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PubMed1988

Role of diuretics, hormonal derangements, and clinical setting of hyponatremia in medical patients.

Because hyponatremia is frequently associated with preceding diuretic treatment and unrestricted fluid intake--conditions which have not been addressed sufficiently in published literature--we studied the pathophysiology and the clinical setting of such hyponatremia in a large group of internal medicine patients. We observed: a) Of an initial 310 patients with chemical hyponatremia only 204 (64%) had an associated plasma hypoosmolality. Since a normal plasma osmolality excludes a disturbance of water metabolism only the 204 patients with hypoosmolar hyponatremia were included in the study. This data shows that plasma osmolality is an essential measurement in any evaluation of hyponatremia. b) In 204 consecutive patients with hypoosmolar hyponatremia the electrolyte disturbance was related to advanced congestive cardiac failure in 25%, decompensated liver cirrhosis in 18%, volume contraction in 28%, syndrome of inappropriate antidiuretic hormone secretion in 19% and renal insufficiency in 4%. c) Plasma vasopressin was measurable in 90% of the 204 patients. It is known that radioimmunoassays to measure vasopressin fail to reliably detect low concentrations of circulating vasopressin (less than 0.5 pg/ml). It may therefore be stated that hypoosmolar hyponatremia was generally characterized by a failure of antidiuretic hormone suppression. d) Mean daily fluid intake of hyponatremic patients was 2.35 +/- 0.15 l. In the presence of stimulated vasopressin this large a fluid intake is bound to worsen the severity of hyponatremia. e) Of 204 patients 126 were treated with diuretics at the time of study. In these patients hyponatremia worsened during such treatments and was associated with evidence of prerenal azotemia. However there were no significant differences between diuretic-treated and -untreated patients with respect to plasma vasopressin stimulation and amount of fluid intake.(ABSTRACT TRUNCATED AT 250 WORDS)

Aldosterone↗
PubMed1985

[Mechanisms of postobstructive polyuria].

Postobstructive diuresis occurs after relief of bilateral ureteral obstruction despite the persistent decrease in renal cortical perfusion and glomerular filtration rate (GFR). After an initial transient rise in renal blood flow (RBF) during acute ureteral obstruction, tubular damage and progressive vasoconstriction with decreased RBF, especially of medullary perfusion, are observed with chronic obstruction. These are associated with an activation of the renin-angiotensin system and of renal prostaglandin (PG) synthesis with enhanced production of the vasoconstrictor thromboxane A2. Azotemia and extracellular fluid volume (ECFV) expansion result from impaired renal function. Mechanisms of polyuria following relief from bilateral chronic obstruction include enhanced PGE-mediated medullary blood flow, structural and functional tubular damage with decreased sodium reabsorption and (vasopressin-resistant) impaired renal concentrating ability, osmotic diuresis, activation of natriuretic factors following ECFV-expansion, and sometimes iatrogenic excessive fluid replacement. The resulting loss of fluid and electrolytes represents a major hazard in patients after surgical correction of congenital or acquired urinary tract obstruction.

Animals↗
PubMed1978

[Action of furosemide in experimental acute renal failure (author's transl)].

The action of furosemide was studied in glycerol-induced acute renal failure of rats. Acute renal failure was induced by an intramuscular injection of 50% glycerol (10 ml/kg). A marked increase in plasma urea concentration was found after the glycerol injection. Urea concentration increased to a maximal value of 339 +/- 67 mg/100 ml at the third day after glycerol application. 36% of the animals died within the first 4 days after glycerol. Furosemide (20 mg/kg) was injected intraperitoneally daily and for the first time 24 h after injection of glycerol Mortality and azotemia of acute renal failure was not improved by this drug.

Acute Kidney Injury↗
PubMed1985

Endotoxin-induced acute renal failure in mice. Effects of indomethacin and the thromboxane-synthetase antagonist UK 38.485.

Functional acute renal failure (ARF) was induced within 24 h following i.p. injection of 200 micrograms E. coli endotoxins (ET) into C3H/HeHan mice. Pre- and post-treatment with either UK 38.485, a selective thromboxane (TX)-synthetase inhibitor, or with the cyclo-oxigenase inhibitor, indomethacin (IM), does not prevent acute renal failure in these mice. Histologically, only very little fibrin degradation and few microthrombi are present 24 h later in the kidneys, so that disseminated intravascular coagulation (DIC) mechanisms cannot have caused the significant azotemia. Slight histological changes are accentuated in the UK 38.485-treated group. Only the indomethacin group has a significantly increased mortality as compared to all other groups. We conclude from our study that with low dosages of endotoxins functional ARF can be induced in mice without a circulatory shock and early mortality and that both UK 38.485 and IM are of little value in preventing it.

Acute Kidney Injury↗
PubMed1991

Hepatorenal and splenorenal artery bypass for salvage of renal function.

Hepatic and splenic arteries have been used increasingly as inflow sources to avoid aortorenal bypass in patients whose cardiac dysfunction may be exacerbated by aortic clamping and in patients with previous aortic grafting in whom periaortic dissection is more hazardous than incising undisturbed tissue planes. During an 18-month period, eight patients with atherosclerotic renal artery stenosis and azotemia were treated with six hepatorenal and five splenorenal artery bypasses. Serum creatinine improved initially in all patients. Severe hypertension, present in five patients, improved significantly in four (80%). In one-half the gastroduodenal branch of the hepatic artery was suitable for end-to-end anastomosis to the renal artery, obviating the need for an interposition graft. Hepatorenal bypass is a safe, simple procedure that has been associated with few complications, although occasional transient subclinical evidence of hepatic dysfunction has been reported. Splenorenal bypass requires a relatively more hazardous exposure and is associated with a low risk of splenic and pancreatic injury, especially when the spleen and splenic flexure of the colon are mobilized to expose the splenic artery. The risk of splenic injury is substantially reduced when the splenic artery is approached through the retroperitoneum at the base of the transverse mesocolon as described.

Anastomosis, Surgical↗
PubMed1977

Transerythrocytic concentrations of urea and creatinine in normals and in azotemic patients.

Preliminary studies in our laboratory suggested alterations in the distribution of urea and creatinine between red cells and plasma in azotemic patients, as compared to normal controls. The present studies compare plasma erythrocyte concentrations of urea and creatinine in azotemic patients and in control subjects. Effects of adding exogenous urea and creatinine to the blood of control subjects were also studied. The findings suggest alterations of solute distribution patterns in azotemic blood. Specifically, the proportions of the solutes in cells appear reduced in azotemia.

Creatinine↗
PubMed1975

Determination of the glomerular filtration rate by the minute diuresis at a specific gravity of 1001.

A new method is described for determination of the glomerular filtration rate, based on the fact that at an urinary specific gravity of 1001 the final urine is concentrated 6.67 times, as compared with the primary glomerular filtrate. The glomerular filtration rate is evaluated by multiplication of the minute diuresis at a specific gravity of 1001 by the factor 6.67. In this manner the chemical analysis of urine and blood is avoided. Urine with a specific gravity of 1001 is obtained by water loading much the same as in the dilution test of Volhard. For checking the accuracy of the method, comparative studies were conducted with creatinine clearance in 36 patients and with 51Cr-EDTA clearance in 33 patients. The difference in the values of the glomerular filtration rate, evaluated by the above-mentioned two methods and the new method was statistically not significant (p greater than 0.05). The method is recommended for the early detection of disturbances in the glomerular function prior to the occurrence of azotemia.

Diuresis↗
PubMed1978

Differences in the distribution of urea and creatinine between red cells and plasma in normal and azotemic blood as assessed by autoanalyzer and manual chemical methods.

It has been proposed that urea and creatinine may bind to red cell constituents. In the present studies, whole blood and plasma concentrations of urea and creatinine were compared using autoanalyzer techniques (that require solutes to pass through a dialysis membrane) and manual techniques (with no dialysis membrane). Blood samples from 11 normal and 10 azotemic subjects were studied. Concentration differences between plasma water and red cell water for these solutes were significant in normals with standard manual but not with autoanalyzer methods. Accordingly, red cell water concentrations in normals were greater with manual methods than with autoanalyzer methods. In azotemics, differences between red cell and plasma water concentrations and differences in red cell water concentrations between methods were proportionately less. The findings suggest that accumulation of these solutes in the red cell in azotemia is predominantly in the freely diffusable form. Any chemical interference of red cell proteins and/or solute binding to red cell constituents yields significant discrepancies between manual and autoanalyzer methods only at lower BUN and creatinine concentrations.

Autoanalysis↗
PubMed1989

Phase I study of cancer therapy with recombinant interleukin-2 administered by intravenous bolus injection.

Sixty-six patients with disseminated malignancy were treated with recombinant interleukin-2 (IL-2) on a three times a week (M, W, F) IV-bolus injection schedule. Doses ranged from 0.001 to 14.0 x 10(6) units/M2 body surface area. Consecutive groups of 3-5 patients were placed on each dose level and were maintained on that level except for dosage de-escalation for toxicity. Toxicity to all major organ systems were noted with major toxicity including fever and chills, anorexia, fatigue and malaise, arthralgias and arthritis as well as hepatic and renal toxicity. All toxicity reversed within one week of drug cessation. Renal toxicity manifested by azotemia, arthritis and fatigue were the common dose limiting toxicities and the maximally tolerated dose was 12 x 10(6) units/M2. Pharmacokinetic studies indicated a short half-life (T1/2 alpha = 7-23 minutes). At doses over 0.5 x 10(6) units/M2 increases in absolute lymphocytes and eosinophil counts were noted. All T lymphocyte subsets increased. Maximal increases were seen at 4-8 x 10(6) units/M2 with a lesser increase at 10-14 x 10(6) units/M2 dosage level. Circulating NK cells also increased while circulating LAK cells were detected during therapy. Partial responses were noted in 3 patients with melanoma. These lasted 4, 6 and 16 months and involved pulmonary, pulmonary plus mesenteric and retro-orbital plus hepatic metastases respectively in these patients.

Drug Evaluation↗
PubMed1987

Systemic lupus erythematosus. Follow-up study of 148 patients. II: Predictive factors of importance for course and outcome.

The predictive value of a number of clinical and laboratory variables for the mortality of 148 patients with systemic lupus erythematosus (SLE) with a mean observation period of 8 years and a 10-year-survival of 80 per cent was calculated by means of differentiated survival rate analyses and stepwise regression analyses. The predictive power of several variables increased if the calculations were based on deaths caused by SLE rather than on the total mortality rate. The survival rate decreased after 1973 because a diagnosis of SLE was made in some patients with terminal disease who would have remained without a diagnosis before that time. The causes of death and the treatment were identical before and after 1973. The presence of a high number of diagnostic ARA criteria within the first year of observation was a predictor of decreased survival. Severe but non-fatal infections (meningitis, septicemia, pneumonia) significantly reduced the survival rate. Patients with proteinuria and azotemia, within the first 2 years of observation, had a 10-year-survival of 70 per cent. The survival of patients with CNS manifestations was not significantly reduced. The butterfly rash and the presence of lymphopenia were predictors of decreased survival, whereas the presence of DNA antibodies had no predictive value for survival.

Adolescent↗
PubMed1974

Halothane hepatitis with renal failure treated with hemodialysis and exchange transfusion.

A 38-year-old white female, hepatitis B antigen negative, developed fluminating hepatic failure associated with oliguria and severe azotemia after two halothane anesthesia and without exposure to other hepatotoxic drugs or blood transfusions. She was treated with multiple hemodialysis and exchange blood transfusion. The combined treatment corrected the uremic abnormalities and improved her level of consciousness. the liver and kidney function gradually improved, and she made a complete recovery, the first recorded with hepatic and renal failure under these postanesthetic conditions. Further evaluation of this combined treatment used for this patient is warranted.

Acute Kidney Injury↗
PubMed1990

Salmon calcitonin in the acute management of hypercalcemia.

Salmon calcitonin has been used for the management of acute hypercalcemia for the past several years. Unlike other hypocalcemic agents, it is effective within 2 hours after first dosing. This pharmacologic agent shows peak effect at 24-48 hours and has a duration of action of 4-7 days in most cases. Its effectiveness may diminish thereafter despite continuous administration (the so-called "escape phenomenon"). Salmon calcitonin has been shown to be effective in the management of acute hypercalcemia due to a variety of causes, and, because of its low toxicity profile, it may be administered to patients with congestive heart failure or azotemia. Salmon calcitonin is also an analgesic agent in patients with pain associated with bone metastases and may be used in conjunction with other hypocalcemic agents such as mithramycin, the bisphosphonates, or gallium nitrate to prolong the clinical response to more than 1 week. Salmon calcitonin is therefore effective and safe in the management of acute hypercalcemia.

Adrenal Cortex Hormones↗
PubMedDate not supplied

Platelet hyper- and hypoaggregability in different microangiopathic complications of diabetes mellitus.

In vitro platelet aggregometry was performed in 201 patients with diabetes mellitus, and in 106 controls. The complication-free and retinopathic patients showed hyperaggregability to collagen and arachidonic acid, and also to epinephrine and adenosine diphosphate when neuropathy occurred. Patients with nephropathy, both with and without azotemia, had diminished in vitro platelet responses to each of the four stimuli as compared to age- and sex-matched controls. These characteristics were independent of the type of diabetes. It is concluded that diabetic nephropathy is characterized by reduced platelet in vitro reactivity. Further research is necessary to explain in vitro hypoaggregability in contrast to the numerous proofs of in vivo hyperfunction of platelets in diabetes.

Adolescent↗
PubMed2002

Acute and crescentic glomerulonephritis.

Acute nephritic syndrome is clinically characterized by hematuria, proteinuria, oliguria, and volume overload with or without azotemia and histologically be acute proliferative glomerulonephritis. Acute post streptococcal glomerulonephritis is the commonest cause in children. There is a preceding infection prior to this condition in majority. This is one of the comonest causes of renal edema in children. Early recognition, prompt and aggressive therapy and adequate follow-up are mandatory. Prognosis is usually good unless associated with severe renal failure and crescentic glomerulonephritis where the outcome is relatively poor unless treatment is early and adequate. Pathologically acute proliferative nephritis is with diffuse proliferative glomerulonephritis with or without crescents. Immunosuppressive therapy is not needed in simple acute proliferative glomerulonephritis but is essential in modifying the outcome of crescentic glomerulonephritis. Delayed resolution, severe renal failure at onset, progressive renal failure and associated systemic features like skin rashes, joint pains, hepatosplenomegaly and persistent fever are the indications for biopsy. Overall the prognosis in classical post streptococcal acute proliferative glomerulonephritis is good.

Acute Disease↗
PubMedDate not supplied

Vasculitis in children.

Vasculitis in children is uncommon and hardly any information is available from India. We, at PGIMER, Chandigarh, have diagnosed and followed many children with vasculitis of different types though not all, which occur in children. In this article, we have given an overview of the vasculitides that we have encountered along-with a review of relevant literature. We have described 8 children with classical PAN and have highlighted a higher frequency of CNS involvement in our patients. Amongst the 10 BCPAN children, as many as 8 had peripheral gangrene which resulted in auto-amputation in 7. Gangrene of such severity has not been previously reported in this condition. We have also included 30 children with HSP. Gastrointestinal involvement was noted in 86.7% of children and in one of these, it was severe enough to result in hypovolemic shock. Such severe bleeding is very rare. Two of our patients with HSP came late to us after having been operated for an 'acute abdomen' elsewhere. Although renal involvement was seen less frequently than reported in the literature, the severity of involvement was greater (nephrotic range proteinuria in 62% and azotemia in 50%). We have only limited experience of Kawasaki Disease but it appears that children with this disorder are probably not being diagnosed in the acute stage in our country.

Adolescent↗
PubMedDate not supplied

Acute glomerulonephritis.

Acute glomerulonephritis (AGN) manifests with abrupt onset of hematuria, facial edema, hypertension and impairment of renal function. The commonest form of AGN in developing countries is that following a beta hemolytic streptococcal infection where the glomerular injury is mediated by deposition of immune complexes. In the usual patient with moderately severe poststreptococcal AGN (PSAGN) the above-mentioned features are present However, gross or microscopic hematuria may be the only abnormality. A similar picture may occasionally be produced by a variety of infections (when GN is referred to as post-infectious and the mechanism of glomerular damage and the renal histology are similar to that in PSAGN), primary renal glomerular disorders (e.g. membranoproliferative GN, IgA nephropathy), collagen vascular diseases (systemic lupus erythematosus), systemic vasculitis (Henoch Schonlein purpura) and hereditary nephritis and some nonglomerular conditions. PSAGN may also present with one or more of its complications such as profound volume expansion with heart failure and hypertensive encephalopathy. PSAGN resolves rapidly and has an excellent prognosis. Patients with severe renal involvement and life threatening complications need expert supportive management. AGN with associated systemic features or very pronounced azotemia, nonstreptococcal AGN and unresolving GN need prompt, appropriate evaluation that often includes a renal biopsy. If extensive crescentic changes are found (crescentic GN), aggressive immunosuppression will be necessary.

Acute Disease↗
PubMed1976

Studies on the pathophysiology of acute renal failure. I. Correlation of ultrastructure and function in the proximal tubule of the rat following administration of mercuric chloride.

Acute renal failure was induced in male rats by the subcutaneous injection of 4 mg HgC12 per kg body weight. Changes in the proximal tubule were studied by light and electron microscopy at six time intervals from 15 min to 24 h. Renal function was monitored at 6 and 24 h. Between 15 min and 3 h changes were similar in all regions of the proximal tubule (pars convoluta and pars recta). Dispersion of cytoplasmic polysome groups was widespread and mitochondrial matrices were condensed in some cells. No changes were noted in the brush border but increased endocytotic activity occurred in some convoluted tubules at 1 and 3 h. At 6 h severe changes had occurred in the pars recta in the medullary rays. Microvilli of the brush border were focally absent, the mitochondria were swollen and the endoplasmic reticulum was dilated. At this time only subtle changes occurred in the pars recta in the outer stripe of the outer medulla. However by 24 h necrosis was widespread throughout the pars recta, yet changes in the proximal convoluted portion were minimal. A significant azotemia, decreased GFR and increased FENa+ and FEK+ occurred at 6 and 24 h after HgC12 injection. Thus HgC12 at 4 mg per kg body weight produced reproducible renal failure and necrosis involving the pars recta of every nephron but necrosis did not begin in the pars recta until after 6 h while acute renal failure was probably initiated much earlier. The following hypothesis is presented. HgC12 initially interacts with the entire proximal tubule. Although injury is sublethal in the pars convoluta it is responsible for greatly diminished sodium reabsorption and is related to the pathogenesis of the renal failure through feedback mechanisms involving the macula densa and release of renin. This results in renal hemodynamic alterations, decreased GFR and other functional disturbances associated with renal failure. The development of necrosis in the pars recta appears to be a relatively late event, possibly due to further accumulation of Hg++ in this region. In any case, the necrosis appears pathogenetically dissociable from the mechanism of acute renal failure.

Acute Kidney Injury↗
PubMed1981

How accurate is ultrasonography in detecting hydronephrosis in azotemic patients?

Screening for hydronephrosis continues to be an essential part of the evaluation of patients with azotemia of unknown cause. To determine whether sonography is as reliable as nephrotomography for screening purposes, we carried out a prospective, comparative study. Sixty-two patients were evaluated. Mean serum creatinine was 4.3 mg/dl. Of 116 kidneys, 45 were obstructed according to urographic criteria and 42 of these were correctly called hydronephrotic by sonography. The 3 false negative sonographic studies occurred in 2 patients. All 3 kidneys contained radiopaque calculi visible on the plain abdominal film. Of the 71 nonobstructed kidneys, 5 were mistakenly called hydronephrotic by ultrasound, giving a false positive rate of 7%. We believe it is appropriate to use gray-scale ultrasound as a screening test for urinary obstruction in azotemic patients providing the plain abdominal radiograph shows no calcifications.

Adolescent↗