Clinical findings in the renal victims of a catastrophic disaster: the Marmara earthquake.

BACKGROUND: The clinical course of acute renal failure (ARF) related to crush syndrome is very complex, because of co-existing surgical and/or medical complications. After the devastating Marmara earthquake that struck Turkey in August 1999, 639 patients were identified with nephrological problems, whose clinical findings have been the subject of this analysis. METHODS: Specific questionnaires asking about 63 variables were sent to 35 reference hospitals that treated the victims. Clinical findings of the renal victims were analysed. RESULTS: At admission, high fever was noted in 31.8% of the patients; the temperature of non-survivors was higher (P=0.027). Mean blood pressure was higher in survivors (P=0.004) and dialysed victims (P <0.001). Most (61.4%) patients were oligo-anuric; oliguria lasted for 10.8+/-7.2 days. Thoracic and abdominal traumas were associated with a higher risk of mortality. 397 fasciotomies and 121 amputations were performed in 790 traumatized extremities. Fasciotomies were associated with sepsis (P<0.001) and dialysis needs (P<0.0001), while amputations were associated with mortality (P<0.0001). Medical complications, which were associated with dialysis needs (P<0.0001) and mortality (P<0.0001), were observed in 51.5% of patients. In a multivariate analysis model of medical complications, disseminated intravascular coagulation (DIC) (P<0.0001, OR=5.81), and adult respiratory distress syndrome (ARDS) (P=0.0001, OR=4.53) were predictors of mortality. CONCLUSIONS: In the aftermath of catastrophic earthquakes, clinical findings of the renal victims can predict the final outcome. While fasciotomies indicate dialysis needs, extremity amputations, abdominal and thoracic traumas are associated with higher rates of mortality in addition to DIC and ARDS.

Renal dysfunction in allogeneic hematopoietic cell transplantation.

BACKGROUND: Allogeneic hematopoietic cell transplantation (HCT), formerly called bone marrow transplantation, can potentially cure various malignant and non-malignant diseases, but it is associated with a high risk of toxicity. We have previously shown an overall 21% incidence of severe acute renal failure in patients undergoing autologous HCT. The present study evaluated renal dysfunction in patients undergoing allogeneic HCT. METHODS: The clinical course of 88 adult patients who received allogeneic HCT at the University of Colorado Health Science Center was analyzed. Renal dysfunction was classified as follows: Grade 0 = normal renal function; Grade 1 =>25% decrement in GFR but twofold increase in serum creatinine; Grade 3 =>twofold increase in serum creatinine and need for dialysis. RESULTS: Of the 88 patients, 81 (92%) patients had some degree of renal dysfunction (Grade 1, 20 patients; Grade 2, 32 patients; Grade 3, 29 patients). Severe nephrotoxicity (Grade 2 and Grade 3 renal dysfunction) was associated with significantly higher frequencies of sepsis, hepatic toxicity and hepatic veno-occlusive disease (VOD), and lung toxicity. The overall mortality rate at the end of 6 months was 58%. Grade 3 renal dysfunction was associated with a significantly increased risk of mortality (82.6%). CONCLUSION: A 92% incidence of renal dysfunction in allogeneic HCT patients was found. Lung and liver toxicities were significantly correlated with developing renal dysfunction, and the mortality rates for patients with Grade 3 renal failure exceeded 80%.

The Marmara earthquake: admission laboratory features of patients with nephrological problems.

BACKGROUND: Earthquakes are major causes of morbidity and mortality. North-western Turkey was struck by a devastating earthquake in August 1999, which caused several thousand deaths. Among the most important morbid events in survivors were acute nephrological problems. METHODS: Within the first week of the disaster, specific questionnaires asking about 63 clinical and laboratory parameters were sent to 35 reference hospitals that were treating the victims. Of the registered 639 victims, 423 were admitted within the first 3 days of the disaster; the admission laboratory data of these 423 patients are the subject of this analysis. RESULTS: In the 423 patients (233 males, mean age 31.3+/-14.4 years), time under the rubble was 10.7+/-10.4 h. Mean values at admission were as follows: serum potassium 5.4+/-1.3 mEq/l, creatine phosphokinase 58205+/-77889 IU/l, albumin 2.6+/-0.7 g/dl, phosphorus 5.2+/-1.8 mg/dl, haematocrit 35.0+/-9.3%, leukocyte count 14945+/-6614/mm(3), platelet count 183975+/-134012/mm(3), blood urea nitrogen 55.1+/-28.9 mg/dl, and creatinine 3.9+/-2.3 mg/dl. Serum potassium above 6.5 mEq/l was noted in 91 patients (22.7%), an alarming finding for risk of fatal arrhythmias. Non-survivors were characterized by higher figures of serum potassium (P=0.001), as well as lower haematocrit (P=0.028), platelets (P<0.001), and serum albumin (P=0.003). In a multivariate analysis model of admission laboratory parameters, serum creatinine (P<0.001, o.r.=2.19), potassium (P=0.001, o.r.=3.64), and phosphorus (P=0.004, o.r.=1.78) predicted dialysis needs, whereas serum albumin (P=0.028, o.r.=0.23) and creatinine (P=0.039, o.r.=0.60) were related to mortality. CONCLUSIONS: Admission laboratory data may be useful for predicting dialysis needs and survival chance of disaster victims. High incidences of some life-threatening abnormalities dictate the need for empirical therapy even in the field.

Caspases, Bcl-2 proteins and apoptosis in autosomal-dominant polycystic kidney disease.

BACKGROUND: Apoptosis is a characteristic feature of human autosomal-dominant polycystic kidney disease (ADPKD). The Han:Sprague-Dawley (SPRD) rat model closely resembles human ADPKD and presents an opportunity to investigate the apoptotic pathway in the pathogenesis of this disease. METHODS: Han:SPRD rats were studied during the early stages of ADPKD (newborn, 2 and 6 weeks old). Apoptotic cells were detected by the TUNEL (Tdt-mediated dUTP nick end-labeling) assay. Caspase-3 activity was measured using the fluorescent substrate DEVD-AMC and cleavage of poly (ADP-ribose) polymerase [PARP]. Expression of pro- and anti-apoptotic B-cell lymphoma (Bcl-2) proteins was detected on Western blot analysis. RESULTS: TUNEL (+) cells, caspase-3 activity and caspase-mediated PARP breakdown were significantly increased in 2-week-old heterozygous (Cy/+) and homozygous (Cy/Cy) rat kidneys compared to normal littermate controls. In Cy/+ rat kidneys, decreased expression of anti-apoptotic Bcl-XL coincided with increased caspase-3 activity at 2 weeks of age while expression of Bcl-2, another anti-apoptotic protein, increased at 6 weeks of age. In Cy/Cy rat kidneys, decreased expression of Bcl-XL and increased expression of Bcl-2 was present at 2 weeks of age. Pro-apoptotic Bax and Bad expression was unchanged at 2 weeks of age in both Cy/+ and Cy/Cy rat kidneys. CONCLUSIONS: Activation of caspase-3 and dysregulation of the balance between pro- and anti-apoptotic Bcl-2 family members, specifically a down-regulation of anti-apoptotic Bcl-XL, correlates with increased apoptosis in polycystic Han:SPRD rat kidneys.