Increased brain natriuretic peptide and atrial natriuretic peptide plasma concentrations in dialysis-dependent chronic renal failure and in patients with elevated left ventricular filling pressure

Brain natriuretic peptide (BNP) and atrial natriuretic peptide (ANP) plasma concentrations were measured in patients with dialysis-dependent chronic renal failure and in patients with coronary artery disease exhibiting normal or elevated left ventricular end-diastolic pressure (LVEDP) (n = 30 each). Blood samples were obtained from the arterial line of the arteriovenous shunt before, 2 h after the beginning of, and at the end of hemodialysis in patients with chronic renal failure. In patients with coronary artery disease arterial blood samples were collected during cardiac catheterization. BNP and ANP concentrations were determined by radioimmunoassay after Sep Pak C₁₈ extraction. BNP and ANP concentrations decreased significantly (P < 0.001) during hemodialysis (BNP: 192.1 ± 24.9, 178.6 ± 23.0, 167.2 ± 21.8 pg/ml; ANP: 240.2 ± 28.7, 166.7 ± 21.3, 133.0 ± 15.5 pg/ml). The decrease in BNP plasma concentrations, however, was less marked than that in ANP plasma levels (BNP 13.5 ± 1.8%, ANP 40.2 ± 3.5%; P < 0.001). Plasma BNP and ANP concentrations were 10.7 ± 1.0 and 60.3 ± 4. 0 pg/ml in patients with normal LVEDP and 31.7 ± 3.6 and 118.3 ± 9.4 pg/ml in patients with elevated LVEDP. These data demonstrate that BNP and ANP levels are strongly elevated in patients with dialysis-dependent chronic renal failure compared to patients with normal LVEDP (BNP 15.6-fold, ANP 2.2-fold, after hemodialysis; P < 0.001 or elevated LVEDP (BNP 6.1-fold, ANP 2.0-fold, before hemodialysis; P < 0.001), and that the elevation in BNP concentrations was more pronounced than that in ANP plasma concentrations. The present results provide support that other factors than volume overload, for example, decreased renal clearance, are also involved in the elevationin BNP and ANP plasma levels in chronic renal failure. The stronger elevation in BNP concentrations in patients with chronic renal failure and in patients with elevated LVEDP and the less pronounced decrease during hemodialysis suggest a different regulation of BNP and ANP plasma concentrations.[/ p]Abbreviations ANP atrial natriuretic peptide - BNP brain natriuretic peptide - LVEDP left ventricular end-diastolic pressure Correspondence to: C. Haug     

Importance of luxury flow for critically ill patients receiving a left ventricular assist system

The presence of a significant organ dysfunction does not immediately exclude patients from consideration for treatment with a left ventricular assist system (LVAS). However, in treating morbid circulatory shock patients with multiple organ failure, it is important to know the preoperative and postoperative factor or factors related to the recovery of the damaged organ function. In this study, we retrospectively analyzed patients receiving a LVAS at our institution and tried to determine the important factors related to the survival of patients with multisystem failure. Twenty-seven patients who underwent LVAS placement at Saitama Medical School Hospital between 1993 and 2003 were included in this study. The preoperative risk factors analyzed were renal dysfunction, respiratory dysfunction, hepatic dysfunction, the existence of active infection, and the combination of all four factors. As a postoperative factor, the pump flow index (mean LVAS pump flow during the first 2 weeks after LVAS surgery divided by the body surface area) was analyzed. None of the analyzed preoperative factors could predict survival after LVAS surgery, but a pump flow index of less than 2.5 l/min/m² had a significant relationship with death after LVAS surgery. Further analysis revealed that all the patients with a pump flow index of 3.0 l/min/m² or more could overcome preoperative organ dysfunction. Congestive heart failure patients with multisystem failure need luxury pump flow for successful LVAS surgery; this factor could be especially important in device selection and postoperative management.     

Digital subtraction angiography (DSA): New perspectives in angiography

Summary Digital subtraction angiography (DSA) has strongly influenced angiographic procedures. Because it is less invasive it has increased the total number of angiographies in all places where it was introduced. The paper gives an introduction to the procedure explaining the roles of digital and subtraction in DSA. It is written from a technical point of view. The examples are taken from and with the DVI system.     

Monitoring effects of α-human atrial natriuretic polypeptide (α-hANP) on left ventricular function in patients with essential hypertension with a cardiac probe

The effects of -hANP on left ventricular function were studied with a cardiac probe in ten patients with essential hypertension. Our data showed that intravenous administration of -hANP significantly elevated left ventricular function. At 5 min, the elevation of EF, RCO, ER, RSV, PFR were 13.23% (P<0.02), 12.7 (P<0.02), 0.618 (P<0.02), 0.133 (P<0.05), 0.283 (P<0.01), respectively. At 10 min, the increase of EF, ER, were 11.07% (P<0.02) and 0.233 (P<0.01), respectively. Atriopeptin significantly reduced systolic and diastolic blood pressure from 2 min to 20 min (P<0.001–0.05).Supported by IAEA Grant No. 4062/RI/RB     

“Cross-over” duplication of middle cerebral artery,agenesis of internal carotid artery and saccular aneurysms

Summary The authors describe a patient with anomalous branches of the left internal carotid artery, cross-over duplication of its middle cerebral artery and agenesis of the contra-lateral internal carotid artery associated with two aneurysms successfully clipped. Pertinent literature is reviewed.     

Optic pit syndrome

In a study of 15 eyes with optic pits fluorescein angiography revealed that only pits associated with serous detachment of the macular retina showed fluorescence in the late venous phase, while the pits uncomplicated by detachment remained hypofluorescent throughout the test. This finding strongly supports the hypothesis that the subretinal fluid producing the macular detachment originates from leakage of vessels located in the floor of the pit. In addition a high incidence of anomalies was found to be associated with optic pits. Therefore the author suggests to call the association between optic pit and large optic disc, parapapillary chorioretinal changes, cilioretinal vessels, situs inversus and eventual other vessel abnormalities, the optic pit syndrome.     

Left ventricular function before and after kidney transplantation. A prospective study in patients with juvenile-onset diabetes mellitus

The aim of the present investigation was to discover whetherdisturbed left ventricular (LV) function limits renal replacementtherapy in patients with juvenile onset diabetes mellitus. Seventeenpatients given functioning kidney grafts were studied non-invasively(M-mode echocardiography, apexcardiography, phonocardiography)before renal transplant and an average of six, 13 and 44 monthsafter transplant. The main pretransplant findings were pronouncedLV hypertrophy with impaired diastolic LV function (prolongedrelaxation time + signs of decreased LV distensibility) anda hyperdynamic circulation. Most of these abnormalities were significantly less severe aftersuccessful kidney transplantation. LV mass decreased by 37%44 months after transplant (p<0.01) and LV diastolic andsystolic volumes decreased with a subsequent increase in ejectionfraction from 0.65 to 0.78 (p<0.01). The LV distensibilityand filling pattern improved significantly while the prolongedrelaxation time was unchanged. These findings imply that pretransplant disturbances in LV functionare related more to factors such as hypertension, volume overloadand uraemia than to diabetes per se because no pronounced improvementin the metabolic disorder resulting from diabetes can be expected,even after the most successful transplant. Disturbed LV functionshould not, therefore, exclude uraemic diabetics from renalreplacement.     

Review of 1,000 consecutive cases of severe head injury treated before the advent of CT scanning

Summary This is a review of 1,000 consecutive cases of severe head injury admitted to our Neurosurgical Department between January 1973 and August 1976, before the advent of CT scanning. All patients were comatose following head injury (GCS8) and were treated homogeneously by the same neurosurgical team by a protocol that included immediate resuscitation on arrival, diagnosis of intracranial lesions by angiography, early surgery when needed, mechanical ventilation, steroids, and mannitol. Extracranial lesions, even if preponderant, were treated by various specialists in the Neurosurgical Department, which for all practical purposes operated as an Emergency Department. Admission criteria were very broad with no preadmission selection. The overall mortality for this series was 45%. A little less than half the patients made good recoveries or remained moderately disabled (47%); 6% were severely disabled, and 2% survived in a persistent vegetative state. More than two-thirds of the patients were brought to our Neurosurgical Department after a short stay at a general hospital; 72% were admitted within 6 hours of injury; 71% were traffic accident victims; and 34% had significant associated extracranial injuries. Carotid angiography was performed in 78% of the patients and indicated the presence of an intracranial haematoma requiring surgery in 36% of the whole series. Mortality was significantly higher in operated than in unoperated patients (56% versus 39%); those treated surgically, however, were older, in worse clinical condition, and showed a higher incidence of acute subdural haematomas associated with brain contusion. Carotid angiography proved very effective in revealing the presence of an expansive lesion but failed to reflect the severity of brain damage, since the group with negative angiograms showed a high mortality (52%). Patients with a lucid interval had a higher percentage of surgical lesions than those with immediate coma (58% versus 26%); but fully 42% of them did not require surgery, and 25% had negative angiograms. From the prognostic point of view the clinical data elicited after initial resuscitation were highly predictive of the outcome: some individual neurological signs, such as mydriasis, posturing and eye movements, were not inferior to the GCS score in that respect. Age also proved a strong predictor, since elderly patients are more likely to have severe subdural and parenchymal lesions and their clinical severity is accordingly greater.Our series amounts to a data bank of cases both contemporary to and in good agreement with that collected by Jennett and his associates in their 1977 multinational study; and it affords a useful reference in the assessment of epidemiological variations and alternative management in relation to outcome.     

倍他乐克逆转高血压左室肥厚的临床观察

目的　比较 2药对高血压左室肥厚患者的疗效及运动后对心率、血压的影响。方法　采用随机分组法将 80例高血压左室肥厚的病人分成两组 ,倍他乐克组和硝苯地平组 ,治疗前后查超声心动图 ,测定IVST、PWT及LVMI ,心率及血压。结果　① 2药降压效果无明显差异。② 2组患者IVST、PWT、LVMI的下降幅度相同。③中度体力活动后 ,倍他乐克组心率增快 9± 2次 ,收缩压、舒张压上升均小于 3kPa(7 5mmHg) ,硝苯地平组心率增快 2 0± 4次 ,2组相比P <0 0 1,具有显著意义 ;收缩压、舒张压上升幅度均为 3 4± 1 2kPa(2 6±9mmHg) ,明显大于倍他乐克组。④结论　 2药对高血压患者的左心室肥厚有相似的逆转作用 ,但倍他乐克可减少体力活动时血压及心率的上升 ,对心脏更具有保护作用。     

颈动脉粥样斑块与冠状动脉病变

目的 研究颈动脉粥样斑与冠状动脉病变的关系。方法 将82例冠心病待排和冠心病患者按冠状动脉造影结果分成正常组和冠脉粥样病变组,同期超声检测颈动脉粥样硬化程度。结果 颈动脉粥样斑块与冠脉弱粥样硬化之间有较密切的关系。颈动脉粥样斑块对狭窄性冠状动脉病变预测的敏感性为71.7%,特异性为91.9%,阳性和阴性预测值分别为91.7%和73.9%,其准确性为81.7%。结论 颈动脉超声检测可作为预测冠状动脉粥样硬化有价值的指标。