R. Daelemans

Propylene glycol-induced side effects during intravenous nitroglycerin therapy

Propylene glycol, an alcohol frequently used as a solvent in medical preparations, is considered non-toxic. We found that this solvent, used in a commercially available IV nitroglycerin solution, may cause hyperosmolality, hemolysis and lactic acidosis. The influence of kidney function as the main determinant in causing accumulation of this solvent and consequently hyperosmolality is emphasized. A review of the literature dealing with propylene glycol is given. The possible mechanisms of neurological disturbances occurring during IV nitroglycerin therapy are discussed.

Abdominal compartment syndrome related to noninvasive ventilation

ObjectiveTo study the effects of noninvasive positive pressure ventilation (NIPPV) on intra-abdominal pressure.Design and settingSingle case report from a tertiary teaching hospital.Patients and methodsA 65-year-old man who experienced a sudden respiratory and cardiovascular collapse during NIPPV. This was caused by gastric overdistension due to aerophagia followed by raised intra-abdominal pressure leading to intra-abdominal hypertension and abdominal compartment syndrome.ResultsThe respiratory and cardiovascular problems resolved immediately after the introduction of a nasogastric tube. This resulted in normalization of IAP.ConclusionsThis is the first case reported of an abdominal compartment syndrome related to NIPPV. Clinicians should be aware of this possible complication while using NIPPV.

Oxidative Injury to Erythrocytes, Cell Rigidity and Splenic Hemolysis in Hemodialyzed Patients before and during Erythropoietin Treatment

The oxidative injury to erythrocytes, red blood cell (RBC) rigidity and splenic hemolysis was assayed in 17 chronically hemodialyzed patients before and during recombinant erythropoietin (EPO) treatment. When a stable hematocrit between 30 and 35% had been established for at least 4 months, a statistically significant increase in RBC volume, hemoglobin concentration, hematocrit, reticulocyte count, and several RBC enzymes (2,3-diphosphoglycerate, glucose 6-phosphate dehydrogenase, pyruvate kinase, hexokinase) was noted. This indicated significant RBC rejuvenation under the influence of EPO. However, no significant improvement in the RBC oxidative sensitivity, RBC deformability, splenic RBC volume, slow mixing splenic RBC volume, and the intrasplenic RBC transit time could be disclosed. These data confirm the existence of an extra-erythrocytic factor in uremic plasma, which is partly responsible for a reduced RBC life span in hemodialysis patients despite EPO treatment.

Treatment of severe Thallium intoxication

CASE REPORT We report a successfully treated case of severe thallium intoxication. In spite of very high serum thallium (5,240 micrograms/L), symptomatology was minor and recovery complete. Prussian Blue was administered, diuresis was enhanced by intravenous fluids and a prolonged hemodialysis was started early. High blood flows (300 mL/min) and intravenous potassium chloride supplements, to mobilize thallium from the tissues, resulted in good clearances (96 to 150 mL/min). In order to prevent the well known complications, we recommend aggressive treatment of severe thallium intoxication.

Reduced Glutathione for the Treatment of Anemia during Hemodialysis: A Preliminary Communication

In 4 chronic hemodialysis patients we have tested whether the administration of reduced glutathione (GSH; Glutamed, Boehringer Mannheim Italia; 1,200 mg i.v.) at the end of each hemodialytic session during 90 days could minimize oxidative damage to the red blood cells (RBC) and reduce the recombinant human erythropoietin requirements. Treatment with GSH was followed by an increase in RBC GSH content (n = 3), a normalization of the ascorbine cyanide test (n = 4), an increase in RBC survival (n = 3), and a reduction in 2 patients of the erythropoietin need (41 and 26%, respectively, after 3 months of therapy). When the GSH supplements were terminated, we noticed after 3 months a re-establishment of the baseline values. On the other hand, malonyldialdehyde, RBC deformability, and RBC splenic pool were abnormal before and remain abnormal during the test period. Since no adverse reactions were noticed, these findings seem to indicate the GSH could ameliorate the intraerythrocytic oxidative defense and could be as useful drug in the treatment of anemia in patients affected by chronic renal failure.

A massive, near-fatal cocaine intoxication in a body-stuffer. Case report and review of the literature

The last decade an increase has been seen in drug smuggling. Body-packing and body-stuffing are the terms used for intracorporeal concealment of illicit drugs (mainly cocaine and heroine, but sometimes also amphetamines and cannabinoids). These body-packets are especially prone to rupture. In order to avoid systemic cocaine toxicity, which can involve nearly every organ and therefore nearly every subspecialty of medicine urgent diagnosis is necessary. Obtaining a detailed history remains crucial. Further clues to diagnosis are given by the urinary drug concentrations and the benzoylecgonine/cocaine ratio in urine. Plain abdominal films, CT and contrast studies of the bowel can be helpful in identifying the package but are of limited value. In addition to activated charcoal, polyethylene glycol-electrolyte lavage solution, enteral feeding and laxatives (not paraffin) can be used to eliminate the body-package by enhancing bowel transit. Alkalinisation of gastric fluids enhances hydrolysis to cocaines major inactive metabolite benzoylecgonine. If the package fails to progress through the gut or if mechanical obstruction occurs surgical removal is indicated. In no way endoscopic removal of the package should be attempted. Systemic symptoms should be treated by blocking the sympathetic overreactivity; this can be done with diazepam (Valium), labetalol (Trandate) or esmolol. Flumazenil (Anexate), lidocaine (Xylocaine) and pure beta-blockers like propranolol (Inderal) are to be avoided.

Functional Acute Renal Failure in a Patient with Carcinoid Syndrome

Acute renal failure occurred in a patient with a carcinoid syndrome whenever he developed a flushing episode. Renal biopsy performed during one of these oliguric episodes did not reveal any lesions which could explain this reversible form of renal insufficiency. Urinary indices were not conclusive. Alteration of intrarenal hemodynamics by vasoactive compounds is proposed to be the causative mechanism of this relapsing acute oliguric renal failure.

Acute Oligo‐Anuria During Ovarian Hyperstimulation Syndrome

Severe ovarian hyperstimulation developed in a young woman during ovulation induction with human menopausal and chorionic gonadotropins. This was complicated by acute functional renal insufficiency with vascular overfilling and incipient pulmonary edema, possibly caused by indo‐methacine and fluid treatment. The pathogenetic mechanisms involved are discussed.

Bone lead and renal failure.

M.E. De Broe, MD, PhD, Head of the Department of Nephrology-Hypertension, University of Antwerp, p/a University Hospital Antwerp, Wilrijkstraat 10, B-2650 Edegem-Antwerp (Belgium) Dear Sir, Winterberg et al. [1] recently reported on higher bone lead levels (μg/g wet weight) in a small group of hemodi-alysis patients as compared to two small groups of patients with chronic renal failure or after renal transplantation. These results were reported as a reply to the observations of Martegani et al. [2], who found increased erythrocyte zinc protoporphyrin IX levels in hemodialy-sis patients as compared to chronic renal failure patients. These authors also found important amounts of chelat-able lead in the ultrafiltrate by treatment with EDTA during hemofiltration in patients normally under dialysis. They concluded that lead body burden depends on renal function and is increased in hemodialysis patients as compared to chronic renal failure or healthy subjects [1,2]. These findings are not in agreement with our findings published in 1988. Indeed we could not find any correlation between the degree of renal failure and bone lead by measuring bone lead/gram wet weight and lead/calcium ratio in transiliac bone biopsies of 35 patients with moderate degree of renal failure and 153 dialysis patients [3]. Levels in dialysis patients with well-documented analgesic nephropathy (n = 10) and no occupational lead exposure were in the same range as those from deceased subjects (cadavers) with past normal renal function and without clearly documented lead exposure (table 1). Winterberg et al. [1] give no information on the occupational or environmental lead exposure in their hemodialysis group. Indeed, we found [3] high levels of bone lead Table 1. Mean transiliac bone lead and bone lead/calcium ratio (mean ± SD)

Relation Between Red Blood Cell Function and β2-Microglobulin Concentration in Hemodialysis

It has recently been recognized with increasing frequency that patients maintained on regular hemodialysis develop amyloid arthropathy after several years (1,2,3). It was reported that a major constituent of this amyloid is a new form of amyloid fibril protein homologous to β2-microglobuline (β2M) (4).