Biomedical subjects
Publications and source records attributed to C Canavese.
Two patients with progressive dialysis encephalopathy (PDE) were subjected to serial EEG recording and neuropsychological tests in order to assess the value of the investigations as indices of the course of PDE during desferrioxamine treatment. EEG proved unreliable for this purpose.
Urokinase treatment, previously employed with success in the declotting of deep venous thrombosis and arteriovenous shunts in patients undergoing regular dialytic treatment (RDT), was used in 23 cases of arteriovenous fistula thrombotic occlusion in 18 RDT patients. The treatment was successful in 65.2% of the cases without any negative side effects, except 1 case which may have developed a pulmonary embolism. Patients with severe hypofibrinolysis may need larger doses or may have a recurrence of the thrombotic episode. All therapeutic failures correlated with the presence of fibrosis or sclerosis.
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In addition to a hemorrhagic diathesis, uremia is accompanied by a clotting tendency, caused by a marked fall in fibrinolytic capacity. Measurement of lysis time of whole blood diluted with phosphate and acetate buffers and of euglobulin lysis times showed that accumulation of inhibitors is primarily responsible. These probably belong to the class of small molecules abnormally retained in uremia. Hemodialysis (HD) offers the best method of correction, mainly because of better elimination of these inhibitors. In contrast, hemofiltration (HF) and, particularly, intermittent peritoneal dialysis (IPD) are much less effective. In IPD, protein loss via the peritoneum is also responsible for a loss of fibrinolytic activators, so that fibrinolysis becomes even poorer, exposing the patient to an increased risk of vascular complications.
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In spite of the anticoagulant activity of heparin platelet deposition and contact activation of coagulation occurs during dialysis. We have studied platelet counts, fibrinogen, platelet factor 4, beta-thromboglobulin, thromboxane B2, FRA, C3d and kallikrein values, whole blood and euglobulin lysis times and membrane areas in haemodialysis using cuprophan and cellulose acetate and in haemofiltration with polyacrilonitrile. Deposits on all the three membranes included leucocytes, platelets and fibrin. The coagulation and fibrinolytic systems are activated more intensively with cellulose acetate and more prolongedly with polyacrilonitrile. Platelet factor 4 and beta-thromboglobulin increases suggest platelet activation, only partially dependent on arachidonic acid-mediated pathway as thromboxane B2 is not increased. The complement system is activated whereas serum kallikrein does not alter, suggesting that platelets rather than factor XII are crucial in contact activation.
Haematochemical, urinary and tissue parameters were examined in the elaboration of the coagulation and fibrinolysis profile in 33 cases of systemic lupus erythematosus in different stages of the disease. Coagulation abnormalities varied from hypo- to hyper-coagulability, these being often associated in the same patient, either simultaneously or at different stages of the disease. Activation of coagulation, closely related to the immunological activity of the disease, was present in 80% cases in the acute stage, and 36% of those in the remission stage. The lupus-like anticoagulant was not much involved, and platelets were the prime figures in the haemostatic abnormalities of lupus, those being the preferred target of direct antibody activities, or possibly of immune complexes as well. Activation of the coagulatory cascade is not uncommonly accompanied by a thrombophilic tendency coupled with signs of consumption, this being the expression of a continuously stimulated haemostatic balance.
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Results observed during short-period dialysis management lasting 8 months in 80 patients are presented. There was no significant change in blood chemistry and clinical pictures, through intra- and interdialytic well-being improved. Six, out of 33 patients and to be transferred from 12 hr per week to more prolonged treatment periods due to the rapid onset of sub-dialysis symptoms. No patients receiving 15 hr per week required such a change. The reasons for failure in these six subjects are discussed, together with the indications for a choice of 12 or 15 hr periods.