Fatal destructive cervical spondyloarthropathy in two patients on long-term dialysis.

Two patients with fatal cervical cord compressive myelopathy are described, both of whom had been on dialysis for more than 15 years. Destructive changes were noted in mid and upper cervical regions, with soft tissue mass in the atlanto-occipital region in one patient. Clinical and radiographic findings suggest both amyloid and hyperparathyroidism as possible etiologies for these destructive spinal changes. Clinicians should be aware that the full picture of quadriparesis may be associated with destructive spondyloarthropathy (DSA) in long-term dialysis patients.

Combined use of nifedipine and diltiazem for the treatment of severe hypertension.

Calcium channel blockers are a heterogeneous group of drugs that have enhanced our ability to concurrently control blood pressure, treat coronary artery disease, and avoid many of the side effects of previously available antihypertensive agents. Patients with severe hypertension may require multiple agents for adequate control of blood pressure because of either poor control with one agent or side effects from high doses of a single agent. Laboratory investigations have shown a synergistic effect on receptor binding, as well as increased drug levels with the concurrent use of diltiazem and a dihydropyridine calcium channel blocker (nifedipine or nicardipine). It is as yet unknown whether these effects on receptor binding and increased drug levels translate into greater clinical efficacy in blood pressure control. We have reported what we believe to be the first case in which this interaction was used successfully to control previously poorly controlled hypertension, while minimizing side effects.

[Hyporeninemic hypoaldosteronism. Case report and attempt at pathophysiological classification (author's transl)]. / Hipoaldosteronismo hiporreninémico. Presentación de un caso e intento de clasificación fisiopatológica.

A 75 year-old male presented with hyperkalemia unexplained by a moderate renal insufficiency, low basal levels of aldosterone and renin with a subnormal response to walking and saline depletion, and normal glucocorticoid function. The hyperkalemia was corrected by fluorocortisone administration. The concept of hypoaldosteronism is reviewed, defining it as an isolated aldosterone deficiency and thus excluding the combined deficiency of cortisol and aldosterone and the suprarenal enzyme deficits that simultaneously involve mineralocorticoid and glucocorticoid synthesis. Depending on the presence or absence of alterations of the renin-angiotensin axis, this infrequent syndrome can be pathophysiologically classified as low, normal or high renin hypoaldosteronism. The characteristic features of each type are described, and emphasis is made on the need for a high index of suspicion when unexplained hyperkalemia is present in order to perform the appropriate tests to confirm or rule out hypoaldosteronism.

Hepatorenal syndrome following hemihepatectomy.

The hepatorenal syndrome following right hemiphepatectomy is reported in a previously healthy patient who sustained a shotgun wound in the abdomen. In spite of the development of severe oliguric renal insufficiency and the administration of massive amounts of volume expanders and furosemide, the urine sodium concentration remained very low, therby excluding the diagnosis of acute tubular necrosis. Although severe hyperbilirubinemia developed, the prothrombin time was only slightly abnormal and the liver doubled in size in the 2 weeks after surgery. The study of functional renal failure in patients with liver disease other than decompensated cirrhosis and with significant preservation of hepatic function may suggest that factors other than a circulating toxin participate in mediating the hepatorenal syndrome.