Serum potassium in stage 5 CKD patients on their first presentation in a dialysis service of a county hospital in western Romania

CKD patients present deficient elimination of potassium. Ambulatory treatment with hypotensors, mainly angiotensin-renin system inhibitors, can be associated in these patients with potassium retention and risk of hyperkalemia. In pre-dialysis stage-5 CKD patients, the use of medication accompanied by hyperkalemia increases risks of developing it. Using diuretics like spironolactone also increases this risk. Serum potassium can also increase in case of inappropriate consumption of potassium-rich food (bananas). Since ambulatory care does not always rigorously control hyperkalemia in CKD patients we consider it is useful to screen patients when they are referred to dialysis services. The screening can reflect the management of ambulatory CKD patients under treatment with ACE-I and ARB hypotensors. We remark that beta-blockers are attributed a (limited) role in increasing the values of serum K.

MATERIAL AND METHOD

We studied a group of 477 stage-5 CKD patients referred for dialysis to The Dialysis Centre of the Emergency County Hospital Timişoara. The average age of the patients was 57.41 +/- 14.26 years. 260 were males and 217 females. All were stage-5 CKD with GFR < 15 mL/min/1.73 m2, with a group average value of eGFR of 5.72 +/- 2.81 mL/min/1.73m2. Our investigations showed hypokalemia in 14 patients (2.93%). Hyperkalemia was found in 179 patients. Of these, 124 had mild hyperkalemia (5.5-6.4 mEq/L), 45 patients had medium hyperkalemia (6.5-7.5 mEq/L) and 10 (2.09%) had severe hyperkalemia (K > 7.5 mEq/L).

DISCUSSION

Hyperkalemia was more frequent in patients who had been treated with blockers of the renin-angiotensin system than in patients who had used other hypotensors or who had not needed hypotensors and had not taken diuretics. Severe hyperkalemia (K > 7.5 mEq/L) was present both in patients treated with blockers of the renin-angiotensin system and in those treated with other hypotensors and in 1 case without hypotensor or diuretic treatment. 2 cases treated with blockers of the renin-angiotensin-aldosterone system with severe hyperpotassemia associated antialdosteronic diuretics, cumulating hyperpotassemic effects. Diuretic treatments with loop diuretics influenced the values of serum K of most patients. Hyperkalemia represents an important problem in nephrology because of the risks it induces in the treatment ofpre-dialysis CKD patients and it requires attentive monitoring.

Assessment of arterial stiffness in patients with CKD stage 5 when initiating chronic hemodialysis for vascular access and for preventing cardiovascular events

We consider that re-assessment of the vascular status is necessary, even mandatory, in patients with CKD when initiating dialysis because of two reasons:--assessment of vascular remodelling is important for establishing the artery-venous fistula as it can supply appreciative data on its success and duration;--vascular remodelling plays an important part in cardio-vascular pathology of patients dialysed, with the required consecutive prophylactic measures. In chronic kidney disease, calcium deposits at extra-skeletal level also affect the vessels, determining calcifications of both the vascular intima and media. Atherosclerosis and arteriosclerosis are present in patients with CKD and they contribute to diminishing the elasticity of the artery wall by vascular remodelling. Vascular remodelling determines thickening of the artery wall, respectively of the thickness of the arterial intima-media. Thus, arteries lose their elasticity, and the wall of the arterial tree wall turns stiff. Arterial stiffness is a process that precedes the development-proper of atherosclerosis, determined by cumulative exposure to various risk factors. Atherosclerosis is a focal process, in which indemne areas alternate with areas with atheroma plaques at intima level, and arteriosclerosis is a diffuse process located at the level of the arterial media. Non-invasive assessment of arterial stiffness can be achieved by analyzing pulse wave velocity and the augmentation index. We studied a group of 35 patients with chronic kidney insufficiency, CKD, stage 5, with an average age of 52.03 +/- 17.36 years, of whom 15 (43%) were females and 20 (57%) were males. The investigated parameters presented the following average values: PWV = 16.7 +/- 1.27 m/s; IMT = 1.63 +/- 0.18 mm; Aix = 36.14 +/- 9.98%; AAI = 0.78 +/- 0.2. The assessment of vascular stiffness in chronically dialysed patients offers better appreciation of vascular stiffness. Knowing the amplitude of the vascular remodelling process is of special importance for deciding the place and modality of performing the vascular access with regard to replacing the kidney function and to preventing cardiovascular events in dialysed patients.

International evaluation of unrecognizably uglifying human faces in late and severe secondary hyperparathyroidism in chronic kidney disease. Sagliker syndrome. A unique catastrophic entity, cytogenetic studies for chromosomal abnormalities, calcium-sensing receptor gene and GNAS1 mutations. Striking and promising missense mutations on the GNAS1 gene exons 1, 4, 10, 4

Hypotheses explaining pathogenesis of secondary hyperparathyroidism (SH) in late and severe CKD as a unique entity called Sagliker syndrome (SS) are still unclear. This international study contains 60 patients from Turkey, India, Malaysia, China, Romania, Egypt, Tunisia, Taiwan, Mexico, Algeria, Poland, Russia, and Iran. We examined patients and first degree relatives for cytogenetic chromosomal abnormalities, calcium sensing receptor (Ca SR) genes in exons 2 and 3 abnormalities and GNAS1 genes mutations in exons 1, 4, 5, 7, 10, 13. Our syndrome could be a new syndrome in between SH, CKD, and hereditary bone dystrophies. We could not find chromosomal abnormalities in cytogenetics and on Ca SR gene exons 2 and 3. Interestingly, we did find promising missense mutations on the GNAS1 gene exons 1, 4, 10, 4. We finally thought that those catastrophic bone diseases were severe SH and its late treatments due to monetary deficiencies and iatrogenic mistreatments not started as early as possible. This was a sine qua non humanity task. Those brand new striking GNAS1 genes missense mutations have to be considered from now on for the genesis of SS.

Is survival enough for quality of life in Sagliker Syndrome-uglifying human face appearances in chronic kidney disease?

BACKGROUND

It is known that secondary hyperparathyroidism (SH) and particularly skeletal changes is a severe condition in chronic kidney disease (CKD). Sagliker syndrome (SS) is a very prominent feature in CKD including uglifying human face appearances, short stature, extremely severe maxillary and mandibulary changes, soft tissues in the mouth, teeth-dental abnormalities, finger tip changes and severe psychological problems.

METHODS

In the last 8 years we have confronted 36 extremely incredible SS cases in CKD by performing an international study in Turkey, India, Malaysia, Romania and Egypt.

RESULTS

In addition to the uglifying human face appearance, we found extremely severe X-ray and tomographical, pantomographical, histo-pathological changes in the head and whole body. Finally, we compared previous face pictures with recent ones. Just a few years earlier they had been pretty and good-looking young boys and girls. By investigating their history, we understood they had not received proper therapy and were in the late-irreversible period.

CONCLUSION

SS is a serious and severe complication of CKD. Late and improper treatment leads to abnormalities throughout skeleton particularly in the skull and face. Changes particularly in children and teens become irreversible-disastrous for appearance and psychological health. Appropriate treatment must begin as early as possible in specialized centers. It is possible that SS patients may survive long-term with dialysis, but with all those particular changes could anyone claim this type of life would continue in an acceptable way without extending their height, correcting all the changes in the skull and face, remodeling new faces and most particularly convincing the patients to deal with all those tragi-dramatic psychological problems?

A clinical description of rifampicin-induced acute renal failure in 170 consecutive cases

Rifampicin re-administration may cause immunologically mediated acute tubulo-interstitial injury. Retrospectively, 170 consecutive cases with acute renal failure (ARF) following re-treatment with rifampicin (71% males, 29% females, age 21 to 68 years) were analysed, which accounted for 12% of all ARF patients treated by two large dialysis referral centres in Romania, Timisoara and Iasi, between 1974-2001 and 1988-2001, respectively. The most frequent clinical features of rifampicin-induced ARF were: Anuria, gastro-intestinal (abdominal pain, nausea, vomiting and diarrhoea) and "flu-like" symptoms. Urine analysis revealed sterile leucocyturia in 54%, proteinuria in 31%, haematuria in 26% and haemoglobinuria in 7% of cases. Haemolytic anaemia was frequent, found in 66% of the patients; half of these had Hct values of < 30%, thrombocytopenia and also more severe renal damage (a longer anuric phase and a slower recovery of the renal function), thus suggesting a severe multi-target autoimmune aggression. The association of hepatic injury--not explained by prior hepatic disease, B or C hepatitis virus infection or history of alcohol abuse--was encountered in 17% of the cases, without a significant influence on the renal and the general outcome. The outcome of rifampicin-induced ARF is generally favourable, with complete recovery of the renal function within 30 days in 52% of the cases and within 90 days in 92% of the cases. The mortality rate was 3.5%, compared to 21% for the overall ARF population treated during the same period (p < 0.05).

[Specific features of acute renal failure in patients treated with rifampicin]

This retrospective study was performed on 92 patients diagnosed with acute renal failure (ARF) post discontinuous rifampicin treatment, admitted between 1974-2000, in Hemodialysis Center of 1st Timisoara Clinical County Hospital. The passage from the continuous treatment (7/7) to discontinuous RMP treatment triggered the ARF in 77 patients and the restart of the treatment after one year or more of treatment arrest, lead to ARF in 15 cases. The ARF symptomatology appeared in the first 12 hrs of treatment resumption in 14.13% cases and in 85.87% after 38.5 +/- 8.2 hrs. The most frequent symptoms were lumbar pain in 76.08%, nausea and vomiting in 60.86%, abdominal pain (52.17% of cases) flu-like (fever, chills, myalgia), jaundice, diarrhea, hypotension, confusion and hypertension in only 7.6% of cases. In 94.56% of cases renal symptoms appeared in normal kidneys. The renal injury evolution was favorable, with significant improvements after 20 days in serum and urine biological parameters. The antibodies anti-RMP were present in serum 55.43% of patients, in 80.39% of them, the presence of antibodies was related to high values of gamma-globulins. In 33.69% of patients sterile leukocyturia, considered a marker of interstitial nephritis, was present. The most frequent associated ARF complications were the hemolytic anemia emphasized by high levels of unconjugated bilirubin and positive Coombs' test in 93.3% of patients, and liver injuries, present in 41.69% of cases. Thrombocytopenia was registered in 27.7% of cases, infections in 28.6%, gastrointestinal complications in 11.95%, and cardiovascular complications in 9.78% of cases, these severe forms leading to the death of patients. The ARF post discontinuous rifampicin treatment presents a favorable evolution even when it is associated with other organ or systems complications. The ARF and associated complications are due to the specific immune system activation by rifampicin, and by direct toxic effects of rifampicin at tissues level.

Urinary infection in patients with chronic renal failure on hemodialysis

A group of 37 hemodialyzed patients with chronic renal failure were investigated within a period of 6 months to 9 years. Of these patients five presented quantitatively significant bacteriuria noncorrelated with the causal nephropathy. Of the 9 patients with urologic past history two presented urinary infection. Urinary bacterial immunofluorescence was constantly positive in all the cases in which bacteriuria was significant and, at least in one determination when the germ count was below 10,000/ml. This finding was also supported by the increase of gammaglobulinemia and of the circulating immune complexes in all the cases investigated as well as of the B lymphocytes in one third of cases. Fifty percent of the patients presented T lymphocytopenia with excess of suppressor lymphocytes and deficit of the helper ones. It can, therefore be assumed that in patients with chronic renal failure nondialyzable antigens persist in the renal parenchyma where they stimulate anticorpogenesis but at a low level owing to some immune disturbances present in such patients.

[Causes of failure in surgical arteriovenous anastomoses]

The causes of failure in surgical arteriovenous anastomoses are discussed with reference to 60 operations performed on 52 patients suffering from chronic renal insufficiency in the uremic stage. The various technical variants applied are shown, as well as the early and late complications and the order in which reinterventions were performed. The work concludes with an original mathematical study of the blood output in the three fistula variants practiced by the authors, designed to supply evidence of their functional value.

[Renal complications after rifampicin]

Six observations are presented of patients receiving intermitent rifampicin treatment (900 mg twice weekly) that developed acute renal failure during treatment (4 cases) or when treatment was taken up again, after an interruption of 6 months (2 cases). Following anuria of 4--14 days and nitrogen retention between 248 and 521 mg, the evolution was favourable. Clinical, biological and immunological data (anti-rifampicin antibodies were detected in 1/8 and 1/16 in 3 cases) suggest the immune origin of this type of renal accidents.