The objective of this study was to identify the factors associated with important clinical outcomes in a case-control study of 213 patients with lupus nephritis. Included were 47% Hispanics, 44% African Americans and 9% Caucasians with a mean age of 28 years. Fifty-four (25%) patients reached the primary composite outcome of doubling serum creatinine, end-stage renal disease or death during a mean follow-up of 37 months. Thirty-four percent African Americans, 20% Hispanics and 10% Caucasians reached the primary composite outcome (P < 0.05). Patients reaching the composite outcome had predominantly proliferative lupus nephritis (WHO classes: 30% III, 32% IV, 18% V and 5% II, P < 0.025) with higher activity index score (7 +/- 6 versus 5 +/- 5, P < 0.05), chronicity index (CI) score (4 +/- 3 versus 2 +/- 2 unit, P < 0.025), higher baseline mean arterial pressure (MAP) (111 +/- 21 versus 102 +/- 14 mmHg, P < 0.025) and serum creatinine (1.9 +/- 1.3 versus 1.3 +/- 1.0 mg/dL, P < 0.025), but lower baseline hematocrit (29 +/- 6 versus 31 + 5%, P < 0.025) and complement C3 (54 +/- 26 versus 65 + 33 mg/dL, P < 0.025) compared to controls. More patients reaching the composite outcome had nephrotic range proteinuria compared to controls (74% versus 56%, P < 0.025). By multivariate analysis, CI (hazard ratio [95% CI] 1.18 [1.07-1.30] per point), MAP (HR 1.02 [1.00-1.03] per mmHg), and baseline serum creatinine (HR 1.26 [1.04-1.54] per mg/dL) were independently associated with the composite outcome. We concluded that hypertension and elevated serum creatinine at the time of the kidney biopsy as well as a high CI are associated with an increased the risk for chronic renal failure or death in patients with lupus nephritis.

An ischemic hand in a hemodialysis patient is a serious condition. It causes significant pain and discomfort but also can lead to tissue necrosis and the eventual loss of digits and even the entire hand. Although stealing of blood away from the high-resistance forearm arteries into the low-resistance arteriovenous access generally is assumed to be the cause, a great majority of both wrist and elbow accesses demonstrate retrograde flow without any evidence of hand pain or ischemia. Consequently, demonstration of retrograde flow alone does not predict or indicate the existence of distal ischemia. In this context, the term "arterial steal syndrome" is a misnomer to indicate the presence of peripheral ischemia. Recent studies have shown that, in many cases, arterial stenotic lesions cause distal hypoperfusion and result in hand ischemia. In other cases, distal arteriopathy as a result of generalized vascular calcification and diabetes is the culprit. Because any or a combination of the three mechanisms (retrograde flow, stenotic lesions, and distal arteriopathy) can lead to peripheral ischemia, distal hypoperfusion ischemic syndrome is a more appropriate term to denote hand ischemia. Treatment should start with a detailed history and physical examination to help rule out other (nonischemic) causes of hand pain. A complete arteriogram to evaluate the circulation of the extremity from the aortic arch to the palmar arch is essential. The choice of treatment modality and procedure to apply should be based on this evaluation. This report reviews the pathophysiology and presents current strategies to ameliorate distal hypoperfusion ischemic syndrome.

Background and objectives: Physical examination has been highlighted to detect vascular access stenosis; however, its accuracy in the identification of stenoses when compared with the gold standard (angiography) has not been validated in a systematic manner.Design, setting, participants, & measurements: A prospective study was conducted of 142 consecutive patients who were referred for an arteriovenous fistula dysfunction to examine the accuracy of physical examination in the detection of stenotic lesions when compared with angiography. The findings of a preprocedure physical examination and diagnosis were recorded and secured in a sealed envelope. Angiography from the feeding artery to the right atrium was then performed. The images were reviewed by an independent interventionalist who had expertise in endovascular dialysis access procedures and was blinded to the physical examination, and the diagnosis was rendered. Cohen's was used as a measurement of the level of agreement beyond chance between the diagnosis made by physical examination and angiography.Results: There was strong agreement between physical examination and angiography in the diagnosis of outflow (agreement 89.4%, ‫؍‬ 0.78) and inflow stenosis (agreement 79.6%, ‫؍‬ 0.55). The sensitivity and specificity for the outflow and inflow stenosis were 92 and 86% and 85 and 71%, respectively. There was strong agreement beyond chance regarding the diagnosis of coexisting inflow-outflow lesions between physical examination and angiography (agreement 79%, ‫؍‬ 0.54).Conclusions: The findings of this study demonstrate that physical examination can accurately detect and localize stenoses in a great majority of arteriovenous fistulas.

No abstract

Physical examination (PE) has been highlighted to detect vascular access stenosis with high degree of accuracy when performed by an interventional nephrologist (IN) with expertise in physical examination. This study examines the accuracy of PE compared with angiography when performed by a nephrology fellow (NF). It also compares NF results to that of IN. Didactic and hands-on PE training was provided to a renal fellow for 1 month during an interventional nephrology rotation. Forty-five and 142 consecutive cases of arteriovenous fistula dysfunction were examined by the NF and IN, respectively. Preprocedure PE was performed by the NF and IN and the finding secured in a sealed envelope. Angiography from the feeding artery to the right atrium was then performed. The images were reviewed by an independent interventionalist with expertise in endovascular dialysis access procedures and the diagnosis was rendered. The reviewer was blinded to the physical examination. Cohen's Kappa was used as a measurement of the level of agreement beyond chance between the diagnosis made by physical examination and angiography. Because of its success, ease of performance, prompt availability, and cost-effectiveness physical examination is emerging as an important element in the detection of arteriovenous access stenosis (1-7). The application of physical examination and its accuracy in the detection of vascular access stenosis when compared with the gold standard (angiography) has been documented previously (5-9). However, to the best of our knowledge, the accuracy of physical examination in the detection of stenosis when performed by a renal fellow in training and its comparison to angiography has not been previously evaluated.This analysis was conducted to examine the accuracy of physical examination of fistula stenosis by a renal fellow in training. In addition, the study also evaluated the differences in detection of stenosis by a renal fellow and an interventional nephrologist with experience in physical examination (7-9). MethodsForty-five consecutive cases with arteriovenous fistula dysfunction referred for angioplasty underwent a complete physical examination by a renal fellow in training before any angiography was undertaken. The fellow had received 1 month of intense training in physical examination. Both didactic and hands-on physical examination education was provided to the fellow during the month on interventional nephrology rotation. At the same time, 142 patients underwent physical examination by an experienced interventional nephrologist. The elements of the physical examination used in this study were based on recent information by Beathard (2-6). Briefly, inspection (arm, shoulder, breast, neck, and face edema and presence of collaterals), palpation, and auscultation were performed in a systematic fashion. Palpation was not just limited to the body of the access. It was carefully performed from the anastomosis all the way to the chest wall. Pulse (hyperpulsatile, normal, and weak) and thrill ⁄ bruit (continuo...