Pronounced renal vasoconstriction and systemic hypertension in renal transplant patients treated with cyclosporin A versus FK 506

This prospective study investigated hypertension and renal vasoconstriction developing during the 1st year after renal transplantation in patients randomly allocated to treatment with FK 506 (n = 28) or CyA (n = 13). Starting doses were 0.2–0.3 mg/kg per day for FK 506 and 5–8 mg/kg per day for CyA; doses were subsequently adjusted to trough levels (5–15 ng/ml for FK 506 and 100–150 ng/ml for CyA). We compared 24-h ambulatory blood pressure measurement, antihypertensive treatment, serum creatinine, and resistance index (RI), measured by Doppler ultrasound at the level of the interlobar artery. Until month 2 of treatment, FK 506-treated patients had a significantly lower RI (8 %) and better renal graft function, as evidenced by significantly lower serum creatinine values. Some 13 % of FK 506-treated patients, compared to 70 % of CyA-treated patients (P < 0.01), needed additional antihypertensive drugs after transplantation to keep blood pressure stable. FK 506 treatment, at the above-mentioned dosages, was associated with a significantly higher number of infections (urinary tract infection, pyelonephritis, and pneumonia). We conclude that CyA produces greater renal vasoconstriction and systemic hypertension than FK 506, as reflected in higher renal interlobar artery RI values and a greater need for antihypertensive treatment. After 2 months of treatment and a reduction in CyA trough levels, the renal effects (i. e., lower RI and lower creatinine values), but not the systemic hypertensive effects, disappear. Received: 25 March 1997 Received after revision: 25 September 1997 Accepted: 8 October 1997     

Time course and relationship between plasma selenium concentrations, systemic inflammatory response, sepsis, and multiorgan failure

Background: Selenium plays an important role in defence against acute illness.We investigated, in intensive care unit (ICU) patients, thetime course of plasma selenium concentrations and their relationshipto systemic inflammatory response syndrome (SIRS), organ dysfunction/failure,infection, and ICU outcome. Methods: Plasma selenium and laboratory indices of organ dysfunction/failure,tissue inflammation, and infection were measured daily duringthe ICU stay in 60 consecutive ICU patients, 15 in each of foura priori defined subgroups: ICU controls (no SIRS); uncomplicatedSIRS; severe SIRS; and severe sepsis/septic shock. Results: Plasma selenium concentrations were below standard values forhealthy subjects (74 µg litre^–1) in 55 patients(92%). Selenium concentrations decreased during the ICU stayin all groups, except controls, to a minimum value that waslower in patients with organ failure, particularly in thosewith infection. The minimum plasma selenium was inversely correlatedto admission Acute Physiology and Chronic Health EvaluationII and Simplified Acute Physiology System II scores, indicatorsof inflammation, and the maximal degree of organ dysfunction/failureduring the ICU stay. Plasma selenium was positively correlatedwith minimum platelet count, minimum plasma antithrombin activity,and protein C activity. In a receiver operator characteristicanalysis, SAPS II score [area under the curve (AUC) = 0.903]and minimum selenium concentration (AUC = 0.867) were the strongestpredictive factors for ICU mortality. Conclusions: In critically ill surgical patients, plasma selenium concentrationsare generally low with a greater decrease during the ICU stayin patients with organ failure, especially when attributed toinfection. Lower plasma selenium concentrations are associatedwith more tissue damage, the presence of infection or organdysfunction/failure, and increased ICU mortality.     

Ventilatory strategies in septic patients

Background

Mortality in intensive care unit (ICU) patients is affected by multiple variables. The possible impact of the mode of ventilation has not yet been clarified; therefore, a secondary analysis of the “epidemiology of sepsis in Germany” study was performed. The aims were (1) to describe the ventilation strategies currently applied in clinical practice, (2) to analyze the association of the different modes of ventilation with mortality and (3) to investigate whether the ratio between arterial partial pressure of oxygen and inspired fraction of oxygen (PF ratio) and/or other respiratory variables are associated with mortality in septic patients needing ventilatory support.

Methods

A total of 454 ICUs in 310 randomly selected hospitals participated in this national prospective observational 1-day point prevalence of sepsis study including 415 patients with severe sepsis or septic shock according to the American College of Chest Physicians/Society of Critical Care Medicine criteria.

Results

Of the 415 patients, 331 required ventilatory support. Pressure controlled ventilation (PCV) was the most frequently used ventilatory mode (70.6 %) followed by assisted ventilation (AV 21.7 %) and volume controlled ventilation (VCV 7.7 %). Hospital mortality did not differ significantly among patients ventilated with PCV (57 %), VCV (71 %) or AV (51 %, p?=?0.23). A PF ratio equal or less than 300 mmHg was found in 83.2 % of invasively ventilated patients (n?=?316). In AV patients there was a clear trend to a higher PF ratio (204?±?70 mmHg) than in controlled ventilated patients (PCV 179?±?74 mmHg, VCV 175?±?75 mmHg, p?=?0.0551). Multiple regression analysis identified the tidal volume to pressure ratio (tidal volume divided by peak inspiratory airway pressure, odds ratio OR?=?0.94, 95 % confidence interval 95% CI?=?0.89–0.99), acute renal failure (OR?=?2.15, 95% CI?=?1.01–4.55) and acute physiology and chronic health evaluation (APACHE) II score (OR?=?1.09, 95% CI?=?1.03–1.15) but not the PF ratio (univariate analysis OR?=?0.998, 95 % CI?=?0.995–1.001) as independent risk factors for in-hospital mortality.

Conclusions

This representative survey revealed that severe sepsis or septic shock was frequently associated with acute lung injury. Different ventilatory modes did not affect mortality. The tidal volume to inspiratory pressure ratio but not the PF ratio was independently associated with mortality.     

Comparison of robotic-assisted and open radical cystectomy in a community-based, non-tertiary health care setting

We examined the safety and feasibility of transitioning from open radical cystectomies to robotic-assisted laparoscopic cystectomies in a community-based, non-tertiary health care setting. A retrospective review and analysis of our most recent 14 unselected consecutive patients who underwent open cystectomy was compared to our first 14 unselected consecutive patients who underwent robotic-assisted laparoscopic cystectomy. Perioperative and pathologic outcomes were reviewed to determine the safety and oncologic equivalence of the two procedures. From 2003 to 2010, 14 consecutive patients underwent an open cystectomy and from 2010 to 2012 another 14 consecutive patients underwent a robotic-assisted laparoscopic cystectomy. The operative time was significantly longer in the robotic group (6 h 23 min vs. 4 h 28 min; p < 0.05) and intraoperative blood loss was significantly lower compared with the open radical cystectomy (ORC) group (470 ml vs. 942 ml; p < 0.05). Regarding complications, 21 % of robotic-assisted radical cystectomy (RARC) patients experienced major complications versus 14 % of ORC patients. Overall, there was no statistically significant difference in complication rates or length of hospital stay between the ORC and RARC groups. No pathologic differences were noted between the two groups and lymph node counts were similar in the two groups, with the median numbers being 11.9 and 9.5 in RARC and ORC, respectively. RARC can be accomplished in a community-based, non-tertiary health care setting without compromising perioperative or pathologic outcomes during the institution of this minimally invasive procedure.     

Cardiovascular morbidity and mortality in patients with diabetes mellitus type I after kidney transplantation: a case-control study

BACKGROUND: The proportion of diabetics among patients requiring renal replacement therapy continues to increase in most western countries. The acceptance rate for renal transplantation varies among transplant centers and is influenced by the current opinion on the outcome of transplantation in diabetics. Controlled data on patient and graft survival in type I diabetics, however, are scarce. METHODS: We performed a retrospective case-control analysis on patient and graft survival and the cardiovascular morbidity of patients with type I diabetes after renal transplantation versus carefully matched non-diabetic transplant recipients. Match criteria were duration of previous hemodialysis, age and date of renal transplantation. Moreover, risk factors for cardiovascular disease in uremic patients were evaluated at the time of registration for renal transplantation and at the end of the observation period. RESULTS: Seventy-seven matched pairs were enclosed. Patient survival was significantly worse in the diabetic patients, graft survival was comparable in both groups, when graft loss because of patient's death was censored. In the diabetic patients, risk of death (odds ratio: 4.38) as well as the prevalence of cardiovascular morbidity (odds ratio: 4.47) were significantly higher than in the matched nondiabetic controls. Cox regression analysis showed that diabetes mellitus was an independent risk factor for patient survival; no association was found with hypertension, hyperlipidemia, hyperparathyroidism, calcium x phosphate product, body mass index and HbA1c. Cardiovascular morbidity, however, was already significantly higher in the diabetic group at the time of registration. CONCLUSIONS: Diabetes mellitus type I has a dominant impact on morbidity and mortality after renal transplantation and is associated with an approximately 4-fold higher risk of death. Cardiovascular disease accounts for the significantly worse long-term outcome of diabetic patients after renal transplantation.     

Dialyse- und Ultrafiltrationsverfahren bei kardiorenalem Syndrom

Renal failure is common in patients with severe heart failure and this complex pathophysiological interaction is classified as cardiorenal syndrome. In these patients hydropic decompensation is the main reason for hospitalization. In patients with refractory heart failure characterized by diuretic resistance and congestion due to volume overload, ultrafiltration has to be considered. In cases of acute decompensated heart failure with deterioration of renal function, extracorporeal ultrafiltration is the preferred treatment modality. On the other hand, patients suffering from chronic decompensated heart failure, particularly patients with ascites, will profit from the treatment-specific advantages of peritoneal ultrafiltration. A prerequisite for an optimized care of patients with cardiorenal syndrome is the close collaboration between intensive care physicians, cardiologists and nephrologists.     

Inflammation-associated ADAMTS13 deficiency promotes formation of ultra-large von Willebrand factor

In a prospective, longitudinal study, we investigated the association between decreased ADAMTS13 activity and impaired hemostasis, as well as organ dysfunctions in patients with systemic inflammation due to extracorporeal cardiopulmonary circuit or with severe sepsis. Similar to negative acute phase proteins, ADAMTS13 activity declined stepwise according to the extent of inflammatory responses. A marked imbalance between ADAMTS13 activity and VWF antigen level was associated with the appearance of ultra-large VWF multimers in plasma, with organ dysfunction and lethality. Our data support the view that systemic inflammation results in an ADAMTS13 deficiency which activates hemostasis.