- Email: [email protected]
Pathophysiology of Acute Renal Failure in Septic Shock: From Prerenal to Renal Failure
ADRENAL, HYPERTENSION, RENAL PHYSIOLOGY AND RENAL FAILURE
Results: Twenty-seven patients underwent an anterior transabdominal procedure, whereas 2 1underwent a posterior retroperitoneal procedure via bilateral incisions. Age, weight, and diagnostic categories of Gushing’s syndrome were similar between the two groups as well as serum cortisol and 24-hour urinary cortisol levels. Operative time, estimated blood loss, and transfusion requirements were not different between the groups, even though adrenal glands excised through the anterior approach were significantly larger. Acute morbidity was similar between the groups. However, 17 (81%)of 21 patients who underwent posterior bilateral adrenalectomy suffered from chronic back pain, compared with 2 (7%) of 27 via the anterior approach. Five of these patients in the posterior group considered the pain incapacitating, and the mean time t o return to work was significantly longer in the posterior group because of back pain. Conclusions: The anterior approach to bilateral adrenalectomy has comparable intraoperative complications and early morbidity compared to the posterior approach. The posterior approach has a very high incidence of chronic incision-related back pain. The anterior approach is the preferred open surgical technique in most patients undergoing bilateral adrenalectomy for Cushing‘s syndrome without other contraindications for undergoing laparotomy.
Editorial Comment: The authors compared the anterior to posterior surgical approach for bilateral adrenalectomy. The only significant difference was considerable back pain with the posterior approach. Regarding operative time, blood loss and morbidity, both approaches were similar. However, laparoscopic bilateral adrenalectomy for bilateral Cushing‘s disease probably will become the preferred method, which will eliminate many of the complications noted in this article and result in an earlier return to work. In several previous reports of such series the results have been truly impressive. W. Scott McDougal, M.D. Pathophysiology of Acute Renal Failure in Septic Shock: From Prerenal to Renal Failure
H. A. BOCK,Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland Kidney Int., suppl., 53: S15S18, 1998 No Abstract Editorial Comment: In this review the pathophysiological events leading to acute renal failure in the clinical setting are described. It is important to note, as the author suggests, that only 10 to 3Wo of patients with acute renal failure will leave the hospital alive. Generally, it is not acute renal failure that determines the prognosis but the diseases which led to its development. The author lists 5 basic causative mechanisms of acute renal failure, including hypotensiodischemia, endotoxin and cytokines, oxidant injury, vasoconstrictors and nephrotoxic antibiotics. Hopefully, by understanding the pathophysiological event, therapies for reversing renal deterioration will be developed. However, at this time there are no significant maneuvers which result in reversal of the renal failure in the majority of circumstances. W. Scott McDougal, M.D. Kidneys on Vacation: The Notion of Renal Work and the Introduction of Nonpharmacological Therapies
T. LENNERT r n F. C . LUFT,Department ofpediatrics, Klinikum Benjamin Franklin, Free University of Berlin and Franz Volhard Clinic, Virchow Klinikum, Humboldt University of Berlin, Berlin, Germany h e r . J. Kidney Dis., 2 9 777-780,1997 “Wisdoms of today become the follies of tomorrow,” remarked none other than Franz Volhard, who first classified renal disease. In earlier times, nephrologists relied less on controlled randomized prospective trials and more on common sense. One such notion was the idea that kidneys could be “rested” by requiring them to make less urine. Particularly in Germany early in this century, patients with chronic renal disease were advised to go to Assuan in Egypt, where the warm sunny weather and low humidity decreased their urinary output. Thus, a “vacation” was prescribed for sick kidneys, and indeed, early in his career Volhard also supported this notion. In a small but excellent study, Loewy, Wohlgemuth, Bickel, and Schweitzer concluded that a decreased urinary output, rather than decreasing renal work, would require a considerable increase in concentration of excreted solutes, a task that patients with renal insufficiency would not be likely able to meet. These findings, as well as the observation that renal patients often failed to return from Egypt, caused Volhard to change his mind. Reprinted with permission from National Kidney Foundation, Inc. Editorial Comment: This particularly eqjoyable article chronicles some of the inappropriate ideas of the past. The authors note that in the early part of the century a prevalent concept was that by reducing urine output, kidneys could rest and diseased kidneys would be able to repair. Thus, the prevailing opinion in Germany was to send patients to Egypt where the humidity was low and the temperature was high. Many of these patients consequently died of uremia. Some questioned the wisdom of this concept and several physiolo&sts debunked the myth.
2027
Results: Twenty-seven patients underwent an anterior transabdominal procedure, whereas 2 1underwent a posterior retroperitoneal procedure via bilateral incisions. Age, weight, and diagnostic categories of Gushing’s syndrome were similar between the two groups as well as serum cortisol and 24-hour urinary cortisol levels. Operative time, estimated blood loss, and transfusion requirements were not different between the groups, even though adrenal glands excised through the anterior approach were significantly larger. Acute morbidity was similar between the groups. However, 17 (81%)of 21 patients who underwent posterior bilateral adrenalectomy suffered from chronic back pain, compared with 2 (7%) of 27 via the anterior approach. Five of these patients in the posterior group considered the pain incapacitating, and the mean time t o return to work was significantly longer in the posterior group because of back pain. Conclusions: The anterior approach to bilateral adrenalectomy has comparable intraoperative complications and early morbidity compared to the posterior approach. The posterior approach has a very high incidence of chronic incision-related back pain. The anterior approach is the preferred open surgical technique in most patients undergoing bilateral adrenalectomy for Cushing‘s syndrome without other contraindications for undergoing laparotomy.
Editorial Comment: The authors compared the anterior to posterior surgical approach for bilateral adrenalectomy. The only significant difference was considerable back pain with the posterior approach. Regarding operative time, blood loss and morbidity, both approaches were similar. However, laparoscopic bilateral adrenalectomy for bilateral Cushing‘s disease probably will become the preferred method, which will eliminate many of the complications noted in this article and result in an earlier return to work. In several previous reports of such series the results have been truly impressive. W. Scott McDougal, M.D. Pathophysiology of Acute Renal Failure in Septic Shock: From Prerenal to Renal Failure
H. A. BOCK,Division of Nephrology, Kantonsspital Aarau, Aarau, Switzerland Kidney Int., suppl., 53: S15S18, 1998 No Abstract Editorial Comment: In this review the pathophysiological events leading to acute renal failure in the clinical setting are described. It is important to note, as the author suggests, that only 10 to 3Wo of patients with acute renal failure will leave the hospital alive. Generally, it is not acute renal failure that determines the prognosis but the diseases which led to its development. The author lists 5 basic causative mechanisms of acute renal failure, including hypotensiodischemia, endotoxin and cytokines, oxidant injury, vasoconstrictors and nephrotoxic antibiotics. Hopefully, by understanding the pathophysiological event, therapies for reversing renal deterioration will be developed. However, at this time there are no significant maneuvers which result in reversal of the renal failure in the majority of circumstances. W. Scott McDougal, M.D. Kidneys on Vacation: The Notion of Renal Work and the Introduction of Nonpharmacological Therapies
T. LENNERT r n F. C . LUFT,Department ofpediatrics, Klinikum Benjamin Franklin, Free University of Berlin and Franz Volhard Clinic, Virchow Klinikum, Humboldt University of Berlin, Berlin, Germany h e r . J. Kidney Dis., 2 9 777-780,1997 “Wisdoms of today become the follies of tomorrow,” remarked none other than Franz Volhard, who first classified renal disease. In earlier times, nephrologists relied less on controlled randomized prospective trials and more on common sense. One such notion was the idea that kidneys could be “rested” by requiring them to make less urine. Particularly in Germany early in this century, patients with chronic renal disease were advised to go to Assuan in Egypt, where the warm sunny weather and low humidity decreased their urinary output. Thus, a “vacation” was prescribed for sick kidneys, and indeed, early in his career Volhard also supported this notion. In a small but excellent study, Loewy, Wohlgemuth, Bickel, and Schweitzer concluded that a decreased urinary output, rather than decreasing renal work, would require a considerable increase in concentration of excreted solutes, a task that patients with renal insufficiency would not be likely able to meet. These findings, as well as the observation that renal patients often failed to return from Egypt, caused Volhard to change his mind. Reprinted with permission from National Kidney Foundation, Inc. Editorial Comment: This particularly eqjoyable article chronicles some of the inappropriate ideas of the past. The authors note that in the early part of the century a prevalent concept was that by reducing urine output, kidneys could rest and diseased kidneys would be able to repair. Thus, the prevailing opinion in Germany was to send patients to Egypt where the humidity was low and the temperature was high. Many of these patients consequently died of uremia. Some questioned the wisdom of this concept and several physiolo&sts debunked the myth.
2027