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Oguzhan Sıtkı Dizdar,1 Ozerhan Ozer,2 Selahattin Erdem,2 Ali Ihsan Gunal3 1Department of Internal Medicine and Clinical Nutrition, Kayseri Training and Research Hospital, Kayseri, Turkey; 2Department of Internal Medicine, Kayseri Training and Research Hospital, Kayseri, Turkey; 3Department of Internal Medicine Division of Nephrology, Kayseri Training and Research Hospital, Kayseri, Turkey Background/purpose: One of the most common complications of the peritoneal dialysis (PD) is the infection of the exit site of the peritoneal catheter. The aim of the present study was to evaluate the efficacy of the subcutaneous gentamicin injection around the cuff as a part of routine treatment of the resistant exit site infection (ESI).Methods: If the exit site remains infected after a 2-week systemic antibiotics treatment, it is defined as resistant ESI. In these cases, systemic antibiotics were discontinued and a subcutaneous 40-mg gentamicin injection was administered around the external cuff of the PD catheter every 3 days. A total of three or four injections were given to each patient.Results: A subcutaneous gentamicin injection was administered around the cuff in thirteen patients for the treatment of resistant ESI over a 2-year period. The median follow-up time in cured patients was 12 months. Eleven of the thirteen patients had been apparently cured of their resistant ESI, with no recurrence. None of the patients had a gentamicin-resistant species. Subcutaneous gentamicin-related adverse effect was not observed in any patient.Conclusion: Subcutaneous gentamicin injection around the cuff is a well-tolerated and effective strategy for treating resistant ESI. To gain widespread approval of this therapy and reach a consensus about ESI management, additional studies are needed. Keywords: peritoneal dialysis, subcutaneous gentamicin, local treatment, catheter, efficacy

Background: We aimed to describe the thiamine status in hospitalized hypervolemic heart failure (HF) and/or renal failure (RF) patients treated with furosemide and to investigate whether there was a difference in furosemide-related thiamine deficiency between patients with RF and HF., Methods: Patients who were diagnosed as hypervolemia and treated with intravenous furosemide (at least 40mg/day) were included in this prospective observational study. Whole blood thiamine concentrations were measured 3 times during hospital follow-up of patients., Results: We evaluated 61 hospitalized hypervolemic patients, of which 22 (36%) were men and 39 (64%) were women, with a mean age of 69.00±10.39 (45-90) years. The baseline and post-hospital admission days 2 and 4 mean thiamine levels were 51.71±20.66ng/ml, 47.64±15.43ng/ml and 43.78±16.20ng/ml, respectively. Thiamine levels of the hypervolemic patients decreased significantly during the hospital stay while furosemide treatment was continuing (p=0.029). There was a significant decrease in thiamine levels in patients who had HF (p=0.026) and also, thiamine was significantly lower in HF patients who had previously used oral furosemide before hospitalization. However, these findings were not present in patients with RF., Conclusions: Thiamine substantially decreases in most hypervolemic patients receiving intravenous furosemide treatment during the hospital stay. Thiamine levels were significantly decreased with furosemide treatment in especially HF patients, but the decrease in thiamine levels did not detected at the same rate in RF patients. Diuretic-induced thiamine loss may be less likely in RF patients, probably due to a reduction in excretion., (Copyright © 2021 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Elevated C-reactive protein (CRP) levels as an inflammatory marker have been associated with poor outcomes in patients with chronic kidney disease (CKD). However, its single assessment may not reflect clinical significance before an adverse clinical endpoint. We studied the CRP level trajectories, which may be related with the intensity of the inflammatory process, and its association with time-to-first hospitalization in CKD., Methods: A cohort of 739 patients with stage 3-4 CKD were retrospectively observed for seven years. The time-to-event outcome was all-cause hospitalization. Clinical and laboratory features were measured at baseline. Longitudinal changes in naturally logged CRP levels were modeled using the Joint Longitudinal-Survival model adjusted with baseline covariates., Results: Logged CRP changes were evaluated with a median measurement (interquartile range) of 4 (2, 7), during a median (interquartile range) follow-up of 2.3 (1.2, 3.9) years. The estimated mean increase in logged CRP was 0.35 mg/L per year. 299 (40.5%) patients reached the endpoint, and increase in logged CRP with time was associated with increased risk of hospitalization (HR 1.96; 95% CI 1.05-3.66; p = 0.034), but baseline logged CRP did not have a significant effect on the time-to-first hospitalization (HR 0.98; 95% CI 0.85-1.13; p = 0.736)., Conclusion: All-cause hospitalization was associated significantly with CRP trajectories. Temporal evolutions of these repeatedly measured biomarkers might predict clinical outcomes in patients with CKD and may be useful for individual risk profiling. Furthermore, early management may provide an opportunity to better patient survival., (© 2021. The Author(s), under exclusive licence to Springer Nature B.V.)

Serum albumin is a major determinant of hospitalization in patients with end-stage renal disease (ESRD). Previous reports generally use the Poisson model to evaluate the relationships between outcome and response variables. However, hospitalization data are often overdispersed, and few studies using appropriate methods exist in the literature.This retrospective cohort study included 426 patients with ESRD receiving hemodialysis treatment between 2014 and 2018. Using a negative binomial regression model with hierarchical multivariable adjustments, we investigated the relationship between serum albumin, hospital admissions, and total hospitalization days. Mean age and mean baseline serum albumin levels were 64.7 ± 11 years and 3.5 ± 0.5 g/dL, respectively. At least one hospitalization was identified in 402 (94%) patients. The incidence rate was 1.48 (95% CI, 1.41-1.56) admissions per patient-year during the follow-up period of 5 years. A negative linear association was observed between serum albumin and hospitalization frequency. Hospitalization rates (95% CI) were 1.81 (1.65-1.98), 1.44 (1.3-1.59), 1.36 (1.22-1.51), and 1.33 (1.2-1.48) per patient-year in serum albumin levels ≤3, 3.1 to ≤3.3, 3.4 to ≤3.7, and ≥3.8 g/dL, respectively. Case mix-adjusted incidence rate ratio was 0.82 (95% CI, 0.70-0.94), while it was robust to further adjustments for malnutrition and inflammation markers. Similar results were observed in hospitalization days and time to the first hospitalization. These findings, which result from the negative binomial model using overdispersed data, suggest that lower serum albumin is related to increased hospitalization rates and hospital days in incident hemodialysis patients., (© 2020 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Background: Linagliptin does not require dose adjustment in diabetes mellitus patients with chronic kidney disease (CKD). But, renal effects of linagliptin are not clear. Our aim was to examine the effect of linagliptin on renal disease progression in only insulin dependent type 2 diabetes mellitus (DM) patients with CKD., Methods: Stage 3-4 CKD patients were randomized into 2 groups in this prospective randomized controlled study. In the first group, linagliptin 5mg was added in addition to the background insulin therapy. In the second group, patients continued their insulin therapy. Patients were followed up at 3-month intervals for one year., Results: The study population consisted of 164 patients (90 patients in linagliptin group, 74 patients in other group) with a mean age of 67.5±8.8 years. eGFR significantly increased in linagliptin group (p=0.033), but decreased in other group (p=0.003). No significant change was observed in total insulin dose in linagliptin group (p=0.111), but in other group, total insulin dose significantly increased (p<0.001). Proteinuria levels decreased in both groups, but there was no significant change. In the multiple logistic regression analysis, male gender and proteinuria emerged as variables that showed significant association with increased risk and the use of linagliptin emerged as variable that showed significant association with decreased risk for CKD progression., Conclusion: Linagliptin in DM patients with CKD was able to improve renal progression without significant effect on proteinuria and glucose control. With regard to treating diabetic nephropathy, linagliptin may offer a new therapeutic approach., (Copyright © 2020 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Increased blood pressure variability (BPV) is associated with higher cardiovascular risk. The association between BPV and fluid status in hypertensive patients has not been investigated so far. The aim of the present study was to determine the contribution of fluid balance to BPV and impact on endothelial and cardiac functions among primary hypertensive patients., Methods: This is a prospective interventional study conducted in primary hypertensive patients with one-year follow-up. Volume status measurements by a body composition monitor, ambulatory blood pressure (BP) monitoring, echocardiographic and carotid intima-media thickness (CIMT) measurements were performed at enrollment and at twelfth. Patients in one of the two groups were kept negative hydrated during trial with diuretic treatment. Patients in other group were positively hydrated (hypervolemic) at enrollment, antihypertensive drugs other than diuretics (vasodilator agents) were added or intensified according to the BP monitoring. Average real variability (ARV) index was used for establishing the prognostic significance of BPV., Results: The study population consisted of 50 patients with a mean age of 54.5±8.8 years. At the end of one-year follow-up, patients in negative hydrated group were found to have significantly lower BP, CIMT, left ventricle mass index (LVMI) and systolic and diastolic ARV. More weight gain and higher systolic BP were major risk factors of high systolic ARV. Patients who have improvement in CIMT and LVMI were considered as target organ damage (TOD) recovery present. In negatively hydrated group, TOD significantly reduced during trial. In patients who have TOD recovery, BPV significantly more reduced like systolic and diastolic BP. Significant risk factors associated with the presence of TOD were 24h systolic BP and daytime and night time diastolic ARV and night time diastolic BP., Conclusion: Addition of diuretic to established treatment or intensified diuretic treatment and keeping patients in negative hydration status resulted in reduction in BPV at twelfth month of follow-up. More weight gain and higher systolic BP are major risk factors of high systolic ARV, but not hypervolemia. BPV, especially diastolic ARV, was significantly associated with TOD., (Copyright © 2020 Sociedad Española de Nefrología. Published by Elsevier España, S.L.U. All rights reserved.)

Purpose: Nutritional status and micronutrient levels of end stage renal disease (ESRD) patients may vary depending on the mode of renal replacement therapy (RRT). We aimed to compare the effects of hemodialysis, peritoneal dialysis (PD) and renal transplantation (RT) on micronutrient levels and nutritional status in ESRD patients., Patients and Methods: A total of 77 ESRD patients who had not received RRT were included in this prospective longitudinal study. All ESRD patients underwent a blood serum analysis that assessed the micronutrients such as selenium, copper, zinc, chromium, retinol, thiamine and vitamin B6 as well as a nutritional status assessment. After the baseline assessments and the initiation of RRT was accomplished, all patients were followed for 6 months., Results: The study showed significant improvements in subjective global assessment scores (percentage increases in score A were 26.6 and 36.6; p = 0.039 and p = 0.001; respectively), mid-arm circumference and the skin-fold thicknesses (p < 0.001, p < 0.001; respectively) in the RT and hemodialysis groups. The examinations at sixth month revealed a significant increase in body weight (4.8 kg; p = 0.002) and albumin levels (0.6 g/dL; p < 0.001) in only RT group. Zinc, thiamin and vitamin B6 were the most deficient micronutrients (44.1 %, 24.7 % and 35.1 %; respectively) in ESRD patients. There was a significant increase in selenium and retinol levels (p = 0.020 and p < 0.001; respectively) but a significant decrease in thiamin levels (p = 0.041) in RT patients. A significant increase in retinol levels (p = 0.028) and a significant decrease in thiamin levels (p = 0.022) was observed in the hemodialysis patients. However, no significant change in micronutrient levels was observed in the PD patients., Conclusion: The results support the recommendation that ESRD patients should be supplemented with water-soluble vitamins, especially thiamine and vitamin B6, and trace elements, especially zinc. RT appears to be superior to other modes of RRT when examining SGA score, anthropometric measurements, albumin and micronutrient levels., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflicts of interest., (Copyright © 2020 Elsevier GmbH. All rights reserved.)

Background: The objective of this study was to determine the effects of strict volume control and nondipper situation on cardiovascular disease in chronic hemodialysis patients., Methods: This study is an observational and cross-sectional study including 62 patients with normotensive chronic hemodialysis using no antihypertensive drugs. A series of measurements including ambulatory blood pressure monitoring, left ventricular mass index by echocardiography, common carotid artery intima-media thickness by ultrasound, and body fluids by bioimpedance analysis were conducted for all subjects., Results: The patients were divided into two groups as dippers and nondippers according to their ambulatory blood pressure monitoring results. Average 48 h systolic, diastolic, and mean arterial blood pressure and nocturnal systolic, diastolic, and mean arterial blood pressure were significantly different between the dipper and nondipper groups (p<0.05). Before and after dialysis, extracellular fluid/intracellular fluid and extracellular fluid/dry body weight ratios were significantly higher in the nondipper group. Left ventricle mass index and interventricular septum thickness were significantly higher in the nondipper group (p<0.05). Left ventricle ejection fraction was significantly lower and common carotid artery intima-media thickness was higher in the nondipper group with a statistical significance (p<0.05). A two-predictor logistic model was fitted to the data to predict the comparability of dippers and nondippers., Conclusion: According to logistic regression analysis, the odds ratio for daytime diastolic blood pressure indicates that nondippers are 0.45 times more likely to have high blood pressure than dippers in daytime. But in night time, nondippers are about 2.55 times more likely to have high blood pressure comparing to dippers. An important finding of this study is that nondipping pattern is associated with cardiac hypertrophy and lower left ventricle ejection fraction in dialysis of patients with no hypertension. The results also suggest that applying strict volume control to achieve a normal blood pressure alone is not sufficient to reduce the risk of cardiovascular morbidity and mortality if the patients do not have a dipper status of nocturnal blood pressure.

Introduction: This study has been performed for the purpose of researching the complications occurred at patients who took metformin overdose in an attempt to suicide. None of the patients has the diagnosis of diabetes mellitus and never used metformin., Materials and Methods: This retrospective cross-sectional study was carried out with 21 patients who has neither diagnosed diabetes mellitus nor taken metformin for suicide before., Results: It was observed that there is a moderate, negative (r = -0.63) statistically significant correlation (P < 0.001) between the time of applying to the hospital and arterial blood pH at the arrival and a statistically significant positive mild correlation (P < 0.041) between applying and blood lactate level (r = 0.45), and a moderate positive (r = 0.63) and statistically significant correlation (P < 0.001) between the total metformin dose and blood lactate level at the arrival and a positive, moderate (r = 0.68) significant correlation (P < 0.001) between the creatinine and metformin dose at the arrival. Lactic acidosis has been detected at 8 of 21 patients, 6 patients were hemodialized, 2 patients needed mechanical ventilation, and 2 patients died. It is observed that there is no mortality for early hemodialized patients., Conclusion: The most important reason of the mortality in patients who has metformin intoxication is metformin-associated lactic acidosis (MALA). It was considered that hemodialysis therapy could be effective in MALA., Competing Interests: There are no conflicts of interest.

Objective: The aim of this study was to examine the effect of volume status on the progressions of renal disease in normovolemic and hypervolemic patients with advanced non-dialysis-dependent chronic kidney disease (CKD) who were apparently normovolemic in conventional physical exam-ination., Materials and Methods: This was a prospective interventional study performed in a group of stage 3-5 CKD patients followed up for 1 year. Three measurements were made for volume and renal status for every patient. The fluid status was assessed by a bioimpedance spectroscopy method. A blood pressure (BP) value > 130/80 mm Hg prompted the initiation or dose increment of diuretic treatment in normovolemic patients., Result: Forty-eight patients (48%) were hypervolemic. At the end of the 1-year follow-up, hypervolemic patients were found to have a significantly lower estimated glomerular filtration rate and higher systolic BP compared to baseline. Hypervolemia was associated with an increased incidence of death., Conclusion: We have shown that maintenance of normovolemia with diuretic therapy in normovolemic patients was able to slow down and even improve the progression of renal disease. Volume overload leads to an increased risk for dialysis initiation and a decrease in renal function in advanced CKD. Volume overload exhibits a stronger association with mortality in CKD patients., (© 2018 The Author(s) Published by S. Karger AG, Basel.)

Purpose: The issue of unidentified volume expansion is well recognized as a cause for resistance to antihypertensive therapy. The aim of study is to identify contribution of negative fluid balance to hypertension control and impact on endothelial and cardiac functions among primary hypertensive patients who do not have kidney failure., Materials and Methods: This is a prospective interventional study with one-year follow-up. Preceded by volume status measurements were performed by a body composition monitor (BCM), the patients were put on ambulatory blood pressure monitoring for 24 hours. Then, echocardiographic assessments and flow-mediated dilation (FMD) and carotid intima-media thickness (CIMT) measurements were completed. Patients in one of the two groups were kept negative hydrated during trial with diuretic treatment., Results: At the end of one-year follow-up, patients in negative hydrated group were found to have significantly lower CIMT, left ventricle mass index, left ventricular end-diastolic diameter, mean systolic and diastolic BP, non-dipper patient ratio, and higher FMD. In negatively hydrated group, target organ damage significantly reduced during trial., Conclusions: The significance of negative hydration status with respect to blood pressure control, endothelial and cardiac functions within primary hypertensive patients who do not suffer from kidney failure has been demonstrated.

Sodium and fluid retention in dialysis patients is associated with hypertension and vascular changes that may ultimately lead to serious cardiovascular complications. Achieving and maintaining dry weight appears to be an effective but forgotten strategy in controlling and maintaining normal blood pressure among hypertensive patients on dialysis. A crucial question is how to determine 'dry weight'. Normotension without the use of antihypertensive medications in conjunction with a cardio-thoracic index below 48% is the most important criterion showing that the dry weight is achieved.

Aim: Carpal tunnel syndrome (CTS) is one of the frequent problems of the patients who underwent hemodialysis (HD). The role of venous hypertension due to arteriovenous fistula (AVF) has not been clarified completely; therefore, we aimed to investigate the role of venous hypertension due to AVF in hemodialysis patients who had CTS., Patients and Methods: We included 12 patients who had been receiving HD treatment for less than 8 years and the newly diagnosed CTS patients with the same arm of AVF. All patients were diagnosed clinically and the results were confirmed by both nerve conduction studies and electromyography. Open carpal tunnel release surgery was performed on all of them. Venous pressure was measured in all patients before and after two weeks of surgery., Results: There were significant differences before and after the surgery with regard to pressures (P > 0.05). After the surgery, all carpal ligament specimens of the patients were not stained with Congo red for the presence of amyloid deposition., Conclusion: Increased venous pressure on the same arm with AVF could be responsible for CTS in hemodialysis patients. Carpal tunnel release surgery is the main treatment of this disease by reducing the compression on the nerve.

A 70-year-old male patient was admitted complaining of weakness and pain in his arms and lower limbs. His serum creatine kinase and serum creatinine were markedly elevated (36,248 IU/L and 2.8 mg/dL, respectively). He had taken dexketoprofen trometamol because of a common cold, which had developed the previous night. Acute kidney injury caused by dexketoprofen-induced rhabdomyolysis was diagnosed by ruling out other possible causes, such as dermato/polymyositis, myxedema, brucellosis, and hepatitis. Dexketoprofen administration was stopped. As diuresis did not restore spontaneously, the patient was treated with I.V. alkaline solutions and mannitol. Hemodialysis was performed because of anuria and severe metabolic acidosis. The patient's renal function later recovered. In conclusion, dexketoprofen may be a potential risk factor for acute kidney injury and rhabdomyolysis.

Cognitive dysfunction is a well-known complication of chronic renal failure that is evident in 30% of hemodialysis (HD) patients. However, the pathogenesis of this dysfunction is unknown. Left ventricular hypertrophy could develop in hypertensive HD patients without establishing normovolemia. Our aim was to evaluate the effect of strict volume control by salt restriction and ultrafiltration on cognitive functions in HD patients. This cross-sectional study was composed of 22 HD patients who were normotensive by applying a strict volume control, 24 HD patients who were normotensive by receiving anti-hypertensive drugs, and 20 healthy controls. The strict volume control was defined as managing of blood pressure control by strict salt restriction and insistent ultrafiltration. P300 recording as an indicator of cognitive disfunction was measured when blood pressures were reached at target level at the end of six-month follow-up period. In all patients, dimensions of the heart were evaluated with echocardiography on an interdialytic day. The cardiothoracic ratio and echocardiographic dimensions were significantly lower in patients with strict volume control. P300 amplitudes were significantly lower in patients on antihypertensive drugs than in patients with strict volume control (9.5 +/- 5.1 versus 11.3 +/- 5.4 muV). P300 latency was longer in patients on antihypertensive drugs than in the control group and patients with strict volume control (359.9 +/- 39.6 versus 345.6 +/- 36.7 ms). Our results suggest that hypervolemia may be one of the causal and potentially modifiable factors of cognitive dysfunction. Strict volume control may have beneficial effects on cognitive functions in hemodialysis patients.

Cardiac adverse effects of intravenous pulse methylprednisolone administration are well known, but there is little information about the cardiac side effects of oral methylprednisolone in the literature. We present a 41 year-old man with membranoproliferative glomerulonephritis in whom developed atrial fibrillation after oral methylprednisolone therapy.

We describe a 60-year-old woman who became comatose after a single dose of gabapentin for right-sided sciatalgia. The patient was improved by hemodialysis. Gabapentin toxicity should be considered when mental status changes develop in patients with renal failure after even a single dose.

Background: Uraemic pruritus is a common and distressing symptom in patients on haemodialysis for chronic renal failure. Gabapentin is an anticonvulsant that alleviates neuropathic pain. We conducted a double-blind, placebo-controlled, crossover study to assess its effectiveness against renal itch., Methods: We enrolled in the trial 25 adult patients on haemodialysis who were asked to daily record the severity of their pruritus on a visual analogue scale. The patients were randomly assigned to receive gabapentin for 4 weeks followed by placebo for 4 weeks or the reverse sequence. Gabapentin or placebo were administered thrice weekly, at the end of haemodialysis sessions., Results: The mean pruritus score of the cohort before the study was 8.4 +/- 0.94. After placebo intake, it decreased to 7.6 +/- 2.6 (P = 0.098). The score of four patients decreased by >50% following placebo. After gabapentin administration, the mean score decreased significantly, to 1.2 +/- 1.8 (P = 0.0001), although one patient's symptoms did not improve significantly. No patient dropped out of the study due to adverse effects from gabapentin., Conclusions: Our study shows that gabapentin is safe and effective for treating uraemic pruritus in haemodialysis patients. Our results also support the neuropathic hypothesis of uraemic pruritus.

Background: Left ventricular hypertrophy (LVH) is an important predictor of mortality in dialysis patients. The loss of residual renal function (RRF) appears to occur more rapidly in hemodialysis than continuous ambulatory peritoneal dialysis (CAPD). It is more likely that volume expansion in patients on CAPD may preserve RRF. The aim of this study was to investigate whether there is a cause-effect relationship between volume overload and preserving RRF in new hemodialysis patients., Methods: Nineteen patients with end-stage renal disease (ESRD) starting hemodialysis therapy were included in the study. At the beginning, their elevated blood pressures (BP) were treated with antihypertensive drugs. Thereafter, until normovolemia and normal BP were obtained, strict volume control was applied. The effects of both treatment modalities on the loss of RRF and LVH were evaluated prospectively., Results: At the initial examination, all of the patients were hypertensive and had markedly increased left ventricular mass index (LVMI). The daily urine production was 1575+/-281 mL. At the end of drug treatment period lasting three months, although BP significantly decreased, daily urine production and LVMI only decreased by 12% and 6%, respectively. At the end of the period in which strict volume control was applied, the body weight significantly decreased (from 60+/-5 to 55+/-8 kg, p<0.0001). This decrease in body weight was accompanied by marked decreases in dilated cardiac chamber size and more importantly daily urine production. At the end of this period, while 7 of 19 patients had no residual urine production, residual urine production was below 200 mL/d in the remaining 12 patients. Although the period of volume control was short, there was significant reduction in the LVMI (decreased from 251+/-59 to 161+/-25 gr/m2, p<0.0001)., Conclusion: The results of our prospective study have clearly shown that the persistence of residual renal function in patients with ESRD starting hemodialysis therapy may largely depend on volume overload. Equally interesting was the finding that despite significantly reduced BP level with hypotensive drugs, there was no marked regression in LVMI. In the contrary, after the volume control period, LVMI was significantly decreased. Our results support the hypotheses that decrease in volume may be more important than pressure reduction in regressing the left ventricular hypertrophy.

This study analyzes the effects of fluid resuscitation in the crush victims of the Bingol earthquake, which occurred in May 2003 in southeastern Turkey. Questionnaires asking about demographic, clinical, laboratory, and therapeutic features of 16 crush victims were filled in retrospectively. Mean duration under the rubble was 10.3 +/- 7 h, and all patients had severe rhabdomyolysis. Fourteen patients were receiving isotonic saline at admission, which was followed by mannitol-alkaline fluid resuscitation. All but two patients were polyuric. Admission serum creatinine level was lower than and higher than 1.5 mg/dl in 11 and 5 patients, respectively. Marked elevations were noted in muscle enzymes in all patients. During the clinical course, hypokalemia was observed in nine patients, all of whom needed energetic potassium chloride replacement. Four (25%) of 16 victims required hemodialysis. Duration between rescue and initiation of fluids was significantly longer in the dialyzed victims as compared with nondialyzed ones (9.3 +/- 1.7 versus 3.7 +/- 3.3 h, P < 0.03). Sixteen fasciotomies were performed in 11 patients (68%), nine of which were complicated by wound infections. All patients survived and were discharged from the hospital with good renal function. Early and vigorous fluid resuscitation followed by mannitol-alkaline diuresis prevents acute renal failure in crush victims, resulting in a more favorable outcome.

Background: Nephrogenic ascites refers to the condition of refractory ascites of unknown aetiology and occurs mainly in patients with end-stage renal disease who are undergoing haemodialysis. Despite many treatment modalities, nephrogenic ascites remains difficult to control and has a poor prognosis., Methods: We investigated six such patients who had developed severe, apparently refractory ascites during haemodialysis. They all had seriously disturbed cardiac dimensions and function. They were treated with repeated isolated ultrafiltration and severe salt restriction, while their cardiac functions were monitored with echocardiography., Results: After a mean of 18+/-4 l of fluid per patient was removed in 27+/-8 days, ascites disappeared in all patients. Blood pressure and cardiothoracic indices were decreased from 130+/-20/83+/-10 to 95+/-11/60+/-6 mmHg (P<0.02) and from 0.61+/-7 to 0.47+/-5 (P<0.02), respectively. At the end of treatment, heart rates had decreased from 102+/-10 to 85+/-6 beats/min. Previously increased left atrial diameters, end-systolic and end-diastolic dimensions of the left ventricles, and right ventricular diameters reached normal values. Ejection fractions initially decreased in all patients, and then increased slightly to markedly after treatment., Conclusion: Nephrogenic ascites is a component of right-sided cardiac congestion mediated by volume overload, and it should be treated with severe salt restriction and frequent ultrafiltration with haemodialysis and, if that fails, with daily isolated ultrafiltration.