Late treatment of paracetamol poisoning with mercaptamine.

Forty patients who had taken overdoses of paracetamol were treated with mercaptamine. Twenty-three patients given mercaptamine within 10 hours of poisoning had normal liver function tests at follow-up, and one could not be traced. In 16 patients mecraptamine was begun more than 10 hours after ingestion of paracetamol ("late" mercaptamine). Eight of these patients developed severe liver damage, which in six was moderate or severe before mercaptamine administration. Acute renal failure occurred in two patients; in one other renal function was temporarily severely impaired. At follow-up two patients were not available, and one admitted moribund had died soon after admission. The remaining 13 all had normal liver function tests. It is concluded that late mercaptamine is not dangerous and may prevent further liver damage.     

Intravenous acetylcysteine in paracetamol induced fulminant hepatic failure: a prospective controlled trial.

OBJECTIVE--To see whether intravenous acetylcysteine would improve outcome in patients with fulminant hepatic failure after paracetamol overdose. DESIGN--A prospective randomised controlled study. SETTING--The Institute of Liver Studies, King''s College Hospital, London. PATIENTS--50 consecutive patients (21 male) aged 16-60 with fulminant hepatic failure after paracetamol overdose who had not previously received acetylcysteine. INTERVENTIONS--Conventional intensive liver care plus either acetylcysteine (25 patients) in the same dose regimen as used early after a paracetamol overdose, except that the infusion was continued until recovery from encephalopathy or death, or an equivalent volume of 5% dextrose (25 patients). MAIN OUTCOME MEASURES--Survival; incidence of cerebral oedema, renal failure, and hypotension requiring inotropic support; liver function as assessed by prolongation of the prothrombin time; and degree of encephalopathy. RESULTS--The rate of survival was significantly higher in the acetylcysteine treated group than in the controls (48% (12/25 patients) v 20% (5/25); p = 0.037, 95% confidence interval for difference in proportions surviving 3% to 53%). Acetylcysteine treated patients had a lower incidence of cerebral oedema (40% (10/25) v 68% (17/25); p = 0.047, 95% confidence interval for difference in incidence 2% to 54%), and fewer developed hypotension requiring inotropic support (48% (12/25) v 80% (20/25); p = 0.018, 95% confidence interval 7% to 57%). Rates of deterioration and recovery of liver function, however, were similar in the two groups. No adverse reactions to acetylcysteine were seen. CONCLUSIONS--Acetylcysteine is safe and effective in fulminant hepatic failure after paracetamol overdose.     

Acute Paracetamol Poisoning

Of 41 cases of acute paracetamol poisoning one died of gastrointestinal haemorrhage and acute massive necrosis of the liver, three became jaundiced, and 13 others had biochemical evidence of hepatocellular damage. Liver damage is a toxic effect which is present in most patients who ingest more than 15 g. of paracetamol. One patient with liver damage survived renal failure due to acute tubular necrosis. It is suggested that the renal lesion was also the result of paracetamol overdosage.Profound hypoglycaemia and metabolic acidosis may also complicate severe poisoning. Plasma levels of para-aminophenol fall rapidly, and procedures currently used to enhance the elimination of the drug cannot be expected to prevent development of hepatic damage.     

Paracetamol and conventional antimalarial drugs induced hepatotoxicity and its protection by methionine in rats

Hepatotoxicity, induced in rats, by treatment with high doses of paracetamol and chloroquine was confirmed by estimating blood transaminase levels. Hepatoprotective effect was determined by administering combination of methionine (10% of paracetamol/chloroquine, p.o.) and hepatotoxic drugs quinine. The results were confirmed by histopathological examination of liver. Paracetamol (7 g/kg) and chloroquine (970 mg/kg) administration increased significantly the transaminase levels. Methionine alone did not produced any change. Hepatonecrosis induced by paracetamol, chloroquine alone and their combinations and its protection with methionine was revealed by histopathological study whereas the combination of paracetamol and methionine showed no significant histopathological difference when compared to the normal liver section. The results reveal that, methionine significantly prevented the rise in transaminases levels produced by hepatotoxic doses of paracetamol and chloroquine. But, to prevent occasional cases of paracetamol overdosage, it is not advisable to give methionine concurrently with paracetamol to patients who are taking paracetamol therapeutically.     

Pneumococcal vaccine immunization of patients with renal impairment

The immunogenicity of the polyvalent pneumococcal vaccine was studied in renal allograft recipients and dialysis patients. There was no significant overall difference in the antibody response of the allograft recipients compared to control subjects at 1 month following immunization. Chronic hemodialysis patients had significantly lower postvaccination antibody levels for 6 of 12 serotypes. Better graft function in the allograft recipients correlated positively with higher antibody levels. Azathioprine and prednisone in dosages employed had no consistent effect on antibody response. No deterioration of renal function ascribable to the vaccine was observed. Patients were sampled at 1, 2, and 3 1/2 years following immunization. Geometric mean titers (GMT) were calculated for all the serotypes per group for each time of sampling. There was a significant decrease with time in antibody GMTs for all the groups (P less than 0.01). Chronic hemodialysis patients had significantly lower GMTs than control subjects and allograft recipients at 1, 2, and 3 1/2 years postimmunization (P less than 0.05). The 3 1/2 years postimmunization antibody levels were very low in dialysis patients, suggesting that reimmunization of these patients may be required.     

Efficacy of benzbromarone in hyperuricemic patients associated with chronic kidney disease

We have retrospectively evaluated the uric acid control status and renal function changes over a period of up to 7 years in 35 patients with renal impairment who had stage 3 or higher chronic kidney disease (CKD; stage 3 in 32 patients, stage 4 in 2 patients, and stage 5 in 1 patient) associated with hyperuricemia and were receiving monotherapy with benzbromarone as an antihyperuricemic drug. Serum uric acid levels significantly decreased from 8.5 ± 0.9 to 6.1 ± 0.8 mg/dL at 6 months and were subsequently controlled at less than 7.0 mg/dL in most patients. Most patients received benzbromarone at a dose of 25-50 mg/day, whereas 150-200 mg/day was used in some patients with stage 4 or 5 CKD. No significant changes in estimated glomerular filtration rate (eGFR) from the baseline value of 46.2 ± 11.5 mL/minute/1.73 m(2) were found after benzbromarone therapy. Although the renal function impairment did not improve by reducing the serum uric acid levels with benzbromarone, the renal function did not deteriorate further on the therapy. These results suggest that benzbromarone is applicable to the management of hyperuricemia associated with renal impairment.     

肾移植术后HCMV感染与淋巴细胞亚群及肾功能的相关性

目的：肾移植患者由于术前透析及术后服用免疫抑制剂,显著增加了人巨细胞病毒（Humancytomegalovirus,HCMV）原发感染和潜伏感染被激活的机会。观察HCMV感染情况与血T淋巴细胞亚群及肾功能的变化,以探讨其相关性及临床意义。方法：跟踪收集40例肾移植患者术前、术后血标本,应用RT-PCR技术检测HCMV,流式细胞术检测淋巴细胞亚群,结合肾功能判断是否发生急性排斥或移植肾功能恢复延迟。结果：肾移植术后HCMV感染率为52．5％,10例出现症状性感染（25％）,出现阳性时间35．7±15．3天。症状性感染组CD3-bCD4＋的水平和CD4＋／CD8＋的比值较无活动性感染组和正常对照组均降低,CD8＋水平较其他组升高,差异有显著性意义（P〈0．05）。无症状性活动感染者与无活动性感染者各指标比较差异无显著性。活动性感染组急性排斥或移植肾功能恢复延迟发生8例（38．1％）,无活动性感染组发生1例（5．2％）,差异具有统计学意义（x^2=6．15,P〈0．05）。结论：肾移植术后HCMV感染能显著引起T淋巴细胞亚群变化,尤其是CD4＋／CD8＋。并与急性排斥或移植肾功能恢复延迟密切相关联,在其发生发展中可能起着重要的作用。三者相互联系、相互作用、互为因果,对进一步机制的研究及临床诊断治疗、预后方面有一定意义。     

Efficacy of Benzbromarone in Hyperuricemic Patients Associated with Chronic Kidney Disease

We have retrospectively evaluated the uric acid control status and renal function changes over a period of up to 7 years in 35 patients with renal impairment who had stage 3 or higher chronic kidney disease (CKD; stage 3 in 32 patients, stage 4 in 2 patients, and stage 5 in 1 patient) associated with hyperuricemia and were receiving monotherapy with benzbromarone as an antihyperuricemic drug. Serum uric acid levels significantly decreased from 8.5 ± 0.9 to 6.1 ± 0.8 mg/dL at 6 months and were subsequently controlled at less than 7.0 mg/dL in most patients. Most patients received benzbromarone at a dose of 25–50 mg/day, whereas 150–200 mg/day was used in some patients with stage 4 or 5 CKD. No significant changes in estimated glomerular filtration rate (eGFR) from the baseline value of 46.2 ± 11.5 mL/minute/1.73 m² were found after benzbromarone therapy. Although the renal function impairment did not improve by reducing the serum uric acid levels with benzbromarone, the renal function did not deteriorate further on the therapy. These results suggest that benzbromarone is applicable to the management of hyperuricemia associated with renal impairment.     

The combined effects of dopamine (DA) and the DA antagonists EGYT-2509, chlorpromazine and haloperidol on the kidney function

In anaesthetized dogs renal function was investigated in four successive 20-min periods in four experimental series. (1) In the first series following the first period (serving as control) 2.5 micrograms/kg/min of dopamine (DA) dissolved in 0.5 ml/min of Ringer's solution was infused into the left renal artery (period 2), than during periods 3 and 4. It was found that first (period 2) and second (period 3) doses of DA induced a significant decrease of about 20-30% in renal vascular resistance, and an increase of about 15-25% in renal blood flow. At the same time, systemic arterial blood pressure fell by 10%. The other investigated parameters of the left kidney (Cinulin, CPAH, sodium, potassium and water excretion) did not differ from the respective parameters of the intact right kidney. (2) In the second experimental series following the first period (prior to period 2) 1.0 mg/kg of the DA antagonist EGYT 2509 was administered intravenously. Prior to the period 3 again 1.0 mg/kg of EGYT 2509 and prior to period 4 2.0 mg/kg of EGYT 2509 was given intravenously. During periods 2 through 4 2.5 micrograms/kg/min of DA was infused into the left renal artery. It could be ascertained that EGYT 2509 abolished the renal effects of DA while not inducing any decrease in arterial blood pressure. (3) In the third experimental series, following the control period, prior to periods 2,3 and 4, 1.0 mg/kg, 1.0 mg/kg and 2.0 mg/kg chlorpromazine respectively, was administered i.v. followed by the infusion of DA into the left renal artery. After the administration of chlorpromazine arterial blood pressure and renal vascular resistance fell concomitantly and DA failed to induce any further changes in these parameters. According to our experiments chlorpromazine abolishes the effect of DA on kidney function. (4) In the fourth series, prior to DA infusion the dogs were given 0.5 mg/kg (period 2) then again 0.5 mg/kg and finally 1.0 mg/kg of haloperidol intravenously. Haloperidol decreased arterial blood pressure as well as renal vascular resistance, thus renal blood flow did not change. Renal blood flow could then be increased by DA infused into the left renal artery. It seems that haloperidol could not abolish the vascular effects of DA in the kidney. Our experiments indicate that substance EGYT 2509 possesses the most marked dopaminergic antagonistic effect, chlorpromazine had also been effective, while haloperidol had proved to be practically ineffective.     

Frequency and Type of Renal and Electrolyte Disorders in Fulminant Hepatic Failure

Of 48 patients with fulminant hepatic failure who progressed to grade III or IV encephalopathy 38 showed evidence of renal impairment. In 32 of these patients the underlying cause could be placed initially into one of three categories—prerenal uraemia (4 patients), acute tubular necrosis (16), and “functional renal failure” (12). The latter differed in several respects from that seen with liver failure secondary to cirrhosis. The frequency and type of renal impairment was the same in those patients in whom the fulminant hepatic failure had resulted from an overdose of paracetamol as in the other aetiological groups.Abnormalities in plasma electrolytes were common—in particular hypernatraemia occurred in 11 patients from an osmotic diuresis precipitated by hypertonic dextrose or fructose given intravenously, and from the sodium in the fresh frozen plasma used to correct the coagulation disturbance when renal excretion of this ion was inappropriately low.     

Panniculectomy in preparation for renal transplantation: a new indication for an old procedure to reduce renal transplantation-associated wound complications

End-stage renal disease patients who have lost a significant amount of weight are increasingly being evaluated for kidney transplantation. An abdominal panniculus, almost uniformly observed, creates an area predisposed to wound complications. Consequently, a panniculus may limit a patient's candidacy for transplantation. The authors describe their preliminary experience utilizing panniculectomy as a prophylactic procedure to reduce wound complications following kidney transplantation in patients whose panniculus would exclude them from renal transplantion. A single-institution chart review was conducted of nine patients with end-stage renal disease who underwent a panniculectomy in preparation for transplantation. Clinical outcomes and complications were reviewed. The nine patients included three men and six women with a mean age of 54.5 years and a mean body mass index of 28.3 kg/m. Four patients had diabetes. All patients underwent an uncomplicated panniculectomy, with a mean resected weight of 3.0 kg, and a mean length of hospital stay of 1.75 days. No one required blood transfusions. All patients were followed postoperatively for 3 months. Complications included an abscess and a skin dehiscence treated with local wound care. After recovery, patients were referred to the transplant center for re-evaluation for kidney transplantation. Thus far, four of these nine patients have undergone transplantation. This case series suggests that panniculectomy can be performed safely in patients with end-stage renal disease. Furthermore, panniculectomy gives these otherwise unsuitable kidney transplant candidates access to a life-saving operation.     

Hepatoprotective activity of Hemidesmus indicus R. br. in rats

Treatment of rats with paracetamol and CCl4 produced a significant increase in the levels of serum glutamate pyruvate transaminase (SGPT), serum glutamate oxaloacetate transaminase (SGOT), alkaline phosphatase (ALP), total and direct bilirubin. Rats pretreated with methanolic extract of roots of H. indicus (100-500 mg/kg body weight, po) exhibited rise in the levels of these enzymes but it was significantly less as compared to those treated with paracetamol or CCl4 alone. The results of methanolic extract of H. indicus were comparable with the standard hepatoprotective agent silymarin (100 mg/kg). Maximum hepatoprotective effect was found to be at the dose of 250 mg/kg body weight in case of CCl4 induced hepatic damage while 500 mg/kg body weight in case of paracetamol induced hepatic damage. The results suggest that methanolic extract of H. indicus roots possesses a potential antihepatotoxic activity.     

Genotoxic effects of paracetamol in V79 Chinese hamster cells

Paracetamol was studied for possible genotoxic effects in V79 Chinese hamster cells. Paracetamol (0.5 mM for 30 min) reduced the rate of DNA synthesis in exponentially growing V79 cells to about 50% of control. A further decrease in the DNA synthesis was seen during the first 30 min after termination of paracetamol exposure. Paracetamol (3 and 10 mM for 2 h) caused a small increase in DNA single-strand breaks, as measured by the alkaline elution technique. After 16 h elution, the amount of DNA retained on the filters was 79 and 70% of controls in cells treated with 3 and 10 mM paracetamol respectively. No indication of DNA damage was seen in measuring the effect of paracetamol (0.25-10 mM for 2 h) on unscheduled DNA synthesis in growth-arrested cultures of V79 cells. At the highest concentrations (3 and 10 mM paracetamol), decreased unscheduled DNA synthesis was observed. Also UV-induced DNA-repair synthesis was inhibited by 3 and 10 mM paracetamol. DNA-repair synthesis was, however, inhibited at a much higher concentration than that inhibiting replicative DNA synthesis. The number of sister-chromatid exchanges (SCE) increased in a dose-dependent manner on 2 h exposure to paracetamol from 1 mM to 10 mM. At the highest dose tested (10 mM), the number of SCE increased to 3 times the control value. Co-culturing the V79 cells with freshly isolated mouse hepatocytes had no further effect on the paracetamol induced sister-chromatid exchanges. The present study indicates that paracetamol may cause DNA damage in V79 cells without any external metabolic activation system added.     

The role of iron in the paracetamol- and CCl4-induced lipid peroxidation and hepatotoxicity

Treatment of non-induced or phenobarbital-induced, glutathione-depleted mice with 400 mg/kg paracetamol led to a marked ethane exhalation as an index of in vivo lipid peroxidation (LPO) and to a significant elevation of liver-specific serum enzyme activities. Similar effects were seen with rats treated with 0.5 ml/kg CCl4. Pretreatment with the iron-chelating agent desferrioxamine (DFO) clearly suppressed lipid peroxidation in all cases, but inhibited only the CCl4-induced hepatotoxicity. Treatment of mice with desferrioxamine alone showed no hepatotoxicity at all, nor did it influence liver GSH-levels. In addition, DFO had no effect on hepatic microsomal enzyme activities responsible for the bioactivation of both paracetamol and CCl4. These findings are consistent with the theories which indicate that lipid peroxidation requires the presence of Fe2+-ions, regardless of the initiating agent, and that LPO is involved in CCl4-toxicity, but most probably not in paracetamol-induced liver damage. Furthermore, Fe2+-ions might play a role as mediators of CCl4-hepatotoxicity.     

Paracetamol (acetaminophen) decreases hydrogen sulfide tissue concentration in brain but increases it in the heart, liver and kidney in mice

The biological action ofN-acetyl-p-aminophenol - paracetamol (acetaminophen) has been demonstrated to involve different mechanisms and is still not clear. Hydrogen sulfide (H2S) has been shown to play an important role in many physiological and pathological processes including nociception. The interaction between acetaminophen and endogenous H2S is unknown. Twenty four female CBA strain mice were administered intraperitoneal injections of N-acetyl-p-aminophenol solution: paracetemol in doses of 30 mg/kg b.w. per day (group D1, n = 8) or 100 mg/kg b.w. per day (group D2, n = 8).. The control group (n = 8) received physiological saline in portions of the same volume--0.2 ml. The measurements of tissue H2S concentration were performed with the Siegel spectrophotometric modified method. In the brain, the H2S tissue level decreased, but more significantly in the lower drug dose group. Conversely, there was a significant rise in the H2S tissue concentration in D1 and D2 groups in heart and kidney with the increase more pronounced in the group with the lower paracetamol dose. In the liver only the higher acetaminophen dose elicited a change in H2S concentration, increasing after administration of acetaminophen at 100 mg/kg. Our study demonstrates that paracetamol induces H2S tissue concentration changes in different mouse organs.     

Impaired renal functional reserve and albuminuria in essential hypertension

The stimulatory effects of an infusion of amino acids on glomerular filtration rate has previously been used to measure renal functional reserve and detect glomerular hyperfiltration. Thirty four patients with mild to moderate essential hypertension and seemingly normal renal function and 22 healthy controls were given infusions of amino acids to investigate whether renal functional reserve is reduced in essential hypertension and to detect patients at risk of renal damage. Although basal creatinine clearance increased after the infusion of amino acids in the controls (mean 27·9 ml/min; 95% confidence interval 18·2 to 37·6), the overall change was lower in the patients (mean 13·4 ml/min; 8·3 to 18·5), 11 of the 34 showing no increase at all. In these 11 non-responders the mean systolic blood pressure was higher than that in the 23 others (178·5 mm Hg v 157 mm Hg, respectively). Mean urinary albumin excretion was abnormal in the patients (93·3 mg/24 h; 44·2 to 142·4); eight of the 11 non-responders had an albumin excretion above the normal range (>20 mg/24 h). In the 11 patients without renal functional reserve a positive correlation was found between basal creatinine clearance and albumin excretion (r=0·695).As consumed renal reserve and albuminuria are markers of glomerular hyperfiltration studying renal function before and after infusion of amino acids can detect hypertensive patients at risk of progressive renal damage.     

The renal response to the ingestion of fluid by the fetal sheep

To see if the variability in fetal urine flow and sodium excretion was related to fetal drinking activity, renal function was investigated in two groups of oesophageally-ligated fetuses and one group of non-ligated fetuses. There was no significant difference in urine flow, sodium excretion or glomerular filtration rate in the ligated fetuses compared with the non-ligated fetuses. Furthermore, oesophageal ligation had no effect on the variability in urine flow and sodium excretion rate. The response of fetal kidney to ingestion of fluid was investigaeed in 2 groups of oesophageally-ligated fetuses. In one group it was shown that ingestion of 20 ml/kg of amniotic fluid by the fetus had no consistent effect on fetal renal function. In the other group it was shown that the ingestion of 200 ml water also had no consistent effect on fetal renal function. The water load caused a rise in fetal blood pressure and a fall in plasma osmolality. Since there was no significant increase in free water clearance and fetal plasma osmolality decreased then rose towards control levels, it is concluded that the oral water load was absorbed from the fetal gastrointestinal tract and diffused out of the fetal compartment across the placenta. These experiments show that fetal drinking is probably not responsible for the variability often seen in fetal urine flow and sodium excretion rate.     

Inhibition of compensatory renal growth by indomethacin

Renal prostaglandins may be important in the modulation of compensatory renal growth. Reductions in renal mass are associated with increased synthesis of these substances by the remaining kidney, and inhibition of prostaglandin synthesis diminishes renal function in partially nephrectomized animals and in patients with reduced functioning renal mass. We examined the effects of uninephrectomy and treatment with indomethacin on renal prostaglandin E2 and 6-keto prostaglandin F1 alpha concentrations in adult male Sprague Dawley rats. The renal content of these prostaglandins was significantly increased in the remaining kidney two days following uninephrectomy (p less than 0.01). Treatment with 5 mg/kg/day of indomethacin over this period abolished the compensatory increase in renal prostaglandin synthesis and significantly attenuated compensatory increases in renal mass, protein and RNA concentrations (p less than 0.05). No alterations in kidney weight, protein or RNA concentrations were found in intact animals treated with the same dose of indomethacin. These findings suggest renal prostaglandins may participate in the biological events leading to compensatory renal growth.     

关木通水煎剂对大鼠肾脏毒性的实验研究

目的:了解关木通水煎剂对大鼠肾脏毒性作用的毒理学特点。方法:分别给予正常大鼠0．625g·kg-1和10g·kg-1关木通,观察其对肾脏形态和功能的影响。结果:给予0．625g·kg-1。关木通8w k,大鼠肾脏形态和功能无改变。给予10g·kg-1关木通8wk,大鼠小管细胞变性明显,并有肾间质纤维化。结论:长期应用药典剂量关木通不造成明显的肾脏损害,而较大剂量应用则可致明显的肾功能异常。