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P141 Crystal induced acute renal failure
s12
Abstracts
I European
Journal
of Internal
the elevated CK level be caused by hypocalcemia? This finding has been reported in animals as well humans mainly in hypoparatyroidism or as a result of Vitamin D deficiency. In both cases CK returned to normal upon correction of hypocalcemia. Could the elevated serum CK level be associated with hyponatremia? This association was reported to occur in hypothyroidism, rhabdomyolysis or due to drug administration such as indapamide. None of these were present in our patient. Whether elevated CK level is due to hyponatremia or hypocalcemia is still unknown. More clinical research is needed.
P140 Dialysate as food H.L. Tjiong, J.W.O. vd Berg, J.L.D. vd Wiel, A. van Egmond, M.W.J.A.
Wattima, Fieren,
T. Rietveld, L. van Dijk, A. G.R. Swart (Rotterdam, NL)
Background: Obesity and protein malnutrition occur in many patients on peritoneal dialysis due to unintentional glucose absorption, anorexia and loss of amino acids and protein through peritoneal clearance. It will lead to a decrease in lean body mass and a loss in quality of life. We hypothesized that an amino acid/glucose mixture as dialysate will have a positive effect on nitrogen economy. Aim of the study: Investigate whether combined intraperitoneal administration of amino-acids and glucose (in proportions similar to what is usually found in food) during nocturnal cycling in patients on Continuous Cyclic Peritoneal Dialysis (CCPD) will have beneficial effects on nitrogen metabolism and economy. Study design. A single, random order cross over, open study, in 8 patients, comparing in 2 periods of 7 days each a mixture of amino-acids and glucose (Nutrineal/Fysioneal) vs. glucose (Fysioneal) containing dialysates during nighttime cycler assisted peritoneal dialysis Primary endpoints. Nitrogen balance, whole body protein turnover, incorporation into body protein of dialysate supplied ammo nitrogen. Methods: During the study an automatic cycler device regulates mixing of equal volumes of amino acid 1.1% (Nutrineal@) and glucose (Fysioneal”) in each dialysis cycle. Nitrogen balance is studied. Whole body protein turnover is determined using a primed continuous infusion of 13C- labelled leucine intravenously during the nocturnal dialysis on either mixture. The net absorption and incorporation into body protein of dialysate-supplied, deuterium labelled, amino acids is calculated by following the change over time in deuterium enrichment in dialysate, plasma and plasma albumin. Preliminary conclusions: The protocol is complicated but feasible. The study is still in progress, until now. five patients have been included. The results in four patients, recently completed, show a diminished protein breakdown, a not significantly stimulated protein synthesis, and as a result a 30% less negative protein balance during amino acid peritoneal dialysis (p=O.O2).
P141 Crystal induced acute renal failure L. de Matias, R. Sanchez, M.J. Femandez-Reyes, C. Sam, J. Gonzalez, R. Gonzalez, I. Leon, A. Herrero, E. Ferreira, J. Moreno (Madrid, E) Introduction: Drug induced nephrotoxicity is an important cause of acute renal failure. In many cases, it is due to the intratubular precipitation of drug crystals that are insoluble in urine. There are additional risk factors such as previous renal insufficiency, volume depletion and the use of high drug doses, that can increase the likelihood of crystal formation. Methods: Two clinical cases of acute renal failure due to the use of Trimethropim-Sulfametoxazole (TMP-SMX) are presented. In both cases high doses were used. After a short period of treatment, renal function deteriorated and sulfonamide crystals were detected in the urine. CASE I: A 29-year-old male, presents to the Emergency Room with
Medicine
14 (2003)
Sl-S1.59
purple-eritematous skin lesions on left hand and foreann due to an accident at work with wood. The culture of these lesions was positive for Nocardia and treatment with high doses of TMP-SMX was started. One week after the treatment, worsening of renal function was detected (Creatinine 1.8 mg/dl) and sulfonamide crystals were detected (pH 5) in the urine. CASE 2: A 78-year-old woman with past medical history of Reumathoid Artritis, on Methotrexate, was admitted complaining of weight loss, fever and disseminated nodular, purple-pink skin lesions. On Physical examination, bibasal fine crackles on pulmonary auscultation were remarkable. The Chest X-ray and the CT scan performed showed bilateral nodular lesions and the culture of the skin lesions’ biopsy was positive for N. asteroides. She was started on high doses of TMP-SMX, and 48 hours after, the renal function deteriorated (Cr=6; basal 1.8). Conclusions: Sulfonamides are antibiotics that can often induce the formation of crystals whose intratubular precipitation is the cause of acute renal failure. This pathology has become more frequent with the current increase in the use of sulfonamides in the treatment or prophylaxis of immunodepressed patients’ infections. Renal failure due to crystal precipitation is usually reversible with drug cessation, urine alkalinization and correction of the risk factors.
P142 Stevens-Johnson Syndrome succesfully treated with plasmapheresis E. Skaragka, G. Tzatzagou, S. Karakoulakis, S. Goutkidou, K. Koutsiou, R. Papadopoulos, G. Skaragkas (Thessaloniki, GR) Stevens-Johnson Syndrome is an immune-complex mediated hypersensitivity complex that is a severe expression of erythema multiforme. It typically involves the skin and the mucous membranes. Significant involvement of oral, nasal, eye, vaginal, urethral, GI and lower respiratory tract mucous membranes may develop in the course of the illness. The causative agent may be any drug as well as viral infections and malignancies, but in about half of cases, no specific etiology can be identified. Two cases of Stevens-Johnson Syndrome are presented below: A 28 and a 22 year-old female patients were admitted to our hospital in the last year with severe Stevens-Johnson Syndrome. The insulting agent appeared to be cefaclor and paracetamol respectively. On admission they had generalized bullous lesions, some of them ruptured leaving extensive areas of denuted skin. They both had oral mucosa eruptions while the former had also urinary tract involvement. We began plasmapheresis on admission in both cases. The sessions were carried out every other day and were combined with potassium hypermanganate baths. The first patient underwent 10 plasmapheresis sessions while the second 8. During treatment they were closely investigated for fluid and electrolyte disorders for adequate correction. The plasma-exchange therapy was well tolerated by our patients. Their general condition was dramatically improved and they both left hospital in about a month after admission. We believe that both these two reports are interesting as there are few cases of StevensJohnson Syndrome in the medical literature, treated with plasmapheresis. Furthermore, both patients recovered completely without any complications.
P143 A rare case of retro A. Al Suhary, J.E. (Rotterdam, NL)
peritoneal Nienhuis,
fibrosis E. Kats,
L.C.W.
de Jonge,
A.
Dees
Objective: Retro peritoneal fibrosis (RPF) requires multidisciplinary treatment. Case and results: A 73-year-old, previous healthy, man complained of a dull non-colicky pain in both flanks and he had difficulty in starting to urinate. The physical examination was normal, except for a benign
Abstracts
I European
Journal
of Internal
the elevated CK level be caused by hypocalcemia? This finding has been reported in animals as well humans mainly in hypoparatyroidism or as a result of Vitamin D deficiency. In both cases CK returned to normal upon correction of hypocalcemia. Could the elevated serum CK level be associated with hyponatremia? This association was reported to occur in hypothyroidism, rhabdomyolysis or due to drug administration such as indapamide. None of these were present in our patient. Whether elevated CK level is due to hyponatremia or hypocalcemia is still unknown. More clinical research is needed.
P140 Dialysate as food H.L. Tjiong, J.W.O. vd Berg, J.L.D. vd Wiel, A. van Egmond, M.W.J.A.
Wattima, Fieren,
T. Rietveld, L. van Dijk, A. G.R. Swart (Rotterdam, NL)
Background: Obesity and protein malnutrition occur in many patients on peritoneal dialysis due to unintentional glucose absorption, anorexia and loss of amino acids and protein through peritoneal clearance. It will lead to a decrease in lean body mass and a loss in quality of life. We hypothesized that an amino acid/glucose mixture as dialysate will have a positive effect on nitrogen economy. Aim of the study: Investigate whether combined intraperitoneal administration of amino-acids and glucose (in proportions similar to what is usually found in food) during nocturnal cycling in patients on Continuous Cyclic Peritoneal Dialysis (CCPD) will have beneficial effects on nitrogen metabolism and economy. Study design. A single, random order cross over, open study, in 8 patients, comparing in 2 periods of 7 days each a mixture of amino-acids and glucose (Nutrineal/Fysioneal) vs. glucose (Fysioneal) containing dialysates during nighttime cycler assisted peritoneal dialysis Primary endpoints. Nitrogen balance, whole body protein turnover, incorporation into body protein of dialysate supplied ammo nitrogen. Methods: During the study an automatic cycler device regulates mixing of equal volumes of amino acid 1.1% (Nutrineal@) and glucose (Fysioneal”) in each dialysis cycle. Nitrogen balance is studied. Whole body protein turnover is determined using a primed continuous infusion of 13C- labelled leucine intravenously during the nocturnal dialysis on either mixture. The net absorption and incorporation into body protein of dialysate-supplied, deuterium labelled, amino acids is calculated by following the change over time in deuterium enrichment in dialysate, plasma and plasma albumin. Preliminary conclusions: The protocol is complicated but feasible. The study is still in progress, until now. five patients have been included. The results in four patients, recently completed, show a diminished protein breakdown, a not significantly stimulated protein synthesis, and as a result a 30% less negative protein balance during amino acid peritoneal dialysis (p=O.O2).
P141 Crystal induced acute renal failure L. de Matias, R. Sanchez, M.J. Femandez-Reyes, C. Sam, J. Gonzalez, R. Gonzalez, I. Leon, A. Herrero, E. Ferreira, J. Moreno (Madrid, E) Introduction: Drug induced nephrotoxicity is an important cause of acute renal failure. In many cases, it is due to the intratubular precipitation of drug crystals that are insoluble in urine. There are additional risk factors such as previous renal insufficiency, volume depletion and the use of high drug doses, that can increase the likelihood of crystal formation. Methods: Two clinical cases of acute renal failure due to the use of Trimethropim-Sulfametoxazole (TMP-SMX) are presented. In both cases high doses were used. After a short period of treatment, renal function deteriorated and sulfonamide crystals were detected in the urine. CASE I: A 29-year-old male, presents to the Emergency Room with
Medicine
14 (2003)
Sl-S1.59
purple-eritematous skin lesions on left hand and foreann due to an accident at work with wood. The culture of these lesions was positive for Nocardia and treatment with high doses of TMP-SMX was started. One week after the treatment, worsening of renal function was detected (Creatinine 1.8 mg/dl) and sulfonamide crystals were detected (pH 5) in the urine. CASE 2: A 78-year-old woman with past medical history of Reumathoid Artritis, on Methotrexate, was admitted complaining of weight loss, fever and disseminated nodular, purple-pink skin lesions. On Physical examination, bibasal fine crackles on pulmonary auscultation were remarkable. The Chest X-ray and the CT scan performed showed bilateral nodular lesions and the culture of the skin lesions’ biopsy was positive for N. asteroides. She was started on high doses of TMP-SMX, and 48 hours after, the renal function deteriorated (Cr=6; basal 1.8). Conclusions: Sulfonamides are antibiotics that can often induce the formation of crystals whose intratubular precipitation is the cause of acute renal failure. This pathology has become more frequent with the current increase in the use of sulfonamides in the treatment or prophylaxis of immunodepressed patients’ infections. Renal failure due to crystal precipitation is usually reversible with drug cessation, urine alkalinization and correction of the risk factors.
P142 Stevens-Johnson Syndrome succesfully treated with plasmapheresis E. Skaragka, G. Tzatzagou, S. Karakoulakis, S. Goutkidou, K. Koutsiou, R. Papadopoulos, G. Skaragkas (Thessaloniki, GR) Stevens-Johnson Syndrome is an immune-complex mediated hypersensitivity complex that is a severe expression of erythema multiforme. It typically involves the skin and the mucous membranes. Significant involvement of oral, nasal, eye, vaginal, urethral, GI and lower respiratory tract mucous membranes may develop in the course of the illness. The causative agent may be any drug as well as viral infections and malignancies, but in about half of cases, no specific etiology can be identified. Two cases of Stevens-Johnson Syndrome are presented below: A 28 and a 22 year-old female patients were admitted to our hospital in the last year with severe Stevens-Johnson Syndrome. The insulting agent appeared to be cefaclor and paracetamol respectively. On admission they had generalized bullous lesions, some of them ruptured leaving extensive areas of denuted skin. They both had oral mucosa eruptions while the former had also urinary tract involvement. We began plasmapheresis on admission in both cases. The sessions were carried out every other day and were combined with potassium hypermanganate baths. The first patient underwent 10 plasmapheresis sessions while the second 8. During treatment they were closely investigated for fluid and electrolyte disorders for adequate correction. The plasma-exchange therapy was well tolerated by our patients. Their general condition was dramatically improved and they both left hospital in about a month after admission. We believe that both these two reports are interesting as there are few cases of StevensJohnson Syndrome in the medical literature, treated with plasmapheresis. Furthermore, both patients recovered completely without any complications.
P143 A rare case of retro A. Al Suhary, J.E. (Rotterdam, NL)
peritoneal Nienhuis,
fibrosis E. Kats,
L.C.W.
de Jonge,
A.
Dees
Objective: Retro peritoneal fibrosis (RPF) requires multidisciplinary treatment. Case and results: A 73-year-old, previous healthy, man complained of a dull non-colicky pain in both flanks and he had difficulty in starting to urinate. The physical examination was normal, except for a benign