RESUMEN
Adverse effects of nonsteroidal antiinflammatory drugs are frequently seen because of the extremely widespread use of these agents. Nephrotoxicity is relatively uncommon with the drug ibuprofen and, when present, is usually rapidly reversible. Fatal acute renal failure from ibuprofen has never been reported. This is the case of a patient with multiple medical problems who had near-fatal acute renal failure after the ingestion of 36 g ibuprofen, and who required dialysis for several months, at which point renal function improved. He did not admit to ibuprofen ingestion at the time of admission, and some of the clinical manifestations, including anion gap metabolic acidosis, respiratory alkalosis, and mental status abnormalities, could be accounted for by renal failure. Hence, this diagnosis was not considered during admission. However, the patient admitted to ibuprofen ingestion after his mental status improved with hemodialysis. A number of other variables were present that probably contributed to the development of acute renal failure, such as the presence of long-term renal insufficiency, hypotension, and possibly other drug ingestion. Acute renal failure with massive ibuprofen ingestion may be fatal or may show delayed reversibility even after necessitating dialysis for several months.
Asunto(s)
Lesión Renal Aguda/etiología , Ibuprofeno/toxicidad , Riñón/efectos de los fármacos , Lesión Renal Aguda/complicaciones , Lesión Renal Aguda/terapia , Adulto , Antiinflamatorios no Esteroideos/farmacología , Antiinflamatorios no Esteroideos/toxicidad , Humanos , Ibuprofeno/farmacología , Riñón/lesiones , Masculino , Diálisis Renal , Trastornos Relacionados con SustanciasRESUMEN
In attempting to identify variables that might account for the frequent absence of edema in HIV-infected patients with end-stage renal disease, we evaluated 24 consecutive patients at our institution who had HIV infection and developed end-stage renal disease. Clinical and laboratory data prior to the initiation of hemodialysis were recorded and compared between patients with and without edema. Only 11 of the 24 study patients had edema while the remainder did not. The prevalence of diarrhea was significantly less in patients with edema (one of 11 patients compared to eight of 13 with no edema, p < 0.02, odds ratio 0.063). Prior weight loss was significantly less in the patients with edema (9.1 +/- 1.3 kg vs 15.5 +/- 2.2 kg, p < 0.05). Use of antiretroviral therapy was significantly greater in patients with edema (p < 0.05, odds ratio 10.1). None of the patients were receiving diuretics. Blood pressure was significantly higher (p < 0.001) in patients with edema, and serum albumin was low in both groups but did not differ (edema, 24 +/- 2 g/L; no edema, 21 +/- 3 g/L). Four patients had albumin levels as low as 2, 8, 9, and 10 g/L, yet they had no edema. CD4 counts were lower in patients without edema (62 +/- 16 x 10(6) cells/L vs 283 +/- 38 x 10(6) cells/L, p < 0.001). Absence of diarrhea was predictive of the presence of edema with a sensitivity of 91% and specificity of 62% while mean arterial blood pressure > 95 mm Hg was predictive of the presence of edema with a sensitivity of 82% and specificity of 77%. CD4 of > 100 x 10(6) cells/L was predictive of the presence of edema with a sensitivity of 91% and specificity of 77%. These data support the hypothesis that hemodynamic factors may play a role in the frequent absence of edema in patients with HIV infection and renal failure, and variables including diarrhea, low blood pressure, weight loss, and more advanced stage of HIV infection may account for this observation. Hence, the absence of edema should not dissuade the clinician from considering the possibility of advanced renal failure in HIV-infected patients.
Asunto(s)
Edema/complicaciones , Infecciones por VIH/complicaciones , Fallo Renal Crónico/complicaciones , Adulto , Antivirales/uso terapéutico , Presión Sanguínea , Recuento de Linfocito CD4 , Diarrea/complicaciones , Diarrea/diagnóstico , Edema/diagnóstico , Femenino , Infecciones por VIH/tratamiento farmacológico , Humanos , Fallo Renal Crónico/terapia , Masculino , Estudios Prospectivos , Diálisis Renal , Estudios Retrospectivos , Sensibilidad y Especificidad , Equilibrio Hidroelectrolítico , Pérdida de PesoRESUMEN
We undertook the present study to determine whether there might be variables other than CD4 counts which might help predict survival of HIV-infected patients who are placed on chronic hemodialysis, survival which often is extremely poor. We studied prospectively (n = 18) and retrospectively (n = 6) 24 consecutive HIV-positive patients on chronic hemodialysis at our institution over a 7-year period and recorded clinical and laboratory variables at the time of initiation of dialysis. The mean survival for the group as a whole was 11 +/- 8 (range 2-32) months. A highly significant positive correlation was found between survival and CD4 counts (p < 0.001) and blood pressure (systolic, p < 0.02; diastolic, p < 0.05; mean arterial, p < 0.05). Infection rate and urine protein excretion both had significant negative correlations with survival (p < 0.01 and p < 0.02, respectively). The presence of edema appeared to have a positive effect on survival (p < 0.01). The use of antiretroviral therapy resulted in significantly greater survival of HIV-infected patients (15.2 +/- 2.2 vs. 6.2 +/- 1.2 months, p < 0.01). Using a general linear model, it was found that CD4 count and systolic, diastolic, and mean arterial blood pressures and infection rate all were independent estimators of survival. We conclude that variables other than CD4 counts might also be useful in predicting survival in HIV-infected patients on chronic hemodialysis.
Asunto(s)
Nefropatía Asociada a SIDA/mortalidad , Diálisis Renal , Nefropatía Asociada a SIDA/inmunología , Nefropatía Asociada a SIDA/terapia , Adulto , Recuento de Linfocito CD4 , Causas de Muerte , Femenino , Humanos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Estudios Retrospectivos , Tasa de SupervivenciaRESUMEN
The significance of hypochondriacal complaints in elderly depressives was explored. Sixty percent of patients had such symptoms on admission. Twelve percent were delusional. At discharge, hypochondriasis was present in 40% of the sample, with 0% delusional. Hypochondriasis was associated with anxiety (P less than .05) and somatic concerns (P less than .001), but not with complaints of depressed mood, suicidality, or short-term outcome. In dependent physical illness ratings did not correlate with hypochondriasis, however nonpsychotropic medication use did (P less than .01). Improvement in hypochondriacal complaints with treatment, yet persistence of less intense hypochondriacal concerns after remission suggests that these features may represent an admixture of state and trait phenomena in elderly depressives.
Asunto(s)
Trastorno Depresivo/psicología , Hipocondriasis/epidemiología , Factores de Edad , Anciano , Anciano de 80 o más Años , Trastorno Depresivo/complicaciones , Femenino , Estado de Salud , Humanos , Hipocondriasis/complicaciones , MasculinoRESUMEN
Studies were performed to assess the role of changes in the excretion of citrate, a metabolic precursor of bicarbonate, in acid-base balance in diuretic-induced metabolic alkalosis. Rats on a low-chloride diet with sodium sulfate added were studied during a base-line period, 3 days of furosemide administration, and 4 days post-furosemide. During the period of furosemide administration, net acid excretion and plasma bicarbonate concentration increased. In the post-furosemide period, net acid excretion remained higher than base line but plasma bicarbonate concentration did not increase further. Citrate excretion was significantly higher in the post-furosemide period than in base line. Studies substituting sodium neutral phosphate or sodium bicarbonate for dietary sodium sulfate demonstrated greater increases in net acid excretion post-furosemide and, again, no increase in plasma bicarbonate concentration during this period. Citrate excretion was greater than in the sulfate group. The increment in citrate excretion was proportional to the base "load," defined with respect to changes in net acid excretion and/or dietary bicarbonate. Thus, in these studies alterations of base excretion in the form of citrate play an important role in acid-base balance during diuretic-induced metabolic alkalosis.