Bilateral ureteral obstruction and renal failure caused by massive retroperitoneal hematoma: is there a pelvic compartment syndrome analogous to abdominal compartment syndrome?

OBJECTIVES: To describe an intrapelvic compartment syndrome analogous to abdominal compartment syndrome and to characterize its diagnosis and treatment. DESIGN: Retrospective analysis. SETTING: Level I trauma center. PATIENTS: Three patients with pelvic ring or acetabular fractures presented with bilateral ureteral obstruction, renal organ failure, and anuria due to direct compression of both ureters in the true pelvis by a massive retroperitoneal hematoma. INTERVENTION: Surgical therapy consisted of fracture stabilization, decompression of the retroperitoneal space, and evacuation of the hematoma. Persistent isolated bleeding points were either embolized preoperatively or ligated. RESULTS: After decompression, all three patients promptly recovered their renal organ function. CONCLUSION: An intrapelvic compartment syndrome can be defined as bilateral ureteral obstruction and renal failure caused by a massive intrapelvic hematoma with increased retroperitoneal pressure. Diagnostic differentiation of anuria in patients with pelvic ring or acetabular fractures must include intrapelvic compartment syndrome. Early diagnosis and treatment are mandatory.     

Current usefulness of procaine penicillin in the treatment of pneumococcal pneumonia

Kidney transplantation offers the opportunity of an improved quality of life for those patients suffering from renal failure. Unfortunately, this treatment is not available to all people as this is influenced by the increasing demand for a limited supply of suitable organs. This situation is particularly alarming for the UK's Asian population with their higher susceptibility to end-stage renal failure which has resulted in a greater demand for transplants. Consequently, the proportion of Asians on transplant waiting lists is growing rapidly. Coupled with this are problems of cross-racial tissue type matching which has led to longer waiting times for a transplant. The situation is clear, there is an urgent need to address the number of Asians requiring a kidney transplant otherwise the human and economic costs will be very severe. In the short term there needs to be a greater number of donors coming forward from the Asian communities to increase the pool of suitable organs. In the long term, there needs to be greater attention on preventive strategies to reduce the number of Asians requiring renal replacement therapy.     

Studies on the carboxyl terminal peptides of human seminal plasma inhibin (HSPI). Chemical synthesis and in vivo biological activity of the disulfide loop peptide 67-94 of HSPI

In this study, we attempted to analyze the differences between renal failure associated with methylprednisolone (MP) pulse therapy and natural deterioration of renal function that was unrelated to MP administration. Of 80 patients with renal or collagen disease who received MP pulse therapy at our hospitals, 13 were selected for the study whose serum creatinine levels increased more than 0.5 mg/dl from baseline values following therapy. Somewhat arbitrarily, 7 patients were placed in an MP-associated renal deterioration group (group 1) in which serum creatinine levels returned naturally, or following induced diuresis, to baseline levels, and 6 patients in an MP-independent natural deterioration group (group 2) in which renal function progressively deteriorated. Renal function similarly deteriorated in the two groups following pulse therapy, irrespective of the degree of crescent formation. Our data suggested that hypoproteinemia is the most important index for differentiating MP-associated renal failure from natural deterioration of renal function unrelated to MP pulse therapy. In patients that are nephrotic and have impaired renal function, worsening of renal function following pulse therapy may partly be due to transient MP-associated renal failure. On the other hand, in patients without hypoproteinemia, worsening of renal function is most likely due to active primary disease and is probably not associated with MP pulse therapy.     

Accumulation of glyceryl ether lipids in Wolman''s disease

Glomerular filtration rate and renal plasma flow may be normal, reduced or increased in cirrhosis. The mechanism of departures from normal is not known. Other renal functional changes in cirrhosis include avid sodium reabsorption, impaired concentrating and diluting abilities, and partial renal tubular acidosis. Fluid and electrolyte disorders are common. Sodium retention with edema and ascites should generally be treated conservatively because they tend to disappear as the liver heals and because forced diuresis has hazards. The indications for diuretics are (1) incipient or overt atelectasis; (2) abdominal distress; and (3) possibility of skin breakdown. Hyponatremia is common and its mechanism and treatment must be assessed in each patient. Hypokalemia occurs and requires treatment. Respiratory alkalosis and renal tubular acidosis seldom need therapy. The hepatorenal syndrome is defined as functional renal failure in the absence of other known causes of renal functional impairment. The prognosis is terrible and therapy is unsatisfactory. The best approach is not to equate the occurrence of renal failure in cirrhosis with the hepatorenal syndrome. Rather the physician should first explore all treatable causes of renal failure, eg, dehydration, obstruction, infection, heart failure, potassium depletion, and others.     

Hypertension in renal failure

Hypertension is a common component of the morbidity associated with renal failure. The mechanisms that contribute to high blood pressure are reviewed in this section. Also covered are therapies to reduce hypertension, the treatment goals of those therapies, and the outcomes of antihypertensive therapy on kidney function in patients with renal failure. Various antihypertensive agents are specifically addressed, and a treatment paradigm is presented for combination antihypertensive drug therapy, which is usually necessary in the antihypertensive therapy of patients with renal failure.     

Distribution of lesions in cattle infected with Mycobacterium bovis

Recent extension of the use of recombinant growth hormone (rhGH) to non-growth hormone-deficient patients necessitates close attention to possible complications in these patients, including effects on bone. Recent studies on the use of rhGH in children with chronic renal failure (CRF) provide some early data. No significant differences in radiographic osteodystrophy scores, serum calcium, phosphorus, or parathyroid hormone (PTH) levels were found between treated and untreated groups. Alkaline phosphatase increased transiently. The effect of renal osteodystrophy on growth response has not yet been reported. Animal models demonstrate that GH stimulates chondrocyte proliferation. Experimental data further suggest that GH can weaken the epiphyseal plate. Slipped capital femoral epiphysis has been reported in GH-deficient patients, before, during, and after GH therapy. In CRF patients treated with GH, slipped capital femoral epiphysis has also been reported. As renal osteodystrophy and hypocalcemia are risk factors for this condition, the relationship to GH therapy is unclear in these patients. Avascular necrosis, known to be associated with slipped capital femoral epiphysis and CRF, has also been reported in patients receiving GH, although the relationship to the therapy is unknown. Children with CRF treated with rhGH should be serially monitored for renal osteodystrophy, slipped capital femoral epiphysis, and avascular necrosis with serial radiographs and serum calcium, phosphorus, alkaline phosphatase, and PTH levels.     

Seasonal variation of neuropeptide Y actions on growth hormone and gonadotropin-II secretion in the goldfish: effects of sex steroids

Tumor lysis syndrome is a critical illness characterized by massive tumor cell death leading to severe hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia, and acute renal failure in patients with rapidly growing cancers (especially Burkitt's lymphomas with extensive abdominal bulk). It may be preventable with allopurinol therapy combined with aggressive intravenous fluid therapy aimed at establishing an ongoing alkaline diuresis. In most cases renal failure is completely reversible; however, fatal hyperkalemia and volume overload may develop. Therefore, aggressive management with hemodialysis often is necessary to maintain life support while tumor burden is controlled with cytoreductive therapy. Early recognition and management by a team approach in the intensive care unit where careful monitoring is available serves to forestall severe renal failure, thereby improving short-term prognosis in susceptible patients.     

Renal replacement therapy in multiple myeloma and systemic amyloidosis

Renal failure frequently complicates both multiple myeloma and systemic amyloidosis. Renal replacement therapy (RRT) may be poorly tolerated and its role in such patients is not clearly defined. Of fifty patients (26 males and 24 females) referred to a single centre because of renal failure associated with multiple myeloma or systemic amyloidosis 37 progressed to end-stage renal failure and 30 of these patients received RRT. Nine patients have been treated by CAPD, 13 by haemodialysis, and 8 patients have required both forms of dialysis. Overall one year and two year survival rates were 66% and 57% respectively. The median duration on RRT was 7.5 months (range 1-96 months) with a 51% one year, and a 46% two year survival rate. Of 7 patients with amyloidosis who underwent renal transplantation, 3 died within 6 months of transplantation. Undiagnosed cardiac involvement contributed to this early mortality. We conclude that renal replacement therapy is appropriate for some patients with multiple myeloma and systemic amyloidosis who develop endstage renal failure. Careful assessment and selection of patients is necessary prior to renal transplantation.     

The diagnosis and treatment of blunt renal trauma

225 patient with blunt renal trauma were treated from 1955 to 1994. Coexistent injuries of other organs were noted in 79 patients (35.11%). The extent of renal trauma was not demonstrated by hematuria. B-ultrasonography seemed to be best for the diagnosis of renal trauma. Abdominal incision was helpful to explore injuries of other organs and manage renal trauma. Early treatment of renal trauma was necessary for the treatment of shock and prevention of serious complication.     

Alpha-thalassemia carrier identification by DNA analysis in the screening for thalassemia

Recent advances in technology have not substantially changed the high mortality rate associated with acute renal failure (ARF). To obtain a simple, valid prognostic index, we retrospectively evaluated the relative importance of demographic data, causes (acute insults) of renal failure, and comorbid clinical conditions for the outcome in 102 ARF patients who received renal replacement therapy with an overall mortality rate of 65% (66 of 102). There were no significant differences between survivors and nonsurvivors in age and gender. Mortality according to acute insults was similar to that of the whole population studied. Of the 10 clinical conditions at the time of the first renal replacement therapy, mechanical ventilation (p = 0.0002), cardiac failure (p = 0.0006), hepatic failure (p = 0.003), central nervous system dysfunction (p = 0.005), and oliguria (p = 0.04) were found to be significantly related to mortality by univariate analysis. Furthermore, multivariate analysis demonstrated that only mechanical ventilation, cardiac failure, and hepatic failure were significant risk factors. Survival was directly related to the number of significant variables in univariate analysis: zero, 89% (8 of 9); one, 62% (21 of 34); two, 19% (5 of 27); three, 10% (2 of 20); four, 0% (0 of 8); five, 0% (0 of 4). This simple and early prognostic index, derived from the assessment of clinical conditions which were easily determined at the patient's bedside, could be useful for outcome prediction in ARF patients requiring renal replacement therapy.     

Fish oil therapy in IgA nephropathy

IgA nephropathy often progresses to endstage renal failure over a period of many years, and any therapy directed to IgA nephropathy will most likely have to be administered over an extended period of time. Therefore, optional therapy should be effective and free of long-term adverse effects. Besides fish oil, prednisone has also been investigated for treatment of IgA nephropathy, with a lack of consistent results; severe adverse effects are common with long-term use. Several studies have shown positive although not overly impressive results; therefore optimal therapy for slowing the progression of renal failure secondary to IgA nephropathy has not been established. Problematic issues with available studies included the following: (1) most of the clinical studies previously discussed were short-term, contained small numbers of patients, and most but not all were uncontrolled; (2) early reports involving fish oil therapy demonstrated conflicting results regarding its efficacy, including one study that observed increased progression of renal disease in patients treated with fish oil; however, recent studies have shown more promise for fish oil therapy for up to 2 years of treatment; and (3) since most of the studies were conducted over a short period of time, it is difficult to assess long-term effects and safety of oil treating IgA nephropathy, a disease that progresses to ESRD over 10-20 years. However, given the low number of adverse effects and apparent low risks associated with this relatively safe food supplement therapy observed in most clinical trials of up to 2 years duration, fish oil may slow the progression of renal failure in patients with IgA nephropathy. Therefore, with appropriate monitoring of renal function and blood tests, treatment with fish oil 6-12 g/d should be considered in patients with IgA nephropathy.     

Acute renal failure--which treatment modality is the best?

Despite the progress in animal research concerning the pathophysiology and the progress in clinical practice regarding the methods of therapy, the incidence and mortality of acute renal failure remain high, especially when other organs are involved. New pharmacological interventions have led to the perspective that in the near future it may be possible to prevent and/or ameliorate this devastating syndrome. Continuous dialysis therapy and the selection of a biocompatible membrane may possibly help the critically ill patient especially when parenteral nutrition and correction of electrolyte and acid-base disturbances are important. Nevertheless, more solid data are needed and one should take into consideration that acute renal failure is a multifactorial syndrome. The type of dialysis itself is not the only matter which has to be evaluated since the mortality rate can be correlated with the number of involved organs before or after the initiation of acute renal failure and with the severity of the original disease. In clinical practice, a large number of prospective studies and more sophisticated statistical methodology are needed in order to evaluate the proper treatment modality.     

Multiorgan trauma

A case is presented of a patient with multiorgan trauma. The main diagnostic problem was coexisting haemorrhage. Curable skin defects were healed after several covering them with intermediate thickness mesh grafts. The postoperative course was complicated with sepsis and acute non-inflammatory renal failure with polyuria.     

Influence of urinary management on urologic complications in a cohort of spinal cord injury patients

OBJECTIVE: To study urologic complications in patients with spinal cord injury (SCI) in relation to their bladder management. DESIGN AND SETTING: A cohort study of patients with SCI in a rehabilitation center. PARTICIPANTS: One hundred eighty-two patients were studied; demographic data, disease characteristics, and urologic history were obtained for each. INTERVENTION: Patients responding to a questionnaire were given a clinical exam. Their medical records were reviewed, with particular attention given to the following urologic complications: lithiasis, urinary infections, orchiepididymitis, urethral trauma, vesicorenal reflux, and renal failure. RESULTS: Results are reported for 123 patients. Time since SCI was 8 years. Intermittent catheterization was the main method of bladder management. Only 32 patients had changed their method of vesical voiding. Urinary complications had developed in 75% of patients. The most common complication was urinary infection. Vesicoureteral reflux occurred in 26% of patients using percussion. Trauma related to catheterization was the main problem with intermittent catheterization, responsible for a high rate of orchiepididymitis. CONCLUSION: Intermittent catheterization is the most-used method of bladder management, but with a nonnegligible rate of urethral trauma in men. Percussion and Credé maneuver appear to be acceptable techniques of bladder management if the patient is closely monitored.     

The pathogenesis and consequences of AGE formation in uraemia and its treatment

Advanced glycation endproducts (AGEs) accumulate in uraemia as a consequence of diminished clearance of low molecular weight forms which retain their reactivity and may subsequently combine with circulating and tissue macromolecules. Successful renal transplantation is the only form of renal replacement therapy which effectively clears these circulating AGEs; both haemodialysis and peritoneal dialysis are comparatively ineffective although high-flux haemodialysis confers some benefits. De novo AGE formation may be accelerated in uraemia due to carbonyl and oxidative stress leading to further accumulation. The consequences for the patient with chronic renal failure may be acceleration of vascular disease, renal failure progression and dialysis-related amyloidosis. Accelerated peritoneal AGE formation as a consequence of treatment with peritoneal dialysis fluids may be detrimental to peritoneal membrane function but does not appear to contribute to systemic elevation of AGEs.     

Current therapy of chronic renal failure

The course of chronic renal failure is generally progressive and mediated by several factors that operate in combination. Several extrarenal events which may cause transient or permanent deterioration of renal function, are important, because their correction may slow the progression of renal disease e.g. volume disorders, infection, nephrotoxic agents. In progression of chronic renal disease leading factors are hypertension, proteinuria and high protein/phosphorus intake. Number of evidence suggests that ameliorating hypertension, reducing proteinuria slow the progression of chronic renal failure. Clinical studies in diabetic nephropathy demonstrated that the renoprotective effect of ACE inhibitors was independent of their effect of systemic blood pressure. In ESRD patients access for renal replacement therapy should be obtained as early as possible. An A-V fistula may take several weeks to mature especially in diabetic or elderly patients. Early dialysis has been advocated in diabetic patients. In general, patients can start ESRD therapy when residual kidney function drops to 5-10% of normal value. High quality of dialysis should be provided to the uremic patient with respect of successful renal transplantation.     

Aminoglycoside-induced nephrotoxicity

In severe gram-negative infections aminoglycosides generally remain the first-line antibiotic. Their use is limited by the high risk of side effects and, especially, nephrotoxicity. High peak levels are crucial for antibacterial activity, whereas toxic side effects are determined by the more prolonged trough levels. Thus, aminoglycosides should not be given by intramuscular injection because the peak levels achieved are inadequate, whilst long-lasting elevated plasma trough levels result. On administration of a daily single dose intravenously high antibacterial efficacy can be combined with low nephrotoxicity. Besides the dose-dependent bactericidal effect, the post-antibiotic effect of aminoglycosides is of importance. The main site of nephrotoxicity are the proximal tubule epithelial cells. Renal toxicity is usually reversible after discontinuation of drug therapy. Toxic acute renal failure is not uncommon (5-35%) and usually dependent on the underlying disease, preexisting renal function, hydration state, age, cumulative dose, additional medication, previous therapy with aminoglycosides and the choice of the specific aminoglycoside. By implementing a single daily dose regimen in conjunction with adequate hydration, alkalization therapy with bicarbonate, monitoring of plasma trough levels and minimization of the duration of therapy (5 days), development of renal impairment can be prevented in the large majority of patients. Hence, acute renal failure has become an avoidable, and much less frequently observed complication of aminoglycoside therapy due to these measures.     

Vascular endothelial growth factor/vascular permeability factor is detectable in the sera of tumor-bearing mice and cancer patients

Quinine-induced acute renal failure attributed to the hemolytic-uremic syndrome has been infrequently reported. A case of acute renal failure due to acute interstitial nephritis associated with ingestion of quinine and the subsequent response to steroid therapy is described.     

Rhabdomyolysis in European viper bite

The case of a child who presented with severe rhabdomyolysis associated with renal failure after a viper bite is reported. Rhabdomyolysis is a serious complication resulting from systemic envenomation and is uncommon after viper bites in Europe. It may be due to oedema, myotoxic agents and haemorrhagic factors and may be responsible for two types of potentially fatal complications, i.e. acute renal failure and hyperkalaemia. The present case highlights the need to investigate routinely for rhabdomyolysis after viper bites. Antivenom therapy is recommended as soon as signs of envenomation are present, without waiting for the onset of complications.     

Reversible brainstem auditory evoked potential abnormalities in jaundiced Gunn rats given sulfonamide

Renal transplantation therapy performed for amyloid nephropathy is controversial because of the fatal effects of the disease. Amyloidosis is a relatively frequent disease and is generally associated with familial Mediterranean fever (FMF) in Turkey. Renal transplantation in the treatment of amyloid nephropathy started in January 1985. Till now, 18 (3.2%) renal transplantations have been performed on patients who had amyloid nephropathy. The mean follow-up period was 34.6 months. Fourteen renal grafts still function well (creatinine: 1-3.2 mg/dL). The overall 1-year patient and graft survival rates were 88.9% and 83.0%, respectively. These rates are not statistically different from renal transplantations done for other cases of renal failure. Therefore, patients with end-stage renal failure due to amyloidosis can be considered as appropriate candidates for renal transplantation.