ケツエキ トウセキ カンジャ ノ チョウキ セイメイ ヨゴ ヨソク インシ トシテノ トウセキゴ ノ ケッショウANP ト BNPノウド ノ ユウヨウセイ : 15ネンカン ノ ヨゴ チョウサ

透析患者52人において心胸比を透析前に,収縮期血圧,血清アルブミン,血漿心房性ナトリウム利尿ペプチド(atrial natriuretic peptide ; ANP),脳性ナトリウム利尿ペプチド(brain natriuretic peptide ; BNP),血漿レニン活性(plasma renin activity ; PRA),血漿ノルアドレナリン(plasma noradrenaline ; PNA)濃度を透析直後に測定した.患者は上記測定の中央値で高低2群に分けてKaplan-Meier (KM)生存曲線を求め,両群の比較をLogrank法で行った.生存期間に及ぼす因子解析は測定値を説明変数,生存期間を目的変数としてCox比例hazard法で行った.いずれもp<0.05を有意と判定した. 15年間で43人が死亡し,うち40人が病死であった. KM生存曲線は高年齢群(p<0.001),高ANP群(p=0.006),高BNP群(p=0.039)で有意に生存期間が短く,心胸比,収縮期血圧,血清アルブミン, PRA, PNAにおいては高低2群間に有意差を認めなかった. Cox比例hazard法による単変量解析では年齢(p<0.001),心胸比(p=0.011), ANP (p=0.003), BNP (p=0.002)が生命予後の有意なリスク因子となり,多変量解析ではp値は年齢<0.001,心胸比0.965, ANP 0.055, BNP 0.041となり,年齢とBNPが生命予後の独立したリスク因子であった.以上より透析患者において透析直後の血漿BNP濃度は長期生命予後の独立したリスク因子であり,血漿ANP濃度もリスク因子としてBNPに次いで重要であることが示された.This study was designed to clarify the clinical significance of post-dialysis plasma vasoactive substances including atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), plasma renin activity (PRA) and noradrenaline (PNA) as a survival predictor in chronic hemo-dialysis (HD) patients. Immediately after HD, blood samples were collected for the measurements of serum albumin, ANP, BNP, PRA and PNA in 52 HD patients. During 15-year follow-up period 43 patients died ; 40 of diseases, 2 accident, 1 suicide. Patients were divided into two groups using the median of their age and clinical and laboratory variables. Kaplan-Meier survival analysis revealed that the groups of older age, higher plasma ANP and BNP concentration had significantly lower survival rates as compared with each counterpart (p<0.001, p=0.006, p=0.039, respectively). Univariate and multivariate Cox proportional hazard regression analyses were used to assess the potential association of their age, and clinical and laboratory variables with a survival rate. As a result of Univariate Cox hazard analysis, age, cardiothoracic ratio (CTR), and plasma ANP, and BNP concentrations had significant relationship with overall mortality (p<0.001, p=0.011, p=0.003, and p=0.002, respectively). However, stepwise multivariate analysis revealed that the significant relationship with overall mortality was shown for their age (p<0.001) and BNP (p=0.041). These results demonstrated that the post-dialysis plasma BNP concentration was an independent risk factor for long-term survival and the post-dialysis plasma ANP concentration was also an important risk factor next to the BNP concentration

Perioperative airway management for aortic valve replacement in an adult with mucopolysaccharidosis type II (Hunter syndrome)

Abstract We herein report anesthetic management during aortic valve replacement for aortic valve regurgitation in a patient with adult mucopolysaccharidosis type II (MPS type 2) (Hunter syndrome). This disorder is rare and related to the accumulation of a mucopolysaccharide in lysosomes. It affects various organs, including the airways, heart, and central nerves. In children with MPS type 2, the risk of airway obstruction during anesthesia/sedation is high, and the degree of difficulty increases with aging. The patient described herein was a 33-year-old male without mental retardation. Before surgery, trismus, megaloglossia, and the disturbance of cervical vertebral excursion were noted, suggesting difficulties with ventilation/intubation. Anesthesia was induced under sedation/spontaneous respiration. A laryngeal deployment was conducted using a video laryngoscope; however, the Cormack grade was III. Nasotracheal fiber intubation was performed, and airway obstruction occurred. A muscle relaxant was administered, facilitating ventilation. However, subglottic stenosis, which was not detected before the surgery, made the tracheal tube insertion difficult. Aortic valve replacement was performed without complications. A detailed postoperative examination of the airways revealed oropharyngeal soft tissue outgrowth, narrowing of the upper airway, subglottic stenosis, and displacement/circumflex of the airway axis. Either awake intubation or rapid induction can be selected for this patient; however, either way have risks of airway obstruction. It is important that strategies under light anesthesia or incomplete neuromuscular blockade should be avoided for such our patient as suggested in the JSA airway management guidelines. A preoperative multidisciplinary airway assessment and simulation are important