26 Research Way
East Setauket NY 11733
Medical School: Other - Unknown
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License #: 171725
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Arteriojejunal Fistula Presenting with Recurrent Obscure GI Hemorrhage in a Patient with a Failed Pancreas Allograft. - Case reports in transplantation
We present a case of a patient with a failed pancreaticoduodenal allograft with exocrine enteric-drainage who developed catastrophic gastrointestinal (GI) hemorrhage. Over the course of a week, she presented with recurrent GI bleeds of obscure etiology. Multiple esophago-gastro-duodenoscopic (EGD) and colonoscopic evaluations failed to reveal the source of the hemorrhage. A capsule endoscopy and a technetium-labeled red blood cells (RBC) imaging study were similarly unrevealing for source of bleeding. She subsequently developed hemorrhagic shock requiring emergent superior mesenteric arteriography. Run off images revealed an external iliac artery aneurysm with fistulization into the jejunum. Coiled embolization was attempted but abandoned because of hemodynamic instability. Deployment of a covered endovascular stent into the right external iliac artery over the fistula site resulted in immediate hemodynamic stabilization. A high index of suspicion for arterioenteric fistulae is needed for diagnosis of this uncommon but eminently treatable form of GI hemorrhage in this patient population.
Triple Diuretics and Aquaretic Strategy for Acute Decompensated Heart Failure due to Volume Overload. - Case reports in cardiology
Diuretics, including furosemide, metolazone, and spironolactone, have historically been the mainstay of therapy for acute decompensated heart failure patients. The addition of an aquaretic-like vasopressin antagonist may enhance diuresis further. However, clinical experience with this quadruple combination is lacking in the acute setting. We present two hospitalized patients with acute decompensated heart failure due to massive fluid overload treated with a combination strategy of triple diuretics in conjunction with the aquaretic tolvaptan. The first patient lost 72.1â€‰lbs. (32.7â€‰kg) with an average urine output of 3.5 to 7.5â€‰L/day over eight days on combined therapy with furosemide, metolazone, spironolactone, and tolvaptan. The second patient similarly achieved a weight loss of 28.2â€‰lbs. (12.8â€‰kg) over 4 days on the same treatment. Both patients maintained stable serum sodium, potassium, and creatinine over this period and remained out of the hospital for more than 30 days. Thus, patients hospitalized with acute decompensated heart failure due to volume overload can achieve euvolemia rapidly and without electrolytes disturbances using this regimen, while being under the close supervision of a team of cardiologists and nephrologists. Additionally, this therapy can potentially decrease the need for ultrafiltration and the length of hospital stay.
Reversible left ventricular dysfunction and acute kidney injury in a patient with nonamyloid light chain deposition disease. - Clinical nephrology
Non-amyloid light chain deposition disease (LCDD) is a rare entity that most commonly presents as proteinuria and/or renal dysfunction. We report on a patient who initially presented with acutely decompensated heart failure and subsequently developed nephrotic range proteinuria with attendant advanced renal dysfunction. The diagnosis of LCCD was made on renal biopsy.She was treated with five cycles of bortezomib and dexamethasone followed by cyclophosphamide priming for peripheral blood stem cell (PBSC) mobilization and auto logousstem cell transplant (ASCT). Four years later, she remains in very good partial response (VGPR) with a left ventricular ejection fraction (LVEF) of 58% and serum creatinine of 1.1 mg/dl. This observation supports the approach of aggressive management of patients with LCDD who have multiple organ failure.
Intestinal infarction and portal vein thrombosis in a patient with henoch schonlein purpura. - Case reports in rheumatology
Henoch Schonlein purpura is a systemic vasculitis that commonly affects children and teenagers but also affects adults of all ages. In most instances it has a benign course. Organ involvement, particularly in adults, and notably the kidneys and gastrointestinal tract may require therapeutic intervention and may have a less favorable outcome. We report a case of a 58-year-old man who presented with purpura and who rapidly developed catastrophic intestinal vasculitis, leading to his demise.
Retroperitoneal mass in a patient with Wegener's granulomatosis. - Clinical nephrology
Wegener's granulomatosis (WG) is a necrotizing vasculitis that classically involves the upper and lower respiratory tracts and kidneys. Uncommonly, other sites may also be involved. We report on a patient previously diagnosed with and treated for WG who presented with flank pain and on further imaging was found to have a retroperitoneal mass. A surgical specimen of the tissue revealed multiple foci of necrotizing vasculitis. Consideration should be given to the possibility that mass-like lesions in patients with WG may not be tumors since the management and outcome differ from that of an active vasculitis.
Exit-site care in peritoneal dialysis. - Contributions to nephrology
Exit-site infection (ESI), tunnel infection and associated peritonitis are major causes of morbidity and catheter loss in chronic peritoneal dialysis patients. Meticulous exit-site care is vital in preventing ESI. Avoiding trauma to the exit-site and daily cleaning of the exit-site with a dedicated antimicrobial soap is essential for the longevity of the peritoneal dialysis catheter. Antibiotics cream and disinfectant agents including povidone-iodine, chlorhexidine, electrolytic chloroxidizing solutions (Amuchina 10% - ExSept Plus, Amuchina 5% - ExSept) are useful to keep the resident micro-organisms inhibited. ESI rates in peritoneal dialysis patients treated with Amuchina 10% (ExSept Plus) and Amuchina 5% (ExSept) for the exit-site care are similar or lower compared to povidone-iodine or chlorhexidine. Electrolytic chloroxidizing (Amuchina 10% - ExSept Plus and Amuchina 5% - ExSept) solutions for exit-site care are effective for prevention and treatment of ESI.
High body mass index in muscular patients and flank position are risk factors for rhabdomyolysis: case report after laparoscopic live-donor nephrectomy. - Journal of endourology / Endourological Society
Rhabdomyolysis is well known after traumatic crush injuries or ischemia involving muscles. Postoperatively, it most likely is secondary to surgical positioning and patient muscle mass. We report a case after laparoscopic live-donor nephrectomy.A muscular 35-year-old man underwent elective left laparoscopic live-donor nephrectomy in a 70 degrees flank position with four ports. He was in the right-side lying position with hip flexion (flank position) for approximately 4 hours. A kidney bridge had been placed between the iliac crest and the rib cage. Postoperatively, the patient had light-pinkish urine and low urine output. There was marked induration of the buttocks and significant pedal and scrotal edema. With judicious use of alkalinization and diuretics, the patient did not require dialysis, and renal function returned to base level by postoperative day 20. The recipient of the kidney had a normal postoperative course.Rhabdomyolysis is a syndrome of muscle necrosis and release of intracellular components into the circulation. Acute renal failure secondary to myoglobinuria is a common complication. We currently use little flexion of the table during donor nephrectomy and bring the table to a neutral position immediately after kidney retrieval. Postoperatively, one needs a high index of suspicion for rhabdomyolysis to avoid or at least promptly recognize this rare but potentially serious condition after any operation lasting >or=4 hours.
Membranous glomerulonephritis in a patient with an adrenal ganglioneuroma. - American journal of kidney diseases : the official journal of the National Kidney Foundation
Membranous glomerulonephritis has been reported in association with several tumors. This report is the first case of membranous glomerulonephritis associated with an adrenal ganglioneuroma. The sera obtained from the patient at presentation stained the fibrillary component of the ganglioneuroma and the glomerular basement membrane of the kidney. The antibodies present in the patient's serum also reacted with the glomerular basement membrane of several normal and randomly selected abnormal kidneys, including 1 from a patient with Alport's syndrome. The patient's sera contained a circulating tumor antigen-specific antibody that cross-reacted with an antigen present on the podocyte membrane of the renal glomeruli. The resection of the ganglioneuroma resulted in a complete remission of the nephrotic syndrome within months of removal of the tumor. This was associated with loss of antibodies in the patient's serum. The patient was not treated with steroids or any immunosuppressive agents. The patient remains in remission with normal renal function after 9 years of follow-up.
Regional citrate anticoagulation for continuous venovenous hemodiafiltration using calcium-containing dialysate. - American journal of kidney diseases : the official journal of the National Kidney Foundation
Regional anticoagulation with trisodium citrate for continuous venovenous hemodiafiltration (CVVHDF) is an effective and safe alternative to heparin, especially in patients at high risk for bleeding. However, regional citrate anticoagulation is not used widely because current protocols are complex, labor intensive, and cumbersome. Existing protocols require the use of calcium-free dialysate with a continuous systemic calcium infusion to prevent hypocalcemia. We evaluated Anticoagulant Citrate Dextrose Formula A (ACD-A) solution for regional anticoagulation in CVVHDF in combination with a commercially available calcium-containing dialysis solution.Thirty-eight patients in the intensive care units underwent citrate-based CVVHDF using low-calcium peritoneal dialysis solution (calcium, 5.0 mg/dL [1.25 mmol/L]). ACD-A infusion rate was adjusted to maintain postfilter ionized calcium (iCa++) levels at 1.0 to 2.0 mg/dL (0.25 to 0.5 mmol/L). Calcium chloride (10%) solution was administered intravenously every 6 hours on an as-needed basis to maintain systemic serum iCa++ levels at 3.5 to 4.0 mg/dL (0.88 to 1.0 mmol/L).CVVHDF was performed for a total of 394 days using 149 hemofilters. Mean hemofilter life span was 63.5 +/- 27.1 hours. Seventy-five percent, 61%, and 49% of hemofilters were patent at 24, 48, and 72 hours, respectively. No patient experienced a change in clinical status caused by hypocalcemia and/or signs and symptoms of citrate toxicity. Four patients developed metabolic alkalosis requiring 0.1 N of hydrochloric acid infusion.Our simplified technique of regional citrate anticoagulation for CVVHDF using calcium-containing dialysate is not associated with increased hemofilter clotting and obviates the need for a continuous systemic calcium infusion and calcium-free dialysate.
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26 Research Way East Setauket, NY 11733
181 Belle Mead Rd
6 Technology Drive Suite 100
205 N Belle Mead Ave
6 Technology Dr Suite 100