Renal calcium and magnesium handling in water immersion in nephrotic patients.

The effect of water immersion to the neck on renal calcium and magnesium handling was studied in 11 nephrotic patients. There was an increase in the urinary excretion of both calcium and magnesium on immersion, and a return towards preimmersion control values in the hour following immersion. Clearances of calcium and magnesium, and fractional excretion of calcium and of magnesium all increased significantly during water immersion, and decreased in the postimmersion hour. However, magnesium excretion was 10-50 times greater than calcium excretion. Fractional excretion of sodium was highly significantly related to fractional excretion of calcium (p less than 0.001) and magnesium (p less than 0.001). The relationship between fractional excretion of phosphate and fractional excretion of calcium was statistically significant (p less than 0.05), as was that between fractional excretion of phosphate and that of magnesium (p less than 0.01). Magnesium and calcium fractional excretions were significantly correlated (p less than 0.01). It was concluded that the increase in calcium and magnesium excretion on immersion is likely to be related to the sodium diuresis caused by central hypervolemia due to immersion.

Rapid correction of severe lactic acidosis with massive isotonic bicarbonate infusion and simultaneous ultrafiltration.

Patients with severe lactic acidosis and oliguria who receive large amounts of sodium bicarbonate may develop fluid overload and hyperosmolarity. We infused massive amounts of isotonic sodium bicarbonate and simultaneously removed the excess sodium and water with ultrafiltration if 2 patients with lactic acidosis. The first patient received 1,125 mmol of bicarbonate over 4.5 h with a rise in pH from 7.00 to 7.36 and in HCO3 from 3.5 to 15.7 mmol/l. The second received 968 mmol of bicarbonate over 5.25 h with a rise in pH from 7.00 to 7.27 and in HCO3 from 5.3 to 14 mmol/l. Blood pressure remained stable or rose, electrolytes normalized, excess fluid was removed, and a higher pH was maintained. Isotonic bicarbonate infusion with simultaneous ultrafiltration is a safe and rapid method of correcting the metabolic status of patients with severe lactic acidosis who have not responded to standard therapy.

Aluminum absorption in the rat everted gut sac.

Intestinal absorption of aluminum was studied in rat everted gut sacs. Aluminum transport and aluminum uptake in the jejunum initially rose with increasing bath aluminum concentration, but reached a plateau with high bath aluminum concentrations. The aluminum transport was inhibited by dinitrophenol, absence of glucose, and a temperature of 4 degrees C. There was no change with acute renal failure, chronic renal failure, parathyroidectomy, or parathyroid hormone injection. The aluminum absorption from the rat jejunum appears to involve an energy-dependent, carrier-mediated mechanism.

Renal phosphate handling in nephrotic syndrome during water immersion.

In 11 patients suffering from nephrotic syndrome, renal phosphate handling was studied in water immersion up to the neck. There was a rapid onset of phosphate diuresis which continued to increase throughout water immersion; and an increase in fractional excretion of phosphate (FEPO4) continuing throughout immersion and decreasing in the hour after immersion. TmPO4/GFR did not change on immersion. TmPO4/Inulin clearance gave higher figures than TmPO4/creatinine clearance due to secretion of creatinine in 9 of 11 patients. There was a transitory increase in PTH during immersion, but mean immersion plasma levels of PTH did not change when compared to preimmersion control values. FEPO4 was more frequently significantly correlated with FECL than to FENa in nephrotics.

Renal salt and water handling in water immersion in the nephrotic syndrome.

1. Eleven nephrotic patients were immersed up to the neck in 1.3 m of water at 34 degrees C for 4 h. 2. A diuresis began, within the first hour of, and continued throughout, immersion. The urine osmolality fell significantly and decreased to hypotonic levels in the first hour of immersion and increased gradually during the remainder of immersion and postimmersion. 3. Throughout immersion there was a steady increase in urinary sodium and chloride excretion and a sharp fall in the postimmersion hour. 4. Overall fractional excretion of sodium and of chloride increased steadily throughout immersion and fell during the post-immersion hour. 5. There was an increase in urinary potassium excretion on immersion but no change in fractional excretion of potassium. There was an initial increase in distally reabsorbed sodium/chloride on immersion, as expressed by positive values of CH2O in the first hour of immersion. 6. Plasma aldosterone levels were initially elevated in only two out of nine patients. There was a significant fall in plasma aldosterone levels on immersion, but there was no correlation between sodium/chloride handling and aldosterone levels on immersion.

Water immersion in nephrotic syndrome.

Five adults suffering from nephrotic syndrome were immersed up to the neck in 1.3 m of warm water for four hours. There was a mean weight loss of 2 kg; 1 kg was lost through sweat and 1 kg was lost through urine. Thirty-five millimoles of sodium was excreted in the urine in four hours, 15 times more than on control days. The urine became hypotonic to plasma in the first two hours of immersion. Aldosterone levels did not change on immersion in three patients, but fell from elevated levels in two others. It is concluded that water immersion up to the neck in nephrotic patients warrants further investigation as a therapeutic agent in those cases that are not responding to conventional diuretic therapy.

Home and medical center hemodialysis. Dollar comparison and payback period.

Cost of home hemodialysis training was compared with that of continuing hemodialysis at a satellite medical center. The "payback period" was defined as the time after which higher home training and start-up charges equaled and were surpassed by the initially lower satellite charges. This period was 14.4 months. Total cost of home hemodialysis training and start-up at our institution was $15,149.32. Ambulatory medical center hemodialysis during the same period (3 1/2 months) was $6,853.58. Initially, therefore, the cost of home dialysis is $8,295.74 more. However, after 14.4 months, there is an equalization point subsequent to which home hemodialysis costs $7,472.40 less each year. For a subgroup of patients, those with malignant and severe systemic diseases with reduced survival with hemodialysis, home hemodialysis has no economic advantage.

Infection complicating intrapericardial steroid instillation in uremic pericarditis.

Short-term, indwelling, percutaneous pericardiocentesis for drainage with local steroid instillation has been advocated for refractive uremic pericarditis. It is reported to be almost universally successful and to cause only minor complications. We describe a patient in whom this technique lead to purulent pericarditis (Staphylococcus aureus) requiring pericardiectomy.

Beta-thromboglobulin levels in the nephrotic syndrome.

Beta-thromboglobulin (BTG), a platelet-specific protein released on platelet aggregation, was measured in 13 patients with clinical and biochemical evidence of the nephrotic syndrome. All 13 patients had increased concentrations of BTG compared to both 10 normal controls and to 12 non-nephrotic azotemic patients (p < 0.001). In five patients with the nephrotic syndrome in remission, the BTG levels returned to normal. These results support the contention that the nephrotic syndrome is associated with a state of hypercoagulability and suggest that increased platelet aggregation may be the primary underlying mechanism.

Maintenance hemodialysis. Survival beyond the first decade.

In a retrospective analysis of maintenance dialysis (MD) in a relatively homogeneous population of 24 patients (18 men, six women) who first received MD between 1964 and 1968 and who were initially free of other complicating diseases, we have confirmed that age at initiation of dialysis, sustained hypertension, and elevated calcium-phosphate product are significant risk factors for cardiovascular mortality. In patients without these risk factors sepsis has become the major cause of death, accounting for five (35.7%) of 14 deaths. The limit for long-term survival in an MD patient in whom the well-recognized risk factors are prevented or controlled is not yet apparent.