Acute reversible renal failure in a patient with paroxysmal nocturnal hemoglobinuria.

We present the case of a young male with 2-month history of intermittent upper abdominal pain who developed diarrhea, anorexia, tea-color urine, and decreased urine output. He was found to be in severe acute renal failure requiring hemodialysis, four sessions in 10-day period. By the end of the second week of hospitalization renal function gradually improved with total recovery of function to a baseline creatinine of 1.1 mg/dl 25 days after the diagnosis of acute renal failure. His workup included Ham's test, water sugar test, and RBC fragility test which confirmed the diagnosis of paroxysmal nocturnal hemoglobinuria.

Reversible renal insufficiency, hyperuricemia and gouty arthritis in a case of hypothyroidism.

We present the case of a young man with 3-month history of generalized weakness and lethargy, constipation, weight gain, and swelling in the lower extremities. He was found to have an elevated serum creatinine of 203 mumol/l (2.3 mg/dl), markedly elevated TSH, severe hypercholesterolemia, hyperuricemia, a 24-hour urine creatinine excretion rate of 16.8 mmol/d (1.9 g/d), a creatinine clearance of 58 ml/min, and a uric acid excretion rate of 4.2 mmol/d (700 mg/d). With the impression of primary hypothyroidism, the patient was started on levothyroxine supplementation at which point he developed a classic gouty arthritis of right first metatarsophalangial joint. Six weeks after thyroid replacement therapy his serum creatinine had declined to 124 mumol/l (1.4 mg/dl), and 24-hour urine creatinine excretion rate declined to 11.5 mmol/d (1.3 g/d) with an estimated creatinine clearance rate of 65 ml/min. This was accompanied by reduction in serum uric acid and cholesterol levels, and a decline in uric acid excretion rate. Eighteen months later his creatinine had further declined to 88.4 mumol/l (1.0 mg/dl).

Insulin-requiring diabetes mellitus, hyperlipidemia, and anginal chest pains as prominent features of pheochromocytoma.

We report the case of a 60-year-old man with recent onset of poorly controlled diabetes mellitus, frequent anginal chest pains, paroxysmal hypertension, hyperlipidemia, and mild renal insufficiency. The patient was found to have pheochromocytoma of the left adrenal gland, resection of which resulted in total resolution of diabetes, hypertension, chest pain, hyperlipidemia and renal failure.

Spontaneous systemic anaphylaxis as an unusual presentation of hydatid cyst: report of two cases.

We report two cases presenting with severe spontaneous systemic anaphylactic reaction who were subsequently found to have hydatid cyst(s) in one or more intra-abdominal organs. This unusual presentation in otherwise asymptomatic patients, without known precipitating factors, i.e., trauma, or accidental (needle aspiration or surgical) rupture of the cyst emphasizes that physicians in endemic regions should keep a high index of suspicion for the hydatid disease as a possible etiology for seemingly idiopathic anaphylactic reaction.

Outcome of polymicrobial peritonitis in continuous ambulatory peritoneal dialysis patients.

Polymicrobial peritonitis is a relatively uncommon, but potentially serious complication that develops in continuous ambulatory peritoneal dialysis (CAPD) patients. Its cause and optimal management remain controversial. The authors reviewed the frequency and natural history of polymicrobial peritonitis in 432 CAPD patients. Of 1,405 episodes of peritonitis, 80 were polymicrobial (6%). Patients with polymicrobial peritonitis were similar to all CAPD patients in age, gender, race, and underlying renal disease. Diabetes mellitus, human immunodeficiency virus (HIV) status, and clinically apparent gastrointestinal disease did not predisposes patients to polymicrobial peritonitis. Thirty days after the polymicrobial peritonitis, 64 patients remained on CAPD (80%), and at 180 days 48 patients continued CAPD. Prior exit-site infections were present in 12 patients (14%) with polymicrobial peritonitis. Only 22% of patients required catheter removal to treat the infection. We conclude that polymicrobial peritonitis accounts for 6% of the total episodes of peritonitis; diabetes, HIV infection, and underlying gastrointestinal disease are not more prevalent in patients with multiorganism infections. Most patients continue CAPD therapy at 30 and 180 days after the episode of polymicrobial peritonitis.

Pulse oral calcitriol to treat hyperparathyroidism in 43 CAPD patients.

To further study the effect of pulse oral calcitriol on the level of intact parathyroid hormone (iPTH), we have studied the response of 43 patients treated with 5.0 mcg calcitriol bi-weekly for one year. Mean iPTH decreased from 603 pg/mL +/- 262 (+/- SD) to 222 pg/mL +/- 185 (p < 0.001). Thirty-six patients responded showing a decrease in iPTH from baseline; 7 patients showed no decrease in iPTH. Transient hypercalcemia (calcium > 10.5 mg/dL) was noted in 6 patients of the responder group which corrected with temporary discontinuation of pulse therapy. Pulse oral calcitriol is an effective therapy to decrease elevated iPTH levels in continuous ambulatory peritoneal dialysis (CAPD) patients with hyperparathyroidism.

Selected outcome criteria and adequacy of dialysis in diabetic and elderly patients on CAPD therapy.

There has been a gradual increase in the number of diabetic and elderly patients maintained on continuous ambulatory peritoneal dialysis (CAPD) replacement therapy. Eighty randomly selected patients were studied over two years. Weekly normalized urea clearance (KT/Vurea), weekly creatinine clearance/1.73 m2 body surface area (BSA) (Ccr), and protein catabolic rate (PCR) were measured. Selected clinical outcome criteria were assessed. Weekly KT/Vurea was correlated with weekly Ccr (r = 0.538, p < 0.001), and weekly KT/Vurea was correlated with PCR (r = 0.393, p < 0.001). Patients were then stratified according to presence or absence of diabetes mellitus and age > 60 or < or = 60 years. Diabetic and nondiabetic patients had similar weekly KT/Vurea, weekly Ccr, PCR, serum albumin levels, weekly erythropoietin (EPO) requirements, peritonitis rates, and CAPD-related hospitalization rates. The total hospitalization rates, however, were higher in diabetic patients. Elderly and younger patients had similar weekly KT/Vurea, weekly Ccr, PCR, serum albumin levels, and weekly EPO requirements. Elderly patients, however, had higher peritonitis rates and higher total and CAPD-related hospitalization rates.

Weekly KT/V urea and selected outcome criteria in 56 randomly selected CAPD patients.

The optimal way to objectively measure the adequacy of continuous ambulatory peritoneal dialysis (CAPD) therapy remains controversial. It has been suggested that one-third or more of all CAPD patients are presently receiving "inadequate dialysis" when dialysis prescriptions are not carefully calculated. To better define the therapy being delivered in a large, freestanding CAPD center, weekly KT/V urea and creatinine clearance per 1.73 m2 body surface area were measured in 56 of 180 patients randomly selected from our unit in whom dialysis prescriptions were arbitrarily determined by nurses and physicians. In addition, protein catabolic rates and selected clinical outcome criteria were assessed. Weekly KT/V urea correlated with weekly creatinine clearance (r = 0.50) as well as with the protein catabolic rate (r = 0.45). Patients were arbitrarily divided into three groups based on KT/V urea measurements. Thirty percent of the patients had weekly KT/Vs < or = 1.4, 41% had KT/Vs between 1.5 and 1.8, and 29% had weekly KT/Vs > or = 1.9. Significant differences were not noted in hospitalization rates, erythropoietin doses, or serum albumin concentrations in patients with KT/Vs < or = 1.4 and in patients with KT/Vs > or = 1.9. Peritonitis rates were highest in the patients with KT/V > or = 1.9. Therefore, in patients randomly selected from our large CAPD center, 30% of the patients had weekly KT/V urea measurements < or = 1.4. The clinical significance of this finding remains uncertain.