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It appears that children can develop a degenerative muscle condition called rhabdomyolysis in association with influenza. This condition may lead to kidney failure. Laboratory evidence of rhabdomyolysis was found in a 14-year-old African-American female with kidney failure who had recently had flu-like symptoms. A muscle protein important for oxygen transport called myoglobin was found in the patient's urine. Blood tests revealed the presence of influenza type A infection. Markers of kidney function were abnormal and urine production later stopped. Muscle function and urine production returned to normal after treatment.

This prospective study evaluated the radiographic, endoscopic, histologic, and clinical characteristics of nodular duodenitis found in 17 of 50 (34%) patients with end-stage renal disease. By comparison, nodular duodenitis was noted in only 23 of 557 (4%) consecutive endoscopies in a general medical population. Endoscopic nodular duodenitis consisted of two or more nodules, 2.5–7.0 mm in diameter, with apical erythema, with or without tip erosions. Eight patients had nodules in the bulb only, eight had diffuse duodenal nodules, and a single patient had nodules only in the second portion of the duodenum. Singlecontrast barium x-rays were sensitive in detecting the nodules only when they were 5 mm or greater in diameter. Some degree of inflammatory infiltrate was found in 14 of 17 (82%) of the patients with nodular duodenitis; 10 of 17 had a moderate to severe histologic grade compared to 3 of 18 (P=0.015) patients with a normal endoscopic appearance to the duodenum. Several patients with endoscopic nodular duodenitis, in whom biopsies were taken both of the nodule and surrounding mucosa, were found to have a focal histologic lesion which consisted of villous blunting and thickening due to fibrosis and a chronic inflammatory infiltrate or lymphoid aggregate in the stroma. A higher incidence of peptic ulcers occurred in the nodular duodenitis group (3 of 17) compared to the remainder of the group (0 of 33) during a mean follow-up of 38 months (P=0.03). Resolution of the nodules occurred in six patients following successful renal transplant (four patients) and following vagotomy and pyloroplasty (two patients). These findings would suggest that nodular duodenitis, in patients with end-stage renal disease, represents a subset of duodenitis with a characteristic radiographic, endoscopic, and histologic appearance.

A prospective study was undertaken to determine the incidence of upper gastrointestinal disease in 85 chronic renal failure (CRF) patients on hemodialysis. Upper gastrointestinal x-rays were obtained for 83 patients, and enlarged gastric and duodenal folds were seen in 12% (10/83) and 42% (35/83) of the cases, respectively. Panendoscopy performed on 60 persons revealed gastritis in 22% (13/60), nodular duodenitis in 60% (35/ 60), and esophagitis in 13% (8/60). No peptic ulcers were identified either radiologically or endoscopically. Pathologic examination of mucosal biopsy specimens demonstrated gastritis in 46% (21/46) and duodenitis in 43% (22/51) of patients. A highly significant correlation was found between endoscopic and radiologic duodenitis (P <.0001) and also between endoscopic and pathologic gastritis (P <.05), but not between endoscopic and pathologic duodenitis. We have demonstrated a high incidence of mucosal inflammation but not ulcer disease in CRF patients. These lesions may predispose these individuals to gastrointestinal bleeding following renal transplantation.(Arch Intern Med 138:1214-1217, 1978)

Nine patients with high-output cardiac failure from arteriovenous forearm dialysis fistulas are reviewed, and six new cases are presented. Decreases in cardiac output with temporary fistula occlusion ranged from 0.3 to 11.0 liters/min (mean, 2.9 liters/min); fistula flow rates varied from 0.6 to 2.9 liters/min (mean, 1.5 liters/min). Surgical correction of high-flow fistulas resulted in notable improvement of cardiac failure in 13 of 14 patients. Although cardiac failure in individuals who are receiving long-term dialysis treatment is usually caused by intrinsic cardiac disease, volume overload, or anemia, forearm fistulas with large flow rates may be an important contributing factor. Correction of these large flow rates by banding or closure can substantially improve cardiac function in selected patients.(Arch Intern Med 136:292-297, 1976)

Over a two-year period, 100 venous angiograms were performed on 75 patients because of difficulty with vascular access. Seventy percent of the patients had decreased arterial flow or increased venous resistance. High output failure, sepsis, and aneurysm formation were also found. Venous angiography of the fistula demonstrated significant stenosis in 40% of the cases as well as total occlusion by thrombus in 9%, aneurysm formation in 7%, and abnormal fistula needle placement or anatomic abnormalities in 20% of the cases. Definitive diagnosis with the aid of venous angiography permitted specific surgical intervention in 62% of the cases, and identified new sites for needle placement in 18% of the cases, thus prolonging fistula life and reducing the need for new fistula placement. Our experience with local cellulitis of the fistula site and sepsis is also discussed.(Arch Intern Med 138:1117-1121, 1978)

Two cases of neurotoxic reaction to penicillin and carbenicillin were observed. Penicillin has long been known to be neurotoxic when given in "massive" doses to patients with reduced renal function. Carbenicillin, a new semisynthetic penicillin, should be considered to have the same neurotoxic potential as penicillin. Signs of neurotoxic reaction should be sought in patients with diminished renal function who receive large doses of penicillin or its derivatives. Appropriate reductions in dose should be made in patients developing signs of neurotoxic reaction to penicillin.