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By: Dimitri T. Azar, MD, B.A.
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In the United States diabetes management safe ddavp 10 mcg, about 220 diabetes insipidus breakthrough ddavp 10mcg discount,000 patients are presently undergoing dialysis and another 80 diabetes type 2 leg pain 10mcg ddavp amex,000 are living with a functioning renal transplant diabetes signs and treatment effective ddavp 10mcg. Because of the progressive nature of chronic renal disease and our increasing ability to slow this progression, the association with worsening hypertension, and the predilection of these patients for cardiovascular disease, we should recognize and carefully monitor such patients. Systemic diseases frequently involve and potentially destroy the kidneys (Table 104-1). There is now good evidence that essential hypertension is caused by renal genetic mechanisms and that the propensity for the development of renal disease in response to renal injury may also, and separately, be partly genetically determined. For almost all causes except polycystic kidney disease, progressive renal disease is more common in African-American than white individuals by a factor of about 2 to 3:1. Predictors of the development of diabetic glomerulosclerosis are hypertension, poor glycemic control, microalbuminuria, and the development of proliferative retinal vascular disease. If treatment commences at the stage of microalbuminuria and before fixed albuminuria (300 mg/24 hours) develops, especially if combined with improved glycemic control, progression to diabetic glomerulosclerosis may be prevented. Evidence is increasing that microalbuminuria (>30 mg/24 hours) is a harbinger of hypertensive nephrosclerosis and that progression to fixed albuminuria may be diminished by some, but probably not all, antihypertensive drugs. Microalbuminuria is certainly well documented as a cardiovascular risk factor, and that alone justifies intensifying antihypertensive treatment in such patients. It has not yet been established whether normalization of blood pressure can delay or stop progression once the serum creatinine concentration is elevated and/or fixed albuminuria has developed. Nor it is yet known which is the best antihypertensive to use in such clinical circumstances; a large trial is in progress. Very large cysts, onset of the disease at an early age, and hypertension are associated with progression in polycystic kidney disease, and intense study is also ongoing to determine how to stop progression in that disease. The relevant causative genes are known, but how the defective protein product of these genes contributes to progressive renal cyst formation and loss of renal function has not yet been elucidated. Focal glomerulosclerosis and membranoproliferative glomerulonephritis are the most likely chronic glomerulonephritides to progress quickly in adults. No therapy has yet been proved to consistently prevent progression in these glomerular diseases in randomized controlled studies. The listed tubulointerstitial diseases offer a chance for amelioration or normalization of renal function if, for example, obstruction can be relieved before too much renal function has been lost. Cessation of analgesic abuse is likewise potentially beneficial, especially if the patient is still in the stage of chronic renal insufficiency. Because many transient and benign causes of proteinuria are possible, population screening is not justified at present. Occasionally, patients with primary tubulointerstitial disease may have polyuria and nocturia because impaired renal concentrating ability is an early feature secondary to predominant damage to the renal medulla. Patients with progressive primary glomerular disease may have nephrotic syndrome. Patients with systemic disease potentially involving the kidney must be regularly checked for proteinuria and abnormal urinary findings on microscopy. As noted, diabetics should also be routinely monitored for microalbuminuria before the development of fixed proteinuria. Screening for hypertension is cost-effective, and all patients with hypertension should be screened by urinalysis. Patients with uremic manifestations, the pathophysiology of which is discussed later, can have a myriad of different complaints referable to almost any organ system. Initial misdiagnosis is common, especially for anemic, gastrointestinal, and cardiovascular manifestations. In some specific renal diseases, other symptoms may call the causative disease into question. Polycystic kidney disease can be characterized by recurrent acute pain in renal cysts and/or gross hematuria. Patients with reflux nephropathy may come to attention with recurrent pyelonephritis or persistent hypertension after what is believed to have been preeclamptic toxemia of pregnancy. These nephrons then adapt and enlarge, and clearance per nephron markedly increases. In most patients, however, disease progression is more gradual and nephron adaptation is possible. This process has been studied extensively in animal models, especially in rats with bilateral segmental renal infarction or a 12/3 nephrectomy.
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Initial report from this important analysis evaluating antiplatelet therapy in patients with symptomatic atherosclerosis blood sugar emotions purchase ddavp 10mcg mastercard. This large-scale meta-analyses showed that aspirin reduces vascular occlusive events in about one fourth of patients with symptomatic vascular disease and in patients undergoing vascular procedures diabetic ketoacidosis in cats buy 10 mcg ddavp visa. This report of the largest blinded controlled trial in patients with symptomatic atherosclerotic vascular disease provides convincing evidence for the efficacy and safety of clopidogrel therapy diabetes medication v purchase ddavp 10mcg free shipping. This report demonstrates that peptide antagonists of platelet fibrinogen receptors decrease the thrombotic risk of angioplasty diabetes insipidus patient information ddavp 10mcg low price. No specific prophylaxis is required for low-risk general surgery patients younger than 40 years or those undergoing minor operations with no clinical risk factors other than early ambulation postoperatively. Moderate-risk general surgery patients who are older than 40 years and undergoing major surgery without additional risk factors should be treated prophylactically with low-dose heparin (5000 U subcutaneously every 12 hours). If pregnancy is planned while the patient is receiving long-term anticoagulant prophylaxis, subcutaneous heparin anticoagulation should be substituted for the warfarin before pregnancy begins. Long-term antithrombotic therapy is not indicated in patients with aortic valve disease in the absence of associated mitral valve disease or atrial fibrillation. Although clopidogrel (or ticlopidine) would presumably produce similar protection, no formal confirmation has been reported. Antiplatelet agents alone, without warfarin, do not offer sufficient protection against systemic embolism. Patients with bioprosthetic valves and sinus rhythm or valves in the aortic position may benefit from long-term aspirin therapy (325 mg/day) without anticoagulants. Because standard (unfractionated) heparin must be given parenterally, with regular monitoring of its anticoagulant effects and frequent adjustment of dosage, its use is largely limited to in-hospital settings. Standard heparin may be administered intravenously by bolus injection, continuous infusion, or subcutaneous injection. Continuous infusion is associated with fewer bleeding complications than intermittent bolus injection is and provides excellent protection against recurrent venous disease. Thus the anticoagulant response to heparin is not linear but increases disproportionately in intensity and duration with increasing doses. When given by continuous infusion, standard heparin requires accurate administration and should be given in a separate intravenous line. Plasma heparin levels are unexpectedly low after subcutaneous administration because entry of heparin into the intravascular space from the subcutaneous deposits is delayed, thereby enhancing rapid saturable clearance by binding to endothelium and macrophages. Like standard heparin they are heterogeneous in size, but average 4000 to 5000 daltons. Depolymerization of standard heparin changes its anticoagulant profile, bioavailability, pharmacokinetics, and effects on platelet function and experimental bleeding. Patients treated with standard doses of either heparin or warfarin have a 2 to 4% per year frequency of bleeding episodes requiring transfusion. The risk of major bleeding is increased in patients older than 65 years; in patients with a history of stroke, gastrointestinal bleeding, atrial fibrillation, and co-morbid conditions such as uremia and anemia; and with infrequent monitoring. The most common minor episodes involve urinary, gastrointestinal, and vaginal bleeding. In general, any new or painful symptom in a patient receiving anticoagulants should be considered a manifestation of a potential bleeding complication until proved otherwise. Bleeding episodes occurring within this therapeutic range are frequently due to focal pathologic lesions such as an occult neoplasm unmasked by the therapy, especially in the gastrointestinal or genitourinary tract. Reversal of heparin is achieved by protamine sulfate, a basic nuclear histone containing one third of its residue as arginine. It is routinely given after heparinization during cardiopulmonary bypass surgery in amounts approximately equal to the total administered heparin. The protamine may dissociate or metabolize more rapidly than heparin, thereby accounting for the occasional open heart surgical patient who exhibits "rebound" heparinization after surgery. Heparin-associated thrombocytopenia occurs in about 1 to 3% of treated patients (see Chapters 183 and 184). Thus it is prudent to check the platelet count before heparin is given and on the fifth day after initiating heparin therapy or with any bleeding episode. Two main clinical types are recognized: the more common modest thrombocytopenia of early onset, possibly caused by the platelet proaggregating effect of some contaminating fraction of heparin itself, and the less common severe delayed-onset thrombocytopenia caused by heparin-dependent immune destruction. Occasionally, patients with severe thrombocytopenia also experience threatening thromboembolic events attributable to platelet activation mediated by heparin-induced antibodies. In patients with severe thrombocytopenia, heparin therapy should be stopped and an alternative direct antithrombin used, such as hirudin, bivalirudin, or argatroban.
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Periodic assessment of the effectiveness of chelation therapy should include an estimate of iron burden blood glucose blood pressure generic 10 mcg ddavp with amex. A yearly cardiac evaluation should be performed in an effort to diabetes nerve pain proven ddavp 10 mcg detect clinical evidence of cardiac disease and should include a complete history and physical examination blood sugar weight loss discount ddavp 10mcg fast delivery, electrocardiogram diabetes type 2 nutrition generic 10mcg ddavp mastercard, echo-cardiogram, and chest radiograph. A Holter monitor should be used in any patient who complains of palpitations or who is noted on physical examination to have an irregular heartbeat. Potential iron-induced damage to the endocrine glands should be evaluated by glucose tolerance testing, thyroid function tests, and cortisol determinations. Hormone replacement therapy is dictated by the results of basal and/or provocative endocrine function studies. Various complications associated with the use of deferoxamine include visual disturbances, tinnitus, and renal dysfunction (azotemia and proteinuria). All of these complications are reversible on discontinuation of treatment with the drug and generally do not recur when the drug is subsequently given at lower doses. For these reasons, annual ophthalmologic and audiologic evaluations are strongly recommended for patients receiving chronic deferoxamine therapy. Allogeneic bone marrow transplantation (see Chapter 182) is increasingly effective for patients with homozygous beta-thalassemia. Since the initial report in 1982, over 800 patients have undergone bone marrow transplantation in a single center in Italy, as well as smaller numbers of patients at other institutions. Among good-risk children (defined by good compliance with chelation and the absence of hepatomegaly and portal fibrosis), the 3-year event free survival rate is 95%. Older patients or those exhibiting one or more risk factors have rejection-free survival rates of less than 75%. One alternative form of therapy involves the manipulation of globin gene expression with drugs such as 5-azacytidine, hydroxyurea, erythropoietin, or butyrate analogues. The rationale for such trials is that these agents are known to stimulate fetal hemoglobin synthesis and that gamma-globin chain augmentation may compensate for the reduced beta-chain synthesis, thereby normalizing the ratio of alpha- to non-alpha-chain; the result could be decreased transfusion requirements, decreased extramedullary hematopoiesis, and reduced iron overload. Although some patients have responded to these therapies very impressively, the overall low response rate observed thus far and the requirement for frequent parenteral administration of several of the agents have tempered enthusiasm for this approach. Nonetheless, these initial successes have led investigators to examine the efficacy of related classes of orally administered agents to stimulate Hb F production. It is hoped that these agents, when given alone or in combination, may display increased efficacy in a larger proportion of patients. Finally, gene therapy has been directed at replacing or compensating for the defective beta-globin alleles, especially in view of the comparative ease of obtaining hematopoietic stem cells. Although this approach remains theoretically attractive, its current application is not feasible and will require a convergence of technologic advances in several areas. Improvement in gene transfer methodologies and the ex vivo isolation and expansion of hematopoietic stem cells, as well as other logistic concerns, remain formidable tasks. Careful study documenting the beneficial effects of aggressive chelation therapy in thalassemia patients with and without established cardiac disease secondary to iron overload. Lucarelli G, Galimberti M, Polchi P, et al: Bone marrow transplantation in adult thalassemia. Lucarelli G, Galimberti M, Polchi P, et al: Marrow transplantation in patients with thalassemia responsive to iron chelation therapy. These two references establish the current protocols, including selection criteria, morbidity, and mortality, in adult and pediatric thalassemia patients undergoing bone marrow transplantation. Up-to-date summary of the molecular, cellular, and clinical aspects of the congenital disorders of human hemoglobin. It is the oxidation state of the iron moiety in hemoglobin that determines its oxygen-carrying capacity. The iron in deoxyhemoglobin is in the ferrous form, which allows oxygen to bind to it easily. In addition, the oxygen affinity of the accompanying ferrous hemes in the hemoglobin tetramer is increased. As a result, the oxygen dissociation curve is left shifted and oxygen delivery is impaired. During deoxygenation, some oxygen leaves hemoglobin as a superoxide (O2 -) radical, leaving the iron in a ferric state and creating a steady-state level of methemoglobin. This reaction is referred to as hemoglobin auto-oxidation and occurs spontaneously at a rate of about 3% per day.
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