Sirolimus and mycophenolate mofetil as calcineurin inhibitor-free immunosuppression in a cardiac transplant patient with chronic renal failure.

Chronic renal failure triggered by calcineurin inhibitor (CNI)-based immunosuppression is a common complication after cardiac transplantation. Sirolimus and mycophenolate mofetil (MMF) are 2 newer immunosuppressive agents with no documented nephrotoxic side effects. This case report describes a patient with ongoing chronic renal failure 10 months after cardiac transplantation on cyclosporine-based immunosuppressive therapy. Conversion of the immunosuppressive regimen from cyclosporine to sirolimus and MMF resulted in freedom from acute rejection, excellent cardiac graft function and consistently improved renal function. This case illustrates the beneficial potential of sirolimus and MMF as CNI-free and safe long-term immunosuppression in a patient with chronic renal failure after heart transplantation.     

The role of complement, C5a and its receptors in sepsis and multiorgan dysfunction syndrome.

Sepsis continues to be a major clinical problem that is difficult to treat, as the pathophysiology of the disease is still unclear. Despite promising experimental strategies, therapeutic interventions have been largely unsuccessful. There is now increasing evidence that the disturbance of innate immunity during sepsis and multiorgan dysfunction syndrome (MODS) may be linked to uncontrolled activation of the complement system. Especially, the powerful anaphylatoxin C5a seems to play a key role in the development of immune paralysis. In this review, we describe our present understanding of the role of complement in the inflammatory response during sepsis and MODS.     

Blood pressure reduction in pregnancy by sodium chloride.

Volume expansion in the presence of elevated aldosterone availabilityis a hallmark of normal pregnancy. Intravascular volume depletioncharacterizes severe pregnancy-associated disease conditionssuch as intra-uterine growth retardation, chronic hypertensionor pre-eclampsia [1]. Two hypotheses have been forwarded toexplain volume depletion in pregnancy: the first hypothesischarges inappropriate sensing of vascular ‘overfilling’,resulting in an increased transendothelial loss of fluid tothe extravascular compartment. In contrast, the second hypothesisfocuses on vascular ‘underfilling’ due to inappropriatelylow aldosterone levels. The second hypothesis is based on theassumption that a compensatory increase in the circulating fluidvolume is required in normal pregnancy to support fetal substratedelivery. According to the second concept, maternal blood pressureincreases due to counter-regulatory mechanisms when placentalblood supply is reduced [2]. In support of the ‘underfilling’hypothesis are observations that a     

Impact of early dietary gamma-linolenic acid supplementation on atopic eczema in infancy

Polyunsaturated fatty acids (PUFAs) are components of cell membranes and may play an immunomodulating role in the pathogenesis of atopic dermatitis (AD). The goal was to determine the impact of PUFAs on AD by dietary supplementation of infants. Based on the parents' decision on their babies' primary feeding, mothers and newborns were randomized to the supplementation with gamma-linolenic acid (GLA) or placebo for up to 6 months. Breastfed infants received GLA by supplementing their mothers. Formula diet was commercial whey hydrolysate unsupplemented with PUFAs. Of 131 eligible infants, 24 developed AD within the first year of life. Of these, nine belonged to the exclusively breastfed group (n = 58), 14 to the combined-fed group (n = 53), and one to the never breastfed group (n = 20). We could not find an influence of GLA on the development of AD. In subjects with AD, at 1 yr of age the serum-immunoglobulin E (IgE) was the lowest in the GLA-supplemented group A-subjects. In the GLA-supplemented group, GLA-levels in breast milk were similar in atopic and non-atopic infants. In the non-supplemented group the GLA-content of breast milk was 0.07% of total fatty acids in atopic infants vs. 0.17% in non-atopic infants (p < 0.01). Dietary GLA-supplementation could not prevent AD. Interestingly, the number of infants developing AD was the lowest in never breastfed children. In infants suffering from AD, GLA-supplementation seemed to reduce total IgE in the first year of life.     

Mesenteriale Ischämie

In the past decade laparoscopic surgery replaced many open operations in general surgery. Apart from therapeutic uses in cholecystectomy, appendectomy, hernia surgery, gastric fundoplication, and increasingly also large intestine surgery, it is indicated diagnostically first of all for unclear abdominal findings and for staging of intra-abdominal malignancies. To date laparoscopy has been used occasionally for diagnosis and therapy of mesenteric ischemia. Patients suffering from mesenteric ischemia are usually old and have comorbid conditions. Quick diagnosis and therapy are necessary due to the pathogenesis of the disease. The low rate of morbidity as well as the easy availability of laparoscopy in principle favor the employment of laparoscopy also for mesenteric ischemia. Against the background of increasing experience in the area of laparoscopic surgery, this study gives an overview of the present value of laparoscopy for mesenteric ischemia.     

Valproic acid induced encephalopathy--19 new cases in Germany from 1994 to 2003--a side effect associated to VPA-therapy not only in young children.

Valproic acid (VPA) is a broad-spectrum antiepileptic drug and is usually well-tolerated. Rare serious complications may occur in some patients, including haemorrhagic pancreatitis, bone marrow suppression, VPA-induced hepatotoxicity and VPA-induced encephalopathy. The typical signs of VPA-induced encephalopathy are impaired consciousness, sometimes marked EEG background slowing, increased seizure frequency, with or without hyperammonemia. There is still no proof of causative effect of VPA in patients with encephalopathy, but only of an association with an assumed causal relation. We report 19 patients with VPA-associated encephalopathy in Germany from the years 1994 to 2003, none of whom had been published previously.