Eli A. Friedman

Patients' Understanding of Their Treatment Plans and Diagnosis at Discharge

OBJECTIVE To ascertain whether patients at discharge from a municipal teaching hospital knew their discharge diagnoses, treatment plan (names and purpose of their medications), and common side effects of prescribed medications. PATIENTS AND METHODS From July to October 1999, we surveyed 47 consecutive patients at discharge from the medical service of a municipal teaching hospital in New York City (Brooklyn, NY). Patients were asked to state either the trade or the generic name(s) of their medication(s), their purpose, and the major side effect(s), as well as their discharge diagnoses. Patients were excluded if they were not oriented to person, place, and time, were unaware of the circumstances surrounding their admission to the hospital, and/or did not speak or understand English. RESULTS Of the 47 patients surveyed, 4 were excluded. Of the remaining 43 patients, 12 (27.9%) were able to list all their medications, 16 (37.2%) were able to recount the purpose of all their medications, 6 (14.0%) were able to state the common side effect(s) of all their medications, and 18 (41.9%) were able to state their diagnosis or diagnoses. The mean number of medications prescribed at discharge was 3.89. CONCLUSIONS Less than half of our study patients were able to list their diagnoses, the name(s) of their medication(s), their purpose, or the major side effect(s). Lacking awareness of these factors affects a patients ability to comply fully with discharge treatment plans. Whether lack of communication between physician and patient is actually the cause of patient unawareness of discharge Instructions or if this even affects patient outcome requires further study.

Excess morbidity in patients starting uremia therapy without prior care by a nephrologist

Many inner-city residents with progressive renal disease do not receive specialist care from a nephrologist, and often arrive in the emergency room manifesting life-threatening uremic symptoms requiring emergency rescue dialysis. We examined the relationship between the quality of medical care received during progression to end-stage renal disease, and the clinical condition and morbidity at initiation of renal replacement therapy. During a 5-year period (January 1990 to December 1994), we prospectively studied 139 consecutive inner-city residents with a confirmed diagnosis of chronic renal failure who were starting uremia therapy. At onset of study, subjects were sorted into one of three groups depending on the extent of medical care received during the 3 years immediately preceding initiation of hemodialysis: nephrologist, nonnephrologist (physician), or no medical care. Information obtained from each subject included length of hospital stay during the admission for initiation of dialysis therapy and the type of hemodialysis vascular access used for first dialysis treatment (permanent v temporary). Predialysis blood urea nitrogen concentration, serum creatinine concentration, serum albumin concentration, and serum bicarbonate concentration were measured once immediately before the first dialysis. The 139 study subjects (62 men and 77 women) comprised 116 blacks (83%), 15 Hispanics (11%), and eight whites (6%), and had a mean age of 56 +/- 15 years (+/-SD). Only 59 (43%) subjects received prior specialist nephrologist care, and their mean length of hospital stay (12 +/- 23 days) was shorter than that of subjects who received nonnephrologist care (n = 63 [45%]; 25 +/- 21 days) or those who received no prior medical care (n = 17 [12%]; 29 +/- 23 days) (P = 0.002). Temporary hemodialysis vascular access was used for the first dialysis in all 17 (100%) of the subjects with no prior medical care, in 56 (89%) of the 63 subjects who received prior care from a nonnephrologist, and in 21 (36%) of the 59 subjects who received prior care from a nephrologist (P = 0.0001). Subjects who received prior care from a nephrologist had a lower mean serum creatinine concentration at initiation of dialysis (11 +/- 4.4 mg/dL) than did either the subjects who received nonnephrologist care (13 +/- 5.4 mg/dL) or no medical care (16 +/- 5.7 mg/dL) (P = 0.003). In addition, subjects who received prior care from a nephrologist had less severe metabolic acidosis than the subjects in the other two groups (P = 0.04). We infer that initiation of uremia therapy is delayed in inner-city residents with progressive renal failure who do not receive specialist nephrologic care, and that as a consequence these patients suffer excess short-term morbidity.

Delayed referral of black, Hispanic, and older patients with chronic renal failure

Delayed referral (defined as a serum creatinine concentration > 4 mg/dL at referral) of patients with chronic renal failure to the nephrologist is common in the United States. We retrospectively examined the records of 220 consecutive patients referred to an urban teaching hospital nephrology division for evaluation of chronic renal failure from January 1987 to December 1994 to detect any relationship between race, renal diagnosis, or age and the timing of referral of medically-insured patients with chronic renal failure. We documented serum creatinine concentration and hematocrit at referral, length of time under the care of a nephrologist (interval from referral to initiation of dialysis), and total number of clinic visits. The 220 study subjects (120 women, 100 men) included 139 blacks (63%), 61 whites (28%), 16 Hispanics (7%), and 4 Asians (2%) aged 51.7 +/- 1.06 years (mean +/- standard error of the mean) at referral. At referral, nonwhites (black and Hispanic patients) had a greater mean serum creatinine concentration than whites (4.3 +/- 0.38 v 3 +/- 0.24 mg/dL; P = 0.001), as well as a lower mean hematocrit (31.7% +/- 1.3% v 34.7% +/- 0.9%; P = 0.001). Mean length of time under the care of a nephrologist was shorter in nonwhites (13 +/- 0.8 months) than whites (43.5 +/- 4.8 months; P = 0.001). Delayed referral was almost six times more likely in nonwhites than whites (odds ratio, 5.6; 95% confidence interval [CI], 1.52 to 20; P = 0.008) and five times more likely in those aged older than 55 years than in those 55 years or younger (odds ratio, 4. 7; 95% CI, 1.37 to 16; P = 0.01). The greater the serum creatinine concentration at referral, the greater the odds of receiving less than 12 months of nephrologic care before initiation of dialysis (odds ratio, 1.8; 95% CI, 1.04 to 3.13; P = 0.03). We conclude that even among those patients with health insurance, delayed referral to the nephrologist is more likely in black, Hispanic, and older patients with chronic renal failure than in their white or younger counterparts.

Pilot Study of Probiotic Dietary Supplementation for Promoting Healthy Kidney Function in Patients with Chronic Kidney Disease

IntroductionUremic syndrome consists of nitrogenous waste retention, deficiency in kidney-derived hormones, and reduced acid excretion, and, if untreated, may progress to coma and eventual death. Previous experience suggests that oral administration of a probiotic formulation of selected microbial strains may extend renoprotection via intraintestinal extraction of toxic waste solutes in patients with chronic kidney disease (CKD)stages 3 and 4. This report presents preliminary data from a pilot study.MethodsThis was a 6-month prospective, randomized, double-blind, placebo-controlled crossover trial of a probiotic bacterial formulation conducted in four countries, at five institutions, on 46 outpatients with CKD stages 3 an nd 4: USA (n=10), Canada (n=113), Nigeria (n=115), and Argentina (n=8). Outcomes were compared using biochemical parameters:blood urea nitrogen (BUN), serum creatinine, and uric acid. General well-being was assessed as a secondary parameter by a quality of life (QQOL) questionnaire on a subjective scale of 1–10.ResultsOral ingestion of probiotics (90 billion colony forming units [CFUs]/day) was well tolerated and safe during the entire trial period at all sites. BUN levels decreased in 29 patients (63%, P<0.05), creatinine levels decreased in 20 patients (43%, no statistical significance), and uric acid levels decreased in 15 patients (33%, no statistical significance). Almost all subjects expressed a perceived substantial overall improvement in QOL (86%, P<0.05).ConclusionThe main outcomes of this preliminary trial include a significant reduction of BUN, enhanced well-being, and absence of serious adverse effects, thus supporting the use of the chosen probiotic formulation for bowel-based toxic solute extraction. QOL and BUN levels showed statistically significant differences in outcome (P<0.05) between placebo and probiotic treatment periods at all four sites (46 patients). A major limitation of this trial is the small sample size nd elated inconsistencies.

Zidovudine Is Beneficial in Human Immunodeficiency Virus Associated Nephropathy

Human immunodeficiency virus associated nephropathy (Hivan) is a distinct renal disease described in patients infected with the human immunodeficiency virus (HIV). Hivan is characterized by a nephrotic syndrome, enlarged kidneys, a histologic finding of focal and segmental glomerulosclerosis, and a very rapid progression to end-stage renal disease (ESRD). No therapeutic intervention has been shown, in a prospective evaluation, to either alter the course of established Hivan or to influence the emergence of Hivan in HIV-infected patients. We conducted a prospective study on 23 consecutively selected patients seen between 1989 and 1992 who were infected with the HIV, 14 (61%) of whom had significant proteinuria (> or = 2+). Percutaneous kidney biopsy was performed in 5 (36%) of the 14 subjects who had significant proteinuria, and histologic examination of the kidney tissue revealed focal and segmental glomerulosclerosis in all 5 cases. Of the 14 subjects with proteinuria, 8 (57%) also had azotemia (serum creatinine level > or = 1.3 mg/dl). Nine (39%) of 23 subjects admitted intravenous drug use, while 9 (39%) of 23 subjects have had an opportunistic infection before enrollment in the study. The known duration of HIV infection before initiation of zidovudine therapy was 10.3 +/- (SD) 8 months. The mean CD4 count before zidovudine therapy was 195.9 +/- 117 (range 21-654) cells/mm3. The mean dose of zidovudine administered was 543 +/- 117 (range 400-800) mg daily for a period of 20.4 +/- 11 (range 6-38) months.(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise in Hemodialysis Patients after Treatment with Recombinant Human Erythropoietin

To assess the effect of substantial increases in blood hemoglobin (Hb) caused by treatment with recombinant human erythropoietin (rhEPO) on exercise capacity in maintenance hemodialysis patients, we evaluated 10 patients (7 men and 3 women) at a mean age of 44.3 +/- 8.4 years on maintenance hemodialysis for a mean of 29.7 +/- 30.2 months by treadmill exercise to exhaustion. The patients were tested before administration of rhEPO and after a minimum 1 g/dl rise in Hb. With a change in Hb from 7.1 +/- 1.4 to 9.8 +/- 2.1 g/dl, peak oxygen consumption (VO2 peak) with exercise increased 50.3 +/- 9% (T1 = 15.1 +/- 5.3, T2 = 22.7 +/- 4.6 ml O2/kg/min, p less than 0.05). Respiratory exchange ratio (RER) at a given submaximal exercise level (3 mph, 6% of elevation) decreased significantly (T1 = 1.13 +/- 0.24, T2 = 0.92 +/- 0.08, p less than 0.05). The rhEPO-mediated increase in Hb was associated with an increased VO2 peak--an improvement of the peak exercise capacity and a reduced submaximal RER--reflecting a reduction in anaerobic metabolism at activities of daily living.

Probiotic dietary supplementation in patients with stage 3 and 4 chronic kidney disease: a 6-month pilot scale trial in Canada

ABSTRACT Aim: This was a pilot clinical trial to assess biochemical and clinical effects of an oral probiotic dietary supplement in chronic kidney disease (CKD) patients (stages 3 and 4). Methods: A prospective, randomized, double-blind, crossover, placebo-controlled, 6-month trial of probiotic bacteria was conducted in 16 outpatients in Ontario, Canada. Primary endpoints included effect on hematologic, biochemical, and fecal variables, and on general well-being as assessed by quality of life (QOL). These outcomes were evaluated from biochemical parameters, mainly blood urea nitrogen (BUN), creatinine, uric acid, and C-reactive protein (CRP) as a general inflammatory marker. QOL was assessed on a subjective scale of 1 to 10 as the secondary parameter. Trial registration: This pilot study forms part of registered trial NCT00760162. Results: A total of 13 patients completed the study. Three patients dropped out: one was the receiver of a transplant. The second dropped out for unknown reasons and the third died of myocardial infarction (unrelated to probiotic bacteria or the protocol). Among the 13 patients who completed the trial, the mean change in BUN concentration during the probiotic treatment period (−2.93 mmol/L) differed significantly (p = 0.002) from the mean change in BUN concentration during the placebo period (4.52 mmol/L). In addition, the mean changes in uric acid concentration were moderate during the KB period (24.70 μmol/L) versus during the placebo period (50.62 μmol/L, p = 0.050), and the changes in serum creatinine concentration were insignificant. Neither gastrointestinal nor infectious complications were noted in any subject with improved QOL. Conclusion: Orally administered probiotic bacteria selected to metabolize nitrogenous wastes may be tolerated for as long as 6 months. A major limitation of this trial is its small size that may have precluded detection of changes in other biochemical or hematologic parameters that would be evident in larger cohorts. Extension of the evaluation of this probiotic bacterial mixture will include a dose escalation trial in a similar prospective, placebo-controlled, and double-blind study site.

Erythropoietin in diabetic macular edema and renal insufficiency

Erythropoietin was administered to five anemic azotemic diabetic subjects for 1 year to assess the effect of increasing red cell mass on clinical well-being and the course of renal functional decline. None of the subjects manifested worsened hypertension or cerebrovascular or cardiovascular complications despite an increase in mean hematocrit from a baseline mean of 29.6% to a mean of 39.5%. The serum creatinine concentration after 1 year of treatment with erythropoietin was 3.7 mg/dL, which was unchanged from the baseline value of 3.5 mg/dL. Plasma viscosity remained constant as red cell mass increased. Although the viscosity of whole blood rose as the hematocrit increased, it was within the range of normal blood viscosity for an equivalent hematocrit. The favorable impact of erythropoietin treatment on three diabetic subjects who had macular edema and anemia is described. One hypothesis to explain the benefit of a raised hematocrit on both diabetic nephropathy and retinopathy is that the metabolic, hormonal, and hemodynamic components of the diabetic syndrome, in concert, produce tissue and cellular hypoxia that is ameliorated in part by the greater oxygen-transporting capacity of a raised red cell mass. The pseudohypoxia of diabetes may be implicated in the pathogenesis of diabetic neuropathy, retinopathy, muscular dysfunction, and nephropathy.

Outcome of severe acute renal failure in patients with acquired immunodeficiency syndrome

Among a spectrum of renal disorders encountered in patients infected with the human immunodeficiency virus (HIV), the lesion studied most often has been the glomerular disease known as HIV-associated nephropathy. Of the other coincidental renal perturbations reported, the most significant are a heterogenous group encompassing potentially reversible acute renal failure (ARF), primarily acute tubular necrosis. While HIV-associated nephropathy may frequently be seen in asymptomatic HIV-seropositive individuals, acute tubular necrosis almost always is encountered in patients with clinical acquired immunodeficiency syndrome (AIDS). We analyzed our decades experience in the management of 146 HIV disease patients with ARF (132 AIDS patients and 14 HIV-seropositive patients) and compared it with a contemporaneous group of 306 non-HIV subjects with ARF. All patients evaluated for ARF between January 1984 and December 1993 by the Renal Division at Kings County Hospital Center, Brooklyn, NY, were reviewed. Only those patients with ARF who reached a serum creatinine concentration of 530 mumol/L or higher were included in the analysis. Ninety-one percent of 146 HIV disease patients with ARF were less than 50 years old compared with only 33% of the 306 non-HIV subjects (P < 0.001). Septicemia was directly or indirectly responsible for 75% of patients with ARF in the AIDS group and for 39% in the non-HIV subjects (P < 0.006). Urinary tract obstruction was the cause of ARF in 54 of 306 (17%) non-HIV patients compared with none in the HIV group (P < 0.00001).(ABSTRACT TRUNCATED AT 250 WORDS)

Gouty Arthritis in End-Stage Renal Disease: Clinical Course and Rarity of New Cases

We studied 201 end-stage renal disease (ESRD) patients sustained on maintenance hemodialysis (MD) (n = 164) and chronic ambulatory peritoneal dialysis (CAPD) (n = 37) to determine (1) the frequency of acute attacks of gouty arthritis (GA) in those ESRD patients who had GA before dialytic therapy, and (2) the incidence of new-onset GA in hyperuricemic long-term (> 12 years) ESRD patients on MD. The 2-month mean of predialysis serum uric acid levels was calculated for each subject and the prevalence of hyperuricemia ascertained. There were 25 patients on MD for more than 12 years, and this group was evaluated and analyzed separately from those patients on dialytic therapy for less than 12 years; the mean of each of their predialysis uric acid values was calculated for each subject for at least 60% of the time they have been on dialysis. Patients who had GA before or after initiation of dialytic therapy were identified, and the frequency of acute attacks of GA determined. The presence of treated hypertension in each subject was noted. Thirteen of 201 patients had clinically active GA before commencing dialytic therapy, and each recalled a minimum of two painful attacks of GA per year before the initiation of ESRD therapy. Mean duration of ESRD for these 13 patients was 25 +/- 3.8 months; painful attacks of GA have not recurred in nine patients (70%), and the frequency of attacks declined by 50% in the remaining four patients (30%), despite persistent hyperuricemia in all 13.(ABSTRACT TRUNCATED AT 250 WORDS)