Urinary tract infection in oliguric patients with chronic renal failure

We studied 182 patients with chronic renal failure by urinalysis and urine cultures. Of the patients 27 per cent had significant bacteriuria (more than 10(5) per ml.), 38 per cent had significant pyuria (more than 10 white blood cells per high power field), 19 per cent had urinary tract infection and 7 per cent had symptomatic urinary tract infection. All 12 patients with symptomatic urinary tract infection had significant bacteriuria and 11 had significant pyuria, while 1 had 5 to 10 white blood cells per high power field. Incidences of urinary tract infection differed depending on the primary renal disease (12, 13, 41 and 67 per cent for chronic glomerulonephritis, diabetic nephropathy, polycystic kidney and chronic pyelonephritis, respectively). Among the patients with chronic glomerulonephritis no significant differences were seen in frequencies of bacteriuria and urinary tract infection between male and female patients or between those who did and did not undergo hemodialysis. Also, no significant correlation was seen between bacteriuria and daily urine output but pyuria was significantly more frequent in oliguric patients or those on hemodialysis.

[Oliguric and non-oliguric renal failure in high risk patient in intensive care units (author's transl)]

Oliguric and non-oliguric acute renal failure was studied in a group of 28 high risk patients in an intensive care unit. Of these, 15 (53.5%) presented oliguric and 13 (46.4%) non oliguric acute renal failure. Causal agents of the renal failure were postoperative in 14 cases, mainly peritonitis; medical in 10 and posttraumatic in 4. Oliguric renal failure was most commonly medical, while non-oliguric renal failure was predominantly postoperative in origin (p less than 0.05). Results of urinalysis indicative of renal failure were similar in both groups: NAO, osmolarity, FeNa, BUN o/p and creatinine o/p, as were degree and course of renal failure, and the appearance of complications and indications for dialysis. There was no significant difference in mortality rate between oliguric (93%) and non-oliguric (85%) patients; total mortality was 89%. The results of this study clearly show that non-oliguric acute renal failure carries the same poor prognosis in high risk patients in intensive care units as do the oliguric forms of the entity.

Disturbance of serum lipid metabolism in acute renal failure

Serial studies of serum lipids were performed on five patients with acute renal failure (ARF) due to five different causes (Of five patients one did not achieve complete recovery.). There were striking alterations in serum lipid levels at the period of oliguria in all patients, characterized by an increase in triglycerides (TG) and an extreme decrease in HDL-cholesterol (HDL-C). These conditions gradually returned to normal as the patients improved. The restoration to normal of the altered lipid levels were preceded by normalization of serum creatinine (S-Cr) and followed by creatinine clearance (Ccr). These fluctuational patterns of the lipid levels in the course of illness were observed similarly in all patients who recovered, despite the difference in the cause of their diseases. Improvement of the lipid metabolism was not observed in the one patient who did not recover. These results suggest that the alteration in lipid metabolism of ARF is due to renal impairment and not related to uremic state per se.

Renal hemodynamics in oliguric and nonoliguric acute renal failure of rabbits

The role of renal hemodynamic alterations in the curtailment of renal functions was studied in uranyl acetate-induced oliguric (ORF) and nonoliguric (NORF) renal failures of rabbits. 5 days after drug injection, renal functional and morphological changes were most remarkable. A depression of Cin and elevation of serum creatinine concentration were more marked in ORF than in NORF. Renal blood flow was high as compared to controls. Cortical blood flow redistributed to the inner cortex. There was no significant difference in renal blood flow or cortical flow distribution between renal failure models. The findings suggest the minor roles of renal blood flow and cortical flow distribution in maintaining renal failure in these nephrotoxic models. Prominent tubular necrosis was found in ORF but not in NORF. Arterial inulin concentration during retrograde ureteral infusion of 14C-inulin solution was significantly high in ORF as compared to controls and NORF. However, this inulin leakage was too small to explain severely curtailed inulin clearance.

Isolated ultrafiltration in the therapy of volume overload accompanying oliguric vascular shock states

Isolated ultrafiltration (removal of plasma water and solute without dialysis) was used as a "last resort" therapy in three patients with diuretic and pressor resistant oliguria complicating severe volume overload and vascular shock. The improvement in clinical and hemodynamic parameters is reported and the possible mechanisms of action (decreased pulmonary capillary wedge pressure and increased colloid osmotic pressure) are discussed.

Comparison of two coronary prognostic indices

Two coronary prognostic indices for patients treated in a coronary care unit, namely the Norris Index and the Chapman-Gray Index were compared. Both were found to be reliable but the Chapman-Gray Index with its ready reckoner was more convenient and was subject to fewer subjective data.

Oliguria and its sequelae

Fifty-nine patients were seen with oliguria in 1975. Forty had acute renal failure (ARF) and 19 rapidly reversible oliguria (RR). The causes of the oliguria were medical (64%), surgical (27%) and obstetrical (9%). The following were valuable in the assessment of patients with oliguria: urine sodium concentration (UNa) and osmolality, coagulation studies and high dose intravenous urography. Patients presenting with a high UNa or a coagulation abnormality were more likely to have ARF. Central venous pressure monitoring was helpful in the initial management but the administration of diuretics was not. Twenty patients with ARF were treated conservatively and the remainder by dialysis. Infection was both the commonest complication of ARF and the most frequent cause of death. Seventy percent of those with ARF died. Death was more common in the elderly or patients with a medical aetiology. The mortality of ARF remains high in spite of advances in the management of its metabolic and infective complications because of the acceptance of more high risk patients. An improved awareness of the preventable causes of oliguria is apparent.

Iododerma after high dose urography in an oliguric patient

A case of iododerma caused by iodinated urographic contrast media is presented. It seems possible that iodide is split from the organic molecule in patients with severe renal impairment.

Mechanisms for oliguria in acute renal failure

Warm ischemic (90 minutes) acute renal failure (ARF) was evaluated in the dog and found to cause polyuric ARF in the injured kidney if the opposite normal kidney was removed. In contrast, if the normal kidney were left intact, oliguric ARF was noted in the injured kidney. To further evaluate the mechanisms for oliguria and polyuria, chronic reinfusion of urine from a normal kidney into the inferior vena cava (ureterocaval anastomosis) resulted in polyuria in the opposite warm ischemic injured kidney; whereas chronic reinfusion of urine into the portal vein (ureteroportal anastomosis) resulted in profound oliguria in the opposite injured kidney. In separate additional experiments, urine acutely infused into the inferior vena cava at a rate of 0.38 ml/minute caused a significantly greater diuretic and renal hemodynamic response than seen with urine infused into the portal vein. Acute infusions of urea solution (0.38 ml/minute) with the same osmolality of urine were completely devoid of diuretic and renal hemodynamic effects. These studies reveal that urine contains a powerful hemodynamic and diuretic factor which appears to convert oliguric to polyuric ARF following warm ischemic renal injury in the dog. This factor is not urea and can be destroyed by the liver.

Nonoliguric acute renal failure

To delineate the clinical spectrum of nonliguric renal failure, we studied prospectively 90 patients with acute renal failure 54 of whom were nonoliguric throughout their periods of azotemia. Although the causes of nonoliguric renal failure varied, nephrotoxic failure occurred more frequently in nonoliguric than in oliguric subjects (P is less than 0.01). As com pared to oliguric patients, those without oliguria had significantly lower urinary sodium concentrations (P is less than 0.05) and fractional excretions of sodium (P is less than 0.02), had shorter hospital stay (P is less than 0.01), had fewer septic episodes, neurologic abnormalities, gastrointestinal bleeding and acidemia, required dialysis less frequently (P is less than 0.001) and had lower mortality rate (26 per cent in nonoliguric vs. 50 per cent in oliguric patients -- P is less than 0.05). Nonoliguric renal failure occurs more often than is generally recognized and causes less morbidity and mortality than oliguric acute renal failure.

Renal cortical microabscesses as cause of reversible acute renal failure

We report a case of renal cortical microabscesses which presented as oliguric acute renal failure. Prior to the biopsy the patient was suspected of having acute pyelonephritis with acute tubular necrosis. Biopsy was performed to rule out rapidly progressive glomerulonephritis as a cause of his renal failure. To our surprise, we found multiple small microabscesses in the renal cortiex. Renal cortical microabscesses should be considered as a reversible acute renal failure.

Right ventricular involvement in acute myocardial infarction

Involvement of the RV in AMI is not as rare as previously thought and may lead to a particular clinical and hemodynamic syndrome with raised RV filling pressures, hypotension and oliguria. Major extension to the RV from inferior LV infarctions can be recognized by ST segment elevations iead CR4R or V4R. The significance of anterior RV extension and of RV papillary muscle infarction is still largerly unknown. It has been suggested from autopsy studies that the prognosis of patients with RV involvement might be poor healed extensive RV infarction is rarely seen. Indeed, ST segment elevation in lead CR4R indicating RV involvement has been found to carry a poor short-term prognosis. An increased awareness of the possibility of impaired RV function and of the special therapeutic considerations in some of these patients may increase survival.

The significance of extracapillary proliferation. Clinicopathological review of 60 patients

Renal biopsy and clinical data from 60 patients with extracapillary proliferation (crescent formation) in greater than or equal to 50% of glomeruli were correlated. Nephropathy was related to infection (15 cases) malignancy (4 cases) and trichlorethylene exposure (2 cases). Isolated proteinuria was found 0.5-20 years before biopsy in 16 patients. Outcome was significantly related to percentage of crescentic involvement. Oligoanuria and impaired function at presentation were bad prognostic signs but preceding infection was favourable. Diverse histological and immunofluorescent findings indicate that extracapillary glomerulonephritis is not a single entity. The clinical course is not always rapidly progressive.

Postoperative metabolic alkalosis and acute renal failure: rationale for the use of hydrochloric acid

Metabolic alkalosis secondary to chloride depletion, especially following gastrointestinal surgery and associated with acute renal failure, is a frequent clinical occurrence. Management of the resultant acid-base disturbance mandates chloride replacement. The presence of oliguria limits the choice of accompanying cation. The use of intravenous hydrochloric acid to correct and maintain proper chloride balance, secondary to external gastric fluid losses, is recommended as a straightforward approach. Two brief case synopses are presented. Both patients, florid examples of profound chloride depletion, required large amounts of intravenous hydrochloric acid. The options regarding the choice of chloride solution, hazards involved, and a simplified schema of replacement therapy are presented. Combined gastrointestinal and renal dysfunction create unusual biochemical and clinical alterations and may result in a complex management problem.

Myocardial infarction in the newborn: a case report complicated by cardiogenic shock and associated with normal coronary arteries

Fatal myocardial infarction occurring in a neonate is reported. The patient presented with a clinical picture of cardiogenic shock simulating a hypoplastic left heart syndrome. Etiology of the myocardial infarction is uncertain for the coronary arteries were patent, anatomically and histologically normal, and there was no significant associated cardiac defect. The possible etiologies in relationship to myocardial infarction in the neonatal period are presented.