Recurrent acute renal failure with idiopathic paroxysmal myoglobinuria.

A second episode of myoglobinuric renal failure requiring dialysis developed in a muscular 30-year-old man. His first episode, which was not exercise-related, had occurred in childhood and was accompanied by chills, fever, and leukocytosis, whereas the second followed unaccustomed exertion 15 years later. Despite two occurrences of severe renal failure and intermittent episodes of myoglobinuria, renal function is presently normal. Idiopathic paroxysmal myoglobinuria may produce recurrent life-threatening acute renal failure; however, the prognosis for recovery, as evidenced by this case, appears favorable.     

The significance of hyponatraemia in liver failure

It is possible by means of peritoneal dialysis to correct hyponatraemia occurring in liver failure. The normalization is not, however, attended by any apparent improvement in liver function, hepatic encephalopathy or renal function. Likewise correction of the serum ammonia level did not improve the clinical picture.     

Clinical and pathological features of six cases of sarcoidosis presenting with renal failure

Six patients with biopsy-proven renal sarcoidosis presented with renal failure of unknown origin; in none was the diagnosis of sarcoidosis initially considered. The serum creatinine concentration at the time of presentation ranged from 265 to 1380 μmol/l (3.0 to 15.6 mg/dl), with a mean of 787 μmol/l (8.9 mg/dl). Although only two patients were hypercalcemic at the time of presentation, the 24-hour urinary excretion of calcium was increased in three of the four patients in whom it was measured, and renal calculi were present in one case. Renal biopsy revealed interstitial nephritis and tubular atrophy in all cases, as well as nephrocalcinosis in three cases and noncaseating granulomas negative for acid-fast bacilli in four cases. In each patient steroid therapy led to a rapid improvement in renal function (mean post-treatment serum creatinine level 274 μmol/l [3.1 mg/dl]). The follow-up period ranged from 8 months to 8 years (mean 3.0 years). In three patients renal function remained stable with low-dose steroid therapy. In two cases recurrent hypercalcemia and deteriorating renal function accompanied steroid withdrawal but resolved with its reinstitution. In one additional case reversible deterioration in renal function accompanied tapering of the steroid dose; however, there was no hypercalcemia.     

Acute renal failure due to non-traumatic rhabdomyolysis

Seventeen patients with acute renal failure of diverse aetiology showed myoglobinuria and elevated levels of serum creatine phosphokinase (mean 119·2 Sigma u./ml) and adolase (mean 88·5 Sibley-Lehninger (SL)u./ml), indicating the presence of diffuse muscle cell injury. The primary conditions which led to rhabdomyolysis and acute renal failure were burns, eclampsia, prolonged labour, crush injury, epileptiform convulsions, status asthmaticus, viral myositis and intoxication with chemicals including copper sulphate, mercuric chloride and zinc phosphide. In 10 non-myoglobinuric patients with acute renal failure, serum creatine phosphokinase was normal (mean 8·9 Sigma u./ml) and serum aldolase was only slightly elevated (mean 11·2 SL u./ml). Although uric acid was elevated in both groups, the values were significantly higher in myoglobinuric (mean 0·728 ± 0·199 mmol/l) compared to non-myoglobinuric patients (mean 0·583 ± 0·093 mmol/l). During the oliguric phase, hypocalcaemia was observed in 82·2% of myoglobinuric patients and in 20% of non-myoglobinuric patients. Ten out of 15 patients with myoglobinuric renal failure developed hypercalcaemia during the diuretic phase whereas only 3 non-myoglobinuric patients showed a transient hypercalcaemia. Although the mean serum potassium was somewhat higher in the myoglobinuric patients, the difference between the 2 groups was not significant. It is concluded that acute renal failure associated with non-traumatic rhabdomyolysis is not infrequent and may occur in a variety of conditions where gross evidence of muscle injury is lacking.     

前列腺素E_1对慢性肾功能不全氮质血症患者的肾保护作用

目的 :探讨前列腺素E1 (PGE1 )对慢性肾功能不全患者的肾保护作用。方法 :测量我院 3年来 78例慢性肾功能不全患者用前PGE1 治疗前后的肾功能、2 4h尿蛋白 ,并用彩色多普勒监测其肾血流变化。结果 :78例经PGE1 治疗后肾血流明显改善 ,肾功能好转 ,尿蛋白减少。结论 :PGE1 具有改善肾血流、保护慢性肾功能不全患者残肾功能效果显著且副作用小的优点 ,是治疗慢性肾功能不全的理想药物     

上、下臂动静脉内瘘对血透患者心功能影响的对比研究

目的 :比较血透患者上臂、下臂动静脉内瘘 (AVF)对心功能的影响。方法 :采用彩色多普勒超声检查测定血透患者上臂、下臂动静脉内瘘的血流量、左室射血分数 (EF)值 ) ,比较上臂、下臂动静脉内瘘造瘘前、造瘘后一年心功能的改变。结果 :2 0例中上臂内瘘 7例 ,瘘流量在 960～ 25 4 0 ml/ min之间 ,平均 175 0± 368.4 2 ml/ min;下臂内瘘 13例 ,瘘流量在 390～ 910 ml/ min之间 ,平均 65 0± 143.12 ml/ min。 2 0例中 ,3例于透析间期时有心衰发作 ,其中 2例为下臂内瘘、瘘流量为 690 ml/ min和 960 ml/ min;1例为上臂内瘘、瘘流量为 960 ml/ min。此 3例均于透析开始时已有心衰的临床表现 ,而且因经费不足 ,透析不规则。其余 17例透析间期均无心衰发作 (包括上臂瘘流量达到 2 4 10 ml/ min)。结论 :动静脉内瘘可导致高心输出性心衰 ,其发生与造瘘前心功能状态、透析的规则性有关。上、下臂动静脉内瘘对心功能的影响无明显的差异     

急性肾衰竭治疗的研究现状

急性肾衰竭是临床常见的危重症,其主要特征是肾功能急剧下降,病死率较高。近年来,国内外在连续肾脏替代疗法、药物治疗、细胞因子及营养治疗急性肾衰竭上有了新的进展。     

肝肾联合移植的临床研究(附5例报告)

目的探讨肝肾联合移植的手术技术和临床处理经验.方法给5例患者(2例为肝炎后肝硬化、肝功能不全合并慢性肾功能衰竭,2例为原发性肝癌合并慢性肾功能衰竭,1例为多囊肝、多囊肾)行一期肝肾联合移植.器官切取均采用原位灌注腹部多器官联合切取技术.4例采用改良背驮式(腔静脉成形)原位肝移植术,肾移植采用常规方法;1例采用器官串簇移植技术.结果术后移植肝功能均恢复良好,移植肾发生急性肾功能衰竭2例次.术后并发ARDS 1例次,应激性溃疡1例次.1例患者术后7天死于多器官功能衰竭,其余4例患者经相应治疗后恢复良好.随访13～17个月,4例患者存活.结论肝肾联合移植是治疗肝肾功能不全的有效方法.预防移植肾的急性肾功能衰竭和ARDS是肝肾联合移植的关键环节.     

Managing liver failure

Liver disease is rare in childhood, but important new developments have altered the natural history and outcome. It is important that clinicians are aware of these diseases and their management. Acute liver failure is most often due to viral hepatitis, paracetamol overdose, or inherited metabolic liver disease. The clinical presentation includes jaundice, coagulopathy, and encephalopathy. Early diagnosis is necessary to prevent complications such as cerebral oedema, gastrointestinal bleeding, and renal failure. Early supportive management, in particular intravenous N-acetylcysteine, may be effective but liver transplantation is usually the definitive treatment and thus early referral to a specialist unit for liver transplantation is mandatory. Chronic liver failure may be due to unresolved neonatal liver disease, either inherited biliary hypoplasia or extrahepatic biliary atresia, while in older children, autoimmune liver disease or cystic fibrosis are the commonest causes. Treatment includes specific medication, nutritional support, and liver transplantation, which now has a 90% survival with good quality life.     

Acute renal failure after envenomation by the common brown snake

A non-fatal case of acute renal failure after envenomation by a common brown snake (Pseudonaja textilis) is described. The renal failure required dialysis but resolved rapidly. There were no signs of neurotoxic envenomation or myoglobinuria. A mild disturbance of coagulation was noted with severe thrombocytopenia. This is the first documented case of renal failure (acute tubular necrosis) after envenomation by the common brown snake to present with this clinical picture. It is also the first clinical evidence that an Australian snake venom may contain a direct nephrotoxic component.     

肝肾联合切取的肾移植临床研究

目的 探讨尸体肝肾联合切取时保证供肾质量的方法。方法 总结2001年9月-2005年9月31例尸体肝肾联合切取的经验，分析器官切取过程中出现并发症的原因和预防措施及肾移植的临床效果。结果 肝肾联合切取过程中，右肾静脉损伤1例，左肾动脉损伤2例，肾灌注不佳3例。移植肾功能恢复满意。结论 尸体肝肾联合切取是值得提倡的方法，可以保证供肾质量。     

血浆置换联合持续性血液透析滤过治疗肝衰竭的疗效分析

目的回顾性分析人工肝血浆置换联合持续性血液透析滤过治疗肝衰竭的疗效及其影响因素。方法收集2008年1月至2012年12月于佛山市第一人民医院在内科综合治疗基础上接受血浆置换联合持续性血液透析滤过治疗的肝衰竭患者77例,观察人工肝治疗前后的临床症状、生化指标(转氨酶、胆红素、凝血功能、肾功能、电解质)和不良反应。结果人工肝治疗的肝衰竭患者,治疗后临床症状改善有效率为64.9%,转氨酶、总胆红素、凝血功能、肾功能、电解质均较治疗前有明显改善,差异有统计学意义(P0.05),其疗效与肝衰竭分期相关,以早期有效率最高(P0.05)。治疗过程中出现35例次不良反应,经对症处理后,所有不良反应均可缓解。结论在内科综合治疗基础之上,血浆置换联合持续性血液透析滤过治疗能有效治疗肝衰竭患者,不良反应少,可作为治疗肝衰竭的重要手段。     

Chronic renal failure in a patient with bilateral ureterocele

Ureterocele is a congenital anomaly, in which there is mal-development of the caudal segments of the ureter. There is a female preponderance with most cases seen in Caucasians. Among the reported complications of this condition, chronic renal failure occurring in the setting of ureterocele has not been well documented. We report a case of a young girl with bilateral ureterocele presenting with chronic renal failure, whose management presented a diagnostic failure and inadequate treatment.Ureterocele is a rare congenital cystic dilatation of the terminal segments of the ureter at its opening into the urinary bladder.1 The condition occurs almost exclusively in Caucasians.2 Ureterocele have been variously classified based on the anatomical and functional criteria. A simple and frequently used classification was developed by the American Academy of Paediatrics (AAP).3 There are controversies surrounding the etiology of ureterocele. However, the most commonly accepted theory in the pathogenesis of ureterocele is the incomplete dissolution of the Chwalla’s membrane during developmental stages. Other theories include incomplete masculinization and excessive dilation of the intramural ureter during the development of the bladder and trigone, and obstruction of the ureteral orifice. Commonly, ureteroceles are predisposed to urinary stasis and subsequent infection in neonatal periods. Ureterocele may manifest as failure to thrive in children, and abdominal or pelvic pain in adults. Other modes of presentation include; hematuria, purulent urine, and pyelonephritis. Urinary incontinence or retention may also be seen in the presence of obstruction at the level of the bladder. Ultrasonography is a useful diagnostic imaging tool in the prenatal and early childhood period.4 However, a voiding cystourethrography (VCU) and intravenous pyelography (IVP) for evaluation of the urinary tract and the voiding status are essential in the assessment of the excretory function. The degree of obstruction and the differential functions of the kidneys can be demonstrated with diuretic renograms. Cystoscopy, an endoscopic procedure that allows direct inspection and examination of the urinary tract is a helpful diagnostic procedure in the management of ureterocele. Management of ureterocele may not be generalized due to varied complications that may ensue. Endoscopically or surgically, unroofing of the ureterocele can be performed. The surgical procedures include excision of ureteroceles and reimplantation of ureters into the bladder for bladder level surgery, and partial heminephrectomy and ureterectomy for upper-level surgery. Endoscopic treatment includes transurethral puncture and transurethral incision, which are applicable mainly to the intravesical types. Despite the rarity of this condition among the Black race, there is a need for a high index of suspicion in order to prevent a possible irreversible renal failure among other associated complications. We report a rare case of chronic renal failure in an 18-year-old girl with bilateral ureterocele. Our objective in presenting this particular case is to highlight chronic renal failure requiring renal replacement therapy as a unique complication of ureterocele in a poor resource constrained developing country.     

原位肝移植术后早期并发症的防治

目的: 总结原位肝移植患者早期并发症的防治策略。方法: 对9例原位肝移植患者的早期ICU处理进行回顾性分析。结果: 痊愈8例,死亡1例,围手术期成活率88.9%(8/9),平均ICU停留时间(11.3±4.8)天,ICU期间发生的并发症主要包括细菌感染2例,真菌感染1例,急性排斥反应2例,下腔静脉狭窄1例,急性肾功能不全1例,1例死亡患者的死亡原因为严重肺部感染、多器官衰竭。结论: 掌握原位肝移植术后患者的特殊病理生理学改变,并有针对性的进行ICU管理是提高原位肝移植早期存活率的关键。     

Acute renal failure in multiple myeloma

Two cases of acute renal failure complicating multiple myeloma are reported. In both, the renal failure preceded the diagnosis of multiple myeloma. In one case oliguria occurred after performance of a venogram; renal function returned to normal after two weeks of intermittent peritoneal dialysis, emphasizing the reversibility of the renal failure in some cases.     

Urinary insulin levels in health and disease��a concise review

The kidneys are the most important extrahepatic site of insulin breakdown and play a significant role in regulating the systemic insulin level in normal subjects. In man, a renal arteriovenous insulin concentration difference of about 30% has been measured, and since ‘insulin clearance’ values are less than the glomerular filtration rates, insulin is probably removed from blood by a combination of filtration and tubular secretion. In normal subjects a constant fraction of circulating insulin is removed by the kidney. This fraction is independent of the arterial concentration but varies with creatinine clearance. Of the amount filtered, most is completely resorbed and degraded by the cells of the proximal convoluted tubules. These cells have a high insulinase content and recent evidence would point to the possible existence of a renal tubular transport mechanism for insulin. The amount of insulin excreted in the urine is small and does not exceed 2% of the filtered load. In diabetics the insulin requirements often decrease with progressive renal failure. Derangements in carbohydrate metabolism have been noted in patients with renal failure while ‘insulin clearance’ is elevated in uraemia, chronic and acute renal failure. In nephrotic syndrome there is no change in renal insulin excretion. In severe trauma, ‘insulin clearance’ is elevated in patients with normal renal function despite a relative hypoinsulinaemia for the prevailing degree of glycaemia.     

Renal retention of sodium in cirrhosis and fulminant hepatic failure

Abnormal renal retention of sodium is a characteristic finding in both cirrhosis and fulminant hepatic failure. In cirrhosis the pathogenesis varies according to the level of renal perfusion. When this is normal, hyperaldosteronism is probably the most important factor and this results from an increased release of renin by the kidney. The stimulus to the latter may be a shunting of blood from the outer cortical to juxtamedullary nephrons, although there is no direct relationship between the changes in intrarenal blood flow distribution and sodium excretion. The patients with hyperaldosteronism fail to escape from its sodium retaining effects because of impaired production of natriuretic hormone, which in turn is the result of a failure to expand the ‘effective’ extracellular fluid volume, because of ascites formation.     

Effect of pregnancy on moderate renal failure in reflux nephropathy

During a 10 year study of women with reflux nephropathy 20 women had plasma creatinine concentrations in the range 0.2-0.4 mmol/l (2.3-4.5 mg/100 ml). Six experienced pregnancies exceeding 12 weeks' gestation. Pregnancy was associated with rapid deterioration in function in all six, resulting in end stage renal failure in four women within two years after delivery despite adequate control of blood pressure. Of the 14 women who did not have a prolonged pregnancy, four had periods of uncontrolled hypertension, all of which were related to non-compliance or loss from follow up, or both. Uncontrolled hypertension was also associated with accelerated renal failure, and all four women progressed quickly to end stage renal failure. The remaining 10 women were observed for from five to 10 years; in all 10 renal function deteriorated slowly, and none reached end stage renal failure within seven years. It is concluded that pregnancy in patients with reflux nephropathy and moderately severe renal failure has a deleterious effect on renal function.     

Cadaver Renal Homotransplants: Initial Experiences

Four renal homotransplants were carried out between cadaver donors and four recipients, all of whom were in terminal chronic renal failure. Immune suppression was attempted with azathioprine (Imuran), actinomycin C and prednisone; no radiation was used, nor were the recipient's kidneys, spleen or thymus removed. One patient died with disseminated histoplasmosis at two weeks; another with irreversible homograft rejection at 30 days; a third patient died of septicemia after 9½ weeks with stable renal function. The fourth patient, whose transplant had been ischemic for 190 minutes and had not functioned for 2½ weeks thereafter, eventually achieved good function which remained unchanged to 7½ months. Changes in urinary enzyme excretion and in the I¹³¹ renogram and meralluride scan were of value in assessing homograft rejection.     

风湿性心脏病的肾脏损害：附103例临床分析

风湿性心脏病可累及肾脏,临床上对于肾脏损害的报导较少。为探讨其对肾脏损害的影响,本文收集了近8年来我院风心病并肾损害的住院病人103例进行分析,以供同道参考。