Renal failure hearing loss,tinnitus hypnose berlin yahoo,sinus problems x ray mod - Reviews

This website is dedicated to the development and dissemination of medical information that may be useful to those who practice Operational Medicine. A number of diseases and special conditions can cause the kidneys to stop working normally. Older people and those with serious medical problems are less likely to regain their previous health. Other blood tests as erythrocyte sedimentation rate (ESR) and antinuclear antibodies (ANA) can be used to diagnose an infection, an autoimmune disease or other diseases if the patient history and symptoms suggest that one of these diseases could be present. Renal scintigraphy (may help assess renal blood flow, if normal, or to determine if an obstruction is present). Renal transplantation is the best treatment for most patients with end-stage renal disease and is associated with significant improve-ments in quality of life and survival of patients with successful kidney grafts.
Calcineurin inhibitors (CNIs), including cyclosporine (CSA) and tacrolimus have been the cornerstones of an immunosuppressive regimen, which usually includes 2 or more additional agents, such as glucocorticoids, a purine antagonist (mycophenolic acid or azathioprine).
High-risk patients treated with more intensive immunosuppression include those with increased levels of preformed antibody (panel-reactive antibody [PRA] >20%-50%), repeat transplantation after early immunologic loss of a previous graft, and African Americans. Polyclonal IgG antibodies are derived from horse (lymphocyte immune globulin) or rabbit (antithymocyte globulin [ATG]) sera after injecting the animals with human lymphocytes or human thymocyte, respectively. Daclizumab and basiliximab are monoclonal antibodies modified to be humanized or chimeric antibodies that bind to the alpha chain of the interleukin-2 receptor (IL-2R) on T cells and thereby impair lymphocyte proliferation. Basic maintenance immunosuppression for many years consisted of 3 types of drugs in combination: glucocorticosteroid (GC) (prednisone), a purine antagonist (azathioprine or mycophenolate mofetil), and a CNI (CSA) or TAC. TAC is a macrolide antibiotic somewhat more potent than CSA which has side effects that are distinct from and overlap with those of CSA (Table 2).
The frequency of outpatient visits at the transplantation center is generally determined by the individual post-transplantation course of each patient.
The advent of new and more potent immunosuppressive agents has reduced the frequency of acute rejection but has introduced other complications of renal transplantation. Historical clues to allograft dysfunction include changes in weight and urine output, conditions leading to and symptoms of volume depletion, fever, chills, pain over the allograft, significantly higher or lower blood pressures, failure to adhere to the prescribed immunosuppressant medications, and the addition of a new medication, such as a diuretic, NSAID, ACE inhibitor or ARB, nephrotoxin, or a CYP 3A4 enzyme inhibitor that can increase or a medication that can decrease CNI levels (Table 4).
Medical complications create the most common cause of graft loss, namely, death of the recipient with a functioning graft. Approximately 60% of renal transplant recipients develop hyperlipidemia by 1 month after initiation of immunosuppressive therapy.
The cumulative incidence of post-transplantation new-onset diabetes mellitus (NODM) at 12 and 36 months after transplantation has been reported to be approximately 16% and 24%, respectively,10 but the true incidence is difficult to assess because of the absence of a uniform definition of NODM.
Hyperkalemia can be associated with the use of ACE inhibitors and ARBs, beta blockers, CNI, type IV renal tubular acidosis (RTA), and significant renal failure, especially with high-potassium diets.
Hypomagnesemia is commonly the result of the magnesuric effect of SRL and CNI, and may be associated with tremors. Both f emale and male kidney recipients lose up to 8% of bone mass during the first 18 months after transplantation. Guidelines from the American Society of Transplantation recommend a baseline dual-energy x-ray absorptiometry (DEXA) scan at the time of transplantation, at 6 months after transplantation in all patients, and then annually in patients with abnormal results. Allopurinol should be avoided in patients who are taking azathioprine or used in a reduced dosage with lower dose azathioprine because of the high risk of interaction leading to severe myelo suppression, hepatotoxicity, or other adverse effects (Table 2).
Immunosuppression creates a greater risk of infection, especially in the current era, because many potent immunosuppressants and antibody induction therapies are now used in broad combinations. CMV infections represent one of the most common and serious infections in renal transplant recipients.
The clinical presentation ranges from a subtle flu-like syndrome to life-threatening pneumonia. Polyoma BK virus is a more recently recognized viral infection that can affect the renal allograft early and late after transplantation. Quantitative measurements of BK virus in the blood can strongly suggest BK nephropathy, but a graft biopsy with in situ hybridization or immunohistochemical techniques is required for a definitive diagnosis. The 10-year prevalence of post-transplantation malignancy in the United States is reported to be as high as 30%. PTLD represents a spectrum of tumors, most often in the form of non-Hodgkin’s lymphoma (NHL).
Maintenance immunosuppression for renal transplantation typically consists of 3 types of drugs in combination: a glucocorticosteroid, purine antagonist (azathioprine or mycophenolate mofetil), and calcineurin inhibitor (cyclosporine or tacrolimus). The most common combination of oral immunosuppressants for renal transplantation currently is prednisone, tacrolimus, and mycophenolate mofetil. Any acute rise in the serum creatinine level to more than 20% to 25% in a kidney transplant recipient warrants careful investigation. Typically, acute rejection (cellular or antibody mediated) occurs most frequently within the first 6 months after transplantation. Cardiovascular disease is the leading cause of death among kidney transplant recipients because of the high prevalence of cardiovascular risk factors before and after transplantation, including hypertension, hyperlipidemia, renal dysfunction, and diabetes mellitus.
Ahsan N, Hricik D, Matas A, et al: Prednisone withdrawal in kidney transplant recipients on cyclosporine and mycophenolate mofetila€”a prospective randomized study. Braun WE: Cardiovascular and other non-infectious complications after renal transplantation in adults. Fellstrom B: Risk factors for and management of post-transplantation cardiovascular disease. Kasiske BL, Snyder JJ, Gilbertson D, Matas AJ: Diabetes mellitus after kidney transplantation in the United States.
Kasiske BL, Snyder JJ, Gilbertson DT, et al: Cancer after kidney transplantation in the United States. Pascual M, Curtis J, Delmonico FL, et al: A prospective, randomized clinical trial of cyclosporine reduction in stable patients greater than 12 months after renal transplantation. Ahsan N, Hricik D, Matas A, et al: Prednisone withdrawal in kidney transplant recipients on cyclosporine and myco-phenolate mofetila€”a prospective randomized study.
Normally kidneys filter the toxic byproducts (waste) and maintain normal levels of water, salt and minerals (electrolytes) in the blood. If the patient is in hospital, investigations performed for other conditions can detect the kidney damage.
When blood flow to the kidneys decreases, toxic byproducts and excess fluid are not removed properly from the body.
People who have had heart surgery or abdominal or bone marrow transplant have a higher risk. They can detect high levels of metabolic products in blood and a chemical imbalance in the body and can help diagnose and detect diseases or infections.
An increase in blood creatinine (serum creatinine) is usually the first sign of acute renal failure.
Estimates the remaining functional kidney by comparing the blood levels of creatinine with the levels of urine creatinine.
The existence of eosinophils in the urine may indicate an allergic reaction that destroys the kidney. Because patient and graft survival rates 1 year after transplantation are currently higher than 90% for recipients of living and deceased donor kidneys, there will be large numbers of successful recipients requiring long-term care and chronic immunosuppression. High-risk recipients typically receive induction therapy consisting of monoclonal or polyclonal antibodies administered intravenously beginning in the perioperative period. They target several T cell surface epitopes (CD2, CD3, CD4, and CD25) and, in the case of lymphocyte immune globulin, induce long-term depletion of T lymphocytes.
They typically have minimal side effects and do not increase the recipient's susceptibility to infection or malignancy. Because of numerous potential glucocorticoid (GC) toxicities (Table 1) and CNI toxicities (Table 2), many new regimens have been developed that incorporate rapid GC elimination, or CNI dose reduction or elimination. Their immunosuppressant actions are mediated through a number of pathways, mainly directed toward redistribution of lymphocytes and macrophages to the lymphoid tissue and inhibition of the production of cytokines (eg, IL-1, IL-2, IL-6), tumor necrosis factor-alpha (TNF-alpha), and interferon gamma (IFN-gamma). Each functions as a base immunosuppressant around which additional agents are added to construct the complete immunosuppressant regimen. Azathioprine is a prodrug converted in the body via a nonenzymatic reaction to 6-mercaptopurine, a purine analogue that acts as an antimetabolite and blocks the synthesis of nucleotides, thereby inhibiting T and B cell proliferation.1 Its major side effects are leukopenia and possible myelosuppression, increased susceptibility to infection, increased susceptibility to cancer, particularly PTLD and skin cancer, hepatotoxicity, and alopecia. Its major side effects are diarrhea, leukopenia, anemia, and tissue-invasive cytomegalovirus (CMV) disease.


SRL has a very long half-life (approximately 65 hours), so that trough level monitoring should be done 5 to 7 days after initiating the medication. Follow-up is focused on monitoring the patient for acute rejectiona€”an otherwise unexplained rise in serum creatinine level of 20% to 25% and varying clinical signs of decreased urine output, weight gain, edemaa€”and cardiovascular disease, malignancy, infectious complications, usually pulmonary or urinary tract, delayed technical complications (eg, renal artery stenosis, lymphocele, obstruction), worsening hypertension, new-onset or poorly controlled diabetes mellitus, hyperlipidemia, excessive weight gain, fluid retention and CHF, excessive diuresis and volume contraction, and immunosuppressant management for appropriate blood levels and toxicities.
The differential diagnosis of an acute rise in serum creatinine level of more than 20% to 25% is similar to that for acute renal failure (prerenal, renal arterial, renal parenchymal, post-renal), with special emphasis on the time interval from transplantation, and awareness that the CNI immunosuppressants being used can themselves be nephrotoxic (Fig. Although the frequencies of obstruction and transplantation artery stenosis are low, these need to be evaluated promptly with graft ultrasound or other techniques, because treatment would usually require a transplantation surgeon or interventional radiologist. The physical examination should focus on volume status with orthostatic hypotension, significantly higher or lower blood pressures, allograft tenderness or bruit, swelling in the allograft area, diminished femoral pulses, particularly on the side of the allograft kidney, and evidence of congestive heart failure or infection. SRL, CSA, and corticosteroids are major factors contributing to hyperlipidemia, in addition to other more usual factors (eg, obesity, genetic predisposition, hypothyroidism, diabetes mellitus, nephrotic-range proteinuria, and allograft dysfunction). It is well known that increasing levels of hypertension contributed to progressive graft loss. Risk factors for NODM are age older than 50 years, obesity, African American and Hispanic ethnicities, family history of DM, hepatitis C, and use of CSA, TAC, and GC.
Hypophosphatemia may be seen even in the early post-transplantation period and may be caused by residual secondary hyperparathyroidism and impaired proximal tubular phosphate reabsorption because of GC use, and is usually asymptomatic. Hyperkalemia requires treatment that begins with the treatment of any drug or diet cause and, according to the degree of elevation, the use of diuretics, exchange resin, or even dialysis, if extreme.
Magne-sium supplementation should be started when the serum magnesium level falls below the lower level of the reporting laboratory, or kept within the upper normal range if the patient has tremors not due to other causes. An assessment of kidney transplant recipients at a mean of 6 years after transplantation has shown that bone loss, in the form of osteopenia or osteoporosis, affects 88% of recipients.
Hyperuricemia occurs in a larger number of CNI-treated recipients, primarily those receiving CSA, because of decreased glomerular filtration of uric acid. Conversion from azathioprine to MMF avoids the problem and usually permits doses closer to those for nontransplantation patients. Before prophylaxis programs were used, these infections occurred 1 to 6 months after transplantation, with a peak at approximately 6 weeks. It can be tissue invasive and affects the gastrointestinal tract, liver, retina , central nervous system, and myocardium. The interval between transplantation and diagnosis is age dependent, 8 years for recipients 40 to 60 years of age, and 3 years for those older than 60 years. The incidence of NHL peaks in the first year after transplantation and is associated with EBV virus infection in more than 90% of the cases.
When acute renal failure is suspected, a complete evaluation is needed to determine the cause of kidney failure.
Primary care physicians and internists are becoming increasingly involved in this type of care will need basic information about immunosuppression and the medical management of these patients.
The choice of agents is often protocol driven but is usually adapted to each recipient's risk profile. The major early side effect of lymphocyte immune globulin is the cytokine release syndrome: fever, chills, myalgia, and shortness of breath. Alemtuzumab, originally approved for the treatment of chronic lymphocytic leukemia, is a humanized murine monoclonal antibody directed against the surface protein CD52 expressed on T and B lymphocytes, monocytes, and macrophages. Rapid GC withdrawal within the first few days after transplantation is usually achieved with antibody induction. Prednisone dosage is gradually decreased after transplantation to 5 to 7.5 mg daily unless the patient has been on a rapid GC withdrawal protocol. Initiation of CSA in the post-transplantation period usually requires signs of renal recovery because of potential nephrotoxicity. Often, diarrhea can be avoided by dosing three times daily rather than twice daily using the same total daily dose. It should be noted that although mTOR inhibitors and reduced doses of TAC or CSA may be used together, they can be more nephrotoxic and have inferior graft survival. Concurrent management with the primary care physician or local nephrologists may vary among centers but will usually be a joint effort, with continuing contact with the transplantation center nephrologists.
Laboratory studies should include a complete metabolic panel, serum phosphorus magnesium and uric acid, complete blood count (CBC) with differential, immunosuppressant blood levels, urinalysis, urine culture, and other studies based on the patient's presentation. Evidence of carotid or peripheral arterial occlusive vascular disease should be checked at least annually on physical examination and followed with duplex ultrasound and pulse volume recordings, respectively. The basis of post-transplantation hypertension is often multifactorial and includes one or a combination of several factors, such as continued renin output from native kidneys, immunosuppressants (CNI, GC), graft renal artery stenosis, chronic allograft injury, liberal sodium intake, excess weight, hyperaldosteronism, and genetic factors. The use of MMF, azathioprine, statins, and ACE inhibitors does not increase the risk for developing NODM. Corticosteroid use is a major factor in bone loss, along with persistent hyperparathyroidism. In addition to the typical site of acute gout in the first metatarsophalangeal joint, post-transplantation gout may occur in the upper extremities and larger joints (e g , wrists, shoulders, elbows, knees, hips). However, both colchicine and allopurinol can have serious side effects in patients with reduced renal function, and careful consideration must be given to monitoring or even avoiding use of these agents.
In the first few months after transplantation, infections are usually caused by common bacterial and fungal infections associated with the surgical wound, vascular catheters and ureteral stents, organisms transmitted with the donor organ, nosocomial urinary tract infections (UTIs) and pneumonias, and Clostridium difficile-associated diarrhea.
The primary diagnostic test is quantitative CMV DNA determined by the polymerase chain reaction assay. It is a ubiquitous virus that remains in a latent state in up to 90% of the general population. For sulfa-allergic patients, prophylaxis is achieved with oral dapsone or monthly inhaled pentamidine for up to 1 year.
A dermatologist should be part of the long-term transplant care team for prompt evaluation of suspicious lesions and full skin examinations annually.
It differs from that in the general population by its extranodal, CNS, and allograft involvement. Uremic syndrome (uremia) is a serious complication of prolonged and severe acute renal failure.
Late side effects include prolonged (up to years) depletion of T lymphocytes, thereby increasing the potential risk of opportunistic infections, post-transplantation lymphoproliferative disorder (PTLD), and possibly autoimmune disease. It can cause prolonged T lymphocyte depletion, with risks for opportunistic infection, PTLD, and possibly autoimmune disease. Late withdrawal of GC has a high risk of rejection.3 CNI withdrawal has been attempted by conversion to less nephrotoxic SRL. Both CSA and TAC are metabolized by the hepatic enzyme system cytochrome P-450 3A4 (CYP 3A4), which is responsible for the metabolism of numerous drugs (Table 3). The concomitant use of azathioprine with allopurinol, a xanthine oxidase inhibitor used to lower serum uric acid levels, typically in patients with gout, increases the risk of side effects and requires dose adjustments (Table 2).
An imaging study, including a graft ultrasound to detect evidence of obstruction and evaluate graft arterial and venous blood flow, should be performed promptly.
Stress testing is often needed for asymptomatic individuals who are also at high risk but may not experience chest pain because the underlying diseasea”€diabetes mellitus with its neuropathya”€can blunt symptoms of angina pectoris. First-line therapy should include both a low-fat diet and 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor (statin). Hypercalcemia is most often caused by persistent hyperparathyroidism but may resolve with a longer period of good graft function.
Hypothyroidism and hypogonadism are other possible factors that need to be evaluated and treated if indicated. The emerging regimen of GC avoidance may be promising for limiting osteoporosis, whereas GC withdrawal creates a significant risk of rejection. Major adverse effects of colchicine include diarrhea, myopathy, nausea, vomiting, myelosuppression, teratogenicity, hepatocellular toxicity, and seizures.
Infections beyond 4 months often include opportunistic pathogens because of the cumulative effects of intensive immunosuppressive therapy after transplantation.
However, experience has shown that CMV may occur within a few weeks after cessation of antiviral prophylaxis. About 30% to 60% of kidney transplant recipients develop BK viruria after transplantation, and 10% to 20% of patients develop BK viremia.
Permitted vaccines include influenza, inactivated injectable poliomyelitis (Salk), pneumococcal (Pneumovax), tetanus, and polysaccharide typhoid vaccines.


Therapy involves major reduction or complete elimination of nonglucocorticoid immunosuppressants and, in some cases, chemotherapy, surgical excision, and radiotherapy.
Careful measurement of urine output over time, can also help monitor fluid balance in a person with kidney failure.
Alternatively, careful dose reduction can be successfully achieved in select patients.4 Combined use of a CNI and SRL has the potential for severe nephrotoxicity. Consequently, for these drugs and those described later, it is worthwhile to consider the treatment approaches shown in Table 2.
However, SRL may prolong acute tubular necrosis and cause proteinuria, certain glomerulopathies, and thrombotic microangiopathy. There is an increased risk of myopathy or rhabdomyolysis because of the pharmacokinetic interaction of statins with CSA, TAC, and SRL.
Selection of medications should take into consideration drugs affected by impaired renal function and interaction with immunosuppressants.
However, in some cases of hyperparathyroidism, hypercalcemia may persist, and treatment with the calcium-sensing drug cinacalcet should be considered. The important pathogens include viruses (CMV, Epstein-Barr virus [EBV], BK polyoma), fungi (Aspergillus, Cryptococcus), bacteria (Listeria monocytogenes), and other organisms (Pneumocystis jiroveci, Nocardia).
Among these patients, 5% to 10% develop BK nephropathy; of these, approximately 70% lose the allograft and the remainder exhibit some kidney dysfunction. It may be aggressive and respond poorly to therapy, especially if there is CNS involvement. The original formulation (Sandimmune) has been largely replaced by the newer CSA formulations (Neoral) or modified CSA (eg, Gengraf, Eon, other generics) that exhibit better absorption and bioavailability.
SRL, as well as CSA and TAC, also can cause renal magnesium wasting and potentially significant hypomagnesemia. It has been recommended that the maximum dose of statins be reduced in patients receiving either CSA or TAC. Because of the surge in new drugs for diabetes treatment, NODM often requires management by an endocrinologist. Beyond 6 months, community-acquired bacterial and viral infections, recurrent urinary tract infections, opportunistic infections, parvovirus B19, and persistent hepatitis B or C virus (HBV, HCV) infections can develop. BK infection may be associated with ureteral stenosis and possible obstruction, tubulointerstitial nephritis, and a progressive rise in the serum creatinine level, with ultimate allograft failure. These CSA preparations should not be casually substituted for one other because of increased risk of rejection or toxicity.
Other side effects, typically dose-related, include hypercholesterolemia, hypertriglyceridemia, edema, hypertension, anemia, thrombocytopenia, leukopenia, interstitial pneumonitis, delayed wound healing, skin rash, mouth ulcers, and myalgia.
Consequently, the creatine kinase (CK) enzyme and alanine aminotransferase (ALT) levels should be monitored regularly. ACE inhibitors and ARBs may be useful to help preserve renal function, particularly in diabetics, but generally should not be used when transplantation renal artery stenosis is present. Modification of the immunosuppressive regimen, if necessary, should be done with the aid of a transplantation nephrologist. Other causes of hypercalcemia should also be evaluated, particularly excessive vitamin D and calcium intake, hyperthyroidism, and malignancies such as lymphomas and multiple myeloma.
BK infection must be evaluated in any episode of renal dysfunction and prospectively evaluated approximately every 3 to 6 months in the first year after transplantation.
More frequent acute rejections and inferior allograft survival have been reported with SRL than with CNI. If diet and statin treatment fail to control the hypercholesterolemia, other treatment measures include switching from SRL or CSA to TAC, and adding ezetimibe are recommended.
Other potential side effects include angioedema, cough, hyperkalemia, anemia, and hemodynamic effects that cause a rise in the serum creatinine level. GC tapering or discontinuation should be avoided or done with extreme caution because of the high risk of acute rejection. Monitoring trough levels (C0) is the appropriate way to monitor Sandimmune, but the newer formulations may be better monitored with levels determined 2 hours after the dose is taken (C2). Diuretics may cause hypovolemia, leading to a rise in the serum creatinine level, hypokalemia, hypomagnesemia, and hyperuricemia. Blood levels of CNIs may be increased by some calcium channel blockers (eg, verapamil, diltiazem, amlodipine), so appropriate monitoring of blood levels is advised with initiation of these calcium channel blockers (See Tables 2 and 4).
Blood flows through tiny tubes and intricate networks of blood vessels within the kidneys to the glomeruli in order to undergo the filtration process.
Blood cells and other components such as protein cannot pass through the walls because of their bigger size.
These include fluids, salts and minerals that are taken back into the body and not excreted. This could be sudden or rapid in onset in case of acute renal injury or damage or acute renal failure. Creatinine is a component released from the damaged muscle tissues and excreted normally by the kidneys.
Over long term this may lead to abnormal fluid and electrolyte levels in blood, abnormal levels of acids in blood, abnormal levels of minerals and electrolytes including sodium, potassium, calcium and phosphates and also lead to anemia. Blood levels of creatinine, urea, potassium, and other metabolites and electrolytes are raised. Urine output is lowest in this phase and there is retention of fluids leading to edema and swelling of legs and face. As the blood levels of urea and creatinine rise, there may be affliction of the brain leading to convulsions or seizures, drowsiness, coma, and death. Urine becomes copious and less concentrated and contain traces of proteins and blood cells. Decreased levels of active vitamin D in renal failure leads to a decrease in intestinal absorption of calcium. This could delay blood clotting and lead to nose bleeds, heavy menstrual bleeding, gastrointestinal bleeding, excessive bruising of the skin even on minor trauma etc. Dialysis or transplantation of a healthy donor kidney is required for living at this stage.
When renal failure occurs after long term kidney disease, it is called chronic renal failure. Some of the causes include:- Diabetic nephropathy or diabetic kidney disease Hypertensive nephropathy or kidney damage caused by persistent high blood pressure Long term glomerulonephritis Polycystic kidney disease Renal Failure Diagnostic Approach Renal failure denotes loss of kidney functions. This could be acute or sudden or chronic or long term as a result of chronic kidney disease. If there is protein but little or no blood, it indicates tubular damage or interstitial disease. Blood is also tested for electrolytes and minerals like sodium, potassium, calcium, phosphates, magnesium etc.
While in acute kidney injury there is a sharper rise in creatinine in blood indicating sudden onset renal damage, in chronic renal damage the levels rise more gradually but progressively as the glomerular filtration rate (GFR) declines. The patient may present with declining volume of urine, electrolyte imbalances and accumulation of fluids in the body. These include dehydration, severe fall in blood volume due to shock, blood loss or extensive burns, heart failure, cardiogenic shock,  anaphylactic shock, septic shock, Renal failure including those that are caused by diseases of the kidneys.
This includes acute tubular necrosis, toxins and drugs that damage kidneys, hemoglobinuria, myoglobinuria, myeloma light chains, pyelonephritis or acute glomerulonephritis. This obstruction maybe at the level of the ureter or at the level of the outflow of the urinary bladder.
Commonly chronic renal failure is the end result of kidney damage caused by diseases such as diabetes, high blood pressure etc. In fact most people who present with acute renal injury already have some degree of chronic renal damage.



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17.02.2014 admin



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