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.

[Systemic inflammatory reactions to extracorporeal therapy measures (I): Hemodialysis and hemofiltration]. / Systemische Entzündungsreaktionen extrakorporaler Therapieverfahren (I): Hämodialyse und Hämofiltration.

Hemodialysis and hemofiltration (intermittent or continuous) are the most frequently applied extracorporeal treatment strategies, enabling survival of patients with acute or chronic renal failure. To a various degree on the other hand they induce an undesirable inflammatory response summarized as bioincompatibility. Apart from the quality of the dialysate the composition of the dialytic membrane itself appears to be of very great importance in triggering this inflammatory process. The main humoral and cellular mechanisms underlying this inflammatory response are the activation of complement cascade, the activation of blood cells, the release of cytokines and the induction of nitric oxide synthesis. Various laboratory tests have confirmed a lower degree of inflammatory response on using synthetic membranes in comparison with cuprophane membranes. The importance of these differences in the treatment of dialysis patients with respecto to intradialytic complications and long-term morbidity and mortality, is, however, still a matter of debate. The results of clinical investigations to date are conflicting and have not yet clearly proven, whether implementation of synthetic membranes is of any benefit to dialysis patients or not. Apart from the cost factor there is no argument in favour of using cuprophane membranes.

[Endogenous digitalis-like factor in liver cirrhosis and cholestasis]. / Endogenous digitalis-like factor bei Leberzirrhose und Cholestase.

Endogenous digitalis-like factor (EDLF), an inhibitor of membrane Na+/K(+)-ATPase, is discussed to be involved in the pathogenesis of cirrhogenic portal hypertension, ascites formation and development of functional hepatorenal failure. Therefore, we investigated the serum content of this mediator in patients with liver cirrhosis Child-Pugh stage A, B, and C (n = 27) by means of enzyme immunoassay with a specific digoxin antibody. Furthermore, a correlation analysis was performed in order to find out correlations between signs of cell injury, cholestasis, synthetic cell function, ascites formation, and hepatorenal failure. Our results demonstrate that EDLF is significantly elevated in Child C cirrhosis (0.61 +/- 0.15 ng/ml) in comparison to Child A cirrhosis (0.013 +/- 0.2 ng/ml) and is also higher than in Child B cirrhosis (0.23 +/- 0.25 ng/ml). In patients without ascites EDLF (0.056 +/- 0.19 ng/ml) differs significantly from that of patients with non-complicated ascites (0.156 +/- 0.176 ng/ml) and from that of patients with therapy refractory ascites (0.66 +/- 0.17 ng/ml) or hepatorenal failure (1.56 ng/ml). There are no correlations between EDLF and renal function. Significant correlations were demonstrated for cholestasis (serum bilirubin), synthesis function (serum protein, Quick's value, cholinesterase, fibrinogen, albumin), and the degree of portasystemic encephalopathy (number connection test). We conclude that EDLF may act as a mediator in the process of progressive portal hypertension and its complications due to cirrhosis. This process of progression is caused by the inhibition of Na+/K(+)-ATPase, vasoconstriction, and endothelin secretion.

[Status of ultrasound diagnosis in differential cholestasis diagnosis]. / Stellenwert der Ultraschalldiagnostik in der Differentialdiagnostik der Cholestase.

Differentiating between the hepatocellular "internal" and the "surgical" or "endoscopic" cholestasis syndrome has become a domain of sonography. There is a 92 to 99% success rate, due to the possibility of diagnosing by means of sonography dilations of the gall bladder, the extrahepatic biliary tract and the intrahepatic bile ducts, as well as numerous diseases of the hepatobiliary system and of the pancreas. Congested intra- and extrahepatic bile ducts indicate the presence of a deep-seated distal obstruction, such s a prepapillary concrement, an inflammatory or malignant papillary stenosis or of a process in the area of the head of the pancreas. If the intrahepatic bile ducts alone are dilated the obstructive process has to be assumed near the portal fissure of the liver. Frequent causes are directly demonstrable tumors or metastases on the hilum or high-lying concrements. By using sonography, the level of obstruction can be determined correctly in about 90% of cases, while the cause of obstruction can be diagnosed in about 60 to 70%. In most cases intrahepatic cholestase can only be demonstrated indirectly through the absence of a bile duct dilation. Characteristic diffuse changes in the liver (e.g. fatty liver, cirrhosis, cardiac liver) or intrahepatic space claims-may be in combination with an ultrasound-directed puncture-may support or confirm the diagnosis.