Pneumocystis carinii pneumonia: a lethal complication of "pulse" methylprednisolone therapy.

A previously healthy, HIV-negative, 67-year-old man developed rapidly progressive glomerulonephritis. Following "pulse" methylprednisolone therapy he developed Pneumocystis carinii pneumonia. This complication should be recognized as a potential hazard of "pulse" steroid therapy.

Occurrence of renal tubular dysfunction in lupus nephritis.

We prospectively evaluated 30 patients who presented with active systemic lupus erythematosus (SLE) for the presence of tubular abnormalities. All patients fulfilled the American Rheumatology Association criteria for SLE. When appropriate, a renal biopsy was performed. Of the 30 patients studied, 12 had no abnormal tubular study results, whereas 18 patients had some form of defect in the handling of potassium, sodium, or hydrogen ions. Eight patients had distal renal tubular acidosis (dRTA) due to an isolated proton secretory defect. Five had dRTA of the gradient or acid back-leak type. Two had an unresponsive voltage-dependent form of dRTA; one had a responsive voltage-dependent form of dRTA. One individual had hyporeninemic hypoaldosteronism and one had dRTA plus hypoaldosteronism. Clinically, patients with the abnormal tubular study results more often presented with nephritis or nephrotic sediment, peripheral edema, or anemia. Renal biopsies failed to demonstrate any difference in glomerular histologic findings and calculated activity, chronicity, or interstitial indexes. We conclude that SLE may be associated with a variety of tubular defects.

Myocardial infarction with normal results of coronary angiography following diltiazem withdrawal.

Abrupt withdrawal of calcium channel blocking agents has been associated with symptoms of ischemic heart disease, but acute myocardial infarction has not been noted. Herein is described a severely uremic patient who had an acute myocardial infarction shortly after discontinuance of diltiazem, although results of subsequent coronary arteriography were normal. It is postulated that myocardial damage occurred because of increased intracellular calcium flux, augmented myocardial contractility, and/or drug withdrawal-related coronary spasm.

Hypertension, mineralocorticoid-resistant hyperkalemia, and hyperchloremic acidosis in an infant with obstructive uropathy.

An 8-week-old infant with hypertension, hyperkalemia, and hyperchloremic acidosis, presumably due to chloride shunt type of distal renal tubular acidosis, is described. The patient's renin-aldosterone axis was intact. The infant was also found to have an obstructed solitary kidney. Despite correction of the obstruction and improvement in the glomerular filtration rate accompanied by normal development, hyperkalemia and renal tubular acidosis persisted. The defect was still demonstrable 9 months following relief of the obstruction. We conclude that neonatal obstructive uropathy can result in renal tubular acidosis of the chloride shunt type. The reversibility of this defect is, as yet, unknown.

Systemic lupus erythematosus presenting with hyporeninemic hypoaldosteronism in a 10-year-old girl.

Hyperkalemia has been noted to occur spontaneously in patients with long-standing systemic lupus erythematosus who did not have advanced renal insufficiency. The patients previously described all had relatively normal renin-aldosterone systems, and the hyperkalemia was thus presumed to be secondary to a primary defect in renal tubular potassium secretion. We describe at 10-year-old girl with lupus nephritis, without significant renal insufficiency, who had hyperkalemia from hyporeninemic hypoaldosteronism postulated to be due to vasculitis involving the afferent/efferent arterioles and juxtaglomerular apparatus.

In vivo effects of acute changes in osmolality and sodium concentration on myocardial contractility.

Effects of acute changes in osmolality and sodium concentration (Na) on myocardial contractility (MC) were examined in anesthetized dogs. Using a carotid to left anterior descending bypass, 4 cc of NaCl and/or dextrose of varying osmolality as injected and the percentage of change in MC measured. At Na = O mEq/L, a positive inotropic response occurred, which varied inversely as osmolality increased from 300 (MC = 100 +/- 23%) to 700 mOsm/L (MC = 39 +/- 10%, p less than 0.01). Similar ranges of positive responses of lesser magnitude were noted at Na = 75 mEq/L. At Na = 150, 190, or 350 mEq/L, similar increments in osmolality caused an increasingly negative inotropic response. An inverse relationship between Na and MC was noted with osmolality held constant. Injections of the nonionic contrast agent, P297, in 5% dextrose or 0.9% NaCl, resulted in 28 +/- 3% or -17 +/- 4% (p less than 0.01) change in MC, respectively. Sodium concentration and osmolality have independent effects on MC. Hyperosmolality/hypernatremia causes a negative inotropic response while hyponatremia causes a positive one.

Incidence of subclavian dialysis catheter-related infections.

Since 1981, we have performed more than 1,300 dialyses in 74 patients who have had subclavian dialysis catheters (SDCs) in place for a total of 3,065 days. Sixty-one (82%) of these patients have had their SDCs in place for seven to 21 days, including 37 (50%) for longer than 21 days. We have had six culture-proved and three possible (culture-negative) cases of SDC-related infections. Staphylococcus aureus (four cases) and Staphylococcus epidermidis (two cases) were the only organisms isolated. These infections were easily managed with antibiotics and removal of the SDC. There were no infection-related deaths. We believe that the SDC is a safe means of administering hemodialysis.

Rapid access for emergency dialysis.

Vascular access for acute hemodialysis or ultrafiltration in critically ill patients frequently requires cannulation of large-caliber veins. Repeated cannulation of these vessels present a finite risk of hemorrhage or hematoma. A teflon catheter introducer sheath system (TIS) allows for repeated use of the central circulation, requires only one major vascular entry, and can be adapted for either hemodynamic monitoring or emergency hemodialysis. Forty-six acute hemodialysis have been performed in 25 critically ill patients who have had TIS in place for hemodynamic monitoring. Dialysis was performed by inserting a femoral dialysis catheter through the TIS in place of the Swan-Ganz catheter. We have had no complications using the approach for emergency hemodialysis, and adequate dialysis was accomplished.

Contralateral hemothorax secondary to chronic subclavian dialysis catheter.

Subclavian vein catheterization offers a rapid, safe method for providing acute or short term hemodialysis. The technique has been associated with very few complications. 3 patients are described who developed hemothorax several weeks after the placement of a subclavian catheter. Perforation of the superior vena cava by the tip of the cannula could be demonstrated only by the injection of contrast media into the catheter.

In vitro correlation of glutamine and glutamate renal ammoniagenesis during adaptation.

Renal slices from 191 rats in various states of acid-base balance were investigated for their ability to produce ammonia from both glutamine and glutamate. Under a variety of conditions, in three different type studies, a significantly similar correlation existed between ammonia adaptation from glutamine and glutamate. This relationship was maintained during acute and chronic acidosis and during alkalotic inhibition of renal ammoniagenesis. We conclude from our findings that ammonia adaptation in rats secondary to acute and chronic acidosis is similar, although incomplete during acute acidosis. Our results further support the hypothesis that the rate of glutamate deamination is a major mechanism for overall renal ammonia adaptation in rats during acid-base changes.

Surgery, nutritional support, and survival in patients with end-stage renal disease.

In 216 patients with end-stage renal disease (ESRD) undergoing 406 major operations, surgery was elective in 143 cases (mortality, 1.4%) and nonelective in 263 (mortality, 11.1%). Of 82 patients who received 105 pretransplant operations to prevent posttransplant complications, eg, gastrointestinal hemorrhage, urinary tract sepsis, and azathioprine intolerance, surgical mortality was 1.9%, with 80 patients becoming active candidates for transplantation. Sepsis requiring surgical care occurred in 54 patients, in 36 of these in the posttransplant period. Parenteral and enteral hyperalimentation was used as a therapeutic adjunct in 40 of these patients. Overall mortality in those with septic complications was 35.2%, 22.5% in the nutritional support group and 71.4% in the group not receiving hyperalimentation. Improved survival rates can be achieved for surgical emergencies in ESRD, particularly in the posttransplant immunosuppressed patient, if both definitive surgical intervention and nutritional support are actively applied.

The role of splenectomy in cadaveric renal transplantation.

We analyzed 50 consecutive cadaver renal transplants to ascertain what benefit, if any, accrued from pretransplantation splenectomy. Because antithymocyte globulin was administered in a random fashion to some patients, its effects were also analyzed. Recipient modification with either modality enhanced graft survival in first transplants when compared to no modification (splenectomy versus no modification 62 versus 27%, p = 0.06; ATG versus modification 75 versus 27%, p = 0.01). The collective experience with splenectomy, its rationale, and its complications are discussed.

Segmental infarction of the omentum: a cause of the semi-acute abdomen.

Segmental infarction of the omentum is an unusual cause of the acute or "semi-acute" abdomen. Because of its rarity, the nonspecificity of its signs and symptoms and the almost total lack of information regarding its natural history, it is very rarely diagnosed correctly prior to laparotomy or autopsy. We report a 51-year old obese woman with chronic hypertension, congestive heart failure and renal insufficiency, who developed recurrent severe abdominal pain. The diagnosis of primary omental disease was entertained because of the triad of persistent localized abdominal pain, lack of grossly disturbed visceral function and the presence of hemoperitoneum. This was confirmed by laparotomy.

Protein-calorie malnutrition and cutaneous anergy in hemodialysis maintained patients.

In 52 unselected patients maintained in intermittent hemodialysis, protein calorie malnutrition was present in 10 patients (19%). Complete cutaneous anergy to four intradermal skin antigens. (Candida, tuberculin, Streptokinase-dornase, and mumps) and failure to respond to contact sensitization to dinitrochlorobenzene was present in 60% of the patients. No correlation between cutaneous anergy and protein calorie malnutrition could be demonstrated.

Vascular access: long-term results, new techniques.

Effective approaches to unique problems of vascular access in renal failure have evolved from a five-year experience with 840 angioaccess procedures. Standard techniques plus innovations have required only 0.62 operations per year per patient with an average access life of 1.6 years. Classical forearm external arteriovenous (AV) cannulas and internal AV fistulas provided vascular access in 392 patients, while 61 required more complex procedures due to failure of primary cannulas and fistulas, inherently small forearm vessels, and iatrogenic vessel loss. Secondary techniques include reverse fistula, vascular graft AV fistulas using expanded polytetrafluoroethylene (E-PTFE), and arterioarterial (AA) jump graft. Presently, the new renal failure patient receives a forearm radiocephalic AV fistula; the cannula is restricted to emergency or short-term hemodialysis and may later be converted to a subcutaneous fistula. The reverse fistula is attempted before using E-PTFE grafts. Upper extremity AV and AA loops can then be constructed de novo or from the reverse fistula.