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Adomako EA, Sambandam KK. Challenges in diuretic therapy: A case-based discussion. Am J Med Sci 2022; 364:386-393. [PMID: 35472337 DOI: 10.1016/j.amjms.2022.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 03/17/2022] [Accepted: 04/15/2022] [Indexed: 01/25/2023]
Abstract
Diuretics are amongst the most prescribed medications in both the inpatient and outpatient settings. They are used extensively in diverse disease states including heart failure, acute and chronic kidney disease, cirrhosis, and diseases of excess capillary permeability such as sepsis, malignancy, and malnutrition. All are characterized by total body sodium overabundance which commonly manifests as edema. The use of diuretics is however not bereft of complications. These complications frequently limit the correction of hypervolemia, resulting in continued patient suffering and frustration for the clinician. In this review, we employ a case-based approach to discuss three common challenges encountered during diuretic therapy: diuretic resistance that characterizes the nephrotic syndrome, diuretic-induced metabolic alkalosis, and diuretic-associated hyponatremia. We empower the clinician to effectively meet these challenges by providing a mechanistic understanding of these complications and their solutions.
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Affiliation(s)
- Emmanuel A Adomako
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kamalanathan K Sambandam
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Lionaki S, Liapis G, Boletis JN. Pathogenesis and Management of Acute Kidney Injury in Patients with Nephrotic Syndrome Due to Primary Glomerulopathies. ACTA ACUST UNITED AC 2019; 55:medicina55070365. [PMID: 31336742 PMCID: PMC6681356 DOI: 10.3390/medicina55070365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 07/03/2019] [Accepted: 07/08/2019] [Indexed: 01/10/2023]
Abstract
Acute kidney injury in the context of nephrotic syndrome is a serious and alarming clinical problem. Largely, acute kidney injury is a relatively frequent complication among patients with comorbidities while it has been independently associated with an increased risk of adverse outcomes, including death and chronic kidney disease. Nephrotic syndrome, without hematuria or with minimal hematuria, includes a list of certain glomerulopathies; minimal change disease, focal segmental glomerulosclerosis and membranous nephropathy. In the light of primary nephrotic syndrome, pathophysiology of acute kidney injury is differentiated by the nature of the primary disease and the severity of the nephrotic state. This review aims to explore the clinical circumstances and pathogenetic mechanisms of acute kidney injury in patients with nephrotic syndrome due to primary glomerulopathies, focusing on newer perceptions regarding the pathogenesis and management of this complicated condition, for the prompt recognition and timely initiation of appropriate treatment in order to restore renal function to its baseline level. Prompt recognition of the precise cause of acute kidney injury is crucial for renal recovery. Clinical characteristics, laboratory and serological findings along with histopathological findings, if required, will reveal the implicated pathway leading to individualized approach and management.
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Affiliation(s)
- Sophia Lionaki
- Nephrology Department & Transplantation Unit, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece.
| | - George Liapis
- Department of Pathology, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - John N Boletis
- Nephrology Department & Transplantation Unit, Laiko Hospital, Faculty of Medicine, National & Kapodistrian University of Athens, 11527 Athens, Greece
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Ellis D. Pathophysiology, Evaluation, and Management of Edema in Childhood Nephrotic Syndrome. Front Pediatr 2015; 3:111. [PMID: 26793696 PMCID: PMC4707228 DOI: 10.3389/fped.2015.00111] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/07/2015] [Indexed: 01/22/2023] Open
Abstract
Generalized edema is a major presenting clinical feature of children with nephrotic syndrome (NS) exemplified by such primary conditions as minimal change disease (MCD). In these children with classical NS and marked proteinuria and hypoalbuminemia, the ensuing tendency to hypovolemia triggers compensatory physiological mechanisms, which enhance renal sodium (Na(+)) and water retention; this is known as the "underfill hypothesis." Edema can also occur in secondary forms of NS and several other glomerulonephritides, in which the degree of proteinuria and hypoalbuminemia, are variable. In contrast to MCD, in these latter conditions, the predominant mechanism of edema formation is "primary" or "pathophysiological," Na(+) and water retention; this is known as the "overfill hypothesis." A major clinical challenge in children with these disorders is to distinguish the predominant mechanism of edema formation, identify other potential contributing factors, and prevent the deleterious effects of diuretic regimens in those with unsuspected reduced effective circulatory volume (i.e., underfill). This article reviews the Starling forces that become altered in NS so as to tip the balance of fluid movement in favor of edema formation. An understanding of these pathomechanisms then serves to formulate a more rational approach to prevention, evaluation, and management of such edema.
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Affiliation(s)
- Demetrius Ellis
- Division of Pediatric Nephrology, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine , Pittsburgh, PA , USA
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Abstract
Idiopathic childhood nephrotic syndrome generally has a favorable long-term prognosis. Prompt administration of and improved guidelines for monitoring therapy have decreased morbidity and mortality. The treatment goal is to induce prompt remission while minimizing complications and adverse events. Aggressive therapy induces remission and decreases the frequency of relapse in most patient populations; however, such treatment often results in unnecessary toxicity. We critically assessed the current clinical evidence that supports each pharmacologic therapy. For each drug regimen, the risks and monitoring parameters required to reduce complications and optimize therapy are discussed. Some of the treatments are the common corticosteroid approaches, cytotoxic therapies (chlorambucil, cyclophosphamide), cyclosporine, less frequently used drugs (e.g., levamisole), and experimental therapies. Further studies are needed to identify the most effective and least toxic therapeutic regimens for inducing and maintaining remission in children with nephrotic syndrome.
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Affiliation(s)
- Renee F Robinson
- Department of Pediatrics, College of Medicine and Public Health, The Ohio State University, Columbus, Ohio, USA.
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BAXTER JH, GOODMAN HC, ALLEN JC. Effects of infusions of serum albumin on serum lipids and lipoproteins in nephrosis. J Clin Invest 1998; 40:490-8. [PMID: 13688076 PMCID: PMC290745 DOI: 10.1172/jci104276] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Sjöström PA, Odlind BG, Beermann BA, Karlberg BE. Pharmacokinetics and effects of frusemide in patients with the nephrotic syndrome. Eur J Clin Pharmacol 1989; 37:173-80. [PMID: 2792172 DOI: 10.1007/bf00558227] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The renal handling and effects of an intravenous bolus of frusemide with and without plasma volume expansion with dextran or albumin, and with large variations in plasma albumin concentration, have been studied in five patients with the nephrotic syndrome. Decreased renal sensitivity to frusemide was found in only one patient, who also had hypovolaemia and an activated renin-angiotensin-aldosterone system. Plasma volume expansion increased the diuresis but not the saluresis, and slightly increased renal sensitivity to frusemide. An increase in albuminuria after albumin infusion did not reduce the sensitivity to frusemide. A decrease in plasma albumin concentration from 33 g.l-1 after albumin infusion to 23 g.l-1 after infusion of dextran caused a substantial increase in the renal clearance (from 84 to 123 ml.min-1), non-renal clearance (from 72 to 138 ml.min-1), and apparent volume of distribution (from 13 to 23 l) of frusemide, probably as a consequence of an increase in the unbound fraction. The rate of urinary excretion of frusemide was highest after albumin infusion, despite the fact that its renal clearance was lowest then.
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Affiliation(s)
- P A Sjöström
- Department of Internal Medicine, Orebro Medical Center Hospital, Sweden
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Bohman SO, Jaremko G, Bohlin AB, Berg U. Foot process fusion and glomerular filtration rate in minimal change nephrotic syndrome. Kidney Int 1984; 25:696-700. [PMID: 6482174 DOI: 10.1038/ki.1984.76] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Reduced glomerular filtration rate (GFR), not due to hypovolemia, has been reported in patients in the proteinuric phase of the minimal change nephrotic syndrome (MCNS). A group of children with MCNS was studied to investigate the possible relationship between the fusion of glomerular epithelial foot processes and the reduction in GFR. The degree of foot process fusion was estimated as the harmonic true mean of foot process width and the length density of epithelial slit pores as determined by quantitative electron microscopic stereology. In the patients investigated GFR ranged between 40 and 127 ml/min/1.73 m2 body surface area, the filtration fraction between 6.9 and 22.5%, and the serum albumin concentration between 14 and 46 g/liter. The mean foot process width, which varied between 330 and 870 nm, showed a close correlation with GFR (r = -0.859) and the filtration fraction (r = -0.812), as well as with the serum albumin concentration (r = -0.756). As expected, a reduction of epithelial slit pore length occurred concomitant with the broadening of the foot processes. These results agree with the hypothesis that the reduction in the total length of glomerular epithelial slit pores, due to the fusion of foot processes, results in a reduced glomerular capillary permeability to water and small solutes.
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Hara M, Meyer D. The size of the juxtaglomerular apparatus in glomerulonephritis with the nephrotic syndrome: a morphometrical study of renal biopsies. VIRCHOWS ARCHIV. A, PATHOLOGICAL ANATOMY AND HISTOLOGY 1975; 367:1-14. [PMID: 809904 DOI: 10.1007/bf00430768] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The juxtaglomerular apparatus was histoplanimetrically studied in renal biopsies of 65 cases of membranoproliferative glomerulonephritis and 64 cases of minimal proliferative intercapillary glomerulonephritis (MPI) ("minimal changes"). The juxtaglomerular cell complex (JGC complex) consisting of the epithelioid cells (granular cells) and the Goormaghtigh's cells (agranular or lacis cells) was significantly enlarged in the nephrotic syndrome. 10 to 14 days' duration of the nephrotic syndrome was shown to be sufficient to bring about an enlargement of the JGC complex. After a successful treatment of the nephrotic syndrome with steroids, there was no enlargement of the JGC complex. The enlarged JGC complex persisted despite steroid treatment in the steroid-resistant nephrotic syndrome, although a mild suppressive effect of steroids on the size of the JGC complex was observed. There was no significant relationship between hypertension and the size of the JGC complex. Creatinine retention tended to be associated with an enlargement of the JGC complex. The macula densa was not enlarged in the nephrotic syndrome, in contrast to the enlarged JGC complex.
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Rocha A, Marcondes M, Malnic G. Micropuncture study in rats with experimental glomerulonephritis. Kidney Int 1973; 3:14-23. [PMID: 4693689 DOI: 10.1038/ki.1973.3] [Citation(s) in RCA: 41] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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CHINARD FP. Starling's hypothesis in the formation of edema. BULLETIN OF THE NEW YORK ACADEMY OF MEDICINE 1962; 38:375-89. [PMID: 13879000 PMCID: PMC1804810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/24/2023]
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Metcoff J, Janeway CA. Studies on the pathogenesis of nephrotic edema. The journal The Journal of Pediatrics 1961. [DOI: 10.1016/s0022-3476(61)80114-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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CALCAGNO PL, RUBIN MI. Physiologic considerations concerning corticosteroid therapy and complications in the nephrotic syndrome. J Pediatr 1961; 58:685-706. [PMID: 13689894 DOI: 10.1016/s0022-3476(61)80115-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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SCHEURLEN PG, KLAUS D. Fl�ssigkeitshaushalt und Volumenregulation bei extremen Serumalbuminmangel (Analbumin�mie). ACTA ACUST UNITED AC 1960; 38:1075-80. [PMID: 13747560 DOI: 10.1007/bf01494298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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CORCORAN AC, MACLEOD C, DUSTAN HP, PAGE IH. Effects of Chlorothiazide on Specific Renal Functions in Hypertension. Circulation 1959; 19:355-9. [PMID: 13629796 DOI: 10.1161/01.cir.19.3.355] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Oral administration of chlorothiazide depresses glomerular filtration, increases blood urea, maintains sodium output in the face of decreased filtered sodium load, and paradoxically for a diuretic, in these and in tests done shortly after intravenous administration, increases the efficiency of water reabsorption.
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LOWE TE. FURTHER OBSERVATIONS ON THE RELATION BETWEEN BODY FLUID VOLUME AND URINE FLOW IN MAN. AUSTRALASIAN ANNALS OF MEDICINE 1958; 7:235-42. [PMID: 13584269 DOI: 10.1111/imj.1958.7.3.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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GITLIN D, JANEWAY CA, FARR LE. Studies on the metabolism of plasma proteins in the nephrotic syndrome. I. Albumin, gamma-globulin and iron-binding globulin. J Clin Invest 1956; 35:44-56. [PMID: 13278400 PMCID: PMC438777 DOI: 10.1172/jci103251] [Citation(s) in RCA: 162] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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SCHACHTER D. Renal function in health and disease. Med Clin North Am 1955; New York No.:681-98. [PMID: 14369195 DOI: 10.1016/s0025-7125(16)34675-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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CHINARD FP, LAUSON HD, EDER HA, GREIF RL, HILLER A. A study on the mechanism of proteinuria in patients with the nephrotic syndrome. J Clin Invest 1954; 33:621-8. [PMID: 13152202 PMCID: PMC1087278 DOI: 10.1172/jci102933] [Citation(s) in RCA: 66] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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