A case report of systemic capillary leak syndrome (Clarkson's disease)

Systemic capillary leak syndrome (SCLS) is a very rare disorder also known as Clarkson's disease. The condition is characterized by recurrent episodes of severe capillary hyperpermeability resulting in severe hemoconcentration, hypoalbuminemia, hypovolemia and shock. We describe a 41‐year‐old previously healthy man who was admitted to hospital on several occasions with rapidly developing hypovolemic shock accompanied by extreme hemoconcentration and hypoalbuminemia. Our case is similar to other reports describing patients with SCLS where the initial suspicions have been pointing towards septic shock. He received a combination of prophylactic treatment with theophylline, β‐agonists, immunoglobulins and statins but eventually died after a severe episode of SCLS that ended with recurrent cardiac arrest. Clinical autopsy revealed pulmonary edema and acute and chronical organic fluid overload. SCLS should be kept in mind when treating patients suffering from attacks of severe idiopathic edema and mimics recurrent septic shock where no pathogen is found. The pathogenesis is unknown and the attacks may be lethal.     

Systemic capillary leak syndrome associated with compartment syndrome and rhabdomyolysis

Systemic capillary leak syndrome (SCLS) is a rare disorder characterized by recurrent spontaneous episodes of hypovolaemic shock due to marked plasma shifts from the intravascular to the extravascular space. This presents as the characteristic triad of hypotension, haemoconcentration and hypoalbuminemia often with an associated monoclonal gammopathy. We describe a patient with SCLS who required aggressive fluid resuscitation and emergency fasciotomies for compartment syndrome with rhabdomyolysis. At presentation the patient was considered to have severe erythrocytosis and was therefore initially referred to a haematologist, which appears to be a frequent sequence of presentation for patients with SCLS. This patient also highlights the importance of muscle compartment pressure monitoring during volume resuscitation in patients with SCLS.     

Systemic capillary leak syndrome. Case report

We here report the case of a patient with systemic capillary leak syndrome (SCLS). This syndrome is a rare condition characterized by recurrent episodes of hypotension with hemoconcentration and hypoproteinemia. It is due to unexplained episodic capillary hyperpermeabilty that results in fluid and protein shift from the intravascular to the interstitial space: generalized edema, shock and renal failure follow. A 59 yo man was admitted to our intensive care unit because of unexplained shock with hemoconcentration, renal failure, and metabolic acidosis. Previous attemps to reverse shock in a medical ward with crystalloids and dopamine failed. An abdominal CT scan, a TEE, and chest X ray study were inconclusive. No sign or history of major infections or anaphylaxis were present. The patient was resuscitated with massive fluid infusions and norepinephrine on the guide of a Swan Ganz catheter. The diagnosis was made on the basis of a previous episode of severe shock complicated with renal failure and a compartment syndrome, the hemoconcentration, and the negative cardiopulmonary findings. A small amount of monoclonal immunoglobulin G, kappa chain, found in the serum confirmed the diagnosis. The SCLS should be considered in the differential diagnosis of idiopathic and anaphylactic shock. Patients may benefit from a prophylactic treatment with theophilline and terbutaline.     

The systemic capillary leak syndrome: a scarcely known nephrological entity

The idiopathic systemic capillary leak syndrome (SCLS) is a rare life-threatening disorder characterized by periodic episodes of hypovolemic shock, due to plasma leakage from the intravascular to the interstitial space, as reflected by accompanying hypoalbuminemia, hemoconcentration and edema. Here we report the case of a 65-year-old woman affected by SCLS who required aggressive resuscitation with norepinephrine, steroids, albumin and crystalloids. Then, a long-term prophylaxis with a ?(2)-adrenergic receptor agonist and theophylline was started. In conclusion, though SCLS is a rare entity, the associated morbidity and mortality require the physician's awareness to provide timely therapy. Underrecognition in the medical community and rarity of this syndrome have precluded analysis by rational clinical trial designs that are necessary to determine more targeted and adequate therapy. This report is meant to enhance awareness of SCLS in the nephrology community.     

Effect of fluid resuscitation with and without endothelin A receptor blockade on hemoconcentration and organ function in experimental pancreatitis

BACKGROUND: Intravascular fluid loss contributes to pancreatitis-associated multiple organ dysfunction and is thus a major target for therapy in this life-threatening disease. AIM: To evaluate intravascular fluid loss and extravascular fluid sequestration together with cardiorespiratory and renal function in a well-established rat model of severe acute pancreatitis (AP) and to investigate the effect of fluid resuscitation with and without endothelin receptor A blockade on these parameters. METHOD: Induction of AP in rats by a standardized bile salt infusion into the pancreatic duct and intravenous cerulein hyperstimulation. Six hours after AP induction, animals were randomized into 4 groups to receive (1) no therapy; (2) 4 ml/kg/h Ringer's lactate (RL) i.v.; (3) 8 ml/kg/h RL i.v., or (4) 4 ml/kg/h RL plus an endothelin receptor antagonist. Target parameters measured before and after AP induction and during the 24-hour observation period included: mean arterial blood pressure, heart rate, hematocrit, arterial blood gases, urine production, ascites and pleural effusions. RESULTS: After 6 h, all animals presented with severe hemoconcentration (hematocrit >57%) and oliguria (<0.5 ml/6 h). Cardiorespiratory parameters were within the normal range. Up to 12 h after AP induction, animals without therapy had an increased hematocrit and oliguria and developed metabolic acidosis. Animals receiving fluid resuscitation had a significant drop in hematocrit and maintained compensated blood gas values. A significant increase in urine production was only observed in animals given 8 mg/kg/h RL. Between 12 and 24 h, urine production significantly increased with fluid resuscitation and respiratory parameters stabilized except for animals treated with 8 ml/kg/h RL which developed arterial hypoxia and hypercapnia. CONCLUSIONS: Intravascular fluid loss and extravascular fluid sequestration together with decreased urine production characterize the early phase of this model of severe AP. Massive fluid resuscitation necessary for increasing urine output may lead to respiratory distress. Reduction of intravascular fluid loss by endothelin receptor blockade is associated with improved renal and respiratory function.     

Therapy for microcirculatory disorders in severe acute pancreatitis: Comparison of delayed therapy with ICAM-1 antibodies and a specific endothelin a receptor antagonist

Many of the complications in severe acute pancreatitis result from the amplifying effects of microcirculatory disruption. The pathogenesis of these microcirculatory disorders is multifactorial and involves various vasoactive mediators. Thus questions arise as to which vasoactive mediators are most important and how long after the onset of disease vasoactive mediator blockade may be effective. The present study compares the effect of delayed therapy with two vasoactive mediator antagonists, previously tested with promising results in other studies in a well-established rodent model of severe acute pancreatitis. Twelve hours after induction of acute pancreatitis, rats were randomized to therapy with intracellular adhesion molecule-l (ICAM-1) antibody (2 mg/kg b&29), endothelin A receptor antagonist (ET-RA) (40 mg/kg LU 135252), or saline solution (volume equivalent). After 12 hours of fluid resuscitation, animals under-went repeat laparotomy for intravital microscopic determination of capillary blood flow, leukocyte rolling, and capillary permeability in the pancreas and colon. Other measurements included cardiorespiratory parameters, hematocrit, pleural effusions, ascites, urine production, and survival. Compared to saline treatment, both ICAM antibody and ET-RA significantly enhanced capillary blood flow in the pancreas and colon, reduced leukocyte rolling, and stabilized capillary permeability. These beneficial effects on microcirculation were associated with decreased fluid loss into the third space and improved renal function and survival. Although both antagonists likewise enhanced capillary blood flow and reduced leukocyte rolling, ET-RA was significantly more effective than ICAM antibody in counteracting capillary leakage, thereby further reducing fluid sequestration. The present study confirms the beneficial effects of endothelin and ICAM antagonists in severe acute pancreatitis, even with delayed therapy, suggesting that both compounds are candidates for further clinical testing. Selective endothelin A receptor blockade appears to be especially attractive for clinical use not only because it was superior to ICAM antibody in the present study but also because of its favorable pharmacologic properties and (preliminary) positive results in clinical phase 2 studies currently underway for other diseases. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

Therapy for microcirculatory disorders in severe acute pancreatitis: Effectiveness of platelet-activating factor receptor blockade vs. endothelin receptor blockade

Many of the complications of severe acute pancreatitis are the result of the amplifying effects of microcirculatory disruption. The factors causing microcirculatory disorders in acute pancreatitis involve vasoactive mediators such as platelet-activating factor (PAF) and endothelin-1 (ET) activated during the inflammatory response to pancreatic injury. To further evaluate the potential therapeutic role of specific receptor antagonists (RA) to these mediators, the present study compares the effect of PAF and ET receptor blockade on microcirculation and organ function in a well-established rodent model of severe acute pancreatitis. Six hours after acute pancreatitis induction, rats were randomized to therapy with ET-RA (50 mg/kg LU-135252), PAF-RA (82 μg/kg WEB-2170), or NaCl 0.9% (volume equivalent). After 18 hours of fluid resuscitation, animals were relaparototnized for intravital microscopic determination of capillary blood flow, leukocyte rolling, and capillary permeability in the pancreas and colon. Other measurements included cardiorespiratory parameters, hematocrit, pleural effusions, ascites, urine production, and survival. Compared to saline treatment both ET-RA and PAF-RA significantly improved capillary blood flow in the pancreas and colon, reduced leukocyte rolling, and stabilized capillary permeability. The beneficial effects of receptor antagonist treatment on microcirculation were associated with decreased fluid loss into the third space, improved renal and respiratory function, and survival. Although both receptor antagonists likewise improved capillary blood flow, ET-RA was significantly more effective in counteracting leukocyte rolling and capillary leakage, thereby further reducing fluid sequestration. The present study confirms the beneficial effects of PAF and ET receptor blockade on microcirculation inside and outside the pancreas, organ function, and survival when given at the early stage of severe pancreatitis. Because ET-RA was more effective in stabilizing capillary permeability and avoiding subsequent fluid loss into the third space, we propose that ET-RA should be tested in a clinical trial (either in comparison or in addition to PAF-RA). Presented at the Thirty-Ninth Annual Meeting of The Society for Surgery of the Alimentary Tract, New Orleans, La., May 17–20, 1998.     

Target blood pressure for hypotensive resuscitation

Background

Good outcomes have resulted from hypotensive resuscitation of hemorrhagic shock patients. We hypothesized that mean arterial pressure (MAP) 60 mmHg is the target blood pressure for hypotensive resuscitation during uncontrolled hemorrhagic shock in trauma.

Methods

To determine the effective target MAP for hypotensive resuscitation during uncontrolled hemorrhagic shock, we randomly assigned 80 rats to one of 8 treatment groups (n = 10 for each group). We then observed the effects of different target MAPs (control, 40, 50, 60, 70, 80, 90 mmHg, and sham) on fluid resuscitation of uncontrolled hemorrhagic shock. Blood pressure, serum lactate, hematocrit, fluid therapy, blood loss, and plasma cytokine levels were measured at 0, 30, 90, 120, 180, 240, 300 min after the start of the surgical procedure.

Results

A target MAP of 90, 80 and 70 mmHg had increased blood loss and decreased hematocrit and IL-6 and TNF-α production. A target MAP of 60, 50 and 40 mmHg had lower blood loss, good hematocrit, higher IL-6 and TNF-α production, and decreased animal survival. Only target MAPs of 40 and 50 had and decreased animal survival. The differences in blood loss, hematocrit, lactate, post-resuscitation MAP, survival, IL-6, IL-10, and TNF-α production between rats with a target MAP of 60 mmHg and those with a target MAP of 70 mmHg were not significant. The amount of fluid therapy in the BP 60 groups was less than in the BP 70 groups (P < 0.001).

Conclusion

A MAP of 60 mmHg should be considered for evaluation in human studies as a target for hypotensive resuscitation.     

An association of lower serum citrulline levels within 30 days of acute rejection in patients following small intestine transplantation

INTRODUCTION: In a prospective protocol we studied whether serum citrulline level within 30 days of an acute rejection was predictive of the episode. METHODS: An acute rejection episode was defined as the date of occurrence of any biopsy-proven rejection in which treatment was initiated until two successive biopsies showed no further rejection. We compared the mean citrulline level based on values determined within 30 days of the start of an acute rejection episode with the mean citrulline level measured on the same patient during a rejection-free period. Serum citrulline measurements were available immediately prior to the occurrence of rejection for 22 patients who experienced 37 episodes. RESULTS: For the 12 episodes of mild rejection, the mean serum citrulline level +/- SE (standard error) was 15.0 + 2.3 micromol/L prior to rejection and 18.8 +/- 2.4 micromol/L during the rejection-free periods. A paired t test of the mean differences was not significant (P = 17). For the 25 episodes of moderate or severe rejection, the mean serum citrulline level was 12.4 +/- 1.1 micromol/L before rejection and 18.8 +/- 2.0 micromol/L during the rejection-free periods. A paired t test of the mean difference was statistically significant (P = .002). CONCLUSIONS: Although further study of citrulline as a marker for the early detection of acute rejection episodes is needed, our hope is that its use will help to prevent some of these early episodes from evolving into full-blown moderate or severe grades of rejection.     

Endothelin receptor blockade in severe acute pancreatitis leads to systemic enhancement of microcirculation, stabilization of capillary permeability, and improved survival rates

BACKGROUND: We previously demonstrated that therapy with a new endothelin A receptor antagonist (ET-RA) significantly reduced mortality rates in severe acute pancreatitis (AP) in the rat without attenuating local signs of disease severity (intrapancreatic protease activation, acinar cell necrosis). This raised the question as to why ET-RA was so effective. The purpose of this study was to assess the effect of ET-RA on microcirculation (particularly capillary permeability) within and outside of the pancreas on intravascular fluid loss and extravascular fluid sequestration and on distant organ function. METHODS: Severe AP was induced in rats by standardized intraductal bile acid infusion and cerulein hyper-stimulation. Starting 6 hours (n = 24 rats) and 12 hours (n = 30 rats) after the onset of AP, animals randomly received either the ET-RA (LU-135252) or saline solution with fluid resuscitation (6 mL/kg/h Ringer's lactate). At 24 hours, animals were relaparotomized for intravital microscopic determination of capillary blood flow, leukocyte rolling, and capillary permeability in the pancreas and colon. Further monitoring included cardiorespiratory and renal parameters, hematocrit levels and quantification of ascites and pleural effusions, and acinar cell necrosis at autopsy. Groups of sham-operated healthy animals (n = 6 animals each) that had been treated according to the same protocol served as control animals. RESULTS: ET-RA treatment that was started 6 hours after AP-induction significantly decreased hematocrit levels (38% +/- 1% vs 45% +/- 2% with saline solution treatment), reduced ascites and pleural effusions (6.7 +/- 1.3 mL vs 11.9 +/- 1.3 mL), and improved urine production (4.8 +/- 0.5 mL vs 2.9 +/- 0.6 mL) and respiratory parameters. Moreover, all microcirculatory parameters were improved; in particular, capillary permeability was stabilized (158% +/- 9% vs 248% +/- 8% in the colon). These beneficial effects were also seen when therapy was delayed until 12 hours after AP induction. Pancreatic necrosis was not significantly reduced. The overall mortality rate was 12% in ET-RA-treated animals and 42% in saline solution-treated control animals (P <.05). In healthy animals ET-RA did not significantly alter the target parameters, except for a reduction of capillary permeability in the pancreas. CONCLUSIONS: Improved microcirculation and stabilized capillary permeability in ET-RA-treated animals together with reduced intravascular fluid loss and extravascular fluid sequestration and improved renal and pulmonary function (1) may explain improved survival in this model, (2) support the hypothesis that systemic disease sequelae significantly contribute to outcome in AP, and (3) suggest that ET-RA may be a promising therapeutic tool in AP because it counteracts microcirculatory disorders that contribute to pancreatitis-associated organ dysfunction even when therapy is delayed to a point at which pancreatic injury may no longer be influenced.     

液体复苏对严重脓毒症及脓毒性休克患者的治疗作用研究

目的评价液体复苏手段对严重脓毒症或脓毒性休克的治疗作用。方法通过液体复苏使20例严重脓毒症或脓毒性休克患者达到如下治疗目标：中心静脉压8—12mmHg（机械通气者12—15mmHg）、平均动脉压65～90mmHg、混合静脉血氧饱和度〉70％。测定达标前后血流动力学、组织灌注、血管内皮细胞功能的变化。结果液体复苏达标后,肺动脉楔压明显升高（P〈0．01）,心指数及体循环阻力指数增加（P〈0．01）,肺循环阻力指数下降（P〈0．01）,左心室做功指数上升（P〈0．01）;组织灌注指标中动脉血乳酸（ABL）在复苏后下降（P〈0．01）,胃黏膜二氧化碳分压与动脉血二氧化碳分压差（Pg—aCO2）在复苏后明显下降（P〈0．01）,血管内皮细胞功能中内皮素及血管性假血友病因子在液体复苏后下降（P〈0．05）。结论液体复苏早期达标可改善严重脓毒症或脓毒性休克患者血流动力学和组织灌注并可减轻血管内皮细胞的损伤,是一种有效的治疗方式。     

Ablative surgery for necrotizing pancreatitis.

We have confirmed again that bile and trypsin injected in dogs under high pressure produce highly lethal necrotizing pancreatitis responsive to fluid resuscitation. Animals undergoing pancreatectomy show a reduction in serum amylase levels and hemoconcentration (reflected in hematocrit levels) after pancreatectomy, an effect that may be related to removal of the source of vasoactive substances liberated in pancreatitis. Qualitatively, survivors of pancreatectomy exhibit accelerated convalescence. Pancreatectomy, however, does not increase survival once the disease process is established and may be harmful. This experimental study does not support the clinical use of pancretectomy but rather emphasizes the utility of adequate fluid resuscitation in the treatment of severe pancreatitis.     

Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections

SUMMARY BACKGROUND DATA: Standard management of gallstone-associated acute pancreatitis calls for cholecystectomy to be performed during the same hospitalization after acute symptoms have subsided. However, infectious complications are common when cholecystectomy is performed sooner than 3 weeks after severe acute pancreatitis. Fluid collections, common in patients with moderate to severe acute pancreatitis, are additionally problematic. No previous study has examined the role of peripancreatic fluid collections and subsequent pseudocyst in outcomes after cholecystectomy in these patients. OBJECTIVES: We compare results of delaying cholecystectomy after moderate to severe acute pancreatitis with early cholecystectomy. METHODS: Since 1987, all patients with moderate to severe gallstone-associated acute pancreatitis and associated fluid collections were addressed. Moderate to severe acute pancreatitis was defined as > 5 Ranson prognostic indicators. Fluid collection was established by computed tomography (CT) scan. Patients were evaluated for duration of hospitalization, complications of cholecystectomy, resolution or persistence of pseudocysts, nonoperative interventions performed on pseudocysts, intercurrent episodes of acute pancreatitis during the monitoring period, episodes of sepsis, and mortality. RESULTS: A total of 187 patients with moderate to severe gallstone-associated acute pancreatitis survived their acute stage; 151 had peripancreatic fluid collections. Seventy-eight of the 187 had early cholecystectomy, 62 of whom had fluid collections; 109 were monitored before cholecystectomy, 89 of whom had fluid collections. Fluid collections resolved without intervention in 36 (40%) of 89 in the monitored group and in 13 (21%) of 62 in the early cholecystectomy group. Percutaneous drainage was performed in 16 (18%) of 89 in the monitored group and in 31 (50%) of 62 in the early cholecystectomy group. Sepsis occurred in 6 (7%) of 89 in the monitored group and 29 (47%) of 62 in the early cholecystectomy group. Complications of cholecystectomy occurred in 6 (5.5%) of 109 of the monitored patients and in 34 (44%) of 78 in the early cholecystectomy group. Fifty-three patients in the monitored group and 49 patients in the early cholecystectomy group required operative pseudocyst-enterostomy. This procedure was combined with cholecystectomy in the monitored patients. Mean hospitalization was longer in the early operation group. CONCLUSION: Cholecystectomy should be delayed in patients who survive an episode of moderate to severe acute biliary pancreatitis and demonstrate peripancreatic fluid collections or pseudocysts until the pseudocysts either resolve or persist beyond 6 weeks, at which time pseudocyst drainage can safely be combined with cholecystectomy.     

围手术期液体治疗策略的研究进展

背景 采用合理的液体治疗策略对外科手术患者进行液体治疗是围手术期管理的重要内容,可以显著降低围手术期并发症发生率,缩短患者住院天数,改善预后.目的 对围手术期液体治疗策略的发展过程、近年来该领域的研究进展以及目前尚存在争议的问题进行回顾和总结,为临床液体治疗策略的选择和后续研究提供借鉴.内容 回顾了围手术期液体治疗策略...     

重症急性胰腺炎早期液体治疗策略的探讨

目的探讨重症急性胰腺炎(SAP)早期两种不同液体治疗策略对患者预后的影响。方法回顾性分析我院2000年1月至2011年11月期间收治的符合入选标准且达到液体治疗目标的97例SAP患者,2000年1月至2004年12月期间收治的患者采用传统的液体治疗方法(简称传统治疗组,n=34),2005年1月至2011年11月期间收治的患者采取的早期目标指导的液体治疗策略(简称早期目标治疗组,n=63),比较2组间急性生理与慢性健康状况Ⅱ评分(APACHEⅡ)、器官功能不全评分(Marshall)、多器官功能障碍综合征(MODS)发生率、胰腺感染率和住院病死率的差异。结果与传统治疗组相比,早期目标治疗组患者液体治疗后第3天时的APACHEⅡ和Marshall评分较传统治疗组明显降低(APACHEⅡ评分:7.38±4.01比11.35±4.27,P=0.011;Marshall评分:4.13±2.06比6.82±3.15,P=0.016)。另外,早期目标治疗组患者入院后7 d内MODS发生率、胰腺感染率和住院病死率也较传统治疗组有所降低(MODS:46.0%比61.8%,P=0.139;胰腺感染率:31.7%比44.1%,P=0.226;住院病死率:15.8%比23.5%,P=0.355),但其差异均无统计学意义。结论本研究有限的病例结果提示,早期目标指导的液体治疗可在一定程度上缓解SAP病情,但能否改善SAP患者预后有待临床进行前瞻性随机对照研究。     

Takotsubo cardiomyopathy in a chronic spinal cord injury patient with autonomic dysreflexia: A case report

Context: Takotsubo cardiomyopathy (TC) is a transient stress-induced cardiomyopathy with left ventricular dysfunction of unknown etiology. A well accepted theory for the pathophysiology of TC is attributed to a massive catecholamine release [1]. This case report will review a chronic tetraplegia patient who was diagnosed with TC after a severe episode of autonomic dysreflexia (AD). He experiences mild episodes of AD several times a day; however, he had never experienced the severity of symptoms that was associated with this episode which led to his hospitalization. Autonomic dysreflexia is a syndrome of imbalanced sympathetic input secondary to loss of descending central sympathetic control in spinal cord injury due to noxious stimuli below the level of the injury, which occurs when the injury level is at thoracic level 6 (T6) or above [2].Findings: In this specific case, it is presumed that the massive catecholamine release associated with this severe AD episode resulted in TC. Although TC has been diagnosed after other instances of acute stress, it is unknown for it to be diagnosed after AD in a chronic setting.Clinical Relevance: The long-term effects of AD have not been well studied, and this case illustrates the importance of education to recognize and manage AD in the spinal cord patient who frequently has episodes of AD.     

Pretransplant systemic inflammation and acute rejection after renal transplantation

BACKGROUND: There are presently no established pre-transplant tests that consistently identify patients who may be at increased risk for acute rejection episodes after renal transplantation. We studied whether pretransplant serum levels of C-reactive protein (CRP), a marker for the presence of systemic inflammation, would predict the occurrence of acute rejection episodes after renal transplantation. METHODS: Pretransplant serum was tested for CRP level in 97 consecutive renal transplant recipients. Time to acute rejection after transplantation was stratified by CRP level and compared using the Kaplan-Meier method. In addition, Cox regression multivariate analysis was performed to assess whether any pretransplant covariates could independently predict the subsequent occurrence of acute rejection episodes. RESULTS: Pretransplant mean CRP levels were higher in patients who subsequently had a rejection episode versus those who had no rejection (22.2+/-2.9 vs. 11.7+/-1.8 microg/ml, respectively, P=0.003). Patients less than the median CRP value had a significantly longer time to rejection compared to those with higher CRP levels (P=0.002). Similarly, patients within the lowest CRP quartile had longer times to rejection when compared with the highest quartile (P=0.006). Cox proportional hazards regression multivariate analysis identified CRP level as the only independent pretransplant risk factor for rejection identified (P=0.044). CONCLUSIONS: Pretransplant systemic inflammation as manifested by elevated serum CRP level independently predicts the risk of acute rejection after renal transplantation and may be useful in stratifying patients at the time of transplantation according to immunological risk. Thus, assessment of pretransplant systemic inflammatory status may be helpful in prospective individualization of immunosuppression therapy after renal transplantation.     

烧伤延迟复苏与细胞集落刺激因子

为探讨严重烧伤延迟复苏血清粒细胞集落刺激因子（Ｇ－ＣＳＦ）的变化规律及其与感染发生，发展，预后的关系，采用大鼠３０％ＴＢＳＡⅢ度烧伤模型，动态了观察了大鼠在立即复苏与延迟复苏两种条件下，外周血白细胞数量，血清（Ｇ－ＣＳＦ）和肿瘤坏死因子－α（ＴＮＦ－α）含量，中性粒细胞吞噬功能；采用大鼠３０％ＴＢＳＡⅡ度烧伤延迟复苏合并早期创面感染模型，动态观察应用重组粒细胞－巨噬细胞集落刺激因子（ｒｈＧＭ－ＣＳ     

Survival from acute renal failure after severe burns

We describe a patient with 50 per cent, third degree flame burns who had a history of paint thinner inhalation for over 10 years. Moreover, chlorpromazine had been administered for the treatment of insomnia caused by chronic thinner intoxication. He developed oliguric acute renal failure soon after the burn injury, although adequate resuscitation therapy was given, and survived following frequent haemodialysis. Although survival from acute renal failure after severe burns is rare, once the diagnosis of acute renal failure has been made, haemodialysis should be instituted as early as possible. Furthermore, in a severely burnt patient with episodes of chronic and acute intoxication from organic chemicals or drugs which may have caused renal damage, acute renal failure may occur, so that careful observation is advised.     

Systemic capillary leak syndrome resulting in compartment syndrome and the requirement for a surgical airway

We report on a case of systemic capillary leak syndrome associated with a monoclonal band on plasma electrophoresis. In our patient hospital admission was precipitated by ischaemic pain in the left lower limb, associated with polycythaemia, renal failure and hypovolaemic shock. Fluid resuscitation, venesection and renal replacement therapy were instituted but a compartment syndrome developed necessitating surgery. Failure of tracheal intubation resulted in the requirement for a surgical airway. Despite surgical and resuscitative efforts the outcome was fatal from hypovolaemia and hyperkalaemia. We aim to highlight the difficulties in managing this condition and to remind healthcare workers to include it in the differential diagnoses for patients presenting with polycythaemia; in particular polycythaemic patients with a monoclonal band on plasma electrophoresis.