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Zeynep Kendi Celebi, Orhan Kucuksahin, Elif Peker, Sim Kutlay, Gokhan Nergizoglu, Kenan Ates and Oktay Karatan


Granulomatosis polyangiitis (Wegener's granulomatosis) is an ANCA-associated necrotising vasculitis. The disease involves upper respiratory tract, the lungs and kidneys but central nervous system (CNS) involvement is 1-5%.

A 40-year-old male patient was admitted to the hospital with joint pain, rash, aphthous lesions. The skin biopsy from the lesion showed leukocytoclastic vasculitis. The patient had c-ANCA positive and was diagnosed granulomatosis polyangiitis. He was treated with a pulse steroid and cyclophosphamide. Before the 5th session of therapy, the patient developed hemoptysis and hematuria. Thorax CT (computarized tomography) showed a diffuse alveolar hemorrhage and hence plasmapheresis and IVIG (intravenous immunoglobulin) were added to the treatment. Two days after IVIG, the patient developed globe vesical, headache and respiratory arrest. MR (magnetic resonance) showed CNS involvement. The patient was treated with a pulse steroid, but did not respond to therapy and died after 5 months since establishing the diagnosis.

More studies are needed to identify effective treatment and course of disease for patients with central nervous system involvement.

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Patrick M. Honore, Rita Jacobs, Elisabeth De Waele, Viola Van Gorp, Olivier Joannes-Boyau, Jouke De Regt, Willem Boer and Herbert D Spapen

. Subclinical AKI--an emerging syndrome with important consequences. Nat Rev Nephrol 2012;8:735-9. 4. Ronco C, Kellum JA, Haase M. Subclinical AKI is still AKI. Crit Care 2012;16:313. 5. Ronco C, Stacul F, McCullough PA. Subclinical acute kidney injury (AKI) due to iodine-based contrast media. Eur Radiol 2013;23:319-23. 6. Kashani K, Al-Khafaji A, Ardiles T, Artigas A, Bagshaw SM, Bell M, et al. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care 2013;17:R25. 7. Hoste

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Patrick M. Honore, David De Bels, Luc Kugener, Sebastien Redant, Rachid Attou, Andrea Gallerani and Herbert D. Spapen

To the editor Pharmacokinetic and dose-response data suggest a vitamin C (vit C) dose largely exceeding 3 g daily in critically ill patients. We recently proposed higher vit C dosing in cardiac arrest patients who require continuous renal replacement therapy (CRRT).[ 1 ] In a reaction, Spoelstra-de Man et al . rebutted that increasing the vit C dose above 2 g/day during continuous veno-venous hemofiltration (CVVH) was unnecessary when normal plasma vit C concentrations are targeted. They based their standpoint on calculating less vit C removal during CVVH

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Faruk Elyigit, Harun Akar, Utku Erdem Soyaltın and Ferhat Ekinci

treatment of metformin overdose. Nephrol Dial Transplant 1997; 12: 1046-1047. 5. Perincek G, Edis EC, Guldiken S, Uyanik MS. A Rare Outcome Induced by Metformin Intoxication: Severe Lactic Acidosis and Sudden Cardiac Arrest. Kartal Training and Research Medicine Journal 2009; XX(1): 42-44. 6. Zheng L. Metformin as a Rare Cause of Drug-Induced Liver Injury, a Case Report and Literature Review. Am J Ther 2016; 23(1): e315-e317. 7. Nammour FE1, Fayad NF, Peikin SR. Metformin-induced cholestatic hepatitis. Endocr Pract 2003; 9

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Zhi-Yong Peng

. Clinicians can use these biomarkers to determine which patients might be candidates for novel therapeutic strategies intended to improve kidney outcomes. Remote ischemic preconditioning (RIPC) with upper-arm blood pressure cuff inflations prior to surgery was used to prevent or decrease ischemic reperfusion induced AKI in patients for cardiac surgery. In those who had an increase in [TIMP-2]·[IGFBP7] after RIPC and prior to cardiopulmonary bypass, the incidence of AKI was reduced compared to those who did not have elevated cell cycle arrest biomarkers.[ 12 ] This suggests

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Christian Verborgh

LL, Hoedemaekers CW, Mollnes TE, van der Hoeven JG. Rewarming after hypothermia after cardiac arrest shifts the inflammatory balance. Crit Care Med 2012;40:1136-42. 7. Ju NY, Gao H, Huang W, Niu FF, Lan WX, Li F, et al. Therapeutic effect of inhaled budesonide (Pulmicort® Turbuhaler) on the inflammatory response to one-lung ventilation. Anaesthesia 2014;69:14-23. 8. Chen Q, Yu W, Shi J, Shen J, Hu Y, Gao T, et al. The effect of venovenous extra-corporeal membrane oxygenation (ECMO) therapy on immune inflammatory response of cerebral

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Patrick M. Honore, Rita Jacobs, Olivier Joannes-Boyau, Willem Boer, Elisabeth De Waele, Viola Van Gorp and Herbert D. Spapen

, Artigas A, Bagshaw SM, Bell M, et al. Discovery and validation of cell cycle arrest biomarkers in human acute kidney injury. Crit Care 2013;17:R25. 27. Konrad FM, Mik EG, Bodmer SI, Ates NB, Willems HF, Klingel K, et al. Acute normovolemic hemodilution in the pig is associated with renal tissue edema, impaired renal microvascular oxygenation, and functional loss. Anesthesiology 2013;119:256-69. 28. Leal-Noval SR, Muñoz-Gómez M, Jiménez-Sánchez M, Cayuela A, Leal-Romero M, Puppo-Moreno A, et al. Red blood cell transfusion in non

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Patrick M. Honore, David De Bels, Thierry Preseau, Sebastien Redant and Herbert D. Spapen

circulation because of the dilution of extracorporeal blood returning to patients’ circulation, the replacement of calcium, and the liberation of calcium from calcium–citrate and magnesium–citrate complexes when citrate is metabolized. As a result, a systemic effect on coagulation does not occur unless specific conditions are present, such as impaired liver or skeletal muscle function ( e.g ., after a cardiac arrest). [ 1 , 2 ] Citrate is converted to citric acid in the liver, yielding three molecules of bicarbonate (although this may considerably vary depending on

Open access

Hongting Wang, Zuan-tao Lin, Yulin Yuan and Tianfu Wu

injury and renal recovery following cardiac surgery PLoS One 2014 9 e93460 18 Bihorac A, Chawla LS, Shaw AD, Al-Khafaji A, Davison DL, Demuth GE, et al . Validation of cell-cycle arrest biomarkers for acute kidney injury using clinical adjudication. Am J Respir Crit Care Med 2014; 189: 932-9. 10.1164/rccm.201401-0077OC Bihorac A Chawla LS Shaw AD Al-Khafaji A Davison DL Demuth GE et al. Validation of cell-cycle arrest biomarkers for acute kidney injury using clinical adjudication Am J Respir Crit Care Med 2014 189 932 9 19 Kitamura T, Qian BZ, Soong D, Cassetta L

Open access

Ran Zhu and Xiao-Chun Ma

, interventricular septum flattening, or right ventricular systolic abnormality. Diagnostic protocol of PE combined with ultrasonography The adoption of a diagnostic protocol can often minimize missed diagnosis and narrow down the etiology, such as the diagnosis protocol for shock or sudden cardiac arrest. There are two types of PE diagnostic protocol combined with ultrasound, one is in search for the probability of PE and the other is in search for the etiology of dyspnea. PE Diagnostic Protocol in search for PE Probability: For patients with probable PE and unstable