Eben I. Feinstein

Clinical and metabolic responses to parenteral nutrition in acute renal failure. A controlled double-blind study.

1. Thirty patients with acute renal failure who were unable to eat adequately were evaluated while they received parenteral nutrition with glucose alone (n = 7), glucose and 21 g/day essential amino acids (EAA, n = 11) or glucose, 21 g/day essential and 21 g/day nonessential amino acids (ENAA, n = 12). Energy intake did not differ with the three treatments. Patients were studied in a prospective double blind fashion. 2. Thirteen patients recovered renal function and 11 survived to leave the hospital. Those in whom renal failure was attributed to hypotension and/or sepsis had a poorer recovery of renal function (17%) and survival (17%). Recovery of renal function and survival was greater in patients on the medical service as compared to the surgical service and in those who received more energy. Recovery of renal function was worse in those treated with dialysis. There were no differences in recovery of renal function of survival among the three treatment groups. 3. Many patients were markedly catabolic as indicated by nitrogen balances, urea in nitrogen appearance rates (UNA), serum protein concentrations, and plasma amino acid levels. There was no correlation between the degree of catabolism and recovery of renal function or survival. Mean UNA in individual patients also correlated with body weight. Among the three groups, however, UNA was significantly less with the group receiving EAA as compared to ENAA. 4. Serum protein concentrations were lower than normal in all treatment groups. Serum albumin fell significantly during the treatment in the more catabolic patients. Plasma amino acid levels tended to fall in all three groups and concentrations at the end of the treatment were frequently lower than normal. 5. These data suggest that acute renal failure patients who are unable to eat adequately are often hypercatabolic and have a high mortality, particularly if hypotension or sepsis is the cause of renal failure. The improved survival in those with higher energy intakes, the high rate of net protein breakdown, the low serum protein levels and the reduced plasma concentrations of both essential and nonessential amino acids suggest that greater quantities of energy and both essential and nonessential amino acids may be beneficial to such patients.

Hyponatremia in hospitalized patients with the acquired immunodeficiency syndrome (AIDS) and the AIDS-Related complex☆

STUDY OBJECTIVE To determine the frequency, etiology, and clinical association of hyponatremia in patients with the acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC). PATIENTS AND METHODS A prospective analysis of 167 patients with AIDS and 45 patients with ARC admitted on 259 occasions to a large metropolitan teaching hospital during a 3-month period. RESULTS Eighty-three patients (39%) with hyponatremia (serum sodium concentration less than 135 mmol/L) were observed during 99 hospitalizations, for a frequency of 38%. The mean (+/- standard error) of the lowest serum sodium concentration was 128 +/- 1 mmol/L in the hyponatremic patients and 138 +/- 1 mmol/L in the normonatremic patients. Hyponatremia was present on admission during 57 hospitalizations and was associated with gastrointestinal losses and hypovolemia in 43%. When hyponatremia developed during hospitalization, 68% of the patients were clinically euvolemic and had a syndrome consistent with inappropriate secretion of antidiuretic hormone (SIADH). Patients with hyponatremia were hospitalized longer than those with normal serum sodium concentrations (17 +/- 1 versus 9 +/- 1 days, p < 0.001). In addition, the mortality rate in the hyponatremic group was higher than that in the normonatremic group (36.5% versus 19.7%, p < 0.01). CONCLUSION Hyponatremia is a common electrolyte disorder in patients hospitalized with AIDS or ARC and is frequently associated with gastrointestinal losses or SIADH as well as increased morbidity and mortality.

Thyroid Function in Patients with Nephrotic Syndrome and Normal Renal Function

Alterations of thyroid hormone indices have been described in patients with nephrotic syndrome. However, the majority of these patients also had either diabetes mellitus or significant renal failure,

Alterations of Thyroid Hormone Indices in Acute Renal Failure and in Acute Critical Illness with and without Acute Renal Failure

The present study evaluated thyroid hormone indices of patients with acute renal failure without other systemic illnesses (n = 12), as compared to patients with critical illnesses in the presence (n = 16) and absence (n = 6) of acute renal failure. Abnormalities in the group with acute renal failure alone included decreased serum levels of total T4 and T3, and elevated levels of free rT3. Serum levels of free T4 by equilibrium dialysis and the enzyme immunoassay, T3 uptake ratios, TSH and total rT3 were normal. These findings are consistent with the presence of decreased binding of T4 and rT3 to their serum carrier proteins. Critically ill patients with acute renal failure differed in that they had lower total T4 and T3 levels and elevated T3 uptake ratio values. As in the group with acute renal failure alone, total rT3 levels were normal and free rT3 values were elevated. The group with critical illness alone differed only in that the total rT3 concentrations were elevated in all patients. The alterations of thyroid hormone indices in acute renal failure are similar to those of other nonthyroidal illnesses with the exception of the normal total rT3 levels. This suggests that the failing kidney or the metabolic consequences of uremia specifically affect rT3 metabolism.

Plasma Levels of Main Granulocyte Components during Hemodialysis

Complement activation occurs during hemodialysis, and its intensity depends on the type of dialyzer and whether it is new or reused. Neutrophil degranulation also occurs during hemodialysis with release of lactoferrin, myeloperoxidase and elastase. However, it is unclear whether this event is induced by complement activation and whether it is attenuated by reuse. We examined complement activation and neutrophil degranulation during 10 consecutive hemodialyses using the same cuprophane dialyzer. Also the effect of rinsing the latter with 25% human albumin was studied. The rise in plasma C3a and C5a was markedly higher (p less than 0.01) during the first than the second use. Plasma levels of lactoferrin and myeloperoxidase increased significantly (p less than 0.01) during the first use, and levels were not affected by reuse. In contrast, plasma elastase increased with the first use and decreased with each subsequent use. Treatment of the dialyzer with albumin did not affect the magnitude of rise in plasma levels of C3a or lactoferrin but was associated with a significant reduction in plasma elastase. The data show that neutrophil degranulation is not dependent on complement activation and that the two processes could be dissociated.

Acquired Cystic Disease of the Kidneys: Computed Tomography and Ultrasonography Appraisal in Patients on Peritoneal and Hemodialysis

Screening chronic hemodialysis patients (CHD) for acquired cystic disease of the kidneys (ACDK) and its complications (hemorrhage and neoplasm) has become accepted management. We evaluated patients on CHD as well as patients on chronic peritoneal dialysis (CPD) for ACDK. The kidneys of 80 chronic dialysis patients were examined by CT and real time sonography. Forty-four were hemodialysis and 36 were peritoneal dialysis patients. ACDK was found in more than 90% of both CHD and CPD patients who had been dialyzed longer than three years. Bilateral renal carcinoma was detected in one hemodialysis patient. Our results show that chronic peritoneal dialysis patients are also at risk for ACDK and its associated complications. A similar natural history for the development of ACDK in both forms of dialysis suggests that the same screening precautions should be instituted for chronic peritoneal dialysis patients.

Balloon expandable stents to treat central venous stenoses in hemodialysis patients.

Vascular access failure in hemodialysis patients remains a significant problem. The use of thrombolytic agents and balloon angioplasty instead of or in conjunction with surgical revision, has been helpful in increasing the life span of vascular access in these patients. The application of newer endovascular therapies, such as vascular stents, may further improve the salvage rate of hemodialysis access sites. These stents may be particularly valuable in treating stenoses in large central veins. We present 2 cases in which a balloon-expandable Palmaz stent was used to treat a central venous stenosis causing signs of vascular access failure.

Severe Hyperuricemia in Patients with Volume Depletion

Profound hyperuricemia (19-42 (27 +/- 3.3) mg/dl) was noted in seven adult patients with volume depletion and marked prerenal azotemia (SUN, 155 +/- 30 mg/dl and serum creatinine 5.2 +/- 1.1 mg/dl). The serum level of uric acid returned to normal following the administration of 3.2 +/- 0.4 liters of saline/day over a period of 3.4 +/- 0.6 days. Throughout the course of the illness, there were significant correlations (r = 0.83, p less than 0.01) between the serum levels of both urea nitrogen and creatinine and those of uric acid. Because of the rapid reversibility of this hyperuricemia with hydration, it should be differentiated from other clinical conditions associated with acute renal failure and profound hyperuricemia.

Carpal tunnel syndrome and chronic hemodialysis.

Carpal Tunnel Syndrome and Chronic Hemodialysis Dear Sir, Referring to the letter by Walts et al. [1] published in your journal, our work is at odds with theirs. In our clinic we have monitored 176 patients in a program of chronic hemodialysis for periods ranging from 3 to 144 months (x = 67.6). Eight patients (3 male and 5 female) manifested carpal tunnel syndrome (CTS); their ages ranged from 40 to 81 years (x = 61.1). The duration of dialysis treatment was 91.5 months (range 72–144). These results contrast with the 176 months (14.7 years) that the said authors [1] speak of. Our work coincides with previously reviewed literature [2–5]. In 5 of these cases the syndrome was bilateral and in 3 unilateral (a total of 13 occurrences). In each case it was the arm with a functioning arteriovenous fistula which was affected; given that this was the sole vascular access no further surgical intervention was required. We pursued 5 anatomopathological studies with Congo red and thioflavine T manifesting a total of 9 interventions (8 patients). In only 1 case did we find deposits of amyloid. None of the affected patients presented indices of systemic amyloidosis. In the development of CTS, the patients in a program of chronic hemodialysis showed a marked preference for the arm carrying the vascular access despite the fact that neither vascular alterations nor inflammatory changes were noted in the anatomopathological studies effected. We observed no statistically significant relation with any special type of nephropathy such as presented by our patients: hyperuricemic nephropathy (2 cases), glomeru-lonephritis (2 cases), nephroangiosclerosis (1 case, showing the only incidence of amyloid deposits), tubular aci-dosis (1 case) and undefined etiologies (2 cases). Nor was any relation observed with the dialytic procedure, hypervolemia, or the various biochemical parameters studied (urea, creatinine, phosphocalcic metabolism, PTH and hematocrit count). According to our experience, CTS is a complication of periodic hemodialysis that does not show an elevated incidence of amyloid deposits, and in general appears after the sixth year of substitutive treatment. References Walts, A.E.; Goodman, M.D.; Matorin, P.A.: Amyloid, carpal tunnel syndrome, and chronic hemodialysis. Am. J. Nephrol. 5: 225–226 (1985). Halter, S.K.; DeLisa, J.A.; Stolov, W.C; Scardapane, D.; Sher-rard, D.J.: Carpal tunnel syndrome in chronic renal dialysis patients. Archs phys. Med. Rehabil. 62: 197–201 (1981). Schwarz, A.; Keller, F.; Seyfert, S.; Poll, W.; Molzahn, M.; Dist-ler, A.: Carpal tunnel syndrome: a major complication in long-term hemodialysis patients. Clin. Nephrol. 22: 133–137 (1984). Kachel, H.G.; Altmeyer, P.; Baldamus, C.A.; Koch, K.M.: Deposition of an amyloid-like substance as a possible complication of regular dialysis treatment. Contr. Nephrol. vol. 36, pp. 127–132 (Karger, Basel 1983).

Nutrition in Acute Renal Failure

Malnutrition and loss of lean body mass are common occurrences in patients with acute renal failure. The degree of wasting is variable: it is likely that those patients who have the highest catabolic stress tend to be the sickest patients, the ones with the most number of co-morbid events, and those with the highest mortality rate. Indeed, a recent review of a large number of patients with acute renal failure listed hypercatabolism as one of the significant risk factors for poor outcome (1). Inadequate nutrition may affect outcome by impairing immune responses to infection and by slowing wound healing. This review will deal with several aspects of the nutritional therapy of patients with acute renal failure: the causes and mediators of the catabolic process in these patients, the role of amino acid infusions and caloric intake in nutritional therapy and finally the newer techniques for maintaining fluid balance during nutritional therapy in the oliguric patient.