Dina Zevin

Severe Hyponatremia After Water Intoxication: A Potential Cause of Rhabdomyolysis

A 28-year-old woman, treated for schizophrenia, developed severe hypotonic hyponatremia (serum Na: 109 mEq/L) after several days of compulsive water drinking. The patient was admitted in a coma and required intensive supportive therapy. Rhabdomyolysis quickly followed with high serum creatine phosphokinase levels and myoglobinuria. A high volume alkaline diuresis was initiated. Renal failure or compartment syndrome did not complicate the clinical picture. The mechanisms causing water intoxication and hyponatremia are discussed as are the possible pathogenetic explanations behind acute hyponatremia and rhabdomyolysis.

Non-Occlusive Mesenteric Ischemia in Chronically Dialyzed Patients: A Disease with Multiple Risk Factors

Background: Non-occlusive mesenteric ischemia (NOMI) can be a fatal complication in dialysis patients. Intradialytic hypotension is usually the precipitating factor. The occurrence of 16 cases in 5 years (1998–2002), compared with only 4 in previous years, led us to investigate other risk factors contributing to NOMI. A control group of stable hemodialysis patients was used for comparison. Results: 20 patients were studied: 17 diagnosed surgically, and 3 clinically. The mean age was 70.8 ± 1.8 years, and the male:female ratio 7:13. Nineteen patients were on hemodialysis. Clinically overt atherosclerosis was present in 17 patients. Preceding dialysis-associated hypotension was identified in all patients studied and access thrombosis in 6 patients. In all patients, abdominal pain was the presenting symptom. Initial abdominal examination was unimpressive in 16 patients. The hemoconcentration, leukocytosis and metabolic acidosis were the most prominent laboratory findings. 5/11 abdominal sonograms showed intestinal pathology. 2/3 angiographies were diagnostic. Three patients responded to early fluid challenge and did not require surgery. Pathology was related to the area of the superior mesenteric artery in all 15 patients operated. Twelve (60%) patients died from the event. The 1-year mortality rate was 17/20 patients (85%). Possible contributing factors, other than dialysis-associated hypotension, included: high-dose recombinant human erythropoietin (rhEPO) therapy (179 ± 35 vs. 116 ± 10 U/kg/week in the control group, p < 0.05); metastatic calcifications (abdominal aorta 14/14, aortic valve 11/18; medial calcification of mesenteric arteries in 2/11 pathology specimens); digoxin, and hypoalbuminemia. Conclusions: The increased incidence of NOMI in dialysis patients may be related to overly aggressive rhEPO therapy and the unsuspected presence of mesenteric arterial medial calcifications. Identification of patients at risk, prevention of intradialytic hypotension and a controlled increase in dry weight may help to reduce the incidence of NOMI in chronically dialyzed patients.

Improved Immunogenicity of a Novel Third-Generation Recombinant Hepatitis B Vaccine in Patients with End-Stage Renal Disease

Hepatitis B (HBV) infection remains a significant epidemiological problem in the end-stage renal disease (ESRD) population. Vaccination programs using second-generation vaccines lead to effective seroprotection in only 50–60% of these patients. The purpose of this case series was to describe our experience with a novel third-generation vaccine, Bio-Hep-B®, in ESRD patients who had not developed protective anti-HBs titers following a second-generation HBV vaccination protocol. Twenty-nine ESRD patients who had not responded in the past to a standard second-generation HBV vaccination protocol were included in this series. Each patient received 10 µg of Bio-Hep-B® intramuscularly at 0, 1 and 6 months. A month after completion of the vaccination protocol, anti-HBs antibody levels were measured. Following immunization, 25 of 29 patients (86%) developed seroprotective anti-HBs levels ≧10 mIU/ml. There was a significant difference in the titers of anti-HBs antibodies prior to and following vaccination (p < 0.0001). Statistical analysis of the variables age, gender, diagnosis, dialysis mode, weight, hemoglobin, albumin, and KT/V failed to detect predictors of antibody response. A retrospective analysis of the results of a second-generation vaccination program for the years 1999–2001 in our department showed that 19 of 36 (56.4%) ESRD patients developed seroprotection. In conclusion, the results of this study show that the third-generation HBV vaccine Bio-Hep-B® is highly immunogenic in the population of ESRD patients who did not respond in the past to a second-generation vaccine. This enhanced seroprotection offers hope that the new vaccine will reduce the rate of non-responders and help to eliminate HBV infection from dialysis centers.

Subclavian Vein Stenosis, Permanent Cardiac Pacemakers and the Haemodialysed Patient

Two cases of subclavian vein stenosis secondary to permanent cardiac pacemakers are presented. Both stenoses were asymptomatic until arteriovenous fistulae/grafts were constructed in order to initiate haemodialysis. One patient experienced severe oedema of the arm which necessitated surgical closure of the graft. A literature review into major venous stenosis and cardiac pacemakers reveals an asymptomatic, but evidently underestimated, problem. As more elderly patients will be accepted onto haemodialysis programmes, this above-mentioned problem may become more common. Therapeutic answers as to haemodialysis access are discussed in these patients with permanent pacemakers who need haemodialysis.

Platelet Count and Thrombopoietic Activity in Patients with Chronic Renal Failure

The frequency of thrombocytopenia in patients with chronic renal failure (CRF) is controversial. This study was undertaken to investigate the platelet count in 55 patients with end-stage renal disease on maintenance hemodialysis and in 19 patients with CRF before hemodialysis had begun. In both groups platelet counts were similar and significantly reduced, 175,000 +/- 6,500 and 181,000 +/- 10,800 compared to 253,000 +/- 3,700/mm3 in the control (p less than 0.0001). 31% of hemodialysis patients had thrombocytopenia (platelet count less than 150,000/mm3). The megakaryocyte number in their bone marrow aspirate was not reduced. Primary renal disease, androgen treatment or parathyroidectomy did not affect the platelet count. Thrombopoietic activity using 75Se-selenomethionine incorporation into platelets measured in 7 thrombocytopenic patients was found to be reduced, 6.77 +/- 0.29 vs. 9.06 +/- 0.27 (X 10(-2)%: p less than 0.001). This study shows that the platelet count is reduced and mild thrombocytopenia is frequent in patients with CRF. A possible cause for the platelet count reduction is insufficient thrombopoietic activity.

Inhibition of platelet aggregation by contrast media.

The effect of 30% Urografin on platelet aggregation induced by adenosine diphosphate (ADP), epinephrine, and arachidonic acid was examined. In vivo and in vitro experiments in 10 nondiabetic subjects and in vitro experiments in 7 diabetic-uremic patients showed a statistically significant decrease in platelet aggregation 20 minutes after in vitro incubation or in vivo infusion with Urografin. Urografin concentration was about 2.4-2.5%. The possibility of bleeding induced by contrast media and the connection with acute renal failure in diabetic-uremic patients are discussed.

Erythrocytosis Associated with Renal Artery Thrombosis in a Patient with Polycystic Kidney Disease on Hemodialysis

We report a case of erythrocytosis in a patient with end-stage renal failure on chronic hemodialysis. The patient with polycystic kidney disease had an average Hb level of 10 g/dl while on hemodialysis for 3 years. He developed erythrocytosis (Hb 17.6 g/dl) following a cadaveric renal transplantation. No signs suggesting polycythemia vera were found. Nonrenal causes of secondary erythrocytosis such as anoxia, hemoglobinopathies or tumors were excluded. Angiography showed renal artery occlusion of the native kidney. Serum erythropoietin level was 85 U/l (normal 52 +/- 31 U/l) as measured by 3H-thymidine uptake. It is suggested that ischemia caused by the renal artery thrombosis stimulated the erythropoietin production in the native polycystic kidney.

Unusual case of crescentic glomerulonephritis associated with malignant lymphoma : a case report and review of the literature

Renal lesions in non-Hodgkins lymphoma are rare. Furthermore, to the best of our knowledge, only 5 cases of crescentic glomerulonephritis associated with non-Hodgkins lymphoma have been previously described. We report a case of crescentic glomerulonephritis and renal failure which preceded the diagnosis of non-Hodgkins lymphoma. Following steroid therapy there was a resolution of these histological findings a year later.

Enalapril Attenuates Glomerular Hyperfiltration following a Meat Meal

It has been shown that the glomerular filtration rate increases after a meat meal. We examined in humans whether enalapril, which has been shown to decrease glomerular capillary pressure in rats with chronic renal failure, could attenuate the renal response to a meat meal. Twelve healthy volunteers were studied after an oral protein load, 1.5 g/kg body weight, as lean cooked beef meat, and on a separate day, after eating the same meal with prior oral intake of enalapril. On the control day, creatinine clearance increased from 114.3 +/- 4.7 before the meal to 137.1 +/- 4.7 ml/min/1.73 m2 after the meal (p less than 0.001). On the enalapril intake day, creatinine clearance increased from 113.7 +/- 5.6 before the meal to 128.3 +/- 5.8 ml/min/1.73 m2 after the meal (p less than 0.01). However, the mean increase in creatinine clearance was lower on the enalapril intake than on the control day (14.0 +/- 4.3 vs. 21.0 +/- 4.1%, p less than 0.05). Mean arterial pressure before the meal was lower on the enalapril intake day than on the control day (76.2 +/- 3.5 vs. 84.2 +/- 3.6, p less than 0.01). Likewise, postprandial mean arterial pressure was lower on the enalapril day compared with the control day (69.9 +/- 2.8 vs. 78.5 +/- 3.7, p less than 0.01). We conclude that enalapril blunts the hyperfiltration which follows a meat meal.

Androgen-Associated Hepatoma in a Hemodialysis Patient

A patient on hemodialysis treatment developed hepatocellular carcinoma (HCC) after long-term therapy with androgenic anabolic steroids. The tumor progressed very rapidly, and there was no evidence of regression despite discontinuation of the drug. In view of the evidence of an increased of malignancy in patients with chronic uremia and hemodialysis, and of the higher frequency of HCC correlated to treatment with C17-alkylated anabolic steroids, it is necessary to further evaluate the efficiency of this treatment in the aforementioned group of patients.