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Peritoneal dialysis is the preferredform of dialysis during pregancy because it is continuous and lacks the wide variation in chemistries, weight and blood pressure, and avoids the use of anticoagulation necessary during hemodialysis.
This is a case report of a successful vaginal delivery of a 35 week healthy baby boy to a patient with end stage renal disease receiving peritoneal dialysis.
Although conception and successful pregnancy is uncommon in patients with end stage renal disease receiving dialysis, there have been several reported cases of pregnancy with varying outcomes in those receiving hemodialysis and peritoneal dialysis (114).
A 24-year-old female with end stage renal disease of unknown etiology was hypertensive and had small kidneys on ultrasound at the time of diagnosis.
On April 18, 1991, approximately one year after she started peritoneal dialysis, during a transplant evaluation, she was noted to be 10 weeks pregnant. We aimed for monthly PET and 24 hour urine collections for volume, BUN andcreatininedeterminations.
Since we were not sure how long she would be able to maintain the pregnancy, we medicated her with betamethasone starting at week 28 to week 35 to promote fetal lung maturation. The CAPD nurse's role towards a successful outcome is to maintain daily open communication with the patient. For those patients with end stage renal disease of child bearing age who do not want to have children, birth control education and methods should be provided to them. Redrow M, Cherem L, Elliott I, Mangalat I, Mishler RE, Bennet WM, Lutz, Sigala I, Byrnes I, Phillipe M, Hou S, Schon D.
Dosage adjustment according to renal function decreases iatrogenic risk and irreversible renal impairment [1]. Although the necessity of dosage adjustment is probably underestimated in clinical practice, few studies have considered this issue in hospitalized patients and the means to improve the use of medications in renal impairment [2,3,5,8]. This prospective criterion-referenced survey described residents’ practice through clinical vignettes, a valid and comprehensive method of assessing quality of care and one that is able to control adequately for case-mix variation [12].
It also included four clinical vignettes (Table 1), simulating drug prescription in patients with various degrees of renal impairment.
The reference chosen for assessment was the 1999 edition of the Vidal dictionary [13].This dictionary pools the manufacturers’ summaries of product characteristics.
In French hospitals, residents change departments every 6 months during the 2–5 years of their residency. An investigator was present at the administration office to deliver the questionnaire to the residents.
Among the 118 residents, 71 (60% of the residents) came to register at the hospital administration office at the beginning of the semester. The necessity of dosage adjustment in renal impairment was considered to be a frequent problem in hospital prescription by 85% of the residents (n = 58). Among the 16 simulated orders, the median number of appropriate orders per resident was nine (range 0–15) (Table 2). Abstract - Atrial fibrillation (AF) represents a growing medical problem that affects older individuals and those with a genetic predisposition to this condition. The incidence of atrial fibrillation (AF), a complex disease with multifactorial etiologies, has been increasing worldwide. This review of AF is based on a symposium offered during the 2011 Scientific Sessions of the American Heart Association, held November 12a€“16, 2011, in Orlando, Florida.
In Chinese patients of the Guangzhou Biobank Cohort, obesity (as defined by waist circumference or body mass index) was independently associated with a substantial risk of developing AF.3 Furthermore, the reported prevalence of AF in geographic regions of China is highly variable (unpublished observations).
Despite major advances in the diagnosis, risk stratification, and management of AF over the past two decades, mortality due to AF remains unchanged.
BIOLOGY AND GENETICS OF AF Based on a presentation by Stanley Nattel, MD, Professor and Paul-David Chair in Cardiac Electrophysiology, University of Montreal, Montreal, Quebec, Canada.
Atrial fibrillation results from increased ectopic activity in the atria, which can trigger susceptible substrates and lead to reentrant arrhythmia. Isolation of the pulmonary veins followed by isolation of the superior vena cava and the coronary sinus and then linear ablation (Figure 3) remains the most commonly used technique for catheter-based ablation.
Despite many recent advances, ablation may result in embolic stroke, pulmonary vein stenosis, atrioesophageal fistula, atrial flutter, complete heart block, or recurrent arrhythmia. Schematic depiction of pulmonary vein isolation and linear ablation, the most common catheter-based technique for treating atrial fibrillation. Based on a presentation by Isabelle Van Gelder, MD, Professor of Cardiology, Interuniversity Cardiology Institute and University of Groningen, Groningen, the Netherlands. A physician who chooses not to use ablation for managing patients with AF may need to ponder the relative effectiveness of rate control versus rhythm control. In the AFFIRM study, 4,060 patients with AF were randomized to undergo rate control or rhythm control.8 The results suggested that rhythm control offered no survival benefit but was linked to a higher incidence of drug-related side effects.
In addition to rate versus rhythm control, anticoagulation is central to the management of AF.
Explanations for the underuse of warfarin are multifactorial, most commonly advanced age, which is highly correlated with increased intracranial hemorrhage, and previous bleeding diathesis (eg, gastrointestinal bleeding). The results of these trials have emphasized the delicate balance between effective anticoagulation and the risk of hemorrhagic and thrombotic complications (Figure 4, Table 1). These studies have provided a wealth of data (Table 2) that demonstrate the efficacy of oral anticoagulation therapy with minimal monitoring of the international normalized ratio (INR) in patients with AF and a range of CHADS2 scores.
Concerns persist regarding the usefulness and cost-effectiveness of these agents in the setting of excellent control of the INR.2 In addition, drug interactions between both dabigatran and rivaroxaban with P-glycoprotein inhibitors (eg, dronedarone, ketoconazole) are of concern. The transition of a new class of drugs from the clinical trial arena into clinical practice is often fraught with regulatory and logistic concerns.
Approximately one year after starting peritoneal dialysis for end stage renal disease of unknown etiology, this patient was noted to be pregnant during a transplant evalution. Peritoneal dialysis has been reported to be the preferred form of treatment because: 1) it is a continuous therapy with less variation in electrolytes and other solutes, 2) there are fewer to no episodes of severe hypotension compared to hemodialysis, 3) heparin is not needed as an anticoagulant and 4) the hematocrit is higher without the use of erythropoietin or blood transfusion. The results of frequent measurements of BUN and creatinine generation and removal and peritoneal equilibration test (PET) during pregnancy are reported. She opted to continue the pregnancy after she was infornled of the risks and complications associated with pregnancy in patients with end stage renal disease. At week 16, she combined manual and cycler peritoneal dialysis to deliver at least 10 liters of dialysate daily. Once she was on peritoneal dialysis, her blood pressure was normal without antihypertensive medication. BUN and creatinine removal was calculated from the BUN or creatinine concentrations determined during the PET study multiplied by the volume removed. Improvements in dialysis technology have provided patients with better clearances of uremic toxins. Whether the patient is receiving hemodialysis or peritoneal dialysis, the amount of BUN and creatinine removed must be increased in order to keep the respective plasma concentrations within reasonable range.
Information regarding symptoms, blood pressure control, adequate nutrition, compliance to peritoneal dialysis regimen and medications, and to provide emotional support to the patient who is basically confined to the house and attached to a cycler for 20 hours per day can be achieved on the telephone. Successful pregnancy in a diabetic patient treated with continuous ambulatory peritoneal dialysis.
Although fitting orders to renal function avoids overdosage and therefore iatrogenic risk, dosage adjustment is rarely made.


All the residents approached for the survey accepted the offer to complete the questionnaire. Considering the iatrogenic risk related to the lack of dosage adjustment, attention should be drawn to increasing residents’ awareness of dosage adjustment in renal impairment and to providing them with better information on patients’ renal function.
Measuring the competence of physicians and the quality of their actual practice has proven to be difficult and problematic.
A questionnaire was distributed in May 2000 to the residents who assumed new positions in the Hospital Pitie Salpetriere (Assistance Publique, Hopitaux de Paris), a 2070-bed, tertiary care teaching hospital.
These drugs had been chosen in collaboration with a nephrologist and a pharmacist as they are frequently prescribed in general practice, or are well known to need adjustment in renal impairment (such as gentamicin), such that residents from medical or surgical departments might prescribe them regularly.
Creatinine clearance, which is not assessed directly in daily practice, was not provided in the survey, but could be calculated. The resident was to ratify each patient’s order or to change the dosage (with a choice between reducing the concentration or volume required per dose, or increasing the dosing interval). The study took place at the hospital administration office, where the residents come to register at the start of the semester. They completed this anonymous questionnaire alone and returned it immediately to the investigator.
According to the calculated clearance of creatinine, the appropriateness of the 16 orders was determined (four medications and four patients’).
Four percent of the residents (n = 3) reported checking if the dosage needs adjustment for any level of serum creatinine. Speakers at the 2011 Scientific Sessions of the American Heart Association (AHA) described risk factors for AF as well as current best practice for treating affected patients.
Newer treatment options, including ablation and oral anticoagulation, are now available, yet management of this disease continues to consume significant healthcare resources annually, and its morbidity and mortality remain high. Lip, MD, Professor of Cardiovascular Medicine, University of Birmingham, and Consultant Cardiologist and Director, Haemostasis Thrombosis and Vascular Biology Unit, University Department of Medicine, City Hospital, Birmingham, UK. Over the past two decades, the aging US population has experienced a 66% increase in hospitalizations for AF. Although most studies of AF are hospital-based, there is a growing need for more community-based investigations, which likely would better represent the general population. For this reason, ablation efforts mostly have focused on targeting pulmonary vein tissue and the myocardial tissue cuff adjacent to these structures. Although surgical ablation also is an option, the invasive nature of this procedure makes it less preferable. The choice to control rate or rhythm should be individualized for each patient and depends upon the patienta€™s age, type of symptoms, duration of disease, and the presence of additional comorbidities and stroke risk factors. For example, some patients who are especially susceptible to the long-term adverse effects of electroanatomical remodeling of the atria may benefit from maintenance of sinus rhythm.
Hylek, MD, MPH, Associate Professor of Medicine, Section of General Internal Medicine, Boston University, Boston, Massachusetts. Use of the CHADS2 score to determine which patients are appropriate candidates for anticoagulation therapy has been well established. However, the most likely explanation relates to the complex dosing, intensive monitoring, and multiple drug-drug interactions associated with warfarin therapy. If anticoagulation is appropriate, the agent must be carefully chosen to prevent tipping the scale in either direction. The FDA has issued warnings about increased bleeding related to the use of the drug in patients older than 75 years of age and the risk of rebound thromboses in patients who are transitioning from rivaroxaban to warfarin. Often, safety warnings are issued after FDA approval; further, the addition of a new drug to other drugs a patient is already taking may compromise compliance. We believe this is the first reported PET study performed in a pregnant patient receiving peritoneal dialysis.
At week 32 she was delivering 161iters of dialysate daily using the cycler except for two 2 hour dwell exchanges during the day.
Note that more urea was removed by peritoneal dialysis than by urinary excretion while more creatinine was removed by urinary excretion than by peritoneal dialysis.
We followed only the plasma BUN and creatinine concentrations to assess adequacy of dialysis. Any changes in blood flow to the peritoneum were not associated with obvious alterations in PET results. As BUN and creatinine generation increases and peritoneal volume decreases, the frequency of peritoneal exchanges must increase in order to adquately remove uremic toxins. In order to maintain adequate removal of uremic toxins, this patient with end stage renal disease receiving peritoneal dialysis as a treatment modality required frequent peritoneal dialysis exchanges as the peritoneal volume decreased with concomitant increase in uterine size. The objective of this study was to assess residents’ prescribing behavior in renal impairment, through a standardized simulated clinical setting. The hospital had 118 residents; 71 of them were asked to complete a questionnaire including four vignettes, simulating drug prescription in four ‘patients’ with various degrees of renal impairment (16 orders). Among the 16 simulated orders, the median number of appropriate orders per resident was nine. Because they control for case mix, vignettes or written cases simulations allow assessment among different providers and between organizations that may care for different populations of patients under different systems of care. This hospital has all major surgical and medical activities, with 40 in-patient departments, including 114 units, and >70 000 patients hospitalized every year.
It corresponds to the Physician’s Desk Reference and is the French reference for prescription. The investigator specified that the purpose of the study was not to test the knowledge of the residents, but to comprehend their behavior when prescribing drugs in renal impairment. Of these, 73% were medical residents, 3% were residents in anesthesia, and 24% had a surgical speciality.
Ablation is a common treatment option, although researchers continue to test other procedures in their quest to optimize patient outcomes. As the population ages, physicians face ongoing challenges in managing this disease, its complications, and associated comorbidities. Zipes, MD, Distinguished Professor Emeritus of Medicine and former Director of the Cardiology Division and Krannert Institute of Cardiology at Indiana University, Indianapolis, and Alan Camm, QHP, BSc, MD, FRCP, FRCPE, FESC, FACC, FAHA, FCGC, Professor of Cardiology at St. The annual cost per patient to treat AF is $3,600,2 and it is anticipated that 12a€“15 million patients worldwide will be diagnosed with AF by the year 2050. Thus, our understanding of AF and its treatment has improved, yet the disease burden remains high, and ongoing research is needed to improve clinical outcomes. In addition to the pulmonary vein antrum, however, rotors, ganglionated plexi, and other triggers also exist. Adapted from a presentation by Hakan Oral, MD, at the 2011 Scientific Sessions of the American Heart Association. Sinus rhythm is, indeed, a marker for improved survival.15 For this group, ablation (preferably catheter-based pulmonary-vein isolation) with or without the use of adjunctive antiarrhythmic drugs is the recommended strategy. Nevertheless, Waldo and others16 reported that 55% of hospitalized patients at high risk for thromboembolic disease were not receiving anticoagulation therapy with warfarin. For these reasons, great effort has been devoted to the study of novel oral anticoagulants such as dabigatran, rivaroxaban, apixaban, and edoxaban to treat patients with AF.


Overall, however, the newer oral anticoagulants provide growing options within the medical arsenal, which will improve patient care and outcomes. Mortality trends in patients diagnosed with first atrial fibrillation: a 21-year community-based study. The natural history of atrial fibrillation: incidence, risk factors, and prognosis in the Manitoba Follow-Up Study.
Mechanisms of atrial tachyarrhythmias associated with coronary artery occlusion in a chronic canine model. Pitx2 prevents susceptibility to atrial arrhythmias by inhibiting left-sided pacemaker specification. Role of the CHADS2 score in the evaluation of thromboembolic risk in patients with atrial fibrillation undergoing transesophageal echocardiography before pulmonary vein isolation. A comparison of rate control and rhythm control in patients with recurrent persistent atrial fibrillation. Rhythm or rate control in atrial fibrillationa€”Pharmacological Intervention in Atrial Fibrillation (PIAF): a randomised trial. Optimal treatment strategy for patients with paroxysmal atrial fibrillation: J-RHYTHM study.
Rate control vs rhythm control in patients with nonvalvular persistent atrial fibrillation: the results of the Polish How to Treat Chronic Atrial Fibrillation (HOT CAFE) study.
Relationships between sinus rhythm, treatment, and survival in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) Study. Hospitalized patients with atrial fibrillation and a high risk of stroke are not being provided with adequate anticoagulation. During pregnancy the hematocrit is frequently diminished as a result of volume overload and dilution.
The increase in endogenous creatinine clearance is unexpected since glomerular filtration rate is assumed to be at its maximum and without renal reserve when the creatinine clearance is so low.
The BUN and creatinine concentrations at week 35 were obtained after the patient was off peritoneal dialysis for more than 6 hours while she was being evaluated by the nephrologist and obstetrician for admission to the hospital for delivery. The cycler allowed this patient to continue self care and accomplish this goal at home while maintaining a quality of life. The patients had an order of gentamicin sulfate, diclofenac sodium, and amlodipine bensylate. Considering the renal function of their patients, 62% of residents wrote an inappropriate order for gentamicin, 42% wrote an inappropriate order for diclofenac, and 52% wrote an inappropriate order for enalapril.
They have been described as a valid way of assessing quality of care [9–12].The objective of this study was to assess residents’ prescribing behavior in ‘patients’ with renal impairment, through a standardized simulated clinical setting using hypothetical vignettes.
A fourth drug, enalapril maleate, was to be started, in the context of high blood pressure, with three possible dosages and the possibility of not prescribing it.
Residents were encouraged to act as they would for genuine patients, and to check any document they would use for usual prescribing, but not more. Fifty percent had already performed at least six postgraduate semesters, with seniority ranging from postgraduate semester 1 to 10 (out of 10).
The US Food and Drug Administration has approved several new anticoagulants recently, and other new agents that may be useful in treating patients with AF are in development.
Tremendous progress has been made in the past several decades in treating AF, yet mortality has not improved, and the incidence of AF continues to rise.1 An understanding of the underlying mechanisms of AF is instrumental to improving its treatment.
This global epidemic affects various populations and ethnic groups and carries a high risk of stroke, all-cause mortality, heart failure, and associated hospitalizations. Techniques such as complex fractionated atrial electrograms (CFAEs) and isoproterenol infusions can be used to identify such structures. Because such remodeling is time dependent, this strategy should be employed early, after the decision to use rhythm control has been made. She developed tachycardia so she was switched to methyldopa with good blood pressure control.
Her volume status was maintained at her "dry weight" based on clinical assessment despite weight gain associated with pregnancy.
At the time of delivery and 13 weeks post partufi at week 48 endogenous creatinine clearance returned to her baseline value. For each drug, the resident could maintain the order, discontinue the order, or change the dosage.
Although no adjustment to renal function was required, 28% of the residents decreased the dosage of amlodipine and ordered an underdose. Changes in glomerular filtration rate should be estimated by the clearance of creatinine calculated using the Cockcroft and Gault formula [7]. We considered the initial prescription of enalapril before further adjustment, which could have been made according to enalapril titration.
A Vidal dictionary was placed in an obvious position near the investigator, and was available for consultation if the residents requested it. The presentations spanned the full spectrum of AF, from epidemiology and global impact to biology, genetic factors, and treatment options.
These methods must be used cautiously, however, because they can trigger passive activation of foci not responsible for generation and propagation of this arrhythmia, which would result in false-positive results. Approximately one month later, her liver enzymes were elevated and she was symptomatic with pruritus. A fourth drug, enalapril maleate, was to be started, with three possible dosages and the possibility of not prescribing it.
In daily routine, glomerular filtration is determined from the measurement of serum creatinine, which has severe limitations. Residents were also told to spend the same time on the questionnaire as they would actually take to write orders. Furthermore, these diagnostic strategies actually may lead to the initiation of an arrhythmia or may induce contractile dysfunction. This was accomplished at home with a cycler so the patient was able to continue self care and maintain a quality of life.
The reference chosen for assessment was the Vidal dictionary, which corresponds to the Physician’s Desk Reference and is the French reference for prescription.
In addition, an apparently minor increase in serum creatinine can reflect a marked fall in glomerular filtration rate (Figure 1). She had a negative hepatitis C antibody, direct coombs, and ultrasound of the gall bladder . Another factor that made this event a success was the total commitment on the part of the spouse and other family members who helped with her exchanges as well as managing daily household tasks. For that reason, the estimation of glomerular filtration rate through the calculation of creatinine clearance is mandatory in every patient.
Her blood pressure was finally controlled with varying doses of hydralazine and atenolol for the remainder of the pregnancy.



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