- Email: [email protected]
SERUM METHIONINE IN LIVER FAILURE
1036 Case 5 (F, age at onset 49).-Almost continuous stuttering; one fit; depressed; impaired memory (May, 1978). Subtotal parathyroidectomy 2 weeks previously. Now no stuttering, cheerful, memory improved.
LOW DOSE DOPAMINE INFUSION IN ACUTE RENAL FAILURE
,
They have not received desferrioxamine or any specific drug therapy apart from antiepileptics. Administration of aluminium hydroxide has been stopped; two have functioning transplants and those who continue-with haemodialysis use deionised water. No patient has acquired DE and the incidence of spontaneous fractures has diminished dramatically since all of our home dialysis patients whose domestic water contains more than 0 - 0mg/1 of aluminium have used deionisers. Ackrill’s patient acquired DE while using a deioniser although he had used untreated water for some time before. His first symptoms coincided with an attack of pericarditis. This reinforces my belief that DE may be precipitated in patients who carry large body burdens of aluminium by any circumstance, such as immobilisation, surgery, or administration of corticosteroids, which induces a catabolic state in bone. Department of Medicine, Hallamshire Hospital, Sheffield S10 2JF
M. M. PLATTS
SERUM METHIONINE IN LIVER FAILURE
SIR,-I refer to your editorial (Oct. 11) on Biochemical Monitoring of Encephalopathy in Liver Failure. D. J. Collins, R. Robinson, and I (Clin Chim Acta 1978; 88: 277-81) have described a simple
SIR,-Our experience with low dose dopamine infusion in early oliguric acute renal failure (ARF) accords with that of Dr Henderson and his colleagues (Oct. 18, p. 827). However, we use a dose of 2 fg kg-Imin’’. We find that irrespective of the primary pathology, continuous infusion of dopamine promotes a diuresis,
reducing dialysis requirements and simplifying management. Thus haemodialysis to maintain salt and water balance is seldom required. Although certain patients continue to experience a rise in serum urea and creatinine, they remain symptom-free at high blood levels. This finding suggests either that saline retention contributes significantly to the symptoms of uraemia or that dopamine infusion promotes the urinary excretion of unknown factors which contribute to symptoms. In view of our early experience with dopamine, we have extended its use to prophylaxis against the development of ARF in high risk patients. Thus, we start a low dose infusion of dopamine in all patients with acute pancreatitis, bacterial toxaemia, haemorrhagic shock, ’and severe trauma requiring admission to the intensive care unit. We do not yet have sufficient data for statistical analysis but our impression is that ARF has been averted in some patients. Intensive Care Unit, Whiston Hospital,
Prescot,
Merseyside
automated colorimetric assay of the methionine content of serum which permits the biochemical progress of acute liver failure (ALF) to be followed with some precision. Concentrations above 300 tmol/1 are diagnostic of ALF, and in ALF the level correlates with the presence and severity of encephalopathy until the disease is far advanced. The test is very useful in the planning and management of artificial liver support. Its value in ALF can be compared with that of the blood urea in renal failure. In chronic liver failure high readings are usual, but the correlation with encephalopathy appears to be less exact. Warwick Warwick
L35 5DR
A. R. LUKSZA S. T. ATHERTON
BLOOD COMPONENTS FOR DEVELOPING COUNTRIES
SIR,-It was kind of Dr Lovric and co-workers (Oct. 4, p. 724) to our data. Our first 11 bags of cryoprecipitate prepared by this
cite
Hospital,
ALAN KNELL
gravity-sedimentation technique in a household refrigerator with an
overnight
thaw at 4°C contained 71-150 units of factor VIII per bag (average 112). As Lovric et al. point out, we treated two of our severe haemophiliacs (F-VIII:C <1%) during three bleeding episodes, with this cryoprecipitate. F-VIII:C was determined by the one-stage method before and 10 min after termination of infusion. The average rise of F-VIII:C was 1 - 6 U/kg bodyweight and the average recovery was 89%. During a recent international conference where we presented our results,2 it was pointed out that our preparation might contain platelet aggregates and that, during the freezing-thawing process, vasoactive substances released by lysed platelets might have potentially harmful effects. Our preparations do contain platelets, up to lOlt/1 in some bags. However, we have infused over 50 bags of cryoprecipitate to seven ofour haemophiliacs without any untoward effects. We believe that the technique is applicable in all developing countries without refrigerated centrifuges. Haemophilia care in developed countries has reached the "comprehensive" stage; in less developed countries haemophiliacs need primary health care which, in our opinion, should include basics such as case-finding (correct diagnosis) and prevention of exsanguination.
(F-VIII:C)
PAS STAINING AND IMMUNOGLOBULIN CLASSES IN MYELOMA
SIR,-Dr Jacobs and colleagues (Aug. 16, p. 363) present interesting data on the cytochemical periodic-acid/Schiff (PAS) reaction in 104 cases of myeloma and Waldenstrom’s macroglobulinemia. They say that it is wrong to correlate a positive PAS reaction in plasma cells with the presence of IgA proteins since 20% of IgG myelomas are also positive with this cytochemical test. In our experience, with a modification of the PAS technique (periodic acid 01% in 60 min), we observed in 96 myelomas positive staining for IgA and negative staining for IgG proteins in plasma cells. We consider that the positive PAS of some IgG myelomas is caused, not by the staining of immunoglobulin carbohydrate which is present in very small quantities (2 - 5%),2 but by an accumulation of cytoplasm or membrane polysaccharides. Moreover, with their peripheral distribution and grain-like appearance IgG myeloma proteins differ from the IgA myeloma proteins, which are tiny, like grains of dust, and homogeneously distributed in the cytoplasm. J. GROZDEA INSERM U.100, J. F. DE BOISSEZON Centre Hospitalier Universitaire Purpan, 31059 Toulouse, France
M. GUIRAUD MARTIN
Department of Clinical Pathology, Faculty of Medicine, University of North Sumatra, Pirngadi Hospital, Medan, Indonesia
J.
Syafei, Tann G Cara sederhana memisahkan cryoprecipitate In: Wiradisuna S, ed. Proceedings of the Third Indonesian National Congress of Haematology, 1980, 85 2. Syafei, Tann G. Cryoprecipitate production by gravity sedimentation: a simple technic applicable in leser developed countries without refrigerated centrifuges In. Proceedings of the First International Haemophilia Conference, 1980; 102. 1.
1.
Hayhoe FGJ, Quaglino D, Doll R. The cytology and cytochemistry of acute leukaemia. London: HMSO, 1964: 16-17 EC In- Miescher PA, Muller-Eberhard HJ, eds. Textbook immunopathology, 2nd ed. New York. Grune & Stratton, 1976: 31-43.
2. Franklin
GINO TANN SYAFEI
of
LOW DOSE DOPAMINE INFUSION IN ACUTE RENAL FAILURE
,
They have not received desferrioxamine or any specific drug therapy apart from antiepileptics. Administration of aluminium hydroxide has been stopped; two have functioning transplants and those who continue-with haemodialysis use deionised water. No patient has acquired DE and the incidence of spontaneous fractures has diminished dramatically since all of our home dialysis patients whose domestic water contains more than 0 - 0mg/1 of aluminium have used deionisers. Ackrill’s patient acquired DE while using a deioniser although he had used untreated water for some time before. His first symptoms coincided with an attack of pericarditis. This reinforces my belief that DE may be precipitated in patients who carry large body burdens of aluminium by any circumstance, such as immobilisation, surgery, or administration of corticosteroids, which induces a catabolic state in bone. Department of Medicine, Hallamshire Hospital, Sheffield S10 2JF
M. M. PLATTS
SERUM METHIONINE IN LIVER FAILURE
SIR,-I refer to your editorial (Oct. 11) on Biochemical Monitoring of Encephalopathy in Liver Failure. D. J. Collins, R. Robinson, and I (Clin Chim Acta 1978; 88: 277-81) have described a simple
SIR,-Our experience with low dose dopamine infusion in early oliguric acute renal failure (ARF) accords with that of Dr Henderson and his colleagues (Oct. 18, p. 827). However, we use a dose of 2 fg kg-Imin’’. We find that irrespective of the primary pathology, continuous infusion of dopamine promotes a diuresis,
reducing dialysis requirements and simplifying management. Thus haemodialysis to maintain salt and water balance is seldom required. Although certain patients continue to experience a rise in serum urea and creatinine, they remain symptom-free at high blood levels. This finding suggests either that saline retention contributes significantly to the symptoms of uraemia or that dopamine infusion promotes the urinary excretion of unknown factors which contribute to symptoms. In view of our early experience with dopamine, we have extended its use to prophylaxis against the development of ARF in high risk patients. Thus, we start a low dose infusion of dopamine in all patients with acute pancreatitis, bacterial toxaemia, haemorrhagic shock, ’and severe trauma requiring admission to the intensive care unit. We do not yet have sufficient data for statistical analysis but our impression is that ARF has been averted in some patients. Intensive Care Unit, Whiston Hospital,
Prescot,
Merseyside
automated colorimetric assay of the methionine content of serum which permits the biochemical progress of acute liver failure (ALF) to be followed with some precision. Concentrations above 300 tmol/1 are diagnostic of ALF, and in ALF the level correlates with the presence and severity of encephalopathy until the disease is far advanced. The test is very useful in the planning and management of artificial liver support. Its value in ALF can be compared with that of the blood urea in renal failure. In chronic liver failure high readings are usual, but the correlation with encephalopathy appears to be less exact. Warwick Warwick
L35 5DR
A. R. LUKSZA S. T. ATHERTON
BLOOD COMPONENTS FOR DEVELOPING COUNTRIES
SIR,-It was kind of Dr Lovric and co-workers (Oct. 4, p. 724) to our data. Our first 11 bags of cryoprecipitate prepared by this
cite
Hospital,
ALAN KNELL
gravity-sedimentation technique in a household refrigerator with an
overnight
thaw at 4°C contained 71-150 units of factor VIII per bag (average 112). As Lovric et al. point out, we treated two of our severe haemophiliacs (F-VIII:C <1%) during three bleeding episodes, with this cryoprecipitate. F-VIII:C was determined by the one-stage method before and 10 min after termination of infusion. The average rise of F-VIII:C was 1 - 6 U/kg bodyweight and the average recovery was 89%. During a recent international conference where we presented our results,2 it was pointed out that our preparation might contain platelet aggregates and that, during the freezing-thawing process, vasoactive substances released by lysed platelets might have potentially harmful effects. Our preparations do contain platelets, up to lOlt/1 in some bags. However, we have infused over 50 bags of cryoprecipitate to seven ofour haemophiliacs without any untoward effects. We believe that the technique is applicable in all developing countries without refrigerated centrifuges. Haemophilia care in developed countries has reached the "comprehensive" stage; in less developed countries haemophiliacs need primary health care which, in our opinion, should include basics such as case-finding (correct diagnosis) and prevention of exsanguination.
(F-VIII:C)
PAS STAINING AND IMMUNOGLOBULIN CLASSES IN MYELOMA
SIR,-Dr Jacobs and colleagues (Aug. 16, p. 363) present interesting data on the cytochemical periodic-acid/Schiff (PAS) reaction in 104 cases of myeloma and Waldenstrom’s macroglobulinemia. They say that it is wrong to correlate a positive PAS reaction in plasma cells with the presence of IgA proteins since 20% of IgG myelomas are also positive with this cytochemical test. In our experience, with a modification of the PAS technique (periodic acid 01% in 60 min), we observed in 96 myelomas positive staining for IgA and negative staining for IgG proteins in plasma cells. We consider that the positive PAS of some IgG myelomas is caused, not by the staining of immunoglobulin carbohydrate which is present in very small quantities (2 - 5%),2 but by an accumulation of cytoplasm or membrane polysaccharides. Moreover, with their peripheral distribution and grain-like appearance IgG myeloma proteins differ from the IgA myeloma proteins, which are tiny, like grains of dust, and homogeneously distributed in the cytoplasm. J. GROZDEA INSERM U.100, J. F. DE BOISSEZON Centre Hospitalier Universitaire Purpan, 31059 Toulouse, France
M. GUIRAUD MARTIN
Department of Clinical Pathology, Faculty of Medicine, University of North Sumatra, Pirngadi Hospital, Medan, Indonesia
J.
Syafei, Tann G Cara sederhana memisahkan cryoprecipitate In: Wiradisuna S, ed. Proceedings of the Third Indonesian National Congress of Haematology, 1980, 85 2. Syafei, Tann G. Cryoprecipitate production by gravity sedimentation: a simple technic applicable in leser developed countries without refrigerated centrifuges In. Proceedings of the First International Haemophilia Conference, 1980; 102. 1.
1.
Hayhoe FGJ, Quaglino D, Doll R. The cytology and cytochemistry of acute leukaemia. London: HMSO, 1964: 16-17 EC In- Miescher PA, Muller-Eberhard HJ, eds. Textbook immunopathology, 2nd ed. New York. Grune & Stratton, 1976: 31-43.
2. Franklin
GINO TANN SYAFEI
of