Is there a role for Chlamydia pneumoniae in hemodialysis vascular access thrombosis?

Significant evidence suggests that Chlamydia pneumoniae has a major role in occlusive vascular disease. Vascular access thrombosis in chronic hemodialysis patients is a frequent problem; the underlying pathological state is stenosis caused by endothelial hyperplasia. There is presently no literature concerning C pneumoniae in vascular access thrombosis. We embarked on a study to evaluate the possible role of C pneumoniae in access failure. Ten consecutive patients with thrombosed polytetrafluoroethylene (PTFE) conduit arteriovenous fistulae undergoing surgical thrombectomy and revision were studied. We sought to detect C pneumoniae using both culture and polymerase chain reaction (PCR) methods. An excisional biopsy of the stenotic vein segment just above the anastomosis with the PTFE graft was obtained at surgery. Vein samples weighing at least 30 mg were aseptically placed in transport media and stored at 4 degrees C for up to 24 hours. The samples then were sonicated, inoculated in Hep-2 cell culture vials containing confluent monolayers, and passaged three times over 2 weeks. Detection was by direct fluorescent antibody staining. Both culture and PCR were performed in an active chlamydia research laboratory. None of the 10 samples was positive for C pneumoniae by culture or PCR. Based on our preliminary pilot study, we do not believe C pneumoniae has a major role in endothelial hyperplasia and consequent graft loss in the hemodialysis patients we studied.

A pharmacodynamic study of clopidogrel in chronic hemodialysis patients.

Combination antiplatelet agents, particularly aspirin and ticlopidine, have found increased use in the prevention of arterial thrombosis. Clopidogrel, a thienopyridine derivative, like ticlopidine was recently approved by the U.S. Food and Drug Administration (FDA) for the reduction of ischemic events in patients with myocardial infarction, stroke, or peripheral arterial disease and appears to have much less hematologic toxicity than ticlopidine has. Thrombosis of hemodialysis access grafts is a major cause of morbidity in this patient population. Combination antiplatelet agents may be particularly useful in the prevention of hemodialysis access graft thrombosis. In preparation for such a study, we have performed a pharmacodynamic study of the platelet inhibitory effects of clopidogrel in patients on maintenance hemodialysis. Nine chronic hemodialysis patients were studied. Baseline platelet aggregation studies were performed, after which the subjects were begun on clopidogrel 75 mg daily. Platelet aggregation studies were repeated after 14 days of therapy. Drug was stopped and a final set of platelet aggregation studies were performed 7 days later. Because clopidogrel acts by inhibiting adenosine diphosphate (ADP)-induced platelet aggregation, we used ADP as the agonist in the platelet aggregation studies. We also measured the time required to achieve hemostasis after removing the dialysis needles at the termination of a dialysis session. Patients were carefully monitored for any adverse reaction to clopidogrel. Fourteen days' treatment with clopidogrel inhibited ADP-induced platelet aggregation from 48 to 23% with ADP 2 microM (P=0.0113), from 59 to 38% with ADP 5 microM (P=0. 0166), and from 66 to 44% with ADP 10 microM (P=0. 0172). This inhibition of platelet aggregation was reversed 7 days after stopping clopidogrel. Clopidogrel administration did not affect the time required to achieve hemostasis after removal of the dialysis needles. No adverse reactions were noted. No patient had evidence of bleeding, rash or gastro-intestinal (GI) upset. Clopidogrel inhibits ADP-induced platelet aggregation in subjects receiving chronic maintenance hemodialysis. The magnitude of inhibition is similar to that reported in nonuremic subjects with atherosclerosis. This inhibition is reversible within 7 days of discontinuing the drug. No adverse reactions to the drug were noted in this short-term (14-day) trial.

A review of the effects of correction of acidosis on nutrition in dialysis patients.

Metabolic acidosis is a condition that is commonly encountered in both chronic renal failure (CRF) and in end-stage renal disease (ESRD). Known complications and surmised consequences associated with the acidosis of renal disease include bone lesions, depression of myocardial contractility, and growth retardation. Conversely the correction of acidosis in children with renal tubular acidosis improves growth velocity. This is also the case in children with CRF. The conclusion drawn from this study was that the correction of metabolic acidosis improved serum albumin concentrations in patients on hemodialysis and that this correction also induced a decrease in the nPCR.

Hypothermia-induced hypokalemia.

Hypothermia may be seen both as a presenting problem and as a part of therapeutic strategy. An illustrative case is presented. In our case of severe head trauma, hypothermia was used as a therapeutic modality to minimize the brain injury. While hypothermic, the patient developed severe hypokalemia and was supplemented with 400 mEq of potassium. Upon rewarming, severe hyperkalemia occurred with resultant fatal arrhythmias. Severe hypokalemia may be seen in hypothermic patients, which represents a shift of potassium rather than a true loss. Careful management of this electrolyte problem must be given to avoid hyperkalemia with rewarming.

Vancomycin-resistant enterococcus in end-stage renal disease.

The percentage of nosocomial vancomycin-resistant enterococci (VRE) has been increasing rapidly in the United States. This has recently resulted in recommendations to reserve vancomycin use for cases with proven resistance to other antimicrobials. We prospectively investigated the incidence of VRE in our dialysis population and compared it with a control group of 40 clinic patients with chronic renal insufficiency (CRI) who had a serum creatinine level greater than 1.5 mg/dL, but were not undergoing dialysis. The incidence of VRE on our campus is almost 10%, which is similar to US data. We studied 50 chronic hemodialysis (HD) patients and 50 peritoneal dialysis (PD) patients. Each patient had a rectal swab test performed and cultured for the presence of enterococci. Antimicrobial exposures over the 6 months before the initial swab test were reviewed in each patient. At least one repeated swab test was performed in 30 CRI, 45 HD, and 37 PD patients. From the initial swab culture, vancomycin-sensitive enterococci (VSE) were isolated in 65% of CRI, 54% of HD, and 70% of PD patients. No CRI or HD patients had VRE isolated and 2% (1 of 50) of PD patients had VRE isolated. The remaining patients had no enterococci isolated. Review of antimicrobial exposures in the 6 months before the initial swab test showed 0% of CRI, 32% of HD, and 36% of PD patients received vancomycin. Other antimicrobials were administered to 40% of CRI, 46% of HD, and 78% of PD patients in the same time period. In the month immediately preceding the initial swab test, 0% of CRI, 12% of HD, and 22% of PD patients received vancomycin and 18% of CRI, 20% of HD, and 36% of PD patients received other antimicrobials. Results from repeated cultures showed that 57% of CRI, 40% of HD, and 38% of PD patients changed their culture status related to VSE, VRE, or no enterococci present. Cultures of 342 swabs from 140 patients yielded three VRE isolates in two patients. We conclude that despite the frequent use of vancomycin and other antimicrobials, the incidence of VRE in our renal population is less than the reported incidence. Given this lack of VRE isolates, we recommend the continued judicious use of vancomycin in treating renal patients and continued enterococcal sensitivity surveillance.

Correction of metabolic acidosis and its effect on albumin in chronic hemodialysis patients.

Serum albumin concentration has been strongly associated with risk of death in hemodialysis patients, with mortality increasing as albumin decreases. Metabolic acidosis stimulates protein catabolism and decreases protein synthesis. A study was undertaken to investigate the effect of increasing predialysis serum bicarbonate (HCO3) concentrations on the nutrition of hemodialysis patients as measured by albumin and total lymphocyte count (TLC). Metabolic acidosis was defined as a predialysis serum bicarbonate concentration of < or = 18 mEq/L. Thirty-six hemodialysis patients were enrolled in the study. Each had been stable on hemodialysis for > or = 3 months and each had a mean serum bicarbonate concentration of < or = 18 mEq/L on predialysis monthly laboratory values during the preceding 3 months. The subjects were randomized into 2 groups. The first group consisted of 18 control subjects who were dialyzed on a standard bicarbonate bath of 35 mEq/L. The second group consisted of 18 experimental patients who were dialyzed on a bicarbonate bath of 40 mEq/L. Subjects in the experimental group who had predialysis serum bicarbonate concentrations less than 22 mEq/L after 2 weeks on the higher bicarbonate bath were additionally supplemented with oral sodium bicarbonate at a dosage of 1 mEq/kg dry weight/d. Monthly predialysis laboratory values were checked for all subjects and included serum electrolytes, blood urea nitrogen, calcium, and albumin. TLCs were obtained at the initiation and at the conclusion of the study. Intact parathyroid hormone, blood pressures, and interdialytic weight gains were also followed. The study lasted 16 weeks; 32 subjects completed the study (16 in each group). There were no statistically significant differences between the two groups at the initiation of the study. The serum bicarbonate concentrations were significantly different between the two groups at the end of the study (control HCO3 17.3 +/- 3.2 mEq/L v experimental HCO3 20.2 +/- 2.9 mEq/L; P = 0.01). Serum albumin concentrations and TLCs were not statistically different (P > 0.05) between the two groups at the end of the study (control albumin 3.88 +/- 0.28 g/dL v experimental albumin 3.76 +/- 0.26 g/dL and control TLC 1,780.0 +/- 779.4/mm3 v experimental TLC 2,020.1 +/- 888.0/mm3). Potassium, intact parathyroid hormone, interdialytic weight gain, blood pressures, Kt/Vs, and protein catabolic rates did not differ. We found that the change in serum bicarbonate concentration was well-tolerated and was without any demonstrable side effects. We conclude that increasing the serum bicarbonate concentration by 3 mEq/L for 16 weeks has no effect on the indicators of nutrition that we measured (serum albumin and TLC).

The effect of needle gauge on recirculation, venous pressure and bleeding from puncture sites.

We performed a prospective, randomized study of various needle gauges and the effect on recirculation, venous pressure, and puncture site bleeding. All patients (n = 21) in our unit consented and participated. We studied 14, 15, 16, and 17 gauge needles, 2.5 cm in length with a "backeye" conformation. Each of the four needle gauges were studied twice in a randomized order. Needle were placed with the arterial needle pointed toward the arterial anastomosis and the venous needle pointed toward the venous anastomosis. The arterial and venous needles were placed at least 6 cm apart. Venous pressure and bleeding from puncture sites were recorded and analyzed in relation to needle gauge. Recirculation was calculated using the 3 needle technique. Blood pump flow rates (QBS) of 200 and 500 cc/min were studied with each needle gauge during the first 0.5 hour of dialysis. Data were analyzed using MANOVA and chi square. Recirculation at a QB of 200 cc/min was similar for all needle gauges (13-15%). At a QB of 500 cc/min the recirculation was 19% for the 17 gauge needles and 27% for the 14 gauge needles (p < 0.01). Venous pressure increased with decreasing needle size: 83 mmHg at QB 200 cc/min for 14 gauge needles, 147 mmHg at QB 200 cc/min for 17 gauge needles, and 204 mmHg and 382 mmHg respectively for QB 500 cc/min with needle gauges of 14 and 17. Bleeding occurred with 15 gauge needles on two occasions and four times with 14 gauge needles. There were no bleeding episodes with 16 or 17 gauge needles (p < 0.03). In conclusion, recirculation is greater with larger gauge needles at QB 500 cc/min. Bleeding is related to larger gauge needles. Hence, smaller gauge needles (17 gauge) appear move advantageous than larger gauge needles.

Renal hypouricemia: prevention of exercise-induced acute renal failure and a review of the literature.

Isolated renal hypouricemia from defective uric acid reabsorption and/or secretion is a well-described entity, with a prevalence of 0.12% to 0.20% in Japan. It is rarely associated with exercise-induced acute renal failure (ARF). The etiology of ARF is debated. Prevention of ARF in renal hypouricemia has not been previously addressed. A 29-year-old Pakistani man had recurrent exercise-induced ARF. He was found to have isolated renal hypouricemia; serum uric acid 0.5 mg/dL, 24-hour urine uric acid 472 +/- 25 mg (+/- SD), and fractional excretion of uric acid 55.2% to 69.4%. Both pyrazinamide and probenecid decreased fractional excretion of uric acid and uric acid excretion rate (UV(Urate)) in our patient, suggesting either a partial presecretory and postsecretory reabsorption defect or increased secretion. We investigated renal uric acid excretion during exercise in our patient and four control subjects. All five subjects underwent a physical fitness test (PFT). Our patient developed ARF. Uric acid excretion rate increased in our patient, from 0.48 mg/min at baseline to 1.49 mg/min 4 hours after the PFT, as did the urine uric acid to urine creatinine ratio (UUa)/UCr) (0.29 to 1.49). In the controls, UV(Urate) and UUA/UCr were unchanged after the PFT: UV(Urate) was 0.46 +/- 0.10 mg/min at baseline and 0.59 +/- 0.04 mg/min 4 hours after the PFT, while UUA/UCr was 0.30 +/- 0.04 at baseline and 0.36 +/- 0.04 at 4 hours. All five subjects took allopurinol 300 mg daily for 5 days and repeated the PFT. In our patient, allopurinol prevented the ARF as well as the exercise-induced increases in UV(Urate) (0.28 mg/min to 0.22 mg/min) and UUA/UCr (0.25 to 0.17). In the controls, the UV(Urate) and UUA/UCr responses to exercise were not altered. We conclude that increased renal excretion of uric acid during exercise was responsible for the ARF in our patient with renal hypouricemia and that successful prophylaxis with allopurinol is possible.

Pneumoperitoneum in peritoneal dialysis patients.

There has been recent controversy regarding the clinical significance of pneumoperitoneum in patients undergoing peritoneal dialysis. The incidence of pneumoperitoneum has been estimated to be 21.2% to 33.7% in prior studies of peritoneal dialysis patients. Of the peritoneal dialysis patients with pneumoperitoneum, only a small percentage (5.9% to 14.3%) had documented visceral perforations. The controversy arises in that anywhere from 20% to 100% of peritoneal dialysis patients with pneumoperitoneum and peritonitis had visceral perforation, and 32.4% to 57.1% of chronic ambulatory peritoneal dialysis patients had asymptomatic pneumoperitoneum of unknown etiology. These disparate incidences made clinical interpretation of pneumoperitoneum difficult. In addition, prior study result disagreed as to the usefulness of the extent of pneumoperitoneum in predicting visceral perforation. We retrospectively reviewed 694 chest x-ray film and acute abdominal series reports from 1982 to 1993 in 75 peritoneal dialysis patients, with 9.3 +/- 1.3 (mean +/- SEM) x-ray films per patient. The reports were confirmed by reviewing 363 x-ray films (52%). Eight patients (10.7%) had 10 episodes of pneumoperitoneum. Six of these eight patients had asymptomatic pneumoperitoneum from a known etiology: four had undergone abdominal surgery for catheter placement the prior week and two had catheter manipulation immediately preceding the x-ray. One patient had three episodes of pneumoperitoneum: one after catheter placement and two not associated with a known etiology for pneumoperitoneum while on the cycler. One patient had a surgically confirmed colonic perforation with a large pneumoperitoneum and peritonitis.(ABSTRACT TRUNCATED AT 250 WORDS)

Variable blood pump flow rates and the effect on recirculation.

There has been a movement in the dialysis community towards higher blood pump flow rates (QB) during dialysis. However, the effects of increased QB on recirculation and consequently the impact on clearances have not been well quantified for clinically relevant QBS. We studied the effect of QB on recirculation in 16 patients in a prospective fashion. Blood pump speeds of 200, 250, 300, 350, 400, 450, and 500 cc/min were studied in a randomized order. For QBS of 350 cc/min and greater, 14-gauge needles were used; at lower QBS, 16-gauge needles were used. The needles were positioned at least 5 cm apart. Recirculation studies were done after stabilization of QB during the first 15 minutes of dialysis with a dialysate temperature of 37 degrees C and minimal transmembrane pressure. Recirculation was calculated using the three-needle technique. All patients had an angiogram performed upon completion of the study. Effective clearances were calculated to demonstrate the effect of QB on Recirculation rates increased with increased QB (r = 0.43). Recirculation was 12.1% +/- 1.2 (Mean +/- SEM) at a QB of 200 cc/min versus 23.8% +/- 3.0 at a QB of 500 cc/min (p < 0.05). Venous pressures increased with increasing QBS, 120.0 mmHg +/- 7.3 at a QB of 200 cc/min to 204.2 mmHg +/- 9.1 at a QB of 500 cc/min. Bleeding from needle puncture sites only occurred with use of the 14-gauge needles (p = 0.02). Effective dialyzer urea and B12 clearances for six different dialyzers increased at a considerably lower rate beyond a QB of 300 cc/min.(ABSTRACT TRUNCATED AT 250 WORDS)

Ultrastructural immunolabeling: a unique diagnostic tool in monoclonal light chain-related renal diseases.

Ultrastructural labeling can play a key role in the evaluation of morphologic expressions of monoclonal light chain-related renal diseases in cases where light microscopy, electron microscopy, and immunofluorescence data, even when combined, are not definitive in conveying a diagnosis and, in other cases, in clarifying the findings by providing immunomorphologic correlation. The important role of ultrastructural labeling is highlighted by the fact that in some of these cases bone marrow aspirates and biopsy specimens obtained at the time of the evaluation of the renal specimens are often unable to establish unequivocally a diagnosis of plasma cell dyscrasia. This is in part because renal manifestations commonly precede overt diagnostic bone marrow alterations. Overt bone marrow findings and clinical manifestations may be preceded for as long as 16 years by the renal manifestations. Determination or confirmation of monoclonality and detection of early deposition of monotypical light chains before the finding of ultrastructural morphologic correlates (ie, subendothelial, punctate, granular, electron-dense material) represent unique attributes of this technique. The increased sensitivity of ultrastructural immunolabeling compared with other available diagnostic techniques and its exquisite immunomorphologic correlative capabilities result in a comprehensive evaluation. Sixteen monoclonal light chain-related renal disease cases with early, unusual, or equivocal immunomorphologic manifestations that may have not been characterized properly if ultrastructural labeling had not been performed are presented. The crucial role played by ultrastructural labeling in evaluating these cases and establishing an accurate diagnosis is illustrated and emphasized.

The significance of hematuria in the anticoagulated patient.

BACKGROUND: There have been many case reports of substantial renal disease in association with anticoagulation, yet the intensity of anticoagulation has changed over the years. In 1986, the American College of Chest Physicians and the Heart, Lung, and Blood Institute recommended a decrease in anticoagulation intensity. In addition, a variety of new methods to investigate hematuria have evolved, including computed tomography and red blood cell morphologic analysis. Because of these developments, we initiated a prospective study to evaluate the relationship between anticoagulation, microscopic hematuria, and major genitourinary tract disease. METHODS: To determine the incidence, prevalence, and cause of microscopic hematuria, patients receiving long-term anticoagulation therapy and controls not receiving such therapy were monitored with monthly urinalyses in a 2-year prospective study. Patients who developed hematuria were further studied for genitourinary tract disease. The incidence of hematuria was analyzed with regard to relative levels of anticoagulation. RESULTS: The incidence of hematuria in the anticoagulated and control groups was 0.05 and 0.08 per 100 patient-months, respectively. The prevalence of hematuria was 3.2% in the anticoagulated group and 4.8% in the control group. Genitourinary tract disease was identified in 81% of patients with more than one episode of microscopic hematuria, and the cause of hematuria did not vary between groups. There was no correlation between the level of anticoagulation and the incidence of hematuria. CONCLUSIONS: Anticoagulation at currently recommended levels does not predispose patients to hematuria. Identifiable genitourinary tract disease is present in the majority of anticoagulated patients with microscopic hematuria.

Special Forces Medical Sergeants (18 Delta) recertification.

Special Forces Medical Sergeants (18 Delta) in the U.S. Army play a key role in delivering medical care in both combat and civil affairs arenas. Given the breadth of skills required and potential decrement of skills with time, recertification is desirable and mandated. However, there are no formal courses for recertification of 75% of the tasks. A course to fill this need is being developed. A general outline of the course is set forth. To date, the course has recertified 18 Deltas in several areas, received favorable evaluations from the students, and been embraced by the Special Forces battalion leadership. Additional benefits include the instructional staff developing a deployment combat perspective for their area of instruction and better integration between active Army and reserves. Thus far, the course has been very successful.

Increased norepinephrine secretion in patients with the nephrotic syndrome and normal glomerular filtration rates: evidence for primary sympathetic activation.

Considerable controversy exists in regard to the state of arterial circulatory integrity in patients with the nephrotic syndrome. Increased sympathetic nervous system activity, along with activation of the renin-angiotensin-aldosterone system and the nonosmotic release of vasopressin, is seen in other states of arterial underfilling. Thus, in the present study, sympathetic nervous system activity was assessed by determining plasma norepinephrine secretion and clearance rates using a whole-body steady-state radionuclide tracer method in 6 edematous patients with the nephrotic syndrome of various parenchymal etiologies and 6 normal control subjects in the supine position. Patients were withdrawn from all medications 7 days prior to study. Mean creatinine clearances and serum creatinine concentrations were normal in both the nephrotic syndrome patients and controls (99 +/- 13 vs. 112 +/- 15 ml/min, p = NS, 1.1 +/- 0.1 vs. 0.8 +/- 0.0 mg/dl, p = 0.03, respectively). However, the nephrotic syndrome patients exhibited significant hypoalbuminemia (2.0 +/- 0.4 vs. 3.8 +/- 0.1 g/dl, p < 0.01). The supine plasma norepinephrine level was elevated in the patients with the nephrotic syndrome as compared with controls (240 +/- 58 vs. 119 +/- 22 pg/ml, p = 0.07). More significantly, the secretion rate of norepinephrine was markedly increased in nephrotic patients (0.30 +/- 0.07 vs. 0.13 +/- 0.02 micrograms/m2/min, p < 0.05), whereas the clearance rate of norepinephrine was similar in the two groups (2.60 +/- 0.29 vs. 2.26 +/- 0.27 l/min, p = NS). Plasma renin activity and plasma aldosterone, arginine vasopressin and atrial natriuretic peptide concentrations were not different in nephrotic syndrome patients compared with controls.(ABSTRACT TRUNCATED AT 250 WORDS)

Exit-site care--is it time for a change?

Peritoneal catheter exit-site infections (ESI's) continue to impact significantly on morbidity and catheter longevity. The controversy concerning protocols for daily exit-site care continues for frequency, methodology, cleansing agent, and dressing. Routine daily exit-site care prior to January 1991 consisted of daily showers using liquid soap, povidone scrub, rinsing the shower, and drying with a 4 x 4-in. gauze pad. Catheters have always been immobilized, either with tape or an immobilizing device. Hydrogen peroxide was used only when needed to soften crust formation prior to showering. A light dressing, usually 2 x 2 in., was optional. A recent survey revealed that povidone iodine was the antiseptic of choice for catheter care in 75% of the respondents. However, povidone iodine irritates and dries the skin predisposing it to infection. ESI's are prospectively monitored as part of our quality improvement (QI) program. An incidence of 0.76 episodes/patient-year was noted between January 1989 and May 1991. Given the relative high frequency of ESI's, the protocol was modified and introduced during the January-May 1991 time frame. Routine care now consists of daily showers using only CC-500, a gentle antibacterial cleaner (Care-Tech Laboratories, Inc.), rinsing in the shower, and drying with a 4 x 4-in. gauze. Use of hydrogen peroxide and dressings has remained the same. Additionally, a protocol addressing the prophylaxis for traumatized exist sites was initiated. The incidence of ESI's has dropped significantly to 0.12 episodes/patient-year. Although our population size is small (n = 18), this study does point out the utility of prospectively monitoring trends for appropriate indicators within a QI program.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of intraperitoneal neostigmine on peritoneal transport characteristics in CAPD.

Lymphatics have been suggested to play a major role in the absorption of dialysate, which consequently affects the adequacy of peritoneal dialysis. Neostigmine has been found to decrease lymphatic absorption in rats, presumably by causing constriction of the lymphatic stomata. We investigated the effect of neostigmine on seven continuous ambulatory peritoneal dialysis (CAPD) patients in a prospective study. We performed modified peritoneal equilibration tests both with and without intraperitoneal neostigmine in a random order. Radiolabeled albumin (0.8 mg) was added to 2 liters of dialysate +/- 2.0 mg neostigmine. We evaluated ultrafiltration and creatinine, phosphate, and urea clearances. The dialysate bag and the peritoneum were scanned at the initiation and conclusion of the four-hour dwell period. We found no change in ultrafiltration, residual volumes, creatinine, phosphate and urea clearances, or albumin recovered. Of the seven patients exposed to neostigmine, four had diarrhea, abdominal cramps, nausea, and vomiting. In conclusion, we found that 2 mg i.p. neostigmine did cause significant side-effects and did not alter transport characteristics in CAPD patients.

Prostatic involvement in Wegener's granulomatosis.

Two cases of Wegener's granulomatosis presenting with prostatic involvement are described and compiled with the five previously detailed cases. Each of these patients presented with obstructive symptoms, proteinuria, leukocyturia, and hematuria. The urinary sediment normalized with treatment of the underlying granulomatous vasculitis. Wegener's granulomatosis is a rare cause of prostatic obstructive symptoms, but should be considered whenever the relatively unusual entity of granulomatous prostatitis is diagnosed. One patient was initially treated exclusively with trimethoprim-sulfamethoxazole (TMP-SMX). He responded, but noted recurrence during the 15th month of treatment. We also report on this patient's antineutrophil cytoplasmic antibody (ANCA) titers, which correlated with clinical assessment and predicted recurrence 2 months before elevation of the Westergren sedimentation rate (WSR) and clinical diagnosis.

Conjugated estrogens reduce endothelial prostacyclin production and fail to reduce postbypass blood loss.

Intravenous conjugated estrogens correct bleeding times and reduce bleeding in uremia, gastrointestinal telangiectasias, and liver disease. One study found a similar benefit in patients undergoing open heart surgery. The mechanism by which conjugated estrogens improve bleeding times is unknown. We report on the effect of estrogens on endothelial prostacyclin production and bleeding in coronary bypass surgery. In a randomized, double-blind trial, 16 male patients undergoing elective coronary artery bypass surgery received four daily infusions of conjugated estrogens (0.6 mg/kg/day) or placebo, preoperatively. Groups were similar with respect to age, preoperative hemostatic profiles, and pump time. Conjugated estrogens significantly reduced greater saphenous vein endothelial prostacyclin production in the estrogen group compared to control subjects. Postoperative blood loss was not reduced, with a trend toward increased blood loss in the treatment group. We have shown that conjugated estrogens reduce endothelial prostacyclin production and fail to reduce blood loss in coronary bypass surgery.