John A. D'Elia

Effects of Saline, Mannitol, and Furosemide on Acute Decreases in Renal Function Induced by Radiocontrast Agents

BACKGROUND Injections of radiocontrast agents are a frequent cause of acute decreases in renal function, occurring most often in patients with chronic renal insufficiency and diabetes mellitus. METHODS We prospectively studied 78 patients with chronic renal insufficiency (mean [+/- SD] serum creatinine concentration, 2.1 +/- 0.6 mg per deciliter [186 +/- 53 mumol per liter]) who underwent cardiac angiography. The patients were randomly assigned to receive 0.45 percent saline alone for 12 hours before and 12 hours after angiography, saline plus mannitol, or saline plus furosemide. The mannitol and furosemide were given just before angiography. Serum creatinine was measured before and for 48 hours after angiography, and urine was collected for 24 hours after angiography. An acute radiocontrast-induced decrease in renal function was defined as an increase in the base-line serum creatinine concentration of at least 0.5 mg per deciliter (44 mumol per liter) within 48 hours after the injection of radiocontrast agents. RESULTS Twenty of the 78 patients (26 percent) had an increase in the serum creatinine concentration of at least 0.5 mg per deciliter after angiography. Among the 28 patients in the saline group, 3 (11 percent) had such an increase in serum creatinine, as compared with 7 of 25 in the mannitol group (28 percent) and 10 of 25 in the furosemide group (40 percent) (P = 0.05). The mean increase in serum creatinine 48 hours after angiography was significantly greater in the furosemide group (P = 0.01) than in the saline group. CONCLUSIONS In patients with chronic renal insufficiency who are undergoing cardiac angiography, hydration with 0.45 percent saline provides better protection against acute decreases in renal function induced by radiocontrast agents than does hydration with 0.45 percent saline plus mannitol or furosemide.

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.

Coronary Angiography and Acute Renal Failure in Diabetic Azotemic Nephropathy

Thirteen juvenile-onset diabetics with azotemic diabetic nephropathy (mean serum creatinine level, 6.8 mg/dl) being evaluated fro renal transplantation underwent cardiac catheterization with angiography. All were followed for development of acute renal failure. Twelve (92%) developed some evidence of acute renal failure. Two required potassium exchange resin therapy. Six required dialysis acutely. There were no deaths. All patients who received greater than 65 ml/m2 of iodinated contrast developed acute renal failure. No patient with a hemoglobin value greater than 9.9 g/dl required dialysis or potassium exchange resin. The single patients without acute renal failure received less than 50 ml/m2 of iodinated contrast and had the highest hemoglobin value (12.0 g/dl). No cardiac or angiographic variables were predictive of acute renal failure. In this group at high risk for acute renal failure, radiographic contrast procedures should only be done if the information to be obtained is weighed against the potential for injury.

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.

Asymptomatic Coronary Artery Disease: Angiography in Diabetic Patients Before Renal Transplantation: Relation of Findings to Postoperative Survival

Twenty-one juvenile-onset diabetic patients with azotemic nephropathy underwent coronary angiography and left ventriculography before renal transplantation or chronic hemodialysis. Two-year survival of 12 patients with no coronary artery disease (group A) was 88% compared to 22% for nine patients with coronary artery disease (group B) (P less than 0.025). Each group A patient underwent renal transplantation (nine live-related, three cadaveric). Four group B patients received cadaveric allografts. Among group A patients two cadaveric allografts functioned while in group B patients no allografts were successful. In the absence of coronary artery disease, results were similar to those reported for nondiabetic persons. In the presence of coronary artery disease, 62% of the deaths were due to myocardial infarction or sudden death. These results indicate that atherosclerotic coronary artery disease is a major determinant of survival in diabetic patients undergoing chronic hemodialysis or renal transplantation.

Myocardial dysfunction without coronary artery disease in diabetic renal failure

Fifteen patients with diabetes of juvenile onset and azotemic nephropathy were found to have no evidence of significant coronary artery disease after cardiac catheterization, coronary angiography and ventriculography. Three groups were delineated in terms of myocardial function. There were no differences among the groups in age, sex distribution, duration of diabetes, hypertension or azotemia, presence of surgical arteriovenous fistula or blood concentrations of hemoglobin, cholesterol, urea nitrogen, creatinine or uric acid. Some evidence of myocardial dysfunction was found in eight patients (59 percent)—four with diffuse myocardial dysfunction and four with elevation of left ventricular end-diastolic pressure alone. The hypothesis of a diabetic cardiomyopathy is discussed in terms of a spectrum that may include patients with pressure-volume abnormalities alone; patients with increased left ventricular end-diastolic pressure and an abnormal pressure-volume curve; and patients with a diffusely abnormal ventriculogram, decreased ejection fraction, increased left ventricular end-diastolic pressure and an abnormal pressure-volume curve.

Asymptomatic coronary artery disease: angiographic assessment of diabetics evaluated for renal transplantation.

SUMMARY Twenty-one insulin-dependent diabetics with azotemic nephropathy were evaluated for renal transplantation by selective coronary angiography and cine left ventriculography. All had hypertension, retinopathy, neuropathy, and required salt restriction plus diuretics for volume overload. There was no clinical or electrocardiographic evidence of ischemic coronary artery disease in twenty.Ten patients (five males, five females, mean age 29.3 years; mean duration of diabetes 18.9 years; mean serum cholesterol 264 mg%) had no significant coronary artery disease and no ventricular wall motion abnormalities.Nine patients (seven males, two females; mean age 38.7 years; mean duration of diabetes 21.9 years; mean serum cholesterol 239 mg%) had significant coronary artery disease, seven demonstrating focal abnormalities in left ventricular wall motion.Two patients (one male, one female; mean age 36.5 years; mean duration of diabetes 28.5 years; mean serum cholesterol 250 mg%) had no significant coronary artery disease, but demonstrated diffusely abnormal left ventricular wall motion with diminished ejection fraction.Thirty-eight percent had significant coronary artery disease unpredictable by electrocardiographic clinical data. The finding of no significant coronary artery disease in 52% of a group with severe renalhypertensive complications of diabetes is surprising. Two patients may have a demonstrated cardiomyopathy.

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.