Effects of valsartan on progression of kidney disease in Japanese hypertensive patients with advanced, predialysis, chronic kidney disease: Kanagawa Valsartan Trial (KVT).

Suppression of the renin-angiotensin system is known to slow progression of chronic kidney disease (CKD). However, few trials have been performed with Japanese patients. This study investigated whether the angiotensin receptor blocker (ARB) valsartan would delay the progression of kidney disease more effectively than conventional treatment in Japanese hypertensive patients with advanced, predialysis CKD. In a multicenter, randomized, open-label trial, 303 patients with hypertension and CKD with serum creatinine levels 2.0 mg dl(-1) were assigned to receive either conventional therapy plus valsartan (valsartan add-on group) or conventional therapy without ARB (control group). The primary outcome was a change in serum creatinine levels. Changes in urinary protein levels and time to onset of renal events were analyzed as secondary end points. There were no between-group differences in blood pressure during the study. Changes in serum creatinine and urinary protein levels did not differ between the groups. However, the rate of renal events, including doubling of serum creatinine levels or end-stage renal disease, was significantly lower in the valsartan add-on group than in the control group. The addition of valsartan decreased the risk by 42.6% after adjustment for baseline variables. The addition of valsartan to conventional therapy significantly slowed the rate of renal function decline and delayed the need for renal replacement therapy in Japanese hypertensive patients with advanced CKD.

Comparative study of nifekalant versus amiodarone for shock-resistant ventricular fibrillation in out-of-hospital cardiopulmonary arrest patients.

BACKGROUND: In Japan, intravenous nifekalant (NIF) was often used for direct current cardioversion-resistant ventricular fibrillation (VF), until the use of intravenous amiodarone (AMD) was approved in 2007. The defibrillatory efficacy of NIF and AMD has thus far not been compared for resuscitation. METHODS AND RESULTS: Between August 2007 and April 2009, 403 consecutive out-of-hospital patients with cardiopulmonary arrest were transferred to the Emergency Medical Service of Tokai University. Of these, 30 patients with first defibrillation failure or VF recurrence were enrolled for this NIF/AMD study. The final defibrillation success (and hospital survival rate) was 67% (10/15) in the AMD and 47% (7/15) in the NIF group. The discharge survival rate was 53% (8/15) in the AMD and 21% (4/15) in the NIF group (P = 0.06). Notably, all 4 survivors in the NIF group could take up normal daily life again, whereas this was restricted to only 2 patients from the 11 survivors in the AMD group. The difference is probably partly attributable to longer time from AMD administration to defibrillation success compared with NIF. In the cases of defibrillation failure, VF continued in 4/8 by NIF, however, asystole or pulseless electrical activity occurred in 4/5 patients by AMD. CONCLUSIONS: AMD may be borderline superior over NIF to facilitate defibrillation in out-of-hospital patients with cardiopulmonary arrest. However, from the view point of preservation of brain function, NIF is not inferior to AMD for CPR.

Lactate as a prognostic factor in carbon monoxide poisoning: a case report.

Carbon monoxide (CO) poisoning results in various neuropsychological impairments, including delayed encephalopathy (DE) and death. However, factors related to these outcomes are unknown. A group suicide was attempted by 3 young people--a 31-year-old man (patient 1), a 21-year-old woman (patient 2), and a 20-year-old man (patient 3)--by burning charcoal in a closed car. At the emergency department, hypotension and hyperthermia were severe in patient 1, moderate in patient 2, and absent in patient 3, although all the patients were comatose. The initial serum lactate levels were 75.1 mg/dL in patient 1, 41.9 mg/dL in patient 2, and 26.3 mg/dL in patient 3, although the carboxyhemoglobin levels were approximately equal in all the patients. Hyperbaric oxygen therapy (HBOT) was immediately initiated and continued for 10 days in all the cases; however, the outcomes of these patients varied considerably. Patient 1 remained comatose and died on day 31 because of central diabetes insipidus after shock. Patient 2 recovered from coma and was discharged; however, she was rehospitalized for DE on day 45 and recovered completely after another 10-day HBOT. Patient 3 gained consciousness and recovered completely with no sequelae during the 1-year follow-up. From these cases, we can consider that the initial blood lactate may correlate with the patient outcomes and prove to be a useful prognostic factor. Thus, we should particularly consider elevated lactate levels in CO poisoning.

Successful treatment of a case with acute hepatic failure following hot bath immersion.

Heat stroke is often complicated by hepatic dysfunction as a manifestation of multiple organ dysfunctions, but acute hepatic failure rarely progresses to become the major morbid condition of heat stroke. We encountered a case who survived life-threatening classic heat stroke; the patient developed this condition, subsequently associated with acute hepatic failure, while bathing at home. A 73-year-old man was found in the bath in his home with unconsciousness, and was transferred to a nearby hospital. At the time he was in a coma, but no remarkable abnormalities were detected on blood examination. Rubor of his entire body beneath the cervical region was recognized. Under the diagnosis of a burn with consciousness disturbance, he was referred and transferred to our hospital. He was comatose and his axillary body temperature was 39.7°C. His consciousness improved after admission, but blood examination revealed rhabdomyolysis, DIC and hepato-renal dysfunction. Subsequent blood examination findings showed rapid exacerbation. On the 2nd hospital day, PT% was 12, INR was 4.8. On the 3rd hospital day, serum ALT was elevated to 3,873 U/L, and the patient had hyperammonemia. On the 13th hospital day, serum total bilirubin was elevated to 33 mg/dl. Thereafter, additional conservative treatment produced gradual recovery of hepatic function.

Continuous venovenous hemodiafiltration for life-threatening mitochondrial myopathy with lactic acidosis and rhabdomyolysis.

We report here the clinical course of a 31-year-old male who recovered from a fulminant form of mitochondrial myopathy with lactic acidosis. The patient was transferred to our hospital with acute dyspnea and a convulsive seizure. On admission, he was in a state of shock, and presented with severe high-output heart failure, acute renal failure, and rhabdomyolysis. Treatment with continuous venovenous hemodiafiltration (CVVHDF) resulted in an excellent response, with no signs of hemodynamic instability. This case suggests that CVVHDF with serial hemodynamic monitoring may be effective in treating hypotensive patients with a life-threatening mitochondrial disorder.

Screening procedure for the analysis of distigmine bromide in serum by high-performance liquid chromatography-electrospray ionization mass spectrometry.

A screening procedure was developed for the identification and quantification of distigmine bromide in serum samples by using liquid chromatography (LC)-electrospray ionization (ESI)-mass spectrometry (MS). In this method, distigmine bromide was analyzed in 0.5 mL serum by using pancuronium bromide as the internal standard, and gradient elution was performed using a reversed-phase column and a mixture of 10 mM-ammonium formate and methanol as the mobile phase. A highly sensitive assay could be performed with simple solid phase extraction using a cation exchange cartridge column by carrying out selected ion monitoring analysis in the positive ion detection mode. The procedure was validated in terms of linearity (0.9973 at 2.5 ng/mL). The inter- and intra-day precisions (coefficient of variation; CV%) were <8.5% and < 9.7%, respectively. The analytes were evaluated for stability and were found to be stable in serum for 1 week at 4 degrees C and 4 weeks at -30 degrees C, and successfully applied to in the analysis of two overdose cases. This method is sensitive and useful for the detection, quantification, and confirmation of distigmine bromide in serum.