Severe Chronic Renal Insufficiency Research Articles

Exacerbation of Congestive Heart Failure After Administration of Polyethylene Glycol–Electrolyte Lavage Solution

To report a patient with exacerbation of congestive heart failure after administration of polyethylene glycol-electrolyte lavage solution (PEG-ELS). A MEDLINE search was performed, using the terms congestive heart failure (CHF), gastric lavage, colonoscopy, irrigation, and gastroparesis, of English-language articles published from January 1980 through January 1995, as well as review of pertinent articles' bibliographies. A 45-year-old white woman with left ventricular systolic dysfunction and diabetic gastroparesis received 4 L of a PEG-ELS as preparation for colonoscopy. Within 24 hours she presented to the emergency department with shortness of breath and increased bilateral lower extremity edema. She was admitted and treated with intravenous furosemide therapy. After aggressive diuresis her symptoms returned to baseline and she was discharged. The literature search revealed no report of a patient requiring hospitalization as a result of sodium and water retention after bowel preparation with PEG-ELS. CHF is not considered a contraindication to the use of this solution; however, most studies that included patients with heart failure did not describe the degree of left ventricular dysfunction. Our patient's severe CHF, in combination with chronic renal insufficiency, resulted in significant retention of sodium and water. Patients with severe left ventricular dysfunction and chronic renal insufficiency who are being considered for procedures that necessitate bowel cleansing with PEG-ELS may be at risk for sodium and water retention and exacerbation of CHF.

Plasma protein homeostasis in chronic hemodialysis patients.

The concentrations of 25 plasma proteins were measured in 29 patients with chronic renal insufficiency. All the patients had terminal renal failure and were treated with intermittent hemodialysis, but were otherwise in good general condition at the time of investigation. The plasma levels of 8 proteins with M(r) < 50 kD were significantly elevated compared to normal subjects. In contrast, only 2/17 proteins of greater size were found in increased concentrations. The degree of increase in concentration differed substantially between individual low molecular weight proteins, suggesting a complex metabolism in addition to delayed renal elimination. Acute phase proteins and immunoglobulins were not affected by renal insufficiency per se, although erythrocyte sedimentation rates were generally high. The synthesis of acute phase proteins increased normally during the course of inflammation. We conclude that although the sedimentation rate is of no value, complicating inflammatory processes can be traced by quantitative analysis of acute phase proteins, including C-reactive protein, even in patients with severe chronic renal insufficiency.

Loop Diuretics for Chronic Renal Insufficiency: A Continuous Infusion Is More Efficacious Than Bolus Therapy

To test the hypothesis that a continuous, low-dose infusion of a loop diuretic is more efficacious and better tolerated than conventional intermittent bolus therapy in patients with severe chronic renal insufficiency (CRI). Randomized, crossover clinical trial with subjects serving as their own controls. The General Clinical Research Center of Indiana University Hospital, Indianapolis, Indiana. Eight adult volunteers with severe stable CRI (mean creatinine clearance, 0.28 mL/s; range, 0.15 to 0.47 mL/s) were recruited from the outpatient nephrology clinics of Indiana University Medical Center. On admission, diuretic drugs were withdrawn and patients were equilibrated on an 80 mmol/d sodium, 60 mmol/d potassium metabolic diet. Patients were randomized to receive a 12-mg intravenous dose of bumetanide given either as two 6-mg bolus doses separated by 6 hours or as the same total dose administered as a 12-hour continuous infusion. When sodium balance was re-established, each patient was crossed over to the alternative study limb. All patients completed both phases of the study. Comparable amounts of bumetanide appeared in the urine during the study period (infusion, 912 +/- 428 micrograms; bolus, 944 +/- 421 micrograms; difference, 32 micrograms; 95% CI, -16 micrograms to 80 micrograms, P = 0.16). The continuous infusion resulted in significantly greater net sodium excretion (infusion, 236 +/- 77 mmol; bolus, 188 +/- 50 mmol; difference, 48 mmol; CI, 16 mmol to 80 mmol, P = 0.01). No patient had episodes of drug-induced myalgias during the continuous infusion compared with 3 of 8 patients with bolus therapy. In patients with severe CRI, a continuous intravenous infusion of bumetanide is more effective and less toxic than conventional intermittent bolus therapy. Continuous administration will probably be useful in patients with severe CRI who have not achieved an adequate natriuresis or who show evidence of drug toxicity with standard diuretic dosing regimens. A similar benefit may occur in selected diuretic-resistant patients with cardiac or hepatic disease, and studies in these patients seem warranted.

Cyclosporine-induced pericardial effusion after cardiac transplantation

In the last 5 years, there has been a significant proliferation in the number of centers in which orthotopic cardiac transplantation is performed. This has been attributed to better surgical management, patient selection criteria and the introduction of cyclosporine as the immunosuppressant of choice. 1 Initially, it was hoped that cyclosporine would prevent the problems of sudden, catastrophic rejection, development of a Cushingoid appearance and other complications of high-dose steroid therapy. It was also hoped that by monitoring drug levels and titrating the dose, the incidence and severity of rejection would decrease, the length of hospitalization in the immediate postoperative period would decrease and both short-term and long-term survival would increase. 2 It soon became apparent, however, that long-term cyclosporine immun osuppression is associated with severe systemic hypertension and progressive chronic renal insufficiency. 3 Both complications of cyclosporine therapy may lead to the necessity of decreasing the dose of cyclosporine, a readjustment of immunosuppressive protocols to low-dose triple drug therapy (azathioprine, prednisone and cyclosporine) and even the necessity of withdrawing cyclosporine. 4 Less frequently, we have observed significant pericardial effusions in patients who have received cardiac allografts. We will discuss our observations of pericardial disease in the orthotopic cardiac recipient maintained on cyclosporine.

Renovascular operations in patients with chronic renal insufficiency: Do the benefits justify the risks?

To define the benefits and risks of renal revascularization or nephrectomy in patients with both severe hypertension and chronic renal insufficiency, we analyzed 98 patients who underwent renovascular operations after serum creatinine levels exceeded 2 mg/dl. This subset of patients was selected from a retrospective review of 652 renal operations performed at the Mayo Clinic for renovascular disease between 1970 and 1981. Special attention was given to the type of operations, their effect on hypertension and renal function, specific factors that affected operative deaths, and late survival. Unilateral renal operations were performed in 48 patients with bilateral procedures in 50. Simultaneous aortic reconstruction was necessary in 55 patients (56%). Postoperative diastolic blood pressure was less than 90 mm Hg in 55% of patients and 90 to 100 mm Hg in an additional 33%. Seventy-six percent of patients required less antihypertension medication. Serum creatinine improved or stabilized in 69%. Ninety percent of patients avoided any early or late renal dialysis. The operative mortality rate was 7.1% and tended to be higher in patients with a serum creatinine greater than 3 mg/dl and in those with past myocardial infarction (p = 0.05). The late survival rate was 64% at 5 years. The main cause of operative and late death was myocardial infarction. In conclusion, most patients with renovascular hypertension and early chronic renal insufficiency can be benefited by surgical revascularization or nephrectomy. Future improvement in early and late survival may require a more aggressive approach to the identification and correction of significant coronary artery disease.

Oral piretanide in chronic renal failure.

1 The effects of high doses of piretanide, a new diuretic agent chemically related to frusemide and bumetanide were evaluated in twelve patients with severe chronic renal insufficiency (creatinine clearance below 25 ml/min). 2 Patients received either 30 mg or 60 mg piretanide orally after a water load of 11. Urine volume and the excretion of electrolytes, creatinine, urea and uric acid were measured over the subsequent 24 h. 3 Piretanide produced an effective diuresis and natriuresis in these patients, its action being broadly similar to those of bumetanide and frusemide observed in previous studies.

Does uremic enterocolitis exist?

In rats a severe but compensated chronic renal insufficiency was induced by stepwise 9/10 nephrectomy. Despite this severe chronic renal insufficiency we observed no relevant pathological changes in the intestinal mucosa. In particular, we found no evidence of mucosal erosions, ulceration or pseudomembranous colitis, findings which are traditionally thought to be characteristic of the uremic state. This was also true of those animals dying prematurely from uremia. Thus serious doubts arise about the existence of "uremic enterocolitis", doubts which also proved justified after a critical review of the literature on human pathology.

Surgical management of persistence or recurrence after subtotal parathyroidectomy for primary hyperparathyroidism

(1) In an experience with 44 patients requiring subtotal parathyroidectomy for primary hyperparathyroidism due to multiple gland involvement, persistence was identified in 3 patients and recurrence in 3, resulting in a failure rate of 14 per cent. (2) The development of chronic renal insufficiency secondary to hyperparathyroidism appears to be an aggravating factor in the failure of subtotal parathyroidectomy to control hypercalcemia in such cases. An associated MEN-1 syndrome may possibly also be a predisposing factor. (3) Overlooked supernumerary hyperfunctioning parathyroid glands may be the cause of persistent hypercalcemia. (4) If reoperation is performed, ultrasonography of the neck and computerized tomography of the mediastinum are justified preoperatively for localization studies. (5) If hyperplasia of the preserved remnant of parathyroid is the only explanation for failure of subtotal parathyroidectomy, its removal is justified with autotransplantation of parathyroid tissue and freezing of additional tissue for possible future use. (6) The presence of moderate or severe chronic renal insufficiency, related to primary hyperparathyroidism, appears to justify total parathyroidectomy with autotransplantation for primary hyperparathyroidism due to multiple gland involvement. (7) Periodic reevaluation is indicated for all patients after operation, especially subtotal parathyroidectomy, for primary hyperparathyroidism due to multiple gland involvement. If mild or borderline hypercalcemia persists or recurs, close follow-up study is indicated.

A Study of the Renin-Angiotensin System in Patients with Severe Chronic Renal Insufficiency

Plasma renin activity was measured before and after dialysis in 27 uremic patients on a chronic dialysis program. Pre-dialysis renin levels were variable; the highest value occurred in the only patient with malignant hypertension. With this exception, there was no correlation between blood pressure and renin. Renin substrate levels were normal. After dialysis, renin activity rose significantly. There is a suggestive correlation between the decrease in mean arterial pressure and the increase in renin activity during dialysis. Biopsy and autopsy specimens of four kidneys examined with the Bowie stain demonstrate some normal JG cells with granules in the severely scarred kidneys. These cells may synthesize renin at an enormous rate to maintain normal plasma levels. In addition, uremic plasma appears to be deficient of a normal inhibitor or possibly contains an accelerator of the reaction between renin and its substrate.

The Qualitative Platelet Defect in Chronic Renal Insufficiency.

Excerpt A qualitative platelet abnormality exists in certain patients with renal failure. We studied this phenomenon in five patients with bleeding due to severe chronic renal insufficiency. The de...

The Limits of Renal Functional Adjustment in Uremia.

s1 May 1961The Limits of Renal Functional Adjustment in Uremia.S. E. Bradley, M.D., F.A.C.P.S. E. Bradley, M.D., F.A.C.P.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-54-5-1061_2 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptThe capacity of the kidney to adjust to various stressful conditions has been studied in patients with severe chronic renal insufficiency, secondary to chronic renal disease.Changes in excretion of water, sodium, and potassium have been studied in relation to output of inulin and sodium para-aminohippurate during abdominal compression or assumption of the upright position. The results indicate a much more pronounced ability to alter urinary composition and volume than is evident clinically.... This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: New York, N. Y. (CS) PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 May 1961Volume 54, Issue 5Page: 1061-1061KeywordsChronic kidney diseaseExcretionPotassiumRenal diseasesSodium ePublished: 1 December 2008 Issue Published: 1 May 1961 PDF downloadLoading ...

AMBULATORY MANAGEMENT OF AZOTEMIA AND CLINICAL UREMIA

DURING a nine month period, 21 patients with azotemia and clinical uremia having serum creatinine concentrations of over 3 mg. and serum urea concentrations of over 80 mg. per hundred cubic centimeters were treated in the Clinic for Renal Disease of the Stanford University School of Medicine. Their illnesses varied in severity from azotemia without symptoms to frank clinical uremia. Most of these patients were in the terminal stage of glomerular nephritis. One patient had polycystic kidneys, and 1 had chronic uremia of obscure origin. It has been our experience, which is in conformity with past experience gained in the Clinic, that such patients can be managed satisfactorily on an ambulatory basis until the final stages of renal failure. In addition, the irregular and unpredictable course of severe chronic renal insufficiency has impressed on us the fact that there is always some hope that the patient may continue to lead