Electrophysiological studies on uremic patients-comparison of peritoneal dialysis and hemodialysis.
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Biomedical subjects
Publications and source records attributed to F del Greco.
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NAPA pharmacokinetics were studied in 6 functionally anephric patients. Distribution and nonrenal elimination of this drug were found to be the same as in individuals with normal renal function but renal clearance was reduced, resulting in a mean elimination t 1/2 of 41.9 hr (6.2 hr in normal subjects). Renal clearance of NAPA correlated well with ClCr. Dialysis removed NAPA from both red blood cells and plasma and increased ClT approximately fourfold. Dialysis itself resulted in a 77% reduction in ClS that limited the total amount of NAPA removed by this procedure. This reduction in ClS was sustained for at least 3 hr after dialysis and attenuated rebound in plasma NAPA concentrations.
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Fourteen cases of acute renal failure secondary to administration of radiographic contrast media were observed, eight within a 15-month period. No patient had multiple myeloma, and only three were diabetic. Predisposing factors included renal hypoperfusion, preexisting renal insufficiency, hyperuricemia, age of more than 60 years, solitary functioning kidney, and exposure to several contrast studies at closely spaced intervals. Control of blood volume and serum uric acid, appropriate spacing of radiographic studies, and possibly urinary alkalinization and hypouricosuric drugs in high-risk patients are recommended to decrease the incidence and morbidity of contrast-mediated nephropathy.
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Twice a wekk the dialysis was carried out for four hours, since a lack of personnel and institutions excluded a therapy repeated three times a week. The patients should optimally be treated for three hours three times a week. Patients dialysed by this means show favourable values of blood pressure under a minimum antihypertensive medication. They are less anaemic and in most cases more active than those patients who are dialysed twice a week. The use of the short time dialysis with capillary kidneys of a large surface increased the number of the patients treated and improved the functional capacity of the chronic dialysis programme.
A 67-yr-old woman who ingested approximately 7 gm procainamide developed severe hypotension, renal insufficiency, and life-threatening cardiac toxicity. Hemodialysis doubled the rate of procainamide elimination and increased fourfold the clearance of NAPA, the N-acetylated metabolite of procainamide. Observations of procainamide and N-acetylprocainamide (NAPA) plasma levels during the patient's recovery suggest that lethargy and profound hypotension can be expected when these levels total 60 mug/ml and that severe cardiac toxicity should be anticipated with levels totaling 42 mug/ml or more. Hemodialysis also permitted investigation of the effects of hypotension on the pharmacokinetics of these compounds. The apparent volume of procainamide distribution was reduced from a normal value of 2 L/kg to 0.76 L/kg, and that of NAPA from 1.4 L/kg to 0.63 L/kg. The elimination + 1/2 of procainamide was prolonged from the normal of 3 hr to 10.5 hr, and that of NAPA from 6 to 35.9 hr. Procainamide absorption was also slowed in this clinical setting, causing procainamide plasma levels to continue rising for some time after toxicity was first recognized.
Diuretics act primarily by blocking reabsorption of sodium at four major sites in the nephron. Clinically useful agents that block sodium reabsorption effectively in the proximal tubule are lacking. Furosemide (Lasix), ethacrynic acid (Edecrin), and possibly organomercurial agents are effective in the ascending limb of Henle's loop. Thiazides are the major agents acting in the early distal tubule. In the late distal tubule and collecting duct, spironolactone (Aldactone) and triamterene (Dyrenium) are useful, especially in combination with diuretics which act more proximally. In treating edematous states, initial therapy with thiazides is effective in most patients who do not exhibit moderate or severe renal insufficiency, severe hyperaldosteronism with excessive distal reabsorption of sodium in exchange for potassium, or excessive sodium reabsorption in the proximal tubule or ascending limb. Nonedematous states in which diuretic therapy is useful include hypertension, hypercalcemia, hypercalciuria, diabetes insipidus, and acute renal failure.
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