Tumoral calcinosis of the gluteal region in a child: case report with overview of different soft-tissue calcifications

Tumoral calcinosis is a distinct clinical and histologic entity that is characterized by a large deposition of calcium that resembles a neoplasm and is found predominantly in adolescents and young adults in the periarticular tissues of large joints. The authors describe the clinical presentation of a 15-year-old boy admitted at our pediatric day-surgery center for surgical management of tumoral calcinosis of the left gluteal region. Complete surgical excision is the treatment of choice.     

Renal Cortical Nephrocalcinosis Following Acute Renal Failure Due to Polytrauma

Renal cortical nephrocalcinosis is a rare condition in which there is calcification within the renal parenchyma. This article reports a 33-year-old patient who developed acute renal failure following multiple injuries leading to hemorrhagic shock. His renal failure improved gradually, though he required dialysis support for two months. Serial ultrasounds showed a progressive decrease in renal size, and a radiograph of the abdomen showed speckled calcification in both renal areas. A CT scan of abdomen showed diffuse cortical calcification involving the entire right kidney and upper half of the left kidney.     

An Improvement in the Outcome of Acute Renal Failure

Background: Acute renal failure (ARF) requiring hemodialysis (HD) treatment is related to high mortality. The aim of this study was to analyze the influence of age, disease severity, and catabolism intensity on ARF outcome in patients requiring HD treatment during a 15‐year period (1987–2001). Methods: The retrospective, single‐center study included 583 patients, 428 male, 155 female, age 49 ± 15 years, treated by intermittent HD using cuprophane membranes with surface area of 1.3 m². Liano's Acute Tubular Necrosis Individual Severity Score (ATNISS) score and Hypercatabolism Depuration Score (HDS) score were calculated to estimate disease severity and catabolism intensity in ARF patients. Results: Average age of patients significantly increased during the 15‐year period for more than one decade (44 to 55 years; p = 0.0359), especially during the last five‐year period (47 ± 14.5 vs. 53 ± 14.7, p = 0.00015). Disease severity showed significant increase comparing periods 1992–1996 and 1997–2001 (ATNISS 0.385 ± 0.197 vs. 0.437 ± 0.208; p = 0.00137), while catabolism intensity during these periods was similar (HDS 0.569 ± 0.145 vs. 0.582 ± 0.127; p = 0.357). Despite the older and more severely ill population of ARF patients, mortality showed a sustained decrease during the 15‐year period. Mortality in the period from 1987 to 1991 (49/83; 59%) was similar with the period 1992–1996 (χ² = 0.44, p = 0.5081), but significantly higher than in the period 1997–2001 (114/250; 45.6%; χ² = 3.98, p = 0.0471). Conclusion: The results showed an improvement in the outcome of patients with ARF requiring HD treatment, despite increasing age, disease severity, and use of bioincompatible membranes.     

Spectrum of Acute Renal Failure and Factors Predicting Its Outcome in an Intensive Care Unit in India

Identification of factors causing acute renal failure (ARF) and its associated poor prognosis in critically ill patients can help in planning strategies to prevent ARF and to prioritize the utilization of sparse and expensive therapeutic modalities. Most of the studies in such patients have been done in the developed world, and similar data from the developing world is sparse.

We analyzed 45 consecutive patients who developed ARF in the intensive care unit (ICU) during a 12-month period. Demographic and detailed biochemical profile, previous chronic illness, precipitating factors, number of failed organs, type of ARF (oliguric/nonoliguric), and need for and type of renal replacement therapy (RRT) received were recorded at the time of admission to ICU and during the course of illness. The mean age of these patients was 43.1 years, with 75.6% being males. Hypotension, sepsis, and use of nephrotoxic drugs were common precipitating factors for ARF in these patients. However, multiple precipitating factors were present in the majority (80%): 81.5% had at least one organ failure prior to development of ARF, 71.1% had oliguria, and 71.1% required RRT. Intermittent hemodialysis was the most common form of RRT given. Patient mortality was 64.4%, with 15 of the 16 surviving patients becoming dialysis independent. We observed an increase in mortality from 0% to 100%, depending on the number of failed organs from one to six. On comparing the predictor outcomes between survivors and nonsurvivors by multivariate analysis, only the number of failed organs at the time of ARF (2.6 ± 0.9 vs. 4.5 ± 0.8) and serum albumin <3.0 g/dL were found to be statistically significant.

To conclude, ARF in critically ill patients is multifactorial in origin and carries a high mortality. Mortality in these patients increases with increasing numbers of failed organs and with a serum albumin of <3.0 g/dL.     

Acute Renal Failure in Polytraumatized Patients: Prediction of Outcome

Prediction of outcome of acute renal failure (ARF), particularly inpatients with multisystem organ failure (MSOF), is a very important issue and a very difficult task. In patients with ARF as a consequence of severe polytrauma, frequent complications (e.g., sepsis, respiratory insufficiency, DIC, hepatic insufficiency, etc.) contribute to a hyperbolic state, and in the case of synergistic action, they start the mechanism of MSOF. In 33 patients (1 female, 32 male, 38.61 ± 8.79 years) with severe polytrauma acquired in war combat, ARF developed requiring hemodialysis (HD) treatment. Seventeen out of 33 (51.4%) recovered renal function. In 12 out of 33 patients, MSOF occurred with less successful recovery results. The analysis of pathophysiologic mechanisms of MSOF appearance and ARF outcome has shown the importance of blast injuries, bowel injury, respiratory insufficiency requiring assisted ventilation, and sepsis. Although severe hemorrhage and shock are the common mechanism of ARF appearance in these patients, it seems that wounds by themselves can be of great importance, as abdominal wounds are more frequently associated with ARF and MSOF than in other types.     

美国克利夫兰大学急性肾衰竭风险评分系统在我国成人心脏手术患者中的应用

目的探讨美国克利夫兰大学急性肾衰竭风险评分系统(the Clinical Score to Predict Acute Renal Failure,简称Cleveland评分系统)预测中国心脏手术患者术后发生急性肾衰竭(ARF)行肾脏替代治疗(RRT)及患者院内死亡的应用价值。方法将2005年1月至2009年12月期间上海交通大学医学院附属仁济医院收治的所有成人心脏手术患者2 153例纳入研究,其中男1 267例,女886例;年龄58.70(18～99)岁。术前按Cleveland评分分值将所有患者分层:0～2分(n=979),3～5分(n=1 116),6～8分(n=54),9～13分(n=4),比较各组间术后发生ARF行RRT的发生率、多器官功能衰竭(MOSF)的发生率及病死率。应用受试者工作特征(ROC)曲线评价该评分预测术后发生ARF行RRT、患者院内死亡的准确性。结果 0～2分、3～5分、6～8分、9～13分组术后发生ARF行RRT的发生率分别为0.92%、1.88%、12.96%和25.00%(χ2=55.635,P=0.000),MOSF发生率分别为1.23%、1.88%、3.70%和25.00%(χ2=16.080,P=0.001),病死率分别为0.92%、4.21%、25.93%和50.00%(χ2=71.470,P=0.000),4组差异均有统计学意义。Cleveland评分预测术后行RRT的ROC曲线下面积(AUC)为0.775[95%CI(0.713,0.837),P=0.000],预测院内死亡AUC为0.764[95%CI(0.711,0.817),P=0.000]。结论 Cleveland评分系统可有效预测中国成人心脏手术后发生ARF需RRT治疗的风险,为及早对高危人群采取有效的预防措施提供依据。     

经皮肾穿刺造瘘在梗阻性肾功能不全中的临床价值

目的：探讨经皮肾穿刺造瘘（PCN）在梗阻性肾功能不全诊治中的临床价值。方法：对49例梗阻性肾功能不全患者在B超引导下行PCN引流肾积水（脓）,经造瘘管造影了解梗阻原因及部位,病情好转稳定后手术解除梗阻。结果145例患者经引流后BUN、Cr均有下降,手术解除梗阻后恢复好。4例患者经引流后BuN、Cr无明显下降,继续行血透治疗。无死亡病例。结论：在梗阻性肾功能不全的诊治中,PCN能尽快引流肾积水（脓）,改善肾功能,避免血液透析或减少血透次数,减轻患者经济负担;可动态监测肾功能变化,避免治疗上的盲目性;建立的通道为二期手术打开方便之门,尤其是结石梗阻性肾功能木全诊治具有重要的应用价值;使急症手术变为择期手术,降低了手术死亡率及术后并发症发生率;同时经肾造瘘管造影可提高诊断符合率。这种方法微创安全,简单有效,经济实惠,值得推广。     

Acute Renal Failure in the State of Qatar: Presentation and Outcome

Despite major improvements in health care, acute renal failure is still one of the main prognostic factors in terms of patient mortality and long-term morbidity. This cohort prospective study to evaluate the patterns and outcomes of renal failure in Qatar was performed between January and June 2005. Of the 213 patients followed prospectively from referral to the end of their hospitalization, 66.7% were males and 33.3% females. Their overall mean age was 60 years; the majority were referred from critical care units. Comorbidity was present in 87% of all patients. Volume depletion, hypotension, and sepsis were the main predisposing factors for renal failure. Eighty three patients (39%) needed renal replacement treatment and 130 (61%) were treated conservatively. The majority of critical care patients needed dialysis. Overall mortality was 23.9%, 7% needed chronic dialysis, and 69.1% were discharged with normal or mild renal impairment. This study showed that acute renal failure was a major factor affecting patient mortality in Qatar. Early treatment of predisposing factors may improve overall patient outcomes.     

云南地区116例急性肾功能衰竭的临床分析

目的 探讨急性肾功能衰竭(Acute renal failure ARF)的发病情况、病因及死亡原因,以提高急性肾衰竭(ARF)的诊治水平.方法 回顾性分析116例ARF的临床资料,探讨其发病情况、病因与预后关系等.方法 116例ARF病例,肾前性、肾性、肾后性ARF分别占50.00%、39.66%、10.34%.死亡6例,总病死率为5.17%,其中肾前性因素所致ARF病死率占66.67%,明显高于肾性、肾后性因素所致ARF(p<0.05).结论 引起ARF的病因以肾前性因素为主,肾前性ARF病死率最高,积极治疗原发病的同时,若明确ARF病因和死亡原因,早期充分血液净化、对症支持治疗可改善ARF预后,降低病死率.     

Predictive Value of Bedside Effective Renal Plasma Flow for Renal Recovery in Severe Acute Renal Failure

Single injection, single blood sample, effective renal plasma flow (ERPF) estimated by^l3lI-orthoiodohippurate can be performed accurately and conveniently without urine collection at the bedside. The purpose of this study was to determine if ERPF early in the course of severe acute renal failure (ARF) predicts recovery of renal function in hemodynamically stable patients. Over 18 months, ERPF was determined in 33 such patients with ARF in whom an etiologic diagnosis could be established. Eight patients died within 2 months of onset and while on dialysis, did not have an autopsy, and were not considered further. Six patients (Group A) either remained on dialysis after at least 6 months follow-up or had irreversible renal disease at autopsy. In Group B (19 patients, 13 of whom were dialyzed), serum creatinine returned to less than 2.0 mg/dL (n = 16) or was decreasing without dialysis. Peak serum creatinine (Group A 11.2 ± 1.4; Group B 10.1 ± 1.3 mg/dL) did not differ between groups. Oliguria was present in 75% of Group A patients and in 25% of Group B patients. Initial ERPFs differed (p < 0.001) between Group A (90 ± 11) and Group B (204 ± 20 mL/min). Initial ERPF was greater than 125 mL/min in 15 Group B patients but in no Group A patients; the false-positive rate was 21% and the false-negative rate was 0%. We conclude that at a time when the etiology of ARF is often not established, an initial ERPF of 125 mL/min or greater predicts recovery of renal function and less than 125 mL/min suggests that renal function will not recover. Serial studies improve the diagnostic accuracy of this test.     

Predictors of Outcome in Malarial Renal Failure

We studied 38 patients with acute renal failure (ARF) due to malaria over a 5-year period between 1990 and 1994 at the Institute of Urology and Transplantation. There were 30 males and 8 females who ranged in age from 13 to 75 years. Most were critically ill on presentation with blood urea levels between 116 and 587 mg% and serum creatinine concentrations between 3 and 30 mg%. Anemia accompanied by hyperbilirubinemia was a result of severe hemolysis. Antimalarial therapy consisted of quinine sulfate, chloroquine, or both. Of the 38 patients, 32 required hemodialysis and eventually recovered normal (n = 29) or near normal (n = 3) function. Six patients died.     

The Clinical Outcome of End-Stage Renal Disease Patients Who Return to Peritoneal Dialysis After Renal Allograft Failure

Background

With the increased numbers of kidney transplantations, more patients return to dialysis after graft loss (DAGL). The aim of this study was to investigate the safety and efficacy of peritoneal dialysis (PD) after graft loss compared with transplant-naive PD patients (TN-PD).

Method

This study was conducted on 715 patients who started PD between 1988 and 2009, including 47 who started PD after allograft loss (DAGL-PD) and 668 in the (TN-PD) group.

Result

The mean ages were 40.8 ± 10.7 in DAGL-PD group and 51.03 ± 14.20 in TN-PD group (P < .01). The most common cause of end-stage renal disease in DAGL was primary glomerulonephritis (76.6%), but it was diabetes mellitus (38.9%) in the TN-PD group (P < .05). Patient survival rates at 1, 5, and 10 years were not different: 100%, 86%, and 57% versus 91%, 70%, and 62%, respectively. PD survival rate at 1, 5, and 10 years did not show significant differences: 98%, 95%, and 88% versus 95%, 80%, and 66%, respectively. The most common causes of death in both groups were infection (DAGL, 26.7%; TN-PD, 24.5%) followed by cardiovascular disease (DAGL, 20.0%; TN-PD, 19.6%); the distribution of causes did not differ significantly (P > .05).

Conclusion

The clinical outcomes of PD in DAGL group were comparable with those of TN-PD patients. Therefore, PD could be considered as a dialysis modality for patients who experience allograft failure.     

Parameters of Inflammation in Morbid Obesity: Lack of Effect of Moderate Weight Loss

Background  Obesity has been associated with a chronic activation of the acute-phase response. The aims of our study were to investigate whether levels of inflammatory cytokines are higher in obese patients, to evaluate their relationship with metabolic syndrome, and to analyze the effect of moderate weight loss upon their levels. Methods  Sixty-seven severe or morbid obese patients were compared with 67 controls. Patients were submitted to a 4-week very low calorie diet followed by a low calorie diet for 2 months. Exclusion criteria were organic disease, ischemic heart disease or stroke, diabetes mellitus, hyperlipidemia, and hypertension. An evaluation was performed before and after the diet, in which fibrinogen, blood count, high-sensitive C-reactive protein (CRP), interleukin 6 (IL-6), and tumoral necrosis factor α (TNF-α) were measured. The Student t test was employed to compare differences between the groups and Pearson correlation coefficients were calculated. Results  Obese patients showed higher levels of CRP (P < 0.001), IL-6 (P < 0.001), TNF-α (P < 0.001), leukocyte (P = 0.001), and neutrophil count (P < 0.001) than controls. In obese patients, inflammatory parameters were significantly correlated with anthropometric parameters and did not differ between obese subjects with or without metabolic syndrome. Moderate weight loss (excess weight loss 19.6%) was achieved through dieting, but no change was observed in any inflammatory parameter. Conclusions  Obesity is associated to a chronic inflammatory state that seems to be due to an increased secretion of cytokines, and this state is not related to the presence of metabolic syndrome. Moderate weight loss does not ameliorate this inflammatory state in the short term.     

Acute Renal Failure in Leptospirosis

Leptospirosis acute renal failure is reviewed: its prevalence, clinical characteristics, physiopathologic mechanisms, histology, mortality, follow-up, prophylaxis, and treatment.     

Nutrition in Acute Renal Failure

We report the fifth, to our knowledge, published case of spontaneous intraperitoneal bladder rupture after normal, vacuum-assisted in this occasion, vaginal delivery of a 29-year-old female patient. Diagnosis was established not by imaging or intraoperative findings, but, rather, by the examination and comparison of patient’s blood, urine, and peritoneal fluid urea and creatinine levels, which, due to the patient’s delayed referral and sequent development of uroperitoneum and hyponatremic renal pseudofailure, were abnormal and characteristic of her medical condition. The patient was successfully managed conservatively and was discharged the sixth day after admission. Due to the rare nature of such medical condition and based on the relative literature, we propose a diagnostic and management algorithm for such cases.     

The Effects of Acute Renal Failure on Long-Term Renal Function

The relationship between acute renal failure (ARF) and long-term renal function remains unknown. We therefore undertook a study of patients at the Baltimore VA Hospital to examine the effects of a bout of acute renal injury on long-term renal function. We retrospectively reviewed the relationship between serum creatinine and time of observation for 6058 individuals who had values greater than 1.4 mg/dL in any two consecutive years. Individuals were stratified according to total years of observation with a minimum of two years. Severity of acute renal injury was divided into mild, moderate, and severe with elevations in baseline creatinine of <50%, 50–300% and >300% respectively. Sporadic elevations in creatinine were evident in 8–15% of the population. There were a total of 1328 episodes of acute renal failure in 916 patients that were suitable for analysis. Mild ARF on a substrate of normal or mildly abnormal renal function resolved without long-term sequelae. Moderate and severe ARF occurred more frequently on a background of reduced renal function but baseline function was retained in at least 60% of patients. We conclude that ARF is more frequent in patients with chronic kidney disease but it is not invariably associated with an accelerated course to end-stage renal disease or death. Overall, the majority of ARF events resolved without adverse long-term effects suggesting appropriate management in the majority of instances.     

肾活检在老年急性肾衰竭临床应用的探讨

目的：探讨肾活检术对老年急性肾衰竭的应用价值,提高老年急性肾衰竭的诊治水平。方法：66例不明原因老年急性肾衰竭均行实时超声引导肾自动穿刺活检术,分析其成功率、并发症,总结肾活检后诊断和治疗的修正率。结果：66例肾活检取材均成功;其中取材不良4例（6.1%）,取材良好62例（93.9%）;3例出现轻度并发症（4.5%）,其中肉眼血尿2例,肾周血肿1例,未出现严重并发症;66例中病因误诊19例,26例治疗方案有较大调整。结论：老年急性肾衰竭患者行经皮肾脏穿刺活检术安全且成功率高;相当部分老年急性肾衰竭病因被误诊,对不明原因老年急性肾衰竭应及时行肾活检术,以免延误诊治。     

表现为急性肾衰竭的IgA肾病11例临床与病理分析

目的：探讨IgA肾病并发急性肾衰竭(ARF)的临床与病理特点。方法：回顾分析11例IgA肾病并发ARF的临床与病理资料。结果：(1)本组11例IgA肾病患者并发ARF，占我院同期IgA肾病的1．28％(11／860)；(2)本组患者7例患者以浮肿、少尿为首发症状，3例以反复肉眼血尿为主诉、1例以恶性高血压为主要症状，6例患者蛋白尿≥2．0g／d；(3)肾活检示系膜增生性肾炎7例、新月体肾炎1例、增生硬化性肾炎伴新月体形成1例，余2例为In肾病的基础上伴发急性肾小管间质性肾炎。(4)本组资料中8例患者行激素加MP／CTX冲击治疗，4例予以单纯对症处理；8例肾功能恢复正常，1例肾功能部分缓解，2例患者肾功能进展行维持性透析治疗，总有效率为81．8％。结论：IgA肾病并发ARF发生率不低，病理可表现为多种病理类型，病理改变轻，预后好，多数患者肾功能可以恢复正常。