, there were no major changes in the leucocyte or platelet counts during everolimus treatment. Serum creatinine levels were maintained or decreased slightly. One patient experienced a transient increase in serum creatinine during an episode of pneumonia, but levels decreased again after resolution of infection and temporary everolimus dose reduction. Serum cholesterol and triglyceride levels increased, but remained within acceptable limits. One patient receiving enteric-coated mycophenolate sodium 1440 mg/day experienced increasing everolimus trough blood levels and anaemia after conversion, and was therefore likely to have been over-immunosuppressed. Abrupt conversion to everolimus from CsA was effective and well-tolerated in renal transplant recipients. A reduction in MPA dosage at the time of conversion may be necessary to prevent over-immunosuppression.
Nephrol Dial Transplant 2006 Jul
PMID:Conversion to everolimus in maintenance patients--current clinical strategies. 1681 53

We experienced a case manifesting progressive multifocal leukoencephalopathy (PML) in a hemodialytic patient with hepatitis C virus-induced liver cirrhosis and human T-cell lymphotropic virus type-1 (HTLV-1)-associated uveitis. A 57-year-old male patient had received chronic hemodialysis therapy for 10 years, during which he received multiple blood transfusions and HTLV-1-associated uveitis developed. He complained of visual disturbance and disorientation. Brain CT scan showed diffuse and multifocal low density areas in occipital and temporal lobes, with gray matter relatively spared. MRI imaging showed high intensity lesions in the same areas. Cerebrospinal fluid culture was negative, but using nested PCR, rearranged regulatory region of JC virus DNA was detected. His consciousness level gradually deteriorated and complete paraplegia developed. Seven months after admission, he died of pneumonia. An autopsy confirmed the diagnosis of PML. Notably, mononuclear cell infiltration, gliosis and demyelinating lesions but no nuclear inclusion bodies were observed in the thoracic cord, which suggested HTLV-1-associated myelopathy. Because JC virus is activated under immunocompromised conditions, precipitating factors in this case appear multifactorial; depressed immune system induced by chronic hemodialysis as well as blood-borne hepatitis C virus/HTLV-1 infection might contribute to the activation of dormant JC virus and the development of florid clinical manifestation of PML.
Ther Apher Dial 2006 Jun
PMID:A case report of progressive multifocal leukoencephalopathy in a human T-cell lymphotropic virus type 1-infected hemodialytic patient. 1681 97

Endotoxin-removal direct hemoperfusion column containing polymyxin B immobilized fibers (PMX-DHP) is an effective procedure for the treatment of sepsis-induced acute respiratory distress syndrome (ARDS). We investigated retrospectively the effects and appropriate timing of PMX-DHP induction for directly induced ARDS in 38 patients. PMX-DHP was carried out twice for two hours. Blood pressure, heart rate (HR) and PaO(2)/FIO(2) (PF) ratio, leukocytes, platelets, endotoxin, inflammatory cytokines and clusters of differentiated peripheral neutrophils and monocytes were measured before and after PMX-DHP. Acute Physiology and Chronic Health Evaluation (APACHE) II scores, Sequential Organ Failure Assessment (SOFA) scores and lung injury scores (LIS) were determined at the time of starting PMX-DHP. The underlying causes of ARDS were pneumonia in 29 patients and aspiration pneumonia in 9 patients. The patients were divided into Survivors (n = 21) and Nonsurvivors (n = 17). Mortality was 45% at 30 days after PMX-DHP. The APACHE II and SOFA scores and the LIS were not significantly different between the two groups. The time from the onset of ARDS to the start of PMX-DHP was significantly delayed between the two groups. PMX-DHP significantly improved the PF ratio, HR and systolic blood pressure in the Survivors compared to the Nonsurvivors. The function of active monocytes in the peripheral blood was significantly suppressed after PMX-DHP. This early induction of PMX-DHP is indicated for directly induced ARDS. In the Nonsurvivors, this delay could have led to undesirable responses to oxygenation and circulation after PMX-DHP.
Ther Apher Dial 2007 Apr
PMID:Effects of PMX-DHP treatment for patients with directly induced acute respiratory distress syndrome. 1738 35


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