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We investigated the safety and efficacy of magnesium hydroxide as a phosphate binder in patients with end-stage renal disease on maintenance hemodialysis. 9 volunteers participated in a four-phase study during which each ingested (1) no phosphate binders, (2) magnesium hydroxide (Mg(OH)₂) alone, (3) Mg(OH)₂ and aluminum hydroxide (Al (OH)₃) together and (4) Al(OH)₃ alone. Serum magnesium (SMg) concentrations were maintained at less than 4.5 mEq/l (2.3 mmol/l) in all subjects while they were ingesting 0.75–3 g Mg(OH)₂/day and no magnesium toxicity was noted. In individuals taking a constant daily dose, SMg remained stable over 8–12 weeks. Serum phosphorus (SP) decreased from 9.0 mg/dl (2.9 mmol/l) during the control period to 8.1 mg/dl (2.6 mmol/l) during the Mg(OH)₂ period (p < 0.05) and increased from 6.1 mg/dl (2.0 mmol/l) during the Mg(OH)₂ and Al(OH)₃ period to 7.0 mg/dl (2.3 mmol/l) during the Al(OH)₃ period (p < 0.05) indicating that Mg(OH)₂ could significantly lower SP. However, SP was best controlled (6.1 mg/dl; 2.0 mmol/l) when Al(OH)₃ and Mg(OH > 2 were used together and all participants preferred the combination therapy to either of the agents alone. These results indicate that Mg(OH)₂ is a potentially useful adjunct to Al(OH)₃ for managing hyperphosphatemia in patients on maintenance hemodialysis. In this short-term study Mg(OH)₂ was well tolerated and with appropriate monitoring did not cause uncontrolled hypermagnesemia. Further studies are clearly required to determine whether long-term therapy with Mg-containing agents is safe in dialysis patients.

Sleep disorders have been shown to be more prevalent in adults and children with chronic kidney disease (CKD) and on dialysis. To date, the prevalence and impact of restless legs syndrome (RLS) in various stages of CKD has not been evaluated. The object of this study was to determine the prevalence of RLS in children with CKD in different stages, and to evaluate its impact on sleep and daytime functioning. We conducted a clinic-based or telephone survey of 26 patients in varying stages of CKD to assess for RLS, sleep schedule, and daytime sleepiness. Thirty-five percent of children met criteria for RLS, the majority being in CKD stages 1-4. There were no significant differences seen in sleep schedule and daytime sleepiness between those children with or without RLS. We found that there is an increased prevalence of RLS in children with CKD compared to the general population. This suggests that children with all stages of CKD should be routinely screened for RLS symptoms.

During a 5-year period, we evaluated seven infants and two fetuses who presented with enlarged, hyperechoic kidneys. In each, the initial clinical diagnosis was autosomal recessive polycystic kidney disease (ARPKD). Among the seven unrelated infants were three Caucasian and four African-American infants. No syndromic stigmata were evident in any of these infants. At the time of the initial evaluation, the family data were incomplete for four infants. The two fetuses were presumed to be at-risk for ARPKD based on the diagnosis in previous siblings. Renal histopathology was evaluated in all nine cases and revealed a spectrum of cystic disease ranging from ARPKD to glomerulocystic kidney disease to autosomal dominant polycystic kidney disease to diffuse cystic dysplasia. In the eight cases for whom liver histopathology was available, varying degrees of biliary dysgenesis were evident. We present a detailed analysis of the key histopathological features in each case and discuss the histopathological findings in an embryological context. In addition, we address the current role of molecular genetics in the diagnostic evaluation.

This document presents milestones designed for programs to use in semi-annual review of resident performance and reporting to the ACGME. Milestones are knowledge, skills, attitudes, and other attributes for each of the ACGME competencies that describe the development of competence from an early learner up to and beyond that expected for unsupervised practice. In the initial years of implementation, the Review Committee will examine milestone performance data for each program's residents as one element in the Next Accreditation System (NAS) to determine whether residents overall are progressing. The internal medicine milestones are arranged in columns of progressive stages of competence that do not correspond with postgraduate year of education. For each reporting period, programs will need to review the milestones and identify those milestones that best describe a resident's current performance and ultimately select a box that best represents the summary performance for that sub-competency (See the figure on page v.). Selecting a response box in the middle of a column implies that the resident has substantially demonstrated those milestones, as well as those in previous columns. Selecting a response box on a line in between columns indicates that milestones in the lower columns have been substantially demonstrated, as well as some milestones in the higher column. A general interpretation of each column for internal medicine is as follows: Critical Deficiencies: These learner behaviors are not within the spectrum of developing competence. Instead they indicate significant deficiencies in a resident's performance. Column 2: Describes behaviors of an early learner. Column 3: Describes behaviors of a resident who is advancing and demonstrating improvement in performance related to milestones. Ready for Unsupervised Practice: Describes behaviors of a resident who substantially demonstrates the milestones identified for a physician who is ready for unsupervised practice. This column is designed as the graduation target, but the resident may display these milestones at any point during residency. Aspirational: Describes behaviors of a resident who has advanced beyond those milestones that describe unsupervised practice. These milestones reflect the competence of an expert or role model and can be used by programs to facilitate further professional growth. It is expected that only a few exceptional residents will demonstrate these milestones behaviors. For each ACGME competency domain, programs will also be asked to provide a summative evaluation of each resident's learning trajectory. Additional Notes The "Ready for Unsupervised Practice" milestones are designed as the graduation target but do not represent a graduation requirement. Making decisions about readiness for graduation is the purview of the residency program director (See the Milestones FAQ for further discussion of this issue: "Can a resident/fellow graduate if he or she does not reach every milestone?"). Study of Milestone performance data will be required ...