Case history The patient is 65-year old African American male with history of hypertension. He was admitted to hospital with lethargy, disorientation, and confusion. His clinical evaluation and CT of the head revealed subarachnoid hemorrhage. He had h/o stroke 5 years ago. The patient didn’t have fever, but did have a diarrhea of 1-day duration. He is receiving parenteral feeding and his urine output is 4L/day. His physical examination revealed blood pressure of 100/70mmHg, with heart rate of 100 BPM. He has dry mucous membranes and the rest of examination was unremarkable. His laboratory investigation showed sodium 159meg/L, K+ 4.6meg/L, chloride 114mEq/L, HCO3 26mEq/L, creatinine 1.9mg/L, Blood urea nitrogen 64mg/L, and glucose 200mg/L His urine sodium 70mEq/L, and urine osmolality 380mOsm/Kg H2O. His volume status is slightly dry, and he weighs 70Kg. Case discussion This case illustrated several information including polyuria with parenteral nutrition, low blood pressure and dry mucous membranes denoting low extracellular fluids volume. High serum sodium, and high urine osmolality in the face of hypovolemia and hypernatremia. As a consequence of his illness he suffered from low perfusion to the kidneys with worsening kidney function. Hypernatremia is a common electrolyte abnormality and defined as a serum sodium >145mEq/L (1,2,3). Hypernatremia is hyperosmolar state caused by a decrease in total body water (TBW), relative to electrolytes content (4). Therefore, hypernatremia is a water problem not sodium problem. It often occurs in elderly and hospitalized patients with restricted access to water and in those with impaired thirst mechanism (hypodipsia/adepsia) or mental status changes. Developing hypernatremia is virtually impossible if the thirst mechanism is intact and water is available. Hyper-osmolality caused by hypernatremia and water loss can lead to neurological cell shrinkage and brain injury. Loss of volume also can leads to circulatory collapse and organ failure. Hypernatremia is considered…
Two Options the sweetest among them is bitter: Fournier-gangrene associated with sodium-glucose co-transporter 2-inhibitors
The authors discuss a case of sodium-glucose co-transporter 2 inhibitor associated with Fournier-gangrene in a patient with type-2 diabetes millets. The patient had extensive surgical intervention and skin graft but succumbed to her disease.
Large urinary bladder leiomyoma causing right hydronephrosis, a rare case report: diagnosis and management
Background Leiomyoma of the urinary bladder is a rare tumor despite the routine use of ultrasonography. These tumors are typically asymptomatic, sometimes present with hematuria, dysuria, and bladder outlet obstruction. Leiomyoma is a benign tumor which is detected incidentally and rarely causes upper urinary tract changes. (1, 2) We present an extremely rare case of leiomyoma in urinary bladder causing right hydronephrosis and presenting with flank pain. Case summary A 42 years female presented with flank pain in the emergency room as result of hydronephrosis in the right kidney. Imaging of urinary tract revealed 6 x 6.5 cm, a well-circumscribed tumor with right hydroureteronephrosis suggestive of leiomyoma of the urinary bladder. Excision of leiomyoma was done intravesically with preservation of bilateral ureteral orifices’. Conclusion Our case highlights despite being a large tumor there was no ureteral involvement. The hydronephrosis was the result of compression from large sized leiomyoma which was successfully managed by excision of leiomyoma.
Mineral-Bone Disorders in Chronic Hemodialysis Patients in Sub-Saharan Africa: Dakar Experience (Senegal West Africa)
Introduction: Mineral bone disorders (BMD) are almost constant complications in chronic hemodialysis patients. The objective of our study was to determine the prevalence and profiles of BMD in chronic hemodialysis patients. Patients and methods: This is a six-year descriptive and analytical retrospective study from January 1st, 2010 to December 31st, 2015, at the hemodialysis department of the University Hospital Center (CHU) Aristide Le Dantec. Were also included patients on chronic hemodialysis for at least 3 months, with at least one prescribed amount of parathyroid (PTH). For each included patient, the epidemiological, dialytic, diagnostic and therapeutic parameters were collected and analyzed. Results: Over 86 patients, 71 (82.5%) had BMD. The average age was 48.92 ± 15.5 years old, with a sex ratio of 0, 65. Nephroangiosclerosis was the most frequent initial nephropathy (56.3%). The dialysis seniority was 5.2 ± 2.9 years old and 93% of patients profited from 3 sessions of 4 hours per week. Eleven patients (15.5%) had previous aluminum intoxication. Fifty-eight patients (81.6%) had secondary hyperparathyroidism, 12.6% had adynamic osteopathy (OA), and 1.4% had osteomalacia. In patients with secondary hyperparathyroidism, the average age was 48.6 ± 15 years old. 37.9% of these patients had articular pains, 22.4% had bone pains and 13.8% had spontaneous fractures. Eleven patients had hypocalcemia and only one patient had mild hypercalcemia. 46.5% of patients had normal phosphatemia; 29.3% had hypophosphatemia and 24.13% had hyperphosphatemia. Average PTH was 913.85 ± 331.65 ng/ml. 73% of patients had 25-OH-Vit D insufficiency; 72.7% of patients had high total PAL. Therapeutically, 91.4% of patients had been treated with calcium carbonate; 25.9% with a treatment based on non-calcium phosphorus chelators; 69% of patients received vitamin D and 15.5%, calcimimetic treatment. 22% of patients under medical treatment normalized their PTH. Parathyroidectomy was performed in 6.9% of patients. The average age in…
Illusive Dynamic Nadirs and Masks of Postoperative Hyponatraemia and the TURP Syndrome: Volumetric Overload Over Time (VO/T) Concept for Resolving its Puzzle
Introduction and Objective Postoperative hyponatraemia (HN) causes serious morbidity and mortality, of which the transurethral resection of the prostate (TURP) syndrome is a unique model. It is an illusive puzzle with unclear definition, unknown aetiology, difficult diagnosis and disputed therapy. Clinical presentation ranges from prodromal symptoms to severe signs of circulatory shock and multiple vital organ dysfunction/ failure (MVOD/F) or death. All severe cases were reported retrospectively and attributed to multiple toxic/ dilution hypotheses interchangeably with recognized clinical conditions. The overlooked VO/T causes dynamic HN nadirs and masks making it a complex clinical/biochemical jigsaw puzzle with false and missing pieces. The objective here is to resolve this puzzle. Patients and Methods: Investigations based on clinical observations, critical literature analysis, physics-physiological and clinical prospective studies done over the past 32 years. Observations and deductive analysis identified VO/T insult, HN nadirs, clinical paradoxical masks of shock and MVOD/F. Documented evidence provided correct puzzle pieces and stepping-stones that led to new understanding, rejecting false and discovering missing ones. Prospective studies verified and quantified VO/T insult causing secondary, tertiary HN nadirs and osmotic gaps. Severity depends on VO over T and fluid type of sodium-free (VO1) and sodium-based (VO2) fluids and tonicity as well as patient’s variables of body weight and hormones. The results of all prospective studies on VO, HN nadirs, and clinical severity grades have contributed to resolving the puzzle that is impossible to resolve using a single prospective study. Results: “VO over T” causes the biochemical and clinical features of HN and the TURP syndrome. Dilutional HN “shock” and “VO” concepts were reported 45 and 11 years ago but VO insult remained invisible. The puzzle was resolved after unraveling the dynamic role of T in HN nadirs, discovering missing pieces and refuting unduly incriminated dilutional and toxic hypotheses. 3.5l of VO1…
Epidemiological Profile and Histopathological Aspects of Malignant Tumors of Testicle in Yaounde and Douala (Cameroon)
Objective: Determine the epidemiological profile and histopathological aspects of testicular cancer in the two major cities of Cameroon, Yaoundé and Douala. Patients and methods: It was a retrospective cross-sectional descriptive study conducted in the reference structures approved for anatomopathological examination in Yaoundé and Douala. The study was conducted over a 17-year period (2001-2017). We included all cases of histologically confirmed testicular tumors. Variables included frequency, year of diagnosis, sociodemographic data, clinical aspects, types of sampling, gross macroscopy, and histological types. Results: We collected 81 cases of testicular tumors (49 benign tumors and 32 malignant tumors), with a mean age of diagnosis of 36.27 ± 18.9 years. For malignant tumors, the mean age was 40.25 ± 25.02 years, the predominant age group was 20-29 years (25%), the predominant type of specimen was the orchidectomy %, the predominant histological types were germ cell tumors with 30% seminomas. Conclusion: Testicular tumoral pathology affects more young man and is dominated by seminoma-type germ tumors.
The study goal was to find the most optimal approach to the treatment of patients with urolithiasis. The study involved 4014 patients with stones of different localization. Patients with benign prostatic hyperplas-ia (BPH) were investigated with IPSS, PSA, and uroflowmetry. 3175 ureteropyeloscopies were performed. Separately, we studied the results of treatment of 427 patients with ureterolithiasis in combination with BPH, which underwent ureterolithotripsy. Percutaneous nephrolithotrip-sy was performed in 412 patients, most of the procedures were per-formed according to the classical technique. The other research purpose was prophylaxis optimization of the recurrent urolithiasis. 152 patients participated in the experimental part. Some of the patients were taken from the clinical part of the study. All patients were with recurrent calci-um oxalate urolithiasis. Patients were divided into two groups: the 1st group (74 patients) did not receive treatment during the follow-up peri-od, the second group (42 patients) received treatment in the volume of thiazide diuretics, water load, citrate mixtures, calcium preparations in-side. During the entire follow-up (6 months), all patients underwent a comprehensive urological examination. Eventually have been estimated that surgery should not be the final stage of treatment of the urolithiasis. Urolithiasis requires constant monitoring of patients, and the priority task of a urologist is to prevent recurrent stone formation. This is achieved through the appointment of adequate conservative therapy, which includes thiazide diuretics, citrate mixtures, calcium preparations, water intake in adequate amount, and if necessary, magnesium prepara-tions. The final choice of conservative treatment depends on the type of stone. The change in the concentration of crystallization inhibitors (biku-nin and osteopontin) is a predictor of an early relapse of the urolithiasis, which can be used in monitoring patients in the postoperative period.
The transurethral resection of the Prostate (TURP) syndrome and acute dilutional hyponatraemia (HN): A comprehensive literature review from first incidence in 1947 to disappearance in 2018
Introduction and objective: To report on the literature review on the TURP syndrome from its first report in 1947 to disappearance from urology in 2018 Material and methods: The literature on the TURP syndrome from 1947 to 2018 was reviewed. We summarise the evidence on its incidence, prevalence, patho-aetiology, clinical picture and management. With the introduction of normal saline as irrigating fluid for the TURP procedure, the TURP syndrome as characterised with hyponatraemia (HN) has been eradicated. We introduce the concept of volumetric overload shocks (VOS) to be prepared when another syndrome induced by saline overload strikes. Results: The TURP syndrome is induced by massive absorption of the sodium-free irrigating fluid and is characterized with acute dilutional HN- hence it is eradicated with use of saline as irrigant. It presents with shock and multiple vital organ dysfunction and was easily mistaken for one of the recognised shocks calling for further volume expansion with isotonic solutions with disastrous consequences. Identifying the concept of VOS does not only help in the management of the TURP syndrome but also with recognizing the syndrome induced by saline overload. Hypertonic sodium therapy has proved effective in treatment. Conclusion: The review demonstrates that VOS in clinical practice is of two types; Type 1 (VOS1) induced by sodium-free fluid and type 2 (VOS2) induced by sodium-based fluids- the later has no serum marker of HN. Both conditions present with multi-system organ dysfunction but one system may predominate. VOS2 presents as the adult respiratory distress syndrome.
Hypokalemia is a common finding in hospitalized patients. In most cases the cause will be obvious. However, in a subgroup of patients the cause is occasionally uncertain and establishing the diagnosis may present difficulties and can become a challenge. In such cases, measurement of urinary indices e.g. trans-tubular potassium gradient [TTKG] and random urine potassium/creatinine concentrations along with blood acid/base parameters and assessment of urinary excretion of potassium, chloride, calcium and creatinine have been employed in the differential diagnosis. TTKG and urine potassium/creatinine ratio are used as a rapid appropriate index of potassium excretion and to establish a proper diagnosis and management in this medical emergency. It helps to differentiate between hypokalemia caused by redistribution or renal potassium wasting. Urinary chloride excretion and urinary calcium/creatinine ratio in conjunction with plasma acid/base values, aldosterone, renin and cortisol values are used for narrowing the differential diagnosis of refractory hypokalemia. Conclusions: Calculating the trans-tubular potassium concentration gradient, urinary potassium/creatinine ratio, urinary chloride excretion and urinary calcium/creatinine ratio in conjunction with plasma acid/base values provided simple and reliable tests for differential diagnosis of causes of refractory hypokalemia and to provide a proper management in the intensive care unit and in the emergency until advanced further tests to be done.
Renal Ischemia-reperfusion Induces Renal Collagen Deposition Through Nadph Oxidase Activation in Rats
Introduction:Acute kidney injury (AKI) may predispose the onset of chronic kidney disease (CKD) and hypertension through changes in renal NADPH oxidase and renal fibrosis. Objectives: To investigate, in rats, whether AKI induces later renal fibrosis through NADPH oxidase activation. Methodology: This protocol was approved by the Committee of Ethics in Animal Experimentation of UFPE (nº 23076.060473/2014-91). Male Wistar rats (120 days-old; n=8) were submitted to AKI through bilateral renal ischemia-reperfusion injury (IR; 45 min ischemia followed by 30 days of reperfusion). One group (n=8) was submitted to IR in the presence of oral apocynin administration (100 mg/kg) 24 hours before and after IR, to inhibit NADPH oxidase activity, while other (n=8), received daily oral treatment with apocynin (100 mg/kg) 24 hours after reperfusion until the end of experiment. These groups were compared to a control group submitted to simulation of IR procedure. Thirty days after reperfusion, it was evaluated creatinine clearance (ClCreat) and systolic blood pressure (SBP), as well as kidney collection, to evaluate lipid peroxidation, NADPH oxidase activity and collagen deposition. Statistical analysis was performed using one-way ANOVA followed by Newman-Keuls test (P