Acute renal failure secondary to acute pyelonephritis

A six year-old girl presented with acute oliguric renal failure, secondary to acute, non-obstructive pyelonephritis. Evidence for pyelonephritis as the cause of renal failure included: the evolution of typical changes on serial intravenous pyelograms, an acute interstitial inflammatory exudate on percutaneous renal biopsy, and gram-positive cocci on gram stain of the biopsy tissue. Although a specific causative organism was not conclusively identified, enterococcus was isolated from the initial catheterized urine specimen. The patient recovered from the acute illness but was left with impaired renal function, hypertension, and cortical scarring. Acute, non-obstructive pyelonephritis can produce acute renal failure in children and must be considered in the differential diagnosis of this syndrome.     

Acute renal failure in renal allograft recipients and patients with native kidneys

Techniques for the separation/concentration of micro-organisms from background food matrices can be applied to increase the speed of analysis and ease of isolation and detection of target micro-organisms. One recent example of such a technique is the immunomagnetic separation (IMS) procedure that has been used for the separation of specific micro-organisms from foods. This paper describes the use of a novel biosorbent consisting of a Salmonella-specific bacteriophage (phage) immobilized to a solid phase that was used for the separation and concentration of Salmonella from food materials. This work has shown that a Salmonella-specific phage-based biosorbent could remove Salmonella from culture fluid and separate Salmonella from suspensions of other Enterobacteriaceae. The ease of production of phage, high affinity of phage-cell interaction and the ability of phage to infect host cells in heterogeneous environments indicates the potential of such a biosorbent as the basis for a reliable separation system in food microbiological analysis.     

Acute renal failure in patients with type 1 diabetes mellitus

Acute renal failure (ARF) is a serious condition which still carries a mortality of around 50%. People with diabetes may be at increased risk of developing ARF, either as a complication of diabetic ketoacidosis or hyperosmolar coma, increased incidence of cardiovascular disease, or due to increased susceptibility of the kidney to adverse effects in the presence of underlying diabetic renal disease. During the period 1956-1992, 1,661 cases of ARF have been treated at Leeds General Infirmary. Of these, we have identified 26 patients also having type 1 diabetes. ARF due to diabetic ketoacidosis is surprisingly uncommon (14 cases out of 23 patients whose notes were reviewed). All cases of ARF complicating ketoacidosis in the last decade have been associated with particularly severe illness requiring intensive care unit support, rather than otherwise 'uncomplicated' ketoacidosis. We discuss the conditions that may result in ARF in patients with diabetes and the particular difficulties that may be encountered in management.     

Quantification of creatinine kinetic parameters in patients with acute renal failure

BACKGROUND: Urea kinetic modeling (UKM) and creatinine (Cr) kinetic modeling (CKM) are used in the nutritional evaluation of end-stage renal disease (ESRD) patients. Both the UKM-derived normalized protein catabolic rate (nPCR) and the CKM-derived estimate of lean body mass (LBM) may also provide important information in critically ill acute renal failure (ARF) patients. Estimation of LBM may be particularly useful as previous data demonstrate that malnutrition adversely influences outcome in ARF patients. METHODS: Eleven critically ill ARF patients (age 52 +/- 21 years; mean +/- SD) treated with continuous venovenous hemofiltration (CVVH) were the study group. They were analyzed at steady state with a single-pool variable-volume model that determined the creatinine generation rate (GCr) by a methodology that we have previously described. RESULTS: The CVVH ultrafiltrate production rate was 913 +/- 49 ml/hr, yielding a blood Cr clearance of 15.2 +/- 0.9 ml/min and a steady state serum Cr of 3.4 +/- 1.7 mg/dl. Daily creatinine generation normalized to body wt (creatinine index: CI) was 6.3 +/- 0.8 and 10.6 +/- 3.0 mg/kg/day for females (N = 4) and males (N = 7), respectively (P < 0.05). Estimated mean LBM was 30.0 +/- 2.0 and 41.2 +/- 7.0 kg in females and males, respectively (P < 0.05), while the same parameter normalized to body wt was 0.50 +/- 0.05 and 0.52 +/- 0.10, respectively. These values are substantially lower than those previously reported for both normal and ESRD patients. Regression analysis demonstrated both GCr (r2 = 0.96; P < 0.001) and LBM (r2 = 0.96; P < 0.001) were significantly correlated with steady state serum Cr in a linear manner. However, no significant correlation (r2 = 0.06; P = 0.24) between nPCR and CI was observed. CONCLUSIONS: These data suggest critically ill ARF patients have severe somatic protein depletion. This malnourished state is likely due to deficits established prior to the development of ARF, such as those secondary to underlying chronic illnesses or prolonged hospitalization, and deficits related to acute hypercatabolism. Quantitative assessment of malnutrition in ARF patients with this CKM-based methodology may permit a better understanding of predisposing factors and, consequently, facilitate the development of interventions designed to prevent malnutrition in these patients.     

Acute renal failure in pregnancy

Between 1982 and 1992, 18 cases of pregnancy-related acute renal failure (PR-ARF) were observed (9% of the total number of ARF). Mean age of the women was 32 years (22-40 years). Uterine hemorrhage and preeclampsia/eclampsia were the major causes of ARF, accounting for 61% of the cases. Patchy renal cortical necrosis was suspected in 2 cases whereas signs of disseminated intravascular coagulation (DIC) or microangiopathic hemolytic anemia were present in 6 (33%) and 9 (50%) cases, respectively. Ten women required hemodialysis; and 6 of them, additional plasma exchange sessions. Five patients (28%) died during the acute phase of the illness, mainly due to brain damage, hepatic failure, and sepsis. Among the survivors, a complete (61.5%) or partial recovery (23.1%) was usually seen, but irreversible renal failure was recorded in 2 cases with postpartum hemolytic uremic syndrome (HUS). Short-lasting oligoanuria (< 3 days) represents a good prognostic index. However, the presence of vascular injury (cortical necrosis, HUS) seems to carry a poor prognosis. In conclusion, PR-ARF is still a critical occurrence, associated with serious prognosis for both women and kidneys. So far, the most effective measures remain the careful prevention and the aggressive management of the obstetric complications.     

Acute phase proteins in acute pancreatitis

INTRODUCTION: Most attacks of acute pancreatitis are self-limiting, but in 10-20% of cases, however, severe diseases with systemic complications develop. During the last few years, it has been recognized that acute phase proteins have an important role in the pathophysiology of acute pancreatitis. The present study examines the value of C-reactive protein, alpha-1-antitrypsin and orosomucoid in the assessment of severity of acute pancreatitis. MATERIAL AND METHODS: 150 adult patients suffering from acute pancreatitis by Mayer's clinical criteria (10) were divided in two groups. The first one (n = 50) consisted of patients with severe form of the disease and the second (n = 100) of patients with a mild form of acute pancreatitis. Acute phase proteins (C-reactive protein, alpha-lantitrypsin and orosomucoid) were determined quantitatively in both groups on the 1, 2, 3, 7 and 14th day of the disease onset. RESULTS: Increase in C-reactive protein values was observed in both groups. There was statistically significant greater increase in C-reactive protein in patients with severe acute pancreatitis than in those with mild form of the disease. C-reactive protein values fell slowly in all patients. Serum alpha-1 antitrypsin values were less increased than C-reactive protein values. There was a greater increase in patients with severe form of disease. The increase of orosomucoid was seen only after the third day of the disease onset and there was not a significant difference in values between the two groups. DISCUSSION: One of the most important problems in treating patients with acute pancreatitis is to detect patients with a severe form of the disease as early as possible, so that adequate treatment can be started immediately. The severity of acute pancreatitis is graded by Ranson and Imrie scores, but they request 48 hours for prognosis to be defined. Despite intensive research, no single laboratory test or pathophysiologic parameters have been found to accomplish early diagnosis. Recent studies suggest that single biologic markers such as acute phase proteins may soon allow a simple and early assessment of the prognosis. CONCLUSION: This study suggests that a C-reactive protein is a good early marker for the severity of acute pancreatitis. The high increased levels at the beginning point to serious course of disease in future. The increase of alpha-1-antitrypsin is of a similar importance, while the increased orosomucoid, appearing only after the third day, is of no importance in relation to the prognosis of the disease.     

Risk factors for acute renal failure in trauma patients

OBJECTIVE: To elucidate the risk factors for the development of acute renal failure (ARF) in severe trauma. DESIGN: Prospective observational study. SETTING: A general intensive care unit (ICU) of a university hospital. PATIENTS: A cohort of 153 consecutive trauma patients admitted to the ICU over a period of 30 months. RESULTS: Forty-eight (31%) patients developed ARF. They were older than the 105 patients without ARF (p = 0.002), had a higher Injury Severity Score (ISS) (p < 0.001), higher mortality (p < 0.001), a more compromised neurological condition (p = 0.007), and their arterial pressure at study entry was lower (p = 0.0015). In the univariate analysis, the risk of ARF increased by age, ISS > 17, the presence of hemoperitoneum, shock, hypotension, or bone fractures, rhabdomyolysis with creatine phosphokinase (CPK) > 10000 IU/l, presence of acute lung injury requiring mechanical ventilation, and Glasgow Coma Score < 10. Sepsis and use of nephrotoxic agents were not associated with an increased risk of ARF. In the logistic model, the need for mechanical ventilation with a positive end-expiratory pressure > 6 cm H2O, rhabdomyolysis with CPK > 10000 IU/l, and hemoperitoneum were the three conditions most strongly associated with ARF. CONCLUSIONS: The identified risk factors for post-traumatic acute renal failure may help the provision of future strategies.     

Acute methemoglobinemia and hemolytic anemia with phenazopyridine: possible relation to acute renal failure

An 18-year-old woman with no prior history of renal or hematologic dysfunction developed severe, acute methemoglobinemia after an overdose of phenazopyridine hydrochloride (Pyridium). The methemoglobinemia was reversed acutely with methylene blue, and during the course of ten days, the patient developed a hemolytic anemia with "bite cells" and acute renal failure. The patient recovered fully with conservative management. Several putative pathophysiologic explanations for the development of methemoglobinemia, hemolytic anemia, and renal failure following oxidative stress are considered and include a direct toxic effect on the renal tubules or methemoglobin-caused damage. Renal failure as a complication of phenazopyridine-related methemoglobinemia and hemolytic anemia should be borne in mind in cases of overdosage with this common drug.     

Outcomes in acute renal failure

OBJECTIVE: To compare, using decision analytic techniques, maternal and fetal risk and benefits of three strategies for the management of preterm labour after 32 weeks. These strategies are empiric tocolysis, no tocolysis, or amniocentesis for fetal maturity testing. DATA SOURCES: Published medical literature provided the probabilities, including those for tocolysis efficacy, maternal and neonatal outcomes, and steroid efficacy. DATA: Synthesis Separate decision trees were created for hypothetical cohorts of patients presenting with preterm labour at 32, 34, and 36 weeks of gestation to compare strategies. The primary outcome was the total number of expected adverse maternal and neonatal events for each strategy at each gestational age. RESULTS: At 32 weeks tocolysis yielded the lowest total number of adverse maternal and neonatal events. At 34 weeks, both tocolysis and no tocolysis yielded similar overall outcomes. At 36 weeks most clinical outcomes were good regardless of strategy. CONCLUSIONS: This analysis supports the empiric use of tocolytics at 32 weeks. At 34 weeks, either tocolysis or no tocolysis appear to be reasonable alternatives. At 36 weeks no tocolysis is probably preferred. This analysis also suggests that amniocentesis should not be employed in the management of preterm labour at these gestational ages.