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Nephrol Dial Transplant (1998 ) 13: 526526
however, that patients with IgA nephropathy are at particular
tension when first seen by nephrologists.risk of developing pre-eclampsia.
We conclude that the present patient had underlying IgA In conclusion, the high mortality rate observed in our
patients is comparable to those reported in the literature.nephropathy associated with pre-eclampsia. We recommend
that renal biopsy be performed after severe and/or atypical Our series shows that MOF patients with lower hematocrit,
serum albumin or serum total protein, having sepsis or beingpre-eclampsia to reassess the renal risk of further pre-
eclampsia. oliguric, needing vasopressor drugs or mechanical ventilation
seem to have higher death rate. APACHE II score and the
Division of Nephrology Atsuhiro Yoshida number of OSF at the time of the initial renal consultation
Nagoya Daini Red Cross Hospital Kunio Morozumi appear to be useful in predicting the outcome in these
Third Department of Internal Asami Takeda patients. Survival seems to be negatively linked to the severity
Medicine Katsushi Koyama of associated diseases.
Nagoya City University Medical Yasuhiro Ohtsuka It would be desirable to start prospective multicentre
School Tadashi Oikawa studies with the purpose of determining patient characteristics
Nagoya, Japan and score systems applicable in predicting the outcome in
MOF patients with ARF.
Fresenius Medical Care Dialysis B. Csiky
Acute renal failure in patients with multiorgan failure:
Centre M. Molna
´r
risk factors influencing survival
2nd Department of Medicine A. Kara
´tson
Department of Anaesthesiology and L. Boga
´r
Sir, Intensive Care Unit
The mortality of acute renal failure (ARF ) still exceeds 50% University Medical School of Pe´cs
(it can reach up to 80% in Intensive Care Unit patients), Hungary
and so does the mortality of several forms of multiorgan
1. Wardle EN. Acute renal failure and multiorgan failure. Nephrol
failure (MOF ) [1 ]. Mortality of ARF seems to be determined
Dial Transplant 1994; 9[Suppl. 4 ]: 104–107
by the severity of associated diseases rather than by the ARF
2. Cosentino F, ChaffC, Piedmonte M. Risk factors influencing
itself. Because of the high mortality rate and enormous
survival in ICU acute renal failure. Nephrol Dial Transplant 1994;
treatment costs, from early days much interest has been
9[ Suppl. 4]: 179 –182
shown in determining the prognosis of these patients. With
3. Liano F. Severity of acute renal failure: the need of measurement.
this aim, multiple aspects have been studied [ 2]. There is a
Nephrol Dial Transplant 1994; 9[Suppl. 4 ]: 229–238
debate in the literature about the usefulness of different
4. Douma CE, Redekop WK, van der Meulen JH et al. Predicting
mortality in intensive care patients with acute renal failure treated
patient characteristics and score systems in predicting the
with dialysis. J Am Soc Nephrol 1997; 8: 111 –117
outcome of ARF patients of Intensive Care Units ( ICU )
5. Groeneveld ABJ, Tran DD, van der Meulen JH, Nauta JJP,
[3,4 ]. The aim of the present study was to evaluate character-
Thijs LG. Acute renal failure in the medical intensive care unit:
istics and indices suited to predict mortality in MOF patients
predisposing, complicating factors and outcome. Nephron 1991;
with ARF.
59: 602–610
We studied retrospectively data of 39 patients with MOF
requiring renal replacement therapy, admitted consecutively
to the ICU of our Medical Centre from April 1, 1994 to
Fucus vesiculosus: a nephrotoxic alga?
December 31, 1996. This was a mixed population of medical
and surgical patients. All were treated with intermittent
haemodialysis carried out with cuprophan or polysulphone Sir,
In January 1995, a 18-year-old female was admitted to ourfilters. We considered only death or discharge from ICU as
valid outcomes. Student’s t-test and x2-test were used to unit because of polyuria and polydypsia. The patient com-
plained of extreme faintness and her general condition wasassess whether individual variables differed significantly
between survivors and non-survivors at a P<0.05. poor. The patient had been on a hypocaloric diet over the 3
months prior to the admittance and had actually lost ~10 kgThe overall mortality rate was 74.3%. The mean age of
the patients was 53±18.8 years. There was no difference in in weight; as an adjunctive therapy prescribed by an herbalist,
she was also taking marine oak (fucus vesiculosus) in 400 mgage, gender, serum creatinine, urea nitrogen, serum potas-
sium, and blood pressure between survivors and non- tablets (three tablets three times a day). Her personal history
was negative for renal diseases and she denied any othersurvivors at the time of the initial renal consultation. The
APACHE II score at the time of the initial renal consultation medication. Laboratory testing revealed: blood creatinine,
8.7 mg/dl; glycosuria ( 500 mg/dl ); moderate proteinuria andwas significantly higher in non-survivors than in survivors
(28.8±5.50 vs 21.0±2.79, P<0.005). The number of organ leucocyturia; serum autoantibodies, negative. Renal sampling
performed by automatic Trucut needle yielded moderatesystem failure (OSF ) [5 ] was 2.4±0.97 in survivors and
3.1±0.90 in non-survivors (P<0.05). Survivors had higher interstitial fibrosis, widespread tubular degeneration, and
diffuse lymphomonocytic infiltrate; the glomeruli displayedhematocrit (30.8±5.29 vs 24.6±4.87, P<0.05), higher serum
total protein (58.9±9.04 g/l vs 48.0±7.88 g/l, P<0.005) and scarce and focal mesangial proliferation, but the basal mem-
brane appeared as intact (Figure 1a). Direct IF testing wasserum albumim levels ( 31.9±2.52 g/l vs 27.4±4.31 g/l,
P<0.05) than non-survivors. Sepsis occurred in 45% of the negative. Positive peroxydase staining was obtained for
T-lymphocyte-related UCHL1 (CD45 RO) and monocyte-non-survivors and 30% of the survivors (P<0.01) . Sixty-two
per cent of the non-survivors and 40% of the survivors related KP1 (CD68 ) antibodies, respectively (Figure 1b, c).
To exclude contamination by heavy metals, we performed(P<0.01) were oliguric at the time of the initial renal
consultation. Forty-nine per cent of the survivors and 76% a quantitative analysis on the marine oak powder the tablets
were composed of. For this purpose, we used an atomicof the non-survivors needed mechanical ventilation
(P<0.01). Thirty per cent of the survivors and 56.8% of the adsorbance spectrophotometer ( Varian Spectra-20) supplied
with a graphite miniwave plus an autosampler; before testing,non-survivors received vasopressor drugs because of hypo-
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Nephrol Dial Transplant (1998 ) 13: 527 527
cortical necrosis, but the most common pathologic feature is
interstitial fibrosis, tubular atrophy, and lymphomonocytic
infiltration [5,6 ] . In spite of a generally favourable prognosis,
some cases of residual functional impairment have been
described [7]. Our patient was completely cured 1 year after
the disease onset, and at present time she is in good health.
In our country, the lack of an adequate regulation about
the therapeutic sale of herbalistic products is probably based
upon the false conviction that ‘natural’ products are harmless
and that phytotherapy is henceforth to be preferred to
‘conventional’ medicine. In particular, the intake of marine
alga preparations as an adjuvant principle in slimming diets
has been progressively enhanced by the prescription-free sale.
Although a direct nephrotoxicity of this drug might hardly
be proven, its pathogenicity can be related to the content of
heavy metals as an heritage of growth in heavy polluted
water [8 ].
We hope that this report can stimulate the Italian Health
Authorities to request similar licensing procedures for both
synthetic drugs and ‘natural’ products.
Departments of Nephrology and P. A. Conz
Dialysis, G. La Greca
Infectious Diseases, and Institute of P. Benedetti
Pathology P. A. Bevilacqua
S. Bortolo Hospital L. Cima
Vincenza, Italy
Department of Pharmacology
Padova University
Italy
1. Appel GB, Kunis CL. Acute tubulo interstitial nephritis. In:
Cotran RS, ed. Tubulo-interstitial nephropathies. Churchill-
Livingstone, New York: 1982: 151–183
2. Brown MM, Rhyne BC, Goyer RA, Fowler BA. Intracellular
effects of chronic arsenic administration on renal proximal tubule
cells. J Toxicol Environ Health 1976; 1: 505–514
3. Fowler BA. The morphologic effects of mercury, cadmium, lead
and arsenic on the kidney. In: Trace Metals in Water Supplies:
Occurrence, Significance and Control. Proceedings Sixteenth water
quality conference. Champaign-Urbana: Department of
Engineering, University of Illinois: 1974; 65– 76
4. Kleinknicht D, Landais P, Goldfarb B. Drug associated acute
renal failure: a prospective multicenter report. Proceedings
EDTA–ERA 1988; 22: 1002
5. Prasad GVR, Rossi NF. Arsenic intoxication associated with
tubulo-interstitial nephritis. Am J Kidney Dis 1995; 26: 373–375
6. Gimenez A, Mampaso F. Characterization of inflammatory cells
in drug induced tubulointerstitial nephritis. Nephron 1986; 43: 239
7. Kida H, Abe T, Tomosugi M. Prediction of the long-term
outcome in acute interstitial nephritis. Clin Nephrol 1984; 22:
55–59
8. Rosemarin A, Notini M, Holmgren K. The fate of arsenic in the
Baltic Sea. Fucus vesiculosus ecosystem. Ambio 1985; 6: 342–345
(c)
(a)
(b)
Fig. 1. (a) Renal biopsy specimen showing moderate interstitial
fibrosis with widespread lymphomonocytic infiltrate (PAS 250×).
Feasibility of a native arteriovenous fistula as the initial
(b) Renal biopsy specimen: immunohistochemistry with UCHL 1
type of permanent vascular access in the majority of
(CD45RO) antibody showing interstitial T-lymphocytes (avidine-
biotin-peroxidase 250×). (c) Renal biopsy specimen: Antibody KP 1
chronic haemodialysis patients
(CD68) revealing interstitial monocytes (avidine-biotin-peroxidase
250×).
Sir,
The April 1997 issue of NDT brought two contributions
[1,2 ] concerning the impact of vascular access on morbiditysamples were pre-digested with concentrated nitric acid.
Chemical quantitative analysis gave the following results: and mortality of the chronic haemodialysis patients. Woods
and Port stated in an Editorial Comment [1] that despitearsenic, 21.3 mg/kg; cadmium, 0.3 ppm; mercury, 0.06 ppm;
and chrome, 4 ppm. evidence showing the superiority of a native AV fistula over
an AV graft because of lesser complication incidence and aThe real incidence of ‘heavy metal nephropathy’ is not
known because the clinical presentation is non-specific and longer life, a trend has been documented in the United States
away from use of an AV fistula and towards use of an AVrenal biopsy is necessary to confirm the diagnosis [1 –6 ].
Arsenic can evoke either an acute tubular necrosis or a graft. As a result <30% of the American patients [3] have
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