Antoine Kaldany

Nephrotoxicity from angiographic contrast material: A prospective study

Three hundred and seventy-eight hospitalized patients undergoing nonrenal angiography were evaluated for subsequent changes in renal function. Acute renal failure was defined as a rise in the serum creatinine level of 1.0 mg/dl or more. Several factors that appeared to play no significant role in causing acute renal failure included: the volume of contrast material injected, the anatomic site of injection and the presence of a prior history of cardiovascular disease or diabetes mellitus. The single risk factor identified was the presence of preexistent azotemia (blood urea nitrogen of 30 mg/dl and serum creatinine of 1.5 mg/dl). Whereas nonazotemic patients had a 2 percent incidence of definite acute renal failure, patients with chronic azotemia (mean blood urea nitrogen/creatinine = 47/2.3 mg/dl) had a 33 percent incidence. Three patients required short-term dialysis, and two required potassium-exchange resin therapy. No patient required permanent dialysis, and no patient died of acute renal failure. The persistence of a positive nephrogram 24 hours after angiography was a sensitive detector of a rise in the serum creatinine level although more expensive than the creatinine determination. While urine sediment analysis confirmed the diagnosis in many cases, it was relatively insensitive. Monitoring of urine volume proved to be of little value. We recommend a screening serum creatinine determination 24 to 48 hours after infusion of angiographic contrast material in azotemic patients.

Plasma Renin Activity and Hypertension in Diabetes Mellitus

Plasma renin activity (PRA) was determined in 48 patients with diabetes mellitus in sodium balance on a 10-20 mEq. Na diet. Nine were normotensive (group I), 11 were hypertensive without diabetic nephropathy (group II), and 28 had hypertension and nephropathy (group III). Results were compared with those in 16 normal subjects and 49 nondiabetic patients with essential hypertension in similar Na balance. Mean supine PRA did not differ significantly among groups I and II, normal subjects, and patients with essential hypertension. Group III diabetics had a supine PRA of 2.4 ± 0.4 ng./ml./hr. ( ± S.E.M.), significantly lower than the other diabetic groups (P < 0.005) and normal subjects (P < 0.05). Upright PRA was 12.8 ± 2.2 in group I diabetics, similar to that in normal subjects (13.3 ± 2.3), and 8.1 ± 1.4 in group II diabetics, similar to that in essential hypertensives (6.8 ± 0.8). In group III diabetics, upright PRA was 4.0 ± 0.5, significantly lower than that in any other group. These results suggest that (1) PRA is normal in normotensive diabetics, (2) upright PRA in diabetics with hypertension but no nephropathy is similar to that in essential hypertension, and (3) patients with diabetes, hypertension, and nephropathy have “low renin hypertension,” explaining the virtual absence of malignant hypertension in this group. Although the major mechanism for this low PRA may be volume expansion, indicating the need for potent diuretics, other mechanisms include hyalinization of the afferent arteriole, decreased cathecholamine stimulation of renin release, and inadequate conversion of prorenin to renin.

Reversible Rapidly Progressive Renal Failure with Nephrotic Syndrome Due to Fenoprofen Calcium

Excerpt Nonsteroidal antiinflammatory drugs have been reported to cause reversible acute renal failure (1-4). Unlike the so-called phenacetin-induced analgesic nephropathy (5), the nephrotoxicity o...

Aldosterone Responsiveness in Patients with Diabetes Mellitus

Plasma aldosterone (PA) and plasma renin activity (PRA) were determined in 44 diabetics, of whom nine were normotensive but not nephropathic (group 1), 10 were hypertensive but not nephropathic (group 2), and 25 were hypertensive and nephropathic (group 3); they were kept in balance on a diet composed of 10 to 20 mEq. of sodium (Na) and 100 mEq. of potassium (K). Supine PA in group 1 was 38 ± 7 ng. per deciliter, whereas in normals it was 24 ± 2 ng. per deciliter (P < 0.05); beyond that, neither supine nor upright PA or PRA differed significantly from normal in groups 1 and 2. By contrast, in group 3, supine PA was 13 ± 1 ng. per deciliter and PRA 2.0 ± 0.2 ng./ml. and upright PA was 39 ± 7 ng. per deciliter and PRA 3.8 ± 0.5 ng./ml., all significantly lower than those in the other groups (P < 0.01). Nine patients, one in group 1 and eight in group 3, had low supine and upright PA and PRA; four had hyperkalemia. An additional nine patients in group 3 had low upright PA, with normal or low PRA; two had hyperkalemia. Of the 18 patients with low upright PA, K correlated with glucose (R = 0.46, P < 0.05). These results suggest (1) the renin-aldosterone system generally responds normally in diabetics without nephropathy but responds subnormally when nephropathy is present, (2) hyporeninemic hypoaldosteronism is frequent in diabetics with nephropathy but may occur in the absence of clinical nephropathy, and (3) hyperkalemia in some diabetic patients may be secondary to hypoaldosteronemia and hyperglycemia.

Use of Dacron cuffed silicone catheters as long-term hemodialysis access.

Sixty-five Dacron™ cuffed, dual lumen, silicone central venous dialysis catheters (Quinton PermCath, Seattle, WA) were inserted in 51 patients as the sole form of permanent access for chronic hemodialysis. Six and 12 month actuarial survival rates of patients for all catheters were 53% and 35%, respectively. When calculations included revisions, 6 and 12 month actuarial catheter survival rates were 61% and 43%, respectively. The major limiting factors in survival using long-term catheters remain infection and thrombosis. Dacron cuffed, dual lumen, central venous, dialysis catheters can provide long-term vascular access for hemodialysis in high risk patients.

Reversible Acute Pulmonary Edema due to Uncontrolled Hyperglycemia in Diabetic Individuals with Renal Failure

On eight separate occasions, four functionally anephric diabetic patients (on maintenance hemodialysis) experienced episodes of severe hyperglycemia with acute interstitial and alveolar pulmonary edema demonstrated clinically and by chest x-ray without electrocardiographic or enzymatic evidence of an acute myocardial lesion. Three patients had normal stress 201Tl scanning. The fourth patient, who experienced three such episodes, had normal coronary angiograms and only a mild elevation of the left-ventricular end-diastolic pressure. Clinical and chest x-ray improvement were immediate following insulin therapy and control of hyperglycemia, without phlebotomy or dialysis. Since these episodes were observed during a 1-yr period, this syndrome may be more common than suspected. It is concluded that in functionally anephric diabetic individuals: (1) pulmonary edema can be precipitated by uncontrolled diabetes; (2) endogenous fluid shifts may contribute to the cause of acute pulmonary edema; (3) clinical and radiologic improvement can be achieved with adequate insulin therapy; and (4) blood glucose levels should be monitored and controlled in diabetic patients with renal failure.

Diabetic Renal Transplantation

Fifty-three juvenile onset diabetics have received 59 renal allografts: 31 from living related donors and 27 from cadaveric donors. The average patient age was 34 years and the duration of diabetes was 27 years at the time of transplantation. Patient survival rates for living related recipients at 1 and 2 years were 97 and 94 per cent, respectively. Patient survival rates for cadaveric recipients at 1 and 2 years were 85 and 66 per cent, respectively. Renal allograft survival rates for living related recipients were 81 per cent at 1 year and 71 per cent at 2 years. Cadaveric renal allograft survival rates were 22 per cent at 1 year and 20 per cent at 2 years. The role of pre-transplant coronary angiography relative to patient selection and a recent decrease in our perioperative mortality are discussed.

Effect on platelet function of hypoalbuminemia in peritoneal dialysis.

Chronic renal failure is associated with functional platelet defects. Peritoneal dialysis is associated with improvement in platelet function. This study demonstrates that the hypoalbuminemia resulting from peritoneal dialysis may account for part of the improvement. Platelet aggregation was measured when plasma albumin was less than 3 g/dl and again when the albumin level was raised to greater than 4 g/dl. Normal albumin levels were associated with decreased platelet function when the slope of aggregation to ADP and epinephrine were used as the study parameters. Patients with peritoneal dialysis given albumin to correct their plasma albumin level also acquired reduced platelet aggregation.

Cardiorenal Failure: Treatment of Refractory Biventricular Failure by Peritoneal Dialysis

Fifteen patients with New York Heart Association Class IV functional cardiac disability whose mild-to-moderately severe renal failure had produced life-threatening fluid overload underwent dialytic therapy. Ten were dialyzed by the peritoneal route initially and five were switched from hemodialysis to peritoneal dialysis because of hemodynamic instability. All patients improved, resulting in renewed responsiveness to more conservative measures (2), stabilization for cardiac surgery (4), or less-restricted lifestyle out of hospital (9). We recommend consideration of peritoneal dialysis when biventricular and renal failure are refractory to conventional therapy.

Increased Infection Rate in Diabetic Dialysis Patients Exposed to Cocaine

Three hundred ninety-seven insulin-dependent diabetic dialysis patients were screened by nursing staff for analgesic-seeking behavior. Thirty-eight patients were identified and classified as prescription abusers (n = 26) or illicit drug users (n = 12). The nine cocaine users, when compared with 14 insulin-dependent diabetics on dialysis matched by protocol, were found to be similar in terms of diabetic retinopathy and metabolic neuropathy. Although statistically not significant, cerebrovascular and cardiovascular complications were more common in the study group. Gastroenteropathy with malnutrition was more common the study group (P less than 0.025). Infection rate and severity were markedly worse in the cocaine group: bacterial cellulitis, sepsis, and abscess each increased greater than fourfold. All the visceral infections were in the cocaine-using group. Hepatitis viral antigen and antibody was increased 10-fold in the cocaine users. Recommendations for management of dialysis patients with analgesic-seeking behavior are formulated in light of these findings.