Jarl Ahlmén

Renal Hemodynamics and Limitations of Creatinine Clearance in Determining Filtration Rate in Glomerular Disease

A series of 160 Inulin/PAH clearances in 126 subjects was performed with the main emphasis on glomerular disorders. In 90 observations (67 subjects) simultaneous creatinine clearances were available. Earlier findings of the occurrence of high and supernormal CPAH in some cases of glomerulonephritis have been supported and extended to systemic lupus erythematosus. Low filtration fractions in various types and stages of glomerulonephritis and systemic lupus erythematosus even at rather advanced renal impairment were observed and contrasted against the findings in cryptogenetic (essential) hypertension. High CCr/CIn ratios have been observed not only in cases of advanced renal insufficiency but also in glomerular disorders in subjects with a mild or moderate reduction in Cm and a maintained or high CPAH at serum creatinine levels from 0.7 to 1.5 mg per 100 ml. Here, CCr/CIn ratios may be as high as 2.0 to close to 4. In some glomerular disorders, notably S.L.E., membranous glomerulonephritis, and transplant ...

Treatment of Antidepressant Poisoning with Resin Hemoperfusion

1 The object of this study was to evaluate hemoperfusion in tricyclic antidepressant (TCA) poisoning. 2 Eight patients with severe TCA-poisoning and one patient with maprotiline poisoning were treated with resin hemoperfusion (HP). All patients were in Grade III or Grade IV coma with a QRS interval of 100 ms or greater. Hemoperfusion was started and continued until a satisfactory clinical response was obtained or for up to a maximum of 4 h. 3 Clearance values and extraction ratios were calculated during HP. The extraction ratio for all drugs was high (0.91-0.98) showing an effective clearance of these drugs from the blood compartment. After termination of HP a rebound effect of blood concentrations was seen in five cases. The total amount of the drug recovered was in no case greater than 3.1% of the estimated amount ingested. 4 It is therefore difficult to ascribe the clinical improvement seen in these patients during HP to the removal of significant amounts of the drug taken.

Thallium Poisoning - Toxin Elimination and Therapy in Three Cases

Three cases of thallium poisoning occurred within the same family after eating a meal of poisoned sour milk. The 58 year old mother died after four days cardiovascular insufficiency. Massive thallium concentrations were found in blood, urine, liver and kidney. The 59 year old father presented after four days with a neurology typical for classic thallotoxicosis with potentially lethal blood thallium levels. This patient recovered after therapy including Prussian Blue, forced diuresis and two six hour hemoperfusions with a charcoal column. Urinary elimination of thallium over two weeks was almost 300 mg, whereas a maximum total of 63 mg were removed with hemoperfusion. A retrospective estimate of the total dose ingested and the large distribution volume of thallium suggest that hemoperfusion did not affect the course of the intoxication. The 28 year old son, later convicted for homicide, was admitted on the tenth day after the meal with very discrete neurological symptoms. This patient had low blood and urine thallium levels. He recovered uneventfully after treatment with Prussian Blue and forced diuresis. However, both surviving patients developed alopecia after two weeks. All three patients had raised liver transaminases. Intensive therapy with gut decontamination, Prussian Blue and forced diuresis should be the mainstay of therapy.

Treatment of Podophyllin Poisoning with Resin Hemoperfusion

1 A 43-year-old man was admitted in a coma after oral ingestion of a suspected lethal dose of podophyllin solution in alcohol. 2 Hemoperfusion with a resin filter was started 7 h after ingestion. Hemoperfusion rapidly decreased plasma concentrations of podophyllotoxin with an extraction ratio of 0.76 over the filter. The relatively low plasma concentrations of podophyllotoxin and consequently small amount removed might be explained by the rapid metabolism of the drug to an unknown derivate. 3 This metabolite was completely cleared during passage over the filter, suggesting the removal of significant amounts of podophyllotoxin metabolites. 4 No neurological deficit was observed before or after hemoperfusion. At a two-month follow-up the patient remained healthy. Hemoperfusion may possibly prevent the development of coma and neurologic deficit with loss of deep tendon reflexes.

Treatment of Oral Theophylline Poisoning

Two patients, 15 and 20 years old, were admitted after an overdose of theophylline in a slow-release preparation. The gradual occurrence of clinical symptoms reflected the slow gastrointestinal absorption of the drug, and therefore active treatment was not started until 10 and 12 hours after intake, respectively. Peak s-concentrations were 275 and 1295 mumol/l, respectively. One patient was treated with hemoperfusion only, whereas the more severely intoxicated patient was treated with combined hemoperfusion and hemodialysis. Only about 0.2 g theophylline was eliminated by hemodialysis in this patient compared to a calculated amount of 6.9 g by hemoperfusion. Severely theophylline-intoxicated patients should be treated with supportive therapy and hemoperfusion.

Ambulatory 24-Hour Blood Pressure and Peptide Balance in Hemodialysis Patients

Blood pressure regulation during intermittent hemodialysis treatment involves many different mechanisms. Eight normotensive patients without antihypertensive drugs on intermittent hemodialysis treatment, mean age 50 years, were studied with 24-hour blood pressure measurements. Atrial natriuretic peptide (ANP) and neuropeptide Y (NPY) were determined concomitantly. Eight control individuals matched for age and sex were investigated in the same way. A significant increase of both systolic and diastolic blood pressure, heart rate and pathological circadian rhythm was seen among the dialysis patients. High levels of ANP were found before and after dialysis. NPY showed steady state levels through the 24 hours and did not differ between the two groups. Overhydration is a probable cause of the disturbed blood pressure regulation and increased ANP-values.

Successful Kidney Transplantation in a Man with Dacron “Trouser” Prosthesis

The case history of a male patient, 62 years old, in preterminal uremia at transplantation with a cadaveric kidney is described. Twelve years before the transplantation he was operated on because of an aortic aneurysm where the abdominal aorta and both iliac arteries were substituted with a Dacron prosthesis. The kidney was anastomosed to this vessel substitute and functioned excellently for more than five years and the patient was completely rehabilitated.

Resin Hemoperfusion in Chloroquine Poisoning

A 46-year-old woman was admitted after ingestion of 10 g chloroquine phosphate. The patients clinical condition deteriorated with characteristic ECG changes, low blood pressure, and respiratory depression. Resin hemoperfusion (HP) was started 4.5 h after admission at a flow of 250 mL/min for 4 h. Clearance over the resin column was 136 mL/min. Although the patient rapidly improved, a total of no more than 200 mg (2%) was removed. Total body clearance of chloroquine was increased by only 5% during HP. Treatment should therefore be directed toward aggressive supportive therapy rather than techniques to increase elimination.

CAPTOPRIL IN HYPERTENSION AFTER RENAL TRANSPLANTATION

: The experience with captopril is limited in patients who are hypertensive after renal transplantation. An increased risk of side effects has been expected because of immunosuppressive therapy and a reduced renal function. We have used captopril in 58 transplanted patients with hypertension. On previous antihypertensive treatment diastolic blood pressure could not be maintained below 100 mm Hg. All patients were on immunosuppressive therapy using prednisolone in combination with azathioprine or cyclosporin. Before captopril treatment the mean s-creatinine concentration was 225 +/- 143 mumol/l. Fifty-four patients were treated for more than four weeks and 28 of them for six months or more. The mean daily dose of captopril was 90 mg. All patients also used furosemide and 2/3 were on a beta-blocker. Captopril was discontinued in nine cases within the first two months, in three because of an unsatisfactory effect on BP, in four because of side effects and in two after successful treatment of a renal artery stenosis of the transplant. The patients who were treated with captopril within the first year after transplantation responded better than patients where treatment was started more than one year after transplantation (p less than 0.05). Half of the patients given captopril early even showed a decrease of s-creatinine during treatment. Captopril in combination with a diuretic and a beta-blocker reduces blood pressure in patients with treatment resistant hypertension following renal transplantation. The risk for serious side effects is small provided that the captopril dose is low and white cell counts and s-creatinine levels are closely monitored.

Captopril in Hpertension After Renal Transplantation.

The experience with captopril is limited in patients who are hypertensive after renal transplantation. An increased risk of side effects has been expected because of immunosuppressive therapy and a reduced renal function. We have used captopril in 58 transplanted patients with hypertension. On previous antihypertensive treatment diastolic blood pressure could not be maintained below 100 mm Hg. All patients were on immunosuppressive therapy using prednisolone in combination with azathioprine or cyclosporin. Before captopril went mean s-creatinine concentration was 225 ± 143 μmol/l. Fifty-four patients were treated for more than four weeks and 28 of them for six months or more. The mean daily dose captopril was 90 mg. All patients also used furosemide and 2/3 were on a beta-blocker. Captopril was discontinued in nine cases within the first two months, in three because of an unsatisfactory effect on BP, in four because of side effects and in two after successful treatment of a renal artery stenosis of the transplant. The Patients who were treated with captopril within the first year after transplantation responded better than patients where treatment was started more than one year after transplantation (p < 0.05). Half of the patients given captopril early even showed a decrease of s-creatinine during treatment. Captopril in combination with a diuretic and a beta-blocker, reduces blood pressure in patients with treatment resistant hypertension following renal transplantation. The risk for serious side effects is small provided that the captopril dose is and white cell counts and s-creatinine levels are closely monitored.