Charles L. Smith

Serum calcium fractions in essential hypertensive and matched normotensive subjects.

Concentrations of serum total calcium and serum calcium fractions were compared between 28 hypertensive subjects and 28 race-sex-age-matched normotensive controls. Mean levels of serum total calcium were not different between the two groups. Hypertensive subjects had lower mean serum levels of ultrafilterable calcium (-0.32 mg/dl; p = 0.01), ionized calcium (-0.07 mg/dl; p = 0.09), and complexed calcium (-0.23 mg/dl; p = 0.04) and higher levels of protein-bound calcium (+0.36 mg/dl; p = 0.07). Estimated dietary calcium intake was similar in the two groups. These findings add to the evidence that essential hypertension is associated with perturbations in calcium metabolism.

Risk factors for fractures in kidney transplantation.

Background. Risk factors for fracture after kidney transplantation need to be identified to target patients most likely to benefit from preventive measures. Methods. Medical records were reviewed for 1572 kidney transplants done at a single center between February, l963 and May, 2000 with 6.5±5.4 years of follow-up. Results. One or more fractures occurred in 300 (19.1%), with multiple fractures in 101 (6.4%). After excluding fractures of the foot or ankle (n=130 transplants, 8.3%), avascular necrosis (n=86, 5.5%), and vertebral fractures (n=28, 1.8%), there were one or more fractures in 196 (12.5%), with a cumulative incidence of 12.0%, 18.5%, and 23.0% at 5, 10, and 15 years, respectively. In multivariate Cox proportional hazards analysis, age had no effect on fractures in men. Compared with men and younger women, women 46–60 and >60 years old were, respectively, 2.11 (95% confidence interval 1.43–3.12, P =0.0002) and 3.47 (2.16–5.60, P <0.0001) times more likely to have fractures. Kidney failure from type 1 and 2 diabetes increased the risk by 2.08 (1.47–2.95, P <0.0001) and 1.92 (1.15–3.20, P =0.0131), respectively. A history of fracture pretransplant increased the risk by 2.15 (1.49–3.09, P <0.0001). Each year of pretransplant kidney failure increased the risk by 1.09 (1.05–1.14, P <0.0001). Obesity (body mass index >30 kg/m2) was associated with 55% (17–76%, P =0.0110) less risk. Different immunosuppressive medications, acute rejections, and multiple other factors were not independently associated with fractures. Conclusions. The population of transplant patients at high risk for fracture can be identified using age/gender, pretransplant fracture history, diabetes, obesity, and years of pretransplant kidney failure.

Renal pedicle injury in patients with multiple injuries.

In a study of 41 patients seen over 24 years, renal pedicle injuries were associated with life-threatening multiple system injuries and the immediate surgical management of these associated injuries by general surgeons took precedence over that of the renal pedicle injury. The result was the delayed diagnosis of the renal pedicle injury with loss of function of the kidney. In an effort to improve the renal salvage rate aggressive management of renal pedicle injuries with immediate radiologic evaluation and early surgical treatment was instituted in 1969. The records of 41 renal pedicle injuries from 1959 to 1983 were evaluated. Blunt external trauma was the cause in 76%. All 41 patients had multiple system injuries, averaging 3.7 associated injuries per patient, with 35 (85%) having a laparotomy for intra-abdominal injuries and an overall mortality rate of 44%. Conservative management was followed in 13 patients, with injury to the renal artery in nine and a branch of the renal artery in four, with a renal loss/delayed nephrectomy rate of nine of nine (100%) renal artery injuries. Immediate surgical management was performed in 23 patients, with injury to the renal artery in nine, the renal artery and renal vein in four, a branch of the renal artery in two, and the renal vein in eight, with a renal salvage rate of seven of 21 (33%) renal artery and/or vein injuries. Five patients died on admission or on the operating room table. A significant renal salvage rate resulted from immediate radiologic evaluation and early surgical treatment of renal artery/vein injuries compared to zero salvage rate with conservative management.

Medical evaluation and management of calcium nephrolithiasis.

Stone disease is a common medical problem, frequently recurs, and is associated with significant morbidity. Because appropriate medical therapy significantly decreases stone recurrence, this disorder must not be ignored by nonurologists. Even the single stone-former should be offered a metabolic evaluation.

Renal trauma found during laparotomy for intra-abdominal injury

Whether renal injury found during a laparotomy for intra-abdominal injury should have surgical or nonsurgical management is controversial. Five hundred twenty-one renal injuries were found during laparotomy for such injury in 513 patients. Blunt external trauma was the cause in 88%. A modified operating room table enabled performance of immediate intravenous pyelogram during the laparotomy. More severe degrees of renal injury (laceration, rupture, pedicle injury) were present in 135 (26%) of the renal injuries. Immediate surgical management of 102 more severe renal injuries resulted in nephrectomies in 37 (36%), delayed renal surgery in one (0.9%), and renal salvage in five of 18 (27%) main renal artery and/or vein injuries. Nonsurgical management of the remaining 23 resulted in nephrectomies in three (13%), delayed renal surgery in six (26%), total renal loss in seven of seven (100%) main renal artery injuries and an overall nephrectomy/total renal loss rate of 39%. With immediate surgical management of the more severe degrees of renal injury there was a slight increase in the salvage of kidneys and a marked decrease in delayed renal surgery and morbidity.

Simultaneous bladder and prostatomembranous urethral rupture from external trauma

Simultaneous bladder and prostatomembranous (posterior) urethral ruptures from external trauma occur in 10 to 29 per cent of male patients with traumatic rupture of the posterior urethra. The records of 47 male patients with traumatic rupture of the posterior urethra were evaluated. A total of 8 patients (17 per cent) had simultaneous rupture of the bladder (4 extraperitoneal, 3 intraperitoneal and 1 both) and posterior urethra (5 complete and 3 partial ruptures). A fractured pelvis was present in all 8 patients, with an average of 3.1 associated injuries per patient. Both ruptures were diagnosed preoperatively in only 1 patient. In male patients with multiple injuries, including a fractured pelvis and rupture of the posterior urethra, a concomitant rupture of the bladder must be suspected and sought at surgical exploration.

Type of blunt renal injury rather than associated extravasation should determine treatment.

The significance of extravasation of dye during excretion urography in blunt renal injuries has been controversial, with some believing that extravasation, even if copious, is largely innocuous and characterized by spontaneous resolution, and others believing extravasation is an indication for surgical correction of the underlying blunt renal injury. Thirty-two patients with extravasation diagnosed on excretion urography after blunt external trauma were evaluated. Immediate surgical management of the renal injury was performed in 18 patients who had a contusion in 1, laceration in 13, rupture in 3, and pedicle injury in 1, and averaged 2.0 associated injuries per patient. Conservative management of the renal injury was performed in 14 patients who averaged 1.1 associated injuries per patient. Ten of the 14 patients had a large renal laceration splitting the kidney or disrupting a pole with extravasation and none settled to normal. The data showed that extravasation with a small laceration resolved spontaneously while extravasation with a major disruption of the kidney did not settle to normal.

Sensitivity of Erythrocytes to Oxidant Stress in Uremia

The erythrocytes from 19 chronic hemodialysis patients were examined for Heinz bodies and their sensitivity to oxidant stress. Heinz bodies were found in 63% of patients and an elevated level of oxidized hemoglobin in 36%. When exposed to acetylphenhydrazine oxidant stress, 84% had a normal response and 95% had stable reduced glutathione levels. Ascorbic-acid-induced oxidant stress was tolerated by 84%. The activities of enzymes associated with the hexose monophosphate shunt were examined and found to be intact. This study demonstrates an increased number of Heinz bodies in hemodialysis patients. However, this is not due to an increased sensitivity to oxidant stress. Other mechanisms must be sought to explain the presence of Heinz bodies in these patients.

When should the stone patient be evaluated? Early evaluation of single stone formers.

Nephrolithiasis is a common disease, associated with high morbidity in terms of hospitalization and surgery, and probably low, but nonetheless present, mortality. Evaluation is low in risk to the patient, is probably cost-effective, and nearly always reveals one or more abnormalities which, when specifically treated, will alter the natural history of the disease process.

Deaths from urologic injury due to external trauma

The priority for treatment of a urologic injury in multiple injured patients from external trauma should be determined by the frequency of death from the urologic injury. The medical records of 2,058 patients with urologic injury from external trauma including 214 deaths were reviewed. Four deaths were attributed mainly to the urologic injury; one early in the postinjury period from continued severe hemorrhage from a ruptured kidney managed conservatively and three 6 to 8 weeks after injury from sepsis with a pelvic abscess from a ruptured urethra or bladder. The remaining 210 deaths were attributed to the associated injuries and occurred in the more severely injured older patients compared to the survivors. Death in multiple injured patients was rarely due to the urologic injury.