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Appropriate care in chronic renal insufficiency (CRI) includes blood pressure and diabetes control, as well as the investigation and management of anemia, acidosis, and bone disease. There is a lack of data on the control of these parameters at the time of referral to a nephrologist. Similarly, early referral has been emphasized in the literature, yet very little published has examined current referral patterns.A single-center retrospective/prospective review of all new outpatient referrals to nephrologists in Halifax, Canada, in 1998 and 1999 was conducted to identify patients with CRI (serum creatinine1.6 mg/dL [141 micromol/L] for men or1.2 mg/dL [106 micromol/L] for women). Quality of prereferral care was based on data from the initial clinic visit.Of 1,050 charts reviewed, 411 patients met the study criteria. Twenty-six percent of patients had diabetes mellitus, 18% were referred with a calculated glomerular filtration rate less than 15 mL/min, and blood pressure was optimally controlled (130 mm Hg systolic and80 mm Hg diastolic) in only 24%. Only 44% of patients were administered an angiotensin-converting enzyme inhibitor. Patients were administered an average of 1.9 antihypertensive agents. Significant anemia (hemoglobin10 g/dL) was present in 21%, and appropriate investigations were performed in only 35% of these patients. Calcium levels less than 8.6 mg/dL (2.15 mmol/L) were found in 19% of patients, and only 14% of these patients were started on calcium supplement therapy. Phosphate levels greater than 5.0 mg/dL (1.6 mmol/L) were seen in 20% of patients, and 14% of these patients were on phosphate-binder therapy. Parathyroid hormone levels were more than five times normal values in 18% of patients, and 25% of patients had bicarbonate levels less than 23 mmol/L.A significant proportion of patients referred with CRI receive inadequate prereferral care. Continuing education programs and referral guidelines must not only emphasize the importance of early referral, but also address the related consequences of CRI to delay the progression of renal disease and avoid complications.

Management of idiopathic crescentic and diffuse proliferative glomerulonephritis: Evidence-based recommendations. Idiopathic crescentic glomerulonephritis (GN) often presents with a rapid loss of renal function and pathology showing extensive crescent formation. The disease is caused by different immunopathogenetic mechanisms, pauci-immune, often antineutrophil cytoplasmic antibody (ANCA)-positive microvasculitis, anti-glomerular basement membrane (GBM) antibody disease, and immune complex formation. Historical reviews reveal poor renal prognosis, even after treatment with oral steroids and cytotoxic drugs. Prognosis has improved in the last decade. In this article, evidence-based recommendations for management are presented. Because of the high risk of end-stage renal disease (ESRD), early aggressive therapy is recommended, despite weak supporting evidence. Treatment for anti-GBM antibody-induced crescentic GN should be initiated early and should include pulse methylprednisolone, a two-week course of plasmapheresis and two months of treatment with corticosteroids and cyclophosphamide (grade B and C). Treatment for pauci-immune crescentic GN should be pulse methylprednisolone, followed by oral corticosteroids and cyclophosphamide for 6 to 12 months (grade B). Recurrences can be managed similarly (grade B), along with appropriate supportive therapy. In patients who develop ESRD, successful transplantation can be performed. Diffuse endocapillary proliferative GN is classically postinfectious. It generally has a good prognosis when no crescent formation occurs. Adult patients with persistent proteinuria, hypertension, and renal function impairment need careful follow-up and management to modify progressive hemodynamic injury.

Despite ongoing discussion of dialysis rationing in the nephrology community, there are little available data describing current practice in treatment selection for very ill renal patients with a poor prognosis. We report a prospective survey of end-stage renal patients referred to our Canadian regional dialysis center who were not accepted to the dialysis program on the grounds of poor prognosis and low quality of life. One quarter of patients referred during 1992 were not accepted to the program, with a mean age of 74 ± 11 years. Patients were predominantly female and most suffered from a combination of renovascular and cardiovascular disease, with very poor functional capacity as determined by the Karnofsky scale. Nonacceptance to the dialysis program did not create legal difficulties or requests for second opinions. Based on our experience, we propose guidelines for nonacceptance of patients to dialysis programs.

Prevention of hemodialysis subclavian vein catheter infections by topical povidone-iodine. Subclavian catheter (SCC) related infections are a major cause of morbidity in hemodialysis patients, the vast majority due to staphylococci species Povidone-iodine (PI) has proven anti-staphylococcal activity. Therefore, a randomized controlled trial of topical PI ointment was undertaken to evaluate the impact of this prophylactic intervention on the incidence of SCC related infections in hemodialysis patients. The role of S. aureus nasal carrier state in the acquisition of infection was also evaluated. Patients requiring SCC for temporary hemodialysis access were randomized to receive the treatment (T; N = 63) or sterile gauze dressings alone (C; N = 66). Catheter duration ranged from 2 to 210 days in both groups, with a mean of 38.6 days in T and 36.2 days in C (NS). Exit site (ES) infections were significantly less in T (5%) versus C (18%) (P < 0.02); tip colonization (TC) was 17% in T versus 36% in C (P < 0.01), while the incidence of septicemia (S) was also significantly less in C (2%) versus C (17%; P < 0.01). S. aureus nasal carriers were at a threefold higher risk of SCC related septicemia (0.009/day) than noncarriers (0.003/day; P < 0.05). The beneficial effect of PI ointment was most evident in this high risk group of S. aureus carriers: ES = 0% T versus 24% C, TC = 12% T versus 42% C, S = 0% T versus 29% C, P < 0.05. There were no adverse effects of the treatment. The routine application of topical PI ointment to temporary hemodialysis catheter exit sites is effective in reducing SCC related infections.

A 22-year-old North American Indian prima gravida developed hypertension and edema at 28 weeks' gestation. A 24-hour urine collection contained 600 mg of protein, but no serum creatinine was measured. Despite bed rest and antihypertensive therapy with atenolol and a-methyl-DOPA, hypertension persisted. In addition, there were increases in transaminase levels. There was ultrasonographic evidence of intrauterine growth retardation, so delivery was made by cesarean section at 30 weeks' gestation of an 850-g male infant, who subsequently did well. Hypertension persisted postpartum to levels up to 210/120 mm Hg despite therapy with atenolol, 100 mg/d. Five weeks' postpartum, the patient complained of bilateral flank pain and edema. Serum creatinine was found to be 450 J.LmoJjL (normal

A 39-year-old woman became lethargic after working outside in her garden for several hours on a hot day. Over the next 10 days she became progressively more confused, ataxic, and was unable to look after her family. There was no history of vomiting, fever, chills, or use of medication. Her children claimed that she had taken some fluids in the form of fruit juice each day. Past history showed that 18 years before the current illness, the patient had required therapy for tuberculous meningitis. Of particular interest, at that time the patient was admitted with a stiff neck, seizures, and a serum sodium concentration of 113 mmollL (mEq/L). At the time of discharge, the serum sodium concentration was always higher than 150 mmol/L, and on one occasion reached 157 mmollL. She had not been ill since antituberculous therapy was completed, and no electrolytes had been checked until the current admission. When brought to the hospital by her husband, she was disheveled and incontinent, with a blood pressure of 80/60 mm Hg, and was disoriented and inappropriate. There were no localizing signs on neurologic examination. The admission laboratory data are given as day I in Table 1. Urine sodium and potassium levels were 128 and 102 mmollL, respectively. The patient was volume-repleted with 0.9% saline intravenously (IV) until her systolic blood pressure exceeded 100 mm Hg. Rehydration was then continued with 0.45% and 0.25 % saline. Urine output on the first day was approximately 700 mL. Despite gradual rehydration, the patient's mental status was slow to improve, and she was transferred to a university hospital 72 hours later. At that time she was normovolemic on examination, with a blood pressure of 120/80, no edema, and a jugular venous pressure 1 cm above the sternal angle. The laboratory data are reported as day 3 in Table I. The urine sodium and potassium were 284 and 20 mmollL, respectively, and the urine volume on that day was 1,800 mL. Because of ongoing confusion and failure of 0.9% saline infusions to raise the serum sodium level, the patient was treated with 1 Lid of 3 % saline IV for 3 days, and a fluid restriction. Serum electrolytes became normal, and the patient's mental state slowly returned to normal with no apparent residual damage in memory or cognitive function. The patient was then managed with a fluid restriction of 800 mLld, but due to a recurrence of hyponatremia (serum sodium, 132 mmollL, urine osmolality, 700 mOsm/L) therapy with demeclocycline, 300 mg twice daily, was instituted. On a prescribed daily fluid intake of 1.5 L, the serum sodium returned to normal, and urine osmolality averaged 450 mOsm/L. On day 21, the patient's serum sodium concentration was reported to be 158 mmollL, with a serum osmolality of 319 mOsm/L. The serum sodium concentration had been normal on day 16, and had risen gradually, but the patient was not thirsty. Review of her weight and fluid balance records from day 16 to 21 showed that the patient had a cumulative negative fluid balance of at least 3 L, because of her failure to ingest the prescribed fluid volume due to adipsia. Demeclocycline therapy was briefly withheld, oral fluids were given with closer nursing supervision, and the hypernatremia was corrected. Further investigation revealed no evidence of adrenal or thyroid insufficiency, nor of use of any drugs associ1tted with syndrome of inappropriate ADH secretion (SlADH). A computed tomography (CT) scan of the brain was initially normal, but a repeat study with contrast injection and analysis of coronal sections through the sella suggested the presence of a welldemarcated low-density lesion (but of higher density than cerebrospinal fluid) in the left hypothalamic area in association with the third ventricle.