Surgical treatment of persistent exit-site infections.

Persistent exit-site infections and tunnel infections (ESI/TI) are a cause for removal of Swan neck catheters (SNC). Previous studies report variable success in the treatment of these infections by surgical exposure and removal of the subcutaneous external cuff. We report our experience with this technique. All 5 patients with persistent ESI/TI were successfully treated with antibiotics and surgical intervention. All cultures grew Staphylococcus aureus. Average time to complete healing after surgical exposure was 39.4 days. Mean follow-up after complete healing was 164.8 days. There were no subsequent episodes of ESI/TI in these patients. None of the catheters subsequently malfunctioned or developed leaks. Persistent ESI/TI in Swan neck catheters can be successfully treated with surgical exposure and removal of the subcutaneous external cuff.

Acid dialysate correction of metabolic alkalosis in renal failure.

Severe metabolic acidosis may occur during hemodialysis when the incorrect acid dialysis concentrate from a two-part bicarbonate dialysis system is used in an acetate dialysis machine. We deliberately applied this technique to correct severe metabolic alkalosis in a patient with chronic renal failure. Rapid correction of the metabolic alkalosis was achieved and the procedure was well tolerated.

Effects of feto-placental markers with plasma exchange in pregnancy.

To evaluate changes in feto-placental markers with plasma exchange in pregnancy, two patients at varying stages of pregnancy referred to a tertiary care hospital and requiring plasma exchange for intercurrent problems were evaluated. Alpha-fetoprotein, human chorionic gonadotropin, and free estriol were sequentially measured in the patients' plasma and in the fluid removed, thus permitting calculations of permeability rates and clearances. Despite markedly different molecular weights, all three feto-placental markers had similar permeabilities and clearances. While in both patients maternal levels of alpha-fetoprotein and human chorionic gonadotropin decreased rapidly with plasma separation and rebounded rapidly to baseline, free estriol responded differently and did not appear to decrease with therapy. Maternal levels of feto-placental markers only transiently changed with plasma exchange during pregnancy and rapidly returned to baseline with no apparent consequences to the pregnancy.

Acute plasma separation with hemodialysis equipment.

Although plasma separation has been reported to have a relatively small complication rate in large series of healthy outpatients, little attention has been directed to the evaluation of the safety and effectiveness of the therapy in acutely ill, hospitalized patients. The experience of using standard hemodialysis equipment and membrane plasma separators with 281 plasma separation treatments in 49 patients over the last 7 yr is reported and analyzed. The data reveal a 1.4% incidence of hypotension and a 0.4% incidence of hematuria in the 281 treatments--rates similar to those reported in outpatients. In addition, analysis of the diseases and patients treated over the 7 yr reported demonstrates a marked shift from immunological and hematological disorders towards neurological disorders. The data suggest that plasma separation may be easily and safely performed by any institution capable of performing acute hemodialysis.

Adequacy of dialysis in CAPD and cycler PD; the PET is enough.

Assessment of adequacy of dialysis has become a necessary part of all peritoneal dialysis programs; this task is particularly burdensome in home cycler patients. To test the hypothesis that the Peritoneal Equilibration Test (PET) reliably predicts clearance, as measured by classical clearance methodology, both CAPD and cycler patients underwent PET tests and clearance studies. In cycler patients, Dialysis to Plasma Ratios (D/P) for urea nitrogen (UN) and D/P for creatinine as determined by clearance methods correlated extremely well with those obtained by PET test. D/P creatinine also correlated well (clearance versus PET) in CAPD patients; D/P UN approached unity in all CAPD patients with dwell times of 4 hours or longer. In all cases, the PET prescription was highly accurate in predicting 24-hour clearance results. These results are useful in those patients in whom 24-hour home collections are inconvenient or impossible, especially in cycler patients.

Trace element content of moonshine.

Although the contamination of illicit whiskey with lead is widely accepted, the potential for exposure to other trace elements from drinking "moonshine" is less well appreciated. To better understand the potential for trace element poisoning, we undertook an analysis of samples of Georgia moonshine. Although a number of elements were not found in significant quantities to be considered harmful, four elements (copper, zinc, lead, and arsenic) were present in potentially toxic concentrations. The possible implications and sources of the contamination are discussed.

Moonshine-related arsenic poisoning.

Twelve sequential cases of arsenic poisoning were reviewed for possible sources of ingestion. Contaminated illicit whiskey (moonshine) appeared to be the source in approximately 50% of the patients. An analysis of.confiscated moonshine revealed that occasional specimens contained high levels of arsenic as a contaminant. Although arsenic poisoning occurs relatively infrequently, contaminated moonshine may be an important cause of the poisoning in some areas of the country.

Isolated ultrafiltration in the therapy of volume overload accompanying oliguric vascular shock states.

Isolated ultrafiltration (removal of plasma water and solute without dialysis) was used as a "last resort" therapy in three patients with diuretic and pressor resistant oliguria complicating severe volume overload and vascular shock. The improvement in clinical and hemodynamic parameters is reported and the possible mechanisms of action (decreased pulmonary capillary wedge pressure and increased colloid osmotic pressure) are discussed.

Serum electrolyte and acid base composition. The influence of graded degrees of chronic renal failure.

Data from 41 ambulatory patients with graded degrees of uncomplicated, chronic renal failure were used to define the quantitative relationship between serum acid-base and electrolyte composition and the serum creatinine level. Even in patients with only moderate renal insufficiency, serum total carbon dioxide (tCO2) content was reduced significantly. This early fall in tCO2 was offset by an increase in serum chloride (Cl-), serum undetermined anton concentration (A-) remaining normal. In patients with more severe degrees of renal insufficiency, further decrements in tCO2 occurred that were proportional to the increment in serum creatinine. These latter decrements in tCO2 were associated with equivalent increments in A-, serum Cl- remaining unchanged at the elevated level observed during moderate renal insufficiency. Confidence limits of 95% for tCO2 and A- were calculated from the data.

Isolated ultrafiltration in the treatment of fluid overload in cardiogenic shock.

Dramatic improvement in measured hemodynamic values, arterial blood gas values, and renal function was quickly achieved by the use of isolated ultrafiltration in a patient with cardiogenic shock refractory to medical management. Swift venous access was obtained by femoral catheterization, and the rapid removal of 3,500 mL of ultrafiltrate was well tolerated. This technique may afford another mode of therapy in patients with refractory cardiogenic shock associated with severe volume overload.

Interstitial immunofluorescence in nephritis of Sjögren's syndrome.

A patient with Sjögren's syndrome (SS) developed mild renal insufficiency without significant proteinuria; the diagnosis of interstitial nephritis secondary to SS was made on the basis of history, serological data and renal biopsy. The renal biopsy revealed immunofluorescence of the interstital infiltrates and the importance of this finding in the differential diagnosis of interstitial nephritis is considered. In addition, further studies to detect anti-renal antibodies and circulating immune complexes are reported and the possible interpretation of the results is discussed in regard to pathogenesis.

Chronic renal insufficiency from cortical necrosis induced by arsenic poisoning.

A 39-year-old man had anuria and azotemia and was found to be suffering from acute arsenic poisoning. After two peritoneal dialyses, partial renal function returned, and the patient has survived for five years without dialysis. Renal cortical necrosis was demonstrated by renal biopsy and renal calcification. We suggest that arsenic be added to the list of substances capable of causing renal cortical necrosis and recommend consideration of this complication in cases of arsenical poisoning.

Neuromuscular disease in tertiary hyperparathyroidism.

A 38-year-old woman with chronic renal failure had disabling proximal myopathy of the lower extremities. Investigation revealed "tertiary hyperparathyroidism". Neuromuscular evaluation, including clinical examination, electromyogram, and muscle biopsy, revealed neuropathic muscle disease. These findings are quite similar to the neuromuscular changes in primary and secondary hyperparathyroidism. This suggests that the same neuropathic mechanism may be present in all forms of parathyroid hyperfunction.