Influence of renal replacement therapy on outcome of patients with acute renal failure.

There are many controversial results about the influence of acute renal failure (ARF) and renal replacement therapy (RRT) on patient outcome in intensive care units. This retrospective study compared demographics. severity, course, and prognosis of ARF during 36 months (period 1, 1991 through 1993; 128 cases) and 18 months (period 2, 1994 through 1995; 141 cases). Compared with period 1, during period 2 there was a markedly increased incidence of ARF. There were no significant differences in patient demographics or etiology of renal failure, but the therapeutic approach to ARF was quite different. During period 2, RRT was started at earlier stages of renal insufficiency (that is, less elevated creatinine serum concentrations or reduced diuresis). Additionally, there was a significant increase in the numbers of continuous RRT (CRRT) replacing the discontinuous mode of dialysis treatment. Compared with period 1, mortality was reduced from 78.9 to 59.6% during period 2 (P < 0.001). There were no differences in mortality between the patients from internal and surgical wards. Mortality in patients treated with CRRT was in period 1 and in period 2 higher than mortality in patients treated with intermittent RRT, but these results are biased by a preferred use of CRRT in severely ill patients with an unstable circulatory system. These data suggest that the early onset of RRT reduces the mortality of intensive care unit patients with ARF independent of underlying diseases. An influence of the method of RRT, sex, and age on outcome of patients with ARF could not be proven.

[Paraneoplastic IgA nephritis as the initial symptom of bronchial carcinoma]. / Paraneoplastische IgA-Nephritis als Erstsymptom eines Bronchialkarzinoms.

We report on a 45-year old patient who was treated for IgA-Nephritis for 9 months. During treatment he developed coughing and dyspnoea which led to diagnose a central stenosing NSCLC at the tracheobronchial angle. Cancer treatment by x-ray showed a good response, e.g. significant reduction of cancer volume and a remarkably improved renal function. In the course of tumour progression (3 months after initial treatment) retention parameter deteriorated again and the patient needed to be dialysed. Palliative laser therapy had no influence on renal function. The close linkage between tumour regression and the extent of IgA nephritis suggest that the preceding IgA nephritis was paraneoplastic and hence a primary symptom of the NSCLC.

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)

[Thromboembolic risk factors in kidney transplantation: hemorheologic examination in secondary polycythemia]. / Thromboembolische Risikofaktoren bei Nierentransplantierten--hämorheologische Untersuchungen bei sekundärer Polyglobulie.

Cardiovascular risk factors will increase the lethality of kidney patients being under dialysis treatment and after transplantation. This risk is additionally increased after transplantation by secondary polycythemia. The paper investigates the rheological properties of the blood of 20 patients affected by secondary polycythemia after kidney transplantation, 10 patients without polycythemia after kidney transplantation and 19 test persons. Plasma viscosity, erythrocyte aggregation and whole blood viscosity were determined. As a result, an increase of erythrocyte aggregation without their deformability being changed could be found in patients affected by polycythemia after kidney transplantation. The reduced thrombocyte aggregation identified in these patients can be explained by the influence of therapy.

[Thromboembolism risk factors in kidney transplant patients with secondary erythrocytosis in relation to hemorheologic aspects]. / Untersuchungen zum Problem thromboembolischer Risikofaktoren bei Nierentransplantierten mit sekundärer Polyglobulie unter hämorheologischen Aspekten.

In patients undergoing dialysis and patients who underwent a transplantation of a kidney cardiovascular risk factors increase the lethality to 50%. A secondary polyglobulia (Pg) after transplantation enhances the risks of thromboembolism. In 180 patients who underwent a transplantation we saw in 11% a polyglobulia with 50% of thromboembolic complications. For the study of the secondary polyglobulia and other risk factors haemorheologic investigations were carried out on 20 patients who underwent a transplantation with Pg, 10 patients who underwent a transplantation without Pg and 19 healthy test persons. In patients with secondary polyglobulia we found a slightly increased plasma viscosity and an increase of the aggregation of the erythrocytes without decrease of their deformability. A decreased deformability of the erythrocytes in patients who underwent a transplantation with Pg and diabetes results in an additional risk, as was casuistically observed on a patient with 2 amputations of the legs and 2 myocardial infarctions. Our findings confirm the correctness of the isovolaemic haemodilution for the avoidance of additional cardiovascular complications in patients who underwent a transplantation of a kidney with polyglobulia.

[Pregnancies following kidney transplantation--clinical problems and genetic studies]. / Schwangerschaften nach Nierentransplantation--klinische Problematik und genetische Untersuchungen.

Successful transplantations of the kidney by means of the medical rehabilitation also improve the reproductive rehabilitation of the young patients with distinct wish for children. In these cases the increased infectious, genetic, rejection and tumour risks as well as a limited transplant survival time require particular consideration. On 15 pregnancies among 151 patients in the Regional Dispensary for Patients who underwent kidney transplantations in Halle the clinical and genetic problems are discussed. A patient with preexisting risk factors under interdisciplinary intensive care bore a healthy child who is now 10 years old. The mother is still alive 12 years after the transplantation. Studies on 6 pregnancies in 3 patients who underwent a transplantation revealed 1 normal delivery and 5 interruptions for somatic and genetic indications. 2 female patients are alive 5 and 12 years after transplantation, 1 female patient again undergoes dialysis. From 9 pregnancies by 8 fathers who underwent transplantation 8 children were born (4-10 years) and 1 interruption had to be made. 4 patients live in the 8th to 11th year with the first transplant and 1 patient lives with the second transplant for 8 years. 4 patients again underwent dialysis, one patient died. Human-genetic problems are existing in the autosomal-recessively hereditary Alport-syndrome by the daughter as gene-carrier. 15 analyses of chromosomes on 396 investigated mitoses resulted in chromosomal break rates of 2, 4.7 and 5% in three children at the end of the second year of age, in the mother of 7% in the 4th year and in 2 fathers of 4 and 22% in the 4th and 5th year after transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Results of immunosuppressive therapy of chronic glomerulonephritis in 400 patients]. / Ergebnisse der immunsuppressiven Therapie der chronischen Glomerulonephritis bei 400 Patienten.

For the judgment of the success of the immunosuppressive therapy of chronic glomerulonephritis 400 patients (242 males and 158 females) at an average age of 31.2 years were examined after an average duration of treatment of 31.9 months. Apart from the renal function (serum creatinine), the histological and immunohistological form of the glomerulonephritis for the valuation further clinico-paraclinical data were taken into consideration: proteinuria, nephrotic syndrome, arterial hypertension and the combination of nephrotic syndrome and arterial hypertension. At the beginning of the treatment 293 of 400 patients (73.2%) had a normal renal function, 107 of 400 patients (26.8%) were initially renal-insufficient. 16 of 400 patients (4.0%) had additionally a pyelonephritis and 12 of 400 patients (3.0%) had a lupus nephritis. 27 of 400 patients (6.9%) developed a terminal renal insufficiency after an average duration of observation of 40.5 months. Complications caused by therapy were registered in 104 of 400 patients (26.0%). Recommendations for the present therapy of chronic glomerulonephritis are formulated.

[Oxygen exchange processes between the dialyzing fluid and the blood during hemodialysis and resultant practical consequences]. / Sauerstoffaustauschvorgänge zwischen Spüllösung und Blut während der Hämodialyse und abgeleitete praktische Konsequenzen.

The polarographic measuring technique was used to examine the processes of oxygen exchange between dialysing fluid and blood during haemodialysis in 21 patients of the chronic haemodialysis programme. During haemodialysis there is a tendency for the arterial oxygen partial pressure to fall; on the statistical average this is slight, in individual cases it is a marked tendency. With the apparatus KNA 302 (without degassing facilities) the blood is slightly oxygenated. This is less with the apparatus KN 401 (not very effective degassing facilities). With complete degassing of the dialysis solution a loss of oxygen through the membrane would be expected. This loss could be avoided by complete degassing of the dialysis solution and subsequent oxygenation. Various ways of realizing extrapulmonary oxygenation during haemodialysis in order to counteract the described tendency to hypoxaemia are pointed out. They should be particularly important when pulmonary means are exhausted (acute dialysis, shock lung).

[Dialysis osteopathy with spontaneous fractures, progressive demineralization and therapy resistance]. / Zum Problem der Dialyseosteopathie mit Spontanfrakturen, progressiver Demineralisierung und Therapieresistenz.

In 25 (33.8%) of 74 chronically haemodialysed patients a distinct osteopathy with bone pain, spontaneous fractures, arthralgias and weakness of the muscles due to dialysis was present. In comparison to a group without complaints the duration of the dialysis was longer by 6 months, the mineral contents of the bones was decreased in 38%, in the comparative group in 22%. A progressive demineralisation was found in 46%, in the comparative group in 20%. Hypercalcaemias under vitamin D2 caused a therapy resistance. In 1 exemplary case (type IIc, PTH 0.3 micrograms/l) in the 3rd year of dialysis a fracture of the neck of the femur took place and an endoprosthesis was implanted. There was a progressive demineralisation of about 16%. The suspicion of a typical combination with an encephalopathy due to dialysis did not confirm itself. A pseudocyst in the brain was found. The differential diagnosis to the hypercalcaemia-induced psychosis in the osteopathy due to dialysis is discussed. In a prophylactic application dihydrotachysterine proved favourable for avoidance of an osteopathy due to dialysis. Parallel to the clinical progressing of the osteopathy due to dialysis a progressive demineralisation could be demonstrated at the peripheral mineral contents of the bones. Extreme losses of minerals appeared from the 4th to the 59th month of dialysis from - 16% to - 37% and from the 22nd to the 87th month from plus 11% to minus 14% of the age-and-sex-specific normal values. Successful transplantations led to the stagnation of the progressive demineralisation, unsucessful transplantations increase them. The influence of the non-refined water for the production of dialysate by possible aluminium intoxications on the development of the osteopathy due to dialysis is discussed.

[Behavior of important serum lipid fractions in chronic hemodialysis patients and following kidney transplantation]. / Zum Verhalten wichtiger Serumlipidfraktionen bei chronisch hämodialysierten Patienten und nach Nierentransplantation.

In patients in the chronic programme of haemodialysis and 51 patients with transplanted kidney selected lipid-chemical parameters were investigated and compared. 1. Disturbances of the lipid metabolism more frequently occurred in patients with transplanted kidney than in chronically haemodialyzed patients. 2. Triglycerides, total cholesterol and LDL cholesterol were more frequently increased in patients with transplanted kidney than in chronically haemodialysed patients. 3. The HDL cholesterol of patients with transplanted kidney was only somewhat higher in comparison to patients in the chronic haemodialysis programme. 4. Sex-specific differences of the HDL cholesterol level were neither in chronically haemodialysed patients nor in patients with transplanted kidney. 5. Klimov-index and LDL/HDL cholesterol quotient referred to a permanently high risk of cardiovascular complications even after transplantation of a kidney.

[Effect of ultraviolet irradiation on renal osteopathy in patients in the chronic hemodialysis program]. / Einfluss der ultravioletten Bestrahlung auf die renale Osteopathie bei Patienten im chronischen Hämodialyseprogramm.

Under influence of the ultraviolet radiation the formerly lowered 25-hydroxycholecalciferol (25-OH-CC) level increases in persons with healthy kidneys. Such investigations were not yet carried out in patients undergoing dialysis. Since the insufficiency of active vitamin-D-metabolites plays an essential role in the development of the renal osteopathy, since 1978 in 13 patients undergoing dialysis a regular ultraviolet radiation has been performed, in order to stimulate the cutaneous vitamin-D-production. The time of observation was 31.7 +/- 14.3 months. Deionized water served for the production of dialysate. The calcium content was about 3.5 +/- 3.8 mval/l. The patients had very rarely bone and joint complaints. Severe clinical complications of renal osteopathy developed only in one female patient in the 3rd year of dialysis with a fracture of the neck of the femur as well as in a 2nd patient after transplantation of a kidney with permanently progressing demineralization and spondylitis. Controls of the courses showed only in 18.2% a progressing loss of the peripheral mineral content of the bones. The alkaline phosphatase was not increased, the alkaline bone phosphatase appeared with low and not provable activities. A suppression of the secondary hyperparathyroidism could not be proved. Parathormone was increased with 2.30 +/- 1.90 micrograms/l. The 25-OH-CC-levels were normal or slightly increased with 39.1 +/- 12.4 micrograms/l, whereas they were essentially lower in a comparative group without ultraviolet radiation. Therefore in connection with the very low rate of complications of the renal osteopathy with normalized 25-OH-CC-levels new therapeutic possibilities were the result in patients undergoing dialysis after ultraviolet radiation. The increasing importance consists also in the fact that 90% of the human vitamin-D-need are supplied via skin and it was proved by animal experiments that also after bilateral nephrectomy the formation of the active vitamin-D-metabolite 1,25-dihydroxycholecalciferol is possible by photosynthesis.

[The problem of sodium metabolism in chronic kidney failure]. / Zum Problem des Natriumhaushaltes bei chronischer Niereninsuffizienz.

The endogenous 24-hour-clearance and the sodium excretion during 24 hours in the urine were investigated on 12 healthy persons with chronic nephropathies, 5 patients with condition after acute renal failure and 75 patients with condition after transplantation of a kidney. A correlation between the quantity of urine and the excretion of sodium in 24 hours could be proved in patients with a retention to 884.0 mumol/l creatinine in the serum. Only with further restriction of the renal function a reduction of the sodium excretion during 24 hours below 150 mmol becomes significant. In 16 of 25 patients in the early phase of the again occurring renal function after transplantation the sodium excretion more rapidly improved than the creatinine clearance. In 20 patients with chronic crises of rejection in 15 cases the creatinine clearance and the sodium excretion simultaneously decreased. In one patient the rejection began with a reduction of the sodium excretion.

[Cytomegalovirus infections following kidney transplantation - clinical and serological studies of the early and late phases]. / Zytomegalievirus-Infektionen nach Nierentransplantation -- klinische und serologische Untersuchungen in der Früh- und Spätphase.

In 71 patients after kidney transplantation the cytomegalovirus-antibody state was recognized with the help of the indirect fluorescence antibody test in a period of 24 months. The first estimations were performed in 33 patients in the early phase up to the 3rd month and in 38 patients in the late phase up to the 100th months after transplantation. Of 13 patients who had been controlled already before operation only 3 patients were seronegative. After this twice a seroconversion with clinically manifest cytomegalovirus infection appeared, in one case an irreversible failure of the graft developed. In the late phase 4 patients remained seronegative. Of these patients also in one case the chronic rejection caused the entering into the dialysis programme. -- A positive cytomegalovirus-antibody state was found in the early phase in 30 of 33 patients and in the late phase in 34 of 38 patients. An active cytomegalovirus infection was present in the early phase in 11 of 30 and in the late phase in 11 of 34 patients. In the early phase the clinical symptoms fever, leukopenia and hepatitis were more frequent and more expressed than in the late phase. In 7 of the 11 patients in the early phase and in 8 of 11 patients with active cytomegalovirus infection in the late phase rejections occurred which in 2 of the 7 patients in the early phase and in 5 of the 8 patients in the late phase led to the loss of the graft. In inactive cytomegalovirus infection an irreversible course thrice appeared in 11 patients with rejections. Three typical instances are demonstrated: 1. The course of an active cytomegalovirus infection in the early phase with rejection and irreversible failure of the graft. 2. The reactivation of a latent cytomegalovirus infection by uncontrollable rejection processes. 3. The course of an active cytomegalovirus infection without clinical complications and with transition into an inactive stage in minimal immunosuppression. The treatment is performed with immunosuppression of a possibly low dosage, the avoidance of increases of prednisolone in cytomegalovirus-associated rejections, the intravenous application of human-gamma-globulin as well as the prevention or intensive treatment of superinfections. In these cases the close relations between rejection processes, immunosuppressive therapy, superinfections and cytomegalovirus infections should find the necessary consideration.

[Evaluation of the mineral content of peripheral bones (radius) by photon-absorption technique in normals as well as in patients with various types of bone diseases (author's transl)]. / Ermittlung des peripheren Knochenmineralgehaltes bei Normalpersonen und Patienten mit verschiedenen Knochenerkrankungen, bestimmt mit Hilfe der Photonenabsorptionstechnik am Radius.

The evaluation of the mineral content of peripheral bones by measuring the photon absorption of the radius has proven to be a valuable method for routine clinical work: for diagnosis, follow-up and control of therapy. While there was a significant difference in the findings of normal persons compared with those of patients suffering from osteoporosis, renal osteodystrophy, osteogenesis imperfecta and skeletal fluorosis, there was no difference between normals and these patients suffering from Bechterew, Scheuermann, coxarthrosis, spondylosis, skoliosis and rheumatoid arthritis. Normal values for the mineral content and width or the radius at the junction of the middle and lower third--based on 8000 examinations--are mentioned.

[The kidney and diuretics]. / Niere und Diuretika.

In an experiment carried out on 5 awake dogs with different size of the kidney could be shown that the diuretic effect of the xanthines is only slight and depends on the number of nephrons got. The application of thiazides, which possess a long-term effect, is indicated only up to a value of the creatinine clearance of about 25 ml/min/1.73 m2. At the beginning retention of the substances contained in the urine furosemide can still be used in high doses. In 18 patients with values of serum creatinine between 2-20 mg/100 ml also with a dosage up to 500 mg furosemide within 24 hours the Na+-concentration in the urine did not exceed a value of 90 mval/l. These findings are explained in the sense of the proof of a limit of the possibilities of a conservative treatment of the chronic renal insufficiency with furosemide.

[Hemofiltration of lysozyme in dialysis patients]. / Die Hämofiltration des Lysozyms bei Dialysepatienten.

With the help of the haemofiltration on the capillary dialysator CDAK 4 the behaviour of lysozyme (muramidase) was investigated in 20 dialysis patients. In 6 of 55 cases a measurable lysozyme concentration in the haemofiltrate was found. A relation to the size of the serum lysozyme level could not be established. The influence of defective capillaries is discussed. Despite the in most cases not measurable lysozyme concentrations in the haemofiltrate a decrease of the serum lysozyme level taking place parallel to creatinine could be proved during dialysis. Examinations of the influence of the renal rest function in dialysis patients with a rest diuresis resulted in a lower lysozyme concentration in the serum than in patients with complete anuria. These findings allow conclusions to the behaviour of low-molecular proteins in the kidney of dialysis patients and to their losses on the dialysis membrane.

[Differential diagnosis and therapy of nephrogenic hemorrhagic diathesis]. / Differentialdiagnose und Therapie der nephrogenene hämorrhagischen Diathesen.

For the development of nephrogenic haemorrhagic diatheses in the first place a decreased function of the thrombocytes and a thrombocytopenia are responsible. An inhibition in the intrinsic system may be referred to a lesion of the thrombocytic factor 3. Up to now defects in the extrinsic system do not allow a systematic classification. The best causal therapy are an effective haemodialysis and a renal transplantation. The detection of defects in the coagulation system is of importance for the dosed heparinisation and the control of the treatment with cytostatics for the immune suppression. Among 33 patients undergoing dialysis only 3 patients the Quick-value was reduced to 50% in 9 patients the thrombocyte values were below 150,000 mm3 and in 2 patients below 100,000 mm3. Among 28 carriers with renal graft only in 1 case the Quick-value was reduced to about 50%. In 12 patients the thrombocyte values were decreased below 150,000 mm3 and in 4 patients below 100,000 mm3. A correlation between the two global tests was not to be proved.