Fenoldopam to prevent renal replacement therapy after cardiac surgery. Design of the FENO-HSR study

INTRODUCTION

Acute kidney injury requiring renal replacement therapy is a serious complication following cardiac surgery associated with poor clinical outcomes. Until now no drug showed nephroprotective effects. Fenoldopam is a dopamine-1 receptor agonist which seems to be effective in improving postoperative renal function. The aim of this paper is to describe the design of the FENO-HSR study, planned to assess the effect of a continuous infusion of fenoldopam in reducing the need for renal replacement therapy in patients with acute kidney injury after cardiac surgery.

METHODS

We're performing a double blind, placebo-controlled multicentre randomized trial in over 20 Italian hospitals. Patients who develop acute renal failure defined as R of RIFLE score following cardiac surgery are randomized to receive a 96-hours continuous infusion of either fenoldopam (0.025-0.3 µg/kg/min) or placebo.

RESULTS

The primary endpoint will be the rate of renal replacement therapy. Secondary endpoints will be: mortality, time on mechanical ventilation, length of intensive care unit and hospital stay, peak serum creatinine and the rate of acute renal failure (following the RIFLE score).

CONCLUSIONS

This trial is planned to assess if fenoldopam could improve relevant outcomes in patients undergoing cardiac surgery who develop acute renal dysfunction. Results of this double-blind randomized trial could provide important insights to improve the management strategy of patients at high risk for postoperative acute kidney injury.

[Anesthesia for non-cardiac surgery in children with congenital heart diseases]

The incidence of congenital heart diseases accounts for 8-10 over 1000 liveborn. In Italy about 4000-4500 babies each year are born with congenital heart diseases; 50% of those babies (2000-2200) need cardiac surgery shortly after birth or within the first few months of life. Of the remaining 50%, half undergoes cardiac surgery later on in life and half does not necessitate any surgery; 30% of all cardiac operations consist of palliative procedures and the remaining 70% consist of one-stage corrective procedures. Improvements achieved both in surgical and anesthesiologic techniques, and in cardiopulmonary bypass and myocardial protection, have led to better results in pediatric cardiac surgery, with excellent long term survival rate, even for the more complex variants of congenital heart malformations. Therefore anesthesiologists are now more often required to deal with patients affected by congenital heart defects, for other than cardiac problems. Accurate investigation of patient's clinical history is strongly suggested. Moreover knowledge and familiarity with the modifications of the physiology, occurring in congenital heart disease patients, are mandatory for the choice of the more appropriate anesthesiologic strategy for each patient, in order to optimise the risk-benefits ratio and achieve a less traumatic impact on the cardio-circulatory and respiratory equilibrium. With the aim of achieving better results, interaction between anesthesiologist, cardiologist, pediatrician, surgeon and sometime neonatologist and cardiac surgeon, is strongly recommended in the evaluation of risks, and in decision making of strategies and timing of treatment.

Uncoupling of inflammatory chemokine receptors by IL-10: generation of functional decoys

As originally demonstrated for the interleukin 1 (IL-1) type II receptor, some primary proinflammatory cytokines from the IL-1 and tumor necrosis factor families are regulated by decoy receptors that are structurally incapable of signaling. Here we report that concomitant exposure to proinflammatory signals and IL-10 generates functional decoy receptors in the chemokine system. Inflammatory signals, which cause dendritic cell (DC) maturation and migration to lymphoid organs, induce a chemokine receptor switch, with down-regulation of inflammatory receptors (such as CCR1, CCR2, CCR5) and induction of CCR7. Concomitant exposure to lipopolysaccharide (LPS) and IL-10 blocks the chemokine receptor switch associated with DC maturation. LPS + IL-10-treated DCs showed low expression of CCR7 and high expression of CCR1, CCR2 and CCR5. These receptors were unable to elicit migration. We provide evidence that uncoupled receptors, expressed on LPS + IL-10-treated cells, sequester and scavenge inflammatory chemokines. Similar results were obtained for monocytes exposed to activating signals and IL-10. Thus, in an inflammatory environment, IL-10 generates functional decoy receptors on DC and monocytes, which act as molecular sinks and scavengers for inflammatory chemokines.

Development of Recombinant Diagnostic Reagents Based on pp85(U14) and p86(U11) Proteins To Detect the Human Immune Response to Human Herpesvirus 7 Infection

Human antibodies raised in response to human herpesvirus 7 (HHV-7) infection are directed predominantly to one or more HHV-7-infected cell proteins with apparent molecular masses of about 85 to 89 kDa. The genes that encode these proteins are unknown. However, several HHH-7 genes that possibly encode proteins in this molecular mass range have been identified. Thus, the proteins encoded by open reading frame U14 (85 kDa) and U11 (86 kDa) were expressed as recombinant proteins in bacteria. Of 13 human serum specimens that recognized the 85- to 89-kDa protein(s) of HHV-7-infected cells by immunoblotting, 12 were also reactive with recombinant pp85(U14) and 8 were reactive with p86(U11). It is concluded that (i) the HHV-7 immunodominant protein is pp85(U14) and (ii) the lack of posttranslational modifications in procaryotically expressed pp85 does not adversely affect the reactivity of human sera. Monoclonal antibody (MAb) 5E1 is an HHV-7-specific MAb directed to pp85(U14). Here, the HHV-7-specific epitope in pp85(U14) was finely mapped to the C′ terminal region between amino acid residues 484 and 502. However, as indicated by the low level of reactivity of human sera with the HHV-7-specific epitope recognized by MAb 5E1, human sera recognize additional epitopes of pp85(U14) that are required for their full reactivity.

A new patch for the Norwood procedure

The problems related to the pediatric pulmonary homograft availability and the possible transmission of viral infection led us to design a new patch for aortic enlargement in the Norwood procedure for hypoplastic left heart syndrome. This sterile bovine pericardial patch is not expensive and can be tailor-made.

Interrupted aortic arch and aortopulmonary window: one-stage repair in the first week of life

Aortic arch interruption associated with an aortopulmonary window is a rare congenital malformation that needs an early diagnosis and surgical treatment to avoid irreversible pulmonary lesions. Here we describe a case of a successful one-stage surgical repair in a 3-day-old neonate, without the use of prosthetic material, for the correction of the aortic arch interruption.

Aortic coarctation with hypoplastic arch in neonates: a spectrum of anatomic lesions requiring different surgical options

Hypoplasia of the transverse aortic arch is frequently associated with isthmic coarctation in many patients referred for operation in early infancy, and the surgical technique should be adjusted to suit each type of anatomic lesion. Referring to the anatomic description of hypoplastic aortic arch reported by Moulaert and associates, between January 1988 and July 1991 we operated on 32 consecutive infants (< or = 3 months old) using a surgical approach based on the echocardiographic and angiographic findings; 20 patients (62%) were younger than 2 weeks of age and 20 patients (62%) had associated intracardiac lesions. According to the location, extension, and size of the hypoplasia of the aortic arch, we had three groups of patients: in group 1 (21 patients) we performed resection and extended end-to-end anastomosis, as previously described in 1985; in group 2 (5 patients) we performed resection, posterior end-to-end anastomosis, and anterior subclavian flap enlargement; and in group 3 (6 patients) we performed direct side-to-end anastomosis between ascending and descending aorta through a median sternotomy. One patient died during the postoperative course in group 3. With a mean follow-up time of 26 months we had 4 cases (13%) of "residual" or "recurrent" coarctation in group 1, successfully repaired at 2 months of age by an anterior approach in 2 patients and by percutaneous angioplasty in the others. In conclusion, hypoplastic aortic arch in neonates represents a common difficulty, and optimal reconstruction of the entire aortic arch is mandatory to reduce operative mortality and incidence of recoarctation, especially when there are complex associated intracardiac lesions or left ventricular dysfunction.

Successful surgical repair of an aortico-left ventricular tunnel in a two day old child

Repair of an aortico-left ventricular tunnel was successfully accomplished on the second day of life in a neonate with severe cardiac failure. During pregnancy an echocardiographic diagnosis of aortic insufficiency (AI) was made and the type of the malformation was completely clarified after birth. Repair was accomplished using an open patch aortoplasty technique as suggested by Bjork.

Tubular supravalvar aortic stenosis: replacement of ascending aorta in a young patient

The diffuse form of supravalvar aortic stenosis represents a surgical challenge when ascending aorta and proximal aortic arch are involved. We describe a technique performed on a 14-year-old patient with normal aortic annulus and severe diffuse supravalvar aortic stenosis in which the replacement of ascending aorta and proximal aortic arch with a tubular prosthetic graft completely relieved the obstruction as confirmed by cardiac catheterization.

[Psychometric and electromyographic studies in patients with chronic uremia subjected to periodic hemodialysis]

Twenty-five patients suffering from chronic renal insufficiency and who had been undergoing dialysis for a long time were tested on the Wechsler-Bellevue Intelligence Scale with a control of twenty-five subjects of the same age with a comparable educational and social background. The results of the statistical analysis of the difference between the two groups demonstrates a significant psychological deterioration in the group of uremic patients which was particularly noticeable in the performance test. The rate of deterioration was not significantly related to the duration of the dialysis. At the same time electromyography (motor conduction velocity of the S.P.E. nerve) show in 40% of the uremic patients evidence of neuropathy.

[The kidney in shock. A new experimental method for the induction of controlled shock. I]

In this research we identify a new experimental model to study the shock-kidney, since this complication occurs with discreet frequency during high surgery operation. The model that better reproduce the surgical shock-kidney is the controlled hypovolemic shock. We used for this experiment five pigs of weight between 40 and 50 kg and were studied the following data: Ecg, arterial pressure, central venous pressure, diuresis (by incannulation of both ureters), renal arterial flow, levels of the renin in the renal vein. The measurements were made before, during and after the shock. The hypovolemic shock was induced by removing from carotid artery a sufficient quantity of blood to bring the pressure to 45-50 mmHg. This pressure level was kept constant for 120 min and then was reported to normal level by introducing the blood previously removed. During the experiment no kind of drugs were used.

[Behavior of several prostaglandins (PGA, PGB, PGE 1, PGE 2, PGF 1, PGF 2) in normal and leukemic leukocytes. Radioimmunological method on intact cells]

The behaviour of prostaglandins A, B, E 1, E 2, F 1 and F 2 has been examined in the granulocytes and lymphocytes of the peripheral blood of normal subjects and in circulating leucocytes of patients with CML, AML, CLL and ALL. At the same time, modifications of PGE 2 in the granulocytes of normal subjects and in patients with CML or AML before and after phagocytosis of latex particles were monitored. The general observation was a lowering in PGE and PGF in acute myeloid and lymphatic leukaemia, while the variations in CML and CLL were rather complex. Also observed was a reduction in PGE 2 in AML but not in CML, including a reduced response to phagocytosis in granulocytes. The data are compared with previous reports of AMPc and GMPc in the same cells and commented on, taking into consideration their possible reflexion on the proliferative and functional activity of the cells examined.