Oliguric acute renal failure in mycosis fungoides with lymphomatous infiltrates in the kidneys.

OBJECTIVE: To present the clinical picture of acute renal failure in patients with mycosis fungoides (MF) and renal lymphomatous infiltrates. To analyze the pathogenesis of renal failure. METHODS: Correlation of clinical picture, urinary findings, imaging reports and autopsy findings in two patients with long-standing MF who died with renal failure. CASE SUMMARIES: Both subjects had sustained oliguria in the last 2 weeks. One patient had persistent hypotension, normal urinalysis, normal renal sonogram, and scarce interstitial lymphomatous infiltrates with preservation of renal parenchymal architecture. He was thought to have ischemic acute renal failure not directly linked to the lymphomatous infiltrates. The second patient developed hypertension one month prior to death, and had moderate proteinuria, hematuria, pyuria, grossly enlarged kidneys with hypoechoic masses, and extensive replacement of the renal parenchyma by lymphomatous infiltrates. This picture is typical of renal failure secondary to lymphomatous replacement of the kidneys. CONCLUSIONS: The development of oliguric renal failure in MF with renal lymphomatous infiltrates may have varying clinical and imaging manifestations and pathogeneses. Potentially reversible pathogenic mechanisms should be systematically investigated, particularly if the overall clinical picture is not characteristic of renal failure secondary to lymphomatous replacement of the parenchyma.

Elevated free phenytoin and free valproic acid concentrations in sera of patients infected with human immunodeficiency virus.

Seizures are common in patients infected with human immunodeficiency virus (HIV). Phenytoin and valproic acid are common anticonvulsants, and both drugs are strongly bound to serum albumin. Because patients infected with HIV are often on polytherapy, using homeopathic medicines, and may also have hypoalbuminemia, elevated free drug concentrations may occur in these patients. The authors prepared one serum pool from patients infected with HIV but receiving no bactrim and the other pool from HIV patients receiving bactrim. They supplemented both HIV pools and normal pool (diluted with 0.9% saline to mimic albumin concentration of HIV pools) with a known concentration of phenytoin or valproic acid. After incubation at 37 degrees C for 3 hours, they measured free phenytoin and free valproic acid concentrations in the protein free ultrafiltrates using fluorescence polarization immunoassays. The total drug concentrations in original sera were measured by microparticle enzyme immunoassays. None of the patients had any significant liver or renal disease. The aliquots of HIV pools and normal pool were supplemented with the same concentration of phenytoin or valproic acid. The concentration of free phenytoin and free valproic acid were significantly elevated in patients with HIV (mean = 2.52, SD = 0.11 micrograms/ml for phenytoin; mean = 41.5, SD = 1.5 micrograms/ml for valproate) compared to controls (mean = 1.50, SD = 0.0 7 micrograms/ml for phenytoin; mean = 19.9, SD = 0.5 micrograms/ml for valproate). The concentrations of both free phenytoin and valproic acid were further elevated in patients prepared in the HIV pool who were receiving bactrim (mean = 2.81, SD = 0.09 micrograms/ml for phenytoin; mean = 44.0, SD = 1.1 micrograms/ml for valproate), but when normal serum pool was supplemented with 4.4 mg/dl of bactrim (concentration of bactrim in HIV pool) and supplemented with the same concentration of phenytoin or valproic acid, the observed free concentrations were much lower (mean = 1.65, SD = 0.05 micrograms/ml for phenytoin; mean = 26.1, SD = 1.4 micrograms/ml for valproate). This indicates that hypoalbuminemia and bactrim concentrations do not account for the observed free drug concentrations in patients with HIV. The authors also observed elevated free phenytoin and valproic acid in sera from three individual patients with AIDS compared to normals (normal serum diluted with 0.9% saline to mimic the albumin concentration of serum collected from a patient with HIV and then both specimens supplemented with the same concentration of phenytoin or valproic acid.

Rapid automated determination of lipid hydroperoxide concentrations and total antioxidant status of serum samples from patients infected with HIV: elevated lipid hydroperoxide concentrations and depleted total antioxidant capacity of serum samples.

Excessive production of oxygen free radicals causes the oxidation of circulating or membrane lipids, proteins, and DNA. Patients infected with HIV usually have severe malnutrition in the AIDS stage of disease. Therefore, they may be at higher risk of oxidative stress. We measured lipid hydroperoxide concentration, antioxidant status, cholesterol, triglyceride, iron, ceruloplasmin, and transferrin concentrations in the serum samples of 14 patients infected with HIV and compared our results with the results from 14 volunteers who served as controls. Lipid hydroperoxide concentrations in serum samples were measured by a colorimetric assay in which hemoglobin catalyzes the reaction of lipid hydroperoxide with a methylene blue derivative, yielding methylene blue. The total antioxidant capacity of serum was measured by the ability of serum to inhibit the formation of ferrylmyoglobin by metmyoglobin and hydrogen peroxide. Both assays were automated on the Syva-30R analyzer (Behring, San Francisco, Calif). We measured serum cholesterol and triglyceride concentrations by using the Vitro 950 analyzer (Johnson & Johnson, Rochester, NY). The lipid hydroperoxide concentrations were significantly elevated (mean, 1.44; SD, 0.95 micromol/L) in patients with HIV compared with control subjects (mean, 0.25; SD, 0.24 micromol/L). In contrast, the total antioxidant capacity was significantly lower in patients with HIV (mean, 1.04; SD, 0.13 mmol/L of trolox equivalent) compared with control subjects (mean, 1.66; SD, 0.09 mmol/L). We observed a fair correlation between serum lipid hydroperoxide concentrations and serum triglyceride concentrations in patients with AIDS. The correlation between serum hydroperoxide concentration and antioxidant status of serum was relatively poor. The lipid hydroperoxide assay was linear, from 0.1 micromol/L to 50 micromol/L. The within-run and between-run coefficients of variation were 3.5% and 4.5%, respectively, at a lipid hydroperoxide concentration of 2.5 micromol/L. The total antioxidant capacity assay was linear, from 0.1 to 2.5 mmol/L of trolox equivalent. The within-run and between-run coefficients of variation were 1.4% and 4.2% for the standard, with a target total antioxidant capacity of 1.5 mmol/L of trolox equivalent. We conclude that our automated assays for determination of total antioxidant status of serum and lipid hydroperoxide products may be helpful screening tests followed by measuring individual antioxidants, such as tocopherol, ascorbic acid, and other antioxidants for patients with severe deficiency of antioxidant status.