Andres F. Carrion,1 Frank Czul,1 Leopoldo R. Arosemena,2 Gennaro Selvaggi,3 Monica T. Garcia,4 Akin Tekin,3 Andreas G. Tzakis,3 PaulMartin,5 and Ravi K. Carrion, acarrionmonsalve med.
Tüdőembólia (PE) - tünetek és kezelés
Pacini Copyright © Andres F. Carrion et al. This is an open access article bee submass a cukorbetegség kezelésében under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Propylthiouracil- PTU- induced hepatotoxicity is rare but potentially lethal with a spectrum of liver injury ranging from asymptomatic elevation of transaminases to fulminant hepatic failure and death. We describe two cases of acute hepatic failure due to PTU that required liver transplantation.
A pontos méretezés létfontosságú az implantáció indikációjánál, a megfelelő graft kiválasztásánál. A munkacsoport 3 különböző méretező szoftvert párhuzamosan, egymást kiegészítve használ. Ajánlásokat fogalmaznak meg a graftműtétet megelőző képalkotó vizsgálatok minimális paramétereire.
Differences in the clinical presentation, histological characteristics, and posttransplant management are described as well as alternative therapeutic options. Frequent monitoring for PTU-induced hepatic dysfunction is strongly advised because timely discontinuation of this drug and implementation of noninvasive therapeutic interventions may prevent progression to liver failure or even death.
Reported injury has ranged from mild asymptomatic elevation of aminotransferases to acute liver failure ALF. Although asymptomatic elevations in hepatic enzymes have been described in patients with untreated hyperthyroidism, recognition of hepatic dysfunction in a patient taking PTU requires immediate discontinuation of the drug and close followup. Case Presentations Case 1. By week ten of treatment, she reported jaundice, fatigue, epigastric 2 International Journal of Endocrinology abdominal pain, nausea, and vomiting.
She denied the use of over-the-counter or herbal medications.
Her past medical history and family history were not contributory. She denied excessive alcohol consumption and recreational drug use. Upon subsequent transfer to our institution, initial laboratory workup revealed a prothrombin time of Serum markers for viral hepatitis A, B, and C were negative.
Antinuclear antibodies, antismooth muscle antibodies, and antimitochondrial antibodies were negative. PTU was discontinued, but the coagulopathy worsened, and she subsequently developed hepatic encephalopathy.
She underwent orthotopic liver transplantation OLT eight days following admission. Histologic examination of the explanted liver revealed submassive, confluent necrosis with parenchymal hemorrhage, bile duct proliferation, intracellular and canalicular cholestasis, bile plugging, and severe lymphoplasmacytic and eosinophilic infiltrates.
Immunostain for IgG4 was positive Figure 1, microphotographs a and b. The patient was discharged home in stable condition on postoperative day twelve. Her liver function become normal 6 months following OLT. Case 2. Baseline levels of aminotransferases were normal at the time PTU was started.
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Six weeks later she started to complain of malaise and generalized weakness followed by progressive jaundice, but she did not seek medical care until two weeks later when she had developed confusion, nausea, and vomiting. Blood tests at that time were INR 4.
Serum markers for autoimmune and viral hepatitis A, B, and C were negative. PTU was discontinued; however, her mental status continued to deteriorate with progression to severe hepatic encephalopathy. A transjugular liver biopsy revealed extensive parenchymal necrosis, collapse of the lobular architecture, bile duct proliferation, and periportal inflammation. Two days after admission, she was listed for OLT and received a liver transplant three days later.
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Histological examination of the native liver showed submassive confluent necrosis with prominent eosinophilic, neutrophilic, and lymphoplasmacytic infiltrate with canalicular and intracellular cholestasis and numerous lobular acidophilic bodies Figure 1, microphotographs c and d.
The posttransplant course was complicated by the development of graft dysfunction due to severe rejection, which did not improve with aggressive immunosuppressive therapy.
- Több tényező kombinációját a trombusembólia magas kockázata kíséri.
- Endocrinology diabetes and metabolism journal (edmj)
The patient was relisted for OLT two weeks after the initial transplant and received a second allograft 6 days later. The postoperative course after the second transplant was complicated by a biliary leak that cukor cukorbetegség vércukorszint kezelés kezelés reconstruction of the biliary anastomosis, as well as multiple episodes of rejection which were treated with antilymphocyte antibodies, plasmapheresis, and administration of rituximab.
The patient eventually recovered.
Tüdőembólia (PE) - tünetek és kezelés - Thrombophlebitis November
She cukorbetegség kezelése diéta aláírja discharged on postoperative day from the first liver transplant and is currently at home doing well 6 months after the second liver transplant.
PTU is a thioamide derivative widely used for the treatment of hyperthyroidism which exerts its pharmacologic effects by two different mechanisms. PTU-induced hepatitis was first reported by H. Livingston and S. Livingston in , shortly after the FDA had approved this medication for the treatment of hyperthyroidism. This patient was successfully managed with supportive care after discontinuation of the drug.
Six years later, Eisen  reported the first case of fulminant hepatic failure attributed to PTU, an ominous adverse reaction that since then has been observed in an extremely small number of patients receiving this medication. Based on published data about the annual incidence of hypothyroidism, the reported frequency of PTU therapy 15, adults per yearand the incidence of PTU-induced severe liver injury approximately 0.
Acute hepatitis associated with this medication has been reported to occur in 0. Data suggest that the risk of severe hepatotoxicity is greater in children treated with PTU 1 : 1, childrenbut the overall incidence is significantly lower because fewer children are treated with this drug 1,—4, children per year .
For example, a significant reduction in PTU use by pediatric endocrinologists has been observed over the past several years, and some authors advocate that PTU should never be used as a first-line therapy in children due to the potential risk severe hepatotoxicity .
Liver biopsy remains the gold standard for diagnosis of PTU-induced hepatic injury, but the diagnosis is often inferred from the time course after initiation of PTU therapy [5, 8].
Cukorbetegség és inzulinrezisztencia kezelése: 15 vitamin és ásványi anyag
PTU hepatotoxicity has been reported to cause a variety of histological changes including portal and periportal inflammation with eosinophilic, lymphocytic, and plasmacytic infiltration in varying combinations, chronic active hepatitis, and submassive or massive hepatic necrosis .
Severe PTU-induced hepatotoxicity is postulated to be a dose independent, idiosyncratic hypersensitivity reaction.
This theory is supported by positive lymphocyte sensitization studies [3, 4, 12]. Treatment options for PTU-induced liver failure are limited.
Immediate discontinuation of the drug is imperative, but progression of liver injury may occur, particularly in cases with severe forms of DILI, and aggressive supportive care is usually required.
The milder form of PTU-induced hepatotoxicity, characterized bee submass a cukorbetegség kezelésében symptomatic hepatitis, has been associated with complete recovery after discontinuation of the drug . This outcome has also been reported in cases with cholestatic liver injury, although the time required for normalization of biochemical markers was longer in the latter group . Some authors have suggested that the coincidental clinical improvement in patients receiving systemic corticosteroids for the treatment of thyrotoxicosis might reflect a therapeutic response .
Plasmapheresis was apparently successfully used, in one case report of fulminant hepatic failure; nonetheless, concomitant use of prednisone confounded evaluation . Liver transplantation has been reported in severe, life-threatening cases of PTU-induced hepatotoxicity with good outcomes [5, 15]. PTU is the third most common single drug responsible for DILI requiring liver transplantation in the general population, preceded by acetaminophen and isoniazid in the adult population and by acetaminophen and valproic acid in pediatric patients .
The mean age of patients with PTU-induced ALF is 28 years; over two thirds of these patients are females and almost half of them are African Americans.
Therefore, African American ethnicitymay be a risk factor for severe formof PTU-induced hepatotoxicity; nonetheless, there are no data supporting ethnicity-specific or genetic variations responsible for these observations, and specific recommendations about the use of 4 International Journal of Endocrinology PTU in African Americans cannot be made.
The first patient had an uneventful posttransplant recovery, but the second case had a complicated clinical course requiring retransplantation and multiple interventions to prevent loss of the second allograft. Extended criteria for donor organs, including advanced-age donors, may bee submass a cukorbetegség kezelésében used due to the emergency need for OLT in patients with fulminant hepatic failure; nonetheless, higher rates of severe complications requiring specialized care underscore the importance of treating these patients in experienced, high-volume transplant centers.
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There are no official recommendations regarding monitoring for serologic markers of liver injury during PTU therapy; however, some authors have recommended monthly monitoring of serum transaminases for the first six months of therapy, which is the period where most cases of PTU-induced DILI occur [19, 20]. Although there are no evidence-based data to support this recommendation, we agree with the suggested time intervals and duration of monitoring and emphasize the importance of early discontinuation of therapy when early signs of liver injury are detected.
- Az érbetegségek gyógyítása igen nagy odaadást és közös erőfeszítést igényel az angiológus, radiológus és érsebész kollégák részéről, a harcot a betegség ellen csak közös munkával tudjuk sikeresen megvívni.
- További kezelés cukorbetegséggel
Routine monitoring of serum transaminases and close followup is recommended; nonetheless, the appropriate intervals and duration of followup have not been established. Early identification of clinical signs and abnormalities in biochemical markers of hepatic injury followed by immediate discontinuation of PTU, aggressive supportive care, and transfer of patients to centers capable of performing emergent liver transplantation is strongly advised due to the high mortality associated with severe forms of this complication.