Value of albumin dialysis therapy in severe liver insufficiency

Abstract A blood purification system, molecular adsorbents re-circulating system (MARS), is based on the removal of both protein-bound and water-soluble substances and toxins in the liver. We treated a total of 88 patients within 2 years. Of these patients, 45 had acute liver failure (ALF), 31 had acute decompensation of chronic liver disease, eight had graft failure and four had miscellaneous conditions. Of the patients with ALF, 80% survived; in 23 patients their own liver recovered and 13 patients underwent successful transplantation. Only 23% of patients with acute-on-chronic liver failure survived. Most of them were not considered for transplantation due to their having liver failure from alcoholism and from not abstaining from drinking. MARS is a promising therapy for ALF, allowing the patient's own liver to recover or allowing enough time to find a liver graft. Best results were achieved in patients who had been intoxicated with a lethal dose of toxin. On the other hand, we did not observe much benefit in patients with severe acute-on-chronic liver failure (AcoChr) who did not undergo liver transplantation.     

肌病肾病代谢综合征治疗进展

肌病肾病代谢综合征是急性动脉阻塞致骨骼肌溶解的严重并发症。积极治疗原发病，及早补液扩容、碱化尿液、早期血液净化治疗是降低截肢率、病死率的关键。本文就肌病肾病代谢综合征治疗进展作一综述。     

A prospective evaluation of changes in neuropsychological and liver function tests following transjugular intrahepatic portosystemic stent-shunt

Background/Aims: This study was designed to assess changes in: (a) neuropsychological tests, measures of memory, quality of life and scores for anxiety and depression; (b) liver function tests; and (c) the relationship between these following transjugular intrahepatic portosystemic stent-shunt.Methods: Twenty-nine patients undergoing transjugular intrahepatic portosystemic stent-shunt for recurrent variceal haemorrhage, 12 matched patients with cirrhosis and variceal haemorrhage manage with variceal band ligation and 16 normal controls were studied. Patients in any of the groups who were clinically encephalopathic were excluded from the study. Serial changes in the conventional liver function tests and Indocyanine green clearance, and psychometric function (Hospital Anxiety Depression Scale, Rivermead Behavioral Memory Test, Quality of Life and the memory and reaction sub-tests of the Cambridge Automated Neuropsychological Test Assessment Battery) were measured prior to and 1, 3, 9 and 15 months following transjugular intrahepatic portosystemic stent-shunt.Results: Over a mean follow up of 9.1 months in the transjugular intrahepatic portosystemic stent-shunt group (range 3–28), one patient (3%) developed clinically detectable encephalopathy. Sixty-seven percent of patients with cirrhosis showed evidence of subclinical encephalopathy as compared with the control population. Significant deterioration occurred in the reaction sub-tests of the Cambridge Automated neuropsychological Test Assessment Battery in patients, both in the transjugular intrahepatic portosystemic stent-shunt group and the controls with cirrhosis, during follow up. Transjugular intrahepatic portosystemic stent-shunt was followed by significant deterioration in levels of anxiety and psychological component of the quality of life. The Rivermead Behavioural Memory Test and the memory sub-test of the Cambridge Automated Neurpsychological Test Assessment Battery did, however, improve significantly at 1 and 15 months after transjugular intrahepatic portosystemic stent-shunt, respectively. Serum alanine aminotransferase, bilirubin and indocyanine green clearance deteriorated significantly following transjugular intrahepatic portosystemic stent-shunt (p<0.001, p<0.001 and p<0.0001, respectively). Significant correlation was observed between changes in the indocyanine green clearance and changes in the complex and simple reaction time subtests of the Cambridge Automated Neuropsychological Test Assessment Battery (r=0.6 and r=0.66, respectively).Conclusions: The results of this study showed that about 67% of patients with cirrhosis were subclinically encephalopathic and that temporary deterioration occurred in the Cambridge Automated Neuropsychological Test Assessment Battery during follow up, both in patients having transjugular intrahepatic portosystemic stent-shunt and in the controls with cirrhosis. These parallel the changes in the liver function tests and indocyanine green clearance. Temporary deterioration was also observed in the Quality of Life and Hospital Anxiety Depression Scale in the transjugular intrahepatic portosystemic stent-shunt group, although the measures of memory improved. Further studies should address the biochemical mechanisms of these changes and the role of prophylactic measures.     

Use of epr oximetry with india ink to measure the po2 in the liver in vivo in mice

The partial pressure of oxygen (pO₂) of the liver in vivo in unanesthetized mice was determined using electron paramagnetic resonance (EPR) oximetry with India ink. The EPR spectra were obtained using a low-frequency (1.2 GHz) EPR spectrometer with a loop gap cavity resonator. The line width of the India ink used in this experiment was reversibly broadened by oxygen and was particularly sensitive to pO₂ below 30 torr. After the administration of India ink into the tail vein, the India ink particles were taken up mainly by Kupffer cells in the liver and in part by phagocytes in the spleen. The pO₂ measured in the normal liver was about 14 torr and was constant for the 2-week experimental period. The pO₂ decreased when measured at 1, 2, and 6 days after treatment with a hepatotoxin (carbon tetrachloride (CCI₄)); within 2 weeks, it returned almost to the initial level. Measurements by EPR at sacrifice of controls and CCI₄-treated mice indicated that more than 90% of the India ink went to the liver; the spleen contained 4.7% of total amount in control mice and 8.8% in CCI₄-treated mice when measured 2 weeks after the treatment. These data indicate the usefulness of India ink for measuring the pO₂ of the liver in vivo and that the pO₂ in the Kupffer cells is decreased when the liver is damaged by CCI₄.     

Minor,moderate and severe head injury

Summary The future role of the neurosurgeon in the management of head injury is reviewed in terms of the care of patients with minor, moderate and severe head injuries. In minor head injury it is predicted that there will be increasing pressure on the neurosurgeon to undertake the management and follow-up of all patients who have sustained head injury, and this will place a considerable additional load on each neurosurgical unit. This is based on a survey of 1919 head injuries admitted in one calendar year (1981), consisting of 93 severe injuries (GCS < 8), 210 moderate injuries (GCS 8–12), and 1616 minor injuries (GCS 13/14). In moderate injuries CT will assume a major role in detecting hematoma early and identifying contusions. There may yet be a role for steroids in these cases and there should be a greater use of neurorehabilitation, instead of the current overemphasis on the severely injured. In severe injury future efforts will be to prevent early secondary insults and to find better methods of controlling raised intracranial pressure.     

Subkapsularës leberhämatom bei HELLP-syndrom

Zusammenfassung Das HELLP-Syndrom (Hemolysis, Elevated Liver enzymes, Low Platelets) tritt als Komplikation einer Schwangerschaftspräeklampsie auf und kann zu ausgedehnten subkapsulären Leberhämatomen führen. Wegen der Rupturgefahr der Hämatome besteht eine lebensbedrohende Notfallsituation für Mutter und Ungeborenes. Anhand von 2 Fallbeispielen wird das interdisziplinäre Vorgehen diskutiert. Mit Diagnosestellung der subkapsulären Leberhämatome sollte die notfallmäßige Entbindung durch Sectio erfolgen. Dann kann die chirurgische Entscheidung für eine konservative, abwartende Therapie mit Intensivüberwachung oder für eine Notfalloperation im Falle einer Leberkapselruptur ohne vermeidbares Risiko getroffen werden.

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Subcapsular liver hematoma with HELLP-syndrome — an interdisciplinary urgency

Summary The HELLP-syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets), known as a complication during pregnancy, is associated with preeclampsia and may cause subcapsular liver hematomas. In case of hepatic rupture the lives of mother and unborn are threatened. Therefore, an interdisciplinary diagnostic and therapeutic approach is discussed and compared to two examples. The diagnosis of subcapsular liver hematoma must lead to urgent delivery through Cesarean section. Thereafter, the surgeon may decide between observation on an intensive care unit and urgent operation in case of hepatic rupture, without endangering the unborn.

     

Nodular sarcoidosis of the liver and spleen: Appearance on MR images

Small nodular lesions in the liver and spleen have been reported as an infrequent manifestation of sarcoidosis. Five patients with this appearance on either dynamic contrast material—enhanced computed tomographic (CT) or ultrasound scans underwent magnetic resonance (MR) imaging with and without dynamic gadolinium enhancement. The lesions were relatively uniform in size, ranging from 0.5 to 1.5 cm. On CT scans, they were hypoattenuating relative to surrounding parenchyma. On MR images, the lesions were hypointense relative to background parenchyma with all sequences. No substantial enhancement was observed in the lesions, although lesion conspicuity decreased over time on serial postcontrast images. Lesion conspicuity was greatest on either T2-weighted fat-suppressed (T2FS) images or early-phase dynamic contrast-enhanced images. Abdominal adenopathy was seen in three of the five patients and was hyperintense relative to liver on T2FS images in two and intermediate in intensity in one patient.     

Adjuvant treatment with ursodeoxycholic acid reduces acute rejection after liver transplantation

Acute rejection, occurring with a reported frequency of 50–70%, is still a dominating problem after liver transplantation. Medication with ursodeoxycholic acid (UDCA) has beneficial effects in different cholestatic conditions and has also been shown to reduce HLA class I antigen expression on hepatocytes in patients with PBC. Since August 1989 we have consecutively treated all patients with primary graft function with UDCA (n = 41). Patients transplanted in the first half of 1989 served as a control group (n = 8). All patients in this study were given sequential quadruple drug immunosuppression. The treatment group were given oral UDCA 10 mg/kg per day. During the first postoperative month, 17% of the UDCA-treated patients had an episode of acute rejection compared with 75% of the control patients (P < 0.01). Liver biochemistry tests 1 month postoperatively were significantly better in patients treated with UDCA. The results suggest that adjuvant treatment with UDCA reduces acute liver graft rejection.     

Liver lesion detection,characterization, and effect on patient management: Comparison of single-phase spiral CT and current MR techniques

This study compares liver lesion detection, characterization, and effect on patient management between single-phase spiral CT and MRI using spoiled gradient echo (SGE), T2-weighted fat-suppressed spin echo, and serial post gadolinium SGE. All patients with suspected liver lesions who underwent spiral CT and MRI within a 1-month period between January 1993 and September 1996 were included in the study. Spiral CT and MRI were interpreted prospectively in a blinded fashion by separate individual experienced investigators, and lesion detection and characterization were determined. Confirmation was obtained by surgery (6 patients), biopsy (18 patients), imaging follow-up (36 patients), or combined reading of all imaging studies and clinical follow-up (29 patients). Effect on patient management was determined by combined chart review and interview of the patients' physicians and by retrospective clinical assessment performed by a surgical oncologist and medical oncologist separately. Eighty-nine patients were included in the study. Regarding true positive lesion detection, 295 and 519 lesions were detected on spiral CT and MR images, respectively, which was significantly different on a patient-by-patient basis (P < .001). More lesions were detected on MR than on spiral CT in 44 of 89 patients (49.4%), and 11 of these 44 patients had lesions shown on MRI in whom no lesions were apparent on CT images. No patients had true positive lesions shown on spiral CT that were not shown on MRI. Regarding lesion characterization, 129 and 466 lesions were characterized on spiral CT and MRI images, respectively, which was significantly different on a patient-by-patient basis (P < .001). More lesions were characterized on MR than CT images in 67 patients (75.3%). Regarding effect on patient management, chart review with physician interview demonstrated that findings on MRI provided information that altered patient management as compared with findings on spiral CT in 57 patients. Retrospective clinical evaluation by the surgical and medical oncologist showed that MRI was considered to have a greater effect on patient management than spiral CT in 58 and 55 patients, respectively. Comparing current MRI technique to single-phase spiral CT, MRI detected more lesions in 49.4% and characterized more lesions in 75.3% of patients investigated for focal liver disease. MRI had a greater effect on patient management in each of the three methods than singlephase spiral CT in more than 61% of patients.