Anemia

Anemia in renal failure results in multisystemic disabling symptoms, excess cardiovascular morbidity (left ventricular hypertrophy, ischemic heart disease, congestive heart failure), worsening of diabetic retinopathy, and possibly accelerated progression renal failure.

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Once azotemia is detected, a comprehensive history and physical examination should be per­promptly detect the most readily reversible cause of renal insufficiency, a foley catheter should be placed and kidney ultrasound obtained to help exclude outlet obstruction (prostate, uterus). Sonography also will establish the presence of two kidneys, while defining kidney size and location. In hypertensive individuals, a difference in kidney size of more than 2-cm raises suspicion of unilateral renal artery stenosis.

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The paucity of specific symptoms and signs in early renal insufficiency necessitates vigilance to detect renal failure. Depending on muscle mass, the serum creatinine concentration becomes elevated only after 60 to 70% of glomerular filtration rate is lost.

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Application of evidence-based management of progressive renal insufficiency prior to onset of end-stage renal disease (ESRD) affords a reasonable probability of decreasing mortality and morbidity while delaying ESRD. This review provides strategies that may prolong the interval between discovery of kidney disease and ESRD, and also may improve patient outcomes in chronic renal insufficiency.

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In this study, when we adjusted for several con-founders (excepting gestational age), we observed an elevated risk for neonatal mortality among twin births to unmarried mothers regardless of the racial group. Loading the gestational age variable into the model confirmed that shortened gestation was the pathway (intermediary variable) through which the preponderance of neonatal mortality among twins of single mothers was mediated. While some studies did not find single motherhood to be linked to adverse perinatal events, other population-based reports observed higher-than-expected levels of adverse birth outcomes in unmarried gravidas in consonance with our results. However, our investigation differs from previous reports in that our analysis was restricted to the neonatal period, with birth population limited to twins. Our findings strengthen the case that single motherhood is an obstetric risk factor that deserves extra attention.

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Out of a total of 446,570 twins delivered in the United States, 395,540 (88.6%) were live births to either white (325,130 or 82.2%) or to black mothers (70,410 or 17.8%). Results of comparisons between twins of married versus those of single gravidas with respect to selected sociodemographic characteristics stratified by race are summarized in Table 1. Regardless of race, single mothers were younger, less educated and less likely to have adequate prenatal care than their married counterparts. They were also more likely to smoke and consume alcohol during pregnancy. However, there was racial divergence concerning parity. Among blacks, primiparity was more preponderant among single mothers, while the contrary was the case among whites.

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The data set, “The Matched Multiple Birth File,” assembled by the National Center for Health Statistics (NCHS) was used for this analysis. This data set includes U.S. live births and fetal deaths among twins and higher order multiples for the years 1995 through 1998. The completeness of this file is excellent (99%), and the procedures for quality control of the data are explained in detail elsewhere. Since correct analysis of multiple and correlated data such as that of twins is not possible without prior matching, the NCHS undertook the matching of records for deliveries involving multiple gestations for the years 1995-1998. The first stage of the matching involved the building of an algorithm consisting of variables from live birth and fetal death records that were considered the most uniquely identifying to the pregnancy. Live birth and fetal death records, which had identical values for these variables, were then identified. If the number of records with identical information equaled the reported plurality (e.g., two records reported as twins) these records were considered members of the same multiple and assigned a unique set identification number. In those instances where the number of records with identical data exceeded the reported plurality of the records, visual review was conducted and matching done as appropriate. Approximately, 93% of all records were matched in this first stage. All other records were considered unmatched and included in subsequent matching procedures that involved use of additional variables and a composite of algorithmic combinations in addition to using manual identification methods. Perfect matching was finally achieved for 98.8% of the records, and the whole process has been adequately validated and found to be very accurate.

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