THU0518 ACCURACY OF DUAL-ENERGY COMPUTED TOMOGRAPHY FOR THE DETECTION OF BONE MARROW EDEMA IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS

Background:

An important applications of the Dual energy computed tomography DECT in the field of musculoskeletal radiology is the detection of bone marrow edema (BME), using a post-processing software to remove calcium in trabecular bone by using a “virtual non-calcium (VNCa)” subtraction process DECT have been successfully employed in the evaluation of the extent of BME in patients with sacroiliitis (1)

Objectives:

The aims of this study were i)to evaluate the discriminating capacity of DECT versus MRI in the detection of BME of the sacroiliac joints in patients with axial-SpA and to define the optimal cutoff; ii) to define of inter-observer agreement between radiologists

Methods:

All patients underwent a pelvic DECT examination, within 30 days of the MRI imaging, (Somatom Force; Siemens Healthineers, Enlangen, Germany). Each exam was evaluated by two operators: an experienced radiologist and a radiologist in training. The dedicated software also allows the precise calculation of the attenuation values in the region of interest (ROI). On the reformatted color-coded dual-energy virtual non-calcium images bone marrow signal is depicted in green and corresponding to high signal intensity on T2-weighted fat suppression MR images (Fig. 1). With the consent of the two operators, three ROIs were manually positioned for each side of the sacroiliac joints in the subchondral region of the proximal, middle and distal thirds of each joint head, respectively. The interobserver agreement analysis was carried out in the semi-quantitative evaluation of the scores assigned in CT. The accuracy of DECT for the detection of BME compared to MRI was analyzed using the Receiver Operating Characteristics (ROC) curve method

Figure 1.

Patient with SpA A. Short tau inversion recovery MR image demonstrating extensive BME in both iliac and sacral subchondral bone, indicating active sacroiliitis. B. CT Semicoronal multiplanar reformatted grayscale image shows signs of structural change. C. Semicoronal multiplanar reformatted color-coded dual-energyVNCaimage reveals bone marrow signal involving both sacroliliac joints, corresponds toBMEon the MR image

Results:

56 axial-SpA patients have been evaluated, 30 males and 26 females, a mean age of 48.6 ± 12.3 years, a mean disease duration of 5.5 ± 2.9 years, a mean C-reactive protein level of 3.0 ± 2.5 mg/dl. The inter-rater agreement of readers showed a high statistical significance greater than 0.80, in particular the weighted kappa is 0.815, with a standard error of 0.04 and a 95% variability coefficient between 0.73 and 0.89. Sensitivity, specificity, and positive likelihood ratio in the identification of BME at DECT were 95.8%, 83.3% and 6.67, respectively. The differences in mean CT number (HU) among the four levels of edema category were significant (p<0.0001). The AUC was 0.905 in the differentiation of the presence of BME from no edema (Fig. 2). A cutoff value of –14.8 HU yielded overall sensitivity of 82.86% and specificity of 90.48%, with an LR+ of 8.70, in the detection of BME

Figure 2.

Graph shows ROC curves from CT numbers (in Hounsfield units) derived from DECT images in the detection of sacroiliitis with and without BME. AUC was 0.905

Conclusion:

We confirm the potential of DECT for the detection of BME of the sacroiliac joints in patients affected by SpA. This new method appears to be very useful, not only in the diagnostic phase, but also for the monitoring of patients.

References:

[1]Carotti M, Salaffi F, Beci G, Giovagnoni A. The application of dual-energy computed tomography in the diagnosis of musculoskeletal disorders: a review of current concepts and applications. Radiol Med. 2019;124(11):1175-1183.

Disclosure of Interests:

None declared

The Epidemiology of Cardiac Surgery-Associated Acute Kidney Injury

Purpose

To describe current knowledge on the epidemiology of cardiac surgery-associated acute kidney injury (CSA-AKI) and to formulate recommendations for clinical practice and a research agenda.

Methods

After a modified Delphi analysis by the Acute Dialysis Quality Initiative (ADQI), 4 questions on the epidemiology of CSA-AKI and recommendations for clinical practice and a research agenda were formulated and addressed.

Results

Existing studies on CSA-AKI use over 35 different definitions for CSA-AKI. In addition, there may be important differences in patient characteristics and procedures. This explains the significant variations in reported incidence. Most studies report on CSA-AKI as defined by the need for renal replacement therapy. However, even small decreases in kidney function are associated with a worsened outcome. The workgroup formulated the recommendation to use the AKIN consensus criteria for AKI. One should differentiate early CSA-AKI, caused by the procedure, and late CSA-AKI, associated with the procedure. There may be different clinical scenarios: acute on chronic CSA-AKI, AKI prior to CS, and AKI occurring post CS. Risk factors should be differentiated between pre-, intra-, and post-CS, and between patient-, process-, and procedure-related. Endpoints should include both short-term and long-term outcomes.

Conclusions

Existing data on the epidemiology of CSA-AKI are difficult to compare due to variations in definition and patient cohort. A modified Delphi analysis resulted in a series of recommendations for future research on CSA-AKI.

First Clinical Trial for a New Crrt Machine: The Prismaflex

A new CRRT machine has been designed to fulfill the expectations of nephrologists and intensivists operating in the common ground of critical care nephrology. The new equipment is called “Prismaflex” (Gambro-Dasco, Mirandola, Modena) and it is the natural evolution of the Prisma machine that has been utilized worldwide for CRRT in the last decade.

We performed a preliminary “alfa trial” to establish usability, flexibility and realiability of the new device. Accuracy was also tested by recording various operational parameters during different intermittent and continuous renal replacement modalities. Forty-one runs were conducted on 13 patients and the difference between delivered and prescribed parameters was always lower than 2%. We concluded that the new Prismaflex is a well designed new machine for CRRT and can be safely and effectively utilized in the critical care nephrology setting.

Hepatic PPARs: their role in liver physiology, fibrosis and treatment

Complex molecular and cellular mechanisms are involved in the pathway of liver fibrosis. Activation and transformation of hepatic stellate cells (HSCs) are considered the two main reasons for the cause and development of liver fibrosis. The peroxisome proliferator-activated receptors (PPARs) belonging to the family of ligand-activated transcription factors play a key role in liver homeostasis, regulating adipogenesis and inhibiting fibrogenesis in HSCs. Normal transcriptional function of PPARs contributes to maintain HSCs in quiescent phase. A reduced expression of PPARs in HSCs greatly induces a progression of liver fibrosis and an increased production of collagen. Here, we discuss role and function of PPARs and we take into consideration molecular factors able to reduce PPARs activity in HSCs. Finally, although further validations are needed, we illustrate novel strategies available from in vitro and animal studies on how some PPARs-agonists have been proved effective as antifibrotic substances in liver disease.

Prospective multicenter study on epidemiology of acute kidney injury in the ICU: a critical care nephrology Italian collaborative effort (NEFROINT)

Acute kidney injury (AKI) is an independent risk factor for mortality in critically ill patients whose epidemiology has been made unclear in the past by the use of different definitions across various studies. The RIFLE consensus definition has provided a unifying definition for AKI leading to large retrospective studies in different countries. The present study is a prospective observational multicenter study designed to prospectively evaluate all incident admissions in 10 Intensive Care Units (ICUs) in Italy and the relevant epidemiology of AKI. A simple user-friendly web-based data collection tool was created with the scope to serve for this study and to facilitate future multicenter collaborative efforts. We enrolled 601 consecutive patients into the study; 25 patients with End-Stage Renal Disease were excluded leaving 576 patients for analysis. The median age was 66 (IQR 53-76) years, 59.4% were male, while median SAPS II and APACHE II scores were 43 (IQR 35-54) and 18 (IQR 13-24), respectively. The most common diagnostic categories for ICU admission were: respiratory (27.4%), followed by neurologic (17%), trauma (14.4%), and cardiovascular (12.1%). Crude ICU and hospital mortality were 21.7% and median ICU length of stay was 5 days (IQR 3, 14). Of 576 patients, 246 patients (42.7%) had AKI within 24 hours of ICU admission while 133 developed new AKI later during their ICU stay. RIFLE-initial class was Risk in 205 patients (54.1%), Injury in 99 (26.1%) and Failure in 75 (19.8%). Progression of AKI to a worse RIFLE class was seen in 114 patients (30.8% of AKI patients). AKI patients were older, with higher frequency of common risk factors. 116 AKI patients (30.6%) fulfilled criteria for sepsis during their ICU stay, compared to 33 (16.7%) of non-AKI patients (P<0.001). 48 patients (8.3%) were treated with renal replacement therapy (RRT) in the ICU. Patients were started on RRT a median of 2 (IQR 0-6) days after ICU admission. Among AKI patients, they were started on RRT a median of 1 (IQR 0-4) days after fulfilling criteria for AKI. Median duration of RRT was 5 (IQR 2-10) day. AKI patients had a higher crude ICU mortality (28.8% vs. non-AKI 8.1%, P<0.001) and longer ICU length of stay (median 7 days vs. 3 days [non-AKI], P<0.001). Crude ICU mortality and ICU length of stay increased with greater severity of AKI. Two hundred twenty five patients (59.4% of AKI patients) had complete recovery of renal function, with a SCr at time of ICU discharge which was ≤120% of baseline; an additional 51 AKI patients (13.5%) had partial renal recovery, while 103 (27.2%) had not recovered renal function at the time of death or ICU discharge. Septic patients had more severe AKI, and were more likely to receive RRT with less frequency of renal function recovery. Patients with sepsis had higher ICU mortality and longer ICU stay. The study confirms previous analyses describing RIFLE as an optimal classification system to stage AKI severity. AKI is indeed a deadly complication for ICU patients where the level of severity correlated with mortality and length of stay. The tool developed for data collection resulted user friendly and easy to implement. Some of its features including a RIFLE class alert system, may help the treating physician to collect systematically AKI data in the ICU and possibly may guide specific decision on the institution of renal replacement therapy.

End of life in the Intensive Care Unit

A bio-social revolution has been prompted by the capacity of artificial organ support technology to effectively sustain and/or replace many of the functions of vital organs. The consequent possibility of manipulating the dying process has generated many problems, which range from the necessity of rationing scarce and expensive resources to the definition of optimal care for dying people and the necessity of redefining death itself. In all of these situations, facts and values are strictly interconnected, and actions should be accompanied by careful bioethical reflection. In this text, we will briefly explore these issues in an attempt to illustrate the main problems related to the management of end-of-life care in the intensive care environment. We also present the protocol we use to make and implement difficult end-of-life decisions in our intensive care unit.

[A pilot study comparing pulse high volume hemofiltration (pHVHF) and coupled plasma filtration adsorption (CPFA) in septic shock patients]

High-volume hemofiltration (HVHF) and coupled plasma filtration adsorption (CPFA) have shown potential to improve the treatment of sepsis in animals, but there have been no studies comparing these two treatments in humans. Our aim was to compare the hemodynamic effects of HVHF and CPFA in septic shock patients with acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT). We performed a cross-over study enrolling patients with septic shock and AKI who were receiving CRRT. Patients were treated with pulse HVHF and continuous veno-venous hemofiltration (CVV H) on day 1 and CPFA and CVV H on day 2 or vice versa. HVHF was performed for 8-10 hours with a replacement fluid rate of 85 mL/kg/h. CPFA was performed for 8-10 hours with a plasma flow rate of 15%. CVV H was performed for the rest of the day with a replacement fluid rate of 35 mL/kg/h. The primary endpoints were changes in mean arterial pressure, vasopressor requirement (expressed as vasopressor score, VS), and noradrenaline dose after pulse HVHF and CPFA. The two treatments were compared using nonparametric tests. We enrolled 8 patients (median age 70.5 years, SOFA 12.5, SAPS II 69.5). There was a trend towards a reduction in VS with HVHF and CPFA (HVHF p=0.13, CPFA p<0.05). There was no significant difference between the two treatments in terms of percentage change in VS score (p=0.22). The data from this pilot study provide no evidence for a difference in hemodynamic effects between pulse HVHF and CPFA in patients with septic shock already receiving CRRT. A larger sample size is needed to adequately explore this issue.

When the ICU patient refuses vital supports

The aim of this paper is to discuss the problem of caring for ICU patients who request forgoing of intensive supports; in particular, evaluating their competence and building effective relationships among the patients themselves, their relatives and the health care team. The histories of 2 adult competent ICU patients 2 asked that vital intervention be forgone are presented, together with the discussion of problems posed by such a request and of possible solutions which respect patients' autonomy and bystanders needs. These patients were hospitalized in an Italian general 14 bed ICU. The patients' request were weighted against their prognosis and their view of life, in order to evaluate their reliability. Also the refusal of either treatment or outcome was evaluated, in order to effectively safeguard the patients' interests. The request of one patient was satisfied and he was allowed to die, after all the involved people had understood and accepted the final decision. The second patient, who was somehow forced to undergo intensive treatment, is alive and satisfied with having been cured. In Italy too, autonomy is an increasingly applied principle in end-of-life decisions in ICUs. It is usually tempered by a consideration about the patients' best interest as perceived by involved bystanders.

Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial

BACKGROUND

Continuous veno-venous haemofiltration is increasingly used to treat acute renal failure in critically ill patients, but a clear definition of an adequate treatment dose has not been established. We undertook a prospective randomised study of the impact of different ultrafiltration doses in continuous renal replacement therapy on survival.

METHODS

We enrolled 425 patients, with a mean age of 61 years, in intensive care who had acute renal failure. Patients were randomly assigned ultrafiltration at 20 ml/h-1/kg(-1) (group 1, n = 146), 35 ml/h(-1)/kg(-1) (group 2, n = 139), or 45 ml/h(-1)/ kg(-1) (group 3, n = 140). The primary endpoint was survival at 15 days after stopping haemofiltration. We also assessed recovery of renal function and frequency of complications during treatment. Analysis was by intention to treat.

RESULTS

Survival in group 1 was significantly lower than in groups 2 (p = 0.0007) and 3 (p = 0.0013). Survival in groups 2 and 3 did not differ significantly (p = 0.87). Adjustment for possible confounding factors did not change the pattern of differences among the groups. Survivors in all groups had lower concentrations of blood urea nitrogen before continuous haemofiltration was started than non-survivors. 95%, 92% and 90% of survivors in groups 1, 2 and 3, respectively, had full recovery of renal function. The frequency of complications was similarly low in all groups.

INTERPRETATION

Mortality among these critically ill patients was high, but increase in the rate of ultrafiltration improved survival significantly We recommend that ultrafiltration should be prescribed according to patient's bodyweight and should reach at least 35 ml/h(-1)/kg(-1).

Principles, protocols and patients: the practical management of a limit in ICU

The definition and management of a limit is a common but sometimes extremely complex problem in the Intensive Care Unit (ICU). Guidelines and consensus documents have been published in order to help clinicians. Yet, many controversial issues are brought into question. Legal rules are sometimes vague and derive more from the interpretation of various and unrelated principles (which vary from country to country) than from a clear ad hoc law. In this sense, the practical management of a limit in ICU is usually run by a dual normativity: an external one, which derives from the cultural, moral and legal values of the society, and an internal one, which depends on the particular clinical and human situation, namely the values of everybody involved in (the patient, his/her relatives, the health staff) and the relationships among these people. The considerable freedom left for the decision by an open communication is a great and favourable potential which must be used in the interest of the patient's and of his/her family.

Assessment of adequacy of ICU admission

BACKGROUND

Direct costs of critical care are increasing more than in other health care sectors. Tools are needed to evaluate adequacy of ICU admission in order to have a proper allocation of ICU resources.

OBJECTIVE

evaluation of different ways used to assess adequacy of ICU admission.

METHODS

STUDY TYPE

12 months prospective descriptive study.

SETTING

24 Intensive Care beds of a 1000 beds tertiary hospital in Italy.

PATIENTS

2314 patients admitted to Cardiac Surgery, General and Postoperative Intensive Care Units.

INTERVENTIONS

all patients admitted to the ICUs were studied. Information was collected for the patients' age, source of admission, diagnoses, surgical status, reason for admission, SAPS II score, NEMS daily score, LOS, ICU outcome. The number of available beds (ventilated or not) and nurse working hours were obtained.

RESULTS

2373 patients were admitted to the ICs, with an overall readmission rate of 2.5%, and a total amount of 8084 NEMS record. The mean Work Utilization Ratio was significantly different between the three IC and between working and weekend days in PACU and CSU. The 49.7% of the NEMS points is scored by the SAPS II 43-78 patients, corresponding to the 29.2% of >24 h admissions. The level of care provided and the trend of each admission was derived from NEMS score according to Iapichino. The proportion of HT records in each IC was 88.3% in ICU, 73.1% in PACU and 91.2% in CSU; the outcome (dead/discharged) was significantly different between LT and HT.

CONCLUSIONS

Despite the difficulties imposed by he rigid nurses' work organization in Italy, a daily data collection about level of care, severity of illness, workload utilization could provide, together with standard administrative indexes, the necessary framework to assess and to improve adequacy of ICU admission.

Adsorption in sepsis

The pathophysiology of sepsis offers a highly complicated scenario. In sepsis, endotoxin or other gram-positive-derived products induce a complex and dynamic cellular response, giving rise to several mediators known to be relevant in the pathogenesis of septic shock such as specific mediators, substances responsible for up- or down-regulation of cytokine receptors and cytokine antagonists, inactivators of translational or transductional pathways, and precursor molecules. In this review, we delve into some new concepts stemming up from the use of sorbents in continuous plasma filtration. Nonspecific simultaneous removal of several mediators of the inflammatory cascade have led to improved outcomes in animal models of septic shock and to improved hemodynamics in a pilot clinical study. It seems of great importance to explore all possible treatment techniques that may have a direct impact on circulating mediators of sepsis and that also may interfere with the imbalance between proinflammatory and anti-inflammatory substances in the critically ill patient with multiple organ failure. In this view, the application of sorbents appears to open new and interesting therapeutic options. The search for innovative treatments specifically targeted to the special needs of the critically ill patients seems therefore more important than the attempt to adjust concepts and technologies that are normally applied to patients with chronic renal failure.

Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial

BACKGROUND

Continuous veno-venous haemofiltration is increasingly used to treat acute renal failure in critically ill patients, but a clear definition of an adequate treatment dose has not been established. We undertook a prospective randomised study of the impact different ultrafiltration doses in continuous renal replacement therapy on survival.

METHODS

We enrolled 425 patients, with a mean age of 61 years, in intensive care who had acute renal failure. Patients were randomly assigned ultrafiltration at 20 mL h(-1) kg(-1) (group 1, n=146), 35 mL h(-1) kg(-1) (group 2, n=139), or 45 mL h(-1) kg(-1) (group 3, n=140). The primary endpoint was survival at 15 days after stopping haemofiltration. We also assessed recovery of renal function and frequency of complications during treatment. Analysis was by intention to treat.

RESULTS

Survival in group 1 was significantly lower than in groups 2 (p=0.0007) and 3 (p=0.0013). Survival in groups 2 and 3 did not differ significantly (p=0.87). Adjustment for possible confounding factors did not change the pattern of differences among the groups. Survivors in all groups had lower concentrations of blood urea nitrogen before continuous haemofiltration was started than non-survivors. 95%, 92%, and 90% of survivors in groups 1, 2, and 3, respectively, had full recovery of renal function. The frequency of complications was similarly low in all groups.

INTERPRETATION

Mortality among these critically ill patients was high, but increase in the rate of ultrafiltration improved survival significantly. We recommend that ultrafiltration should be prescribed according to patient's bodyweight and should reach at least 35 mL h(-1) kg(-1).

Bioethical issues related to continuous renal replacement therapy in intensive care patients

OBJECTIVE

To examine the ethical approach of intensivists and nephrologists to continuous renal replacement therapy (CRRT).

DESIGN

A questionnaire.

SETTING

The First International Course on Critical Care Nephrology.

PARTICIPANTS

The participants in the course (around 500).

RESULTS

Most participants think that establishing ethical criteria for managing CRRT is a medical task, as clinicians have adequate criteria for defining futility. However, many responders would grant the request of starting futile CRRT or would maintain it if requested by the family. Only 55% believe that informed consent is necessary for initiating CRRT; one out of four would start or maintain unwanted life-saving CRRT. In case of lack of equipment, the majority would select the patients, excluding the worst one or on a "first-come, first-served" basis. Withholding and withdrawing are regarded differently by most responders. Again, most think that every vital support should be withdrawn when futile, but practical and psychological aspects still influence the final decision. Responders think that ethics critical care committees can help in the management of ethical problems in ICU.

CONCLUSIONS

Our results show that several ethical questions are still unsolved and that practical and psychological aspects of the treatment process can be stronger than bioethical principles.

Use of adsorptive mechanisms in continuous renal replacement therapies in the critically ill

The pathophysiology of sepsis is becoming a more complicated scenario. In sepsis, endotoxin or other gram-positive derived products induce a complex and dynamic cellular response giving rise to several mediators known to be relevant in the pathogenesis of septic shock, such as specific mediators. substances responsible for up- or down-regulation of cytokine receptors and cytokine antagonists, inactivators of nuclear factor-kappaB or signal transduction pathways, and precursor molecules. In this article, we delve into some new concepts stemming from the use of sorbents in continuous plasma filtration. The rationale is based on the assumption that the nonspecific removal of several mediators of the inflammatory cascade and cytokine network may improve outcome in a rabbit model of septic shock and hemodynamics in a pilot clinical study. The importance of looking for innovative treatments specifically targeted for the special needs of the critically ill patients rather than using concepts and technology applied to the treatment of chronic renal failure is underlined.

Results from ethical international surveys on the management of the continuous renal replacement therapy

OBJECTIVE

To examine the ethical approach of clinicians to the continuous renal replacement therapy (CRRT).

DESIGN

Review of international surveys.

RESULTS

Many surveys have been carried out in order to evaluate the clinical approach and management of the continuous renal replacement therapy (CRRT). Nothing has been proposed in order to evaluate it from a bioethical point of view, even if many surveys dealt with the problem of the ethically correct administration of vital supports. These data demonstrate that an ethically correct approach to the management of life-saving support can be sometimes difficult. Results of a recent study on the ethical approach of intensivists and nephrologists to CRRT will be shown and discussed.

CONCLUSIONS

Several ethical questions in the management of CRRT and other vital support are still unsolved. Practical and psychological aspects of the curing process are sometimes stronger than bioethical principles.

Present and future options in continuous renal replacement therapies of sepsis and MOF

Conventional continuous extracorporeal treatments such as hemofiltration and hemodiafiltration have not achieved significant reduction in cytokine plasma levels, in spite of their increasing popularity mainly related to the unnecessary fluid restriction thereby rendering adequate caloric intake possible (Actualités Nephrologiques, 1994). This is mainly due to reduced filtration, to saturability of the adsorption-related phenomena and to the absence of a convective mass transfer. New approaches have been more recently introduced. The concept of blood purification has been applied in some new innovative techniques that use non-selective or selective sorbents. We will focus on the criteria used by others and us to assess the efficiency in vitro and in animal models of sepsis of more recently introduced non-selective and selective devices. Among the innovative techniques, modalities aimed at the plasma treatment will receive emphasis. These modalities that are based on plasma filtration with the use of different sorbents. The preliminary results obtained from ongoing clinical trials will be presented. We will also expand on the technical, biological and clinical aspects that should be addressed in order to establish a new modality as innovative in the treatment of sepsis.

Human natriuretic factor in cirrhotic patients undergoing orthotopic liver transplantation

We measured the plasma levels of atrial natriuretic factor (ANF) during orthotopic liver transplantation (OLT) in eight adult patients with cirrhosis and ascites. The aim of this study was to determine whether significant differences in ANF concentration may be detected during the individual phases of OLT and to correlate these changes with hemodynamics. In each patient a hemodynamic assessment was achieved using a Swan-Ganz fiber optic catheter for continuous monitoring of cardiac output (CO), systemic vascular resistance index (SVRI), right filling pressure as assessed by central venous pressure (CVP), and left filling pressure by means of pulmonary arterial wedge pressure (PAWP). During reperfusion a clear-cut increase in ANF values was observed (P < 0.05). Concurrently, an increase in CVP (P < 0.05) and a decrease in SVRI were observed without any significant increase in diuresis. These data suggest that ANF might play a role in the development of the reperfusion syndrome.

Aprotinin efficacy on intraoperative bleeding and transfusion requirements in orthotopic liver transplantation

BACKGROUND

Bleeding complications frequently occur during orthotopic liver transplantation (OLT), particularly in patients with liver cirrhosis. Enhanced fibrinolytic activity in plasma was seen to play a key role in the development of the hemostatic disorder and of hemorrhages. Aprotinin, a serine protease inhibitor, has been used in the prevention and/or treatment of hyperfibrinolytic states.

STUDY DESIGN AND METHODS

In the present study, the effect of aprotinin on bleeding complications and transfusion requirements was investigated in OLT patients with liver cirrhosis. Seven consecutive cirrhotic patients undergoing OLT were infused with aprotinin following an original protocol (1,000,000-KIU intravenous loading dose plus 500,000 kallikrein-inhibitory units per hour until skin closure). Seven previous cirrhotic OLT patients not receiving aprotinin were used as controls.

RESULTS

In the treated group, a significant decrease in the number of transfused units of packed red cells (48.7%, p < 0.01), fresh-frozen plasma (24.4%, p < 0.05), platelets (35.9%, p < 0.01), and autologous blood (55.2%, p < 0.01) was observed as compared with the control group. Moreover, the mean length of operation was significantly shorter in the aprotinin-infused patients than in untreated patients (8.3 +/- 1.2 vs. 10.1 +/- 1.8 hours, respectively; p < 0.01)). In the aprotinin-treated group, the antifibrinolytic efficacy was confirmed by the lack of increase in D-dimer levels and decrease of fibrinogen in plasma; on the contrary, these changes were always seen in the group not receiving aprotinin.

CONCLUSION

Infusion of aprotinin during OLT in cirrhotic patients can be recommended for the prevention of hyperfibrinolysis-triggered bleeding, thus reducing transfusion requirements. A possible protective effect on the primary nonfunction of the grafted liver is suggested.

Protein C, factor VII and prothrombin time as early markers of liver function recovery or failure after liver transplantation

Irreversible initial non-function of the graft liver is a life-threatening early complication of orthotopic liver transplantation (OLT), which needs immediate retransplantation if the patient is to survive. Since protein C (PC) is a vitamin K dependent protein synthesized in the liver and with the same half-life as factor VII (FVII), the behaviour of PC in patients undergoing OLT was studied in comparison with prothrombin time (PT) and FVII. Twelve OLT patients were divided into two groups on the basis of clinical outcome: group A (six cases) in which OLT was successful, and group B (six cases) who developed initial non-function of the graft liver. PT, FVII activity (FVII:act) and antigen (FVII:Ag) and PC activity (PC:act) and antigen (PC:Ag) were carried out on six blood samples collected during the operation. At baseline, coagulation disorders were in agreement with the underlying liver disease, but no differences were seen between the two groups when all tests were considered. Ten minutes, 1, 2 and 3 h after liver reperfusion, mean PT and FVII:act were always significantly increased in good responder patients compared to non-responders. FVII:Ag and PC:Ag were significantly higher in group A than in group B starting 2 h after the liver graft reperfusion; no difference was seen in PC:act levels between the two groups. In addition, PC:Ag mean levels were increased with respect to corresponding PC:act values in non-responder patients, suggesting a qualitative rather than quantitative defect of protein synthesis due to liver damage. In conclusion, PT and FVII:act were more sensitive than PC activity as early prognostic indices of clinical outcome in OLT.

Increased acylphosphatase levels in erythrocytes from hyperthyroid patients

Acylphosphatase activity and content were measured in erythrocytes from hyperthyroid patients and healthy controls. In addition, the soluble enzymes glucose-6-phosphate dehydrogenase, hexokinase, and the membrane bound (Na+ + K+)-ATPase and Ca2+-ATPase were assayed. Our results confirmed previous studies indicating a decrease of (Na+ + K+)-ATPase and an increase of Ca2+-ATPase activity in hyperthyroid erythrocytes. While glucose-6-phosphate dehydrogenase was not significantly changed, hexokinase and acylphosphatase activities were significantly higher in the hyperthyroid group. Both activities and content of acylphosphatase returned to normal levels in erythrocytes from treated patients, when they were euthyroid. These findings suggest that an excess of thyroid hormones may stimulate acylphosphatase biosynthesis in erythroid cells and indicate a potential clinical usefulness of this enzyme in hyperthyroidism.