MULTIPLE MYELOMA WITH RENAL FAILURE A CASE FOR INTENSIVE TREATMENT

Abstract: A series of nine consecutive patients with multiple myeloma and renal failure is presented. All patients were treated with urinary alkalinisation with sodium bicarbonate and/or acetazolamide, diuresis with saline, mannitol and/or furosemide, pulse melphalan and prednisone and, where indicated, allopurinol and aluminium hydroxide. A substantial and sustained improvement in renal function has been achieved in all nine patients. Of five patients with a urea more than 25 mmol/L at presentation, the median survival to date is 64 weeks. Of these patients only one has died – not from renal failure but pneumonia, eighteen months after presentation. The others are alive and well. The results confirm the effectiveness of these measures in both improving renal function and prolonging survival, and suggest a more optimistic prognosis for patients with multiple myeloma and renal failure.     

连续性肾脏替代治疗与间歇性血液透析治疗重症急性肾衰的比较研究

目的：回顾性研究连续性肾脏替代治疗（ＣＲＲＴ）与间歇性血液透析（ＩＨＤ）治疗重症急性肾衰的疗效及影响预后的因素。方法：收集１９７８年１２月～１９９８年１２月住院的重症ＡＲＦ患者１９３例,其中１０１例行ＣＲＲＴ（ＣＲＲＴ组）,９２例行ＩＨＤ（ＩＨＤ组）,回顾性对比分析两组患者的临床资料、疗效和预后。结果：ＣＲＲＴ组６０例（５９４％）存活,４１例（４０６％）死亡,ＩＨＤ组５９例（６４１％）存活,３３例（３５９％）死亡,两组无差异,但ＣＲＲＴ组病情明显重于ＩＨＤ组：患者年龄更大,平均动脉压低,ＡＰＡＣＨＥⅡ积分高,衰竭器官数目多,需要机械通气和升压药物的患者数高于ＩＨＤ组（Ｐ＜００５）,ＣＲＲＴ组中存活者平均ＡＰＡＣＨＥⅡ积分与ＩＨＤ组死亡者相似。ＣＲＲＴ组血流动力学稳定,容量状态精确平衡,氮质血症控制更佳,ＡＲＦ持续时间缩短。结论：①重症ＡＲＦ的预后受年龄的影响,与原发病因和疾病严重程度有关;②ＣＲＲＴ治疗重症ＡＲＦ的疗效优于ＩＨＤ,能改善重症ＡＲＦ的预后。     

FIRST CASE OF AUTOCHTHONOUS HUMAN VISCERAL LEISHMANIASIS IN THE URBAN CENTER OF RIO DE JANEIRO: CASE REPORT

Visceral leishmaniasis is an anthropozoonosis that is caused by protozoa of the genus Leishmania, especially Leishmania (Leishmania) infantum, and is transmitted to humans by the bite of sandflies of the genus Lutzomyia, such as Lutzomyia longipalpis. There are many reservoirs, including Canis familiaris. It is a chronic infectious disease with systemic involvement that is characterized by three phases: the initial period, the state period and the final period. The main symptoms are fever, malnutrition, hepatosplenomegaly, and pancytopenia. This article reports a case of a patient diagnosed with visceral leishmaniasis in the final period following autochthonous transmission in the urban area of Rio de Janeiro. The case reported here is considered by the Municipal Civil Defense and Health Surveillance of Rio de Janeiro to be the first instance of autochthonous visceral leishmaniasis in humans in the urban area of this city. The patient was discharged and is undergoing a follow-up at the outpatient clinic, demonstrating clinical improvement.     

CASE STUDY OF A PATIENT WITH HIV-AIDS AND VISCERAL LEISHMANIASIS CO-INFECTION IN MULTIPLE EPISODES

SUMMARY

Report of a 45-year-old male farmer, a resident in the forest zone of Pernambuco, who was diagnosed with human immunodeficiency virus (HIV) in 1999 and treated using antiretroviral (ARV) drugs. In 2005, the first episode of visceral leishmaniasis (VL), as assessed by parasitological diagnosis of bone marrow aspirate, was recorded. When admitted to the hospital, the patient presented fever, hepatosplenomegaly, weight loss, and diarrhea. Since then, six additional episodes of VL occurred, with a frequency rate of one per year (2005-2012, except in 2008). In 2011, the patient presented a disseminated skin lesion caused by the amastigotes of Leishmania, as identified by histopathological assessment of skin biopsy samples. In 2005, he was treated with N-methyl-glucamine-antimony and amphotericin B deoxycholate. However, since 2006 because of a reported toxicity, the drug of choice was liposomal amphotericin B. As recommended by the Ministry of Health, this report emphasizes the need for HIV patients living in VL endemic areas to include this parasitosis in their follow-up protocol, particularly after the first infection of VL.     

HYPERCALCEMIA DURING RESOLUTION OF ACUTE RENAL FAILURE ASSOCIATED WITH RHABDOMYOLYSIS: EVIDENCE FOR SUPPRESSION OF PARATHYROID HORMONE AND CALCITRIOL

Hypercalcemia during the recovery phase of renal function is a relatively common complication of rhabdomyolysis-associated acute renal failure. The cause is unclear but it has been suggested recently that both hyperparathyroidism and high levels of calcitriol are implicated. We present evidence which does not support these hypotheses. (Aust NZ J Med 1986; 16: 506–508.)     

A TRANSIENT CIRCULATING ANTICOAGULANT LEADING TO ACUTE RENAL FAILURE

A case is reported of an extremely severe, transient, antithrombin-type anticoagulant, which resulted in gross hæmaturia, clot obstruction and acute renal failure. No cause for the appearance of the anticoagulant was discovered. The patient made a full recovery and remains well one year later. This is believed to be the first report of any circulating anticoagulant with such a transient course.     

连续性肾脏替代治疗对外周血细胞因子的影响

目的:研究连续性肾替代治疗(CRRT)对外周血中肿瘤坏死因子(TNF),白细胞介素-1β(IL-1β),白细胞介素-8(IL-8)和内皮衍生血管舒张因子(一氧化氮,NO)浓度的影响.方法:9例重症急性肾衰(ARF)患者在明确诊断之后行CRRT,每天持续10～12h.采用动静脉内瘘或中心静脉留置单针双腔导管建立血管通路,AK-10血泵建立体外循环,血滤器采用FH66D型(聚酰胺膜,0.6m2).治疗前和治疗1h,2h,3h,6h,9h和12h(或结束时)取血和超滤液检测TNF,IL-1β,IL-8和NO的浓度.结果:9例患者均存活且脱离肾脏替代治疗.四种细胞因子在超滤液中均未能检出.CRRT开始1h后外周血中TNF浓度轻度升高,但在治疗过程中缓慢降低,6h时达到最低水平,与治疗前和治疗1h相比差异显著(1064±522 ng/L比1678±789 ng/L和1722±735 ng/L,P值分别＜0.05和＜0.01),随后直到12h时,其浓度基本稳定无显著变化;IL-1β水在治疗后有下降趋势,6h降至最低值,但与治疗前相比差异不显著,6～12h间有所回升,IL-8浓度也呈同样变化趋势.NO水平在CRRT开始后亦缓慢降低,9h时达到最低值,但与治疗前相比差异不显著.结论:使用FH66D型血滤器行CRRT对各种细胞因子的清除效能不同:治疗6h时TNF水平显著降低,IL-1β、IL-8和NO水平在治疗过程中无显著变化;适时更换血滤器可能有助于这些介质的清除.     

WHY THE PERSISTENTLY HIGH MORTALITY IN ACUTE RENAL FAILURE ?

Data from 109 patients in established Summary acute renal failure, referred during the period January, 1969, to April, 1971, have been analysed. Mortality in this group of patients was distressingly high (57%) despite intensive dialysis and intensive general care. Sepsis still remains a major problem both as a precipitating and complicating factor in acute renal failure. Milder forms of renal failure were rarely referred to the unit during this period; most patients being older, more severely ill, and with prolonged oliguria. Since mortality increases with age, irrespective of precipitating cause, the greater age of the series probably accounts for much of the high mortality. Survival from acute renal failure in old patients who had just had surgical operations was rare, and it is in this area that most remains to be done. 29 patients with urine hypo-osmolar or isoosmolar plasma were given frusemide 500 mg. or 250 mg. intravenously; only 7 showed a diuresis, and this was sustained in only 3.     

杜氏利什曼原虫特异性kDNA片段扩增及用于内脏利什曼病诊断的研究

本文报道了用杜氏利什曼原虫特异的一对寡核苷酸引物Ⅰ和Ⅱ进行PCR,扩增微环kDNA分子上一种特异性kDNA片段,进行杜氏利什曼原虫虫种鉴定和病原体检测。敏感性分析表明用此法能够检测到的最低模板DNA需要量为1fg,检测健康犬全血稀释的利什曼原虫前鞭毛体,最低可达2个/ml。扩增六种不同的利什曼原虫kDNA样品,在L.donovani四川人株、四川犬株和L.infantum出现阳性产物,其长度和设计扩增长度一致,扩增产物和地高辛标记的重组质粒探针pLK2斑点杂交结果表明为利什曼原虫kDNA序列。应用此对引物,检测8份内脏利什曼病患者骨髓样品和4份血清样品,经琼脂糖凝胶电泳,Southern杂交证实,分别有7例和2例阳性,显示出可喜的应用前景。     

ACUTE RENAL FAILURE OCCURRING IN SCLERODERMA TREATED WITH CYCLOSPORIN A: A REPORT OF THREE CASES

Cyclosporin A, which is a nephrotoxic agent, has been a mainstayantirejection drug in heart, kidney and lung transplant programmesfor about 10 yr. Renal transplant physicians have become adeptin balancing its powerful immunosuppressive effects with itsundoubted potential nephrotoxicity. Here we report three ofeight systemic sclerosis (SSc) patients treated with cyclosporinA who developed acute renal failure. Consideration is givento the evidence of benefit from this agent in SSc and to themanagement of acute hypertensive renal failure in this disease. KEY WORDS: Systemic sclerosis, Connective tissue disease, Nephrotoxicity