Intractable Edema Research Articles

Dialysis access graft occlusion with contrast and ultrasound guided thrombin injection for intractable arm edema and pseudoaneurysm.

We present the case of a patient with a brachio-basilic graft forearm loop with intractable edema and thrombosed central veins. She showed up with an important edema after some effort and a previously thrombosed pseudoaneurysm with significant growth. She refused angioplasty treatment for central veins, the graft had not been used for dialysis during the last year, so that arteriovenous graft (AVG) ligation was considered. Due to local conditions thrombin percutaneous embolization was performed to avoid possible complications of a conventional surgery approach. AVG occlusion was done in 10 min by fluoroscopy and ultrasound guidance. In 24 h the patient was significantly better and after 1 week she had no edema at all. There were no complications and no recanalization was observed after 3 months. Percutaneous thrombin embolization is a safe and effective technique for AVG occlusion in case of intractable arm edema with central vein thrombosis, and most likely to be considered in other situations where arteriovenous graft or fistula ligature is needed.

Association between Inflammatory Factors in the Aqueous Humor and Hyperreflective Foci in Patients with Intractable Macular Edema Treated with Antivascular Endothelial Growth Factor

Background To evaluate the correlations between the inflammatory factors in the aqueous humor and hyperreflective foci (HRF) in patients with intractable macular edema treated with antivascular endothelial growth factor (anti-VEGF). Methods This study included 17 patients with intractable macular edema (ME) treated with anti-VEGF agents. Inflammatory factors in the aqueous humor were measured by the Cytometric Beads Array before injection, and the numbers of HRF pre- and post-anti-VEGF treatment were counted from four different directions (90 degrees, 45 degrees, 180 degrees, and 135 degrees) in the SD-OCT images, respectively, before treatment and one month after treatment. The correlations between inflammatory factors and the numbers of HRF were assessed. Results The numbers of HRF were reduced significantly after anti-VEGF treatment. The change in the HRFs at the 90-degree location was significantly positively correlated with IL-8 and VCAM-1. The change of all HRFs was significantly positively correlated with IL-8. The HRFs before the treatment also had a positive correlation with IL-8 and VCAM-1. Conclusion After anti-VEGF treatment, the numbers of HRF in intractable ME declined greatly. The higher the levels of IL-8 and VCAM-1 before treatment, the more significant the reduction of HRF after anti-VEGF treatment, which indicated that HRF could be an effective noninvasive imaging indicator for evaluating the effect of anti-VEGF on intractable macular edema. The OCT images at the 90-degree location could better show the inflammatory reaction of patients and also had better clinical significance for the prognosis evaluation of ME associated with inflammation.

Late Effects of Organ Preservation Treatment on Swallowing and Voice; Presentation, Assessment, and Screening.

The prevalence of head and neck cancer (HNC) survivors is on the rise. Treatments for HNC can have a major deleterious impact on functions such as swallowing and voice. Poor functional outcomes are strongly correlated with distress, low quality of life, difficulties returning to work and socializing. Furthermore, dysphagia can have serious medical consequences such as malnutrition, dehydration, and pneumonia. A conservative estimate of the percentage of survivors living with dysphagia in the long-term is between 50 and 60%. Evidence is emerging that functions can worsen over time, sometimes several years following treatment due to radiation-associated fibrosis, neuropathy, intractable edema, and atrophy. Muscles lose their strength, pliability, stamina, and range, speed, precision, and initiation of movements necessary for swallowing and voice functions. Late treatment effects can go unrecognized, and may only be identified when there is a medical complication such as hospitalization for aspiration pneumonia. In the routine healthcare setting methods of evaluation include a detailed case history, a thorough clinical examination and instrumental assessments. Interventions for late treatment effects are limited and it is imperative that patients at risk are identified as early as possible. This paper considers the role of screening tests in monitoring swallowing and detecting aspiration in the long-term. Further work is indicated for addressing this pressing and increasingly common clinical problem.

Abstract TP74: Therapeutic Benefit of Hypothermia After Decompressive Hemicraniectomy in Patients with Ischemic Stroke

Objective: Several reports described a beneficial effect of both decompressive hemicraniectomy and therapeutic hypothermia in the management of intractable cerebral edema caused by ischemic stroke. We compared the clinical course and functional outcome in patient with ischemic stroke who were treated with a combination therapy with decompressive hemicraniectomy and therapeutic hypothermia of 33.5°C (DT) or received decompressive hemicraniectomy alone (DA), respectively. Methods: We retrospectively reviewed of subjects who were received decompressive hemicraniectomy secondary to ischemic stroke involving the middle cerebral artery, internal carotid artery, or both from 2004 to 2015. 26 patients were treated by DA and 10 patients received a combination of DT. functional outcome was assessed at 30 days and at 90 days. Results: Age, initial National institutes of Health Stroke Scale score, volume of cerebral infarction in diffusion weight imaging, risk factors for ischemic stroke were not significantly different between both groups. Median time from symptom onset to decompressive hemicraniectomy were not significantly different. Therapeutic hypothermia was induced after surgery and maintained. (median duration : 159.9 hours). The difference between presurgical and postsurgical midline shift of septum pellucidum and pineal gland in cranial computed tomography scans did not differ significantly between both groups. Duration of need for intensive care or for mechanical ventilation were not significantly different between both groups. There is a difference in mortality rate at 30 days (0% in DT group vs. 26.9% in DA group). The median modified Rankin Scale (mRS) score at 30 and 90 days were 5 and 4, respectively in both groups. Good functional outcome (mRS scores of 0-3) at 90days was observed in 10% of DT group and 5.9% in DA group. Conclusion: The present study suggests that a combination therapy of decompressive hemicraniectomy and therapeutic hypothermia improves mortality rate and functional outcome as compared with decompressive hemicraniectomy alone. The main limitation of this study include its retrospective single-center nature, which may limit generalizablility of the study

Possible prevention of uremic nausea by vitamin D receptor activators in non-dialysis patients with stage 5 chronic kidney disease

BackgroundNausea is a major uremic symptom and a frequent indication for starting dialysis. However, preventive medication for uremic nausea has not yet been identified. Vitamin D receptor activators (VDRAs) may prevent uremic nausea via their pleiotropic actions. The objective of this study was to explore whether VDRA administration during the predialysis period is associated with a reduced prevalence of uremic nausea just prior to beginning dialysis.MethodsA multicenter, retrospective, cross-sectional study was performed to identify a medication to prevent uremic nausea. Patients with stage 5 CKD who were followed-up over 3 months were included. The primary outcomes examined were the prevalence of uremic nausea, congestive heart failure (CHF), and intractable edema at dialysis commencement. The predictor variable was VDRA use during the predialysis period.ResultsOne thousand five hundred and thirty six patients who had just begun dialysis in nine Japanese facilities between January 2006 and October 2013 were included. Two hundred and thirty (15.0%) patients had commenced dialysis because of uremic nausea, and three hundred and ninety two (25.5%) patients had been using VDRAs before initiating dialysis. Logistic regression analysis showed that, among the medications examined in this study, only VDRA use was independently associated with a lower frequency of uremic nausea (OR 0.512, 95% CI 0.347–0.738, P = 0.0003). On the other hand, CHF and intractable edema were not associated with VDRA administration.ConclusionUse of VDRAs during the predialysis period was the only factor associated with a lower prevalence of uremic nausea, suggesting that VDRAs may prevent uremic nausea in patients with advanced CKD.

Clinical effect observation on torasemide in treating children with nephrotic syndrome and refractory edema

Objective To study the clinical effects of torasemide in the treatment of nephrotic syndrome with intractable edema (referred to the infant nephropathy).Methods Clinical analysis was carried out to infants with kidney disease admitted in our department from January 2010 to December 2013,32 cases of infant kidney disease were divided into Torasemide group and Furosemide group,on the basis of the two oral prednisone sufficient quantities [2 mg/(kg · d) or 60 mg/(m2 · d)].Torasemide group,16 patients,were given intravenous infusion of torasemide 1-2 mg/(kg · d),Furosemide group with 16 cases were given intravenous infusion of furosemide 1-2 mg/(kg · d) for 5 days.The patients of two groups were detected for 24 h urine,electrolyte changes,and we recorded the adverse reactions before and after treatment of 2,4,6 days.Changes in the amount of urine,serum potassium and trioxypurine as the primary efficacy endpoint.Results Among the children of two groups with clinical use of torasemide and furosemide,urine output increased significantly as compared with that before treatment,showing edema fading,weight lose.Total efficiency in two groups was statistically significantly different (94％ vs 81％).Serum potassium concentration in Furosemide group was significantly lower than that of Torasemide group (P ＜ 0.05),trioxypurine concentration in Furosemide group was significantly higher than that of Torasemide group (P ＜ 0.05).Conclusion The torasemide in the treatment of nephrotic syndrome with intractable edema has significant clinical curative effect,with less side-effect,without obvious effect to electrolyte and renal function,which is worthy of clinical promotion. Key words: Nephrotic syndrome; Edema; Torasemide; Furosemide; Curative effect

Career lifetime advances in nuclear medicine

When I qualified in 1967, medicine was much simpler, but becoming more interesting. There were new diuretics (ethacrynic acid and furosemide) which really worked ‐ I’m probably one of the last housemen to have used Southey’s tubes for drainage of intractable oedema. We also had new antibiotics such as ampicillin. My surgical skills were minimal, and my first house job was as house surgeon to the cardiothoracic unit at Westminster Hospital, where I clerked the patients, held the retractor and looked after the patients in the postoperative period. This was basically applied physiology ‐ and I enjoyed it. My medical house job was in cardiothoracic medicine, and here I came across my first real taste of what was to become nuclear medicine when we were able to send patients over to University College Hospital (UCH) to have their pulmonary perfusion assessed. 1 Remember, there was no computed tomography (CT), no magnetic resonance imaging (MRI), no ultrasound and little angiography. I enjoyed applied physiology, so I managed to persuade the cardiothoracic unit that they needed a senior house officer in what would now be called intensive care, and they persuaded the Garfield Weston Foundation to fund a post. This included looking after postoperative patients, as well acting as resident doctor to the respiratory and coronary care units (including two hyperbaric tanks). I also found time to go on the course in clinical measurement run by Dr Percy Cliffe’s department, and to teach myself programming in FORTRAN on the IBM 1800 computer. Having decided that a physician’s life was for me, I went to work for Dr Phillip Harvey at St Stephen’s Hospital in Fulham, where I passed MRCP part I, and took part II. I then decided that to be a general physician I needed to learn more neurology, so I got a registrar post in neurology at the Royal Free Hospital ‐ where nuclear medicine re-entered my life. The standard methods of diagnosing intracerebral pathology involved basic ultrasound to look for a shift of the midline structures, followed by angiography, usually by direct carotid puncture. If this did not resolve the issue, the patient went to Queens Square for a pneumoencephalogram. However, the medical physics department at the Royal Free had a rectilinear scanner, and one of my tasks was to inject the patients with the pertechnetate to allow imaging. The images were amazing ‐ it was possible to see a tumour without risk to the patient. I also helped set up and run a Parkinson’s disease clinic for trials of L-DOPA and related agents. 2 Still trying to be a general physician, I went on to a short spell as a locum senior registrar in rheumatology, and then was offered a locum post at Guy’s in endocrinology and nuclear medicine. These were two specialties I had not tried, so I accepted the offer. The nuclear medicine was a revelation. There was exposure to a wide new field. We were measuring glomerular filtration rate using Cr-51-EDTA, looking for pulmonary emboli, carrying out renography using probes to assess kidney function, and localising the placenta in pregnant patients with antepartum haemorrhage using a Sn/In-1113m generator, a probe and a calibrated tea towel. I knew that this felt right for

Management of Patients with Recurrent Nephrosis and Intractable Edema by Intraperitoneal Instillation of Icodextrin Solution

Management of Patients with Recurrent Nephrosis and Intractable Edema by Intraperitoneal Instillation of Icodextrin Solution

A randomized trial comparing losartan with amlodipine as initial therapy for hypertension in the early post-transplant period

Blockade of the renin-angiotensin-aldosterone system in the early post-transplant period remains controversial. Angiotensin II-receptor blockers (ARB) have many benefits to the patient with chronic kidney disease and these benefits may also apply to the renal transplant recipient (RTR). Additionally, there are theoretical benefits of ARB use in RTR. This study was designed to investigate the safety of early ARB use after renal transplantation. RTR with serum creatinine levels <3.0 mg/dl were randomized to receive either ARB (n = 29) or calcium-channel blocker (CCB; n = 27) as initial therapy for post-transplant hypertension. Differences in potassium, creatinine and haemoglobin concentrations were compared at baseline, 3, 6 and 12 months after transplantation. Withdrawal from the assigned treatment was high: 12 in the ARB group (due to hyperkalaemia in six) and 17 in the CCB group (due to intractable oedema in seven and post-transplant erythrocytosis requiring an angiotensin-converting enzyme inhibitor in seven). There were no differences in blood pressure, haemoglobin or creatinine concentration at any time-points. Mean potassium concentrations were only slightly higher in the ARB vs CCB group (range: 4.2-4.3 vs 3.7-3.8 mEq/l, respectively, but clinically significant) and the number of patients with potassium values >6.0 mEq/l was higher in ARB (n = 7) vs CCB (n = 1). These data suggest that hyperkalaemia is the major complication that occurs with the use of ARB in the immediate post-transplant period. ARB use does not affect renal function or complicate the post-transplant management of RTR. Other than reducing the incidence of post-transplant erythrocytosis, ARB use does not cause an excess incidence of anaemia. Strategies to reduce the risk of hyperkalaemia may allow increased use of ARB immediately after kidney transplantation.

The post-thrombotic syndrome.

One of every three patients with deep-vein thrombosis of the lower extremities will develop, within 5 years, post-thrombotic sequelae that vary from minor signs to severe manifestations such as chronic pain, intractable edema, and leg ulceration. The post-thrombotic syndrome (PTS) develops as a result of the combination of venous hypertension due to persistent outflow obstruction or valvular incompetence and abnormal microvasculature or lymphatic function. Among factors potentially related to the development of PTS, recurrent ipsilateral thrombosis plays a major role. Whether the extent and the location of the initial thrombosis are associated with the development of PTS is still controversial. The diagnosis of PTS can be accepted on clinical grounds for patients with a history of venous thrombosis. The combination of a standardized clinical evaluation with the results of compression ultrasonography and Doppler ultrasonography helps diagnose or exclude a previous proximal-vein thrombosis. Prevention of recurrent thrombosis and use of compression elastic stockings are the cornerstones of PTS prevention. The management of this condition is demanding and often frustrating. Although several surgical procedures have been tested, conservative treatment is largely preferable, as more than 50% of patients either remain stable or improve during long-term follow-up, if carefully supervised and instructed to wear proper elastic stockings. Clinical presentation helps predict the prognosis, being the outcome of patients who refer with initially severe manifestations more favorable than that of patients whose symptoms progressively deteriorate over time.

Nodular regenerative hyperplasia of the liver graft after liver transplantation.

Nodular regenerative hyperplasia has not previously been reported in patients who have undergone orthotopic liver transplantation. In this report we describe the clinical, biochemical and histologic findings in nine liver transplant recipients in whom nodular regenerative hyperplasia developed between 6 and 144 mo (median, 64 mo) after transplantation. Six of the patients manifested features of portal hypertension (variceal bleeding, ascites, severe intractable peripheral edema), whereas three patients were asymptomatic at the time of diagnosis. All patients had elevated serum alkaline phosphatase (median, 269 IU; range, 159 to 1182 IU) and gamma-glutamyl transferase levels (median, 247 IU; range 104 to 1513 IU). Other liver function tests remained normal. In five patients, earlier biopsies had identified histological features of venous outflow block, consistent with azathioprine hepatotoxicity. All nine patients had been taking azathioprine up to the time of presentation. After withdrawal of azathioprine, liver function tests improved appreciably in five patients and histologic improvement was documented in four of these who underwent follow-up liver biopsies. In the remaining four patients progressive graft failure ensued and all subsequently underwent repeat liver retransplantation. At a certain stage, nodular regenerative hyperplasia, in the context of a liver graft, becomes an irreversible lesion, emphasizing the need for early identification and withdrawal of the agent.

The edematous hand.

The purpose of this article is to increase the therapist's awareness of the effects of edema on the hand and the need for early treatment. The physiology of tissue fluid production and the two basic types of edema are discussed. The use of elevation, compression, and active exercise are the primary methods of controlling edema in the hand. Various modalities and commercial compression dressings are helpful for intractable edema; however, early intervention and treatment of the edematous hand can prevent subsequent hand dysfunction and sequelae.

Thiopentone in Management of Intractable Cerebral Oedema Associated with Fulminant Hepatic Failure

Thiopentone in Management of Intractable Cerebral Oedema Associated with Fulminant Hepatic Failure

Efficacy of thiopentone in the intractable cerebral oedema of fulminant hepatic failure

Efficacy of thiopentone in the intractable cerebral oedema of fulminant hepatic failure

Successful Use of Continuous Ambulatory Peritoneal Dialysis in Refractory Heart Failure

Four patients with end-stage heart failure, massive ascites refractory to medical interventions and a variable degree of renal failure were treated successfuly with CAPD for eight to 24 months. The New York Heart Association functional class improved in all four. In two patients, who presented initially with signs and symptoms mainly of right-sided heart failure, ejection fraction improved. Each day dialysis achieved a significant degree of ultrafiltration and a negative sodium balance. We propose that CAPD is an alternative therapeutic modality in patients with severe heart failure refractory to the conventional medical treatment. The advent of potent diuretics and preload and afterload reducing agents has had a major impact in the treatment of refractory congestive heart failure. Recently, captopril, an angiotensinconverting enzyme inhibitor, has been used with major benefit in some patients (I). However, some patients still do not respond to these treatments and their management presents a major therapeutic challenge. Furthermore, overzealous therapy with diuretics may lead to intravascular volume depletion resulting in hypotension, azotemia and electrolyte disturbances which further complicate their management. In the past, intermittent peritoneal dialysis (IPD) or hemodialysis (HD) has been used to remove fluid from patients with intractable edema due to heart failure (2 7). But the benefit is only transient and fluid accumulates again, requiring repeated sessions of acute dialysis. However, hypotension is a frequent complication during either form of acute dialysis especially in hemodynamically unstable patients due to rapid removal of large amounts of fluid from intravascular space. Continuous ambulatory peritoneal dialysis (CAPD), whose main characteristic is the slow continuous removal of sodium and water, offers obvious advantages in patients with intractable heart failure. This paper describes our experience of four patients with intractable heart failure who have been treated with CAPD for eight to 24 months.

Sympathetic nerve failure in diabetes.

Sympathetic damage is a striking feature of diabetic neuropathy, probably much more common and important than previously suspected. Degeneration of arterial medial smooth muscle with subsequent medial calcification is a feature of diabetic neuropathy and represents a structural abnormality probably resulting from sympathetic denervation. Loss of vasomotor control is responsible not only for postural hypotension but also for the remarkable increase of peripheral blood flow and arteriovenous shunting in the neuropathic foot. Demineralisation of bones and neuroarthropathic bone and joint destruction may result. Intractable oedema is another consequence of these haemodynamic abnormalities, while in other cases there is a close association of sympathetic defects with painful neuropathies. The possibility of new treatments using sympathomimetic agents to reverse these abnormalities now exists, and ephedrine has already been shown to be highly effective in reducing neuropathic oedema.

Bifrontal decompressive craniotomy for massive cerebral edema.

✓ A large bifrontal craniotomy was used in selected patients judged to carry an unusually high mortality risk due to brain swelling secondary to brain trauma. The procedure enabled exploration of both hemisphere convexities, evacuation of accumulated blood and necrotic brain, and decompression of swollen brain. This report reviews 73 cases operated on at the Massachusetts General Hospital since March, 1962; 18% of these patients survived. The largest experience was with post-traumatic cerebral edema, although intractable edema secondary to mass lesions, hemorrhage, toxic encephalopathy, and pseudotumor cerebri was also treated.

Use of oral mannitol in the oedematous patient.

Oral mannitol 200 g. was given on 24 occasions to patients with intractable oedema (cardiac, renal, or hepatic) and produced a mean weight loss of 3 kg. The procedure was found to be a safe, rapid, and effective method of treating oedema, and it should be used when diuretic therapy proves ineffective, particularly in the presence of hyponatraemia.

Application of Seldinger's Percutaneous Method to Peritoneal Dialysis

PERITONEAL dialysis is an accepted method of management of acute and chronic renal failure, endogenous and exogenous intoxication, as well as intractable heart failure and edema.15The present technique, as described by Maxwell et al,6involves the introduction of a plastic catheter through a trocar of greater diameter into the peritoneal cavity. Its shortcomings include leakage of dialyzing fluid around the catheter through the unnecessarily larger puncture wound,6intraperitoneal infection secondary to the leakage,7and hemorrhage resulting from the trauma of a large trocar. Seldinger's percutaneous method,8widely used in vascular catheterization, minimizes these undesirable effects. According to this method, a small trocar is introduced into the peritoneal cavity and a flexible guide wire is advanced through it; after the trocar is removed, a catheter is slipped over the guide wire which is then withdrawn, leaving the catheter firmly in place. Method We have used

Excessive loss of plasma protein into the gastrointestinal tract associated with primary myocardial disease

The investigation of albumin metabolism in a seventy-nine year old man with primary myocardial disease associated with intractable edema and severe hypoalbuminemia showed that the diminution of plasma albumin was due to both an increase in plasma volume and a diminution in total exchangeable albumin. The synthesis of albumin was accelerated but its catabolism was markedly increased due to the loss of albumin into the gastrointestinal tract. Peroral biopsy of the jejunum showed slight edema of the villi, dilatation of the capillaries and moderate enlargement of the lymphatics of the lamina propria. The thoracic duct, internal jugular vein and subclavian vein were exposed under local anesthesia and it was found that the duct and its tributaries in the neck were markedly dilated and blood refluxed freely into the duct with each systolic venous pulsation. The pressure in the unopened duct was raised and lymph flowed from the cannulated duct at four times the normal rate. It is suggested that several factors are involved in the plasma protein loss that occurs in certain patients with congestive heart failure, namely, raised venous pressure with increased passage of plasma albumin into the interstitial fluid of the villi, impaired lymph drainage of the gastrointestinal mucosa due to impaired lymph flow in the thoracic duct and, in some cases, lymphangiectasia.