Effects of a low phosphorus, low nitrogen diet supplemented with essential amino acids and ketoanalogues on serum triglycerides of chronic uremic patients

The effects were studied of a vegetarian low-protein, low-phosphorus diet supplemented with essential amino acids and ketoanalogues and those of maintenance hemodialysis (MHD) and free diet on the serum triglycerides (STG) of 85 patients with chronic renal failure. Following dietary therapy STG decreased significantly in the 61 male patients (from 185.7 +/- 89.8 to 153.5 +/- 68.7 mg/dl; p less than 0.001), whereas in the females the decrease was not significant (from 189.1 +/- 83.9 to 167.0 +/- 62.2 mg/dl; NS). When patients changed to MHD therapy and free diet STG increased again. We can conclude that the correction of hypogonadism of chronic male uremics largely accounts for the improvement of hypertriglyceridemia, though other factors are likely to contribute.     

Episodic respiratory failure due to focal epileptic activity

We report on a patient with a complicated course after surgical abdominal intervention and episodic life threatening respiratory failures successfully treated with carbamazepine after diagnosis of a ponto-medullary lesion in the MRI.     

Therapy of suspected intrathoracic parathyroid adenomas

BACKGROUND AND AIMS: Ectopic mediastinal parathyroid adenoma as a cause of primary hyperparathyroidism (pHPT) can normally be resected from conventional collar incision. In rare cases with adenomas deeper in the chest, a transthoracic approach is necessary. PATIENTS/METHODS: We report our experience of 19 patients with suspected mediastinal parathyroid adenomas from a total of 1035 patients with pHPT who were operated on between 1986 and 2000 using an open approach (sternotomy or thoracotomy) or video-assisted mediastinal or thoracoscopic surgery (VAMS/VATS). RESULTS: Fourteen patients underwent an open approach with a success rate of 71% (10 of 14). Four patients remained hypercalcaemic. There were four complications in three patients: three permanent recurrent nerve palsies and one chylus fistula, requiring further surgery. VATS was successful in three of four patients with conversion to sternal splitting because of a false-negative frozen section in one patient. Another patient had parathyroid adenoma retrosternally which could not be resected by means of VAMS and had to be excised using a transsternal approach. There were no complications of minimal invasive procedures. All five patients were normocalcaemic after the operation. CONCLUSION: Ectopic parathyroid adenomas not resectable by means of a collar incision are rare causes of pHPT and comprise 1.25% of all patients with pHPT in our series. For these patients, VATS revealed an alternative to conventional open procedures. In questionable cases, however, the collar incision should precede the VATS procedure.     

Protection of renal function and of nutritional status in uremic rats by means of a low-protein, low-phosphorus supplemented diet

A low-protein, low-phosphorus diet supplemented with essential amino acids and keto analogues was given to 12 rats, starting from the 90th day after subtotal nephrectomy. The purpose was to assess its effect on the residual renal function and on the nutritional status in rats with already established severe renal failure. Ten control rats in the same conditions, following a standard diet supplying normal amounts of protein and phosphorus were also studied. The supplemented diet exerted a well-evident protection of residual renal function and structure: lower rate of decline of creatinine clearance, lower mortality, significant decrease of proteinuria and almost total absence of histological signs of activity. The nutritional status was also well protected by the dietary therapy: increase of body weight, normal values of total serum protein, and low-constant values of urea appearance. In the control rats body weight decreased, total serum protein was lower than normal and the values of urea appearance were increasing simultaneously with a decreasing food intake and body weight.     

Malignant endocrine tumors in patients with MEN 1 disease

BACKGROUND: In contrast with multiple endocrine neoplasia type 2, malignancies are of minor importance in multiple endocrine neoplasia type 1 (MEN 1) syndrome. METHODS: The data for 42 patients with MEN 1 syndrome were evaluated. Twelve patients (29%) had 1 or more associated malignancies: malignant gastrinoma (1 patient), neuroendocrine tumors of the thymus (2 patients), neuroendocrine tumors of the lung (3 patients), neuroendocrine tumor of the ileum (1 patient), adrenocortical carcinomas (2 patients), and a combination of neuroendocrine tumors of thymus, lung or pancreas (3 patients). RESULTS: Despite suspected MEN 1 syndrome in 7 patients, malignancies were detected late in 4 patients and could not be resected curatively. The survival rates for 5 years and 10 years after operation of the malignant tumor were 66% +/- 14% (SE) and 33% +/- 15% (SE), respectively. CONCLUSIONS: In patients at risk for the MEN 1 syndrome, genetic screening is indispensable. Gene carriers have to be followed up closely with hormone analysis and routine examination of the thorax, pancreas, and adrenal glands to detect malignancies as early as possible.     

Ultrasonic tissue characterization of the carotid artery in chronic renal failure patients

The ultrasonic reflectivity of the carotid wall, measured by means of integrated backscatter (IBS) analysis, has recently been evaluated in patients with atherosclerotic diseases and it was considered to be a prognostic marker. We performed B-mode measurement and IBS analysis of the carotid wall in 30 chronic renal failure (CRF) patients (serum creatinine 548 +/- 230 micromol/l) on conservative treatment and free of clinical evidence of cardiovascular complications; 14 were normotensives (NT) and 16 were treated hypertensives (TH). Thirty sex- and age-matched healthy subjects served as controls. The IBS carotid index was significantly higher in CRF patients than in controls (31.7 +/- 3.5 vs. 28.9 +/- 2.3 dB; p < 0.001), and no difference was observed between TH and NT CRF patients. The IBS index was negatively correlated with low-density lipoprotein cholesterol plasma levels (r = -0.46, p < 0.05), and within the group of TH CRF patients the IBS index was also negatively correlated with the body mass index and diastolic blood pressure. The carotid intima-media thickness was similar between uremic patients and controls. This study demonstrates an increment in carotid ultrasonic reflectivity in CRF patients, independent of the presence of overt atherosclerotic damage, and probably related to vascular remodelling linked to CRF. IBS analysis can be a useful tool to detect early changes in arterial wall structure. However, prospective studies should be planned to define its prognostic importance in uremic patients.     

Potential Benefits of Renal Diets on Cardiovascular Risk Factors in Chronic Kidney Disease Patients

Dietary manipulation, including protein, phosphorus, and sodium restriction, when coupled with the vegetarian nature of the renal diet and ketoacid supplementation can potentially exert a cardiovascular protective effect in chronic renal failure patients by acting on both traditional and nontraditional cardiovascular risk factors. Blood pressure control may be favored by the reduction of sodium intake and by the vegetarian nature of the diet, which is very important also for lowering serum cholesterol and improving plasma lipid profile. The low protein and phosphorus intake has a crucial role for reducing proteinuria and preventing and reversing hyperphosphatemia and secondary hyperparathyroidism, which are major causes of the vascular calcifications, cardiac damage, and mortality risk of uremic patients. The reduction of nitrogenous waste products and lowering of serum PTH levels may also help ameliorate insulin sensitivity and metabolic control in diabetic patients, as well as increase the responsiveness to erythropoietin therapy, thus allowing greater control of anemia. Protein-restricted diets may have also anti-inflammatory and anti-oxidant properties.

Thus, putting aside the still debatable effects on the progression of renal disease and the more admitted effects on uremic signs and symptoms, it is possible that a proper nutritional treatment early in the course of renal disease may be useful also to reduce the cardiovascular risk in the renal patient. However, conclusive data cannot yet be drawn because quality studies are lacking in this field; future studies should be planned to assess the effect of renal diets on hard outcomes, as cardiovascular events or mortality.     

Mild hydronephrosis after uncomplicated hysterectomy

Objective

To explore differences in the incidence of hydronephrosis following different hysterectomy methods for benign gynecological disease.

Study design

Retrospective chart review of ultrasound findings on all patients undergoing simple hysterectomy for benign gynecological pathology between July 2004 and September 2008. Elective renal ultrasonography was performed pre-operatively and within 3 days after hysterectomy as part of the routine follow-up in our hospital.

Results

Of 385 eligible patients, six were excluded because of pre-existing hydronephrosis or suspected intra-operative ureteral injury. In the resulting group of 379 patients, abdominal (33.3%), vaginal (11.8%) or laparoscopic hysterectomy (54.9%) was performed. The last group included total laparoscopic hysterectomy (TLH, 20.3%), laparoscopic supracervical hysterectomy (LASH, 19.3%), and laparoscopically assisted vaginal hysterectomy (LAVH, 15.3%). Overall, 56.7% of patients showed mild hydronephrosis (5–15 mm pelvicalyceal dilatation) after surgery. Mostly, it occurred unilaterally. The incidence varied according to the type of procedure, the highest being documented following vaginal hysterectomy (64.4%) and the lowest after LASH (46.6%), but this did not reach statistical significance.

Conclusion

Mild hydronephrosis is a frequent finding after uncomplicated hysterectomy for benign pathology in otherwise asymptomatic patients. Although not statistically significant, there may be variability of mild hydronephrosis depending on the hysterectomy method.