Blood lactate threshold and type II fibre predominance in patients with exertional heatstroke

OBJECTIVES

Severe damage to skeletal muscle is usually seen in patients with exertional heatstroke. Thirty seven young military recruits with exertional heatstroke in Taiwan from 1992 to 1995 were studied to evaluate changes in muscle pathology and blood lactate with exercise.

METHODS

A biopsy sample of the vastus lateralis was taken from recruits within 10 days of the initial presentation. Results were compared with those from 15 controls matched for age and sex. During the recovery period, 90-150 days after exertional heatstroke, 29 patients participated in a constant work load test on the treadmill to assess their blood lactate threshold, and a second biopsy sample was taken. Each biopsy was examined histologically for pathology, distribution of fibre types, and fibre diameter.

RESULTS

Twenty four of the 37 patients with exertional heatstroke developed rhabdomyolysis and 18 of these had type II fibre predominance in their muscle biopsy. The patients with type II fibre predominance had a higher tendency to develop rhabdomyolysis (chi 2 = 6.84, P < 0.01). The time required to reach a blood lactate threshold during a constant treadmill work load after recovery was significantly shorter in the patients with exertional heatstroke who had type II fibre predominance (P < 0.01). There was a positive correlation between the highest value of blood lactate and the percentage of type II fibres in all tested subjects (r = 0.82, P < 0.01).

CONCLUSION

Patients with type II fibre predominance are more susceptible to exertional heatstroke and tend to have a higher blood lactate concentration and a shorter time to reach blood lactate threshold under a treadmill load test.

Infective endocarditis complicated with rapidly progressive glomerulonephritis: a case report

A 26-year-old man who had suffered from intermittent chills and fever over a two month period was quite clear of heart or kidney involved developed acute deterioration of renal function. A new pansystolic murmur over the apex of the heart was heard on auscultation, and echocardiography clearly showed a vegetation about 0.7-0.9 cm in size on the atrial site of the mitral value. Laboratory investigation displayed normochromic anemia with negative Coombs' test. Immunological studies were positive for rheumatoid factor and circulating immune complex. High serum levels of erythrocyte sedimentation rate and C-reactive protein, nephritic sediment of urinalysis and negative blood cultures for bacteria, tuberculosis or fungus were also noted. Abdominal sonography showed normal kidney size, bilaterally. Renal biopsy revealed typical crescentic glomerulonephritis. After intravenous penicillin therapy for two weeks, the serum creatinine level recovered from 6.7 mg/dl to 2.0 mg/dl and circulating immune complex disappeared. In consideration of cardiac insufficiency and the potential risk for complications of the vegetation, the patient underwent mitral valve replacement. Four weeks after operation, all the abnormal data had resolved completely. These data suggested that infective endocarditis with rapidly progressive glomerulonephritis is curable by antibiotic therapy and surgical intervention.

Fatal Aeromonas hydrophila bacteremia in a hemodialysis patient treated with deferoxamine

A 49-year-old woman undergoing long-term hemodialysis and treated with deferoxamine (DFO) 1.5 g twice weekly for aluminum bone disease developed fever and bilateral calf pain caused by myonecrosis with gas gangrene. She had a rapidly fatal outcome. The cultures of blood and aspirates from both calf muscles demonstrated Aeromonas hydrophila. No obvious entry point could be traced. The in vitro growth of the patient's strain was found to be stimulated by the deferoxamine-iron complex in an iron-deprived medium. It is suggested that high-dose DFO therapy in this patient was responsible for promoting a bacterial infection by this microorganism.

Changes in thyroid hormone metabolism in exertional heat stroke with or without acute renal failure

The effects of exertional heat stroke (ExHS), with or without acute renal failure (ARF), on thyroid hormone metabolism were investigated. Eighteen ExHS patients were recruited and divided into two groups based on the presence or absence of ARF. Eleven age-matched healthy subjects served as a control group. Serum values of T3, T4, TSH, free T4 (FT4), rT3, and sulfated T3 (T3S) were measured in these groups during the acute and recovery stages of ExHS. Serum T3, T4, and FT4 levels were reduced, with reciprocal increases in rT3 and T3S levels as the severity of ExHS increased. The following mean levels of thyroid hormones were found (controls vs. ExHS without ARF vs. with ARF): T3, 1514 vs. 1164 vs. 393 pmol/L (P < 0.05 each); T4, 97 vs. 79 vs. 49 nmol/L (P = NS and P < 0.05, respectively); FT4, 20.5 vs. 19.5 vs. 19.0 pmol/L (P = NS each); rT3, 371 vs. 617 vs. 805 pmol/L (P < 0.05 and P = NS, respectively); and T3S, 30.1 vs. 34.2 vs. 71.1 pmol/L (P = NS and P < 0.05, respectively). The serum TSH levels were not significantly different among the three groups. Significantly negative correlations were found between serum creatinine and T3 (r = -0.75; P < 0.001) and T4 levels (r = -0.65; P < 0.001), whereas no relationship was noted between serum creatinine and rT3 values (r = 0.11; P < 0.05). In contrast, a correlation was observed between serum glutamic pyruvic transaminase and rT3 (r = 0.45; P < 0.01). Thyroid function tests returned to normal after patients recovered. In conclusion, our results show that patients suffering from ExHS, with or without ARF, displayed altered serum thyroid function in proportion to the severity of their condition. No significant changes in serum levels of rT3 were observed between the two groups, whereas a positive relationship was observed between serum rT3 and serum glutamic pyruvic transaminase values, suggesting that the changes in serum rT3 levels were more dependent on extrarenal illness than on renal disease per se. The moderate increase in serum T3S levels found in patients suffering from both ExHS and ARF may represent a decrease in tissue 5'-monodeiodinase activity as found in other nonthyroidal illnesses. A return of serum thyroid function tests to normal values after recovery from ExHS suggests that the low T3 state may play a protective role to prevent undesirable catabolic effects. Replacement therapy is thus not recommended.

Circulating angiotensin-converting enzyme, von Willebrand factor antigen and thrombomodulin in exertional heat stroke

1. Military recruits frequently succumb to exertional heat stroke during intensive training. Since widespread endothelial injury is often associated with exertional heat stroke, the relationship between changes in three circulating endothelial cell markers (angiotensin-converting enzyme, von Willebrand factor antigen and thrombomodulin) and exertional heat stroke was studied. 2. Twelve recruits who had succumbed to exertional heat stroke during basic physical training (5000 m running) were included in the study. Another 10 age-matched healthy subjects who had gone through the same physical training regimen were selected as controls. 3. Blood was withdrawn on admission and on discharge for analyses of angiotensin-converting enzyme, von Willebrand factor antigen and thrombomodulin. Other physiological parameters and biochemical analyses reflecting renal and liver functions were also recorded. 4. Our results indicated that these subjects with exertional heat stroke exhibited impaired liver function as revealed by the significant elevation of both serum glutamic oxaloacetic transaminase (P < 0.05) and serum glutamic pyruvic transaminase (P < 0.05) as compared with normal healthy control subjects. Unfortunately, these values remained mostly somewhat elevated on discharge, although serum glutamic oxaloacetic transaminase was reduced dramatically. Indices of kidney functions, including creatinine clearance and uric acid and phosphorus secretion, were not significantly different from those observed in healthy controls. 5. Circulating angiotensin-converting enzyme activities in exertional heat stroke patients on admission were significantly lower than in normal subjects (10.68 +/- 2.15 versus 21.21 +/- 3.18 nmol hippuric acid min-1 ml-1, P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of metabolic acidosis on serum 1,25(OH)2D3 levels in chronic renal failure

Metabolic acidosis has been shown to alter vitamin D metabolism. There is also evidence that calcium may modulate 1,25(OH)2D3 by a parathyroid hormone (PTH)-independent mechanism. To investigate the effect of rapid correction of chronic metabolic acidosis on serum 1,25(OH)2D3 levels by free calcium clamp in chronic renal failure, 20 patients with mild to moderate metabolic acidosis (mean pH 7.31 +/- 0.04) and secondary hyperparathyroidism (mean intact PTH 156.47 +/- 84.20 ng/l) were enrolled in this study. None had yet received any dialysis therapy. Metabolic acidosis was corrected by continuous bicarbonate infusion for 3-4 h until plasma pH was around 7.4, while plasma ionized calcium was held at the preinfusion level by calcium solution infusion during the entire procedure. The plasma pH, bicarbonate, total CO2, sodium, and serum total calcium levels were significantly increased while serum concentrations of alkaline phosphatase and albumin were significantly decreased after bicarbonate infusion. The plasma ionized calcium, potassium, serum magnesium, inorganic phosphorus, and 25(OH)D levels showed no significant change before and after bicarbonate infusion. The serum 1,25(OH)2D3 levels were significantly increased (38.66 +/- 11.77 vs. 47.04 +/- 16.56 pmol/l, p < 0.05) after correction of metabolic acidosis. These results demonstrate that rapid correction of metabolic acidosis raises serum 1,25(OH)2D3 levels in vitamin D-deficient chronic renal failure patients, and may underline the importance of maintaining normal acid-base homeostasis in the presence of secondary hyperparathyroidism in chronic renal failure.

A prospective study of calcium metabolism in exertional heat stroke with rhabdomyolysis and acute renal failure

Intensive training in a humid and warm environment can cause exertional heat stroke (ExHS) and rhabdomolysis (RBD) in military recruits. To investigate the role of vitamin D and monomeric calcitonin (CT) on the calcium metabolism in ExHS with RBD and acute renal failure (ARF), we studied 21 recruits with ExHS (mean age 21.4 years), 7 of which had ARF. Another 11 age-matched recruits with heat exhaustion (HE) and 11 healthy subjects were selected as controls. Our results showed that in 14 ExHS patients without ARF, mean serum creatinine (Cr) levels were significantly higher (151.16 vs. 106.08 mumol/l, p < 0.01), whereas serum osteocalcin (OC) levels were significantly lower (2.22 vs. 4.65 micrograms/l, p < 0.01) than in healthy controls. In 7 patients with ExHS and ARF, the mean serum Cr (774.38 vs. 105.20 mumol/l, p < 0.01), phosphorus (P) (2.26 vs. 1.26 mmol/l, p < 0.05), creatine phosphokinase (CPK) 274,143.97 vs. 85.78 IU/l, p < 0.05), intact parathyroid hormone (I-PTH) (299.81 vs. 18.66 ng/l, p < 0.05) and CT (13.58 vs. 6.63 ng/l, p < 0.01) levels on admission were significantly higher while the mean ionized calcium (iCa) levels were significantly lower than the healthy controls (0.9 vs. 1.18 mmol/l, p < 0.01). The mean serum 25-hydroxyvitamin D [25(OH)D] levels were not significantly different from healthy controls. However, mean serum 1,25-dihydroxyvitamin D [1,25(OH)2D] levels and the ratio of 1,25(OH)2D to 25(OH)D were significantly lower than healthy controls throughout the whole course of ARF. None of the 7 patients with ExHS and ARF developed hypercalcemia during the diuretic phase. Their mean serum I-PTH levels decreased significantly from 299 to 18 ng/l during the recovery phase (p < 0.05). Our study seems to suggest that the abnormal calcium metabolism in this unique patient group is in part caused by persistently decreased renal production of 1,25(OH)2D, although increased monomeric CT levels were associated with hypocalcemia. However, whether or not a causal relationship exists merits further investigation.

Effects of intravenous calcitriol on lipid profiles and glucose tolerance in uraemic patients with secondary hyperparathyroidism

1. Secondary hyperparathyroidism in chronic renal failure may contribute to abnormalities of lipid metabolism and glucose tolerance. Amelioration of secondary hyperparathyroidism has been reported to mitigate the hyperlipidaemia and improve glucose tolerance experimentally. 2. The effect of the partial suppression of hyperparathyroidism by intravenous calcitriol on lipid levels and glucose tolerance was studied in 15 haemodialysis patients with secondary hyperparathyroidism. All received intravenous calcitriol 1 microgram at the end of haemodialysis thrice weekly for eight weeks. Oral glucose tolerance test and plasma lipid profiles including triglyceride, total cholesterol, high density lipoprotein cholesterol (HDL-C), low density lipoprotein cholesterol (LDL-C), apoprotein A-I and apoprotein B were determined simultaneously before and after eight weeks of therapy. 3. Before calcitriol treatment, uraemic patients with secondary hyperparathyroidism displayed a significant higher triglyceride and a significant lower HDL-C and apoprotein A-I as well as marked glucose intolerance with an increment of the area below the glucose curve when compared with healthy control subjects. 4. After eight weeks of calcitriol treatment, there was a significant decrement in serum intact parathyroid hormone (476.45 +/- 48.33 versus 191.37 +/- 30.17 ng/l, P < 0.001) and plasma triglyceride (2.24 +/- 0.34 versus 1.80 +/- 0.29 mmol/l, P < 0.05) as well as a significant increment of plasma apoprotein A-I (38.13 +/- 2.14 versus 44.19 +/- 2.18 mumol/l, P < 0.05), whereas there was no significant change in serum total cholesterol, LDL-C, HDL-C, and apoprotein B.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of intravenous calcitriol on platelet intracellular calcium in uremic hemodialysis patients with secondary hyperparathyroidism

BACKGROUND

To investigate the effect of the reversal of hyperparathyroidism on platelet intracellular free calcium ([Ca2+]i) by pharmacological parathyroidectomy with intravenous calcitriol in uremic patients with secondary hyperparathyroidism (2 degrees HPT).

METHODS

Serum concentrations of intact parathyroid hormone (I-PTH) were measured by two-site immunometric assay, and platelet [Ca2+]i was assessed using the fluorescent indicator fura-2. Fifteen hemodialysis patients with 2 degrees HPT and serum I-PTH 4 times greater than the normal upper limits, were selected for treatment with intravenous calcitriol 1 microgram thrice weekly for one month.

RESULTS

An increase of serum I-PTH (449.17 +/- 52.35 vs 32.52 +/- 1.95 pg/ml) and elevated platelet [Ca2+]i (139.49 +/- 8.78 vs 74.70 +/- 6.48 nM/L) was observed in uremic patients with 2 degrees HPT. Serum I-PTH levels were significantly correlated with platelet [Ca2+]i in uremic patients with 2 degrees HPT (r = 0.736, p = 0.002). The serum I-PTH levels decreased from 449.17 +/- 52.35 to 221.27 +/- 35.66 pg/ml (p < 0.001) and platelet [Ca2+]i fell from 139.49 +/- 8.78 to 97.86 +/- 7.25 nM/L (p < 0.001) after treatment. Fall in platelet [Ca2+]i was related to concomitant reduction in PTH levels (r = 0.572, p = 0.026).

CONCLUSIONS

It was concluded that an increase in cytosolic calcium in uremia may be at least in part induced by PTH. Besides, intravenous calcitriol can provide an effective way to suppress elevated serum I-PTH and attenuate platelet free calcium in uremia with 2 degrees HPT.

Influence of rapid correction of metabolic acidosis on serum osteocalcin level in chronic renal failure

Metabolic acidosis induces a combination of inhibited osteoblastic and stimulated osteoclastic activity. To determine the role of alkali therapy in osteoblast function in chronic renal failure, serum bone isoenzyme of alkaline phosphatase (BAP) and osteocalcin were assessed before and after bicarbonate infusion. Eighteen patients with mild to moderate metabolic acidosis, none of whom had received dialysis therapy, were enrolled in this study. Metabolic acidosis was corrected by continuous bicarbonate infusion while plasma ionized calcium was monitored at 5 min intervals and held at the preinfusion level by calcium solution infusion during the entire procedure. The end-point of the study was reached when the plasma bicarbonate was approximately 24 mmol/l or pH was approximately 7.4 and plasma ionized calcium was clamped at the preinfusion level with only a 0.01 mmol/l fluctuation. The plasma pH (7.31 +/- 0.04 vs. 7.40 +/- 0.03, P < 0.001), bicarbonate (18.46 +/- 2.49 vs. 23.66 +/- 2.72 mmol/l, P < 0.001), serum total calcium, and osteocalcin (15.61 +/- 6.45 vs. 18.79 +/- 6.71 mg/l, P < 0.05) levels were significantly increased, whereas serum concentrations of alkaline phosphatase and albumin levels were significantly decreased after bicarbonate infusion. The serum BAP (1.85 +/- 1.29 vs. 1.79 +/- 1.18 mukat/l, P = 0.252), and inorganic phosphorus levels showed no significant differences before and after bicarbonate infusion. These results demonstrate that rapid correction of metabolic acidosis improves osteoblast function and may underline the importance of maintaining normal acid-base homeostasis in chronic renal failure.

Hyperparathyroidism, glucose tolerance and platelet intracellular free calcium in chronic renal failure

Disturbance in the vitamin D/parathyroid hormone (PTH) axis may be important in the pathogenesis of glucose intolerance and insulin resistance in uraemia. To investigate possible relationships between hyperparathyroidism, intracellular free calcium ([Ca2+]i), and glucose tolerance in chronic renal failure, we measured serum intact PTH (I-PTH) by two-site immunometric assay, platelet [Ca2+]i using the fluorescent indicator fura-2, and plasma glucose and insulin after 14 h overnight fast and at 30, 60 and 120 min following a 75 g oral glucose load, in 18 chronic haemodialysis patients with elevated serum I-PTH. Calcitriol (1 microgram) was administered parenterally at the end of each dialysis session for four weeks. This significantly decreased serum I-PTH (p < 0.001) and platelet [Ca2+]i (p < 0.01). Uraemic patients initially showed marked glucose intolerance, with increased area below the glucose curve compared to healthy controls, but after 4 weeks of calcitriol treatment, this effect was significantly decreased, and there was a significant rise in the area under the insulin curve after glucose load. The insulinogenic index also increased significantly after calcitriol treatment. These data suggest that calcitriol treatment of haemodialysis patient with secondary hyperparathyroidism is associated with increased insulin secretion in response to glucose challenge, and that this change is linked to the decrease in intracellular free calcium.

Effect of intravenous calcitriol on secondary hyperparathyroidism in chronic hemodialysis patients

BACKGROUND

It has become evident that calcitriol can suppress parathyroid hormone (PTH) secretion by direct genomic actions. Intravenous calcitriol that bypasses gastrointestinal degradation might cause less degree of hypercalcemia and greater suppressive effect on PTH secretion. We investigated this PTH-suppressive effect of intravenous calcitriol in hemodialysis patients with secondary hyperparathyroidism.

METHODS

Calcitriol was administered at the end of each dialysis session three times a week in 20 uremic patients, for 12 weeks.

RESULTS

The mean dosage of calcitriol was 2.72 +/- 0.21 microgram per dialysis session. Serum intact PTH and C-PTH decreased (P < 0.05) after 6 weeks of treatment, while serum alkaline phosphatase (Alk-P) decreased 3 weeks later than PTH did. The individual maximal reduction of intact PTH, C-PTH and Alk-P were 77.80%, 67.36% and 45.98%. This PTH-suppression was dose-dependent. Despite the significant reduction of intact PTH by 58.17% after 6 weeks of treatment, no significant increase of serum calcium was found. An increase in serum calcium is not essential for this PTH-suppressive effect of calcitriol. Our observations thus provide another evidence to support the direct inhibitory effect of calcitriol on PTH secretion. Serum calcium, phosphorus, magnesium, albumin and osteocalcin levels did not change significantly. No side effect was found during treatment.

CONCLUSIONS

Intravenous calcitriol is effective and safe in treating hemodialysis patients with secondary hyperparathyroidism. This treatment is more important in patients who are intolerant to oral vitamin D supply and who are candidates for surgical parathyroidectomy.

Experimental IgA nephropathy. Enhanced deposition of glomerular IgA immune complex in proteinuric states

BACKGROUND

IgA nephropathy is induced by the IgA-immune complex (IC). IgA nephropathy associated with heavy proteinuria is considered a more progressive form of the disease. To elucidate the mechanism by which the latter condition occurs, we investigated the effect of proteinuria on the glomerular deposition of IgA-IC.

EXPERIMENTAL DESIGN

BALB/c female mice that had been made proteinuric by adriamycin or bovine serum albumin (BSA) were injected with TEPC-15 hybridoma-derived IgA anti-phosphorylcholine (PC) and individual specific antigens. The 6-hour clearance kinetics of IgA were measured, and the accumulation of IgA deposits and the third complement component (C3) in the glomerulus were analyzed.

RESULTS

The clearance kinetics of 125I-IgA injected together with a specific antigen, PC-conjugated BSA (BSA-PC), showed only a minimal distinction between the experimental (proteinuric) and the control (nonproteinuric) groups of mice. However, analysis of renal tissue by immunofluorescence and light microscopic autoradiography revealed markedly enhanced mesangial IgA-IC deposition in the proteinuric mice receiving IgA and one of three specific antigens, BSA-PC, PC-conjugated cytochrome-c, and a pneumococcal C-polysaccharide. Immunofluorescence also showed augmented mesangial C3 deposition in proteinuric mice that received IgA/PC-conjugated cytochrome-c or IgA/pneumococcal C-polysaccharide. In addition, adriamycin or BSA per se did not influence glomerular IgA-IC localization.

CONCLUSIONS

Glomerular localization of nephritogenic IgA-IC was comparably enhanced in mice with proteinuria induced by various methods. Thus, a vicious cycle for the progression of IgA nephropathy might ensue in proteinuric states.

Rapid correction of metabolic acidosis in chronic renal failure: effect on parathyroid hormone activity

To investigate the effect of rapid correction of chronic metabolic acidosis on circulating intact parathyroid hormone (I-PTH) activity by free calcium clamp in chronic renal failure, 18 patients were enrolled in this study. Metabolic acidosis was corrected by continuous bicarbonate infusion while plasma ionized calcium was clamped at the preinfusion level throughout the entire procedure. The plasma pH, bicarbonate, total CO2, sodium, serum total calcium and 1,25(OH)2 vitamin D3 levels increased significantly while serum concentrations of I-PTH, alkaline phosphatase and albumin showed significant decreases after bicarbonate infusion. The plasma ionized calcium, potassium, serum magnesium and inorganic phosphorus levels showed no significant difference before and after bicarbonate infusion. These results demonstrate that rapid correction of metabolic acidosis attenuates circulating PTH activity in chronic renal failure and may underline the importance of maintaining normal acid-base homeostasis particularly in the presence of secondary hyperparathyroidism.

Lupus nephritis: an analysis of 70 cases

BACKGROUND

The influence of renal morphology and clinical factors at biopsy on the development of renal failure in patients with lupus nephritis remain controversial. We investigated the relation between renal histologic finding and clinical manifestations, and evaluated prognostic factors and short-term prognosis among patients with lupus nephritis.

METHODS

Seventy patients with lupus nephritis were enrolled in the study from 1982 to 1992 at the Tri-Service General Hospital. Renal biopsy specimens from these patients were assessed according to the World Health Organization (WHO) classification, activity and chronicity indices, and clinical parameters. Survival was analyzed by using the day of renal biopsy as the starting point. The end point of renal survival was the date when patient started to receive regular hemodialysis.

RESULTS

In pathological finding, one patient was grouped as Class I (1.4%); 14, as Class II (20%); 15, as Class III (21.4%); 29, as Class IV (41.4%); 9, as Class V (12.9%), and 2, as Class VI (2.9%). The scores of activity indices were highest in Class IV. The blood levels of C3 and C4 in Class V were significantly higher than Class IV. The values of BUN and 24-hour urine protein in Class II were significant lower than Class IV. Patients who progressed to renal failure had significantly higher numbers of death, higher serum creatinine and chronicity index, less creatinine clearance, and higher numbers of hypertension at the time of biopsy. Nephrotic syndrome was not associated with renal failure. Patient and renal survivals did not differ among WHO classifications. The patient and renal survivals were 84%, 60% and 85%, 72% at one and five years, respectively. Seventeen patients (24.2%) progressed to end-stage renal disease and 21 patients (30%) died during the study period. The leading causes of death were sepsis and renal failure.

CONCLUSIONS

WHO classification had little correlation with clinical and renal information. At the time of biopsy the elevated serum creatinine and hypertension were good predictors for end-stage renal disease. Poor patient and renal survivals were found in this study.

Role of plasma catecholamines, autonomic, and left ventricular function in normotensive and hypotension prone dialysis patients

The current study looked at plasma catecholamines, clinical autonomic function tests, and hemodynamic parameters in 10 ESRD patients (five men and five woman, aged 56.4 +/- 3.6) with dialysis hypotension and 10 patients (five men and five women, aged 58.6 +/- 4.2) without dialysis hypotension. Catecholamines were measured using high performance liquid chromatography--electrochemical detection (HPLC-ECD). Dialysis led to a significant decrease in mean arterial pressure (MAP) in the hypotensive group as compared with the normotensive group. Significantly higher basal (predialysis) plasma norepinephrine (NE) and dopamine levels (DA) were found in the hypotensive uremic group as compared with the normotensive group. Levels of plasma epinephrine (EP) were not significantly different between the normotensive and hypotensive groups. In response to postural stimulation, blood pressure fell in both groups, but the fall in the hypotensive group was significantly greater. Percentage increments of plasma catecholamines in response to postural stimulation in both groups were similar, however. Among the measured hemodynamic parameters, including total peripheral vascular resistance and left ventricular function (cardiac index and fractional shortening), only the cardiac index showed significantly lower values in the hypotensive group after dialysis, as compared with the normotensive group. Results of four tests of autonomic function indicated that although both groups responded similarly to hand-grip and cold-pressor tests, impaired responses to orthostasis and Valsalva maneuver after dialysis were observed in the hypotensive group. The MAP changes in dialysis in the hypotension prone group correlated inversely with predialysis plasma NE, but not with EP and DA.(ABSTRACT TRUNCATED AT 250 WORDS)

Lupus nephritis, emphasizing tubulointerstitial lesions: a clinico-pathological analysis

Tubulointerstitial lesions (TIL) such as interstitial inflammation, fibrosis and tubular atrophy are frequently found in classes of lupus nephritis. A retrospective study evaluate lupus nephritis, the relationship between TIL and glomerular lesions, and the significance of TIL in assessing the severity and prognosis for cases of lupus nephritis. Between June 1983 and Jan 1990, 492 renal biopsies were performed. Lupus nephritis was diagnosed in 37 patients who fulfilled the American Rheumatology Association (ARA) criteria for Systemic lupus erythematosus (SLE). The results showed a significant correlation between degree of TIL and impairment of renal function. Degree of TIL and severity of glomerular lesions must be considered simultaneously to predict renal function of patients with lupus nephritis.

Quality of life assessment in end-stage renal disease patients with maintenance hemodialysis therapy

This is a pilot study assessing the quality of life for a total of twenty uremic patients being treated with maintenance hemodialysis. It includes eight males and twelve females with a mean age of fifty three years, having been on hemodialysis for an average of forty-five months (from five to 143 months). The quality of life study was obtained from a structured questionnaire, which contained 10 categories including: sense of well-being, sense of mood, family life, marriage life, neighborhood relationships, friend relationships, working ability, job condition, intelligence condition and life satisfaction. Each category consisted of 3 to 5 items, with a maximum score of 100 points. Among these 20 patients, the highest score on the quality of life study is marriage life with 80.4 +/- 10.0 points, the lowest score is life satisfaction with 59.7 +/- 15.3 points. There was no significant difference in the scores of quality of life between different sex groups. The scores in the sense of well-being group greater than 60 years were lower than those less than 60 years with a significant difference (P less than 0.05). A significant difference was also found in both the sense of well-being and sense of mood depending on the duration of hemodialysis therapy. Those who received hemodialysis therapy more than 3 years produced better scores in the sense of well-being and sense of mood category than those who received hemodialysis less than 3 years.

Role of creatine phosphokinase in predicting acute renal failure in hypocalcemic exertional heat stroke

Recruits frequently develop hypocalcemia in exertional heat stroke (ExHS) with rhabdomyolysis and acute renal failure (ARF) from intensive training. It usually indicated severe skeletal muscle damage. However, the relative risk of ARF in ExHS patients complicated with hypocalcemia was unknown. The present study was undertaken to evaluate the value of peak serum creatine phosphokinase (CPK) level in predicting ARF in ExHS patients with hypocalcemia. Sixty-eight army recruits with ExHS were hospitalized at the Tri-Service General Hospital, Taiwan: 17 with ARF and hypocalcemia (group A); 7 with ARF but without hypocalcemia (group B); 20 without ARF but with hypocalcemia (group C); and 24 without ARF or hypocalcemia (group D). In the 24 patients with ARF (groups A and B) the serum phosphate and peak CPK levels were significantly higher than in patients without ARF (groups C and D; p < 0.001), serum calcium levels were also significantly lower in the former (p < 0.001). In the 37 patients with hypocalcemia (groups A and C), the peak serum CPK levels were significantly higher than in those without hypocalcemia (groups B and D; p < 0.001). There was a higher proportion of hypocalcemic patients with peak serum CPK levels greater than 10,000 U/l among ARF compared with patients without ARF (chi 2 = 12.48, p < 0.001). In 24 patients with ARF, there was a negative correlation between serum Ca and peak CPK levels (t = 3.37, r = -0.58, p < 0.01). However, a positive correlation was found between serum creatinine and peak serum CPK levels in 37 patients with hypocalcemia (t = 2.47, r = 0.39, p < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of erythropoietin on neutrophil chemiluminescence in hemodialyzed patients

Erythropoietin (EPO) has been used widely for correcting anemia in hemodialyzed (HD) patients. Enhancement of phagocytic function during EPO treatment of HD patients has been studied, but no data have been available on the effect of EPO on neutrophil chemiluminescence (CL) after challenge with phorbol myristate acetate (PMA). CL was measured in prehemodialysis whole blood samples from 15 stabilized patients and 15 normal healthy control subjects (C) after challenge with PMA. Before EPO treatment, CL was noted to be significantly higher in HD patients than in C, which changed significantly after 5 weeks of treatment (Rx) and continued for 13 weeks of Rx. There was a significant increase in hematocrit in these HD patients after 5 weeks that persisted until the 13th week. It was concluded that there is a significant decrease in whole blood CL in response to challenge with PMA during correction of anemia in HD patients treated with EPO. This study demonstrated that EPO could decrease enhanced PMA-activated reactive oxygen metabolite production and suggested that this decrease may protect against tissue damage, including red blood cell hemolysis in the uremic milieu.

Assessment of proteinuria by using the protein/creatinine ratio of single-voided urine

Quantitative 24-hour urine protein excretion is used in the diagnosis, the monitoring of therapeutic effects and the prognosis of renal disease. However, this method is time-consuming, cumbersome and often inaccurate. Many studies have shown that the single voided urine protein/creatinine (Pr/Cr) ratio relates well with 24-hour urine protein excretion and can be substituted for evaluating some conditions. In our study, 41 patient with renal disease (25 men, 16 women) with a mean age of 43 years (range, 20-79 years), not only collected 24-hour urine, but also collected single voided urine at four different times. There was an excellent correlation between 24-hour urine protein excretion and the single voided urine Pr/Cr ratio at various degrees of creatinine clearance and ranges of proteinuria. The highest correlation was found in urine specimens collected at 16:00 hours with a correlation coefficient (r) of 0.91. Other urine specimens also showed a good relation with a correlation coefficient of above 0.80. The creatinine clearance (Ccr) greater than or equal to 70 ml/min group showed a better relationship than the Ccr less than 70 ml/min group. The proteinuria more than 1.0 g/day group also showed a better relationship than the group with proteinuria of less than 1.0 g/day. However, these differences were not statistically significant. No significant differences between the different age groups or sexes, using the single voided urine Pr/Cr ratio to estimate the 24-hour urine protein excretion were found. It is concluded that the single voided urine Pr/Cr ratio correlates highly with 24-hour urine protein excretion and could be an alternative means for disease monitoring and screening.

Induced hyperglycemia protects rats against mercuric chloride nephrotoxicity

Male Sprague-Dawley rats made diabetic (n = 20) by injection of streptozotocin 65 mg/kg and weight matched controls (n = 19) were divided into unilaterally nephrectomized and intact groups prior to challenge with HgCl2 (3 mg/kg). Diabetic rats (D2, n = 9) did not show a rise in serum creatinine concentration (0.56 +/- 0.10 vs 0.48 +/- 0.10 mg/dl) after HgCl2 challenge, while control rats (C2, n = 10) had a significant (p less than 0.001) rise in serum creatinine levels (0.40 +/- 0.14 vs 2.60 +/- 0.42 mg/dl). Uninephrectomized rats (D1, n = 11) did not alter the protection afforded by diabetes (creatinine 0.69 +/- 0.14 vs 0.67 +/- 0.13 mg/dl), but control uninephrectomized rats (C1, n = 9) had a substantial rise (p less than 0.001) in serum creatinine (0.51 +/- 0.13 vs 3.81 +/- 0.72 mg/dl). We conclude that induced hyperglycemia protects rats against mercuric chloride toxicity.

Hepatitis B virus-associated membranous glomerulonephropathy

A variety of extrahepatic abnormalities have been described in patients with hepatitis B viral infection, including the prodromal arthritis (serum sickness-like) syndrome, polyarteritis nodosa, and glomerulonephropathy. Five patients with hepatitis B virus (HBV)-associated membranous glomerulonephropathy (MGN) were persistent carriers of HBsAg. The deposition of HBsAg in the renal lesions of these patients was proved by using monospecific antibody and immunofluorescence technique. These findings support the hypothesis of an etiological correlation of hepatitis B viral infection with some cases of MGN. HBV-associated MGN may be much more frequent in the world than previously reported, and more cases must be collected for the understanding of this unique entity.

Immunoglobulin A nephropathy and ankylosing spondylitis. Report of two patients in Taiwan and review of the literature

We describe 2 patients with immunoglobulin A (IgA) nephropathy in association with ankylosing spondylitis. Renal biopsy demonstrated mesangial proliferative glomerulonephritis with prominent IgA, C3c, and less intense properdin deposition in the glomeruli. Intraglomerular clumps of virus-like particles were also observed in the kidney sample from one patient (case 2), who had an abnormal liver function. Our findings support the hypothesis that here is a possible common pathogenesis responsible for the concurrence of both IgA nephropathy and ankylosing spondylitis.

Low risk of contrast media-induced acute renal failure in nonazotemic type 2 diabetes mellitus

The risk of developing contrast media-induced acute renal failure was studied in 49 randomly selected nonazotemic type 2 adult diabetic patients subjected to IVU. There were 19 men and 30 women in the group whose mean age was 62 +/- 10 years (range, 38 to 82 years). In preparation for IVU, patients were neither dehydrated nor given a laxative. The IVU was performed in the morning, using sodium diatrizoate and meglumine diatrizoate. Serum creatinine levels were measured pre-IVU and on days 1, 3, and 6 after the IVU. A total of three patients (6%) had an elevation of serum creatinine greater than 25% above the baseline by post-IVU day 3. One patient developed oliguria (less than 400 ml/24 hr) that lasted 2 days. Creatinine clearances of the three patients showing contrast media toxicity were 74, 60, and 105 ml/min pre-IVU. In each of the three patients, a return to pre-IVU serum creatinine concentration was noted within 2 weeks. It is concluded that the risk of acute renal failure post-IVU is small in hydrated nonazotemic type 2 diabetic patients.