USE OF THE ARTIFICIAL KIDNEY—Its Place in the Treatment of Acute Renal Failure

Of 57 patients with severe, but potentially reversible, acute renal failure who were observed during a recent four-year period, some had dialysis with an artificial kidney and some did not.Twenty survived with the standard “conservative” management alone; 19 survived with a combination of “conservative” and “intensive” (that is, artificial kidney) treatment; 18 patients died.One error that was made in the management of all 18 patients who died, was excessive delay in the use of the artificial kidney.Hemodialysis should be used whenever serious electrolyte abnormality exists, whenever the blood urea nitrogen exceeds 150 mg. per 100 cc. or whenever clinical signs of uremia first appear. One or more of these indications will usually, but not always, become evident between the fifth and the eighth day of virtual anuria.     

The Kolff-Merrill artificial kidney; clinical application in acute renal insufficiency

Acute renal insufficiency is often called "lower nephron nephrosis." Its recognition, its prognostic significance, and its therapy by conservative measures are receiving increasing clinical emphasis. The mortality rate in this complicated syndrome still remains unduly high. One method of therapy of anuric patients whose lives are in jeopardy because of fulminating uremia or critical potassium intoxication is use of an artificial kidney to "purify" the blood stream by means of extracorporeal dialysis.The author describes clinical (and laboratory) experience with ten such dialyzed patients, eight of whom presented the classical picture of acute renal insufficiency. Four died, one from unrecognized coronary occlusion, another from antecedent, overwhelming peritonitis. Two other patients with chronic kidney disorders received no benefit from dialysis and died of renal disease. Good biochemical and clinical response was brought about in six cases of lower nephron nephrosis. Presumably, these six patients would have died had they not been subjected to artificial dialysis.     

Why do patients with lupus nephritis die?

Over 20 years 42 of 138 patients with systemic lupus erythematosus "died"--that is, suffered actual death or went into terminal renal failure, or both; data from 41 were available for analysis. In most patients the causes of death were multiple. Twenty seven patients went into terminal renal failure, of whom 25 were offered dialysis treatment. Three regained renal function later, 12 survived on dialysis or with functioning kidney allografts--almost all with inactive lupus--but 13 died after starting dialysis, most within a few weeks or months. The principal causes were active lupus or infection. In those patients with renal failure after rapid deterioration in renal function (n = 14) there were nine deaths, while of 10 patients with a slow evolution into renal failure, only four died. Four patients with impaired and 10 with normal renal function died, again most often from complications of lupus or from infection. Vascular disease was a major cause of death in seven patients, all but two of whom were young; of 15 postmortem examinations, eight showed severe coronary artery atheroma, and three surviving patients required coronary bypass operations. Analysis of the timing of death or entry into renal failure showed that in 12 out of 13 patients who died within two years of onset the lupus was judged to be active, while this was true in only eight out of 19 patients who died later. Six of the seven vascular deaths occurred later than two years from onset, while only nine of 26 renal "deaths" occurred before two years; deaths from infections (n = 13) were distributed equally. Despite this and aggressive treatment of active disease, the principal cause of actual death was uncontrolled lupus.     

Life change events, ballistocardiography and coronary death.

Thirty-six men and women who experienced a documented myocardial infarction, half of whom ultimately died from their disease and half of whom survived over a six-year period, provided longitudinal recent life changes and ballistocardiographic data. The 18 patients who died from their coronary disease indicated a significant buildup in life changes which peaked approximately one year prior to death; their serial ballistocardiograms indicated a significant buildup in average force of contraction which was seen to peak approximately six months prior to death. The 18 post-infarction patients who survived the six-year follow-up showed neither a buildup in life change nor a buildup in the ballistocardiographic index of cardiac contraction force. These findings of a life change peak preceding ballistocardiographic evidence of an "overworked" heart are discussed in terms of their possible medical and psychophysiological significances.     

Subcapsular hematoma of the liver in infants of very low birth weight.

Between January 1982 and May 1986 a large subcapsular hemorrhage of the liver (SHL) was diagnosed in six infants who weighed 1000 g or less at birth at Royal Alexandria Hospitals, Edmonton. The diagnosis of a ruptured SHL was made between 4 and 18 days of life by means of clinical and sonographic findings in four of the infants; an intact SHL was diagnosed at autopsy in the other two. None of the cases was associated with parenchymal rupture of the liver. Thrombocytopenia was present in five of the six infants and in all four infants with hemoperitoneum. Other possibly relevant antecedent events included mechanical ventilation (in all six), administration of indomethacin (in all six), hypoxia (in five), bilateral pneumothorax necessitating repeated pleural drainage (in three), external cardiac massage (in three) and septicemia (in two). Two of the three infants who underwent surgery survived the operation but later died of unrelated events. One infant who was managed conservatively also survived. A large SHL should be considered in all infants of very low birth weight with unexplained hypovolemia or anemia.     

Peritoneal Dialysis in Acute and Chronic Renal Failure

Clinical experience with peritoneal dialysis in eight cases of acute and four cases of chronic renal failure is presented. Seven of the acute cases survived but in some of these hemodialysis was also employed. The relatively simple technique of peritoneal dialysis was found to be effective, although slower than hemodialysis. In three of the cases it was selected in preference to hemodialysis. Its main advantages are that it does not require elaborate arrangements, or the use of blood or anticoagulants. The authors conclude that when the peritoneum is intact the method can be employed whenever the use of a temporary kidney substitute is indicated.     

Prolonged pregnancy: the management debate.

A prospective trial was conducted to compare the effects of conservative management of prolonged pregnancy (conservative group) with routine induction of labour at 42 weeks'' gestation (active group) in otherwise uncomplicated pregnancies. Of the 402 pregnancies studied, 207 (51%) were allocated to conservative management and 195 (49%) were allocated to have labour induced. The groups were well matched for age, parity, and smoking habits. One hundred and sixty six (80%) of the patients in the conservative group went into spontaneous labour. Of the remainder, two underwent elective caesarean section, 19 had labour induced because of clinical concern, and the remaining 20 had labour induced at the patient''s own request. One hundred and twenty five (64%) of the patients in the planned active group underwent induction of labour. Of the remaining 70, 49 went into spontaneous labour and 21 (11%) asked that they should not have labour induced. Comparison of the two groups showed no difference in the length of the first stage of labour but a trend towards an increased need for intervention for fetal distress (p less than 0.06) in the active group. There were no differences in the length of the second stage, the need for intervention, or the mode of delivery. In terms of Apgar scores the neonatal outcome was not significantly different between the two groups, but a greater proportion of the babies (15% v 8%) in the active group required intubation. Umbilical cord venous pH estimated in the last 183 consecutive deliveries in the study showed a significantly lower mean value in the active group (p less than 0.05). There was no difference in birth weight between the two groups. Two deaths occurred in the study. There was a stillbirth in the conservative group at 292 days after massive abruption, and one neonatal death in the active group owing to multiple congenital abnormalities. The outcome for mother and baby in patients from both groups who went into spontaneous labour was generally good. The outcome for patients for whom conservative management was planned but induction became necessary was no different from that of patients who underwent planned induction at term. Thus from our results we can find no evidence to support the view that women with normal prolonged pregnancy should undergo routine induction of labour at 42 weeks'' gestation.     

Further Assessment of Rosette Inhibition Test in Clinical Organ Transplantation

The rosette inhibition test was used in the clinical management of organ allografts to estimate the amount of immunosuppressive drugs necessary to prevent rejection. In patients surviving more than three months renal function appeared to be better than in a similar group of patients managed without the test. It is suggested that this was due to a reduction in the number of clinical or subclinical rejection episodes. On the other hand, the test indicates that in many cases the level of immunosuppression should be much higher, and if this advice is followed the patients become increasingly exposed to the risk of infection. In other words, those patients with good renal function remained well, whereas those who might otherwise have rejected their kidney and survived had in fact died of sepsis.     

Management of extra-pulmonary tuberculosis (excluding miliary and meningeal) in south and west Wales (1976-8).

In a retrospective survey of the management of extrapulmonary tuberculosis lymph node and genitourinary tuberculosis were found more commonly than bone and joint or gynaecological disease. Only 29% of patients received 18 moths'' chemotherapy while 31% received nine to 12 months'' treatment with rifampicin and isoniazid regimens and 34% had short-course chemotherapy with other regimens. Five patients were not offered any chemotherapy after diagnosis, and in five patients the diagnosis was overlooked because of administrative errors. One patient died from tuberculosis (renal). Poor drug compliance appeared less of a problem than in pulmonary tuberculosis. Only 14% of patients had their disease managed solely by consultants who were not specialists in chest disease. Liaison with a chest consultant did not necessarily ensure chemotherapy for 18 moths.     

Buffy coat autografts for patients with chronic granulocytic leukaemia in transformation

We have treated 20 patients with chronic granulocytic leukaemia (CGL) in transformation with cytotoxic drugs or with cytotoxic drugs and whole-body irradiation followed by transfusion of autologous blood cells collected at diagnosis and stored in liquid nitrogen. The mean number of nucleated cells autografted was 25.1 X 10(8)/kg (range: 12.5-40.1). Full myeloid engraftment occurred in 18 patients; it was partial in one patient and unassessable in another. The median survival for the 20 patients post-graft was 14 weeks. Two patients are alive, one now in recurrent transformation, and one in second chronic phase that has lasted 52 weeks. For the 18 patients who died the mean survival was 24 weeks (range: 2-125). Two patients with predominantly myelosclerotic transformation showed evidence of engraftment. One patient successfully autografted developed features consistent with graft-versus-host disease which proved fatal. We conclude that autografting may offer substantial palliation for some but not all patients with CGL in transformation.     

Emotional problems in children; the uses of drugs in therapeutic management

The repair of intracardiac defects under direct vision by opening the heart to expose the operative field, with the aid of hypothermia or a pump-oxygenator, is now a practical clinical method. Twelve patients were operated upon by this method. In eight patients an atrial septal defect was repaired during total circulatory occlusion under hypothermia. The seven patients in this group who had uncomplicated atrial defects survived the operation and are doing well after a short follow-up period. One patient with an unrecognized, associated ventricular defect died at the time of operation. Four patients were operated upon during total cardiac by-pass with the DeWall bubble-oxygenator. The first three patients survived operation and are continuing to do well after a brief follow-up period. In the fourth patient an atrioventricularis communis was repaired by the reconstruction of an atrial and ventricular septum with a plastic prosthesis. This patient died at the end of operation.     

Risk of severe outcomes among patients admitted to hospital with pandemic (H1N1) influenza

Background

We describe the disease characteristics and outcomes, including risk factors for admission to intensive care unit (ICU) and death, of all patients in Canada admitted to hospital with pandemic (H1N1) influenza during the first five months of the pandemic.

Methods

We obtained data for all patients admitted to hospital with laboratory-confirmed pandemic (H1N1) influenza reported to the Public Health Agency of Canada from Apr. 26 to Sept. 26, 2009. We compared inpatients who had nonsevere disease with those who had severe disease, as indicated by admission to ICU or death.

Results

A total of 1479 patients were admitted to hospital with confirmed pandemic (H1N1) influenza during the study period. Of these, 1171 (79.2%) did not have a severe outcome, 236 (16.0%) were admitted to ICU and survived, and 72 (4.9%) died. The median age was 23 years for all of the patients, 18 years for those with a nonsevere outcome, 34 years for those admitted to ICU who survived and 51 years for those who died. The risk of a severe outcome was elevated among those who had an underlying medical condition and those 20 years of age and older. A delay of one day in the median time between the onset of symptoms and admission to hospital increased the risk of death by 5.5%. The risk of a severe outcome remained relatively constant over the five-month period.

Interpretation

The population-based incidence of admission to hospital with laboratory-confirmed pandemic (H1N1) influenza was low in the first five months of the pandemic in Canada. The risk of a severe outcome was associated with the presence of one or more underlying medical conditions, age of 20 years or more and a delay in hospital admission.The first cases of pandemic (H1N1) influenza in Canada were reported on Apr. 26, 2009. Retrospective case-finding determined that the onset of symptoms in the first Canadian case, involving a traveller returning from Mexico, occurred on Apr. 12, 2009. The first patient admitted to hospital began to experience symptoms on Apr. 18.During the first few weeks of the outbreak, in-depth follow-up and reporting of cases was conducted in keeping with the World Health Organization’s pandemic plans for each country to comprehensively assess its first 100 cases.¹ By mid-May, many Canadian jurisdictions moved away from this approach because it became increasingly taxing on both public health human resources and laboratory capacity. It was decided that reporting of individual cases would continue nationally only for patients who were admitted to hospital or who died. We provide a detailed review of the disease characteristics and outcomes, including risk factors for admission to intensive care unit (ICU) and death, of patients admitted to hospital in Canada during the first five months of the pandemic.     

Duration of Last Attack in 998 Fatal Cases of Coronary Artery Disease and its Relation to Possible Cardiac Resuscitation

All the deaths attributed to coronary artery disease and occurring in Belfast during one year were studied.The frequency distributions of the cases by interval of time between onset of the last attack and death are given for those not admitted to hospital, for those admitted to hospital, and for those already in hospital for some other cause of illness.Sixty per cent. of all the deaths occurred outside hospital. This indicates that the problem of cardiac resuscitation in coronary artery disease is to a considerable extent an extra-hospital one.Twenty-seven per cent. of the men and 22% of the women died within 15 minutes, but the median period of survival was 3 hours 30 minutes for men and 6 hours 18 minutes for women.The median time interval from the onset of the attack to sending for medical aid was 1 hour 17 minutes for men and 1 hour 6 minutes for women, and from summoning medical aid to sending for the ambulance 59 minutes for men and 1 hour 26 minutes for women. Ninety-six per cent. of the ambulance journeys to the patient were accomplished in less than 20 minutes.It was found among men, but not among women, that the duration of survival tended to be longer in older patients and in second or subsequent attacks.Of the 596 who did not gain admission to hospital 229 (23% of all the 998 patients) were known to have survived for more than half an hour after the onset of the fatal attack; 182 (18%) survived for more than one hour; and 143 (14%) survived for more than two hours. It is among these that there would appear to be special scope for the cardiac ambulance, providing that medical aid is sought and the ambulance is summoned without delay.     

Metastatic adenocarcinoma of the colon presenting as a monarthritis of the hip in a young patient

Background

Leiomyosarcoma of the inferior vena cava is a rare tumor that presents in an insidious manner with non-specific symptoms. Given its rarity, there are no consensus guidelines to its management. The aim of this study was to report the clinical experience in the management of patients presenting to our institution during a 12 year period.

Patients and Methods

Four patients with leiomyosarcomas of the inferior vena cava were managed at our institution during the period reviewed. Patient details were identified through a search of the pathology department computerized database, and case notes were retrospectively reviewed to obtain details of presentation and management.

Results

There were 3 females and 1 male with a mean age of 59 years. All tumors were identified within 2 months of first symptoms. Three of the 4 had localized tumors whilst 1 patient had lung metastases at presentation. The three patients with resectable tumors underwent radical surgical excision of the tumor, and two patients had postoperative radiotherapy. One patient died of recurrence at 7 months, and another at 30 months. The third patient is currently well and disease free at 16 months. The fourth patient with metastatic disease was treated with chemotherapy alone and survived 36 months.

Conclusion

Leiomyosarcoma of the inferior vena cava is an uncommon tumor that presents with non-specific symptoms. At the time of presentation, tumors are usually large and resection is challenging but probably offers the best opportunity for long-term survival.     

Risk Factors for the Failure of Spinal Burst Fractures Treated Conservatively According to the Thoracolumbar Injury Classification and Severity Score (TLICS): A Retrospective Cohort Trial

Background

The management of thoracolumbar (TL) burst fractures is still controversial. The thoracolumbar injury classification and severity score (TLICS) algorithm is now widely used to guide clinical decision making, however, in clinical practice, we come to realize that TLICS also has its limitations for treating patients with total scores less than 4, for which conservative treatment may not be optimal in all cases.

Purpose

The aim of this study is to identify several risk factors for the failure of conservative treatment of TL burst fractures according to TLICS algorithm.

Methods

From June 2008 to December 2013, a cohort of 129 patients with T10-l2 TL burst fractures with a TLISC score ≤3 treated non-operatively were identified and included into this retrospective study. Age, sex, pain intensity, interpedicular distance (IPD), canal compromise, loss of vertebral body height and kyphotic angle (KA) were selected as potential risk factors and compared between the non-operative success group and the non-operative failure group.

Results

One hundred and four patients successfully completed non-operative treatment, the other 25 patients were converted to surgical treatment because of persistent local back pain or progressive neurological deficits during follow-up. Our results showed that age, visual analogue scale (VAS) score and IPD, KA were significantly different between the two groups. Furthermore, regression analysis indicated that VAS score and IPD could be considered as significant predictors for the failure of conservative treatment.

Conclusion

The recommendation of non-operative treatment for TLICS score ≤3 has limitations in some patients, and VAS score and IPD could be considered as risk factors for the failure of conservative treatment. Thus, conservative treatment should be decided with caution in patients with greater VAS scores or IPD. If non-operative management is decided, a close follow-up is necessary.     

Development of salinity tolerance in the marine pulmonate Amphibola crenata (Gmelin)

Growth and survival of veligers of Amphibola crenata (Gmelin) were followed in a range of salinities from 4 to 35%. In salinities of 18%. and below, growth was slowed and a large proportion of veligers died. In 4 to 12%., no larvae survived to metamorphosis, but these low salinities were tolerated for short periods.Newly post-metamorphic snails and juveniles collected from the field survived well even at 4%., showing that greater tolerance of low external salinities developed at metamorphosis. Examination of the physiology of adult snails suggested that this may be due to the development of osmoregulating mechanisms, because the adults maintain the blood hyperosmotic to the medium in 4 and 9%. The kidney, however, does not seem to be involved in this regulation because urine is isosmotic with the blood. An extra-renal mechanism of salt uptake is, therefore, postulated.     

Feasibility of Modified Surviving Sepsis Campaign Guidelines in a Resource-Restricted Setting Based on a Cohort Study of Severe S. Aureus Sepsis

Background

The Surviving Sepsis Campaign (SSC) guidelines describe best practice for the management of severe sepsis and septic shock in developed countries, but most deaths from sepsis occur where healthcare is not sufficiently resourced to implement them. Our objective was to define the feasibility and basis for modified guidelines in a resource-restricted setting.

Methods and Findings

We undertook a detailed assessment of sepsis management in a prospective cohort of patients with severe sepsis caused by a single pathogen in a 1,100-bed hospital in lower-middle income Thailand. We compared their management with the SSC guidelines to identify care bundles based on existing capabilities or additional activities that could be undertaken at zero or low cost. We identified 72 patients with severe sepsis or septic shock associated with S. aureus bacteraemia, 38 (53%) of who died within 28 days. One third of patients were treated in intensive care units (ICUs). Numerous interventions described by the SSC guidelines fell within existing capabilities, but their implementation was highly variable. Care available to patients on general wards covered the fundamental principles of sepsis management, including non-invasive patient monitoring, antimicrobial administration and intravenous fluid resuscitation. We described two additive care bundles, one for general wards and the second for ICUs, that if consistently performed would be predicted to improve outcome from severe sepsis.

Conclusion

It is feasible to implement modified sepsis guidelines that are scaled to resource availability, and that could save lives prior to the publication of international guidelines for developing countries.     

Survival after Orthotopic Liver Transplantation: A Follow-up Report of Two Patients

Two adult patients with terminal fatal liver disease were treated by orthotopic transplantation. One survived 11 months and died as a result of recurrent biliary intra-abdominal sepsis; the other patient is alive and well in the 18th month after transplantation and has virtually normal liver function. It is concluded that liver grafting can provide valuable therapy.     

Factors influencing patient choice of dialysis versus conservative care to treat end-stage kidney disease

Background:

For every patient with chronic kidney disease who undergoes renal-replacement therapy, there is one patient who undergoes conservative management of their disease. We aimed to determine the most important characteristics of dialysis and the trade-offs patients were willing to make in choosing dialysis instead of conservative care.

Methods:

We conducted a discrete choice experiment involving adults with stage 3–5 chronic kidney disease from eight renal clinics in Australia. We assessed the influence of treatment characteristics (life expectancy, number of visits to the hospital per week, ability to travel, time spent undergoing dialysis [i.e., time spent attached to a dialysis machine per treatment, measured in hours], time of day at which treatment occurred, availability of subsidized transport and flexibility of the treatment schedule) on patients’ preferences for dialysis versus conservative care.

Results:

Of 151 patients invited to participate, 105 completed our survey. Patients were more likely to choose dialysis than conservative care if dialysis involved an increased average life expectancy (odds ratio [OR] 1.84, 95% confidence interval [CI] 1.57–2.15), if they were able to dialyse during the day or evening rather than during the day only (OR 8.95, 95% CI 4.46–17.97), and if subsidized transport was available (OR 1.55, 95% CI 1.24–1.95). Patients were less likely to choose dialysis over conservative care if an increase in the number of visits to hospital was required (OR 0.70, 95% CI 0.56–0.88) and if there were more restrictions on their ability to travel (OR = 0.47, 95%CI 0.36–0.61). Patients were willing to forgo 7 months of life expectancy to reduce the number of required visits to hospital and 15 months of life expectancy to increase their ability to travel.

Interpretation:

Patients approaching end-stage kidney disease are willing to trade considerable life expectancy to reduce the burden and restrictions imposed by dialysis.Stage 5 chronic kidney disease is a major health issue worldwide and has a mortality that exceeds many cancers.^1,2 The treatment options for stage 5 (i.e., end-stage) kidney disease include dialysis, kidney transplantation and supportive nondialytic treatment (conservative care). A national report by the Australian Institute of Health and Welfare estimates that for every patient with chronic kidney disease who undergoes dialysis or transplantation, there is one other patient whose disease is managed conservatively.³Conservative care includes the multidisciplinary management of uremic symptoms through diet and medications, such as erythropoietin and diuretics, as well as psychosocial support and eventual palliative care. The reported median survival with conservative care for end-stage kidney disease is between 6 and 32 months. For some patients, particularly the elderly and those with ischemic heart disease, this period may be equal to or greater than their expected survival with dialysis.^4–7 Dialysis usually prolongs life, but it can impose a substantial burden on patients and their families and may be associated with a reduction in quality of life. The decision to start dialysis thus involves an assessment of both the evidence-based outcomes for the population in question and the preferences of the individual patient.Incorporating patient preferences for treatment of stage 5 chronic kidney disease is recommended in clinical guidelines;⁸ however, little is known about the trade-offs that patients are willing to consider when choosing between dialysis and conservative care. Discrete choice experiments are used to quantify patient preferences. These experiments are grounded in economic theory^9,10 and allow the measurement of patients’ strengths of preferences for different characteristics of treatment and the trade-offs involved. Real-world decisions are closely simulated through the simultaneous consideration of all treatment characteristics.¹¹ Discrete choice experiments are a valid and reliable approach to eliciting preferences for health care^12–14 and have been used to measure the preferences of patients with chronic kidney disease in terms of organ donation and allocation, and end-of-life care.¹⁵Knowing patients’ preferences for the treatment of stage 5 chronic kidney disease is necessary to plan appropriate health care services and enhance the quality of care. With this study, we aimed to quantify the extent to which the characteristics of dialysis influence patient preferences for treatment and to assess the trade-offs patients were willing to make between these characteristics.