Coal Mine Dust Desquamative Chronic Interstitial Pneumonia: A Precursor of Dust-Related Diffuse Fibrosis and of Emphysema

Background:

Diseases associated with coal mine dust continue to affect coal miners. Elucidation of initial pathological changes as a precursor of coal dust-related diffuse fibrosis and emphysema, may have a role in treatment and prevention.

Objective:

To identify the precursor of dust-related diffuse fibrosis and emphysema.

Methods:

Birefringent silica/silicate particles were counted by standard microscope under polarized light in the alveolar macrophages and fibrous tissue in 25 consecutive autopsy cases of complicated coal worker's pneumoconiosis and in 21 patients with tobacco-related respiratory bronchiolitis.

Results:

Coal miners had 331 birefringent particles/high power field while smokers had 4 (p<0.001). Every coal miner had intra-alveolar macrophages with silica/silicate particles and interstitial fibrosis ranging from minimal to extreme. All coal miners, including those who never smoked, had emphysema. Fibrotic septa of centrilobular emphysema contained numerous silica/silicate particles while only a few were present in adjacent normal lung tissue. In coal miners who smoked, tobacco-associated interstitial fibrosis was replaced by fibrosis caused by silica/silicate particles.

Conclusion:

The presence of silica/silicate particles and anthracotic pigment-laden macrophages inside the alveoli with various degrees of interstitial fibrosis indicated a new disease: coal mine dust desquamative chronic interstitial pneumonia, a precursor of both dust-related diffuse fibrosis and emphysema. In studied coal miners, fibrosis caused by smoking is insignificant in comparison with fibrosis caused by silica/silicate particles. Counting birefringent particles in the macrophages from bronchioalveolar lavage may help detect coal mine dust desquamative chronic interstitial pneumonia, and may initiate early therapy and preventive measures.

Pilot Randomized Controlled Trial of Laparoscopic Cholecystectomy vs Active Nonoperative Therapy for the Treatment of Biliary Dyskinesia

BACKGROUND

Despite widespread adoption by the surgical community, high-quality prospective data supporting the practice of laparoscopic cholecystectomy (LC) for the treatment of biliary dyskinesia (BD) are lacking.

STUDY DESIGN

Adult patients meeting criteria for diagnosis of BD (Rome III symptoms, normal ultrasound, gallbladder ejection fraction < 38%) were randomized to either LC or a trial of nonoperative (NO) therapy with a low-dose neuromodulator (amitriptyline 25 mg/day). Patients in the NO arm were allowed to cross over to the surgical arm and remain in the study for any reason. Besides collection of basic demographics and medical/surgical history, patients were administered a standardized quality of life (QOL) assessment (Short Form-8) and a symptom-specific questionnaire (Rome III criteria) at enrollment and monthly through the study to assess the effect of treatment on biliary symptoms and overall QOL.

RESULTS

Thirty patients were enrolled over 12 months (15 LC, 15 NO). In the LC group, 13 underwent LC, 1 refused surgery, 1 withdrew. In the NO group, 14 crossed over to the LC group (13 of whom had LC), yielding 26 patients who underwent LC. The SF-8 physical scores (PCS-8) were significantly improved at both the first and last follow-up visits (p < 0.0001, p = 0.0003, respectively). The SF-8 mental scores (MCS-8) were also significantly improved at both the first and last follow-up visits (p = 0.0187, p = 0.0017, respectively). With median follow-up of 12 months (range 3 to 14 months), all 26 reported relief of pain.

CONCLUSIONS

This pilot study raises doubts regarding the feasibility of a randomized trial, presumably due to both clinician and patient bias toward LC and the lack of "gold-standard" nonoperative treatments. However, these prospective data indicate that, with careful patient selection (standardized symptom criteria/imaging methodology), LC results in pain relief and significant improvement in QOL in BD patients. Further prospective study of these findings is warranted.

Improving the Care of Dual Eligible Patients in Rural Federally Qualified Health Centers: The Impact of Care Coordinators and Clinical Pharmacists

BACKGROUND

Dual eligible persons are those covered by both Medicare and Medicaid. There were 9.6 million dual eligible persons in the United States and 82 000 in West Virginia in 2010. Dual eligibles are poorer, sicker, and more burdened with serious mental health conditions than Medicare or Medicaid patients as a whole. Their health care costs are significantly higher and they are more likely to receive fragmented ineffective care.

PURPOSE

To improve the care experience and health care outcomes of dual eligible patients by the expanded use of care coordinators and clinical pharmacists.

METHODS

During 2012, 3 rural federally qualified community health centers in West Virginia identified 200 dual eligible patients each. Those with hospitalizations received more frequent care coordinator contacts. Those on more than 15 chronic medications had drug utilization reviews with recommendations to primary care providers. Baseline measures included demographics, chronic diseases, total medications and Beers list medications, hospitalization, and emergency room (ER) use in the previous year. Postintervention measures included hospitalization, ER use, total medications, and Beers list medications.

RESULTS

Out of 556 identified patients, 502 were contacted and enrolled. Sixty-five percent were female. The median age was 69 years, with a range of 29 to 93 years. Nineteen percent (19%) of patients were on 15 or more medications, 56% on psychotropic medication, and 33% on chronic opiates. One site showed reductions of 34% in hospitalizations and 25% in ER visits during the intervention year. For all sites combined, there was a 5.5% reduction in total medications and a 14.8% reduction in Beers list medications.

CONCLUSIONS

A modest investment in care coordination and clinical pharmacy review can produce significant reductions in hospitalization and harmful polypharmacy for community dwelling dual eligible patients.

Gastric Electrical Stimulation for Refractory Gastroparesis: Predictors of Response and Redefining a Successful Outcome

Predictors of a favorable response and measures of success with gastric electrical stimulation (GES) for gastroparesis remain elusive. Published results remain inconsistent with respect to patient perceived benefit, despite statistical improvements in objective measures of symptom severity. We performed a retrospective analysis of 56 patients with gastroparesis who underwent insertion of a gastric electrical stimulator during the study period. Data included demographics, symptoms, total symptom severity score (TSS, range 0–24, initial and most recent), and gastric emptying times. TSS were grouped into four severity categories (0–10, 11–14, 15–18, 19–24). TSS improvement was defined as movement to a lower severity category. Perception of improvement was compared with that of TSS score improvement using χ2 test. Etiology as a predictor of improvement was measured using logistic regression. Initial mean TSS was 21, and post-treatment TSS was 13.5. Improvement was significant for individual symptoms and in reduction of TSS for both diabetic/idiopathic etiologies (P ≤ 0.001). No correlation was noted between likelihood of success/failure and gastric emptying times ( P = 0.32). Thirty-eight improved (moved to lower TSS category), whereas 18 failed (remained in same category) (P ≤ 0.001), which correlated with perception of improvement. Of 18 failures, 14 (77.7%) were idiopathic. On logistic regression, diabetics were more likely than idiopathic patients to move to a lower TSS category (odds ratio 14, P = 0.003) and even more likely to improve based on patient perception (odds ratio 45, P = 0.005). GES produces far more consistent improvement in diabetics. Further study of GES in idiopathic gastroparesis is needed. Application of the proposed TSS severity categories allowed differentiation of small, statistically significant (but clinically insignificant) reductions in TSS from larger, clinically significant reductions, thereby permitting more reliable application of TSS to the evaluation of GES efficacy.

Gastric electrical stimulation for refractory gastroparesis: predictors of response and redefining a successful outcome

Predictors of a favorable response and measures of success with gastric electrical stimulation (GES) for gastroparesis remain elusive. Published results remain inconsistent with respect to patient perceived benefit, despite statistical improvements in objective measures of symptom severity. We performed a retrospective analysis of 56 patients with gastroparesis who underwent insertion of a gastric electrical stimulator during the study period. Data included demographics, symptoms, total symptom severity score (TSS, range 0-24, initial and most recent), and gastric emptying times. TSS were grouped into four severity categories (0-10, 11-14, 15-18, 19-24). TSS improvement was defined as movement to a lower severity category. Perception of improvement was compared with that of TSS score improvement using χ(2) test. Etiology as a predictor of improvement was measured using logistic regression. Initial mean TSS was 21, and post-treatment TSS was 13.5. Improvement was significant for individual symptoms and in reduction of TSS for both diabetic/idiopathic etiologies (P ≤ 0.001). No correlation was noted between likelihood of success/failure and gastric emptying times (P = 0.32). Thirty-eight improved (moved to lower TSS category), whereas 18 failed (remained in same category) (P ≤ 0.001), which correlated with perception of improvement. Of 18 failures, 14 (77.7%) were idiopathic. On logistic regression, diabetics were more likely than idiopathic patients to move to a lower TSS category (odds ratio 14, P = 0.003) and even more likely to improve based on patient perception (odds ratio 45, P = 0.005). GES produces far more consistent improvement in diabetics. Further study of GES in idiopathic gastroparesis is needed. Application of the proposed TSS severity categories allowed differentiation of small, statistically significant (but clinically insignificant) reductions in TSS from larger, clinically significant reductions, thereby permitting more reliable application of TSS to the evaluation of GES efficacy.

Patency in Arteriovenous Grafts in Hemodialysis Patients

Objective:

It is difficult to maintain a working access for patients on hemodialysis. Despite current Dialysis Outcome Quality Initiatives recommendations of “Fistula First,” not everyone qualifies for a fistula, and those patients undergoing the alternative treatment, a graft, can experience graft failure. This study examines factors associated with arteriovenous graft (AVG) patency.

Methods:

A retrospective analysis was completed for all the patients who had an AVG during 2005 to 2010. Data were collected from electronic medical records, including date of first and subsequent interventions, salvage technique (surgical vs percutaneous), medical comorbidities, and use of antiplatelet medications (aspirin and clopidogrel). Continuous variables were compared with 2 sample t tests, and categorical variables with chi-square/Fisher exact test. Logistic regression was used to determine the odds ratio for risk factors associated with patency. A P value of <.05 was considered significant. All analyses were done using SAS 9.2 (SAS Institute Inc, Cary, North Carolina).

Results:

A total of 193 unique patients had an AVG. Of the 193 patients, 64% were female, 83% were hypertensive, and 64% were diabetic. The locations of the grafts were 80% arm, 15% forearm, and 5% thigh. Configurations, including loop and straight, were 34% and 63%, respectively. Comorbidities were not associated with patency. Primary patency was not found to be different with respect to location and configuration of graft and type of intervention. Primary patency for patients taking only aspirin (n = 43) and only clopidogrel (n = 17) were significantly different from patients on a combination of aspirin and clopidogrel (n = 7), with a P = .0051 and P = .0447, respectively.

Conclusion:

Neither location nor configuration affects the primary patency of AVGs. Aspirin alone is not inferior to aspirin and clopidogrel. Further prospective studies may be warranted to establish a consensus regarding medications and patency with AVGs.

The Roles of Angiogenesis in Malignant Melanoma: Trends in Basic Science Research over the Last 100 Years

Blood vessels arose during evolution carrying oxygen and nutrients to distant organs via complex networks of blood vessels penetrating organs and tissues. Mammalian cells require oxygen and nutrients for survival, of which oxygen has a diffusion limit of 100 to 200 μm between cell and blood vessel. For growth beyond this margin, cells must recruit new blood vessels, first by vasculogenesis, where embryonic vessels form from endothelial precursors, then angiogenesis which is the sprouting of interstitial tissue columns into the lumen of preexisting blood vessels. Angiogenesis occurs in many inflammatory diseases and in many malignant disease states, including over 90% of solid tumours. Malignant melanoma (MM) is the most lethal skin cancer, highly angiogenic, highly metastatic, and refractory to all treatments. Raised serum levels of vascular endothelial growth factor (VEGF) strongly correlate MM disease progression and poor prognosis. Melanoma cells secrete several proangiogenic cytokines including VEGF-A, fibroblast growth factor (FGF-2), platelet growth factor (PGF-1), interleukin-8 (IL-8), and transforming growth factor (TGF-1) that modulate the angiogenic switch, changing expression levels during tumour transition from radial to invasive vertical and then metastatic growth. We highlight modern and historical lines of research and development that are driving this exciting area of research currently.

Percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy for moderate sized kidney stones

OBJECTIVE

To compare the outcomes of percutaneous nephrolithotomy (PNL) and extracorporeal shock wave lithotripsy (ESWL) for moderate sized (1-2 cm) upper and middle pole renal calculi in regards to stone clearance rate, morbidity, and quality of life.

METHODS

All patients diagnosed with moderate sized upper and middle pole kidney stones by computed tomography (CT) were offered enrollment. They were randomized to receive either ESWL or PNL. The SF-8 quality of life survey was administered preoperatively and at 1 week and 3 months postoperatively. Abdominal radiograph at 1 week and CT scan at 3 months were used to determine stone-free status. All complications and outcomes were recorded.

RESULTS

PNL established a stone-free status of 95% and 85% at 1 week and 3 months, respectively, whereas ESWL established a stone-free status of 17% and 33% at 1 week and 3 months, respectively. Retreatment in ESWL was required in 67% of cases, with 0% retreatment in PNL. Stone location, stone density, and skin-to-stone distance had no impact on stone-free rates at both visits, irrespective of procedure. Patient-reported outcomes, including overall physical and mental health status, favored a better quality of life for patients who had PNL performed.

CONCLUSION

PNL more often establishes stone-free status, has a more similar complication profile, and has similar reported quality of life at 3 months when compared with ESWL for moderate-sized kidney stones. PNL should be offered as a treatment option to all patients with moderate-sized kidney stones in centers with experienced endourologists.

Early and Late Clinical Outcomes of Endovascular Aneurysm Repair in Patients with an Angulated Neck

This study analyzed the clinical outcome in endovascular aneurysm repair (EVAR) patients with an angulated aortic neck. Two hundred thirty-eight EVAR patients underwent postoperative duplex ultrasonography and/or computed tomographic angiography, which was repeated every 6 to 12 months. Aortic neck angle was classified into < 45° (A1, n= 129), ≥ 45 to < 60° (A2, n = 43), and ≥ 60° (A3, n = 42). The perioperative complication rates for groups A1, A2, and A3 were 13%, 5%, and 29%, respectively ( p = .006). Proximal type I early endoleaks occurred in 9%, 33%, and 38% in groups A1, A2, and A3, respectively ( p < .0001). Intraoperative proximal aortic cuffs were needed in 7%, 28%, and 33% in groups A1, A2, and A3, respectively ( p < .0001). However, the rate of late reintervention was comparable in all groups. Postoperatively, the size of abdominal aortic aneurysm decreased or remained unchanged in 97%, 95%, and 84% in A1, A2, and A3, respectively ( p = .0147). The rates of freedom from late type I endoleak at 1, 2, and 3 years were 90%, 85%, and 85% for A1; 74%, 74%, and 68% for A2; and 64%, 64%, and 53% for A3 ( p = .0013). EVAR can be used for patients with an angulated aortic neck but was associated with a higher rate of early and late type I endoleaks and early interventions.

Prospective randomized trial of routine versus selective shunting in carotid endarterectomy based on stump pressure

BACKGROUND

The use of shunting in carotid endarterectomy (CEA) is controversial. This randomized trial compared the results of routine (RS) vs selective shunting (SS) based on stump pressure (SP).

METHODS

Two-hundred CEA patients under general anesthesia were randomized into RS (98 patients) or SS (102 patients), where shunting was used only if systolic SP (SSP) was <40 mm Hg. Clinical and demographic characteristics were comparable in both groups. Patients underwent immediate and 30-day postoperative duplex ultrasound follow-up. Analysis was by intention-to-treat.

RESULTS

Of 102 SS patients, 29 (28%) received shunting. Indications for CEA were similar (42% symptomatic for RS; 47% for SS, P = .458). The mean internal carotid artery diameter was comparable (5.5 vs 5.5 mm, P = .685). Mean preoperative ipsilateral and contralateral stenosis was 76% and 38% for RS (P = .268) vs 78% and 40% for SS (P = .528). Mean preoperative ipsilateral and contralateral stenosis was 79% and 56% in the shunted (P = .634) vs 78% and 34% in the nonshunted subgroup of SS patients (P = .002). The mean SSP was 55.9 mm Hg in RS vs 56.2 for SS (P = .915). The mean SSP was 33 mm Hg in the shunted vs 65 in the nonshunted subgroup (P < .0001). Mean clamp time in the nonshunted subgroup of SS was 32 minutes. Mean shunt time was 35 minutes in RS and 33 in SS (P = .354). Mean operative time was 113 minutes for RS and 109 for SS (P = .252), and 111 minutes in shunted and 108 in the nonshunted subgroup (P = .586). Mean arteriotomy length was 4.4 cm for RS and 4.2 for SS (P = .213). Perioperative stroke rate was 0% for RS vs 2% for SS (one major and one minor stroke, both related to carotid thrombosis; P = .498). No patients died perioperatively. Combined perioperative transient ischemic attack (TIA) and stroke rates were 2% in RS vs 2.9% in SS (P > .99). The overall perioperative complication rates were 8.3% in RS (2 TIA, 3 hemorrhage, 1 myocardial infarction [MI], and 1 asymptomatic carotid thrombosis) vs 7.8% in SS (2 strokes, 1 TIA, 3 hemorrhage, 1 MI, and 1 congestive heart failure; P = .917).

CONCLUSIONS

RS and SS were associated with a low stroke rate. Both methods are acceptable, and surgeons should select the method with which they are more comfortable.

Brain death: a challenging diagnosis in trauma patients

Brain death is a catastrophic consequence of trauma, and diagnosing it can be a challenging for physicians because it presents in numerous ways. Since existing recommendations are not applicable to all hospitals because of the requirement of special equipment and highly-trained personnel, a committee of health care professionals at Charleston Area Medical Center in Charleston decided to review the available literature and create a new set of protocols regarding brain death. This article summarizes the findings of the committee and provides recommendations for physicians working with trauma patients.

A comparison of neural networks for computing predicted probability of survival for trauma victims

TRISS is a statistical method for predicting the probability of survival of trauma victims. Analysis of data from the Trauma Registry at Charleston Area Medical Center showed that only 48% of the trauma fatalities in the 5-year period 1992-1996 were correctly predicted by TRISS. Trauma practitioners from other Trauma Centers report similar problems with TRISS. Researchers have suggested improvements that range from simply changing the input variables and/or regression coefficients in TRISS to using an entirely different model. In this study we describe a method of calculating survival probabilities using Artificial Neural Networks (ANN). This method was chosen because of the similarity of the ANN output function to the function that produces the TRISS probability of survival. Additional variables were added based on the results of other research efforts as well as analysis of the CAMC Trauma Registry. A comparison was made between the abilities of TRISS to predict fatalities and to approximate probability of survival. The ANN outperformed TRISS in predicting fatalities in a training set (68.1% correct vs. 47.9% correct) and in a testing set (61.3% correct vs. 51.3% correct). More importantly, the ANN produced better estimates of predicted deaths. Using a data set that included 119 deaths, the ANN model predicted 125 deaths for a 5% relative error. The predicted number using TRISS was 86 for a relative error of 27.7%. Since effective quality improvement for trauma care depends on accurately identifying cases that fall outside the expected results, a more accurate predictive tool allows a more focused review of those significant cases, thus conserving resources without compromising quality. Neural Networks appear to be a predictive tool that can provide probability of survival estimates that are more accurate than TRISS.

The Development and Outcomes of a Statewide Network of Hospital-Based Palliative Care Teams

BACKGROUND

Health care systems need to be developed that meet the palliative care needs of patients and their families.

OBJECTIVE

The West Virginia Initiative to Improve End-of-Life Care charged its Palliative Care Delivery System Task Force with developing hospital-based palliative care teams in West Virginia.

SETTING/SUBJECTS

A descriptive study of a state-community partnership to improve palliative care.

MEASUREMENTS

Numbers of member hospitals, number and nature of palliative care consultations, number of patients referred to hospice programs.

RESULTS

What began as a palliative care network of five hospitals has grown into a network of 16. Network members advise one another on financing, staffing, and obtaining administrative buy-in, and the network leaders provide educational programs to prepare physicians and nurses to serve as consultants on hospital-based palliative care teams. There was a 300% increase in the number of palliative care consultations between 2000 and 2003 in 49 of West Virginia's 55 counties. Analysis of the submitted data collections forms has allowed the network to promote improvement in palliative care consultations in member hospitals and to initiate interventions on a statewide basis to improve decision-making with the appropriate legal agent, treatment of pain, and referral of patients for hospice care.

CONCLUSION

Hospital participation in the Palliative Care Delivery System Task Force led to a sustained membership organization, the West Virginia Palliative Care Network that promotes hospital-based palliative care.

Incidence of colorectal cancer in West Virginia from 1993-1999: an update by gender, age, subsite and stage

The sensitivities of different screening methods for pre-cancerous adenomas may affect the apparent anatomical distribution of colorectal cancers. Our objective was to describe changes in the distribution of left and right-sided colon cancers by time while adjusting for age, gender, stage and year of diagnosis. We studied the 7,895 cases of colorectal cancer reported to the West Virginia Cancer Registry between 1993 and 1999 and termed cancers proximal to, but not including the sigmoid colon as "right-sided," and the remaining tumors as "left-sided." Multivariate analyses were used to differentiate the effects of age and gender on changes in tumor location over time. The impact of screening was shown by the increase in the percentage of localized disease from 30.5% among cancers in the proximal colon to 37.6% in the distal colorectum. In contrast, the percentage of regional disease decreased from 50% among cancers in the proximal colon to the distal colorectum. The male to female ratios also increased from the proximal colon to the distal colorectum. Incidence rates, regardless of time, increased with advancing age for cancers located in all anatomical subsite groups, but more substantially for proximal colon cancer than for descending and distal colorectal cancers. For males ages > 85 and for females who are > 75 years of age, the cancer rates arising in the proximal colon exceeded observed in groups but more substantially for proximal colon cancer than for descending and distal colorectal cancers. For males age > 85 and females > 75, the cancer rates arising in the proximal colon exceeded those arising in the distal colorectum. This shift occurred at a younger age among females than males. The apparent shift of colorectal cancers to more proximal locations with advancing age has important implications for screening strategies. A further decrease in the relative incidence of left-sided colon cancers may require modifying current practices to include more frequent use of screening colonoscopy, particularly in women ages 75 years or older.

Competencies and concerns in end-of-life care for medical students and residents

A palliative medicine comfort-confidence survey developed by Weisman et al was utilized to assess self-reported competence and comfort with four end-of-life dimensions and determine future educational preferences. The survey was completed by 3rd and 4th year medical students (M3 and 4) and residents PGY 1-5. Self-reported competence increased with level of training. All trainees indicated the least comfort with 1) discussing home-hospice referrals; 2) conducting a family conference; 3) discussing the change from curative to comfort care; and 4) discontinuing i.v. hydration in a dying patient not taking oral nourishment. When withdrawing parenteral antibiotics from a non-decisional dementia patient with sepsis at the request of his legal guardian, M3 and 4 expressed a greater concern for violating medical practice standards while PGY4 and 5 showed a greater concern for the violation of personal religious or ethical beliefs. Pain management, pain assessment, hospice care and end-of-life communication where the most requested topics for future education.

Non-dialytic treatment of acute hyperkalemia in the dialysis patient

Acute hyperkalemia occurs commonly amongst patients with chronic renal failure and is especially common in noncompliant individuals. These patients often present to the emergency room with weakness. This editorial addresses the issue of non-dialytic treatment of hyperkalemia. Is emergency dialysis indicated in every case? In my opinion, acute dialysis can often be delayed until the hospital's dialysis unit opens for "regular working hours."

Effect of single dose resin-cathartic therapy on serum potassium concentration in patients with end-stage renal disease

Hyperkalemia in patients with renal failure is frequently treated with a cation exchange resin (sodium polystyrene sulfonate, hereafter referred to as resin) in combination with a cathartic, but the effect of such therapy on serum potassium concentration has not been established. This study evaluates the effect of four single-dose resin-cathartic regimens and placebo on 5 different test days in six patients with chronic renal failure. Dietary intake was controlled. Fecal potassium output and serum potassium concentration were measured for 12 h. Phenolphthalein alone caused an average fecal potassium output of 54 mEq. The addition of resin caused an increase in insoluble potassium output but a decrease in soluble potassium output; therefore, there was no significant effect of resin on total potassium output. Sorbitol plus resin caused less potassium output than phenolphthalein plus resin. On placebo therapy, the average serum potassium concentration increased slightly (0.4 mEq/L) during the 12-h experiment. This rise was apparently abrogated by some of the regimens that included resin; this may have been due in part to extracellular volume expansion caused by absorption of sodium released from resin. Phenolphthalein regimens were associated with a slight rise in serum potassium concentrations (similar to placebo); this may have been due to extracellular volume contraction produced by high volume and sodium-rich diarrhea and acidosis secondary to bicarbonate losses. None of the regimens reduced serum potassium concentrations, compared with baseline levels. Because single-dose resin-cathartic therapy produces no or only trivial reductions in serum potassium concentration, and because this therapy is unpleasant and occasionally is associated with serious complications, this study questions the wisdom of its use in the management of acute hyperkalemic episodes.

Effect of mineralocorticoid activity on transtubular potassium gradient, urinary [K]/[Na] ratio, and fractional excretion of potassium

Clinical assessment of potassium derangements may require evaluation of mineralocorticoid status. Several indirect indices of mineralocorticoid activity based on renal electrolyte excretion have been proposed and include the transtubular potassium gradient, urinary [K]/[Na] ratio, and renal fractional excretion of potassium. We studied the impact of high mineralocorticoid activity versus blocked mineralocorticoid activity on these indices in otherwise normal subjects who ingested a defined diet. Eight normal subjects received either fludrocortisone or spironolactone for 4 days. After a washout period of > or = 2 weeks, each subject then received the opposite regimen. Subjects ingested an identical high-potassium diet during both experimental periods. The renal fractional excretion of potassium and transtubular potassium gradient were calculated using standard formulas. Fludrocortisone caused an increase in body weight and no significant reduction in serum potassium concentration, while spironolactone decreased body weight and increased plasma potassium concentration. After 1 or 2 days of treatment with fludrocortisone, the average values for all urinary indices of mineralocorticoid activity were significantly higher than after 1 or 2 days of treatment with spironolactone. However, the differences between these indices in the fludrocortisone and spironolactone test periods diminished by day 3 and were nonexistent by day 4. In conclusion, the transtubular potassium gradient, [K]/[Na] ratio, and renal fractional excretion of potassium reflect acute changes in mineralocorticoid activity. However, these indices do not discriminate between states of high and low mineralocorticoid activity lasting longer than 2 to 3 days.

Effect of three laxatives and a cation exchange resin on fecal sodium and potassium excretion

BACKGROUND/AIMS

The treatment of hyperkalemia in patients with renal insufficiency often includes the ingestion of sorbitol and a cation exchange resin. Sorbitol alone may be used to remove sodium and water from overloaded patients. The efficacy of these regimens has never been compared with other laxative or laxative-resin combinations. The aim of the study was to compare the relative effect of three laxatives with different mechanisms of action, alone and in combination with resin, on fecal sodium and potassium excretion.

METHODS

Sodium, potassium, and water excretion in 12-hour stool collections were analyzed after various laxative-resin combinations in normal subjects.

RESULTS

Correctol (yellow phenolphthalein) (Schering Plough Health Care Products, Memphis, TN) was more effective than sorbitol or sodium sulfate in causing fecal sodium and potassium loss. Resin recovery in stool was much greater with phenolphthalein than with other laxatives, and more potassium was excreted in stool with phenolphthalein-resin than with phenolphthalein alone or other laxative-resin combinations. Sorbitol caused more undesirable gastrointestinal symptoms than did sodium sulfate or phenolphthalein.

CONCLUSIONS

In normal people, phenolphthalein (1) is preferable to other laxatives in causing fecal sodium and potassium excretion, (2) hastens resin transit through the intestine compared with other laxatives, and (3) produces greater fecal potassium excretion when combined with resin than phenolphthalein alone or other laxative-resin combinations.

The post-transurethral resection of prostate syndrome: therapeutic proposals

Absorption of large volumes of irrigation fluid during transurethral resection of the prostate (TURP) can produce hyponatremia, coma, blindness, and cardiorespiratory depression. This has been termed the "post-TURP syndrome." The pathophysiology and management of this syndrome are controversial. A case of severe post-TURP syndrome due to the absorption of hypotonic glycine irrigant is reported. This patient developed severe hyponatremia, slight hypo-osmolality, hyperglycinemia, hyperserinemia, hyperammonemia, and hypocalcemia. He became comatose, profoundly hypotensive, bradycardic, and transiently blind. Because of this combination of severe biochemical, neurologic, and hemodynamic abnormalities, we elected to treat this patient with hemodialysis. The biochemical and clinical manifestations resolved completely. The pathophysiology and treatment of this disorder are discussed and a role for hemodialysis is suggested.

Can maintenance cyclosporine be used in psoriasis without decreasing renal function?

Nephrotoxicity attributable to cyclosporine therapy is dose dependent and unlikely to occur in psoriasis treatment protocols using less than 5 mg/kg/d in otherwise healthy patients. Any long-term or maintenance protocol should include regular monitoring of urea nitrogen/creatinine levels and blood pressure. Cyclosporine is a potent drug, and it is reasonable to monitor its administration to otherwise healthy psoriasis patients with yearly measurement of glomerular filtration rate (GFR), especially in elderly patients or patients with diminished renal reserve (eg, diabetes). There is no convincing evidence of irreversible renal dysfunction in psoriasis patients on low-dose cyclosporine protocols, nor is there evidence that cyclosporine in low doses in completely safe or banal. Therefore, we suggest monitoring GFR at 3, 6, and 12 months after initiating therapy, provided serum creatinine level is stable. If serum creatinine level increases by > 30% over baseline, GFR should be monitored more frequently and the dose of cyclosporine adjusted if there is a persistent decrease.

Reperfusion of ischemic skeletal muscle causes erythrocyte hemolysis and decreases subsequent oxidant-mediated lung injury

A prior transient hindlimb ischemia/reperfusion (I/R) insult decreased acute lung injury in rats subsequently treated with cobra venom factor. I/R-mediated protection was associated with erythrocyte hemolysis, increased plasma catalase activity, and increased plasma hydrogen peroxide scavenging activity. In contrast, hindlimb I/R did not increase lung catalase activity, and large amounts of injected catalase were required to increase lung catalase activity. The results suggest that limited I/R in one organ can induce systemic processes that may decrease a subsequent O2 metabolite-mediated injury in another distant organ. The mechanism may involve release of catalase from hemolyzed erythrocytes at levels that are not sufficient to measurably increase total lung catalase activity.

Calcium acetate control of serum phosphorus in hemodialysis patients

Calcium acetate has many characteristics of an ideal phosphorus binder. It is a readily soluble salt that avidly binds phosphorus in vitro at pH 5 and above. One-dose/one-meal balance studies show it to be more potent than calcium carbonate or calcium citrate. We studied chronic (3-month) phosphorus binding with calcium acetate in 91 hyperphosphatemic dialysis patients at four different centers. All phosphorus binders were stopped for 2 weeks. Calcium acetate at an initial dose of 8.11 mmol (325 mg Ca2+) per meal was then used as the only phosphorus binder. Dose was adjusted to attempt control of predialysis phosphorus level less than 1.78 mmol/L (5.5 mg/100 mL). Final calcium acetate dose was 14.6 mmol (586 mg) Ca2+ per meal. Sixteen patients developed mild transient hypercalcemia (mean, 2.84 mmol/L [11.4 mg/dL]. Initial phosphorus values in mmol/L (mg/dL) were 2.39 (7.4); at 1 month, 1.91 (5.9); and at 3 months, 1.68 (5.2). Initial calcium values in mmol/L (mg/dL) were 2.22 (8.9); at 1 month, 2.37 (9.5); and at 3 months, 2.42 (9.7). Initial aluminum values in mumol/L (micrograms/L) were 2.99 (80.7); and at 3 months were 2.54 (68.4). Initial C-terminal parathyroid hormone (C-PTH) values in ng/mL were 14.6; at 1 month, 11.9; and at 3 months, 13.2. Sixty-nine patients then entered a double-blind study. Phosphorus binders were stopped for 1 week. Calcium acetate (at a dose established in a prior study) or placebo was then administered for 2 weeks. Next, patients were crossed to the opposite regimen for 2 weeks. Initial phosphorus was 2.36 mmol/L (7.3 mg/100 mL) and calcium 2.22 mmol/L (8.9 mg/100 mL).(ABSTRACT TRUNCATED AT 250 WORDS)

Functional similarities of hepatic cystic and biliary epithelium: studies of fluid constituents and in vivo secretion in response to secretin

Hepatic cysts are a frequent manifestation of autosomal dominant polycystic kidney disease, but little is known about their functional characteristics. The goals of our study were to define the composition of hepatic cyst fluid and to determine whether hepatic cysts secrete in response to intravenously administered secretin. We percutaneously punctured five hepatic cysts and one proximal renal cyst from six subjects with autosomal dominant polycystic kidney disease and one solitary hepatic cyst from a subject without autosomal dominant polycystic kidney disease. Most fluids had an electrolyte composition similar to serum. Fluid from all hepatic cysts had glutamyltranspeptidase concentrations above those found in serum [( cyst]/[serum] = 4.93 +/- 5.92), contained secretory component (the epithelial receptor for polymeric IgA) and had glucose concentrations less than 15 mg/dl. Fluid from both hepatic and renal cysts of subjects with autosomal dominant polycystic kidney disease, but not from the subject with the solitary hepatic cyst, demonstrated extensive changes in the electrophoretic mobility of several serum proteins. Initial intracystic pressures ranged from 16 to 40 cm H2O, were reduced 57% to 97% after aspiration of a portion of cyst fluid and were held constant during the secretion study. Within 8 min of the intravenous administration of secretin, secretion of fluid increased in two of three hepatic cysts and in the renal cyst. The electrolyte composition of cyst fluids was not altered by secretin. These data suggest that hepatic cystic epithelium has functional characteristics of biliary epithelium and that secretion by both hepatic and renal cysts may be hormonally regulated.

Calcium acetate, an effective phosphorus binder in patients with renal failure

Calcium salts are increasingly used as phosphorus binders in patients with chronic renal failure. Calcium carbonate is the principal salt presently utilized, however, other calcium salts may be more effective and safer phosphorus binders. Theoretical calculations, in vitro experiments, and in vivo studies in normal subjects have shown calcium acetate to be a more effective phosphorus binder than other calcium salts. This salt has not previously been studied in patients with chronic renal failure. We used a one-meal gastrointestinal balance technique to measure phosphorus absorption, calcium absorption and phosphorus binding in six patients with chronic renal failure. Calcium acetate was compared with calcium carbonate and placebo. Equivalent doses (50 mEq Ca++) of calcium acetate bound more than twice as much phosphorus (106 +/- 23 mg) as calcium carbonate (43 +/- 39 mg) P less than 0.05. When phosphorus binding was factored for calcium absorption, calcium acetate bound 0.44 mEq HPO4 =/mEq absorbed Ca++ compared with 0.16 mEq HPO4 = bound/mEq Ca++ absorbed with calcium carbonate. More efficient phosphorus binding permits serum phosphorus concentration to be controlled with lower doses of calcium salts. The higher phosphorus binding/calcium absorption ratio coupled with a lower dose indicates that less calcium will be absorbed when calcium acetate is used for phosphorus control. Markedly positive calcium balance, hypercalcemia and ectopic calcification should be less likely to occur with this drug than other calcium salts.

Cyclosporine therapy for psoriasis: serum creatinine measurements are an unreliable predictor of decreased renal function

With increasingly widespread use of cyclosporine for the treatment of psoriasis, it is imperative to identify reliable markers of cyclosporine-induced nephrotoxicity. Five patients with extensive psoriasis and no significant preexisting renal disease were treated with oral cyclosporine (average dosage, 5 mg/kg per day; average duration of treatment, 9 weeks). Changes in serum creatinine measurements made immediately before and at the end of treatment were compared with changes in glomerular filtration rate as determined by 125I-iothalamate clearance. During treatment, the average serum creatinine value only increased from 1.0 +/- 0.2 to 1.1 +/- 0.3 mg/dl (+/- standard deviation), whereas iothalamate-based estimates of glomerular infiltration rate decreased from 100 +/- 22 to 63 +/- 37 ml/min/1.73 m2 (p less than 0.02). Simultaneous 125I-iothalamate and 24-hour creatinine clearances were obtained in two patients at the end of treatment and at 2 weeks after cyclosporine therapy. Glomerular filtration rates determined by iothalamate clearance were 14% to 30% lower than those calculated by 24-hour creatinine clearances. Neither serum creatinine measurements nor creatinine clearances (whether calculated or measured) accurately reflect the cyclosporine-induced decline in renal function as determined by glomerular filtration rate. In contrast, 125I-iothalamate clearance is a more accurate measurement of glomerular filtration rate, which provides a sensitive marker for monitoring potential cyclosporine-induced nephrotoxicity.

Effect of the time of administration of calcium acetate on phosphorus binding

Phosphorus binders are given to patients with renal failure to increase gastrointestinal excretion of phosphorus. To determine the relative importance of the binding of dietary as compared with endogenous phosphorus and to determine the optimal dose schedule, we gave either 4.4 g of calcium acetate (25 mmol of calcium) or a placebo to six normal subjects on each of seven different schedules in a randomized sequence. The net gastrointestinal balance of phosphorus and calcium was determined by a one-day lavage technique. After a meal containing approximately 12 mmol of phosphorus, the mean phosphorus absorption (+/- SE) measured 9.17 +/- 0.36 mmol (78 percent) with placebo but decreased to 3.81 +/- 0.58 mmol (31 percent) when calcium acetate was given immediately before the meal (representing binding of 5.36 +/- 0.77 mmol of phosphorus). Similar binding was observed when calcium acetate was given immediately after the meal and when half the dose was given before and half after the meal. In contrast, when calcium acetate was given two hours after the meal or while the subject was fasting, phosphorus binding was reduced to 2.00 +/- 0.52 mmol and 1.81 +/- 0.84 mmol, respectively. Calcium absorption from calcium acetate averaged 21 +/- 1 percent when the binder was given with a meal; absorption from calcium acetate averaged 40 +/- 4 percent when the binder was given while the subject was fasting. We conclude that calcium acetate increases fecal excretion of phosphorus by binding both dietary and endogenous phosphorus, but the binding of dietary phosphorus is quantitatively much more important. For the most efficient phosphorus binding, calcium (and presumably other phosphorus-binding cations) should be given with meals.

Reduction of dietary phosphorus absorption by phosphorus binders. A theoretical, in vitro, and in vivo study

Antacids used to decrease phosphorus absorption in patients with renal failure may be toxic. To find more efficient or less toxic binders, a three-part study was conducted. First, theoretical calculations showed that phosphorus binding occurs in the following order of avidity: Al3+ greater than H+ greater than Ca2+ greater than Mg2+. In the presence of acid (as in the stomach), aluminum can therefore bind phosphorus better than calcium or magnesium. Second, in vitro studies showed that the time required to reach equilibrium varied from 10 min to 3 wk among different compounds, depending upon solubility in acid and neutral solutions. Third, the relative order of effectiveness of binders in vivo was accurately predicted from theoretical and in vitro results; specifically, calcium acetate and aluminum carbonate gel were superior to calcium carbonate or calcium citrate in inhibiting dietary phosphorus absorption in normal subjects. We concluded that: (a) inhibition of phosphorus absorption by binders involves a complex interplay between chemical reactions and ion transport processes in the stomach and small intestine; (b) theoretical and in vitro studies can identify potentially better in vivo phosphorus binders; and (c) calcium acetate, not previously used for medical purposes, is approximately as efficient as aluminum carbonate gel and more efficient as a phosphorus binder than other currently used calcium salts.

Inhibition of colony-stimulating factor (CSF) production by postburn serum: negative feedback inhibition mediated by lactoferrin

Fatal infections in severely burned patients are often preceded by a decline in the production of colony-stimulating factor (CSF) and the proliferation of granulocyte-macrophage stem cells (CFU-GM), and overwhelming sepsis is often associated with leukopenia. The underlying mechanisms accounting for these granulopoietic defects are poorly understood, but the fact that postburn serum has been shown to inhibit CSF production suggests that a humoral factor or factors may play a role. Previous work has demonstrated that plasma levels of lactoferrin (LF), a known inhibitor of CSF production, are elevated following burn injury. To determine if LF is responsible for serum-mediated inhibition of CSF production, serial plasma levels of LF were measured in 18 burn patients using an enzyme-linked immunoabsorbent assay (ELISA). LF was elevated within 24 hours of injury and was associated with an absolute granulocytosis which rapidly declined, reaching a nadir at postburn days 3 through 5. Postburn serum, especially when collected during the first 24 hours following burn injury, inhibited in vitro CSF production by normal human peripheral blood mononuclear cells. Pre-incubation of postburn serum with an LF antibody restored normal CSF production. These data suggest that LF may play an important role in the regulation of postburn granulopoiesis.

Rapid isolation of total RNA from mammalian tissues

A rapid procedure for the isolation of total RNA from small amounts of mammalian tissue (35 to 150 mg) is described. Tissues were homogenized in the presence of RNase inhibitors but in the absence of strong detergents. Contaminants were removed by phenol/chloroform extraction and Sephadex column chromatography. Total RNAs were precipitated with ethanol and sodium acetate. The RNAs isolated were intact and suitable for mRNA quantitation via Northern blot or slot-blot analyses. This procedure isolates total RNAs in high yield and purity, without CsCl ultracentrifugation, and is especially useful when mRNAs must be quantitated from many samples.

Total enteral nutrition versus total parenteral nutrition after major torso injury: attenuation of hepatic protein reprioritization

Reprioritization of hepatic protein synthesis, a process involving accelerated production of acute-phase proteins at the expense of constitutive proteins, accompanies major trauma. The impact of isocaloric, isonitrogenous total enteral nutrition (TEN) versus total parenteral nutrition (TPN) on hepatic reprioritization was investigated in a prospective, randomized trial. Of the 59 patients with an abdominal trauma index (ATI) greater than 15 but not more than 40, 45 evaluable patients were followed. Results from 36 (18 TEN, 18 TPN) evaluable patients revealed that mean serum levels of acute-phase proteins increased, whereas mean serum levels increased to a greater extent in the TPN group. The maximal increase from baseline for the acute-phase response in both groups occurred at postinjury day 5 and was significantly higher for alpha 1-antitrypsin (alpha 1AT, p = 0.03) and orosomucoid (p = 0.02) in the TPN group. Nonacute-phase proteins reached a nadir at day 10 in the TPN group and increased in the TEN group; significant differences between TEN and TPN groups appeared for albumin (p = 0.004) and retinol-binding protein (RBP, p = 0.03); alpha 2-macroglobulin (alpha 2M) approached significance at day 10 (p = 0.07). When change from baseline values was compared, day 10 increases in alpha 2M were significantly higher (p = 0.04) in the TEN group. These data suggest that postinjury TEN attenuates reprioritization of hepatic protein synthesis in patients sustaining major trauma.

Osmotic effects of polyethylene glycol

Polyethylene glycol (PEG) has been used to increase the osmotic pressure of fluids used to cleanse the gastrointestinal tract. However, little is known about its osmotic activity. To investigate this activity systematically, solutions of PEG of differing molecular weights were made and subjected to measurement of osmolality by both freezing point depression and vapor pressure osmometry. Measured osmolality was increasingly greater than predicted from average molecular weight as PEG concentration increased. Measurement of sodium activity in NaCl/PEG solutions by means of an ion-selective electrode suggested that the higher than expected osmolality could be due in part to interactions that, in effect, sequestered water from the solution. Osmolality was consistently greater by freezing point osmometry than by vapor pressure osmometry. To determine which osmometry method reflected biologically relevant osmolality, normal subjects underwent steady-state total gut perfusion with an electrolyte solution containing 105 g/L of PEG 3350. This produced rectal effluent that was hypertonic by freezing point osmometry but isotonic by vapor pressure osmometry. Assuming that luminal fluid reaches osmotic equilibrium with plasma during total gut perfusion, this result suggests that the vapor pressure osmometer accurately reflects the biologically relevant osmolality of intestinal contents. We conclude that PEG exerts more of an osmotic effect than would be predicted from its molecular weight. This phenomenon may reflect interactions between PEG and water molecules that alter the physical chemistry of the solution and sequester water from the solution.

Role of vitamin D-dependent and vitamin D-independent mechanisms in absorption of food calcium

We measured net calcium absorption and the calcium content of the digestive glands secretions in people with widely different serum concentrations of 1,25 dihydroxy vitamin D (hereafter referred to a 1,25-D). Patients with end stage renal disease on hemodialysis served as a model of human 1,25-D deficiency; they were also studied when they had abnormally high serum 1,25-D concentrations as a result of short periods of treatment with exogenous 1,25-D. Normal subjects were studied for comparison. The amount of calcium secreted into the duodenum by the digestive glands was found to be trivial compared to the calcium content of normal or even low calcium meals; therefore, values for net and true net calcium absorption differed only slightly. There was a linear correlation between true net calcium absorption and serum 1,25-D concentration. By extrapolating the short distance to a zero value for serum 1,25-D, D-independent true net calcium absorption was estimated. By subtracting D independent from true net calcium absorption, values for D-dependent absorption were obtained. For a given level of meal calcium intake, D-dependent calcium absorption was found to be directly proportional to serum 1,25-D concentration. At any given value for serum 1,25-D, absorption via the D-dependent mechanism was approximately the same with a low (120 mg) calcium meal as it was when meal calcium intake was increased to 300 mg. We interpret this to mean that the D-dependent mechanism is saturated or nearly saturated by low calcium meals. The D-independent absorption/secretion mechanism resulted in secretion (a loss of body calcium in the feces) when intake was low (120 mg per meal) and absorption when intake was normal. All of the increment in calcium absorption that occurs when low or normal calcium meals are supplemented with extra calcium is mediated by the D-independent mechanism.

Protein abnormalities in adult respiratory distress syndrome, tuberculosis, and cystic fibrosis sera

Crossed immunoelectrophoresis (X-IEP) revealed several abnormalities in serum proteins from patients with adult respiratory distress syndrome (ARDS), tuberculosis (TB), and cystic fibrosis (CF). The two quite different kinds of pulmonary disease, one acute (ARDS) and the other chronic (TB and CF) exhibited serum changes specific for each disease and abnormalities associated with inflammation and pathogenesis, in general. In ARDS sera, most proteins were extremely low, presumably due to leakage into the lungs through damaged tissue, while the acute-phase proteins, orosomucoid, alpha 1-antitrypsin, alpha 1-antichymotrypsin, and haptoglobin, were markedly high when compared to the overall protein pattern. The extremely high alpha 1-antichymotrypsin values were not seen in corresponding TB and CF sera. Numerous TB patients had elevated alpha 1-antitrypsin, alpha 1-antichymotrypsin, and haptoglobin, but only the alpha 1-antitrypsin population mean was significantly different from normal. Gc-globulin, ceruloplasmin, and beta-lipoprotein were higher and alpha 1-lipoprotein and inter-alpha-trypsin inhibitor lower than normal. All other quantitative serum changes were not statistically significant. Surprisingly, all TB patients belonged to the Gc-1-1 genotype in contrast to the Gc-1-1, Gc-1-2, Gc-2-2 polymorphisms of the other populations. CF homozygote sera revealed statistically significant increases in the acute-phase proteins, alpha 1-antitrypsin, alpha 1-antichymotrypsin, and haptoglobin, while orosomucoid, transferrin, IgA, and IgG tended to be higher than normal. The tendency for higher levels of transferrin indicated possible iron deficiency in some patients. In contrast, prealbumin, alpha 1-lipoprotein, and inter-alpha-trypsin inhibitor were significantly depressed in CF patients. CF heterozygotes shared the decrease of alpha 1-lipoprotein with the patients while exhibiting small but significant depressions of alpha 2-macroglobulin and IgG. Though not statistically significant, lowered concentrations of alpha 1-antitrypsin were evident for the heterozygotes.

Crossed immunoelectrophoretic analysis of ARDS lavage proteins

Serum proteins in normal and ARDS bronchoalveolar lavages were analyzed using crossed immunoelectrophoresis. Normal lavages demonstrated relatively few proteins (albumin, alpha 1-antitrypsin, transferrin, and haptoglobin) in low concentrations. In contrast, substantial amounts of all identifiable serum proteins were detected in ARDS lavages. IgA was apparently locally produced. Two of the largest proteins, beta-lipoprotein (mol wt greater than 2 million) and IgM (mol wt approximately 900,000) were found to be complexed as evidenced by their coprecipitation in a single spike in ARDS lavage. Electrophoretic modifications of ARDS albumin and alpha 1-antitrypsin precipitation peaks and partial identity spurring of the alpha 1-lipoprotein peak with other precipitation loops indicated possible complex formation between these proteins and other possibly pathogenic lung fluid constituents. Similarly, modifications of orosomucoid and Gc-globulin peaks indicated possible molecular alterations resulting from interactions with other components. The relatively few protein modifications exhibited in ARDS lavages together with alpha 1-antitrypsin-protease complex formation confirm the relative absence of substantial proteolytic activity in ARDS edema fluids obtained within 12 hr of the onset of the syndrome demonstrated in previous studies.

Bowel infarction as a cause of death in dialysis patients

Bowel infarction as a frequent occurrence in patients with end-stage renal disease has not been previously recognized. This report describes 12 dialysis patients with nonocclusive bowel infarction. All patients with bowel infarction had large weight losses secondary to vomiting, diarrhea, or ultrafiltration when undergoing dialysis, preceding the development of this disease. Of the potential risk factors analyzed, frequent and severe hypotension (systolic blood pressure, less than 100 mm Hg) when receiving dialysis occurred more commonly in patients developing bowel infarction. The weight loss was not often recognized initially as an important compromising problem. A fatal outcome was experienced in nine of the 12 patients. We conclude that bowel infarction may be a significant cause of morbidity and mortality in dialysis patients.