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PubMed2003

Scleroderma renal crisis.

Renal crisis occurs in patients who have systemic sclerosis with rapidly progressive diffuse cutaneous thickening early in their disease. SRC is characterized by malignant hypertension, hyperreninemia, azotemia, microangiopathic hemolytic anemia, and renal failure. SRC was almost uniformly fatal, but in most cases it can now be successfully treated with ACE inhibitors. This therapy has improved survival, reduced the requirement for dialysis, and often allowed for the discontinuation of dialysis 6 to 18 months later. Prompt diagnosis and early, aggressive initiation of therapy with ACE inhibitors will result in the most optimal outcome.

Acute Kidney Injury↗
PubMed1996

Scleroderma renal crisis.

Renal crisis occurs in systemic sclerosis patients with rapidly progressive diffuse cutaneous thickening early in their disease. SRC is characterized by malignant hypertension, hyperreninemia, azotemia, microangiopathic hemolytic anemia, and renal failure. This complication, which in the past has been almost uniformly fatal, is now successfully treated in most cases with ACE inhibitors. This therapy has improved survival, reduced requirement for dialysis, and in those on dialysis has often allowed discontinuation of this procedure 6 to 18 months later. Prompt diagnosis and early, aggressive initiation of therapy with ACE inhibitors will result in the most optimal outcome. Chronic nonrenal crisis renal insufficiency is unusual and rarely progresses to significant renal dysfunction.

Humans↗
PubMed1997

Urinary tract infection in urology, including acute and chronic prostatitis.

Heightened awareness of patients with increased risk for severe or potentially severe UTIs is paramount for early diagnosis and treatment. Urologic assessment of these patients is frequently necessary for cure and to prevent significant sequelae. Unresolved infections are usually caused by resistant bacteria and are treated by modification of therapy based on antimicrobial sensitivity testing. When unresolved bacteriuria is caused by organisms sensitive to the initial antimicrobial therapy, azotemia or a large bacterial mass density should be suspected. Recurrent infections at close intervals or with the same organism are usually caused by a bacterial focus in an acquired or congenital abnormality of the urinary tract, such as infection stones. The bacterial focus must be removed to cure the recurrent infections. If the bacterial focus within the urinary tract cannot be removed, long-term, low-dose antimicrobial suppression will prevent the morbidity of recurrent infections. Reinfection requires careful bacteriologic monitoring and low-dose prophylactic, intermittent, or postintercourse antimicrobial therapy. In the setting of prostatitis syndrome, the patient must first be classified into one of three categories: bacterial prostatitis, nonbacterial prostatitis, or pelviperineal pain syndrome. Bacterial prostatitis frequently responds to appropriate antimicrobial agents, whereas nonbacterial prostatitis and pelviperineal pain require an empiric multimodal approach.

Adult↗
PubMed2001

Transcatheter interventions for the treatment of peripheral atherosclerotic lesions: part I.

Transcatheter endovascular procedures are increasingly used to treat symptomatic peripheral atherosclerosis. This two-part review identifies the existing evidence supportive of the application of transcatheter treatments for peripheral atherosclerotic lesions. The first part addresses the treatment of obstructive lesions that cause limb claudication and critical ischemia, renovascular hypertension and azotemia, and mesenteric ischemia. Studies were identified via a search of MEDLINE (January 1993 through April 1999) and reference lists of identified articles. When multicenter prospective randomized trials or other high-quality studies were unavailable, a preference was given to studies with at least 50 patients per treated group and a minimum mean follow-up duration of 6 months. Data presented in tables are proportionally weighted averages from included studies. For each application, the authors assessed the quality of evidence (QOE; efficacy, safety, and, where available, cost-effectiveness) and made recommendations with appropriate caveats. There is higher QOE supporting the more established treatments such as lower limb percutaneous transluminal angioplasty (PTA) with stent placement and thrombolysis. Treatments such as renal artery PTA and stent placement and mesenteric and brachiocephalic PTA are in wide use, but high QOE supporting general application is lacking. Blanket recommendations based on established efficacy and cost-effectiveness cannot be made. However, the use of transcatheter therapies can be supported in specific circumstances based on an expected reduction in procedure-related morbidity and/or mortality rates. It is hoped that the identification of deficiencies in the literature will inform and inspire critically needed research in this area.

Angioplasty, Balloon, Coronary↗
PubMedDate not supplied

Renal artery stent placement for the management of ischemic nephropathy.

PURPOSE: To evaluate the angiographic and clinical results of percutaneously implanted renal artery endoprostheses (stents) for the treatment of patients with ischemic nephropathy. MATERIALS AND METHODS: During a 52-month period, 45 patients with azotemia (serum creatinine > or = 1.5 mg/dL) and atheromatous renal artery stenosis untreatable by, or recurrent after, balloon angioplasty were treated by percutaneous placement of Palmaz stents. Stent implantation was unilateral in 32 cases and bilateral in 11 cases. Clinical results were determined by measurements of serum creatinine and follow-up angiography. Clinical benefit was defined as stabilization or improvement in serum creatinine level. Angiographic patency was defined as less than 50% diameter recurrent arterial stenosis. RESULTS: Stent placement was technically successful in 51 of 54 (94%) renal arteries. Technical failures were stent misdeployment requiring percutaneous stent retrieval (n = 2) and inadvertent placement distal to the desired position (n = 1). Complications included acute stent thrombosis (n = 1) and early initiation of hemodialysis (within 30 days; n = 1). There were two periprocedural deaths. With use of life-table analysis, clinical benefit was seen in 78% of patients at 6 months (n = 36), 72% at 1 year (n = 24), 62% at 2 years (n = 12), and 54% at 3 years (n = 3). In patients with clinical benefit, average creatinine level was reduced from 2.21 mg/dL +/- 0.91 before treatment to 2.05 mg/dL +/- 1.05 after treatment (P = .018). Lower initial serum creatinine level was associated with a better chance of clinical benefit (P = .05). No other variables affected outcome, including patient age, sex, diabetes, implanted stent diameter, unilateral versus bilateral stent placement, or ostial versus nonostial stent positioning. Conventional catheter angiography or spiral computed tomographic (CT) angiography performed in 19 patients (28 stents) at a mean interval of 12.5 months demonstrated primary patency in 75%. Maintained stent patency appeared to correlate with renal functional benefit. CONCLUSIONS: Percutaneous renal artery stent placement for angioplasty failures or restenoses provides clinical benefit in most patients with ischemic nephropathy.

Aged↗
PubMed2002

Autocystectomy following extensive genitourinary tuberculosis: presentation and management.

Genitourinary tuberculosis is an important cause of morbidity in developing and developed countries. We describe a case of extensive genitourinary tuberculosis in which there was complete destruction of the right kidney, stricture of the entire left ureter and an autocystectomized bladder. He presented in azotemia with urinary incontinence and was managed by right nephroureterectomy, ileal replacement of left ureter and ileal neobladder after a preliminary nephrostomy and antituberculous chemotherapy.

Adult↗
PubMed1982

Oxaprozin disposition in renal disease.

Effects of renal disease on the disposition kinetics of oxaprozin, a nonsteroidal antiinflammatory analgesic, were assessed in 15 subjects who were normal, renally impaired, or who had been undergoing hemodialysis. Oral dose clearance (Cloral), volume of distribution at steady-state (V88d), and elimination half-life (t 1/2) did not substantially differ among the three groups. Mean fraction unbound oxaprozin in plasma (fup) increased from 0.08% in the normal group to 0.18% and 0.28% in the two azotemic groups. Consequently, unbound drug kinetic parameters, including intrinsic clearance (Clint) and V88du of unbound drug were reduced from 2.9 l/hr/kg and 193 l/kg in normal subjects to approximately 1.6 l/hr/kg and 91 l/kg in azotemic patients. The smaller volume of distribution is consistent with a decrease in oxaprozin tissue binding in azotemia. The decreased plasma and tissue binding and lower Clint suggest that, in the treatment of azotemic patients with rheumatoid arthritis, the dose of oxaprozin should begin at 600 mg once a day.

Adult↗
PubMed1986

Piretanide, a potent diuretic with potassium-sparing properties, for the treatment of congestive heart failure.

The diuretic and clinical efficacy and safety of piretanide, a new high-ceiling loop diuretic, was determined in patients with mild to moderately severe congestive heart failure. Piretanide (n = 20) administered orally in a daily dosage of up to 24 mg was compared with placebo (n = 18) for 28 days, using a double-blind, randomized, parallel design. Patients were hospitalized during the first 5 days of the study when dosage titration was established and 24-hour fractionated urine collections were obtained. Piretanide caused significant diuresis for 3 hours after ingestion with a natriuretic response noted for up to 6 hours. While occasional kaliuretic response was noted, it did not significantly increase 24-hour urinary potassium excretion. Only one patient treated with the highest allowed dose of piretanide developed mild hypokalemia. An improvement in New York Heart Association functional class status was noted after piretanide therapy. In contrast, patients who received placebo exhibited no significant improvement. BUN increased in nine piretanide-treated patients; two were discontinued from the study because of progressive azotemia. However, there was no significant increase in serum creatinine levels. Other blood, physical, ECG, and audiometric examinations also revealed no significant abnormalities. The study suggests that oral piretanide is a relatively safe and effective diuretic for treating congestive heart failure with a potential advantage of having potassium-sparing properties.

Adult↗
PubMed1975

Active and passive immunization to angiotensin in experimental acute renal failure.

A number of studies support, and others fail to support, the concept that the renin-angiotensin system plays a key role in the pathogenesis of acute renal failure. This study, employing active and passive immunization against angiotensin II, was designed to examine the primacy of circulating angiotensin as a mediator of this syndrome. Neither mode of immunization significantly affected the degree of azotemia or the marked reduction of inulin clearance expected in rats subjected to glycerol-induced myohemoglobinuria. Twenty-four hours after challenge, inulin clearance (Cin) in actively immunized rats fell to 3.2% of control and that of unimmunized rats given the same dose of glycerol was 2.5% of control. Although there was some variation among groups of passively immunized rats, Cin of one group being 18% of control, Cin of the other groups was less than 3% of control. The dose and binding capacity of the immune globulin used here were essentially the same as those reported in another study in which immunization was thought to be of prophylactic value in rats subjected to s.c. administered glycerol injections. Technologic differences unrelated to immunization are suggested to have caused the difference in results in the two studies, and it seems doubtful that circulating angiotensin plays a key role in the pathogenesis of myohemoglobinuric acute renal failure in the rat.

Acute Kidney Injury↗
PubMed1975

Renal function after release of chronic unilateral hydronephrosis in man.

Differential renal function studies performed on ten patients after release of unilateral hydronephrosis revealed that the previously obstructed kidney exhibits abnormalities in a number of physiological indexes. Many of the obstructed kidneys had an impairment of glomerular filtration rate, concentrating ability, acidification, sodium reabsorption and tubular maximal secretion of para-aminohippurate with normal urinary dilution. Despite impairment of sodium and water reabsorption, none of these patients, nor 20 additional patients, had a significant postobstructive diuresis from the previously obstructed kidney. All of the patients had normal total renal function. Thus, the changes observed were a result of the obstructive injury and were not related to azotemia or aberrations in water or sodium metabolism.

Adolescent↗
PubMed1976

Factors in the dialysis regimen which contribute to alterations in the abnormalities of uremia.

While hemodialysis therapy in its present form is capable of sustaining life, dialysis patients are not metabolically normal and we are unable to say what technical factors contribute adequate therapy. Recent efforts to resolve these problems have led to the assumption that substances in the molecular weight range of 800 to 3000 daltons may be pathogenic in uremia and these may not be effectively removed by dialysis. Accordingly, four groups of patients (ten each) underwent changes in their routine which were theoretically designed to alter independently the concentration of small (urea) and "middle" molecules in the blood. In two groups, the concentration of urea was theoretically increased or decreased while the concentration of so-called middle molecules was maintained unchanged. In the remaining two groups, middle molecule concentration was theoretically increased or decreased while small molecule concentration was unchanged. Patients were evaluated prior to and after completing altered dialysis therapy. The results suggest three related conclusions. First, the uremic syndrome may be viewed as a constellation of abnormalities which can be subgrouped by association so that azotemia may be correlated with neuropathic disease and hypertension with weight gain or body size, for example. Second, those physiologic variables which changed after altered dialysis tended to deteriorate with increasing concentration of small molecules in the blood and remained independent of theoretical changes in middle molecules. Finally, when patients are relatively under-dialyzed, they may spontaneously modulate the reduced removal of metabolites such as urea by decreasing the dietary intake of nutrients.

Adult↗
PubMed1977

Effect of dithiothreitol on mercuric chloride- and uranyl nitrate-induced acute renal failure in the rat.

The current study was undertaken to examine the effects of dithiothreitol (DDT), a sulfhydryl-reducing agent and heavy metal chelator, on the course of heavy metal-induced acute renal failure in the rat. Groups of rats in metabolic cages received uranyl nitrate (UN) alone, UN plus DTT, mercuric chloride (HgCl2) alone, and HgCl2 plus DTT. UN injected alone produced azotemia, decreased creatinine clearance, and rising fractional sodium excretion over the 48 hr of study. These effects of UN on renal function were not observed when DTT was administered 30 min after UN injection. Qualitatively similar results were obtained with HgCl2-induced acute renal failure. Groups of rats were killed at 6 hr after UN plus DTT, HgCl2 alone, or HgCl2 plus DTT; and determinations of plasma renin activity (PRA) and renin activities of the superficial and deep juxtaglomerular apparatus (JGA) were performed. PRA's and JGA renins were increased in animals receiving either UN or HgCl2 alone, but not in the rats receiving both DTT and UN or HgCl2. The effect of DTT on distribution of 203Hg was also examined. Treatment with DTT did not alter the renal accumulation of 203Hg, suggesting that this agent does not act by limiting renal exposure to the heavy metals. Thus, DTT ameliorates the course of heavy metal-induced ARF, and this effect is associated with prevention of heavy metal-induced alterations in sodium excretion and renin-angiotensin system activity.

Acute Kidney Injury↗
PubMed1978

Statural growth of children with renal disease.

Growth retardation occurs in 35 to 65% of children with kidney disease. It is especially common in children with congenital diseases of the kidney, anomalies, and inherited disorders. Acquired disease, however, also may impair growth, particularly where renal function (GFR) is below 25 ml/min/1.73 m2. Therapy used in renal disease, notably prednisone, also impairs growth. Chronic dialysis therapy, both hemodialysis and peritoneal, are associated with poor growth. Several specific changes in renal disease are associated with growth failure. These include, in addition to azotemia, acidosis, hyposthenuria, renal osteodystrophy, endocrine disorders and resistance to hormone action, and nutritional disturbances.

Body Height↗
PubMed1978

Radioimmunoassay for urinary renal tubular antigen: a potential marker of tubular injury.

A human proximal renal tubular epithelial antigen (designated HRTE-1) was isolated and purified from a crude tubular preparation (Fx1A) by a process of salt fractionation, DEAE anion-exchange chromatography, and Sephadex G-200 gel filtration. Utilizing 125I-HRTE-1 and a rabbit antiserum specific for the proximal tubular brush border, as determined by immunofluorescent microscopy, a radioimmunoassay by competitive protein-binding was developed. HRTE-1 was demonstrated in serum and urine and in extracts of a variety of body organs. A range of concentrations for normal random urine samples and 24-hr urine excretion rates were determined. Random urine samples from 36 patients with a variety of functional and pathologic renal disorders were assayed for the HRTE-1 antigen. Twenty-three of 24 patients with either chronic nephropathy or pre-renal azotemia had normal urinary antigen concentrations, despite wide differences in urine flow rates, the degree of existing renal function, and the amount of proteinuria. Ten of 12 patients with acute tubular necrosis, however, had statistically abnormal HRTE-1 concentrations (high in eight patients, undetectable in two). These findings suggest that HRTE-1 antigen can be detected in both normal and pathologic urines, that altered antigen concentrations can be documented in at least one renal disorder, and that quantitation of HRTE-1 in urine may have clinical value as a marker of acute rubular injury.

Acute Kidney Injury↗
PubMed1979

Preventing hemorrhage in high-risk hemodialysis: regional versus low-dose heparin.

Hemodialysis in patients with increased risk for hemorrhage can be accomplished with either a regional or a low, total dose of heparin. In a prospective study of 69 series of dialyses performed on an alternating schedule of heparinization for each patient, bleeding complications during and immediately following dialysis occurred in 23 of 122 dialyses (19%) with regional heparin compared to 13 of 133 dialyses (10%) with low-dose heparin (P less than 0.05). The incidence of hemorrhage correlated with the estimated degree of bleeding risk both at expected and at occult bleeding sites, and was the same or higher with regional heparin in all categories. Hemorrhage was not correlated with preexisting coagulation abnormalities, concurrent anticoagulant drugs, level of azotemia, or ability to successfully limit systemic heparinization during dialysis. The incidence of partial clotting of the dialyzer was 3 to 5% with both heparin protocols. We conclude that regional heparinization has no clinical or practical advantage over low-total-dose heparin in preventing bleeding associated with hemodialysis.

Hemorrhage↗
PubMed1980

Effects of dietary intake and hemodialysis on protein turnover in uremic children.

The dynamic aspects of protein metabolism in uremic children were studied by using newly developed gas chromatography and mass spectrometry micromethods for determining nitrogen-15 enrichment in plasma lysine during a continuous i.v. infusion of 15N-lysine. Protein flux in uremic children was low and varied directly with protein and energy intake, which themselves were closely related in the diets consumed by the study subjects. Hemodialysis did not alter acutely protein flux. Protein flux in children undergoing chronic hemodialysis was still reduced below normal but was higher than that in nondialyzed uremic children at each level of protein-energy intake. The ratio of protein flux to protein intake was 0.05 +/- 0.003 g of protein x kg-1 x day-1 x kcal ingested in the nondialyzed uremic children, but it increased to a normal vaue of 0.11 +/- 0.03 g x kg-1 x day-1 x kcal in those on longterm hemodialysis. We conclude that the low protein turnover rates in our uremic population reflect the decreased protein-energy intake commonly found in such patients and that reduction of azotemia by chronic hemodialysis may improve whole body transport at a given energy intake.

Adolescent↗
PubMed1981

Dynamics of glomerular ultrafiltration following open-heart surgery.

To elucidate how individual determinants might lower the rate of glomerular ultrafiltration (GFR) in some patients following cardiac surgery, we performed hemodynamic measurements and clearance of inulin (as a measure of GFR), PAH (as a measure of effective renal plasma flow [ERPF]), and dextran-40. Two groups of 17 patients each were distinguished by the presence or absence of prerenal azotemia. Glomerular hypofiltration (GFR = 21 +/- 2 vs. 76 +/- 6 ml/min/1.73 m2, P less than 0.001) in the former was accompanied by depressed left ventricular function, arterial pressure, and ERPF (152 +/- 26 vs. 317 +/- 32 ml/min/1.73 m2, P less than 0.001). To determine if factors beside ERPF play a role in lowering GFR, we calculated the efferent oncotic pressure (pie). Failure of GFR to change over a 24-hour period despite increases in ERPF suggested that both patient groups were at filtration pressure disequilibrium (FPD). This condition permits calculation of a unique glomerular ultrafiltration coefficient (Kf). Over a range of pressures for transcapillary hydraulic pressure (deltaP), such that 3 less than or equal to (deltaP - pie) less than or equal to 10 mm Hg (to simulate FPD), Kf was less than 0.08 ml . sec-1 . mm Hg-1 . 1.73 m-2 in azotemic, but exceeded this value in nonazotemic patients. Although a selective reduction of Kf is predicted to lower the fractional clearance of dextrans, these were significant elevated in azotemic relative to nonazotemic patients (molecular radii 30 - 40 A). A theoretical analysis of the latter data suggests that over the foregoing range of FPD, a 15 to 30% decline in deltaP combined with a 30 to 0% reduction in Kf from values in nonazotemic patients best explains the experimental findings in azotemic patients.

Cardiac Surgical Procedures↗
PubMed1984

Responses of the ischemic acute renal failure kidney to additional ischemic events.

To test whether the ischemic acute renal failure (IARF) kidney has increased susceptibility to additional ischemic events, IARF was induced in female Sprague-Dawley rats [40 min of bilateral renal artery occlusion (RAO)] and either 18 or 48 hr later, at the height of morphologic injury, they were rechallenged with either 25 or 40 min of RAO. Changes in renal function (GFR, blood flow), morphology, and adenine nucleotide (AN) concentrations in response to these second ischemic challenges were compared to those of normal kidneys subjected to a single ischemic event. In additional experiments, rates of recovery from IARF were compared between rats subjected to one or two bouts of RAO (40 min, 24 hr apart). IARF kidneys retained a significantly greater percent of their baseline GFR and had comparable or higher absolute GFRs after 25 or 40 min of RAO than control rats. IARF rats showed no significant exacerbation of their underlying morphologic injury by superimposing a second ischemic event. IARF kidneys (24 hr post RAO) had normal AN concentrations, and by 30 min of reflow from a second 40 min of RAO, they re-established their AN energy charge and retained AN pools as well as control kidneys. A second 40-min bout of RAO did not significantly prolong recovery rates from the first 40-min ischemic event. In additional experiments, intraperitoneal injection of normal urine or solute matched artificial urine (urea, creatinine, NaCl) into normal rats to mimic the degree of azotemia seen in the IARF rats induced significant and comparable protection against 40 min of RAO. We conclude that the IARF kidney, at or near the height of its functional and morphologic injury, does not have increased susceptibility to additional ischemic insults. Rather a modicum of protection appears to exist, possibly due to renal-failure-induced increments in solute loads per nephron.

Acute Kidney Injury↗