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Saturday, May 1, 2010

About Kidney Transplantation

* Definition of Kidney Transplantation
* Description of Kidney Transplantation
* Treatment of Kidney Transplantation
* Questions To Ask Your Doctor About Kidney Transplantation

Definition of Kidney Transplantation
Article updated and reviewed by Nader Najafian, MD, Assistant Professor of Medicine, Harvard Medical School and Associate Physician, Renal Division--Brigham & Women's Hospital on May 17, 2005.

Kidney Transplantation is the surgical procedure of placing a fully functioning kidney into a person with severe kidney failure. This procedure is usually an elective one, performed in patients who have undergone careful preoperative assessment and preparation, since dialysis enables these patients to be maintained in relatively good condition until the time of surgery. The transplanted kidney may originate from a deceased donor (cadaver transplantation) or from a related or unrelated person (living transplantation).

Description of Kidney Transplantation
The function of the kidneys is to filter the blood in the body and to purify it by ridding it of soluble waste products and excess water (which is then eliminated in the form of urine). Total kidney failure, which may be gradual or sudden in onset, results in the accumulation of these waste products and water in the blood. These waste products can poison you unless removed. In addition, the excess water can accumulate in the lungs and prevent the patient from getting enough oxygen. Either processes or a combination of both can result in death.

The most common causes of kidney failure include:

* infection and inflammation of any part of the kidney structure

*

* damage to kidney tissue from some systemic diseases such as uncontrolled high blood pressure and untreated diabetes) or injury

* • damage to kidney tissue through some medications, including overuse of some over the counter pain killers such as Motrin and Aspirin

* polycystic kidneys (an inherited condition in which the tissues of the kidneys are gradually destroyed by cysts)

* failure of normal kidney development from before birth

There are two major treatment modalities for patients with kidney failure: dialysis or transplantation. In dialysis, the blood is artificially filtered through a machine or by diverting the bloodstream through another permeable membrane in the body itself. Despite numerous medical and technological advances over the last few years, dialysis patients feel very unwell. This is not surprising as even the most efficient hemodialysis regimens can only remove 10-12% of the small solute toxins as compared to normal functioning kidneys. Even though the kidney dialysis can keep the patients alive, these patients still suffer from poor quality of life, extreme dietary restrictions and the psychological burden of depending on a machine. Kidney transplantation is the treatment of choice in qualified patients with kidney failure as it has the greatest potential for restoring a healthy and productive life. This operation allows a patient to lead an independent existence instead of being reliant on regular kidney dialysis. It also allows a liberating return to a normal diet. The transplant procedure success rate has improved over the last years with one-year graft survivals exceeding 90% in most centers. A critical shortage of donor organs is the major limitation to expanding the use of this treatment. Many patients with end-stage renal (kidney) disease are suitable for transplantation. Fifty percent of all kidney transplants are received from cadaver donors and the others are received from living, related, or unrelated donors.

Regular kidney dialysis is a short-term solution to kidney failure: the blood is artificially filtered through a machine or by diverting the bloodstream through another permeable membrane in the body itself. The ideal treatment for total kidney failure is kidney transplantation.

One-third to one-half of all patients with end-stage renal (kidney) disease are suitable for transplantation. Two-thirds of all kidney transplants are recieved from cadaveric donors, and one-third are recieved from living, related donors.

Kidney Transplantation Surgery

The aim of the surgery is to supply a single, fully functioning kidney. One kidney provides more than enough filtration and regulating capacity for all purposes and is grafted into its own position while the existing (non-functioning) kidneys remain in place. The existing kidneys are removed only if they cause persistent infection or high blood pressure, and they will not interfere with the transplant procedure or functioning of the new organ. As soon as the transplanted kidney is connected to the blood vessels, it will begin purifying the blood of waste products.

Patients are required to take medications such as corticosteroids, cyclosporine, and/or azathioprine to suppress their immune system in order to prevent rejection of the transplanted kidney.

Post-operative Effects

More often than not, the first week after kidney transplantation is a grace period when things keep getting better. However, the clear sailing can be misleading, since many kidney recipients spend time in the hospital soon after discharge when the functioning of their new kidney diminishes. These episodes are almost always successfully treated by adjusting the medication regimen.

By far the two most common causes of diminished renal function are rejection and the toxic effects of cyclosporine. About 70 percent of all recipients will manifest some signs of organ rejection, and most will also have some evidence of cyclosporine toxicity. Both problems manifest themselves as decreasing urinary output and rising laboratory values of blood BUN (Blood Urea Nitrogen) and creatinine (a component of urine). These problems are usually treated simultaneously by adding extra doses of steroids.

Managing Rejection

Immediately after kidney transplant surgery, the mainstays of drug therapy are prednisone and cyclosporine, and sometimes azathioprine. It should be emphasized that cyclosporine is enormously beneficial for two reasons: first, in improving long-term survival of the kidney; and second, in permitting the rapid tapering off of the prednisone. Nevertheless, it is critically important that, as long as the transplanted organ is functioning, some level of maintenance immunosuppression (suppression of immunologic response, usually with reference to grafts or organ transplants) is necessary. If at any point a recipient stops taking the medications, rejection can occur - even ten or fifteen years after the transplant.

The important point to remember is that most recipients can expect to have some problems getting adjusted to their new organ, and that after the initial discharge it may be necessary to return to the hospital for one or more additional short stays. New drugs may be needed, and the doses of the anti-rejection medications will probably require adjustment. This fine-tuning is a normal part of recovering.

The vast majority of renal transplants are successful. Thus, the statement that someone is suffering rejection, which understandably sounds disturbing, is not cause for undue alarm. Most cases of rejection can be reversed, and the other causes of abnormal renal function also can be corrected. Well over 80 percent of recipients leave the hospital with a kidney functioning sufficiently to keep them off of dialysis.
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Treatment of Kidney Transplantation
Kidney Transplantation Surgery

The aim of the surgery is to supply a single, fully functioning kidney. One kidney provides more than enough filtration and regulating capacity for all purposes and is grafted into its own position while the existing (non-functioning) kidneys remain in place. The existing kidneys are removed only if they cause persistent infection or high blood pressure, and they will not interfere with the transplant procedure or functioning of the new organ. As soon as the transplanted kidney is connected to the blood vessels, it will begin purifying the blood of waste products. Patients are required to take medications that suppress the immune system for the rest of their lives to avoid the rejection of the kidney grafts.

Post-operative Effects

In most cases, particularly in patients that get good quality kidneys from family and friends (living donors), the transplanted kidneys start working immediately after transplantation and no further hemodialysis is required. In 20-30% of cases, particularly patients who get cadaver kidneys with poorer organ quality, the kidney may not function immediately and further dialysis may be needed. Regardless, all the transplant patients need to be monitored very closely in the first month after the procedure, as many of the immunosuppressive drugs need to be adjusted carefully. This usually requires clinic visits up to two to three times a week in the first month. By far the two most common causes of diminished renal function are rejection and the toxic effects of cyclosporine. About 30% of all recipients will manifest some signs of organ rejection, and most will also have some evidence of cyclosporine toxicity. Both problems manifest themselves as decreasing urinary output and rising laboratory values of blood BUN (Blood Urea Nitrogen) and cretonne (a component of urine). These problems are usually treated simultaneously by adding extra doses of steroids. As too low a dose of immunosuppressant drugs can result in rejection, too much of it can result in infections or cancer over time. That is the reason why patients need close follow-up by a kidney transplant specialist.

Managing Rejection

After kidney transplant surgery, the mainstays of drug therapy are usually a combination of two to three immunosuppressive medications, such as prednisone, cyclosporine, tacrolimus, or rapamycin, and sometimes azathioprine or cellcept. Initially, higher doses of these drugs are used as the risk of rejection is highest immediately after transplantation. With time, the levels of these drugs can then be tapered down. Nevertheless, it is critically important that, as long as the transplanted organ is functioning, some level of maintenance immunosuppression (suppression of immunologic response, usually with reference to grafts or organ transplants) is necessary. If at any point a recipient stops taking the medications, rejection can occur - even ten or fifteen years after the transplant.

The vast majority of renal transplants are successful with over 90% of organs functioning after the first year. Thus, the statement that someone is suffering rejection, which understandably sounds disturbing, is not cause for undue alarm. Most cases of rejection can be reversed, and the other causes of abnormal renal function also can be corrected.

Questions To Ask Your Doctor About Kidney Transplantation
How long is the waiting time to get a cadaver kidney?

Who would be qualified to donate a kidney to me (family, spouse, and friends)?

How can potential interested donors be evaluated?

How is the surgery performed?

How long does the surgery take?

How many kidney transplantations have you performed?

What medications will you be prescribing?

What are the side effects of immunosuppressive drugs?

How long will you prescribe steroids or any other medication?

What should be expected after the surgery?

Juvenile Diabetes

* Definition of Juvenile Diabetes
* Description of Juvenile Diabetes
* Causes and Risk Factors of Juvenile Diabetes
* Symptoms of Juvenile Diabetes
* Diagnosis of Juvenile Diabetes
* Treatment of Juvenile Diabetes
* Questions To Ask Your Doctor About Juvenile Diabetes

Definition of Juvenile Diabetes
Juvenile diabetes mellitus is now more commonly called Type 1 diabetes. It is a syndrome with disordered metabolism and inappropriately high blood glucose levels due to a deficiency of insulin secretion in the pancreas.

Description of Juvenile Diabetes
After a meal, a portion of the food a person eats is broken down into sugar (glucose). The sugar then passes into the bloodstream and into the body's cells via a hormone called insulin. Insulin is produced by the pancreas.

Normally, the pancreas produces the right amount of insulin to accommodate the quantity of sugar. However, if the person has diabetes either the pancreas produces little or no insulin, or the cells do not respond normally to the insulin. Sugar builds up in the blood, overflows into the urine and passes from the body unused.

Diabetes can be associated with major complications involving many organs including the heart, eyes, kidneys, and nerves, especially if the blood sugar is poorly controlled over the years.

Types Of Diabetes

Diabetes mellitus is a chronic disease caused by the inability of the pancreas to produce insulin or by the body to appropriately use the insulin it does produce. There are two main types of diabetes, Type 1 and Type 2.

Type 1 diabetes (also called insulin-dependent diabetes or juvenile diabetes) is caused by autoimmune destruction of the B cells of the pancreas which normally secrete insulin. Those patients require insulin injections for survival.

Type 2 diabetes (or non-insulin-dependent diabetes) is much more common and results from insulin resistance, mainly due to obesity, with inadequate additional production of insulin by the body. In other words, the pancreas produces a reduced amount of insulin or the cells do not respond to the insulin, or both.

Complications of Diabetes

If juvenile diabetes is left unmanaged, damage can occur to:

* Eyes - leading to diabetic retinopathy and possible blindness

* Blood vessels - increasing risk of heart attack, stroke and peripheral artery obstruction

* Nerves - leading to foot ulcers, impotence, and digestive problems

* Kidneys - leading to kidney failure

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Causes and Risk Factors of Juvenile Diabetes
An estimated 17 million people in the U.S. have diabetes, of which about 1.4 million have Type 1 diabetes. The highest prevalence of Type 1 diabetes is in Scandinavia, where it comprises up to 20 percent of the total number of patients with diabetes.

The prevalence of Type 1 diabetes is about 5-10 percent of the total number of diabetes patients in the U.S., while in Japan and China, less than 1 percent of patients with diabetes have Type 1. Approximately 35 American children are diagnosed with juvenile diabetes every day.

The exact cause of Type 1 diabetes (juvenile diabetes) is still unclear. However, it is believed that Type 1 diabetes results from an infectious or toxic insult to persons whose immune system is genetically predisposed to develop an aggressive autoimmune response either against altered pancreatic B antigens (proteins) or against molecules of the B cell resembling a viral protein (called molecular mimicry). It is not caused by obesity or by eating excessive sugar.

The risk of juvenile diabetes is higher than virtually all other severe chronic diseases of childhood. Juvenile diabetes tends to run in families. Brothers and sisters of a child with juvenile diabetes have at least 100 times the risk of developing juvenile diabetes as a child in an unaffected family.

Symptoms of Juvenile Diabetes
The symptoms of Type 1 diabetes (juvenile diabetes) may occur suddenly, and include:

* Frequent urination

* Increased thirst

* Extreme hunger

* Unexplained weight loss

* Extreme weakness and fatigue

* Urinating at night (nocturnal enuresis)

* Blurred vision

* Numbness or tingling in the hands or feet

* Heavy or labored breathing

* Drowsiness or lethargy

* Fruity odor on the breath

Diagnosis of Juvenile Diabetes
A child with the above symptoms must be seen by a physician as soon as possible.

Besides a complete history and physical examination, the doctors will do a battery of laboratory tests. There are numerous tests available to diagnose diabetes such as urine test, blood test, glucose-tolerance test, fasting blood sugar and the glycohemoglobin (HbA1c) test.

A urine sample will be tested for glucose and ketones (acids that collect in the blood and urine when the body uses fat instead of glucose for energy). A blood test is used to measure the amount of glucose in the bloodstream. A glucose-tolerance test checks the body's ability to process glucose. During this test, sugar levels in the blood and urine are monitored for 3 hours after drinking a large dose of sugar solution.

The fasting blood sugar test involves fasting overnight and blood being drawn the next morning. The glycohemoglobin test reflects the cumulative effects of high blood glucose (and measures the degree of control over blood glucose after treatment begins).

Treatment of Juvenile Diabetes
Treatment of Type 1 diabetes involves:

* Diet

* Insulin

* Self-monitoring of blood glucose

* Exercise

Questions To Ask Your Doctor About Juvenile Diabetes
Does the child have Type 1 diabetes?

How can this best be managed?

What is diabetic ketoacidosis?

What changes in diet will be required?

Is there a specific meal plan?

What type of insulin should be used - what is the frequency and dosage?

How can exercise help the child - how much, and what type?

At what age should the child self-administer insulin?

What restrictions and limitations will be placed upon the child's life?

Should the child's teacher or school nurse be alerted to the situation?

Are there any support groups or organizations regarding the care of a child with diabetes?

What is the prognosis?

Amniocentesis

* Definition of Amniocentesis
* Description of Amniocentesis
* Questions To Ask Your Doctor About Amniocentesis

Definition of Amniocentesis
Amniocentesis is a simple medical procedure used to obtain small samples of the amniotic fluid surrounding the fetus.

Description of Amniocentesis
In the first half of the pregnancy (between the 14th and 18th week) the doctor may perform an amniocentesis when:

* The age of the mother is 35 years of age or older. The risk of bearing children with chromosomal birth defects increases as a woman ages, thus if a woman will be 35 or older at the time of delivery, most physicians offer the option of prenatal testing for chromosomal disorders. Among the most common of these disorders is Down syndrome, a combination of mental and physical abnormalities caused by the presence of an extra chromosome.

* A previous child or pregnancy resulted in a birth defect. If a couple already has a child (or pregnancy) diagnosed with a chromosomal abnormality, a biochemical birth defect, or a neural tube defect, the couple may be offered prenatal testing during subsequent pregnancies.

* Family history shows an increased risk of inheriting a genetic disorder. Couples without a previously affected child may also be offered prenatal testing if their family medical histories indicate their children may be at increased risk of inheriting a genetic disorder.

* One or both prospective parents may be "carriers" of a disorder, or a disorder may "run in the family." Prenatal testing would be done only if the suspected condition can be diagnosed prenatally.

* There is suspected neural tube defects. These defects of the spine and brain, including spina bifida and anencephaly, can be diagnosed by measuring the level of alphafetoprotein (AFP) in the amniotic fluid. Amniocentesis to measure AFP is offered if there is a family history of neural tube defects, or if earlier screening tests of AFP in the mother's blood indicate that the pregnancy is at increased risk.

* The doctor wants to assess fetal lung maturity. Fetal lung assessment is important if the mother needs to deliver the baby early. By testing the amniotic fluid doctors can tell whether the baby's lung's are developed enough to breathe on their own.

* Detection of Rh disease is needed. Rh disease causes antibodies in the mother's blood to attack fetal blood cells and an amniocentesis detects the disease and enables the doctors to take appropriate measures to reduce complications.

Questions To Ask Your Doctor About Amniocentesis
Should an amniocentesis be done?

Is there a possibility the baby will have birth defects?

When should the amniocentesis be done?

How will the test be done?

What will the amniocentesis show?

What are the possible outcomes?

Cesarean Section

* Definition of Cesarean Section
* Description of Cesarean Section
* Questions To Ask Your Doctor About Cesarean Section

Definition of Cesarean Section
Cesarean childbirth consists of an operation to deliver a baby through an incision in the abdomen.

Description of Cesarean Section
Until recently the operation was usually used as a last resort because of a high rate of maternal complications and death. With the availability of antibiotics to fight infection and the development of modern surgical techniques, the once high maternal mortality rate has dropped dramatically. As a result, the cesarean childbirth rate has increased dramatically.

There are three main types of cesarean operations, each named according the location and direction of the uterine incision:

Low Transverse, a transverse (horizontal) incision in the lower uterus

Low Vertical, a vertical incision in the lower uterus

Classical, a vertical incision in the main body of the uterus

Today, the low transverse incision is used almost exclusively. It has the lowest incidence of hemorrhage during surgery as well as the least chance of rupturing in later pregnancies.

Sometimes, because of fetal size (very large or very small) or position problems (breech or transverse), a low vertical cesarean may be performed.

In the classical operation, a larger vertical incision allows a greater opening; it is used in some emergency situations as well as for fetal size or position problems. This approach involves more bleeding in surgery and a higher risk of abdominal infection. All subsequent deliveries must be by cesarean section after a classical delivery due to the higher risk of uterine rupture.

Although any uterine incision may rupture during a subsequent labor, the classical is more likely to do so, and more likely to result in death for the mother and fetus than a low transverse or low vertical incision.

There are many reasons why a woman might need to deliver by Cesarean section, although not all doctors agree on when one is really necessary. The most common reason is failure to progress (FTP) in labor, where labor has stalled because the cervix has stopped dilating or uterine contractions are weak. The second most common reason for cesarean section is fetal distress. Sometimes the baby can not tolerate the strong contractions associated with labor. When the fetal heart tracing becomes non-reassuring, a cesarean section is usually performed. Another common reason for cesarean section is previous cesarean section or surgery on the uterus. Women who delivered by a classical cesarean section in a previous pregnancy must deliver by cesarean section for all following pregnancies. However, women with a history delivering by low transverse cesarean section are given the choice of scheduling a repeat cesarean section or trying to deliver vaginally. Also some women with a history of surgery to remove fibroids may need to deliver by cesarean section.

Other less common reasons for a cesarean section are listed below:

Cephalopelvic Distortion (CPD. Another indication of cesarean delivery is cephalopelvic disproportion (CPD), a rare condition in which the baby's head is too large to fit through the mother's pelvis.

Malposition of the fetus. In breech position, the baby's buttocks or feet are positioned to come out first instead of the head. Twins might need to be delivered by cesarean if the first baby or both are breech. Malposition of the fetus does not necessarily mean a cesarean delivery.

Vaginal bleeding/placenta previa/placental abruption. Vaginal bleeding late in pregnancy often indicates placenta previa, a low-lying placenta that covers part or all of the inner opening of the cervix. If the bleeding does not stop with bedrest, the doctor probably will perform a cesarean, to prevent hemorrhage. Vaginal bleeding late in pregnancy also may indicate placental abruption, where the placenta separates from the uterine wall before delivery. In some cases of mild abruption, it may be possible to deliver vaginally. If there is heavy bleeding or fetal distress caused by abruption (abruption can lead to maternal shock, which, together with a reduced amount of functioning placenta, can deprive the fetus of adequate oxygen), a cesarean generally is necessary.

Other situations. If you have vaginal herpes and active sores in the vaginal area, your doctor might do a cesarean to try to prevent your passing on the disease to your baby. A cesarean section is usually performed in mothers with HIV before labor to prevent transmission HIV from mother to baby. Women diagnosed with invasive cervical cancer who have bulky cancer lesions on the cervix are offered classical cesarean section to deliver the baby. Lastly, women pregnant with a baby with bleeding problems may be offered a cesarean section to prevent birth trauma to the infant.

Malpractice concerns, a woman’s preference, obesity and insurance coverage are also factors which may play a role in whether to perform a cesarean delivery.

Until recently, it was medically accepted that once a woman had a cesarean, she should have all of her children by cesarean because of the concern about tearing the incision. Yet studies have shown "once a cesarean, always a cesarean," no longer holds true for most women. Today, the option of attempting to give birth through the vagina is open to women who have had previous low transverse incision cesarean births, and over half of these have successful vaginal deliveries.

If vaginal delivery is a possibility for you, here are some reasons why you may wish to attempt it:

Less risk. A vaginal delivery usually has fewer complications for the mother than a cesarean birth. As there is no abdominal incision, the risks of infection, bleeding, or other problems resulting from surgery or anesthesia are much lower.

Shorter recovery. Your stay in the hospital is likely to be briefer after vaginal delivery. The average time spent in the hospital is 1 to 3 days, whereas the average stay after a cesarean birth is 3 to 5 days. Recovery at home is faster as well, since women who deliver by cesarean must limit their activity for 4 to 6 weeks to allow the abdominal incision to heal.

More involvement. Some women wish to be awake and fully involved in the birth process. There may also be more limitations on the presence of others in the room during the cesarean birth process

Questions To Ask Your Doctor About Cesarean Section
What circumstances require cesarean delivery?

Are indications of fetal distress confirmed by a fetal scalp blood test?

Is a second opinion sought before proceeding to all but emergency surgery?

Must I have intravenous infusion during labor, or can I eat and drink lightly?

What are some specifics about the facility where I will deliver. Does it require a specific management plan, such as active management of labor?

Does it offer a constant labor companion, or allow you to bring your own?

CD4 Lymphocyte Monitoring

* Description of CD4 Lymphocyte Monitoring
* Questions To Ask Your Doctor About CD4 Lymphocyte Monitoring

Description of CD4 Lymphocyte Monitoring
Monitoring lymphocyte counts in a patient with HIV infection is one way to assess the degree of immunosuppression and the risk of developing opportunistic infections.

For several years after exposure to human immunodeficiency virus (HIV), an infected person will typically have either no symptoms or only minor ones such as chronically swollen lymph nodes. However, despite the absence of noticeable symptoms, HIV may be silently causing damage.

HIV infects and kills certain white blood cells called CD4 lymphocytes, reducing their number. The number of CD4 cells usually declines over time in an HIV-infected person. CD4 lymphocytes act as the 'on switch' for part of the immune system, so as the number of CD4 cells drops, damage to the immune system may progress.

Over time, individuals become increasingly susceptible to infections caused by organisms that are usually controlled by people with adequate immune systems. Those infections are called opportunistic infections.

Years after infection, HIV-infected people may develop symptoms such as night sweats, chronic diarrhea, fatigue, fever, and various skin problems. These symptoms vary in severity for each individual. If the individual receives no treatment and further immune impairment occurs, the body becomes susceptible to life-threatening complications.

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Questions To Ask Your Doctor About CD4 Lymphocyte Monitoring
What is the CD4 count?

Has the count dropped since it was last taken?

How accurate is the count?

At what level should treatment begin?

How can the symptoms be controlled?

What preventive measures should be taken?

When should the count be repeated?

Is HIV counseling available?

Congestive Heart Failure

* Definition of Congestive Heart Failure
* Description of Congestive Heart Failure
* Causes and Risk Factors of Congestive Heart Failure
* Symptoms of Congestive Heart Failure
* Diagnosis of Congestive Heart Failure
* Treatment of Congestive Heart Failure
* Questions To Ask Your Doctor About Congestive Heart Failure

Definition of Congestive Heart Failure
Article updated and reviewed by Neil Siecke, MD, Clinical Insturctor, UCSD Division of Cardiology on July 28, 2005.

Congestive heart failure (or heart failure) occurs when the heart is unable to pump enough blood (which provides oxygen) to the muscles, tissues, and other organs of the body.

Statistics on Heart Failure

* A person aged 40 years or older has a one in five chance of developing heart failure.

* About five million Americans have been diagnosed with heart failure.

* About 550,000 new cases are diagnosed each year.

* Heart failure is the most common hospital discharge diagnosis with more than one million hospital stays each year.

* The costs of treating heart failure in the United States exceed $27 billion.

* The risk of heart failure increase with age: 10% of both men and women over 75 have been diagnosed with heart failure.

Statistics derived from the American Heart Association, Heart Disease and Stroke Statistics — 2005 Update

Description of Congestive Heart Failure
There are three ways that the pumping ability of the heart can be affected:

1. The mechanical pump can be ineffective, reducing the ability of the heart to move blood forward.

2. The valves that allow blood to go forward and prevent it from going backwards can fail.

3. The electrical controls for the pump can fail.

Problems with the Pump

Problems with the pumping functions of the heart are the most common cause of heart failure. The heart is actually made up of two pumps, one which pumps blood to the lung (the right heart) and the other which pumps blood to the rest of the body (the left heart). The left heart is usually stronger and is also more likely to fail.

The heart can fail for one of two reasons. If it is weak, it can not expel the appropriate amount of blood with each heart beat. It will try to compensate by beating faster, but there are limits to this. How much blood is expelled with each beat is called the ejection fraction (EF). Normally the heart expels about 50% of the blood in chamber with each beat; however, when the heart is weak, this number can fall to 30% or even lower. Symptoms typically begin when the EF falls to around 40%. This type of failure is known as systolic dysfunction.

The other type of heart failure is called diastolic dysfunction. With diastolic dysfunction, the EF is normal. The problem is that the heart does not fill appropriately. It becomes too stiff and can not enlarge fast enough to accept the appropriate amount of blood into the chamber before contracting to move the blood forward. Because the heart is not filling fast enough, blood backs up behind the heart in the lungs.

The right heart can also fail. The right heart is designed to pump against low pressure, as the blood pressure in the lungs is usually < 40 mmHg. If this pressure becomes elevated, the pump is unable to push the blood forward and it will collect in the veins of the legs and abdomen. The most common cause for high blood pressure in the lungs is backing-up from left heart failure, but other causes such as pulmonary hypertension, blood clots in the lungs, and severe emphysema can also raise this pressure.

Causes for Systolic Dysfunction (Weak Hearts:

* A previous heart attack is the most common cause for a weak heart; the muscle tissue in this area dies and is replaced by scar tissue which has no pumping activity; just having multiple areas of blocked arteries can also weaken the heart

* Certain kinds of viral infections can attack the heart muscle

* Alcohol abuse

* Illicit drugs such as methamphetamine and cocaine

* Certain, mostly older, chemotherapy drugs

* Some auto-immune disorders

* Rarely the heart weakens after pregnancy, known as post-partum cardiomyopathy

Causes for Diastolic Dysfunction (Stiff Hearts):

* High blood pressure for many years is the most common cause of a stiff hear; a blood pressure greater than 160/90 mmHg doubles the risk of a person with a blood pressure of 140/80

* Diabetes seems to worsen the effects of high blood pressure

* Hypertrophic Cardiomyopathy (a group of genetic abnormalities that results in thickened hearts)

* Infiltrative diseases such as amyloidosis

* Some valvular problems also cause the heart to become stiff

* Certain diseases of the pericardium, or lining, around the heart

Problems with the Valves

The heart has four valves that allow the blood to move forward and prevent it from going backwards. The valves can fail either because they become clogged and do not allow blood to move forward easily, or they can become leaky in which case too much blood flows backward, and not enough moves forward.

Most valve problems will result in a murmur. The murmur may begin many years before the problem becomes noticeable, but this is not always the case.

Reasons that the valves can fail include the following:

* Congenital (birth) defects

* Calcification of the valve

* Infection of the valve (Rheumatic Fever is the most common)

* Heart attacks can also damage the valve

Problems with the Electrical Controls of the Heart

The electrical system controls how often, or how fast, the heart beats and coordinates the movements among the various chambers of the heart for optimal efficiency. Beating too fast, too slow, or irregularly can all result in heart failure. The generic name for these problems is an arrhythmia.

The normal heart rate is 60 to 80 beats per minute. The most common reason for the heart to beat to rapidly is excess stimulation, such as a thyroid problem. The most common reason for beating too slow is bad connection between the chambers (heart block). An irregularly beating heart is often caused by atrial fibrillation.

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Causes and Risk Factors of Congestive Heart Failure
The two most common causes of heart failure are high blood pressure and coronary artery disease (disease of the artery). Up to 75 percent of all patients with heart failure have a history of high blood pressure, and at least 50 percent have a history of coronary artery disease.

Specific causative factors for the four (4) forms of heart failure are listed below.

1. Systolic heart failure can be caused by coronary artery disease; high blood pressure; metabolic disorders, such as thyroid disease, vitamin deficiency or diabetes; infection; toxin exposure to cobalt, alcohol, cocaine and chemotherapeutic agents; infiltrative diseases, such as cardiac amyloidosis and hemochromatosis; neuromuscular disease; collagen vascular disease; valvular heart disease or peripartum cardiomyopathy.

2. Diastolic heart failure can be caused by coronary artery disease; high blood pressure; myocardial relaxation; left ventricular elastic recoil; ventricular-ventricular interaction; pericardial restraint; intrathoracic pressure or passive chamber properties.

3. Left-sided heart failure can be caused by high blood pressure; hypertrophic cardiomyopathy (an enlarged left ventricle and a thick ventricular wall); anemia; hyperthyroidism; heart valve defect, such as aortic valve stenosis and aortic insufficiency; congenital heart defect; heart arrhythmias; myocardial infarction or cardiomyopathy (disease of the heart muscle).

4. Right-sided heart failure can be caused by pulmonary hypertension; lung disease, such as chronic bronchitis and emphysema; tricuspid insufficiency or congenital heart defect, such as septal defect, pulmonary stenosis or tetralogy of Fallot.

Symptoms of Congestive Heart Failure
All of the types of heart failure can result in similar symptoms, including the following:

* Shortness of breath, especially with activity such as walking

* Difficulty breathing when lying flat in the bed

* Waking up at night short of breath

* Fatigue

* Weakness

* Pale, blue or cool skin

* Palpitations

* Changes in blood pressure

* Fainting for no apparent reason

* Swelling in the abdomen

* Swollen legs

Symptoms of right-sided heart failure include:

* Swollen legs

* Liver and spleen enlargement

* Swollen neck veins

* Fluid buildup in the stomach

* Swollen abdomen

* Slow weight gain

* irregular heart rhythm

* Nausea

* Vomiting

* Appetite loss

* Weakness

* Fatigue

* Dizziness

* Fainting episodes

Diagnosis of Congestive Heart Failure
A health history, physical exam, chest x-ray, and electrocardiogram (EKG) should be done in every person suspected of heart failure. Most patients will also have an echocardiogram (an ultrasound study of the heart). A blood test (BNP) can also be useful in diagnosing heart failure.

The health history will consist of questions about symptoms and how long they have been present, previous heart problems, other health problems, , and use of alcohol or other drugs.

During the physical exam, the doctor will listen to the heart and lungs with a stethoscope to detect the sounds associated with heart failure (such as murmurs or the sound of fluid in the lungs).

Additionally, the doctor will look for evidence of fluid build-up, such as swollen or enlarged neck veins, an enlarged liver, an expanding abdomen and swollen ankles.

A chest x-ray may reveal an enlarged heart or fluid in the lungs. It may also suggest another reason for the symptoms such as pneumonia or damage to the lungs.

An echocardiogram uses ultrasound waves to obtain images of heart structures. The echocardiogram can tell if the heart pumping ability is weak or stiff. It can also diagnose problems with the valves, or it may suggest that a person has had a previous heart attack.

Treatment of Congestive Heart Failure
The treatments for heart failure have improved dramatically over the last five to 10 years. Most subjects can be managed to the point where they have few symptoms, but this often requires that they take five or more medications per day.

When deciding how to treat heart failure, the most important question is what caused the heart failure in the first place and to reverse that if possible. If the problem is from a bad valve, surgery will usually be required to replace or repair the valve. If the problem is electrical, a pacemaker may be needed to regulate the heart beat or other treatments to slow the heart rate. If the problem is from blocked arteries, either an angioplasty or a bypass surgery is usually attempted. Most patients will end up taking several medications to improve their symptoms or help the heart recover.

Medication

The first treatment is usually a diuretic medication. These medicines work by forcing the kidney to excrete more salt and water. This will help to remove the excess fluid from the lungs and/or the legs. These medications can quickly make a patient feel better. Examples include furosemide (Lasix), bumetanide (Bumex), and hydrochlorothiazide (HCTZ).

Angiotensin-converting enzyme inhibitors (ACE inhibitors) are used to reduce the blood pressure and to encourage the healthy recovery of the heart function. They work by restoring imbalances in several hormones. There are approximately 10 different brands available with similar effectiveness. Examples include: captopril (Capoten), enalapril (Vasotec), and lisinopril (Prinivil, Zestril).

Some patients will develop a cough when treated with an ACE Inhibitor. They will usually be prescribed a closely related type of medication known as an angiotensin receptor blocker (ARB). Examples include valsartan (Diovan) and losartan (Cozaar).

Recently, some studies have suggested that African-Americans may not respond as well as other ethnicities to ACE inhibitors. They may instead be prescribed a combination of hydralazine and isosorbide. Beta-blockers were originally thought to be harmful for subjects with heart failure as they tend to reduce the pumping ability of the heart. They work by blocking the effect of adrenaline, a stress hormone, that can be very high in patients with heart failure. We now know that adrenalin is harmful to the heart. Beta blockers can dramatically improve the function of the heart over time, but if the heart muscle is weak, they must be started at low doses and gradually increased over time. Examples of beta-blockers include carvedilol (Coreg) and metoprolol (Toprol XL).

Digoxin (Lanoxin) has been used for several centuries to treat heart failure. It is an herbal extract that mildly increases the heart's pumping action so more blood is ejected with each heartbeat. Care must be taken to avoid high blood levels of this medication.

Other medications may also be needed to lower the blood pressure, lower the level of cholesterol, replace potassium lost in the urine, or prevent blood clots.

Electrical Devices:

* Defibrillators (ICDs) have been shown to prevent sudden cardiac death (a fatal arrhythmia) in certain groups of people with heart failure. These are small devices that are placed under the patient’s skin and monitor the electrical activity of the heart. If a problem is detected, the device will give the heart an electrical shock which is designed reset the heart and restore a healthy heart rhythm.

* Biventricular Pacemakers are advanced types of pacemakers that can stimulate both the right and left side of the heart at the same time if an electrical problem has caused them to become out of sync. These devices function much like typical pacemakers, but they require a more complicated installation to reach the left side of the heart.

Dietary, Lifestyle and Health Changes

* Restrict salt (sodium) intake. Restricting sodium minimizes fluid retention.

* Avoid caffeine. Avoiding caffeine lowers the risk of an increased heart rate or abnormal heart rhythms.

* Limit or stop alcoholic beverage consumption.

* Check your weight everyday. If your weight suddenly increases, you may be retaining fluid and may need to adjust your medications.

* Don't smoke or chew tobacco.

* Don't use illegal drugs.

* Exercise regularly, within your doctor's guidelines.

* Rest. Adequate rest helps conserve energy and decreases demands on the heart.

* Reduce stress.

* Get a flu and pneumonia shot.

Questions To Ask Your Doctor About Congestive Heart Failure
What form of heart failure is it?

What is the cause of the condition?

How serious is the condition?

Should a specialist be consulted?

What type of treatment will you be recommending?

Will surgery be recommended?

Will you be prescribing any medication?

What are the side effects?