Beneficial effects of verapamil in renal-risk surgical patients.

OBJECTIVE: To test whether the administration of calcium channel antagonists, such as verapamil (V), on the day before, during, and for 24-36 h after an important abdominal intervention, can lower the onset of acute renal failure (ARF), mostly in renal-risk patients, such as the aged. DESIGN: Randomized, nonblinded study. SETTING: Three surgical care university departments and two intensive care units of the same hospital (S. Anna, Ferrara, Italy). PATIENTS: Thirty-five elderly patients (61-83 years old) entered the study: 18 of them were given V; 17 were not treated and were considered as controls. The two study groups were overlapping as regards age, renal risk, and surgical challenge. The patients who underwent ARF (5 in the treated group, 7 among the controls) were rejected from the study. INTERVENTIONS: V was given on the eve of surgery at a dose of 80 mg/8 h per os and then through slow infusion (5 mg/4-6 h) during the next intra- and postoperative 24-36 h. Abdominal surgery was performed owing to gastric cancer (8 cases), colorectal neoplasia (10 cases), gallstone disease (4 cases), subrenal aortic aneurysm (6 cases), and iliofemoral obstructive arteriopathy (7 cases). MEASUREMENTS: Serum creatinine (SCr) was assessed to test renal function; 24-h urinary levels of brush-border enzymes (gamma glutamyl transferase, or gGT), lysosomal enzymes (N-acetyl-beta-D-glucosaminidase, or NAG), and beta 2-microglobulin (or beta 2M) were determined at T0 (on the eve of surgery), T1 (first and second day after), and T2 (7th and 8th day after) to demonstrate possible tubule cell damage. RESULTS: In the evaluated patients (13 treated with V and 10 untreated): (a) the 24-h urinary levels of gGt and NAG persisted unchanged throughout the study in the treated patients, whereas in the controls the same indices exhibited significant (p < 0.01) increases at T1 and T2; (b) the 24-h urinary levels of beta 2M showed significant (p < 0.01) increases in both groups from T0 to T1; however, at T2 these values tended to return to normal ranges in the treated patients, whereas they continued to be elevated in the untreated group. As regards the patients who underwent postoperative ARF, in the treated group urine output was significantly larger (p < 0.01 at T1 and p < 0.001 at T2), SCr was significantly (p < 0.05) lower, and the renal function recovered earlier (within 10 +/- 3 vs. 22 +/- 9 days) than in the controls. CONCLUSIONS: The administration of calcium channel antagonists to renal-risk patients during surgery and immediately before and after it has failed to prevent the onset of postoperative ARF. Nevertheless this procedure has been shown to somehow reduce surgery-mediated lesions of the tubule cells, as demonstrated by the finding of elevated urinary enzymes only in the untreated group.

Usefulness of the assessment of urinary enzymes and microproteins in monitoring ciclosporin nephrotoxicity.

The clinical usefulness of serial assays of urinary N-acetyl-beta-D- glucosaminidase (NAG), gamma-glutamyltransferase (GGT) and beta 2-microglobulin (beta 2M) were tested to evaluate and follow up the nephrotoxicity resulting from the prolonged administration of ciclosporin (CS). Three groups of patients were studied for 18 months: group A: functioning renal transplant patients (n = 13) on maintenance therapy from 12-31 months with CS and prednisone; group B: functioning renal transplant patients (n = 11) treated with prednisone and azathioprine; group C: patients (n = 10) affected by autoimmune steroid-unsensitive uveitis, free from previous renal disorder and treated with CS (for 8-16 months) at progressively decreasing doses. In groups A and B, the urinary enzymes and beta 2M underwent overlapping increases, so that these parameters cannot be considered reliable indices of CS-induced nephrotoxicity. This is due to the fact that transplanted kidneys are already altered by concomitant or preexisting affections, or by persistent immunologic injury. Conversely, in patients with uveitis, the serial assays of such urinary parameters prove to be quite reliable to evidence clinically yet unrecognizable kidney involvement due to prolonged CS administration. High enzymuria has been shown to be an earlier marker of nephrotoxicity only in nephropathy-free patients; on the other hand, the regression of elevated beta 2Muria into normal ranges indicates complete tubule cell recovery.

Henoch-Schönlein purpura after Salmonella hirschfeldii infection.

The authors present a case of Henoch-Schönlein purpura in a young soldier (19 years old) which they consider important for its etiology and the length of its oligoanuric phase. The syndrome followed a Salmonella hirschfeldii infection, and a protracted oligoanuric phase was followed by nephrotic syndrome and selective glomerular proteinuria which lasted for 1 year. The young man recovered after the eradication of the Salmonella. It seems possible that there was an overall anomalous regulation of the 'lymphoid system of the mucosa', perhaps dependent on a genetic predisposition.

Life-threatening hyponatremia caused by vinblastine.

Some days after the administration of a third bolus of ABVD (adriamycin, bleomycin, vinblastine, dacarbazine) a patient affected by immunoblastic lymphoma underwent a neurotoxic crisis. The episode lasted 1 week and was followed by a dramatic fall in plasma sodium (104 mEq I-1), associated with a proportionally lesser decrease in plasma chloride and phosphate. Despite the lowest plasma osmolality, detectable levels of circulating ADH were present. After 36 h the hyponatremic episode improved after the infusion of hypertonic sodium chloride. Nevertheless the patient lapsed into a hypotonic coma. The urinary concentrations of the main tubular enzymes (gamma-glutamyltranspeptidase, N-acetyl-glucosaminidase, alpha-glucosidase) proved very high and successively decreased slowly. The most likely cause of such hyponatremic episode is vinblastine. The drug acted through: (a) an already known inappropriate release of ADH, and (b) a hitherto unreported tubular lesion, which impaired the reabsorption of sodium and other coupled solutes.

Tubule recovery after obstructive nephropathy relief: the value of enzymuria and microproteinuria.

The recovery of tubules after relief of obstructive nephropathy may be investigated through serial assessment of the urinary excretion of tubular enzymes alpha-glucosidase, gamma-glutamyl-transferase and N-acetyl glucosaminidase as well as of the microprotein beta-2-microglobulin. We studied 21 patients in whom obstructive nephropathy was relieved by operative or nonoperative methods. Anuria persisted from 2 to 14 days. In these patients urinary excretion of alpha-glucosidase, gamma-glutamyl-transferase, N-acetyl glucosaminidase and beta-2-microglobulin, as well as the serum creatinine were assessed weekly. Serum creatinine was the earliest index to return to normal (within 9 to 26 days). Enzymuria returned to normal within 35 to 45 days, whereas normal urinary excretion of beta-2-microglobulin occurred more than 100 days after relief of obstructive nephropathy. N-acetyl glucosaminidase and gamma-glutamyl-transferase proved to be more reliable than alpha-glucosidase in detecting recovery of the luminal membrane of the proximal tubule. The return to normal of urinary beta-2-microglobulin levels has been shown to occur later, since more specific and complex intracellular functions underlie this index. The pathophysiological aspects of recovery of obstructive nephropathy may be considered similar to those observed in ischemic acute renal failure, since in both instances hemodynamic changes are involved.

Exercise-induced urinary abnormalities in long-distance runners.

The post-exercise urine samples from 122 long-distance runners showed evident abnormalities upon microscopic examination in 95% of all subjects. Proteinuria, alone or with microscopic hematuria, was frequently found. Macroscopic hematuria was a rare occurrence. The urine samples collected in 30 runners before, immediately after the race, and 6, 12, 24, 36, and 48 h later showed a significant post-race decrease in the osmolarity and a significant increase in gamma-glutamyl transferase and N-acetyl-beta-glucosaminidase enzyme activity. Plasma renin activity and plasma aldosterone, determined before and after the race in nine runners, showed a significant increase in the post-race samples. The abnormal urinary findings disappeared in all cases within 24-36 h. It can be concluded that urinary abnormalities are very common after exercise. These abnormalities are most often of a "renal" origin, probably due to a temporary hemodynamic impairment, partially of glomerular but principally of tubular function.

[Renal contrast radiography study in hypertensive patients: comparison of the nephrotoxicity of ionic and non-ionic contrast media]. / L'indagine contrastografica renale nel paziente iperteso: confronto della nefrotossicità tra mezzi di contrasto ionici e non ionici.

The results of a study carried out on 32 patients with arterial hypertension about nephrotoxic effect obtained with a new non-ionic contrast agent have been reported. The diagnostic approach was based on the determination of the urinary excretion of two characteristic enzymes of the proximal tubule-epithelial cells (alfa-glycosidase and gamma-glutamil-transferase) and of a microprotein (beta-2-microglobulin) filtered by glomeruli and readsorbed and catalized by epithelial cells. The method used show an increased sensitivity and reliability in the early recognition of a kidney damage as well as in the control of anatomic and functional changes, in comparison with the classic parameters (azotemia, creatininemia). The results show a significantly lower enzymuric and microproteinuric level using non-ionic contrast media, also, in the patients at relatively higher risk of kidney damage. This results should be interpreted in favour to a lower potential nephrotoxicity of non-ionic contrast media and their elective use in the patients with a higher risk of kidney damage.

Amniotic fluid beta 2-microglobulin (beta 2-m) as an index of fetal maturity.

Amniotic fluid beta 2 microglobulin (beta 2-m) levels were measured by radioimmunoassay in 78 pregnant women between the 14th and the 42nd week of gestation. 62 were healthy subjects, while eight were affected by EPH gestosis, seven by diabetes (cl. B-F) associated with Rh immunization in one case, one by hydramnios. There was no significant correlation either between beta 2-m and creatinine (n = 18), or between beta 2-m and lecithin sphingomyelin ratio (L/S) (n = 16), although low concentrations of beta 2-m were usually observed after the 35th week of gestation. It is noteworthy that only in one case out of seven with amniotic levels less than 5 microgram/ml L/S ratio was less than 2.

Ureterosigmoidostomy and cancer of the colon. Report of a case.

A possible and quite frequent complication of uretero-sigmoidostomy can be the late development of a colic cancer at the site of the ureteric reimplantation. On the basis of the literature and of a personal observation, the accent is put on what can be done to discover the tumor in any early phase; the possibility that the increased risk of cancer should limit the colic urinary diversions for an exstrophy of the bladder is also discussed.

Impairment of the mental status of patients on regular dialysis treatment.

The purpose of this study was to assess the mental status of 42 patients on regular dialysis treatment (RDT) by using the Wechsler Adult Intelligence Scale (WAIS) and Wechsler Memory Scale (WMS). Findings were correlated with serum aluminium levels, PTH levels, residual renal function (RRF) and duration of RDT. An impairment of neuropsychological performance related to the duration of RDT was found. However, a possible role of PTH and of absence of RRF could not be excluded. These observations suggest that standard haemodialysis strategies are not able to prevent pathological changes in the brain of uraemic patients.