American journal of kidney diseases : the official journal of the National Kidney Foundation
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Comparative Study
Metabolic acidosis in advanced renal failure: differences between diabetic and nondiabetic patients.
Metabolic acidosis is almost invariably a consequence of advanced renal failure, although its severity can vary widely. To evaluate the determinants of the severity of metabolic acidosis, with special interest in determining if there is any difference in the prevalence and severity of metabolic acidosis between patients with and without diabetes, 113 predialysis patients with renal failure were studied. Criteria for inclusion onto the study were: creatinine clearance (Ccr)/1.73 m2 less than 30 mL/min, no alkali therapy within the previous 30 days, and the absence of respiratory diseases. ⋯ By multiple logistic regression analysis, the best determinants for a serum bicarbonate level greater than 19 mmol/L were: the diagnosis of diabetic nephropathy (odds ratio, 0.107; P = 0.0002), Ccr-Cu (odds ratio, 0.824; P = 0. 014), and age (odds ratio, 0.966; P = 0.046). In conclusion, patients with diabetes with advanced renal failure showed a less severe metabolic acidosis, which cannot be explained by gastrointestinal hydrogen ion losses, drugs, or reduced protein catabolic rate. Patients with diabetes may have a more efficient extrarenal generation of bicarbonate than end-stage renal failure patients without diabetes.
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Case Reports
Pneumoperitoneum caused by a perforated peptic ulcer in a peritoneal dialysis patient: difficulty in diagnosis.
Peritonitis due to viscus perforation in peritoneal dialysis (PD) patients can be catastrophic. We describe the first reported case of perforated peptic ulcer (PPU) in a PD patient. This 78-year-old man presented with a 1-day history of mild abdominal pain. ⋯ Free air in the abdomen, although suggestive of PPU, is also not uncommon in PD patients without viscus perforation. Because PD has to be discontinued after laparotomy and exploratory laparotomy may be fatal in high-risk patients, other diagnostic methods should be used to confirm viscus perforation before surgery. PPU, which can be proved by air inflation and contrast radiography, should be suspected in PD patients with pneumoperitoneum and peritonitis.
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A 43-year-old woman took a large amount of depakote (divalproex, a slow-release form of valproate), became comatose, and developed severe hypotension refractory to fluid resuscitation and high-dose vasopressors. The serum valproic acid (VPA) concentration on admission was 1,380 microgram/mL (therapeutic range, 50 to 100 microgram/mL). She also had metabolic acidosis, thrombocytopenia, and normal renal and liver functions. ⋯ After 6 hours of hemodialysis with a high-flux dialyzer, her serum VPA concentration decreased from 940 microgram/mL to 164 microgram/mL, coincident with improvement in clinical status. The half-life of VPA was reduced to 2.4 hours with hemodialysis, whereas it was 7.2 hours before the procedure. Hemodialysis could be a valuable therapeutic intervention in VPA toxicity.