Therapeutical aspects of using citalopram in burns

CONCLUSION OF THE ICU: Preliminary results from this stage of our study demonstrate a significant decrease of the duration of oedema, probably due to the effects of the inhibition of vascular hyperpermeability. This means that patients under Citalopram therapy can undergo surgical procedures such as necrectomies and autografts sooner because they are stabilized as early as the beginning of their treatment. Particularly the patients with burned faces and deep dermal burns have a better prognoses in respect to cosmetics. CONCLUSION OF THE PSYCHOLOGIST: From the beginning of the study to the present time, no patient experienced PTSD. The compared group of out-patients had been treated on average of 3 months when the first signs of a reduction in the clinical symptoms of PTSD was registered. The clinical onset of the therapeutical effect--on average in the third week--is comparable with references from anxiety or inhibitory depression treatment by using Citalopram. We suggest, at present, that the above-mentioned, preliminary results of our study have shown that Citalopram treatment has a beneficial effect on emotional disturbances in severely burned patients. CONCLUSION OF THE SCAR SPECIALIST: Seropram is a very useful preparation in burn praxis. When we apply it as a bolus 40 mg i.v. immediately after admission to the ICU, the scarring process is very good and hypertrophic scars are not seen. When we apply Seropram in the form of a continual infusion, using the injectomat during a 24-hour period, scarring is better than in the control group, but hypertrophic scarring is not out of the question.

Prevention and therapy of postburn scars

The cosmetic and functional result in postburn scar deformities is influenced by following factors: 1. The type of patient's central nervous system and his response to burn injury. 2. Depth and site of burn areas. 3. Early excision and grafting. 4. Infection complications, their severity and location. 5. Fixation of dressings should be done using elastic materials and applied for so long until stabilisation of scars is completed. Elastic materials should be combined with rigid pressure and pressure massage. 6. Congenital predisposition of the patient to hypertrophic scarring.

Use of continuous blood volume monitoring to detect inadequately high dry weight

A continuous blood volume monitoring (CBVM) device (Inline Diagnostics, Riverdale, USA) was used to study response to prescribed ultrafiltration during haemodialysis (HD) in 66 stabilised HD patients. Fifty percent of patients showed the expected linear decrease in BV right from the beginning of HD (group 1), 32% exhibited no decrease at all (group 2), while eighteen percent formed the transient group 3 which showed a plateau of varying length after which a decrease occurred. The correct setting of dry weight was verified through evaluation of the ratio of extracellular fluid volume to total body water (VEC/TBW) in 26 patients by means of whole body multifrequency impedometry MFI (Xitron Tech., San Diego, USA) and through measurement of the Vena Cava Inferior diameter (VCID) pre and post HD (in 6 and 5 patients from groups 1 and 3 and from group 2, respectively). The mean VEC/TBW in groups 1 and 3 was 0.56 pre and 0.51 post HD as compared to 0.583 and 0.551 in group 2. VCID decreased on average by 14.1% in groups 1 and 3 but remained stable in group 2. Both findings thus confirmed inadequately high estimation of dry weight. Since CBVM is extremely easy to perform it can be used as a method of choice in detecting inadequately high prescribed dry weight. The status of the cardiovascular system must always be considered before final judgement is made.

[Measurement of water content and distribution using whole-body multifrequency impedance in a healthy population in diseases of the kidney]

BACKGROUND

The whole-body multifrequency impedometry (MFI) is a new noninvasive method suggested for assessment of hydration status and distribution of the total body water into extra- and intracellular compartment. However, due to its as yet limited use reference values are still lacking. The aim of this work was to evaluate total body water (TBW) and its intra- (VIC) and extracellular compartment (VEC) from electrical resistances of intra- and extracellular fluid and to measure cell membrane capacity by means of MFI in healthy population and in renal patients.

METHODS AND RESULTS

MFI investigation was performed in 21 healthy individuals (group A), 19 patients followed for renal insufficiency but not yet dialysed (group B) and in 15 haemodialysis patients (group C). The bioimpedance analyzer BIS 4000B (Xitron Technologies, San Diego, USA) was used throughout the study. TBW values established by means of MFI corresponded very closely to those ones calculated from Watson's formulae. The ratio VEC/TBW was found to be related to age with regression analysis parameters being very similar both in group A and groups B, C: group A: VEC/TBW = 0.4696 + 0.0011. Age (r = 0.512) groups B, C: VEC/TBW = 0.4574 + 0.0016. Age (r = 0.420). (For group C the post-dialysis values were used). Close correlation of VEC changes with ultrafiltered volume during haemodialysis session (r = 0.87 pri n = 87) indicates mostly extracellular origin of ultrafiltrate. The highest capacity of the cellular wall was found in healthy individuals, the lowest values were seen in the dialysed group. During dialysis the capacity rose to values seen in the non-dialysed group of renal patients. Interindividual scater over 40% in CIC value is caused by differences in body size. Normalized capacity CIC/VIC in healthy group is 0.104 nF/L +/- 10% on average. In renal patients values from 0.73 to 0.9 nF/L were seen. With regard to low variation of CIC/VIC in health, this parameter can be considered a possible candidate for screening assessment of the renal patients' hydration status.

CONCLUSIONS

MFI was found suitable for monitoring of water content and distribution in the body both in out-patient department as well as during haemodialysis.

Influence of the dialyzer membrane material on sodium transport in hemodialysis

Traditionally Gibbs-Donnan coefficients based on the mean charge of plasma proteins are used as the only correction factor in equations describing sodium transport across the dialyzer membrane. This ignores the possible impact of the membrane material. Correction coefficients (CC) of the whole dialyzer were measured during in vivo dialysis as a quotient of dialysate to plasma sodium in an equilibrated state for different membrane materials used in commercially available dialyzers. Their mean value and correlation with total plasma protein content (TPP) were evaluated. CC for the six materials evaluated differed both in the intercept and slope of the regression line CC versus TPP: Cuprophan 1: CC = 1.0253 - 0.00017 x TPP; Hemophan 1: CC = 1.119 - 0.00175 x TPP; Hemophan 2: CC = 1.095 - 0.00111 x TPP; PMMA: CC = 1.0353 - 0.00044 x TPP; SCE:CC = 1.114 - 0.00145 x TPP; and Cuprophan 1:CC = 1.0562 - 0.00065 x TPP. The observed differences are attributed to the different charge densities of the membrane materials and suggest that for a precise description of sodium transport, the role of the membrane material needs to be considered.

Analysis of the urea generation rate and the protein catabolic rate in hemodialyzed patients

The urea generation rate (G) and the protein catabolic rate (PCR) have been investigated in two groups of hemodialyzed patients over a whole week cycle, one with zero residual renal function (Kr = 0) dialyzed thrice weekly and the other dialyzed twice weekly with nonzero residual renal function. The two-pool model of urea kinetics was used. No relationship between patients' age and the PCR was found, and also no difference in the PCR between males and females was seen. All patients with a PCR < 0.8 g/kg/day had a midweek predialysis plasma urea level well below 25 mmol/L, which clearly documents the value of a kinetic approach in early detection of patients at risk for malnutrition. In the thrice weekly dialyzed group, a statistically significant relationship was found between PCR and KT/V:PCR = 0.582 + 0.253 x KT/V, r = 0.374 with p < 0.05. In the twice weekly dialyzed group with nonzero Kr, contribution of the residual renal function had to be included into KT/V to reach a level of statistical significance of PCR = 0.697 + 0.18 x KT/V, r = 0.481 with p < 0.05. With regard to values of Kr encountered in the investigated group (0-3.5 ml/min), its influence upon PCR is higher than a volumetrically equal increase in excretorial efficacy of the artificial kidney. The G in the thrice weekly dialyzed group was found to be dependent on the length of the interdialytic interval over which it was evaluated. Over the intervals Friday-Monday, Monday-Wednesday, and Wednesday-Friday the following mean values of G were obtained: 0.155, 0.180, and 0.188 mmol/min, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Study on sodium and potassium balance during hemodialysis

To acquire data for adequate ultrafiltration (UF) control, sodium and potassium balance was investigated during hemodialysis (HD) in 16 hemodialyzed patients. Overall balances were evaluated from concentration measurements of the in- and outflowing dialysate and pre- and postdialysis plasma. The diffusive and convective part of the electrolyte removal and its intra- and extracellular space (ICS, ECS) component were calculated. During a 5-h HD, 40-110 mmol of potassium is removed, predominantly by diffusion (72-88%). Calculation shows that 40-70% of the removed amount is taken from the ICS. Sodium's overall HD showed much higher scatter, ranging from positive values to 500 mmol removal. The diffusive component was positive in most cases. By ultrafiltration sodium is removed in all cases. Calculations also showed in all cases that sodium was delivered to the ICS. This is in contradiction with the general belief that exchangeable sodium is distributed solely in ECS (1,2,6,7). This may be a sign of the effort to keep changes of ICS osmotic load at a minimum. Based on the finding of the exchange of sodium for potassium in the cellular wall, a method has been devised to calculate the UF fraction removed from EC (UFEC) expressed as a coefficient KEC = UFEC/UFToT, with UFToT being the total fluid volume removed during the HD session.

[Prediction of needs in dialysis therapy]

Planning of future needs of Renal Replacement Therapy (RRT) Programme is frequently based on comparison of national data with data from other countries. Often, the dynamics of RRT development is disregarded and dialysis and transplantation assessed as separate entities, too. Such approach may lead to underestimation of present level of RRT availability and overestimation of immediate future needs. Transplantation activity and number of patients requiring dialysis are interrelated variables. Under steady state, their relation may be described as N = TX + U where N denotes incidence of chronic renal failure, TX transplantation activity, and U stands for mortality rate of dialysed population. Considering mortality rate equal to 10% of dialysed population (P), an equation describing the interrelation of transplantation activity and number of patients requiring dialysis may be devised: P = (N - TX)/0.1. This equation can be used to calculate target values of RRT programme. The time course of RRT needs to reach the target figures may be predicted from a simple differential equation dP/dT = N - 0.1. P - TX, taking into account dynamic character of this process.

[Nephrologic aspects of HIV infection]

The authors present a review of nephrological complications of HIV infection. The latter can be divided into electrolyte disorders and disorders of the water balance, acute renal failure, non-specific affections of the glomeruli, tubules and renal vessels and so-called HIV nephropathy. While the three former groups of complications are non-specific, coincidental, HIV nephropathy is obviously a specific complication of HIV infection. It is characterized by the nephrotic syndrome with rapid progression to irreversible renal failure. As to the histological appearance, it is focal segmental glomerulosclerosis. Survival of asymptomatic HIV infected patients in a dialyzation programme does not differ from other patients. The prognosis in case of developed AIDS is, however, unfavourable. Transplantation of HIV positive donors and recipients is not recommended. The authors present also basic data on the possible nephrotoxicity of the most frequently used preparations in the treatment of HIV infected subjects.

[The effect of erythropoietin therapy on biocompatibility in hemodialysis]

In order to evaluate the treatment with erythropoietin (EPO) on selected indicators of biocompatibility the authors examined 8 patients dialyzed for prolonged periods before treatment (HTK = 0.23, median), during EPO treatment (Recormon, administered by the s.c. route, HTK = 0.28) in the course of 4-hour haemodialysis on dialyzers with a Cuprophan membrane. The examination before and during treatment was made under equal conditions. Heparinization was also equal despite the fact that during EPO in four patients the residual blood volume in the dialyzer was increased. Comparison of the results before treatment and during EPO treatment did not reveal at any of the collection times (before dialysis, during the 15th, 10th, 60th and 235th minute of the procedure significant differences in the number of leucocytes, plasma concentrations of the C5a complement component, number of thrombocytes and activated coagulation times. Plasma concentrations of the thrombin-antithrombin III complex were in EPO during the 60th minute of haemodialysis significantly lower (p < 0.05) than before EPO. The authors conclude that EPO treatment does not have a significant effect on changes in the number of leucocytes in blood during haemodialysis nor on the activation of complement by an alternative way. EPO does not lead to a greater activation of the coagulation system during haemodialysis; the lower concentration of the thrombin-antithrombin III complex suggests the opposite. Explanation of this finding, similarly as detection of the cause of the increased residual blood volume in some patients, calls for further investigation.

[Clinical study of biocompatibility of dialysis membranes made from non-modified and modified cellulose]

Basic biocompatibility parameters of dialysis membranes made of non-substituted regenerated cellulose (NRC) and cellulose membranes with hydroxyl groups substituted, to a higher (H) or lower (L) degree, by dl-ethyl-amino-ethyl groups (DEAE), or by acetate (CA) were investigated in a 16-week clinical study, involving 10 long-term haemodialysis patients. In the 15th minute of dialysis, the decrease in blood leukocyte count, while using NRC (0.24 +/- 0.03 of baseline value, arithmetic mean +/- SEM) was deeper compared with that seen in DEAE-L (0.88 +/- 0.10, p < 0.001), in DEAE-H (0.79 +/- 0.10, p < 0.01), and in CA (0.73 +/- 0.05. p < 0.05). In the 15th minute of the procedure, C5a concentrations, reflecting complement activation, were higher in NRC (4.4 +/- 0.51 micrograms/L) than in DEAE-L (1.41 +/- 0.22, p < 0.001), in DEAE-H (1.68 +/- 0.47, p < 0.01), and in CA (1.68 +/- 0.22, p < 0.01). Activated clotting times were, in the 10th minute of the procedure, significantly longer in NRC (2.94 +/- 0.37 of baseline value) than in DEAE-H (1.74 +/- 0.10, p < 0.05) and, by the end of dialysis, the difference between these membranes (NRC: 1.47 +/- 0.21, DEAE-H: 0.85 +/- 0.08, p = 0.07) was close to the level of statistical significance. The authors conclude: 1. Substitution of the hydroxyl groups of regenerated cellulose reduces the decrease in leukocyte count and complement activation in the initial phase of haemodialysis. 2. At the same time, substitution by DEAE groups may raise thrombogenicity, as indicated by the shorter activated clotting times.(ABSTRACT TRUNCATED AT 250 WORDS)

[14 years of the peritoneal dialysis program at the internal medicine department in Strahov (1978-1991)]

The authors present an account of 14 years experience of the department as regards treatment of chronic renal failure by peritoneal dialysis. Initial experience revealed that this method is feasible as an alternative of haemodialyzation treatment even in case of limited technical possibilities (using the so-called bottle system) but treatment was associated with a high incidence of peritonitis. During the subsequent period the incidence of peritonitis was substantially reduced in conjunction with the elaboration of hygienic provisions, enlightment of patients and a change from the regime of continual exchanges in a home environment to a regime of intermittent peritoneal dialysis performed mostly in hospital. Experience assembled in the department was also important. The longest period of treatment is 60 months. In another 18 patients it is more than 20 months. The most frequent cause of termination is loss of the ultrafiltration capacity of the peritoneum. Several patients had successful transplantations. The prolonged experience can be used at present when the so-called bag system is introduced.

[Results of studies of indicators of hemostasis in hemodialyzed patients during administration of 1-deamino-8-D-arginine vasopressin]

The fibrinolytic activity (FA) evaluated according to the euglobulin clot lysis time was in haemodialyzed patients (3.0 +/- 0.2 arb. u.) lower than in patients with chronic renal failure treated by conservative methods (4.7 +/- 0.6, p less than 0.05) and than in healthy subjects (4.2 +/- 0.4, p less than 0.05). After stimulation by intravenous administration of 1-deamino-8-D-arginine vasopressin the FA in haemodialyzed patients rose to (4.5 +/- 1.6), less than in conservatively treated (14.1 +/- 2.1, p = 0.06) and than in healthy subjects (18.2 +/- 3.9, p less than 0.001). By using specific methods it was proved that the inadequate rise of FA in haemodialyzed patients after stimulation is conditioned by a defect of the release of the plasminogen tissue activator from the vascular wall. Contrary to healthy subjects (7.0 +/- 1.3 vs. 16.7 +/- 2.3 ng/ml, p less than 0.01) is plasma concentration in haemodialyzed subjects (5.3 +/- 0.5 vs. 7.9 +/- 0.8, NS) did not increase significantly. Repeated examinations of some of the haemodialyzed patients revealed that almost 20 months of regular haemodialysis do not lead to further changes of basal (2.9 +/- 0.3 vs. 2.8 +/- 0.2) nor stimulated (4.2 +/- 0.5 vs. 4.8 +/- 0.9) FA. Basal plasma concentrations of the von Willebrand factor were in the dialyzed patients (89.1 +/- 8.8%) higher than in healthy subjects (67.2 +/- 4.4, p less than 0.05). After stimulation the concentration of the von Willebrand factor increased significantly in healthy subjects (99.1 +/- 4.3, p less than 0.01), but not in dialyzed patients (82.9 +/- 3.1, NS), obviously due to the pathological reactivity of their vascular wall. The above findings may be associated with thromboses and atherosclerosis in patients on long-term dialysis.

An equation for calculating postdialysis plasma sodium

Well defined dry weight is a must for adequate UF control during haemodialysis (HD). However, interdialytic weight gain (delta BW) must not be excessive. delta BW is closely related to interdialytic thirst which in turn is strongly influenced by post-dialysis plasma sodium (CPNa post), but little is known about the desired CPNa post. The points below serve as a basis for establishing this value. a) Thirst is mediated by osmoreceptors. b) A strong correlation has been found between delta BW and intradialytic increase in plasma sodium but no such correlation exists with the interdialytic increase in plasma urea. This indicates that fluid intake between dialyses depends solely on electrolytes. c) Pre-dialysis plasma sodium in an individual is stable, indicating that the patient is at his "set value" of electrolyte osmolality. d) Half of the potassium removed during HD comes from the extra- and half from the intracellular space. Assuming that it is desirable not to disturb a patient's pre-dialysis osmotic steady state, it can be calculated that the desired CPNa post should be higher than the pre-dialysis value by half of the intradialytic plasma potassium drop, i.e., approx. CPNa post = CPNa pre + 1 to 2 mmol/l.

Bile composition in patients with chronic renal insufficiency

Very little is known about bile composition in the end stage of chronic renal sufficiency. Patients with this condition are either assigned to a dialysis-transplantation programme, or are treated temporarily with a low-protein diet. Our study was designed to determine bile composition both in a group of ten patients treated with a low-protein diet over a long period of time, and in 11 patients on regular haemodialysis. The patients on haemodialysis were found to have increased bile cholesterol and an increased saturation index in the bile, i.e. changes implying increased risk of cholecystolithiasis. These changes were further enhanced by the effect of a low-protein diet with subsequent increases in cholesterol values and the bile saturation index, as well as a decrease in primary and an increase in secondary bile acids in the bile, i.e. a change in the spectrum of bile acid characteristic for cholecystolithiasis.

[Kidney transplantation in diabetics]

Diabetic nephropathy affects half the type I diabetics and is their most frequent cause of death. While in some countries diabetics account for 25-30% of all newly admitted patients in dialyzation-transplantation programmes, in the CSSR the number of diabetic patients treated by dialyzation or transplantation is small. From August 1985 to June 1988 in the Institute of Clinical and Experimental Medicine a total of 15 isolated transplantations of the kidneys were made in 13 diabetics with serious late complications of diabetes. At present all recipients survive (1-35 months) and only two are treated by an artificial kidney. Progressing vascular complications were in two instances the cause of gangrene of the lower extremity, one recipient had a central cerebrovascular attack. Despite this, successful transplantation caused a marked improvement of the general condition and quality of life. The compensation of diabetes was also, due to intensified insulin therapy, satisfactory in the majority of recipients. Hitherto assembled experience indicates that when the patient is prepared in time, which includes diabetological, nephrological and opthalmological treatment, the results of transplantation treatment in diabetic patients can be comparable with results in should be developed in all transplantation centres in the CSSR and uraemic diabetics should be eliminated from the dialyzation transplantation programme only in case of fundamental contraindications.

Is heparin responsible for enhanced platelet aggregation after haemodialysis?

The platelet aggregation--enhancing action of heparin with adenosine diphosphate and epinephrine was tested in vitro in a group of volunteers. This action of heparin can be eliminated by protamine sulphate which has no effect on platelet aggregation. In dialyzed patients the aggregation effect of heparin manifested itself after haemodialysis and could also be abolished by protamine sulphate. We therefore assumed that the heparin used during dialysis was one of the factors accounting for the increased platelet aggregation after dialysis.