Reduced incidence of radiocontrast-induced nephropathy in ICU patients under theophylline prophylaxis: a prospective comparison to series of patients at similar risk.

OBJECTIVE: To investigate whether the adenosine-antagonist theophylline reduces the incidence of contrast-induced nephropathy (CIN). DESIGN AND SETTING: Prospective, comparison to series of patients at similar risk of CIN in a university hospital medical ICU. PATIENTS: 78 ICU patients with at least one risk factor for CIN undergoing 150 consecutive contrast examinations. INTERVENTIONS: Administration of 200 mg theophylline/70 kg BW intravenously 30 min before that of 100 ml or more low-osmolarity contrast medium (CM). MEASUREMENTS AND RESULTS: Concentrations of serum creatinine and blood urea nitrogen (BUN), urine volume, fluid balance, and the incidence of CIN [increase in creatinine > or =20.5 mg/dl (= 44.2 micromol/l) within 48 h] were monitored for 48 h. Despite the large number of risk factors (6.8 per patient) including a high dose of CM (169.4 ml), impaired renal function (51%), diabetes (38%), aminoglycosides (61%), vancomycin (53%), catecholamines (52%), creatinine concentrations were not increased 24 h (1.40+/-0.92 mg/dl) or 48 h (1.38+/-0.88 mg/dl) after CM [1.47+/-1.0 mg/dl (= 130+/-88 micromol/l)] vs. baseline. The fluid balance was not different before (+3 ml/h) and after CM (-9 ml/h). The urine volume slightly increased after CM and theophylline (184 ml/h vs. 164 ml/h). Only three patients (2%) developed CIN. The incidence was significantly lower than that of 14% (78/565) in the control series with patients at comparable risk of CIN (p < 0.0001). CONCLUSIONS: Using a theophylline prophylaxis the incidence of CIN in patients with increased risk of CIN is as low as 2%.

Albumin dialysis: effective removal of copper in a patient with fulminant Wilson disease and successful bridging to liver transplantation: a new possibility for the elimination of protein-bound toxins.

BACKGROUND: Acute liver failure may be the first manifestation of Wilson disease. If copper elimination fails, liver transplantation is the only remaining therapeutic option. Albumin dialysis, a new method for the removal of protein-bound toxins, was performed in a patient with fulminant Wilson disease. METHODS: An 18-year-old man with Wilson disease presented with hyperacute liver failure, hepatic encephalopathy III, oligo-anuric renal failure, haemolytic anaemia, rhabdomyolysis, pancreatitis and thrombocytopenia. He was treated with albumin dialysis using a 44 g/l albumin-containing dialysate and a slow dialysate flow rate (1-2 l/h). The other details of the technique used are similar to routine continuous veno-venous haemodiafiltration. RESULTS: One hundred and five milligrams of copper were removed by albumin dialysis within the first six treatments, resulting in normalisation of blood-copper levels. Successful treatment of the multiorgan failure was achieved. Hepatic encephalopathy improved within 2 days. The patient initially refused liver transplantation. Therefore 35 additional albumin dialysis treatments were performed. Forty-three grams of bilirubin (an indicator of detoxified substances in the liver) and 196 mg of copper were removed. Multiorgan failure, in particular hepatic encephalopathy, did not recur during 59 days of treatment. Eventually, the patient agreed to liver transplantation and that was successful. CONCLUSION: Albumin dialysis is a new method for the effective treatment of fulminant Wilson disease, resulting in the removal of protein-bound toxins copper and bilirubin. It may serve as a new treatment option in hyperacute liver failure of other origin, acting as an extracorporeal detoxifier.

Liver transplantation for the treatment of fulminant hepatic failure induced by the ingestion of ecstasy.

Methylenedimethoxymethamphetamine (MDMA), more commonly known as ecstasy, is a synthetic amphetamine derivative used by teenagers and young adults in the United States as well as in Western Europe as a "dance drug". Though a number of complications associated with this drug have been reported, there is little information pertaining to hepatoxity as a result of MDMA ingestion. This case report is about an 18-year-old female patient who regularly used ecstasy on weekends over a 2-month period. Within 2 days after accepting a "hit" of the substance at a party, she was admitted to the hospital because of lethargy, vomiting, abdominal pain, stool discoloration, icterus, and darkened urine. On day 7 she developed fulminant hepatic failure with reduced hepatic coagulation factors and grade IV encephalopathy. Orthotopic liver transplantation was carried out 10 days following the ingestion. The patient made a full recovery within 72 h and was released from the hospital 6 weeks later. Histopathological examination of the removed liver revealed a nutritive-toxic liver necrosis. This case demonstrates that the ingestion of ecstasy, even on an infrequent basis, can lead to acute fulminant liver necrosis, and that this life-threatening complication can be treated successfully by liver transplantation.

Supplemental immunoglobulin (ivIgG) treatment in 163 patients with sepsis and septic shock--an observational study as a prerequisite for placebo-controlled clinical trials.

In a multicenter observational study of 163 medical and surgical patients with a total of 173 episodes of sepsis or septic shock (Elebute sepsis score: 19.0 +/- 0.5), the effects of supplemental i.v. immunoglobulin (i.v. IG) treatment (unmodified polyvalent IgG pH 4.25, n = 123; for Pseudomonas sepsis, n = 50, Pseudomonas IgG) on multiple organ failure (MOF) were investigated by means of APACHE II score changes (pretreatment: 23.7 +/- 0.6). In 44% of the cases ("responders"), a prompt improvement in APACHE II score (defined as decrease greater than or equal to 4) was evident from day 0 to day 4 after onset of therapy, thus being in close time relationship to the i.v. IG administration. This improvement, associated with a better prognosis (mortality 24% vs. 55%), was found in all subgroups, most importantly the following: polyvalent IgG vs. Pseudomonas IgG treatment; medical vs. surgical patients; moderate vs. severe MOF; and gram-positive vs. gram-negative septicemia. In a small-sized second comparative nonrandomized control group (n = 27, antibiotic treatment alone) of septic patients (Elebute: 14.7 +/- 1.0) with similar MOF severity (APACHE II: 23.6 +/- 1.4), the response rate (30%) was, though not statistically significant, lower by one-third. The optimal baseline score ranges for patient inclusion into future placebo-controlled randomized i.v. IG trials were found to be 20-35 for the APACHE II score and 12-27 for the Elebute score.

[Acute initial manifestation of systemic lupus erythematosus in the puerperium]. / Akute Erstmanifestation eines systemischen Lupus erythematodes im Wochenbett.

Lupus erythematosus first diagnosed in pregnancy or puerperium is a problem both for the obstetrician and for the internist. We report on a case of lupus manifestation with signs and symptoms similar to sepsis diagnosed in the puerperium.

[Systemic candidiasis in intensive care patients after antibiotic therapy]. / Systemische Candidose bei Intensivpatienten nach Antibiotika-Therapie.

The authors report fluconazole treatment of 19 I.C.U. patients in critical situations. 9 of these patients had septic multiorgan failure. All patients had received long term antibiotic treatment for at least seven days. The difficulties in clinical and laboratory diagnosis of systemic candidosis which requires treatment are discussed. All patients showed good response to fluconazole treatment concerning the opportunistic mycotic infection; none of the patients died because of systemic candidosis. Severe side effects were not observed.

[Unusual therapeutic problems posed by acute kidney failure. Importance of bicarbonate dialysis]. / Les problèmes thérapeutiques particuliers posés par l'insuffisance rénale aiguë. Intérêt de la dialyse au bicarbonate.

The severity of acute renal failure is linked to the associated multiple visceral failures. These failures represent therapeutical challenges that the authors discuss on the basis of their experience of the last 10 years 7 of which being based on the use of bicarbonate dialysis.

Artificial organ support strategies in combined renal, circulatory, pulmonary and liver failure.

Within recent years we have significantly broadened the indication for the treatment of acute renal failure in intensive care patients, even in the presence of multiple organ failure. This was made possible by: 1. safe heparinization of the extracorporeal circulation while avoiding bleeding tendencies 2. hemofiltration of patients threatened by pulmonary complications early during renal failure and 3. the simultaneous use of various special intensive care measures. By this approach we have succeeded in a number of cases to break the chain of complications leading to multiple organ failure and death.

[Concentration of C-peptide in correlation to kidney function (author's transl)]. / C-Peptid-Konzentration im Serum in Abhängigkeit von der Nierenfunktion.

Recently, the radioimmunological determination of C-peptide came into interest because of the jugdement of the remaining function of the islet apparatus in insulin-dependent diabetics. As the degradation of C-peptide preferably takes place in the kidney we performed an intravenous glucose load in 32 patients with kidney diseases. The following results were obtained: 1. In patients with a healthy carbohydrate metabolism a clear correlation exists between the concentration of creatinine on the one hand, the creatinine-clearance and the fasting C-peptide concentration respectively the measured amount of C-peptide on the other hand. 2. The more advanced the renal insufficiency the better is the correlation between the parameter of the kidney function and the C-peptide concentration. 3. In diabetic patients there shows to be no clear correlation between the C-peptide levels and the kidney function. --In insulin-dependent diabetics the amount of C-peptide is only of diagnostic use if the renal function is well known.

[The effect of thyroxine on the 2,3-diphosphoglycerate content of erythrocytes in vivo and in vitro]. / Der Einfluss von Thyroxin auf den 2,3-DPG-Gehalt der Erythrozyten in vivo und in vitro.

After ending a continous treatment with thyroxine the average dropping of the 2,3 DPG level was 0.4 mumol/ml. T4 decreased on the average by 7.6 microgram/ml. One time application of 1 mg thyroxine p.o. led within 24 hours to an increase of the 2,3 DPG level of -chi = 0.2 mumol/ml, the pH in the erythrocytes increased by 0.02 on the average. Blood incubation with thyroxine added in a concentration of -chi = 24 microgram/100 ml showed no increase of 2,3 DPG, pH and phosphate, while there was a significant acidosis and increase of phosphate in the control blood. The lactate production was significantly lower and glucose consumption was significantly higher in the blood with thyroxine.