Urinary sodium balance in patients with cirrhosis: relationship to quantitative parameters of liver function.

The relationship between the impairment in hepatic and renal function in cirrhosis has not been well established. This study investigated urinary sodium excretion in comparison with quantitative parameters of liver function in 75 patients with various degrees of cirrhosis kept on a constant salt diet of 120 mmol/d for 5 days before the start of the study. The aminopyrine breath test (ABT), indocyanine green (ICG) elimination, galactose elimination capacity (GEC), and hepatic sorbitol elimination (HSE) served as quantitative parameters of liver function. Results for the quantitative tests were compared with those for the Child-Pugh score. Urinary sodium excretion showed a significant nonlinear relationship to ABT (r = .70; P < .0001). Less-significant correlations were observed for ICG (r = .60), the Child-Pugh score (r = -.57), GEC (r = .44), and HSE (r = .34). Because a number of significant correlations were observed between the different liver function tests, multivariate analysis was used to further elucidate the relationship between hepatic function and sodium excretion. Only one independent predictor of urinary sodium excretion could be identified, and that was the ABT (P < .02). More than half of the nonascitic patients showed a urinary sodium excretion of less than 80% of dietary sodium intake, indicating impaired renal sodium handling in preascitic cirrhosis. Based on the 95% confidence interval (CI) for ABT of nonascitic patients with normal (mean ABT 0.56% dose x kg/mmol CO2; 95% CI: 0.44 to 0.69) and reduced urinary sodium excretion (mean ABT 0.26% dose x kg/mmol CO2; 95% CI: 0.18 to 0.35), a threshold level of ABT of about 0.4 (% dose x kg/mmol CO2) for conservation of normal urinary sodium excretion in cirrhosis can be defined. This ABT value reflects an approximate 50% reduction in function compared with the mean of cirrhotic patients with normal liver and kidney function (0.81% dose x kg/mmol CO2). The presence of ascites was also associated with a reduction in ABT to below 0.4 (% dose x kg/mmol CO2), while, for all other parameters, either the cut-off point was close to the lower limit of normal or no cut-off level could be detected. In conclusion, the results of the present study provide further evidence that the impairment in urinary sodium excretion in cirrhosis is related to hepatic function. The data suggest a nonlinear relationship. Because ABT has been shown to reflect functional hepatocellular mass, the occurrence of sodium retention and ascites appears to be related to a threshold of an approximate 50% reduction in functional liver cell mass.

Studies on adaptation to complete dentures. Part II: Oral stereognosis and tactile sensibility.

High oral perception is thought to contribute to poor adaptation to new dentures. The aim of this study was to evaluate the oral stereognosis and tactile sensibility in edentate subjects and relate these to patient age and capability of adaptation to new prostheses. A total of 67 patients were provided with new complete dentures 2-3 weeks before the experiment. In 54 subjects, the oral stereognosis was evaluated by 12 different test-pieces, which were placed unseen on the tongue and had to be recognized. In 38 patients, the oral tactile sensibility was determined in the premolar area using copper foils. The capability of adaptation was evaluated by a questionnaire. Denture retention was assessed by clinical examination. The number of correctly identified test-pieces and the average identification time were related to the age, but no relation was found to patients' capability of adaptation. The tactile sensibility was found to be impaired with age and diminished capability of adaptation. Both adaptation and oral tactile sensibility were significantly lower in subjects with poor lower-denture retention. In conclusion, the results cannot support a relationship between high oral stereognosis and adaptation problems. However, good denture retention facilitates the adaptation process.

[Primary diffuse leptomeningeal leiomyomatosis]. / Primäre diffuse leptomeningeale Leiomyomatose.

A female patient aged 28 fell ill with manifestations of sensory aphasia, headache and signs of cerebral compression. Except for a bilateral papilledema there were no further pathological clinical and paraclinical findings. Later on, amaurosis, deafness, anosmia and generalized muscular hypotonia developed. The nuclear magnetic resonance image revealed a major accumulation of contrast medium in the leptomeninx. Biopsy demonstrated a mesenchymal neoplasm in the leptomeninx. After a strong rise in intracranial pressure, the patient died from a bulbar brain syndrome. Microscopy revealed a diffuse neoplasm limited to the leptomeninx of brain and spinal cord as well as the immediate neighbourhood of small cortical vessels which, by morphological criteria, was classified as low-grade malignant. With the aid of electron microscopy, the tumour cells could be identified as descendants of smooth muscle cells.

[Senear-Usher syndrome: acquired hemophilia caused by the occurrence of a factor VIII inhibitor]. / Senear-Usher-Syndrom: Begleithämophilie durch das Auftreten eines Faktor-VIII-Hemmkörpers.

A 25-year-old woman who had suffered from pemphigus for 2 years developed widespread, scalded skin-like lesions after stopping an immunosuppressive treatment. Histological and immunofluorescence studies confirmed the diagnosis of pemphigus erythematosus. Apart from IgG pemphigus antibodies, granular deposits for IgM at the dermoepidermal junction and circulating antinuclear IgM-antibodies could be detected. Despite of restarting an immunosuppressive regime, the patient developed severe hemophilia due to the occurrence of a factor VIII antiglobulin. Its possible immunopathologic basis is discussed.