[The quality of the treatment of diabetics in kidney failure in Germany]. / Behandlungsqualität niereninsuffizienter Diabetiker in Deutschland.

BACKGROUND AND OBJECTIVE: In recent years there has been a rapid increase in the number of dialysis-dependent diabetics in Germany. Survival on dialysis is not satisfactory and damage acquired in the preterminal stage of renal failure is thought to play an important role. Late referral to a nephrologist and insufficient quality of medical management are thought to contribute importantly to poor outcome. This hypothesis was evaluated in the present study. PATIENTS AND METHOD: The data of all 173 diabetic patients (16 with type 1, 157 with type 2 diabetes, 90 men, 83 women, mean age 63.3 [31-95] years), who had been referred in 1996 for the first time to five renal units, were retrospectively assessed using a structured protocol. RESULTS: Patients were usually referred in advanced renal failure (median creatinine clearance 29 ml/min, range 1-216) with insufficient control of systolic (170 [120-260] mmHg) and diastolic blood pressure (90 [60-180] mmHg), insufficient antihypertensive therapy (without treatment 32 of 173 patients; median number of classes of antihypertensive agents used 2 [range 1-6]; ACE inhibitors 79 of 173 patients), high HbA1c (7.9 [4.9-15.7]%) and LDL cholesterol (176 [67-307] mg/dl). Immediate dialysis was required in 45 patients. CONCLUSION: The data document insufficient quality of treatment and late incorporation of a nephrologist into the medical team involved in the care of diabetic patients. Changes in the structure of diabetes care are necessary to improve treatment quality.

Laboratory tests of iron status: correlation or common sense?

We demonstrate that simple correlation between the various tests of iron status is not sufficient for examining their value in diagnosing iron deficiency (ID). Three degrees of ID are recognized: Iron depletion (ID grade I) is defined by decreased total body iron and normal iron support to erythropoiesis, as diagnosed by decreased storage iron, decreased ferritin, normal sideroblast count, normal zinc protoporphyrin (ZPP), and transferrin saturation >15%. When the iron supply to erythropoiesis becomes insufficient, as diagnosed by transferrin saturation < or = 15%, increased ZPP, and decreased sideroblast count, iron-deficient erythropoiesis (ID grade II) occurs. When finally hemoglobin is below its normal range, iron-deficiency anemia (ID grade III) results. The various tests for ID cannot be compared without taking into account the severity of the deficiency. Depending on the grade of ID examined, the correlation of markers seen in our patients' data varied considerably. We conclude that a "best" marker of ID does not exist. However, the different tests efficiently complement each other by detecting different stages and individually show the clinical extent of ID. Ferritin reflects the iron stores. ZPP indicates whether the ID in a given patient is clinically relevant or not. Finally, the extent of a clinically relevant ID can be assessed by the measured ZPP, hemoglobin concentration, and red cell indices.

The rising tide of endstage renal failure from diabetic nephropathy type II--an epidemiological analysis.

In recent years there has been a substantial increase in the proportion of patients requiring renal replacement therapy who suffer from diabetes mellitus. In the lower Neckar region, a survey has been made comprising all patients admitted for renal replacement therapy from 1.1.1993-30.6.1994. Out of a total of 225 patients admitted, 95 suffered from diabetes (10 type I, 85 type II). The estimated annual incidence of terminal renal failure with diabetes was 52/mio/year. At the same time, 79 patients who suffered from diabetes were admitted to the renal unit in Heidelberg (outpatient clinic and ward) for evaluation of de novo renal failure (approximately 176/mio/year); standard primary chronic renal disease was found in 19/79 of these diabetic patients (25%). The discrepancy between the annual incidence of (i) renal failure and of (ii) terminal renal failure suggests that a high proportion of patients with diabetes (mainly type II) and renal failure, dies prior to reaching terminal renal failure. Potential reasons for the increasing incidence of endstage renal failure from diabetes type II are (i) the increasing prevalence of type II diabetes in Germany in recent decades, (ii) aging of the population in view of the known greater prevalence of type II diabetes in older individuals and (iii) improved survival of patients with type II diabetes secondary to diminished cardiovascular mortality. Particularly because of the latter factor a further increase of endstage renal failure in patients with type II diabetes must be anticipated.

Central role of zinc protoporphyrin in staging iron deficiency.

In iron deficiency, zinc protoporphyrin (ZPP) is produced instead of heme, and the ZPP concentration in erythrocytes is increased (normal < or = 40 mumol/mol heme). We investigated the relevance of ZPP for staging iron deficiency. ZPP was determined by hematofluorometry in samples from 103 patients. Nineteen patients with iron depletion showed decreased serum ferritin (12.1 +/- 4.4 micrograms/L) with normal ZPP and hemoglobin (Hb). Twelve patients with iron-deficient erythropoiesis had decreased ferritin (10.4 +/- 2.4 micrograms/L), increased ZPP (72 +/- 9 mumol/mol heme), and normal Hb concentrations. In 72 patients with iron-deficiency anemia, ferritin was < 12 micrograms/L. In mild anemia (Hb between 100 and 120 g/L, and normal erythrocyte indices), ZPP was 100 +/- 16 mumol/mol heme. In severe anemia (Hb < 100 g/L, decreased erythrocyte indices), ZPP values were significantly higher (265 +/- 109 mumol/mol heme). We conclude that measurements of ZPP, ferritin, and Hb can reliably be combined to classify the degree of iron deficiency.

Zinc protoporphyrin in anemia of chronic disorders.

Hematofluorometric determination of zinc protoporphyrin (ZPP) is a screening method for the assessment of iron deficiency (ID). Chronic disorders are frequently accompanied by anemias of unclear origin, most probably caused by an impairment of iron metabolism. We investigated the relevance of ZPP for the detection of derangements of iron metabolism in anemias of chronic disorders (ACD). In 19 patients with ACD caused by chronic inflammatory non-neoplastic diseases, ZPP was determined and correlated with ferritin, transferrin saturation, and hemoglobin (Hb). Marrow sideroblast counts and semiquantitative grading of the marrow hemosiderin were performed in all patients to exclude ID and to show the decreased iron bioavailability. In all ACD patients who exhibited the typical laboratory findings of disturbed iron metabolism, such as hypoferremia, decreased transferrin saturation, decreased bone marrow sideroblasts, and increased marrow hemosiderin, strongly elevated ZPP levels were found (131 +/- 23 mumol/mol heme). ZPP returned to normal after successful treatment of the underlying disease. This is shown in three patients with polymyalgia rheumatica. We conclude that the fluorometric determination of ZPP allows detection and quantification of derangements of iron metabolism associated with chronic inflammatory disorders. By recording the derangements quantitatively, ZPP allows monitoring of therapy of chronic inflammatory diseases.

Washing erythrocytes to remove interferents in measurements of zinc protoporphyrin by front-face hematofluorometry.

Zinc protoporphyrin (ZPP) is determined by hematofluorometry of whole blood to detect iron deficiency in blood donors. In hospitalized patients, ZPP did not correlate with established markers of iron status. We performed 4500 ZPP measurements with the Aviv front-face hematofluorometer in samples from 475 patients and measured ferritin, transferrin saturation, hemoglobin, and erythrocyte indices. We found that the fluorometric determination is affected by substances dissolved in plasma but that this interference can be eliminated by using washed erythrocytes. In validation tests the within-day variation was < 3.5%; the day-to-day variation was < 6.8%. In 130 healthy persons without iron deficiency, ZPP was < or = 40 mumol/mol heme, which we consider a normal value. Mean ZPP in 46 iron-deficient patients was 256 (SD 105) mumol/mol heme (correlation with ferritin: -0.73; with hemoglobin: -0.85; P < 0.001). When washed erythrocytes are used, the hematofluorometric determination of ZPP is sensitive and specific for detecting iron deficiency in otherwise healthy individuals and hospitalized patients.

Immunogenicity of recombinant hepatitis B vaccine in dialysis patients.

Eighty-eight dialysis patients were vaccinated with recombinant hepatitis B vaccine prepared in yeast. Fourty-nine patients were immunized 3 times (months 0, 1, 6) intragluteally with 40 micrograms hepatitis B surface antigen (HBsAg) per dose. Only 32 of them (65.3%) showed anti-HBs concentrations above 10 IU/l with a geometric mean titer (GMT) of 180.7 IU/l after 3 vaccinations, whereas all of the 16 healthy controls, vaccinated 3 times with a 10-micrograms dose of the same vaccine batch, had specific antibodies higher than 10 IU/l (GMT 897.4 IU/l). Responses of patients were slightly higher than those of dialysis patients vaccinated in an earlier study with plasma-derived vaccine according to the same schedule. Results in 20 patients immunized 6 times intragluteally with 40 micrograms HBsAg/dose in monthly intervals were not better (at month 7, 65% showed anti-HBs concentrations greater than 10 IU/l; GMT = 126.6 IU/l), and 19 patients receiving 6 times 20 micrograms HBsAg monthly showed significantly lower responses (anti-HBs greater than 10 IU/l in 42% of vaccinees, GMT = 89.5 IU/l). The vaccine was tolerated well; side-effects were slight, and no serious adverse reactions were observed. In conclusion, recombinant hepatitis B vaccine is comparable to plasma-derived vaccine also in the case of dialysis patients; a 6-dose schedule does not seem to have much advantage compared to the conventional 3-dose regimen.

[Prophylaxis of gastroduodenal complications after renal transplantation (author's transl)]. / Zur Prophylaxe gastroduodenaler Komplikationen nach Nierentransplantation.

Gastroduodenal bleeding or perforation following renal transplantation constitute a serious complication with a high lethality. 82 patients with terminal renal insufficiency were grouped in 4 categories with increasing gastroduodenal risk factors. Parameters for judging gastroduodenal risk consisted of gastric acid secretion, history and endoscopic demonstration of acute or chronic ulcer disease. 33 transplant candidates of groups I (hypochlorhydria, no ulcer) and II (normochlorhydria, no ulcer) were treated by medical prophylaxis alone. 23/33 were transplanted without prophylactic surgery, 1 patient in group II with erosive duodenitis before transplantation died from bleeding duodenal ulcer. Patients of group III (hyperchlorhydria up to 40 mval/h, MAO, no ulcer) received selective proximal vagomty, patients of group IV (hyperchlorhydria, 40 mval/h MAO and/or ulcer) underwent selective gastric vagotomy and 50% gastric resection. In 25 of 49 patients of group III and IV prophylactic operations were performed without serious complications. In 16 later on transplantated patients no gastrointestinal bleeding occurred. 2 patients of group III without gastric operation had minor bleedings out of erosive lesions in the gastric antrum and duodenal bulb, that could be managed by medical treatment. The positive experience with prophylactic gastric surgery in this limited number of patients seems to advocate a broader application of such a protocol. A considerable rise in gastric secretion was demonstrated in 19/21 patients during the first 3 years following the commencement of dialysis, BAO rose by an average of 72,2%, MAO by 41%. Thus, gastric analysis should be repeated once a year. Erosive gastritis and duodenitis seem to predispose for bleeding episodes after renal transplantation, this diagnosis should prompt prophylactic SPV.

[Anaesthesia and postoperative care in terminal renal insufficiency. Experiences in 132 cases (author's transl)]. / Anästhesie und postoperative Behandlung bei terminaler Niereninsuffizienz--Erfahrungen bei 132 Patienten.

A retrospective study was carried out examining the complication- and mortality-rate in 132 patients with terminal renal insufficiency who underwent major surgery: partial gastrectomy, bilateral nephrectomy and vascular surgery at the lower extremities. The anaesthetic management consisted primarily of general anesthesia and muscle relaxation except for vascular surgery at lower extremities where continuous epidural anaesthesia was used. The problems of the anaesthetic management and postoperative care including dialysis are discussed. Although this group of patients is at high risk, the complications can be kept at a minimum with appropriate anaesthetic management and postoperative care.