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Treatment of Nephrotic Edema with Bumetanide
1259
J\1ISCELLAl\JEOUS
encountered in treating patients with acute azotemia. In principle, it often is relatively easy to separate these 2 entities. In practice, however, both conditions may occur in the same clinical setting and present with comparable physical findings. Many authors have used the values of urine/plasma creatinine concentration ratio and the urinary sodium concentration to help differentiate these entities. Unfortunately, a gray zone exists in which the urinary sodium concentration, urinary osmolality and urine/plasma creatinine ratio may not· be absolutely diagnostic of either acute tubular necrosis or true renal failure. In this excellent review article the author outlines the use of 2 new parameters: 1) the renal failure index and 2) the fractional excretion of sodium. A basic understanding of the limitations of each determination is reviewed, based on the values required for their calculations. In addition, parameters to suggest potential recovery versus progressive decline are outlined. It is emphasized that the further any value strays from the expected limits the less likely it supports a valid diagnosis. In the case of both of these forms of determination it is preferable to note carefully any departures in the urine osmolality, urine/plasma creatinine concentration ratio, and the urinary sodium concentration and accepting any single number value as being absolutely diagnostic. W.J.C. 2 figures, l table, 13 references
Treatment of Nepm·otic Edema With Bumetanide
G.
LEMIEUX, M. BEAUCHEMIN, A. Goucoux AND P. VINAY, Nephrology-Metabolism Division, Renal Clinic and Renal Laboratory, Hotel-Dieu Hospital and Department of Medicine, University of Montreal, Montreal, Canada
Canad. Med. Ass. J., 125: 1111-1112 (Nov. 15) 1981 Bumetanide (3-n-butylamino-4-phenoxy-5-sulfamoyl-benzoic acid) is a loop of Henle diuretic with effects on the excretion of sodium and water similar to those of furosemide. The drug has been used to treat congestive heart failure and ascites secondary to cirrhosis of the liver. However, reports on the effect of bumetanide on edema associated with renal disorders are few to date. The authors report their crossover study in which 2 to 6 mg. bumetanide were compared to 40 to 160 mg. furosemide daily in the treatment of 10 patients with nephrotic syndrome and massive edema. The 2 drugs, both of which act on the loop of Henle, were found to be equally effective. Patients with renal insufficiency responded poorly to both drugs. Although bumetanide is 40 times more potent by weight than furosemide, this is not necessarily an advantage. However, it is effective and, thus, an alternative agent in the treatment of nephrotic edema in patients who, for unknown reasons, may be refractory to treatment with l diuretic but may respond to another. This may be the case in 2 patients in this study. W. W.H 2 tables, 10 references
The Etiology of Chord.ee KAPLAN AND W. A. BROCK, Department of Surgery/ Urology, University of California Medical Center, and Children's Hospital and Health Center, San Diego, California
G. W.
UroL Clin. N. Amer., 8: 383-387 (Oct.) 1981
1'he authors attempt to revievv ogic information and clinical observations to presem the current theories on chordee. Based on these experimental observations it appears that chordee is a normal stage of embryogenesis and that persistence of chordee in extrauterine life most likely represents a failure at some stage of urethral or penile development. Presumably, this is attributable to an androgen deficiency or a tissue insensitivity to androgen. The 5 basic categories of chordee result in deficiency of ventral penile skin, corpus spongiosum or Buck's fascia, a congenitally short urethra or a deficient ventral corpus cavernosum. Based on this category of etiologies the authors recommend various surgical approaches to the problem of chordee. W.J. C. 1 table, 14 references
Patient Response to Impending Death
F.
GLENN,
Cornell University Medical College, New York City
N. Y. State J. Med., 81: 1869-1872 (Dec.) 1981 The responses of a patient to impending death often relate to age or to the medical situation. Children and teenagers :;iel8 years old often respond to death with the feeling of terror. The typical response of patients between 18 and 64 years old is that of surprise and rebellion. The more elderly patient accepts the idea of death as undesirable but inevitable. Examples of special situations include the military casualities of World War II in which one tended to accommodate quickly to the poor chance of survival and those patients who were ready to undergo a high risk cardiovascular operation that might provide successful rehabilitation. The author gives other examples of individual responses to impending death. Some individuals react with bitterness when they learn that their lifestyle and ambitions are to be interrupted. Others accept it and plan to make things easier for their family and friends. Another type of reaction is one that is seen in patients who not only accept the idea of impending death but also renew the lifestyle with increasing vigor. Lastly, there is the type of patient who meets the news with equanimity and does not require much knowledge of the gravity of the situation. The author makes a plea for further patient education to reduce fears associated with dying. J.D.S. 9 references
Death and Dying J. G. WILDERS, New York N. Y. State J. Med., 81; 1884-1886 (Dec.) 1981 The dying patient's feeling of isolation, as indicated earlier by Dr. Elisabeth Kubler-Ross, is highlighted in this article. Although most families try to hide the truth from the dying patient, increased communications about life and death generally tend to increase acceptance and feeling of peace. The dying patient requires someone nearby for support. The attending physician must accept the following responsibilities in caring for the dying patient: 1) recognition of the emotional and spiritual problems of the sick or dying patient, 2) understanding of the religious aspects of such a crisis, 3) respect for the special religious practices available for the dying patient and 4) the suggestion of help from the appropriate clergyman. J.D.8.
J\1ISCELLAl\JEOUS
encountered in treating patients with acute azotemia. In principle, it often is relatively easy to separate these 2 entities. In practice, however, both conditions may occur in the same clinical setting and present with comparable physical findings. Many authors have used the values of urine/plasma creatinine concentration ratio and the urinary sodium concentration to help differentiate these entities. Unfortunately, a gray zone exists in which the urinary sodium concentration, urinary osmolality and urine/plasma creatinine ratio may not· be absolutely diagnostic of either acute tubular necrosis or true renal failure. In this excellent review article the author outlines the use of 2 new parameters: 1) the renal failure index and 2) the fractional excretion of sodium. A basic understanding of the limitations of each determination is reviewed, based on the values required for their calculations. In addition, parameters to suggest potential recovery versus progressive decline are outlined. It is emphasized that the further any value strays from the expected limits the less likely it supports a valid diagnosis. In the case of both of these forms of determination it is preferable to note carefully any departures in the urine osmolality, urine/plasma creatinine concentration ratio, and the urinary sodium concentration and accepting any single number value as being absolutely diagnostic. W.J.C. 2 figures, l table, 13 references
Treatment of Nepm·otic Edema With Bumetanide
G.
LEMIEUX, M. BEAUCHEMIN, A. Goucoux AND P. VINAY, Nephrology-Metabolism Division, Renal Clinic and Renal Laboratory, Hotel-Dieu Hospital and Department of Medicine, University of Montreal, Montreal, Canada
Canad. Med. Ass. J., 125: 1111-1112 (Nov. 15) 1981 Bumetanide (3-n-butylamino-4-phenoxy-5-sulfamoyl-benzoic acid) is a loop of Henle diuretic with effects on the excretion of sodium and water similar to those of furosemide. The drug has been used to treat congestive heart failure and ascites secondary to cirrhosis of the liver. However, reports on the effect of bumetanide on edema associated with renal disorders are few to date. The authors report their crossover study in which 2 to 6 mg. bumetanide were compared to 40 to 160 mg. furosemide daily in the treatment of 10 patients with nephrotic syndrome and massive edema. The 2 drugs, both of which act on the loop of Henle, were found to be equally effective. Patients with renal insufficiency responded poorly to both drugs. Although bumetanide is 40 times more potent by weight than furosemide, this is not necessarily an advantage. However, it is effective and, thus, an alternative agent in the treatment of nephrotic edema in patients who, for unknown reasons, may be refractory to treatment with l diuretic but may respond to another. This may be the case in 2 patients in this study. W. W.H 2 tables, 10 references
The Etiology of Chord.ee KAPLAN AND W. A. BROCK, Department of Surgery/ Urology, University of California Medical Center, and Children's Hospital and Health Center, San Diego, California
G. W.
UroL Clin. N. Amer., 8: 383-387 (Oct.) 1981
1'he authors attempt to revievv ogic information and clinical observations to presem the current theories on chordee. Based on these experimental observations it appears that chordee is a normal stage of embryogenesis and that persistence of chordee in extrauterine life most likely represents a failure at some stage of urethral or penile development. Presumably, this is attributable to an androgen deficiency or a tissue insensitivity to androgen. The 5 basic categories of chordee result in deficiency of ventral penile skin, corpus spongiosum or Buck's fascia, a congenitally short urethra or a deficient ventral corpus cavernosum. Based on this category of etiologies the authors recommend various surgical approaches to the problem of chordee. W.J. C. 1 table, 14 references
Patient Response to Impending Death
F.
GLENN,
Cornell University Medical College, New York City
N. Y. State J. Med., 81: 1869-1872 (Dec.) 1981 The responses of a patient to impending death often relate to age or to the medical situation. Children and teenagers :;iel8 years old often respond to death with the feeling of terror. The typical response of patients between 18 and 64 years old is that of surprise and rebellion. The more elderly patient accepts the idea of death as undesirable but inevitable. Examples of special situations include the military casualities of World War II in which one tended to accommodate quickly to the poor chance of survival and those patients who were ready to undergo a high risk cardiovascular operation that might provide successful rehabilitation. The author gives other examples of individual responses to impending death. Some individuals react with bitterness when they learn that their lifestyle and ambitions are to be interrupted. Others accept it and plan to make things easier for their family and friends. Another type of reaction is one that is seen in patients who not only accept the idea of impending death but also renew the lifestyle with increasing vigor. Lastly, there is the type of patient who meets the news with equanimity and does not require much knowledge of the gravity of the situation. The author makes a plea for further patient education to reduce fears associated with dying. J.D.S. 9 references
Death and Dying J. G. WILDERS, New York N. Y. State J. Med., 81; 1884-1886 (Dec.) 1981 The dying patient's feeling of isolation, as indicated earlier by Dr. Elisabeth Kubler-Ross, is highlighted in this article. Although most families try to hide the truth from the dying patient, increased communications about life and death generally tend to increase acceptance and feeling of peace. The dying patient requires someone nearby for support. The attending physician must accept the following responsibilities in caring for the dying patient: 1) recognition of the emotional and spiritual problems of the sick or dying patient, 2) understanding of the religious aspects of such a crisis, 3) respect for the special religious practices available for the dying patient and 4) the suggestion of help from the appropriate clergyman. J.D.8.