Twelve prosthetic hip and knee replacements (eight bipolar endoprosthetic replacements, three conventional total hip replacements, and one hemiarthroplasty of the knee) were implanted between 1978 and 1988 in eleven patients who underwent hemodialysis for chronic renal insufficiency. Five replacements (three conventional total hip replacements, one bipolar endoprosthetic replacement, and one hemiarthroplasty of the knee) in four patients had a failure due to the loosening of the component. In these four patients, the median age at operation was 51 years and the average length of follow-up was 6 years. One of these patients died of infection in both loosened total hip replacements seven years and four months after the operation.
During the two-year period from July, 1981, through August, 1983, eleven patients with chronic renal failure on maintenance dialysis were treated by orthopedic procedures. Orthopedic surgeries were performed safely on eight of the eleven patients.Patients on maintenance dialysis must be carefully evaluated and prepared for elective surgery. For example, we must be aware of the alterations that accompany with chronic renal failure, including changes in body fluid composition, abnormalities of serum electrolytes, acid-base disorders, anemia, platelet dysfunction, and increased susceptibility to infection. Special care should be taken to lose as little blood as possible during the operation and to prevent postoperative infection.If we take time to carefully prepare the patient for operation, orthopedic surgical procedures can be performed safely on patients with chronic renal failure on maintenance dialysis.
Dear Sir,Minimal-change nephrotic syndrome (MCNS) accounts for 15–25% of the adult-onset nephrotic syndromes [1]. Most cases of MCNS are idiopathic, although identifiable causes, such as drugs, hematological malignancies, and food allergies, have been reported [2, 3, 4, 5]. However, there is no case report of missed abortion for this association in the literature. We hereby describe a case of MCNS with acute renal failure (ARF) secondary to missed abortion.A 20-year-old primigravid female was admitted to the hospital at 8 weeks of gestation, and her pregnancy was complicated by a missed abortion. She had no history of renal disease, and urinalysis was negative for protein and blood. She requested a dilatation and curettage to be withdrawn for financial reasons. At 10 weeks of gestation, whe was admitted again, complaining of malaise, and physical examination revealed edemas of the face and lower extremities with a blood pressure of 114/68 mm Hg. Investigation showed that she had nephrotic syndrome with serum albumin 2.8 g/dl, total protein 5.0 g/dl, cholesterol 184 mg/dl, and urinary protein 15 g/24 h. Other laboratory data included hematocrit 37%, white blood cell count 9,400/mm3, platelet count 23 × 104/mm3, serum urea nitrogen 6.5 mg/dl, serum creatinine 0.4 mg/dl, negative antinuclear antibody, and complement levels within normal limits. A dilatation and curettage was performed at this time. As heavy proteinuria remained with worsening edema and because she developed ARF with serum creatinine 3.1 mg/dl during the next 10 days, a percutaneous renal biopsy was performed. On light microscopy, the biopsy specimen examined by serial sections contained 18 glomeruli, all showing normal glomerular and tubulointerstitial appearances (fig. 1). Immunofluorescence microscopy revealed absence of glomerular deposits of immunoglobulin, complements, and fibrinogen. On electron microscopy, extensive foot process effacement was evident, and no electron-dense deposits were seen (fig. 2). Thus, a diagnosis of minimal-change nephropathy was made by histological appearances.Prednisolone therapy, 60 mg/day, was started. Within 10 days, serum creatinine decreased to the normal level following a decline in proteinuria once it reached a maximal concentration of 4.4 mg/dl. A full remission of the nephrotic syndrome was obtained within 3 weeks, and the prednisolone dose was tapered subsequently. Five weeks after cessation of the proteinuria, her prednisolone dose was decreased to 20 mg/day and has been maintained for 2 months without a relapse of the syndrome until this day.Several factors might have contributed to ARF in our patient. However, transient ischemia due to the dilatation and curettage seemed to be improbable, because blood loss in the treatment was minimal with stable blood pressure and because the biopsied specimen of the kidney had no tubular changes. Our patient was not administered nonsteroidal anti-inflammatory drugs and diuretics, and improvement in renal function with predonisolone therapy alone suggests that ARF in our patient was attributable to MCNS. A dead fetus might cause a disorder of T lymphocytes which probably led to the onset of MCNS. This is, to our knowledge, the first published case of MCNS with ARF associated with missed abortion, although the exact mechanism is unclear.
