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By: C. Nerusul, M.A., Ph.D.

Professor, UTHealth John P. and Katherine G. McGovern Medical School

Dr Winearls was appointed consultant in Oxford in 1988 and was Clinical Director 1995 to 2009 antibiotic natural purchase discount cipro on-line. He has been Secretary and later Clinical Vice President of the Renal Association and an Editor of the Oxford Textbook of Clinical Nephrology infection board game buy cipro 250 mg on-line. He received his medical degree from the University of Iowa and completed his Internal Medicine residency and fellowship training in Nephrology at Hennepin County Medical Center where he is currently Director of Nephrology. Dr Kasiske is former Deputy Director of the United States Renal Data System and former Editor-in-Chief of American Journal of Kidney Diseases. Dr Kasiske is the Director of the Scientific Registry of Transplant Recipients and has over 160 scientific publications in major peer-reviewed journals, and 230 review articles, editorials and textbook chapters. Dr Wheeler has served on the editorial boards of American Journal of Kidney Diseases and Journal of the American Society of Nephrology and is presently Co-Editor for Nephrology Dialysis Transplantation. She orchestrates and supervises the guideline development process and didactic curriculum that provides Work Group members with formal instruction on topics related to guideline development. As project director on individual guidelines, she directs and supervises the collection, evaluation, grading, and synthesis of evidence and the drafting and revisions of the final evidence report. She provides methodological guidance and training to Work Group members at meetings regarding topic refinement, key question formulation, data extraction, study assessment, evidence grading, and recommendation formulation. She provides nephrology expertise in the interpretation and review of guideline recommendations and evidence reports. In this capacity, Kidney International Supplements (2013) 3, 128­133 biographic and disclosure information Dr Uhlig possesses unique knowledge as a methods expert in evidence synthesis and critical literature appraisal in the domain of nephrology. From 2006 to 2007, she served as Co-Editor of American Journal of Kidney Diseases. Her teaching and research focus includes evidence-based medicine, systematic review, clinical practice guideline development, and critical literature appraisal. Dr Uhlig lectures on guideline topics and is a co-instructor of an annual course on meta-analysis in the Master of Science Program at the Sackler School of Graduate Biomedical Sciences at Tufts University. She completed a fellowship in Clinical Care Research and participated in the conduct of systematic reviews and critical literature appraisals for this guideline. Ms Earley also heads the actual evidence review, which includes running searches, screening, data extraction, drafting of tables and methods sections, proofing of guideline drafts, and critical literature appraisals. She participates in the conduct of research projects at the Center and actively collaborates with other members of the Center on independent research topics and manuscript submissions. She screens abstracts and articles, extracts data, and assists in the drafting and editing of evidence tables. Dr Haynes also assists in the development of clinical practice guidelines and conducts systematic reviews and critical literature appraisals. Lamont reported no relevant financial relationships Kidney International Supplements (2013) 3, 128­133 133 acknowledgments. We are also especially grateful to the Work Group members for their expertise throughout the entire process of literature review, data extraction, meeting participation, the critical writing and editing of the statements and rationale, which made the publication of this guideline possible. The entire Work Group and its Co-Chairs would also like to extend a special debt of gratitude to Michael Cheung, who has committed time and energy above and beyond, to the formatting and proof reading of the completed manuscript. Finally, and on behalf of the Work Group, we gratefully acknowledge the careful assessment of the draft guideline by external reviewers. The Work Group considered all of the valuable comments made and where appropriate, suggested changes were incorporated into the final publication. Participation in the review does not necessarily constitute endorsement of the content of this report by the above individuals, or the organization or institution they represent. Lower estimated glomerular filtration rate and higher albuminuria are associated with mortality and end-stage renal disease. Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative metaanalysis. Lower estimated glomerular filtration rate and higher albuminuria are associated with allcause and cardiovascular mortality. Glomerular filtration rate, proteinuria, and the incidence and consequences of acute kidney injury: a cohort study. Frailty and chronic kidney disease: the Third National Health and Nutrition Evaluation Survey. Demographic and clinical characteristics associated with glomerular filtration rates in living kidney donors. The association between age and nephrosclerosis on renal biopsy among healthy adults.

Although valproic acid is highly protein bound at therapeutic serum levels antibiotic resistance lancet buy discount cipro 250mg on-line, saturation of protein binding in overdose (binding decreases to 35% at 300 mg/L) makes valproic acid favorably disposed to enhanced removal methods oral antibiotics for sinus infection purchase discount cipro line. Hemodialysis may result in a four- to tenfold decrease in elimination half-life in overdose patients. Dialysis also corrects metabolic disturbances and removes valproic acid metabolites. Consider dialysis in patients with serum valproic acid levels exceeding 850 mg/L, since these cases are associated with higher morbidity and mortality. Charcoal hemoperfusion (alone and in series with hemodialysis) has also been utilized with clearances similar to those observed with hemodialysis. Theoretically, repeated doses of charcoal may enhance clearance by interruption of enterohepatic recirculation, but no controlled data exist to confirm or quantify this benefit. Another benefit is enhanced gastrointestinal decontamination after large or massive ingestion, since single doses of charcoal are inadequate to adsorb all ingested drug. Nonselective alpha-adrenergic blocking agents (eg, phenoxybenzamine, phentolamine, and tolazoline) have been used in clinical practice since the 1940s. The first selective alpha-1 blocker, prazosin, was introduced in the early 1970s; doxazosin, indoramin, terazosin, trimazosin, urapidil, and tamsulosin (approved for benign prostatic hypertrophy) are newer alpha-1­selective agents. A reflex sympathetic response results in tachycardia and occasionally cardiac arrhythmias. Prazosin and other newer alpha-1­specific agents are associated with little or no reflex tachycardia; however, postural hypotension is common, especially in patients with hypovolemia. No fatalities have been reported except with indoramin overdose and excessive intravenous doses of phentolamine. A 19-year-old man became hypotensive after taking 200 mg and recovered within 36 hours. Two elderly men ingesting 40­120 mg were found comatose with Cheyne-Stokes breathing and recovered after 15­18 hours. Two adults developed profound hypotension (with tachycardia) requiring pressor support following 1. Acute overdose may cause headache, nausea, dizziness, weakness, syncope, orthostatic hypotension, warm flushed skin, and palpitations. Severe hypotension may result in cerebral and myocardial ischemia and acute renal failure. First-time users of alpha-1 blockers may experience syncope after therapeutic dosing. Diagnosis is based on a history of exposure and the presence of orthostatic hypotension, which may or may not be accompanied by reflex tachycardia. Hypotension usually responds to supine positioning and intravenous crystalloid fluids. There is no clinical experience with extracorporeal drug removal for these agents. Terazosin and doxazosin are long-acting and eliminated 60% in feces; thus, repeat-dose activated charcoal may enhance their elimination. The mechanism by which excessive amounts of vitamin A produce increased intracranial pressure is not known. Chronic excessive use and large intravenous doses can produce increased levels of the metabolite oxalic acid. Urinary acidification promotes calcium oxalate crystal formation, which can result in nephropathy or acute renal failure. Chronic ingestion of excessive amounts of vitamin D enhances calcium absorption and produces hypercalcemia. Chronic overdose may alter neuronal conduction, resulting in paresthesias and muscular incoordination. Most acute overdoses of multivitamins are associated with nausea, vomiting, and diarrhea.

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Measures of tubular microproteinuria (beta-microglobulin infection rate in hospitals buy cipro 250 mg cheap, retinol-binding protein bacteria life cycle buy genuine cipro line, albumin, and metallothionein) are used to monitor the early and toxic effects of Cd on the kidney. Observe for at least 6­8 hours and treat wheezing and pulmonary edema (see pp 7­8) if they occur. After significant exposure, it may be necessary to observe for 1­2 days for delayed-onset noncardiogenic pulmonary edema. Treat fluid loss caused by gastroenteritis with intravenous crystalloid fluids (see p 16). Pinot F et al: Cadmium in the environment: sources, mechanisms of biotoxicity, and biomarkers. Besides its well-known presence in coffee, tea, colas, and chocolate, it is available in many over-the-counter and prescription oral medications and as injectable caffeine sodium benzoate (occasionally used for neonatal apnea). Botanical forms of caffeine, including yerba mate, guarana (Paullinia cupana), and kola nut (Cola nititum) are common constituents of "thermogenic" dietary supplements widely touted for weight loss and athletic enhancement (see also p 215). Although caffeine has a wide therapeutic index and rarely causes serious toxicity, there are many documented cases of accidental, suicidal, and iatrogenic intoxication, some resulting in death. In addition, with overdose there is considerable beta-1 and beta-2 adrenergic stimulation secondary to release of endogenous catecholamines. Caffeine is rapidly and completely absorbed orally with a volume of distribution of 0. Its elimination half-life is approximately 4­6 hours but can range from 3 hours in healthy smokers to 10 hours in nonsmokers; after overdose the half-life may be as long as 15 hours. In infants less than 2­3 months old, metabolism is extremely slow and the half-life may exceed 24 hours. The reported lethal oral dose is 10 g (150­200 mg/kg), although one case report documents survival after a 24-g ingestion. Coffee contains 50­200 mg (tea, 40­100 mg) of caffeine per cup depending on how it is brewed. As with theophylline, chronic administration of excessive doses may cause serious toxicity with relatively low serum concentrations compared with an acute single ingestion. The earliest symptoms of acute caffeine poisoning are usually anorexia, tremor, and restlessness. With serious intoxication, delirium, seizures, supraventricular and ventricular tachyarrhythmias, hypokalemia, and hyperglycemia may occur. Hypotension is caused by excessive beta-2­mediated vasodilation and is characterized by a low diastolic pressure and a wide pulse pressure. Chronic high-dose caffeine intake can lead to "caffeinism" (nervousness, irritability, anxiety, tremulousness, muscle twitching, insomnia, palpitations, and hyperreflexia). Diagnosis is suggested by the history of caffeine exposure or the constellation of nausea, vomiting, tremor, tachycardia, seizures, and hypokalemia (also consider theophylline; see p 354). Serum caffeine levels are not routinely available in hospital laboratories but can be determined at commercial toxicology laboratories. Toxic concentrations may be detected by cross-reaction with theophylline assays (see Table I­33, p 44). Coffee drinkers have caffeine levels of 1­10 mg/L, while levels of 80 mg/L have been associated with death. Beta blockers effectively reverse cardiotoxic effects mediated by excessive beta-adrenergic stimulation. Gastric emptying is not necessary if activated charcoal can be given promptly, although gastric lavage should be considered for massive ingestion. Seriously intoxicated patients (with multiple seizures, significant tachyarrhythmias, or intractable hypotension) may require hemodialysis or charcoal hemoperfusion (see p 55). Toxicity from calcium antagonists may occur with therapeutic use (often owing to drug interactions) or as a result of accidental or intentional overdose. Overdoses of calcium antagonists are frequently life threatening and represent an important source of druginduced mortality. Lowering of blood pressure through a fall in peripheral vascular resistance may be offset by reflex tachycardia, although this reflex response may be blunted by depressant effects on contractility and sinus node activity.

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Adaptation of educational resources and longer consultation times may be required [278] and family rather than individual consultations may be relevant antibiotics for dogs for diarrhea cheap cipro 1000 mg free shipping. Cultural barriers can include low health literacy bacteria normally carried by about a third of the population cheap cipro 500 mg mastercard, high level of tolerance to problems and unwillingness to see a male physician [278]. Primary care is generally well placed to diagnose, screen and coordinate interdisciplinary care. New models of care should follow best practice and be co-designed with both women and health professionals. Needs differ by individual and life stage and diagnosis is a time of greater need. Culturally appropriate care involves more than linguistic considerations and is just as important for women who speak English but are not of the cultural majority. Weight was also a highly ranked, prioritised outcome by both health professionals and women during the guideline development process. Summary of systematic review evidence One high quality systematic review with a low risk of bias was identified to answer this question. Due to the inconsistencies and methodological weaknesses of included studies, caution is recommended when interpreting the combined metaanalyses and results of the systematic review. There were three studies that used exercise and three that used combined lifestyle modification programmes (including diet, exercise and behaviour), with the outcome measurements reported at various times (12, 16, 24, and 48 weeks). None of the studies addressed fertility outcomes such as pregnancy, live birth and miscarriage. While some studies reported on menstrual regularity and ovulation, the findings were reported in a variety of ways and it was not possible to estimate the overall effects of lifestyle on these outcomes. The recommendations also consider important psychosocial, cultural and ethnic aspects in relation to lifestyle interventions and were informed by evidence generated for other clinical questions under emotional wellbeing and under specific lifestyle interventions. Engagement of health practitioners and financial barriers for patients may present implementation issues. Dietary intervention studies have shown benefit with weight loss [314], however retention and sustainability prove challenging, suggesting a need for additional strategies. Behavioural and cognitive behavioural intervention approaches target behaviours, their antecedents and consequences and cognitions that maintain positive energy balance and promote weight gain [316] and are common in weight management. Behaviour therapy results in significantly greater weight loss than placebo, and behaviour/cognitive behaviour therapy combined with diet and exercise has efficacy. The intervention was not well defined or replicable and metabolic, reproductive and psychosocial outcomes were not assessed. These compared comprehensive lifestyle intervention (diet, behaviour and physical activity) over 24 weeks with placebo [318, 319] with variable but limited benefits. Behavioural change techniques in combination with diet and exercise interventions, increased weight loss over diet and/or physical activity alone [320]. Self-management has positive impacts [320] and family support improves outcomes, [320]. Overall, this underpins international guidelines recommending integration of: 1/ established behaviour change techniques 2/ self-management/self-monitoring and 3/ social support to preventative and treatment lifestyle interventions [320. Combining behavioural/cognitive behavioural weight loss components with intensive interventions, including very low calorie diets and weight loss medications, also improves weight loss than these interventions alone [322-325]. Continued contact after treatment (face-to-face or telephone) also improves weight-loss maintenance. In the general population, behavioural and cognitive behavioural interventions have strong empirical support and are recommended in international guidelines on the treatment of excess weight [e. Emphasis on self-management components enhances weight loss and healthy lifestyle behaviour change and are incorporated into advice on lifestyle interventions for the general population. Skill levels among health professionals may vary, presenting implementation challenges. Clinical need for the question Specific dietary composition in lifestyle interventions remains controversial. Summary of systematic review evidence Four articles reporting three studies were identified to answer this question. A systematic review [331] and more recent large scale studies [332] show that in the general population, there is no benefit of any one diet type and that hormone levels including insulin do not predict responses.