Aetiology and outcome of acute renal failure secondary to war related trauma and infectious disease in Croatia

Summary: The aim of our study was to explore the aetiology and the outcome of acute renal failure (ARF) during the war in Croatia. of the 2132 patients admitted to our hospital between April 1990 and November 1992 due to war related trauma, 11 (0.5%) developed ARF. We believe that the development of ARF in these patients was secondary to an overwhelming septic process. Most of our patients suffered from multiple organ failure. of the 11 patients suffering from ARF due to war related trauma only four recovered (63.6% had died). We attribute the lethal outcome to the progression of the septic process. Patients who developed ARF due to infectious diseases unrelated to trauma had a different prognosis. Acute renal failure caused by the Hantan virus ran a benign course, in both its oliguric and non-oliguric form. Patients who developed ARF as a complication of leptospirosis also had a good prognosis. Although ARF is usually of a multifactorial genesis, our study aimed to emphasize the importance of disseminated septic processes as a cause of ARF.     

Orthostatic acute renal failure in a renal transplant

Complications due to ureteric obstruction are an occasional cause for renal transplant dysfunction. Here we report an unusual case of orthostatic renal failure in a renal transplant recipient. Our patient had the previously reported predisposing risk factors including: female sex, obesity, and lax abdominal musculature. It is important to recognize this unusual complication of renal transplantation early in order to preserve long-term graft function. Received: 23 December 1996 Received after revision: 6 May 1997 Accepted: 13 May 1997     

Hot bath for the treatment of chronic renal failure

Background: Dialysis and its complications were debated recently. There was lack of an adjuvant renal replacement method to reduce the complications of patients with chronic renal failure and dialysis itself. Materials and methods: In this article, we reviewed the role of thermal sweating in treating of the patients with chronic renal failure, and the role of traditional Chinese medicine in the therapy of chronic kidney diseases. Results: Thermal sweating can reduce interdialytic weight gain and improve the patients’ blood pressure; Chinese herbal medicine can promote the excretion of uremic toxicities and relieve the skin disorders of these patients. Conclusions: Traditional Chinese medicine-mediated hot bath could be one of the adjuvant renal replacement methods.     

Post-liver transplant acute renal failure: factors predicting development of end-stage renal disease

BACKGROUND: Acute renal failure (ARF) occurs in 5-50% of patients undergoing orthotopic liver transplantation (OLT). The aim of this study was to determine factors that might predict the development of end stage renal disease (ESRD) in patients who had ARF after OLT. METHODS: We studied all OLT recipients between 9/1/1988 through 12/31/2000. RESULTS: A total of 1602 patients underwent OLT during the study period. About 350 patients (22%) developed ARF requiring dialysis post-operatively. One hundred and twenty-three (39.8%) died within a year after OLT. Median follow up was 5.8 yr (range 1-12 yr). Forty-three patients (23%) developed ESRD over median of 3.79 yr (range 1-8 yr). Multivariate logistic regression analysis revealed creatinine levels > 1.7 mg/dL at 1 yr (p < 0.001), cyclosporine as immunosuppression (p = 0.026), and the presence of diabetes pre-OLT (p < 0.001) to be associated with the development of ESRD. The development of ESRD did not decrease patient survival (p = 0.111). ESRD patients who received subsequent kidney transplantation had significantly improved survival rates (p = 0.005). CONCLUSIONS: Serum creatinine levels at 1 yr, cyclosporine as immunosuppression, and the presence of diabetes pre-OLT are independent predictive factors for the development of ESRD. ESRD patients who received kidney transplantation had higher 10-yr survival rates when compared with patients maintained on dialysis.     

Antenatal oligohydramnios of renal origin: long-term outcome.

BACKGROUND: Prognosis of fetuses with renal oligohydramnios (ROH) is often still regarded as poor. Neonatal complications and the long-term follow-up of fetuses with ROH in two pediatric centres are described. Method. 23 fetuses (16 males, 7 females) were included as patients. Primary diseases included congenital anomalies of the kidney and urinary tract (n = 16), autosomal recessive polycystic kidney disease (n = 4) and renal tubular dysgenesis (n = 3). The analysis includes retrospective chart review. RESULTS: Seven children died (30%), the majority (n = 4, 17%) within the neonatal period due to pulmonary hypoplasia and renal insufficiency. Fourteen patients (61%) required postnatal mechanical ventilation for a median of 4 (range 1-60) days; 11 infants had an associated pneumothorax. All 16 surviving children have chronic kidney disease (CKD) at a current median age of 5.7 years (range 0.5-14.5), managed conservatively in eight patients [median glomerular filtration rate 51 (range 20-78) ml/min/1.73 m(2)]. Eight patients reached end-stage renal disease at a median age of 0.3 years (range 2 days to 8.3 years), including one patient with pre-emptive kidney transplantation. Five of the patients requiring dialysis underwent successful renal transplantation at a median age of 3.5 years (range 2.5-4). Growth was impaired in seven children requiring growth hormone treatment. Cognitive and motor development was normal in 12 (75%) of the 16 patients and showed a delay in four children, including two with associated syndromal features. CONCLUSION: ROH is not always associated with a poor prognosis and long-term outcome in survivors is encouraging. The high incidence of neonatal complications and long-term morbidity due to CKD requires a multidisciplinary management of these children.     

Twelve years experience of acute renal failure in Taiwan

Summary: A retrospective analysis of the records of 287 patients diagnosed with acute renal failure (ARF) who were admitted between 1 January 1983 and 30 November 1994 to the emergency Service Department of the National Taiwan University Hospital, Taiwan was conducted. A total of 176 men (61.3%) and 111 women (38.7%) were surveyed. the classification of ARF by year revealed a progressive increase in case numbers. the majority (57.5%) of the patients were elderly, particularly in the years 1987-88 and 1993-94, the differences (aged compared with the young) being statistically significant. There were 176 patients (61.3%) in the pre-renal group (with evident intravascular volume depletion, haemodynamic instability or sepsis, with a urine excretion of sodium (FE_Na<1%), 43 (15%) in the renal group (urine analysis revealing protenuria, granular casts or/and tubular epithelial casts and without response to treatment of volume repletion), and 27 (9.4%) in the postrenal group (diagnosed when there were supporting image studies). Overall mortality was 63% and the pre-renal ARF patients had the poorest survival rate (25.6%). the classification of mortality rates by diagnostic category and year revealed a persistently high mortality rate. We conclude that: there are increasing patients with ARF each year; aged patients comprise the majority of cases; and the mortality rate remains high because of the high mortality rate of the pre-renal group, which was due to the presence of complicating underlying diseases and concomitant organ failure. the effects of having an ageing population were also apparent.     

Comparison of cellulose diacetate and polysulfone membranes in the outcome of acute renal failure. A prospective randomized study.

BACKGROUND: Whether the nature of haemodialysis (HD) membranes can influence the outcome of acute renal failure (ARF) remains debatable. Recent studies have suggested that dialysis with bioincompatible unsubstituted cellulosic membranes is associated with a less favourable patient outcome than dialysis with biocompatible synthetic membranes. Since we generally use a modified cellulosic membrane with substantially lower complement- and leukocyte-activating potential than cuprophane, for dialysis of patients with ARF, and because there are no data in the literature regarding the influence of modified cellulosic membranes on the outcome of patients with ARF, we compared the outcome of ARF patients dialysed either with cellulose diacetate or with a synthetic polysulfone membrane. We also investigated the potential role of permeability by comparing membranes with high-flux versus low-flux characteristics. METHODS: This prospective, randomized, single centre study included 159 patients with ARF requiring HD. Patients were stratified according to age, gender, and APACHE II score and then randomized in chronological order to one of three dialysis membranes: low-flux polysulfone, high-flux polysulfone and meltspun cellulose diacetate. RESULTS: Aetiologies of ARF and the prevalence of oliguria were similarly distributed among the three groups. There was no significant difference between the three groups for survival (multivariate Cox's proportional hazards model, P=0.57), time necessary to recover renal function (P=0.82), and number of dialysis sessions required before recovery (P=0.86). Multivariate analysis showed that survival was significantly influenced only by the severity of the disease state (APACHE III score, P<0.0001), but not by the nature of the dialysis membrane (P=0.57) or the presence of oliguria (P=0.24). CONCLUSIONS: Among patients with ARF requiring HD survival and recovery time are not significantly influenced by the use of either meltspun cellulose diacetate or the more biocompatible high-flux or low-flux polysulfone. Dialysis using modified cellulose membranes is just as effective as dialysis using synthetic polysulfone membranes, but at a lower cost. In addition, the flux of the membrane did not influence patient outcome.     

腹腔镜引导下腹膜透析管置放术

目的　探讨腹腔镜引导下放置腹膜透析管的方法。　方法　选择 9例慢性肾功能衰竭患者 ,在腹腔镜引导将Tenckhoff腹膜透析管置入腹腔并经皮下隧道引出。　结果　所有病例腹膜透析管均放置成功。手术时间 10min～ 2 0min。均成功的进行了腹膜透析。患者术后 2～ 7天出院。　结论　腹腔镜引导放置腹膜透析管技术具有透析管定位准确 ,手术切口小 ,术后疼痛轻。优于常规开腹技术     

The epidemiology of chronic renal failure and provision of renal services in Albania

Tirana, the only dialysis facility in Albania (pop 4 million),has a stock of 12 patients and three haemodialysis machines.To determine the need for renal services in Albania we studiedthe incidence and outcome of patients with chronic renal failure(CRF) referred to the renal service in Tirana (pop 300000) over1 year. Case-notes of all patients with a serum creatinine concentration300 µmol/l during the study period (1992) were examinedand outcome at 2 years recorded for each patient. In all, 84 patients (mean age 41.6±17.5 years, 56% male)were referred to nephrologists of whom 35 (42%) came from Tirana,giving an annual incidence of 116 per million pop. 77% wereunder 40 and had no co-morbid illness. Glomerulonephritis, themost common renal diagnosis, affected 26% patients. 22% patients(mean age 38±18.1) died within 2 years and only 5% receiveddialysis. The mean age of those who received dialysis was 29±8.3compared with those who were not dialysed (42±18.0).The 59 patients (24 from Tirana i.e. 80 per million) who werealive with advanced CRF (creatinine > 500) had a mean creatinineof 623±93 µmol/l and would be candidates for dialysis.Patients with progressive renal failure in Albania are regularlyfollowed and treated with antihy-pertensives and dietary modification.The need for RRT, however, is not being met even for young patientswith no co-morbidity.     

Effects of late referral to a nephrologist in patients with chronic renal failure

BACKGROUND: We lack information about the role of late diagnosis of end-stage renal disease (ESRD), late nephrological referral and its impact on biochemical variables and first hospitalization in East Anatolia, Turkey. METHODS AND RESULTS: For a total of 101 ESRD patients, dialysis was initiated between January 1998 and December 2002 at the Yuzuncu Yil University Hospital. Early referral (ER) and late referral (LR) were defined as the time of first referral or admission to a nephrologist greater or less than 12 weeks, respectively, before initiation of haemodialysis (HD). RESULTS: The need for urgent dialysis was less among the early referral cases compared with the late referral cases (P = 0.03). Patients with LR started dialysis with lower levels of haemoglobin (8.6 vs 9.5 g/dL, P < 0.05) bicarbonate (16 vs 12 mEq/lt, P < 0.03) and albumin (2.9 vs 3.29 mg/dL, P < 0.02) and with higher serum levels of blood urea nitrogen (173 vs 95 mg/dL, P < 0.001), creatinine (10 vs 7.9 mg/dL, P < 0.001) and potassium (5.3 vs 4.8, P < 0.04). Hospitalization duration beginning at dialysis was significantly longer in the LR group (27.3 +/- 24) compared with the ER group (13.4 +/- 7.5, P < 0.001). When the groups were compared in terms of distance between the patients home and hospital, there were significantly more patients living far away from hospital (i.e. >100 km) in the LR group compared with the ER (P < 0.0001) group. CONCLUSION: Early referral to a nephrology unit and/or early diagnosis of ESRD results in better biochemical variables, shorter first hospitalization length and a higher percentage of elective construction of AVF and the availability to start with an alternative dialysis modality (i.e. CAPD).     

Acute renal failure in infants in the tropics

This study records our experience with 40 infants who developed acute renal failure in a tropical environment over a period of 2 years. All the patients required intermittent peritoneal dialysis. Septicaemia (88%) and acute gastroenteritis (55%) constituted the leading causes of acute renal failure. Haemolytic uraemic syndrome was present in six (18%) patients. An elevated serum creatinine (85%), metabolic encephalopathy (75%), uncompensated metabolic acidosis (75%) and hyperkalaemia (48%) were the major indications for dialysis, while fluid overload was present in only 18% of the infants. Intermittent peritoneal dialysis was used in all the patients and was found to be effective. Procedural complications were minor and infrequently encountered. The clinical course and laboratory data consistent with haemolytic uraemic syndrome was observed in six patients, and acute tubular necrosis was the predominant renal lesion in the remainder. Mortality was 75%. The aetiology of acute renal failure in infants in the tropics differs significantly from that in the West, and even within a given country marked regional variations exist.     

Simultaneous heart and kidney transplantation in patients with end-stage heart and renal failure.

Combined simultaneous organ transplantation has become more common as selection criteria for transplantation have broadened. Broadening selection criteria is secondary to improved immunosuppression and surgical techniques. The kidney is the most common extrathoracic organ to be simultaneously transplanted with the heart. A series of 13 patients suffering from both end-stage heart and renal failure underwent 14 simultaneous heart and kidney transplantations at Temple University Hospital between 1990 and 1999. This is the largest series reported from a single center. Three patients died during the initial hospitalization for an in-hospital mortality of 21%. Of 10 patients who left the hospital, 1-year survival was 100% and 2-year survival 75%. One patient required retransplant for rejection within the first year. Overall mortality at 1 and 2 years was 25 and 41%, respectively. Four out of nine (44%) patients greater than 5 years post-transplant were alive. Of the 10 patients who left the hospital, 66% were alive at 5 years. One patient succumbed to primary nonfunction of the cardiac allograft, while the four other deaths were secondary to bacterial or fungal sepsis. The patient's racial backgrounds were equally divided between African-American and white. These results are similar to those reported in a United Network of Organ Sharing Database (UNOS) registry analysis of 84 simultaneous heart and kidney transplants that found 1- and 2-year survival to be 76 and 67%, respectively. Simultaneous heart and kidney transplantation continues to be a viable option for patients suffering from failure of these two organ systems, although the results do not match those of heart transplant alone.     

肾组织移植对慢性肾功能衰竭大鼠促红细胞生成素的调节作用

目的研究鼠婴肾组织移植于肾包膜下对促红细胞生成素的调节作用,为临床应用治疗肾性贫血提供理论依据。方法以Wistar雄性大鼠建立慢性肾功能衰竭动物模型为受体,将鼠婴肾组织块多点植入受体肾包膜下。治疗期间用EPO酶联免疫(ELISA)试剂盒测定血清EPO水平;观察肾组织病理改变,用免疫组化方法检测EPO在移植物中的表达。结果①60d时D组血清促红细胞生成素(1.768±0.140)mu/mL高于B组(1.160±0.324)mu/mL(P<0.01),与C组(2.329±0.125)mu/mL也有差异(P<0.05)。②移植后60d,移植物的体积由1mm3增至3-4mm3大小,表面血管网丰富,光镜下见肾小球、肾小管结构正常;③移植物EPO免疫组化,发现移植物EPO着色颗粒主要分布于肾皮质的肾小管,明显多于病例对照组大鼠肾组织(P<0.05)。结论通过对移植物的形态观察和功能测定,证明肾组织移植是一种有效的治疗手段,有可能为慢性肾性贫血提供一种新的途径。     

Significant benefits after renal transplantation in patients with chronic heart failure and chronic kidney disease

Background: Chronic heart failure (CHF) and chronic kidney disease (CKD) are serious medical conditions with significant morbidity and mortality and often coexist. Because of perioperative risks in these patients, they may not be considered a candidate for renal transplantation (RTx).

Material and methods: We compare retrospectively RTx outcomes [graft/patient survival, rejection rates and adverse cardiac events] in study group [low left ventricular ejection fraction (LVEF) ≤45% by echocardiogram, n?=?63] and control group [normal LVEF ≥50%, n?=?537] from a developing country.

Results: The mean EF was 35?±?5.6 and 57?±?3% for the study and control groups, respectively (p?Conclusion: RTx may play a role in reversing LV systolic dysfunction. Once thought by many to be a contraindication for renal transplantation, this appears not to be the case. The outcomes between the 2 groups are comparable and transplant is an option for even low EF patients.     

Pump-assisted hemofiltration in infants with acute renal failure

Hemofiltration is accepted management for acute renal failure in critically ill patients. However, in infants, obtaining arterial access or adequate flow through the access is often difficult. We report our technique and experience with pump-assisted hemofiltration (PAHF) in ten infants with acute renal failure. In five patients, doublelumen venous catheters provided access, while two catheters at separate sites were used in the remaining patients. In all patients, hemofilters were used with standard intravenous tubing added to pre-filter tubing and placed through a standard volumetric infusion pump for regulation of blood flow. The infants, aged 5–575 days, weighed from 2.8 to 11.4 kg and had primary diagnoses of post-operative congenitial heart disease in five, sepsis in four, and renal dysplasia in one. The duration of PAHF averaged 158±115 h (range 20–332 h). Complications included bleeding at a catheter or surgical site in one patient each and asymptomatic hyponatremia in five patients. Thus, with adequate nurse training, PAHF using a volumetric infusion pump for blood regulation can be acceptable therapy in acute renal failure in infants.     

Pediatric acute renal failure: outcome by modality and disease

Two hundred and twenty-six children who underwent renal replacement therapy (RRT) from 1992 to 1998 were retrospectively reviewed. The mean age, at the onset of RRT, was 74±11.7 months and weight was 25.3±9.7 kg. RRT therapies included hemofiltration (HF; n=106 children for an average of 8.7±2.3 days), hemodialysis (HD; n=61 children for an average of 9.5±1.7 days), and peritoneal dialysis (PD; n=59 children for an average of 9.6±2.1 days). Factors influencing patient survival included: (1) low blood pressure (BP) at onset of RRT (33% survival with low BP, vs 61% with normal BP, vs 100% with high BP; P<0.05), (2) use of pressors anytime during RRT (35% survival in those on pressors vs 89% survival in those not requiring pressors; P<0.01), (3) diagnosis (primary renal failure with a high likelihood of survival vs secondary renal failure; P<0.05), (4) RRT modality (40% survival with HF, vs 49% survival with PD, vs 81% survival with HD; P<0.01 HD vs PD or HF), and (5) pressor use was significantly higher in children on HF (74%) vs HD (33%) or PD (81%; P<0.05 HD vs HF or PD). In conclusion, pressor use has the greatest prediction of survival, rather than RRT modality. Patient survival in children with the need for RRT for ARF is similar to in adults and, as in adults, is best predicted by the underlying diagnosis and hemodynamic stability. Received: 15 February 2001 / Revised: 5 June 2001 / Accepted: 8 August 2001     

Endothelin in chronic renal failure.

The aims of the present study were to determine plasma endothelin (ET) in chronically uraemic patients, the renal clearance of endogenous ET in normal dog and man, and the effect of acute volaemic expansion on ET. The mean plasma ET concentration in haemodialysis patients was 57.5 +/- 5 pg/ml before haemodialysis and remained unchanged at 52.5 +/- 5 pg/ml after haemodialysis. They were thus significantly elevated both before and after haemodialysis (P less than 0.01) compared with plasma ET in normal subjects of 20.8 +/- 0.8 pg/ml. There was no evidence of ET clearance across the cuprophane membrane of the dialyser. Resting plasma ET values in the 15 non-dialysed uraemic patients ranged between 20 and 52.5 pg/ml (mean 38.2 +/- 2.3 pg/ml), significantly greater than those observed in controls (P less than 0.01). In CAPD patients, plasma ET was also significantly (P less than 0.01), elevated (63 +/- 10 pg/ml) when compared to controls, and similar to those observed in patients before haemodialysis. In dogs, mean ET did not diminish between the aorta and the renal vein (28.1 +/- 1 versus 28.4 +/- 2 pg/ml). In man mean ET did not significantly decline between the renal artery and the renal vein (17 +/- 3 to 13 +/- 0.8 pg/ml). In the seven healthy subjects who received 2000 ml of isotonic saline intravenously ET remained unchanged (24 +/- 2; 23 +/- 1 and 23 +/- 2 pg/ml before and 1 and 2 h after starting hydration respectively). We have thus shown that plasma ET is elevated in patients with chronic renal failure especially those on dialysis and CAPD.(ABSTRACT TRUNCATED AT 250 WORDS)     

Erythrocyte susceptibility to oxidative stress in chronic renal failure patients under different substitutive treatments

An increased oxidative stress is now considered one of the major risk factors in chronic renal failure (CRF) patients that may be exacerbated by dialysis. It has been postulated that this increased oxidative stress might cause an augmented red blood cell (RBC) membrane lipid peroxidation with the consequent alteration in membrane deformability. The aim of this study was to evaluate RBC susceptibility to an in vitro induced oxidative stress and RBC antioxidant potential in different groups of CRF patients undergoing different substitutive treatment modalities. Fifteen end-stage CRF patients were evaluated in conservative treatment, 23 hemodialysis (HD) patients, 15 continuous ambulatory peritoneal dialysis (CAPD) patients, 15 kidney transplanted patients, and 16 controls. Their RBCs were incubated with the oxidative stress-inducing agent tert-butylhydroperoxide both in the presence and in the absence of the catalase inhibitor sodium azide, and the level of malondialdehyde (MDA) (a product of lipid peroxidation), was measured at 0, 5, 10, 15, and 30 min of incubation. In addition, the RBC content of reduced glutathione (GSH) was measured by HPLC. As opposed to the controls, RBCs from end-stage CRF patients exhibited an increased sensitivity to oxidative stress induced in vitro, both in the absence and presence of a catalase inhibitor, as demonstrated by a significantly higher level of MDA production at all the incubation times (P < 0.05). Different substitutive treatments had different impacts on this phenomenon; CAPD and kidney transplantation were able to normalize this alteration while HD was not. GSH appeared to be related to the increase in RBC susceptibility to oxidative stress; its content being significantly elevated in end-stage CRF and HD patients as compared with CAPD and transplanted patients and controls (P < 0.05). No significant changes were observed in the RBC glutathione content during the HD session. The increase of GSH in RBCs of end-stage CRF and HD patients seems to indicate the existence of an adaptive mechanism under increased oxidative stress occurring in vivo. Unlike HD, the beneficial effect of CAPD on the anemia of dialysis patients might partly be due to a condition of lower oxidative stress that might in addition counterbalance the cardiovascular negative effects of dislipidemia of CAPD patients.     

Peritoneal dialysis for acute renal failure in children

Fifty infants and children with acute renal failure were treated with acute peritoneal dialysis between 1987 and 1990. The patients were dialyzed using either a catheter introduced percutaneously over a guide-wire (n=40) or a Tenckhoff catheter (n=10). The cause of the acute renal failure was primary renal disease in 17 children, cardiac disease in 19, and trauma/sepsis in 14. Peritoneal dialysis succeeded in controlling metabolic abnormalities, improving fluid balance, and relieving the complications of uremia. The procedure had few major complications. Overall mortality was 50%, reflecting the serious nature of the underlying diseases. We conclude that acute peritoneal dialysis is a safe and effective treatment in most pediatric patients with acute renal failure. Our series of patients treated with acute peritoneal dialysis serves as a basis of comparison for the evaluation of new modalities of therapy in childhood acute renal failure.