The recovery of the fluid balance after hemodialysis and hemofiltration.

Dialysis dysequilibrium syndrome is a frequent complication of renal replacement therapy and seems to be related to changes in fluid balance. From previous studies it is known that these changes are less pronounced during hemofiltration (HF), leading to a lower incidence of complaints compared to hemodialysis (HD). To assess the severity and duration of the dysequilibrium syndrome, intracellular (ICV) and extracellular fluid volumes (ECV) were measured during and after HD and HF by means of a non-invasive conductivity method. Blood volume changes were calculated from pre- and post-treatment erythrocyte counts. Seven HD and eight HF patients were studied. Ultrafiltration volume did not differ between both groups. Blood volume decrease was less during HF due to a significant decrease in ICV, the latter being in contrast to an ICV increment during HD. The significant decrease in ICV led to a less severe decrease in ECV (90 versus 85%). Overall, this resulted in a better vascular refill during HF. At the end of treatment ICV and ECV were not in equilibrium yet. During the recovery period ICV increased roughly 3% in the HF group. In the HD group some patients showed an increase while others showed a decrease in ICV. Overall, no change in ICV was noticed. During recovery ECV decreased further in both groups. The measured recovery period was significantly shorter after HF (245 +/- 68 min) than after HD (299 +/- 37), supporting the hypothesis that HF is a more physiological way of treatment compared to HD.     

κ I light chain AL amyloidosis presenting with rapidly progressive renal and hepatic failure with unusual renal amyloid distribution

A 65-year-old man suffering from generalized edema and jaundice was admitted to our hospital. Laboratory findings revealed marked renal dysfunction with heavy proteinuria as well as liver dysfunction with severe obstructive jaundice. On renal biopsy, the diagnosis of AL amyloidosis associated with κ I light chain was made. Interestingly, amyloid deposits were restricted to the glomeruli. Although hemodialysis was initiated, the patient died due to further deterioration of hepatic function. On autopsy, severe intrahepatic cholestasis was observed, and there was marked deposition of AL amyloid in the liver. Literature reviews showed that rapidly progressive renal failure is common in AL amyloidosis patients who presented with acute hepatic failure due to severe intrahepatic cholestasis. However, the detailed renal pathology in this condition has not been documented. The present case is very interesting because rapidly progressive renal and hepatic failure was simultaneously observed, and renal amyloid deposition was restricted to the glomeruli.     

Incidental67Ga uptake into an appendiceal mucocele in a patient with sigmoid colon cancer

We report a case of sigmoid colon cancer in which visualization of an appendiceal mucocele was unexpectedly found during⁶⁷Ga scintigraphy, and discuss a proposed mechanism of uptake.     

A case of cuff stenosis following tracheostomy responding well to T-tube stent insertion: with special reference to methods of dilating the stenosed site.

A 74-year-old man, receiving home oxygen therapy (HOT), required tracheal intubation and artificial ventilation because of methicillin-resistant staphylococcus aureus (MRSA)-induced pneumonia. Tracheostomy was additionally performed. One month later, he had recovered from pneumonia and the tracheostomy tube was withdrawn, allowing the patient to be discharged. One month after discharge, the patient began to complain of wheezing and difficulty in breathing and was thus admitted again to the hospital. Emergency bronchoscopy revealed cuff stenosis. A bronchofiberscope, 4.8 mm in outer diameter (o.d.), was unable to pass through the stenosed site. After the airway was secured by passing a Mini-Trach II tube (4.0 mm in inner diameter (i.d.) and 5.4 mm o.d.) through the stenosed site via the previous tracheostomy stoma, we changed the inserted tracheal tube every other day, replacing it each time with a tube of progressively larger i.d. and o.d. We went from 5.0 mm i.d. (6.9 mm o.d.) to 6.0 mm i.d. (8.2 mm o.d.), 7.0 mm i.d. (9.6 mm o.d.) and finally to 8.0 mm i.d. (10.9 mm o.d.). In this way, the stenosed site was gradually dilated. Finally, a silicon T-tube with 9.0 mm i.d. (11.0 mm o.d.) was inserted via the tracheostomy hole into the trachea and left there. At present, 2 years after the procedure, the patient is continuing HOT and is being followed at an outpatient internal medicine clinic. Cuff stenosis affects the trachea concentric-circumferentially and often relapses even after laser therapy. For these reasons, stent insertion is usually considered as necessary when dealing with cuff stenosis. Our technique of tracheal dilation is safe and simple, and does not require any special device or tool other than tracheal tubes. We report that silicon T-tube stents are optimal for treatment in cases of cuff stenosis.     

Citrate versus heparin anticoagulation in chronic haernodialysis patients

Anticoagulation with citrate at a rate of 0.68 mM/min in combinationwith a calcium and magnesium-free dialysate and i.v. supplementationof calcium and magnesium at rates of 0.18 mM/min and 0.08 mM/minrespectively, was compared with lowdose heparin. The heparindose was a loading dose of 2500 IU and a sustaining infusionof 750–1250 IU/h; or a loading dose of 1250 IU and a sustaininginfusion of 500–750 IU–h until I h before the endof the dialysis if the patlent was taking concomitantly coumarinanticoagulation for a Goretex shunt. Six chronic haemodialysispatients changed from heparin to citrate anticoagulation becausethey reported bleeding between dialyses. Heparin, after 2 hdialysis, induced a significant 10% prolongation of each patient'swholeblood activated clotting tlme (WBACT) as compared to thepredialysis value: while the WBACT at the dialyser outlet wasless than 3% prolonged as compared to the patient's WBACT. However,after 2 h cltratc the patient's WBACT was not prolonged butthe WBACT at the dialyser outlet was 20–100°A longer,indicating a better anticoagulation of the extracorporeal systemwithout systemic effects. With heparin the shunt pressure time(SPT). i.e. the time needed to stop bleeding from the puncturesites of the Goretex shunts. was 12 of 28 tlrnes 20 niln ormore Citrate reduced these episodes by 75%. Thus citrate should be considered for chronic haemodialysispatients who are at risk of bleeding because of the concomitantuse of anticoagulants. Other patients who could benefit fromcltrate are those with premorbid vascular abnormalities suchas intestinal arterlovenous malforniations. diabetic retinopathymalignant hypertension or adult polycystic kidney disease. Claimsthat cltrate gave improved biocompatibility. 1.e. less leukopeniaor thrombocytopenia. were not confirmed. lndications that citratecaused better dialysis efficiency were found. but should beconfirmed In a greater number of patients.     

Water Intoxication in a Schizophrenic Patient with Rhabdomyolysis

Abstract: We report a case of water intoxication in a 54-year-old female schizophrenic patient with rhabdomyolysis. She had been admitted to a mental hospital, and treated with spiperone 6 mg daily. On August 3, 1992, the coma following a convulsion occurred. Laboratory data initially showed marked hyponatremia and hypochloremia with decreased serum potassium, and a gradual increase in serum creatine phosphokinase (CPK). The elevation in serum CPK with marked hyponatremia observed in the present patient was probably caused by excessive drinking of water. In this patient, the CPK elevation revealed the rhabdomyolysis.     

Inhibition of metabolism of beta-alanine and D-beta-aminoisobutyric acid by D-cycloserine.

Significant increases in the concentrations of β-aminoisobutyric acid and β-alanine in the urine of patients under D-cycloserine treatment for tuberculosis were found during a study of biochemical changes caused by surgical operation. β-Alanine increased in all cases on the administration of cycloserine at a clinical dose. β-Aminoisobutyric acid excretion was increased by cycloserine treatment only in the genetic low excretors of this amino acid, but not in the high excretors who lack the degradative enzyme, D-β-aminoisobutyrate:pyruvate aminotransferase. Injection of cycloserine increased the concentrations of the amino acids in the liver of rats, and inhibited strongly D-β-aminoisobutyrate: pyruvate and β-alanine:α-ketoglutarate aminotransferases. The increase in the amino acids and the enzyme inhibition occurred after D-cycloserine disappeared from the liver. The inhibition was not caused by D-cycloserine itself, but by its metabolite, D-aminoxyalanine, which was isolated and identified from urine of rats after injection of D-cycloserine. The toxicity of D-aminoxyalanine was also determined using mice, and the relation with clinical toxic effects of D-cycloserine is discussed.