RESUMEN
A 31-y-old epileptic man developed coma and shock after suicidally ingesting large amounts of valproic acid and gabapentin. His peak valproic acid, level was 1306.9 micrograms/mL (therapeutic range = 30-100 micrograms/mL). His peak gabapentin level was 60.0 micrograms/mL (therapeutic range = 2.0-8.0 micrograms/mL). His hypotension was refractory to crystalloid and pressor infusions, but resolved during concurrent hemoperfusion and hemodialysis to enhance elimination of valproic acid. Concurrent hemoperfusion and hemodialysis, in series, produced a maximum valproic acid plasma clearance of 55.4 mL/min versus a maximum reported intrinsic valproic acid plasma clearance of 10.6 mL/min. concurrent hemoperfusion and hemodialysis, in series, should be considered in hemodynamically unstable patients with valproic acid poisoning whose clinical condition is worsening in spite of aggressive supportive care.
Asunto(s)
Acetatos/envenenamiento , Aminas , Anticonvulsivantes/envenenamiento , Ácidos Ciclohexanocarboxílicos , GABAérgicos/envenenamiento , Hemoperfusión , Diálisis Renal , Ácido Valproico/envenenamiento , Ácido gamma-Aminobutírico , Adulto , Anticonvulsivantes/administración & dosificación , Biomarcadores/sangre , Biomarcadores/orina , Análisis Químico de la Sangre , Cromatografía en Capa Delgada , Coma/inducido químicamente , Coma/terapia , GABAérgicos/administración & dosificación , Gabapentina , Cromatografía de Gases y Espectrometría de Masas , Humanos , Hipotensión/inducido químicamente , Hipotensión/terapia , Unidades de Cuidados Intensivos , Masculino , Choque/inducido químicamente , Choque/terapiaRESUMEN
To evaluate the efficacy of low dose megestrol on malnourished dialysis patients we treated 16 dialysis patients with persistent hypoalbuminemia ( < 3.5 gm/dl for 2 consecutive months) and adequate dialysis at a dose of 20 mg orally twice daily. Twelve patients on peritoneal dialysis and 4 on hemodialysis were followed for 4.3 +/- 0.6 m (2-11 m). Within one month serum albumin rose from 2.7 +/- 0.1 to 3.0 +/- 0.2 gm/dl (p < 0.05) and remained elevated at the end of follow-up (3.1 +/- 0.2, p < 0.05 vs. pre-treatment levels). In the 12 responders (increase of albumin > 0.3 gm/dl), all of whom reported improved appetite, the maximal increase of serum albumin in 2 months was 0.8 +/- 0.1 gm/dl (range: 0.3-1.2). Four patients did not respond (change of albumin: -0.05 +/- 0.18, range: -0.6-0.2) because of encephalopathy, amyloidosis, depression or noncompliance. One patient stopped megestrol because of vaginal bleeding from uterine leiomyoma. Three patients died from causes unrelated to the megestrol. Our preliminary study suggests that low dose megestrol (40 mg per day) increases serum albumin levels in 75% of dialysis patients with malnutrition. It is well tolerated but may cause vaginal bleeding from uterine tumors.
Asunto(s)
Megestrol/uso terapéutico , Trastornos Nutricionales/tratamiento farmacológico , Diálisis Peritoneal/efectos adversos , Congéneres de la Progesterona/farmacología , Congéneres de la Progesterona/uso terapéutico , Diálisis Renal/efectos adversos , Albúmina Sérica/metabolismo , Administración Oral , Adulto , Anciano , Nitrógeno de la Urea Sanguínea , Peso Corporal/efectos de los fármacos , Femenino , Estudios de Seguimiento , Humanos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Masculino , Megestrol/administración & dosificación , Megestrol/efectos adversos , Persona de Mediana Edad , Trastornos Nutricionales/sangre , Trastornos Nutricionales/etiología , Congéneres de la Progesterona/administración & dosificación , Congéneres de la Progesterona/efectos adversos , Albúmina Sérica/efectos de los fármacos , Transferrina/metabolismo , Resultado del Tratamiento , Triglicéridos/sangreRESUMEN
A patient who presented with acute renal failure and anasarca secondary to crescentic glomerulonephritis superimposed on existing membranous glomerulonephropathy of 15 years' duration is described. The patient responded to an initial course of prednisone but failed to respond to a second course after relapse. The differential diagnosis of acute renal failure in the setting of nephrotic syndrome is discussed. Eighteen cases of crescentic glomerulonephritis superimposed on membranous glomerulonephropathy are reviewed. The clinical setting is heterogeneous with variable presentation and outcome. It appears that patients without antiglomerular basement membrane antibodies have a better prognosis than those who have antibodies. Patients with membranous glomerulonephropathy who develop unexplained acute renal failure should undergo early renal biopsy in order to rule out unexpected pathologic complications.
Asunto(s)
Lesión Renal Aguda/etiología , Glomerulonefritis Membranosa/complicaciones , Anciano , Biopsia , Glomerulonefritis Membranosa/patología , Humanos , MasculinoRESUMEN
PURPOSE: The increased use of thrombectomy with deliberate pulmonary embolization of thrombus following initial thrombolysis for occluded hemodialysis fistulas prompted the authors to measure the prevalence of pulmonary embolism (PE) due to the procedure. PATIENTS AND METHODS: Thirty-one patients with 43 acutely thrombosed polytetrafluoroethylene hemodialysis fistulas were treated with thrombolysis/thrombectomy. Perfusion lung scans were obtained in 22 patients. Patients were also continuously monitored for clinical signs or symptoms of PE. RESULTS: Perfusion scans were interpreted as consistent with PE in 59% of those studied, but no clinical signs or symptoms were present in 41 of the 43 cases (95%). However, two patients developed both signs and symptoms of acute PE in the postprocedural period and died. One had underlying pulmonary disease and had undergone thrombectomy before. The other had chronic heart disease. CONCLUSION: Thrombolysis/thrombectomy is usually safe and effective, even though many patients develop subclinical PE. The authors urge extreme caution in patients who have underlying pulmonary or cardiac disease and/or have undergone the procedure before.