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Hyponatremia is common in advanced liver cirrhosis. Recently it has attracted an interest as a possible prognostic factor for liver cirrhosis complications. This study was conducted to assess the prevalence of hyponatremia in complicated cirrhotic patients admitted to medical ICU and to identify its relationship to development and severity of these complications. 200 patients with liver cirrhosis were included in this study. According to serum sodium, they were classified into three groups: group 1 with serum sodium ≤130 meq/L (severe hyponatremia), group 2 with serum sodium from 131 to 135 meq/L (mild hyponatremia) and group 3 with serum sodium ≥136 meq/L (normo-natremia). Demographic, clinical, and laboratory variables were prospectively recorded for analysis. In our studyThe prevalence of total hyponatremia was 131/200 patients (65.5%) and those with severe hyponatremia were 91/200 (45.5%) .There was a statistically significant increase in frequency of occurance (p>0.01) and relative risk each of ascites (1.3fold),intractable ascites (9.5fold), spontaneous bacterial peritonitis (2.6fold), hepatic hydrothorax (1.5fold) and hepatic encephalopathy (2.8fold), in hyponatremic groups compared to normonatremic one while there was no significant difference regarding hepatorenal syndrome, esophageal varices and variceal bleeding between different groups. Also there was a statistically significant negative correlation betwee serum sodium level and the two scoring systems: Child-Pugh score (r =-0.690, p<0.001) and Model for Endstage Liver Disease (MELD) score(r =-0.586, p<0.001). We can conclude that In critically ill patients with liver cirrhosis, the prevalence of total hyponatremia(Na ≤ 135 meq/L) was 65.5% while those with severe hyponatremia (Na ≤130) was 45.5%. Low serum sodium level was associated with high complications of liver cirrhosis. The relative risk of occurance, frequencies and severity of ascitis, intractable ascitis, hepatic hydrothorax, hepatic encephalopathy and spontineous bacterial peritonitis were increased in cirrhotic patients especially those with serum sodium levels ≤ 130 meq/L.So the Management of hyponatremia may decrease the incidence and severity of the liver cirrhosis complications with better quality of their life. Thus more interest should be tried towards the use of vasopressin receptor antagonists as a line of treatment of complicated cirrhotic patients with hyponatremia without salt overload

A little is known about the behavior of the renin-angiotensin system (RAS) in glomerulo-nephritis (GN), although it is activated in other models of injury. To study renal angiotensin-converting enzyme (ACE) messenger ribonucleic acid (mRNA) gene expression in patients with GN to determine its role in the disease process and other factors that may influence the course of the disease and the prognosis, e.g. treatment with ACE inhibitor (ACEI) drugs, we studied 20 patients with GN allocated to two groups: ten patients received an ACEI drug and ten patients did not receive ACEI in addition to a control group of ten healthy subjects. Routine and special laboratory investigation, histopathological studies and quantitative polymerase chain reaction analysis for renal ACE mRNA were done for both the study and the control groups. There was a statistically significant increase in ACE mRNA gene expression in the GN groups than in control group, but no statistically significant difference in ACE mRNA gene expression between the patients group that received and the group that did not receive ACEI. A significant correlation was found between the ACE mRNA gene expression and the mean blood pressure, serum creatinine, blood urea nitrogen and 24-h urinary protein. In conclusion, a higher level of ACE mRNA gene expression in patients suffering from GN may suggest a role of the RAS in the process of GN, perhaps contributing to glomerular hypertrophy and matrix overproduction. The use of ACEI drugs possibly slows the rate of progression of renal failure and plays a role in controlling the pathophysiology.

Background: To study the epidemiology of circulatory shock secondly to assess different pattern of circulatory shock among adult critically ill patients admitted to medical ICU of internal medicine department Zagazig University during the study period and finally to study the clinical outcome (morbidity and mortality) of different pattern of circulatory shock. Methods and subjects: The current Cross-sectional cohort study had been carried out on 694 patients with circulatory shock who were admitted in medical ICU with criteria of peripheral circulatory failure. The included patients were subdivided into three groups according to the provisional and definitive diagnosis of type of circulatory shock depending on CVP, echocardiography, cardiac output and laboratory investigations as follow: Group1: hypovolemic shock group ,Group 2: cardiogenic shock group and Group 3: septic shock group. All patients were subjected to thorough medical and clinical history taking and full clinical assessment. Blood samples were withdrawn for routine investigations (Complete blood count, Kidney function tests, Liver function tests, CRP, INR, Arterial blood gases (ABG), Mean saturation of central venous oxygen (ScvO2) and serum lactate. Shock severity was assessed by using APACHE IV score and SOFA score. Results: The frequency of circulatory shock patients is 13.9% per year. Hypovolemic shock was the major cause of circulatory failure in the studied population followed by septic shock and finally cardiogenic shock. The severity assessment parameters including APPACHE IV score , SOFA score, length of hospital stay and GCS were statically significant difference among the three studied groups, with significant increase in APPACHE IV score and SOFA score in cardiogenic group. APPACHE IV score and SOFA score were significant independent predictor of survival. The outcome measures of our populations during their ICU stay and after discharge to the medical words shows that mortality increase progressively with increase the length of ICU stay, there was significant difference in survival among the three groups, the most favorable outcome is hypovolemic group, and the worst was observed in the cardiogenic shock group. Conclusions: Circulatory shock is a life threatening condition associated with high mortality so early recognition and early intervention will decrease morbidity and mortality in critically ill patients. CVP, echocardiography and laboratory investigations especially serum lactate and SCVO2 are easy, reliable and available in all emergency departments. All can help in early diagnosis of type of circulatory shock. Calculation of APPACHE IV score and SOFA score were easy and reliable which potentially allow one to diagnose life-threatening condition and treat them before laboratory results are back.

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