B-type natriuretic peptide-directed ultrafiltration improves care in acutely hospitalized dialysis patients.

In an observational study in 19 consecutive acutely hospitalized dialysis patients, ultrafiltration (UF) volume was determined by B-type natriuretic peptide (BNP) levels. Patients were ultrafiltrated daily until they achieved a target BNP level <500 pg/mL. The UF volumes ranged from 2 to 5 L per session. All patients were male veterans aged 68+/-11 years (mean +/- SD), 74% were diabetic, 47% were African Americans, 58% underwent prevalent dialysis, and 53% had an arteriovenous fistula. Left ventricular ejection fraction on 2-dimensional echocardiography was 43.8%+/-27.9% (n=16). The admission BNP was 2412+/-1479 pg/mL (range, 561-5000 pg/mL) and BNP at hospital discharge was 1245+/-1173 pg/mL (range, 345-5000 pg/mL) (nonparametric Wilcoxon P=.0013). Admission weight was 88.9+/-27.9 kg and at discharge was 78.1+/-25.6 kg (P=.0002). The number of antihypertensive medications taken was 3.8+/-2.0 at admission and 2.3+/-1.7 at discharge (P=.0005). The number of patients with >2 blood pressure medications decreased from 14 to 6 (Fisher exact test, P=.02). The systolic/diastolic/mean arterial blood pressure decreased from admission to discharge (153.6+/-43.8/80.6+/-21.8/102.4+/-27.3 to 132.1+/-27.9/68.9+/-14.6/89.9+/-16.5 mm Hg; P=.0222/.0139/.0329, respectively). Although all patients were volume-overloaded at admission according to BNP criteria (>500), only 42% were identified as having heart failure. BNP-directed UF is safe because it minimizes symptomatic hypotension, identifies occult congestive heart failure in a large number of patients, and significantly reduces blood pressure in addition to reducing body weight and number of medications used.

Elevated lipase and diabetic ketoacidosis associated with aripiprazole.

CONTEXT: Atypical antipsychotic agents are associated with diabetes mellitus and pancreatitis. Aripiprazole, a new antipsychotic, has never been implicated to cause either diabetes mellitus or pancreatitis. We present a patient who developed diabetes mellitus after being started on aripiprazole. CASE REPORT: A 33 year-old male with schizophrenia presented with fatigue, dyspepsia and epigastric pain. Patient was found to have hyperglycemia, diabetic ketoacidosis, and hyperlipasemia. Imaging studies of the pancreas were normal. Patient was started on aripiprazole treatment 18 months prior to this episode and had experienced progressive weight gain since then. Work up for other causes of pancreatitis was negative. CONCLUSIONS: Diabetes mellitus in this patient was probably a complication of aripiprazole due to progressive weight gain. In the absence of radiologic evidence of pancreatitis, hyperlipasemia was probably secondary to diabetic ketoacidosis. Possible causes of hyperlipasemia and its significance in diabetic ketoacidosis are discussed.