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A patient with congenital generalized lipodystrophy developed nephrotic syndrome with progressive renal glomerulosclerosis attributed to diabetic nephropathy. Renal transplantation was performed and the patient was discharged with normal renal function. Marked hyperlipidemia (17,500 mg/dl) persisted. One month later renal malfunction developed, and an open renal biopsy was performed when there was no response to antirejection therapy. Massive lipid deposition in renal tubular cells with tubular necrosis and hemorrhage was present but only minimal evidence of graft rejection. Rejection therapy was tapered and renal function stabilized. Death occurred 2 months later because of pulmonary sepsis. Patients with generalized lipodystrophy and severe hyperlipidemia may be at an unusually high risk for renal homograft destruction.
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PMID:Renal transplantation in a patient with lipoatrophic diabetes. A case report. 36 May 16

From August 1974 to January 1985, 53 patients (26 men; seven Maoris) mean age 45 (SD 15) years, with diabetes mellitus for a mean of 12 (SD nine) years had a renal biopsy and were followed. Indications for biopsy were nephrotic syndrome, proteinuria, renal impairment (five) and hematuria (one). Mean plasma creatinine concentration was 0.22 (SD 0.18) mmol/L and protein excretion 3.4 (SD 2.5) g/24 h. Diabetic nephropathy was demonstrated in 39 patients and significantly associated with retinopathy and insulin dependent diabetes mellitus (IDDM). Of the 39 patients followed for 25.7 (SD 22.8) months, 18 had died (nine myocardial infarction, six uremia, two sepsis, one stroke) and nine had begun dialysis. The five-year cumulative renal survival was 28%. The presence of the nephrotic syndrome and the plasma creatinine concentration at presentation were the best predictors of survival. Diabetics with IDDM of 20 years duration, retinopathy and heavy proteinuria, who survive the other complications of their disease, are likely to have diabetic nephropathy requiring renal replacement therapy.
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PMID:Renal disease in diabetics--which patients have diabetic nephropathy and what is their outcome? 324 62

We have evaluated the incidence, prevalence, predisposing factors and evolution of urinary tract infection (UTI) developing late after transplantation in 63 patients whose graft had lasted at least 3 months and whose follow-up averaged 7 years. Beyond 3 months after transplantation incidence of UTI decreases progressively, from 25 to 0%, 50% of the patients remaining free of infection throughout the period of observation. Neither the original kidney disease except perhaps diabetic nephropathy nor the presence of vesicoureteral reflux were predisposing factors. Incidence and prevalence in females were twice that in male. Late UTI did not affect graft or patient survival, or graft function at 5 years. Most UTI were asymptomatic and had a benign course. However, in 3 patients septicemia or graft dysfunction ensued demonstrating the need for continuous monitoring of urine cultures.
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PMID:Late urinary tract infection after transplantation: prevalence, predisposition and morbidity. 388 73

Data on end-stage renal disease (ESRD) patients in Kuwait were collected retrospectively and prospectively starting in mid-1988. The study period covered 4 1/2 years from 1 January 1986 to 30 June 1990. Epidemiological characteristics of ESRD patients and their disposal by dialysis and transplantation were analysed and compared with previous reports from Kuwait, neighbouring countries, Europe, and USA. A total of 647 patients received renal replacement therapy (RRT) in Kuwait during the study period. This gave an incidence rate of 72 patients per year per million of population. The prevalence rate for patients on maintenance dialysis was 80.6 per million population in mid-1988. Nearly one-fifth of total patients (19.6%) were older than 60 years of age and one-third (30.8%) were identified as 'high risk' category. As for Kuwaiti nationals alone on RRT 29.7% were above 60 years of age and 44.2% were high-risk patients. We have noticed a steady decline in the number of patients who accepted continuous ambulatory peritonial dialysis (CAPD) for dialytic support. Chronic tubulointerstitial disease resulting from atrophic pyelonephritis was the leading cause of ESRD amongst both Kuwaiti nationals and expatriates. Though diabetic nephropathy was only the third leading cause of ESRD (14.7%) in the total population, it was more frequent (21.2%) among Kuwaitis. The gross mortality rate on dialysis was 14.7%. The major causes of death were related to cardiovascular diseases (60%) and sepsis (24.2%).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:End-stage renal disease and renal replacement therapy in Kuwait--epidemiological profile over the past 4 1/2 years. 809 Mar 33

Over a period of 6 years, 9 patients with diabetic nephropathy received renal allografts at Groote Schuur Hospital. This low figure represents 2.8% of the total number of renal transplants done at our institution, and is evidence of concern about the apparent poor results of transplantation in these patients. After 2 years, patients and graft survival rates in diabetics were 87% and 62% respectively. Vascular disease was a major problem. Six patients developed limb gangrene, and symptomatic coronary and cerebrovascular disease developed in 2 patients. Infections were common and included wound sepsis, cellulitis, candidiasis and urinary tract infections. Diabetes was poorly controlled after transplantation in 5 patients. Proliferative retinopathy was present in 6 patients but remained stable after transplantation. Despite very strict selection criteria, the results of renal transplantation in diabetic patients remain poor. Better treatment strategies are needed to justify acceptance of these patients for transplantation.
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PMID:Transplantation for diabetic nephropathy at Groote Schuur Hospital. 845 9

Between February 1988 and December 1994, 25 patients underwent simultaneous kidney and segmental pancreatic transplantation. Diabetes type I with the end-stage renal disease secondary to the diabetic nephropathy was the indication for this procedure. The original method of the four vascular anastomoses was introduced to prevent early pancreatic graft thrombosis. The cross section of the pancreatic segment was anastomosed to Roux--en Y loop in 80% cases and in 20% ductal occlusion with Ethiblock was performed. One-year survival rate for kidney and the pancreas was 81% and 57% and five - years survival rate 57% and 42%, respectively. One - year and five - year survival rate for the patients was 72% and 68%, respectively. The most serious complication leading to the graft removal was intrapancreatic abscess. Sepsis was the main cause of the death among transplant patients.
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PMID:[Personal experience with simultaneous transplantation of pancreas segment and kidney]. 865 56

Renal failure with severe uremia is still an important cause of mortality, despite effective renal replacement therapy. Cardiopulmonary arrest (CPA) is the most severe complication during hemodialysis (HD). To acquire more information about cardiopulmonary resuscitation (CPR) during HD, we retrospectively enrolled 24 patients (11 males and 13 females) who had CPR during HD in a medical center during a 3-year period. Their mean age was 66.8 +/- 16.8 years. The CPR rate of the patients from our outpatient department (0.02%) was significantly lower than that from general wards (0.11%), the intensive care unit (ICU, 0.16%), or the emergency room (ER, 0.38%). Eighteen patients (75%) were initially resuscitated successfully. Only 11 patients (45.8%) survived more than 24 h after CPR, and 2 patients (8.3%) survived more than 1 month, but none survived until discharge. The rates of surviving 24 h and surviving to discharge during HD were lower than those in the general wards, the ICU or the ER. Sepsis (33.3%) and cardiogenic shock (25%) were the two leading causes of death. For analyzing factors affecting the outcome of CPR, we divided the patients into 2 groups by survival time (<==24 vs. >24 h). Patients with heart disease or with prolonged CPR durations (>30 min) had shorter survival. No significant survival difference between the 2 groups was found due to factors of age, sex, diabetic nephropathy, pre-arrest morbidity scores, pre-arrest laboratory data, renal failure pattern, HD duration, the preceding HD time and ultrafiltrated volume.
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PMID:Clinical findings and outcomes of intra-hemodialysis cardiopulmonary resuscitation. 1046 Sep 36

We report a rare case of hypothermia with acute renal failure in a patient suffering from diabetic nephropathy. A 71-year-old male who had been receiving insulin therapy for the treatment of diabetes mellitus complicated with advanced diabetic nephropathy since 1998 was malnourished with an extremely decreased muscle mass. Without any prolonged exposure to excessively low external temperatures or hypothyroidism, pituitary insufficiency, adrenal insufficiency, sepsis, hypoglycemia, and diabetic ketoacidosis, acute hypothermia appeared together with an aggravation of diabetic nephropathy. His skin temperature fell to below measurable levels and his rectal temperature fell to 30.0 degrees C. His consciousness was drowsy and the hypothermia was not accompanied by shivering. Skeletal muscle is known to play an important role as a center of heat production and shivering thermogenesis in skeletal muscle mainly operates on acute cold stress. Therefore, in this case, hypothermia may have occurred because the shivering thermogenesis could not fully act on the acute cold stress due to the dramatically reduced muscle mass. We should always keep in mind that older, malnourished diabetic patients can easily suffer from impairments of the thermoregulatory system.
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PMID:Hypothermia with acute renal failure in a patient suffering from diabetic nephropathy and malnutrition. 1080 30

Diabetic nephropathy is a leading cause of end-stage renal disease, and its prevalence and incidence vary greatly from country to country, being highest in the United States and Japan. In the United States, diabetic nephropathy accounts for approximately 40% of patients beginning renal replacement therapy. Type 2 diabetes is the largest and fastest-growing single disease that requires dialytic therapy. Most patients succumb to cardiovascular causes, including coronary artery disease and myocardial infarction, sudden death, cardiac failure, and stroke. The survival from cardiovascular complications is relatively better in East Asian countries and to a lesser extent in Mediterranean countries compared with countries that traditionally have higher cardiovascular death rates. Peripheral vascular disease and sepsis contribute to increased morbidity and mortality. Amputation of limbs secondary to peripheral vascular disease in particular has adverse effects on rehabilitation. Asymptomatic hypoglycemia may develop in hemodialysis patients. Such hypoglycemia is not associated with a hormonal balance but is postulated to be due to blunted hormonal response to hypoglycemia. Diabetic muscle infarction is another rare complication attributable to diabetic microangiopathy; magnetic resonance imaging may help in the diagnosis. Risk factors for increased mortality include advanced age, poor glycemic control before starting dialysis, smoking, left ventricular hypertrophy, hypoalbuminemia, and neuropathy, in particular, autonomic dysfunction. In addition to adequate dialysis, it is advisable to achieve tight blood pressure control (at least <140/90 mm Hg and preferably much lower), better blood glucose control (hemoglobin A(1c), <7%), correction of nutritional status, and appropriate foot care.
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PMID:Hemodialysis in diabetic patients. 1157 54

Diabetes mellitus carries a great burden on healthcare costs due to its growing population and high co-morbidity. This adverse effect sustains even when patients develop end-stage renal disease (ESRD). We here present data showing the effect of diabetes on economic costs in dialysis therapy in Taiwan. As of the end of 1997, we have 22,027 ESRD patients with a prevalence and incidence rate of 1013 and 253 per million populations, respectively. Diabetic nephropathy is the second most common cause of the underlying renal diseases, but accounts for 24.8% of the prevalent patients and 35.9% of the incident cases. The diabetic patients engendered 11.8% more expense for care of dialysis than the non-diabetic patients (US $26,988 vs. US $24,146 per patient-year). Higher inpatient cost mainly account for the difference. As compared to non-diabetic patients, the diabetic patients had 3.5 times more inpatients costs (US $1325 vs. US $4677 per patient-year), and higher proportion of inpatient-to-annualized cost ratio (5.5 vs. 17.3%) resulting from their more frequent hospitalization (0.59 vs. 1.13 times per patient-year) and longer hospital stay (6.7 vs. 18.9 days per patient-year). The major causes responsible for a more frequent hospitalization were cardiovascular disease, poorly controlled hyperglycemia, sepsis and failure of vascular access. The annualized costs for care of dialysis patients in Taiwan, including inpatient and outpatient costs, averaged US $25,576 per patient-year. This value is approximately half of that in most of the western countries and Japan. Thus, a more cost-effective way to achieve savings is to reduce the high incidence rate of dialysis population and to maximize the quality of dialysis treatment for avoiding hospitalization. Recent studies had shown that tight blood pressure control, intensive glycemic control, and use of angiotensin converting enzyme inhibitors in diabetic patients significantly reduced not only the rate of progressive renal failure, but also substantially reduced the cost of complications and led to higher cost effectiveness. Once diabetic patients reach stage of ESRD, an optimized pre-ESRD care and consideration of kidney transplantation are essential in terms of better patient survival and cost savings.
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PMID:The impact of diabetes on economic costs in dialysis patients: experiences in Taiwan. 1158 Sep 69


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