[Treatment of acute renal failure in Germany: Analysis of current practice]. / Versorgung des akuten Nierenversagens auf deutschen Intensivstationen: Analyse der aktuellen Behandlungspraxis.

BACKGROUND AND OBJECTIVES: There are currently no reliable data on the differential use of renal replacement therapy (RRT) options for critically ill patients with acute renal failure in Germany. PATIENTS AND METHODS: A questionnaire-based survey was delivered to 2265 German intensive care units. The questionnaire contained 19 questions regarding RRT. RESULTS: A total of 423 German intensive care units participated in the survey. The offered modalities of RRT varied significantly: the smaller the facility, the fewer different RRT options were available. Intermittent dialysis procedures were available in only 35% of hospitals with up to 400 beds. In university hospitals, hemodynamically unstable patients were exclusively treated by continuous RRT, whereas in hospitals with up to 400 beds, intermittent RRT was also used. In addition, treatment practice was also dependent on the specialization of the treating physicians: Isolated acute renal failure was treated more often intermittently by nephrologists compared to anesthesiologists (79.7 vs. 43.3%). Nephrologists also used extracorporeal RRT more often in cardiorenal syndrome (54.3 vs. 35.8%), whereas anesthesiologists preferred them in sepsis (37.3 vs. 23.1%). The choice of anticoagulant varied as well: Hospitals with up to 400 beds offered regional citrate anticoagulation in only 50% compared to 90% of university hospitals. CONCLUSIONS: Currently, RRT treatment in acute renal failure on German intensive care units seems to be dependent on the size, local structures, and education of the intensivists rather than patient needs. Our results demonstrate the necessity to establish cross-disciplinary standards for the treatment of acute renal failure in German intensive care units.

Aldosterone resistance in kidney transplantation is in part induced by a down-regulation of mineralocorticoid receptor expression.

BACKGROUND: After renal transplantation immunosuppressive drugs-like cyclosporin A (CsA) and FK506 induce either hypoaldosteronism or pseudo-hypoaldosteronism presenting with hyperkalemia and metabolic acidosis. We investigated the relationship between renal allograft function under CsA therapy and plasma aldosterone concentration, potassium- and water homeostasis and mineralocorticoid receptor (MR) expression level in peripheral leukocytes. METHODS: We studied 21 renal transplant patients under CsA therapy and 12 healthy controls. Transplant recipients were studied before and under fludrocortisone treatment. Using quantitative reverse-phase polymerase chain reaction (RT-PCR) specific for the MR, we analyzed the level of expression of MR in peripheral leukocytes. RESULTS: In acidotic transplant recipients (HCO(3) 18.5 +/- 1.2 mM) renal function was only slightly impaired with 2.0 +/- 0.2 mg creatinine/dL when compared with 1.8 +/- 0.3 mg/dL (ns) in non-acidotic patients (HCO(3) 23.0 +/- 2.8 mM). Mean plasma aldosterone levels in renal transplant recipients did not differ from control levels (150 +/- 33 pg/mL vs. 148 +/- 33 pg/mL, ns). In contrast, the expression level of MR in peripheral leukocytes of renal transplant recipients treated with CsA was significantly decreased when compared with healthy controls without renal disease (120 +/- 78 vs. 423 +/- 73 RNA molecules/0.5 microg total RNA, p < 0.01). The level of expression of MR in renal transplant recipients did not differ between acidotic patients and non-acidotic patients (ns). The application of fludrocortisone reversed hyperkalemia and metabolic acidosis without significant effect on MR expression. CONCLUSIONS: The present data demonstrate that hyperkalemia and metabolic acidosis following CsA treatment in kidney transplantation might be associated with a down-regulation of MR expression on peripheral leukocytes. Electrolyte imbalance is reversible on application of fludrocortisone. This observation supports fludrocortisone treatment in transplant patients with severe electrolyte disturbances.

Decreased mineralocorticoid receptor expression in blood cells of kidney transplant recipients undergoing immunosuppressive treatment: cost efficient determination by quantitative PCR.

AIMS: Electrolyte imbalances caused by impaired ion transport are a frequent side effect of immunosuppressive treatment in renal transplant recipients. Clinical symptoms resemble features of hypoaldosteronism, although concentrations of aldosterone are in the normal range. Because immunosuppression might affect the hormone receptor status of cells, mineralocorticoid receptor (hMR) expression by peripheral blood leucocytes (PBL) was studied in these patients. METHODS: Twenty one renal transplant recipients being treated with cyclosporine A and 19 healthy controls were tested. hMR expression was quantified by means of competitive reverse transcription polymerase chain reaction (cRT-PCR) and compared with receptor binding studies with subsequent Scatchard plot analysis carried out previously on 20 renal transplant recipients and 25 controls. Advantages of PCR were summarised and compared with Scatchard plot analysis. RESULTS: Cyclosporine A caused a 37% decrease in hMR molecules on PBL in 75% of renal transplant recipients, and this effect was attributable to the downregulation of hMR transcription. PCR was 99% specific for the detection of hMR in PBL and highly reproducible. CONCLUSIONS: Decreases in hMR protein and RNA in PBL of transplant recipients revealed an inhibitory effect of cyclosporine A on hMR transcription. Because hMR acts as a transcription factor, the expression of several genes involved in electrolyte homeostasis is affected, leading to signs of nephrotoxicity that require therapeutic adjustments. Because of the small volume of blood, the assay can be repeated during treatment and is therefore useful for measuring treatment outcomes. Lower costs and the absence of radioactive challenge are further advantages of the PCR method.

Effect of cyclosporine A on Na+/K(+)-ATPase, Na+/K+/2Cl- cotransporter, and H+/K(+)-ATPase in MDCK cells and two subtypes, C7 and C11.

We investigated the influence of cyclosporine A (CsA) on key plasma membrane ion transport systems Na+/K(+)-ATPase, Na+/K+/2Cl- cotransporter, and H+/K(+)-ATPase in MDCK cells and two subtypes, C7 and C11, serving as a model system to study principal (C7) and intercalated (C11) cell properties of the distal nephron. The transport activity of Na+/K(+)-ATPase was significantly decreased in all cell types on CsA administration (8 x 10(-6) M) for 2 days, whereas the protein levels of Na+/K(+)-ATPase alpha-subunit in plasma membranes isolated from MDCK, C7, and C11 cells remained unchanged. The transport activity of Na+/K+/2Cl- cotransporter was significantly inhibited by CsA only in MDCK and C11 cells, but again plasma membrane protein levels were not altered. In contrast, C7 cell plasma membranes showed an increase of transport protein content, although the Na+/K+/2Cl- cotransporter activity was not affected by CsA. The H+/K(+)-ATPase transport activity remained unchanged in all three cell types. These data indicate that in C7 cells CsA might induce insertion of transporters into the plasma membrane, thus compensating the decrease of transport activity observed in MDCK and C11 cells. Furthermore, CsA significantly inhibited cell proliferation at 4 x 10(-6) M for C7 and C11 cells and at 8 x 10(-6) M for MDCK cells. Proliferation was completely abolished at 1.6 x 10(-5) M CsA. After 48 h of CsA incubation, the intracellular sodium concentration increased in all three different cell types; however, it stayed within the physiological range of mammalian cells. We, therefore, suggest that CsA is capable of reducing Na+/K(+)-ATPase and Na+/K+/2Cl- cotransporter activities in cells of the distal nephron, thereby contributing to the hyperkalemia observed in patients treated with CsA.