[A man with dyspnoea after a kidney transplant]. / Een man met kortademigheid na niertransplantatie.

We present a 62-year-old man with a kidney transplant in the past. Because of progressive dyspnoea a CT-scan was made, which showed ground glass in the upper fields with calcifications. He was diagnosed with metastatic pulmonary calcification, which is mostly seen in patient with renal failure and secondary hyperparathyroidism.

Comparative Survival among Older Adults with Advanced Kidney Disease Managed Conservatively Versus with Dialysis.

BACKGROUND AND OBJECTIVES: Outcomes of older patients with ESRD undergoing RRT or conservative management (CM) are uncertain. Adequate survival data, specifically of older patients, are needed for proper counseling. We compared survival of older renal patients choosing either CM or RRT. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: A retrospective survival analysis was performed of a single-center cohort in a nonacademic teaching hospital in The Netherlands from 2004 to 2014. Patients with ESRD ages ≥70 years old at the time that they opted for CM or RRT were included. Patients with acute on chronic renal failure needing immediate start of dialysis were excluded. RESULTS: In total, 107 patients chose CM, and 204 chose RRT. Patients choosing CM were older (mean±SD: 83±4.5 versus 76±4.4 years; P<0.001). The Davies comorbidity scores did not differ significantly between both groups. Median survival of those choosing RRT was higher than those choosing CM from time of modality choice (median; 75th to 25th percentiles: 3.1, 1.5-6.9 versus 1.5, 0.7-3.0 years; log-rank test: P<0.001) and all other starting points (P<0.001 in all patients). However, the survival advantage of patients choosing RRT was no longer observed in patients ages ≥80 years old (median; 75th to 25th percentiles: 2.1, 1.5-3.4 versus 1.4, 0.7-3.0 years; log-rank test: P=0.08). The survival advantage was also substantially reduced in patients ages ≥70 years old with Davies comorbidity scores of ≥3, particularly with cardiovascular comorbidity, although the RRT group maintained its survival advantage at the 5% significance level (median; 75th to 25th percentiles: 1.8, 0.7-4.1 versus 1.0, 0.6-1.4 years; log-rank test: P=0.02). CONCLUSIONS: In this single-center observational study, there was no statistically significant survival advantage among patients ages ≥80 years old choosing RRT over CM. Comorbidity was associated with a lower survival advantage. This provides important information for decision making in older patients with ESRD. CM could be a reasonable alternative to RRT in selected patients.

Dutch guideline for the management of electrolyte disorders--2012 revision.

Electrolyte disorders are common and often challenging in terms of differential diagnosis and appropriate treatment. To facilitate this, the first Dutch guideline was developed in 2005, which focused on hypernatraemia, hyponatraemia, hyperkalaemia, and hypokalaemia. This guideline was recently revised. Here, we summarise the key points of the revised guideline, including the major complications of each electrolyte disorder, differential diagnosis and recommended treatment. In addition to summarising the guideline, the aim of this review is also to provide a practical guide for the clinician and to harmonise the management of these disorders based on available evidence and physiological principles.

Binary ultrasonography for the internist: yes or no, that's the question!

The authors discuss the pros and cons with regard to ultrasound for the internist. They state that ultrasonography is seldom used by internists and they suggest several reasons for this. After a brief review of the literature they conclude that using ultrasound would probably benefit patients and would lead to a more rapid diagnosis and an increase in safety while performing invasive diagnostic and therapeutic interventions. The authors suggest that internists use ultrasound in a different way compared with radiologists, cardiologists, etc. They introduce the term binary ultrasound: ultrasound should be used to answer clinical questions with a yes or a no.

Extremely high serum ferritin levels as diagnostic tool in adult-onset Still's disease.

The diagnosis of adult-onset Still's disease (ASD) is difficult to establish due to the nonspecific clinical and laboratory findings. A markedly raised serum ferritin level is a typical finding, although it is not well understood why ferritin levels are extremely high in ASD. We discuss several possible explanations leading to the extremely high levels of ferritin.

Catheter replacement in continuous arteriovenous hemodiafiltration: the balance between infectious and mechanical complications.

OBJECTIVE: To assess the optimal moment of central vascular catheter replacement balancing infectious and mechanical complications in continuous renal replacement therapies in critically ill patients with acute renal failure. METHODS: Prospective sequential trial with historical controls to compare liberal catheter replacement when clinically indicated with routine catheter replacement every 5 days in consecutive patients treated by continuous arteriovenous hemodiafiltration in a level I secondary referral intensive care unit of a university-affiliated teaching hospital. Intention-to-treat analysis. MEASUREMENTS AND MAIN RESULTS: Twenty-two patients underwent catheter replacement when clinically indicated (group II), and 21 patients served as historical controls (group I). The groups were comparable for sex, age, Acute Physiology and Chronic Health Evaluation II scores, comorbidity, and creatinin and urea levels at the start of continuous arteriovenous hemodiafiltration. In group I, 71 catheters were used for 346 treatment days, and in group II, 68 catheters were used for 495 treatment days. The mean duration of catheterization was 4.9 +/- 2.0 days vs. 7.3 +/- 4.5 days, respectively (Student's t-test p <.001). There was no significant difference between the incidence of colonization of catheters (46.8% in group I vs. 39.1% in group II; chi-square p =.35) In group I, bacteremia and catheter sepsis occurred in two patients, whereas this did not occur in group II. The occurrence of mechanical complications was comparable in both groups (15.5% in group I vs. 19.1% in group II). There were significantly more mechanical complications with arterial vs. venous catheters (17 vs. 7; chi-square p =.027). CONCLUSION: When catheters were changed as clinically indicated, they remained significantly longer in situ vs. being replaced routinely every 5 days; infectious and mechanical complications were comparable. The incidence of catheter sepsis was low (2.2%), and no prosthesis infection occurred. Catheter replacement when clinically indicated seems to be as safe as routine replacement every 5 days.

The impact of equations on calculation of lean body mass by bioelectrical impedance analysis in RDT patients.

Several equations are available to derive lean body mass (LBM) from bioelectrical impedance analysis (BIA). The purpose of this study was to investigate in dialysis patients the impact of the equation used on the outcome of LBM assessment. To avoid dyshydration as a confounder, vena cava diameter measurement was used to assess normohydration in the 21 patients studied. Five equations were compared. In a previously published study to assess total body water using antipyrine as a gold standard, Deurenberg's formula was advocated to be used in the estimation of LBM by BIA. Therefore, this formula was used as a basis for comparison with the other four equations. One equation gave results comparable to those obtained by Deurenberg's formula. Despite high correlations and agreement according to Bland and Altman analysis, the other three equations showed a significant difference with Deurenberg-derived LBM. Thus, the equation used has a major impact on the outcome of LBM estimations.

[Acute tumor lysis syndrome due to mono-therapy with a corticosteroid in a patient with non-Hodgkin lymphoma]. / Acuut tumorlysissyndroom door monotherapie met een corticosteroïd bij een patiënt met non-Hodgkin-lymfoom.

A 20-year-old man was hospitalised because he nearly suffocated when lying on his back. After bronchoscopy which revealed severe external compression of the airways, suddenly respiratory insufficiency developed. Because a malignant lymphoma was suspected chemotherapy was started, using monotherapy with prednisolone as the risk of acute tumour lysis syndrome (ATLS) is high with polychemotherapy of bulky tumours. Nevertheless ATLS developed, for which haemodialysis had to be applied. The tumour, a T-cell lymphoblastic non-Hodgkin lymphoma with high grade malignancy, was treated successfully with cyclophosphamide, doxorubicin, vincristine en prednisone. ATLS is characterized by hyperkalaemia, hyperuricaemia, hyperphosphataemia, hypocalcaemia, lactate acidosis and acute renal failure. It can occur in the course of aggressive cytoreductive therapy in rapidly growing lymphoproliferative malignancies with large tumour size, due to massive tumour cel lysis. Corticosteroid monotherapy is a very rare cause of ATLS.

Cefepime compared with ceftazidime as initial therapy for serious bacterial infections and sepsis syndrome.

In an open randomized multicenter comparative study, we evaluated the safety and efficacy of cefepime (CP; 2.0 g given intravenously every 12 h) and ceftazidime (CZ; 2.0 g given intravenously every 8 h) as initial treatment for adult patients with suspected serious bacterial infections. A total of 133 patients entered the study, of whom 114 were evaluable for clinical and microbiological response assessment: 56 received CP and 58 received CZ. About 50% (30 who received CP and 25 who received CZ) fulfilled the criteria of the sepsis syndrome. The treatment groups were comparable with respect to sex distribution, mean age, underlying diseases, treatment duration, APACHE II score, and type of infection. The most commonly cultured microorganisms were members of the family Enterobacteriaceae, Streptococcus pneumoniae, and Staphylococcus aureus. The causative microorganisms were eradicated from 92% (37 of 40) of patients with a microbiologically documented infection who underwent treatment with CP; they were eradicated from 86% (42 to 49) of patients who received CZ. The responses of only clinically documented infections in the CP group were 90% (27 of 30 patients); in the CZ group they were 87% (26 of 30 patients). When patients fulfilled the criteria of the sepsis syndrome (septic shock excluded), the causative microorganisms were eradicated from 89% (16 of 18) of CP-treated patients and 86% (12 of 14) of CZ-treated patients. None of these differences was statistically significant. Mortality was the same in both groups (four patients in each group) and was not attributable to the study medication. In conclusion, CP is at least as effective and as safe as CZ, as initial antimicrobial therapy for suspected serious bacterial infections in nonneutropenic patients with or without the sepsis syndrome. CP has the additional advantage in that it can be given twice daily, which may lead to a decrease in hospital costs.

The importance of plasma protein for blood volume and blood pressure homeostasis.

To evaluate the influence of plasma protein concentration and colloid osmotic pressure (COP) on blood volume and blood pressure, we studied 40 patients with the nephrotic syndrome (plasma protein 41.1 +/- 5.3 g/liter, COP 10.9 +/- 2.2 mm Hg) and 43 patients with chronic renal failure (plasma protein 65.0 +/- 5.8 g/liter, COP 22.4 +/- 3.0 mm Hg) at overhydration, during gradual edema removal to normal hydration, and occasionally, to mild dehydration. The number of measure points was 113 in the nephrotic syndrome and 92 in renal failure. In both groups blood volume was normal at normal extracellular fluid volume (ECFV). Elevation of ECFV to 300% of normal in the nephrotic syndrome occurred with only a modest elevation of blood volume (NS). Elevation of ECFV to 200% of normal in the patients with renal failure was attended by a major elevation of blood volume (P less than 0.01). Reduction of ECFV to about 10% below normal was accompanied by parallel blood volume reduction in both groups. Blood pressure was comparable at normohydration, and increased to clearly hypertensive levels only in the renal failure group with increasing ECFV and blood volume (P less than 0.01). No major blood pressure difference was observed between normal and subnormal hydration, but hypotension was observed twice in the nephrotic group. Apparently, patients with severe hypoproteinemia due to the nephrotic syndrome are generally able to preserve their blood volume even when free of edema. However, their blood volume is not elevated in overhydration, in contrast to patients with renal failure who are normoproteinemic. This difference in regulation of extracellular fluid distribution is probably related to the hypoproteinemia, and its effect to reduce tissue-fluid protein.

Effect of changes in posture on circulatory homeostasis in patients with the nephrotic syndrome.

To assess whether the upright posture causes circulatory hypovolaemia in patients with the nephrotic syndrome (NS), we studied 12 subjects with NS and 12 healthy subjects during recumbency, 110 min of standing, followed again by recumbency. Control blood-pressure was 134/88 +/- 4/3 mmHg in the patients and 113/75 +/- 2/3 mmHg in the normal subjects (P less than 0.01), and remained higher in the patients throughout the procedure. Heart rate was continuously higher in the patients (P less than 0.05), but acceleration on standing was normal. The blood volume, which was not different during recumbency, had fallen below that in normal subjects after 25 min of standing (P less than 0.05), due to excessive plasma volume reduction (-16.8 +/- 0.8% in the patients against -11.7 +/- 1.2% in the normals, P less than 0.02). Plasma renin activity (PRA) was higher in the patients while recumbent (P less than 0.001) but not during standing, due to a blunted response in some. No significant differences in plasma noradrenaline were found, but four patients reacted with an excessive rise in plasma noradrenaline and heart rate. This subset, which had high PRA levels as well, comprised the only subject who experienced orthostatic hypotension. It is concluded that during standing an excessive drop in plasma volume leads to a lowered blood volume in NS patients. This forms a paradox with the heart rate acceleration and noradrenaline levels, which were mostly normal, and with the blood-pressure, which remained slightly elevated. Even in a few patients with enhanced stimulation of heart rate and noradrenaline, blood-pressure was found to be high in the majority of cases. PRA was usually found to be increased but, in part, independent of posture.

Lowered tissue-fluid oncotic pressure protects the blood volume in the nephrotic syndrome.

We have studied the role of adjustments of tissue-fluid colloid osmotic pressure (COP) in the maintenance of the blood volume in 10 patients with the nephrotic syndrome before and after diuretic treatment until dry weight. A mean weight reduction of 13.5 +/- 6.4 kg was attended by a fall in blood volume in 3 patients and no change in 6, but the final blood volume was within the normal range: 84.3 +/- 3.7 ml/kg (normal value: 87.6 +/- 8.8 ml/kg). Albumin content and COP of tissue-fluid, obtained with subcutaneous wicks, were low before edema removal and rose slightly after it, parallel to changes in the plasma. Thus, the transcapillary gradient in COP did not change: 6.5 +/- 1.5 mm Hg before and 6.2 +/- 1.7 mm Hg after diuretic treatment. Considering the low COP, 8.6 +/- 1.6 mm Hg in edematous and 11.7 +/- 3.7 mm Hg in dry conditions, this gradient was only slightly below the value of about 10 mm Hg normally found with this technique. We conclude that a lowered tissue-fluid COP is important for the preservation of blood volume in dry patients with the nephrotic syndrome. In addition, this adaptation can explain why the blood volume is often normal and not expanded despite the sometimes huge overhydration in these patients.

Preservation of blood volume during edema removal in nephrotic subjects.

During the gradual removal of edema with diuretics in 21 edematous patients with the nephrotic syndrome (NS) we monitored blood volume. For comparison, nine healthy subjects were studied after equilibration on diets containing 20, 200, and 1138 mEq sodium. The initial extracellular fluid volume (ECFV) in the patients exceeded the final ECFV by 63.4 +/- 8.4%. In 10 patients with a very low plasma oncotic pressure (8.2 +/- 0.4 mm Hg, Group 1), the blood volume changed little. In Group 2 (plasma oncotic pressure 13.4 +/- 1.0 mm Hg), it was 11.0 +/- 2.5% higher at entry than after edema withdrawal. In the normal volunteers, the highest sodium intake raised the ECFV by 21.4 +/- 4.1%. The accompanying rise in blood volume, 11.2 +/- 3.0%, was larger than in the patients of Group 1 (2.4 +/- 1.9%, P less than 0.04), but not of Group 2 (8.1 +/- 1.9%, NS) at similar degrees of expansion. There was no difference in blood volume between the edema-free patients and the normal subjects at low-sodium diet. The course of blood pressure and creatinine clearance during edema removal gave no evidence that functional hypovolemia was induced, but the plasma renin activity was higher than in the normal subjects at similar degrees of expansion. We conclude that the blood volume to ECFV relationship curve is flattened in the presence of hypoalbuminemia. Thus, the increase in blood volume that normally follows ECFV expansion is less in patients with the NS, but a drop below normal upon removal of edema is absent also.

Lowered protein content of tissue fluid in patients with the nephrotic syndrome: observations during disease and recovery.

To find out why most patients with the nephrotic syndrome maintain a normal blood volume despite a reduced plasma colloid osmotic pressure (COP), we measured the transcapillary (plasma-tissue fluid) COP difference in 12 patients with the nephrotic syndrome, as well as in 6 patients during complete (n = 3) and partial (n = 3) recovery. Subcutaneous nylon wicks were used to collect tissue fluid. The albumin content was also measured. The albumin content and COP were lowered in both plasma and tissue fluid in the nephrotic phase, and rose gradually during recovery. During these changes the transcapillary COP difference only rose slightly: from 6.2 +/- 1.7 mm Hg when the plasma COP was below 10 mm Hg (n = 11) to 8.7 +/- 1.5 mm Hg when the plasma COP exceeded 20 mm Hg (n = 12). These observations indicate that in hypoproteinemia preservation of the intravascular volume is strongly dependent on maintenance of the difference in oncotic pressure across the capillary wall.

Plasma volume recovery after ultrafiltration in patients with chronic renal failure.

We studied the effect of standardized ultrafiltration (UF, 2 liters in 60 min) on plasma volume (PV, 131I-albumin space) and its recovery, with special reference to the tissue hydration before UF. Twenty-one UF sessions were performed in 15 patients with endstage renal failure. The PV reduction, which varied considerably, was maximal at the end of UF (range, -0.7 to -21.9%); after that PV recovered reaching a plateau in the second hour after UF. A highly significant negative correlation was found between the interstitial fluid volume (IVF, calculated from 82Br space-PV) and the PV reduction at this stage (r = -0.89, P less than 0.0001). Despite avoidance of major changes in total extracellular fluid in the next 24 hr, a further restoration of PV took place which was partial in subjects with normal tissue hydration, but complete or even excessive in grossly overfilled subjects. This PV repletion was accompanied by an increase in the intravascular mass of albumin (P less than 0.02). The negative correlation between initial IFV and PV change persisted after 24 hr (r = -0.83, P less than 0.0005). In most occasions the blood pressure fell, but only in eight occasions frank hypotension followed. Heart rate remained remarkably unaltered, even during hypotensive episodes. Changes in plasma renin activity followed no uniform pattern. Our findings indicate that the tissue hydration state has a strong influence on changes in PV during fluid removal and the subsequent repletion of PV.