M M Avram

State University of New York, New York City, New York, United States

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Publications (60)291.84 Total impact

  • M.M. Avram · N. Mittman

    No preview · Article · Jan 2008
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    D A Blaustein · M M Avram

    Preview · Article · Jun 2007 · Kidney International
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    ABSTRACT: Nutritional status is associated with clinical outcomes in dialysis patients. Inflammation may cause malnutrition and increases the risk of poor outcomes. We have investigated the relationship between nutritional markers, an inflammatory marker, and survival in 177 peritoneal dialysis (PD) patients, enrolled from 1991 to 2005. In 53 patients, bioimpedance analysis (BIA) measurements were conducted from November 2000. In a subgroup of 42 patients, we measured high-sensitivity C-reactive protein (CRP) and various nutritional markers including prealbumin serially from May 2003. All the patients were followed to April 2006. Mean enrollment albumin and prealbumin levels were 3.61±0.51 g/dl and 35.8±11.3 mg/dl, respectively. Mean and median enrollment CRPs were 13.53±20.81 (s.d.) and 7.15 mg/l, respectively. Higher enrollment levels of nutritional markers such as albumin (P
    Preview · Article · Dec 2006 · Kidney International
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    ABSTRACT: It is necessary to provide adequate amounts of bioavailable iron to correct any deficit and maintain body iron stores in anemic patients with chronic kidney disease (CKD). Although dosing regimens for intravenous iron sucrose exist, simplification of these regimens may produce financial savings and reduce the time commitment of both patients and clinicians. We have explored high-dose (500 mg or greater) intravenous iron sucrose regimens in patients with CKD and summarize our findings here. Three studies used 500 mg intravenous iron sucrose doses on 2 or more successive days, and one study examined the feasibility of a single total dose infusion of 1000 mg. We conclude that patients do not tolerate 1000 mg doses as a single infusion. On the other hand, a dosing regimen of 500 mg iron sucrose given intravenously over 3 h on successive days is safe and effective in replenishing and maintaining body iron stores. Finally, in anemic CKD patients not receiving erythropoietic hormone therapy, we found an increase in hemoglobin concentrations, and no deleterious effect on glomerular filtration rate 6 months after they were treated with iron sucrose.Keywords: anemia, chronic kidney disease, iron sucrose, ferritin, hemoglobin, therapy
    Full-text · Article · Nov 2006 · Kidney International
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    M M Avram

    Preview · Article · Nov 2006 · Kidney International
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    N Mittman · R Khanna · S Rani · J Chattopadhyay · M M Avram
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    ABSTRACT: Secondary hyperparathyroidism (SHPT) is a common complication of chronic kidney disease. The medical management of SHPT in hemodialysis (HD) patients commonly utilizes intravenously administered vitamin D, either calcitriol or newer analogs (paricalcitol or doxercalciferol). Recent published reports have suggested that the use of paricalcitol in HD patients offers a morbidity or mortality advantage in comparison to treatment with calcitriol. The objective of this study was to compare the biochemical markers of SHPT during serial treatment with calcitriol and paricalcitol. We converted all HD patients in our large urban dialysis center from calcitriol to paricalcitol using a 1:3 conversion ratio, based on published data. Demographic, clinical, and laboratory data were collected, and comparisons of individual patient mean values were made after adjusting for equivalent doses. In addition, we recorded the number of missed doses during 6 months of therapy with calcitriol and with paricalcitol. Seventy-three patients were treated with calcitriol for at least 6 months before conversion to paricalcitol, and then completed 6 months of treatment with paricalcitol. Converting from calcitriol to paricalcitol resulted in lower serum calcium (P=0.048), lower calcium-phosphorus product (P=0.014), reduced biointact parathyroid hormone (P=0.029), and reduced serum alkaline phosphatase (P=0.0002). Most dramatically, there was a highly significant difference in the number of missed doses (P<0.0001). This study, the first comparing long-term calcitriol to paricalcitol treatment in the same HD patients, offers several important clues that may explain outcome differences reported in large pooled reports.Keywords: secondary hyperparathyroidism, parathyroid hormone, vitamin D, end-stage renal disease, hemodialysis
    Preview · Article · Nov 2006 · Kidney International
  • P A Fein · S J Madane · A Jorden · K Babu · R Mushnick · M M Avram · I Grosman
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    ABSTRACT: Protein malnutrition is now well established as an important contributory factor to the high mortality in peritoneal dialysis (PD) patients. Low dietary protein calorie intake is one of the factors leading to protein malnutrition. If PD patients develop difficulty eating, percutaneous endoscopic gastrostomy (PEG) feeding may prove beneficial in providing adequate nutrition. Studies on the effectiveness of PEG feeding in PD patients are limited to pediatric patients. The objective of the present study was to assess the outcome of PEG feeding in adult patients with end-stage renal disease (ESRD) on PD. We retrospectively reviewed charts from May 1992 to February 2000 of 10 consecutive patients in our center who had had feeding tubes inserted. The patients' ages ranged from 37 to 81 years, with mean age of 65. Of the 10 patients, 7 were male, 5 were diabetic, and 1 was infected with the human immunodeficiency virus. Two patients had cerebrovascular accident (CVA) with dysphagia, 3 had multi-infarct dementia, 2 had anoxic encephalopathy, 2 had dementia, and 1 had calciphylaxis with anorexia. Of the 10 patients, 9 failed to eat because of neurologic disorders. Two patients who had functioning PEG feedings before starting PD had no complications. Only 2 of 8 patients already on PD continued with long-term PD after a PEG was inserted. Both patients whose PD was not interrupted at the time of PEG placement immediately developed peritonitis. Of the 6 patients who were maintained on hemodialysis (HD), 2 developed peritonitis within one week of starting PEG feedings. The other 4 had no complications from PEG feedings while being maintained on HD, but 1 developed peritonitis when PD was resumed. Of the 5 patients who developed peritonitis, 3 experienced fungal peritonitis. In PD patients, PEG feeding is associated with frequent complications. However, PEG placement prior to PD initiation appears to be safe. Maintaining patients on HD for at least 6 weeks appears to decrease the incidence of peritonitis, but does not eliminate it. Use of anti-fungal prophylaxis and maintenance of the patient on HD for longer than 6 weeks may produce better results.
    No preview · Article · Feb 2001 · Advances in peritoneal dialysis. Conference on Peritoneal Dialysis
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    ABSTRACT: Previously we reported that HD treatment dose by urea reduction ratio (URR) is an important and independent determinant of more than 7 years survival in 253 HD pts. In the present work we have studied the effect of dialysis dose measured by URR with larger number of pts and extended follow-up period (more than 12 years). The objective of this study was to determine whether dialysis treatment dose as measured by URR is an independent predictor of long-term mortality in HD pts. We enrolled 404 HD pts treated at the Long Island College Hospital from January, 1987 and followed them up to June, 1999. Mean age was 60±16 (SD) yrs; female, 55%; African American, 56%; diabetic, 47%;. Mean cumulative URR was 62% ± 6.3 over the 12-year study period. Mean URR was higher in females (65% vs. 60% males, P<0.0001), and non-diabetics (63% vs. 62% diabetics, P<0.05). Over a period of 12 years, mean cumulative URR correlated positively with hematocrit (r=0.33, P<0.05) and ferritin (r=0.32, P<0.05) and negatively with body weight (r=-0.33, P<0.05), creatinine (r=-0.18, P<0.05) and anion gap (r=-0.31, P<0.05). Observed 12 years cumulative survival of pts stratified by three groups of URR was determined by Kaplan Meier method. Pts with URR 60%-65% had the best survival. Interestingly, the survival rate of pts with URR>65% (highest URR group) was significantly lower than pts with URR 60%-65%. Expected survival, adjusting for confounding variables, yielded similar results. Mean serum creatinine level was significantly lower in pts with highest URR (>65%) group (9.9 vs. 11.5 for <60% and 11.4 for 60%-65%, P<0.0001). In Cox's proportional hazards model, when we adjusted for mean creatinine, the relative risk of mortality for pts with URR>65% became significantly lower compared to those with URR<60%, and similar to those with URR 60%-65%. This suggests that higher mortality in pts with URR>65% may be due to poor nutritional status, particularly lower muscle mass. Dialysis treatment dose in terms of cumulative URR can independently predict more than 12 years survival in HD pts.
    No preview · Article · Mar 2000 · ASAIO Journal

  • No preview · Article · Mar 2000 · ASAIO Journal

  • No preview · Article · Mar 1999 · ASAIO Journal
  • M.M. Avram · R. Sreedhara · N. Mittman
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    ABSTRACT: Despite improvements in dialysis technology and overall improvements in healthcare, the mortality rate of end-stage renal disease (ESRD) patients in the United States remains high-at 21.3 % in 1995. Inadequate dialysis, malnutrition, and other serious comorbid conditions may all contribute to the high mortality rate in dialysis patients. The high mortality rate of ESRD patients has prompted investigators to examine causes and predictors of mortality in these patients. Some of these predictors include demographic and clinical characteristics such as age, race, gender, and diabetic status; nutritional status as evaluated by albumin, pre-albumin, creatinine, cholesterol and, more recently, parathyroid hormone (PTH) levels; dialytic factors such as the dose of dialysis; and assessed functional health status. This article looks at the relative significance of these predictors as determined by the authors through clinical studies and insights gained through their own long-term successes. The authors encourage analysis of outlier patients in order to garner clues to prolonged survival.
    No preview · Article · Jan 1998 · Dialysis & Transplantation
  • M M Avram · R Sreedhara · N Mittman

    No preview · Article · Mar 1997 · ASAIO Journal
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    ABSTRACT: Patients undergoing dialytic therapy for end-stage renal disease (ESRD) have greater morbidity and mortality than age-matched individuals with similar demographics in the general population. Risk factors for early death during treatment for ESRD include advanced age, diabetes, hypertension, and malnutrition. We questioned whether the level of serum prealbumin at the start of uremia therapy might serve as a marker of subsequent survival in patients treated with maintenance hemodialysis (HD) and peritoneal dialysis (PD). Study cohorts included 111 HD and 78 PD patients followed for up to 5 years. Selected demographic characteristics and biochemical variables were tested for correlation with survival in each cohort. Variables evaluated included age, race, gender, diabetic status, and serum concentrations of albumin, creatinine, cholesterol, and prealbumin. For comparison, expected survival was calculated with Cox proportional hazards analysis, which accounts for confounding variables. We found that a higher relative risk (RR) of death in HD patients correlated with older age, the diagnosis of diabetes, and a serum prealbumin < 30 mg/dL. In PD patients, older age and the presence of diabetes correlated with a higher RR of death than in the standard population. When nutritional variables were analyzed separately, prealbumin < 30 mg/dL was the strongest variable that predicted mortality in HD patients (RR = 2.64, P = 0.002) and also predicted increased risk of mortality in PD patients (RR = 1.8, P = 0.035). Observed and expected survival was significantly higher in patients with enrollment prealbumin greater than 30 mg/dL in both HD and PD. The serum prealbumin level correlated significantly with other measures of nutrition, including serum albumin, serum creatinine, and serum cholesterol, in both HD and PD patients. Among tested markers of nutritional status, prealbumin level appears to be the single best nutritional predictor of survival in ESRD patients.
    No preview · Article · Dec 1996 · American Journal of Kidney Diseases
  • N Mittman · M M Avram
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    ABSTRACT: In summary, dyslipidemia is a common feature of various renal syndromes. Whether this perturbed lipid metabolism results in accelerated atherosclerosis and increased cerebrovascular and cardiovascular morbidity and mortality remains a subject of inquiry. Also undefined is the role of dyslipidemia in the progression of renal injury. The malnutrition that becomes a dominant morbid feature in patients on maintenance renal replacement therapy provides a caveat against aggressive intervention for modest hyperlipidemia once dialysis is instituted. Individualized assessment of end organ atherosclerotic disease and cardiovascular risk factors should form the basis for modification of the treatment plan (ie, pharmacological intervention) should nonpharmacological means prove ineffective.
    No preview · Article · Jun 1996 · Seminars in Nephrology

  • No preview · Article · Apr 1996 · ASAIO Journal
  • N. Mittman · M M Avram · K. OO · J. Licht

    No preview · Article · Apr 1996 · ASAIO Journal
  • N Mittman · M M Avram · K Oo · J Licht · R. Sreedhara

    No preview · Article · Mar 1996 · ASAIO Journal

  • No preview · Article · Mar 1996 · ASAIO Journal
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    ABSTRACT: Our objective was to examine the influence of various demographic, clinical, and enrollment biochemical variables on the long-term survival of continuous ambulatory peritoneal dialysis (CAPD) patients. This was a prospective cohort study investigating the relationship between demographics and enrollment biochemical markers and mortality in CAPD patients in a CAPD unit in a large tertiary care teaching hospital. One hundred and sixty-nine patients in the CAPD program were enrolled between 1989 and 1994, and were followed up to 60 months. Independent predictors of mortality determined by Cox proportional hazards model included age, diabetes, serum albumin and creatinine. Enrollment level of serum albumin, and creatine can predict mortality in CAPD patients up to 60 months. Markers of visceral and somatic nutrition at enrollment are important predictors of mortality in CAPD patients up to five years.
    No preview · Article · Feb 1996 · Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis
  • M M Avram · R Sreedhara · N Patel · J Chattopadhyay · T Thu · Fein PA
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    ABSTRACT: Cardiovascular disease (CVD) is the single most important cause of mortality in hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD) patients. An increased lipoprotein (a) [Lp(a)] level in HD patients is associated with CVD. However, Lp(a) levels in CAPD patients are controversial, and their association with CVD has not been established. In the present study, prevalent CAPD and HD patients [excluding those who were human immunodeficiency virus (HIV)-positive] attending the Long Island College Hospital from June, 1990 to July, 1995 underwent analysis of lipid profile including Lp(a). Total and low-density lipoprotein cholesterol, triglycerides, apolipoprotein (apo) A, and apo B were all significantly increased in CAPD patients compared to HD patients. Serum Lp(a) levels were also significantly higher in CAPD patients than in HD patients (51 +/- 32 vs 34 +/- 23 mg/dL, p < 0.001). CAPD patients who had a history of myocardial infarction (MI) or coronary artery disease (CAD) at enrollment had significantly higher Lp(a) levels compared to those who did not have a history of MI or CAD. CAPD patients who died of CVD had higher Lp(a) levels than patients who died of non-CVD causes. In the Cox model with backward stepwise selection, a history of CVD was associated with a significantly elevated relative risk (RR) of mortality (RR = 1.84, p = 0.014). Expected survival by all causes of mortality and by cardiac mortality was significantly shorter in patients with a history of CVD than in those without a history of CVD. Thus, elevated Lp(a) is related to increased CVD and therefore may contribute to increased mortality in CAPD patients.
    No preview · Article · Feb 1996 · Advances in peritoneal dialysis. Conference on Peritoneal Dialysis