Experimental production of acute renal tubular necrosis. I. The role of gram-negative bacteria. II. The toxicity of acid hematin. III. Acid hematin -- the etiologic pigment

Intraoperative blood salvage: medical controversies

Although a great deal has been learned about the medical aspects of intraoperative blood salvage, several fundamental medical issues remain controversial. As pressure increases to maximize the use of IBS, more research will be needed on the application of salvage techniques in cancer surgery and in the presence of bacterial contamination. The reintroduction of the use of devices that do not wash salvaged blood have reopened investigations into the effects of reinfusion of partially hemolyzed and partially clotted salvaged blood on coagulation, renal function, and cardiopulmonary performance. More studies are also needed so that empirically based standards of practice for the collection and storage of salvaged blood can be established. No longer confined to a few pioneering surgical departments, IBS is now widely practiced and likely to continue to grow rapidly. Knowledge and research of the medical issues surrounding its use will become increasingly valuable in transfusion medicine.

Renal lesions in ischaemic kidneys infused with haemoglobin: an electron microscopic study

Male Wistar rats were used to study changes in ultrastructure of proximal renal tubular cells after an haemoglobin (Hb) load with or without temporary renal ischaemia. An i.v. injection of stroma-free Hb was given either 30 min before, immediately after, or 2 h after ischaemia. Appropriate control groups were used for comparison. Electron microscopic examination was performed on kidneys removed 48 h after treatment. Hb transport and degradation was markedly delayed by renal ischaemia. Hetero-ambi- and autolysosomes were found after Hb load, and the number of lysosomes was higher in animals with ischaemia than in sham-operated controls given Hb. Renal cellular damage was more pronounced in rats given Hb either 30 min before or 2 h after ischaemia than in those subjected to either Hb load or ischaemia alone. The findings show deleterious effects of haemoglobinuria in conjunction with renal ischaemia.

Protection by plasma proteins of the isolated lamb heart perfused with stroma-free hemoglobin at 38 degrees

Isolated lamb hearts were perfused for eight hours at 38 degrees with stroma-free hemoglobin solution (SFHS). The preservation of cardiac structure and function was studied. Control hearts perfused with blood (N = 6) developed no ventricular failure or significant weight gain (13% +/- 5), showed no alteration of cellular ultrastructure, and little interstitial edema. Hearts perfused with 7% (N = 7) or 11% (N = 5) SFHS contracted less well, became edematous (22% and 44% weight gain) and showed altered mitochondria, capillary endothelial swelling and hemoglobin extravasation into the interstitial space. The addition of 5-7% albumin to SFHS (N = 9) markedly reduced interstitial edema (weight gain 11% +/- 13), preserved mitochondria, prevented endothelial swelling, and limited transcapillary escape of hemoglobin. Thus isolated hearts perfused with SFHS develop vascular endothelial damage and an increase in capillary permeability. The addition of plasma proteins to the perfusate protects against this injury.

Autologous blood transfusion

Autologous blood transfusion is a procedure in which blood is removed from a donor and returned to his circulation at some later time. Autologous transfusion can be performed in three ways: (1) preoperative blood collection, storage, and retransfusion during surgery; (2) immediate preoperative phlebotomy with subsequent artificial hemodilution and later return of the phlebotomized blood; and (3) intraoperative blood salvage and retransfusion. All three methods of autologous transfusion offer a potentially superior method of blood transfusion which eliminates many of the problems and complications associated with the banking and administration of homologous donor blood.

Experimental acute renal failure in primates. Clinical and histopathologic evaluation in light and electron microscopy

Acute renal failure or its equivalent, acute tubular necrosis, was induced in rhesus monkeys by a combination of dehydration, hemorrhagic hypovolemia, and packed cell transfusion. Clinicopathologic changes were studied at different time intervals. Increasing edematous swelling and disintegration of the epithelial cells in the convoluted tubules, thick loops of Henle, and collecting tubules during the first four hours were conspicuous. As a result, intratubular cellular detritus, red blood cells, and various types of casts were increased progressively between one and four hours, and decreased thereafter. As the time progressed, edema was subsiding but the absorption granules and fat droplets were increased in size and number from one to twenty-four hours. These findings would indicate widespread cellular degeneration and necrosis. Consequently, tubular integrity was impaired leading to necrosis, denuded tubular basement membranes, and occasional tubulorrhexis. Concurrently, some dilated peritubular or interstitial capillaries were ruptured releasing red blood cells and cellular debris, which eventually were picked up by the damaged tubules. Although the regeneration of the renal parenchyma was in progress after sixteen hours, groups of subcapsular tubules were dilated showing flattened epithelial cells. The glomerular capillaries were either dilated or engorged, empty or collapsed during the experiment. Bowman's spaces contained red blood cells and varying amounts of cellular debris. Although the clinicopathologic changes reported here may be attributed to one or more of the following factors, hypoxia, toxic effects and dehydration, most of the changes were apparently due to hypoxia.

Crush syndrome: a report of 2 cases and a review of the literature

The crush syndrome was first defined as a clinical entity in 1941. This paper reports 2 patients suffering from the syndrome as a result of being trapped for several hours during the Moorgate tube train disaster. An account of the initial course, management and complications is presented and discussed with reference to the available literature on the subject.

[Acute renal failure after the infusion of hemoglobin solutions with or without red cell ghosts in rabbits (author's transl)]

Out of 85 rabbits 2j received a purified 6% hemoglobin solution free of ghosts (1,8 gHb/Kg) and were compared to 14 animals receiving the same dose of a crude hemoglobin solution containing ghosts. 11 rabbits had 5 infusions with a daily dose of 1,2 g Hb/Kg of the stromafree solution. Controls were partly untreated partly infused with saline. Creatinin, urea, electrolytes, and haptoglobin were determined in the serum oxygen consumption was measured separately in cortex and medulla by Warburg technique, and all kidneys examined histologically. In both groups 20% of the animals died spontaneously. Both groups exhibited the typical morphological and functional signs of acute renal failure. There was an increase in creatinin, urea, and potassium in the serum and a gain in kidney weights. In cortex and medulla we found a 20% drop in O2 consumption in both groups. Thus there was no evidence that ghosts play any role in the pathogenesis of renal failure in hemolysis or in the course of Hb-infusions. even after 5 infusions with lower dose renal damage was demonstrable. The drop in haptoglobin levels indicates, that renal ischemia may be induced by a disturbance in hemoglobin breakdown. The pathogenesis of renal damage has to be elucidated before Hb-solutions come into therapeutical use.

Treatment of severe burns with aqueous silver nitrate (0.5 percent)

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