[Stent PTA in secondary symptomatic proximal subclavian artery obstruction]. / Stent-PTA bei sekundär symptomatischen proximalen Subclaviaobstruktionen.

Stent-PTA of secondary symptomatic proximal subclavian artery stenosis In comparison with conventional surgical revascularisation, percutaneous transluminal angioplasty (PTA) is an alternative treatment for short stenoses or occlusions involving the origin of the subclavian artery. If there is clinical suspicion of subclavian artery obstruction (e.g. blood pressure difference in both arms), digital subtraction angiography of the aortic arch and upper limb should be performed prior to creating radial haemodialysis shunts or coronary bypass crafting involving the internal mammary artery. PTA and stenting can be successfully carried out in symptomatic secondary proximal subclavian artery stenosis, e.g. in radial haemodialysis fistulas with distal ischaemia.

R-hirudin as anticoagulant in regular hemodialysis therapy: finding of therapeutic R-hirudin blood/plasma concentrations and respective dosages.

Recently heparin-induced thrombocytopenia type II has been diagnosed more frequently and does not exclude hemodialysis patients. Up to now, recombinant hirudin is the only available anticoagulant showing no immunologic cross reactions with heparin. However, the use of r-hirudin in hemodialysis patients with different degrees of residual renal functions is impossible using standard dosages because elimination of r-hirudin varies depending on the degree of residual renal function. Therefore the first study was carried out using consecutive r-hirudin anticoagulated hemodialyses to determine the appropriate dose of r-hirudin. Ten hemodialysis patients with creatinine clearance values ranging between 0 and 13 mL/min/1.73m2 were anticoagulated with r-hirudin. An initial bolus of 0.1 mg/kg bwt before the first hemodialysis, resulted in an average r-hirudin blood concentration of 305 ng/mL at the end of treatment. The dose for each of the following four hemodialyses was adjusted individually to reach the minimum therapeutic r-hirudin blood concentration. At the end of these treatments the mean blood r-hirudin concentration was 422 ng/mL. The necessary mean doses ranged between 0.008 and 0.125 mg/kg bwt correlating to the creatinine clearance values of the patients. All hemodialyses of the study were effective and safe. Bleeding times determined during r-hirudin anticoagulation were significantly lower than control values measured 2 days after a heparin administration. The study proved that r-hirudin may be an efficient and safe heparin alternative as a hemodialysis anticoagulant when the individual's residual renal function is noted for dosage and dose adjustment and is controlled by drug monitoring using the ecarin clotting time.

Further advances of chronic renal replacement therapy in eastern Germany, 1994 versus 1989.

Unlike the other former Soviet-block countries, Eastern Germany/the "GDR", had the opportunity to the re-unification with a highly developed western country, the Federal Republic of (West) Germany in 1990. In order to record the following rapid improvements in renal replacement therapy, we performed our own survey in Eastern Germany--excluding Eastern Berlin--by questionnaire, comparing the years 1989/December, and 1994/December. 112 of the 113 dialysis facilities for adult regular dialysis patients replied to our questionnaire (99%). From 1989 to 1994, the number of dialysis centers increased from 53 to 113 (-->213%), reaching 7.9 centres p.m.p. Of these facilities, 29% were hospital centers, 48% were private dialysis units, and 23% were run by nonprofit dialysis organizations. The number of dialysis stations increased from 602 to 1,719 (-->286%), i.e. 120 stations p.m.p. The number of patients in regular dialysis treatment rose from 2,127 to 5,335 (-->251%), that means a prevalence of 373 patients p.m.p. In 1989, 67 new patients (p.m.p.) had been accepted for maintenance treatment (incidence), in contrast to 130 new patients p.m.p. in 1994 (-->194%), now under the conditions of unlimited accessibility to dialysis treatment. Questions referring to this point--the incidence of new patients--were only asked in Thüringen (2.5 mio. inhabitants). Alternative treatment modalities became feasible under the new conditions in Eastern Germany. In contrast to 99% hemodialysis patients in December 1989, at the end of 1994 92.8% of the patients were treated by hemodialysis, 2.0% by hemofiltration, and 5.2% by peritoneal dialysis, predominantly CAPD.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of diagnostic criteria for analgesic nephropathy in patients with end-stage renal failure: results of the ANNE study. Analgesic Nephropathy Network of Europe.

It was found that in Belgium, renal imaging techniques, demonstrating a decreased renal mass of both kidneys combined with either bumpy contours or papillary calcifications, were the only methods to reliably diagnose analgesic nephropathy (AN) in patients with end-stage renal failure. However, these criteria were selected in an area with a high prevalence of this disease (15.6% of the dialysis population at December 1990). To evaluate the criteria selected to diagnose AN in populations with lower or unknown prevalences of AN, the Analgesic Nephropathy Network of Europe (ANNE) was formed, consisting of 23 dialysis units from 14 European countries and Brazil. During 1991-1992, 598 new patients with equivocal diagnosis of renal disease (excluding biopsy-proven glomerulonephritis, polycystic disease, diabetic nephropathy and other systemic diseases) and who began renal replacement therapy in the ANNE centres were evaluated by a short questionnaire and two renal imaging techniques: sonography and either tomography or computed tomography (CT) scan. A comparison of 82 abusers (daily use of analgesic mixtures for at least 5 years) and 495 controls corroborated the excellent diagnostic performance of the renal imaging techniques for AN. We recommend the use of these renal imaging criteria in all patients without a clear renal diagnosis in order to obtain a more reliable insight into the magnitude of the AN problem in different countries.

Differences in intravenous and subcutaneous application of recombinant human erythropoietin: a multicenter trial.

The aims of this clinical study were to compare the maintenance doses for intravenous (i.v.) and subcutaneous (SC) administration of recombinant human erythropoietin (rhEPO) and to investigate whether there is any difference in the increase of the packed cellular volume (PCV) per week under i.v. and SC administration of rhEPO from two production sites (Genetics Institute, Cambridge, USA; and Boehringer Mannheim, Penzberg, Germany). A total of 90 patients suffering from end-stage renal disease were included in the study. All patients had already been treated for at least 6 months with chronic hemodialysis. The study was carried out as a randomized, multicenter parallel group comparison study with a 1-week pretreatment phase, a subsequent 8-week double-blind phase, and a final open phase. The final open phase consisted of a correction phase and a maintenance phase. The production site had no influence on the PCV increase per week, and there were no differences with respect to tolerability. The median rhEPO dose required to maintain the target PCV of 30 to 35 vol.% was 33 U/kg body weight three times a week in the i.v. group compared with 22 U/kg in the SC group (i.e., an average of 30% less with SC administration). Development or aggravation of hypertension under rhEPO therapy was observed, especially during the correction phase and more frequently in the SC group than in the i.v. group. During the maintenance phase, there was no essential difference between the two groups.

Evolution of renal replacement therapy in East Germany from 1989 to 1992.

Diminished availability of facilities for renal replacement therapy is known to cause spuriously low acceptance and treatment rates. In this context the evolution of renal replacement therapy in the former German Democratic Republic is a useful model to study and to quantify some of the relevant factors. We performed a survey in all dialysis units for adults in East Germany (excluding East Berlin) by questionnaire, achieving a response rate of 97%. From December 1989 to December 1992 the number of dialysis centres increased from 53 to 96 (+81%), reaching 6.7 centres p.m.p. Of these facilities, 45% were hospital units, 29% private units, and 26% dialysis units run by non-profit health care organizations. The number of dialysis stations for regular dialysis treatment increased from 602 to 1276 (+112%), i.e. 89 stations p.m.p. In parallel, the number of chronic dialysis patients increased from 2127 to 3848 (+81%), i.e. 267 patients p.m.p. A more detailed survey was carried out in Thüringen and part of Sachsen, in a region covering 5 million inhabitants. The acceptance rate for chronic dialysis treatment has increased from 49 to 107 patients p.m.p. (+115%). The average age of new patients increased from 49 to 59 years, the proportion of patients aged > or = 65 years increased from 16 to 42% and the proportion of diabetics from 13 to 35%. Introduction of alternative treatment modalities became possible, with 2.3% of the patients receiving haemofiltrations and 3% CAPD. The proportion of HBs-antigen-positive patients decreased from 14.2% to 5%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Dialysis treatment of chronic renal failure]. / Die Dialysebehandlung bei chronischer Niereninsuffizienz.

Of the patients with chronic renal replacement therapy in Germany, only 27% are living with a functioning graft, while the other 73% are dialysis patients. At the end of 1990, there were about 30,000 patients on regular dialysis treatment in Germany. Without selection for chronic dialysis, the average age of newly accepted patients is 61 years. More than 30% of the new dialysis patients are diabetics. Intermittent haemodialysis (89.5%), intermittent haemofiltration (4.5%), and peritoneal dialysis (6%) are the different methods of chronic dialysis treatment in Germany. The 5-year-survival rate with regular haemodialysis treatment is 67%, for 50 years old patients without diabetic nephropathy (EDTA, Europe).

Pharmacology of r-hirudin in renal impairment.

The pharmacokinetic properties of r-hirudin were studied in nine patients suffering from different degrees of renal insufficiency. To this end, r-hirudin was administered intravenously at dosages of 0.1 mg/kg. The elimination half-life t1/2 beta was determined in blood plasma and the cumulative r-hirudin excretion in urine was measured over 48 h. In healthy volunteers t1/2 beta was 0.9 +/- 0.2 h; the cumulative r-hirudin excretion in urine after 48 h amounted to 38 +/- 10% of the dose administered, most of this quantity was excreted during the first hours. In seven patients with chronic renal failure, t1/2 beta was 15 to 41 h; in three of these patients cumulative urinary r-hirudin excretion was increased to 70-80%, in four patients cumulative r-hirudin excretion in urine within 48 h amounted to 39 +/- 8%, but was delayed in time. In 2 bilaterally nephrectomized patients, t1/2 beta was 168 and 316 h, resp. The renal clearance of hirudin was significantly and linearly correlated with the creatinine clearance (r = 0.872). In all patients aPTT and bleeding time were only moderately prolonged. Because of the modified pharmacokinetic behaviour the administration of hirudin in patients with impaired renal function requires individually adjusted dosages or prolonged administration intervals.

[The diagnosis of analgesic nephropathy]. / Zur Diagnostik der Analgetika-Nephropathie.

Inspired by the large proportion of at least 17% of nephropathy due to analgesics as the basic disease among the patients undergoing chronic dialysis in Erfurt and under the impression of a greatly distributed "underdiagnosis" of this avoidable disease the actual diagnostic possibilities for recognition are demonstrated. Above all, in analgesic syndrome the thinking-of is of greatest importance, and the sensible making of the patient's analgesics history. The presumable diagnosis analgesic nephropathy is than made secure by means of imaging methods, with the help of which the almost pathognomonic papillary necroses can be demonstrated. Finally, the reasons are given for the importance of the exact diagnosis analgesic nephropathy, even in the stage of nephrocirrhosis.

[Bacteriologic studies of bicarbonate dialysate and suitable initial solutions]. / Bakteriologische Untersuchungen von Bicarbonatdialysat und entsprechenden Ausgangslösungen.

Dialysates for the haemodialysis are produced unsterile and usually contain bacteria. Own investigations of bicarbonate dialysate and adequate initial solutions comprised sterility tests, determinations of the germ count and germ tolerance experiments. Only the "acid concentrate" was sterile. In the other solutions Corynebacteria, Acinetobacter and Pseudomonas bacteria dominated as typical water germs. In the fresh reverse osmosis water and the bicarbonate dialysate as well as in the recently produced 35-mmolar and 1-molar NaHCO3-solution the germ count was in each case about 10(5)/l and did not change itself essentially at room temperature within 6 hours. The "acid concentrate" and at a lower level also the 1-molar NaHCO3-concentrate have an antibacterial effect. The reverse osmosis water is the main contamination source for the bicarbonate dialysate, the application of which within 6 hours seems worth being used on account of the low germ count.

[Leptospiroses with acute renal failure--report on 6 dialyzed patients]. / Leptospirosen mit akutem Nierenversagen--Bericht über 6 dialysierte Patienten.

From 1968 to 1981 6 patients with severe leptospiroses were treated: one with leptospirosis icterohaemorrhagiae (Weil's disease), two with leptospirosis copenhageni and three with leptospirosis grippotyphosa. The diagnosis must at first clinically be made from exposition anamnesis and symptoms. In three patients the agglutination lysis reaction had a negative result still between the 10th and 19th day after the beginning of the disease. In all 6 cases a hypercatabolic acute renal failure with azothaemia of high degree was present. The polyuric phase developed 10 to 18 days after the beginning of the disease, the serum creatinine values normalized 20 to 35 days after the beginning of the disease. The parenteral nutrition and the dialysis therapy were particular points in the complex therapy of the patients. 4 patients were haemodialysed - 3 of them after primary peritoneal dialysis - 2 patients were only peritoneally dialysed. On account of the hypercatabolism and the intestinal paralysis the haemodialysis is to be preferred, as a rule, to the peritoneal dialysis. Also in the haemodialysis of patients with leptospirosis modern developments should be taken into consideration: bicarbonate-containing dialytic solution and in haemorrhagic diathesis the heparin-free dialysis. All 6 own patients survived. When connecting these data with other reports from Central and South Europe the lethality of dialysed cases with leptospirosis is about 42% (25 of the 59 patients died). In 4 of 5 of our patients with leptospirosis a clear hyperamylasaemia was present, apparently the expression of the involvement of the pancreas.

[Chronic hemodialysis from the perspective of the dialysis team]. / Die chronische Hämodialyse aus der Sicht des Dialyseteams.

By means of a questionnaire the authors checked the views of dialysis teams on ethical and psycho-emotional questions, on on the adaptation of dialysis patients and on dialysis work itself. The results show that psycho-emotional considerations are of considerable importance in the contact with patients over long periods. The staff think about them but are often not able to arrive at a clear opinion. This indicates that psychological training of the staff is necessary in oder to facilitate and encourage the formation of clear points of view.