Diuretic Abuse Research Articles

Skin signs in anorexia nervosa.

Anorexia nervosa (AN) is a significant cause of morbidity and mortality among adolescent females and young women. AN is associated with severe medical and psychological consequences, including death, osteoporosis, growth delay, and developmental delay. Skin signs are almost always detectable in severe AN and awareness of them may help in the early diagnosis of hidden AN. Skin signs are the expression of the medical consequences of starvation, vomiting, abuse of drugs, such as laxatives and diuretics, and of the psychiatric morbidity. They include xerosis, lanugo-like body hair, telogen effluvium, carotenoderma, acne, hyperpigmentation, seborrhoeic dermatitis, acrocyanosis, perniosis, petechiae, livedo reticularis, interdigital intertrigo, paronychia, acquired striae distensae, acral coldness.The most characteristic cutaneous sign of vomiting is Russell's sign (knuckle calluses). Symptoms due to laxative or diuretic abuse include adverse reactions by drugs. Symptoms due to psychiatric morbidity (artefacta) include the consequences of self-induced trauma. The role of the dermatologist in the management of eating disorders is to make an early diagnosis of the "hidden" signs of eating disorders in patients who tend to minimize or deny their disorder.

Kidney Transplantation Complications Related to Psychiatric or Neurological Disorders

Defining absolute psychiatric or neurological contraindications among kidney transplantation candidates is controversial, especially taking into account that graft outcomes are similar to other groups of patients. The social support network should be exhaustively evaluated to ensure adherence to immunosuppressive therapy and minimization of complications resulting from the neuropsychiatric disorder. We reviewed transplants (n = 668) in our center between January 2001 and August 2008 searching for patients with a diagnosis of neurological or psychiatric disease before renal transplantation. We also reviewed demographic data, social support networks, patient and graft survivals as well as transplant complications. Twelve patients were transplanted with neurological or psychiatric disorders: seven with cognitive impairment and five with psychiatric diseases. Nine patients had good social support networks. The mean follow-up time was 2.65 +/- 2.42 years. The graft loss rate was 34% (n = 4), including only one attributed to a mental disorder, namely, nonadherence to immunosuppressive therapy. Regarding complications, four were related to the neuropsychiatric disorder: hypoglycemia due to insulin overdose, aspiration pneumonia because of altered pharynx-larynx motility, hyponatremia related to diuretic abuse, and malnutrition plus dehydration. Patient survival in this period was 91.7%. The one patient died due to multiple organ failure secondary to respiratory sepsis with a functioning graft. In summary, neuropsychiatric disorders should not be considered to be contraindications for kidney transplantation although a social support network is essential and must be carefully evaluated.

Gitelman Syndrome

Gitelman Syndrome

Chronic hypokalaemia and nephrocalcinosis.

Unravelling chronic hypokalaemia can be a clinical challenge in some patients. History and physical examination can be misleading or inaccurate. Diagnostic steps usually involve assessing urinary potassium excretion, transtubular potassium gradient (TTKG) and concomitant acid–base disturbances. In those patients with low urinary potassium excretion, a gastrointestinal cause for the hypokalaemia would come to mind. In patients with a high urinary potassium excretion, the kidneys themselves are implicated. In any event, acid–base status is extremely helpful and generally indicates which end of the gastrointestinal tract or which level of the nephron is responsible. In patients with high urinary potassium with metabolic alkalosis, the urinary chloride concentration can be particularly helpful in separating surreptitious vomiting from Bartter's syndrome or Gitelman's syndrome. Diuretic abuse may be a confounder; however, metabolic breakdown products and the temporal course of chloride excretion generally solve the mystery. We recently encountered a patient who taxed our diagnostic skills.

A Case Report of an Anorexia Nervosa Patient With End‐stage Renal Disease Due to Pseudo Bartter's Syndrome and Chinese Herb Nephropathy Requiring Maintenance Hemodialysis

The extent of end stage renal disease (ESRD) has not been well documented in anorexia nervosa (AN). We herein describe a 47-year-old female with ESRD who required maintenance hemodialysis (HD) following a 27 year history of AN, and seven years of diuretic and purgative abuse. In spite of HD treatment, her serum inorganic phosphorus level remained elevated (10.2-15.8 mg/dL). Tissue degradation due to catabolism, insufficient dialysis treatment, and use of Chinese herbal medicine, including aristolochic acid, are speculated as the cause of her hyperphosphatemia. We also speculated that the causes of her renal dysfunction are as follows: chronic interstitial nephritis caused by pseudo Bartter's syndrome resulting from chronic abuse of diuretics and purgatives, and Chinese herb nephropathy.

Diuretika-induzierte Ödeme

The diagnosis of "diuretic-induced oedema" was made in 17 women (mean age 42.4 [23-60] years) who had developed generalized oedema after stopping their (chronic) intake of diuretics. Five patients were between 11 and 32% overweight, five of them were unusually old. A further four patients had severe concomitant diseases, such as primary lymphoedema, mitral valve defect and lupus erythematosus. In 10 of the 17 discontinuation was successful: the initial weight gain averaged 3.9 (1.5-7.5) kg. The maximal weight-gain, in a woman in the course of weaning her of the diuretic, was reversed within 20 days. Diuretic withdrawal after more than 20 years in a woman with mitral valve disease caused heart failure. Diuretic abuse caused prerenal failure in one women, but renal function became normal again after stopping of the diuretic and rehydration.

Public awareness of the abuse of herbs and drugs to decrease body weight: a novel national survey in Jordan

The aim of this investigation was to measure the degree of public preferences regarding the various weight-loss practices and to assess the level of awareness regarding the risks and health hazards associated with the application of unhealthful measures to lose weight. Approximately 30,000 individuals selected from various regions in Jordan filled in a self−reported questionnaire. Participants were interviewed by well–trained senior pharmacy students and were asked to report their response to various aspects regarding body weight-loss practices. Of the respondents, 74.55% agreed that dietary restriction is the major intervention to lose weight. A modest majority of respondents (39.09%) believed that nervousness and irritability are serious drawbacks for uncontrolled administration of the hormone thyroxine. The highest percentage of responding females (67.12%) reported diarrhea as a major adverse effect to laxative abuse. The availability and the number of adverse events associated with herbal and dietary supplements to lose weight are on the rise. Obese patients should consider realistic expectations and be encouraged to follow healthy lifestyle interventions. Health care professionals are best suited to educate obese patients about unhealthy practices like laxative and diuretic abuse.

Gym users and abuse of prescription drugs

Gym users and abuse of prescription drugs

Treatment of Eating Disorders in Children, Adolescents, and Young Adults

Treatment of Eating Disorders in Children, Adolescents, and Young Adults

Sodium depletion and hemoconcentration: Overlooked complications in patients with anorexia nervosa?

Objective This study evaluated sodium and fluid balance disturbances in anorexia nervosa. Methods Serum urea, creatinine, urea nitrogen/creatinine ratio, protein concentration, osmolality, electrolytes, hemoglobin, and hematocrit were evaluated on admission, after intravenous fluid supplementation, and at discharge in 14 patients who had anorexia nervosa and were admitted to a medical unit for severe malnutrition and/or medical complications. Diet history and physical signs of salt and water depletion were also evaluated on admission. The diagnosis of plasma volume depletion was considered confirmed if serum urea nitrogen/creatinine ratio was higher than 25. Results Mean body mass indexes were 12.9 ± 2.4 kg/m 2 on admission and 14.2 ± 2.0 kg/m 2 at discharge. Mean duration of hospitalization was 24.2 ± 11.9 d. Plasma volume depletion was found on admission in nine patients (64%), and hyponatremia was associated with hypovolemia (hypovolemic hyponatremia) in three of them. Most of the commonly used indexes of hemoconcentration (hematocrit, hemoglobin, serum urea, and creatinine) were normal on admission but decreased significantly after intravenous fluid supplementation and were maintained at lower levels at discharge ( P < 0.001, P < 0.0004, P < 0.009, and P < 0.001, respectively, compared with admission values). Hemoconcentration masked an underlying anemia (hemoglobin < 12 g/dL) in six patients. Only two of the nine patients with plasma volume depletion had a history of diuretic abuse, and the other seven patients reported long-term sodium restriction as a method to control body weight. Conclusions Plasma volume depletion and hypovolemic hyponatremia are common in the most severely malnourished patients with anorexia nervosa. Clinicians should be aware that, because of malnutrition, the common indexes of hemoconcentration may be within normal range and that hemoconcentration may mask anemia. Further studies are needed to assess the role of neglected behaviors such as sodium and fluid restriction.

Dermatologic Signs in Patients with Eating Disorders

Eating disorders are significant causes of morbidity and mortality in adolescent females and young women. They are associated with severe medical and psychological consequences, including death, osteoporosis, growth delay and developmental delay. Dermatologic symptoms are almost always detectable in patients with severe anorexia nervosa (AN) and bulimia nervosa (BN), and awareness of these may help in the early diagnosis of hidden AN or BN. Cutaneous manifestations are the expression of the medical consequences of starvation, vomiting, abuse of drugs (such as laxatives and diuretics), and of psychiatric morbidity. These manifestations include xerosis, lanugo-like body hair, telogen effluvium, carotenoderma, acne, hyperpigmentation, seborrheic dermatitis, acrocyanosis, perniosis, petechiae, livedo reticularis, interdigital intertrigo, paronychia, generalized pruritus, acquired striae distensae, slower wound healing, prurigo pigmentosa, edema, linear erythema craquele, acral coldness, pellagra, scurvy, and acrodermatitis enteropathica. The most characteristic cutaneous sign of vomiting is Russell's sign (knuckle calluses). Symptoms arising from laxative or diuretic abuse include adverse reactions to drugs. Symptoms arising from psychiatric morbidity (artefacta) include the consequences of self-induced trauma. The role of the dermatologist in the management of eating disorders is to make an early diagnosis of the 'hidden' signs of these disorders in patients who tend to minimize or deny their disorder, and to avoid over-treatment of conditions which are overemphasized by patients' distorted perception of skin appearance. Even though skin signs of eating disorders improve with weight gain, the dermatologist will be asked to treat the dermatological conditions mentioned above. Xerosis improves with moisturizing ointments and humidification of the environment. Acne may be treated with topical benzoyl peroxide, antibacterials or azaleic acid; these agents may be administered as monotherapy or in combinations. Combination antibacterials, such as erythromycin with zinc, are also recommended because of the possibility of zinc deficiency in patients with eating disorders. The antiandrogen cyproterone acetate combined with 35 microg ethinyl estradiol may improve acne in women with AN and should be given for 2-4 months. Cheilitis, angular stomatitis, and nail fragility appear to respond to topical tocopherol (vitamin E). Russell's sign may decrease in size following applications of ointments that contain urea. Regular dental treatment is required to avoid tooth loss.

Somatoform dissociation in eating-disordered patients

This study investigated the role of somatoform dissociation in eating disorders and pathological eating behaviour, relative to the established association of eating pathology with psychological dissociation. The participants were 131 women with DSM-IV diagnoses of anorexic or bulimic disorders and 75 women who had no such disorder. Each woman completed measures of psychological and somatoform dissociation, as well as a measure of bulimic attitudes. The current presence or absence of specific bulimic behaviours was identified during the clinical interview. Levels of both forms of dissociation were higher in the women who had diagnoses of disorders with a bulimic component (bulimia nervosa; anorexia nervosa of the binge/purge subtype) than in the non-clinical or restrictive anorexic women. Somatoform dissociation showed particularly strong links with the presence of bulimic behavioural features (excessive exercise, laxative abuse, diet pill abuse, diuretic abuse) and with bulimic attitudes. The formulation and treatment of cases where there are bulimic features is likely to be enhanced by the assessment of somatoform dissociation.

Impaired renal function in a patient with diuretic abuse

A 31-year-old woman was diagnosed as having Bartter's syndrome in 1978, although suspicions remained that she had been taking diuretics surreptitiously. Careful observation and repeated urinary drug analyses revealed no clue that she had been taking diuretics, until 20 years later, when the urine samples at last disclosed traces of furosemide. At this time she showed proteinuria, of 2 g/day, and hypercholesteremia. The glomerular filtration rate had decreased to 66 ml/min per 1.73 m2. The 24-h urinary concentrations of β2-microglobulin, N-acetyl-β-d-glucosaminidase (NAG) activity, and other urinary enzymes that are indicators of damage in proximal tubular cells, were increased, showing proximal tubular damage. The function of the loop of Henle was evaluated by a hypotonic saline loading test. The fractional distal chloride reabsorption, an index of the solute conservation rate in the loop of Henle, was 65.4%, which was lower than the normal value (88.9 ± 6.2%). The maximal urinary concentrating ability was 357 mOsm/kg·H2O, and a short ammonium chloride loading test showed impairment in the acidification of the urine. The third renal biopsy specimens showed some obsolescent glomeruli, marked juxtaglomerular cell hyperplasia, intraluminal calcification, interstitial infiltration of lymphocytes with fibrosis, and thickening of arteriolar walls with narrow lumens. Patients often attempt to hide their use of diuretics from medical staff, leading to them to make a misdiagnosis of Bartter's syndrome. Although the patient described here has not experienced life-threatening adverse effects from furosemide abuse, some findings appear to be irreversible, suggesting the deterioration of renal function. Patients should realize that longstanding abuse of diuretics causes not only metabolic abnormalities but also the risk of renal damage.

Nutrition and sport

Nutrition and sport

Aetiopathogenesis and pathophysiology of bulimia nervosa: biological bases and implications for treatment.

Bulimia nervosa is an eating disorder characterised by recurrent episodes of binge eating and associated efforts to purge the ingested calories through self-induced vomiting, laxative or diuretic abuse, fasting or intensive exercise. The aetiopathogenesis and pathophysiology of the disorder are currently unclear. Biological bases have been proposed repeatedly, based on several lines of evidence: hunger, satiety and food choice are regulated by neurotransmitters and neuropeptides, and impairment of eating habits may be related to alterations in the secretion of these chemicals; genetic studies suggest that these neurotransmitter systems are dysfunctional in individuals with bulimia nervosa; and the frequent comorbidity of bulimia nervosa with major depressive and obsessive-compulsive disorders, conditions in which multiple alterations of brain biochemical functions have been demonstrated. Data in the literature suggest that levels of noradrenaline (norepinephrine) and serotonin (5-hydroxytryptamine; 5-HT) are lower in individuals with bulimia nervosa than in healthy controls. Levels of dopamine are similar to, or lower than, those in controls. After remission of the disorder, noradrenergic function returns to that seen in controls, whereas dopaminergic and serotonergic function rebound to levels higher than in controls. Among the neuropeptides, alterations in the levels of neuropeptide Y, peptide YY, beta-endorphin, corticotrophin-releasing hormone, somatostatin, cholecystokinin and vasopressin have been found in the symptomatic phase of bulimia nervosa, with a return to levels seen in controls after remission. Pharmacological treatment of bulimia nervosa that is directed at correction of the neurochemical alterations observed is difficult because of the complexity of the impairments. However, such treatment is necessary and should be continued long after symptomatic remission to ensure reinstitution of cerebral biochemical homeostasis.

Vascular Hyperpermeability in Nephrotic Edema

Background/Aim: There is increasing evidence that hypoalbuminemia and the inability of the renal distal tubule to excrete salt are not the only factors responsible for nephrotic edema. We tested the possibility that vascular hyperpermeability also plays a role in the pathophysiology of nephrotic edema in human primary glomerulonephritis. Methods: We investigated the capillary permeability by means of a standardized test using albumin labelled with technetium (^99mTc-albumin) in 20 healthy adults and in 101 nephrotic adult patients comprising 60 patients with idiopathic nephrotic syndrome (INS; minimal-change nephropathy and segmental glomerulosclerosis), 32 with idiopathic membranous nephropathy (IMN) and 9 patients with idiopathic type I membranoproliferative glomerulonephritis (MPGN). The patients and healthy controls were also compared with a group of women (n = 25) with idiopathic cyclic edema, a disease in which an increase in capillary permeability plays a pivotal role. The capillary permeability measured by the Landis isotope test is normal in edematous patients with cardiac and renal impairment unrelated to glomerular disease, cirrhosis, hypothyroidism, lymphatic obstruction and diuretic abuse. As values were not normally distributed, nonparametric analysis of variance was used (Kruskal-Wallis test), and patient groups were compared with healthy controls and with women with idiopathic cyclic edema by means of the two-tailed nonparametric Mann-Whitney test. The effects of high-dose steroids and Ginkgo biloba extract (Tanakan^®; an agent able to improve capillary permeability) were analyzed by means of the two-tailed nonparametric Wilcoxon test. Results: The capillary permeability was significantly increased (Mann-Whitney test) in each glomerular disease group compared with the healthy controls. ^99mTc-albumin extravasation values (%; median and range in parentheses were the following: healthy controls 0 (0–8.4); idiopathic cyclic edema patients 11.5 (8–24), p < 0.001; INS 20 (0–50), p < 0.0001; IMN 12.5 (0–40), p < 0.001, and MPGN 10 (0–40), p < 0.05. An increase in capillary permeability exceeding the upper limit of control values ( >8% of ^99mTc-albumin extravasation) was observed in 88% of INS, in 53% of IMN and in 44% of MPGN patients. The increase in capillary permeability (%) was greater in idiopathic nephrotic patients than in idiopathic cyclic edema patients (p < 0.005, Mann-Whitney test) and was markedly reduced in nephrotic patients receiving high-dose steroids (n = 8) [before 25 (8–40); after 0 (0–25), p < 0.005 (Wilcoxon’s test)] and high doses of G. biloba extract (n = 16) [before 30 (8–50); after 2.5 (0–20, p < 0.0005 (Wilcoxon’s test)]. Conclusions: We conclude that capillary permeability is severely altered in most of the nephrotic patients with primary glomerulonephritis. These results strongly suggest that the capillary hyperpermeability plays a role in the pathophysiology of nephrotic edema in primary glomerular disease, especially in INS. We postulate that this widespread abnormality in capillary permeability is related to the release of vascular permeability factor and other cytokines by immune cells.

Recurrent binge eating in black American women.

Recurrent binge eating is a core diagnostic feature of bulimia nervosa and binge eating disorder, and in samples of white women has been associated with obesity and psychiatric symptoms. Eating disorders have been believed to occur primarily among white women; in fact, the limited preliminary data available suggest that black women may be as likely as white women to report binge eating. To examine race differences in prevalence of behavioral symptoms of eating disorders and clinically significant recurrent binge eating. Community survey. General community in Connecticut and Boston, Mass. A community sample of 1628 black women and 5741 white women (mean age, 29.7 years) participated in a telephone survey designed to ascertain the presence, during the preceding 3 months, of binge eating and extreme weight control behaviors (vomiting, laxative or diuretic abuse, or fasting). Interviewer-based phone assessment of recurrent binge eating and behavioral symptoms of eating disorders. Black women were as likely as white women to report binge eating or vomiting during the preceding 3 months, and were more likely to report fasting and the abuse of laxatives or diuretics. Recurrent binge eating was more common among black women than among white women. In both race groups, recurrent binge eating was associated with elevated body weight and increased psychiatric symptoms. Results suggest that recurrent binge eating is a significant problem among black and white women. Health professionals need to be ready to respond to this health risk behavior.

Molecular pathogenesis of Bartter’s and Gitelman’s syndromes

A 42-year-old man presented to UCLA with a history of chronic hypokalemia and hypomagnesemia. His medical history was unremarkable except for occasional cramps in his calves. He had no history of laxative or diuretic abuse or of vomiting, and he was taking no medications. His 47-year-old brother also had a history of chronic hypokalemia and hypomagnesemia and severe intermittent muscle cramps. He was being treated with amiloride and magnesium supplementation. Both parents and a third brother were asymptomatic and had no electrolyte abnormalities. Physical examination revealed a well-developed white male in no distress. His blood pressure was 110/70 mm Hg: heart rate. 72 beats/min; jugular venous pressure was estimated to be 7 cm: his chest was clear to auscultation. Cardiovascular examination disclosed a regular rate and rhythm, and no murmurs. rubs, or gallops; his abdomen was nontender without hepatosplenomegaly. Neurologic examination revealed cranial nerves 2-12 intact, no sensory or motor deficit, and no Chvostek or Trousseau sign. He did not have peripheral edema. Laboratory values were: serum sodium, 136 mEq/liter; potassium, 2.4 mEq/liter; chloride. 94 mEq/liter; total CO 2 , 28 mEq/liter; venous pH, 7.47 and PCO 2 , 38 mm Hg; BUN, 10 mg/dl; serum creatinine. 0.7 mg/dl; ionized calcium, 1.25 mmol/liter; total calcium, 9.2 mg/dl; phosphorus, 3.2 mg/dl; magnesium, 1.1 mg/dl; supine plasma renin, 16.6 ng/ml/hr; supine aldosterone, 168 pg/ml; PTH, 13 pg/ml; 1,25(OH) 2 vitamin D, 42 pg/ml. Urine chemistries were: sodium, 64 mEq/liter; potassium. 42 mEq/liter; chloride, 58 mEq/liter; calcium, I mg/dl; magnesium, 4.3 mg/dl; phosphorus, 67.4 mg/dl; and creatinine, 81 mg/dl, A diuretic screen was negative. The patient was discharged on no medications and has remained asymptomatic.

Eating disorders.

Anorexia nervosa and bulimia nervosa are primarily psychiatric disorders characterized by severe disturbances of eating behaviour. Anorexia nervosa has been well documented in pre-pubertal children. Eating disorders are most prevalent in the Western cultures where food is in abundance and for females attractiveness is equated with thinness. Eating disorders are rare in countries like India. As Western sociocultural ideals become more widespread one may expect to see an increase in number of cases of eating disorders in non-Western societies. Etiological theories suggest a complex interaction among psychological, sociocultural, and biological factors. Patients with anorexia nervosa manifest weight loss, fear of becoming fat, and disturbances in how they experience their body weight and shape. Patients with bulimia nervosa present with recurrent episodes of binge eating and inappropriate methods of weight control such as self-induced vomiting, and abuse of diuretics and laxatives. Major complications of eating disorders include severe fluid and electrolyte disturbances and cardiac arrhythmias. The most common cause of death in anorexia nervosa is suicide. Management requires a team approach in which different professionals work together. Individual and family psychotherapy are effective in patients with anorexia nervosa and cognitive-behavioral therapy is effective in bulimia nervosa. Pharmacotherapy is not universally effective by itself. Patients with eating disorders suffer a chronic course of illness. The pediatrician plays important role in early diagnosis, management of medical complications, and psychological support to the patient and the family.

“Ox Hunger”: Psychoanalytic Explorations of Bulimia Nervosa

Bulimia, a term derived from Greek words meaning “ox” and “hunger,” is a food obsession characterized by repeated overeating binges followed by purges of forced vomiting, prolonged fasting, or abuse of laxatives, enemas, diuretics and amphetamines. It provides temporary relief to emotional pain. If untreated, bulimia causes serious medical and dental problems. In this paper, I first present an overview of the historical development of bulimia nervosa as a clinical entity and then explore the syndrome from a psychoanalytic perspective, focusing on the Freudian drive-conflict model, the pathology of early object relations, and attachment theory. A case is presented and treatment implications are discussed.