420
CHAPTER 26
infusion of dextrose-saline should be given. Resonium-A (Sodium Polystyrene Sul-
phonate) is indicated in hyperkalaemia associated with severe oliguria or anuria and 15 g
should be given 3-4 times daily by mouth in a little water. Resonium should be dis
continued as soon as the serum potassium level falls to 5 mEq/1 to avoid potassium
depletion. Therefore, biochemical control is necessary during treatment.
Anaemia.
Anaemia, associated with more or less profound albuminuria, as found in the
case described earlier, is one of the classical symptoms of progressive renal deficiency.
Anaemia may be obscured in certain cases by haemoconcentration as a result of vomiting,
diarrhoea and excessive use of diuretics. Its main causes are: blood loss, particularly
due to gastrointestinal haemorrhages, haemolysis associated with severe abnormalities
of red blood cells, associated with thrombocytopaenia (haemolytic-uraemic syndrome)
and deficiency of the bone marrow, which according to Moor (1957) and Erslev (1967)
does not respond with compensatory erythroid hyperplasia in the presence of anaemia.
The important researches of Jacobson
et al.
(1957), Erslev (1960, 1967), Naets (1960),
Reissmann
et al.
(1960) have shown that hypoxia caused by anaemia will result in stimu
lating activity of erythropoitin, an erythropoitic hormone in the plasma, which promotes
differentiation of bone marrow stem cells to early red cell precursors (Erslev, 1960).
These findings have confirmed my views about the importance of the oxygen carrying
erythrocytes in preventing tissue hypoxia and, therefore, the need of blood transfusions
in paraplegics suffering from pressure sores and osteomyelitis associated with pyelone
phritis and renal deficiency (Guttmann, 1946, 1949, 1953). In a time, when, during
the Second World War, plasma transfusions were generally used to combat nutritional
deficiency, we found blood transfusions, particularly of fresh blood, as the quickest and
most effective therapeutic agent in restoring and maintaining a satisfactory nutritional
condition in paraplegics. In certain stages of renal deterioration with anaemia, blood
transfusions were found to have a distinct beneficial effect in raising the haemoglobin
value and diminishing albuminuria and blood urea. Undesirable effects of repeated
transfusions of full blood can be obviated by transfusions of packed red cells. Additional
treatment with vitamins and iron following blood transfusion is also desirable. However,
once renal deficiency has become greatly advanced, blood transfusions were found of
very limited or of no value at all. No time should be wasted in continuing the conventional
conservative treatment, and dialysis should be instituted as soon as possible.
Oedema.
One of the outstanding clinical symptoms of the nephrotic phase of renal
deficiency in the patient described earlier, was the profound oedema. The distribution of
nephrotic oedema in paraplegics and tetraplegics is similar to that found in non-para
plegic patients including the face (especially following recumbency during sleep), the
legs, ascites, marked swelling of scrotum and penis and, in the terminal stage, pleural
and pericardial effusion.
The underlying causes of oedema in renal deficiency are disturbances of local and
renal mechanisms regulating the salt and water metabolism. The drain upon plasma
albumin is demonstrated in these patients by the heavy albuminuria (see page 418),
resulting in alterations in the hydrostatic and colloid osmotic pressure, resulting in
