Energy metabolism in exertional heat stroke with acute renal failure.

BACKGROUND: Heat stroke is the clinical syndrome produced when the body overheats. It can develop in the army and in healthy civilian populations who physically exert themselves in a hot and humid environment during the summer, and may result in a significant number of heat-related deaths. Since strenuous exercise is one of the major exacerbating and precipitating factors, the incidence of exertional heat stroke (ExHS) is high among military personnel undergoing military training. Furthermore, acute renal failure (ARF) may occur in 25% of patients with ExHS and it can cause metabolic alterations that affect amino acid, carbohydrate, and lipid metabolism. Adequate nutritional support is essential for the treatment of ARF. The most important determinant of nutrient requirement in ARF is the degree of hypercatabolism caused by disease associated with renal function impairment. Indirect calorimetry (IDCM) is the method by which metabolic rate is estimated from measurements of oxygen consumption and carbon dioxide production. It can also provide information about the type and rate of substrate utilization in vivo (protein, carbohydrate, and fat). METHOD: The present clinical study is a comprehensive analysis of metabolic changes which includes energy expenditure (EE) and substrate utilization in 10 patients with ExHS with ARF and 10 patients with exertional heat exhaustion (ExHE) by the use of IDCM. RESULTS: Serum urea nitrogen, creatinine, peak creatine phosphokinase levels and heart rate were significantly increased in ExHS patients during ARF stage. Serum albumin levels were significantly decreased in ExHS patients with ARF. Resting energy expenditure (REE) was increased in patients with ExHS induced ARF and was not correlated with body temperature (r = 0.421). The average increase in EE during ARF stage was about 24%. The respiratory quotient in patients with ExHS induced ARF was lower than that in normal subjects and also in patients with ExHE. Urea nitrogen appearance rate increased in patients with ExHS induced ARF and in patients with ExHE without ARF. The percentage of total REE derived from fat in ExHS induced ARF and ExHE increased, while in patients with ExHS induced ARF and ExHE, the percentages of total REE derived from carbohydrate and protein were lower than those in control subjects. CONCLUSIONS: The present results suggest that patients with exertional heat injury (both ExHS and ExHE) have hypermetabolism during the acute stage. Furthermore, patients with exertional heat-induced rhabdomyolysis and ARF have a moderately higher hypermetabolism than those without ARF during the acute stage. We believe that this mainly reflects a more pronounced reduction of the vital cell mass (muscle) in relation to body weight, and/or a compromised substrate oxidation in ExHS with ARF. Whether or not this subgroup of patients will require a higher energy/caloric support merits further investigation.

Infective endocarditis complicated with rapidly progressive glomerulonephritis: a case report.

A 26-year-old man who had suffered from intermittent chills and fever over a two month period was quite clear of heart or kidney involved developed acute deterioration of renal function. A new pansystolic murmur over the apex of the heart was heard on auscultation, and echocardiography clearly showed a vegetation about 0.7-0.9 cm in size on the atrial site of the mitral value. Laboratory investigation displayed normochromic anemia with negative Coombs' test. Immunological studies were positive for rheumatoid factor and circulating immune complex. High serum levels of erythrocyte sedimentation rate and C-reactive protein, nephritic sediment of urinalysis and negative blood cultures for bacteria, tuberculosis or fungus were also noted. Abdominal sonography showed normal kidney size, bilaterally. Renal biopsy revealed typical crescentic glomerulonephritis. After intravenous penicillin therapy for two weeks, the serum creatinine level recovered from 6.7 mg/dl to 2.0 mg/dl and circulating immune complex disappeared. In consideration of cardiac insufficiency and the potential risk for complications of the vegetation, the patient underwent mitral valve replacement. Four weeks after operation, all the abnormal data had resolved completely. These data suggested that infective endocarditis with rapidly progressive glomerulonephritis is curable by antibiotic therapy and surgical intervention.

Effect of calcitriol treatment on psoriasis in hemodialysis patient: a case report.

The case of a 67-year-old man who has had psoriasis with multiple joints involvement for 30 years and renal failure for 1 year is described. He was admitted because of uremic symptoms and exacerbation of psoriasis. Hypocalcemia and low serum active 1.25(OH)2D3 were also observed. Hemodialysis, oral 1.25(OH)2D3 and CaCO3 supplement were employed. Interestingly, the psoriasis strikingly improved. The relationships among psoriasis, renal failure, 1.25(OH)2D3, serum calcium level and dialysis are discussed.