SHORT REPORTS Fatal cholestatic jaundice in elderly patients taking benoxaprofen Benoxaprofen is a relatively new propionic acid derivative that is extensively prescribed for patients with arthritis. The most important adverse effect so far reported is a photosensitivity skin reaction. We report five cases of cholestatic jaundice with fatal outcome in elderly women taking this preparation. Case reports All patients were women over the age of 80 years and were treated with benoxaprofen 600 mg daily. Case 1-An 86-year-old woman presented in January 1981 with a confusional state. She had a smooth firm liver palpable 6 cm below the costal margin, erythrocyte sedimentation rate of 75 mm in first hour, and a slightly raised alkaline phosphatase activity. She recovered spontaneously and was not seen until June 1981 when benoxaprofen was started for longstanding rheumatoid arthritis. Her final illness began in November 1981, when she

Multifrequency bioimpedance spectroscopy (BIS) is an established method for assessing fluid status in chronic kidney disease (CKD). However, the technique is lacking in predictive value and accuracy. BIS algorithms assume constant tissue resistivity, which may vary with changing tissue ionic sodium concentration (Na+). This may introduce significant inaccuracies to BIS outputs. To investigate this, we used 23 Na magnetic resonance imaging (MRI) to measure Na + in muscle and subcutaneous tissues of 10 healthy controls (HC) and 20 patients with CKD 5 (not on dialysis). The extracellular (Re) and intracellular (Ri) resistance, tissue capacitance, extracellular (ECW) and total body water (TBW) was measured using BIS. Tissue water content was assessed using proton density-weighted MRI with fat suppression. BIS-derived volume indices were comparable in the two groups (OH: HC-0.4±0.9L v CKD 0.5±1.9L, p=0.13). However, CKD patients had higher Na + (HC 21.2±3.0, CKD 25.3±7.4mmol/L; p=0.04) and significantly lower Re (HC 693±93.6, CKD 609±74.3Ohms; p=0.01); Ri and capacitance did not vary. Na + showed a significant inverse linear relationship to Re (rs=-0.598, p<0.01) but not Ri. This relationship of Re (y) and Na + (x) is described equation y=-7.39x+814. A 20% increase in tissue ionic Na + is likely to overestimate ECW by 1.2-2.4L. Tissue Na + concentration has a significant inverse linear relationship to Re. BIS algorithms to account for this effect could improve prediction accuracy of bioimpedance derived fluid status in CKD.

Background Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis (PD). Gastrointestinal (GI) symptoms affect appetite and dietary intake. Adequate nutrition is especially important if surgical interventions are required. Aim To investigate the nutritional management of 23 EPS patients that underwent surgical intervention between 1999 and 2005 at Manchester Royal Infirmary, United Kingdom. Methods EPS was recognized by GI symptoms and diagnostically confirmed by laparotomy, computed tomographic scanning, or biopsy. Results Mean time on PD was 74 months (interquartile range 42 – 89 months). During the 12 months pre-diagnosis, 65% of the group showed significant weight loss ( p = 0.0001), with 8 patients losing >10% of body weight; 74% of patients experienced significant albumin decrease ( p = 0.001); and 56% of patients experienced GI symptoms during the 6 months pre-diagnosis. Nasogastric (NG) feeding was recommended for 8 patients but continued in only 1. 15 patients (mean albumin 27 g/L) commenced parenteral nutrition (PN); 9 patients recovered, with albumin increasing over the 6-month follow-up. Mean hospital time was 62 days for the group receiving neither NG nor PN, compared with 124.3 for the PN/NG group ( p = 0.04). In patients that died of EPS, albumin continued to fall at 3 months post-diagnosis. Conclusion There is currently little guidance for nutritional management of EPS. From this study we recommend ( 1 ) a high level of clinical suspicion for EPS, especially if PD patients have weight loss; ( 2 ) PN may be better than NG feeding but further studies into dual enteral nutrition and PN are needed; ( 3 ) aggressive nutritional supplementation pre- and postoperatively; and ( 4 ) dietitians need to recognize the high risk of refeeding syndrome.

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