Prerequisites to Salvage Profound Biventricular Failure Patients with Ventricular Assist Devices

We conducted chronic experiments to determine how to treat profound biventricular failure systematically with ventricular assist devices (VADs) and to analyze the factors that affect prognoses for this condition. Anoxic arrest was induced in ten goats by aortic cross-clamping under normothermic conditions (38.5° C) for 30 (n= 3), 45 (n= 1), and 60 (n= 6) minutes. A left ventricular assist device (LVAD) was implanted in eight animals, and a biventricular assist device (BVAD) was used in two. Three goats — two of which had undergone anoxic arrest for 30 minutes and one for 60 minutes — whose right atrial pressure (RAP) was approximately 18 mm Hg during the acute stage, recovered in two to three weeks, and the pumps were successfully removed. Pathological findings in these animals showed scattered areas of surviving myocardium, with connective tissue replacing the degenerated myocardium. The remaining five LVAD goats required higher RAPs to maintain circulation and died from various causes. Maintaining circulation without volume loading, even in the presence of arrhythmias, was easier with the BVAD. One BVAD animal that underwent 45 minutes of anoxic arrest recovered from right ventricular failure, and the right pump was removed. The second goat (anoxic arrest, 60 min) on the BVAD failed to recover. Autopsy of the myocardium revealed a thin ventricular wall. Our studies show that the use of VADs allows time for a failing heart to recover, but the potential for healing is affected by the severity of myocardial damage prior to VAD application. We believe that although LVADs can maintain circulation with high RAPs, the use of BVADs might be more beneficial for maintaining systemic organ function in cases of persistent biventricular failure.

Treatment of Acute Myocardial Infarction with Cardiogenic Shock using Left Ventricular Assist Device

We have treated ten cardiogenic shock patients after acute myocardial infarction (AMI) with a left ventricular assist device (LVAD). These patients were later divided into three groups: the first group with ventricular septal perforation, the second with aorto-coronary bypass grafting (ACBG) before LVAD implantation and the third group without ACBG. LVAD maintained the systemic circulation in each group, and cardiac function recovered enough to remove LVAD in 70% of the total patients. Two of three patients in the first group were discharged from hospital. Two weaned cases in the second group died of multiple organ failure and one was discharged, and hemorrhagic necrosis was seen in the bypassed area of the myocardium. One patient of the third group could not be weaned from LVAD because of respiratory failure though his heart function began to recover. Another case in the third group underwent bypass grafting after removal of LVAD. However ACBG surgery should be done very carefully because a patient in shock is occasionally intolerant to major surgery. In all groups, the major cause of death was multiple organ failure which was probably caused by the prolonged low output condition prior to LVAD application. In the light of this experience, it appears that LVAD should be applied before irreversible damage occurs to major organs, including the heart itself. To ensure the timely application of LVAD, some way must be found to introduce systematic application of LVAD into the normal course of AMI treatment.

Experience of Lymphangiography as a Therapeutic Tool for Lymphatic Leakage After Kidney Transplantation

INTRODUCTION

Lymphatic leakage after kidney transplantation is a relatively frequent complication but sometimes resistant to treatment, and there is no fixed treatment algorithm. The effectiveness of therapeutic lymphangiography for postoperative lymphatic or chyle leakage has been reported, but few reports are available regarding patients who have undergone kidney transplantation. In this study, we report our experience with lymphangiography as a therapeutic tool for lymphatic leakage after kidney transplantation.

PATIENTS AND METHODS

Intranodal lymphangiography for lymphatic leakage was performed in 4 patients (3 male, 1 female; age range, 38 to 70 years old) after living kidney transplantation at the Osaka City University Hospital in Japan. The amount of drainage before lymphangiography was 169 to 361 mL/day. The procedure for intranodal lymphangiography was as follows: the inguinal lymph node was punctured under ultrasound guidance, and the tip of the needle was instilled at the junction between the cortex and the hilum, after which Lipiodol was slowly and manually injected.

RESULTS

Lymphangiography was technically successful in 3 out of the 4 patients. In all successful cases, the amount of drainage decreased and leakage finally stopped without additional therapy such as sclerotherapy or fenestration. In 2 cases, we were able to directly detect the leakage site using lymphangiography. The time between lymphangiography and leakage resolution ranged from 8 to 13 days. There were neither complications of lymphangiography nor recurrence of lymphatic leakage in the successful cases.

CONCLUSIONS

Intranodal lymphangiography may be not only a diagnostic tool but also an effective, minimally-invasive, and safe method for treatment of lymphatic leakage resistant to drainage after kidney transplantation.

Beneficial Effects of High-Dose Mizoribine on ABO-Incompatible Living-Related Kidney Transplantation: Two-Year Results by a Japanese Multicenter Study

BACKGROUND

Mizoribine (MZ) has been developed as an immunosuppressive agent in Japan, but it has a less-potent immunosuppressive effect up to 3 mg/kg/d. In the previous study, a Japanese multicenter study, we reported that high-dose MZ, at 6 mg/kg/d, with a calcineurin inhibitor was effective and safe in reducing the frequency of cytomegalovirus (CMV)-related events in ABO-incompatible (ABO-i) living-related kidney transplantation (LKT). In the present study, therefore, we investigated the effects of high-dose MZ with a CNI in ABO-i LKT recipients in a Japanese multicenter study.

METHODS

A total of 37 patients were treated with high-dose MZ (6 mg/kg), a CNI (cyclosporine [CsA] or tacrolimus [Tac]), basiliximab (Bas), rituximab (Rit), and corticosteroids. CsA was started at a dose of 7 mg/kg to maintain blood levels [200 ng/mL (C0), 6000 ng-h/mL (AUC 0-9)]. Tac was started at a dose of 0.2 mg/kg to maintain blood levels [8-10 ng/mL (C0), 100 ng-h/mL (AUC 0-9)]. Bas (20 mg/body) was administrated on day 0 and day 4 after transplantation. Rit (100-200 mg/body) was administrated on day -14 and day -7 before transplantation. MZ was adjusted to maintain target C0 levels of 1.5 to 2.0 μg/mL.

RESULTS

Patient and graft survival rates for 2 years were 100% in the CsA group (n = 22) and 93.3% in the Tac group (n = 15) (not significant, NS). Overall incidence of acute rejection for 2 years was 22.7% in the CsA group and 26.7% in the Tac group. Mean serum creatinine levels at 2 years were 1.29 ± 0.2 mg/dL in the CsA group and 1.21 ± 0.34 mg/dL in the Tac group (NS). The incidence of CMV disease was 0% in both groups, and positive rates of CMV antigenemia were 50.0% and 26.7% in the CsA and Tac groups, respectively (NS). Mean serum uric acid levels were 5.5 ± 1.3 mg/dL and 6.4 ± 1.2 mg/dL at 2 years (NS) in the CsA and Tac groups, respectively.

CONCLUSIONS

A high-dose MZ regimen including calcineurin inhibitor (CsA or Tac), Bas, Rit, and steroids was effective and safe in reducing the frequency of CMV-related events in ABO-i LKT.

Investigation of urinary angiotensinogen in renal transplant recipients

BACKGROUND

Recent studies have indicated that angiotensinogen (AGT) is also locally produced in the kidney and that urinary AGT is a marker of local renal renin-angiotensin system activation. Because urinary AGT levels are significantly higher in patients with chronic kidney disease (CKD) than in patients without CKD and correlate with urinary albumin and other levels, urinary AGT is increasingly recognized as a marker for CKD monitoring, prognosis, and treatment. In this study, we investigated urinary AGT levels in renal transplant recipients.

METHODS

Among the patients who were treated as outpatients at the Department of Urology of Osaka City University Hospital from March 2012 to April 2013, 146 stable renal transplant recipients and 50 donors who gave informed consent were studied. Urinary AGT and creatinine (Cr) levels were measured. The urinary AGT-to-Cr ratio was calculated, and its correlation with clinical parameters was examined.

RESULTS

The urinary AGT-to-Cr ratio of the renal transplant recipients was significantly higher than that of the renal transplant donors (P = .0143). Furthermore, the urinary AGT-to-Cr ratio had a significantly positive correlation with the urinary albumin-to-Cr ratio (ACR; r = 0.39, P < .0001), while on the other hand, it had a significantly negative correlation with estimated glomerular filtration rate (eGFR; r = -0.31, P = .0002). Multiple linear regression analysis of factors associated with eGFR showed that urinary AGT was a significant and independent factor after adjusting for age, sex, and ACR.

CONCLUSIONS

Our results indicated that urinary AGT levels were elevated in renal transplant recipients. In addition, urinary AGT significantly correlated with renal function and degree of albuminuria.

Structural changes in dermal collagen and oxidative stress levels in the skin of Japanese overweight males

OBJECTIVE

It has been reported that obese people have poorly organized dermal collagen structure because of the degradation of collagen fibers, which is caused by an increase in oxidative stress levels associated with the hypertrophy of subcutaneous adipose cells. However, it is unclear whether an increase in oxidative stress levels caused by the accumulation of subcutaneous adipose tissue and a change in the dermal structure also occur in overweight and obese Japanese people. The objectives of this study are to identify structural changes that occur in the dermis and to measure the levels of oxidative stress in Japanese overweight males.

METHODS

The overweight group included 43 Japanese male volunteers aged between 25 and 64 years and with a body mass index (BMI) of ≥25 and <30. The control group included 47 male volunteers aged between 22 and 64 years and with BMI of <25. The 20-MHz Dermascan C® ultrasound scanner with software for image analyses was used. Echogenicity of the upper and lower dermis was measured. The mRNA expression level of heme oxygenase-1 (HMOX1) in hair follicles was quantitatively analyzed by real-time reverse transcription polymerase chain reaction (RT-PCR) and was used as a marker of oxidative stress. Ultrasonographic imaging and collection of hair follicles were performed at the same site on the thigh, abdomen, and upper arm.

RESULTS

The HMOX1 mRNA expression level in the abdomen and thigh was significantly lower in the overweight group than in the control group. Moreover, the echogenicity of the upper dermis of the abdomen and the lower dermis of the abdomen and thigh was significantly lower in the overweight group than in the control group.

CONCLUSION

We detected an increase in oxidative stress levels and a decrease in the density of dermal collagen at the same site on the thigh, abdomen, and upper arm of Japanese overweight males. These findings suggest the fragility of the dermis of Japanese overweight males, which might have been caused by the accumulation of subcutaneous adipose tissue.

Poor glycemic control and decreased renal function are associated with increased intrarenal RAS activity in Type 2 diabetes mellitus

AIMS

The renin-angiotensin system (RAS) plays an important role in the pathogenesis of diabetic nephropathy. The aim of the present study was to investigate intrarenal RAS activity in patients with type 2 diabetes (T2DM).

METHODS

We measured urinary angiotensinogen, a reliable biomarker of intrarenal RAS activity, in 14 controls without T2DM, 25 T2DM patients without nephropathy, 11 chronic kidney disease (CKD) patients without T2DM and 46 CKD patients with T2DM. Associations between urinary angiotensinogen and clinical parameters were examined.

RESULTS

Compared with the controls, urinary [angiotensinogen:creatinine] were significantly higher in T2DM patients without nephropathy (4.70 ± 2.22 vs. 8.31 ± 5.27 μg/g, p=0.037). Age, hemoglobin A1c (HbA1c) and fasting plasma glucose correlated significantly and positively with the log{urinary [angiotensinogen:creatinine]} (r=0.632, p=0.007; r=0.405, p=0.027; r=0.583, p=0.003, respectively) in T2DM patients without nephropathy. In contrast, the urinary [angiotensinogen:creatinine] were not significantly different between CKD patients with and without T2DM (22.7 ± 27.8 vs. 33.5 ± 40.8 μg/g, p=0.740); although they were significantly higher when compared with non-CKD patients. In the CKD patients with T2DM systolic blood pressure, serum creatinine, estimated glomerular filtration rate and urinary [albumin:creatinine] correlated significantly with the log{urinary [angiotensinogen:creatinine]} (r=0.412, p=0.004; r=0.308, p=0.037; r=-0.382, p=0.001; r=0.648, p<0.001, p<0.001, respectively).

CONCLUSIONS

Our findings indicate that poor glycemic control is significantly associated with intrarenal RAS activity in T2DM patients without nephropathy, and that decreased renal function is significantly associated with intrarenal RAS activity in CKD patients with T2DM.

Pneumomediastinum and Subcutaneous Emphysema after High Pressure Air and Sand Injection Injury to the Upper Arm

We present a rare case of a 47-year-old man who developed pneumomediastinum and subcutaneous emphysema after a high pressure hose accidentally injected air and sand particles into his right upper arm. On presentation, he complained of dyspnoea and chest pain. He had palpable subcutaneous emphysema extending from the upper arm to his neck, face, and trunk. Plain X-ray films and computed tomography showed pneumomediastinum and subcutaneous emphysema, but no sand particles. Conservative treatment was done with close observation, and serial radiographs were obtained. There was complete resolution of the mediastinal and subcutaneous air after about two weeks with no evidence of infection. This was an extremely rare case of pneumomediastinum and severe subcutaneous emphysema occurring after accidental air injection injury to the upper arm. With regard to how air entered the mediastinal cavity, possible pathways are discussed. (Hong Kong j.emerg.med. 2014;21:51-54)

Usefulness and Problems of Intraosseous Infusion with the Bone Injection Gun™ Using Simulators Under Confined Space Conditions

Introduction

It is important to have a venous line for infusion as an emergency treatment for patients suffering from crush syndrome or bleeding under confined space (CS) conditions in disaster medicine. However, it is not easy to for Emergency Life-Saving Technicians (ELSTs) to establish a venous line in such settings. Although previous studies have described the use of mechanical intraosseous (IO) devices and IO access while wearing chemical protection gears, problems for the use of IO devices under CS conditions have not been considered. This study aimed to investigate usefulness and problems of using a Bone Injection Gun™ (BIG) for IO infusion by ELSTs and rescue workers in CS conditions.

Methods

The time required and success rate for IO infusion using a BIG in a manikin leg were measured, and for administering intravenous infusion in a manikin arm using either rescue gloves or plastic gloves by ELSTs or rescue workers under CS conditions.

Results

Wearing rescue gloves, ELSTs were significantly faster in placing intraosseous infusion (IOI) compared with rescue workers. The success rate of the placement was not significantly different between ELSTs and rescue workers whether or not they wore rescue or plastic gloves.

Conclusions

Although the finite usefulness of IOI with BIG under CS conditions is indicated, some problems such as the timing of removal of the IOI and difficulty in finding the location of the trocar needle after activating BIG are pointed out. Therefore, there are rooms to consider using IOI with BIG under CS condition. (Hong Kong j.emerg. med. 2014;21:23-30)

Insulin resistance and insulin secretion in renal transplant recipients with hepatitis C

BACKGROUND

Several reports have suggested an association between hepatitis C virus (HCV) infection and new-onset diabetes after transplantation (NODAT). NODAT is a common complication after renal transplantation, and it has been associated with increased long-term morbidity and mortality. HCV-positive recipients may have abnormal glucose metabolism, even though NODAT has never been previously diagnosed. The aim of this study was to analyze the pathogenic factors responsible for glucose metabolism in a series of HCV-positive renal transplant recipients.

METHODS

The study population comprised 16 renal transplant patients who received their grafts from deceased or living donors with anti-HCV antibodies. HCV-negative transplant recipients were individually matched with these HCV-positive recipients by year of transplantation, sex, age, serum creatinine levels, and type of calcineurin inhibitors. None of the patients had been diagnosed with diabetes. Insulin secretion and insulin resistance were determined by a 75-g oral glucose tolerance test (OGTT) and compared between the 2 groups. Categories of glucose tolerance were defined according to World Health Organization criteria.

RESULTS

Glucose intolerance (impaired fasting glucose, impaired glucose tolerance, diabetes mellitus) as assessed by OGTT was detected in 7 of the HCV-positive recipients (43.8%) and 3 of the HCV-negative recipients. The homeostasis model assessment of insulin resistance was greater in the HCV-positive recipients than in the HCV-negative recipients. The homeostasis model assessment of β-cell function was higher in the HCV-positive recipients than in the HCV-negative recipients.

CONCLUSIONS

The frequency of glucose intolerance tended to be higher in HCV-positive recipients. Furthermore, insulin resistance was greater and insulin secretion higher in HCV-positive recipients, which indicated that the increase in insulin secretion compensated for insulin resistance observed in these patients. However, HCV-positive renal transplant recipients may ultimately develop NODAT as this compensation diminishes with time.