Joseph A. Chazan

Severity of Metabolic Acidosis as a Determinant of Bicarbonate Requirements

Abstract In the treatment of metabolic acidosis, the dose of sodium bicarbonate is usually calculated on the assumption that administered bicarbonate distributes in a space equivalent to 50 per cent of body weight. In a patient with profound metabolic acidosis the apparent space of distribution of bicarbonate was over 200 per cent of body weight, although no excessive ongoing acid production or external bicarbonate losses were evident, suggesting that the pre-existing plasma bicarbonate concentration can influence the apparent space of distribution of bicarbonate. This hypothesis was tested with a standard dose of bicarbonate (2.5 mmoles per kilogram of body weight) in 16 dogs with low, normal or high plasma bicarbonate concentration. The concentration increased by 2.8, 5.0 and 5.6 mmoles per liter in the three groups respectively, indicating that the proportion of administered bicarbonate passing into the intracellular space increases with decreasing concentration. In conditions of profound metabolic aci...

Oral estrogens decrease bleeding time and improve clinical bleeding in patients with renal failure

PURPOSEnA prolonged bleeding time is associated with platelet dysfunction and clinical bleeding in patients with renal failure. Parenteral estrogens have been shown to shorten the prolonged bleeding time in patients with chronic renal failure, although the mechanism of action is unknown. We conducted a study to evaluate the efficacy of oral conjugated estrogens in this setting.nnnPATIENTS AND METHODSnFour patients with renal failure, prolonged bleeding time, and clinical bleeding were given 50 mg of conjugated estrogen (Premarin) daily.nnnRESULTSnBleeding time normalized in two cases and was reduced to less than 50% of the pretreatment value in one of the remaining two cases. Bleeding stopped in all patients within two days. Ten dialysis patients with prolonged bleeding time were randomized to a course of 50 mg of Premarin daily or placebo. The bleeding time in all five patients in the Premarin group normalized or decreased to below 50% of the pretreatment value after 7.0 +/- 4.2 days of therapy. The bleeding time did not normalize in the five patients treated with placebo. No side effects attributable to therapy were reported.nnnCONCLUSIONnWe conclude that orally administered conjugated estrogens effectively improve the bleeding tendency in patients with chronic renal failure.

Successful renal transplantation in Wegener's granulomatosis

Two patients with Wegeners granulomatosis, who were in complete remission secondary to cyclophosphamide therapy but who had end-stage renal failure, were treated with renal transplantation. Neither patient has clinical evidence of recurrent glomerulonephritis 10 and 28 months after receiving the renal transplants. Cytotoxic therapy has been proved to be highly effective in inducing and maintaining remission in patients with Wegeners granulomatosis; thus increasingly larger numbers of patients will be seen who, despite being maintained in complete remission, will have markedly impaired renal function due to previous acute damage. Renal transplantation can now be considered an acceptable alternative form of therapy in such patients.

Prolonged Hemolysis from Overheated Dialysate

A patient with chronic renal failure exposed to overheated dialysate (50 degrees C) for 20 minutes developed evidence of delayed and protracted hemolysis, which continued for several days. By contrast, in the only previously reported similar case, sudden gross hemolysis followed by cardiac arrest occurred. It is emphasized that the rapidity and severity of hemolysis due to thermal injury to erythrocytes are dependent upon the duration of exposure and the height of temperature to which extracorporeal blood is exposed. Methods of preventing such incidents and therapeutic approaches are outlined.

Hereditary nephritis: Clinical spectrum and mode of inheritance in five new kindreds☆

Abstract Five new kindreds with hereditary nephritis have been evaluated during the past three years, and a total of seventy-seven patients (forty-eight female and twenty-nine male) with evidence of renal disease have been identified. All affected members had microscopic hematuria, and renal failure developed in thirteen members of four of our families (two female and eleven male); in one family the clinical course was benign, and renal failure did not develop in any of the affected members. Nerve deafness which could be identified by audiometry was a commonly associated finding (forty-five patients), but this was of clinical significance in only fifteen. The mode of inheritance in these five kindreds could be explained as an autosomal dominant. We conclude that hereditary nephritis is a not uncommon form of renal disease which should be considered in every patient with unexplained hematuria, proteinuria or renal failure. Evaluation of such patients should include audiometry, careful family history and, when possible, examination of several close relatives.

Trimethadione (Tridione(R))-induced nephrotic syndrome: A report of a case with unique ultrastructural renal pathology

Abstract The nephrotic syndrome developed in a 15 year old boy with petit mal epilepsy after he received a total dose of approximately 835 g trimethadione (Tridione®) over a three year period. Proteinuria disappeared without specific treatment approximately six months after administration of the drug was discontinued. A review of the clinical course in this patient and in the previously described patients reveals that trimethadione-induced nephrotic syndrome usually responds to withdrawal of the drug. The renal pathology of trimethadione-induced nephrotic syndrome has not been well defined in the past. In our patient the major finding observed by light microscopy was selective infiltration of glomerular capillary loops with eosinophils. Electron microscopy revealed irregular thickening of the basement membrane which contained heteromorphous granular deposits and membranous-bound structures. Processes of eosinophils were adherent to and occasionally infiltrated through the endothelial layer. Although immunofluorescent stains demonstrated the absence of immunoglobulins G (IgG), M (IgM) and A (IgA) or C′3, the cellular localization of eosinophils in the glomeruli suggests an allergic process. We postulate that the unique ultrastructural alterations observed in this patient represented a hypersensitivity reaction to trimethadione.

Analytic Reviews : Acid-Base Abnormalities in Cardiopulmonary Arrest: Varying Patterns in Different Locations Within the Hospital

Arterial blood gas analysis performed in 67 episodes who suffered cardiopulmonary arrest revealed that the degree of acidemia correlated with the location of the patient within the hospital: emergency department (ED), general hospital bed (HB), or intensive care unit (ICU). Acidemia was most severe in patients who pre sented either in the ED (pH = 7.15) or in a HB (pH = 7.10) as a result of combined metabolic (bicarbonate ion [HCO 3 -] = 20 ± 16 and 15 ± 10 mEq/L) and respiratory acidosis (arterial carbon dioxide tension [PaCO2] = 59 ± 30 and 50 ± 24 mm Hg). In contrast, patients in the ICU had only mild acidemia or even alkalemia (pH = 7.28); respiratory acidosis was un common in this setting (PaCO2 = 36 ± 18 mm Hg), and patients exhibited a degree of metabolic acidosis ([HCO3 - ] = 18 ± 8 mEq/L) similar to that seen in patients in EDS or HBS. This relative hypocarbia seen in patients in the ICU was attributed to the fact that most (14 of 22, 64% ) were already receiving mechanical ven tilation at the time of the cardiopulmonary arrest. Pa tients who were successfully resuscitated (20, 30% ) did not differ from those in whom resuscitation failed (47, 70% ) in degree of acidemia or location of arrest. Serum potassium levels obtained in 29 patients at the time of arrest revealed that serum potassium levels were greater than 5.2 mEq/L only 8 times; there was only one mea surement greater than 6.0 mEq/L, which did not corre late with the degree of acidemia.

Influence of the Severity of Metabolic Acidosis on the Response to Bicarbonate Administration.

Excerpt In the treatment of metabolic acidosis the amount of NaHCO3needed to produce the desired increment in plasma bicarbonate concentration (HCO3-) is usually calculated assuming an apparent spa...

Renal osteodystrophy and dialysis artifacts as indicators of identification

Evidence of rare disease may be useful in the identification of unknown remains. Osteodystrophy is a condition commonly associated with chronic renal failure. The presence of renal osteodystrophy and medical artifacts associated with the treatment of kidney failure in human remains may provide information about the individuals medical history. Currently, there are more than 100,000 patients with end stage renal disease in the United States receiving dialysis treatments to replace kidney function, and hundreds of thousands more who have significant chronic kidney failure and are not yet treated with dialysis. Chronic renal failure frequently leads to disorders in the metabolism of vitamin D, calcium, and parathyroid hormone which are extremely difficult to correct. At least three patterns of skeletal change may result: osteitis fibrosa, characterized by increased bone remodelling, increased osteoclastic activity, peritrabecular fibrosis, and a normal mineralization pattern; osteomalacia, with a markedly increased osteoid surface and volume, and impaired mineralization; and mixed osteodystrophy, with increased bone remodelling and moderately impaired mineralization. While these bone changes may not have any clinical manifestations in most patients, they can been seen radiographically and histologically. This evidence may be useful in identifying remains which have been skeletonized, burned, decomposed, or dismembered. Medical artifacts associated with dialysis treatment, such as catheters, polytetrafluoroethylene grafts, and evidence of surgical procedures, are also useful for identification.