1% amino acid peritoneal dialysate: single-cycle study in diabetic patients with end-stage renal disease.

Uremia is associated with multiple abnormalities of carbohydrate and protein metabolism, which are partially corrected by continuous ambulatory peritoneal dialysis with dextrose-based solutions. The hormonal and metabolic effects of amino acid (AA)-based peritoneal dialysis have been studied in nondiabetic uremic patients. Such solutions may be particularly suitable for diabetic patients with end-stage renal disease provided the safety and efficacy of such solutions can be established. We have studied and compared the metabolic and hormonal responses to a single-cycle exchange of dextrose versus a 1% AA-based continuous ambulatory peritoneal dialysis solution in six diabetic patients with end-stage renal disease. In the fasting state and under similar free insulin concentrations, use of the AA solution led to a higher mean glucose concentration (109 +/- 16 mg/dL with dextrose solution v 128 +/- 25 mg/dL with AA solution, P < 0.05). Levels of alanine, lactate, pyruvate, glycerol, non-esterified fatty acids, and triglycerides were similar with the use of either solution. Use of the AA-based solution led to increases in the mean values of the branched chain AAs for the period of the study (valine 131 +/- 10 mumol/L with dextrose solution v 331 +/- 40 mumol/L with AA solution, P < 0.01; leucine 72 +/- 7 mumol/L with dextrose solution v 129 +/- 11 mumol/L with AA solution, P < 0.01; isoleucine 48 +/- 5 mumol/L with dextrose solution v 103 +/- 11 mumol/L with AA solution, P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Familial unilateral renal agenesis and focal and segmental glomerulosclerosis.

Renal dysplasia and agenesis may be a familial disorder. We report the familial occurrence of unilateral renal agenesis and proteinuria that, at least in one case, was related to focal glomerulosclerosis. Whether these abnormalities are related to an intrinsic abnormality in the remaining kidney, hyperfiltration injury, systemic hypertension, or some other poorly defined factor is unclear at present. However, this report, along with previous case reports of familial renal agenesis, suggests that ultrasonographic screening of first-degree relatives of patients with renal agenesis is appropriate. Whether treatments such as dietary protein restriction, use of angiotensin-converting enzyme inhibitors, or other therapeutic interventions will have a beneficial effect in asymptomatic individuals with unilateral renal agenesis remains to be determined.

The nutritional/metabolic and hormonal effects of 8 weeks of continuous ambulatory peritoneal dialysis with a 1% amino acid solution.

Circulating intermediary metabolites, hormones and plasma amino acids (AA) were measured at intervals over 24 hours in seven non-diabetic patients with chronic renal failure treated by continuous ambulatory peritoneal dialysis (CAPD), before and after an 8-week period during which a 1% amino acid dialysis solution replaced two of the four dextrose exchanges. Mean 24-hour concentrations of plasma total and essential amino acid were higher following the AA dialysate (total pre: 2893 +/- 185; total post: 3357 +/- 244; p less than 0.05; essential pre: 751 +/- 47; essential post: 1064 +/- 57 mumol/l; p less than 0.001). Mean 24-hour concentrations of the branched chain amino acids leucine, isoleucine and valine were higher following the AA dialysate (valine pre: 201 +/- 18; valine post: 321 +/- 19; p less than 0.001; leucine pre: 102 +/- 6; leucine post: 127 +/- 9; p less than 0.01; isoleucine pre: 67 +/- 5; isoleucine post: 85 +/- 7 mumol/l; p less than 0.05). Serum albumin increased with use of the AA dialysate (pre: 36 +/- 1; 2 weeks, 40 +/- 1; 4 weeks, 40 +/- 1; 6 weeks, 41 +/- 1; 8 weeks, 38 +/- 2 g/l). 24-hour profiles and mean 24-hour concentrations of blood glucose, serum insulin, serum triglyceride, plasma non-esterified fatty acids (NEFA), plasma 3-hydroxybutyrate and plasma alanine were unchanged after the AA period. Plasma bicarbonate decreased with use of the amino acid solution (pre: 21 +/- 1; 2 weeks, 18 +/- 1; 4 weeks, 18 +/- 1; 6 weeks, 16 +/- 1; 8 weeks, 16 +/- 1 mmol/l). Use of a 1% amino acid solution over an 8-week period in CAPD patients improves the plasma amino acid profile but results in a metabolic acidosis. The other endocrine and metabolic abnormalities of uremia remain unchanged.

Hypophosphatemic effect of 1% amino acid dialysis solution.

Orally administered essential amino acids and their nitrogen free analogues have been shown to ameliorate hyperphosphatemia in uremic patients. The aim of the study was to assess the effect on serum phosphate and ionized calcium of a mixture of non-essential and essential amino acids, administered intra peritoneally as a 1% solution to a group of uremic patients who had been on continuous ambulatory peritoneal dialysis (CAPD) for at least three months. Serum phosphate and ionized calcium were measured at fortnightly intervals during the study period which lasted 16 weeks. All patients performed four 2 liter exchanges with dextrose dialysis solution for the first 4 weeks. Two of the four exchanges were then replaced by a 1% amino acid (AA) dialysis solution for a period of 8 weeks after which all patients reverted to their original regimen. Serum phosphate and calcium were measured fortnightly for a further 4 weeks. Serum phosphate fell significantly after introduction of the AA dialysis solution despite unchanged dietary protein and phosphate intake and no increase in the dose of oral phosphate binders taken by 2 of the 7 patients. Serum ionized calcium remained unchanged during the study period.

Severe renal toxicity due to intermediate-dose methotrexate.

Methotrexate (MTX) is a drug widely used in the treatment of patients with malignant disease. Its well-known side effects include myelosuppression, mucositis and renal damage. These problems are primarily dose-related, tending to occur more frequently when high doses (greater than 1 g/m2) are given. We present four cases in whom severe renal and mucosal toxicity occurred with intermediate doses (200 mg/m2) of MTX despite folinic acid rescue. Possible reasons for this occurrence are discussed and means of avoiding such toxicity are suggested. Three of four patients developed severe loin pain within a few hours of injection; the significance of this symptom in relation to subsequent renal toxicity has implications for early recognition of the problem.

A negative double-contrast barium meal--qualified reassurance.

Four hundred and forty-one consecutive patients referred for endoscopy after a negative double-contrast barium meal were studied to determine the reliability of good quality radiology in excluding significant upper gastrointestinal pathology. Endoscopic abnormalities were detected in 23 patients (5.2%), nine of which were reporting errors. Duodenal ulcer was the commonest lesion missed radiologically, 50% of these patients either having a history of overt upper gastrointestinal bleeding, a family history or impressive symptomatic relief with H2-receptor antagonists. The three patients with radiologically undetected gastric cancer presented with classical symptoms; the radiological demonstration of gastric mucosal atrophy in this clinical context should alert the referring clinician to initiate urgent endoscopy.

Unilateral thyroid swelling due to actinomycosis.

A case of unilateral thyroid swelling due to actinomycosis in a 27 year old farm worker is described. Diagnosis was made by fine needle biopsy under ultrasound control.