Role of epidemiologic information system in sudden death prevention among Croatia's haemodialysis patients

The main aim of Croatia's epidemiological information system is to enable the monitoring of infectious diseases as well as to enable necessary interventions. Its 24-hour epidemiologic alert mechanism made it possible for initial reports of sudden death clusters in haemodialysis units to reach epidemiologists on the night of 12 October 2001. The alert about the sudden deaths among haemodialysis patients in two hospitals has prompted us to do an epidemiological inquiry during that night and early the next morning. It looked at suspicions of a possible link between Baxter Plivadial P-15 lot 2001F075 dialyser and these deaths. As the suspicion was based on a small amount of data, it needed confirmation from a countrywide inquiry involving the other 40 haemodialysis units. A phone inquiry showed that 23 haemodialysis deaths occurred on 8-13 October 2001. It suggested that also dialyser of a different type and lot (P-18 2001B17R) should be incriminated. During the inquiry (October 13), all haemodialysis units were informed of the suspicions regarding incriminated dialysers, and of the necessity of temporary withdrawal of these from use. The withdrawal on 13 October of incriminated dialysers stopped the deaths among haemodialysis patients. No more such sudden deaths have been recorded since that could be linked either to the described period or to this clinical picture.

Sudden deaths of Croatian hemodialysis patients in October 2001

In 2001, there were 2,719 patients with chronic renal failure dialyzed in Croatia. Death rate in this patient group was 10.3%, similar to that in other countries. On October 12, 2001, the Croatian Institute of Public Health received information that four patients unexpectedly died in the dialysis center in Pozega General Hospital in a single day. Within a week, a total of 23 dialysis patients died in Croatia, of whom 5 during hemodialysis, and 18 within several hours after hemodialysis. Those events prompted us to assess the epidemiological situation in all hemodialysis centers in Croatia. We used phone contacts and reports of regional centers to collect the data. Clinical picture of the patients before death was characterized by dyspnea, hypotension, and cardiac arrest; resuscitation was unsuccessful in all cases. Analysis of all possible risk elements associated with hemodialysis revealed that dialysis devices, dialyzate, water, and personnel were different in all cases, and that the only common denominator in all events was dialyzer P-15 or P-18, manufactured by Baxter, USA, and distributed by Pliva, Croatia.

Thrombotic thrombocytopenic purpura--possibilities of treatment and results

Results of treatment of 13 patients fulfilling the criteria for TTP are presented. Thrombocytopenia was present in all patients (100%). Eleven of 13 patients (84.6%) had conciousness disorder, and seven of 13 patients (53.8%) had renal impairment. Immunosuppressive therapy with plasmapheresis and replacement of removed volume with fresh frozen plasma in a dosage of 25 ml/kg body weight resulted in statistically significant increase of platelet count (p = 0.0033), and significant improvement of consciousness as defined by increased Glasgow Coma Score (GCS) (p = 0.0524). In two patients, renal function recovered and, in one patient, hemodialysis was no longer needed. This improvement in a small patient group has no statistical significance.

Possibilities and limits of treatment in patients with thrombotic thrombocytopenic purpura

Results of treatment of 18 patients fulfilling the criteria for TTP are presented. Thrombocytopenia was present in all patients (100%). Sixteen of the 18 patients (88.8%) had mental status changes, and seven of the 18 patients (38.8%) had renal impairment. One patient had a secondary type of TTP, caused by non-Hodgkin's lymphoma of the large intestine (that was diagnosed later) and was excluded from the study. Immunosuppresive therapy with steroids, plasma exchange and replacement of removed volume with fresh frozen plasma in a dosage of 25 ml/kg body weight resulted in a statistically significant increase of platelet count (P = 0.00222), and a significant improvement in consciousness defined by increased GCS after 2 weeks (P = 0.00222). In two patients renal function recovered, and in one of them hemodialysis was no longer needed. This improvement in a small group of patients had no statistical significance. TTP recurred in seven patients. High doses of steroids caused serious side effects in two patients: in one patient, steroid diabetes, and in the other one, intestinal perforation.

Hypothermia and acute renal failure in the elderly

During 1993-1998, in winter time 14 elderly patients: 8 female and 6 male aged 65-88, were treated because of hypothermia. Rectal temperature on admission was 20-34.9 degrees C. Sopor was present in 2 and various grades of coma were present in 10 patients. Arterial hypotension was recorded in 5, and shock in 9 patients. Increased serum creatinine level was found in 8 patients. The mean rectal temperature in the whole group was 31.3 degrees C +/- 4.7, ranging from 20.0 to 34.9 degrees C, and the mean serum creatinine level was 172.2 +/- 93.5, in range of 66.0 to 360.0 mumol/L. Negative correlation between those two parameters was found: r = -0.572. In 2 of them parameters of renal failure were analyzed: urine sodium concentration, creatinine urine/plasma ratio, urine osmolality, urine/plasma osmolality ratio, renal failure index and fractional excretion of filtered sodium. In one of the patients all parameters were within the range of functional oliguria, in an other the urine sodium concentration serum showed acute renal failure, but all other findings showed borderline values between functional oliguria and acute renal failure. Twelve out of 14 patients died within 1-216 hours from admission.

[Disorders of consciousness due to disorders of body fluid composition--case report of a female patient]

We report a female patient presenting with sepsis and multi-organ failure following eclampsia and intrauterine childdeath. In the phase of recovery, the patient developed consciousness disorder and coma characterized by fasciculation, generalized myoclonia and respiratory insufficiency. The clinical picture corresponded to that of Lance Adam's syndrome. A quick change in the composition of body fluids in the polyuric phase of renal insufficiency associated with an antidiuretic hormone deficit was a cause of that disorder. Metabolic dysfunction and hyperexcitability of neurons developed as a result. Hyperexcitability of the caudal part of the medulla oblongata was responsible for the development of myoclonia. Following the correction of that disorder, the patient completely improved.

[Immunotherapy of sepsis and septic shock]

An extraordinary advance in basic sciences and technology did not reduce high lethality rate of the septic shock patients. The lethality rate of those patients was and still is around 50%. A new knowledge about a role of an inflammatory response on the infection in the later fatal course of the septic patients, led to the new approach in the treatment. A trial to block an endotoxin, cytokines, especially TNF and IL-1, as well as some other substances, in experimental models of sepsis, in spite of inconsistent results, is promising. A clinical experiences are disappointing, at first because of our still poor knowledge about various cytokines cascade, feedback mechanisms, cellular protective mechanisms, etc. The new chapter on the treatment of that highly lethal syndrome is open, though a final achievement of that approach is not clear till now.

[Causes of disorders of consciousness in internal medicine intensive care units]

The present study on 5330 patients admitted to the internal intensive care unit over the five year period (1990-1994) indicated that consciousness disorders are most frequently associated with poisoning. On admission, the state of consciousness of 665 of these 5330 patients was retrospectively evaluated. Poisoning by drugs was most common among intoxications (93 patients of 154 cases of poisoning). Coma, which is the most severe manifestation of consciousness disorder, occurred very often in these patients. Poisoning caused by other agents was connected with other forms of consciousness disorders. Low Glasgow Coma Score (GCS) was a severe predictor, while the number of deaths among patients with GCS > 10 was low. Sepsis was the next most common cause of consciousness disorder among our patients (88 patients). Death rate in these patients was high, amounting to almost 50%, regardless of GCS on admission, suggesting that the severity of main event determines the outcome. Glycemia disorders, including hypoglycemia, hyperglycemia as well as hyperosmotic state, did not result in lethal outcome, regardless of GCS on admission. The highest death rate was registered in patients with cardiopulmonary arrest and lowest GCS on admission. Patients with cardiogenic shock, despite high GCS on admission, had high death rate.

[Effectiveness and adverse effects of a single daily dose of gentamicin versus twice daily administration]

The efficacy and toxicity of a single versus double gentamicin dose were compared. Fifty-four ill patients with infection susceptible to gentamicin in Department of Internal Medicine, University Hospital Rebro, Zagreb, were included in this study. The following criteria excluded patients from the study: serious renal failure (creatinine > 250 mumol/l), hearing impairment, condition and immunodeficiency. Patients were randomised to receive either gentamicin 4 mg/kg by infusion over a 30 minute period once daily, a single-dose group (SG) (N = 25), or gentamicin 2 mg/kg intravenously twice daily, a double-dose group (DG) (N = 29). Almost all patients in a single-dose group achieved peak therapeutic concentrations, while trough gentamicin concentrations were below the recommended. In a double-dose group, only 70.5% of the patients obtained peak concentrations, and 7.5% of the patients had inadequately high trough gentamicin concentrations. In a single-dose group, there were no changes in serum creatinine values, while in a double-dose group there was a significant increase in serum creatinine concentration and a decrease in serum creatinine clearance. Risk factors for gentamicin nephrotoxicity were: through gentamicin concentration, older age and initial abnormal renal function. Ototoxic reaction developed in 35% of the patients on a single gentamicin dose and in 44.8% of the patients on a double dose (P > 0.05), and a lesion was more diffuse in this group. Risk factors for gentamicin ototoxicity were: through gentamicin concentration, duration of therapy, older age and abnormal renal function. Therapeutic effect was observed in 96% of the patients in SG and in 86.2% of the patients in DG (P > 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute renal failure in heart transplantation]

In this study the incidence and the development of acute renal failure (ARF) in heart transplant recipients is presented. Among the thirteen heart transplant recipients eight of them developed oliguric or nonoliguric ARF. Besides the known factors such as actual condition of the patient, kidney function, peri and post-operative compromised circulation, our results demonstrate the significance of postoperative cyclosporin concentration in combination with the use of other drugs. The results also show the importance of the way cyclosporin has been administrated. The parenteral route of appliance is connected with the greater risk of higher drug concentration in the plasma than the peroral one. In connection with this is the higher incidence of adverse reactions to cyclosporin given parenterally. In addition to ranitidine and captopril, which have been mentioned earlier, the findings of our study indicate that greater attention has to be paid to the treatment with ketoconazol given in combination with cyclosporin, since it results in decreased cyclosporin clearance. Other nephrotoxic drugs like amphotericin also increase the possibility of renal lesions. The incidence of acute renal failure in this group of patients is high. Our data suggest that the reasons for the development of ARF are multifactorial. These data further suggest that a reasonable way to solve nonoliguric form of acute renal failure is to maintain the "internal balance" and that it is not necessary to perform extracorporeal elimination of nitrogen substances, if there are no additional complications (i.e. gastrointestinal bleeding).(ABSTRACT TRUNCATED AT 250 WORDS)

Ticlopidine improves dialysis clearance of solutes in uremic patients by reducing blood clotting in dialyser fibers

Ticlopidine, a platelet aggregation inhibitor was tested, in a double blind comparative cross-over study versus placebo, in 51 dialysed uremic patients who had increased dialyser blood clotting (> 25 fibers clotted/dialyser). At the end of a 7-day treatment period with 250 mg daily, the clearance of urea, creatinine and phosphate was determined at 30 and 210 minutes of dialysis, as well as the number of fibers clotted at the end of dialysis. Ticlopidine improved dialyser clearances for urea, creatinine and phosphate from 165 +/- 41 to 182 +/- 35 (p < 0.01), 135 +/- 37 to 143 +/- 35 (p < 0.05), and 120 +/- 36 to 130 +/- 35 (p < 0.05) ml/min, respectively, at 30 min of HD and a similar effect was seen after 210 min of dialysis. The number of dialyser fibers clotted after dialysis was reduced by ticlopidine therapy from 110 +/- 48 to 15 +/- 8 (p < 0.01). Ticlopidine reduced the initial dialysis-induced drop in leucocyte count by 20% (p < 0.05); no change in platelet or erythrocyte count was observed. Two out of 51 patients experienced an adverse reaction from ticlopidine (cutaneous haematoma and minor gingival bleeding). We conclude that ticlopidine is an efficient and safe drug for dialysed uremic patients since it can reduce blood clotting and thereby increase dialysis efficiency.

[Mushroom poisoning with a long period of development]

A group of 87 patients with the signs of poisoning with mushrooms with along period of incubation (t = 12.4 +/- 6.2 h) has been reported. Nausea, vomiting and diarrhea dominate in the clinical picture in the first phase and hepatic and/or renal insufficiency in the second phase. Forty-one patients (47.1%) had "only" clinical symptoms without severe parenchymatous impairments. Forty-six (54.9%) had evidence of a hepatic lesion and 8 patients (10.8%) had renal function impaired, 6 of which needed hemodialysis. There was a significant correlation between elevation of serum transaminases and prolongation of prothrombin complex, resulting from the decreased synthetic liver function (SGPT1/PV1r = -0.424, p = 0.00; SGOT1/PV1r = -0.448, p = 0.000) during the first days after poisoning. Hepatic and renal damage was not identical in all the cases, and there was no correlation between the elevation of serum transaminases and retention of nitrogen substances. When analysing the effect of therapy on elevation of serum transaminases and prolongation of prothrombin complex, a significant difference between elevation of serum transaminases and prolongation of prothrombin time was found in patients on competitive inhibition with penicillin or silibinin, as compared to the patients only on plasmapheresis (p = 0.004 for SGOT, p = 0.000 for SGPT). These data unquestionably suggest the efficacy of competitive inhibition in the treatment of poisoning with mushrooms of a long period of incubation. In favour of this therapy also speaks the group of seriously ill patients who were simultaneously on plasmapheresis and competitive inhibition and who had better improvement than those "only" on plasmapheresis (p = 0.004 for SGOT).(ABSTRACT TRUNCATED AT 250 WORDS)

[Ethylene glycol poisoning treated with hemodialysis]

The paper deals with the course of illness in a patient aged 56 years who had ingested accidentally an unknown amount of alcoholic drink followed by 150 ml of 95 percent solution of ethylene glycol. The patient was admitted to the intensive care unit 28 hours after the accident. The serum ethylene glycol concentration reached 14 mg/100 ml. The slow elimination of ethylene glycol during 28 hours before haemodialysis could be explained by the protective effect of ethanol which the patient had consumed before ethylene glycol. The method of extracorporeal haemodialysis was applied for four hours; the membrane surface was 1.3 m2 and blood velocity 200 ml/min. The rate of clearance of ethylene glycol and its metabolites was 110-150 ml/min. The total amount of ethylene glycol eliminated during four hours of haemodialysis came to about 5 g. Four hours from the beginning of the treatment the serum ethylene glycol concentration was not measurable. As the patient developed signs of acute renal failure the haemodialysis method was applied two more times. The patient was dismissed from hospital in good clinical condition, with normal diuresis and repaired renal function on the 13th day from admission.

[Effect of long-term use of lithium on kidney function]

The effect of lithium and other antipsychotic drugs on the renal function in patients with manic-depressive disorders has been investigated. Thirty-four patients (5 males and 29 females) treated with lithium and 21 patients (6 males and 15 females) on other antipsychotic drugs were studied. A control group of 10 persons consisting of healthy subjects, all of whom were taking no medication was also studied. No significant differences in the treatment duration were present between the patients investigated. Although few patients on lithium had glomerular filtration reduced, no statistically significant difference in creatinine clearance was found between the groups. None of the patients had a disturbance in the reabsorption of glucose, amino acids (histidine, lysine, valine, glutamine, glycine, serine, taurine, threonine, alanine, isoleucine) and beta 2-microglobulin. Patients treated with lithium had a significantly reduced urine concentration and higher daily diuresis than did the other two studied groups. A significantly higher overnight elimination of alkaline phosphatase was found in a group of patients taking other antipsychotic drugs. The attained results suggest tubular lesions in patients with manic-depressive psychosis occurring in the association with the prophylactic use of lithium and, at same time, the possibility of the other in association with the other antipsychotic drugs.