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The level of kidney function tends to decline progressively over time in most patients with chronic kidney diseases. Ascertaining risk factors for faster versus slower GFR decline, including type (diagnosis) of kidney disease, nonmodifiable and modifiable factors.
Interventions to slow the progression of kidney disease should be considered in all patients with chronic kidney disease. The intent of this guideline is to examine the literature to determine factors associated with more rapid loss of kidney function in chronic kidney disease. Progression of kidney disease is defined as either (1) decline in the level of kidney function, estimated by measuring GFR, creatinine clearance or serum creatinine, in a patient who has been followed longitudinally with reliable (and comparable) assays of kidney function, or (2) onset of kidney failure, defined by initiation of kidney replacement therapy, either for symptoms or complications of decreased kidney function. The natural history of most chronic kidney diseases is that GFR declines progressively over time (Fig 47) (R). Other studies have shown that certain types of kidney disease may undergo complete remission in a substantial number of patients. The rate of GFR decline is often relatively constant over time in an individual patient; however, the rate of GFR decline is highly variable among patients, ranging from slowly progressive over decades, to rapidly progressive over months (Table 109 and Fig 48) (R, C). Composite plot of reciprocal serum creatinine versus time in six patients with chronic kidney disease. The studies reviewed for this guideline show a wide range in the rate of GFR decline among studies, as well as among individual patients (Table 109). The rate of decline in GFR can be used to estimate the interval until the onset of kidney failure (Table 110) (R). In principle, if the rate of GFR decline is constant over time, then the interval until the onset of kidney failure could be estimated from the current level of GFR and the rate of decline in GFR. First, most of the studies that demonstrated a constant rate of decline in kidney function were retrospective, including only patients who had already progressed to kidney failure.
Second, even among patients in whom the rate appears constant, the rate may change over time. The changes in slope were judged to be spontaneous, since they did not necessarily occur at the time of changes in therapy. Similar changes in slope of GFR decline have sometimes been observed in clinical trials, where they have been attributed to the effect of the interventions (for example, low protein diet, strict blood pressure control, ACE inhibition).
Comparison of GFR decline between diet groups in the Modification of Diet in Renal Disease Study. Third, even if the rate of decline is constant, the precision of the estimate of the slope depends on a number of variables, including the true rate of decline, the number of measurements of kidney function, measurement error, biological variability, and the duration of follow-up.
The rate of GFR decline is related to the type of kidney disease; diabetic kidney disease, glomerular diseases, polycystic kidney disease, and kidney disease in transplant recipients are associated with a faster GFR decline than hypertensive kidney disease and tubulointerstitial kidney diseases (Tables 109 and 111) (C, R).
Few studies specifically related rate of GFR decline to type of kidney disease (Table 111). Additional information regarding different rates of GFR decline depending on underlying cause of kidney disease was extracted from studies of isolated causes of kidney disease or from studies which provided rates of progression for individual causes of kidney disease. The data presented in Table 111 are not easily compared; the study methods varied (retrospective or prospective, observational, or interventional), different measures of kidney function were used, and the effect of interventions or other potential confounders cannot be determined.
The rate of GFR decline is related to some nonmodifiable patient characteristics, irrespective of the type of kidney disease; African-American race, lower baseline level of kidney function, male gender, and older age are associated with a faster GFR decline (C). Six studies addressed the association of race with the rate of GFR decline in either univariate or multivariate analyses.
Twenty-one studies addressed the association of low baseline level of kidney function with the rate of GFR decline in either univariate or multivariate analyses. Eighteen studies addressed the impact of gender on the rate of GFR decline in either univariate or multivariate analyses. Twenty-one studies reported the association of age with the rate of GFR decline in either univariate or multivariate analyses.
The rate of GFR decline is also related to modifiable patient characteristics, irrespective of the type of kidney disease.
Eight studies addressed the association of low baseline serum albumin with rate of GFR decline in either univariate or multivariate analyses. Interventions may slow rate of GFR decline in chronic kidney disease in some circumstances (R).
Strict glycemic control in diabetes slows the development and progression of chronic kidney disease (R). The goals for intensive glycemic control for the prevention of complications of diabetes, including nephropathy, as presented in the ADA guidelines, are summarized below. Among patients with insulin dependent diabetes mellitus (IDDM), 80% who have sustained microalbuminuria develop overt nephropathy in 10 to 15 years, and among these, kidney failure develops in 50%. The role of strict glycemic control in slowing the progression of diabetic kidney disease is less certain. Among patients with non-insulin dependent DM (NIDDM), 20% to 40% of patients with microalbuminuria develop overt nephropathy, and among these, kidney failure develops in 20%. The Steno Type 2 Study compared an intensive multifactor intervention to standard therapy in 160 patients with type 2 diabetes and microalbuminuria.532 The intervention included not only intensive insulin therapy, but also strict blood pressure control, ACE inhibition, dietary fat restriction, exercise, lipid-lowering drugs, anti-oxidants, and aspirin (in patients with coronary heart disease).
The most recently updated Clinical Practice Recommendations (2001)526 of the ADA regarding intensive glycemic control recommend the following treatment goals for patients with diabetes (Table 123). Recommendations for the general population are based on a large body of evidence from observational studies and clinical trials relating blood pressure levels to mortality and cardiovascular disease. The recommended goal of antihypertensive therapy for patients at low or moderate risk for complications is to maintain systolic and diastolic blood pressure less than 140 and 90 mm Hg, respectively.245 These definitions and goals do not differ according to age (among adults), gender, or race. In the general population, the recommended antihypertensive agents are diuretics and beta-adrenergic blockers, because their efficacy in reducing cardiovascular mortality and morbidity has been proven in clinical trials. Based largely on extrapolation from recommendations for the general population and limited observational studies and clinical trials in patients with chronic kidney disease, the NKF Task Force on Cardiovascular Disease recommended target blood pressure levels and strategies for treatment for patients with chronic kidney disease (Table 125). The Task Force recommendations were meant to serve as a guide to clinicians until more definitive recommendations are available.
A KDOQI Work Group has now been established to develop guidelines for the management of high blood pressure in patients with chronic kidney disease not requiring dialysis.
Angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists slow the progression of chronic kidney disease (R). It is important to note that ACE-inhibitors have been found to have beneficial effects on total mortality and cardiovascular disease in diabetic patients without chronic kidney disease.543-545 Although most patients in these studies were hypertensive, the beneficial effect of ACE-inhibitor therapy appeared to be independent of its blood pressure lowering effect. These recommendations are based on a number of randomized trials published over the past decade, which have been summarized recently in a meta-analysis of patient level data.546 In that analysis, data on 1860 nondiabetic patients included in 11 randomized clinical trials of various ACE-inhibitors were pooled.
The available evidence suggests a benefit to using ACE-inhibitors to treat hypertension among proteinuric patients with nondiabetic kidney disease.
The HOPE Study also demonstrated a beneficial effect of the ACE-inhibitor ramipril on total mortality and cardiovascular disease in nondiabetic patients without chronic kidney disease, but with a history of cardiovascular disease and one cardiovascular disease risk factor (including hypertension).545 The beneficial effect of the ACE-inhibitor appeared to be independent of its blood pressure lowering effect.
There is insufficient evidence to recommend for or against routine prescription of dietary protein restriction for the purpose of slowing the progression of chronic kidney disease; individual decision-making is recommended, after discussion of risks and benefits (R).
There is insufficient evidence to recommend lipid-lowering therapy for the purpose of slowing the progression of chronic kidney disease (R). Unfortunately, there are no large, adequately powered, randomized, controlled trials testing the hypothesis that treatment of dyslipidemia preserves kidney function. Reduced blood flow to the kidney, toxic insult, obstruction, inflammation, or infection can result in acute deterioration of kidney function.
Volume depletion accounts for the majority of community acquired cases of acute reduction in the blood flow to the kidney and a resultant reduction in GFR. Common toxic insults encountered in clinical practice are radiocontrast dye, aminoglycoside antibiotics, and NSAIDs.
Finally, obstruction can cause an acute decline in GFR if there is bilateral ureteral obstruction, unilateral ureteral obstruction in a person with a single functioning kidney, or obstruction at the level of the bladder. In summary, there are numerous situations that may cause an acute deterioration in the GFR that are potentially avoidable. A major limitation of this guideline is its failure to provide a semi-quantitative assessment of the relationships between the factors assessed and the outcomes of rate of progression or risk for kidney failure.
It is important to follow each individual’s rate of progression, as there is a wide variation among individuals and disease types and in the response to interventions. There is a broad range of factors that are associated with more rapid decline in kidney function, some of which are amenable to interventions. Certain patient groups, defined by either type of kidney disease, clinical, gender, racial, or age characteristics, are at greater risk for progression of kidney disease—this denotes the need to increase awareness among patients and providers about proper care and the need to institute interventions to attempt to slow progression. Patients with certain causes of kidney disease, and certain modifiable and nonmodifiable characteristics, may be at increased risk for faster rates of GFR decline.
It is thus critical to educate patients and providers regarding the risk factors and to facilitate providing aggressive interventions where indicated.
It is evident that there is a large amount of data in studies of varying size and quality regarding the impact of underlying conditions, patient characteristics, and interventions.
Can metabolic factors be used prognostically for short-term mortality in HIV-infected patients? Although the factors responsible for progression of kidney disease are not known in each case, a variety of factors have been associated with more rapid progression and some therapies have been proven to slow the progression of disease. Kidney replacement therapy includes hemodialysis, peritoneal dialysis or kidney transplantation. The best linear unbiased estimates of GFR slope over 3 years in Study A or overall slope in Study B are shown as a function of baseline GFR. For example, up to 35% of patients with idiopathic membranous nephropathy481 and up to 30% of patients with primary focal segmental glomerulosclerosis482 may undergo remission of disease.
An estimate of the time until kidney failure would be useful to facilitate planning for kidney replacement therapy, or may even suggest that concerns about kidney failure may be unwarranted if life expectancy is short. In principle, the GFR decline could be computed simply from the slope of the regression line relating estimated GFR versus time.
The fraction of patients with decreased GFR in whom the subsequent decline in kidney function is constant is unknown. In a pooled analysis of four studies of 77 patients with an apparently constant rate of decline in the reciprocal of the serum creatinine concentration, 32% to 51% of patients had a significant change in the slope502 (Fig 49). In that study, the second slope was less steep in 61% of cases and more steep in 39% of cases. Estimated mean (┬▒SEM) GFR decline from baseline (B) to selected follow-up times (F) in Study A are shown. For this review, longitudinal studies were compiled to relate the rate of decline in kidney function with the potential associated factors.
The MDRD Study was the largest, with a sample size of 826, while the other two studies had between 138 and 223 subjects. Table 111 shows the reported or estimated rates of GFR decline that were described for different causes of kidney disease. Nonetheless, the crude data suggest a trend for more rapid progression among patients with diabetes, especially those patients with proteinuria or decreased GFR, compared with other causes of kidney disease. Half reported a faster rate of progression among blacks; however, only one study reported a significant association between black race and faster rates of progression in multivariate analysis. The majority of the studies reported a faster rate of progression among individuals with lower baseline kidney function, but about one third reported no association.
The data report either a faster rate of progression or no association with male gender, and a single study reported a faster rate of progression among females. These data generally support either an association of older age with faster rates of GFR decline or no association, except among diabetics, where younger age at diagnosis of diabetes is associated with a faster rate of GFR decline. Higher level of proteinuria, lower serum albumin concentration, higher blood pressure level, poor glycemic control, and smoking are associated with a faster GFR decline. Although these data do not unanimously show that proteinuria is associated with faster rate of GFR decline when controlling for other factors, the studies with larger sample sizes and higher methodological quality and applicability do support the association. The association of low serum albumin with faster rate of GFR decline was more consistently noted in studies of diabetic patients. The studies differed in that they assessed systolic blood pressure, diastolic blood pressure, or mean arterial pressure—two of these or all of these. The studies evaluated one or more of the following factors: high levels of total cholesterol, triglycerides, or low density lipoprotein, and low levels of high density lipoprotein. It was beyond the scope of this Work Group to perform a systematic review of the literature on interventions to lower the rate of GFR decline.
The American Diabetes Association (ADA) has set forth a Position Statement with guidelines for the care of patients with diabetes mellitus (DM),526 with specific attention to the complication of kidney disease,527 based on the results of the Diabetes Control and Complications Trial (DCCT)528 and extensive review of other published research.
Three randomized trials of strict glycemic control in type 2 diabetes also demonstrate a beneficial effect of strict glycemic control on the development and progression of diabetic kidney disease.
Fasting blood glucose values rose over time in both groups; the mean HgbA1c was 11% lower in the intervention group.
The results showed a lower incidence of the development and progression of microalbuminuria.
There was 73% reduction in the incidence of clinical proteinuria in the intervention group.
The optimal frequency of self monitoring of blood glucose for patients with type 2 diabetes is not known, but it should be sufficient to facilitate reaching glucose goals. The Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-VI),245 the most recently updated ADA Clinical Practice Recommendations (2001),526 the NKF Task Force on Cardiovascular Disease in Chronic Renal Disease,9 and a report from the NKF Hypertension and Diabetes Executive Committees Working Group249 were reviewed for this section. There is general agreement that risk stratification should be used in deciding which patients with high blood pressure should be treated and how intensively245 (Table 124).
Target blood pressure is lower in younger patients and related to age, weight and height.533 Patients at greatest risk for complications or who already have evidence of cardiovascular disease are considered for the earliest and more aggressive treatment. Recent studies show equal efficacy of angiotensin converting enzyme inhibitors (ACE-inhibitors) and calcium channel blockers in the general population.534,535 In addition, alternative target blood pressure and medications may be preferred in those subgroups of patients with comorbid conditions. Large-scale epidemiological studies of cardiovascular disease have included few patients with chronic kidney disease, and most clinical trials of antihypertensive agents to prevent cardiovascular disease have excluded patients with decreased kidney function. The MDRD Study is the largest completed randomized trial on strict blood pressure on the rate of GFR decline in nondiabetic kidney disease.
The goals of the Work Group are to determine the recommended blood pressure targets, nonpharmacologic therapy, and antihypertensive drug classes for various causes of kidney disease (including diabetes), with additional recommendations for subgroups of patients based on level of kidney function, level of proteinuria, and, if available, age, gender, and race, for prevention of progression of kidney disease, atherosclerotic cardiovascular disease, and heart failure (including LVH). For this Guideline, the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC-VI),245 the most recently updated ADA Clinical Practice Recommendations (2001),526 and results of a meta-analysis and selected randomized clinical trials were reviewed. Other studies have shown that there is a benefit in reducing the progression of micro albuminuria in normotensive patients with type 1 diabetes and normotensive and hypertensive patients with type 2 diabetes.
In older patients with bilateral renal artery stenosis and in patients with advanced renal disease even without renal artery stenosis, ACE-inhibitors may cause a rapid decline in renal function. Thus, patients with diabetes and hypertension or chronic kidney disease benefit from ACE-inhibitors. All classes of antihypertensive drugs are effective, and, in most cases, multiple antihypertensive drugs may be needed.
The results showed better blood pressure control, lower urine protein excretion and an approximately 30% reduction in the risk of development of kidney failure and the combined endpoint of doubling of baseline serum creatinine or kidney failure in the ACE-inhibitor group.
Thus, non-diabetic patients with chronic kidney disease (especially if they have proteinuria) or cardiovascular disease benefit from ACE-inhibitors. The lack of firm evidence regarding its impact, and the logistic and financial difficulties of providing intensive nutritional intervention, preclude recommendation of a low protein diet in all patients with chronic kidney disease. Some of observational studies have reported that various dyslipidemias are associated with decreased kidney function in the general population and in patients with chronic kidney disease.480,551-554 However, it is impossible to determine from these studies whether dyslipidemias cause reduced kidney function, result from reduced kidney function, or whether other conditions such as proteinuria cause both reduced kidney function and dyslipidemias.
However, there have been several small studies555-566 and a meta-analysis of these studies.567 This meta-analysis included prospective, controlled trials published before July 1, 1999.

The available evidence that partial correction of anemia with erythropoietin (and iron) results in improvement in the rate of decline of GFR is therefore inconclusive. Reduced blood flow to the kidney and intrinsic damage to the kidney because of a nephrotoxic or ischemic insult are the most common causes of acute deterioration of GFR.
The most common precipitants of volume depletion are vomiting, diarrhea, poor fluid intake, fever, and diuretic use.
In particular, these are likely to result in acute decline in GFR if there is an additional insult such as sepsis, volume depletion, heart failure, or treatment with ACE inhibitors. The most common causes of obstruction are prostatic hypertrophy, cancer of the prostate or cervix, or retroperitoneal disorders.
The clinician should become familiar with the most common causes, in order to prevent avoidable worsening of the course of chronic kidney disease.
Most notably, with many of the studies the results were difficult to compare as they use different measures for kidney function: measured GFR or creatinine clearance, estimation equations for GFR or creatinine clearance, or simply serum creatinine. This review of these studies does not provide a conclusive answer to the causes underlying the more rapid rate of progression or increased risk for kidney failure.
There is increasing evidence that certain interventions can slow the decline in GFR and prevent the development of kidney failure in both diabetic and nondiabetic patients. This may require changing the policies of care providers and payers regarding frequency of follow-up and payment for medications. However, there are certain factors whose impact has not been conclusively determined, such as dietary protein intake, hyperlipidemia, and anemia and their treatment. Similarly, in the case of the impact of blood pressure control, conclusions largely come from the observations that patients with lower blood pressures have improved outcomes.
It has been found to respond to therapeutic intervention, thus halting or significantly retarding the progression to dementia. The clinical profile of these complications has not been adequately studied in many tertiary health care centers in India. Blood transfusion-related HIV is still common in developing countries like Nigeria especially among high risk children such as those who require repeated blood transfusions. Several etiological factors have been suggested, with subtle variations in clinical presentation being reported in different studies. Aim: To determine the knowledge and practice of pulp therapy in deciduous teeth by general dental practitioners (GDP) in two cities of southern Saudi Arabia.
It has been established that dyslipidemia and dysglycemia associated with HIV disease reduce the long-term survival of the patients, but their role for predicting prognosis of short-term mortality in HIV patients is unknown. Aim: The purpose of this survey was to identify the causes of teeth extraction in Eastern Nigeria. Drugs used in the treatment of this disease are either costly or are associated with high incidence of adverse effects. There is limited literature on attitude and knowledge of medical students towards ECT from Asian and African countries.
Aim: This study aimed to investigate the effect of radiofrequency of mobile phone on the electrocardiographic parameters in patients with history of ischemic heart disease, taking into consideration the gender factor . The treatment regimens for patients suffering from both diseases generally include prolonged use of anti-diabetic drugs for diabetes and anti-arrhythmic drugs for cardiac arrhythmias. Aim: To assess the Nigerian clinical level medical students' knowledge of dental problems and conditions in relation to the dental specialty that treat them.
Studies have reported significant benefit of exercise in the overall management of hypertension. Aim: The objective of this study was to determine the stillbirth rate at the Imo State University Teaching Hospital, Orlu. However, there are no preoperative and intraoperative criteria which can successfully establish the possibilities for development of postoperative pulmonary edema. Greater understanding of the pathophysiology of neuronal damage in ischemic stroke has generated interest in neuroprotection as a management strategy.
Herein, we report the rare condition of an unbooked case of locked twin that attended our labor room in late stage of labor with arrested after coming head of the first twin, which was dead. Although some authors have performed a meta-analysis of studies, a quantitative data synthesis was not performed for this Guideline. For consideration of therapy for diabetic kidney disease, development and worsening of proteinuria was also included in the definition of progression of kidney disease.
The lower, middle and upper lines represent the 10th, 50th (median), and 90th percentiles of the distribution of GFR slopes, respectively. Indeed, studies have shown that the GFR decline does appear relatively constant over time, although other studies have shown that other continuous relationships (such as the logarithm) or non-continuous (spline) relationships may fit the data better in some cases. However, there are a number of limitations to estimation of the slope and extrapolation of the rate of decline to predict the time to development of kidney failure.
The magnitude of the changes in slope was relatively large in comparison to the first slope (mean of 130% of the value of the first slope).
Coupled with the fact that the elderly start from a lower baseline GFR, older individuals with chronic kidney disease deserve special attention and closer follow-up.
Most studies reporting multivariate analyses showed a significant association between elevated blood pressure, based on any measures of blood pressure, and faster rate of GFR decline.
A similar number of studies showed no significant association between poor glycemic control and faster rate of GFR decline in multivariate analyses. However, the large sample sizes and adequate methodological quality and applicability of the studies supporting the association of smoking with faster rate of GFR decline provide reasonable evidence that there may be a deleterious effect of smoking on rate of progression. The impact of dyslipidemia reported herein is based on whether any one of these factors was associated with a faster rate of progression.
Thus, the goal of this section was to review published guidelines and position statements by reputable national organizations addressing widely accepted interventions.
The difference was observed with a mean HgbA1c of 7.2% in the intensively treated versus 9% in the conventionally treated patients. However, the relative importance of strict glycemic control and any of the other factors cannot be determined from this study. The role of self-monitoring of blood glucose in stable diet-treated patients with type 2 diabetes is not known. This section will discuss primarily the target blood pressure level for patients with chronic kidney disease, with only brief reference to the role of specific antihypertensive agents.
These subgroups include, among others, patients with chronic kidney disease, diabetes, and cardiovascular disease.
Some of the important randomized trials on the target level of blood pressure in patients with chronic kidney disease due to diabetes and other diseases are summarized below.
If blood pressure remains elevated after initiation of an ACE-inhibitor, other antihypertensive agents should be prescribed to achieve target blood pressure.
The beneficial effects of ACE-inhibitors to slow progression appeared to be independent of their effects on blood pressure and proteinuria. The use of ACE-inhibitors must always be done with the consideration that it may have a detrimental effect on GFR in patients with renovascular disease or renal artery stenosis.
If blood pressure remains elevated after initiation of an ACE-inhibitor, other antihypertensive agents should be prescribed to achieve the target blood pressure.
As described earlier (Fig 50), there was an initial faster GFR decline in the low-protein diet group, followed by a slower GFR decline thereafter, but no significant benefit over a 3-year interval.
Each of these explanations is plausible, and only randomized, controlled trials can adequately test the hypothesis that dyslipidemias cause a decline in kidney function. Three trials published only in abstract form were included,555,556,566 but one of these studies has subsequently been published in a peer-reviewed journal.566 All patients were followed for at least 3 months, but in only 5 studies were patients followed for at least 1 year. Further studies specifically addressing the effects of anemia and its treatment on rate of GFR decline are necessary to clarify this issue. Heart failure can effectively result in a reduction of blood flow to the kidney due to reduced cardiac output, in the face of apparent volume overload. Toxins can cause kidney failure via a number of mechanisms including (not an exhaustive list): (1) alteration of kidney blood flow (NSAIDs, ACE inhibitors, cyclosporine, radiocontrast agents), (2) direct tubular injury (aminoglycosides, radiocontrast, amphotericin B), (3) intratubular obstruction (acyclovir, sulfonamides), (4) allergic interstitial nephritis (NSAIDs, penicillins, cephalosporins, sulfonamides). In addition, kidney stones, blood, fungal infection, and bladder malignancy may result in obstruction. Further limiting the comparability of the results across the studies is the wide variation in the selection of analytic techniques and presentation of data. In the case of cause of kidney disease, the conclusion that certain causes are associated with faster rates of progression come from the comparison of studies of single causes, using diverse methods to measure or estimate GFR. Resource-poor countries like Nigeria can hardly afford to provide optimal care for dementia patients. Aim: The authors studied the clinical profile of microvascular diabetes complications [peripheral sensory neuropathy (PSN), diabetic retinopathy (DR), nephropathy] in patients attending a tertiary care hospital in India.
Aim: The aim of this study was to find the prevalence of HIV among transfused children with sickle cell anemia in Enugu. Subjects and Methods: Fifty GDP selected at random from government and private dental clinics were questioned about pulp therapy in deciduous teeth in Abha and Najran cities using a 10-item questionnaire.
Subjects and Methods: Record forms for entering data and a self-addressed return envelope were distributed to 100 dental surgeons in Eastern Nigeria using a simple random selection. Synclisia scabrida is a plant used in ethnomedicine for the treatment of various forms of stomach disorders and menstrual pains.
Aim: The current study assesses the impact of a "Brief ECT Orientation Module" on the knowledge of and attitudes of Indian medical students towards modified ECT. Subjects and Methods: A total number of 356 participants (129 males and 227 females) were admitted in this study.
Aim: The aim of the study is to compare the influence of Mexiletine and Disopyramide on the pharmacodynamics (PDs) of Rosiglitazone in normal and diabetic rats. However, studies on the effect of exercise on psychosocial stress and SUA in the management of hypertension seem scanty. Aim: The objective of this study was to determine the antenatal booking pattern of pregnant women and its determinants. Subjects and Methods : Analysis of the case records of stillbirths that occurred in the institution over a 5-year period from 1 st July 2005 to 30 th June 2010 was made.
The aims were to review the possible etiologic and diagnostic challenges in timely detection of postoperative pulmonary edema and to discuss the various management strategies for prevention of this postoperative complication so as to decrease morbidity and mortality. This paper aims to review the current concept and place of neuroprotection in ischemic stroke.
This review was aimed at highlighting the role of efflux pump mechanisms in microbial resistance to chemotherapeutic agents. We report a case of 72-year-old man with left supernumerary testes in the left hemiscrotum. Menorrhagia may also be due to undiagnosed coagulation defects, endocrine disorders, gynecological abnormalities of the uterus, or other systemic disorders.
The GFR slope estimates are not related to baseline GFR, but the variability in slope estimates is higher at higher levels of baseline GFR. These limitations are related principally to whether the rate of decline is truly constant and the precision of the estimate of the rate of decline. Diagonal dashed lines are extrapolations of the regression lines to earlier and later times. Consequently, the mean error in the interval until reaching the final serum creatinine was also relatively large, 27% of the predicted interval (Fig 49). In the MDRD Study480 and the study by Massy,499 polycystic kidney disease was associated with a faster rate of progression, whereas in the study by Hannedouche,490 polycystic kidney disease was associated with a slower rate of progression.
There were only 7 studies that reported no significant association between elevated blood pressure measures and faster rate of GFR decline in multivariate analysis. Although these data do not unanimously show that poor glycemic control is associated with faster rate of GFR decline when controlling for other factors, the studies with larger sample sizes and higher methodological quality and applicability do support the association. There were 7 studies that reported in multivariate analyses a significant association between dyslipidemia and faster rate of progression. In keeping with the rest of this section the guideline, only this one study was considered for inclusion in an evidence table (Table 122). In addition, meta-analyses of randomized trials or data from selected large randomized trials were used to formulate this guideline. The data suggested a lower prevalence of microalbuminuria in the intervention group and a reduced incidence of declining kidney function. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin-2 receptor blockers are discussed in the next section. The Work Group did not find randomized trials on target blood pressure levels in kidney transplant recipients. In addition, preliminary results of clinical trials with angiotensin receptor antagonists are briefly discussed. This class of agents is contraindicated in pregnancy and therefore should be used with caution in women of childbearing potential. Furthermore, in kidney transplant recipients, ACE-inhibitors may exacerbate hyperkalemia caused by cyclosporine or tacrolimus. These studies have shown either no overall difference in the rate of decline of kidney function in treated compared to untreated groups297,304,306 or compared to pre-treatment rates of decline,568 or a slight benefit in terms of a slower rate of decline of GFR in the treated group294,569 and prolongation of time to ESRD569, or reduced proportion of patients who experienced doubling of baseline serum creatinine in the treated versus untreated groups.305 Each of these studies, as well as a study comparing intravenous with oral iron and erythropoietin for the treatment of anemia in chronic kidney disease,570 also concluded that normalization of hemoglobin or hematocrit had essentially no effect on the rate of decline of kidney function.
The risk of developing acute deterioration of kidney function due to volume depletion is highest in the elderly, as they may already have compromised blood flow to the kidneys due to atherosclerotic disease.
The avoidance of potential nephrotoxins, such as intravenous radiographic contrast, certain antibiotics, and NSAIDs must be based on an individualized assessment of the risks of acute decline in GFR versus the therapeutic benefits of treatment. Unlike with toxic insults, acute decline in GFR due to obstruction is commonly seen in the outpatient setting. Antihypertensive agents, especially ACE-inhibitors and angiotensin-receptor blockers, reduce proteinuria and slow the progression of kidney disease.
A noninterventional prospective cohort study including sufficient numbers of patients with all causes of kidney disease, undergoing similar testing for level of kidney function, would be ideal to evaluate the impact of cause of kidney disease on the rate of decline in GFR.
Subjects and Methods: In this cross-sectional study, patients (n = 1529) with type 2 diabetes mellitus (T2DM) were studied for the presence of complications. Subjects and Methods: This is a descriptive cross-sectional study conducted at the Sickle Cell Clinic of the University of Nigeria Teaching Hospital, Enugu Sixty-nine transfused children with SCA were enrolled after obtaining consent from their caregivers and assent from older children.
Aim: To review the clinical presentation and management measures undertaken for uterine leiomyoma. The data were analyzed using IBM SPSS software version 11.0 and descriptive statistics were obtained. Subjects and Methods: An observational, prospective study was conducted at a tertiary care center over a period of 6 months. The medicinal properties of the plants are claimed to reside in the roots, stems, and the leaves. Subjects and Methods: The study was conducted at a tertiary care multi-specialty hospital associated with a government medical college. They were grouped into: subjects without cardiac diseases (Group I), patients with ischemic heart disease (Group II), and patients with history of cardiac diseases not related to myocardial ischemia (Group III).
Aim: The aim of this study was to determine the effect of continuous training program on SUA and psychosocial status of black African (Nigerian) population with hypertension. Subjects and Methods: A cross-sectional survey of pregnant women attending the antenatal booking clinic at Federal Medical Centre Abakaliki Ebonyi State between April 6, 2011 to August 5, 2011 was undertaken. Data retrieved was analyzed for age of the women, parity, presumptive risk factor for the stillbirth, and booking status of the women. An extensive search of all materials related to the topic was made using library sources including Pubmed and Medline searches.

It was also aimed to elucidate their structure and mechanisms of action so as to integrate the efflux pump mechanisms in the design and development of novel antimicrobial agents.Findings from previous studies and research on this subject assessed through Google search, Pubmed, Hinari websites, as well as standard textbooks on chemotherapy, provided the needed information in the process of this review. Antenatal diagnosis of twin gestation with leading twin breech and second twin cephalic presentation raises index of suspicion of potential locked twin.
Massy and Hannedouche both reported that glomerular disease was associated with a faster rate of progression than tubulointerstitial nephropathy. However, the Work Group concluded that GFR decline is faster than in many other causes of chronic kidney disease given that graft survival rates are approximately 75% at 5 years for living donors and 60% at 5 years for cadaveric donors509 or an approximate half-life until graft failure for kidney transplants of approximately 12 and 7, respectively. These data, though not unanimous, confirm that elevated blood pressure is associated with faster rate of GFR decline when controlling for other factors.
There were 7 studies that reported no significant association between dyslipidemia and faster rate of progression in multivariate analyses.
Of the seven studies, three, including Kuriyama, reported an increased rate of progression among patients with lower hematocrit levels; the remaining studies reported no association. Patients with higher levels of proteinuria at baseline had a greater beneficial effect of the low blood pressure goal. Full detail of the recommendations of the ADA and JNC-VI is beyond the scope of this work, and the reader is referred to these sources for complete guidelines. Thus, treatment of patients with chronic kidney disease with ACE-inhibitors requires knowledge of the expected benefits and risks of therapy and careful attention to blood pressure, kidney function, serum electrolytes, and possible drug interactions. Whether or not the decision is made to pursue a low protein diet, the Work Group reinforces the importance of maintaining a good nutritional status with advancing chronic kidney disease, which generally would involve evaluation and monitoring by a dietitian, and refers the reader to Guideline 9.
For example, in a patient with debilitating arthritis, avoidance of NSAID use should be considered in light of the benefits of reducing pain and immobility; in a patient with coronary artery disease, the avoidance of intravenous radiocontrast should be weighed against the potential benefits of an angioplasty procedure. Alternatively, a sufficiently large prospective interventional trial could achieve a similar goal. An appreciation of the probable burden may help stimulate and galvanize appropriate public health policies in response. Non transfused children matched for age, sex, and social status with the subjects served as control.
Subjects and Methods: A retrospective study was conducted at Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, from January 2002 to December 2006. Consecutive HIV-positive patients hospitalized (both, HIV status known prior to hospitalization and the diagnosis made for the first time at admission) in medical wards from March to May 2010 were studied.
Aim : This study, therefore, is to verify this claim and elucidate the probable mechanism of action by using crude stem extracts of this plant on drug- and stress-induced ulcer models in albino mice.
Electrocardiogram was obtained from each patient when the mobile phone was placed at the belt level and over precordium in turn-off mode (baseline) and turn-on mode for 40 sec ringing. Manual search was carried out and various text books and journals of anesthesia and critical care medicine were also searched.
Efflux pump inhibitors are promising strategies for preventing and reverting efflux-mediated resistance to chemotherapeutic agents.
We report a case of inherited hypoprothrombinemia (factor II deficiency), a rare bleeding disorder as the cause of life-threatening menorrhagia.
The studies varied in the levels of kidney function assessed, sample sizes, and methodological quality. However, these two studies showed a conflicting result regarding the rate of progression associated with hypertensive kidney disease. Loss of kidney function for transplant recipients is influenced by episodes of rejection, use of immunosuppressive agents, patient gender and size, and quality of the donor kidney, among other factors. The data are not sufficient to conclude that dyslipidemia is associated with a faster rate of progression. The data are not sufficient to conclude that anemia is associated with a faster rate of progression.
There have been several secondary analyses of the data, which provide further information on the effectiveness of these interventions.503 Specifically, comparisons of the distributions of GFR slopes between randomized groups in Study A were consistent with a beneficial effect of the low protein diet group.
The results suggested that the rate of decline in GFR was significantly less in patients treated with a lipid-lowering agent compared to placebo.567 No significant heterogeneity in treatment effect was detected between the studies. Aim: This cross-sectional, descriptive study sought to determine the frequency of subclinical mental state abnormalities in a cohort of apparently normal adult Nigerians.
Pulpotomy was suggested as the first line of treatment for pulp-exposed primary tooth by 32 respondents with 44 using Buckley's formocresol and 32 applying it on the pulp for 5 minutes. All patients had their random blood sugars, fasting blood sugars (if possible), fasting lipid profile, and cluster of differentiation 4 (CD4) counts tested at the time of enrollment.
In both male and female gender, there were more teeth extractions between the ages of 11 and 30 years.
Materials and Methods : Crude ethanol and hot water extracts, EE and HWE respectively, of the stem were prepared. The trend showed a statistically significant increase in the mean level of knowledge of dental specialty with an ascent in the clinical level (P = 0.01).
Two hundred and seventeen subjects with mild to moderate (systolic blood pressure (SBP) between 140 and180 and diastolic blood pressure (DBP) between 90 and 109 mmHg) essential hypertension were grouped into continuous (112) and control groups (105).
From the information gathered, it was observed that postoperative cardiogenic pulmonary edema in patients with serious cardiovascular diseases is most common followed by noncardiogenic pulmonary edema which can be due to fluid overload in the postoperative period or it can be negative pressure pulmonary edema (NPPE). In the absence of a readily identifiable cause, all adolescents with menorrhagia should be examined for bleeding disorders. These studies either excluded diabetics, or had a very small proportion of patients with diabetes in the study sample.
At the time of preparation of these guidelines, the African American Study of Kidney Disease and Hypertension (AASK) is nearing completion, and additional information on the benefit of strict blood pressure control in nondiabetic kidney disease is expected in the near future. Consequently, patients with hypertension who have renal insufficiency should receive, unless contraindicated, an ACE-inhibitor (in most cases, along with a diuretic) to control hypertension and to slow progressive renal failure. However, the quality of the studies was generally low, and their small sample sizes and relatively short duration of follow-up make it difficult to conclude that lipid-lowering therapies reduce the rate of decline in GFR in chronic kidney disease. Subjects and Methods: One hundred and thirty-five apparently normal adult Nigerians of both sexes seen at the University of Nigeria Teaching Hospital, Enugu, were interviewed. The patients were followed for a period of 3 months, at the end of which they were categorized as survivors and non-survivors, and the demographic, clinical, and investigational parameters were compared between the above groups.
These extracts were fractionated and separated by chromatographic methods and the fractions pooled together as fractions (PF-1, PF-2, PF-3 respectively) based on their chromatographic mobility and color reactions.
Conclusion: The level of knowledge of dental specialty in this survey was suboptimal and varied with different specialties which may have adverse implication in future patient care. The continuous group involved in an 8 weeks continuous training (60%-79% HR max) of between 45 and 60 min, 3 times per week, while the controls group remain sedentary.
Results : There were a total of 1,142 deliveries within the study period, out of which 206 resulted in stillbirths. NPPE is an important clinical entity in immediate post-extubation period and occurs due to acute upper airway obstruction and creation of acute negative intrathoracic pressure. Neuroprotection is an increasingly recognized management strategy in ischemic stroke that promises to assist clinicians in reducing stroke mortality rates and improving the quality of life of survivors.
Toxicity, more common with the older-generation inhibitors such as verapamil and reserpine, constitutes the greatest impediment to their clinical applications. One of the testes in the left hemiscrotum revealed features of torsion and hemorrhagic necrosis. The interval predicted from the first regression line was 30 months (left vertical dashed line).
Clearly, adequately powered, randomized controlled trials are needed to determine the role of lipid-lowering therapy in retarding the rate of decline in kidney function in patients with chronic kidney disease. The Mini Mental State Examination (MMSE) of Folstein, Folstein, and McHugh was used to assess cognitive function in each subject at a single instance. Statistical Package for Social Science (SPSS) version 11 (Chicago, IL) was used for data analysis.
In pulpectomy procedure 44 respondents preferred zinc oxide eugenol as obturation material with 22 using handheld reamers and 15 using slow-speed lentilospirals for obturation. Data was analyzed by applying Mann-Whitney U test, two sample t-test, Fisher-Exact test, and stepwise logistic regression analysis of significance, using the computer-based program, Stata, version 11.1.
There was a significant improvement in knowledge of medical students on all the three domains of the questionnaire for assessment of knowledge about ECT-related facts. The variation in the level of knowledge with different clinical level suggested gain in knowledge about dental specialty mainly through nonformal means among medical students.
Socio-biological variables and past obstetrics history did not contribute significantly to the gestational age at booking while sickness in index pregnancy, personal wishes, and financial constraint were statistically significant reasons given for seeking antenatal care. NPPE carries a good prognosis if promptly diagnosed and appropriately treated with or without mechanical ventilation.
No efflux pump inhibitor has been approved for routine clinical use, as a result of doubtful clinical efficacy and unacceptably high incidence of adverse effects, particularly inhibition of the P-450 drug metabolizing enzyme.
The evaluation and management of dyslipidemia in patients with chronic kidney disease has been addressed by the NKF Task Force on Cardiovascular Disease in Chronic Renal Disease and is reviewed briefly in Guideline 15.
The chi-square was used to test for significant association of categorical variables and a P-value of less than 0.05 accepted as significant. Ulcer models were induced in albino mice by means of indomethacin, histamine, and stress after prior cytoprotection with orally administered crude extracts and control (cimetidine). A change in attitudes towards ECT was also observed following Brief ECT Orientation Module, especially among those who witnessed ECT administration. The prediction error (difference between the actual and predicted intervals) was 10 months (25% of the actual interval). It is thus unclear whether such severely restricted protein diets can be safely prescribed or even maintained in the absence of frequent dietitian involvement.
The management of dyslipidemia in patients with kidney failure is the subject of an ongoing KDOQI Work Group. Consent was obtained from each person and approval obtained from the hospital's ethics review board. In order of preference Glass ionomer cement (GIC), silver amalgam, and stainless steel crowns were the materials of choice for final restoration of endodontically treated deciduous teeth.
Conclusion: The result of this study shows that dental caries is the commonest reason for tooth extraction in Eastern Nigeria. Results : Phytochemical analysis of the crude extracts and their fractions revealed the presence of cardiac glycosides (+++), tannins (+++), saponins (+), flavonoids (++), carbohydrates (++) and alkaloids (+++).
Conclusion: The findings of the current study suggest that the Brief ECT Orientation Module is effective in improving the knowledge and attitude of medical students towards ECT. The position of mobile at the belt level or over the precordium showed effects on the heart. The maximum mean change in blood glucose for Rosiglitazone and Rosiglitazone + Mexiletine or Rosiglitazone + Disopyramide was observed at 1 h and 8 h in normal and diabetic rats. Nonetheless, the search for efficacious and tolerable efflux pump inhibitors continues because of the potential benefits. Magnetic resonance imaging may provide additional information in complicated cases of polyorchidism. Conclusions: The data showed that neuropathy was the most common microangiopathy and coexisted with other complications in many patients.
All the infected individuals among the subjects were males, had only been transfused once and were from the lower socioeconomic class. All 50 answered in the affirmative when asked if they would like to have additional information about pulp therapy in deciduous teeth.
It is hoped that the study will facilitate the development of treatment and preventive procedures relevant to the problems observed in this part of Nigeria, thus minimizing the loss of teeth and its expected adverse consequences.
Conclusions: The radiofrequency of cell phone prolongs the QT interval in human beings and it interferes with voltage criteria of ECG records in male patients with myocardial ischemia. Conclusion: Most pregnant women access antenatal care late at Abakaliki because of misconception and poverty. There is a need to consider efflux pump substrate selectivity in the design and development of novel chemotherapeutic agents. Old age, long duration of disease, and poor glycemic control are the common risk factors for microvascular complications. The only infected child from the control group was a 7-year-old male and he probably acquired it through vertical transmission since the mother also tested positive to HIV antibody. Conclusion: The study concluded that general dentists were regularly performing pulp therapy in decidous teeth and therefore need to be frequently updated about these procedures.
Mycobacterium tuberculosis as opportunistic infection was found in 42 patients, out of which 13 expired (P=0.02). The crude extracts (EE and HWE) and their fractions (PF-1, PF-2, PF-3) significantly (P = 0.001) protected against indomethacin-, histamine- and stress-induced ulcers.
Conclusion: The study concludes that PD activity of Rosiglitazone was not affected by the anti-arrhythmic drugs. Conclusions: This study concludes and supports the recommendations of moderate intensity (continuous) training program in blood pressure reduction, SUA and psychosocial stress management in hypertension.
Health education and subsidization of cost of medical services will help in reversing the trend of late antenatal booking. Conclusions: Blood transfusion is still a risk factor for HIV transmission among children with sickle cell anemia in Nigeria. The decrease in GIT motility produced by these extracts was comparable to that produced by atropine sulfate.
This study introduced a new statistical methodology for analyzing the blood glucose endpoint. Conclusion : The stillbirth rate at the institution is too high and efforts must be made to reduce it. Strategies that will ensure improved blood transfusion safety at health facilities need to be strengthened.
Conclusion: The symptom of lower abdominal mass correlates with late presentations in our setting.
Conclusions: Low HDL and hypertriglyceridemia also appear to be promising short-term mortality markers in HIV patients apart from established factors like low CD4 counts, co-morbid conditions, and opportunistic infections like M. Conclusion : The findings suggest that these extracts of Synclisia scabrida possess antiulcer and antispasmodic properties, which justify the claims for its use in the treatment of various forms of stomach disorders. These persons thus represent otherwise normal functional individuals with unrecognized mild cognitive impairment who may be at risk of developing overt dementia in future.
This makes the application of newer therapies like laparoscopic myomectomy difficult even when they are available.
Conclusion: The concept of mild cognitive impairment needs further large-scale studies in Nigerians with possible multi-centre participation to fully elucidate the scope of the problem.
Other therapies which are independent of fibroid size (like uterine artery embolization) are not readily available in our environment. This study warrants further studies with a larger sample size to establish HDL and triglyceride as markers of disease progression and short-term mortality in HIV-infection.
This further emphasizes the importance of myomectomy as the most important treatment modality in our environment.

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  1. Seytan_666

    With your blog is you tooth decay has to do with a scarcity of this vitamin.


  2. Bakinskiy_Avtos

    Than the normal levels b's are inclined to have.


  3. Tanchor

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  4. AHMET

    Liver, dessicated liver with blood sugar issues.