Robert A. Gutman

Osteomalacia in Chronic Renal Failure: a Syndrome Previously Reported Only with Maintenance Dialysis

Osteomalacia without marked elevations of parathyroid hormone (PTH) has been described in maintenance dialysis patients. The proposed etiology has centered upon the transfer of an environmental agent (aluminum) from the dialysis water system. The present report describes an azotemic patient, who, prior to the initiation of dialytic therapy, presented with severe osteomalacia and low PTH concentrations for the severity of renal failure. The osteomalacia was documented by bone histology on two occasions 1 year apart, and aluminum deposits at the osteoidmineralized bone interface were demonstrated with histologic techniques. PTH concentrations were within the normal range (less than 0.1 ng/ml) on three widely spaced intervals. No definite statement can be made regarding the etiology of the osteomalacic syndrome in this patient, but maintenance dialysis does not appear to be necessary for its expression.

Amphotericin B Therapy in an Anephric Patient

Serum levels of amphotericin B were serially determined during and after a course of therapy in an anephric patient who developed systemic candidiasis after an unsuccessful renal transplantation. There was no progressive accumulation of drug in serum, and the pattern of disappearance of drug from serum was similar to that published for patients with normal renal function. The dialyzability of amphotericin B was studied in vivo during a 6-h period of hemodialysis, by an in vitro dialysis of amphotericin B in water by using similar equipment, and a Pellicon membrane filter which retains molecular species of 100,000 molecular weight and higher. These studies revealed that the drug is not dialyzable with conventional hemodialysis membranes, regardless of protein binding in plasma, and is excluded from passing through the Pellicon membrane filter.

Acquired Cytomegalovirus Retinitis

49 cases of acquired cytomegalovirus retinitis were reviewed including three new cases in renal allograft recipients and one in a patient with Hodgkin’s Disease. Diagnosis in over 90% of cases was bas

Renal intracortical blood flow distribution, function and sodium excretion in response to saline loading of anesthetized and unanesthetized dogs

SummaryIn order to study the effect of anesthesia on the canine response to saline loading, experiments were performed on 10 dogs, first while awake and then during pentobarbital anesthesia. Individual kidney function and intrarenal blood flow response to saline loading (7.5% body weight) were measured in each condition and all data are reported as the average of a single kidney. CIN is considerably reduced under anesthesia (24.7±3.2 vs. 43.2±3.9 ml/min,P<0.01). A directionally similar reduction of PAH clearance was noted (89±17 vs. 122±13 ml/min). The natriuretic response to saline loading of the dogs reached 290±61 μEq/min while awake, but only 70±27 μEq/min while anesthetized. No measurable increase of CIN or CPAH occurred in response to saline loading either in the anesthetized or unanesthetized state. The natriuresis was entirely due to a rise of CNA/GFR in both circumstances. The change of CNA/GFR in response to saline load was also appreciably larger while awake (1.2→4.7% vs. 0.7→1.8%). Although the fraction of blood flow to the outermost quarter of the kidney was initially the same (31±3 vs. 29±3%) awake or anesthetized, the changes with saline loading were in the opposite direction and the values reached were significantly different (37±3, awake, vs. 27±3%,P<0.05). We conclude that while increased outer cortical blood flow is not necessary for natriuresis, it may occur during sodium loading and may facilitate sodium excretion.

Salicylate-mediated increase in urate removal during hemodialysis: Evidence for urate binding to protein in vivo

Abstract The binding of urate to plasma proteins was estimated by an in vitro technique before and after the administration of aspirin to ten patients undergoing intermittent hemodialysis for chronic renal insufficiency. Six of these patients did not have any detectable binding of urate to plasma proteins in vitro either before or after aspirin administration. Aspirin did not have any effect on the removal of urate during hemodialysis in these six subjects. Four patients exhibited binding of urate to plasma proteins in vitro, which was markedly reduced by the administration of aspirin. In these four subjects, the rate of removal of urate during hemodialysis on five different occasions was significantly increased by the administration of aspirin. This increase in the removal of urate is best explained by an aspirin-mediated release of urate from protein-binding sites in vivo. While previous studies have demonstrated that urate binding to plasma proteins occurs in vitro, this study provides the first evidence to suggest that such binding may also occur in vivo.

Remission of Aseptic Inflammatory Ascites After Nephrectomy of a Failed Allograft

is used only to evaluate postbiopsy complications. In this letter, we describe our experience with prebiopsy color Doppler ultrasound evaluation in 213 consecutive ultrasoundguided percutaneous native kidney biopsies. Prebiopsy imaging demonstrated anomalous lower pole vessels in 5.2% (11/213) of left kidneys and 4.2% (9/213) of right kidneys (Table 1). Imaging informed the decision to biopsy the contralateral kidney in 9 of 11 patients with anomalous left lower pole vessels; in the other 2 cases, it was sufficient to change the approach angle. No major complications were detected. Minor complications, like minor bleeding, were seen in 1.9% (4/213) patients. Recently, Manno et al reported complication rates for 471 patients who had a biopsy without prebiopsy color Doppler ultrasonography. They found postbiopsy bleeding complications in 34.1% of patients, comprising hematoma in 33.3%, gross hematuria in 0.4%, and development of an arteriovenous fistula in 0.4%. The majority of the reported complications were minor (32.9% of all patients), with major complications in 1.2%. The authors found that only sex, baseline partial thromboplastin time, and age were independent predictive factors for postbiopsy bleeding. Our data, specifically our low hematoma rate, suggest that clinically significant postbiopsy hematomas could be related to small anomalous vessels at the lower pole. These anomalies are detectable with prebiopsy color Doppler sonography and could be considered as an independent risk factor for postbiopsy complications. Larger, controlled studies are needed to confirm our data.