Michael Germain | Tufts University School of Medicine (original) (raw)

Papers by Michael Germain

Kidney Medicine, 2020

In patients with advanced-stage chronic kidney disease (CKD), progressive kidney function decline... more In patients with advanced-stage chronic kidney disease (CKD), progressive kidney function decline leads to increased risk for hyperkalemia (serum potassium > 5.0 or >5.5 mEq/L). Medications such as reninangiotensin-aldosterone system inhibitors pose an additional hyperkalemia risk, especially in patients with CKD. When hyperkalemia develops, clinicians often recommend a diet that is lower in potassium content. This review discusses the barriers to adherence to a low-potassium diet and the impact of dietary restrictions on adverse clinical outcomes. Accumulating evidence indicates that a diet that incorporates potassium-rich foods has multiple health benefits, which may also be attributable to the other vitamin, mineral, and fiber content of potassium-rich foods. These benefits include blood pressure reductions and reduced risks for cardiovascular disease and stroke. High-potassium foods may also prevent CKD progression and reduce mortality risk in patients with CKD. Adjunctive treatment with the newer potassiumbinding agents, patiromer and sodium zirconium cyclosilicate, may allow for optimal renin-angiotensinaldosterone system inhibitor therapy in patients with CKD and hyperkalemia, potentially making it possible for patients with CKD and hyperkalemia to liberalize their diet. This may allow them the health benefits of a high-potassium diet without the increased risk for hyperkalemia, although further studies are needed.

Journal of the American Society of Nephrology : JASN, Jan 16, 2017

CKD is steadily increasing along with obesity worldwide. Furthermore, obesity is a proinflammator... more CKD is steadily increasing along with obesity worldwide. Furthermore, obesity is a proinflammatory risk factor for progression of CKD and cardiovascular disease. We tested the hypothesis that implementation of caloric restriction and aerobic exercise is feasible and can improve the proinflammatory metabolic milieu in patients with moderate to severe CKD through a pilot, randomized, 2×2 factorial design trial. Of 122 participants consented, 111 were randomized to receive caloric restriction and aerobic exercise, caloric restriction alone, aerobic exercise alone, or usual care. Of those randomized, 42% were women, 25% were diabetic, and 91% were hypertensive; 104 started intervention, and 92 completed the 4-month study. Primary outcomes were a change from baseline in absolute fat mass, body weight, plasma F2-isoprostane concentrations, and peak oxygen uptake (VO2 peak). Compared with usual care, the combined intervention led to statistically significant decreases in body weight and bo...

Clinical kidney journal, 2017

Chronic kidney disease (CKD) is associated with abnormal lipid profiles and altered high-density ... more Chronic kidney disease (CKD) is associated with abnormal lipid profiles and altered high-density lipoprotein (HDL) particle size patterns. Lower levels of the larger, cardioprotective HDL particles found in CKD may play a role in the increased risk for cardiovascular disease in these patients. The current study was designed to assess the effects of short-term moderate-intensity aerobic exercise training on the HDL particle pattern and overall lipid profiles in stage 3 CKD patients. Forty-six men and women with stage 3 CKD were randomized to either exercise (EX, n = 25) or control (CON, n = 21). Those in the EX group completed 16 weeks of supervised moderate-intensity aerobic exercise three times per week. Serum total cholesterol, HDL cholesterol (HDL-C), triglycerides (TGs), low-density lipoprotein cholesterol (LDL-C), HDL particle size, estimated glomerular filtration rate (eGFR), body composition and peak oxygen uptake (VO2peak) were assessed at baseline and week 16. The rate of c...

Clinical journal of the American Society of Nephrology : CJASN, Jan 3, 2016

We aimed to determine the proportion of patients who switched to dialysis after confirmed plans f... more We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end of life care among patients choosing conservative care with those initiating RRT. A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two-sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival. In total, 102 of 721 patients planned for conservative care, and median age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a...

Clinical journal of the American Society of Nephrology : CJASN, Jan 10, 2016

In using a patient-centered approach, neither a clinician nor a prognostic score can predict with... more In using a patient-centered approach, neither a clinician nor a prognostic score can predict with absolute certainty how well a patient will do or how long he will live; however, validated prognostic scores may improve accuracy of prognostic estimates, thereby enhancing the ability of the clinicians to appreciate the individual burden of disease and the prognosis of their patients and inform them accordingly. They may also facilitate nephrologist's recommendation of dialysis services to those who may benefit and proposal of alternative care pathways that might better respect patients' values and goals to those who are unlikely to benefit. The purpose of this article is to discuss the use as well as the limits and deficiencies of currently available prognostic tools. It will describe new predictors that could be integrated in future scores and the role of patients' priorities in development of new scores. Delivering patient-centered care requires an understanding of patie...

In this chapter we will discuss the emerging issues and controversies in anemia management in Chr... more In this chapter we will discuss the emerging issues and controversies in anemia management in Chronic Kidney Disease (CKD). The normal physiologic control of erythropoiesis and the pathophysiology in CKD will be discussed specifically with regards to current problems with dosing protocols and novel approaches to improve these issues. The causes and treatments of resistance to erythropoiesis stimulating agents (ESAs), hemoglobin cycling and variability will be addressed. The emerging safety concerns with ESAs and novel ESAs that may be safer will be discussed

BMC palliative care, Jan 12, 2015

End-stage renal disease carries a prognosis similar to cancer yet only 20 % of end-stage renal di... more End-stage renal disease carries a prognosis similar to cancer yet only 20 % of end-stage renal disease patients are referred to hospice. Furthermore, conversations between dialysis team members and patients about end-of-life planning are uncommon. Lack of provider training about how to communicate prognostic data may contribute to the limited number of end-of-life care discussions that take place with this chronically ill population. In this study, we will test the Shared Decision-Making Renal Supportive Care communication intervention to systematically elicit patient and caretaker preferences for end-of-life care so that care concordant with patients' goals can be provided. This multi-center study will deploy an intervention to improve end-of-life communication for hemodialysis patients who are at high risk of death in the ensuing six months. The intervention will be carried out as a prospective cohort with a retrospective cohort serving as the comparison group. Patients will b...

Blood purification, 2015

The CKD population is becoming increasingly elderly with multiple comorbidities. For this reason,... more The CKD population is becoming increasingly elderly with multiple comorbidities. For this reason, accurate predictive information related to the progression into ESRD, mortality, and functional decline is critical to allow for optimal shared decision making (SDM). This review will assess the current literature on the methodologies for the estimation of prognosis and prognostic tools developed for CKD. A practical clinical approach is discussed that involves the estimation of prognosis and integration of prognosis into SDM. Key Message: There are validated, easy-to-use prognostic tools that help clinicians engage in effective shared decision making with their CKD patients and family. © 2015 S. Karger AG, Basel.

Transplantation, 2000

Two patients underwent cadaver transplantation with kidneys from a donor with a history of World ... more Two patients underwent cadaver transplantation with kidneys from a donor with a history of World Health Organization Class IV/V lupus nephritis, and we report their clinical and pathological outcome. The donor had a diagnosis of lupus nephritis made by renal biopsy 5 years before donation. At the time of donation, a biopsy was performed on the donor and on one of the recipients at 2 months and 1 year after the transplant. Both recipients underwent uneventful renal transplantation. On the first postoperative day, the donor's final pathological results became available. Although the frozen section seemed to be quite benign, the permanent sections revealed World Health Organization Class II/V lupus nephritis, with full house immunofluorescence and multiple electron dense deposits. Biopsies were performed on recipient #2 at 8 weeks and 1 year after the transplant. These revealed marked diminution followed by complete resolution of all tubular reticular structures and deposits as well as immunofluorescent activity. Both recipients remain with normal renal function and urinalysis at 3 years after the transplant. Although a history of clinically significant renal disease has been considered an absolute contraindication to kidney donation, with appropriate workup and caution, select patients may still be considered, which would increase the potential donor pool.

Transplant International, 1999

With the introduction of cyclosporine (CyA) to clinical transplantation, marked improvement in ea... more With the introduction of cyclosporine (CyA) to clinical transplantation, marked improvement in early renal allograft survival occurred [9]. It was noted, however, that there appeared to be little change in the rate of allograft loss after the first post-transplant year compared to conventional immunosuppression with azathioprine (AZA) and steroids [6, 8]. Several possible explanations exist that address this observation. First, the beneficial effect of CyA could be limited to the early post-transplant period with respect to a decrease in the rate of allograft loss due to acute rejection. CyA may have no effect on the most common cause of allograft loss after the first year: chronic rejection. Alternatively, a decrease in overall, long-term allograft survival caused by a nonimmunologic, chronic CyA nephrotoxicity could overshadow the benefits of CyA on early allograft survival.

Transplant International, 2000

Acute rejection. Chronic rejection Abbreviations A R Acute rejection. CG Cockcroft-Gault (method)... more Acute rejection. Chronic rejection Abbreviations A R Acute rejection. CG Cockcroft-Gault (method)-CR Chronic rejection * CyA Cyclosporine * IoCl Iothalamate clearance 4 Scr Serum creatinine

Psychosomatics, 2004

Renal failure is a common medical condition, and many patients have comorbid psychiatric disorder... more Renal failure is a common medical condition, and many patients have comorbid psychiatric disorders. In this review, which is intended as a resource for consultation psychiatrists, the authors discuss pharmacokinetic considerations and provide information about the use of individual psychotropic medications in patients with renal disease. Most psychotropic medications are fat soluble, easily pass the blood-brain barrier, are not dialyzable, are metabolized primarily by the liver, and are excreted mainly in bile. Consequently, the majority of these drugs can be safely used with the end-stage renal disease population.

Nephrology Dialysis Transplantation, 2013

The burgeoning population of older dialysis patients presents opportunities to provide personaliz... more The burgeoning population of older dialysis patients presents opportunities to provide personalized care. The older dialysis population has a high burden of chronic health conditions, decrements in quality of life and a high risk of death. In order to address these challenges, this review will recommend routinely establishing prognosis through the use of prediction instruments and communicating these findings to older patients. The challenges to prognosis in adults with end-stage renal disease (ESRD) include the subjective nature of clinical judgment, application of appropriate prognostic tools and communication of findings to patients and caregivers. There are three reasons why we believe these conversations occur infrequently with the dialysis population. First, there have previously been no clinically practical instruments to identify individuals undergoing maintenance hemodialysis (HD) who are at highest risk for death. Second, nephrologists have not been trained to have conversations about prognosis and end-of-life care. Third, other than hospitalizations and accrual of new diagnoses, there are no natural milestone guidelines in place for patients supported by dialysis. The prognosis can be used in shared decision-making to establish goals of care, limits on dialysis support or parameters for withdrawal from dialysis. As older adults with ESRD benefit from kidney transplantation, prognosis can also be used to determine who should be referred for evaluation by a kidney transplant team. The use of prognosis in older adults may determine approaches to optimize well-being and personalize care among older adults ranging from hospice to kidney transplantation.

Journal of Pediatric Surgery, 1997

is a known complication after renal trauma. The cause of posttraumatic hypertension can be renal ... more is a known complication after renal trauma. The cause of posttraumatic hypertension can be renal scarring, infarction, hydonephrosis, infection, vascular injury, and parenchymal compression. The authors report on the case of a 16-year-old boy who experienced hypertension after blunt renal trauma. He had a dense fibrous pseudocapsule causing renal parenchymal compression, which lead to hypertension, a Page kidney. Evaluation with computed tomographic (CT) scan, radioisotope renal scan, renal Doppler, and angiogram confirmed the diagnosis. Removal of the renal capsule and the constricting fibrous pseudocapsule was curative.

JAMA, 2003

Mr D was a 78-year-old man with end-stage renal disease (ESRD) from diabetes and hypertensive nep... more Mr D was a 78-year-old man with end-stage renal disease (ESRD) from diabetes and hypertensive nephrosclerosis. He had a prior history of multiple episodes of aspiration pneumonia. For the past 2 years Mr D resided in a convalescent home, where he was visited frequently by his daughter, son, and their families. Mr D was transferred from his skilled nursing facility to the university hospital with cough, fever, and hypoxia. Mr D had had diabetes for 10 years, with repeated hospitalizations for nonketotic hyperosmolar state. Comorbid disorders included vascular dementia, atrial fibrillation, chronic lymphocytic leukemia, emphysema, pleural effusion, colonic diverticulosis, and tubular adenoma. Hemodialysis was begun 30 months prior to his final admission, but he became progressively more lethargic, less verbal, and physically weaker. A formal advance directive was never completed. On several occasions Mr D's children, and both Dr A, his family practice physician, and Dr E, his nephrologist, had discussed Mr D's deteriorating condition and the treatment alternatives that were available, including cessation of dialysis. For some time the family disagreed with respect to the goals of treatment. Despite the episodic illnesses, Mr D still seemed to relish eating and clearly enjoyed visits. Nonetheless, the repeated hospitalizations and Mr D's failure to regain his baseline status after each episode weighed heavily on his children. By the time of his most recent hospitalization, he was no longer able to eat, and talk turned to a feeding tube and other invasive support. His family painfully deliberated over this course of action and finally agreed to dialysis cessation. Mr D was unable to meaningfully participate in this decision. Five days following his last session, Mr D died in the palliative care unit of the hospital.

Clinical Journal of the American Society of Nephrology, 2010

Background and objectives: Anemia Management Protocols in ESRD call for hemoglobin (Hb) monitorin... more Background and objectives: Anemia Management Protocols in ESRD call for hemoglobin (Hb) monitoring every 2 to 4 weeks. Short-term Hb variability affects the reliability of Hb measurement and may lead to incorrect dosing of erythropoiesis stimulating agents. We prospectively analyzed short-term Hb variability and quantified the relationship between frequency of Hb monitoring and error in Hb estimation. Design, setting, participants, & measurements: Using the Crit-Line III TQA device, we prospectively observed Hb during each dialysis treatment in 49 ESRD patients and quantified long-and short-term Hb variability. We estimated Hb from data sampled at regular intervals; 8؋, 4؋, 2؋, or 1؋ per month to establish how well we account for short-term variability at different monitoring intervals. We calculated the Hb estimation error (Hb err) as a root mean-squared difference between the observed and estimated Hb and compared it with the measurement error. Results: The most accurate Hb estimation is achieved when monitoring 8؋ per month (Hb err ‫؍‬ 0.23 ؎ 0.05 g/dl), but it exceeds the accuracy of the measurement device. The estimation error increases to 0.34 ؎ 0.07 g/dl when monitoring 4؋ per month, 0.39 ؎ 0.08 g/dl when monitoring 2؋ a month, and 0.45 ؎ 0.09 g/dl when monitoring 1؋ per month. Estimation error comparable to instrument error information is as follows: 8؋ per month, 15 patients; 4؋ per month, 22 patients; 2؋ per month, 6 patients; 1؋ per a month, 6 patients. Conclusions: Four times a month is the clinically optimal Hb monitoring frequency for anemia management.

Clinical Journal of the American Society of Nephrology, 2010

Background and objectives: Although uremic pruritus (UP) is a highly prevalent complication of ch... more Background and objectives: Although uremic pruritus (UP) is a highly prevalent complication of chronic kidney disease, it remains poorly characterized. There have been no longitudinal studies of natural history, and no health-related quality of life (HR-QOL) instruments have been developed for UP. The objectives of this study were to describe the natural history of UP, to compare rating scales of itching intensity, and to assess usefulness and validity of HR-QOL instruments for UP. Design, setting, participants, & measurements: The intensity, severity, and effects of pathologic itching on HR-QOL were assessed prospectively in 103 patients with UP on chronic hemodialysis. Outcome measures were obtained at scheduled intervals over 3.5 months. Results: Itching daily or nearly daily was reported by 84% of patients and had been ongoing for >1 year in 59%. In 83%, pruritus involved large, nondermatomal areas with striking bilateral symmetry. Two thirds of the patients were using medications such as antihistamines, steroids, and various emollients without satisfactory relief of itching. Statistically significant associations were found among itching intensity, severity, and HR-QOL measures in domains such as mood, social relations, and sleep. Among patients with moderate-to-severe UP, changes in itching intensity of 20% or greater were associated with significant reductions in HR-QOL measures. Conclusions: This first longitudinal study of UP describes key features of UP and its effect on HR-QOL. The assessment instruments we have developed are easily used, are responsive to changes in UP intensity, and should facilitate clinical evaluation and research to meet the needs of afflicted patients.

Kidney Medicine, 2020

In patients with advanced-stage chronic kidney disease (CKD), progressive kidney function decline... more In patients with advanced-stage chronic kidney disease (CKD), progressive kidney function decline leads to increased risk for hyperkalemia (serum potassium > 5.0 or >5.5 mEq/L). Medications such as reninangiotensin-aldosterone system inhibitors pose an additional hyperkalemia risk, especially in patients with CKD. When hyperkalemia develops, clinicians often recommend a diet that is lower in potassium content. This review discusses the barriers to adherence to a low-potassium diet and the impact of dietary restrictions on adverse clinical outcomes. Accumulating evidence indicates that a diet that incorporates potassium-rich foods has multiple health benefits, which may also be attributable to the other vitamin, mineral, and fiber content of potassium-rich foods. These benefits include blood pressure reductions and reduced risks for cardiovascular disease and stroke. High-potassium foods may also prevent CKD progression and reduce mortality risk in patients with CKD. Adjunctive treatment with the newer potassiumbinding agents, patiromer and sodium zirconium cyclosilicate, may allow for optimal renin-angiotensinaldosterone system inhibitor therapy in patients with CKD and hyperkalemia, potentially making it possible for patients with CKD and hyperkalemia to liberalize their diet. This may allow them the health benefits of a high-potassium diet without the increased risk for hyperkalemia, although further studies are needed.

Journal of the American Society of Nephrology : JASN, Jan 16, 2017

CKD is steadily increasing along with obesity worldwide. Furthermore, obesity is a proinflammator... more CKD is steadily increasing along with obesity worldwide. Furthermore, obesity is a proinflammatory risk factor for progression of CKD and cardiovascular disease. We tested the hypothesis that implementation of caloric restriction and aerobic exercise is feasible and can improve the proinflammatory metabolic milieu in patients with moderate to severe CKD through a pilot, randomized, 2×2 factorial design trial. Of 122 participants consented, 111 were randomized to receive caloric restriction and aerobic exercise, caloric restriction alone, aerobic exercise alone, or usual care. Of those randomized, 42% were women, 25% were diabetic, and 91% were hypertensive; 104 started intervention, and 92 completed the 4-month study. Primary outcomes were a change from baseline in absolute fat mass, body weight, plasma F2-isoprostane concentrations, and peak oxygen uptake (VO2 peak). Compared with usual care, the combined intervention led to statistically significant decreases in body weight and bo...

Clinical kidney journal, 2017

Chronic kidney disease (CKD) is associated with abnormal lipid profiles and altered high-density ... more Chronic kidney disease (CKD) is associated with abnormal lipid profiles and altered high-density lipoprotein (HDL) particle size patterns. Lower levels of the larger, cardioprotective HDL particles found in CKD may play a role in the increased risk for cardiovascular disease in these patients. The current study was designed to assess the effects of short-term moderate-intensity aerobic exercise training on the HDL particle pattern and overall lipid profiles in stage 3 CKD patients. Forty-six men and women with stage 3 CKD were randomized to either exercise (EX, n = 25) or control (CON, n = 21). Those in the EX group completed 16 weeks of supervised moderate-intensity aerobic exercise three times per week. Serum total cholesterol, HDL cholesterol (HDL-C), triglycerides (TGs), low-density lipoprotein cholesterol (LDL-C), HDL particle size, estimated glomerular filtration rate (eGFR), body composition and peak oxygen uptake (VO2peak) were assessed at baseline and week 16. The rate of c...

Clinical journal of the American Society of Nephrology : CJASN, Jan 3, 2016

We aimed to determine the proportion of patients who switched to dialysis after confirmed plans f... more We aimed to determine the proportion of patients who switched to dialysis after confirmed plans for conservative care and compare survival and end of life care among patients choosing conservative care with those initiating RRT. A cohort study of 721 patients on incident dialysis, patients receiving transplants, and conservatively managed patients from 66 Australian renal units entered into the Patient Information about Options for Treatment Study from July 1 to September 30, 2009 were followed for 3 years. A two-sided binomial test assessed the proportion of patients who switched from conservative care to RRT. Cox regression, stratified by center and adjusted for patient and treatment characteristics, estimated factors associated with 3-year survival. In total, 102 of 721 patients planned for conservative care, and median age was 80 years old. Of these, 8% (95% confidence interval, 3% to 13%), switched to dialysis, predominantly for symptom management. Of 94 patients remaining on a...

Clinical journal of the American Society of Nephrology : CJASN, Jan 10, 2016

In using a patient-centered approach, neither a clinician nor a prognostic score can predict with... more In using a patient-centered approach, neither a clinician nor a prognostic score can predict with absolute certainty how well a patient will do or how long he will live; however, validated prognostic scores may improve accuracy of prognostic estimates, thereby enhancing the ability of the clinicians to appreciate the individual burden of disease and the prognosis of their patients and inform them accordingly. They may also facilitate nephrologist's recommendation of dialysis services to those who may benefit and proposal of alternative care pathways that might better respect patients' values and goals to those who are unlikely to benefit. The purpose of this article is to discuss the use as well as the limits and deficiencies of currently available prognostic tools. It will describe new predictors that could be integrated in future scores and the role of patients' priorities in development of new scores. Delivering patient-centered care requires an understanding of patie...

In this chapter we will discuss the emerging issues and controversies in anemia management in Chr... more In this chapter we will discuss the emerging issues and controversies in anemia management in Chronic Kidney Disease (CKD). The normal physiologic control of erythropoiesis and the pathophysiology in CKD will be discussed specifically with regards to current problems with dosing protocols and novel approaches to improve these issues. The causes and treatments of resistance to erythropoiesis stimulating agents (ESAs), hemoglobin cycling and variability will be addressed. The emerging safety concerns with ESAs and novel ESAs that may be safer will be discussed

BMC palliative care, Jan 12, 2015

End-stage renal disease carries a prognosis similar to cancer yet only 20 % of end-stage renal di... more End-stage renal disease carries a prognosis similar to cancer yet only 20 % of end-stage renal disease patients are referred to hospice. Furthermore, conversations between dialysis team members and patients about end-of-life planning are uncommon. Lack of provider training about how to communicate prognostic data may contribute to the limited number of end-of-life care discussions that take place with this chronically ill population. In this study, we will test the Shared Decision-Making Renal Supportive Care communication intervention to systematically elicit patient and caretaker preferences for end-of-life care so that care concordant with patients' goals can be provided. This multi-center study will deploy an intervention to improve end-of-life communication for hemodialysis patients who are at high risk of death in the ensuing six months. The intervention will be carried out as a prospective cohort with a retrospective cohort serving as the comparison group. Patients will b...

Blood purification, 2015

The CKD population is becoming increasingly elderly with multiple comorbidities. For this reason,... more The CKD population is becoming increasingly elderly with multiple comorbidities. For this reason, accurate predictive information related to the progression into ESRD, mortality, and functional decline is critical to allow for optimal shared decision making (SDM). This review will assess the current literature on the methodologies for the estimation of prognosis and prognostic tools developed for CKD. A practical clinical approach is discussed that involves the estimation of prognosis and integration of prognosis into SDM. Key Message: There are validated, easy-to-use prognostic tools that help clinicians engage in effective shared decision making with their CKD patients and family. © 2015 S. Karger AG, Basel.

Transplantation, 2000

Two patients underwent cadaver transplantation with kidneys from a donor with a history of World ... more Two patients underwent cadaver transplantation with kidneys from a donor with a history of World Health Organization Class IV/V lupus nephritis, and we report their clinical and pathological outcome. The donor had a diagnosis of lupus nephritis made by renal biopsy 5 years before donation. At the time of donation, a biopsy was performed on the donor and on one of the recipients at 2 months and 1 year after the transplant. Both recipients underwent uneventful renal transplantation. On the first postoperative day, the donor's final pathological results became available. Although the frozen section seemed to be quite benign, the permanent sections revealed World Health Organization Class II/V lupus nephritis, with full house immunofluorescence and multiple electron dense deposits. Biopsies were performed on recipient #2 at 8 weeks and 1 year after the transplant. These revealed marked diminution followed by complete resolution of all tubular reticular structures and deposits as well as immunofluorescent activity. Both recipients remain with normal renal function and urinalysis at 3 years after the transplant. Although a history of clinically significant renal disease has been considered an absolute contraindication to kidney donation, with appropriate workup and caution, select patients may still be considered, which would increase the potential donor pool.

Transplant International, 1999

With the introduction of cyclosporine (CyA) to clinical transplantation, marked improvement in ea... more With the introduction of cyclosporine (CyA) to clinical transplantation, marked improvement in early renal allograft survival occurred [9]. It was noted, however, that there appeared to be little change in the rate of allograft loss after the first post-transplant year compared to conventional immunosuppression with azathioprine (AZA) and steroids [6, 8]. Several possible explanations exist that address this observation. First, the beneficial effect of CyA could be limited to the early post-transplant period with respect to a decrease in the rate of allograft loss due to acute rejection. CyA may have no effect on the most common cause of allograft loss after the first year: chronic rejection. Alternatively, a decrease in overall, long-term allograft survival caused by a nonimmunologic, chronic CyA nephrotoxicity could overshadow the benefits of CyA on early allograft survival.

Transplant International, 2000

Acute rejection. Chronic rejection Abbreviations A R Acute rejection. CG Cockcroft-Gault (method)... more Acute rejection. Chronic rejection Abbreviations A R Acute rejection. CG Cockcroft-Gault (method)-CR Chronic rejection * CyA Cyclosporine * IoCl Iothalamate clearance 4 Scr Serum creatinine

Psychosomatics, 2004

Renal failure is a common medical condition, and many patients have comorbid psychiatric disorder... more Renal failure is a common medical condition, and many patients have comorbid psychiatric disorders. In this review, which is intended as a resource for consultation psychiatrists, the authors discuss pharmacokinetic considerations and provide information about the use of individual psychotropic medications in patients with renal disease. Most psychotropic medications are fat soluble, easily pass the blood-brain barrier, are not dialyzable, are metabolized primarily by the liver, and are excreted mainly in bile. Consequently, the majority of these drugs can be safely used with the end-stage renal disease population.

Nephrology Dialysis Transplantation, 2013

The burgeoning population of older dialysis patients presents opportunities to provide personaliz... more The burgeoning population of older dialysis patients presents opportunities to provide personalized care. The older dialysis population has a high burden of chronic health conditions, decrements in quality of life and a high risk of death. In order to address these challenges, this review will recommend routinely establishing prognosis through the use of prediction instruments and communicating these findings to older patients. The challenges to prognosis in adults with end-stage renal disease (ESRD) include the subjective nature of clinical judgment, application of appropriate prognostic tools and communication of findings to patients and caregivers. There are three reasons why we believe these conversations occur infrequently with the dialysis population. First, there have previously been no clinically practical instruments to identify individuals undergoing maintenance hemodialysis (HD) who are at highest risk for death. Second, nephrologists have not been trained to have conversations about prognosis and end-of-life care. Third, other than hospitalizations and accrual of new diagnoses, there are no natural milestone guidelines in place for patients supported by dialysis. The prognosis can be used in shared decision-making to establish goals of care, limits on dialysis support or parameters for withdrawal from dialysis. As older adults with ESRD benefit from kidney transplantation, prognosis can also be used to determine who should be referred for evaluation by a kidney transplant team. The use of prognosis in older adults may determine approaches to optimize well-being and personalize care among older adults ranging from hospice to kidney transplantation.

Journal of Pediatric Surgery, 1997

is a known complication after renal trauma. The cause of posttraumatic hypertension can be renal ... more is a known complication after renal trauma. The cause of posttraumatic hypertension can be renal scarring, infarction, hydonephrosis, infection, vascular injury, and parenchymal compression. The authors report on the case of a 16-year-old boy who experienced hypertension after blunt renal trauma. He had a dense fibrous pseudocapsule causing renal parenchymal compression, which lead to hypertension, a Page kidney. Evaluation with computed tomographic (CT) scan, radioisotope renal scan, renal Doppler, and angiogram confirmed the diagnosis. Removal of the renal capsule and the constricting fibrous pseudocapsule was curative.

JAMA, 2003

Mr D was a 78-year-old man with end-stage renal disease (ESRD) from diabetes and hypertensive nep... more Mr D was a 78-year-old man with end-stage renal disease (ESRD) from diabetes and hypertensive nephrosclerosis. He had a prior history of multiple episodes of aspiration pneumonia. For the past 2 years Mr D resided in a convalescent home, where he was visited frequently by his daughter, son, and their families. Mr D was transferred from his skilled nursing facility to the university hospital with cough, fever, and hypoxia. Mr D had had diabetes for 10 years, with repeated hospitalizations for nonketotic hyperosmolar state. Comorbid disorders included vascular dementia, atrial fibrillation, chronic lymphocytic leukemia, emphysema, pleural effusion, colonic diverticulosis, and tubular adenoma. Hemodialysis was begun 30 months prior to his final admission, but he became progressively more lethargic, less verbal, and physically weaker. A formal advance directive was never completed. On several occasions Mr D's children, and both Dr A, his family practice physician, and Dr E, his nephrologist, had discussed Mr D's deteriorating condition and the treatment alternatives that were available, including cessation of dialysis. For some time the family disagreed with respect to the goals of treatment. Despite the episodic illnesses, Mr D still seemed to relish eating and clearly enjoyed visits. Nonetheless, the repeated hospitalizations and Mr D's failure to regain his baseline status after each episode weighed heavily on his children. By the time of his most recent hospitalization, he was no longer able to eat, and talk turned to a feeding tube and other invasive support. His family painfully deliberated over this course of action and finally agreed to dialysis cessation. Mr D was unable to meaningfully participate in this decision. Five days following his last session, Mr D died in the palliative care unit of the hospital.

Clinical Journal of the American Society of Nephrology, 2010

Background and objectives: Anemia Management Protocols in ESRD call for hemoglobin (Hb) monitorin... more Background and objectives: Anemia Management Protocols in ESRD call for hemoglobin (Hb) monitoring every 2 to 4 weeks. Short-term Hb variability affects the reliability of Hb measurement and may lead to incorrect dosing of erythropoiesis stimulating agents. We prospectively analyzed short-term Hb variability and quantified the relationship between frequency of Hb monitoring and error in Hb estimation. Design, setting, participants, & measurements: Using the Crit-Line III TQA device, we prospectively observed Hb during each dialysis treatment in 49 ESRD patients and quantified long-and short-term Hb variability. We estimated Hb from data sampled at regular intervals; 8؋, 4؋, 2؋, or 1؋ per month to establish how well we account for short-term variability at different monitoring intervals. We calculated the Hb estimation error (Hb err) as a root mean-squared difference between the observed and estimated Hb and compared it with the measurement error. Results: The most accurate Hb estimation is achieved when monitoring 8؋ per month (Hb err ‫؍‬ 0.23 ؎ 0.05 g/dl), but it exceeds the accuracy of the measurement device. The estimation error increases to 0.34 ؎ 0.07 g/dl when monitoring 4؋ per month, 0.39 ؎ 0.08 g/dl when monitoring 2؋ a month, and 0.45 ؎ 0.09 g/dl when monitoring 1؋ per month. Estimation error comparable to instrument error information is as follows: 8؋ per month, 15 patients; 4؋ per month, 22 patients; 2؋ per month, 6 patients; 1؋ per a month, 6 patients. Conclusions: Four times a month is the clinically optimal Hb monitoring frequency for anemia management.

Clinical Journal of the American Society of Nephrology, 2010

Background and objectives: Although uremic pruritus (UP) is a highly prevalent complication of ch... more Background and objectives: Although uremic pruritus (UP) is a highly prevalent complication of chronic kidney disease, it remains poorly characterized. There have been no longitudinal studies of natural history, and no health-related quality of life (HR-QOL) instruments have been developed for UP. The objectives of this study were to describe the natural history of UP, to compare rating scales of itching intensity, and to assess usefulness and validity of HR-QOL instruments for UP. Design, setting, participants, & measurements: The intensity, severity, and effects of pathologic itching on HR-QOL were assessed prospectively in 103 patients with UP on chronic hemodialysis. Outcome measures were obtained at scheduled intervals over 3.5 months. Results: Itching daily or nearly daily was reported by 84% of patients and had been ongoing for >1 year in 59%. In 83%, pruritus involved large, nondermatomal areas with striking bilateral symmetry. Two thirds of the patients were using medications such as antihistamines, steroids, and various emollients without satisfactory relief of itching. Statistically significant associations were found among itching intensity, severity, and HR-QOL measures in domains such as mood, social relations, and sleep. Among patients with moderate-to-severe UP, changes in itching intensity of 20% or greater were associated with significant reductions in HR-QOL measures. Conclusions: This first longitudinal study of UP describes key features of UP and its effect on HR-QOL. The assessment instruments we have developed are easily used, are responsive to changes in UP intensity, and should facilitate clinical evaluation and research to meet the needs of afflicted patients.