Kostas Katopodis

Effect of L-Carnitine Supplementation on Lipid Parameters in Hemodialysis Patients

It has been reported that cumulative carnitine losses through dialysis membranes may worsen hyperlipidemia during long-term hemodialysis. However, carnitine supplementation has not shown a consistent beneficial response. We undertook the present study to determine if there is any hypolipidemic effect of L-carnitine on Greek dialysis patients in concert with the dialysate buffer composition (acetate or bicarbonate). A total of 28 patients (16 male, 12 female), mean age 43 years (range 21–61), with end-stage renal disease on maintenance hemodialysis for a mean period of 25 months (range 7–84) were studied. The dialysis schedule was 4 h, 3 times/week using cuprophane hollow-fiber dialyzers and acetate (n = 14) or bicarbonate (n = 14) dialysate. In all patients L-carnitine (5 mg/kg body weight) was infused intravenously 3 times/week at the end of each hemodialysis session. Blood samples for carnitine and lipid determinations were obtained before treatment, and 3 and 6 months following treatment. Even though L-carnitine did not modify most of the serum lipid levels, a significant decrease in serum triglycerides was evident in the whole group of patients (from 225 ± 76 to 201 ± 75 mg/dl, p = 0.03). Furthermore, L-carnitine could decrease serum triglycerides only in hypertriglyceridemic patients (from 260 ± 64 to 226 ± 82 mg/dl, p < 0.05). L-Carnitine resulted in a reduction of serum triglycerides in both patients on bicarbonate and on acetate dialysis, while there were no significant differences in the changes of lipid parameters after L-carnitine between the two groups of hemodialysis patients. We conclude that relatively low doses of L-carnitine supplementation could contribute to the management of some hypertriglyceridemic hemodialysis patients.

Spontaneous splenic rupture complicating pancreatitis in a chronic hemodialysis patient.

Sir, – the spec trums of find ings in volv ing spleen dur ing an acute pan cre ati tis ep i sode in clude intrasplenic pseudocyst, splenic ab scess, in flam ma tion of the splenic ves sels and pseudoaneurysms, splenic in farc tion, splenic hem or rhage, hematoma and rup ture [Fish man et al. 1995]. Al though sub capsular splenic hematoma and lim ited parenchymal le sions prob a bly re solve spon ta ne ously, any case of splenic rup ture re quires sur gery [Roderick et al. 1977]. A 65-year-old man un der chronic hemo dialysis for the last 2 years was ad mit ted to our de part ment be cause of up per ab dom i nal pain the last 24 hours. The pa tient had a his tory of re cur rent ep i sodes of acute pan cre ati tis dur ing the last 3 years. There was no ev i dence of intrasplenic ab nor mal ity, biliary tract lithiasis, re cent ab dom i nal trauma nor his tory of al co hol abuse. Clin i cal ex am i na tion re vealed up per left quad rant ten der ness, de creased bowel move ments and fe ver up to 40 °C. Lab o ra tory ex am i na tion showed ane mia, leucocytosis and a 6-fold se rum am y lase in crease. Con ser va tive treat ment was started, but on day 6 the pa tient be came hypotensive. Com puted to mog ra phy showed hemoperito neum due to splenic subcapsular hematoma rup ture (Fig ure 1) and splenectomy was per formed with peritoneal drain age. Pa tient re cov ered to tally on day 14 and lives on in good health in the 2-year fol low-up. Lab o ra tory di ag no sis of pan cre ati tis in ure mia by means of se rum pan cre atic en zyme de ter mi na tion is dif fi cult, be cause in uremic pa tients, am y lase se rum lev els may rise in the ab sence of acute pan cre ati tis. In these in stances, fe cal chymotrypsin can be helpful. In ad di tion, ultrasonographic changes of pan creas seem to be rare and mild in reg u lar hemodialysis pa tients, and they do not gen er ally re flect any rel e vant pancreopathy [Ven trucci et al. 1995]. Pan cre atic en zymes that dis sect into the spleen may erode small intrasplenic ves sels re sult ing in intrasplenic hem or rhage [Lankisch 1990]. When the prob lem is un der es ti mated or if the di ag no sis is de layed, the pa tient may rap idly be come hypotensive and even shocked. This com pli ca tion may be a unique prog nos tic sign, in di cat ing the need for ag gres sive in ter ven tion [Thomp son and Ashley 1997]. Percutaneous drain age in these cases is gen er ally con tra in di cated be cause of the risk of caus ing intraperitoneal hem or rhage [Haff et al. 1977, Vyborny et al. 1988]. It has been sug gested that in hemodialysis (HD) pa tients fi brous fix a tion of splenic hi lum may pre dis pose the spleen to rup ture ei ther as a re sult of a mi nor trauma or be cause of an over looked intrasplenic cyst [Clave et al. 1992]. In ad di tion, splenic subcapsular hema toma in long-term hemodialysis but with out co ex ist ing pan cre ati tis had once been re ported [Korzets et al. 1991]. In this pa tient, no com puted to mog ra phy-evidence of splenic in volve ment dur ing all pre vi ous ep i sodes of acute pan cre ati tis had ever been shown. In ad di tion to this, extrahepatic por tal hy per ten sion as re sult of chronic pan cre ati tis was not the case. Over looked small intrasplenic cysts could be an ex cep tional prob a bil ity be cause of the very short time in ter val be tween ep i Clin i cal Nephrology, Vol. 61 – No. 6/2004 – Letters to the editor 448

SERUM ALUMINUM DETERMINATION BY INSTRUMENTAL NEUTRON ACTIVATION ANALYSIS IN LONG-TERM HAEMODIALYSIS PATIENTS

Serum aluminum levels were determined by instrumental neutron activation analysis in 31 patients undergoing long-term haemodialysis. Aluminum-28 1.778 MeV (T1/2=2.24 min) γ-rays produced by the thermal neutron reaction27Al(n,γ)28Al were detected. Successive irradiation of the samples at epithermal neutron fluence was performed to correct for the interference from the fast neutron reaction31P(n,α)28Al. Serum aluminum level in this group of subjects was adequately represented by a lognormal distribution with a mean and variance of 16.5 μg/l and 16.8 μg/l, respectively. The results obtained were found to be in agreement with serum aluminum determination performed by electrothermal atomic absorption spectrophotometry (r2=0.97). Instrumental neutron activation can provide a rapid technique to routinely monitor long-term haemodialysis patients in order to identify individuals at greater risk to develop aluminum toxicity.

Life-threatening hemorrhage from abdominal aorta following a percutaneous renal biopsy.

We report on a case of life-threatening abdominal aorta hemorrhage following percutaneous renal biopsy. A 42-year-old woman with chronic kidney disease stage 2 and microscopic hematuria underwent a percutaneous renal biopsy to evaluate renal insufficiency. One hour following the biopsy procedure, she complained of an abdominal pain and developed signs ofoligemic shock. In despite of 4 blood units transfusion, the patient continued to be in shock. She was transmitted urgently to the operating room without any other examinations (such as abdominal computer tomography) and underwent an emergency laparotomy. A transverse tear in the abdominal aorta was identified as the bleeding site, and after occlusion, the hemorrhage was stopped. The patient gradually recovered and she was discharged in good clinical condition after a few days.

Individual renal function in polycystic kidney disease: a follow-up study.

Purpose This study was undertaken to determine individual renal function in patients with autosomal dominant polycystic kidney disease (ADPKD). Materials and Methods The authors initially examined (study t1) 25 patients with ADPKD (12 female, 13 male; ages 18 to 68 years). The serum creatinine concentration and glomerular filtration rate, measured by Tc-99m DTPA, were 1.5 ± 0.56 mg/dl and 65.7 ± 31 ml·minute-1·1.73 m2, respectively. Thirteen patients had a follow-up study (t2) 2 years after their initial evaluations. Individual renal function was assessed on Tc-99m DMSA renal scans. Results The mean (± SD) difference between left kidney DMSA (DMSA-L) and right kidney DMSA (DMSA-R) was 7.04 % ± 16.48%. In 20 patients (80%), the left kidney had a lower percentage contribution to the total renal function compared with the right kidney. When the results of the two studies were compared, deterioration in renal function was noted. In the t1 study, the mean serum creatinine concentration and glomerular filtration rate were 1.7 mg/dl and 67.02 ml·minute-1·1.73 m2 respectively, and in the t2 study these values were 2.01 mg/dl and 57.15 ml·minute-1·1.73 m2, respectively. No difference, however, was found in individual renal function in the two studies. Conclusions In patients with ADPKD, the percentage contribution of each kidney to total renal function is not equal and remains stable during the progression of renal failure.