[Rehabilitation results of Turkish immigrants - an analysis of routine data from the Rhineland and Westfalia Pension Insurance]. / Rehabilitationserfolg bei Menschen mit türkischem Migrationshintergrund - Eine Auswertung von Routinedaten der Deutschen Rentenversicherungen Rheinland und Westfalen.

AIMS OF THE STUDY: Approximately 3 million Turkish immigrants are living in Germany, in North Rhine-Westfalia their share amounts to 4.7%. They use the same rehabilitation services as Germans, but their treatment usually shows less positive results - as other studies have shown. The aims of the research project "Immigration and Health Inequalities in Rehabilitation" were (a) to quantify the use of medical rehabilitation by Turkish immigrants in different diagnosis groups, (b) to compare outcomes in different diagnosis groups and (c) to find out whether the results will be explained by immigrant status, or by socio-economic factors accompanying immigrant status. METHODS AND RESULTS: An analysis of routine data from Deutsche Rentenversicherung Rheinland and Deutsche Rentenversicherung Westfalen (Rhineland and Westfalia Pension Insurances) was carried out, pertaining to 363 855 persons who had participated in at least one rehabilitation procedure between 2000 and 2006. 4.8% of all rehabilitees were identified as being of Turkish origin. A modified name-based algorithm was used to help to identify Turkish rehabilitees. The outcome of rehabilitation was measured by comparing the medical discharge assessments. Turkish people were in need of rehabilitation more often because of mental disorders/behavioural disturbances (Turkish men=22.0% vs. non-Turkish men=18.4% [p<0.001]; Turkish women=30.8% vs. non-Turkish women=21.6% [p<0.001]) and less often because of neoplasms (Turkish men=4.7% vs. non-Turkish men =7.8% [p<0.001]; Turkish women=6.4% vs. non-Turkish women=13.9% [p<0.001]). Concerning treatment results in several diagnosis groups Turkish rehabilitees benefitted less from treatment than non-Turkish rehabilitees did (musculoskeletal disorders: OR=2.08 [95%-CI=1.97-2.20]; mental disorders/behavioural disturbances: OR=1.70 [95%-CI=1.57-1.84]; respiratory diseases: OR=1.41 [95%-CI=1.14-1.75]; digestive disorders/metabolic diseases: OR=1.36 [95%-CI=1.11-1.66]). Non-Turkish rehabilitees had higher chances of success, even adjusted by social and performance-related factors. The differences were non-significant only in cardio-vascular disease and neoplasm treatment. CONCLUSIONS: Rehabilitation outcomes are significantly less favourable for Turkish people. The differences found can partially be traced to factors related to their migration background and not only to other social differences or performance-related factors of the health services. Immigrant status, hence, affects rehabilitation outcome and must receive attention in both rehabilitation plans and rehabilitation facilities.

Infection with polyomavirus type BK after renal transplantation.

Tubulointerstitial nephritis caused by polyomavirus of the subtype BK (BK virus nephropathy, BKN) is an important cause of deterioration of renal allograft function after kidney transplantation. In 3 cases of BKN diagnosed at our center, the suspected diagnosis made on the basis of urine cytology and serum PCR was confirmed by electron microscopy and immunohistology of the renal graft biopsy. In 1 patient, stable renal function without further virus detection was seen after reduction of the immunosuppression. In 2 further patients there was loss of graft function. BKN is an important differential diagnosis of unclear deterioration of renal graft function. The risk is particularly high with use of tacrolimus and mycophenolate mofetil (MMF). Urine cytology and serum PCR are suitable screening tests, histology provides conclusive evidence. The only therapeutic option available at present is reduction of immunosuppressive therapy.

Cytokine removal in septic patients with continuous venovenous hemofiltration.

Despite the progress that has been made in intensive care medicine, multiple organ failure is still associated with high mortality. Apart from the prevention of infectious complications, numerous efforts are being made to improve the treatment of sepsis through adequate antibiotic therapy, the development of new respirator therapies, better control of the hemodynamic situation, and adequate renal replacement therapy. Some authors advocate continuous renal replacement therapy not only for acute renal failure but also for the elimination of inflammatory molecules such as cytokines. Continuous renal replacement therapy improves the cardiovascular hemodynamics in patients with multiple organ failure. Therapeutic options such as volume control, clearance of uremic toxins, correction of acid base disturbances and temperature control are improved. Suitable renal replacement therapy improves not only cardiovascular hemodynamics but also patient survival. In current practice, continuous renal replacement therapy is not used to eliminate mediators such as cytokines. In patients with multiple organ failure and compromised cardiovascular hemodynamics, renal replacement therapy should be carried out as early as possible. In the following review, experimental and clinical findings concerning mediator elimination by continuous and intermittent renal replacement therapy are summarized.

Hemodynamically relevant hematuria several months after biopsy of a kidney graft: an unusual cause.

We report the case of a 52-year-old female patient, who after a complicated living donor kidney transplantation, underwent kidney biopsy for suspected rejection. Duplex scanning revealed a small, asymptomatic arteriovenous (AV) fistula which was assessed as being hemodynamically unimportant. During follow-up, several urinary tract infections occurred and recurrent short episodes of hematuria were attributed to cystitis, urethritis and urosepsis. Eight months later, the patient developed suddenly massive hematuria, tamponade of the urinary bladder and hemorrhagic shock as well as urosepsis. Duplex sonography showed a massive pseudoaneurysm in addition to the AV fistula. Arteriography confirmed the Duplex sonographic findings and embolization was performed after treatment of concomitant urosepsis. The fistula was closed completely and bleeding ceased. Although AV fistulas are rare complications of kidney biopsies and in most cases they remain asymptomatic, life-threatening hematuria can present several months after a biopsy due to the development of a pseudoaneurysm. Concomitant infectious complications of the urinary tract, bleeding disorders and other factors can be misleading during the assessment of the cause of gross hematuria. Regular Duplex sonographic follow-up examinations in patients with AV fistulas are advisable.

Contrast-enhanced MR urography in the evaluation of renal transplants with urological complications.

AIM: The diagnostic work-up of renal transplants with impaired function due to urological problems can be difficult. This study was performed to assess sensitivity and specificity of non-invasive contrast-enhanced MR urography (MRU). METHODS AND MATERIALS: Thirty-five patients with renal transplants (25 - 71 years, mean: 53.4 years) with sonographically diagnosed hydronephrosis or perirenal fluid collections were assessed by MR urography. MR examinations were carried out at a 1.5 T clinical scanner (Vision, Siemens, Erlangen, Germany) with a 512 matrix contrast-enhanced fat-suppressed T1-weighted FLASH 3D sequence in breath-hold technique. MIP reconstructions were used to produce MR urography. MRU diagnoses were compared to operative results. RESULTS: In all patients, images with sufficient contrast in the renal collecting system were obtained. Hydronephrosis was confirmed in 20 patients, 8 patients showed a different pathology while 7 had normal findings. Compared to operative results, sensitivity of MRU was 100% with a specificity of 78%, respectively. One ureteral stone was misdiagnosed as a stricture, and 2 suspected ureteral stenoses could not be found upon operation. CONCLUSIONS: Contrast-enhanced MR urography is a highly sensitive and specific non-invasive method to evaluate patients suspected of having typical post-transplant urological complications. It may replace invasive procedures such as antegrade pyelography in the pre-operative work-up.

Renal involvement in sarcoidosis--a report of 6 cases.

This report concerns 6 patients with renal involvement in sarcoidosis. Two of the patients had no clinical symptoms at all. In 3 patients, no extrarenal organ manifestation was found. All 6 patients had elevated levels of serum creatinine, 2 were hypercalcemic. Five patients manifested with mild proteinuria, but in none of the cases was a nephritic sediment with erythrocytes found. Kidney biopsies in 5 patients showed epitheloid cell granulomatous interstitial nephritis, and 1 patient presented with nephrocalcinosis. All patients were treated with corticosteroids. The serum creatinine levels decreased significantly in 4 patients (> 50% decrease), and slightly in 2 patients, elevated serum calcium levels were normalized. Thus, even in the absence of other organ manifestations, sarcoidosis can be the cause of renal insufficiency, and it responds well to corticosteroid treatment. These patients demonstrate the importance of kidney biopsy in the unexplained deterioration of renal function.

Acid-base balance and substitution fluid during continuous hemofiltration.

Critically ill patients with acute renal failure usually present with an unstable acid-base balance, often leading to cardiovascular complications and multi-organ failure. Therefore, to prevent metabolic acidosis, acid-base balance must be normalized and maintained; these patients are primarily treated with continuous hemofiltration techniques using different replacement fluids to influence the acid-base values. Dialysate solutions can be an acetate-based, lactate-based, citrate-based or bicarbonate-based buffer. This article discusses the strengths and weaknesses of each type of hemofiltration replacement fluid.

Congestive heart failure as an indication for continuous renal replacement therapy.

Continuous venovenous hemofiltration (CVVH) is the most widely used renal replacement therapy for the treatment of critically ill patients with acute renal failure on the intensive care unit. Whether or not congestive heart failure is an indication for CVVH is controversial and needs to be discussed. Therefore, we present a patient with congestive heart failure who was treated successfully with CVVH.

Impact of the endothelin system on water and sodium excretion in patients with liver cirrhosis.

BACKGROUND: Impaired renal function in patients with liver cirrhosis is a serious complication and is characterized by sodium and water retention in the absence of identifiable specific causes of renal dysfunction. The endothelin system has been shown to be activated in liver cirrhosis and might contribute to impaired renal function. However, the mechanisms leading to an activation of the endothelin system in these patients and the effects of an activated endothelin system on renal function in these patients are as yet unknown. METHODS: To determine the correlation between the activity of the endothelin system and the ability to excrete water and sodium in patients with liver cirrhosis, we measured plasma endothelin-1 concentrations by reversed phase-HPLC followed by an endothelin RIA and performed an oral water load tests in 10 healthy control subjects and 43 patients with liver cirrhosis. In addition, we analysed possible mechanisms/factors like plasma endotoxin that might contribute to the activation of the endothelin system in liver cirrhosis. RESULTS: This study showed that the endothelin system is activated in patients with liver cirrhosis in a disease-stage-dependent manner. Patients with Child C liver cirrhosis have a 5.45-fold increased plasma ET-1 concentration compared to healthy controls, whereas plasma ET-1 is only increased 2.74-fold in Child A patients. An oral water load test revealed a highly significant (P < 0.0001) inverse correlation between the plasma endothelin-1 concentrations and the ability to excrete a given water load. Plasma endotoxin, a well-known stimulus of ET-1, is significantly (P < 0.03) correlated with plasma ET-1 in cirrhotic patients. The ET-1 concentrations in the ascites of patients with liver cirrhosis were lower and not related to plasma ET-1. CONCLUSION: The activity of the endothelin system in patients with liver cirrhosis depends on the severity of liver impairment. Plasma endotoxin might be an important stimulus of the endothelin system in liver cirrhosis. We observed a highly significant inverse correlation between the plasma endothelin-1 concentrations and the ability to excrete a given water and sodium load, suggesting that the endothelin system plays a role in the regulation of water excretion in patients with liver cirrhosis.

Evidence against a major role of adenosine in oxygen-dependent regulation of erythropoietin in rats.

This in vivo study investigated whether adenosine (ADO) plays a role in oxygen-dependent production of erythropoietin (EPO). Exposure of rats to 0.075% carbon monoxide (CO) for four hours was used as a stimulus for EPO production. To inhibit potential effects of ADO, rats were treated with the non-specific ADO antagonist theophylline, the selective ADO A1 receptor blockers DPCPX and KW-3902, the selective ADO A2 receptor blocker DMPX, and AOPCP, an inhibitor of 5'-ectonucleotidase, an ADO generating enzyme that is expressed on the surface of EPO producing cells. To stimulate ADO receptor activity, animals were treated with the selective ADO A1 and A2 receptor agonists CHA and CGS 21680, the ADO reuptake inhibitors dipyridamole and soluflazine and the ADO desaminase inhibitor EHNA. At doses known to interfere with ADO signal transmission in vivo, none of these substances either influenced EPO serum levels in normoxic rats or affected the approximately 30-fold rise in EPO serum levels and the increase in renal EPO mRNA after exposure to carbon monoxide. Continuous administration of theophylline to normoxic rats for seven days did not alter hematocrit, hemoglobin or EPO serum levels. Taken together, these experiments do not support the hypothesis that ADO plays an important role in the regulation of EPO production.