A comparative randomized and placebo-controlled short-term trial of aspirin and dipyridamole for overt type-2 diabetic nephropathy.

OBJECTIVE: Our aim was to determine the effect of short-term therapy with anti-platelet drugs on type-2 diabetic nephropathy for which a generally accepted therapy is missing. MATERIAL AND METHODS: Seventy-six patients with type-2 diabetic nephropathy, who had normal renal function tests were randomized into the 4 groups; each group (n = 19) received one of the following treatments: aspirin (1000 mg), dipyridamole (750 mg), their combination or placebo daily for 2 months. Blood pressure, fasting blood sugar, serum electrolytes, creatinine clearance and 24 hours urine protein excretion rate was measured just before and at the end of the trial. RESULTS: Proteinuria and urinary protein: creatinine ratio decreased significantly in all 3 groups receiving aspirin and/or dipyridamole compared with the placebo group, also in each of those 3 groups comparing pre- and post-treatment values, while creatinine clearance rate, blood pressure, and blood sugar remained unchanged. At the end of the trial, the percentage proteinuria change was-15.9%,-14.8%,-37.3% and 1.9% in aspirin, dipyridamole, their combination and placebo groups respectively. The percentage proteinuria change had no positive correlation with demographic, clinical and laboratory findings but showed a strong positive correlation with mode of the therapy (r = 0.38, p = 0.0007). The percentage decline in proteinuria was significantly higher in the combination group than in the aspirin and dipyridamole groups. No side effects related to aspirin or dipyridamole was seen during the trial. CONCLUSIONS: Short-term trial of aspirin and/or dipyridamole significantly reduces proteinuria of type-2 diabetic nephropathy, with the most prominent effect seen with combination of the 2 drugs.

A randomized, double-blind, placebo-controlled trial of supplementary vitamins E, C and their combination for treatment of haemodialysis cramps.

BACKGROUND: Muscle cramps that improve after carnitine or vitamin E therapies are common in haemodialysis (HD) patients. Because vitamin C participates in carnitine biosynthesis, and its levels are reduced in uraemia, subclinical vitamin C depletion may contribute to HD cramps. Our aim was to determine the effects of vitamins C, E and their combination on the frequency and intensity of HD cramps. METHODS: In this placebo-controlled, double-blind study, 60 HD-patients were randomized into four therapeutic groups. Each group (n=15) received six identical capsules daily for 8 weeks, containing one of the following: vitamin E (400 mg), vitamin C (250 mg), their combination, or placebo. RESULTS: The frequency and intensity of HD cramps decreased significantly in all three vitamin groups compared with the placebo group at the end of the trial, and compared with the pre-treatment values. At the end of the trial, vitamins E, C, their combination, and placebo produced cramp reductions of 54, 61, 97 and 7%, respectively. The percentage cramp reduction had no significant correlation with age, sex, aetiology of end-stage renal disease, serum electrolytes or HD duration, but showed a positive correlation (r=0.33, P=0.01) with the type of therapy. No vitamin-related adverse effects were encountered during the trial. CONCLUSION: Short-term treatment with the combination of vitamins E and C is safe and effective in reducing HD cramps; however, its safety for prolonged therapy has yet to be evaluated in HD patients.

Toxemic shock, hematuria, hypokalemia, and hypoproteinemia in a case of cutaneous anthrax.

A 20-year-old woman who had daily contact with domestic herbivores presented with a painless and pruritic lesion in her neck; the lesion ulcerated to a black necrotic eschar from which Bacillus anthracis grew. Rapidly expanding edema at the site of the ulcer was followed by shock, hematuria, hypokalemia, and hypoproteinemia. The latter symptoms - unusual for cutaneous anthrax - responded to intravenous penicillin therapy.

Comparison of blood loss with different high-flux and high-efficiency hemodialysis membranes.

UNLABELLED: Iron deficiency is a common problem in patients on chronic HD. Earlier studies have shown significant blood loss per HD session. To identify whether the new more biocompatible high-flux or high-efficiency membranes are also responsible for significant blood loss during HD, we quantitated the amount of blood loss associated with 4 commonly used membranes (F-50, F-80, CA-210, and CT-190). The residual blood in each compartment of extracorporeal circuit was quantitated after total lysis of the red blood cells (RBC), hemoglobin assay, and calculation of the RBC volume using the patient's hemoglobin and hematocrit concentrations just prior to the study. The average residual RBC volume in different membranes was 0.2-0.3 ml. The residual RBC volume in the dialysis lines (arterial or venous) was 0.1-0.2 ml and did not correlate with the residual RBC volume in the dialysis membranes. The residual RBC volume in the whole extracorporeal circuit (HD membrane, arterial and venous lines) ranged from 0.5 to 0.6 ml. It was significantly higher with F-50 vs. CA-210. The residual RBC volume in the dialysis membrane was significantly higher in the F-80 vs. CA-210 and CT-190 dialyzers. There was also significant difference in the residual RBC volume in the arterial lines of F-50 vs. CT-190, and F-50 vs. F-80 dialyzers. CONCLUSION: Our results demonstrate for the first time that the total RBC loss per HD session is minimal in chronic HD patients.

Lipid-lowering effect of polyunsaturated fatty acids in hemodialysis patients.

In this randomized and placebo-controlled trial, safety and lipid-lowering effect of fish and corn oils rich in polyunsaturated fatty acids compared with sesame oil that is mainly saturated were studied in 60 hemodialysis cases allocated to 4 different treatment groups. Each group (n = 15) received either fish oil (1.5 g), corn oil (4.5 g), sesame oil (4.5 g), or placebo, daily. Serum triglyceride, cholesterol, low density lipoprotein cholesterol (LDL-c), and high density lipoprotein cholesterol (HDL-c) were measured before and after 2 months of therapy. Serum HDL-c increased, but LDL-c decreased significantly after fish and corn oil therapy. In addition, serum triglyceride decreased significantly after supplementary fish oil. The ratios of LDL-c to HDL-c, total cholesterol to HDL-c, and triglyceride to HDL-c decreased significantly after fish and corn oil therapy. Sesame oil had no significant effect on the lipid profile of hemodialysis patients. Our results suggest that short-term low-dose supplementary polyunsaturated fatty acids are safe and beneficial for the lipid abnormalities of hemodialysis patients.

Removal of acyclovir during continuous veno-venous hemodialysis and hemodiafiltration with high-efficiency membranes.

We present a critically ill patient with severe renal failure and anuria who underwent hemodialysis (HD), continuous veno-venous hemodialysis (CVVHD) and continuous veno-venous hemodiafiltration (CVVHDF) at different occasions, with 2 commonly used high-efficiency dialyzers (F-8 and CA-210), while receiving i.v. acyclovir. We estimate that during 24 hours of CVVHD with F-8 dialyzer approximately 18% and during 24 hours of CVVHDF with CA-210 dialyzer approximately 65% of the daily administered acyclovir is removed. This is comparable to the amount removed during 4 6 hours of HD, as reported previously. The percentage acyclovir extraction was 84% and 60% during CVVHD and CVVHDF with F-8 and CA-210 dialyzers, respectively. Acyclovir clearance during CVVHD was 14 ml/min and during CVVHDF was 17 ml/min, with F-8 and CA-210 dialyzers, respectively. Acyclovir half-life was 22.5 and 25.5 hours in 2 occasions off any type of renal replacement therapy, and it was 19.5 hours during CVVHDF with CA-210 dialyzer.

Reversible acute renal failure with prolonged oliguria and gross hematuria in a case of paroxysmal nocturnal hemoglobinuria.

A 39-year-old man, a known case of paroxysmal nocturnal hemoglobinuria (PNH), developed severe acute renal failure, prolonged oliguria, and grossly bloody urine. After 8 weeks and 24 sessions of hemodialysis he became polyuric, and his renal function normalized after 10 weeks. The diagnosis of PNH was reconfirmed.

Transient inhibition of glucose utilization by erythrocytes during the acute stage of typhoid fever.

The exact reason for hemolysis of glucose-6-phosphate dehydrogenase-deficient (G6PD) erythrocytes in patients with typhoid fever is unknown. Therefore, glucose utilization by normal and G6PD-deficient erythrocytes was measured during incubation with plasma of healthy controls as well as from patients in acute or recovery stages of typhoid fever. Glucose utilization in normal and G6PD-deficient erythrocytes significantly decreased compared to the controls when incubated with plasma of patients with acute typhoid fever, which normalized to the baseline after recovery from typhoid fever, suggesting an acquired alteration in G6PD enzyme properties by Salmonella typhi or its endotoxins.

Effect of vitamins on the lipid profile of patients on regular hemodialysis.

OBJECTIVE: The aim of this study was to investigate the lipid-lowering effect of vitamins compared to placebo and their short-term supplementation safety in patients on hemodialysis. MATERIAL AND METHODS: Eighty-four hemodialysis patients were randomly allocated to four therapeutic groups. Each group (n = 21) received one of the following treatments: vitamin C (200 mg), E (200 mg), D3 (50,000 IU) or placebo daily. Serum triglyceride, total cholesterol, low-density lipoprotein cholesterol (LDL-c), and high-density lipoprotein cholesterol (HDL-c) were measured before and following 3 months of vitamin therapy. RESULTS: LDL-c and total cholesterol levels as well as the ratios of LDL-c to HDL-c and cholesterol to HDL-c significantly decreased after vitamin C therapy. Triglyceride and the ratio of triglyceride to HDL-c significantly decreased following vitamin D3 therapy. HDL-c increased and the ratio of LDL-c to HDL-c decreased significantly after vitamin E therapy. No major side-effects were encountered during the 3 months' trial. CONCLUSIONS: Short-term supplementary vitamins are safe and beneficial for treatment of lipid abnormalities in hemodialysis patients.

The effects of parathyroidectomy on nutritional and biochemical status of hemodialysis patients with severe secondary hyperparathyroidism.

The nutritional and biochemical parameters of 15 chronic hemodialysis (HD) patients with severe secondary hyperparathyroidism who had undergone total parathyroidectomy (PTX), with a forearm implant, were retrospectively studied at 1, 3, 6, and 12 months pre- and post-PTX. The concentrations of serum calcium and phosphorous significantly decreased in the first 6 months post-PTX. The concentration of blood urea nitrogen significantly increased at 6 and 12 months post-PTX. In contrast with control chronic HD patients who had no weight gain after nonparathyroid surgery, there was a progressive weight gain leading to a significantly higher dry weight at 12 months post-PTX. There was no significant change in serum potassium, albumin, cholesterol, transferrin, bicarbonate, hematocrit, normalized protein catabolic rate (nPCR), or erythropoietin dose at any time point post-PTX. The biochemical parameters of the 8 patients who had more than 5% weight gain, during 12 months post-PTX, were not statistically different from the remaining 7 cases who had weight gain less than 5% (or had lost weight) in the same time period. The same was true for 4 patients with weight gain of more than 10% versus the latter group. In conclusion, HD patients with severe secondary hyperparathyroidism are prone to progressive weight gain post-PTX, which reaches significance by the twelfth month. In 53% of the patients, the weight gain is more than 5% above the baseline. The nutritional and biochemical parameters pre-PTX were not helpful in distinguishing those who developed significant weight gain post-PTX.

Living non-related versus related renal transplantation--its relationship to the social status, age and gender of recipients and donors.

BACKGROUND: Persistent differences between social classes and genders exist in the quality of medical care due to disparities in need and access. METHODS: 149 haemodialysis (HD) patients including 114 renal transplant candidates, and their proposed live donors were interviewed and followed for 4 years. Differences in need and access were analysed among the living non-related compared to related renal transplant according to social status, age and gender of recipients and donors. Also the motive for organ-donation as well as the recipient's survival was compared between living non-related and related renal transplantation. RESULTS: The proportion of females among renal transplant candidates was significantly lower than among HD-patients. Females were significantly less likely to be recipients, but more likely to be donors of renal allografts, particularly if they were unemployed. Initially all of the living non-related donors claimed to have altruistic motives for organ-donation but gift rewarding, drug abuse, unemployment, and economical deadlock, urgent need of money were significantly frequent than among living related donors. The donation process lasted significantly longer in females and in living non-related donors and there was a trend for higher mortality in recipient of living non-related grafts. Almost all of the living non-related donors disappeared after organ-donation without subsequent follow-up. CONCLUSIONS: Females are transplanted less frequently, but donate kidneys more frequently than males in living non-related transplantation programmes. There is an excess of vulnerable people among living non-related donors.

Percutaneous renal biopsy in the 1990s: safety, value, and implications for early hospital discharge.

To determine the parameters associated with significant bleeding and to examine the value of performing a renal biopsy, we studied 83 consecutive patients, including 24 renal allograft recipients, who had undergone percutaneous renal biopsy. The patients were stratified into four groups according to the percentage of decline in their hematocrit (Hct) at 24 hours postbiopsy, as follows: 10% or greater (n = 21; 25%) and less than 10% decline (n = 62; 75%). The latter group was further subgrouped into 5% to 10% (n = 22) and less than 5% decline (n = 40). There was a significant decline in Hct postbiopsy, with a linear correlation between the decrease in Hct at 6 and 24 hours (R2 = 0.47; P < 0.0001), suggesting that the former was a predictor of the latter. There was a linear correlation between the number of passes and number of cores obtained for the first four passes, but an inverse correlation when five passes or greater were required. Interestingly, there was no correlation between bleeding (>10% decline in Hct) and the number of passes or cores obtained. Gross hematuria and blood transfusion requirement were each encountered in three patients (3.6%). Importantly, the prebiopsy clinical diagnosis was altered in 18 of 59 native kidney biopsies (33%) and 10 of 24 transplant biopsies (41%). We conclude that percutaneous renal biopsy using an automated spring-loaded gun device coupled with ultrasound guidance is a safe technique and provides essential clinical information. Importantly, patients with a stable Hct at 6 hours were at low risk for bleeding at 24 hours while hospitalized. It remains to be determined if these findings could be extrapolated to early discharge from hospital.

Lupus nephritis in an anti-nuclear antibody-negative young male. The simultaneous presence of class III and class V renal lesions.

We report about a 27-year-old white male, a known case of class III lupus nephritis with a very high anti-nuclear antibody (ANA) titer, who after 10 years of complete clinical and serological remission presented with sudden development of malar rash, proteinuria and an increase in the serum creatinine. Repeated serologic studies were all negative for ANA. A repeat kidney biopsy disclosed the presence of focal segmental glomerulosclerosis lupus nephritis (class IIIc) superimposed with a new membranous lupus nephritis (class V).

The impact of (1:1) cyclosporine A conversion to its microemulsion formulation on the kidney function of patients with cardiac allografts.

Due to the large variations in the absorption and bioavailability of conventional cyclosporine A (CyA), 1:1 (mg:mg) conversion to its microemulsion formulation (Neoral) has been advocated in transplant recipients. However, the renal hazards and biochemical effects of such conversions and not known in cardiac transplant recipients. In this study, 68 cardiac transplant recipients who were receiving conventional CyA, for a period of 61.3 +/- 36.0 (mean +/- standard error (SE)) months, were switched to the microemulsion formulation (Neoral). The biochemical and renal function tests were evaluated at 1, 3, 6, 9 and 12 months pre- and post-conversion of CyA. The results obtained post-conversion were compared with those of the baseline (pre-conversion). Serum creatinine and uric acid levels significantly increased post-conversion to the microemulsion formulation. One patient required discontinuation of the microemulsion in an attempt to reverse severe renal failure. In spite of a significant decrease in the microemulsion dose at 6, 9 and 12 months, there was a significant increase in the whole blood CyA trough levels at 9 and 12 months of conversion. There was no significant change in blood pressure, serum total cholesterol or potassium post-conversion. Our results suggest that after 1:1 (mg:mg) conversion of CyA to its microemulsion formulation, there will be a significant rise in serum creatinine, uric acid and whole blood trough CyA levels necessitating significant dose reduction. This effect is probably due to the markedly improved absorption and bioavailability of the latter.

Transient renal glucosuria in patients with tetanus.

BACKGROUND/AIMS: During our early years of experience with patients suffering from tetanus, some of them were found to have unexplained renal glucosuria. METHODS: Thus, all the normoglycemic patients with tetanus who were consecutively encountered over the subsequent 8 years were studied for the presence of renal glucosuria. RESULTS: From 92 cases of tetanus admitted to the intensive-care unit, 63 patients had normal blood sugar in the course of their illness. The quantitative measurement of 24-hour urine confirmed the presence of significant renal glucosuria in 52% (n = 33) of these cases. The renal glucosuria was of transient nature and decreased to normal levels in the recovery stage (4 weeks after discharge from the hospital). There was no significant difference in age, sex, severity of disease and site of entry between the two groups of the patients with and without renal glucosuria. CONCLUSION: Significant but transient glucosuria of renal origin possibly induced by tetanospasmin is common in patients with tetanus.

Acute renal failure due to severe Landry-Guillain-Barré syndrome.

BACKGROUND: Blood urea nitrogen (BUN) >60 mg/dl has been reported to occur commonly in patient's with severe Landry-Guillain-Barré syndrome. AIMS: To find out the cause for this high BUN we compared the renal function tests of 30 consecutive cases with severe Landry-Guillain-Barré syndrome to those of 30 controls. RESULTS: Acute renal failure occurred in seven patients with Landry-Guillain-Barré syndrome and none of the control group. Acute renal failure was found more in cases with Landry-Guillain-Barré syndrome compared to controls (P=0.0049). Six out of seven cases with Landry-Guillain-Barré syndrome and acute renal failure had dysautonomia and became oliguric while being in a hypotensive state. Of 30 patients with Landry-Guillain-Barré syndrome seven cases died. From eight patients with dysautonomia six cases who had acute renal failure died. The mortality rate was higher in cases with dysautonomia and acute renal failure (P = 0.0001 and 0.00001, respectively). Interestingly no glomerular disease was found. CONCLUSION: In conclusion acute renal failure can occur commonly in cases with severe Landry-Guillain-Barré syndrome particularly in those with dysautonomia, causing high mortality.

Tetanus in the elderly: is it different from that in younger age groups?

Our aims were to itemize the clinical features and the outcome of tetanus in the elderly, as well as any age and sex differences in its acquisition. Therefore, we compared the demographic and clinical data of 12 elderly (group 1) cases of tetanus with 69 middle-aged patients (group 2) and 12 children (group 3) suffering from the same disease. There was no significant difference between the site of entry and incubation period or in the clinical and paraclinical findings among the three groups of patients. Acute respiratory failure was found more commonly in group 1 than in groups 2 and 3 (p = 0.0167 and p = 0.0006, respectively). It was also more common in group 2 than in group 3 (p = 0.0140). A mild form of tetanus was more often detected in children than in middle-aged and elderly cases (p = 0.0213 and p = 0.0013, respectively). Severe tetanus was seen more often in group 1 than in groups 2 and 3 (p = 0.0167 and p = 0.0006, respectively). Despite this, the mortality rate was not statistically different among the three groups of patients. Females were affected much less frequently than males with a female:male ratio of 1:3 in all three age groups. Our results suggest that elderly patients are at higher risk of acquiring a more severe form of tetanus and the subsequent development of acute respiratory failure. In addition, the disease is more common in males of all age groups, and age and sex have no apparent effect on the outcome of patients with tetanus.

Puerperal tetanus and hysterectomy.

OBJECTIVES: To compare the clinical course and outcome of patients with post-partum tetanus (n = 21) to those of non-post-partum ones (n = 24) and to determine the effect of early hysterectomy on the survival of cases with severe post-partum tetanus (n = 20). METHODS: In this prospective study we compared the clinical course and outcome of post-partum and non-post-partum cases of tetanus admitted to the intensive care unit. Moreover, early hysterectomy was done on every other patient with severe post-partum tetanus (n = 10). Chi-square and Student's t-tests were used for statistical purposes. RESULTS: Post-partum cases were younger (P = 0.002), had a higher incidence of acute respiratory failure and a mortality rate compared to the non-post-partum group. In addition, early hysterectomy did not change the course of severe post-partum cases. CONCLUSION: The mortality associated with post-partum tetanus is comparable to non-post-partum cases and early hysterectomy has no effect on its outcome.