ABSTRACT
Kidneys for transplantation are scarce, and many countries give priority to children in allocating them. This paper explains and criticizes the paediatric priority. We set out the relevant ethical principles of allocation, such as utility and severity, and the relevant facts to do with such matters as sensitization and child development. We argue that the facts and principles do not support and sometimes conflict with the priority given to children. We next consider various views on how age or the status of children should affect allocation. Again, these views do not support priority to children in its current form. Since distinctions based on age ought to be positively justified, the failure of all these attempts at justification implies that the priority to children is ethically mistaken. Finally, the paper points to evidence that the paediatric priority reduces the overall supply of kidneys, at least in the United States. Paediatric priority is a real-world policy that seems discriminatory, in some places probably reduces the supply of organs, has no robust official defence, and is unsupported by mainstream ethical principles. Consequently, it should be ended.
Subject(s)
Ethics, Medical , Health Priorities/ethics , Kidney Transplantation/ethics , Kidney , Tissue and Organ Procurement/ethics , Child , Ethical Analysis , Humans , Morals , United StatesABSTRACT
BACKGROUND: Sepsis as a consequence of central venous hemodialysis catheter colonization is a major cause of morbidity in the hemodialysis population. We have previously shown that the majority of catheters become colonized and that this is associated with peripheral bacteremia. The time period over which this colonization occurs is unknown. METHOD: A prospective study of 31 central venous hemodialysis catheters was performed. Central venous blood cultures were taken from the catheter weekly after insertion. When the central cultures became positive, indicating catheter colonization, peripheral venous blood cultures were taken during dialysis to detect peripheral bacteremia. RESULTS: Twenty-one catheters (68%) became colonized before their removal for reasons other than infection (mean time to colonization 27 days, range 5-115 days). Eleven patients (35%) developed peripheral bacteremia with the same organisms (mean time from colonization to bacteremia 32 days, range 5-26 days). Bacteremia only occurred when blood drawn from the catheter cultured more than 3000 colony forming units per ml. CONCLUSIONS: Bacterial colonization of central venous catheters often leads to bacteremia. The time between insertion and colonization is very variable, but is universally present after 16 weeks. The risk of subsequent bacteremia is related not only to time left in situ, but also the degree of colonization. Surveillance cultures would allow clinicians to detect colonization before bacteremia occurs and take preventative measures.
Subject(s)
Bacteremia/etiology , Catheterization, Central Venous/adverse effects , Catheters, Indwelling/microbiology , Renal Dialysis/instrumentation , Bacteremia/epidemiology , Bacteremia/microbiology , Humans , Prospective Studies , Risk Factors , Staphylococcal Infections/epidemiology , Staphylococcal Infections/etiology , Staphylococcus epidermidis/isolation & purification , Time FactorsABSTRACT
BACKGROUND: Metabolic acidosis adversely affects both protein and bone metabolism in patients with chronic renal failure, and could also affect morbidity and mortality. This trial aimed to investigate the effects of different dialysate bicarbonate concentrations on control of acid base balance, and nutritional status. METHODS: Forty-six stable haemodialysis patients were dialysed using LowBic. (30 mmol/l) or HighBic. (40 mmol/l) bicarbonate dialysate in a single blind double crossover trial, of two consecutive six-month periods. Blood gas analysis, anthropometric indices and dialysis dose were measured, in addition to biochemical indices. RESULTS: Predialysis 'arterial' plasma pH values were significantly higher when using the HighBic. dialysate (LowBic. 7.38 +/- 0.05, HighBic. 7.43 +/- 0.04, P < 0.001), as was predialysis serum total CO2 at all times during the study (P < 0.01). Kt/V, (LowBic. 1.27 +/- 0.19, HighBic. 1.27 +/- 0.25), urea generation rates (UGR) (LowBic. 1.99 +/- 0.77, HighBic. 1.92 +/- 0.77 mmol/min), and normalized protein catabolic rate (NPCR) (LowBic. 1.04 +/- 0.26, HighBic. 0.99 +/- 0.28 g/kg/day) did not differ, and values of parathroid hormone (PTH) were comparable. Triceps skinfold thickness (TSF) showed a significant change (LowBic. 14.8 +/- 6.9-11.8 +/- 5.5, HighBic. 14.9 +/- 6.3-15.8 +/- 6.4 mm, P < 0.05) which was reversed following dialysate change (HighBic. 11.8 +/- 5.5-13.3 +/- 7.2, LowBic. 15.8 +/- 6.4-13.8 +/- 6.7 mm, P < 0.05). No differences in mid upper arm circumference were found. CONCLUSIONS: Bicarbonate dialysate concentrations of 40 mmol/l were safe, well tolerated, and produced better control of acidosis, with an increase in TSF, compared to a bicarbonate concentration of 30 mmol/l.
Subject(s)
Acidosis/blood , Bicarbonates/administration & dosage , Dialysis Solutions/chemistry , Nutritional Status/drug effects , Renal Dialysis , Adult , Aged , Aged, 80 and over , Anthropometry , Bicarbonates/therapeutic use , Cross-Over Studies , Dose-Response Relationship, Drug , Female , Gases/blood , Humans , Kinetics , Male , Middle Aged , Single-Blind MethodABSTRACT
BACKGROUND: The histological criteria for the diagnosis of mild acute rejection in renal transplant biopsies have not been well defined. AIM: To ascertain the value of the Banff criteria for transplant biopsy reporting, particularly for the diagnosis of acute rejection, and the 'borderline' category. METHODS: We compared two systems of histological assessment in 23 transplant biopsy specimens and compared histological diagnoses to separately defined clinical diagnoses. The histological criteria applied were those of the recently described Banff criteria which were compared with our traditional diagnostic method for each specimen. RESULTS: We found the Banff diagnoses more closely related to the clinical outcome than the system of histological diagnosis that we had previously been using. CONCLUSIONS: We conclude that the Banff criteria more accurately reflect the clinical situation.
Subject(s)
Graft Rejection/pathology , Kidney Transplantation/pathology , Kidney/pathology , Postoperative Complications/pathology , Acute Disease , Adolescent , Adult , Aged , Biopsy , Child , Child, Preschool , Diagnosis, Differential , Female , Humans , Kidney Tubular Necrosis, Acute/pathology , Male , Middle Aged , Practice Guidelines as Topic , Treatment OutcomeABSTRACT
In a cross sectional study the mental health of parents of physically and mentally handicapped preschool children was compared with that of parents of healthy preschool children. The social networks of the parents with handicapped children were also studied to determine factors that might influence psychiatric morbidity. The mothers of the handicapped children showed significantly more psychiatric morbidity than the control mothers, but the fathers did not show the same deleterious effect on mental health.
Subject(s)
Disabled Persons , Intellectual Disability , Mental Disorders/epidemiology , Parents/psychology , Adult , Child, Preschool , Cross-Sectional Studies , Female , Humans , Interpersonal Relations , Male , Mothers/psychology , New ZealandABSTRACT
Parents of intellectually and physically handicapped preschool children were asked to nominate helpful and unhelpful elements in the care of their child. Their subjective responses are described. A large proportion were critical of medical services. Doctors seen as helpful recognised and verbally acknowledged the parental contribution to the child's welfare.