Intra-abdominal Hypertension as a Cause of Oliguric Acute Kidney Injury in a Patient with Chronic Lymphocytic Leukemia.

Acute kidney injury (AKI) is a well-known complication in patients with chronic lymphocytic leukemia (CLL). It could occur via diverse mechanisms such as leukemic infiltration, extrarenal obstruction, tumor lysis syndrome, glomerular diseases, and medication side effects. The incidence of kidney disease at the diagnosis of CLL is about 10%. We report a case of AKI, in a patient with a known history of CLL, due to abdominal compartment syndrome, caused by extremely enlarged intra-abdominal lymph masses. To the best of our knowledge, no case of AKI due to such cause has been reported so far.

Cardiovascular toxicity with levetiracetam overdose.

OBJECTIVE: To describe the cardiovascular toxicity and pharmacokinetics of levetiracetam in overdose. CASE REPORT: A 43-year-old female presented 8 h post ingestion of 60-80 g of levetiracetam with mild central nervous system depression, bradycardia, hypotension and oliguria. Her cardiovascular toxicity transiently responded to atropine and intravenous fluids. A bedside echocardiogram demonstrated normal left and right ventricular contractility. Despite her cardiovascular toxicity and oliguria, she had normal serial venous lactates and renal function; and made a complete recovery over 48 h. Her levetiracetam concentration was 463 mcg/ml 8 h post ingestion (therapeutic range 10-40 mcg/ml) and her concentration-time data best fitted a one-compartment model with first-order input and an elimination half-life of 10.4 h. DISCUSSION: Levetiracetam in large ingestions appears to cause bradycardia and hypotension that is potentially responsive to atropine and intravenous fluids. Based on a normal echocardiogram, the mechanism for this effect may be levetiracetam acting at muscarinic receptors at high concentration. The pharmacokinetics of levetiracetam in overdose appeared to be similar to therapeutic levetiracetam dosing.

Rapid clinical assessment to facilitate the triage of adults with falciparum malaria, a retrospective analysis.

BACKGROUND: Most adults dying from falciparum malaria will die within 48 hours of their hospitalisation. An essential component of early supportive care is the rapid identification of patients at greatest risk. In resource-poor settings, where most patients with falciparum malaria are managed, decisions regarding patient care must frequently be made using clinical evaluation alone. METHODS: We retrospectively analysed 4 studies of 1801 adults with severe falciparum malaria to determine whether the presence of simple clinical findings might assist patient triage. RESULTS: If present on admission, shock, oligo-anuria, hypo- or hyperglycaemia, an increased respiratory rate, a decreased Glasgow Coma Score and an absence of fever were independently predictive of death. The variables were used to construct a simple clinical algorithm. When applied to the 1801 patients, this algorithm's positive predictive value for survival to 48 hours was 99.4 (95% confidence interval (CI) 97.8-99.9) and for survival to discharge 96.9% (95% CI 94.3-98.5). In the 712 patients receiving artesunate, the algorithm's positive predictive value for survival to 48 hours was 100% (95% CI 97.3-100) and to discharge was 98.5% (95% CI 94.8-99.8). CONCLUSIONS: Simple clinical findings are closely linked to the pathophysiology of severe falciparum malaria in adults. A basic algorithm employing these indices can facilitate the triage of patients in settings where intensive care services are limited. Patients classified as low-risk by this algorithm can be safely managed initially on a general ward whilst awaiting senior clinical review and laboratory data.

Clinical and laboratory findings in patients with oliguric and non-oliguric hantavirus haemorrhagic fever with renal syndrome: an analysis of 128 patients.

Patients with haemorrhagic fever with renal syndrome (HFRS) may present without significant oliguria. We compared different initial clinical symptoms and laboratory findings in patients who developed oliguric acute renal failure (ARF) with those in patients who did not develop oliguric ARF. Overall, 128 patients with serologically confirmed HFRS were hospitalized at the University Hospital for Infectious Disease, Zagreb, Croatia between January 1999 and December 2010. Clinical signs and laboratory findings were extracted from medical charts, and were assessed for their relationship to the development of oliguric ARF. Puumala virus infection was diagnosed in 101 (79%) patients, and Dobrava-Belgrade virus infection in 27 (21%). Oliguria or anuria developed in 30% of patients. We identified the following risk factors for the development of oliguria and anuria on multivariable analysis: conjunctival hyperaemia or bleeding (relative risk (RR) 1.84, 95% CI 1.09-3.10; p 0.023), diarrhoea (RR 1.45, 95% CI 1.07-1.97; p 0.017), serum sodium of ≤133 mM (RR 2.21, 95% CI 1.34-3.64; p 0.002), and dipstick protein value of >1.5 g/L (RR 1.59, 95% CI 1.09-2.33; p 0.016), as well as hiking in the forest (RR 1.92, 95% CI 1.13-3.26; p 0.016). Our findings may help physicians in the earlier identification of patients with a more severe form of HFRS caused by Puumala and Dobrava-Belgrade viruses. Particular attention should be given to findings such as conjunctival hyperaemia or bleeding, diarrhoea, a low serum sodium level, and proteinuria.

Semiología renal y genitourinaria en pediatría: primera parte / Nephrologoy and urology semiology in children: first part

A pesar de los avances tecnológicos, la historia clínica y el examen físico continúan y continuarán siendo la base de un buen enfoque y aproximación diagnóstica correcta, por ésto, la semiología sigue siendo un área muy importante en la medicina. En ésta revisión se plantea una guía sistemática e integral para la evaluación del sistema nefro-urológico en el niño desde las herramienta básicas y fundamentales como la historia clínica, el examen físico con sus componentessemiológicos en lo normal y lo patológico, integrando además los métodos diagnósticos de laboratorio e imagen disponibles en la actualidad, para lograr un buen enfoque y aproximación diagnóstica en niños con enfermedad renal.

Despite technological advances, medical history and physical examination remain the foundation of a good approach and correct diagnosis; semiology remains a very important area in medicine. In this review a systematic and comprehensive guide for the evaluation of nephron urological system in children is presented, with emphasis in medical history, physical examination and semiotic aspects, in normal and pathological conditions; additionally laboratory and imaging studies available to achieve a good diagnostic approach in children with renal disease are presented.

Paradoxic activation of the renin-angiotensin system in twin-twin transfusion syndrome: an explanation for cardiovascular disturbances in the recipient.

Despite advances in treatment, twin-to-twin transfusion syndrome (TTTS) still carries a high risk for perinatal mortality and morbidity. Simple blood transfer from the donor to the recipient twin cannot explain all of the features of this disease, in particular the recipient's hypertensive cardiomyopathy. We report a case in which TTTS resulted in preterm delivery with early neonatal death of both twins, allowing assessment of the renin angiotensin system (RAS) status of each fetus, both by cord blood renin and aldosterone assay and by renal immunohistochemistry. The donor had severe oliguria/oligohydramnios, whereas the recipient, in addition to severe polyuria/polyhydramnios, had cardiomyopathy, atrioventricular regurgitation, and ascites. Although immunohistochemistry demonstrated that renal secretion of renin was up-regulated in the donor and down-regulated in the recipient, cord blood levels of renin and aldosterone were similar, with high renin levels in both twins. This observation supports the hypothesis that despite renal RAS down-regulation, the recipient is exposed to RAS effectors elaborated in the donor and transferred via placental shunts. This may contribute to cardiomyopathy and hypertension in the recipient, which cannot be accounted for by hypervolemia alone. We thus hypothesized that in TTTS, the recipient's hypertensive cardiomyopathy could be due to a mechanism similar to the classical model of hypertension referred to as "2 kidneys-1 clip." Thus the hypovolemic donor twin, comparable to the clipped kidney, produces vasoactive hormones that compromise the recipient, comparable to the normal kidney, causing hypertension and cardiomyopathy.

Factors determining outcome of acute renal failure patients.

OBJECTIVE: Acute Renal Failure (ARF) is a common medical problem. Delay in diagnosis is associated with increased mortality. Variety of conditions can lead to ARF. Many factors can influence the outcome of ARF. This study was done to find the predictive factors related to outcome of ARF. METHODS: One hundred adult patients of acute renal failure admitted to Ziauddin Hospital were studied. Certain factors related to outcome of ARF were identified and analyzed. RESULTS: Among such factors oliguria, levels of urea, creatinine and potassium were found significant poor prognostic predictors on univariate analysis as far as outcome of treatment modality is concerned. The multivariate analysis revealed that the presence of oliguria is the only significant independent predictor (P<0.001) for good outcome with dialysis. CONCLUSION: Oliguria was found to be the major predictor of non recovery of renal function.

Acute renal failure due to rifampicin: a study of 25 patients.

BACKGROUND: Acute renal failure (ARF) caused by rifampicin typically occurs on intermittent administration. There are isolated case reports and only one series reported in the literature. Systematic data, especially from countries endemic for tuberculosis and leprosy, are sparse. METHODS: We studied demographic, clinical, biochemical, and histopathologic features and prognosis of 25 consecutive patients with rifampicin-associated ARF admitted from July 1990 to June 2000. RESULTS: Rifampicin-associated ARF constituted 2.5% of all cases of ARF seen during the study period. The most common pattern of drug intake resulting in ARF (40%) was ingestion of a single dose preceded by a drug-free period (range, 10 days to 6 years) after a course of daily rifampicin (range, 8 days to 18 months). Onset was with gastrointestinal and flu-like symptoms 4 hours (median) after drug intake. All patients were oliguric. Anemia and thrombocytopenia each occurred in 60% of patients. Acute hepatitis was present in 32%. Among 12 patients who underwent kidney biopsy, 7 patients (58%) had acute interstitial nephritis (AIN). Crescentic glomerulonephritis was seen in 1 patient, and mesangial proliferation, in 3 patients. No single feature at presentation predicted the severity of renal failure. There were no deaths, and all patients recovered renal function. CONCLUSION: Patients with rifampicin-associated ARF were oliguric and presented with gastrointestinal and flu-like symptoms, typically after reintroduction of the drug after a drug-free period. Anemia and thrombocytopenia were common. AIN was the most common biopsy finding. No factor predicted severity, but the renal prognosis was good.

Oliguric acute renal failure in mycosis fungoides with lymphomatous infiltrates in the kidneys.

OBJECTIVE: To present the clinical picture of acute renal failure in patients with mycosis fungoides (MF) and renal lymphomatous infiltrates. To analyze the pathogenesis of renal failure. METHODS: Correlation of clinical picture, urinary findings, imaging reports and autopsy findings in two patients with long-standing MF who died with renal failure. CASE SUMMARIES: Both subjects had sustained oliguria in the last 2 weeks. One patient had persistent hypotension, normal urinalysis, normal renal sonogram, and scarce interstitial lymphomatous infiltrates with preservation of renal parenchymal architecture. He was thought to have ischemic acute renal failure not directly linked to the lymphomatous infiltrates. The second patient developed hypertension one month prior to death, and had moderate proteinuria, hematuria, pyuria, grossly enlarged kidneys with hypoechoic masses, and extensive replacement of the renal parenchyma by lymphomatous infiltrates. This picture is typical of renal failure secondary to lymphomatous replacement of the kidneys. CONCLUSIONS: The development of oliguric renal failure in MF with renal lymphomatous infiltrates may have varying clinical and imaging manifestations and pathogeneses. Potentially reversible pathogenic mechanisms should be systematically investigated, particularly if the overall clinical picture is not characteristic of renal failure secondary to lymphomatous replacement of the parenchyma.

Renal failure in the surviving monochorionic twin after death of the co-twin in utero.

Renal failure in the newborn infant is mainly determined by vascular causes. In this report we describe a patient with a particular vascular cause of renal failure. The patient was the product of a twin pregnancy in which the twin partner died in utero. In retrospect, the twins appeared to be monozygotic. As the pregnancy was studied carefully prenatally by ultrasound, we were able to observe the development of this condition, characterized by oliguria, oligohydramnios, and lung hypoplasia: the oligohydramnios sequence. After organ development had been normal initially, renal function was lost and the oligohydramnios sequence developed in the survivor after the co-twin had died in utero.

Oliguria during laparoscopic surgery: evidence for direct renal parenchymal compression as an etiologic factor.

Abdominal insufflation during laparoscopy has been associated with transient oliguria, which abates after desufflation. Direct renal compression evoking a Page kidney effect was proposed as a mechanism. In an effort to confirm this theory, the left kidney was subjected to 15 mm Hg compression in six anesthetized mongrel dogs. For this, a pressure cuff was placed around the kidney excluding the renal hilar structures. The contralateral kidney was left untouched to serve as a control. After a steady-state period, the pressure cuff was inflated to 15 mm Hg for 2 hours. Cuff desufflation was followed by a 1-hour recovery period. Urine output, glomerular filtration rate (GFR), and effective renal blood flow (ERBF) were measured for both kidneys during each clearance period. For the treated kidneys, the mean urine output decreased 63% (P < 0.05) during compression and increased 109% (P < 0.05) after cuff desufflation. The GFR decreased 21% (P < 0.01) during compression and increased 25% (P < 0.05) during recovery. The ERBF decreased 26% (P < 0.05) during compression, and during the 1-hour recovery period, ERBF did not recover to baseline values. For the control kidneys, there were no significant changes in urine output or GFR during the experimental and recovery periods. These data support the view that direct renal parenchymal compression is an important factor in the development of insufflation-induced oliguria. The clinical implications of insufflation-induced oliguria during laparoscopy deserve further investigation.

Prolonged bleeding time during ciprofloxacin therapy.

Ciprofloxacin is a broad spectum quinolone antibiotic. Side effects reported include nausea and other gastrointestinal symptoms; skin and musculoskeletal side effects may also occur. No bleeding abnormalities or alteration in coagulation have been documented. We report a case where ciprofloxacin appeared to contribute to an idiosyncratic prolongation of bleeding time although a rechallenge 8 months later did not reproduce the effect. Moreover, subsequent investigation of the influence of ciprofloxacin on bleeding parameters in 10 healthy volunteers demonstrated no alterations in bleeding parameters.

The outcome of critically ill elderly patients with severe acute renal failure treated by continuous hemodiafiltration.

OBJECTIVES: To study the outcome of critically ill elderly patients with severe acute renal failure managed by continuous hemodiafiltration. DESIGN: Prospective study. SETTING: Intensive Care Unit of tertiary institution PATIENTS: Seventy-two consecutive critically ill patients of 65 years or older admitted to the ICU with severe acute renal failure. Seventy similar control patients of age < 65 years. INTERVENTION: Treatment of all patients with continuous hemodiafiltration. MEASUREMENTS AND MAIN RESULTS: Safety and effectiveness of therapy were assessed. Main outcome measures were duration of oliguria, of ICU stay, and hospital stay for survivors, and survival to ICU discharge and to hospital discharge. Mean APACHE II score on admission was 29.8 (95% confidence interval: 28.5 to 31.1) and mean organ failure score prior to initiation of continuous hemodiafiltration was 3.9 (95% confidence interval: 3.6 to 4.2). Sepsis was present in 51 cases (70.8%) and bacteremia or fungemia in 24 (33.3%). Fifty-three (73.6%) required mechanical ventilation for > 3 days. Vasopressor drugs were used in 65 (90.2%). Continuous hemodiafiltration controlled azotemia in all patients and was only associated with minor complications. Thirty-four patients (47.2%) survived to ICU discharge and 30 (41.6%) to hospital discharge. Among survivors, duration of oliguria was 11.6 days (95% confidence interval: 9.1 to 14.1), mean duration of ICU stay 8.6 days (95% confidence interval: 6.1 to 11.) and mean duration of hospital stay 33.1 days (95% confidence interval: 28.8 to 37.4). No statistically significant difference in survival was found when these patients were compared to a control group of similar but younger patients who also received ICU care and continuous hemodiafiltration for the treatment of severe acute renal failure. CONCLUSIONS: A greater than 40% survival was achieved in critically ill elderly patients with severe acute renal failure by the use of continuous hemodiafiltration. These patients had an in hospital survival comparable to that of younger patients. These findings support an aggressive renal replacement approach in such patients and suggest that continuous hemodiafiltration may be ideally suited to their management.

Morphometric studies on acute renal failure in humans during the oligoanuric and polyuric phases.

Twelve biopsies from patients in the oligoanuric phase and 17 from patients in the polyuric phase of acute renal failure (ARF) were studied and compared morphometrically with 39 control biopsies. Measurements were taken on silvered semi-thin sections, which were classified according to each of three divisions of the renal cortex. All alterations observed were equally prominent in these three cortical zones. The number of peri- and intertubular capillaries was reduced in both phases of ARF (P less than 0.001), their mean surface area was increased (P less than 0.001), while their total surface area per visual field remained constant. The tubular epithelial tissue was distended in both ARF phases and the tubular lumina were simultaneously widened, as were Bowman's capsular spaces. The causes of these alterations are discussed. The findings are in accord with a concept of the pathogenesis of ARF, which ascribes a central role to damage of individual tubular cells.