921
Hepatitis C antibody and transaminase activities in blood donors SiR,—The value of screening blood donors for non-A, non-B
(NANB)
hepatitis
using
the
surrogate
markers
alanine
aminotransferase (ALT) and antibody to the core of the hepatitis B virus (anti-HBc) has been extensively debated. A raised ALT indicates hepatocellular damage but it is not specific for NANB infection and may be influenced by other viruses, and by age, sex, obesity, drugs, and alcohol. An immunoassay for antibody to hepatitis C virus (anti-HCV) has been developed, and results with this assay suggest that HCV is the major cause of post-transfusion NANB hepatitis."-3 Studies of single random samples collected from blood donors have looked at anti-HCV reactivity and ALT.45** The Queensland Red Cross Blood Transfusion Service has used
computer-stored serial ALT levels to identify donors with a history of abnormal ALT and has correlated these data with anti-HCV positivity. These results should be useful in defining the role of surrogate ALT screening in blood banks as a supplement to anti-HCV testing. Between March, 1988, and December, 1989, blood was collected from 133 control donors with no history of raised ALT (cut-off 46 IU/1) who had made at least three previous donations, from 82 donors with an ALT of 46-100 IU/1 at least three times, and from 74 donors with ALT activities above 100 IU/1 at least once. The samples were stored at - 30°C before anti-HCV testing (Ortho Diagnostics ELISA). The frequency of repeatable anti-HCV reactivity in the three groups was 1/133 (0-6%), 8/82 (10%), and 18/74 (24%), respectively (p < 0-001). 7 anti-HCV reactive donors were tested more than once (two to six samples over 3-17 months); 6 were persistently reactive and the other was negative 13 months later despite ALT levels persistently above 100 IU/1. Samples from the 27 reactive donors were further tested by the Chiron recombinant immunoblot assay (RIBA) for anti-HCV, supplied by Ortho Diagnostics System, and 25 samples showed reactivity consistent with HCV antibody. The 2 negative samples were from the only anti-HCV reactive control donor and from the donor whose anti-HCV reactivity disappeared. The fluctuation of ALT levels in patients with chronic NANB hepatitis is well recognised,2 and all the anti-HCV reactive donors in this study demonstrated this pattern; in 44% ALT levels fluctuated
above and below the cut-off. In these donors, anti-HCV reactivity persisted even when the ALT fell to normal. Inclusion of such donors will underestimate the correlation between anti-HCV reactivity and ALT when studies are conducted on single samples from unselected donors. The frequency of anti-HCV reactivity (10%) or more in our selected donors with raised ALT levels was 16 to 44 times greater than that for anti-HCV reactivity in the first 7366 isolated donations screened, the repeatably reactive rate there being 054%. 161 of those 7366 donors had ALT levels above 46 IU/1 although only 10 of these 161 were among the 40 anti-HCV reactives. A further 3 of the 40 had a history of raised ALT but were normal at the time of anti-HCV testing. We were able to follow up by RIBA 19 of the 40 reactive samples. 14 showed patterns consistent with anti-HCV and the remaining 5 (all ALT normal) were negative. This suggests that the false reactive rate in random donors was higher than among the donors with histories of a raised ALT (5/19 vs 2/27). ALT levels in such a selected group may be indicative of a carrier state of active infection. ELISA and RIBA use the same recombinant antigen. Further confirmatory assays are necessary to elucidate the true frequency of HCV infection.’ Since about 92% of donors with a random single raised ALT level are not anti-HCV positive a realistic protocol for reinstating donors with isolated raised ALT levels in the absence of HCV seroconversion within 12 months can be devised. A strategy can be devised (see figure) that minimises wastage and maximises prevention of transfusion-associated NANB hepatitis. We achieved a high degree of selection of anti-HCV reactive donors by identifying those with persistently raised or fluctuating ALT levels. ALT screening should be of value in identifying donors in the window period before seroconversion, those with aberrant antibody responses not detected by the current assay, and those infected with NANB hepatitis agents other than HCV.5 Red Cross Blood Transfusion Service, Queensland Division, Brisbane, Queensland 4000, Australia
C. MORGAN C. HYLAND I. F. YOUNG
G, Choo Q-L, Alter HJ, et al. An assay for circulating antibodies to a major etiologic virus of human non-A, non-B hepatitis. Science 1989; 244: 362-64. 2. Alter HJ, Purcell RH, Shih JW, et al. Detection of antibody to hepatitis C virus in prospectively followed transfusion recipients with acute and chronic non-A, non-B hepatitis. N Engl J Med 1989; 321: 1494-500. 3. Van Der Poel CL, Ressink HW, Lelie PN, et al. Ann-hepatitis C antibodies and non-A, non-B post-transfusion hepatitis in The Netherlands. Lancet 1989; ii: 1. Kuo
297-98. 4. Kuhl P, Seidl S, Stangel W, Beyer J, Sibrowski W, Flik J. Antibody to hepatitis C virus in German blood donors. Lancet 1989; ii: 324. 5. Alter HJ. Discovery of the non-A, non-B hepatitis virus: the end of the beginning or the beginning of the end. Transfusion Med Rev 1989; 3: 77-81.
Type 2 autoimmune hepatitis and hepatitis C virus infection
Strategy for exclusion or reinstatement of donors.
SIR,-Dr Lenzi and colleagues (Feb 3, p 258) report a high prevalence of serum antibodies to hepatitis C virus (HCV) in patients with anti-liver kidney microsomal antibody (anti-LKMl)positive chronic hepatitis-ie, autoimmune hepatitis type 2.1 However, the part, if any, played by HCV infection in the pathogenesis of chronic liver cell damage in these patients is unclear. We report a case which provides insight into this important issue. The patient, now 56 years old, had occasional biochemical and histological evidence of chronic persistent hepatitis in 1978. Because of seronegative hepatitis B virus markers (HBsAg, anti-HBc, HBeAg, anti-HBe, anti-HBs) and antinuclear (ANA), anti-smooth muscle (SMA), and antimitochondrial (AMA) antibodies, liver disease was diagnosed as sporadic non-A, non-B chronic hepatitis. Clinical and biochemical (ALT 65--119 IU/1, gammaglobulins 15-17 g/1) follow-up continued to indicate chronic persistent hepatitis until May, 1988, when a liver biopsy revealed chronic active hepatitis (ALT 207 IU/1, gammaglobulins 20 g/1). ANA, SMA, and AMA were not detected in serum. On May 18, 1988, treatment with recombinant interferon (IFN) alpha-2-b (Essex Pharma, Munich) was started (3 MU thrice weekly). Despite an
922
decrease in ALT (85 IU/l on July 18), there were no favourable effects of IFN treatment after 6 months, when ALT was 213 IU/1, gammaglobulins 23 g/1 and liver histology showed chronic active hepatitis. At this stage, ANA (1in 40) and SMA (1in 80) first appeared in serum and IFN was withdrawn. In June, 1989, the patient was referred to us. ALT was 256 IU/1, gammaglobulins 22 g/1, SMA 1 in 40, and serum ANA, AMA, gastric parietal cell, and thyroid microsome antibodies were negative. Anti-LKMl (1 in 1280, immunofluorescence test) and anti-HCV (Ortho ELISA) antibodies were positive in serum, and hepatitis B virus markers were negative. HLA phenotype proved to be Al, B8, DR3. T-lymphocyte migration inhibitory factor assay2,3 did not show T-cell reactivity to the hepatocyte asialoglycoprotein receptor (AGPR) (migration index 0-94). Treatment with 6methylprednisolone (40 mg daily) was introduced with some benefit (ALT 110 IU/1, gammaglobulins 18 g/1, anti-LKMl1in 320), although liver histology still showed features of chronic active hepatitis. Serological investigations on stored serum revealed that anti-LKMl (1 in 640) and anti-HCV were detectable before IFN
early
treatment.
The lack of efficacy of IFN strongly suggests that, in this case, HCV replication did not contribute much to the liver cell damage. Whether HCV antibodies were merely a marker of previous infection or indicated continuing infection remains to be established by viral sequence detection analyses.’ Although studies are needed to establish whether HCV infection precedes and determines anti-LKMlantibody production and whether cellular immune reactions to liver cell surface antigen(s) are present in these patients (in our case T-cell reactivity to one such antigen, AGPR, was not seen), our observations suggest that steroids should continue to be the treatment of choice in type 2 autoimmune hepatitis. IFN therapy not only seems to be unwarranted in these patients, but also favours the development of autoantibodies5,6 (also this case) and possible serious exacerbations of liver disease.6
Infectious Diseases Unit, "A Pugliese" Hospital, 88100 Catanzaro, Italy, and Department of Infectious Diseases, "Borgo Trento" Hospital, University of Verona
SANDRO VENTO GIOVANNI DI PERRI ROBERTO LUZZATI TIZIANA GAROFANO ERCOLE CONCIA DANTE BASSETTI
1.
Homberg JC, Abuaf N, Bernard O, et al. Chronic active hepatitis associated with antiliver/kidney microsome antibody type 1: a second type of "autoimmune" hepatitis. Hepatology 1987; 7: 1333-39. 2. Vento S, Hegarty JE, Bottazzo GF, Macchia E, Williams R, Eddleston ALWF. Antigen-specific suppressor cell function in autoimmune chronic active hepatitis. Lancet 1984; i: 1200-04. 3. Vento S, O’Brien CJ, McFarlane BM, McFarlane IG, Eddleston AWLF, Williams R. T lymphocyte sensitization to hepatocyte antigens in autoimmune chronic active hepatitis and primary biliary cirrhosis: evidence for different underlying mechanisms and different antigenic determinants as targets Gastroenterology 1986; 91: 810-17. AJ, Kuo G, Bradley DW, et al. Detection of hepatitis C viral sequences in non-A, non-B hepatitis. Lancet 1990; 335: 1-3. 5. Mayet WJ, Hess G, Gerken G, et al. Treatment of chronic type B hepatitis with recombinant alpha interferon induces autoantibodies not specific for autoimmune chronic hepatitis. Hepatology 1989; 10: 24-28. 6. Vento S, Di Perri G, Garofano T, et al. Hazards of interferon therapy for HBV-seronegative chronic hepatitis. Lancet 1989; ii: 926.
4. Weiner
"Natural"
benzodiazepines
in
man
SIR,-Professor Dencker and Dr Johansson (Feb 17, p 413) report that benzodiazepine-like substances could be detected in mothers’ milk by a radioreceptor technique. The milk concentrations (expressed as equivalents of lorazepam) of the benzodiazepine-like agents varied between 4 and 8 ng/ml. Since the radioreceptor technique is unspecific cross-reacting material might also account for these levels. The stated concentrations would be high enough to be measurable by gas chromatographic and mass spectrometry
analysis. We have used such specific and sensitive techniques (applying the stable isotope dilution technique for exact quantification) to detect "natural" benzodiazepines in the brain of various animals
and in plants.1 When we examined stored brain samples from patients who had died before the clinical introduction of benzodiazepines (to exclude any effects due to unknown ingestion of such drugs) we found low concentrations of diazepam (02-03 ng/g wet weight)? Therefore it is likely that low concentrations of benzodiazepines are also present in other tissues (including breast), but which are probably too low to exert direct pharmacological
effects. Since various benzodiazepines have been found in many plants,1,3,4 the "endogenous" benzodiazepines found in human brain or milk might arise from this food source. Dr Margarete Fischer-Bosch-Institut fur Klinische Pharmakologie, 7000 Stuttgart 50, West Germany 1. Unseld
ULRICH KLOTZ
E, Krishna DR, Fischer C, Klotz U. Detection of desmethyldiazepam and m brain of different species and plants. Biochem Pharmacol 1989; 38:
diazepam
2473-78. E, Fischer C, Rothemund E, Klotz U. Occurrence of ’natural’ diazepam in human brain. Biochem Pharmacol 1990; 39: 210-12. 3. Wildmann J, Mohler H, Vetter W, Ranadaler U, Schmidt K, Maurer R. Diazepam and N-desmethyldiazepam are found in rat brain and adrenals and may be of plant origin.J Neural Transm 1987; 70: 383-89. 4. Wildmann J, Vetter W, Ranadaler UB, Schmidt K, Maurer R, Mohler H. Occurrence of pharmacologically active BZD in trace amounts in wheat and potato. Biochem Pharmacol 1988; 37: 3549-59. 2. Unseld
Thiazides with loop diuretics for severe congestive heart failure SiR,—Dr Kiyingi and colleagues (Jan 6, p 29) report the use of metolazone in severe refractory congestive cardiac failure. Metolazone has been used in this context for nearly 20 years.! However, its impressive effect is not unique; we report the combined use of bendrofluazide with frusemide. Ten patients (table) admitted with severe refractory heart failure were investigated. All failed to respond to frusemide given orally and intravenously, and body weight was unchanged or increased. Bendrofluazide 10 mg (5 mg in 1 patient) orally was added to their treatment, diuresis was established within 24 h, and weight loss was progressive. When diuresis started, bendrofluazide was withdrawn in 6 patients and weight loss continued with frusemide treatment alone, the dose being progressively reduced in 4 patients. In 1 other patient the frusemide was also reduced but bendrofluazide was continued. Only 3 patients were discharged on both frusemide and bendrofluazide. 2 patients who were hyponatraemic on frusemide therapy before the introduction of bendrofluazide remained so; no other patient had hyponatraemia. 9 patients were normokalaemic on frusemide therapy and 1 was hyperkalaemic, but mild hypokalaemia developed in only 2 (both 29 mmol/1). In 6 the serum creatinine/ urea fell and in 3 small increases occurred which reversed after the drug was stopped. In 1 patient, with evidence of at least moderate renal impairment, there was a more pronounced increase in creatinine to 310 umol/1. In all patients fluid retention resolved with PATIENT DETAILS IN RELATION TO BENDROFLUAZIDE TREATMENT
Hepatitis C antibody and transaminase activities in blood donors SiR,—The value of screening blood donors for non-A, non-B
(NANB)
hepatitis
using
the
surrogate
markers
alanine
aminotransferase (ALT) and antibody to the core of the hepatitis B virus (anti-HBc) has been extensively debated. A raised ALT indicates hepatocellular damage but it is not specific for NANB infection and may be influenced by other viruses, and by age, sex, obesity, drugs, and alcohol. An immunoassay for antibody to hepatitis C virus (anti-HCV) has been developed, and results with this assay suggest that HCV is the major cause of post-transfusion NANB hepatitis."-3 Studies of single random samples collected from blood donors have looked at anti-HCV reactivity and ALT.45** The Queensland Red Cross Blood Transfusion Service has used
computer-stored serial ALT levels to identify donors with a history of abnormal ALT and has correlated these data with anti-HCV positivity. These results should be useful in defining the role of surrogate ALT screening in blood banks as a supplement to anti-HCV testing. Between March, 1988, and December, 1989, blood was collected from 133 control donors with no history of raised ALT (cut-off 46 IU/1) who had made at least three previous donations, from 82 donors with an ALT of 46-100 IU/1 at least three times, and from 74 donors with ALT activities above 100 IU/1 at least once. The samples were stored at - 30°C before anti-HCV testing (Ortho Diagnostics ELISA). The frequency of repeatable anti-HCV reactivity in the three groups was 1/133 (0-6%), 8/82 (10%), and 18/74 (24%), respectively (p < 0-001). 7 anti-HCV reactive donors were tested more than once (two to six samples over 3-17 months); 6 were persistently reactive and the other was negative 13 months later despite ALT levels persistently above 100 IU/1. Samples from the 27 reactive donors were further tested by the Chiron recombinant immunoblot assay (RIBA) for anti-HCV, supplied by Ortho Diagnostics System, and 25 samples showed reactivity consistent with HCV antibody. The 2 negative samples were from the only anti-HCV reactive control donor and from the donor whose anti-HCV reactivity disappeared. The fluctuation of ALT levels in patients with chronic NANB hepatitis is well recognised,2 and all the anti-HCV reactive donors in this study demonstrated this pattern; in 44% ALT levels fluctuated
above and below the cut-off. In these donors, anti-HCV reactivity persisted even when the ALT fell to normal. Inclusion of such donors will underestimate the correlation between anti-HCV reactivity and ALT when studies are conducted on single samples from unselected donors. The frequency of anti-HCV reactivity (10%) or more in our selected donors with raised ALT levels was 16 to 44 times greater than that for anti-HCV reactivity in the first 7366 isolated donations screened, the repeatably reactive rate there being 054%. 161 of those 7366 donors had ALT levels above 46 IU/1 although only 10 of these 161 were among the 40 anti-HCV reactives. A further 3 of the 40 had a history of raised ALT but were normal at the time of anti-HCV testing. We were able to follow up by RIBA 19 of the 40 reactive samples. 14 showed patterns consistent with anti-HCV and the remaining 5 (all ALT normal) were negative. This suggests that the false reactive rate in random donors was higher than among the donors with histories of a raised ALT (5/19 vs 2/27). ALT levels in such a selected group may be indicative of a carrier state of active infection. ELISA and RIBA use the same recombinant antigen. Further confirmatory assays are necessary to elucidate the true frequency of HCV infection.’ Since about 92% of donors with a random single raised ALT level are not anti-HCV positive a realistic protocol for reinstating donors with isolated raised ALT levels in the absence of HCV seroconversion within 12 months can be devised. A strategy can be devised (see figure) that minimises wastage and maximises prevention of transfusion-associated NANB hepatitis. We achieved a high degree of selection of anti-HCV reactive donors by identifying those with persistently raised or fluctuating ALT levels. ALT screening should be of value in identifying donors in the window period before seroconversion, those with aberrant antibody responses not detected by the current assay, and those infected with NANB hepatitis agents other than HCV.5 Red Cross Blood Transfusion Service, Queensland Division, Brisbane, Queensland 4000, Australia
C. MORGAN C. HYLAND I. F. YOUNG
G, Choo Q-L, Alter HJ, et al. An assay for circulating antibodies to a major etiologic virus of human non-A, non-B hepatitis. Science 1989; 244: 362-64. 2. Alter HJ, Purcell RH, Shih JW, et al. Detection of antibody to hepatitis C virus in prospectively followed transfusion recipients with acute and chronic non-A, non-B hepatitis. N Engl J Med 1989; 321: 1494-500. 3. Van Der Poel CL, Ressink HW, Lelie PN, et al. Ann-hepatitis C antibodies and non-A, non-B post-transfusion hepatitis in The Netherlands. Lancet 1989; ii: 1. Kuo
297-98. 4. Kuhl P, Seidl S, Stangel W, Beyer J, Sibrowski W, Flik J. Antibody to hepatitis C virus in German blood donors. Lancet 1989; ii: 324. 5. Alter HJ. Discovery of the non-A, non-B hepatitis virus: the end of the beginning or the beginning of the end. Transfusion Med Rev 1989; 3: 77-81.
Type 2 autoimmune hepatitis and hepatitis C virus infection
Strategy for exclusion or reinstatement of donors.
SIR,-Dr Lenzi and colleagues (Feb 3, p 258) report a high prevalence of serum antibodies to hepatitis C virus (HCV) in patients with anti-liver kidney microsomal antibody (anti-LKMl)positive chronic hepatitis-ie, autoimmune hepatitis type 2.1 However, the part, if any, played by HCV infection in the pathogenesis of chronic liver cell damage in these patients is unclear. We report a case which provides insight into this important issue. The patient, now 56 years old, had occasional biochemical and histological evidence of chronic persistent hepatitis in 1978. Because of seronegative hepatitis B virus markers (HBsAg, anti-HBc, HBeAg, anti-HBe, anti-HBs) and antinuclear (ANA), anti-smooth muscle (SMA), and antimitochondrial (AMA) antibodies, liver disease was diagnosed as sporadic non-A, non-B chronic hepatitis. Clinical and biochemical (ALT 65--119 IU/1, gammaglobulins 15-17 g/1) follow-up continued to indicate chronic persistent hepatitis until May, 1988, when a liver biopsy revealed chronic active hepatitis (ALT 207 IU/1, gammaglobulins 20 g/1). ANA, SMA, and AMA were not detected in serum. On May 18, 1988, treatment with recombinant interferon (IFN) alpha-2-b (Essex Pharma, Munich) was started (3 MU thrice weekly). Despite an
922
decrease in ALT (85 IU/l on July 18), there were no favourable effects of IFN treatment after 6 months, when ALT was 213 IU/1, gammaglobulins 23 g/1 and liver histology showed chronic active hepatitis. At this stage, ANA (1in 40) and SMA (1in 80) first appeared in serum and IFN was withdrawn. In June, 1989, the patient was referred to us. ALT was 256 IU/1, gammaglobulins 22 g/1, SMA 1 in 40, and serum ANA, AMA, gastric parietal cell, and thyroid microsome antibodies were negative. Anti-LKMl (1 in 1280, immunofluorescence test) and anti-HCV (Ortho ELISA) antibodies were positive in serum, and hepatitis B virus markers were negative. HLA phenotype proved to be Al, B8, DR3. T-lymphocyte migration inhibitory factor assay2,3 did not show T-cell reactivity to the hepatocyte asialoglycoprotein receptor (AGPR) (migration index 0-94). Treatment with 6methylprednisolone (40 mg daily) was introduced with some benefit (ALT 110 IU/1, gammaglobulins 18 g/1, anti-LKMl1in 320), although liver histology still showed features of chronic active hepatitis. Serological investigations on stored serum revealed that anti-LKMl (1 in 640) and anti-HCV were detectable before IFN
early
treatment.
The lack of efficacy of IFN strongly suggests that, in this case, HCV replication did not contribute much to the liver cell damage. Whether HCV antibodies were merely a marker of previous infection or indicated continuing infection remains to be established by viral sequence detection analyses.’ Although studies are needed to establish whether HCV infection precedes and determines anti-LKMlantibody production and whether cellular immune reactions to liver cell surface antigen(s) are present in these patients (in our case T-cell reactivity to one such antigen, AGPR, was not seen), our observations suggest that steroids should continue to be the treatment of choice in type 2 autoimmune hepatitis. IFN therapy not only seems to be unwarranted in these patients, but also favours the development of autoantibodies5,6 (also this case) and possible serious exacerbations of liver disease.6
Infectious Diseases Unit, "A Pugliese" Hospital, 88100 Catanzaro, Italy, and Department of Infectious Diseases, "Borgo Trento" Hospital, University of Verona
SANDRO VENTO GIOVANNI DI PERRI ROBERTO LUZZATI TIZIANA GAROFANO ERCOLE CONCIA DANTE BASSETTI
1.
Homberg JC, Abuaf N, Bernard O, et al. Chronic active hepatitis associated with antiliver/kidney microsome antibody type 1: a second type of "autoimmune" hepatitis. Hepatology 1987; 7: 1333-39. 2. Vento S, Hegarty JE, Bottazzo GF, Macchia E, Williams R, Eddleston ALWF. Antigen-specific suppressor cell function in autoimmune chronic active hepatitis. Lancet 1984; i: 1200-04. 3. Vento S, O’Brien CJ, McFarlane BM, McFarlane IG, Eddleston AWLF, Williams R. T lymphocyte sensitization to hepatocyte antigens in autoimmune chronic active hepatitis and primary biliary cirrhosis: evidence for different underlying mechanisms and different antigenic determinants as targets Gastroenterology 1986; 91: 810-17. AJ, Kuo G, Bradley DW, et al. Detection of hepatitis C viral sequences in non-A, non-B hepatitis. Lancet 1990; 335: 1-3. 5. Mayet WJ, Hess G, Gerken G, et al. Treatment of chronic type B hepatitis with recombinant alpha interferon induces autoantibodies not specific for autoimmune chronic hepatitis. Hepatology 1989; 10: 24-28. 6. Vento S, Di Perri G, Garofano T, et al. Hazards of interferon therapy for HBV-seronegative chronic hepatitis. Lancet 1989; ii: 926.
4. Weiner
"Natural"
benzodiazepines
in
man
SIR,-Professor Dencker and Dr Johansson (Feb 17, p 413) report that benzodiazepine-like substances could be detected in mothers’ milk by a radioreceptor technique. The milk concentrations (expressed as equivalents of lorazepam) of the benzodiazepine-like agents varied between 4 and 8 ng/ml. Since the radioreceptor technique is unspecific cross-reacting material might also account for these levels. The stated concentrations would be high enough to be measurable by gas chromatographic and mass spectrometry
analysis. We have used such specific and sensitive techniques (applying the stable isotope dilution technique for exact quantification) to detect "natural" benzodiazepines in the brain of various animals
and in plants.1 When we examined stored brain samples from patients who had died before the clinical introduction of benzodiazepines (to exclude any effects due to unknown ingestion of such drugs) we found low concentrations of diazepam (02-03 ng/g wet weight)? Therefore it is likely that low concentrations of benzodiazepines are also present in other tissues (including breast), but which are probably too low to exert direct pharmacological
effects. Since various benzodiazepines have been found in many plants,1,3,4 the "endogenous" benzodiazepines found in human brain or milk might arise from this food source. Dr Margarete Fischer-Bosch-Institut fur Klinische Pharmakologie, 7000 Stuttgart 50, West Germany 1. Unseld
ULRICH KLOTZ
E, Krishna DR, Fischer C, Klotz U. Detection of desmethyldiazepam and m brain of different species and plants. Biochem Pharmacol 1989; 38:
diazepam
2473-78. E, Fischer C, Rothemund E, Klotz U. Occurrence of ’natural’ diazepam in human brain. Biochem Pharmacol 1990; 39: 210-12. 3. Wildmann J, Mohler H, Vetter W, Ranadaler U, Schmidt K, Maurer R. Diazepam and N-desmethyldiazepam are found in rat brain and adrenals and may be of plant origin.J Neural Transm 1987; 70: 383-89. 4. Wildmann J, Vetter W, Ranadaler UB, Schmidt K, Maurer R, Mohler H. Occurrence of pharmacologically active BZD in trace amounts in wheat and potato. Biochem Pharmacol 1988; 37: 3549-59. 2. Unseld
Thiazides with loop diuretics for severe congestive heart failure SiR,—Dr Kiyingi and colleagues (Jan 6, p 29) report the use of metolazone in severe refractory congestive cardiac failure. Metolazone has been used in this context for nearly 20 years.! However, its impressive effect is not unique; we report the combined use of bendrofluazide with frusemide. Ten patients (table) admitted with severe refractory heart failure were investigated. All failed to respond to frusemide given orally and intravenously, and body weight was unchanged or increased. Bendrofluazide 10 mg (5 mg in 1 patient) orally was added to their treatment, diuresis was established within 24 h, and weight loss was progressive. When diuresis started, bendrofluazide was withdrawn in 6 patients and weight loss continued with frusemide treatment alone, the dose being progressively reduced in 4 patients. In 1 other patient the frusemide was also reduced but bendrofluazide was continued. Only 3 patients were discharged on both frusemide and bendrofluazide. 2 patients who were hyponatraemic on frusemide therapy before the introduction of bendrofluazide remained so; no other patient had hyponatraemia. 9 patients were normokalaemic on frusemide therapy and 1 was hyperkalaemic, but mild hypokalaemia developed in only 2 (both 29 mmol/1). In 6 the serum creatinine/ urea fell and in 3 small increases occurred which reversed after the drug was stopped. In 1 patient, with evidence of at least moderate renal impairment, there was a more pronounced increase in creatinine to 310 umol/1. In all patients fluid retention resolved with PATIENT DETAILS IN RELATION TO BENDROFLUAZIDE TREATMENT
