Dramatic efficacy of cyclophosphamide pulsed therapy combined with double-filtration plasmapheresis for treating severe massive pulmonary hemorrhage associated with systemic lupus erythematosus

Abstract Pulmonary hemorrhage (PH) is a rare but fatal complication of systemic lupus erythematosus (SLE). We report a patient with SLE and a massive PH who was treated with double-filtration plasmapheresis synchronized with cyclophosphamide pulsed therapy. The patient showed dramatic improvement immediately and was followed for 3 years without recurrence. Prompt treatment during the acute phase of PH with this short-term intensive combination therapy may offer the best chance of success. There are few reports of long-term followup, especially in Japan.

Experimental small bowel transplantation using a newborn intestine in rats: IV. Effect of cold preservation on graft neovascularization

BACKGROUND/PURPOSE

University of Wisconsin (UW) solution is one of the most superior organ preservation solutions for liver, kidney, and pancreas; however, it still is controversial for intestinal preservation. Here, the authors studied the efficacy of preservation with 2 kinds of solutions, UW and modified TOM (m-TOM) solutions in our experimental newborn intestinal transplantation model. UW solution was used as a standard intracellular and m-TOM solution as an extracellular preservation solution. Lactated ringer (LR) solution was used as a control.

METHODS

Newborn intestine, which were preserved in these solutions for 24 or 48 hours, were transplanted in the subcutaneous spaces of the syngeneic recipients without surgical vascular anastomosis and histologically examined 14 days after grafting. The preserved grafts were evaluated histologically by use of light and electron microscopy just after preservation. The biochemical parameters such as LDH and serotonin also were measured in the supernatants of preservation solutions.

RESULTS

Fresh newborn grafts were revascularized successfully at a rate of 80% (16 of 20). After 24 hours of preservation, 65% (13 of 20), 75% (15 of 20), and 85% (17 of 20) of the grafts were observed to be revascularized in LR, m-TOM, and UW solutions, respectively. After 48 hours of preservation, 60% (12 of 20), 80% (16 of 20), and 80% (16 of 20) of the grafts also were revascularized in the respective solutions (no statistic difference among the groups). The cold-preservation did not affect the neovascularization of newborn intestine until 48 hours. Histologic findings of the preserved intestine and biochemical analyses showed that UW and m-TOM solutions kept villous architectures of the preserved grafts, however, might be harmful to enterochromaffin cells.

CONCLUSION

Long-time preservation of newborn intestine did not interfere with neovascularization and maturation. J Pediatr Surg 36:1805-1810.

Plasma levels of myeloperoxidase and elastase are differentially regulated by hemodialysis membranes and anticoagulants

To examine effects of dialyzer membranes and anticoagulants on hemodialysis (HD)-triggered neutrophil degranulation. We measured plasma myeloperoxidase (MPO) and elastase (ELT) by an enzyme-linked immunoabsorbent assay. During routine HD with a cuprophane membrane and high molecular weight (HMW) heparin, plasma MPO was rapidly upregulated to maximal levels within 15 min after starting extracorporeal circulation. In contrast, the level of plasma ELT gradually increased such that the highest level was achieved at the end of the procedure. When polysulfone and polymethylmethacrylate membranes were substituted for cuprophane, the rise in ELT was markedly suppressed. Polysulfone was also capable of reducing the MPO response, although the effect was less prominent than that for ELT. As for anticoagulants, nafamostat mesylate (NM) completely suppressed the rise in plasma MPO during HD with cuprophane. Low molecular weight (LMW) heparin also partially inhibited this response. In sharp contrast, there was no significant difference in the ELT response between nafamostat, HMW, and LMW heparins. Thus, NM maximally suppressed the rise of plasma MPO but had no effect on the ELT response. Our results suggest that neutrophil degranulation of MPO and ELT is differentially regulated during HD. Polysulfone and NM appear to maximally reduce excessive neutrophil activation.

Active inhibitory effect of nafamostat mesylate against the elevation of plasma myeloperoxidase during hemodialysis

Plasma levels of myeloperoxidase (MPO) were compared between hemodialysis (HD) sessions using heparin and those using nafamostat mesylate (NM) as an anticoagulant by an enzyme immunoassay established in our laboratory. MPO levels were markedly elevated during the entire HD procedure with heparin. In contrast, MPO levels were scarcely elevated during the HD with NM. On the other hand, polymorphonuclear leukocyte-elastase was markedly elevated during both of these HD procedures. These observations indicated that NM selectively attenuated MPO elevation in vivo during HD. This inhibitory effect of NM was further investigated ex vivo. Blood samples from a normal subject were collected with heparin alone, NM alone and a mixture of heparin and NM. Each sample was then circulated in a closed circuit composed of a dialyzer with a cuprophane membrane. MPO levels with heparin alone were shown to markedly rise in the closed system. In contrast, levels of MPO in the blood samples mixed with NM were not elevated even in the presence of heparin. These ex vivo results indicate that NM has an active inhibitory effect on the elevation of plasma MPO induced by granulocyte activation through a dialysis membrane. Our results demonstrate that clinical use of NM as an anticoagulant serves to selectively suppress MPO elevation considered as a consequence of granulocyte activation during HD.

[Atypical leukemia accompanied by vitamin B12 deficiency]

A 76 year old female with atypical leukemia complicated by vitamin B12 deficiency demonstrated marked fluctuation in blast percentage and hemopoiesis over 8 month period. She underwent surgical removal of pancreas head cancer 5.5 years ago. In January 1989 severe pancytopenia and mild increase of bone marrow blast were found. Blood transfusions and inadvertent administration of Vitamin B12 resulted in alleviation of pancytopenia and decrease in blast percentage. Several months later her bone marrow blast exceeded 30%, when serum B12 concentration was below 90 pg/ml. B12 injection and blood transfusion resulted in significant improvement in her hematological condition, but shortly thereafter she died of fulminant hepatitis. Her bone marrow cells showed a polyclonal constitution, as assessed by the RFLP-methylation technique using the PGK gene as a probe. The coexistence of leukemic- and normal clones under Vitamin B12 deficiency conditions and the differing behavior of such clones to B12 supplementation may explain the unusual clinical course observed in this patient.