Vigorous Intravenous Hydration Research Articles

SAT676 Severe Recurrent Pancreatitis In A Familial Partial Lipodystrophy Patient On Metreleptin

Abstract Disclosure: P. Sargin: None. M. Vinicky: None. A. Biglione: None. Lipodystrophy syndromes are congenital or acquired disorders characterized by either total or partial lipoatrophy and often unrecognized by clinicians due to their rarity. Patients with lipodystrophy may demonstrate severe complications of metabolic syndrome since lipids are deposited in non-adipose organs where they induce lipotoxicity resulting in insulin resistance, diabetes mellitus, hypertriglyceridemia, and hepatic steatosis. Familial Partial Lipodystrophy (FPLD) syndromes are one of the four major subtypes of lipodystrophy syndromes. These are heterogeneous, mostly autosomal dominant, and characterized by site-specific subcutaneous adipose tissue loss. The management of patients with FPLD can be challenging with life-threatening complications, heavy dependence on lifestyle modifications, limited treatment options and medication availability. One of the important complications seen in these patients is pancreatitis, related to high triglyceride levels. It can be recurrent and the episodes can be more severe compared to the general patient population. Metreleptin, the human leptin analogue, is the only disease-specific treatment for lipodystrophy syndromes and it has been shown to reduce the complications of leptin deficiency, but it is not currently approved for FPLD in the USA. Previous studies showed improvement of the complications of FPLD with its use. Our case is a 29-year-old woman who has Dunnigan type FPLD with a history of numerous bouts of pancreatitis while on fenofibrate, statin and omega-3-acid ethyl esters, later was on metreleptin for almost 3 years, presented to our hospital with typical symptoms of acute pancreatitis incited by severe hypertriglyceridemia (>1,500 mg/dL). Lipase levels were high at 27,501. Patient was treated with vigorous intravenous hydration, insulin and home metreleptin was continued at the hospital. Despite the initial improvement of the symptoms, on the 6th day of hospitalization, she developed worsening abdominal pain, nausea, and vomiting. CT angiogram of the abdomen showed 2.0 cm splenic artery pseudoaneurysm. Coiled embolization of the superior segmental branch of the splenic artery performed by interventional radiologist which was further complicated by splenic infarction. Her condition improved eventually, she was able to be discharged home. Importance of adherence to medications and special diet was discussed with the patient in length. This case report aims to bring attention to this rare disease and urgent need for further treatment options for these patients to prevent serious complications in this young patient population. Metreleptin is a daily injection which could be challenging to adherence and the consequence can be relapse of pancreatitis. Lack of other treatment options, treatment availability, physician awareness are barriers to optimize the treatment for these complex patients. Presentation: Saturday, June 17, 2023

A Review of Current Clinical Concepts in the Pathophysiology, Etiology, Diagnosis, and Management of Hypercalcemia.

Calcium is the most abundant extracellular cation in the body, and it is responsible for structural and enzymatic functions. Calcium homeostasis is regulated by 3 factors: calcitonin, vitamin D, and parathyroid hormone (PTH). Hypercalcemia is defined by a serum calcium concentration >10.5 mg/dL, and it is classified into mild, moderate, and severe, depending on calcium values. Most cases are caused by primary hyperparathyroidism and malignancies. Various mechanisms are involved in the pathophysiology of hypercalcemia, such as excessive PTH production, production of parathyroid hormone-related protein (PTHrp), bone metastasis, extrarenal activation of vitamin D, and ectopic PTH secretion. The initial approach is similar in most cases, but a definitive treatment depends on etiology, that is why etiological investigation is mandatory in all cases. The majority of patients are asymptomatic and diagnosed during routine exams; only a small percentage of patients present with severe manifestations which can affect neurological, muscular, gastrointestinal, renal, and cardiovascular systems. Clinical manifestations are related to calcium levels, with higher values leading to more pronounced symptoms. Critically ill patients should receive treatment as soon as diagnosis is made. Initial treatment involves vigorous intravenous hydration and drugs to reduce bone resorption such as bisphosphonates and, more recently, denosumab, in refractory cases; also, corticosteroids and calcitonin can be used in specific cases. This review aims to provide a clinical update on current concepts of the pathophysiology of calcium homeostasis, epidemiology, screening, clinical presentation, diagnosis, and management of hypercalcemia.

Calcium Mediates the Phosphaturia in Hypercalcemia of Malignancy

Background: Humoral hypercalcemia of malignancy (HHM) is claimed to be caused by circulating parathyroid hormone like peptide (PTHrP) that shares several of the cardinal biochemical and skeletal histological features with hyperparathyroidism (HPT). Both syndromes are characterized by hypercalcemia from increased renal tubular reabsorption of filtered calcium, increased urinary cyclic AMP, renal phosphate wasting and hypophosphatemia, in contrast to low 1,25(OH)2D levels, metabolic alkalosis, and uncoupled bone formation-resorption rate in HHM. The aim of the study was to reassess if phosphaturia of HHM can be attributed to hypercalcemia rather than to humoral effect of PTHrP. Methods: A prospective study was conducted at Mount Sinai Services at Queens Hospital Center, NY. Results: Nine (four females and five males) out of 20 patients with hypercalcemia of malignancy documented having elevated PTHrP, normal renal function, and low PTH levels were finalized for the study. Serum calcium, phosphate, creatinine, albumin, and PTHrP concentration were determined. On the initiation of hydration, 24 h urine for creatinine, calcium and phosphorous were also collected. Blood and urine tests were repeated after serum calcium levels had been decreased by at least 1.5 mg/dL. All patients received vigorous intravenous hydration with normal saline at 200 cc/h. After the first 24 h, small doses of furosemide were given to two out of nine patients for 48 - 72 h. Hydration has shown statistically significant decrease in serum calcium concentration (13.9 ± 2.1 to 10.8 ± 1.48 mg/dL; P < 0.001) and increase in tubular reabsorption of phosphate (TRP) (69.54±8.16% to 77.85±12.24%; P < 0.01). However, PTHrP levels have shown no statistically significant difference on hydration therapy. Conclusion: Improvement of hypercalcemia by hydration reverses phosphaturia without reducing PTHrP levels. It is being proposed that in HHM, PTHrP can lead to hypercalcemia from uncoupled bone formation-resorption rate through a local autocrine or paracrine action produced by bony micrometastases that could not be demonstrated radiologically, rather than from PTHrP’s humoral effect. J Endocrinol Metab. 2017;7(2):55-60 doi: https://doi.org/10.14740/jem402w

Cholera gravis associated with acute renal failure in a traveler from Haiti to the United States

Cholera is a gastroenteric disease caused by epidemic or pandemic Vibrio cholerae which still is responsible for over 100,000 annual deaths worldwide. Since October 2010, Haiti experienced a cholera outbreak affecting more than 300,000 persons. Few imported cases related to the Haitian epidemic have been reported so far in the United States and Canada. We presented a patient who developed cholera gravis soon after arrival at New York City from Haiti. The patient needed admission to an Intensive Care Unit, for vigorous intravenous hydration, antibiotic therapy, and hemodialysis due to refractory oliguric renal failure. The patient was discharged the day 6 after admission and V. cholerae O1 was isolated from the stool culture. Cholera can be a life-threatening disease; early recognition based on travel history and clinical features is the corner stone for successful management.

Tumor Lysis Syndrome

Tumor lysis syndrome (TLS) refers to the constellation of deranged metabolic state, characterized by hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, and/or azotemia, secondary to rapid breakdown of tumor cells. It is a life threatening emergency that typically follows administration of chemotherapy or may be spontaneous. Malignancies which have a large tumor burden, rapid turnover, as well as speedy breakdown following chemotherapy are susceptible. Acute lymphoblastic leukemia and non-Hodgkins lymphoma (particularly Burkitt's lymphoma) are typically predisposed. TLS is best managed by early anticipation and preventive measures than the complicated task of treating an established TLS. Vigorous intravenous hydration is the cornerstone of prevention as well as treatment. Rasburicase has revolutionized the management. It is available in India for past 1 1/2 y, although the cost is a limiting factor. Children with acute leukemia in developing countries may reach health facility late, with severe anemia and hyperleukocytosis. Exchange transfusion may have to be restored to in such patients to simultaneously correct anemia and hyperleukocytosis and enable safe administration of fluids. Dialysis may be required when the metabolic 'trash' overwhelms the renal excretion, resulting in renal failure. Chemotherapeutic drugs are often administered in a phased manner in susceptible patients, in an attempt to prevent precipitous lysis of tumor cells. Presentation and management of TLS in relevance to the pediatric emergency room is outlined.

Acute Renal Failure Associated with Bilateral Enlargement of the Kidneys: A Rare Manifestation of Acute Lymphoblastic Leukemia (ALL)

We report a 6-year-old patient who presented with acute renal failure resolving after vigorous intravenous hydration. Renal biopsy was taken because of unexplained enlargement of both kidneys. Histological workup showed infiltration by lymphoblasts while blood counts showed a normal differential. Subsequent bone marrow aspiration revealed 34% lymphoblasts of T-lineage origin, leading to the diagnosis of T-ALL. This case underlines that malignant hematologic infiltration should be considered in patients presenting with unexplained renal failure and enlarged kidneys.

Microbiology and Management of Neonatal Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a clinical syndrome of ischemic necrosis of the bowel of multiple etiological factors that include the presence of intestinal ischemia, abnormal bacterial flora, and intestinal mucosal immaturity. Numerous reports have implied that the fecal microflora may contribute to the pathogenesis of NEC. A broad range of organisms generally found in the distal gastrointestinal tract have been recovered from the peritoneal cavity and blood of infants with NEC. The predominant organisms include Enterobacteriaceae (i.e., Escherichia coli, Klebsiella pneumoniae) , Clostridium spp., enteric pathogens (salmonellae, Coxsackie B2 virus, coronavirus, rotavirus), and potential pathogens (Bacteroides fragilis). The goals of the initial management is preventing ongoing damage, restoring hemostasis, and minimizing complications. Medical management includes withholding oral feeding, placement of nasogastric tube, abdominal decompression, paracentesis, vigorous intravenous hydration containing electrolytes and calories, support of the circulation, administration of antibiotics, and surveillance for deterioration or complications that require surgical intervention. Indications for surgery include clinical deterioration, perforation, peritonitis, obstruction, and abdominal mass. Prevention remains crucial to decrease the incidence of NEC. Preventive methods include cautious feeding regimens, the use of maternal breast milk, and the use of probiotics.

Second Prize: Forced versus Minimal Intravenous Hydration in the Management of Acute Renal Colic: A Randomized Trial

The management of acute renal colic is a problem commonly encountered by both urologists and emergency medicine physicians. The classic approach to managing uncomplicated acute renal colic involves hydration, along with imaging and pain control. Previous studies have suggested that hydration has a significant impact on patient comfort, as well as spontaneous stone passage. This study evaluated the effects of maintenance v forced hydration and its effect on the pain experienced from renal colic. Forty male and 18 female patients with a mean age of 41 years suspected to have acute renal colic were identified in the emergency department. After screening and informed consent, the patients were enrolled in the study, and 43 patients were eventually available for analysis. Patients received intravenous (IV) analgesia, imaging with a noncontrast CT scan of abdomen and pelvis, and assignment to either forced IV hydration with 2 L of normal saline over 2 hours (N = 20) or minimal IV hydration at 20 mL of normal saline per hour (N = 23). A visual analog pain scale was completed hourly for a total of 4 hours. Demographic information, laboratory and imaging results, narcotic use in morphine equivalents (ME), and pain scores were recorded and compared. Spontaneous stone passage rates were also calculated by careful patient follow-up. Results were considered statistically significant at p < 0.05. Stone size was equivalent in the two treatment groups (p > 0.05). There was no difference in the narcotic requirement in ME (p = 0.644) between the two groups. Similarly, there was no difference in hourly pain score or stone-passage rates between the groups (p > 0.05). Treatment of uncomplicated renal colic has traditionally included vigorous intravenous hydration, as well as medications for the control of pain and nausea. Our data suggest that maintenance intravenous fluids are as efficacious as forced hydration with regard to patient pain perception and narcotic use. Moreover, it appears the state of hydration has little impact on stone passage.

Tumor lysis syndrome associated with weekly paclitaxel treatment in a case with ovarian cancer

Background. Tumor lysis syndrome (TLS) is characterized by biochemical changes such as hyperuricemia and hyperkalemia due to rapid tumor lysis of malignant cells, usually after chemotherapy. TLS is a rare complication in nonhematological malignancies. Case. A 53-year-old female received intravenous weekly paclitaxel for recurrent ovarian cancer with massive ascites. Five days following the administration of paclitaxel, the patient developed TLS. She responded well to appropriate treatment with a combination of vigorous intravenous hydration, furosemide, allopurinol, and sodium bicarbonate. Conclusion. This case report describes the first patient to develop TLS following paclitaxel administration for ovarian cancer. Our case is extremely exceptional because TLS occurred after the low dosage administration of paclitaxel for relatively insensitive tumor types without any risk factors.

Exertional Rhabdomyolysis

Exertional Rhabdomyolysis

Consensus of primary care in acute pancreatitis in Japan

The incidence of acute pancreatitis in Japan is increasing and ranges from 187 to 347 cases per million populations. Case fatality was 0.2% for mild to moderate, and 9.0% for severe acute pancreatitis in Japan in 2003. Experts in pancreatitis in Japan made this document focusing on the practical aspects in the early management of patients with acute pancreatitis. The correct diagnosis of acute pancreatitis and severity stratification should be made in all patients using the criteria for the diagnosis of acute pancreatitis and the multifactor scoring system proposed by the Research Committee of Intractable Diseases of the Pancreas as early as possible. All patients diagnosed with acute pancreatitis should be managed in the hospital. Monitoring of blood pressure, pulse and respiratory rate, body temperature, hourly urinary volume, and blood oxygen saturation level is essential in the management of such patients. Early vigorous intravenous hydration is of foremost importance to stabilize circulatory dynamics. Adequate pain relief with opiates is also important. In severe acute pancreatitis, prophylactic intravenous administration of antibiotics at an early stage is recommended. Administration of protease inhibitors should be initiated as soon as the diagnosis of acute pancreatitis is confirmed. A combination of enteral feeding with parenteral nutrition from early stage is recommended if there are no clear signs and symptoms of ileus and gastrointestinal bleeding. Patients with severe acute pancreatitis should be transferred to ICU as early as possible to perform special measures such as continuous regional arterial infusion of protease inhibitors and antibiotics, and continuous hemodiafiltration. The Japanese Government covers medical care expense for severe acute pancreatitis as one of the projects of Research on Measures for Intractable Diseases.

Optimization of cardiac preload during laparoscopic donor nephrectomy: A preliminary study of central venous pressure versus esophageal doppler monitoring

While the popularity of laparoscopic donor nephrectomy (LDN) has increased, concern persists about the potential deleterious effects of pneumoperitoneum on renal function. Thus, preload optimization with vigorous intravenous hydration has been recommended. The purpose of this study was to compare central venous pressure (CVP) monitoring with a noninvasive measure of cardiac preload (esophageal Doppler) during LDN. Thirteen patients were studied. Following induction of general anesthesia, a Doppler probe was inserted in the lower third of the esophagus to measure flow time corrected for heart rate (FTc), which is an index of preload. In 10 patients, a catheter was placed in the right internal jugular vein and CVP measured. CVP and FTc were measured at baseline in the supine and right lateral decubitus positions, then 15 and 60 min after the establishment of CO(2) pneumoperitoneum (12-15 mmHg). IV fluids were increased if the FTc fell below 300 msec. Results are expressed as means (+/-SD). Data were analyzed using repeated measures ANOVA. Lateral positioning and pneumoperitoneum significantly increased CVP from baseline ( p < 0.01), while the FTc did not change ( p = 0.57). After 60 min of pneumoperitoneum, the FTc was <300 msec in only one patient. CVP is not an accurate guide for administration of IV fluids during LDN. Esophageal Doppler monitoring can be used to noninvasively follow changes in preload during LDN and is worthy of further study.

Diuretic renogram clearance half-times in the diagnosis of obstructive uropathy: effect of age and previous surgery

Diuretic renography with radiotracers has been used successfully to diagnose obstruction in patients with hydronephrosis. Controversy persists with regard to the best approach for the interpretation of renogram curves: visual analysis or a quantitative index, i.e. the clearance half-time. The latter is often reported to be in the intermediate or non-diagnostic range. It is important to measure the incidence of equivocal half-times in various subsets of patients with hydronephrosis in order to determine in which settings the measurement of this index may be clinically useful. We performed a retrospective study of diuretic renograms performed at our institution between 1997 and 2000 for the evaluation of suspected uretero-pelvic junction (UPJ) obstruction. Vigorous intravenous hydration, exceeding current guidelines, was employed in these patients. Three hundred and seventy-seven renogram curves in 205 patients were analysed. Patients were divided into three groups: >1 year of age; <or=1 year of age; and those who had previously undergone surgical correction of obstruction regardless of age. Patients with reflux or anatomical abnormalities of the urinary tract, those with chronic renal failure, those with bilateral normal clearances before furosemide administration and those with unilateral normal clearances before furosemide administration with contralateral poor renal function were excluded. In the remaining 119 patients, 205 clearance half-times were classified as normal before furosemide, normal after furosemide (half-time, <10 min), prolonged (half-time, >20 min) or intermediate (half-time, 10-20 min). In patients >1 year of age, 37% of 101 renograms showed normal half-times before furosemide, 20% showed normal half-times after furosemide, 44% showed prolonged half-times and none (0%) showed an intermediate half-time. In patients </=1 year of age, there was a statistically significantly different distribution, with 48% of 64 renograms showing normal washout before furosemide, 16% showing normal clearance after furosemide, 19% showing abnormal half-times and 17% showing intermediate half-times. In 33 renograms from patients who had undergone corrective surgery, 49% had normal half-times, 24% had prolonged half-times and 27% had intermediate half-times. It can be concluded that, when using the selection criteria, hydration, acquisition and processing protocols and half-time definition employed in this study, the addition of a clearance measurement in patients older than 1 year with suspected UPJ disease enhances patient classification and may improve the diagnostic confidence. There was a significantly higher incidence of intermediate half-times in patients with native disease aged <1 year than in those >1 year. Caution is advised when interpreting this finding in this age group. The measurement of washout was less useful in patients who had undergone a corrective procedure, because of the high rate of 'indeterminate' and 'abnormal' values in spite of successful surgery. Vigorous intravenous hydration, exceeding current standards, may have contributed to the lower incidence of intermediate half-times than reported previously.

Exercise-Induced Upper Extremity Rhabdomyolysis and Myoglobinuria in Shipboard Military Personnel

During a 6-month Amphibious Task Force deployment to the Mediterranean Sea, five sailors and Marines were admitted to the ship's ward with severe upper extremity pain, elevated serum muscle enzymes, and a urinalysis dip positive for blood in the absence of microscopic hematuria-a finding highly suggestive of myoglobinuria. Each patient had begun a vigorous upper-extremity work-out program in the ship's weight room 1 to 3 days prior to development of symptoms. All responded well to vigorous intravenous hydration, mannitol diuresis, alkalinization of the urine, and skeletal muscle rest. No patient developed acute tubular necrosis. With increasing emphasis on physical fitness and body building, this condition is likely to become more frequent. The most important preventive measure is gradual conditioning. Awareness of this entity and early aggressive management are necessary to avoid the potentially severe complication of renal failure.

Massive cisplatin overdose by accidental substitution for carboplatin. Toxicity and management

Unlike the related drug carboplatin, cisplatin is highly nephrotoxic and must be given with vigorous intravenous hydration at a much lower dose. As the result of an accidental substitution of cisplatin for carboplatin, a 68-year-old woman received a massive overdose of cisplatin without intravenous hydration. Laboratory documentation included measurements of platinum concentrations by atomic absorption spectroscopy and of xeroderma pigmentosum group E (XPE) binding factor, a protein that is involved in the recognition step of DNA repair. Toxicities included severe emesis, myelosuppression, renal failure, and deafness, which are well known. Other toxicities were seizures, hallucinations, loss of vision, and hepatic toxicity, which were unusual and may have been caused by the magnitude of the overdose. As late as day 19, there was a continued cellular response from cisplatin, as evidenced by decreased levels of XPE binding factor in extracts from the patient's peripheral blood lymphocytes. Plasmapheresis was effective in lowering the platinum concentration from greater than 2900 ng/ml to 200 ng/ml and appeared to be of clinical benefit. Even after the onset of renal failure, hydration to increase urine volume resulted in increased urinary excretion of platinum. Granulocyte-macrophage colony-stimulating factor (GM-CSF) was used to ameliorate myelosuppression. The patient received a transplanted kidney from her monozygotic twin sister and survived with no clinically significant deficit except for deafness. No previous reports exist of survival after such a high dose of cisplatin without intravenous hydration. In the future, patients may benefit from similar management and heightened awareness of the possibility of accidental substitution.

Acute iron intoxication in pregnancy: Case report and review of the literature

Limited reports exist regarding acute iron intoxication during pregnancy. The maternal and fetal effects of accidental or deliberate ingestion of large amounts of iron may be catastrophic. A case report of acute iron intoxication, management strategies, and a review of the literature are presented. The cornerstones of effective therapy are aggressive management with emesis induction or gastric lavage, bicarbonate instillation, vigorous intravenous hydration, and chelation therapy with deferoxamine.

Malignant hypercalcemia. The choice of therapy

Malignant hypercalcemia is the leading cause of hypercalcemia in hospital practice and is the most common life-threatening metabolic disorder associated with cancer. 1,2 Left unattended, clinical deterioration is often rapid, resulting in profound volume depletion, azotemia, neuromuscular irritability, and progressive obtundation. When it is properly managed, however, responses may be gratifying, with symptomatic improvement achieved within days of initiation of treatment. The ideal treatment of patients with cancer-related hypercalcemia is cytoreductive therapy directed against the underlying malignancy. For the vast majority of patients, however, this is an unrealistic option, since most have advanced disease and have failed primary cytotoxic therapy. In the acute setting, measures to restore plasma volume and enhance calciuresis with vigorous intravenous hydration remain the cornerstone of therapy. Although this treatment is effective in the short term, fewer than 30% of patients can be expected to achieve normocalcemia with hydration alone, 3,4 and most will require additional

Malignant Hypercalcemia

Malignant hypercalcemia is the leading cause of hypercalcemia in hospital practice and is the most common life-threatening metabolic disorder associated with cancer. 1,2 Left unattended, clinical deterioration is often rapid, resulting in profound volume depletion, azotemia, neuromuscular irritability, and progressive obtundation. When it is properly managed, however, responses may be gratifying, with symptomatic improvement achieved within days of initiation of treatment. The ideal treatment of patients with cancer-related hypercalcemia is cytoreductive therapy directed against the underlying malignancy. For the vast majority of patients, however, this is an unrealistic option, since most have advanced disease and have failed primary cytotoxic therapy. In the acute setting, measures to restore plasma volume and enhance calciuresis with vigorous intravenous hydration remain the cornerstone of therapy. Although this treatment is effective in the short term, fewer than 30% of patients can be expected to achieve normocalcemia with hydration alone, 3,4 and most will require additional

The effect of initial management of hyperleukocytosis on early complications and outcome of children with acute lymphoblastic leukemia.

Data were collected from 124 patients with newly diagnosed acute lymphoblastic leukemia (ALL) and WBC greater than 200,000/microL seen at institutions affiliated with the Children's Cancer Study Group (CCSG) from April 1981 to May 1983. The presenting characteristics, initial management, early complications, and outcome were reviewed. All the children received vigorous intravenous (IV) hydration, alkalinization of the urine, and allopurinol. Thirty-two patients were started on full therapy with no additional measure. One or more special measures believed to reduce the complications of leukostasis and blast cell lysis were administered to 92 patients as follows: small initial doses of prednisone, 63; emergency cranial irradiation, 26; exchange transfusion, 21; and leukopheresis, 19. The incidence of CNS hemorrhage was only 3% (4/124). Seven patients expired during induction and four failed to achieve a remission by day 28. Nineteen patients (15%) had documented bacterial or fungal sepsis. Mild to moderate electrolyte abnormalities occurred in 29 patients: three patients required renal dialysis. Pretreatment with small doses of prednisone did not decrease the incidence of electrolyte abnormalities in those patients when compared with patients who received full chemotherapy. The event-free survival (EFS) for the 106 patients treated on one of the three intensive pilot studies is 55% at 36 months. On multivariate analysis the two significant adverse prognostic factors were massive splenomegaly (P = .02) and WBC count greater than 600,000/microL (P = .05). In conclusion, in patients with hyperleukocytosis the complications of blast cell lysis and leukostasis were manageable with acceptable morbidity and minimal mortality in a group of patients treated with vigorous hydration, allopurinol, and alkalinization of the urine before beginning chemotherapy. Selected patients with severe hyperuricemia and renal dysfunction may benefit from leukopheresis. No beneficial role was demonstrated for the use of small initial doses of prednisone or emergency cranial irradiation.

Risk of renal failure after major angiography.

In 400 patients who underwent major aortography, acute renal dysfunction (ARD) occurred in 11.3%. Of the group with normal renal function before the procedure, 8.2% had ARD and 0.8% required dialysis. Patients with prior abnormal renal function had a 41.7% incidence of ARD, and 8.3% required dialysis as a result of angiography. Vigorous intravenous hydration was used in all patients but did not completely prevent renal problems. Two risk factors not previously emphasized were the injection site (higher risk with abdominal aortic studies) and presence of congestive heart failure requiring treatment with digoxin. Other notable risk factors included contrast load and age. These results emphasized that even with modern contrast agents and application of current concepts of treatment, there remains a risk of renal injury with major angiography.