Rituximab treatment of idiopathic membranous nephropathy.

Idiopathic membranous nephropathy is a common cause of nephrotic syndrome whose pathogenesis may involve B-cell functions. Rituximab is a monoclonal antibody that binds to the CD20 antigen on B cells thereby deleting them. We conducted an open-label pilot trial of rituximab treatment in 15 severely nephrotic patients with proteinuria refractory to angiotensin-converting enzyme inhibition and/or receptor blockade but with adequately controlled blood pressure. Rituximab was given 2 weeks apart and, at 6 months, patients who remained proteinuric but had recovered B-cell counts were given a second course of treatment. Proteinuria was significantly decreased by about half at 12 months. Of the 14 patients who completed follow-up, full remission was achieved in two and partial remission in six patients based upon the degree of proteinuria. Side effects were minor; however, we found no relationship between the response and number of B cells in the blood, CD20 cells in the kidney biopsy, degree of tubulointerstitial fibrosis, starting proteinuria or creatinine values. Rituximab appears effective in reducing proteinuria in some patients with idiopathic membranous nephropathy but prospective identification of responsive patients was not possible.

Nutritional assessment of intensive-care unit patients.

The decision about whether to institute aggressive nutritional support, with its attendant expense and potential morbidity, in critically ill patients remains controversial. We studied numerous commonly used variables for assessment of nutrition to identify critically ill patients at increased risk for the development of infection, for becoming ventilator dependent, and for mortality. We enrolled 111 patients in this study on their third day in the intensive-care unit (ICU). No attempt was made to influence nutritional support, nor was adequacy of such support studied. Although several measurements correlated with outcome, the serum albumin correlated with number of ICU days (r = -0.38; P less than 0.001), with the number of days on a ventilator, and with the number of hospital days. It was the only measurement that correlated with the development of both a new infection (P less than 0.05) and ventilator dependency (P = 0.002). Although the use of the serum albumin concentration in this setting has limitations, it is still the best, most commonly used measurement of nutrition available.

Results of treatment of center hemodialysis patients.

Four hundred eighty-three patients were maintained by hemodialysis in an outpatient hemodialysis center at the Mayo Clinic between 1963 and 1977. Although only 18 patients had experienced a myocardial infarction and 6 had had a cerebral infarction before beginning dialysis, 30 subsequently had acute myocardial infarction and 45 had a stroke. These two complications accounted for 48 of the 98 deaths that occurred during maintenance dialysis. Despite such complications, 183 patients were employed, 124 remained active at home or at school, and 115 were totally disabled. Survival of patients maintained solely by dialysis was 52% at 5 years. For the group as a whole, including patients who received their first allograft, the survival rate at 5 years was 65%.

Status epilepticus as a complication of concurrent electroconvulsive and theophylline therapy.

Status epilepticus that occurs after electroconvulsive therapy is a rarely reported event. Seizures associated with use of theophylline usually result from severe toxicity. We report a case in which status epilepticus occurred after electroconvulsive therapy in a patient who had a theophylline level above the accepted therapeutic range but below that generally associated with seizures. Caution should be exercised in the concurrent administration of electroconvulsive therapy and theophylline preparations.

Acute renal failure treated by slow continuous ultrafiltration. Preliminary report.

We report our initial experience with the use of slow continuous ultrafiltration in the treatment of acute renal failure. Advantages of slow continuous ultrafiltration over conventional hemodialysis are greater blood pressure stability, no need for systemic anticoagulation, augmented fluid input and removal, and enhanced ease of operation. Our results in two patients confirm other reports that this method can be successfully performed in hemodynamically unstable patients with acute renal failure.

Acute intrinsic renal failure induced by indomethacin: role of prostaglandin synthetase inhibition.

Nonsteroidal anti-inflammatory agents are often used to treat acute inflammatory arthritis because of their effectiveness and the infrequency of reported serious side effects. This report describes two patients who had acute intrinsic renal failure that was triggered by indomethacin. Both patients were volume contracted and had other circulatory impairments. Azotemia was so severe as to require temporary hemodialysis in one patient. Intrinsic renal function began to recover within 5 days after discontinuation of indomethacin. At the time that recovery began, urinary prostaglandin excretion increased in both patients. A detailed review of pertinent experimental data indicates that renal production of prostaglandin is an important compensatory response that helps to maintain renal function in the face of diminished renal blood flow. Our cases provide clinical support for this hypothesis and illustrate the fact that indomethacin, by interfering with this protective mechanism, can lead to acute intrinsic renal failure. Clinicians must be aware of this possible complication and use the nonsteroidal anti-inflammatory drugs with caution in patients who have compromised prerenal status.

The utility of serum albumin values in the nutritional assessment of hospitalized patients.

Nutritional assessment was performed on 47 patients admitted to a nephrology service; renal failure was present in 39 of the 47 patients. Values for serum albumin, total iron binding capacity, arm muscle circumference, triceps skin fold, and percent of ideal body weight for height and sex were determined. The 25 patients who had low serum albumin values at admission stayed in the hospital significantly (P less than 0.025) longer than those who had normal serum albumin values. No other abnormal nutrition-related finding or combination of findings was associated with a significantly (P less than or equal to 0.05) longer hospital stay. Low serum albumin values were also found in 11 of the 15 patients with infection. Low serum albumin values were far and away the most common abnormal nutrition-related findings in these infected patients in addition to the finding significantly (P less than 0.025) associated with a longer hospital stay.

Serum lipids in chronic renal failure.

The serum lipids and lipoprotein patterns in 100 adult patients with nonnephrotic chronic renal failure were analyzed retrospectively. Hypertriglyceridemia was found in 43% of these patients. Forty-nine of the 100 had a normal lipoprotein pattern, whereas 42 had type IV hyperlipoproteinemia. This abnormal lipoprotein pattern could not be correlated with the degree of renal impairment, the type of renal disease, or with the patient's age, sex, weight, or diet.