Cases reported "Uremia"

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1/59. Radionuclide renography: a personal approach.

    Recent advances have increased the value of radionuclide renography in evaluating the patient with suspected disease of the genitourinary tract. The use of the consensus process to help standardize procedures and recommend interpretative criteria provides guidance for the nuclear medicine practitioner, serves as a basis to improve the standard of practice, and facilitates pooling of data from different centers. This review draws on the consensus criteria to present a personal approach to radionuclide renography with a particular emphasis on diuresis renography and the detection of renovascular hypertension. patients are encouraged to come well hydrated and void immediately prior to the study. Our standard radiopharmaceutical is 99mTc mercaptoacetyltriglycine (MAG3). Routine quantitative indices include a MAG3 clearance, whole kidney and cortical (parenchymal) regions of interest, measurements of relative uptake, time to peak height (Tmax), 20 min/max count ratio, residual urine volume and a T(1/2) in patients undergoing diuresis renography. A 1-minute image of the injection site is obtained at the conclusion of the study to check for infiltration because infiltration can invalidate a plasma sample clearance and alter the renogram curve. A postvoid image of the kidneys and bladder is obtained to calculate residual urine volume and to better evaluate drainage from the collecting system. In patients undergoing diuresis renography, the T(1/2) is calculated using a region of interest around the activity in the dilated collecting system. A prolonged T(1/2), however, should never be the sole criterion for diagnosing the presence of obstruction; the T(1/2) must be interpreted in the context of the sequential images, total and individual kidney function, other quantitative indices and available diagnostic studies. The goal of ACE inhibitor renography is to detect renovascular hypertension, not renal artery stenosis. patients with a positive study have a high probability of cure or amelioration of the hypertension following revascularization. In patients with azotemia or in patients with a small, poorly functioning kidney, the test result is often indeterminate (intermediate probability) with an abnormal baseline study that does not change following ACE inhibition. In patients with normal renal function, the test is highly accurate. To avoid unrealistic expectations on the part of the referring physician, it is often helpful to explain the likely differences in test results in these two-patient populations prior to the study.
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2/59. Uraemic gangrene syndrome: is parathyroidectomy always necessary?

    This report presents a case of uraemic gangrene syndrome with multiple ulcerations and calcium (Ca) deposits in the vessel walls. High-dosage oral calcium carbonate (CaCO3) treatment alone resulted in rapid wound healing with decreased serum phosphorus (P), Ca x P product and parathormone and only slightly increased Ca levels. We suggest that this should be the first choice of treatment in such cases because positive clinical response can achieve symptom-free status for the patient until kidney transplantation, thus making parathyroidectomy unnecessary.
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3/59. Roentgenographic features of mushroom (amanita) poisoning.

    The clinical and roentgenographic features of six cases of amanita mushroom poisoning were reviewed. The roentgenographic manifestations included adynamic ileus (three patients) and small, irregularly shaped kidneys secondary to the healing process of acute tubular necrosis (one patient). intestinal pseudo-obstruction can result from many medical problems and mushroom poisoning should be considered in its differential diagnosis.
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4/59. Severe electrolyte disturbances and renal failure in elderly patients with combined diuretic therapy including xipamid.

    diuretics are among the most frequently prescribed substances in elderly patients, but they are also associated with the highest incidence of adverse effects in this group of patients. xipamide is a sulfonamide-like diuretic whose action does not depend on transtubular secretion. This characteristic makes it suitable for situations in which the kidney is highly sodium avid. Because of the potency of this substance the risk of adverse reactions like electrolyte disorders or hypovolemia is increased as well. We report seven patients (age 65-85) admitted to the emergency room of the University Hospital of Innsbruck between 1998 and 2002 who had developed serious adverse reactions upon initiation of treatment with xipamide as an additional diuretic. Six of these patients had received combinations with loop diuretics. The disturbances observed were hyponatremia (lowest value 108 mmol/l), hypokalemia (lowest value 1.5 mmol/l) and prerenal azotemia (highest serum urea 269 mg/dl, highest serum creatinine 5.13). CONCLUSION: With the exception of diuretic resistance in severe heart failure or renal insufficiency a combination therapy of xipamide with a second diuretic appears to be associated with an unnecessarily high risk of serious adverse reactions and thus should be avoided. This is especially true for elderly patients.
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5/59. Autocystectomy following extensive genitourinary tuberculosis: presentation and management.

    Genitourinary tuberculosis is an important cause of morbidity in developing and developed countries. We describe a case of extensive genitourinary tuberculosis in which there was complete destruction of the right kidney, stricture of the entire left ureter and an autocystectomized bladder. He presented in azotemia with urinary incontinence and was managed by right nephroureterectomy, ileal replacement of left ureter and ileal neobladder after a preliminary nephrostomy and antituberculous chemotherapy.
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6/59. A necropsy case of interstitial nephritis probably related to cefazolin and methenamine.

    It is the purpose of this paper to alert the medical community on the potential nephrotoxicity of certain agents among certain patients, especially with some types of renal insufficiency. A young man, who was suffering from apparent renal disturbance, died of massive, post-operative bleeding accompanied by uremia. The uremia occurred within a very rapid clinical course and was related apparently to treatment with methenamine, a ruinary disinfectant, and cefazolin, a cephalosporin derivative. The patient was proved to have a fatal, servere interstitial nephritis based on gross and histological findings of the necropsied kidney, i.e., intense cell infiltration mainly in the interstitum of the cortex, absence of glomerular involvement, and marked softening and enlargement. The present case may suggest how to treat patients suffering from untoward renal ailments with various antibiotics.
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7/59. Reappraisal of long-term renal replacement therapy. Renal transplantation: medical versus statistical approach.

    The validity of the numerous statistical methods used for the assessment of the results achieved with renal transplantation performed for terminally uremic patients may be challenged by a medicalized approach of the patient's post transplantation course and outcome. This assumption has been applied to a population of 700 patients who received a grafted kidney in our unit between November 1972 and December 1990. Among 77 patients who had been followed up for 10-15 years after grafting, 75% had not suffered any serious related complication during the first decade after transplantation. In contrast, among the whole transplant population, transplantation entailed either a rapidly fatal issue due to an unpredictable and irreversible complication in 45 patients (6.4%), or a state of chronic illness with severely disabling complications in 150 others (21.5%). At present, the main cause of concern remains, however, the persistent long-term graft loss due to chronic rejection. Nevertheless, the advances and results achieved in the field of organ transplantation in recent years justifies the policy which privileges renal transplantation as the first-choice method of renal replacement therapy for every terminally uremic patient aged less than 60-65 years in whom careful workup does not reveal any clinical/psychological contraindication.
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8/59. Minimally dilated obstructive nephropathy initially suspected as pre-renal azotemia in a kidney donor with volume depletion.

    Although ultrasonography is regarded as the gold standard in the diagnosis of obstructive nephropathy, dilatation is sometimes not observed by ultrasonography. We report upon a case of minimally dilated obstructive nephropathy due to an ureter stone in a kidney donor with volume depletion. A 54-year-old man was admitted due to anuria and abdominal pain of 2 days duration. Ten years previously, his right kidney was donated for transplantation, and one month before admission, he abstained from all food except water and salt, for 30 days for religious reasons. He had lost 8 kg of body weight. On admission, he had clinical signs of volume depletion, i.e., a dehydrated tongue and decreased skin turgor. Laboratory data confirmed severe renal failure, his blood urea nitrogen level was 107.3 mg/dL, and his serum creatinine 16.5 mg/dL. The plain X-ray was unremarkable and ultrasonography showed only minimal dilatation of the renal collecting system. On follow-up ultrasonography, performed on the 5th hospital day, the dilatation of the collecting system had slightly progressed and a small stone was found at ureter orifice by cystoscopy. Removal of stone initiated dramatic diuresis with a rapid return of renal function to normal by the third day.
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9/59. Bone morphogenic protein-4 expression in vascular lesions of calciphylaxis.

    calciphylaxis is characterized by an extensive media-calcification of cutaneous and subcutaneous arterioles and capillaries. Recent studies have provided evidence that vascular calcification is a process with similarities to bone metabolism. Bone morphogenic protein-4 (BMP-4) is physiologically involved in bone development and repair. The presence of BMP-4 in atherosclerosis and in sclerotic heart valves led us to suggest that BMP-4 is also involved in calciphylaxis. A 47-year-old male patient developed end-stage renal failure due to chronic glomerulonephritis. He has had two kidney transplants with an immunosuppressive regimen consisting of cyclosporine A and steroids. He was admitted to our hospital because of an increase in serum creatinine (Cr) and he subsequently developed progressive dermal ulcerations. A skin biopsy led to the diagnosis of calciphylaxis. immunohistochemistry for BMP-4 of a skin specimen from our patient showed strong cytoplasmic immunoreactivity of intradermal cells with clear spatial association to arterioles and hair follicles. Whereas there are identified inhibitors and promoters of vascular calcification, the presence of BMP-4 has not been demonstrated in calcific uremic arteriolopathy. In contrast to atherosclerosis, BMP-4 in calciphylaxis cannot be found in vascular media, but in intradermal cells at the border of arterioles and hair follicles. Therefore, in calciphylaxis BMP-4 can play the role of a cytokine, a growth factor or a media-calcification promoter.
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10/59. Increasing the dose of furosemide in patients with azotemia and suspected obstruction.

    diuresis renography is widely used to distinguish obstructed from nonobstructed kidneys; however, the delivery of furosemide to its site of action in the loop of henle is impaired in patients with azotemia. Consequently, the standard adult dose of 40 mg furosemide could be insufficient to generate an adequate diuretic response. This problem is illustrated by a patient with azotemia with bilateral nephrostomies who underwent Tc-99m MAG3 (mercaptoacetyltriglycine) diuresis renography with 40 mg furosemide to determine if his bilateral ureteral obstruction had resolved. The study showed findings typical for obstruction despite the fact that the patient could not have been obstructed because the nephrostomy tubes had not been clamped. When the study was repeated 6 days later with 80 mg furosemide and clamped nephrostomy tubes, there was good drainage bilaterally excluding obstruction. The nephrostomy tubes were removed and the patient's creatinine has subsequently remained stable for 3 years. In summary, this report illustrates the rationale for increasing the dose of furosemide in patients with azotemia referred for diuresis renography and shows how increasing the dose of furosemide could improve the diuretic response and minimize false-positive or indeterminate results.
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