The Frequency of Withdrawal from Acute Care Is Impacted by Severe Acute Renal Failure

Introduction: In the general intensive care setting, decisions to withdraw life support when patients deteriorate despite aggressive treatment are estimated to occur in 10% of all patients and in 40% of the patients who die. Acute renal failure (ARF) severe enough to necessitate renal replacement therapy (RRT) is associated with in-hospital mortality approximating 50%. Yet the impact of severe ARF on decisions to withdraw treatment has not been previously described. In chronic renal failure patients, voluntary withdrawal from maintenance dialysis occurs in 10%–20% of patients when increasing complications and poor quality of life ensue, and knowing these data facilitates discussions with patients and families. Having similar data for complicated ARF would facilitate decision making for families and caregivers when these difficult situations arise. Methods: All cases of ARF requiring RRT during 2000–2001 at University of Michigan Hospital (n = 383) were entered prospectively into an outcome study at the time RRT was initiated. Comprehensive data collection included demographic and clinical characteristics, outcome and complications, and severity of illness. Additional information for patients who died included cause of death, life-support withdrawal decisions, and the presence of prior advance directives. Results: Overall mortality in severe ARF (i.e., severe enough to require RRT) was 53%. Lifesupport withdrawal occurred in 72% of deaths (compared to 40%–50% reported among general intensive care cases) and was associated with intensive care stay well beyond 2 weeks. Severity of illness, as indicated by modified APACHE III scores, was higher in patients who died than in survivors, but severity of illness was not higher for withdrawal from treatment than death without withdrawal decisions. Life-support withdrawal was not associated with other demographic or clinical characteristics (hospital service, primary admitting diagnosis, ventilator or pressor dependence, sepsis, or initial type of RRT chosen). Prior advance directives were available in 29% of patients overall, but having advance directives did not predict withdrawal from acute treatment. Death occurred within 2 days of withdrawal in more than 90% of cases, emphasizing the severity of underlying illness. Conclusions: Severe ARF reflects the severity of underlying illness, impacts overall survival, and is associated with more frequent withdrawal from aggressive treatment. High severity of illness and prolonged intensive care without improvement beyond 2 weeks presage decisions to withdraw treatment and signal patients and caregivers that death is imminent and that further aggressive care should be reconsidered or limited.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/63219/1/jpm.2004.7.676.pd

Peritoneoscopy in the management of catheter malfunction during continuous ambulatory peritoneal dialysis

Continuous ambulatory peritoneal dialysis is widely used in the maintenance of patients with chronic renal failure. Obstruction or displacement of the chronic dialysis catheter, which prevents dialysate drainage, can compromise ongoing dialysis. Conservative approaches (body position change, saline infusion, and enema) are often unsuccessful and more aggressive therapy may be required. We report the use of peritoneoscopy to reposition malfunctioning peritoneal dialysis catheters. The procedure proved to be safe and gave excellent long-term results.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/44395/1/10620_2005_Article_BF01318180.pd

Epoprostenol (PGI2, Prostacyclin) During High‐Risk Hemodialysis: Preventing Further Bleeding Complications

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/97231/1/j.1552-4604.1988.tb03222.x.pd

Kinetics, dynamics, and bioavailability of bumetanide in healthy subjects and patients with chronic renal failure

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/109801/1/cptclpt1986112.pd

Thoughts and Progress

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/75183/1/j.1525-1594.1999.06248.x.pd

Atrial natriuretic hormone secretion in patients with renal failure

To study the effects of volume overload and renal failure on plasma levels of immunoreactive atrial natriuretic hormone (IR-ANH), we measured levels of this hormone in normal subjects, in patients with advanced chronic renal failure (CRF) with and without clinically evident volume overload, and in patients with end-stage renal disease (ESRD) treated with chronic hemodialysis. The levels were 13 +/- 2 pmol/l in normal volunteers, 77 +/- 24 pmol/lin patients with CRF without volume overload, and 219 +/- 50 pmol/l in patients with CRF and clinically evident volume overload (analysis of variance, p Volume overload appears to be the most important stimulatory factor for ANH secretion in renal failure patients but other mechanisms, especially a decrease in metabolic clearance, may also contribute to elevated plasma levels. The increased secretion of ANH in patients with renal failure may be an important adaptive response to volume overload and hypertension.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/26573/1/0000112.pd

Radiologic features of a pyrophosphate-like arthropathy associated with long-term dialysis

In a series of 28 long-term dialysis patients with musculoskeletal complaints, the radiologic findings in six cases resembled those occurring in the arthropathy of idiopathic calcium pyrophosphate dihydrate deposition (CPPD) disease. These findings included osteophytes, subchondral cysts, and cartilage loss in the metacarpophalangeal joints, patellofemoral joints, wrists, and shoulders. Chondrocalcinosis was present in three of the six cases. There were no significant differences in renal function or levels of serum calcium, phosphorus, iron, ferritin, aluminum, or parathormone between these patients and a control group matched for sex and age. Long-term dialysis may be associated with a metabolic arthritis similar to the arthritis which occurs in CPPD deposition disease. The etiology may include deposition of CPPD crystals, hydroxyapatite, or other calcium-containing substances in joints, or it may be related to a number of dialysis-induced metabolic abnor-malities.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/46785/1/256_2004_Article_BF00350536.pd

Ecosystem Interactions Underlie the Spread of Avian Influenza A Viruses with Pandemic Potential

Despite evidence for avian influenza A virus (AIV) transmission between wild and domestic ecosystems, the roles of bird migration and poultry trade in the spread of viruses remain enigmatic. In this study, we integrate ecosystem interactions into a phylogeographic model to assess the contribution of wild and domestic hosts to AIV distribution and persistence. Analysis of globally sampled AIV datasets shows frequent two-way transmission between wild and domestic ecosystems. In general, viral flow from domestic to wild bird populations was restricted to within a geographic region. In contrast, spillover from wild to domestic populations occurred both within and between regions. Wild birds mediated long-distance dispersal at intercontinental scales whereas viral spread among poultry populations was a major driver of regional spread. Viral spread between poultry flocks frequently originated from persistent lineages circulating in regions of intensive poultry production. Our analysis of long-term surveillance data demonstrates that meaningful insights can be inferred from integrating ecosystem into phylogeographic reconstructions that may be consequential for pandemic preparedness and livestock protection.National Institutes of Health (U.S.) (NIH Centers for Excellence in Influenza Research and Surveillance (CEIRS, contract # HHSN266200700010C))National Institutes of Health (U.S.) (NIH Centers for Excellence in Influenza Research and Surveillance (CEIRS, contract # HHSN272201400008C))National Institutes of Health (U.S.) (NIH Centers for Excellence in Influenza Research and Surveillance (CEIRS, contract # HHSN272201400006C)

Comparison of quality control methods for automated diffusion tensor imaging analysis pipelines

© 2019 Haddad et al. The processing of brain diffusion tensor imaging (DTI) data for large cohort studies requires fully automatic pipelines to perform quality control (QC) and artifact/outlier removal procedures on the raw DTI data prior to calculation of diffusion parameters. In this study, three automatic DTI processing pipelines, each complying with the general ENIGMA framework, were designed by uniquely combining multiple image processing software tools. Different QC procedures based on the RESTORE algorithm, the DTIPrep protocol, and a combination of both methods were compared using simulated ground truth and artifact containing DTI datasets modeling eddy current induced distortions, various levels of motion artifacts, and thermal noise. Variability was also examined in 20 DTI datasets acquired in subjects with vascular cognitive impairment (VCI) from the multi-site Ontario Neurodegenerative Disease Research Initiative (ONDRI). The mean fractional anisotropy (FA), mean diffusivity (MD), axial diffusivity (AD), and radial diffusivity (RD) were calculated in global brain grey matter (GM) and white matter (WM) regions. For the simulated DTI datasets, the measure used to evaluate the performance of the pipelines was the normalized difference between the mean DTI metrics measured in GM and WM regions and the corresponding ground truth DTI value. The performance of the proposed pipelines was very similar, particularly in FA measurements. However, the pipeline based on the RESTORE algorithm was the most accurate when analyzing the artifact containing DTI datasets. The pipeline that combined the DTIPrep protocol and the RESTORE algorithm produced the lowest standard deviation in FA measurements in normal appearing WM across subjects. We concluded that this pipeline was the most robust and is preferred for automated analysis of multisite brain DTI data