Circulatory response to fluid overioad removal and sustained hemodynamic efficacy of slow ultrafiltration in refractory congestive heart failure

To determine to what extent patients with chronic refractory congestive heart failure [rCHF] benefit from slow Ultrafiltration. Prospective, observational study of chronic refractory congestive H.F. Effectiveness data from several sources, including observational studies, published systemic reviews, The New York Heart Association [NYHA] classification of Heart failure and expert opinion. New York Heart Association [NYHA] class III and IV, resting left ventricular ejection fraction < 35%, Dilated cardiomyopathy, Ischemic cardiomyopathy and normal or mild elevated serum creatinine < 3 mg/dl. Forty Patients, eighteen men [45%] and twenty two women [55%], their ages ranged from 32 to 63 years [mean 47 +/- 9 years] with refractory CHF, with NYHA functional class IV [n = 32] represent 80% and class III [n = 8] represent 20% of patients, were selected from intensive care units of Internal Medicine and Cardiology Departments of Tanta university Hospital. Exclusion criteria were patients with advanced valvular heart diseases and patients with chronic renal failure - All patients were subjected to the following assessments : Daily morning B.W, HTC%, Serum electrolytes [Na[+], K[+], Ca[+2]], Blood urea and S. creatinine, Urine output [ml/24h.] and homodynamic monitoring including H.R, Systemic BL Pr and CVP [by double luminal catheter], Chest x-ray P.A view, examination for interstitial and/or clear cut alveolar pulmonary edema before and after ECUF [Extra corporeal ultrafiltration] ECG and Trans-thoracic Echocardiography [M-mode, two dimensional and Doppler Echocardiography]. Controlled ultrafiltration between 0.5-1 L/h., was initiated at a rate of 0.5 L/h to be readjusted subsequently according to the hemodynamic parameters available. All patients were subjected to ECUF treatment ranged from 3 sessions in 12 patients and 4 sessions in 28 patients [mean 3.7 session/ptn], and about 4-6 h/session. Average amount of ultrafiltrate /session ranged from 2-3.5 liters [mean 2.6 +/- 0.4 liter] over duration of 15 days hospital admission. Both number and repetition frequency were decided empirically on the basis of evolution of symptoms and response to drugs. ECUF was discontinued when it was considered clinically that the maximum benefit has been obtained. Highly significant diuresis from [0.34 +/- 0.14 to 2.0 +/- 0.7 L/day] [P < 0.001], reduction in the mean H.R[120 +/- 5.0 to 98 +/- 11.0 beat/min] [P < 0.001], CVP reduction [28.5 +/- 2.0 to 15.5 +/- 7.0 cm water] [P < 0.001], Intra-venous volume as assessed by HCT value [33.8 +/- 2.3% to 37.6 +/- 2.0%], [P < 0.001] before and after ECUF. ECHO was repeated after ECUF revealed highly significant reduction in the mean LVEDD from 7.0 +/- 0.2 cm before to 6.4 +/- 0.6 cm after ECUF [P < 0.001], LVESDfrom 6.5 +/- 0.4 cm before to 5.5 +/- 0.8 cm after ECUF [P< 0.001]. LVEF was 23.8 +/- 4.1% before and increased to 31.2 +/- 8.2% after ECUF [P < 0.001], highly significant reduction in the mean L A dimensions from 5.3 +/- 0.3 cm before to 4.8 +/- 0.6 cm after ECUF [P < 0.001], RV dimensions from 4.7 +/- 0.4 cm before to 4.0 +/- 0.8 cm after ECUF [P < 0.001]. Significant changes in S.urea from 105.7 +/- 55.2 mmol /L to 91.3 +/- 63.04 mmol /L] [P < 0.047], S. creatinine from [1.9 +/- 0.6 to 1.5 +/- 0.9 mmol/L] [P < 0.017] before and after ECUF. ECUF offers a reasonably effective and relatively safe method in the management of r CHF. The relative ease of the procedure and low incidence of complications denote that this technique is an extremely useful one in selected cases of H.F, refractory to the conventional therapy with oliguria and fluid overload

Pro-inflammatory effect of C-reactive protein and interleukin-6 in pre dialysis patients and its relation to atherothrombotic profile

The present study was undertaken to determine the level of circulating C-reactive protein and interleukin-6 in the sera of predialysis chronic renal failure patients and to correlate the levels of CRP and IL-6 with renal function. This study was carried out in Internal Medicine Departments and Tanta university hospitals during the period from September 2003 to April 2005. fifty five subjects were included in this study. They were divided into two main groups. Group I [n = 15] healthy individuals [9 males and 6 females] with mean age 51.1 +/- 9.8 years as a control group ,Group II [n - 40] predialysis chronic renal failure patients [24 males and 16females] with mean age 52.3 +/- 77.5 years. 16patients [40%] were chronic glomerulonephritis, 4 patients [10%] were chronic interstitial nephritis, 3 patients [7.5%] were poly cystic kidney disease, 1 patient [2.5%] was hydronephrosis and 16 patient] 40%] were of unknown causes. They had no other predisposing factors that may elevate the serum levels C-reactive protein or Interleukin-6 e.g infection, diabetes mellitus, other systemic inflammatory diseases or auto immune diseases. This group was subdivided into two subgroups: subgroup [a]: included patients with creatinine clearance 25 ml/min or more [n = 18], and subgroup [b]: included patients with creatinine clearance less than 25 ml/min [n = 22]. All subjects were subjected to full history taking, complete physical examination, abdominal ultrasound and the following investigations : serum creatinine, creatinine clearance, urea, albumin, total serum cholesterol, triglycerides, HDL, LDL, C-reactive protein and interleukin-6. Mean CRP in control group was 2.87 +/- 1.13 mg/L, while in patients group was 10.44 +/- 7.64 mg/L with a highly significant increase in patients group than control group [P < 0.000 1]. Mean CRP in subgroup [a] was 5.08 +/- 2.25 mg/l, while in subgroup [b] was 14.83 +/- 7. 71mg/l with a highly significant increase in subgroup [b] than subgroup [a] [P < 0.0001] Mean IL-6 in control group was 2.37 +/- 1.02 pg/ml, while in patients group was7.39 +/- 4.47 pg/ml ,with a highly significant increase in the group II than the control group [P < 0.0001] Mean IL-6 in subgroup [a] was 4.60 +/- 1.92 pg/ml, while in subgroup [b] was 9.67 +/- 4.70 pg/ml with a highly significant increase in subgroup [b] than subgroup [a] [p < 0.0001]. Significant inverse correlation between creatinine clearance and CRP was found [CRP versus Cr.clr = 0.704, P < 0.0001]. Also, a negative correlation was found between Cr.clr and IL-6 [IL-6 versus Cr.clr = -0.593, P < 0.0001]. There was mild significant correlation between creatinine clearance and HDL [P = 0.001]. A significant correlation between CRP and IL-6 [r = 0.637, P < 0.0001]. Negative significant correlation was found between CRP and albumin [CRP versus albumin r = -0.57, P < 0.0001]. There was increase in CRP and IL-6 and so inflammation and tissue damage, atherosclerosis, coronary and vascular disease with slight hyperlipidemia, which confirm that inflammation have a cardinal role in vascular disease, atherosclerosis and tissue damage in predialysis chronic renal failure patients

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

Study of intrahepatic cholestasis of pregnancy before and after treatment with ursodeoxycholic acid

To investigate bile acids patterns in patients with intrahepatic cholestasis of pregnancy [ICP] and to test the efficacy of ursodeoxycholic acid [UDCA] treatment. The study included a reference group comprised ten healthy pregnant women and 21 patients with ICP, who were randomly divided into 2 groups, one received UDCA for 21 days and followed until delivery [11 cases] and the other received vitamin B as a placebo and followed in time same manner [10 cases]. Bile acids were analyzed by gas chromatography-mass spectrometry in maternal serum at the start, 21 days later and after delivery. They were also analyzed in amniotic fluid and neonatal meconium after delivery. UDCA treatment improved bile acid levels after 21 days and markedly after delivery. Amniotic fluid levels of bile acids were lower in UDGA treated cases than placebo treated cases. Neonatal meconium bile acids were higher in placebo treated ICP cases than reference cases. After delivery, serum TBA and cholic acid in UDC'A treated cases were correlated with those in amniotic fluid [r = 0.91, r = 0.6], with positive correlations with neonatal meconium TBA [r= 0.39]. The obstetric and neonatal outcomes were better in UDCA treated cases tf compared to placebo cases. Ursodeoxycholic acid is effective and safe in patients with intrahepatic cholestasis of pregnancy. It attenuates pruritus, corrects bile acid abnormalities in the mothers and improves fetal and neonatal outcomes

effect of metformin on the endocrine variables in clomiphene resistant polycystic ovarian disease

To investigate the effect of metformin on the endocrine variables in clomiphene resistant polycystic ovarian disease [PCOD]. Departments of Obstetrics and Gynaecology, Internal Medicine and Clinical Pathology, Faculty of Medicine, Tanta University, Egypt. Thirty-three infertile women due to PCOD were enrolled and divided into 23 cases received oral metformin 850 ma/ twice daily for 8 weeks and 10 cases received placebo for the same period. Basic hormonal parameters, serum glucose and insulin were tested before and after treatment. Metformin led to 65% improvement in acne score, 57% menstrual improvement and significant reduction of serum LH androstenedione, DHEAS, free testosterone, glucose and insulin. Highly significant elevation of SHBG was observed. The mean fasting insulin dropped from 28 uU/ml before to 16 uU/ml after therapy and this drop was significantly correlated to changes in testosterone, free testosterone, SHBG and glucose. Metformin may be suggested as a therapy for women with colomiphene resistant polycystic ovarian disease. It can ameliorate hyperinsulinemia, hyperadrogenemia with their impacton the restoration of regular menses and ovulation; and hence improving the pregnancy capability