Diagnostic value of plasma asymmetric and symmetric dimethylarginine levels in liver transplant recipients.

INTRODUCTION: Nitric oxide is an important factor in the pathogenesis of liver cirrhosis. Its synthesis depends on the availability of L­arginine and is inhibited by asymmetric dimethylarginine (ADMA). Symmetric dimethylarginine (SDMA) seems to be a good marker of multiorgan failure, especially renal failure. OBJECTIVES: The aim of the present study was to evaluate the diagnostic significance of dimethylarginines in patients after liver transplantation. PATIENTS AND METHODS: The study included 30 cadaver liver donors and 30 recipients with liver cirrhosis. The following parameters were estimated in donors and in liver recipients before and at days 1 and 3 after transplantation: serum alanine transaminase (ALT), aspartate transaminase (AST), and γ­glutamyltranspeptidase (GGT) activity, international normalized ratio (INR), concentrations of bilirubin, albumin, creatinine, electrolytes, ADMA, SDMA, and L­arginine. RESULTS: Before transplantation cirrhotic patients showed higher bilirubin concentrations, higher ALT and GGT activity, and lower sodium and albumin levels compared with donors. At day 3 after transplantation, we observed a significant increase in ALT, AST, creatinine, sodium, ADMA, SDMA, and L­arginine, and a decrease in bilirubin levels. A significant positive correlation between SDMA and creatinine was found in donors (P <0.001), recipients before transplantation (P <0.0005), and at days 1 (P <0.004) and 2 after transplantation (P <0.0005). A significant positive correlation was also observed before transplantation between ADMA and bilirubin concentrations (P = 0.0264), ADMA and albumin concentrations at day 1 after transplantation (P = 0.02), while a negative correlation was observed between ADMA and INR before transplantation (P = 0.008) and at day 3 after transplantation (P = 0.03) in recipients. CONCLUSIONS: An increase in dimethylarginine levels after liver transplantation seems to be due not only to the dysfunction of the transplanted liver, but also to impaired kidney function caused by the surgery itself and/or the use of a nephrotoxic calcineurin inhibitor--tacrolimus. A significant correlation between serum creatinine and SDMA concentrations both in liver donors and recipients suggests that SDMA renal clearance may have diagnostic value to evaluate the glomerular filtration rate in these patients.

[Cathether related blood stream infection in ICU patients with prolonged central venous catheterisation--cause and prevention]. / Przyczyny i zapobieganie zakazeniom u chorych po zalozeniu cewnika do duzych naczyn krwionosnych.

UNLABELLED: Colonization of the tip of the intravenous catheter is often observed in the ICU practice and can be the source of dangerous bacteriemia (CRBSI--catheter related bloodstream bacteraemia) and sepsis with multiorgan failure. There are many cases conected with bacterial colonization of the tip of the catheter in the ICU practice, which could be the source of dangerous bacteriemia--CRBSI (catheter related bloodstream bacteriemia) and sepsis with organs failure. MATERIAL AND METHODS: 105 patients with sepsis were examined, which clinical state pointed, that CVC was the source of infection. We removed the CVC in this patient, and its tip and patient's blood were examined microbiologically. In the case of positive result, the antibiogram was made. OBJECTIVE: Evaluation of colonisation and infections of central venous catheters and catheter related blood stream infections (CRBSI) in general ICU patients' and with identification of most frequent microorganisms and their antibiotic sensibility. Results. After examining of 105 samples in 37 (35, 24%) cases we did not culture bacteria. From the rest of 68 (64, 76%) samples we cultured 110 bacterial colonies. 8 of them were admitted to be contaminated samples. 60 tips of the catheter were used to proper analysis from which we isolated 102 bacterial colonies: 44 (43.1%) Gram positive cocci, 32 (31.5%) Enterobacteriaceae, 23 (22.5%) glucose non-fermentative gram-negative rods rods Gram negative non glucose fermentation and 3 (2.9%) fungi (C. albicans). We analized 60 blood samples that derived from patients with confirmed catheter colonisation. It was found that 8 blood samples indicated bacteriemia, but only in 2 cases isolated bacteria came from the CVC. Conclusions. (1) The majority of central venous catheters on ICU are colonized by pathogenic microorganisms. (2) Aerobic Gram positive and Gram negative bacteria are responsible for CVCs' infection. (3) Bacterial colonization of CVCs' is not very often the reason of CRBSI. (4) Prolonged use of central venous catheters needs careful prophylactic standards of an microbiological monitoring.

[Rhabdomyolysis, disseminated intravascular coagulation and acute renal failure after severe narcotics intoxication (MDMA, THC, amphetamine)]. / Rabdomioliza, rozsiane krzepniecie wewnatrznaczyniowe i ostra niewydolnosc nerek po ostrym zatruciu srodkami odurzajacymi (MDMA, THC, amfetamina).

More often we are faced with the cases of young people (who are in a serious condition) who land in ICU, because of severe narcotics intoxication, which they took occasionally on the concerts, discotheques and social events. From 1997 we observed rapid increase of admission to hospitals due to amphetamine, MDMA (2,3-methylenedeoxymethamphetamine which is a main component of a tablet called ecstasy) and THC (9-d tetrahydrocannabinols which are a component of sunn hemps) intoxication and decrease of opioid's poisoning. 23 years old patient was admitted to ICU in critical condition after severe narcotics intoxication. Patient was deeply unconscious (GCS 3) with tetraplegia and high temperature (39.6 degrees C). He had endotracheal tube (artificially ventilated) and hypovolemic shock with circulatory insufficiency (blood pressure was supported by 3 catecholamines). We observed many petechias and ecchymoses which suggested vascular haemorrhagic diathesis. It was found that the patient had disseminated intravascular coagulation and rhabdomyolysis with acute renal failure which was treated by dialysis. After 26 days of intensive treatment the patient was conscious, he had also efficient circulatory and respiratory system but with slight improvement of neurological state. In this condition he was admitted on nephrology ward to continue the treatment and start rehabilitation. The presence of high concentration of amphetamine, MDMA and THC in blood, extreme dehydration and electrolytes disturbances caused rhabdomyolysis, DIC syndrome and acute renal failure which make the prognosis worse and complicate the treatment. Estimating probability of death of this patient in SAPS II scale (Simplified Acute Physiology Scale) he has bad prognosis (86 points gives 95% of death probability). The patient is alive (what is a big success), probably thanks to quick arrival to specialized medical centre and dialysis treatment which was started early.

The use of recombinant human activated protein C (rhAPC) in the treatment of severe sepsis in immunosuppressed patients in the course of hematological diseases.

BACKGROUND: Treatment of hemopoietic system neoplasias involves severe complications associated with immunosuppression. We present two cases of treating severe sepsis utilizing recombinant human activated protein C (rhAPC) in the course of bilateral pneumonia in patients with hairy cell leukemia (HCL) and T-cell acute lymphoblastic leukemia (ALL). RhAPC, limited the coagulation cascade by inactivating FVa and FVIIIa, directly and indirectly limiting systemic inflammatory response syndrome (SIRS), and improved the fibrinolysis process. These actions break the pathomechanism of sepsis and improve survival. CASE REPORT: Besides intensive, multidirectional treatment of severe sepsis, Xigris (activated drotrecogin alfa) was administered on the second day in both cases. The infusion continued, as recommended, for 96 hours without complications. During treatment the patients' general condition and respiratory efficiency improved, allowing respirator weaning on days 5 and 8 of therapy. These cases of severe sepsis and immunosuppression indicate a high therapeutic efficacy of drotrecogin alfa (activated). Treatment outcome was uncertain because of the patients' hematological condition, so rapid restoration of respiratory efficiency and no disease progression after discontinuing treatment was a great success, possibly due to implementing Xigris at a relatively early stage of sepsis and the intensive therapy conducted according to Surviving Sepsis Campaign guidelines. CONCLUSIONS: Patient survival in severe sepsis directly depends on early diagnosis and institution of treatment. 1. These cases confirm the effectiveness of drotrecogin alfa in severe sepsis as part of multidirectional therapy. 2. Microorganisms causing atypical pneumonia should be considered in diagnosing infections in patients treated with cytostatic agents.