Pre-/postdilution hemofiltration.

Hemofiltration creates the best conditions for toxin removal and cardiovascular stability in the treatment of chronic renal failure patients. The increase in hematocrit due to erythropoietin, the blood flow rate and the necessary volume of substitution fluid limit the post- or the predilution hemofiltration. The technical progress made now offers the possibility to routinely and safely treat patients with pre-/postdilution hemofiltration. When adjusting the substitution flow rate to the blood flow rate, small-molecule clearances are higher than those in hemodialysis and are close to those in hemodiafiltration.

Acute renal failure in pregnancy.

Acute renal failure (ARF) has become a very rare complication of pregnancy. This results from the virtual disappearance of septic abortion ARF and from the improvement of prenatal care, including the prevention of volume contraction which is mainly due to uterine haemorrhage, early diagnosis, and treatment of other classic maternal complications such as pre-eclampsia and acute pyelonephritis. The incidence of bilateral renal cortical necrosis has also been declining during the last decade. Acute fatty liver, a potentially fatal disease, is often complicated by ARF. Early recognition of this disorder, with prompt termination of pregnancy and intensive supportive therapy, can reduce fetal and maternal mortality rate. The syndrome of idiopathic postpartum renal failure is also associated with a high morbidity and mortality. Beyond supportive treatment, including haemodialysis or peritoneal dialysis and the use of potent antihypertensive drugs to control blood pressure and blood transfusion if necessary, specific therapy as plasma infusion, plasma exchange and antiplatelet drugs may be of value. Both peritoneal dialysis and haemodialysis may be used in gravidas with ARF. Early 'prophylactic' dialysis should be applied to pregnant women. Careful monitoring of fluid balance and anticoagulation is necessary during dialysis.

Acute renal failure in pregnancy.

Acute renal failure has become a very rare complication of pregnancy. This results from the virtual disappearance of septic abortion ARF and from the improvement of prenatal care, including the prevention of volume contraction which is mainly due to uterine haemorrhage, early diagnosis, and treatment of other classic maternal complications such as pre-eclampsia and acute pyelonephritis. The incidence of BRCN has also been declining during the last decade. Acute fatty liver, a potentially fatal disease, is often complicated by ARF. Early recognition of this disorder with prompt termination of pregnancy and intensive supportive therapy can reduce fetal and maternal mortality rate. The syndrome of idiopathic postpartum renal failure is also associated with a high morbidity and mortality. Beyond supportive treatment including haemo- or peritoneal dialysis, the use of potent antihypertensive drugs to control blood pressure and blood transfusion if necessary, specific therapy as plasma infusion, plasma exchange and antiplatelet drugs may be of value. Both peritoneal dialysis and haemodialysis may be used in gravidas with ARF. Early 'prophylactic' dialysis should be applied to pregnant women. Careful monitoring of fluid balance and anticoagulation is necessary during dialysis.

Acute renal failure in pregnancy: 1987.

Acute renal failure has become a rare complication of pregnancy due to the virtual disappearance of septic abortion and to better prenatal care, including prevention of blood volume contraction. The incidence of bilateral renal cortical necrosis also decreased in recent years. Severe preeclampsia-eclampsia may be accompanied by acute tubular necrosis. Acute fatty liver of pregnancy is often associated with renal failure. It is a medical emergency. The diagnosis should be made promptly, before liver failure becomes too severe. This should be followed by immediate delivery. In postpartum hemolytic uremic syndrome, plasma infusion, plasma exchange, and/or antiplatelet drug therapy may be of value.

Influence of renal insufficiency on the pharmacokinetics and pharmacodynamics of terazosin.

Renal insufficiency was not shown to affect the pharmacokinetics of terazosin in fifteen patients receiving oral terazosin (1 mg once daily) for two weeks. Five patients had normal renal function (creatinine clearance 80 ml per minute or more), five had moderate renal insufficiency (creatinine clearance 30 to 79 ml per minute), and five had severe renal insufficiency (creatinine clearance 10 to 29 ml per minute). Urine and blood samples were collected, and blood pressure and pulse rate were determined on days one and 15 of the study. Renal insufficiency had no significant effect on the absorption lag time, rate of absorption, rate of elimination in the urine, volume of distribution, or plasma clearance of terazosin. The plasma half-life of terazosin in patients with normal renal function was 10.0 hours, compared with 8.4 hours in patients with moderate renal insufficiency and 9.8 hours in the group with severe renal insufficiency. There was also no apparent relationship between renal insufficiency and the maximum change in blood pressure or pulse rate. Renal excretion was found to play a minor role in the elimination of terazosin, and this explains the lack of a relationship between renal insufficiency and the pharmacodynamics of terazosin. After the administration of terazosin on day 1 of the study, 1.6 +/- 0.3 percent and 5.1 +/- 1.4 percent of the total dose was excreted in the urine of patients with severe renal insufficiency and normal renal function, respectively. Adverse experiences were reported by four patients and caused one patient to withdraw from the study. Symptoms reported included gastralgia, headache, dizziness, malaise, weakness, and palpitations. The results of this study indicate that terazosin may be safely administered to patients with renal insufficiency without altering the usual dosing regimen.

Pharmacokinetics of warfarin in the nephrotic syndrome and effect on vitamin K-dependent clotting factors.

The behavior of warfarin, a drug tightly bound to albumin, was studied in patients with nephrotic syndrome (NS) to assess the influence of hypoalbuminemia on its pharmacokinetics and its effect on vitamin K-dependent coagulation factors. A single dose of warfarin (8 mg) was given orally to 11 nephrotic patients with normal or nearly normal renal function and to 11 controls. In every subject the following measurements were performed: albuminemia before (t0) warfarin administration; plasma warfarin and vitamin K-dependent coagulation factors (FII, FVII, FIX, FX) levels, before and at time intervals from 0 to 48 h after drug administration; warfarin urinary excretion from 0 to 24 h. Urinary warfarin excretion was null in 19 out of the 22 subjects and very low in two nephrotic patients and in one control. Low serum albumin in NS patients induced a twofold increase of unbound warfarin vs controls (3.5% vs 1.8%, p less than 0.001) which led to a threefold increase in plasma clearance of warfarin (9.70 vs 3.26 ml X min-1, p less than 0.001); as warfarin distribution volume showed only a slight (non significant) increase in NS patients, the elimination half-life was thus markedly shortened in NS patients vs controls (18 vs 36 h, p less than 0.01). Maximum warfarin effect on vitamin K-dependent factor levels occurred at 18 h in controls and 24 h in nephrotics, and these lowest values were similar, in spite of a higher level at 0 in NS patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of hormonal contraception on the course of lupus nephropathy]. / Influence de la contraception hormonale sur l'évolutivité des néphropathies lupiques.

Influence of oral contraceptive therapy on SLE activity was evaluated in 33 female patients with lupus nephropathy. Estroprogestative preparations containing either 50 micrograms (18 cases) or 30 micrograms (11 cases) of ethinylestradiol were used in 29 courses in 28 patients. Onset or exacerbation of clinical SLE activity occurred within 3 months after starting hormonal therapy in 13 cases, an overall incidence of lupus flare-up of 44 percent, involving major renal histological lesions in 5 cases. In contrast, of 16 patients receiving pure progestogen contraceptive therapy with either discontinuous normal dosage progestogens (9 cases) or continuous low-dose norsteroids (7 cases), only one developed clinical or immunological evidence of lupus exacerbation within 3 months of hormonal therapy. We conclude that oral contraceptive therapy using estrogens, even at low dosage, is associated with a high risk of SLE exacerbation. Pure progestogens, which have proven effective and devoid of such unfavorable effects, should be preferred in these patients when hormonal contraception is needed.

PIP: Influence of oral contraceptive (OC) therapy on SLE activity was evaluated in 33 female patients with lupus nephropathy. Estroprogestative preparations containing either 50 mcg (18 cases) or 30 mcg (11 cases) of ethinyl estradiol were used in 29 courses in 28 patients. Onset or exacerbation of clinical SLE activity occurred within 3 months after beginning hormonal therapy in 13 cases, an overall incidence of lupus flareup of 44%, involving major renal histological lesions in 5 cases. In contrast, of 16 patients receiving pure progestogen contraceptive therapy with either discontinuous normal dosage progestogens (9 cases) or continuous low-dose norsteroids (7 cases), only 1 developed clinical or immunological evidence of lupus exacerbation within 3 months of hormonal therapy. We conclude that OC therapy using estrogens, even at a low dose, is associated with a high risk of SLE exacerbation. Pure progestogens, which have proven effective and devoid of such unfavorable effects, should be preferred in these patients when hormonal contraception is needed. (author's)