Falls in elderly hemodialysis patients

The elderly, (age ≥ 65 years) hemodialysis (HD) patient population is growing rapidly across the world. The risk of accidental falls is very high in this patient population due to multiple factors which include aging, underlying renal disease and adverse events associated with HD treatments. Falls, the most common cause of fatal injury among elderly, not only increase morbidity and mortality, but also increase costs to the health system. Prediction of falls and interventions to prevent or minimize fall risk and associated complications will be a major step in helping these patients as well as decreasing financial and social burdens. Thus, it is vital to learn how to approach this important problem. In this review, we will summarize the epidemiology, risk factors, pathophysiology and complications of falls in elderly HD patients. We will also focus on available methods to assess and predict the patients at higher risk of falling and will provide recommendations for interventions to reduce the occurrence of falls in this population.

Congenital club foot in a teaching hospital in Lagos, Nigeria

Congenital club foot has been sparsely reported in literature in Nigeria, although it has been reported as the commonest congenital musculoskeletal abnormality. This study enumerates the point prevalence of this disease in a university teaching hospital in Lagos. Better understanding of the epidemiology in our community should improve awareness, and influence management. Between June 2005 and July 2006, 72 consecutive patients with congenital club feet were seen in the orthopaedic clinic of our Hospital. Demographic data, birth weight, family history, birth facility, maternal age and associated congenital anomalies were recorded and analysed using Statistical Programme for Social Sciences (SPSS) version 15. A total of 72 patients were seen, 28 of whom had bilateral club feet resulting in a total of 100 feet. There were 38 males and 34 females. Only 29% presented in the first month of life and 28% in the second month. Maternal ages ranged between 19 and 38 years and no family history of congenital club foot was given,. Babies delivered outside the orthodox medical system (churches, traditional healers, home etc) constituted 28%. The commonest associated congenital anomalies were tibia hemimelia, hydrocephalus, inguinal hernia and umbilical hernia. A default rate of 28% was observed during treatment. Congenital club foot may not be uncommon in Nigeria. Late presentation and high default rate before correction of the deformity were observed. Establishment of special club foot clinics should reduce the default rate. Training of healthcare workers in maternity units as well as Public awareness should encourage early referral to specialists.

Hypercoagulation and thrombophilia in liver disease

A complex balance exists between endogenous procoagulants and the anticoagulant system in liver disease patients. Hypercoagulable events occur in cirrhosis patients despite the well-known bleeding diathesis of liver disease. These events may be clinically evident, such as in portal vein thrombosis or pulmonary embolism, but these conditions may also be a silent contributor to certain disease states, such as portopulmonary hypertension or parenchymal extinction with liver atrophy as well as thrombosis of extracorporeal circuits in dialysis or liver assist devices. Moreover, liver disease-related hypercoagulability may contribute to vascular disease in the increasingly common condition of non-alcoholic fatty liver disease. Despite the incidence of these problems, there are few widely accessible and practical laboratory tests to evaluate the risk of a hypercoagulable event in cirrhosis patients. Furthermore, there is little research on the use of commonly accepted anticoagulants in patients with liver disease. This article is a result of an international symposium on coagulation disorders in liver disease and addresses several areas of specific interest in hypercoagulation in liver disease. Critical areas lacking clinical information are highlighted and future areas of research interest are defined with an aim to foster clinical research in this field.

Age-related differences in renal function at onset of renal replacement therapy in chronic kidney disease stage 5 patients

BACKGROUND

Guidelines for initiating renal replacement therapy (RRT) are based on renal function and not age, so renal function at onset of RRT is expected to be similar across age groups.

AIM

To evaluate renal function at initiation of RRT across age groups.

DESIGN

Observational cross-sectional study.

METHODS

We extracted data for all incident chronic kidney disease (CKD) stage 5 patients (n = 322 064) commenced on chronic dialysis (haemodialysis and peritoneal) and renal transplant in the US from 1995 to 1999 from the US Renal Data Systems (USRDS). Subjects (n = 662) with incomplete data were excluded. The reminder (n = 321 402) were classified into five age groups: 0-19 years; 20-44 years; 45-64 years; 65-74 years; >/=75 years. Mean values of serum creatinine (Cr, mg/dl), creatinine clearance (CrCl, ml/min), body weight (kg) and body mass index (BMI, kg/m(2)) at onset of RRT were computed. Mean daily urinary creatinine excretion per kg body weight (CrCl x Cr/0.07/weight) was also calculated.

RESULTS

Progressively lower serum creatinine levels were found in adult patients with increasing age (10.70, 8.56, 7.38 and 6.88 mg/dl in those aged 20-44 years, 45-64 years, 65-74 years, >/=75 years, respectively). CrCl was also lower in the same groups (14.76, 13.38, 11.63 and 11.60 ml/min, respectively).

DISCUSSION

Older patients have a greater reduction in renal function than younger patients at onset of RRT, suggesting a delay in initiation of therapy.

Shunt nephritis from Propionibacterium acnes in a solitary kidney

Since its initial description in 1965, immune complex glomerulonephritis associated with ventriculoatrial shunts (VAS) has been reported widely in the literature. The most common incriminating organism is Staphylococcus epidermidis, but less often, an organism generally regarded as nonpathogenic, such as Propionibacterium acnes, has been noted as the cause. Shunt infection usually occurs within a few months after placement or manipulation of the shunt, and shunt nephritis (SN) develops gradually over months to years after. Treatment involves mandatory removal of the shunt and antibiotics; prognosis is variable. We report a case of SN with P acnes that is unusual because of its occurrence in a solitary kidney 6 years after shunt placement, persistently negative blood cultures, and normal complement levels. Percutaneous biopsy of a solitary kidney should be considered if it is expected that the result may guide therapy of progressive renal failure.

Impact of therapeutic plasma exchange on cyclosporine kinetics during membrane-based lipid apheresis

Cyclosporine is used widely as an immunosuppressant in transplant recipients and for various autoimmune diseases. In some cases, these patients require therapeutic plasma exchange (TPE). Cyclosporine is known to be highly bound to lipoproteins, and their removal by TPE would be expected to have an impact on drug dosing. We studied cyclosporine kinetics in a 54-year-old woman who is status post-cardiac transplant and has been receiving weekly TPE for familial hypercholesterolemia. We obtained serial measurements of cyclosporine, low-density lipoproteins, and high-density lipoproteins at scheduled times related to the dosing of the medication on days that she received TPE versus a day she did not. We also measured cyclosporine, low-density lipoprotein, and high-density lipoprotein levels in the fixed volume (3.5 L) of the discarded plasma. Our results show a similar rate of decline of serum cyclosporine levels on TPE days as compared with a day without TPE. Net cyclosporine in the discarded plasma was found to be approximately 1 mg per treatment or less, a relatively insignificant amount when compared with the ingested daily dose of 150 to 250 mg twice a day. Despite substantial removal of lipoproteins, there is minimal impact of TPE on serum levels of cyclosporine, and dosage adjustment is not needed for patients undergoing this procedure.

Maintenance of Glossina palpalis fed through bat's wing membrane on defibrinated blood

Teneral laboratory-bred Glossina palpalis flies were successfully fed through bat's wing membrane on defibrinated blood by means of a technique developed in this laboratory. Using this technique almost 100% of the flies engorged blood through the membrane. Ten to fifteen flies were kept in Standard 'Geigy 10' or 'Geigy 15' cages and records were kept of mortality and the weights of the pupae produced; over 78% of the flies were still after 60 days of the experiment. Over 75% of the membrane-fed G. palpalis females produced pupae in the first 30 days of the females' reproductive life. The mean weight of the pupae produced by the membrane-fed flies was 24.9 mg. The results indicate that membranes made from the African fruit bat wings are usable, and that this type of membrane would be valuable for a medium scale rearing programme for tsetse flies.