Inventors: Shawn P. Firminger, Redmond, WA (US); Jason Garms, Redmond, WA (US); Roderick A. Hyde,... more Inventors: Shawn P. Firminger, Redmond, WA (US); Jason Garms, Redmond, WA (US); Roderick A. Hyde, Redmond, WA (US); Edward K. Y. Jung, Bellevue, WA (US); Chris D. Karkanias, Sammamish, WA (US); Eric C. Leuthardt, St. Louis, MO (US); Royce A. Levien, Lexington, MA (US); Richard T. Lord, Tacoma, WA (US); Robert W. Lord, Seattle, WA (US); Mark A. Malamud, Seattle, WA (US); John D. Rinaldo, Jr., Bellevue, WA (US); Clarence T. Tegreene, Bellevue, WA (US); Kristin M. Tolle, Redmond, WA (US); Lowell L. Wood, Jr., Bellevue, WA (US)
Clinical outcomes associated with pericardial effusions related to uremic pericarditis (UP) have ... more Clinical outcomes associated with pericardial effusions related to uremic pericarditis (UP) have not been clearly differentiated from asymptomatic effusions in patients with ESRD. Our objectives are: 1) to assess whether pericardial effusions associated with UP are more likely to result in
A rising prevalence of end-stage renal disease (ESRD) has led to a rise in ESRD-related pericardi... more A rising prevalence of end-stage renal disease (ESRD) has led to a rise in ESRD-related pericardial syndromes, calling for a better understanding of its pathophysiology, diagnoses, and management. Uremic pericarditis, the most common manifestation of uremic pericardial disease, is a contemporary problem that calls for intensive hemodialysis, anti-inflammatories, and often, drainage of large inflammatory pericardial effusions. Likewise, asymptomatic pericardial effusions can become large and impact the hemodynamics of patients on chronic hemodialysis. Constrictive pericarditis is also well documented in this population, ultimately resulting in pericardiectomy for definitive treatment. The management of pericardial diseases in ESRD patients involves internists, cardiologists, and nephrologists. Current guidelines lack clarity with respect to the management of pericardial processes in the ESRD population. Our review aims to describe the etiology, classification, clinical manifestations...
In-hospital care of end-stage renal disease (ESRD) patients, on hemodialysis, is different from t... more In-hospital care of end-stage renal disease (ESRD) patients, on hemodialysis, is different from the general population in various aspects. Non-nephrologists do not typically receive specialized training to take care of these patients. However, in most circumstances, they serve as the primary attending for these patients in the hospital setting. There is paucity of the literature guiding non-nephrologists on this important issue. This article highlights the key management aspects of in-hospital care of these patients that all the non-nephrologists should know.
Background and Objectives Peritoneal dialysis catheter (PDC) complications are an important barri... more Background and Objectives Peritoneal dialysis catheter (PDC) complications are an important barrier to peritoneal dialysis (PD) utilization. Practice guidelines for PDC placement exist, but it is unknown if these recommendations are followed. We performed a quality improvement study to investigate this issue. Methods A prospective observational study involving 46 new patients at a regional US PD center was performed in collaboration with a nephrology fellowship program. Patients completed a questionnaire derived from the International Society for Peritoneal Dialysis (ISPD) catheter guidelines and were followed for early complications. Results Approximately 30% of patients reported not being evaluated for hernias, not being asked to visualize their exit site, or not receiving catheter location marking before placement. After insertion, 20% of patients reported not being given instructions for follow-up care, and 46% reported not being taught the warning signs of PDC infection. Direct...
Survival of liver transplant candidates with acute renal failure receiving renal replacement ther... more Survival of liver transplant candidates with acute renal failure receiving renal replacement therapy. Background. Acute renal failure (ARF) in the setting of endstage liver disease has a dismal prognosis without liver transplantation. Renal replacement therapy (RRT) is a common bridge to liver transplant despite a paucity of supportive data. We investigated our single-center patient population to determine efficacy of RRT in liver transplant candidates with ARF. Methods. We identified 102 liver transplant candidates receiving RRT for ARF between April 30, 1999 and January 31, 2004. Patients that had initiated RRT intra-or postoperatively or received outpatient hemodialysis or peritoneal dialysis prior to admission were excluded. Survival to liver transplant, shortterm mortality following liver transplant, and selected clinical characteristics were examined. Results. Of patients who received RRT, 35% survived to liver transplant or discharge. Mortality was 94% in patients not receiving a liver and was associated with a higher Acute Physiological and Chronic Health Evaluation (APACHE) II, lower mean arterial pressure, and the use of continuous renal replacement therapy (CRRT). Patients receiving CRRT had greater severity of illness than those on hemodialysis. The 1-year mortality of patients initiating RRT prior to liver transplant was 30% versus 9.7% for all other liver recipients (P < 0.0045). Conclusion. RRT is justifiable for liver transplant candidates with ARF. Though mortality was high, a substantial percentage (31%) of patients survived to liver transplant. Postoperative mortality is increased compared with all other liver transplant recipients, but is acceptable considering the near-universal mortality without transplantation.
Peritoneal dialysis (PD) remains greatly underutilized in the United States despite the widesprea... more Peritoneal dialysis (PD) remains greatly underutilized in the United States despite the widespread preference of home modalities among nephrologists and patients. A hemodialysis-centric model of end-stage renal disease care has perpetuated for decades due to a complex set of factors, including late end-stage renal disease referrals and patients who present to the hospital requiring urgent renal replacement therapy. In such situations, PD rarely is a consideration and patients are dialyzed through a central venous catheter, a practice associated with high infection and mortality rates. Recently, the term urgent-start PD has gained momentum across the nephrology community and has begun to change this status quo. It allows for expedited placement of a PD catheter and initiation of PD therapy within days. Several published case reports, abstracts, and poster presentations at national meetings have documented the initial success of urgent-start PD programs. From a wide experiential base, we discuss the multifaceted issues related to urgent-start PD implementation, methods to overcome barriers to therapy, and the potential impact of this technique to change the existing dialysis paradigm.
The tropical mangosteen fruit has long been prized in Southeast Asia for its traditional healing ... more The tropical mangosteen fruit has long been prized in Southeast Asia for its traditional healing properties. Mangosteen fruit juice is now available in the United States and marketed for its purported health benefits. We describe a case of severe lactic acidosis associated with the use of mangosteen juice as a dietary supplement.
AKI in hospitalized patients, n/N (%) 4747/15154 (31.3%) Range across cohorts 18.9%-69.0% AKI in ... more AKI in hospitalized patients, n/N (%) 4747/15154 (31.3%) Range across cohorts 18.9%-69.0% AKI in ICU patients, n/N (%) 2352/4244 (55.4%) Range across cohorts 31.6%-100% RRT in hospitalized patients, n/N (%) 987/15546 (6.3%) Range across cohorts 4.8%-15.4% RRT in ICU patients, n/N (%) 386/2304 (16.8%) Range across cohorts 11.3%-51.4% CKD in hospitalized patients, n/N (%) 1558/15131 (10.3%) Range across cohorts 5.0%-38.0%
Clinical journal of the American Society of Nephrology : CJASN, Jan 17, 2017
Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. ... more Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. Small solute removal, exemplified by Kt/Vurea, has been broadly applied as a means to quantify the dose of thrice weekly hemodialysis. Yet, the reliance on small solute clearances alone as a measure of dialysis adequacy fails fully to quantify the intended clinical effects of dialysis therapy. This review aims to (1) understand the strengths and limitations of small solute kinetics as a surrogate marker of dialysis dose, and (2) present the prospect of a more comprehensive construct for dialysis dose, one that considers more broadly the goals of ESRD care to maximize both quality of life and survival. On behalf of the American Society of Nephrology Dialysis Advisory Group, we propose the need to ascertain the validity and utility of a multidimensional measure that moves beyond small solute kinetics alone to quantify optimal dialysis derived from both patient-reported and comprehensive cl...
Inventors: Shawn P. Firminger, Redmond, WA (US); Jason Garms, Redmond, WA (US); Roderick A. Hyde,... more Inventors: Shawn P. Firminger, Redmond, WA (US); Jason Garms, Redmond, WA (US); Roderick A. Hyde, Redmond, WA (US); Edward K. Y. Jung, Bellevue, WA (US); Chris D. Karkanias, Sammamish, WA (US); Eric C. Leuthardt, St. Louis, MO (US); Royce A. Levien, Lexington, MA (US); Richard T. Lord, Tacoma, WA (US); Robert W. Lord, Seattle, WA (US); Mark A. Malamud, Seattle, WA (US); John D. Rinaldo, Jr., Bellevue, WA (US); Clarence T. Tegreene, Bellevue, WA (US); Kristin M. Tolle, Redmond, WA (US); Lowell L. Wood, Jr., Bellevue, WA (US)
Clinical outcomes associated with pericardial effusions related to uremic pericarditis (UP) have ... more Clinical outcomes associated with pericardial effusions related to uremic pericarditis (UP) have not been clearly differentiated from asymptomatic effusions in patients with ESRD. Our objectives are: 1) to assess whether pericardial effusions associated with UP are more likely to result in
A rising prevalence of end-stage renal disease (ESRD) has led to a rise in ESRD-related pericardi... more A rising prevalence of end-stage renal disease (ESRD) has led to a rise in ESRD-related pericardial syndromes, calling for a better understanding of its pathophysiology, diagnoses, and management. Uremic pericarditis, the most common manifestation of uremic pericardial disease, is a contemporary problem that calls for intensive hemodialysis, anti-inflammatories, and often, drainage of large inflammatory pericardial effusions. Likewise, asymptomatic pericardial effusions can become large and impact the hemodynamics of patients on chronic hemodialysis. Constrictive pericarditis is also well documented in this population, ultimately resulting in pericardiectomy for definitive treatment. The management of pericardial diseases in ESRD patients involves internists, cardiologists, and nephrologists. Current guidelines lack clarity with respect to the management of pericardial processes in the ESRD population. Our review aims to describe the etiology, classification, clinical manifestations...
In-hospital care of end-stage renal disease (ESRD) patients, on hemodialysis, is different from t... more In-hospital care of end-stage renal disease (ESRD) patients, on hemodialysis, is different from the general population in various aspects. Non-nephrologists do not typically receive specialized training to take care of these patients. However, in most circumstances, they serve as the primary attending for these patients in the hospital setting. There is paucity of the literature guiding non-nephrologists on this important issue. This article highlights the key management aspects of in-hospital care of these patients that all the non-nephrologists should know.
Background and Objectives Peritoneal dialysis catheter (PDC) complications are an important barri... more Background and Objectives Peritoneal dialysis catheter (PDC) complications are an important barrier to peritoneal dialysis (PD) utilization. Practice guidelines for PDC placement exist, but it is unknown if these recommendations are followed. We performed a quality improvement study to investigate this issue. Methods A prospective observational study involving 46 new patients at a regional US PD center was performed in collaboration with a nephrology fellowship program. Patients completed a questionnaire derived from the International Society for Peritoneal Dialysis (ISPD) catheter guidelines and were followed for early complications. Results Approximately 30% of patients reported not being evaluated for hernias, not being asked to visualize their exit site, or not receiving catheter location marking before placement. After insertion, 20% of patients reported not being given instructions for follow-up care, and 46% reported not being taught the warning signs of PDC infection. Direct...
Survival of liver transplant candidates with acute renal failure receiving renal replacement ther... more Survival of liver transplant candidates with acute renal failure receiving renal replacement therapy. Background. Acute renal failure (ARF) in the setting of endstage liver disease has a dismal prognosis without liver transplantation. Renal replacement therapy (RRT) is a common bridge to liver transplant despite a paucity of supportive data. We investigated our single-center patient population to determine efficacy of RRT in liver transplant candidates with ARF. Methods. We identified 102 liver transplant candidates receiving RRT for ARF between April 30, 1999 and January 31, 2004. Patients that had initiated RRT intra-or postoperatively or received outpatient hemodialysis or peritoneal dialysis prior to admission were excluded. Survival to liver transplant, shortterm mortality following liver transplant, and selected clinical characteristics were examined. Results. Of patients who received RRT, 35% survived to liver transplant or discharge. Mortality was 94% in patients not receiving a liver and was associated with a higher Acute Physiological and Chronic Health Evaluation (APACHE) II, lower mean arterial pressure, and the use of continuous renal replacement therapy (CRRT). Patients receiving CRRT had greater severity of illness than those on hemodialysis. The 1-year mortality of patients initiating RRT prior to liver transplant was 30% versus 9.7% for all other liver recipients (P < 0.0045). Conclusion. RRT is justifiable for liver transplant candidates with ARF. Though mortality was high, a substantial percentage (31%) of patients survived to liver transplant. Postoperative mortality is increased compared with all other liver transplant recipients, but is acceptable considering the near-universal mortality without transplantation.
Peritoneal dialysis (PD) remains greatly underutilized in the United States despite the widesprea... more Peritoneal dialysis (PD) remains greatly underutilized in the United States despite the widespread preference of home modalities among nephrologists and patients. A hemodialysis-centric model of end-stage renal disease care has perpetuated for decades due to a complex set of factors, including late end-stage renal disease referrals and patients who present to the hospital requiring urgent renal replacement therapy. In such situations, PD rarely is a consideration and patients are dialyzed through a central venous catheter, a practice associated with high infection and mortality rates. Recently, the term urgent-start PD has gained momentum across the nephrology community and has begun to change this status quo. It allows for expedited placement of a PD catheter and initiation of PD therapy within days. Several published case reports, abstracts, and poster presentations at national meetings have documented the initial success of urgent-start PD programs. From a wide experiential base, we discuss the multifaceted issues related to urgent-start PD implementation, methods to overcome barriers to therapy, and the potential impact of this technique to change the existing dialysis paradigm.
The tropical mangosteen fruit has long been prized in Southeast Asia for its traditional healing ... more The tropical mangosteen fruit has long been prized in Southeast Asia for its traditional healing properties. Mangosteen fruit juice is now available in the United States and marketed for its purported health benefits. We describe a case of severe lactic acidosis associated with the use of mangosteen juice as a dietary supplement.
AKI in hospitalized patients, n/N (%) 4747/15154 (31.3%) Range across cohorts 18.9%-69.0% AKI in ... more AKI in hospitalized patients, n/N (%) 4747/15154 (31.3%) Range across cohorts 18.9%-69.0% AKI in ICU patients, n/N (%) 2352/4244 (55.4%) Range across cohorts 31.6%-100% RRT in hospitalized patients, n/N (%) 987/15546 (6.3%) Range across cohorts 4.8%-15.4% RRT in ICU patients, n/N (%) 386/2304 (16.8%) Range across cohorts 11.3%-51.4% CKD in hospitalized patients, n/N (%) 1558/15131 (10.3%) Range across cohorts 5.0%-38.0%
Clinical journal of the American Society of Nephrology : CJASN, Jan 17, 2017
Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. ... more Urea removal has become a key measure of the intensity of dialysis treatment for kidney failure. Small solute removal, exemplified by Kt/Vurea, has been broadly applied as a means to quantify the dose of thrice weekly hemodialysis. Yet, the reliance on small solute clearances alone as a measure of dialysis adequacy fails fully to quantify the intended clinical effects of dialysis therapy. This review aims to (1) understand the strengths and limitations of small solute kinetics as a surrogate marker of dialysis dose, and (2) present the prospect of a more comprehensive construct for dialysis dose, one that considers more broadly the goals of ESRD care to maximize both quality of life and survival. On behalf of the American Society of Nephrology Dialysis Advisory Group, we propose the need to ascertain the validity and utility of a multidimensional measure that moves beyond small solute kinetics alone to quantify optimal dialysis derived from both patient-reported and comprehensive cl...
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Papers by Leslie Wong