Efficacy and safety of DALI LDL-apheresis at high blood flow rates: a prospective multicenter study.

Direct adsorption of lipids (DALI) is the first LDL-apheresis method compatible with whole blood. Usually, the blood flow rate is adjusted at 60-80 ml/min, which results in session times of about 2 hr. The present study was performed to test the safety and efficacy of low-density lipoprotein cholesterol (LDL-C) and lipoprotein (a) [Lp(a)] removal by DALI at high blood flow rates in order to reduce treatment time. Thirteen chronic DALI patients in seven centers suffering from hypercholesterolemia (LDL-C 162 +/- 42 mg/dl at baseline) and coronary artery disease were treated on a weekly or biweekly basis by DALI apheresis. The blood flow rate QB was held constant for at least two sessions, respectively, and was increased from 60 to 80, 120, 160, 200, and 240 ml/min. All patients had pre-existing av-fistulas. The anticoagulation was performed by a heparin bolus plus ACD-A at a ratio of citrate:blood ranging from 1:20 to 1:90. Clinically, the sessions were well tolerated and only 26/201 sessions (12%) of the treatments were fraught with minor adverse events. Acute LDL-C reductions (derived from LDL-C levels determined by lipoprotein electrophoresis) averaged 72/66/60/53/50/48% for QB=60/80/120/160/200/240 ml/min. Lp(a) reductions were 68/67/62/60/58/56%, whereas HDL-C losses were < or =10%. Routine blood chemistries and blood cell counts remained in the normal range. Treatment times averaged 142/83/45 min at Qb=60/120/240 ml/min. On average, DALI LDL-apheresis could be performed safely and effectively at high blood flow rates up to at least 120 ml/min in patients with good blood access, which significantly reduced treatment time from 142 to 83 min (-42%).

Enhancing patency, safety and cost effectiveness of catheters.

Catheters are generally known to be the last resort for blood access in dialysis. Because of the many problems related to catheter use, catheters are banned from vascular access courses organized by professional societies and the development of catheters and catheter related equipment relies on a few interested medical doctors with limited knowledge of hydraulics and material science. Rather than accepting the need for catheters and the need for improving catheters and catheter related procedures, vascular access meetings typically begin and end with statements saying that the use of fistulas must be increased and catheters must be banned. Several small companies have developed new catheters and catheter related equipment, which potentially overcome many of the problems related to the use of catheters. The authors had the privilege of participating in one of these developments and report about basic features and clinical experience of the DIALOCK blood access port and an antimicrobial catheter locking solution (CLS) which is used with conventional catheters as well as with the DIALOCK.

[Peripheral blood flow in patients with necrobiosis lipoidica (diabeticorum)]. / Untersuchungen zur peripheren Durchblutung bei Patienten mit Necrobiosis lipoidica (diabeticorum).

For the judgment of the peripheral blood supply 16 insulin-dependent diabetics with necrobiosis lipoidica at the lower extremities were compared with 15 insulin-dependent diabetics without necrobiosis lipoidica. The vascular changes in form of retinopathy, nephropathy, neuropathy, hypertension, the results of the radiologically provable vascular changes, oscillograms and impedance plethysmograms as well as the results of the muscle and skin clearance and angioscintigraphy were evaluated. The at last mentioned methods give an insight into the microangiopathy. The apparantly contradicting findings of the muscle clearance (smaller blood supply) and of the skin clearance (increased blood flow) find their explanation by the angioscintigraphically proved different regional parameters of blood flow in the necrobiotic regions. The angiopathic findings are characterized by the enrichment of activity in the marginal seam as a sign of hyperemia and decreased accumulation in the centre as an expression of necrobiosis. The changes of the connective tissue and their causes of development are discussed. Angiopathic and traumatic influences conditioned by metabolism, apart from local peculiarities are taken into consideration.

[Diabetic polyneuropathy. 4. Synopsis of electroneurographic findings in diabetics]. / Die diabetische Polyneuropathie 4. Mitteilung: Synopsis elektroneurographischer Befunde bei Diabetikern.

Sensory conduction velocity of the median nerve, motor conduction velocity of both median and tibial nerves, and corresponding distal laterncies are sufficient parameters to establish the diagnosis of polyneuropathy almost with certainty. Considering these six parameters yielded in detection of peripheral nerve dysfunction in 22% of diabetic patients who were free from clinical signs of polyneuropathy. Electroneurographical findings in 340 out of 677 patients with diabetes mellitus were interpreted as evidence of segmental demyelination. Within this group there was the majority of patients with clinical signs of polyneuropathy and with subclinical signs of peripheral nerve dysfunction. There existed a positive correlation between signs of nerve dysfunction with angiopathy, age and duration of the disease. A second group consisting of 243 diabetics with signs of incipient segmental demyelination with or without signs of axonaal degeneration mainly included juvenile patients with a short duration of the disease and with a low frequency of angiopathy.

[Diabetic polyneuropathy. 3. Electroneurographic findings in diabetics and their relationships to age and duration of diabetes]. / Die diabetische Polyneuropathie. 3. Mitteilung: Elektroneurographische Befunde bei Diabetikern und ihre Beziehung zum Lebensalter und zur Diabetesdauer.

Nerve conduction velocities were determined in patients with diabetes mellitus: motor conduction of the median nerve in 778 patients, sensory conduction of the median nerve in 680 patients and motor conduction of the tibial nerve in 745 patients. In 40.9% out of 778 patients at least one of the three nerve conduction velocities were found within pathological ranges. 30.4% of 227 patients below 19 years of age in whom the duration of the disease did not exceed four years exhibited at least one delayed nerve conduction velocity. Clinical signs of polyneuropathy in children and in adolescents below 19 years of age are rare (0.6%). In contrast delayed nerve conduction velocities were found in 29.4%. Metabolic disturbance of peripheral nerve function is assumed to be responsible in these patients, for angiopathy in children and adolescents is very rare too.

[The diabetic polyneuropathy. I. Relation between impaired function in peripheral nerves and clinical findings]. / Die diabetische Polyneuropathie. 1. Mitteilung: Beziehungen zwischen Funktionsstörungen am peripheren Nerven und klinischen Befunden.

789 patients with diabetes mellitus were studied by clinical and electroneurographical investigation. Motor and sensory conduction velocities of the median nerve and motor conduction velocity of the tibial nerve were determined. 86.1% of the patients suffered from juvenile diabetes, and 13.9% from maturity onset diabetes. Average duration of the disease was 9.5 years, average age of the patients was 26.7 years. Clinical signs of polyneuropathy were found in 19.1%. In 40.9% of the patients at least one of 3 conduction velocities was found to be delayed. Patients with clinical signs of polyneuropathy exhibited delayed nerve conduction velocities and delayed distal latencies. Diagnosis of polyneuropathy almost with certainty is possible by determining the three nerve conduction velocities and the three corresponding distal latencies. 22% of patients without clinical signs of polyneuropathy exhibited electroneurographical signs of impaired peripheral nerve function. Heredity, body weight, lipid metabolism, actual metabolic balance, and treatment were found to be without any significant influence on nerve conduction velocity.

[The diabetic polyneuropathy. II. Polyneuropathy, angiopathy and nerve conduction velocity]. / Die diabetische Polyneuropathies. 2. Mitteilung: Polyneuropathie, Angiopathie und Nervenleitgeschwindigkeit.

789 patients with diabetes mellitus were studied by clinical and electroneurographical examination. Motor conduction velocity of the median and the tibial nerve and sensory conduction of the median nerve were determined. 81.1% of the patients we suffering from diabetes which began in childhood or adolescence, 13.9% were suffering from maturity onset diabetes. Average duration of the disease was 9.5 years, average age was 26.7 years. Clinical signs of polyneuropathy were found in 19.1%. Typical findings were pain and paraesthesia, lack or abolition of triceps surae reflexes, impaired pallaesthesia on lower extremities. 48.3% of 151 patients with clinical signs of polyneuropathy were suffering from combined angiopathy, 32.5% from microangiopathy, 7.9% from macroangiopathy. Severity of complicating retinopathy and macroangio,athy were found to be correlated with polyneuropathy. 58.2% of 323 diabetics with at least one delayed nerve conduction velocity exhibited signs of angiopathy. In nearly 30% of children and adolescents after comparatively short duration of the disease at least one conduction velocity was delayed. In diabetic children and adolescents metabolic disturbances are assumed to cause peripheral nerve dysfunction.

[Necrobiosis lipoidica diabetricorum and serum lipids]. / Necrobiosis lipoidica diabeticorum und Serumlipide

Necrobiosis lipoidica diabeticorum is briefly described. Its high coincidence with hyperlipoproteinaemia in casuistic reports from the literature as well as in about half of the 22 cases observed in our clinic can be taken in favour of possible relations between these conditions. Disturbances of fat metabolism may even be considered important for pathogenesis of necrobiosis in general, the more as at least no optimally regulated fat and carbohydrate metabolism can be achieved by best therapeutic control of carbohydrate parameters in juvenile diabetics. Microangiopathia diabetica seems to exist from the very beginning of diabetes mellitus and may ne a basic etiologic prerequisite for the development of necrobiosis. Topical conditions of certain body regions are said to take part in final precipitation of necrobiotic spots.