Dopamine "renal dose" versus fenoldopam mesylate to prevent ischemia-reperfusion injury in renal transplantation.

Low dose of dopamine is commonly used after kidney transplantation as a reno-protective agent, although its benefits are controversial. Dopamine may increase renal blood flow, decrease resistive index (RI), and induce urine output in normal kidneys. Many authors hypothesized that the vasculature of a denervated renal transplant may not respond to dopamine in the same fashion as healthy native kidneys, which led us to find other drugs to attenuate the ischemia-reperfusion (I/R) injury. Fenoldopam is a selective dopamine1 (DA1) receptor agonist, most of the activity of which resides in the R-enantiomer, which also shows weaker alpha 2-adrenoceptor antagonist activities. Fenoldopam produces a vasidilatory effect in vascular beds that are rich in vascular DA1 receptors, producing increased renal blood flow at doses that do not affect blood pressure. In addition to its renal vasodilator activity, fenoldopam is natriuretic, possibly resulting from a direct effect of DA1 receptors on the proximal convoluted tubule. In animals with spontaneous or drug-induced renal failure, fenoldopam improves renal function. The aim of this study was to investigate the possible effects of fenoldopan mesylate in recent kidney transplants. Creatinine, blood urea nitrogen, urine output, and renal vascular resistive index (IR) were measured using Doppler ultrasound. Two groups of patients with no statistical differences in demographic data were treated with dopamine or fenoldopan, showing no significant difference but a trend favoring the fenoldopan group.

[The recurrence of hepatitic C in orthotopic liver transplantation]. / La recidiva di epatite C nel trapianto ortotopico di fegato (OLT).

BACKGROUND: This study is a review of hepatitis C recurrence in patients undergoing an orthotopic liver transplantation (OLT); to verify how many patients HCV-positive before OLT confirm a persistent viremia after OLT and how many with viremia show hepatitis histological evidence. METHODS: Thirty consecutive patients, 24 males, median age 52.5 underwent OLT for posthepatitic C cirrhosis since January 1993 in the "Transplantation Center" of Genoa. Serology included anti-HCV search, HCV-RNA and HBV-DNA determinations, biopses were performed in the transplanted liver within the month after operation, subsequently at every hepatic enzymes increase. RESULTS: Twenty-one patients are currently alive, median follow-up of 14.5 months. Before OLT anti-HCV antibodies search was positive in all the patients while the HCV-RNA by PCR resulted positive in 17 and negative in 4. Before OLT the HBV-DNA in patients with associated hepatitis B was negative. After OLT 5 patients, of the 17 HCV-RNA positive before OLT, have turned negative then all became again positive from 6 to 12 months later; 2 of the 4 patients HCV-RNA negative before OLT have turned positive, and remained still negative two with hepatitis C associated with hepatitis B. Although viral replication was present in 95% of the patients, clinical and histological evidence of recurrence was ascertained only in 29%. CONCLUSIONS: It should be noted that the hepatitis histological picture doesn't correspond to a severe worsening of clinical conditions, an evolution justifying transplantation. The long-term results of this therapeutic choice are still uncertain due to the high incidence of recurrences.

[Severe infections after orthotopic hepatic transplant]. / Infezioni gravi dopo trapianto epatico ortotopico.

METHODS: The authors analysed severe infections in 43 consecutive patients undergoing orthotopic liver transplant. Prophylaxis and full anti-infection monitoring was performed in all cases. Immunosuppressive therapy was administered in the form of primary cyclosporine in 27 cases and primary OKT3 in 16 cases. RESULTS: Twenty-seven patients are still alive (median 8 months, range 2-40) and 16 died (median 22 days, range 10-92) of whom 4 without and 12 with infection, including two deaths owing to non-correlated causes with infection after recovery. Twenty-three patients underwent 33 episodes of severe infection (plus four with inconclusive positive cultures) without any case of protozoal or viral infection. All episodes occurred within two months of surgery and affected the lung (10), abdomen (7), lung + abdomen (1), urinary tract (1), lung + urinary tract (1), as well as two diffused cases and 7 cases of isolated bacteremia deriving from the donor (1), venous catheters (3), mild otorhinolaryngeal infection (1) and two unknown sources (2). Eighteen infective agents were identified in 45 cases. The bacteria involved in single-agent episodes were: 11 Gram+, 9 Gram- and five fungi. Polymicrobic and bacterial/fungal episodes were repeatedly observed in two and two cases. Postoperative renal insufficiency significantly influenced both the incidence of and mortality due to infection. Overall mortality was also influenced by early graft function, postoperative complications and reoperations, and the incidence of infections by the portal clamping stage, reject and prolonged coma. CONCLUSIONS: The absence of severe viral infections and the gradual reduction of mortality caused by infection appear to be parallel to the aggressive antiviral prophylaxis, the gradual improvement of intra- and postoperative management and primary immunosuppression with OKT3.

[Clinical evaluation of pre-surgical anxiety: changes in plasma levels of the anxiety peptide (diazepam binding inhibitor)]. / Valutazione clinica dell'ansia pre-intervento chirurgico: modificazioni dei livelli plasmatici del peptide dell'ansia (DBI).

The score scale of anxiety (STAI, Y, 1-2) and haematic levels of DBI (diazepam binding inhibitor) were used in 48 surgical patients for clinical evaluation of preoperative anxiety, before and after drugs for preoperative medication. After randomization, were clinically and statistically compared 6 groups according to premedicant drugs (diazepam 0.3 mg/kg; flunitrazepam 0.03 mg/kg; saline; prometazine 0.7 mg/kg); before and after preoperative medication were evaluated the anxiety relief with the score scale, haematic levels of DBI and haemodynamics (systolic and diastolic AP and HR). The results show that DBI can objectively measure the anxiety relief, that not are correlate haematic levels of DBI and score scale, that the best benzodiazepines are diazepam (0.3) and flunitrazepam (0.015) and that the prometazine might give anxiety relief for 5-HT antagonist action. Even if there are limits to study (scanty cases, are missing the range and the brain values of DBI and blood test of DBI is slow method) may be useful the use of score scale and haematic levels of DBI in clinical evaluation of preoperative anxiety relief.

[Clonidine and postoperative shivering]. / La clonidina nel brivido postoperatorio.

Clonidine was clinically evaluated to suppress postoperative shivering in 60 patients who had undergone anesthesia for general, thoracic and vascular surgery. The study was carried out in double blind conditions with comparison of two doses (75 and 150 micrograms) of clonidine, one dose of methylphenidate, and one dose of saline, as control group. The level of inhibition (Goldfarb scale), haemodynamics and temperature were studied. In conclusion, the methylphenidate is drug first choice for postoperative shivering, but clonidine inhibits postoperative shivering without haemodynamic and temperature variations (75 micrograms).

[Experience with the treatment of acute hepatic coma using extracorporeal perfusion of heterologous liver and exchange transfusion]. / Esperienza di trattamento del coma epatico acuto mediante perfusione extracorporea di fegato eterologo ed exsanguinotrasfusione

Extracorporeal pig liver perfusion was adopted in 2 patients with acute hepatic coma due to fulminant hepatitis. Exchange transfusion was used in a third patient, while a fourth was subjected to both procedures. A marked haematological improvement was noted in all cases. Yet, three patients died without showing any clinical benefit. In the fourth case, coma regressed and gradual improvement to the point of complete recovery was achieved. Liver perfusion and exchange transfusion in the same patient were attended by very different clinical effects, though each procedure produced a comparable improvement at the blood chemistry data. Careful analysis of the data suggests that the difference was attributable to discrepancies between the degree of tissue purification achieved.