Valentina Mazzarella

Dialytic treatment of rhabdomyolysis-induced acute renal failure : Our experience

Acute renal failure is the most common complication of rhabdomyolysis, with an 8–20% reported incidence. In particular, rhabdomyolysis associated with acute renal failure is frequently observed in critically ill patients, with a 6–16% reported incidence in Intensive Care Units. Dialytic treatment is necessary to correct hydroelectrolytic imbalance and renal function alterations and it may be a pathogenetic therapy by myoglobin removal. In the present study we evaluated our experience on patients suffering from rhabdomyolysis and acute renal failure subjected to dialytic treatment. We retrospectively studied 28 patients, 17 admitted in our Intensive Care Unit (ICU-patients) and treated by continuous renal replacement therapy (particularly by continuous venovenous hemofiltration, continuous venovenous hemodialysis and continuous venovenous hemodiafiltration) and 11 admitted in our Nephrology Department (NICU-patients) and treated by high-efficiency daily hemodialysis. We excluded one ICU-patient from the study because she was affected with lung end-stage neoplasia and it would have been difficult to evaluate the effects of the dialytic treatment on RML biochemical index and on her final outcome. ICU-patients were older, with a mean age of 64 ± 10 yrs, and were suffering from MODS and typical elderly diseases, such as cardiac and respiratory chronic failure, except from 3 patients with acute liver failure resulting from poisoning, who were relatively younger. In NICU-patients, instead, the mean age was 36 ± 16 yrs and the causes of RML were narcotic drugs abuse, repetitive seizures and vigorous exercise, more frequently observed in young people. In three relatively older NICU-patients RML was due to lipid lowering drugs assumption. Before starting the dialytic treatment, in ICU-patients CPK plasma level was 2615 ± 3586, while K+ was 5.10 ± 1.08 and sCr was 5.69 ± 4.06 In NICU-patients, on the other hand, CPK was 14273 ± 9266, while K+ was 5,75 ± 0.92 and sCr was 5,9 ± 0.4. ICU-patients mortality rate was 50% (8/16 patients) in spite of the good recovery of renal function and the biochemical RML indexes improvement. In NICU-patients, instead, only one patient died for septic complications (he was a heroin-addict and suffered from overdose syndrome). Early dialytic treatment of RML allows not only to avoid life-threatening complications (first of all the acute renal failure) but moreover its a pathogenetic treatment because it removes great amount of myoglobin from the plasma. Beside this, continuous renal replacement therapy allows a successful management of critically ill patients with severe hemodynamic conditions. Nevertheless, the final outcome may be very different between ICU- and NICU-patients, with a higher mortality rate in ICU-patients, suffering from MODS.

Red Blood Cell Membrane Lipid Peroxidation in Continuous Ambulatory Peritoneal Dialysis Patients

We have recently described that in the erythrocytes from uremic patients on chronic hemodialysis, the pentose-phosphate shunt is defective, the membrane concentrations of malonyldialdehyde, resulting from peroxidation of polyunsaturated fatty acids in the membranes themselves, are increased, and the concentrations of vitamin E, an antioxidizing agent, are reduced. In the present study we have analyzed these same metabolic aspects in a group of uremic patients in continuous ambulatory peritoneal dialysis. We have found normal function of the pentose-phosphate shunt, slightly elevated concentrations of malonyldialdehyde compared to controls, but definitely lower than in chronic hemodialysis patients, and higher tocopherol concentrations than in both controls and chronic hemodialysis patients.

Acute renal failure caused by nontraumatic rhabdomyolysis

Nontraumatic rhabdomyolysis may be associated with severe metabolic disturbances. In particular, previous literature has described a 8-20% incidence of acute renal failure in rhabdomyolysis. The aim of this study was to evaluate our experience on 11 patients with acute renal failure treated by high-efficiency daily hemodialysis.

Acute Leukemia in a Uremic Patient Undergoing Erythropoietin Treatment

Dr. Valentina Mazzarella, Ospedale S. Eugenio, Clinica Chirurgica II Università, Piazzale dell’Umanesimo 10, I-00144 Roma (Italia) Dear Sir, Erythropoietin (EPO) has been shown to be an excellent drug to reverse anemia in uremia with few adverse effects. We describe 1 case of leukemia developing during EPO treatment in a uremic patient. In July 1995, we observed a 74-year-old man affected by end-stage renal failure following nephroangiosclerosis on maintenance hemodialysis since January 1993. The patient had a good clinical status except for a persistent anemia: hemoglobin was 7.1 g/dl, hematocrit 20.9%, white blood cell count 6.1 × lOVμl, platelet count 221.0 × 103/μl. EPO treatment (4,000 IU s.c. twice weekly) was started. The hemoglobin value improved after 18 days and became stable, at 8.2 g/dl. Seven weeks after EPO therapy, the patient complained of fever, dyspnea, weakness and leukocytosis. Subsequent laboratory and clinical features showed a picture of acute lymphocytic leukemia (ALL). One month later the patient died during chemotherapy. Campistrus et al. [1] observed acute non-lymphocytic leukemia (ANLL) in a uremic patient in hemodialysis treated with EPO. Uyttebroeck et al. [2] described a transformation to acute myelomonocytic leukemia in a child affected by 5q-syndrome after EPO treatment. Both authors did not exclude that extramedullary hematopoiesis with secondary transformation to leukemia stimulated by EPO occurred. Furthermore the development of acute leukemia was observed in 3/14 patients with myelodysplastic syndromes while on EPO therapy [3]. There is evidence that EPO in vitro can stimulate ANLL blast cells [4]. At present, EPO is employed in anemia associated with all hematologic malignancies and solid tumors except acute myeloid leukemia. An interesting study suggests that in both murine and human systems genetic alterations of the EPO receptor gene are not rare events and could be involved in the occurrence of the erythroleukemic process [5]. We observed 1 case of ALL in a uremic patient and no references have been found on ALL after EPO treatment. It is possible that the anemia was a symptom of a preleu-kemic state. Further investigations are needed in order to clarify whether EPO increases the potential risk of transformation to acute leukemia. Careful use of EPO is important in particular in uremic patients, because the anemia is not always a renal symptom.

Replacement Therapy in Acute Liver Failure

Acute liver failure is generally a fatal disease, although mortality is highly dependent on etiology. Renal failure is a common complication in patients with severe liver disease, and may be due to pre-renal causes, acute tubular necrosis, hepatorenal syndrome and chronic renal disease associated with the underlying chronic liver disease. Orthotopic Liver Transplantation (OLTx) has become the accepted treatment of choice for patients with advanced liver disease; dialytic treatment may be useful in treating renal complication, and to gain time either for liver regeneration or for the acquisition of a donor liver. Among the natural toxic causes of ALF, Amanita Phalloides poisoning (APP) is one of the most frequent. Managing patients suffering from APP may be very challenging; furthermore, treatment must be started in time to be effective. In this study we report our experience on replacement therapy in ALF due to APP.

Dialysis leukopenia and hypoxemia in a patient without measurable complement activity.

SummaryWe have studied complement activity, total leukocyte counts,

Continuous renal replacement therapy: our experience in intensive care unit.

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Leukopenia, Hypoxemia and Complement Activation during a Single Hemoperfusion

and acid-base balance during a single hemodialysis with cuprophan membranes in a patient with hereditary angioedema and C3NeF-positive chronic membranoproliferative glomerulonephritis. Before, during and after the dialytic procedure plasma complement activity (total hemolytic complement, classical and alternative pathway activities) was not detectable and no C3-conversion occurred, while profound leukopenia (from 8,500 to 1,800 leukocytes/µl) and hypoxemia (from 101.8 to 86 mmHg