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Volume 57, No. 6/2002(June)
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Original
Hypertension in renal transplantation: donor and recipient risk factors
D. Ducloux, G. Motte, M. Kribs, A.B. Abdelfatah, C. Bresson-Vautrin, J.M. Rebibou and J.M. Chalopin
409
24$
Abstract
Aims: To determine the respective roles of donor and recipient factors in the subsequent development of hypertension after renal transplantation. Patients and methods: All the patients transplanted between January 1990 and December 1999 who still had a functioning graft 1 year post-transplant (n = 321) were retrospectively studied. Blood pressure was assessed at 1 year post-transplant. Hypertension was defined as a systolic BP > or equal 140 mmHg or diastolic BP > or equal 90 mmHg, or use of antihypertensive medication. Relevant donor and recipient characteristics were recorded. Results: Two-hundred-and-sixty-three patients (82%) were hypertensive. In multivariate analysis, pretransplant hypertension (RR, 1.74, 95% CI, 1.07 to 2.87), anticalcineurin use (RR, 2.59, 95% CI, 1.13 to 5.92), urinary protein excretion (RR, 1.84, 95% CI, 1.06 to 3.18), BMI (RR, 1.08, 95% CI, 1.01 to 1.16), donor age (RR, 1.28, 95% CI, 1.05 to 1.59, for each 10-year increase in donor age) and donor aortorenal atheroma (OR, 2.34; 95% CI, 1.24 to 4.46) were associated with hypertension. Among patients under calcineurin inhibitors, those receiving cyclosporine were more prone to have hypertension than those receiving tacrolimus (88.7% vs 78%; p = 0.04). Conclusion: Both recipient and donor factors contribute to hypertension in RTR.Correspondence to:
Dr. D. Ducloux; Department of Nephrology, Dialysis and Renal Transplantation, Saint Jacques Hospital, Besançon, France
Email: adjusy@wanadoo.fr
D. Ducloux, G. Motte, M. Kribs, A.B. Abdelfatah, C. Bresson-Vautrin, J.M. Rebibou and J.M. Chalopin
Department of Nephrology, Dialysis and Renal Transplantation, Saint Jacques Hospital, Besançon, France Aims: To determine the respective roles of donor and recipient factors in the subsequent development of hypertension after renal transplantation. Patients and methods: All the patients transplanted between January 1990 and December 1999 who still had a functioning graft 1 year post-transplant (n = 321) were retrospectively studied. Blood pressure was assessed at 1 year post-transplant. Hypertension was defined as a systolic BP > or equal 140 mmHg or diastolic BP > or equal 90 mmHg, or use of antihypertensive medication. Relevant donor and recipient characteristics were recorded. Results: Two-hundred-and-sixty-three patients (82%) were hypertensive. In multivariate analysis, pretransplant hypertension (RR, 1.74, 95% CI, 1.07 to 2.87), anticalcineurin use (RR, 2.59, 95% CI, 1.13 to 5.92), urinary protein excretion (RR, 1.84, 95% CI, 1.06 to 3.18), BMI (RR, 1.08, 95% CI, 1.01 to 1.16), donor age (RR, 1.28, 95% CI, 1.05 to 1.59, for each 10-year increase in donor age) and donor aortorenal atheroma (OR, 2.34; 95% CI, 1.24 to 4.46) were associated with hypertension. Among patients under calcineurin inhibitors, those receiving cyclosporine were more prone to have hypertension than those receiving tacrolimus (88.7% vs 78%; p = 0.04). Conclusion: Both recipient and donor factors contribute to hypertension in RTR.Correspondence to:
Dr. D. Ducloux; Department of Nephrology, Dialysis and Renal Transplantation, Saint Jacques Hospital, Besançon, France
Email: adjusy@wanadoo.fr
Original
The LDH ratio as a marker for response to plasma exchange in HUS/TTP of the adult
M. Haas, Z. Leko-Mohr, T. Lang, M. Jansen, P. Knöbl, W.H. Hörl and W. Druml
414
32$
Abstract
Background: Plasma exchange improved the outcome of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) of the adult markedly, but a high number of non-responders remain. Identifying these patients at an early stage would help to optimize therapy. Aim: To determine the value of serologic measures in predicting the response to plasma exchange. Material and methods: We performed a retrospective chart review of 30 patients with HUS/TTP of the adult treated with plasma exchange. According to the treatment protocol, a mean of 42 ± 8.2 ml plasma per kilogram of body weight was exchanged daily for 3 days and continued every second day thereafter. Prior to each session, clinical status and serologic markers for hemolysis and kidney function were obtained. To assess the early individual response to plasma exchange, the decline of LDH from the first to the third cycle was calculated as: LDH concentration before the third session/LDH concentration before the first session (LDH ratio). Results: During the observation period (median 195, range 6 – 1500 days), 80% of the patients responded to therapy with plasmapheresis. None of the serologic measures or clinical signs obtained before initiation of plasma exchange showed a significant correlation with the outcome. After 2 sessions of plasma exchange, only LDH and platelet level had improved markedly in responding patients. The LDH ratio was the best predictive marker for the individual response. An LDH ratio < 0.6 predicted a favorable outcome with a sensitivity of 0.96 and a specificity of 0.83. Conclusion: The LDH ratio might be a useful marker for separating patients responding to plasma exchange from those not responding at an early stage.Correspondence to:
Prof. Dr. W. Druml; Department of Internal Medicine III, Division of Nephrology, University Hospital Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
M. Haas1, Z. Leko-Mohr1, T. Lang2, M. Jansen1, P. Knöbl3, W.H. Hörl1 and W. Druml1
1Department of Internal Medicine III, Division of Nephrology, 2Department of Medical Statistics, and 3Department of Internal Medicine I, Division of Hematology, University Hospital Vienna, Vienna, Austria Background: Plasma exchange improved the outcome of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) of the adult markedly, but a high number of non-responders remain. Identifying these patients at an early stage would help to optimize therapy. Aim: To determine the value of serologic measures in predicting the response to plasma exchange. Material and methods: We performed a retrospective chart review of 30 patients with HUS/TTP of the adult treated with plasma exchange. According to the treatment protocol, a mean of 42 ± 8.2 ml plasma per kilogram of body weight was exchanged daily for 3 days and continued every second day thereafter. Prior to each session, clinical status and serologic markers for hemolysis and kidney function were obtained. To assess the early individual response to plasma exchange, the decline of LDH from the first to the third cycle was calculated as: LDH concentration before the third session/LDH concentration before the first session (LDH ratio). Results: During the observation period (median 195, range 6 – 1500 days), 80% of the patients responded to therapy with plasmapheresis. None of the serologic measures or clinical signs obtained before initiation of plasma exchange showed a significant correlation with the outcome. After 2 sessions of plasma exchange, only LDH and platelet level had improved markedly in responding patients. The LDH ratio was the best predictive marker for the individual response. An LDH ratio < 0.6 predicted a favorable outcome with a sensitivity of 0.96 and a specificity of 0.83. Conclusion: The LDH ratio might be a useful marker for separating patients responding to plasma exchange from those not responding at an early stage.Correspondence to:
Prof. Dr. W. Druml; Department of Internal Medicine III, Division of Nephrology, University Hospital Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
Original
Tolerance of mycophenolate mofetil in end-stage renal disease patients with ANCA-associated vasculitis
M. Haubitz and K. de Groot
421
20$
Abstract
Background: Mycophenolate mofetil (MMF) has been used successfully in patients with ANCA-associated vasculitis as maintenance therapy. Only transient and moderate side effects have been reported with a daily dose of 2 g. Since all the treated patients who have been reported so far had no or only moderate renal insufficiency when MMF was initiated, no data are available regarding side effects in patients with end-stage renal disease (ESRD). Methods: Five ESRD patients with ANCA-associated vasculitis and a relapsing course of their disease were treated. All patients had pretreatment with cyclophosphamide for at least 17 months. MMF was initiated as a remission maintenance therapy, and started with a dose of 1 g/d. The aim was to increase the MMF dose to 2 g/d. Blood counts, liver enzymes and gastrointestinal side effects were monitored. Results: Four patients developed severe anemia, 2 requiring blood transfusion with permanent or temporary cessation of MMF treatment. One patient developed leukopenia. Gastrointestinal symptoms led to a dose reduction to 1 g/d (n = 2) or cessation of treatment (n = 1). Three patients remained on longer MMF treatment; however, their daily dose did not exceed 1 g. Conclusion: MMF, a promising drug regarding maintenance therapy in ANCA-associated vasculitis, seems to have more side effects in ESRD patients, leading to dose reduction or even cessation of treatment. Therefore, in this patient group a lower dose and closer monitoring for side effects seems to be required compared to patients with no or moderate renal insufficiency.Correspondence to:
Dr. M. Haubitz; Department of Nephrology, Medical School Hannover, D-30623 Hannover, Germany
Email: Familie.Haubitz@t-online.de
M. Haubitz and K. de Groot
Department of Nephrology, University Hospital Hannover, Germany Background: Mycophenolate mofetil (MMF) has been used successfully in patients with ANCA-associated vasculitis as maintenance therapy. Only transient and moderate side effects have been reported with a daily dose of 2 g. Since all the treated patients who have been reported so far had no or only moderate renal insufficiency when MMF was initiated, no data are available regarding side effects in patients with end-stage renal disease (ESRD). Methods: Five ESRD patients with ANCA-associated vasculitis and a relapsing course of their disease were treated. All patients had pretreatment with cyclophosphamide for at least 17 months. MMF was initiated as a remission maintenance therapy, and started with a dose of 1 g/d. The aim was to increase the MMF dose to 2 g/d. Blood counts, liver enzymes and gastrointestinal side effects were monitored. Results: Four patients developed severe anemia, 2 requiring blood transfusion with permanent or temporary cessation of MMF treatment. One patient developed leukopenia. Gastrointestinal symptoms led to a dose reduction to 1 g/d (n = 2) or cessation of treatment (n = 1). Three patients remained on longer MMF treatment; however, their daily dose did not exceed 1 g. Conclusion: MMF, a promising drug regarding maintenance therapy in ANCA-associated vasculitis, seems to have more side effects in ESRD patients, leading to dose reduction or even cessation of treatment. Therefore, in this patient group a lower dose and closer monitoring for side effects seems to be required compared to patients with no or moderate renal insufficiency.Correspondence to:
Dr. M. Haubitz; Department of Nephrology, Medical School Hannover, D-30623 Hannover, Germany
Email: Familie.Haubitz@t-online.de
Original
The effects of prolonged physical exercise on renal function, electrolyte balance and muscle cell breakdown
J. Gerth, U. Ott, R. Fünfstück, R. Bartsch, E. Keil, K. Schubert, J. Hübscher, S. Scheucht and G. Stein
425
32$
Abstract
Background: Postexercise proteinuria, hematuria and changes in serum electrolyte balance as well as increased levels of plasma indicators for muscle leakage are believed to be transient and of benign character. Methods: A group of 51 healthy athletes took part in a 100 km race over 14.25 hours. All of them had to reach the finish together. Urine and blood samples were collected before (a) and immediately after running (b) as well as 6 hours after the race (c). Results: The serum concentrations of potassium (4.8 ± 0.5 (a) vs. 4.0 ± 0.3 (c) mmol/l), protein (73.1 ± 5.2 (a) vs. 71.1 ± 3.9 (c) g/l) and albumin (44.0 ± 2.85 (a) vs. 42.9 ± 2.8 (c) g/l) decreased significantly (p < 0.0001, p < 0.05, p < 0.05, respectively) but remained within physiological ranges. The serum sodium concentration decreased immediately after the race (136.9 ± 4.5 (a) vs. 131.1 ± 2.4 (b) mmol/l, p < 0.0001). The fractional sodium excretion decreased 6 hours, but not immediately after the race (0.78 ± 0.59 (a) vs. 0.48 ± 0.82 (c), p < 0.05). Myoglobin (31.8 ± 6.9 (a), 291.5 ± 197.2 (b) and 182.2 ± 135.3 (c) mg/l, p < 0.0001) and creatine kinase (1.13 ± 0.45 (a), 10.76 ± 6.9 (b) and 9.46 ± 15.5 (c) mmol/l, p < 0.0001) increased dramatically. Troponin I was also significantly increased at finish (0.0186 ± 0.0121 (a) vs. 0.0213 ± 0.0165 (b) ng/ml, p < 0.05) and positively correlated with myoglobin and creatine kinase, but remained far below the pathologic range. Serum creatinine and urea remained almost unchanged. Glucosuria and hematuria occurred 6 hours after the run in 9.1% and 6.8%, respectively. The erythrocytes examined by phase-contrast microscopy were not damaged in terms of dysmorphic cells. Glomerular-type proteinuria was found in 11.4% of the participants 6 hours after the race. Conclusions: We conclude that long lasting, mild exertion is harmless for renal function, electrolyte balance and skeletal muscle as well as myocardial metabolism in healthy persons.Correspondence to:
Dr. J. Gerth; Clinic for Internal Medicine IV, Nephrology, Erlanger Allee 101, D-07740 Jena, Germany
Email: jk.gerth@t-online.de
J. Gerth1, U. Ott1, R. Fünfstück1, R. Bartsch2, E. Keil3, K. Schubert3, J. Hübscher4, S. Scheucht3 and G. Stein1
1Clinic for Internal Medicine IV, 2Institute for Occupational and Social Medicine, 3Institute for Clinical Chemistry and Laboratory Diagnostics, and 4Institute for Sports Science, Friedrich-Schiller-University, Jena, Germany Background: Postexercise proteinuria, hematuria and changes in serum electrolyte balance as well as increased levels of plasma indicators for muscle leakage are believed to be transient and of benign character. Methods: A group of 51 healthy athletes took part in a 100 km race over 14.25 hours. All of them had to reach the finish together. Urine and blood samples were collected before (a) and immediately after running (b) as well as 6 hours after the race (c). Results: The serum concentrations of potassium (4.8 ± 0.5 (a) vs. 4.0 ± 0.3 (c) mmol/l), protein (73.1 ± 5.2 (a) vs. 71.1 ± 3.9 (c) g/l) and albumin (44.0 ± 2.85 (a) vs. 42.9 ± 2.8 (c) g/l) decreased significantly (p < 0.0001, p < 0.05, p < 0.05, respectively) but remained within physiological ranges. The serum sodium concentration decreased immediately after the race (136.9 ± 4.5 (a) vs. 131.1 ± 2.4 (b) mmol/l, p < 0.0001). The fractional sodium excretion decreased 6 hours, but not immediately after the race (0.78 ± 0.59 (a) vs. 0.48 ± 0.82 (c), p < 0.05). Myoglobin (31.8 ± 6.9 (a), 291.5 ± 197.2 (b) and 182.2 ± 135.3 (c) mg/l, p < 0.0001) and creatine kinase (1.13 ± 0.45 (a), 10.76 ± 6.9 (b) and 9.46 ± 15.5 (c) mmol/l, p < 0.0001) increased dramatically. Troponin I was also significantly increased at finish (0.0186 ± 0.0121 (a) vs. 0.0213 ± 0.0165 (b) ng/ml, p < 0.05) and positively correlated with myoglobin and creatine kinase, but remained far below the pathologic range. Serum creatinine and urea remained almost unchanged. Glucosuria and hematuria occurred 6 hours after the run in 9.1% and 6.8%, respectively. The erythrocytes examined by phase-contrast microscopy were not damaged in terms of dysmorphic cells. Glomerular-type proteinuria was found in 11.4% of the participants 6 hours after the race. Conclusions: We conclude that long lasting, mild exertion is harmless for renal function, electrolyte balance and skeletal muscle as well as myocardial metabolism in healthy persons.Correspondence to:
Dr. J. Gerth; Clinic for Internal Medicine IV, Nephrology, Erlanger Allee 101, D-07740 Jena, Germany
Email: jk.gerth@t-online.de
Original
Perinatal rupture of the uropoietic system
H.L. Claahsen-van der Grinten, L.A.H. Monnens, R.P.E. de Gier and W.F.J. Feitz
432
32$
Abstract
Aims: Ruptures of the uropoietic system resulting in either urinary ascites or urinoma are rare complications in the neonate. Although ruptures without clear predisposing factors are described, in most cases they are associated with obstructive uropathy. The diagnosis is often delayed and the prognosis is related to the degree of renal damage. There is discussion about possible protective mechanisms of the rupture for renal function in patients with obstructive uropathy. Methods: We retrospectively analyzed the clinical presentation, predisposing factors and the renal function before and after treatment of 10 neonates with a rupture of the pyelum or urinary bladder in our hospital. Results: The group consisted of 9 boys and 1 girl. The average birth weight was 3,880 g. The patients presented with distended abdomen (n = 10), abdominal mass (n = 2), ascites (n = 5), oligohydramnion (n = 2), hypertension (n = 1) and anuria (n = 1). Underlying diagnosis included obstruction of the uretero-pelvic junction (UPJ obstruction) in 3 children and posterior urethral valves in 7 children. Five children presented with urinoma, 3 children had a urinoma in combination with ascites and 2 children had isolated ascites. All children had reduced renal function at the time of diagnosis. In all 10 cases, the serum creatinine decreased after treatment. Scintigraphic investigation with mercapto-acetyltriglycerine (MAG III) demonstrated diminished function and perfusion of all 3 kidneys with UPJ obstruction and isolated urinoma even after treatment. Children with posterior urethral valves and urinoma revealed better function of the ruptured kidney and diminished function of the kidney which was not ruptured. One child with a rupture of the urinary bladder and urinary ascites showed good function and perfusion of both kidneys. Conclusion: Perinatal ruptures of the uropoietic system are rare. The clinical presentation is aspecific. One should consider a rupture of the urinary bladder or pyelum in a neonate with a distended abdomen, hydronephrosis and ascites. The long-term prognosis depends on the underlying diagnosis and the location of the rupture. Probably, a UPJ obstruction with an isolated urinoma is associated with irreversible renal damage of the ruptured kidney. A rupture resulting in urinary ascites apparently provides better decompression with better function of the ruptured kidney. Scintigraphic investigation is necessary for a separate evaluation of the single kidney function.Correspondence to:
Dr. H.L. Claahsen-van der Grinten; University Medical Center St. Radboud, Department of Pediatrics, P.O. Box 9101, NL-6500 HB Nijmegen, The Netherlands
Email: Hl.Claahsen@ t-online.de
H.L. Claahsen-van der Grinten1, L.A.H. Monnens1, R.P.E. de Gier2 and W.F.J. Feitz2
1University Medical Center St. Radboud, and 2Department of Pediatric Nephrology and Urology, Nijmegen, The Netherlands Aims: Ruptures of the uropoietic system resulting in either urinary ascites or urinoma are rare complications in the neonate. Although ruptures without clear predisposing factors are described, in most cases they are associated with obstructive uropathy. The diagnosis is often delayed and the prognosis is related to the degree of renal damage. There is discussion about possible protective mechanisms of the rupture for renal function in patients with obstructive uropathy. Methods: We retrospectively analyzed the clinical presentation, predisposing factors and the renal function before and after treatment of 10 neonates with a rupture of the pyelum or urinary bladder in our hospital. Results: The group consisted of 9 boys and 1 girl. The average birth weight was 3,880 g. The patients presented with distended abdomen (n = 10), abdominal mass (n = 2), ascites (n = 5), oligohydramnion (n = 2), hypertension (n = 1) and anuria (n = 1). Underlying diagnosis included obstruction of the uretero-pelvic junction (UPJ obstruction) in 3 children and posterior urethral valves in 7 children. Five children presented with urinoma, 3 children had a urinoma in combination with ascites and 2 children had isolated ascites. All children had reduced renal function at the time of diagnosis. In all 10 cases, the serum creatinine decreased after treatment. Scintigraphic investigation with mercapto-acetyltriglycerine (MAG III) demonstrated diminished function and perfusion of all 3 kidneys with UPJ obstruction and isolated urinoma even after treatment. Children with posterior urethral valves and urinoma revealed better function of the ruptured kidney and diminished function of the kidney which was not ruptured. One child with a rupture of the urinary bladder and urinary ascites showed good function and perfusion of both kidneys. Conclusion: Perinatal ruptures of the uropoietic system are rare. The clinical presentation is aspecific. One should consider a rupture of the urinary bladder or pyelum in a neonate with a distended abdomen, hydronephrosis and ascites. The long-term prognosis depends on the underlying diagnosis and the location of the rupture. Probably, a UPJ obstruction with an isolated urinoma is associated with irreversible renal damage of the ruptured kidney. A rupture resulting in urinary ascites apparently provides better decompression with better function of the ruptured kidney. Scintigraphic investigation is necessary for a separate evaluation of the single kidney function.Correspondence to:
Dr. H.L. Claahsen-van der Grinten; University Medical Center St. Radboud, Department of Pediatrics, P.O. Box 9101, NL-6500 HB Nijmegen, The Netherlands
Email: Hl.Claahsen@ t-online.de
Original
The emergency department care of hemodialysis patients
M.J. Loran, M. McErlean, G. Eisele, N. Raccio-Robak and V.P. Verdile
439
24$
Abstract
Aims: To describe the emergency department (ED) presentation, evaluation and disposition of maintenance hemodialysis (HD) patients. Materials and methods: A retrospective review of adult HD patients seen 1/1 – 12/31/97. The following was collected: demographics, mode of arrival, chief complaint, etiology of renal failure, evaluation, treatment, disposition, length of stay and facility charges. During the study period, this tertiary care ED had an annual adult census of 45,000. No clinical pathways were in place. Results: 143 patients made 355 visits: 351 charts were available. Mean patient age was 51 (range 20 – 86), 62% were male, 51% were white. 70% presented from home, 26% from dialysis. EMS transported 32%. Medicare insured 78%. Etiologies of renal failure included hypertension (33%), diabetes (27%), HIV (7%) and glomerulonephritis (8%). Complaints were related to infection (18%), dyspnea (17%), vascular access (16%), chest pain or dysrhythmia (15%) and gastrointestinal complaints (12%). ED evaluation included CBC (79%), electrolytes (75%), CXR (57%) and EKG (48%). Antibiotics were administered to 21%. HD was performed earlier than scheduled in 14%. Two hundred and eighteen patients (62%) were admitted (ICU 11%, telemetry 22%), 19 (5%) refused admission and 2 expired in the ED. The average hospital length of stay was 7.8 days (range 1 – 59), with 29% hospitalized more than 1 week, compared to 6.54 days for non-HD patients. The mean facility charge for admitted subjects was $14,758, while the average cost for non-HD admissions was $7,152. Of the 133 patients (38%) who were discharged directly from the ED, the mean length stay was 223 minutes (range 30 to 750) and the mean charge was $658. The mean length of stay for non-HD patients was 124 minutes. Conclusion: The ED evaluation of adult HD patients involves multiple diagnostic modalities, and patients are usually admitted. The admit rate, ED length of stay for discharged patients and hospital charges for care were substantially higher in the HD patients than in the general population. Further research in the ED care of these complex patients should be undertaken.Correspondence to:
Dr. M. J. Loran; Department of Emergency Medicine, Albany Medical College, 47 New Scotland Ave., Albany, NY 12208, USA
Email: loranm@mail.amc.edu
M.J. Loran1, M. McErlean1, G. Eisele2, N. Raccio-Robak1 and V.P. Verdile1
1Department of Emergency Medicine, Albany Medical College, and 2Department of Medicine, Albany Medical College, Albany, NY, USA Aims: To describe the emergency department (ED) presentation, evaluation and disposition of maintenance hemodialysis (HD) patients. Materials and methods: A retrospective review of adult HD patients seen 1/1 – 12/31/97. The following was collected: demographics, mode of arrival, chief complaint, etiology of renal failure, evaluation, treatment, disposition, length of stay and facility charges. During the study period, this tertiary care ED had an annual adult census of 45,000. No clinical pathways were in place. Results: 143 patients made 355 visits: 351 charts were available. Mean patient age was 51 (range 20 – 86), 62% were male, 51% were white. 70% presented from home, 26% from dialysis. EMS transported 32%. Medicare insured 78%. Etiologies of renal failure included hypertension (33%), diabetes (27%), HIV (7%) and glomerulonephritis (8%). Complaints were related to infection (18%), dyspnea (17%), vascular access (16%), chest pain or dysrhythmia (15%) and gastrointestinal complaints (12%). ED evaluation included CBC (79%), electrolytes (75%), CXR (57%) and EKG (48%). Antibiotics were administered to 21%. HD was performed earlier than scheduled in 14%. Two hundred and eighteen patients (62%) were admitted (ICU 11%, telemetry 22%), 19 (5%) refused admission and 2 expired in the ED. The average hospital length of stay was 7.8 days (range 1 – 59), with 29% hospitalized more than 1 week, compared to 6.54 days for non-HD patients. The mean facility charge for admitted subjects was $14,758, while the average cost for non-HD admissions was $7,152. Of the 133 patients (38%) who were discharged directly from the ED, the mean length stay was 223 minutes (range 30 to 750) and the mean charge was $658. The mean length of stay for non-HD patients was 124 minutes. Conclusion: The ED evaluation of adult HD patients involves multiple diagnostic modalities, and patients are usually admitted. The admit rate, ED length of stay for discharged patients and hospital charges for care were substantially higher in the HD patients than in the general population. Further research in the ED care of these complex patients should be undertaken.Correspondence to:
Dr. M. J. Loran; Department of Emergency Medicine, Albany Medical College, 47 New Scotland Ave., Albany, NY 12208, USA
Email: loranm@mail.amc.edu
Original
The mature form of adrenomedullin correlates with brain natriuretic peptide in plasma of chronic hemodialysis patients
T. Suda, A. Osajima, M. Iwamoto, H. Anai, M. Tamura, N. Kabashima, T. Ota, Y. Watanabe, K. Kanegae, M. Okazaki and Y. Nakashima
444
36$
Abstract
Aim: Adrenomedullin (AM), a hypotensive and natriuretic peptide, consists of an amidated mature form (mAM) and an intermediate form in human plasma, of which only mAM exerts biological activity. Like atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), plasma levels of mAM are reported to be significantly elevated in hemodialysis (HD) patients, suggesting that mAM may be stimulated partly by increased body fluid volume in a manner similar to the natriuretic peptides. Here, we examined the relationship between mAM levels and ANP or BNP levels and the effect of HD on plasma mAM in HD patients. Patients and methods: We measured plasma levels of mAM, total AM (tAM), ANP and BNP before and after HD in patients on long-term HD (n = 22, mean age 56.3 ± 3.2 years) using radioimmunoassay. Results: Baseline mAM (2.7 ± 0.3 fmol/ml) and tAM (23.6 ± 2.0 fmol/ml) were significantly higher in HD patients than in healthy subjects (1.1 ± 0.2 fmol/ml, 9.0 ± 2.1 fmol/ml, respectively). HD significantly reduced the levels to 1.2 ± 0.2 fmol/ml and 13.8 ± 1.4 fmol/ml, respectively, although tAM levels were still elevated compared to healthy subjects. Similar plasma ANP and BNP levels were obtained in HD patients. There were significant correlations between mAM and tAM levels before and after HD and between HD-induced changes in mAM and tAM levels. In the pre-HD state, levels of both mAM and tAM correlated significantly with BNP levels, but the correlation of BNP with mAM was closer than that with tAM. In contrast, no correlations were observed between the 2 forms of AM and ANP. Changes in mAM levels during HD also correlated significantly with BNP but not ANP levels, although the changes in tAM did not correlate with those of the 2 natriuretic peptides. Conclusion: Our results suggest that the secretion/metabolism of mAM may be regulated in a manner similar to that of BNP in HD patients.Correspondence to:
Dr. A. Osajima; Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
Email: mdosa@ clnc.uoeh-u.ac.jp
T. Suda, A. Osajima, M. Iwamoto, H. Anai, M. Tamura, N. Kabashima, T. Ota, Y. Watanabe, K. Kanegae, M. Okazaki and Y. Nakashima
Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan Aim: Adrenomedullin (AM), a hypotensive and natriuretic peptide, consists of an amidated mature form (mAM) and an intermediate form in human plasma, of which only mAM exerts biological activity. Like atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP), plasma levels of mAM are reported to be significantly elevated in hemodialysis (HD) patients, suggesting that mAM may be stimulated partly by increased body fluid volume in a manner similar to the natriuretic peptides. Here, we examined the relationship between mAM levels and ANP or BNP levels and the effect of HD on plasma mAM in HD patients. Patients and methods: We measured plasma levels of mAM, total AM (tAM), ANP and BNP before and after HD in patients on long-term HD (n = 22, mean age 56.3 ± 3.2 years) using radioimmunoassay. Results: Baseline mAM (2.7 ± 0.3 fmol/ml) and tAM (23.6 ± 2.0 fmol/ml) were significantly higher in HD patients than in healthy subjects (1.1 ± 0.2 fmol/ml, 9.0 ± 2.1 fmol/ml, respectively). HD significantly reduced the levels to 1.2 ± 0.2 fmol/ml and 13.8 ± 1.4 fmol/ml, respectively, although tAM levels were still elevated compared to healthy subjects. Similar plasma ANP and BNP levels were obtained in HD patients. There were significant correlations between mAM and tAM levels before and after HD and between HD-induced changes in mAM and tAM levels. In the pre-HD state, levels of both mAM and tAM correlated significantly with BNP levels, but the correlation of BNP with mAM was closer than that with tAM. In contrast, no correlations were observed between the 2 forms of AM and ANP. Changes in mAM levels during HD also correlated significantly with BNP but not ANP levels, although the changes in tAM did not correlate with those of the 2 natriuretic peptides. Conclusion: Our results suggest that the secretion/metabolism of mAM may be regulated in a manner similar to that of BNP in HD patients.Correspondence to:
Dr. A. Osajima; Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu 807-8555, Japan
Email: mdosa@ clnc.uoeh-u.ac.jp
Original
Serial ferritin concentrations in hemodialysis patients receiving intravenous iron
B. Kirschbaum
452
24$
Abstract
Background: Treatment of the anemia of chronic renal failure with intravenous iron and erythropoietin is highly effective, but frequently leads to ferritin levels which are much higher than those seen in the general population. High ferritin concentrations raise concern about the potential toxicity of increased body iron stores. Patients and methods: We retrospectively evaluated parameters of iron metabolism over a 4-year period among all our chronic hemodialysis patients who had been receiving intravenous iron and erythropoietin. Initially, patients received intermittent infusions of 300 mg intravenous iron × 3 doses for a low ferritin or low percent saturation of total iron binding capacity (TIBC), but this protocol was subsequently changed to weekly or biweekly infusions of 50 – 100 mg. Results: We observed an improvement in average hemoglobin values, modest increases in serum iron and saturation of iron binding capacity, and a 125% increase in ferritin levels over 4 years. TIBC decreased. Overall, ferritin values increased 79 mg/l for each 1% increase in TIBC saturation. Ten patients with ferritin concentration greater than 1,000 mg/l received a three month course of vitamin C with no decline in the ferritin concentration. Conclusion: Current protocols for iron delivery may result in progressive increases in ferritin levels. Concern about the risks of iron overload should temper the quantity of iron used in dialysis programs.Correspondence to:
B. Kirschbaum, MD; Division of Nephrology, Medical College of Virginia, Virginia Commonwealth University, P.O. Box 980160, Richmond, VA 23298, USA
Email: bkirschb@hsc.vcu.edu
B. Kirschbaum
Division of Nephrology, Virginia Commonwealth University, Richmond, VA, USA Background: Treatment of the anemia of chronic renal failure with intravenous iron and erythropoietin is highly effective, but frequently leads to ferritin levels which are much higher than those seen in the general population. High ferritin concentrations raise concern about the potential toxicity of increased body iron stores. Patients and methods: We retrospectively evaluated parameters of iron metabolism over a 4-year period among all our chronic hemodialysis patients who had been receiving intravenous iron and erythropoietin. Initially, patients received intermittent infusions of 300 mg intravenous iron × 3 doses for a low ferritin or low percent saturation of total iron binding capacity (TIBC), but this protocol was subsequently changed to weekly or biweekly infusions of 50 – 100 mg. Results: We observed an improvement in average hemoglobin values, modest increases in serum iron and saturation of iron binding capacity, and a 125% increase in ferritin levels over 4 years. TIBC decreased. Overall, ferritin values increased 79 mg/l for each 1% increase in TIBC saturation. Ten patients with ferritin concentration greater than 1,000 mg/l received a three month course of vitamin C with no decline in the ferritin concentration. Conclusion: Current protocols for iron delivery may result in progressive increases in ferritin levels. Concern about the risks of iron overload should temper the quantity of iron used in dialysis programs.Correspondence to:
B. Kirschbaum, MD; Division of Nephrology, Medical College of Virginia, Virginia Commonwealth University, P.O. Box 980160, Richmond, VA 23298, USA
Email: bkirschb@hsc.vcu.edu
Original
Intravenous iron administration does not significantly increase the risk of bacteremia in chronic hemodialysis patients
B. Hoen, A. Paul-Dauphin and M. Kessler
457
24$
Abstract
Background: Correction of iron deficiency is critical in chronic hemodialysis patients, and intravenous administration is superior to the oral route in this goal. Recently, concern was raised that intravenous iron administration might promote infection in dialysis patients. Methods: We reviewed the data from a recent prospective study of 985 patients in which no link between iron therapy and bacteremia had been found. We tested the potential role of the administration route of the iron (intravenous vs. oral), the weekly amount of iron administered and the administration rate on the risk for bacteremia in these patients. Results: were 4-fold: in multivariate analysis, neither intravenous iron administration in the whole population nor the weekly amount of iron in the subgroup of i.v. iron-treated patients were significant risk factors for bacteremia; iron was not given more frequently intravenously in bacteremic than in non-bacteremic patients; among patients treated with intravenous iron, the frequency and the amount of iron administered were significantly higher in those who developed bacteremia than in those who did not; and in patients receiving i.v. iron, there was an increased risk of bacteremia associated with concurrent administration of erythropoietin, which was not observed in patients receiving iron orally. Conclusion: This study failed to demonstrate a significant association between intravenous iron administration and the risk of bacteremia in dialysis patients. However, there might be a slightly increased risk of bacteremia in patients given high-frequency, high-dose intravenous iron.Correspondence to:
Prof. Dr. B. Hoen; Service de Maladies Infectieuses et Tropicales, University of Besançon Medical Center, F-25030 Besançon Cedex, France
Email: bruno.hoen@ufc-chu.univ-fcomte.fr
B. Hoen1, A. Paul-Dauphin2 and M. Kessler3
1Service de Maladies Infectieuses et Tropicales, Hôpital Saint-Jacques, Besançon, 2EVAL, Bourg la Reine, and 3Service de Néphrologie, Hôpitaux de Brabois, Vandoeuvre, France Background: Correction of iron deficiency is critical in chronic hemodialysis patients, and intravenous administration is superior to the oral route in this goal. Recently, concern was raised that intravenous iron administration might promote infection in dialysis patients. Methods: We reviewed the data from a recent prospective study of 985 patients in which no link between iron therapy and bacteremia had been found. We tested the potential role of the administration route of the iron (intravenous vs. oral), the weekly amount of iron administered and the administration rate on the risk for bacteremia in these patients. Results: were 4-fold: in multivariate analysis, neither intravenous iron administration in the whole population nor the weekly amount of iron in the subgroup of i.v. iron-treated patients were significant risk factors for bacteremia; iron was not given more frequently intravenously in bacteremic than in non-bacteremic patients; among patients treated with intravenous iron, the frequency and the amount of iron administered were significantly higher in those who developed bacteremia than in those who did not; and in patients receiving i.v. iron, there was an increased risk of bacteremia associated with concurrent administration of erythropoietin, which was not observed in patients receiving iron orally. Conclusion: This study failed to demonstrate a significant association between intravenous iron administration and the risk of bacteremia in dialysis patients. However, there might be a slightly increased risk of bacteremia in patients given high-frequency, high-dose intravenous iron.Correspondence to:
Prof. Dr. B. Hoen; Service de Maladies Infectieuses et Tropicales, University of Besançon Medical Center, F-25030 Besançon Cedex, France
Email: bruno.hoen@ufc-chu.univ-fcomte.fr
Original
Simultaneous non-surgical removal and insertion of peritoneal dialysis catheters for defective drainage: a bedside, day case technique
C.W. McIntyre and R.J. Fluck
462
28$
Abstract
Background: Outflow failure of peritoneal dialysis catheters is a commonly encountered problem. It may be possible to reposition the catheter by a variety of means, but this can be problematical and has variable long-term success. Commonly surgical catheter exchange is utilized, entailing inconvenience, expense and often, a reliance on temporary hemodialysis. We describe a technique allowing exchange of poorly functioning catheters with a relatively simple outpatient/day case percutaneous technique, allowing the continuation of peritoneal dialysis. Methods: We report percutaneous exchange of 25 peritoneal dialysis catheters in 21 patients. The exchanges were performed under local anesthesia with a degree of sedation (if required). It involved the dissection down the distal cuff of the catheter and mobilization of the catheter below it. This was followed by division of the catheter, allowing passage of a guide wire into the peritoneal cavity and insertion of a further peel away sheath and insertion of a new catheter. The new catheter was tunneled out of the existing exit site after removal of the extraperitoneal portion of the old catheter by traction. Results: Outflow failure was associated with fecal loading and malposition of the catheter in 14 out of the 21 patients. Exchange of catheter was successful in all the patients with good pelvic positioning of the replacement catheter in all but 1 of the cases. The mean period until the reinstitution of peritoneal dialysis was 5.1 days (range 0 – 14 days). Temporary hemodialysis was not required for any of the patients. One patient exhibited a small leak of peritoneal dialysis fluid after insertion, but this had spontaneously resolved within 6 days. Protracted satisfactory function of the peritoneal dialysis catheters was obtained in all but 1 of the patients (mean follow-up 51 weeks, range 11 – 73 weeks). Conclusions: We conclude that exchange of peritoneal dialysis catheters for problems with dialysate drainage, utilizing a non-invasive percutaneous technique is both effective and safe.Correspondence to:
Dr. C.W. McIntyre; Department of Renal Medicine, Derby City General Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
Email: chris-mcintyre@ lineone.net
C.W. McIntyre and R.J. Fluck
Department of Renal Medicine, Derby City General Hospital, Derby, UK Background: Outflow failure of peritoneal dialysis catheters is a commonly encountered problem. It may be possible to reposition the catheter by a variety of means, but this can be problematical and has variable long-term success. Commonly surgical catheter exchange is utilized, entailing inconvenience, expense and often, a reliance on temporary hemodialysis. We describe a technique allowing exchange of poorly functioning catheters with a relatively simple outpatient/day case percutaneous technique, allowing the continuation of peritoneal dialysis. Methods: We report percutaneous exchange of 25 peritoneal dialysis catheters in 21 patients. The exchanges were performed under local anesthesia with a degree of sedation (if required). It involved the dissection down the distal cuff of the catheter and mobilization of the catheter below it. This was followed by division of the catheter, allowing passage of a guide wire into the peritoneal cavity and insertion of a further peel away sheath and insertion of a new catheter. The new catheter was tunneled out of the existing exit site after removal of the extraperitoneal portion of the old catheter by traction. Results: Outflow failure was associated with fecal loading and malposition of the catheter in 14 out of the 21 patients. Exchange of catheter was successful in all the patients with good pelvic positioning of the replacement catheter in all but 1 of the cases. The mean period until the reinstitution of peritoneal dialysis was 5.1 days (range 0 – 14 days). Temporary hemodialysis was not required for any of the patients. One patient exhibited a small leak of peritoneal dialysis fluid after insertion, but this had spontaneously resolved within 6 days. Protracted satisfactory function of the peritoneal dialysis catheters was obtained in all but 1 of the patients (mean follow-up 51 weeks, range 11 – 73 weeks). Conclusions: We conclude that exchange of peritoneal dialysis catheters for problems with dialysate drainage, utilizing a non-invasive percutaneous technique is both effective and safe.Correspondence to:
Dr. C.W. McIntyre; Department of Renal Medicine, Derby City General Hospital, Uttoxeter Road, Derby, DE22 3NE, UK
Email: chris-mcintyre@ lineone.net
Case Report
Cerebral, myocardial and cutaneous ischemic necrosis associated with calcific emboli from aortic and mitral valve calcification in a patient with end-stage renal disease
Y. Li, A. Muench, D.H. McGregor and T.B. Wiegmann
468
28$
Abstract
We report the case of a 57-year-old diabetic male with chronic renal failure who developed secondary hyperparathyroidism and calcification of mitral and aortic valves and interatrial septum. Multiple ischemic lesions developed in the skin of hands, feet and penis, and in the brain, and these were presumed to be due to septic emboli from cardiac valvular infective endocarditis. Multiple blood cultures were negative, however, and despite antibiotic therapy the patient expired. Autopsy (limited to trunk) demonstrated multiple calcific emboli in the heart and spleen, apparently derived from the prominent calcific deformities in the aortic and mitral valves. These were associated with acute and organizing myocardial infarcts and acute splenic infarcts, suggesting that the multiple ischemic lesions in the brain were also due to calcific emboli. A possible contributory component of infective endocarditis, however, was indicated by postmortem cultures of aortic and mitral valves positive for Enterococcus faecium. Calcific embolism is a rarely recognized but potentially lethal complication of end-stage renal disease, and the clinical diagnosis and the preventive therapeutic options for the control of the product of calcium and phosphate and/or parathyroidectomy should be considered.Correspondence to:
D.H. McGregor, MD; Department of Pathology & Laboratory Medicine, Veterans Affairs Medical Center, 4801 Linwood Boulevard, Kansas City, MO 64128, USA
Email: McGregor.D@Kansas-City.VA.Gov
Y. Li1, A. Muench2, D.H. McGregor1 and T.B. Wiegmann2
1Department of Pathology and Laboratory Medicine 2Department of Medicine (Nephrology Section), Veterans Affairs Medical Center, Kansas City, MO, USA We report the case of a 57-year-old diabetic male with chronic renal failure who developed secondary hyperparathyroidism and calcification of mitral and aortic valves and interatrial septum. Multiple ischemic lesions developed in the skin of hands, feet and penis, and in the brain, and these were presumed to be due to septic emboli from cardiac valvular infective endocarditis. Multiple blood cultures were negative, however, and despite antibiotic therapy the patient expired. Autopsy (limited to trunk) demonstrated multiple calcific emboli in the heart and spleen, apparently derived from the prominent calcific deformities in the aortic and mitral valves. These were associated with acute and organizing myocardial infarcts and acute splenic infarcts, suggesting that the multiple ischemic lesions in the brain were also due to calcific emboli. A possible contributory component of infective endocarditis, however, was indicated by postmortem cultures of aortic and mitral valves positive for Enterococcus faecium. Calcific embolism is a rarely recognized but potentially lethal complication of end-stage renal disease, and the clinical diagnosis and the preventive therapeutic options for the control of the product of calcium and phosphate and/or parathyroidectomy should be considered.Correspondence to:
D.H. McGregor, MD; Department of Pathology & Laboratory Medicine, Veterans Affairs Medical Center, 4801 Linwood Boulevard, Kansas City, MO 64128, USA
Email: McGregor.D@Kansas-City.VA.Gov
Case Report
Systemic amyloidosis involving the diaphragm and acute massive hydrothorax during peritoneal dialysis
R.F. Gagnon, M. Thirlwell, A. Arzoumanian and A. Mehio
474
28$
Abstract
Hydrothorax secondary to trans-diaphragmatic fluid leakage through a peritoneo-pleural communication is an occasional, potentially serious complication of peritoneal dialysis. The etiology of this condition is not clear, being thought to be due either to congenital or acquired diaphragmatic fenestrations or acquired scarcity of muscle fibers in the tendinous part of the diaphragm which are compounded by increased intra-abdominal pressure during the dwell period of peritoneal dialysis. We report a 54-year-old woman who developed irreversible acute renal failure from adjuvant chemotherapy for ovarian cancer previously resected surgically. Three days after the onset of continuous ambulatory peritoneal dialysis, she developed acute respiratory distress associated with a massive right hydrothorax secondary to a peritoneo-pleural communication demonstrated by scintigraphy. At autopsy 2 weeks later, systemic amyloidosis was surprisingly found and histologic examination of the right hemidiaphragm showed the presence of amyloid, among sparse muscle fibers. This is the first case report of a distinct pathological process, i.e. amyloidosis, involving the diaphragm associated with a peritoneo-pleural communication causing massive hydrothorax at the onset of peritoneal dialysis.Correspondence to:
Dr. R.F. Gagnon; Division of Nephrology, Livingston Hall, Room L4-516, Montreal General Hospital, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
Email: raymonde.gagnon@ muhc.mcgill.ca
R.F. Gagnon1, M. Thirlwell1, A. Arzoumanian2 and A. Mehio3
1Departments of Medicine, 2Radiology and 3Pathology, Montreal General Hospital, Montreal, Canada Hydrothorax secondary to trans-diaphragmatic fluid leakage through a peritoneo-pleural communication is an occasional, potentially serious complication of peritoneal dialysis. The etiology of this condition is not clear, being thought to be due either to congenital or acquired diaphragmatic fenestrations or acquired scarcity of muscle fibers in the tendinous part of the diaphragm which are compounded by increased intra-abdominal pressure during the dwell period of peritoneal dialysis. We report a 54-year-old woman who developed irreversible acute renal failure from adjuvant chemotherapy for ovarian cancer previously resected surgically. Three days after the onset of continuous ambulatory peritoneal dialysis, she developed acute respiratory distress associated with a massive right hydrothorax secondary to a peritoneo-pleural communication demonstrated by scintigraphy. At autopsy 2 weeks later, systemic amyloidosis was surprisingly found and histologic examination of the right hemidiaphragm showed the presence of amyloid, among sparse muscle fibers. This is the first case report of a distinct pathological process, i.e. amyloidosis, involving the diaphragm associated with a peritoneo-pleural communication causing massive hydrothorax at the onset of peritoneal dialysis.Correspondence to:
Dr. R.F. Gagnon; Division of Nephrology, Livingston Hall, Room L4-516, Montreal General Hospital, 1650 Cedar Avenue, Montreal, QC, H3G 1A4, Canada
Email: raymonde.gagnon@ muhc.mcgill.ca
Case Report
A case of mixed membranous nephropathy and purpura nephritis
T. Ehara, T. Muramatsu and H. Shigematsu
480
20$
Abstract
We report the case of a 71-year-old man with mixed glomerular lesions, membranous and necrotizing changes. The patient had abdominal pain and purpurat on the extremities and trunk, followed by melena, and after admission to hospital, proteinuria and occult blood were noted. Laboratory findings were negative for autoimmune disease and viral hepatitis. Renal biopsy showed segmental necrotizing changes and mesangial proliferation with spike formation. Immunofluorescence revealed a granular deposition of IgA predominantly in the mesangial area in contrast to the granular IgG deposition along the glomerular capillary loops. Moreover, electron-microscopically, mesangial as well as subepithelial electron-dense deposits were observed. These data suggest that the patient had 2 distinct types of glomerulonephritis simultaneously: idiopathic membranous nephropathy and purpura nephritis.Correspondence to:
Dr. T. Ehara; Asahi 3-1-1 Matsumoto 390-8621, Japan
Email: eharat@sch.md.shinshu-u.ac.jp
T. Ehara1, T. Muramatsu2 and H. Shigematsu1
1Department of Pathology, Shinshu University School of Medicine, Matsumoto, Japan and 2Internal Medicine, Kofu Municipal Hospital, Kofu, Japan We report the case of a 71-year-old man with mixed glomerular lesions, membranous and necrotizing changes. The patient had abdominal pain and purpurat on the extremities and trunk, followed by melena, and after admission to hospital, proteinuria and occult blood were noted. Laboratory findings were negative for autoimmune disease and viral hepatitis. Renal biopsy showed segmental necrotizing changes and mesangial proliferation with spike formation. Immunofluorescence revealed a granular deposition of IgA predominantly in the mesangial area in contrast to the granular IgG deposition along the glomerular capillary loops. Moreover, electron-microscopically, mesangial as well as subepithelial electron-dense deposits were observed. These data suggest that the patient had 2 distinct types of glomerulonephritis simultaneously: idiopathic membranous nephropathy and purpura nephritis.Correspondence to:
Dr. T. Ehara; Asahi 3-1-1 Matsumoto 390-8621, Japan
Email: eharat@sch.md.shinshu-u.ac.jp
Case Report
High-flux hemodialysis – an effective alternative to hemoperfusion in the treatment of carbamazepine intoxication
J.T. Kielstein, A. Schwarz, A. Arnavaz, O. Sehlberg, H.M. Emrich and D. Fliser
484
16$
Abstract
Carbamazepine intoxication is associated with seizures, coma, arrhythmias and death. In acute intoxication, charcoal hemoperfusion is employed for removal of the drug. This can be associated with thrombocytopenia, coagulopathy, hypothermia and hypocalcemia. Alternatively, we used high-efficiency hemodialysis with a batch dialysis system (Genius), lowering not only serum levels of carbamazepine but removing a considerable amount of the drug as measured in the dialysate. This treatment regimen was compared to treatment by hemoperfusion. A 3.5-hour high-flux hemodialysis was as effective as a 2-hour hemoperfusion. We conclude that high-efficiency hemodialysis is a safe and effective alternative for treating life-threatening carbamazepine intoxication.Correspondence to:
Dr. J.T. Kielstein; Department of Nephrology, Medizinische Hochschule, Carl-Neuberg-Straße 1, D-30625 Hanover, Germany
Email: Kielstein@yahoo.com
J.T. Kielstein1, A. Schwarz1, A. Arnavaz2, O. Sehlberg3, H.M. Emrich2 and D. Fliser1
1Division of Nephrology, 2Department of Clinical Psychiatry and Psychotherapy, and 3Department of Clinical Chemistry, Medical School, Hanover, Germany Carbamazepine intoxication is associated with seizures, coma, arrhythmias and death. In acute intoxication, charcoal hemoperfusion is employed for removal of the drug. This can be associated with thrombocytopenia, coagulopathy, hypothermia and hypocalcemia. Alternatively, we used high-efficiency hemodialysis with a batch dialysis system (Genius), lowering not only serum levels of carbamazepine but removing a considerable amount of the drug as measured in the dialysate. This treatment regimen was compared to treatment by hemoperfusion. A 3.5-hour high-flux hemodialysis was as effective as a 2-hour hemoperfusion. We conclude that high-efficiency hemodialysis is a safe and effective alternative for treating life-threatening carbamazepine intoxication.Correspondence to:
Dr. J.T. Kielstein; Department of Nephrology, Medizinische Hochschule, Carl-Neuberg-Straße 1, D-30625 Hanover, Germany
Email: Kielstein@yahoo.com
Letter to the Editor
Improvement of anemia in hemodialysis patients after pulse oral 1-a-D3 treatment
V. Djordjevic, J. Radivojevic and V. Stefanovic
487
12$
Abstract
V. Djordjevic, J. Radivojevic and V. Stefanovic
