P. McClelland

Reducing sepsis in severe combined acute renal and respiratory failure by selective decontamination of the digestive tract

Fifteen patients with severe combined acute renal and respiratory failure (SCARRF), who required mechanical ventilation and renal replacement therapy for at least 5 days, were treated with a regimen to selectively decontaminate the digestive tract (SDD). In these patients the incidence of significant infection was compared with the infection rate in 12 similar patients with SCARRF who had not received SDD, treated over the preceding 12 months. Both groups were comparable for age, study period, sepsis score, and therapeutic intervention scoring system on admission, although the Acute Physiology and Chronic Health Evaluation score was higher (p less than .05) in the SDD-treated group. Ten (83%) of 12 control patients developed definable infections compared with five (33%) of 15 in the SDD group (p less than .05). Gram-negative bacteria and fungi were responsible for 14 of the 17 infections affecting ten control patients, compared with six of the seven infections in only four SDD patients (p less than .05). The most notable site to benefit was the respiratory tract, with only one patient in the SDD group developing a pulmonary infection compared with five in the control patients (p less than .05). Urine infections may have been reduced from six (50%) of the 12 control patients to two (13%) of the 15 SDD patients, but this difference was not significant. Although survival in the control and SDD group was comparable (42% vs. 40%), mortality overall seemed related to infection. Eleven (73%) of 15 patients with definite infection died, in contrast with five (42%) of 12 who had no infections, although this was not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Arterial thrombosis in the nephrotic syndrome

Thrombosis is a frequent cause of morbidity and mortality in patients with the nephrotic syndrome. Venous thrombotic complications are well recognized but arterial complications are rare. Thrombosis is multifactorial, and has been attributed to a hypercoaguable state due to alterations in blood levels of the various factors involved in the coagulation and fibrinolytic systems, alterations in platelet function, venous stasis, haemoconcentration, increased blood viscosity and possibly the administration of steroids. Thrombosis in general and arterial thrombosis in particular is a significant and potentially serious problem in nephrotic patients. Awareness of the condition and its pathogenesis is needed. Assessment for the risk factors is required to allow appropriate prophylactic measures to be taken.

Multiple organ failure : a role for plasma exchange ?

Two patients with multiple organ failure, septicaemia and a deteriorating clinical course were treated by plasma exchange in addition to standard supportive measures. Dramatic improvements were seen in cardio-respiratory (patient 1), neurological and renal parameters (patient 2) which were attributable to the exchanges. Plasma exchange might be of value as adjunctive therapy where overwhelming septicaemia occurs with multiple organ failure.

Haemodialysis – Related Porphyria Cutanea Tarda and Treatment by Recombinant Human Erythropoietin

Haemodialysis-related porphyria cutanea tarda is a rare, but serious and mutilating skin condition, resulting from extremely high plasma porphyrin levels because of their inadequate clearance by haemodialysis. The treatment is very difficult as chloroquine is ineffective and venesection, the conventional treatment of this disease, is not always an option because of anaemia of end-stage renal disease. We report a case of haemodialysis-related porphyria cutanea tarda and her successful management by recombinant human erythropoietin treatment.

Resistance to recombinant human erythropoietin due to aluminium overload and its reversal by low dose desferrioxamine therapy.

Seventeen severely anaemic and transfusion-dependent haemodialysis patients with a haemoglobin less than 7 g/dl were treated with recombinant human erythropoietin (r-Hu-EPO). Aluminium toxicity was diagnosed by a positive desferrioxamine (DFO) test and bone biopsy. Seven out of eight patients without aluminium toxicity responded to r-Hu-EPO therapy. Similarly all patients with aluminium toxicity (n = 4) but pre-treated with standard dose of DFO prior to r-Hu-EPO therapy responded but none of the patients with untreated aluminium toxicity (n = 5) responded to r-Hu-EPO therapy. In order to achieve adequate response in these patients, r-Hu-EPO and DFO had to be given in combination. The dose of desferrioxamine used to reverse r-Hu-EPO resistance was less and also used for a short time. We therefore confirm r-Hu-EPO resistance owing to aluminium overload and report its successful and safe reversal with low dose DFO therapy.

Delayed recovery of renal function in patients with acute renal failure due to accelerated hypertension.

Five patients with acute renal failure due to accelerated hypertension required regular dialysis treatment for 2-12 months (mean 8.8), before recovering sufficient renal function for dialysis to be withdrawn. Two patients who had prior evidence of chronic renal impairment remained off dialysis for 20 and 27 months before decompensating again to require regular dialysis treatment. Two patients with no prior history of renal disease have remained independent of dialysis for 32 and 48 months. The fifth patient was lost to follow-up after a 7 month dialysis-free period. Delayed recovery of renal function following accelerated hypertension is a distinct possibility and should be considered in such patients before contemplating long term strategies such as renal transplantation.