Therapeutic implications of heparin-induced thrombocytopenia complicating acute hemodialysis.

Although patients undergoing acute hemodialysis (HD) constitute a group at risk for heparin-induced thrombocytopenia (HIT), the optimal therapeutic strategy remains undefined. We describe a case of HIT complicated with right subclavian vein thrombosis in a patient with chronic renal insufficiency undergoing acute HD for oligoanuria and pulmonary edema. Circulating anti-heparin-PF4 complex antibodies were detected. Past medical history was relevant for an otherwise unexplained self-limited episode of thrombocytopenia following acute HD one year earlier after an anterior STEMI. All sources of heparin were discontinued and alternative anticoagulation was initiated with argatroban, a direct-thrombin inhibitor with hepatic clearance, followed by transition to warfarin. Prevention of tunneled HD catheter obstruction was accomplished with low-dose alteplase catheter locking solution. No bleeding occurred with argatroban anticoagulation. Platelet count recovered and no further thrombotic complications were observed. The present report illustrates the diagnostic and therapeutic challenges of HIT complicating acute HD.

[Endovascular aneurysms repair: 100 consecutive cases outcome analysis]. / Cirurgia endovascular de aneurismas daaorta abdominal: análise de 100 casos consecutivos.

OBJECTIVE: To evaluate the effectiveness and clinical outcomes of endovascular aneurysm repair in a single regional centre Methods: The medical records one hundred consecutive patients who underwent elective endovascular repair of nonruptured infra-renal abdominal aortic aneurysm were retrospectively reviewed. The assessed outcomes were all-cause mortality, aneurysm-related mortality, incidence of perioperative complications and reinterventions. Patient demographics and procedure characteristics were also analysed. RESULTS: The patient's mean age was 74.4 years-old. There was a male preponderance, with only 5 women treated. Two-thirds were American Society of Anesthesiologists (ASA) class ≥3. Loco-regional blockade was the anaesthetic technique most commonly used (65%). There were no perioperative deaths. Medical complications occurred in 10.3% of cases, pulmonary and cardiac being the most frequent. The 30-day reintervention rate was 6.1% (SE: 2.4%). The overall median hospital length of stay was 5 days. At 8 years, all cause mortality was 28.5%(SE: 8.5%) and aneurysm-related death was 1.3% (SE: 1.3%). During the follow-up period, 87.9% (SE: 3.7%) of patients remained free from reintervention CONCLUSIONS: In our institution, EVAR is associated with no early mortality and significantly good perioperative outcomes such as low rate of systemic complications, minimal blood loss, low rate of postoperative mechanical ventilation use and short hospital stay. Although the high reintervention rate for EVAR has been confirmed in several studies, our study did not find such a high need for secondary procedures. We found a durable benefit since aneurysm-related mortality is very low and late overall survival is similar to other reports. In this study's setting, our findings support endovascular management of large AAAs.

Ceftriaxone-induced acute reversible encephalopathy in a patient treated for a urinary tract infection.

Encephalopathy is a rare side effect of third- and fourth-generation cephalosporins. Renal failure and previous disease of the central nervous system predispose to this neurotoxicity. We describe a case of encephalopathy with generalised triphasic waves in a patient with pre-existent cerebrovascular disease who was treated with ceftriaxone for a urinary tract infection. Early recognition of this complication is relevant given that ceftriaxone discontinuation reverted the neurological syndrome.

Differential right and left ventricular diastolic tolerance to acute afterload and NCX gene expression in Wistar rats.

This study evaluated right ventricular (RV) and left ventricular (LV) diastolic tolerance to afterload and SERCA2a, phospholamban and sodium-calcium exchanger (NCX) gene expression in Wistar rats. Time constant tau and end diastolic pressure-dimension relation (EDPDR) were analyzed in response to progressive RV or LV afterload elevations, induced by beat-to-beat pulmonary trunk or aortic root constrictions, respectively. Afterload elevations decreased LV- tau, but increased RV-tau. Whereas LV- tau analyzed the major course of pressure fall, RV- tau only assessed the last fourth. Furthermore, RV afterload elevations progressively upward shifted RV EDPDR, whilst LV afterload elevations did not change LV-EDPDR. SERCA2a and phospholamban mRNA were similar in both ventricles. NCX-mRNA was almost 50 % lower in RV than in LV. Left ventricular afterload elevations, therefore, accelerated the pressure fall and did not induce diastolic dysfunction, indicating high LV diastolic tolerance to afterload. On the contrary, RV afterload elevations decelerated the late RV pressure fall and induced diastolic dysfunction, indicating small RV diastolic tolerance to afterload. These results support previous findings relating NCX with late Ca(2+) reuptake, late relaxation and diastolic dysfunction.

Morphologic, molecular and hemodynamic cardiac alterations in a model of nephropathy induced by puromycin aminonucleoside.

INTRODUCTION: Proteinuria and decreased glomerular filtration rate are assuming increased importance in defining cardiovascular risk in chronic renal insufficiency. The aim of this work was to study morphologic, molecular and hemodynamic cardiac alterations in an animal model of proteinuria and renal insufficiency induced by puromycin aminonucleoside (PAN). METHODS: Normotensive rats (n = 14) were injected with PAN (150 mg/kg, i.p.) or with vehicle. Blood pressure was measured daily and the animals were placed in metabolic cages for evaluation of urinary excretion of sodium, protein and creatinine. Fourteen days after PAN administration left ventricular hemodynamics were evaluated through a pressure tip micromanometer and heart morphology was examined. Transmural samples of left ventricle were then taken for mRNA quantification of SERCA2a, phospholamban (PLB), insulin-like growth factor 1 (IGF-1) and glyceraldehyde-3-phosphate dehydrogenase (GAPDH). RESULTS: The animals treated with PAN presented a decrease in creatinine clearance (14th day: 2.24 +/- 0.32 vs. 4.51 +/- 1.08 ml/min) and an increase in proteinuria (14th day: 51.0 +/- 9.0 vs. 3.8 +/- 0.7 mg/mg creatinine), without changes in systolic (14th day: 151 +/- 7 vs. 141 +/- 6 mmHg) or diastolic blood pressure (14th day: 85 +/- 7 vs. 86 +/- 3 mmHg), These alterations were accompanied by cardiac atrophy with decreased left ventricular contractility. A reduction in the SERCA2a/PLB mRNA ratio was observed without significant alteration in the expression of IGF-1 in the left ventricle. CONCLUSIONS: PAN-induced nephropathy is accompanied by cardiac atrophy, left ventricular dysfunction and alterations in the expression of genes involved in myocardial calcium kinetics. These findings were not accompanied by increases in blood pressure and may contribute to our understanding of the increased cardiovascular risk in chronic renal insufficiency.

Worse cardiac remodeling in response to pressure overload in type 2 diabetes mellitus.

BACKGROUND: Diabetic cardiomyopathy is characterized by cardiac structural and functional abnormalities. Additionally, chronic pressure overload conditions are highly prevalent amongst diabetic population and this association leads to a more severe myocardial impairment. The differences in myocardial pathophysiology between type 1 and type 2 diabetes mellitus (DM) still remain to be clarified. Thus, we aimed to investigate biventricular structural and functional changes promoted by the two types of DM and the impact of concomitant chronic pressure overload. METHODS: Wistar rats were injected with streptozotocin (Type 1 DM, T1DM) or fed with a hypercaloric diet (Type 2 DM, T2DM). Pressure overload was imposed in DM animals by aortic constriction and after 5weeks of DM the cardiac function and structure were evaluated. RESULTS: Both types of DM promoted hypertrophy, increased fibrosis and advanced glycation end-products deposition, in the two ventricles. Interestingly, the induced myocardial alterations were distinct. While T1DM stimulated a pronounced hypertrophy and extracellular matrix remodeling, T2DM induced functional impairment. The negative impact of the association of DM with aortic constriction was more pronounced in T2DM, promoting impaired function and increased stiffness, particularly in the right ventricle. CONCLUSIONS: Our study demonstrated that the two types of diabetes induce distinct cardiac alterations per se or when combined with chronic pressure overload. T1DM promoted a more extensive remodeling in cardiac structure while T2DM significantly impaired ventricular function. The impact of pressure overload was more notorious in T2DM as observed by worse myocardial remodeling, suggesting a higher susceptibility to the deleterious effects of chronic pressure overload, namely hypertension, among this diabetic population.

Neonatal extracorporeal membrane oxygenation: Initial experience of Hospital de São João.

The purpose of this series is to report the initial ECMO experience of the Neonatal Intensive Care Unit of Hospital de São João. The first three clinical cases are reported. Case report 1: a 39 weeks gestational age girl with severe lung hypoplasia secondary to a bilateral congenital diaphragmatic hernia. Case report 2: a 39 weeks gestational age girl with a right congenital diaphragmatic hernia and a tracheal stenosis. Case report 3: a 34 weeks gestational age boy, with 61 days of life, with a Bordetella pertussis pneumonia, severe pulmonary hypertension, shock, hyperleukocytosis and seizures.

Cardiac remodeling and dysfunction in nephrotic syndrome.

There is an increased incidence of heart disease in patients with chronic nephrotic syndrome (NS), which may be attributable to the malnutrition and activated inflammatory state accompanying the sustained proteinuria. In this study, we evaluated renal function, cardiac morphometry, contractile function, and myocardial gene expression in the established puromycin aminonucleoside nephrosis rat model of NS. Two weeks after aminonucleoside injection, there was massive proteinuria, decreased creatinine clearance, and a negative sodium balance. Skeletal and cardiac muscle atrophy was present and was accompanied by impaired left ventricular (LV) hemodynamic function along with decreased contractile properties of isolated LV muscle strips. The expression of selected cytokines and proteins involved in calcium handling in myocardial tissue was evaluated by real time polymerase chain reaction. This revealed that the expression of interleukin-1beta, tumor necrosis factor-alpha, and phospholamban were elevated, whereas that of cardiac sarco(endo)plasmic reticulum calcium pump protein was decreased. We suggest that protein wasting and systemic inflammatory activation during NS contribute to cardiac remodeling and dysfunction.

Plasma catecholamines in Buerger's disease: effects of cigarette smoking and surgical sympathectomy.

OBJECTIVES: to study the influence of tobacco exposure and sympathectomy on basal sympathoadrenal function of patients with Buerger's disease. DESIGN: plasma catecholamines were measured before and after smoking, in patients with Buerger's disease (n=13), in patients with Buerger's disease submitted to surgical bilateral lumbar sympathectomy (n=13), and in healthy volunteers (n=16). MATERIALS AND METHODS: venous blood samples were collected before and 2h after smoking one cigarette (0.9mg nicotine). Plasma concentrations (pg/ml) of dihydroxiphenylalanine (pL-DOPA), noradrenalin (pNA), adrenalin (pAD) and 3,4-dihydroxiphenylacetic acid (pDOPAC) were determined. RESULTS: Buerger's patients have low basal plasma catecholamines compared to volunteers: pNA (501 (196-927) vs 1858 (968-3663)) and pAD (71 (31-109) vs 193 (116-334)). Sympathectomy increased pL-DOPA, pAD and pDOPAC, but not pNA. After smoking, pNA only decreased in volunteers (1858 (968-3663) vs 1064 (535-2393)). In Buerger+sympathectomy group, smoking lowered pAD (700 (58-3379) vs 278 (54-429)). CONCLUSIONS: in Buerger's disease there is an impairment of sympathoadrenal function with an altered peripheral adrenergic response to cigarette smoking. Patients submitted to sympathectomy have high pAD, but this benefit is reversed after smoking. This might be clinically relevant given the association between cigarette smoking and the manifestations of Buerger's disease and the controversy on the effectiveness of sympathectomy in the management of the disease.