Elimination of Contrast Agent Gadobutrol with Sustained Low Efficiency Daily Dialysis Compared to Intermittent Hemodialysis.

BACKGROUND: In patients with renal failure, gadolinium-based contrast agents (GBCA) can be removed by intermittent hemodialysis (iHD) to prevent possible toxic effects. There is no data on the efficacy of GBCA removal via sustained low efficiency daily dialysis (SLEDD) which is mainly used in intensive care unit (ICU) patients. METHODS: We compared the elimination of the GBCA gadobutrol in 6 ICU patients treated with SLEDD (6-12 h, 90 L dialysate) with 7 normal ward inpatients treated with iHD (4 h, dialysate flow 500 mL/min). Both groups received 3 dialysis sessions on 3 consecutive days starting after the application of gadobutrol. Blood samples were drawn before and after each session and total dialysate, as well as urine was collected. Gadolinium (Gd) concentrations were measured using mass spectrometry and eliminated Gd was calculated from dialysate and urine. RESULTS: The initial mean plasma Gd concentration was 385 ± 183 µM for the iHD and 270 ± 97 µM for the SLEDD group, respectively (p > 0.05). The Gd-reduction rate after the first dialysis session was 83 ± 9 and 67 ± 9% for the iHD and the SLEDD groups, respectively (p = 0.0083). The Gd-reduction rate after the second and third dialysis was 94-98 and 89-96% for the iHD and the SLEDD groups (p > 0.05). The total eliminated Gd was 89 ± 14 and 91 ± 4% of the dose in the iHD and the SLEDD groups, respectively (p > 0.05). Gd dialyzer clearance was 95 ± 22 mL/min and 79 ± 19 mL/min for iHD and SLEDD, respectively (p > 0.05). CONCLUSIONS: Gd-elimination with SLEDD is equally effective as iHD and can be safely used to remove GBCA in ICU patients.

Implementation of Urgent Start Peritoneal Dialysis Reduces Hemodialysis Catheter Use and Hospital Stay in Patients with Unplanned Dialysis Start.

BACKGROUND: Unplanned start of renal replacement therapy is common in patients with end-stage renal disease and often accomplished by hemodialysis (HD) using a central venous catheter (CVC). Urgent start using peritoneal dialysis (PD) could be an alternative for some of the patients; however, this requires a hospital-based PD center that offers a structured urgent start PD (usPD) program. METHODS: In this prospective study, we describe the implementation of an usPD program at our university hospital by structuring the process from presentation to PD catheter implantation and start of PD within a few days. For clinical validation, we compared the patient flow before (2013-2015) and after (2016-2018) availability of usPD. RESULTS: In the 3 years before the availability of usPD, 14% (n = 12) of incident PD patients (n = 87) presented in an unplanned situation and were initially treated with HD using a CVC. In the 3 years after implementation of the usPD program, 18% (n = 18) of all incident PD patients (n = 103) presented in an unplanned situation of whom n = 12 (12%) were treated with usPD and n = 6 (6%) with initial HD. usPD significantly reduced the use of HD by 57% (p = 0.0005). Hospital stay was similar in patients treated with usPD (median 9 days) compared to those with elective PD (8 days), and significantly lower than in patients with initial HD (26 days, p = 0.0056). CONCLUSIONS: Implementation of an usPD program reduces HD catheter use and hospital stay in the unplanned situation.

Urinary Neutrophil Gelatinase-Associated Lipocalin (NGAL) and proteinuria predict severity of acute kidney injury in Puumala virus infection.

BACKGROUND: Nephropathia epidemica (NE) is a mild form of hemorrhagic fever with renal syndrome (HFRS) that is caused by the Puumala virus. Periodic outbreaks have been described in endemic areas, with a substantial number of previously healthy individuals developing acute kidney injury (AKI). There is a considerable diversity in the clinical course of the disease, and few patients require renal replacement therapy. METHODS: We tested whether urinary neutrophil gelatinase associated lipocalin (uNGAL), urine albumin/creatinine ratio (uACR), urine protein/creatinine ratio (uPCR), urine dipstick protein, C-reactive protein, procalcitonin, leukocyte and platelet count, determined on admission to the hospital, can predict the severity of AKI. Sixty-one patients were analyzed during admission in the emergency department. RESULTS: The variables most strongly associated with peak plasma creatinine concentration were uNGAL (ß = 0.70, p <0.0001), uPCR (ß = 0.64, p = 0.001), uACR (ß = 0.61, p = 0.002), and dipstick proteinuria (ß = 0.34, p = 0.008). The highest AUC-ROC to predict stage 3 AKI according to the acute kidney injury network's (AKIN) classification was seen for uNGAL (0.81, p = 0.001). CONCLUSION: uNGAL accurately predicts the severity of AKI in NE. This could help emergency room physicians predict disease severity and allow for initial risk stratification.

[End-stage renal disease after sarcoma therapy - case 3/2014]. / Terminales Nierenversagen nach Sarkomtherapie - Fall 3/2014.

HISTORY AND ADMISSION FINDINGS: A 67-year-old male patient developed progressive renal failure following successful treatment of a soft tissue sarcoma that comprised surgical resection after neoadjuvant radiochemotherapy with the application of doxorubicin (cumulative dose 180 mg/m²) and ifosfamide (cumulative dose 33 g/m²). INVESTIGATIONS: Plasma creatinine concentration was elevated to 4.5 mg/dl. Upon detection of glucosuria and α1-microglobulinuria renal biopsy was performed. DIAGNOSIS, TREATMENT AND COURSE: Histologic analysis revealed massively injured tubules that could be explained by a toxic effect of ifosfamide. Glomeruli were not affected and appeared normal. After two months of conservative therapy, the patient developed an uremic syndrome requiring hemodialysis. Ever since kidney function did not recover albeit preserved diuresis. CONCLUSIONS: Ifosfamide can cause end-stage renal disease by a tubulotoxic effect that may be the result of a selective intracellular uptake into the proximal tubule via the human organic cation transporter 2 (OCT2).

[Renal failure and recurrent episodes of flash pulmonary edema in a 70-year-old patient]. / Nierenversagen und wiederholte Episoden eines blitzartig auftretenden Lungenödems bei einer 70-jährigen Patientin.

HISTORY AND ADMISSION FINDINGS: We report on a patient presenting with renal failure who developed mutliple episodes of flash pulmonary edema. INVESTIGATIONS: Volume retention due to ischemic nephropathy was found to be the cause. DIAGNOSIS, TREATMENT AND COURSE: She was diagnosed to have a high grade renal artery stenosis in a functional solitary kidney and underwent percutaneous angioplasty. After being anuric and dialysis-dependent, she regained her kidney function leading to resolution of the volume retention and could be weaned from dialysis. CONCLUSIONS: Ischemic nephropathy is often accompanied by recurrent episodes of flash pulmonary edema and responds well to an interventional treatment.

[Painful swollen joints with weakness: what's behind all this? Case 1/2013]. / Schmerzhaft geschwollene Gelenke bei Schwächezustand: was steckt dahinter? - Fall 1/2013.

HISTORY AND ADMISSION FINDINGS: We report on a 58-year-old patient with weight loss, weakness and polyarthralgia. She reported of recurrent drops, painful joints and muscle weakness. INVESTIGATIONS: The patient had swollen joints, clubbing and cachexia. The radiogram of the hands and feet showed a hypertrophic oseoarthropathy. In further investigations we found a tumor in the upper left lung. The histology findings showed a adenocarcinoma of the lung. DIAGNOSIS, TREATMENT AND COURSE: The diagnosis of a secondary hypertrophic osteoarthropathy (Pierre Marie-Bamberger syndrome) due to a adenocarcinoma of the lung was made. The patient refused a radiochemotherapy and decided to go on vacation. Further course is unknown. CONCLUSIONS: Arthralgia is a common symptom for medical consultation. Pierre Marie-Bamberger syndrome is a rare cause of paraneoplastic arthritis. Notice that unspecific symptoms like weakness, weight loss and arthritis may result from paraneoplastic tumor disease.

Effect of buckminsterfullerenes on cells of the innate and adaptive immune system: an in vitro study with human peripheral blood mononuclear cells.

C60 nanoparticles, the so-called buckminsterfullerenes, have attracted great attention for medical applications as carriers, enzyme inhibitors or radical scavengers. However, publications evaluating their immunological mechanisms are still rather limited. Therefore, we aimed to analyze systematically the in vitro influence of polyhydroxy-C60 (poly-C60) and N-ethyl-polyamino-C60 (nepo-C60) on peripheral blood mononuclear cells (PBMC) from healthy individuals, angling their effect on proliferation, expression of surface markers, and cytokine production. We isolated PBMC from 20 healthy subjects and incubated them in a first step only with poly-C60 or nepo-C60, and in a second step together with recall antigens (purified protein derivative, tetanus toxoid, bacillus Calmette-Guérin). Proliferation was determined by (3)H-thymidine incorporation, activation of PBMC-subpopulations by flow cytometry by measurement of the activation marker CD69, and secretion of T helper cell type 1 (TH1)- (interferon-gamma [IFN-γ], tumor necrosis factor beta [TNF-ß]), TH2- (interleukin-5 [IL-5], -13, -10) and macrophage/monocyte-related cytokines (IL-1, IL-6, TNF-α) into the supernatants by enzyme-linked immunosorbent assay. Both fullerenes did not influence T cell reactivity, with no enhanced expression of CD69 and production of T cell cytokines observed, the CD4/CD8 ratio remaining unaffected. In contrast, they significantly enhanced the release of IL-6 and CD69-expression by CD56 positive natural killer cells. PBMC, which had been cultured together with the three recall antigens were not affected by both fullerenes at all. These data indicate that fullerenes do not interact with T cell reactivity but may activate cells of the innate immune system. Furthermore, they seem to act only on 'naïve' cells, which have not been prestimulated with recall antigens, there are however, large inter individual differences.