Lap. Nissen fundoplication leads to better respiratory symptom control than Toupet in the long term of 20 years.

INTRODUCTION: Having performed anti-reflux surgery for thirty years, it was important to reexamine our patients in the long term to enlarge the body of evidence concerning classical and extraesophageal symptoms that are differently controlled by Nissen or Toupet fundoplication. OBJECTIVES: We report a cohort of 155 GERD patients who underwent fundoplication within a tailored approach between 1994 and 2000. Changes in the perioperative functional outcome, GERD symptoms, and quality of life are being analyzed 10 and 20 years after the operation. RESULTS: The operation resulted in a superior quality of life compared to a patient cohort treated with PPI therapy. We found that both surgical methods (laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication) cure classical symptoms equally (heartburn, regurgitation, and dysphagia). GERD patients receiving a Toupet fundoplication seem more likely to suffer from extraesophageal GERD symptoms 10 and 20 years after surgery than patients with a Nissen fundoplication. On the other hand, some patients with Nissen fundoplication report dysphagia even 10 and 20 years after surgery. CONCLUSION: Both the laparoscopic Nissen and Toupet fundoplications provide excellent symptom control in the long term. Moreover, the Nissen fundoplication seems to be superior in controlling extraesophageal reflux symptoms, but at the expense of dysphagia. In summary, tailoring the operation based on symptoms seems advantageous.

Linear or circular: Anastomotic ulcer after gastric bypass surgery.

BACKGROUND: After laparoscopic Gastric Bypass Procedure (GBP), anastomotic ulcers (AU) at the gastrojejunostomy (GJ) occur in up to 16% of the patients. Surgical techniques seem to influence the development of AU, but this is still a matter of discussion. This study aims to compare the incidence of AU in circular-stapled (CS) versus linear-stapled (LS) gastrojejunostomy. METHODS: Single-centre retrospective analysis of 241 (m 77 /f 164) consecutive patients (126 CS, 115 LS) with primary or revisional GBP including Roux-Y-Gastric Bypass (RYGB) and One-Anastomosis Gastric Bypass (OAGB) between 01/2014 and 01/2018. Follow-up with oesophagogastroduodenoscopy was only performed in symptomatic patients. Age, body mass index (BMI), comorbidities, smoking and medication were analyzed in both groups. The data are reported as total numbers (%) and mean ± standard deviation. RESULTS: AU occurred significantly more often in the CS group than in the LS group (p = 0.0034). Moreover, refractory AU and the need for revisional surgery were higher in the CS group. Smoking correlates significantly with the development of AU, whereas other risk factors had no impact on its incidence. CONCLUSION: Linear-stapled gastrojejunostomy with a long and narrow pouch should be the preferable procedure for reducing AU development risk. Smoking cessation minimizes the risk for AU and is a necessary part of the treatment.

Real-time fluorescence and deformability cytometry.

The throughput of cell mechanical characterization has recently approached that of conventional flow cytometers. However, this very sensitive, label-free approach still lacks the specificity of molecular markers. Here we developed an approach that combines real-time 1D-imaging fluorescence and deformability cytometry in one instrument (RT-FDC), thus opening many new research avenues. We demonstrated its utility by using subcellular fluorescence localization to identify mitotic cells and test for mechanical changes in those cells in an RNA interference screen.

Colloidal crystals of compliant microgel beads to study cell migration and mechanosensitivity in 3D.

Tissues are defined not only by their biochemical composition, but also by their distinct mechanical properties. It is now widely accepted that cells sense their mechanical environment and respond to it. However, studying the effects of mechanics in in vitro 3D environments is challenging since current 3D hydrogel assays convolve mechanics with gel porosity and adhesion. Here, we present novel colloidal crystals as modular 3D scaffolds where these parameters are principally decoupled by using monodisperse, protein-coated PAAm microgel beads as building blocks, so that variable stiffness regions can be achieved within one 3D colloidal crystal. Characterization of the colloidal crystal and oxygen diffusion simulations suggested the suitability of the scaffold to support cell survival and growth. This was confirmed by live-cell imaging and fibroblast culture over a period of four days. Moreover, we demonstrate unambiguous durotactic fibroblast migration and mechanosensitive neurite outgrowth of dorsal root ganglion neurons in 3D. This modular approach of assembling 3D scaffolds from mechanically and biochemically well-defined building blocks allows the spatial patterning of stiffness decoupled from porosity and adhesion sites in principle and provides a platform to investigate mechanosensitivity in 3D environments approximating tissues in vitro.

Successful management of recurrent focal segmental glomerulosclerosis.

Primary focal segmental glomerulosclerosis (FSGS) recurs in up to 55% of patients after kidney transplantation. Herein we report the successful management of recurrent FSGS. A 5-year-old boy with primary FSGS received a deceased donor renal transplant. Immediate and fulminant recurrence of FSGS caused anuric graft failure that was resistant to plasmapheresis and rituximab. After exclusion of structural or immunologic damage to the kidney by repeated biopsies, the allograft was retrieved from the first recipient on day 27 and transplanted into a 52-year-old second recipient who had vascular nephropathy. Immediately after retransplantation, the allograft regained function with excellent graft function persistent now at 3 years after transplant. After 2 years on hemodialysis, the boy was listed for kidney retransplantation. To prevent FSGS recurrence, pretreatment with ofatumumab was performed. Nephrotic range proteinuria still occurred after the second transplantation, which responded, however, to daily plasma exchange in combination with ofatumumab. At 8 months after kidney retransplantation graft function is good. The clinical course supports the hypothesis of a circulating permeability factor in the pathogenesis of FSGS. Successful ofatumumab pretreatment implicates a key role of B cells. Herein we provide a description of successful management of kidney failure by FSGS, carefully avoiding waste of organs.

Comparing routine administrative data with registry data for assessing quality of hospital care in patients with myocardial infarction using deterministic record linkage.

BACKGROUND: Assessment of quality of care in patients with myocardial infarction (MI) should be based on data that effectively enable determination of quality. With the need to simplify measurement techniques, the question arises whether routine data can be used for this purpose. We therefore compared data from a German sickness fund (AOK) with data from the Berlin Myocardial Infarction Registry (BMIR). METHODS: We included patients hospitalised for treatment of MI in Berlin from 2009-2011. We matched 2305 patients from AOK and BMIR by using deterministic record linkage with indirect identifiers. For matched patients we compared the frequency in documentation between AOK and BMIR for quality assurance variables and calculated the kappa coefficient (KC) as a measure of agreement. RESULTS: There was almost perfect agreement in documentation between AOK and BMIR data for matched patients for: catheter laboratory (KC: 0.874), ST elevation MI (KC: 0.826), diabetes (KC: 0.818), percutaneous coronary intervention (KC: 0.860) and hospital mortality (KC: 0.952). The remaining variables compared showed moderate or less than moderate agreement (KC < 0.6), and were grouped in Category II with less frequent documentation in AOK for risk factors and aspects of patients' history; in Category III with more frequent documentation in AOK for comorbidities; and in Category IV for medication at and after hospital discharge. CONCLUSIONS: Routine data are primarily collected and defined for reimbursement purposes. Quality assurance represents merely a secondary use. This explains why only a limited number of variables showed almost perfect agreement in documentation between AOK and BMIR. If routine data are to be used for quality assessment, they must be constantly monitored and further developed for this new application. Furthermore, routine data should be complemented with registry data by well-established methods of record linkage to realistically reflect the situation - also for those quality-associated variables not collected in routine data.

The role of lipocalin-2 in liver regeneration.

BACKGROUND & AIMS: Various immune mediators such as interleukin-6 (IL-6) have been implicated in the process of liver regeneration. Lipocalin-2 (LCN2) has been recently characterized as a prototypic immune mediator produced by various cell types being involved mainly in host defence. In addition, numerous studies have demonstrated its clinical value as a biomarker. This study aimed at defining the role of LCN2 in liver regeneration. METHODS: We studied LCN2 expression in wild-type mice in a model of partial hepatectomy (PH). Furthermore, we evaluated liver regeneration after PH in LCN-deficient mice compared to littermate controls. Serum levels of LCN2 were assessed in a small group of patients undergoing hepatic resection. RESULTS: LCN2 is dramatically induced in livers and sera of wild-type mice after PH, whereas liver LCN2-receptor expression was decreased. Sham operations did not affect hepatic and serum LCN2 expression. Although LCN2-deficient mice exhibited increased baseline liver expression indices, LCN2-deficient mice did not differ from wild-type mice with respect to hepatic proliferation suggesting that this molecule is not involved in hepatic repair. Only serum IL-1ß levels were slightly lower in LCN(-/-) mice, whereas IL-6 serum levels did not differ between various tested animal groups. In humans undergoing hepatic resection, LCN2 levels increased significantly within 24 h following surgery. CONCLUSIONS: LCN2, although massively induced in mice after PH, is not relevant in murine hepatic regeneration. Further, human studies have to define whether LCN2 could evolve as biomarker after liver surgery.

Transforming growth factor-ß1 primes proliferating adult neural progenitor cells to electrophysiological functionality.

The differentiation of adult neural progenitors (NPCs) into functional neurons is still a limiting factor in the neural stem cell field but mandatory for the potential use of NPCs in therapeutic approaches. Neuronal function requires the appropriate electrophysiological properties. Here, we demonstrate that priming of NPCs using transforming growth factor (TGF)-ß1 under conditions that usually favor NPCs' proliferation induces electrophysiological neuronal properties in adult NPCs. Gene chip array analyses revealed upregulation of voltage-dependent ion channel subunits (Kcnd3, Scn1b, Cacng4, and Accn1), neurotransmitters, and synaptic proteins (Cadps, Snap25, Grik4, Gria3, Syngr3, and Gria4) as well as other neuronal proteins (doublecortin [DCX], Nrxn1, Sept8, and Als2cr3). Patch-clamp analysis demonstrated that control-treated cells expressed only voltage-dependent K(+) -channels of the delayed-rectifier type and the A-type channels. TGF-ß1-treated cells possessed more negative resting potentials than nontreated cells owing to the presence of delayed-rectifier and inward-rectifier channels. Furthermore, TGF-ß1-treated cells expressed voltage-dependent, TTX-sensitive Na(+) channels, which showed increasing current density with TGF-ß1 treatment duration and voltage-dependent (+)BayK8644-sensitive L-Type Ca(2+) channels. In contrast to nontreated cells, TGF-ß1-treated cells responded to current injections with action-potentials in the current-clamp mode. Furthermore, TGF-ß1-treated cells responded to application of GABA with an increase in membrane conductance and showed spontaneous synaptic currents that were blocked by the GABA-receptor antagonist picrotoxine. Only NPCs, which were treated with TGF-ß1, showed Na(+) channel currents, action potentials, and GABAergic currents. In summary, stimulation of NPCs by TGF-ß1 fosters a functional neuronal phenotype, which will be of relevance for future cell replacement strategies in neurodegenerative diseases or acute CNS lesions.

Nighttime procedures are not associated with adverse outcomes in kidney transplantation.

Surgeries performed during the night are associated with higher complication rates. The aim of this study was to determine the impact of nighttime surgery on the outcome after kidney transplantation. In all, 873 deceased donor kidney transplants were retrospectively analyzed and grouped according to the time of surgery: daytime (8 AM to 8 PM, n = 610) versus nighttime (8 PM to 8 AM, n = 263). Statistical analysis compared patient/graft survival, rate of delayed graft function (DGF), acute rejection rate, and surgical complications. One and 5-year patient and graft survival did not differ between daytime and nighttime transplants. DGF occurred in 31.1% of daytime compared to 37.6% of nighttime procedures (P = 0.06). Acute allograft rejection was observed in 22.6% of daytime compared to 18.3% in nighttime graft recipients (P = 0.15). Nighttime procedures were associated with 22.4% complications compared to 22.1% in daytime procedures (P = 0.92). Most importantly, if transplantations were postponed until the next morning, cold ischemia time (CIT) would have increased from 16.6 h to 24.6 h (P < 0.0001) which would have resulted in decreased long-term survival (P < 0.02). Nighttime kidney transplants are neither associated with a higher surgical complication rate nor worse 5-year outcomes than daytime procedures, thus are justified to keep CIT short.

Renal and circulatory effects of large volume plasma expansion in patients with hepatorenal syndrome type 1.

INTRODUCTION: Hepatorenal syndrome type I (HRS I) may be a consequence of circulatory dysfunction in cirrhotic patients with portal hypertension. This uncontrolled interventional pilot study examines the hemodynamic and renal effects of large volume plasma expansion in HRS I. MATERIAL AND METHODS: 14 cirrhotic patients (8 m, 6 f, age 60 (58-65) years) with HRS I received large volume plasma expansion with up to 400 mL of 20% human albumin solution per 12 over 48 h under hemodynamic monitoring by transpulmonary thermodilution. Creatinine clearances (ClCreat) were calculated for 12-h periods. Plasma expansion was withheld if criteria of volume overload [Extravascular lung Water Index (ELWI) > 9 mL/kg or Global End-Diastolic Volume Index (GEDI) > 820 mL/m(2)] were met. Paracentesis was performed according to clinical necessity and treatment continued for 48 h thereafter. Serum creatinine values were observed for 12 days. RESULTS: Patients received 1.6 (1.5-2.0) g of albumin per kg bodyweight and day for 48 to 96 h. During the treatment period, GEDVI [724 (643-751) mL/m(2) vs. 565 (488-719) mL/m(2) ; p = 0.001], cardiac index (CI) [4.9 (4.1-6.15) L/min/m(2) vs. 3.9 (3.4-5.0) L /min/m(2) ; p = 0.033], urinary output [25 (17-69) mL/h vs. 17 (8-39) mL/h; p = 0.016) and ClCreat [20 (15-47) vs. 12 (6-17); p = 0.006] increased whereas systemic vascular resistance index (SVRI), plasma renin activity (PRA) and plasma aldosterone were significantly reduced. At 48 h there were two complete responses (serum creatinine < 133 µmol/L) and on day 12, 8 patients had a complete response. CONCLUSION: HRS I may respond to large volume plasma expansion with or without paracentesis.

Single-center experience with third and fourth kidney transplants.

Kidney retransplantation is often associated with a higher immunological risk than is primary renal transplantation. Faced with increasing organ shortage and growing waiting lists, results of kidney retransplantation are of particular interest. Fifty-six third and fourth kidney transplants were analyzed retrospectively. Parameters included patient and donor demographics, operative details, incidence of surgical, immunological and infectious complications and patient and graft survival. Patients receiving third kidney grafts had 1- and 5-year patient/graft survival rates of 97.4%/72.9% and 88.9%/53.6%, respectively. Episodes of acute rejection and delayed graft function were observed in 44% and 49% of these patients. Fourth kidney transplantation was associated with 1- and 2-year patient/graft survival rates of 84.8%/68.5% and 63.6%/47%, respectively. Acute rejection and delayed graft function occurred in 33% and in 60% of cases. Acceptable patient and graft survival may be achieved after third and fourth kidney transplantation. Graft losses in this sensitized population are mainly because of rejection. Profound immunosuppression may lead to major infectious problems.

Arterial Hypertension as a Risk Factor for Reduced Glomerular Filtration Rate after Living Kidney Donation.

Living kidney donation represents the optimal renal replacement therapy, but recent data suggest an increased long-term renal risk for the donor. Here, we evaluated the risk for reduced estimated glomerular filtration rate (eGFR), death, and major cardiovascular events such as nonfatal myocardial infarction or cerebrovascular event including TIA (transient ischemic attack) and stroke in 225 donors, who underwent pre-donation examinations and live donor nephrectomy between 1985 and 2014 at our center. The median follow-up time was 8.7 years (1.0-29.1). In multivariate analysis, age and arterial hypertension at baseline were significantly associated with a higher risk of adverse renal outcomes, such as (1) eGFR <60 mL/min/1.73 m2 (age per year: HR (hazard ratio) 1.05, 95% confidence interval (CI) 1.03-1.08, hypertension: HR 2.25, 95% CI 1.22-3.98), (2) eGFR <60 mL/min/1.73 m2 and a decrease of ≥40% from baseline (age: HR 1.08, 95% CI 1.03-1.13, hypertension: HR 4.22, 95% CI 1.72-10.36), and (3) eGFR <45 mL/min/1.73 m2 (age: HR 1.12, 95% CI 1.05-1.20, hypertension: HR 5.06, 95% CI 1.49-17.22). In addition, eGFR at time of donation (per mL/min/1.73 m2) was associated with a lower risk of (1) eGFR <60 mL/min/1.73 m2 (HR 0.98, 95% CI 0.97-1.00) and (2) eGFR <45 mL/min/1.73 m2 (HR 0.95, 95% CI 0.90-1.00). Age was the only significant predictor for death or major cardiovascular event (HR 1.08, 95% CI 1.01-1.16). In conclusion, arterial hypertension, lower eGFR, and age at the time of donation are strong predictors for adverse renal outcomes in living kidney donors.

Prolactin induces MAPK signaling in neural progenitors without alleviating glucocorticoid-induced inhibition of in vitro neurogenesis.

We recently demonstrated that prolactin (PRL) prevents chronic stress-induced inhibition of adult hippocampal neurogenesis. It remained unsettled, however, whether PRL is acting directly on neural stem and progenitors cells (NPCs) or if neurogenesis is affected by an indirect mechanism, for example through the extensively described effects of PRL on the HPA axis. To address this point, we used neurosphere cultures derived from the adult rat hippocampus as an in vitro model for NPCs. Dexamethasone (DEX) was applied to stress the NPCs, and proliferation, survival and differentiation of cells were examined. DEX markedly inhibited proliferation of NPCs and cells entered the G(0) phase of cell cycle. Moreover, DEX reduced NPC survival and repressed astroglial differentiation, which is normally induced by serum or bone morphogenetic protein application. Even though we could demonstrate that NPCs express the PRL receptor and ERK1/2 signaling is induced by PRL, we did not observe any effect of PRL on NPCs proliferation, differentiation or survival, neither in the presence nor during absence of DEX. In summary, our results indicate that PRL action on NPCs and neurogenesis in vivo occurs via an indirect mechanism.

Tetraalkylammonium salts of weakly coordinating aluminates: ionic liquids, materials for electrochemical applications and useful compounds for anion investigation.

In this study, we investigated the tetraalkylammonium salts of the weakly coordinating fluorinated alkoxyaluminates [pftb](-) ([Al(O(C(CF(3))(3))(4)](-)), [hfip](-) ([Al(OC(H)(CF(3))(2))(4)](-)) and [hftb](-) ([Al(OC(CH(3))(CF(3))(2))(4)](-)) in order to obtain information on their undisturbed spectral and structural properties, as well as to study their electrochemical behavior (i.e., conductivities in non-polar solvents and electrochemical windows). Several of the compounds qualify as ionic liquids with melting points as low as 42 degrees C for [NBu(4)](+)[hfip](-). Simple and almost quantitative metathesis reactions yielding these materials in high purity were developed. These [NR(4)](+) salts serve as model compounds for undisturbed anions and their vibrational spectra--together with simulated spectra based on quantum chemical DFT calculations--were used for the clear assignment of the anion bands. Besides, the ion volumes of the anions (V(ion)([pftb](-)) = 0.736 nm(3), V(ion)([hftb](-)) = 0.658 nm(3), V(ion)([hfip](-)) = 0.577 nm(3)) and their decomposition pathways in the mass spectrometric measurements have been established. The salts are highly soluble in non-polar solvents (up to 1.09 mol L(-1) are possible for [NBu(4)](+)[hftb](-) in CH(2)Cl(2) and 0.41 mol L(-1) for [NBu(4)](+)[hfip](-) in CHCl(3)) and show higher molar conductivities if compared to [NBu(4)](+)[PF(6)](-). The electrochemical windows of CH(2)Cl(2), CH(3)CN and 1,2-F(2)C(6)H(4) using the [NBu(4)](+) aluminate electrolytes are up to +0.5 V/-0.7 V larger than those using the standard [NBu(4)](+)[PF(6)](-).

Disease Recurrence-The Sword of Damocles in Kidney Transplantation for Primary Focal Segmental Glomerulosclerosis.

A major obstacle in kidney transplantation for primary focal segmental glomerulosclerosis (FSGS) is the risk of disease recurrence. Recurrent FSGS affects up to 60% of first kidney grafts and exceeds 80% in patients who have lost their first graft due to recurrent FSGS. Clinical and experimental evidence support the hypothesis that a circulating permeability factor is the mediator in the pathogenesis of primary and recurrent disease. Despite all efforts, the causing agent has not yet been identified. Several treatment options for the management of recurrent FSGS have been proposed. In addition to plasma exchange, B-cell depleting antibodies are effective in recurrent FSGS. This indicates, that the secretion and/or activity of the postulated circulating permeability factor(s) may be B-cell related. This review summarizes the current knowledge on permeability factor(s) possibly related to the disease and discusses strategies for the management of recurrent FSGS. These include profound B-cell depletion prior to transplantation, as well as the salvage of an allograft affected by recurrent FSGS by transfer into a second recipient.

Laparoscopic Adjustable Gastric Banding: an Underestimated Risk Factor for the Development of Esophageal Cancer?-a Nationwide Survey.

BACKGROUND: Approximately 14% of Austria's 8.5 million inhabitants have a body mass index (BMI) > 30 kg/m2. The laparoscopic adjustable gastric banding (LAGB) was introduced in Austria in 1994, where about 10.300 patients have received it so far. One of our LAGB patients developed an adenocarcinoma of the distal esophagus 13 years after implantation. OBJECTIVES: In order to calculate whether after LAGB patients are at higher risk for carcinoma of the esophagus, we performed a nationwide survey. METHODS: A questionnaire was sent to all surgical departments in Austria, primarily in order to detect cases with esophageal carcinoma after LAGB, but also to evaluate the policy in Austria concerning preoperative work-up, operation, and follow-up in LAGB patients. RESULTS: Since 1994, 37 of the 119 surgical departments in Austria have performed a total of about 10.300 LAGB implantations. Six patients have been identified with esophageal cancer following LAGB. The WHO statistical report on esophageal cancer shows an incidence of 2.8/100.000 per year in Austria, about 1/3 of which cases are adenocarcinoma of the distal esophagus. CONCLUSION: Following LAGB, the incidence of esophageal cancer might be up to fivefold higher than the aged standardized overall population of Austria.

3D Microenvironment Stiffness Regulates Tumor Spheroid Growth and Mechanics via p21 and ROCK.

The mechanical properties of cancer cells and their microenvironment contribute to breast cancer progression. While mechanosensing has been extensively studied using 2D substrates, much less is known about it in a physiologically more relevant 3D context. Here it is demonstrated that breast cancer tumor spheroids, growing in 3D polyethylene glycol-heparin hydrogels, are sensitive to their environment stiffness. During tumor spheroid growth, compressive stresses of up to 2 kPa build up, as quantitated using elastic polymer beads as stress sensors. Atomic force microscopy reveals that tumor spheroid stiffness increases with hydrogel stiffness. Also, constituent cell stiffness increases in a Rho associated kinase (ROCK)- and F-actin-dependent manner. Increased hydrogel stiffness correlated with attenuated tumor spheroid growth, a higher proportion of cells in G0/G1 phase, and elevated levels of the cyclin-dependent kinase inhibitor p21. Drug-mediated ROCK inhibition not only reverses cell stiffening upon culture in stiff hydrogels but also increases tumor spheroid growth. Taken together, a mechanism by which the growth of a tumor spheroid can be regulated via cytoskeleton rearrangements in response to its mechanoenvironment is revealed here. Thus, the findings contribute to a better understanding of how cancer cells react to compressive stress when growing under confinement in stiff environments.

Haemodynamic effects of plasma-expansion with hyperoncotic albumin in cirrhotic patients with renal failure: a prospective interventional study.

BACKGROUND: Patients with advanced cirrhosis of the liver typically display circulatory disturbance. Haemodynamic management may be critical for avoiding and treating functional renal failure in such patients. This study investigated the effects of plasma expansion with hyperoncotic albumin solution and the role of static haemodynamic parameters in predicting volume responsiveness in patients with advanced cirrhosis. METHODS: Patients with advanced cirrhosis (Child B and C) of the liver receiving albumin substitution because of renal compromise were studied using trans-pulmonary thermodilution. Paired measurements before and after two infusions of 200 ml of 20% albumin per patient were recorded and standard haemodynamic parameters such as central venous pressure (CVP), mean arterial pressure (MAP), systemic vascular resistance index (SVRI), cardiac index (CI) and derived variables were assessed, including global end-diastolic blood volume index (GEDVI), a parameter that reflects central blood volume RESULTS: 100 measurements in 50 patients (33 m/17 w; age 56 years (+/- 8); Child-Pugh-score 12 (+/- 2), serum creatinine 256 micromol (+/- 150) were analyzed. Baseline values suggested decreased central blood volumes GEDVI = 675 ml/m2 (+/- 138) despite CVP within the normal range (11 mmHg (+/- 5). After infusion, GEDVI, CI and CVP increased (682 ml/m2 (+/- 128) vs. 744 ml/m2 (+/- 171), p < 0.001; 4.3 L/min/m2 (+/- 1.1) vs. 4.7 L/min/m2 (+/- 1.1), p < 0.001; 12 mmHg (+/- 6) vs. 14 mmHg (+/- 6), p < 0.001 respectively) and systemic vascular resistance decreased (1760 dyn s/cm5/m2 (+/- 1144) vs. 1490 dyn s/cm5/m2 (+/- 837); p < 0.001). Changes in GEDVI, but not CVP, correlated with changes in CI (r2 = 0.51; p < 0.001). To assess the value of static haemodynamic parameters at baseline in predicting an increase in CI of 10%, receiver-operating-characteristic curves were constructed. The areas under the curve were 0.766 (p < 0.001) for SVRI, 0.723 (p < 0.001) for CI, 0.652 (p = 0.010) for CVP and 0.616 (p = 0.050) for GEDVI. CONCLUSION: In a substantial proportion of patients with advanced cirrhosis, plasma expansion results in an increase in central blood volume. GEDVI but not CVP behaves as an indicator of cardiac preload, whereas high baseline SVRI is predictive of fluid responsiveness.

Effects of plasma expansion with albumin and paracentesis on haemodynamics and kidney function in critically ill cirrhotic patients with tense ascites and hepatorenal syndrome: a prospective uncontrolled trial.

INTRODUCTION: Circulatory dysfunction in cirrhotic patients may cause a specific kind of functional renal failure termed hepato-renal syndrome (HRS). It contributes to the high incidence of renal failure in cirrhotic intensive care unit (ICU) patients. Fluid therapy may aggravate renal failure by increasing ascites and intra-abdominal pressure (IAP). This study investigates the short-term effects of paracentesis on haemodynamics and kidney function in volume resuscitated patients with HRS. METHODS: Nineteen consecutive cirrhotic patients with HRS were studied. Circulatory parameters and renal function were analysed before and after plasma expansion and paracentesis. Haemodynamic monitoring was performed by transpulmonary thermodilution. RESULTS: After infusion of 200 ml of 20% human albumin solution, mean arterial pressure (MAP) and central venous pressure remained unchanged. Global end-diastolic volume index (GEDVI) increased from 791 ml m(-2) (693 to 862) (median and 25th to 75th percentile) to 844 ml m(-2) (751 to 933). Cardiac index (CI) increased from 4.1 l min(-1) m(-2) (3.6 to 5.0) to 4.7 l min(-1) m(-2) (4.0 to 5.8), whereas systemic vascular resistance index (SVRI) decreased from 1,422 dyn s cm(-5) m(-2) (1,081 to 1,772) to 1,171 dyn s cm(-5) m(-2) (893 to 1,705). Creatinine clearance (CC) and fractional excretion of sodium (FeNa) were not affected. During paracentesis, IAP decreased from 22 mmHg (18 to 24) to 9 mmHg (8 to 12). MAP decreased from 81 mmHg (74 to 100) to 80 mmHg (71 to 89), and CI increased from 4.1 l min(-1) m(-2) (3.2 to 4.3) to 4.2 l min(-1) m(-2) (3.6 to 4.7), whereas SVRI decreased from 1,639 dyn s cm(-5) m(-2) (1,168 to 2,037) to 1,301 dyn s cm(-5) m(-2) (1,124 to 1,751). CC during the 12-hour interval after paracentesis was significantly higher than during the 12 hours before (33 ml min(-1) (16 to 50) compared with 23 ml min(-1) (12 to 49)). CC remained elevated for the rest of the observation period. FeNa increased after paracentesis but returned to baseline levels after 24 hours. CONCLUSION: Paracentesis with parameter-guided fluid substitution and maintenance of central blood volume may improve renal function and is safe in the treatment of ICU patients with hepato-renal failure.

Cryoglobulinaemic vasculitis: classification and clinical and therapeutic aspects.

Cryoglobulinaemia may cause cutaneous vasculitis and glomerulonephritis, potentially leading to end stage renal failure. An important proportion of cryoglobulinaemias are secondary to hepatitis C virus infection. Emerging antiviral treatment options offer a chance for causal therapy of these cases of cryoglobulinaemia. This review summarises the classification and clinical and therapeutic aspects of cryoglobulinaemic vasculitis and glomerulonephritis.