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PubMed2000

Atrial natriuretic factor in oliguric acute renal failure. Anaritide Acute Renal Failure Study Group.

Atrial natriuretic peptide (ANP), an endogenous hormone synthesized by the cardiac atria, has been shown to improve renal function in multiple animal models of acute renal failure. In a recent multicenter clinical trial of 504 patients with acute tubular necrosis (oliguric and nonoliguric), ANP decreased the need for dialysis only in the oliguric patients. In the present study, 222 patients with oliguric acute renal failure were enrolled into a multicenter, randomized, double-blind, placebo-controlled trial designed to assess prospectively the safety and efficacy of ANP compared with placebo. Subjects were randomized to treatment with a 24-hour infusion of ANP (anaritide, 0.2 microgram/kg/min; synthetic form of human ANP) or placebo. Dialysis and mortality status were followed up for 60 days. The primary efficacy end point was dialysis-free survival through day 21. Dialysis-free survival rates were 21% in the ANP group and 15% in the placebo group (P = 0.22). By day 14 of the study, 64% and 77% of the ANP and placebo groups had undergone dialysis, respectively (P = 0.054), and 9 additional patients (7 patients, ANP group; 2 patients, placebo group) needed dialysis but did not receive it. Although a trend was present, there was no statistically significant beneficial effect of ANP in dialysis-free survival or reduction in dialysis in these subjects with oliguric acute renal failure. Mortality rates through day 60 were 60% versus 56% in the ANP and placebo groups, respectively (P = 0.541). One hundred two of 108 (95%) versus 63 of 114 (55%) patients in the ANP and placebo groups had systolic blood pressures less than 90 mm Hg during the study-drug infusion (P < 0.001). The maximal absolute decrease in systolic blood pressure was significantly greater in the anaritide group than placebo group (33.6 versus 23.9 mm Hg; P < 0.001). This well-characterized population with oliguric acute renal failure had an overall high morbidity and mortality.

Adult↗
PubMed2004

Re-evaluation and modification of the Stuivenberg Hospital Acute Renal Failure (SHARF) scoring system for the prognosis of acute renal failure: an independent multicentre, prospective study.

BACKGROUND: A prognostic scoring system for hospital mortality in acute renal failure (Stuivenberg Hospital Acute Renal Failure, SHARF score) was developed in a single-centre study. The scoring system consists of two scores, for the time of diagnosis of acute renal failure (ARF) and for 48 h later, each originally based on four parameters (age, serum albumin, prothrombin time and heart failure). The scoring system was now tested and adapted in a prospective study. METHODS: The study involved eight intensive care units. We studied 293 consecutive patients with ARF in 6 months. Their mortality was 50.5%. The causes of ARF were medical in 184 (63%) patients and surgical in 108 (37%). In the latter group, 74 (69%) patients underwent cardiac and 19 (18%) vascular surgery. RESULTS: As the performance of the original SHARF scores was much lower in the multicentre study than in the original single-centre study, we re-analysed the multicentre data to customize the original model for the population studied. The independent variables were the score developed in the original study plus all additonal parameters that were significant on univariate analysis. The new multivariate analysis revealed an additional subset of three parameters for inclusion in the model (serum bilirubin, sepsis and hypotension). For the modified SHARF II score, r(2) was 0.27 at 0 and 0.33 at 48 h, respectively, the receiver operating characteristic (ROC) values were 0.82 and 0.83, and the Hosmer-Lemeshow goodness-of-fit P values were 0.19 and 0.05. CONCLUSION: After customizing and by using two scoring moments, this prediction model for hospital mortality in ARF is useful in different settings for comparing groups of patients and centres, quality assessment and clinical trials. We do not recommend its use for individual patient prognosis.

Acute Kidney Injury↗
PubMed1994

Nasal mechanical ventilation for hypercapnic respiratory failure in chronic obstructive pulmonary disease: determinants of success and failure.

OBJECTIVES: To evaluate the efficacy of nasal mechanical ventilation in patients with chronic obstructive pulmonary disease and hypercapnic respiratory failure and to identify predictors of success or failure of nasal mechanical ventilation. DESIGN: Prospective case series. SETTING: Medical intensive care unit in Veterans Administration Medical Center. PATIENTS: Twelve chronic obstructive pulmonary disease patients treated during 14 episodes of hypercapnic respiratory failure. INTERVENTIONS: Nasal mechanical ventilation in addition to conventional therapy to treat hypercapnic respiratory failure. Patients underwent nasal mechanical ventilation for at least 30 mins, or longer if the therapy was tolerated. Responses to therapy and arterial blood gases were monitored. MEASUREMENTS AND MAIN RESULTS: Half of the episodes were successfully treated with nasal mechanical ventilation. There were no differences in age, prior pulmonary function, baseline arterial blood gases, admission arterial blood gases, or respiratory rate between those patients successfully treated and those patients who failed nasal mechanical ventilation. Unsuccessfully treated patients appeared to have a greater severity of illness than successfully treated patients, as indicated by a higher Acute Physiology and Chronic Health Evaluation II score (mean 21 +/- 4 [SD] vs. 15 +/- 4; p = .02). Unsuccessfully treated patients were edentulous, had pneumonia or excess secretions, and had pursed-lip breathing, factors that prevented adequate mouth seal and contributed to greater mouth leaks than in successfully treated patients (the mean volume of the mouth leak was 314 +/- 107 vs. 100 +/- 70 mL; p < .01). Successfully treated patients were able to adapt more rapidly to the nasal mask and ventilator, with greater and more rapid reduction in PaCO2, correction of pH, and reduction in respiratory rate. CONCLUSIONS: Patients who failed nasal mechanical ventilation appeared to have a greater severity of illness; they were unable to minimize the amount of mouth leak (because of lack of teeth, secretions, or breathing pattern) and were unable to coordinate with the ventilator. These features may allow identification of poor candidates for nasal mechanical ventilation, avoiding unnecessary delays in endotracheal intubation and mechanical ventilation.

Acute Disease↗
PubMedDate not supplied

The National Heart Failure Project: a health care financing administration initiative to improve the care of Medicare beneficiaries with heart failure.

This is the second in a series describing Health Care Financing Administration (HCFA) initiatives to improve care for Medicare beneficiaries with heart failure. The first article outlined the history of HCFA quality-improvement projects and current initiatives to improve care in six priority areas: heart failure, acute myocardial infarction, stroke, pneumonia, diabetes, and breast cancer. This article details the objectives and design of the Medicare National Heart Failure Quality Improvement Project (NHF), which has as its goal the improvement of inpatient heart failure care. (c)2000 by CHF, Inc.

Journal Article↗
PubMedDate not supplied

Heart failure practice improvement effort in the outpatient setting: a health care financing administration initiative to improve the care of medicare beneficiaries with heart failure.

This column is the fourth in a series describing Health Care Financing Administration initiatives to improve care for Medicare beneficiaries with heart failure. The first three papers addressed the background, design, and baseline results of the Health Care Financing Administration national initiative to improve quality of inpatient care for heart failure through the activities of each state's Health Care Financing Administration contractor Peer Review Organization. This paper describes a smaller-scale but equally important endeavor: the Heart Failure Practice Improvement Effort, a pilot project to test the feasibility of assessing and improving heart failure care in the outpatient setting. (c)2001 by CHF, Inc.

Journal Article↗
PubMedDate not supplied

Pharmacotherapy in congestive heart failure: Hyperkalemia in congestive heart failure.

Hyperkalemia is not an uncommon occurrence in the congestive heart failure patient, particularly when renal failure coexists. Hyperkalemia in CHF is typically medication-related. Its occurrence is inevitably linked to the simultaneous ingestion of angiotensin-converting enzyme inhibitors and beta-blockers, and more recently, aldosterone receptor antagonists, such as spironolactone. The most devastating consequence of hyperkalemia is its cardiotoxicity that can be fairly insidious in its rate of development. The therapy of hyperkalemia in congestive heart failure can involve both acute and semiacute management phases. Acute hyperkalemia management includes measures that block the adverse membrane effects of hyperkalemia, such as intravenous calcium administration, and efforts to shift potassium intracellularly, such as occurs with intravenous bicarbonate and/or inhaled beta-agonists. Semiacute management of hyperkalemia includes measures to increase urinary potassium excretion and administration of binding resins, such as Kayexalate®. Prevention is the cornerstone of hyperkalemia management in the heart failure patient and requires that careful attention be directed to both identifying exogenous sources of potassium and pinpointing the maximum tolerable dose of either an angiotensin-converting enzyme inhibitor or an angiotensin-receptor blocker. (c)2001 by CHF, Inc.

Journal Article↗
PubMed1990

Aetiology of icteric hepatitis and fulminant hepatic failure in children and the possible predisposition to hepatic failure by sickle cell disease.

The aetiological agents of acute icteric hepatitis and fulminant hepatic failure were investigated in 47 children less than 12 years of age presenting at our hospital during the period January to December 1987. Hepatitis A virus was the aetiological agent in 72%, hepatitis B virus in 11%, cytomegalovirus in 2% and non A non B in 15%. These results confirm the endemicity of these viruses in the Saudi population and that they can be contracted in early life and could lead to severe hepatitis. Three of the patients who had hepatitis A virus infection developed fulminant hepatic failure and two of them died. Two of the patients who developed fulminant hepatic failure were also suffering from sickle cell disease. This raises the question of a possible predisposition to hepatic failure in sickle cell disease upon infection with hepatitis A virus.

Acute Disease↗
PubMed2000

Incipient ovarian failure and premature ovarian failure show the same immunological profile.

PROBLEM: Incipient ovarian failure (IOF) is characterized by regular menstrual cycles, infertility and a raised early-follicular FSH in women under 40. IOF might be a precursor or a mitigated form of premature ovarian failure (POF). Disturbances in the immune system may play a role in ovarian failure. METHOD OF STUDY: Autoantibodies and lymphocyte subsets were determined in 63 POF patients, 50 IOF patients, and 27 controls. RESULTS: The prevalence of autoantibodies did not differ between the groups. There was a statistically significant difference in lymphocyte subsets between the control group and the POF group, with the IOF group taking an intermediate position. We found a decrease in percentage of T-suppressor cells with a rise in T-helper/T-suppressor cell ratio, a decrease in natural killer cells, and an increase in B lymphocytes and HLA-DR positive T cells. CONCLUSIONS: These data support the concept that IOF is a mitigated form of POF. The question remains whether these changes are the cause or the consequence of the ovarian failure.

Adult↗
PubMed1975

Resistance to acute renal failure afforded by prior renal failure: examination of the role of renal renin content.

In this study, rats recovering from glycerol-induced acute renal failure were found to be protected from mercury-induced nephropathy, and HgCl2 poisoning protected rats from developing myohemoglobinuric renal failure. In view of the widely disparate nature of the renal failure models used, refractoriness appears to relate to an altered sensitivity of the organism itself rather than reflecting resistance to a particular nephropathic challenge. Renal renin content of the rats at the time of rechallenge was normal or high, a finding which contrasts sharply with that of chronically saline-loaded animals which also are refractory to ARF but have a maximally suppressed renal renin content. Renal renin depletion is not essential to the prevention of acute renal failure in the rat.

Acute Kidney Injury↗
PubMed2003

Effect of posture on blood and intraocular pressures in multiple system atrophy, pure autonomic failure, and baroreflex failure.

BACKGROUND: Intraocular pressure (IOP) may be partially under systemic vascular control. This study examined whether a correlation exists between blood and intraocular pressures in patients with autonomic dysfunction. METHODS AND RESULTS: Eleven patients with 3 types of confirmed autonomic dysfunction (multiple system atrophy, pure autonomic failure, and baroreflex failure) were compared with age- and gender-matched controls and had IOP, systolic blood pressure, diastolic blood pressure, heart rates, and calculated mean arterial pressures (MAP) and mean ocular perfusion pressures (MOPP) measured in the supine, sitting, and standing positions. Data were analyzed with a general linear model repeated-measures ANOVA. All pressures for patients showed a dramatic decline (P<0.001) from supine to standing (MAP -31+/-14 mm Hg; IOP -6+/-3 mm Hg; MOPP -25+/-14 mm Hg) compared with controls (MAP +4+/-7 mm Hg; IOP -1+/-2 mm Hg; MOPP +6+/-7 mm Hg). There was no significant change in heart rate from supine to standing for patients compared with controls (P=0.648). Within both the multiple system atrophy (n=5) and pure autonomic failure (n=4) groups, all initial pressures were similar to control pressures in the supine position, whereas patients with baroreflex failure (n=2) had higher mean pressures than respective controls in the supine position. CONCLUSIONS: In autonomic dysfunction, a large decrease in MAP correlated with a large decrease in IOP. These data suggest that the autonomic nervous system, perhaps through an influence on systemic blood pressure, has a significant role in IOP regulation.

Adult↗
PubMed1998

Prospective study of heart rate variability and mortality in chronic heart failure: results of the United Kingdom heart failure evaluation and assessment of risk trial (UK-heart).

BACKGROUND: Patients with chronic heart failure (CHF) have a continuing high mortality. Autonomic dysfunction may play an important role in the pathophysiology of cardiac death in CHF. UK-HEART examined the value of heart rate variability (HRV) measures as independent predictors of death in CHF. METHODS AND RESULTS: In a prospective study powered for mortality, we recruited 433 outpatients 62+/-9.6 years old with CHF (NYHA functional class I to III; mean ejection fraction, 0.41+/-0.17). Time-domain HRV indices and conventional prognostic indicators were related to death by multivariate analysis. During 482+/-161 days of follow-up, cardiothoracic ratio, SDNN, left ventricular end-systolic diameter, and serum sodium were significant predictors of all-cause mortality. The risk ratio for a 41.2-ms decrease in SDNN was 1.62 (95% CI, 1.16 to 2.44). The annual mortality rate for the study population in SDNN subgroups was 5.5% for >100 ms, 12.7% for 50 to 100 ms, and 51.4% for <50 ms. SDNN, creatinine, and serum sodium were related to progressive heart failure death. Cardiothoracic ratio, left ventricular end-diastolic diameter, the presence of nonsustained ventricular tachycardia, and serum potassium were related to sudden cardiac death. A reduction in SDNN was the most powerful predictor of the risk of death due to progressive heart failure. CONCLUSIONS: CHF is associated with autonomic dysfunction, which can be quantified by measuring HRV. A reduction in SDNN identifies patients at high risk of death and is a better predictor of death due to progressive heart failure than other conventional clinical measurements. High-risk subgroups identified by this measurement are candidates for additional therapy after prescription of an ACE inhibitor.

Aged↗
PubMedDate not supplied

Suppressive effect of sarpogrelate hydrochloride on respiratory failure and right ventricular failure with pulmonary hypertension in patients with systemic sclerosis.

We evaluated the effect of 12 months of 300-mg oral sarpogrelate hydrochloride (SH) once daily on the symptoms of Raynaud's phenomenon, respiratory failure and cardiac function in seven patients with systemic sclerosis. Arterial blood gases, pulmonary function, mean pulmonary arterial pressure, left ventricular ejection fraction (LVEF), right ventricular ejection fraction (RVEF), white blood cell count, C-reactive protein and the plasma concentrations of fibrinopeptide A, beta-thromboglobulin, platelet factor 4 and thrombomodulin were evaluated before and 2 and 12 months after SH administration. After 2 and 12 months of SH administration, a significant decrease was found in the frequency and duration of Raynaud's phenomenon, as well as the coldness, numbness and pain of Raynaud's phenomenon. Respiratory failure, as estimated by Hugh-Jones classification, was significantly decreased, whereas the percentage carbon monoxide diffusion capacity was significantly increased. The mean pulmonary arterial pressure decreased significantly, as did plasma fibrinopeptide A, beta-thromboglobulin and platelet factor 4. There was no significant change in LVEF after 2 or 12 months, but after 12 months of SH administration, RVEF increased significantly. In conclusion, use of SH may prevent Raynaud's phenomenon, respiratory failure and right ventricular failure in patients with systemic sclerosis.

Adult↗
PubMed1997

Determining the optimum dose for the intravenous administration of nicardipine in the treatment of acute heart failure--a multicenter study. The Nicardipine Heart Failure Study Group.

Nicardipine is a potent arteriolar vasodilator with a negligible negative inotropic effect. Although intravenous administration of this drug has been reported to be effective in the treatment of heart failure, the optimal dose by this route is not clear. This study was designed to determine the optimum dose for the intravenous infusion of nicardipine in the treatment of heart failure. In Trial 1, nicardipine was administered intravenously at a dose of 0.5 microgram/kg per min to 14 patients with acute heart failure. The dose was increased to 1.0 microgram/kg per min in 13 cases with marked improvement at 2 h. In Trial 2, nicardipine was administered in a double-blind manner to 53 patients at 3 different rates of infusion for 2 h: 1.0 (Group 1, n = 19), 2.0 (Group 2, n = 15), and 3.0 (Group 3, n = 19) micrograms/kg per min. Neither heart rate nor mean right atrial pressure changed in any of the 3 groups. Favorable hemodynamic effects were evident in all groups beginning 30 min after the start of infusion, with an increase in cardiac index (control vs 2 h after infusion, L/min per m2) (Group 1: 2.2 +/- 0.4 vs 3.1 +/- 0.8, Group 2: 2.2 +/- 0.4 vs 2.9 +/- 0.5, Group 3: 2.3 +/- 0.3 vs 3.1 +/- 0.7, all p < 0.01 compared to the control) and a decrease in diastolic pulmonary artery pressure (Group 1: 26 +/- 10 vs 19 +/- 7, Group 2: 27 +/- 10 vs 20 +/- 8, Group 3: 26 +/- 7 vs 18 +/- 5 mmHg, all p < 0.01). The decrease in systolic pressure was greatest in Group 3 (Group 1: 141 +/- 31 vs 119 +/- 18, Group 2: 149 +/- 25 vs 118 +/- 17, Group 3; 147 +/- 27 vs 107 +/- 14 mmHg, all p < 0.01 compared to control, and p < 0.05 between Groups 1 and 3). The intravenous drip infusion of nicardipine is effective in the treatment of heart failure by inducing an increase in cardiac output and a decrease in pulmonary artery wedge pressure. The optimal dose in this study was 1.0 microgram/kg per min.

Acute Disease↗
PubMed2026

ER proteostasis failure in HYOU1 deficiency alters B cells, neutrophils, and interferon signalling.

Hypoxia upregulated 1 (HYOU1) is a stress-inducible ER chaperone. We investigated 2 unrelated patients carrying biallelic HYOU1 variants and presenting with primary immunodeficiency. Patient 1, homozygous for p.Pro444His, displayed failure to thrive, hypoglycemia, B cell lymphopenia, and neutropenia. Patient 2, compound heterozygous for p.Arg262Gln and p.Pro757_Glu758insAla, exhibited recurrent infections, enteropathy, and hypogammaglobulinemia. In Patient 1, while HYOU1 transcription was preserved, the protein was severely reduced. Tunicamycin treatment of dermal fibroblasts showed a blunted unfolded protein response and defective induction of ER stress-responsive genes. Immunophenotyping showed near-absence of circulating B cells, and single-cell RNA sequencing of bone marrow identified an arrest at the pro-B cell stage. Neutrophils displayed hypogranulation and dysregulated IFN- and apoptosis-associated transcriptional signatures, unresponsive to G-CSF. HYOU1 deficiency hence results in ER stress-induced proteostasis failure that simultaneously impairs adaptive immunity through B cell developmental arrest and innate immunity through neutrophil dysfunction and IFN pathway imbalance. This work expands the spectrum of HYOU1 deficiency and further identifies ER proteostasis as a central determinant of immune homeostasis.

Journal Article↗
PubMedDate not supplied

Difficult cases in heart failure: Role of continuous ambulatory peritoneal dialysis in refractory heart failure.

Continuous ambulatory peritoneal dialysis (CAPD) offers a new modality for use in the treatment of refractory congestive heart failure (CHF). Although the use of peritoneal dialysis to treat refractory heart failure is not new, improved understanding of the physiology and technique of this system has allowed its use over prolonged periods of time. The application of continuous peritoneal dialysis to the cardiac patient changes its scope considerably. When combined with current medical treatment, it removes fluid volume effectively and safely providing the best possibility for prolonged medical improvement. Continuous ambulatory peritoneal dialysis should be considered in patients with biventricular failure who have associated comorbidities like pulmonary hypertension and progressive renal insufficiency. We report the management of two such patients with NYHA Class IV heart failure who had become unresponsive to maximum pharmacological management and developed prerenal dialysis and during the 6 month follow up remained on dialysis without developing any significant complications and improved to NYHA class I. (c)1999 by CHF, Inc.

Journal Article↗
PubMed1977

Sterilization failures in Singapore: an examination of ligation techniques and failure rates.

The University Department of Obstetrics and Gynecology, Kandang Kerbau Hospital in Singapore, initiated a study in early 1974 of failure rates for various methods of sterilization and the factors responsible for the failures. During the period January 1974 to March 1976, 51 cases of first pregnancy following ligation were discovered. Cumulative failure rates at 24 months were 0.34 per 100 women for abdominal sterilization, 1.67 for culdoscopic, 3.12 for vaginal, and 4.49 for laparoscopic procedures. Findings for 35 patients who underwent religation showed that recanalization and the establishment of a fistulous opening caused the majority of failures. Clearly, more effective methods of tubal occlusion in sterilization are needed.

Abdomen↗
PubMedDate not supplied

A correlation of radiographic "modes of failure" with clinical failure of cemented stem-type femoral components.

Four modes of failure of cemented stem type femoral components are: pistoning within the medullary canal (mode I); medial migration of the proximal stem and lateral migration of the distal stem (mode II); medial lateral toggle of the distal stem tip (mode III); loss of proximal support with firm fixation of the distal end (mode IV). These radiographic failure patterns have been correlated with clinical findings at revision of 51 loose femoral components. The findings at revision correlated well with the radiographic findings indicating the accuracy of this nomenclature, which simplifies discussion of stem failures. Mode I was found to be the most common, and mode IV the most difficult to revise. Neither age, nor weight nor surgical approach influenced the failure mode. The overall results of revision were poor, with most hips rapidly assuming a IB type of appearance.

Bacterial Infections↗
PubMedDate not supplied

The cardio-renal-anemia syndrome in elderly subjects with heart failure and a normal ejection fraction: a comparison with heart failure and low ejection fraction.

The prevalence and severity of anemia and renal dysfunction in heart failure patients with a normal ejection fraction (HFNEF) is uncharacterized. Two hundred eighty-five consecutive patients admitted to a community hospital with heart failure were stratified by the presence or absence of anemia and a normal or reduced ejection fraction. Comparisons of clinical variables were performed. In this sample, 62% of subjects were anemic, with no difference between those with a normal and a reduced ejection fraction (63% vs. 61%). Anemic HFNEF subjects had a lower glomerular filtration rate (37 +/- 21 mL/min vs. 52 +/- 35 mL/min; p < 0.05) and more severe self-reported symptom scores than nonanemic HFNEF subjects. Multivariate analysis confirmed the association of renal dysfunction and anemia. The authors conclude that the degree and magnitude of anemia in elderly inpatients with heart failure does not differ by ejection fraction. Worse symptoms and more severe renal dysfunction were seen in HFNEF subjects with anemia than in HFNEF subjects without anemia.

Aged↗