Sugammadex-Induced Anaphylactic Shock Reversed With Short-Term Continuous Veno-Venous Hemodiafiltration: A Case Report.

Anaphylaxis is a life-threatening, systemic, hypersensitivity reaction, manifested by urticaria, hypotension, and respiratory symptoms. Antigens that are cleared renally may have protracted exposure in patients with impaired renal function, resulting in prolonged and refractory anaphylactic shock. After administration of sugammadex, a 47-year-old man developed prolonged, refractory anaphylactic shock, with anuria due to acute kidney injury. The patient was treated with continuous, short-term, veno-venous hemodiafiltration. Initiating this therapy in patients with refractory anaphylactic shock and anuria due to an antigen that is excreted renally can expedite recovery.

Anuric Acute Kidney Injury Requiring Dialysis Following Acetazolamide Use for Cataract Surgery.

BACKGROUND Acetazolamide (ACTZ) is commonly used in the prevention and treatment of various clinical conditions, and anuric acute kidney injury (AKI) is one of its known life-threatening complications. CASE REPORT We hereby report the case of a middle-aged man known to have compensated heart failure and hypertension with previously normal kidney function, who received a total dose of 2250mg of ACTZ over 3 days after cataract surgery. One week after the operation, he presented with anuria and severe bilateral renal colic, as well as progressively worsening kidney function and metabolic profile, which eventually required hemodialysis prior to recovery. CONCLUSIONS The cause of the AKI was attributed to intra-tubular obstruction by ACTZ-induced crystalluria, which required discontinuing the offending agent and dialysis to correct the kidney functions.

[Crystalluria in ethylene glycol intoxication]. / La cristallurie dans l'intoxication à l'éthylène glycol.

When seen, some habits of calcium oxalate monohydrate crystals (whewellite) are so typical of ethylene glycol intoxication that they may be helpful for its diagnosis when circumstances are not clearly established.

Acute renal failure following exposure to metallic mercury.

Mercury exists in three forms: elemental, inorganic, and organic. Each form produces a unique profile of toxicity. Acute poisoning with inorganic salts is well-known, but few reports are available regarding oral elemental (metallic) mercury intoxication. Ingestion of metallic mercury is usually of no concern because of poor gastrointestinal absorption. We report a very rare case of acute renal failure (ARF) following ingestion of metallic mercury. A 67-year old man swallowed an unknown quantity of metallic mercury in a suicide attempt. He developed severe pneumonitis and ARF with anuria. The whole blood mercury concentration was extremely high (157.7 µg/dl). In this case, inhalation of vaporized mercury might have contributed to the significant systemic absorption, but chelating therapy was not performed because of severe renal failure. Hemodialysis was performed 13 times and discontinued 26 days after mercury ingestion. Consequently, the patient recovered normal renal function.

Reversible anuric acute kidney injury secondary to acute renal autoregulatory dysfunction.

Autoregulation of glomerular capillary pressure via regulation of the resistances at the afferent and efferent arterioles plays a critical role in maintaining the glomerular filtration rate over a wide range of mean arterial pressure. Angiotensin II and prostaglandins are among the agents which contribute to autoregulation and drugs which interfere with these agents may have a substantial impact on afferent and efferent arteriolar resistance. We describe a patient who suffered an episode of anuric acute kidney injury following exposure to a nonsteroidal anti-inflammatory agent while on two diuretics, an angiotensin-converting enzyme inhibitor, and an angiotensin receptor blocker. The episode completely resolved and we review some of the mechanisms by which these events may have taken place and suggest the term "acute renal autoregulatory dysfunction" to describe this syndrome.

A case of sodium chlorite toxicity managed with concurrent renal replacement therapy and red cell exchange.

INTRODUCTION: Sodium chlorite is a powerful oxidizing agent with multiple commercial applications. We report the presentation and management of a single case of human toxicity of sodium chlorite. CASE REPORT: A 65-year-old man presented to hospital after accidentally ingesting a small amount of a sodium chlorite solution. His principal manifestations were mild methemoglobinemia, severe oxidative hemolysis, disseminated intravascular coagulation, and anuric acute kidney injury. He was managed with intermittent hemodialysis, followed by continuous venovenous hemofiltration for management of acute kidney injury and in an effort to remove free plasma chlorite. Concurrently, he underwent two red cell exchanges, as well as a plasma exchange, to reduce the burden of red cells affected by chlorite. These interventions resulted in the cessation of hemolysis with stabilization of serum hemoglobin and platelets. The patient survived and subsequently recovered normal renal function. DISCUSSION: This is only the second case of sodium chlorite intoxication reported in the medical literature and the first to report the use of renal replacement therapy in combination with red cell exchange in its management.

Acidosis láctica asociada a metformina: incidencia, diagnóstico, factores pronóstico y tratamiento / Metformin-associated lactic acidosis: incidence, diagnosis, prognostic factors and treatment

Describimos el caso de un paciente con acidosis láctica grave y presentamos algunos datos acerca de su incidencia, diagnóstico, factores pronósticos y tratamiento más adecuado. Un paciente varón de 76 años diabético en tratamiento con metformina, hipertenso, dislipémico y con ligero deterioro cognitivo, ingresó en la Unidad de Cuidados Intensivos en estado de shock circulatorio requiriendo tratamiento agresivo con vasopresores y volumen. El paciente presentaba un daño renal agudo con anuria de 3 días probablemente secundario a la deshidratación por vómitos y a la toma de AINES. A consecuencia del daño renal agudo el paciente padeció una acidosis láctica grave asociada a metformina. Se descartó el resto de causas de acidosis metabólica con anion gap aumentado, así como una posible sepsis o rabdomiolisis. La acidosis láctica asociada a metformina es una condición metabólica poco frecuente pero de alta mortalidad. Para disminuir la mortalidad de estos pacientes, es importante hacer un diagnóstico precoz mediante la historia clínica, la exploración física y la analítica con una rápida reanimación mediante volumen, vasopresores, bicarbonato y técnica de depuración extra-renal(AU)

We describe the case of a patient with severe lactic acidosis, as well as presenting some data on its incidence, diagnosis, prognostic factors, and the most appropriate treatment. A 76 year-old male patient with diabetes on treatment with metformin, hypertension, dyslipaemia, and with mild cognitive impairment, was admitted to the Intensive Care Unit in a state of circulatory shock, requiring aggressive treatment with vasopressors and volume. The patient had acute kidney injury with an anuria of 3 days, probably secondary to dehydration to vomiting and to NSAIDs. As a result of the acute renal damage, the patient suffered a severe metformin-associated lactic acidosis. The rest of the causes of metabolic acidosis with an increased anion gap were ruled out, as well as a possible sepsis or rhabdomyolysis. Metformin-associated lactic acidosis is an uncommon metabolic condition, but with a high mortality. To reduce the mortality of these patients, it is important to make an early diagnosis using the clinical records, physical examination, and laboratory tests, with an early resuscitation with volume, vasopressors, bicarbonate, and renal replacement therapy(AU)

Maternal ingestion of diclofenac leading to renal failure in newborns.

BACKGROUND: The use of non-steroidal anti-inflammatory drugs, such as indomethacin, ibuprofen, and nimesulide, during pregnancy has been reported to cause nephrotoxicity in the fetus. However, neonatal renal failure following antenatal exposure to diclofenac has not been reported in the literature. We report three cases of neonatal renal failure, including a pair of twins, following ingestion of diclofenac by the mother during pregnancy. CASE-DIAGNOSIS/TREATMENT: Cases 1 and 2 involved a pair of twins born to a mother with oligohydramnios. The first twin had nonoliguric renal failure with incomplete recovery at day 17 of life. The second twin developed anuria and hyperkalemia on day 2 of life, for which peritoneal dialysis was initiated. After 20 days of peritoneal dialysis, the second twin remained oligo-anuric, developed peritonitis, and died. Case 3 involved a female infant born to a primigravida with severe oligohydramnios. The baby developed oliguria and renal failure after birth, which was managed conservatively. Creatinine normalized by day 15 of life and remained normal at 1 year of age. Ultrasonography in the first week of life showed that all three infants had normal-sized kidneys. Both mothers had been administered diclofenac during pregnancy. CONCLUSIONS: In utero exposure to diclofenac may be associated with neonatal renal failure that may be transient or irreversible. We recommend that the use of diclofenac during pregnancy be avoided.

Acute hemolysis following iodine tincture ingestion.

Iodine tincture poisoning is uncommon regardless of its widespread use as an antiseptic in daily practice. Previously reported effects of iodine-containing antiseptic poisoning included topical irritation, corrosive effects, allergic response, and hepatic or renal injury, which mainly resulted from complications of topical use during surgical procedures. We herein reported an unusual case of severe hemolysis and acute renal failure following intentional ingestion of iodine tincture containing 60 mg/ml iodine and 40 mg/ml potassium iodide in 70% v/v ethanol. The patient completely recovered 8 weeks later after receiving supportive treatment, plasma exchange, and temporary hemodialysis.

Successful treatment of life-threatening pentoxifylline intoxication by high-flux hemodialysis.

High-flux hemodialysis is the method of choice for the treatment of many life threatening intoxications. Reports on intoxication with pentoxifylline are rare, and although pharmacokinetic properties of the drug suggest a potential role for hemodialysis, there are no published reports on extracorporeal treatment attempts. We report the first case of successful treatment of potentially life-threatening pentoxifylline intoxication by high-flux hemodialysis. Based on this single case, dialysis should be considered, especially in anuric patients with pentoxifylline intoxication.

[Fetopathy associated with exposure to angiotensin converting enzyme inhibitors]. / Fetopatia pelo uso de inibidores da enzima de conversão da angiotensina.

Angiotensin Converting Enzyme Inhibitors (ACEI) are commonly used antihypertensive drugs, although contraindicated during pregnancy by fetopathy association such as renal dysgenesis, oligohydramnios, hipocalvaria, pulmonary hypoplasia, intrauterine growth restriction, and neonatal anuric renal failure. The authors present a clinical report of a child that developed neonatal anuric renal failure with peritoneal dialysis support by an in uterus exposure to ACEI with very good recovery. This case and literature review states the need to avoid ACEI prescription to Young women and it's suspension as soon as possible during pregnancy.

Sevelamer reduces the efficacy of many other drugs.

(1) Sevelamer, a phosphate-binding polymer, is used to treat hyperphosphataemia in patients with chronic renal failure. Pharmacokinetic studies and some clinical reports have shown that sevelamer binds many drugs, including furosemide, ciclosporin and tacrolimus, thus making them less effective; (2) It is best to take sevelamer some time before or after other drugs.

[Acute renal failure after acetaminophen poisoning: report of three cases]. / Insuffisance rénale aiguë lors d'intoxication à l'acétaminophène: à propos de trois cas.

PURPOSE: Management of acetaminophen overdose focuses on the risk hepatic failure. However, acute renal failure, although less frequent, can lead to serious metabolic complications and require hemodialysis. We report three cases of acute renal failure related to acetaminophen overdose. CLINICAL FEATURES: Three patients, aged 17-46 yr ingested acetaminophen 19 to 32 g, and were admitted to the intensive care unit because of acute liver failure without hepatic coma. While liver function improved, each patient developed acute renal failure starting on the fourth day. Four sessions of hemodialysis were required in one patient because of anuria. Hepatic function improved from the fourth to the ninth day in each case, whereas renal function recovered later, 10-20 days after ingestion. Investigations were negative for other causes of renal failure, and acute tubular necrosis due to acetaminophen was suspected. CONCLUSION: The pathophysiology of this type of acute tubular necrosis remains unclear and thus, there is no specific treatment. Nevertheless, in all cases of acetaminophen overdose, we suggest following serum creatinine levels during the first week, regardless of the degree hepatic failure or quantity of acetaminophen ingested.

Post-coronarography application of continuous veno-venous hemofiltration in the prevention of contrast nephropathy in patients with complex multisystem deficiency.

BACKGROUND: An increased admission of high-risk patients to diagnostic and interventional radiological procedures with contrast medium has resulted in an increase of contrast-induced nephropathy, which now represents the third main cause of hospital-acquired acute renal failure. The pathogenic mechanism of contrast-induced nephropathy (CN) is unclear, but there is much evidence which indicated an interaction between direct tubular cytotoxicity and osmotic/hemodynamic effects. Continuous veno-venous hemofiltration (CVVH) has shown possible benefits in preventing CN. It is not understood when and how prophylactic strategies should be used either in pharmacological therapies or in continous renal replacement therapy (CRRT) approaches. The aim of this study was to evaluate the efficiency of the CVVH technique in preventing CN secondary to emergency radiological procedures in very high-risk patients. PATIENTS AND METHODS: Twelve patients with severe chronic renal impairment (serum creatinine concentration >2 mg/dl with an estimated glomerular filtration rate (eGFR) <40 ml/min) in association with at least two severe comorbidities (such as previous acute myocardial infarction in hypertensive or diabetic patients obesity, cardiac failure with ejection fraction <40%, severe hypotension) were treated with CVVH after coronarography using an iso-osmolar contrast medium (Visipaque, Iodixanol), with or without percutaneous transluminal coronary angioplasty. Adverse events and their association with the interventional radiological procedure were investigated after hemofiltration. RESULTS: Statistically significant differences were observed for both eGFR and serum creatinine at different time points (pre-, post- and 7 days after the procedure) at p<0.05. Statistical analysis of all the variables related to the radiological procedure and the hemofiltration technique did not cause any modification of renal function between the pre- and post-procedure values. No patient showed signs of cardiovascular instability, nor were any episodes of marked hypotension reported during the dialysis session. No patient showed any adverse effects related to the interventional radiological procedure or to the CVVH technique. Renal function, according to serum creatinine concentration and the e-GFR calculation (Cockcroft), did not worsen but had improved when the patients left hospital, with function rates statistically significantly better compared to that on hospital admission, even 7 days after the radiological procedure. CONCLUSION: The present study suggests the efficiency of the CVVH technique in preventing CN in high-risk patients who need to undergo interventional radiological cardiovascular procedures involving the administration of an iodine-based contrast medium.