Acute renal failure in the intensive care unit. Part 2.
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Acute Kidney Injury↗
Biomedical subjects
H L Corwin
Publications and source records attributed to H L Corwin.
The diagnosis of neoplasia in patients with asymptomatic microscopic hematuria: a decision analysis.
Clinical decision analysis and a computer model were used to evaluate the performance of alternative strategies for the diagnosis of neoplasia in adults with asymptomatic microscopic hematuria. Strategies consisted of sequences of diagnostic tests, including ultrasound, excretory urography, angiography, computerized tomography and cystoscopy. The strategies have a sensitivity of 98 to 100 per cent for bladder cancer and 90 to 94 per cent for renal carcinoma, and a specificity of 99 per cent. The cost per carcinoma diagnosed is $75,000 to $86,000 at 1 per cent prevalence and $5,000 to $5,800 at 15 per cent prevalence. Strategies using cystoscopy or ultrasound as the initial diagnostic test minimized cost and morbidity while maintaining diagnostic accuracy. Excretory urography does not add significantly to diagnostic accuracy but it does add to cost and morbidity.
Adult↗
Sarcoidosis presenting as acute renal failure during pregnancy.
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Acute Kidney Injury↗
The importance of sample size in the interpretation of the renal biopsy.
The number of abnormal glomeruli present in a renal biopsy can be viewed as a binomial distribution. Recognition of this fact permits a quantitative assessment of the effect of biopsy sample size in renal biopsy interpretation. If the percent of glomerular involvement in a biopsy is used to determine the severity of a focal glomerular lesion, a small biopsy sample size will lead to considerable misclassification of disease severity. In addition, a small biopsy sample size will make the exclusion of focal disease difficult.
Biopsy↗
Microscopic hematuria.
Microscopic hematuria is a common problem that may affect up to 13 per cent of the population. The number of RBCs identified in the urine sediment is dependent, in part, upon the technique used in performing the urinalysis. The exact number of RBCs normally excreted into the urine has been difficult to establish. However, three to eight RBCs per HPF would be accepted by most investigators as an acceptable dividing point between normal and abnormal hematuria. Although the prevalence of microscopic hematuria in the general population is high, the number of patients who have serious urologic disease is low. Many diagnostic algorithms are available for evaluating these patients, but at the present time there is still uncertainty regarding how extensive the evaluation should be for patients with asymptomatic microscopic hematuria.
Algorithms↗
Relationship of aluminum to neurocognitive dysfunction in chronic dialysis patients.
Aluminum has been proposed as the causative agent in dialysis encephalopathy syndrome. We prospectively assessed whether other, less severe, neuropsychologic abnormalities were also associated with aluminum. A total of 16 patients receiving chronic dialytic therapy were studied. The deferoxamine infusion test (DIT) was used to assess total body aluminum burden. Neurologic function was evaluated by quantitative measures of asterixis, myoclonus, motor strength, and sensation. Cognitive function was assessed by measures of dementia, memory, language, and depression. There were four patients with a positive DIT (greater than 125 micrograms/L increment in serum aluminum) that was associated with an increase in the number of neurologic abnormalities observed, as well as an increase in severity of myoclonus, asterixis, and lower extremity weakness. Patients with a positive DIT also showed significant impairment in memory; however, no differences were noted on tests of dementia, depression, or language. There was no significant correlation between sex, age, presence of diabetes, mode of dialysis, years of chronic renal failure, years of dialysis or years of aluminum ingestion and any neurologic or neurobehavioral measurement, serum aluminum level, or DIT. These changes may represent early aluminum-associated neurologic dysfunction.
Adult↗
Lupus optic neuritis with negative serology.
A 56-year-old woman with a 12-year history of systemic lupus erythematosus presented with severe optic-disc swelling and blepharitis. At the same time, she developed acute pancreatitis and ultimately died of gram-negative sepsis. Although it appeared that the ocular and systemic disorders were manifestations of lupus, her serum antinuclear antibody and complement levels remained normal throughout her hospital course. Optic neuritis may be secondary to lupus, but the diagnosis is difficult to make when the serology is negative.
Female↗
The prognosis of segmental glomerulonephritis in systemic lupus erythematosus.
Severe segmental glomerulonephritis (Seg GN) (greater than or equal to 50% involvement) in systemic lupus erythematosus (SLE) is classified as diffuse GN (DPGN) in the WHO classification. We tested the validity of the assumption that severe Seg GN and DPGN have the same prognosis by determining the proportion of glomeruli involved by active segmental inflammation in a series of 127 patients and by comparing the prognosis in various categories of Seg GN with patients with DPGN. In Seg GN we found mild involvement (1 to 19%) in 19 patients, moderate involvement (20 to 49%) in 9 patients and severe involvement (greater than or equal to 50%) in 17 patients. There were 28 cases of DPGN. The actuarial five-year survival of patients with mild and moderate Seg GN was 82%. The survival of patients with severe Seg GN and DPGN were 59 and 53%, respectively. The incidence of adverse outcomes, including death, end-stage kidney disease, and deterioration of renal function was similar in patients with severe Seg GN and DPGN, and greater than in patients with mild and moderate Seg GN. Although there was a trend associating increasing glomerular involvement with elevated urinary protein excretion and serum creatinine and decreased serum C3 and C4, the differences were not significant. Cumulative prednisone dose and prednisone given in the first and second years following biopsy were not different in the various categories of Seg GN and DPGN, suggesting that differences in outcome were not related to the amount of prednisone therapy.(ABSTRACT TRUNCATED AT 250 WORDS)
Biopsy↗
The clinical significance of eosinophiluria.
Eosinophils are normally absent from the urine. Their presence has been associated with a variety of clinical conditions affecting the kidney or urinary tract. The authors examined the clinical significance and eosinophils, in particular, for acute interstitial nephritis.
Acute Disease↗
Prediction of outcome in acute renal failure.
In an attempt to predict outcome in acute renal failure (ARF) we have utilized multiple logistic regression to analyze clinical data from 151 patients with ARF seen over a 15-month period. Recovery of renal function occurred in 60% of patients with a 58% survival. Our analysis demonstrated sepsis, respiratory failure, and oliguria to be the major predictors of nonrecovery of renal function. A logistic equation was generated for prediction of outcome and was validated in a second independent group of patients with ARF. Prediction of outcome could be achieved with a sensitivity of 75% and a specificity of 80%. Maximum sensitivity (100%) was associated with a 17% specificity, while maximum specificity (98%) yielded a sensitivity of 20%.
Acute Kidney Injury↗
Eosinophilia in the diagnosis of atheroembolic renal disease.
We report 6 patients with eosinophilia and atheroembolic renal disease. Histologic examination of biopsy of kidney or skin revealed extensive atheroembolic in the vasculature. However, no evidence of vascular or tubulointerstitial inflammation was observed. Eosinophil count ranged from 540 to 2,000 cells/mm3. Upon review of the literature, 80% (29 out of 36) of patients with adequately reported total and differential leukocyte counts had eosinophilia in association with atheroembolic disease. In contrast, review of the clinical records of 40 consecutive patients with acute renal failure seen during an 18-month period uncovered only 1 case of eosinophilia (2.5%). This latter patient was established as having acute interstitial nephritis. Thus eosinophilia appears to be a helpful diagnostic clue to the presence of atheroembolic renal disease.
Acute Kidney Injury↗
Pancreatic enzymes in chronic renal failure.
Serum was obtained from 55 patients, including 43 with stable chronic renal failure (CRF) (28 receiving chronic hemodialysis [CHD] and 15 receiving chronic ambulatory peritoneal dialysis [CAPD]), nine with peritonitis receiving CAPD, and three with pancreatitis receiving CAPD. Total serum amylase activity, lipase activity, isoamylase fractionation, and lipase concentration were used to measure pancreatic enzymes. Amylase activity was increased in 35 of 43 patients with CRF but was greater than threefold elevated in only three. Pancreatic isoamylase activity was greater than 80% in only one patient with CRF but was greater than 80% in all three patients with pancreatitis receiving CAPD. Lipase activity was increased in 26 patients and lipase concentration was elevated in 27. Peritoneal fluid from three patients with pancreatitis receiving CAPD contained high levels of amylase. Serum amylase and lipase are frequently elevated in patients with CRF in the absence of clinical pancreatitis. However, serum amylase activity greater than threefold elevated or the presence of pancreatic enzymes in the peritoneal fluid may suggest coexistent pancreatitis.
Amylases↗
Intraperitoneal hemorrhage associated with systemic lupus erythematosus.
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Adult↗
Acute renal failure.
ARF is a common clinical problem associated with significant morbidity and mortality. Therefore, rapid and accurate diagnosis is imperative. Initial diagnostic strategies should be directed toward distinguishing among prerenal, renal, and postrenal causes of ARF. This can be done by the use of urinary diagnostic indices in concert with radiologic investigation, renal biopsy, and hemodynamic monitoring when appropriate. Treatment of established ARF should be directed toward maintaining fluid and electrolyte homeostasis and controlling complications resulting from retained nitrogenous waste products. This may necessitate the aggressive use of dialysis. As yet, there is no proven means to prevent ARF or alter the course of ARF once it is established.
Acute Kidney Injury↗
Pernicious anemia associated with systemic lupus erythematosus.
We describe a young black female with systemic lupus erythematosus who developed pernicious anemia. She had a positive Schilling test which became normal after steroid therapy in spite of persistence of intrinsic factor antibody and depression of serum complement levels.
Adult↗
Encephalopathy in chronic renal failure responsive to deferoxamine therapy. Another manifestation of aluminum neurotoxicity.
We describe a patient undergoing chronic hemodialysis who developed a neurologic syndrome consisting of seizures, progressive myoclonus, and mild dementia and who responded to chelation therapy with deferoxamine mesylate. Neither her serum nor bone aluminum concentrations indicated aluminum toxicity. However, the presence of a positive deferoxamine-infusion test was suggestive of an elevated body burden of aluminum. Treatment with deferoxamine resulted in marked clinical improvement in her neurologic status within two months. The utility of using the deferoxamine-infusion test rather than serum aluminum levels in evaluating aluminum toxicity in chronic renal failure is suggested.
Aluminum↗
An improved technique for ultrasound guided percutaneous renal biopsy.
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Biopsy, Needle↗
Transient nephrogenic diabetes insipidus associated with pregnancy.
The coexistence of diabetes insipidus and pregnancy is uncommon and can be associated with worsening of the diabetes insipidus. We report a patient who developed a transient nephrogenic diabetes insipidus associated with a pregnancy complicated by preeclampsia. The diabetes insipidus resolved spontaneously within several days after delivery.
Adult↗