摘要:

A 47‐year‐old male was admitted to the hospital because of progressive dyspnea leading to orthopnea. He had a history of insulin‐dependent diabetes mellitus for 23 years with nephropathy and mild renal insufficiency for two years. The patient had undergone triple vessel coronary artery bypass surgery five years prior. Ischemic cardiomyopathy was diagnosed two years previously when heart failure led to multiple hospital admissions. During the past year, congestive heart failure (CHF) was treated with increasing doses of furosemide (maximum 160 mg) and metolazone (10 mg), intermittent intravenous dobutamine, and amrinone infusions. A short trial of an angiotensin converting enzyme (ACE) inhibitor (captopril 12.5–50 mg/day) resulted in hyperkalemia and deterioration of renal function.On admission to the hospital, physical examination revealed a well‐developed and well‐nourished male in respiratory distress. Supine blood pressure was 90/60 mmHg. Jugular veins were distended up to the jaw. Heart rate was 90/min, regular. Heart sounds were distant but an S3 gallop was heard. Wet rales were heard bilaterally over the lungs. Liver was enlarged below the costal margin and was tender to touch. Pitting edema was present in both lower extremities up to the knees.Laboratory data: serum sodium was 130 mEq/l, potassium 5.7 mEq/l, blood urea nitrogen (BUN) 59 mg%, serum creatinine 4.9 mg%, hemoglobin 11.2 gm%. Chest X ray revealed cardiomegaly and pulmonary vascular congestion. EKG showed a normal sinus rhythm with first degree heart block and a left bundle branch block. Echocardiogram revealed moderate left ventricular dilation, moderate global hypokinesia, estimated left ventricular ejection fraction of 20%, mild right ventricular dilation, mild right atrial dilation, mitral regurgitation, and no pericardial effusion. The patient exercised for 4 min and 22 sec in a modified Naughton protocol. Heart response to exercise was accentuated and blood pressure response was flat.The patient received 200 mg of IV furosemide and 5 mg of metolazone with an increase in urine output of only 200 cc over a 2‐hr period. In a 24‐hr urine, output was only 950 cc. Urine sodium was 18 mEq/l, potassium 39 mEq/l, and osmolality 310 mOsm/kg. Because of the continued dyspnea and an arterial oxygen saturation of 68% despite 100% oxygen via face mask, the patient was subjected to 3 hr of isolated ultrafiltration using a femoral Quinton catheter. Three liters of fluid were removed with a drop in pulmonary wedge pressure to 20 from 27 mmHg. Subjectively, the patient started breathing better. Oxygen saturation improved. However, no increase in urine output was observed during the next 48 hr. The symptoms of CHF recurred. Isolated ultrafiltration was repeated with good result.Over the next week, it became apparent that the patient was dependent on ultrafiltration to maintain a symptom‐free status. It was decided to put the patient on chronic dialysis because of chronic renal failure and chronic heart failure. Following multiple discussions with the dialysis educator, the patient chose continuous ambulatory peritoneal dialysis (CAPD) as the form of chronic renal re

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00921.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

This 72‐year‐old white woman with diabetes mellitus (Type II) and ischemic cardiomyopathy was referred for evaluation on the day she was discharged from hospital, November 10, 1992. She was referred by her cardiologist for help managing recurrent episodes of congestive heart failure (CHF) complicated by moderate renal failure, both due to diabetes. In the preceding five months, control of heart failure required multiple visits to the cardiologist and five hospital admissions, for a total of 32 hospital days. The inttrval between admissions was becoming progressively shorter—the last two just 10 days apart. In spite of bumetanide 4 mg qid, metolazone 10 mg qod, Lanoxicaps 0.05 mg qd, hydralazine 25 mg qid, clonidine 0.2 mg tid, and Procardia 60 mg XL qd, the patient would leave the hospital only to experience rapid return of edema, progressive dyspnea on exertion and a nonproductive cough. She always slept on three pillows and was never able to life flat. Review of systems disclosed no symptoms of uremia except perhaps a poor appetite. Past medical history included Type II diabetes mellitus, since 1967; coronary artery bypass grafts in 1983 and 1988; left hemicolectomy for adenocarcinoma, Duke's grade C, 1990 with normal colonoscopy July 1992. Because of a neurogenic bladder, the patient performed self catheterization intermittently. In the more distant past she also had a cholecystectomy, appendectomy, and total abdominal hysterectomy.Physical examination revealed an elderly individual whose neck veins were visible to the angle of the jaw when sitting. Her weight was 66.8 kg, height 165 cm, and blood pressure 150/72 supine and afier 2 min of standing. The lungs were clear to auscultation. No pericardial rub was present. The liver span was 15 cm. No bruit was present and the spleen was not palpable or percussable. Well‐healed right subcostal, right paramedian and infraumbilical (umbilicus to pubis) scars marked her previous surgical procedures. Marked edema was present to above both knees. No asterixis, myoclonus, or fetor uremicus were detected.Laboratory results: April 9, 1992—‐BUN 95 mg/dl, creatinine 4.3 mg/dl, sodium 138 mEq/l, potassium 4.1 mEq/l. chloride 102 mEq/l, total CO228 mEq/l; April 4, 1992—‐albumin 3.2 g/d, total protein 6.4 g/d, cholesterol 173 mg/d, WBC 5,400, lymphocytes 17%, total lymphocyte count 900 cells/mcl.The advantages and disadvantages of hemodialysis and peritoneal dialysis were discussed with the patient and her family. Continuous Ambulatory Peritoneal Dialysis (CAPD) was encouraged because of the continuous ultrafiltration. The potential difficulty in placing the catheter because of multiple prior surgical procedures was explained. The patient elected to try CAPD. A single cuff, curled Tenckhoff peritoneal dialysis catheter was placed laparoscopically by a surgeon in the operating room on November 18, 1992. The catheter placement went without incident and the patient was discharged the same day. Intermittent peritoneal dialysis was started the next day and continued for about 8 hr/day thrice weekly with 1 then 1.5 l exchanges to allow time for wound healing while providing help with volume control. CAPD training was carried out from December 7 to 10. By December 16, her weight was down to 57.3 kg, a loss of 10 kg.As of her clinic visit of April 23, 1993, she had no hospital admissions since November 10, 1992, except for the dialysis catheter insertion. Although she still sleeps on three pillows, the neck veins are flat at a head elevation of 30 degrees and there is no orthopnea or change in respiratory rate lying flat. Ankle edema is again 4 + at 68 kg. Appetite has improved and she attributes part of her increased weight to increased (oral) calorie intake resulting from improved breathing. The dialysis catheter has continued to function well, and no catheter related complications have developed. The 2 l intraperitoneal dialysate volume has not caused any symptoms. The only cardiac or antihypertensive medications are Procardia 60 mg XL and Lanoxi

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00922.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

A 25‐year‐old man with end‐stage renal disease (ESRD) secondary to obstructive uropathy suffered a generalized tonic‐clonic seizure 3 hr after a routine hemodialysis treatment. The associated conditions included well‐controlled mild hypertension and typical anemia of renal disease. There was no prior history of seizures, loss of consciousness, headaches, tremor, symptomatic neuropathy, or notable head trauma. His medications included nifedipine, recombinant erythropoietin, ferrous sulfate, folate, calcitriol, aluminum hydroxide, and calcium carbonate.Physical examination was remarkable only for the presence of a grade I/VI systolic ejection murmur and a patent dialysis access in the left arm. Routine predialysis laboratory data obtained two weeks previously revealed the following: Na 141, K 4.9, Cl 112, CO213 (all electrolyte values are mmol/ l), blood urea nitrogen (BUN) 68 mg/dl, calcium 6.8 mg/dl, phosphorus 4.6 mg/dl, albumin 3.5 g/dl, hematocrit 29, aluminum<1 μg/l. The electrocardiogram was within normal limits.On the day of admission the patient underwent a routine dialysis treatment for 3 hr using a new cellulose acetate dialyzer, bicarbonate‐based dialysate containing potassium 1 mmol/l and calcium 2.5 mmol/l. The patient was well and asymptomatic during dialysis, and his arterial blood pressure was stable at approximately 140/90 mm Hg.Three hours after leaving the dialysis center, he began to experience facial twitching and numbness in his fingers, followed by a single 30‐sec generalized tonic‐clonic seizure. Upon arrival at the emergency department, he was alert and oriented, and complained only of paresthesias in his hands. Review of his medications revealed that he had failed to take the prescribed calcitriol and calcium carbonate for several weeks. Physical examination was unchanged from the previous evaluation except for the presence of Chvostek and Trousseau signs. Laboratory studies revealed the following: Na 145, K 4.6, Cl 110, CO227 (all electrolyte values are mmol/l), BUN 43 mg/dl, glucose 100 mg/dl, albumin 4.9 g/dl, total Ca 7.5 mg/dl, ionized Ca 3.0 mg/dl, magnesium 3.0 mg/dl, and phosphorus 7.0 mg/dl. EKG was normal except for a prolonged QT interval.Upon admission to the hospital, the patient was treated with intravenous calcium gluconate, followed by oral calcium carbonate and calcitriol. Within 48 hr, the patient's serum total and ionized calcium concentrations increased to 8.5 and 4.0 mg/dl, respectively. A CT scan of the head showed no abnormalities. The seizure was felt to be due to hypocalcemia, exacerbated by rapid correction of acidosis with dialysis, leading to further reduction in the ionized calcium concentration. The observed hypocalcemia was attributable to the patient's discontinuation or oral calcium and calcitriol and the absence of a high calcium dialysate, which is appropriate when combined with calcitriol and calcium supplementation, but necessary in their absence. Since discharge, the patient has experienced no further seizure activity and with consistent use of the prescribed oral calcium and calcitriol, his serum calcium has remained above 8 mg/dl, with phosphorus levels rangin

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00923.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

A 55‐year‐old African‐American hemodialysis patient presented to the emergency room with complaints of nausea and vomiting. The patient had been on hemodialysis for two years secondary to diabetic nephropathy. Her baseline blood pressure was approximately 120/70 mm Hg on no antihypertensive medications. Five months previously, she was started on erythropoietin, 2000 units subcutaneously twice weekly, at which time her hematocrit was 23%. Her erythropoietin dose was gradually increased to 3500 units subcutaneously thrice weekly two months prior to admission. With this dosage, her hematocrit increased to 31%. Several weeks prior to admission, the patient's calcium carbonate was increased to correct a rising serum phosphate. In the emergency room her physical examination was remarkable for a blood pressure of 196/94 mm Hg. Funduscopic examination showed changes consistent with diabetic retinopathy but no evidence of papilledema or hemorrhages. Neurologic examination was nonfocal. An electrolyte panel revealed a serum sodium of 139 mEq/1, potassium 4.8 mEq/l, chloride 98 mEq/l, total CO229 mEq/l, blood urea nitrogen (BUN) 50 mg/dl, creatinine 11.4 mg/dl, glucose 125 mg/dl, calcium 13.6 mg/dl, phosphate 5.7 mg/dl, and albumin 4.2 mg/dl.While in the emergency room, the patient sustained a generalized tonic‐clonic seizure. Seizure activity ceased with the administration of diazepam 5 mg intravenously. Electrolytes were repeated immediately after the seizure, with sodium 137 mEq/l, potassium 4.6 mEq/l, chloride 98 mEq/l, and total CO217 mEq/l. Three hours later, electrolytes were again repeated, showing a sodium of 133 mEq/l, potassium 6.0 mEq/l, chloride 100 mEq/l, and total CO226 mEq/l. She was admitted for further evaluation. Phenytoin was begun at 100 mg po tid, and the patient had no further seizures. Without intervention, her blood pressure decreased to 114/70, which was stable over the next several days. Head computerized axial tomographic (CAT) scan, lumbar puncture, and electroencephalogram (EEG) were all unremarkable. The intact PTH level returned at less than 15 pg/ml, and the aluminum level was 14 mcg/ml. Hypercalcemia was treated with intravenous etidronate followed by adjusting the patient's calcium carbonate regimen. Over the next several months, phenytoin was withdrawn, and erythropoietin reintroduced. The patient has remained seizure‐free and normocalcemic over the following twel

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00924.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

A 60‐year‐old African‐American man was admitted to the hospital in October 1991 with seizures and right hemiparesis. He had end‐stage renal disease (ESRD), presumed due to hypertension and/or analgesic nephropathy, and had been on maintenance hemodialysis since July 1987. Noncontrast CAT of the brain revealed mild cortical atrophy and non‐specific while matter ischemic changes. Contrast CAT showed a right hemisphere CVA, and magnetic resonance imaging (MRI) suggested a right frontal meningioma. Cerebral arteriogram was confirmatory, and he underwent resection of the fronto‐parietal tumor in early November 1991.Past medical history included over 20 years of hypertension, angina for five years, gout, and peptic ulcer disease. Cardiovascular evaluation of exertional dyspnea and bilateral calf weakness included a negative thallium stress test and minimal to moderate flow impairment of tibial‐peroneal vessels by Doppler. Low iron stores led to upper and lower endoscopy and a colonic polypectomy. There was a question of an allergic reaction to intravenous iron administration (the patient reported lip swelling), and erythropoietin therapy was started in December 1990 (starting hematocrit was 23%).Hemodialysis access was achieved via a Brescia‐Cimino arteriovenous fistula in his left arm, which developed extensive upper arm and shoulder collaterals, leading to a fistulogram and a diagnosis of subclavian stenosis in January 1989. Angioplasty was successful, and repeat fistulogram was unremarkable in February 1991. Blood pressure control was usually adequate, ranging from 140–180/80–100 on diltiazem, clonidine, and captopril. Occasional elevation to 210/120 were seen. In the months prior to the seizure, his treatments were adjusted because of lowKt/V (by increased dialyzer surface area and increased time). Hematocrit had risen to 30%‐33% with erythropoietin therapy (2000 Units thrice weekly). Hemodialysis was accomplished without heparin use, due to his gastrointestinal bleeding history. He was felt to be gaining “flesh” weight.In late March 1992, he had a tonic‐clonic seizure. Repeat CAT scan of the brain was unchanged. He was started on phenytoin thrice daily, but he discontinued therapy and had two more seizures (with negligible serum levels of phenytoin) in April 1992. In May, he was readmitted after another tonic‐clonic seizure. Phenytoin levels were in the therapeutic range, and CAT scan was again unchanged.Phenobarbital was added to his regimen. Drowsiness limited his compliance, and he had several additional seizures. In late July, he suffered a respiratory a

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00925.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

L. G. is a 37‐year‐old black female, first seen in the Nephrology Clinic in May 1987 with a serum creatinine of 3.7 mg/dl. Ultrasound studies revealed bilaterally contracted kidneys. Over the next 18 months, the patient's renal function continued to deteriorate and she was started on hemodialysis. She stayed on hemodialysis for about one year but finally changed to continuous ambulatory peritoneal dialysis (CAPD) because of multiple vascular access problems. Over the next two and a half years the patient did well on CAPD. Then on a routine breast self‐examination, she discovered a firm, approximately 1.5 cm mass below the right nipple. A mammogram was done which revealed the lesion to be suspicious for malignancy. Biopsy of the lesion revealed a poorly differentiated mammary carcinoma. The patient subsequently underwent a right mastectomy without complication.Past medical history includes cholecystectomy which was done about seven years previously, and an abnormal Tiberoxime Stress Test, but a normal coronary angiogram done as part of her renal transplant evaluation. About four years ago, the patient complained of swelling in the right breast. She was seen by a surgeon and had a mammogram performed which was normal. She had a follow‐up mammogram in 1991 which was again

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00926.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

A 77‐year‐old black female began in‐center hemodialysis in early 1992 because of hypertensive nephrosclerosis. Her past medical history was significant only for a pericardial window done in 1990 because of pericarditis of unknown etiology. Cultures of the pericardial sac and fluid were negative for bacteria and tuberculosis (TB). There was no history of exposure to TB‐She was anergic to both purified protein derivative (PPD) andCandidaskin tests. The patient tolerated dialysis well and gained 2 kg in five months. At that time she complained of severe pain and swelling over her proximal right thumb. She denied a history of trauma. On examination she was afebrile and not ill‐appearing. There was no adenopathy, hepatosplenomegaly, or ascites. The proximal thumb was swollen and tender to palpation but not warm or erythematous. The white cell count, liver function tests, and radiographs of the chest and hand were all negative. Observation and acetaminophen were recommended. The pain worsened but the examination and laboratory findings were unchanged. A repeat hand radiograph showed destruction of the proximal phalanx, consistent with osteomyelitis. Repeat skin tests for TB andCandidawere negative. The patient promptly underwent surgical curettage of the phalanx. The stains were negative for bacteria and mycobacteria, however, the cultures grewM. tuberculosis.She was begun on isoniazid 300 mg/ day, rifampin 600 mg/day, pyrazinamide 600 mg/ day and pyridoxine 50 mg/day with subsequent improvement in her signs and

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00927.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

A 43‐year‐old white female with end‐stage renal disease (ESRD)from idiopathic membranoproliferative glomerulonephritis has been on hemodialysis for three years. Past medical history is unremarkable except for hypertension. Family history is negative. The patient dialyzes thrice weekly with infrequent side effects and works full time as a graphic designer. Menstruation is regular with occasional heavy

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00928.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00929.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

M. D., a 62‐year‐old female with renal disease secondary to bilateral polycystic kidneys and hypertension, opted for continuous ambulatory peritoneal diaiysis (CAPD) when her renal function deteriorated (24‐hr urinary creatinine clearance of 6.8 ml/ min in a total urinary volume of 1200 ml) and uremic symptoms developed. The patient lived about a 3‐hr drive from the nearest dialysis center. This factor weighed heavily in the patient's decision to choose home dialysis.A Swan Neck Missouri peritoneal dialysis catheter was inserted by a surgeon under local anesthesia with no complications. Since the patient was symptomatic from the uremia, peritoneal dialysis using a cycler in the supine position was initiated about 18 hr after the catheter insertion. To avoid dialysis solution leak from the incision site, 1 1 volumes per exchange and a 0.5‐hr cycle time were chosen. The cycler dialysis continued for 36 hr. The amount of ultrafiltration achieved was 2200 ml. The patient received two additional treatments using cycler dialysis during the next seven days before CAPD training was begun. CAPD training was accomplished in five working days. A baseline peritoneal equilibration test (PET) was carried out and thr residual renal function was determined. Based on the D/P creatinine ratio and the glucose results of the PET, the patient was classified as having a high peritoneal membrane transport rate. The renal creatinine and urea clearances were 5.7 and 4.2 ml/min, respectively (24‐hr urine volume

ISSN:0894-0959    

DOI:10.1111/j.1525-139X.1994.tb00930.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY