Immunoadsorption of sensitized kidney transplant candidates immediately prior to surgery.

Patients with anti-human leucocyte antigen (HLA) antibodies from previous transplantation, blood transfusion are highly sensitized and at risk to hyperacute renal graft loss. As these antibodies are identified to be of pathogenic importance, an effective removal may allow successful transplantation. Six 'high risk patients' [panel-reactive antibodies (PRA) >30% or retransplanted patients with an acutely rejected first graft within 6 months from surgery] were treated by protein A immunoadsorption (IA) immediately prior to transplantation. We treated the calculated plasma volume one to three times prior to surgery: mean 4600 mL (range 2100-10 200 mL). After transplantation we repeated the sessions according to antibody (Ab) recurrence, graft function and signs of rejection. The panel reactive Ab were reduced from mean 65% pre-IA (range 35-85) to lowest 15% (range 0-55). After the course they reappeared to 30% (range 0-90). Five of the six patients had no clinical signs of vascular rejection. At a follow-up of mean 54 months (+/-14) four grafts still function with a mean serum creatinine of 172 micromol/L (+/-57). Protein A IA is a safe and effective adjunct in the treatment of highly sensitized patients awaiting renal transplantation. The treatment immediately prior to operation can prevent hyperacute rejection and increases the graft survival in these patients.

Protein A immunoadsorption in a pregnant woman with habitual abortion.

The role of antibodies in the occurrence of recurrent spontaneous miscarriage is well known. However there are many controversial issues in the management of habitual abortion. This paper describes the effect of Protein A immunoadsorption on serum levels of these antibodies and its impact on a case of a successfully treated woman in a outpatient department without need for a central venous catheter. Given the favourable clinical results described in our paper we think it may be relevant for some worse cases in clinical practice and will interest your readers.

Improvement of multiple organ functions in hepatorenal syndrome during albumin dialysis with the molecular adsorbent recirculating system.

Recently, significant improvement of renal function and prolongation of survival were reported in hepatorenal syndrome (HRS) patients treated with the Molecular Adsorbent Recirculating System (MARS). As no impact on extrarenal organ function was documented, this trial looked into multiple organ function changes during MARS in HRS patients. Eight HRS patients (4 male, mean age 42.1 years, range 30-58, all United Network for Organ Sharing [UNOS] status 2A) were treated intermittendly 4-14 times (total 47, mean 5.9 +/- 3.4) between 4 and 8 h/single treatment. The following changes were observed pre- and posttreatment: bilirubin 466 +/- 146 to 284 +/- 134 micromol/L, creatinine 380 +/- 182 to 163 +/- 119 micromol/L, urea 26.4 +/- 10.3 to 12.9 +/- 4.9 mmol/L, plasma sodium 127.5 +/- 7.7 to 137.5 +/- 4.8 mmol/L (all p < 0.01). Mean arterial pressure (MAP) increased from 71.9 +/- 12.8 to 95.6 +/- 7.8 Torr (p < 0.001). Oliguria or anuria, present in all patients, was successfully reverted. Ascites, present in all patients, was not detectable after the treatment period. The hepatic encephalopathy grade decreased from 2.8 +/- 0.8 to 0.8 +/- 0.7 (p < 0.0001). Child-Index decreased from 13.25 +/- 1.3 to 9.4 +/- 1.8 (p < 0.001). The hospital survival rate was 62%. One man underwent successful liver transplantation 18 months after the treatment. We conclude that MARS can improve multiple organ functions in patients with HRS.

Liver support by extracorporeal blood purification: a clinical observation.

Liver failure associated with excretory insufficiency and jaundice results in an endogenous accumulation of toxins involved in the impairment of cardiovascular, kidney, and cerebral function. Moreover, these toxins have been shown to damage the liver itself by inducing hepatocellular apoptosis and necrosis, thus creating a vicious cycle of the disease. We report a retrospective cohort study of 26 patients with acute or chronic liver failure with intrahepatic cholestasis (bilirubin level > 20 mg/dL) who underwent a new extracorporeal blood purification treatment. A synthetic hydrophilic/hydrophobic domain-presenting semipermeable membrane (pore size < albumin size, 100-nm thick) was used for extracorporeal blood detoxification using dialysis equipment. The opposite side was rinsed with ligandin-like proteins as molecular adsorbents that were regenerated online using a chromatography-like recycling system (molecular adsorbent recirculating system [MARS]). Bile acid and bilirubin levels, representing the previously described toxins, were reduced by 16% to 53% and 10% to 90% of the initial concentration by a single treatment of 6 to 8 hours, respectively. Toxicity testing of patient plasma onto primary rat hepatocytes by live/dead fluorescence microscopy showed cell-damaging effects of jaundiced plasma that were not observed after treatment. Patients with a worsening of Child-Turcotte-Pugh (CTP) index before the treatments showed a significant improvement of this index during a period of 2 to 14 single treatments with an average of 14 days. After withdrawal of MARS treatment, this improvement was sustained in all long-term survivors. Ten patients represented a clinical status equivalent to the United Network for Organ Sharing (UNOS) status 2b (group A1), and all survived. Sixteen patients represented a clinical status equivalent to UNOS status 2a, and 7 of these patients survived (group A2), whereas 9 patients (group B) died. We conclude that in acute excretory failure caused by a chronic liver disease, this treatment provides a therapy option to remove toxins involved in multiorgan dysfunction secondary to liver failure.

Diagnostic value of urinary alanine aminopeptidase and N-acetyl-beta-D-glucosaminidase in comparison to alpha 1-microglobulin as a marker in evaluating tubular dysfunction in glomerulonephritis patients.

To estimate the diagnostic value of tubular parameters, the urinary alanine aminopeptidase (AAP), N-acetyl-beta-D-glucosaminidase (NAG) and the alpha(1)-microglobulin (a1M) of 150 patients with histologically proven glomerulonephritis (GN) were determined. In addition, the reabsorption rate of the proximal tubule and the fractional excretion of sodium, the free water clearance and the renal function were assessed by inulin and p-aminohippurate (PAH) clearance. Compared to healthy controls, urinary AAP, NAG and a1M were found significantly elevated in GN patients. Morphological tubular changes were confirmed by significant differences in urinary laboratory parameters. In patients with tubular atrophy, the diagnostic sensitivity and specificity were calculated as follows: AAP (0.94/0.35), NAG (0.75/0.59) and a1M (0.73/0.52). In patients showing tubular protein droplets, the values were 0.90/0.17 for AAP, 0.78/0.76 for NAG and 0.84/0.74 for a1M and in patients with interstitial fibrosis, the values were AAP (0.95/0.35), NAG (0.75/0. 46) and a1M (68/0.38). Urinary AAP, NAG and a1M reflect histologically proven tubulus alteration in GN, although in most cases, the renal function is still intact. AAP indicates very early tubular impairment and, in some cases, AAP is elevated although NAG and a1M are still within normal ranges. We suggest that the enzyme activities are useful in the diagnostics of early stages of the disease.

Improvement of hepatorenal syndrome with extracorporeal albumin dialysis MARS: results of a prospective, randomized, controlled clinical trial.

In hepatorenal syndrome (HRS), renal insufficiency is often progressive, and the prognosis is extremely poor under standard medical therapy. The molecular adsorbent recirculating system (MARS) is a modified dialysis method using an albumin-containing dialysate that is recirculated and perfused online through charcoal and anion-exchanger columns. MARS enables the selective removal of albumin-bound substances. A prospective controlled trial was performed to determine the effect of MARS treatment on 30-day survival in patients with type I HRS at high risk (bilirubin level, > or =15 mg/dL) compared with standard treatment. Thirteen patients with cirrhosis with type I HRS were included from 1997 to 1999. All were Child's class C, with Child-Turcotte-Pugh scores of 12.4 +/- 1. 0, United Network for Organ Sharing status 2A, and total bilirubin values of 25.7 +/- 14.0 mg/dL. Eight patients were treated with the MARS method in addition to hemodiafiltration (HDF) and standard medical therapy, and 5 patients were in the control group (HDF and standard medical treatment alone). None of these patients underwent liver transplantation or received a transjugular intrahepatic portosystemic shunt or vasopressin analogues during the observation period. In the MARS group, 5.2 +/- 3.6 treatments (range, 1 to 10 treatments) were performed for 6 to 8 hours daily per patient. A significant decrease in bilirubin and creatinine levels (P <.01) and increase in serum sodium level and prothrombin activity (P <.01) were observed in the MARS group. Mortality rates were 100% in the control group at day 7 and 62.5% in the MARS group at day 7 and 75% at day 30, respectively (P <.01). We conclude that the removal of albumin-bound substances with the MARS method can contribute to the treatment of type I HRS.

Protein A immunoadsorption (i.a.) in renal transplantation patients with vascular rejection.

Vascular rejection after renal transplantation is connected with a higher frequency of allograft dysfunction or graft loss. Plasmapheresis as an adjunctive therapy in the treatment of humoral mediated acute graft rejection was compared with protein A immunoadsorption. Eleven patients with acute graft rejection and high titers of cytotoxic HLA-Ab and/or signs of vascular rejection at graft biopsy (performed in 9 patients) have been treated. Six of them have a stable graft function, the longest graft survival until now is 41 months, four are back on haemodialysis and one patient died from CMV-pneumonia with a stable graft function 9 months after transplantation. We conclude that IA is a useful adjunctive therapy in the treatment of vascular rejection after renal transplantation. Further investigations are necessary to optimize criteria for inclusion.

Microcirculation of the fingernail fold in CAPD patients: preliminary observations.

OBJECTIVE: To study changes in the peritoneal microcirculation during continuous ambulatory peritoneal dialysis (CAPD) by studying change in the microcirculation of the fingernails of CAPD patients. SETTING: A university department. DESIGN: A cross-sectional study of 10 nondiabetic patients on CAPD. INTERVENTION: Hemorrheological tests of fingernail microcirculation using equipment built at our university. MAIN OUTCOME MEASURES: Microcirculation was characterized by estimation of capillary density, red blood cell (RBC) column diameter, torque index, and RBC flow velocity semiquantitatively using videocapillaroscopy at the fingernail fold and plasma viscosimetry. Findings were correlated with treatment duration, peritoneal clearance, state of capillary morphology and hemodynamics, and lipid and fibrinogen levels. RESULTS: Treatment duration was significantly correlated (p < or = 0.05) with low-density lipoprotein (LDL) (r = 0.776) and clearances of urea (r = -0.583), uric acid (r = -0.666), and potassium (r = -0.764). Changes in capillary morphology were correlated to clearances of urea (r = 0.643) and uric acid (r = 0.701). The fibrinogen concentration increases plasma viscosity (r = 0.799) and deteriorates the capillary state (r = -0.706). In addition, plasma viscosity correlates to cholesterol (r = 0.620, NS) and LDL (r = 0.781), but not to high-density lipoprotein and triglycerides. CONCLUSION: CAPD treatment results in lipid abnormalities and high fibrinogen levels that may cause microvascular damage and poor perfusion. These interactions may explain the deterioration of peritoneal transport in some CAPD patients.

Increased serum level of total homocysteine in CAPD patients despite fish oil therapy.

It has been shown that serum total homocysteine (HC) is a risk factor for vascular disease which characterizes endothelial damage. The incidence of vascular disease is increased in continuous ambulatory peritoneal dialysis (CAPD) patients. Our aim was to investigate: (1) whether concentration of HC correlates with atherosclerotic and inflammatory events, and (2) if fish oil therapy can retard the disturbance in lipid metabolism which promotes atherosclerosis. Fourteen patients with various degrees of impaired peritoneal clearance and lipid metabolism were observed. In all patients the serum HC was elevated. Seven patients were treated with fish oil for three months. The results indicate an average increase of HC (+18%), total cholesterol (+6.6%), aggregation of erythrocytes (+9%), and an average decrease of dialysate-to-plasma creatinine (D/P) ratio (-7%), deformability of erythrocytes (-8%), and normalization of elevated soluble interleukin-2 receptor (sIL-2R) values. Regression analysis of all data demonstrated a significant correlation between HC and parameters of lipid metabolism and hemorheology. There were no significant correlations between HC and peritoneal function and serum cytokine levels. We conclude that the treatment in CAPD patients with fish oil did not improve the lipid metabolism disturbances in atherosclerosis and peritoneal function. Elevated HC confirms the progression of the disease.

[Measuring the thickness of the peritoneum as a dialysis membrane using various osmolar concentrations of dialysis fluid]. / Dickenmessungen am Peritoneum als Dialysemembran unter Verwendung verschiedener Osmolilitäten der Dialyseflüssigkeit.

Thickness measurements solutions on the rat peritoneum using peritoneum using peritoneal dialysis solutions of various osmolalities show a marked reduction of the distances between capillaries and peritoneal surface with increasing osmolality. This may caused by a dehydration of the peritoneum and support the so-called canaliculus theory. If the dehydration of the peritoneum may outlast temporal the dialysis cycle with higher osmolar solution, it could be an explanation for the efficacy of following low-molecular solutions.

[Scanning electron microscopy study of the peritoneum as a dialysis membrane--a morphological study on the etiology of sclerosing peritonitis]. / Rasterelektronenmikroskopische Untersuchung am Peritoneum als Dialysemembran--eine morphologische Untersuchungen zur Atiologie der Sklerosierenden Peritonitis.

Scanning electron microscopy investigations of the surface of rat peritoneum were performed after application of isotonic saline solution and peritoneal dialysis solutions with osmolalities of 375, 528, and 680 mosmol x kg-1 and intraabdominal stay periods of 15, 30, and 45 minutes. Severe morphological changes of the peritoneal surface were shown as clotting and atrophy of microvilli, detachment of surface cells from the basement layer, destruction of the basal lamina and appearance of rough-fibrous submembranous connective tissue, which was observed even after application of isotonic saline solution into the abdominal cavity. In conclusion, sclerosing peritonitis is caused by a fruitless inflammation reaction of the organism against the unphysiological function of the peritoneum as dialysis membrane forced upon peritoneal dialysis.

[Nutritional problems in patients treated with chronic dialysis]. / Zur Ernährungsproblematik bei Patienten mit chronischer Dialysebehandlung.

A food with a protein content of 100-110 g a day determined for dialysis patients was analysed for total weight, water content, protein content, energy content, potassium content and phosphate content during 13 days. During this time 152 individual nutritive substances were offered, which were classified into the group of meats and sausages, egg, milk, milk-products, bakery-goods, potatoes and vegetables. It is to be stated that highly significant positive correlations between the weight of the daily taken food and its content of water, protein, energy, potassium and phosphate are existing, whereby a quantity of 1 kg a day is preferred. For the daily protein intake of 1.0-1.5 g/body weight-1.-d1 required in patients with chronic dialysis treatment, dependent upon dialysis technique and nutritional state, this simultaneously means a dependence of the total quantity of food to be taken in upon body weight, which again has effects on the dialysis regime and the ultrafiltration, since a more or less intensive intake of water, potassium and phosphate is connected with this. The removal of catabolic conditions is a scarcely soluble problem above all in dialysis patients with high optimum weight, by which the often existing inappetence inhibits the necessary increased food intake. The is furthermore rendered difficult in the peritoneal dialysis with peritonitis, since the ultrafiltration is reduced by the inflammation so that the water taken in with food cannot be excreted in a necessary degree.(ABSTRACT TRUNCATED AT 250 WORDS)

[Determination of caries activity levels in children aged 4-6 years by the modified Snyder test]. / 4-6 yas arasindaki çocuklarda modifiye Snyder testi ile dis çürük aktivitesinin saptanmasi.

Modified Snyder Test, which is a good instrument in motivating the patient and determining the effectiveness of preventive programs, is used commonly in Public Health Research programs for measuring the the caries activity levels. In our study, by using modified Snyder Test instead of Snyder Test, which is more preferable because of its' simplicity in application, we determined the caries activity levels of the children, aged between 4-6 years, which remained as an unexamined group in our population up to date. In our study, consisting of fifty children, caries rate was found to be 36% depending on WHO's criteria, while caries percentile for each tooth was 5.8% and df index was 1.18. According to the modified Snyder Test results, 46% of the children had positive results at the end of the 48 hours, which indicates a mild caries activity degree. This result is also in accordance with the caries of the group.

[Optimization of peritoneal dialysis using diffusion curves]. / Zur Optimierung der Peritonealdialyse mit Hilfe von Diffusionskurven.

By taking peritoneal diffusion curves of several substances characterizing the uraemia it is possible, taking into consideration a creatinine clearance of 0.1 ml X s-1, to calculate the quantity of dialysate necessary for this, regarding also the residual renal function at a differently long duration of the dialysis cycle. Moreover, by this way also the clearances of other investigated substances can be calculated. Apart from a sufficient detoxication optimized duration of the disease and consumption of the dialysate are the advances of the method.

[Peritoneum as dialysis membrane--a morphologic study]. / Das Peritoneum als Dialysemembran--eine morphologische Studie.

Different histological staining methods allow a deeper insight into the light microscopic structures of the biomembrane peritoneum. To the wellknown model of the peritoneal resistances according to existing results two other resistances shall be added, namely capillary pericytes and the submesothelial basal membrane. The peritoneal interstice, consisting of muscle and collagenic fibres as well as elastica fibres is penetrated by a well-formed network of reticulum fibres. In these cases is to be recognized a primary structure, characterized by compact, moniliform, doubled, screw-like and fenestrated structures, and a secondary structure, which is characterized by a cylindrical arrangement of these structures. This texture of fibres allows according to morphological points of view an intrainterstitial liquid transport in horizontal and vertical direction, which in irregular position of the anyhow scantily existing capillaries of the peritoneum is prerequisite for a regularly appearing transperitoneal liquid and substance transport in direction of the free abdominal cavity as well as vice versa.

[A new procedure for the revision and reposition of functionless peritoneal dialysis catheters]. / Ein neues Verfahren zur Revision und Reposition funktionsloser Peritonealdialysekatheter.

The most important requirement for satisfactory transperitoneal dialysis is faultless functioning of the Tenckhoff catheter. Suddenly occurring functional disturbances are often caused by wrong positioning and by envelopment of the catheter by tissue, which require surgical correction. A technique for successfully locating and replacing a transperitoneal catheter by means of an operation laparoscope is described.