Obstructive Acute Renal Failure Research Articles

Epidemiological, Clinical, and Evolutionary Aspects of Severe Obstructive Acute Renal Failure Requiring Dialysis in the Nephrology Department of the University Hospital of Brazzaville

Introduction: Obstructive anuria represents a medical and surgical emergency, sometimes necessitating immediate extrarenal replacement therapy. Our study aims to delineate the profile of hemodialyzed patients with obstructive acute renal failure (OARF), detailing indications for hemodialysis and observing the course of the condition. Patients and Methods: This retrospective study covers the period from 2019 to 2022, encompassing all patients with OARF requiring emergency dialysis at the Nephrology Department of the University Hospital of Brazzaville. Data analysis was performed using EPI Info software version 3.3.2 (CDC, Atlanta, USA). Results: The study involved 39 patients, with 69.23% being male. The average age was 58.10 years, and oliguria was the primary presenting symptom (82%). Tumoral obstruction accounted for 76%, while lithiasic obstruction constituted 14%. Two cases of retroperitoneal fibrosis were observed (2.8%). Neoplastic origins included prostate, bladder, cervical, and rectal cancers in 46.67%, 33.33%, 16.67%, and 3.33% of cases, respectively. Indications for hemodialysis were poorly tolerated uremia, acidosis, hyperkalemia, and pulmonary edema in 79.1%, 38.57%, 19.49%, and 13.21% of cases, respectively. The mortality rate was 25.64%. Conclusion: The reliance on hemodialysis in obstructive anuria underscores a delay in patient management. Emergency treatment revolves around urinary tract drainage, followed by addressing the underlying cause. Prevention hinges on early and adequate management of various causal pathologies.

Causes and Prognosis of Cases of Acute Obstructive Renal Failure Managed at the Donka National Hemodialysis Center

Causes and Prognosis of Cases of Acute Obstructive Renal Failure Managed at the Donka National Hemodialysis Center

#5130 THE EXPERIENCE OF SELECTIVE PLASMA EXCHANGE THERAPY IN PATIENTS WITH MULTIPLE MYELOMA

Abstract Background and Aims High concentrations of free light chains (FLCs) in multiple myeloma lead to cast-nephropathy and obstructive acute renal failure in 18-56% of patients. The aim of this research is to estimate the efficiency of extracorporeal free light chains of immunoglobulin elimination under this pathological condition during plasma exchange therapy using selective filters. Method Selective plasma exchange therapy (SEPET) was carried out in 11 patients with multiple myeloma. The patients were 61 [47-69] years old. Paraproteinemia level at primary examination varied from 1.6 to 78.8 g/liter. All patients exhibited proteinuria of 0.56 to 12.7 g/day, Bence Jones protein excretion (from 0.4 to 11.2 g/day) was detected in 9 cases. Blood creatinine levels ranged from 272 μmol/L to 534 μmol/L. None of the patients required renal replacement therapy. FLCs levels above 500 mg/L, irrespective of azotemia level, served as an indication for starting the procedure. All patients received VMP induction chemotherapy after sessions of selective plasma exchange therapy. SEPET was carried out on a “Multifiltrate” (Fresenius) hemodialysis machine in hemofiltration mode. «Evaclio 2C20» plasmafilter (Japan) was used. Patients underwent one procedures of SEPET in a dose of 3 volumes of circulating plasma. Blood flow velocity during varied from 40 to 60 ml/min, the duration of each procedure was 5-6 hours. Plasma substitution was performed with «Prismasol K4» solution - 10.0 L and albumin solution 20%-400 ml. Regulated clotting by nonfractionated heparin was calculated individually from the APTT values. No early or delayed complications of extracorporeal hemocorrection were recorded. FLCs, creatinine levels, and coagulogram results of patients were examined before and after the procedure. Results Analysis of serum FLC values before treatment showed a significant increase of κ- or λ-FLC levels, significantly surpassing normal values: 3-21.5 mg/liter κ-FLC and 5-27 mg/liter λ-FLC, with κ/λ-FLC proportion of 0.25-1.65. The primary levels of involved FLC medians in the group were 472 [312;44700] mg/L for κ-FLC and 163 [ 473; 24673] mg/L for λ-FLC, κ/λ-FLC proportions were 2.89. Through the membrane of the plasma filter “Evaclio 2C20” are sieved and removed substances with a molecular weight less than the molecular weight of albumin (65 kD). Kappa FLCs circulate as monomers of 22 kDa but may assemble into dimers of 45 kDa, particularly lambda FLCs. There is a partial loss of albumin. High molecular weight substances do not pass through this membrane. During SEPET the κ-FLC level in the plasmafiltrate was 272 mg/L, the λ-FLC level was 94 mg/L. After SEPET median serum κ-FLC was 231 mg/L, median serum λ-FLC was 96 mg/L. Compared with baseline data, serum FLC levels decreased after 24 hours, so that median serum κ-FLC was 281 mg/L, median serum λ-FLC was 101 mg/L. Clinical tolerance of extracorporeal detoxification was satisfactory and hemodynamically stable in all patients; and there were no were traumas of blood elements or decrease of serum albumin. Renal function recovered in 3 patients in the course of therapy, improved in 5 patients with renal insufficiency, and remained unchanged in 3 patients. Conclusion The Selective plasma exchange therapy directly removes FLCs excess from circulating blood. Rapid reduction of FLCs level in the course of selective extracorporeal elimination can prevent the development of irreversible renal failure and make it possible to carry out adequate antitumor therapy.

Multifocal Tuberculosis in Immunocompetent Patients through a Clinical Case at Mohamed V Rabat Military Hospital, Urology Department

Tuberculosis is a real public health problem still rampant in an endemic fashion in developing countries. Multifocal forms are observed in immunocompromised patients but can also be observed in immunocompetent subjects. Often misleading aspects, and which can mislead the diagnosis. The authors reported the case of a 32-year-old young man with no particular medical history, immunocompetent, received with acute obstructive renal failure from the outset anuric associated with orchiepididymitis, pulmonary and vertebral involvement on CT scan without physical signs, progressing well under treatment. This form of multifocal tuberculosis can be life-threatening and requires early diagnosis and urgent management.

Complete inguinal bladder hernia causing acute right upper urinary tract obstruction

Case Summary: An 86-year-old male nursing home resident presented with increasing confusion and was initially treated for catheter-associated urinary tract infection. Computed tomography (CT) scan demonstrated complete inguinal bladder hernia with compression of the right vesico-ureteric junction leading to acute obstructive renal failure. Percutaneous nephrostomy was attempted but was not possible due to patient non-compliance. Patient improved with conservative management. Discussion: Bladder involvement in inguinal hernia is rare with most cases being identified at the time of hernia repair and there is a 17% risk of intra-operative bladder injury. Key risk factors include increasing age, male gender, lower urinary tract symptoms and previous hernia repair. Percutaneous nephrostomy followed by inguinal hernia repair is the treatment of choice for most patients. This case highlights that inguinal bladder hernia can lead to acute upper urinary tract obstruction even when the bladder is catheterised. Level of evidence: IV

154 Complete Inguinal Bladder Hernia Causing Acute Obstruction of Right Upper Urinary Tract

Abstract Case Summary An 86-year-old male nursing home resident presented with increasing confusion and was initially treated for catheter-associated urinary tract infection. CT scan demonstrated acute acalculous cholecystitis and complete inguinal bladder hernia with compression of right vesico-ureteric junction leading to acute obstructive renal failure. Percutaneous cholecystostomy and percutaneous nephrostomy were attempted but were not possible due to patient non-compliance. Patient improved with conservative management. Discussion Bladder involvement in inguinal herniae is rare with most cases being identified at the time of hernia repair and there is a 17% risk of intra-operative bladder injury. Key risk factors include increasing age, male gender, lower urinary tract symptoms and previous hernia repair. Percutaneous nephrostomy followed by inguinal hernia repair is the treatment of choice for most patients. Clinicians should aim to make the diagnosis of inguinal bladder hernia pre-operatively to reduce risk of intra-operative bladder injury during hernia repair. Acute acalculous cholecystitis tends to occur in critically ill patients and is a marker of poor prognosis.

MO402ACUTE OBSTRUCTIVE RENAL FAILURE IN URGENT HEMODIALYSIS

Abstract Background and Aims Acute obstructive renal failure is secondary to obstruction of the upper excretory tract occurring bilaterally or in a single anatomical or functional kidney. It accounts for 8 to 14% of all acute renal failure in Morocco. They constitute serious conditions which can jeopardize the functional prognosis of the kidney . The objective of our study is to describe the profile of patients on emergency hemodialysis for acute obstructive renal failure (AKI), the main indications for hemodialysis and to assess the risk factors for mortality. Method It was a 2-year retrospective and descriptive study from January 2018 to December 2019; performed in the nephrology and hemodialysis department CHU IBN ROCHD CASABLANCA. Results A total of 118 patients were counted: 43 women, 75 men or 36.4%, 63.5%, with an average age of 54.3 years "+/- 10.3". The circumstances of discovery were: Oligo anuria 51.5%, hematuria 25%, AEG 24%. The obstacle was neoplastic in 67.79%; lithiasis 26.27%; on pregnancy in 0.84%; bladder malformation 0.84%, and unknown etiologies in 4.2%. The neoplastic origin was cancer of the cervix, followed by the bladder and then the prostate. The average creatinine level was 89.7mg / l. The indication for hemodialysis was: threatening hyperkalemia, uremic syndrome, acidosis and acute pulmonary edema in 56%, 25.8%, 9.6% and 10% of cases, respectively The total number of hemodialysis sessions was 227 hemodialysis sessions with an average number of 1.91. Obstacle removal was performed by percutaneous nephrostomy in 70.8% of cases, by mounting a double J probe in 10% of cases and by ureterostomy in 4.2% of cases. The course was good in 77.9% of the cases, 13.5% progressed to the IRCT. Mortality was 8.4%. Risk factors for mortality were: age, etiology of neoplasia. Conclusion A total of 118 patients were counted: 43 women, 75 men or 36.4%, 63.5%, with an average age of 54.3 years "+/- 10.3". The circumstances of discovery were: Oligo anuria 51.5%, hematuria 25%, AEG 24%. The obstacle was neoplastic in 67.79%; lithiasis 26.27%; on pregnancy in 0.84%; bladder malformation 0.84%, and unknown etiologies in 4.2%. The neoplastic origin was cancer of the cervix, followed by the bladder and then the prostate. The average creatinine level was 89.7mg / l. The indication for hemodialysis was: threatening hyperkalemia, uremic syndrome, acidosis and acute pulmonary edema in 56%, 25.8%, 9.6% and 10% of cases, respectively The total number of hemodialysis sessions was 227 hemodialysis sessions with an average number of 1.91. Obstacle removal was performed by percutaneous nephrostomy in 70.8% of cases, by mounting a double J probe in 10% of cases and by ureterostomy in 4.2% of cases. The course was good in 77.9% of the cases, 13.5% progressed to the IRCT. Mortality was 8.4%. Risk factors for mortality were: age, etiology of neoplasia.

SPONTANEOUS RUPTURE OF DOUBLE J URETERAL STENT

The double J stent is widely used in urological endoscopic surgery with different indications (ureteral stenosis, ureteropelvic junction obstruction, retroperitoneal tumor or fibrosis) and can be a subject to multiple complications including migration, encrustation, stone formation and fragmentation which is a rare complication. We are reporting a rare case of a 42-years-old, followed for cervical cancer since 2018 revealed by an acute obstructive renal failure drained by a left double J ureteral stent (of long duration) and right percutaneous nephrostomy. The patient maintained the double J stent for 2 years. On clinical examination there was a lumbar tenderness on the left side and a hardened vaginal cervix on bimanual vaginal examination. The patient underwent a renovesical ultrasound showing a minimal left ureterohydronephrosis. The uroscanner with reconstruction revealed a fragmented double J stent on the left side.

Renal involvement in IgG4-related disease

IgG4-RD may affect several organs including kidneys. The kidney is involved in approximately 20% of patient with IgG4-RD. The most common intrinsic kidney disease is tubulointerstitial nephritis (IgG4-TIN). Retroperitoneal fibrosis (IgG4-RPF) may induce obstructive acute renal failure. More rarely, IgG4-RKD can manifest as a glomerular disease, in particular as a membranous nephropathy (MN). It mostly affects middle-aged to elderly men and causes acute or chronic renal dysfunction, multiple hypodense lesions on CT-Scan and various extra-renal lesions. Increased serum IgG4 and hypocomplementemia are the most important serological findings for the diagnosis of IgG4-RD and thus should be systematically assessed when IgG4-RKD is suspected. Specific diagnosis criteria for IgG4-TIN including interstitial infiltration of IgG4-positive plasma cells, storiform fibrosis and tubular basement membrane immune complex deposits have been proposed. Corticosteroids are effective and remain the first-line therapy but relapses or severe forms could respond to immunosuppressive therapy.

Acute Obstructive Renal Failure Secondary to Primary Bladder Melanoma

Acute Obstructive Renal Failure Secondary to Primary Bladder Melanoma

Pelvic Exenterations for Cervical Cancer Recurrences—a Safe Option in Indian Scenario

Cervical cancer is still a major health problem in India with majority of patients presenting with locally advanced stages. Management of local recurrences of cervical cancer after chemoradiation is a challenging task. Pelvic exenteration is a radical surgery with en bloc resection of pelvic organs is an accepted treatment modality for local recurrence of cervical cancer. In a low-resource country like India where alternate treatment modalities like chemotherapy and targeted therapy are unaffordable to these patients, this radical surgery may be the only treatment modality which gives long-term survival benefit. The aim of the study is to evaluate the morbidity and survival outcome following pelvic exenteration in patients with recurrent cervical cancer in our institution. After obtaining institutional review board approval, a retrospective audit was conducted of all patients who underwent pelvic exenterative surgery for recurrent cervical cancer in our institution from January 2007 to December 2017. The parameters assessed were age of the patient, histologic type and grade, stage of disease, surgical procedures performed, type of reconstruction, intra-operative complications, length of hospital stay, and post-operative morbidity. Patients were followed until March 2017. Survival time was calculated from the date of surgery to the date of last contact or death. Survival estimation was done by Kaplan-Meier method. Between 2007 and 2017, 30 patients underwent the surgery. Mean age of the cohort was 50.9 years (range 33–67 years). Histological type was squamous cell carcinoma in 23 and adenocarcinoma in 7 patients. Twelve patients had anterior exenteration, one had posterior and 17 had total exenteration. The mean operating time was 367.3 min (210–600 min). No post-operative mortality was observed. Post-operative complications were seen in 66.6% of which the most common was of the urinary tract including 4 patients with recurrent urosepsis, one patient with obstructive uropathy and acute renal failure necessitating laparotomy and ureteric reimplantation. Two patients developed fistulae, one urinary and one bowel. Median follow-up time was 27.5 months (1.8–99.1 months). A five-year overall survival for the cohort was 60.5%. It is suggested that pelvic exenteration is an effective technique with reasonable long-term survival benefit and acceptable morbidity in selected patients with cervical cancer recurrence.

Predictive value of CT scan in the outcome of renal function in patients with acute obstructive renal failure

Objective To evaluate the predictive value of CT scan in the outcome of renal function after decompression procedures in patients with acute obstructive renal failure. Methods Retrospective analysis of clinical information of 76 patients with acute obstructive renal failure between January 2012 and August 2017 was performed. Clinical information included age, cause of obstruction, type of decompression procedures, total renal area and dominant side renal area measured by CT scan, serum creatinine(SCr) level before operation, SCr level in 3 months after decompression. Patients were divided into 2 groups according to creatinine clearance rate (CCr) in 3 months after decompression, including normal renal function group (26 cases, CCr≥50 ml/min) and decompensated renal function group (50 cases, CCr<50 ml/min). The CCr of normal renal function group was (65.3±12.8)ml/min, while the decompensated renal function group was (28.9±11.9)ml/min. The average age of normal renal function group was 48.3 years old, the median value of serum creatinine before operation was 633μmol/L, while the average age of decompensated group was 63.8 years old, the median value of preoperative creatinine was 583 μmol/L. Renal area was measured in CT scan image which was performed when acute obstructive renal failure was diagnosed. Univariate analysis and logistic regression multivariate analysis was used to analyze these parameters. Receiver operating characteristic curve (ROC)was used to evaluate the performance of CT scan for renal function prediction. Results There were significant differences in the renal area between the normal renal function and decompensated renal function group, the total renal area were (3 765.5±628.6)mm2(range 2 375.3-4 853.6 mm2) and (2 493.0±830.6)mm2 (range 476.9-4 225.1 mm2) respectively(P<0.001), while the dominant side renal area were (2 283.5±430.2)mm2 (range 1 654.6-3 383.3 mm2) and (1 655.5±496.2)mm2 (range 476.94-2 816.0 mm2) respectively(P<0.001). The integration area under the ROC curve of the total renal area to predict the outcome of renal function was 0.89. Conclusions The renal area measured in CT scan image might be useful for the early prediction of renal function outcome in patients with acute obstructive renal failure. Key words: Kidney failure, acute; Upper urinary tract obstruction; Tomography; X-ray computed; Renal function

Epidemiological, Clinical and Therapeutic Profile of Obstructive Renal Failure

Aim: To describe the epidemiological, clinical, etiologic and therapeutic aspects of patients with acute obstructive renal failure at the Medical Surgical Center of Urology (MSCU). Materials and methods: this was a descriptive retrospective study of 106 patient records treated for acute renal failure from January 2012 to December 2016. Patients came for spontaneous consultation or were referred. They had benefited from a clinical and paraclinical assessment at the end of which the diagnosis of acute renal failure was retained and then an effective management at the MSCU. The variables studies were clinical, paraclinical, therapeutic and progressive. The treatment included: hemodialysis, urinary diversion (suprapubic, urethrovesical and ureteral), trans-urethral resection of the prostate, trans-urethral resection of the bladder, nephrostomy, endoscopic incision of catheter valves, posterior urethra or laparoscopic nephroureterectomy as indicated. The emergency treatments consisted of removing the obstacle and the etiological treatment was done later. External follow-up consultation varied by etiology. Results: In 4 years we had treated 106 patients, a frequency of 26.5%. The average age was 47.83 years with extreme of 2 and 80 years old. The sex ratio was 68 men for 38 women. The mean serum creatinine level was 37.8 mg/l (335 μmol/l). The etiologies were: prostatic pathologies (n = 38), lithiasic pathologies (n = 20) and gynecological pathologies (n = 18). The treatments were: endoscopic resection of prostate (n = 24), bladder (n = 6), posterior urethral valves (n = 4), JJ probe (n = 27) and nephrostomy (n = 23). The result was good (normalization of creatinine serum) in 79 patients, the persistence of elevated serum creatinine was observed in 4 patients and 18 patients died. Conclusion: Acute obstructive renal failure is a common diagnosis in our exercise setting at MSCU where it can be managed with respect to our technical platform.

Post-Obstructive Diuresis: Physiopathology, Diagnosis and Management after Urological Treatment of Obstructive Renal Failure

Obstructive acute renal failure is both a medical and a surgical emergency. The first treatment modality is urological by relief of obstruction. Post-obstructive diuresis is an abnormal condition of prolonged polyuria, involving both excessive solute and water loss, after acute drainage of obstructed urinary tract system. Physiopathology mechanisms are multiples. In most patients, diuresis will resolve once the kidneys normalize the volume and solute status and homeostasis is achieved. Post-obstructive diuresis can occur in up to 50% of patients with substantial urinary tract obstruction and can be life-threatening if it becomes pathologic. It can be detected by hourly monitoring of diuresis. Medical treatment of post-obstructive diuresis consists of oral or intravenous fluids adjusted to the findings of clinical examination, diuresis (volume and electrolytes) and close monitoring of patient. Fluid compensation should be tapered off over several days. Patients at high risk of post-obstructive diuresis should be identified and appropriately monitored.

A case report: giant urethral calculus

Urethral calculi are rare cases of lower urinary tract stones and represent 1-2% of all urinary stone diseases. They most commonly originate from the upper urinary tract or bladder or are associated with urethral abnormalities such as urethral stricture, urethral diverticulum, and foreign bodies. Occasionally, calculi grow to an enormous size and are labeled as a "giant urethral calculus". Urethral calculi most commonly occur in males. When a stone occludes the urethra, it can cause acute urinary retention, urethral injury, and obstructive renal failure. A 54-year-old male came to the emergency department at Saiful Anwar General Hospital Malang with a chief complaint of suprapubic pain, radiating to the right and left medial thigh and tip of the penis, accompanied by dribbling urine. Back pain radiated to the tip of the penis; there was a history of stone expulsion 4 years before, but he had not sought any medical attention. On physical examination, palpation identified a firm mass, 6 * 3cm, in the ventral penis. Urethrolithotomy (with penile shaft skin degloved to the penoscrotal junction, and ventral incision through two layers with Monosyn 5-0) was performed. A huge stone, 6 * 3.5cm, weighing 60 g was removed. A silicone catheter was maintained for 4 weeks. Postoperative recovery was uneventful. Giant urethral calculi are rare cases, occurring most commonly in males. A diagnosis of urethral calculus should be considered in patients with difficulty in urinating or urine retention who have an additional history of persistent lower back pain and calculus expulsion. Through accurate and proper management, it is important to prevent long-term complications caused by urethral stones.

A rare cause of acute post renal failure: Retroperitoneal fibrosis.

Retroperitoneal fibrosis is an inflammatory process which may cause acute renal failure. In patients who admitted to emergency services with obstructive uropathy, retroperitoneal fibrosis should be considered in the differential diagnosis. We present our ten cases who admitted to emergency department with obstructive acute renal failure related to retroperitoneal fibrosis.

Inguinal Bladder Hernia With Acute Ureteral Obstruction 14 Years After Kidney Transplantation: A Case Report

An 82-year-old man with a history of renal transplantation 14 years earlier presented with acute obstructive renal failure secondary to inguinal herniation of the urinary bladder complicated by ureteroneocystostomy entrapment. After percutaneous nephrostomy tube and endoscopic stent placement, the bladder was reduced and the hernia repaired with the use of a preperitoneal mesh. The postoperative course was uneventful and the renal function returned to normal. Inguinal herniation of the transplant ureter is a rare cause of hydronephrosis, but it has been described in the literature. Bladder hernias do usually not cause urologic complications in the nontransplanted patient, but they can present as an emergency after renal transplantation.

Insuffisance rénale aiguë obstructive : une lecture physiopathologique

Obstructive acute renal failure is a heterogeneous entity as the pathophysiology of intratubular obstruction is quite different from upper tract obstruction. In the former case, tubules are dilated due to a high hydrostatic pressure whereas pressures are normal in urinary upper tract. In the latter case, a high pressure above the ureteral obstacle is responsible for dilated renal cavities leading to extrinsic compression with no or only few dilated tubules though high hydrostatic pressure are recorded within tubules. Obstruction within tubules may be related to crystal formation, exfoliated cells, cellular debris and/or protein gels altogether with cell proliferation, proliferating cells, and recruitment of inflammatory cells. Though fibrosis may develop, the occurrence of atubular glomeruli in several nephrons due to an initial loss of tubular patency highlights the critical importance of maintaining a fluid flow within tubules in order to avoid uncontrolled tubular cell proliferation. The onset of tubular obstruction in few tubules, especially in crystal nephropathy is underestimated especially in chronic kidney disease patients, thus suggesting that some macromolecular solubilizing factors may be potential relevant therapy to prevent (and/or reverse) chronic kidney disease progression or decrease acute renal failure sequelae.

Impact of Insurance Status on the Prognosis of Acute Lower Limb Ischemia

The objective of this study was to investigate if the insurance status of patients impacted the treatment options and prognosis in acute limb ischemia (ALI). A retrospective chart review was performed at a single university tertiary care center using ICD-9 codes for the diagnosis and procedure for ALI from January 2000 to January 2011. A total of 96 patients were diagnosed with ALI, comprising of 66 males and 30 females with a mean age of 56 years (range was 19 - 80 years). Time to presentation and prognosis (rate and level of amputation) were analyzed using insurance status as the independent variable. Patients covered under commercial insurance were compared to patients with Medicare and Medicaid and to patients without any insurance coverage. Statistical analysis was performed using the proportion z test to evaluate differences among the groups investigated. A “p” value of ≤0.05 was considered significant. In this study, ALI occurred more commonly in African Americans (p = 0.0029) and in patients without insurance coverage regardless of race (p = 0.0034). Chronic obstructive pulmonary disease (COPD), hypertension (HTN), and acute renal failure (ARF) were significantly higher in the uninsured group, compared to the insured group (p = 0.0005, 0.0055, and 0.0034, respectively). The time to hospital admission was significantly longer in uninsured patients compared to the insured group (p = 0.0449). The rates of major amputation above the ankle were 46% in patients with commercial insurance, 62% in the government insurance (Medicare and Medicaid) group, and 51% in the uninsured group. There was no significant difference in major versus minor amputation in patients with commercial insurances. However, the rates of major amputation were significantly higher than the rates of minor amputation in both Medicare and Medicaid and uninsured patients (p = 0.005, and <0.0001, respectively). With respect to acute lower limb ischemia, African Americans presented more frequently and were more likely to be uninsured. The incidences of COPD, HTN, and ARF were significantly higher in uninsured patients. The majority of the amputations in Medicare and Medicaid and uninsured populations were likely above the ankle. Results suggest that government insurance coverage does not prevent major amputation in patients with ALI.

Insuffisance rénale aiguë obstructive de l’adulte en réanimation : prise en charge et facteurs pronostiques

L'insuffisance renale aigue obstructive est une cause plutot rare parmi les causes d'insuffisance renale aigue traitees en reanimation. Lors d'une obstruction des voies urinaires, on observe une reduction du debit de filtration glomerulaire. Apres derivation des urines, les risques sont la survenue d'un syndrome de levee d'obstacle et les lesions renales chroniques sequellaires. Le diagnostic positif est le plus souvent simple et dans la moitie des cas, la cause de l'obstruction est tumorale. Si des desordres hydro-electrolytiques et une surcharge hydrosodee majeure peuvent justifier une prise en charge prealable, le traitement repose d'abord sur la derivation des urines. Le syndrome de levee d'obstacle, qui survient dans 60 % des cas chez les patients de reanimation et dure en moyenne deux jours, doit etre pris en charge dans un milieu ou une surveillance etroite est possible. Sa survenue est correlee a une meilleure recuperation renale. L'evolution vers une insuffisance renale terminale reste rare.