Study of slow ultrafilteration as a therapeutic modality for chronic refractory congestive heart failure

Refractory heart failure usually represents the end stage of congestive heart failure in which hypotension and oliguria, lead to progressive generalized edema. The purpose of this study was to assess the efficacy of extracorporeal ultrafilteration [ECUF] as a modality for treatment of patients with refractory congestive heart failure who failed to respond to conventional anti failure measures. The study was carried out at a period for about six months and it included 40 patients, 18 men [45%] and 22 women [55%], they were selected from patients admitted to the intensive care of Internal Medicine Department and cardiology Department of Tanta University Hospital. Selection criteria were NYHA class III and IV heart failure, resting left ventricular ejection fraction [LVEF] <35, normal or mild elevated serum creatinine [patients with chronic renal failure were excluded from the study], lack of satisfactory response to conventional therapeutic regimen. All patients were subjected To ECUF ranged from 3 sessions in 12 patients and 4 sessions in 28 patients [mean 3.7 session/ptn] and between [4-6 hour/session]. It was initated at a rate of 0.5L/h to be readjusted subsequently according to the hemodynamic parameters available. Average amount of ultrafilterate/session ranged from 2.5-3 liters [mean2.6 +/- 0.4]. Both number and repition frequency were decided empirically on the basis of evolution of symptoms and response to drugs. All patients were subjected to the following assessment before and after ECUF: Daily morning checking of body weight [kg], hematocrit value [HTC%], urin output [ml/24h], serum electrolytes [Na[+], K[+]], blood urea and serum creatinine, hemodynamic monitoring including [heart rate, blood pressure and CVP], chest x-ray P-A view for measurment of CTR, E.C.G and transthoracic echocardiography for evaluation of cardiac function. Our results showed that there was significant increase of diuresis from [0.3410.14 to 2.0 +/- 0.7L/day] [p<0.001], significant reduction of mean H.R [120+5.0 to 98 +/- 11.0 beat/min] [p<0.001], significant CVP reduction [28.5 +/- 2.o to 15.5 +/- 7.0 cm water] [p<0.001], decrease of intravenous volume as assessed by significant increase of HCT value from [33.8 +/- 2.3% to 37.6 +/- 2.0%] [p<0.001] after ECUF, significant decrease of S. urea from [105.7 +/- 55.2 to 91.3 +/- 63.o4 mmol/L] and S. creatinine from [1.9 +/- 0.6 to 1.5 +/- 0.9 mmol/L] after ECUF. ECHO repeated after ECUF revealed highly significant reduction in the mean LVEDD from [7.0 +/- 0.2 cm to 6.4 +/- 0.6 cm] [p<0.001], reduction of LVESD from [6.5 +/- 0.4 cm to 5.5 +/- 0.8 cm] [p<0.001], reduction in mean LA dimension from [5.3 +/- 0.3 cm to 4.8 +/- 0.6 cm] [p<0.001], reduction of RV dimension from [4.7 +/- 0.4 cm to 4.0 +/- 0.8 cm] [p<0.001], significant increase of LVEF from [23.8 +/- 4.1 to 31.2 +/- 8.2] [p<0.001]: ECUF offers a reasonable effective and relatively safe method in the treatment of refractory heart failure. The relative ease of the procedure and low incidence of complications denote that this technique is a useful one in selected cases of heart failure, refractory to the conventional therapy with oliguria and fluid overload

Role of C-peptide and NA[+], K[+] atpase in the pathology of diabetic micro-vascular complications

The purpose of this study is aiming to find out the correlation between erythrocytes membrane Na[+], K[+] ATPase activity, duration of diabetes, C-peptide level, hyperglycemic control and micro-vascular complications. This study was carried out on the following groups: [Group I control group]: included [n = 10] normal healthy subjects, [Group II]: included [n = 30] diabetic patients without complications, 10 of these patients were insulin dependent diabetics [IDD], 10 were non-insulin dependent diabetics [NIDD] treated with insulin and 10 were non-insulin dependent diabetics [NIDD] treated with oral hypoglycemic drugs, [Group III] [n = 30] diabetic patients with neuropathy, 10 of these patients were insulin dependent diabetics [IDD], 10 were non-insulin dependent diabetics [NIDD] treated with insulin and 10 were non-insulin dependent diabetics [NIDD] treated with oral hypoglycemic drugs, [Group IV] [n = 30] diabetic patients with nephropathy, 10 of these patients were insulin dependent diabetics [IDD], 10 were non-insulin dependent diabetics [NIDD] treated with insulin and 10 were non-insulin dependent diabetics [NIDD] treated with oral hypoglycemic drugs. Beside careful history taking, full clinical examination and routine investigations, all the studied groups were subjected to the following estimations, fasting blood glucose level, Glycosylated Hb level, Na[+] K[+] ATPase activity and serum C-peptide level. The mean values of the duration of diagnosis of diabetes were significantly higher in diabetics with complications [neuropathy and nephropathy] when compared to the diabetics without complications [P < 0.001] but no significant differences were present when diabetics with complications [neuropathy and nephropathy] were compared with each other [P > 0.05]. The mean values of the fasting blood glucose level were significantly higher in all diabetic groups when compared to the control group [P < 0.001] but no significant differences were present when diabetic groups compared with each other [P > 0.05]. The mean values of glycosylated hemoglobin levels were significantly higher in all diabetic groups when compared to the control group [P < 0.001] but there were no significant differences when diabetic groups compared with each other [P < 0.05]. The mean values of C-peptide levels were significantly lower in all diabetic groups when compared to the control group [P < 0.001], but no significant differences when diabetic groups compared with each other [P > 0.05]. The mean values of erythrocytes membrane Na[+], K[+] ATPase activity were significantly lower in IDD patients and NIDD patients with insulin therapy of all groups when compared with control group [P < 0.001] and it were significantly lower in NIDD patients with oral hypoglycemic therapy of complicated groups [neuropathy and nephropathy] when compared with control group [P < 0.01], but there were no significant difference between NIDD patients with oral hypoglycemic therapy of non-complicated group and control group [P > 0.05]. Also, It was found that the activity was significantly lower in diabetics with neuropathy and nephropathy when compared with diabetics without complications [P < 0.001], but no significant differences were present between diabetics with nephropathy and diabetics with neuropathy when compared with each other [P > 0.05], there is no significant correlation between Na[+], K[+] ATPase with duration, fasting blood glucose and glycosylated hemoglobin, but, there was sign positive correlation between Na[+], K[+] ATPase and C-peptide. Also, non significant correlation was present between C-peptide with duration, fasting blood glucose and glycosylated hemoglobin. Decrease in erythrocytes membrane Na[+], K[+] ATPase activity in diabetic patients occurs when serum C-peptide level is low, these two factors have a role in the development of diabetic complications, and there is no relation with duration of diabetes or hyperglycemic control. C-peptide and insulin stimulate the activity of Na[+], K[+] ATPase, but there is still strong argument for the physiological role of C-peptide in humans. This finding needs to be confirmed by more studies on patients with diabetes to establish if C-Peptide together with insulin could be beneficial in restoring Na[+], K[+] ATPase activity and improvement of diabetic complications

Assessment of serum and ascitic fluid leptin in spontaneous bacterial peritonitis

This study was designed to assess leptin changes in serum and ascitic fluid of patients with decompensated cirrhosis and clarify if it plays a role in the pathogenesis of SB and relation of this role- if any-to TNF alpha in those patients 30 subjects were included in the study; 10 healthy control, 10 cirrhotic patients with sterile ascites, and 10 with spontaneous bacterial peritonitis [SBP]. All participants were subjected to full clinical examination, and a range of laboratory test. ELISA test was used to assess levels of leptin and TNF alpha both in serum and ascitic fluid. The results show elevation of serum and ascitic fluid leptin and TNF alpha in cirrhotic cases versus control, with ascitic/serum ratio > 1 suggesting intra abdominal production of both cytokines. Both serum and ascitic fluid leptin and TNF alpha were significantly higher in patients with SBP than those with sterile ascites and were positively correlated. Our results suggest elevation of serum and ascitic fluid leptin to play an immunological role in pathogenesis of SBP, and TNF alpha to be a putative candidate involved in this mechanism