RESUMO
Hypernatremia secondary to urea-induced solute diuresis is due to the renal excretion of electrolyte-free water. This concept is explained here step-wise physiologically with the help of a clinical vignette.
RESUMO
A 28-year-old female with history of hypothyroidism, Sjögren's Syndrome, and Systemic Lupus Erythematosus (SLE) presented with complaints of severe generalized weakness, muscle pain, nausea, vomiting, and anorexia. Physical examination was unremarkable. Laboratory test showed hypokalemia at 1.6 mmol/l, nonanion metabolic acidosis with HCO3 of 11 mmol/l, random urine pH of 7.0, and urine anion gap of 8 mmol/l. CT scan of the abdomen revealed bilateral nephrocalcinosis. A diagnosis of type 1 RTA likely secondary to Sjögren's Syndrome was made. She was started on citric acid potassium citrate with escalating dosages to a maximum dose of 60 mEq daily and potassium chloride over 5 years without significant improvement in serum K+ and HCO3 levels. She had multiple emergency room visits for persistent muscle pain, generalized weakness, and cardiac arrhythmias. Citric acid potassium citrate was then replaced with sodium bicarbonate at 15.5 mEq every 6 hours which was continued for 2 years without significant improvement in her symptoms and electrolytes. Amiloride 5 mg daily was added to her regimen as a potassium sparing treatment with dramatic improvement in her symptoms and electrolyte levels (as shown in the figures). Amiloride was increased to 10 mg daily and potassium supplementation was discontinued without affecting her electrolytes. Her sodium bicarbonate was weaned to 7.7 mEq daily.
RESUMO
Although primary toe-to-hand transplantation is performed with increasing frequency, its use is still controversial because of the lack of any comparative studies documenting its safety and efficacy. Between August of 1990 and December of 1993, 175 consecutive toe-to-hand transplantations for crush and avulsion injuries were performed in 122 patients. The average interval between injury and primary reconstruction was 7 days, and the average interval between injury and secondary reconstruction was 10.7 months. Follow-up ranged from 18 to 91 months, with an average follow-up of 58 months. There were 31 primary transplantations and 144 secondary transplantations. The survival rate was 96.8 percent (30 of 31) for primary reconstruction and 96.5 percent (139 of 144) for secondary reconstruction. Intraoperative anastomotic revision was necessary in 3.2 percent (one of 31) of primary transplantations and 7.6 percent (11 of 144) of secondary transplantations. Three primary toe-to-hand transplantations (9.7 percent) and 17 secondary toe-to-hand transplantations (11.8 percent) were re-explored in the postoperative period. Each group had one superficial infection. The infection rate was 6.5 percent and 0.7 percent in the primary and secondary groups, respectively. Other complications included partial skin loss, which occurred in one patient (3.2 percent) in the primary group and six patients (4.2 percent of 144 transplantations) in the secondary group. Secondary procedures to improve function were necessary in six secondary transplantations (4.2 percent) and in none of the primary transplantations. There was no statistical difference between the two groups in terms of survival, intraoperative anastomotic revision, re-exploration, future secondary procedure, infection, and complications. This series demonstrates that primary toe-to-hand transplantation can be performed in the suitable candidate safely with as much success as secondary reconstruction. Primary toe transplantation can potentially reduce the overall period of recovery and rehabilitation, allowing the patient to return to work sooner. Further study to evaluate and compare the final functional outcome and return to work time between primary and secondary toe-to-hand transplantation is needed.
