Nephrologists' subjective attitudes towards end-of-life issues and the conduct of terminal care.
Adult; Humans; Middle Aged; Pilot Projects; *Attitude of Health Personnel; Data Collection; *Attitude to Death; Empirical Approach; *Euthanasia; *Terminal Care; Advance Directive Adherence; Advance Directives; Death and Euthanasia; Nephrology; Withholding Treatment; Ethics; Medical; Active
Decisions which determine the duration and outcome of terminal care should be influenced by patient autonomy. Studies suggest, however, that end-of-life decision-making is more complex than a single principle and that physicians may be responsible for selected aspects of terminal care independent of patient choice. To study how nephrologists' perceptions toward end-of-life issues may affect decision-making, we anonymously surveyed 125 of them. The study employed the straightforward terminology of "hastening death" rather than adopting the ambiguous term "euthanasia" or the narrow term "assisted suicide." Subjective physician profiles demonstrated that nephrologists who are less comfortable with dying patients were significantly less likely to report that they omitted life-prolonging measures (p = 0.02) and more likely to report that they would not initiate measures in order to hasten death even were it legal (p = 0.04). Ninety-eight percent of nephrologists reported omissions in terminal care with patient knowledge and 80% without patient knowledge. In contrast, forty-three percent of the nephrologists said that were it to become legal to initiate measures in order to hasten death, they would "never" do so. The ethical framework utilized for discontinuation of dialysis decisions incorporated medical benefit (cancer as criterion, 48%; multisystem complications, 84%; dementia 79%) and quality of life criteria. Twenty-five percent of nephrologists admitted difficulty with advance directives if the directives clashed with heir beliefs. ESRD end-of-life decision-making in the USA may be altered by the subjective characteristics of nephrologists. In particular, nephrologists' level of discomfort with patient mortality is linked with their reported management of terminal patients.
Rutecki G W; Cugino A; Jarjoura D; Kilner J F; Whittier F C
Clinical nephrology
1997
1997-09
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
Endothelin-1 as a therapeutic target in autosomal dominant polycystic kidney disease
proliferation; hypertension; receptor; expression; Urology & Nephrology; growth-factor; renal damage; endothelin-1; excretion; polycystic kidney disease; chronic kidney disease; ADPKD; endothelin-1 antagonists; autosomal dominant; tolvaptan; urinary endothelin-1; water permeability
Aims: Endothelin-1 (ET-1) is associated with the pathophysiology of autosomal dominant polycystic kidney disease (ADPKD) via cyst progression. Elevated concentrations of ET-1 in ADPKD correlate with many phenotypic changes in the kidney such as renal cyst development, interstitial fibrosis, and glomerulosclerosis. In addition, an imbalance between renal ETA and ETB receptors possibly leads to more severe disease progression. The objective of this review is to determine whether evaluating the efficacy of these drugs in treatment of cystic kidney disease may be a worthwhile aim, as determined by results from animal and human models. Materials and methods: PubMed/Medline, Embase, and Google Scholar databases were searched using the key words "endothelin, endothelin-1 antagonists, and autosomal dominant polycystic kidney disease". All animal and human studies describing the effects of endothelin and endothelin-1 antagonists in ADPKD subjects were included in the review. Results: Urinary ET-1 concentrations could serve as a noninvasive surrogate biomarker for kidney ET-1 levels, as it is inversely associated with eGFR, independent of age, sex, and blood pressure. Elevated urinary excretion of ET-1 may be a biomarker for early renal injury. Antagonization of ET-1 may hopefully be a novel therapy for slowing progression of kidney damage in ADPKD. Conclusion: Based on the literature reviewed in this manuscript, it is proposed that further research evaluating the efficacy of endothelin antagonists in treatment of cystic kidney disease is warranted. More human studies need to be performed with larger sample sizes. Therefore, the recommendation for treatment is inconclusive at this time.
Raina R; Chauvin A; Vajapey R; Khare A; Krishnappa V
Clinical Nephrology
2019
2019-06
Article information provided for research and reference use only. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="http://doi.org/10.5414/cn109598" target="_blank" rel="noreferrer noopener">10.5414/cn109598</a>
EOSINOPHILS IN URINE REVISITED
acute interstitial nephritis; eosinophiluria; Urology & Nephrology
The finding of eosinophils in the urine has been suggested to be useful in establishing the diagnosis of acute interstitial nephritis (AIN). The diagnostic accuracy of this test has not yet been defined. It is the purpose of this study to define the specificity, sensitivity, and the predictive positive and negative values for the presence of eosinophils in the urine. One hundred forty-eight patients with pyuria were tested for the presence or absence of urinary eosinophils. In this group consecutively admitted to the hospital with WBC in the urine, 4% of patients had urinary eosinophilia of greater than 1 eosinophil per 100 cells. Since none of this group had the diagnosis of AIN, the false positive rate was 4% and the specificity was 96%. In a selected group of patients in which the diagnosis of AIN was suspected by a nephrology consultant, urinary eosinophils were found in 6 of 15 patients with a confirmed diagnosis of AIN but were also found in 10 of 36 patients with another renal diagnosis. The sensitivity for eosinophiluria was 40% and the specificity was 72% with a positive predictive value of only 38%. We conclude that eosinophiluria is not an accurate test for the diagnosis of AIN. The false positive and negative rates are too high to confirm an AIN diagnosis.
Ruffing K A; Hoppes P; Blend D; Cugino A; Jarjoura D; Whittier F C
Clinical Nephrology
1994
1994-03
Journal Article
<a href="http://doi.org/10.1007/bf00860746" target="_blank" rel="noreferrer noopener">10.1007/bf00860746</a>
Geriatric renal function: Estimating glomerular filtration in an ambulatory elderly population
Urology & Nephrology; age; geriatrics; Cockroft-Gault; creatinine clearance; iohexol; iothalamate; renal function; serum creatinine
In elderly individuals, serum creatinine may remain normal as glomerular filtration rate (gfr) declines. Therefore, the estimation of glomerular filtration utilizing mathematical models incorporates age as an important variable. In order to adjust drug dosages and diagnose renal disease earlier in the elderly, a variety of such simplified estimates of gfr have been applied. Unfortunately, no estimator is as accurate as the cumbersome gold standards (e.g. inulin or iothalamate clearance) and the reliability of each may vary with the particular clinical setting. The purpose of this study was to critically evaluate three commonly used estimators of gfr - i.e., creatinine clearance (CC), Cockroft-Gault (CG), and 100 over serum creatinine (100/SC)- comparing them to iothalamate clearance (IC) in a group of healthy ambulatory geriatric subjects (n = 41; ages 65-85). IC declined 1 ml/min per year of age in our sample. CC demonstrated a similar decline, a correlation of 0.83 with IC, and moderate error relative to IC of 17% at the mean (standard error [SE] = 12.3), In contrast, 100/SC correlated only 0.56 with IC, demonstrated a large positive bias (41 ml/min). and showed no age-related decline. An age correction to 100/SC similar to that utilized in the CG formula was clearly necessary. Despite the age and weight correction used in the CG formula, we found the estimates from it to be inaccurate (correlation = 0.5; SE = 23.8). A simpler age-corrected formula (Est. IC = 1/2 [100/SC] + 88 - age) was derived and proved significantly superior to CG in our ambulatory geriatric sample, but still exhibited enough error (SE = 16.4) to question its clinical utility. It appears that serum creatinine based estimates of gfr in the elderly may not provide accurate results.
Baracskay D; Jarjoura D; Cugino A; Blend D; Rutecki G W; Whittier F C
Clinical Nephrology
1997
1997-04
Journal Article or Conference Abstract Publication
n/a
Postoperative Acute Pulmonary Edema: A Rare Presentation Of Pheochromocytoma
acute pulmonary edema; catecholamine-induced cardiomyopathy; pheochromocytoma; Urology & Nephrology
Fahmy N; Assaad M; Bathija P; Whittier F C
Clinical Nephrology
1997
1997-08
Journal Article or Conference Abstract Publication
n/a
Flavobacterium-meningosepticum Septicemia And Peritonitis Complicating Capd
bacteremia; infection; multivorum; susceptibility; Urology & Nephrology
Marnejon T; Watanakunakorn C
Clinical Nephrology
1992
1992-09
Journal Article or Conference Abstract Publication
n/a