Echocardiographic evaluation of left ventricular dimensions and function in chronic hemodialysis patients with cardiomegaly.

Results obtained by echocardiography in chronic hemodialysis patients with cardiomegaly show that there is a cardiomyopathy of congestive type at least in a small number of hemodialysis patients. A reduced contractility of the left ventricular myocardium with increased dimensions of the left ventricle in a uremic metabolic situation suggests that these cardiomyopathies are of uremic origin. Possible causes of "uremic cardiomyopathy" are discussed with reference to the literature.

[Arterial hypertension (author's transl)]. / Arterielle Hypertonie.

Arterial hypertension represents the most prevalent disease on our country. Due to cardiovascular complications, early invalidism and increased mortality are common. There is general agreement that genetic influences, overweight and increased uptake of salt are predisposing factors. In about 5--10% of all hypertensive patients an underlying cause can be incriminated. Among these cases of secondary hypertension less than 10% can be treated by surgery alone. Hypertension teaching programs in other countries using conventional treatment protocols have met with considerable success in all types including borderline-hypertension.

Use of large-bore catheters in the internal jugular vein as an access route for emergency hemodialysis.

Our experience with catheterization, mainly of the internal jugular vein, using a large-bore catheter (Shaldon catheter) with 279 patients and a total of 359 catheter placements, is reported. The subclavian vein was used for vascular access in 57 additional patients (80 catheters) and the femoral vein in four patients (six catheters). Percutaneous puncture of the jugular, subclavian and femoral veins in a total of 340 patients (445 catheters) was necessary for emergency hemodialysis, hemofiltration, hemoperfusion, plasmapheresis or, in the case of patients on regular hemodialysis, for temporary vascular access while awaiting the availability of another access site. Complications were less frequent with the internal jugular point of entry than with others, based on our experience and the literature published. Cannulation of the superior vena cava through the internal jugular vein therefore appears to be a most appropriate route for rapid vascular access when emergency extracorporeal blood treatment is required.

[Therapeutic plasma exchange in severe tropical malaria]. / Therapeutischer Plasma-Austausch bei schwer verlaufender Malaria tropica.

Cases of malaria are being seen ever more frequently in the Federal Republic of Germany, presenting both diagnostic and therapeutic problems. Three recent cases of severe malignant falciparum malaria are presented, one ending fatally. In the other two, plasma exchange combined with haemodialysis led to a cure.

[Use of large-bore catheters inthe internal jugular vein as an access for acute hemodialysis (author's transl)]. / Erfahrungen mit grosslumigen Verweilkathetern in der V. jugularis interna als Zugang für akute Hämodialysen.

For almost 2 decades, the chosen method for hemodialysis has been the transcutaneous Seldinger technique, using large-bore catheters. Traditionally, the femoral or subclavian veins have been used. We report our experience on introducing the catheter (Shaldon Catheter) into the internal jugular vein in 237 cases in 194 patients. the percutaneous insertion was necessary for acute hemodialysis, hemofiltration, hemoperfusion, or for temporary vascular access. This method was using for plasmapheresis, too. Major complications did not occur, which is in agreement with other authors, where by the frequency of complications relating to the catheter itself has been lower using this approach. It thus seems that the cannulation of the superior vena cava through the internal jugular vein is a suitable means of obtaining fast vascular access for the purposes of hemodialysis, hemofiltration, hemoperfusion or plasmapheresis.

Detection of renal tubular lesions after abdominal aortography and selective renal arteriography by quantitative measurements of brush-border enzymes in the urine.

Quantitative determination of brush-border enzyme excretion in the 24-hour urine is a much more sensitive index of renal tubular damage after aortography and selective renal arteriography than the conventional renal function tests such as serum creatinine and clearance determinations. Among the five brush-border enzymes which we investigated, alkaline phosphatase (AP) was the most sensitive diagnostic pointer. In 90% of hypertensive patients without detectable pre-existing renal parenchymal damage, abnormal levels of AP excretion in the urine were found on the same day as or on the day after the intra-arterial injection of contrast medium. Measurement of other brush-border enzymes does not provide any further diagnostic information. Provided there is no pre-existing renal parenchymal damage, the lesion caused by the contrast medium is transient and is usually reversed within 48 h. For the early detection of tubular lesions caused by tri-iodinated benzoic acid derivatives, AP excretion in the 24-hour urine should be measured at least twice--on the day of the contrast medium injection and on the following day.

Indications of plasmapheresis and selection of different substitution solutions.

Substitution solutions used for plasmapheresis (PH) may be human albumin, serum protein conserves or plasma. 746 plasmapheresis carried out on 88 patients with a variety of diseases were examined and the side effects due to the substitution solutions were investigated. Side effects occurred in less than 10% of the cases where the four substitution solutions were used. The least side effects were observed in treatments using human albumin as substitution. Side effects increased for serum protein conserves, followed lyophilised plasma and were highest for fresh frozen plasma. In view of these possible side effects the criteria for PH should be strictly observed and the substitution solution should meet clinical requirements.

Nitrendipine in patients with end-stage renal disease and hypertension.

Calcium antagonists reduce the calcium uptake in vascular cells. The reduction of intracellular calcium leads to vasodilatation and lowering of the blood pressure. The cardiac output is increased, for example, by nitrendipine and related agents, so that the supply of blood to essential organs is improved. Despite the blood pressure decrease, the plasma renin activity increases only slightly and the plasma aldosterone concentration not at all after administration of nitrendipine. The effects of nitrendipine were examined in a study carried out over a period of 6 months on 10 patients suffering from renal hypertension and end-stage renal disease requiring compulsory dialysis. In all patients, adequate blood pressure control was achieved with, in some cases, low doses of nitrendipine combined with other antihypertensive medication. Nitrendipine was very well tolerated, and no side effects were observed.

Drug-resistant bronchial asthma successfully treated with plasma exchange.

Two patients suffering from allergic bronchial asthma who showed no improvement despite six and four weeks, respectively, of drug therapy were successfully treated with therapeutic plasma exchange. The first patient had no attacks over a period of five months, and the other patient had none for over one year. Although this report only deals with single observations, we believe that therapeutic plasma exchange is of particular value for patients with severe allergic bronchial asthma because it eliminates in addition to immunocomplexes other substances, including antigens, rapidly from the blood. This means that it is possible to directly intervene in the pathomechanism. However, further investigations are necessary in order to corroborate this successful therapy.

[Behavior of oxypolygelatine (Gelifundol) in patients with dialysis-dependent kidney failure]. / Verhalten von Oxypolygelatine (Gelifundol) bei Patienten mit dialysepflichtiger Niereninsuffizienz.

Colloidal solutions are used with increasing frequency as plasma replacement, in addition to thrombosis prophylaxis, for treating disturbances of the microcirculation and hemodilution as well as for cases of decreases in blood pressure during hemodialysis and hemofiltration treatments. The effects of the dextran, hydroxyethyl amylum and gelatine preparations available very greatly, for example with regard to expander effect, half life, elimination etc. Gelatine solutions have a particularly short intravascular retention and therefore appeared to us to be especially suitable for treating decreases in blood pressure and states of shock during hemodialysis and hemofiltration. We examined the behaviour of 5,5% oxypolygelatine (OPG) in 11 patients during dialysis treatment (6 patients with a residual diuresis smaller than 500 ml/24 h, 5 patients with a residual diuresis larger than 500 ml/24 h). Before each of the 12 treatments 250 ml OPG was administered to all patients. 48 hours later 86-93% of the infused OPG had been eliminated. Despite repeated doses no remarkable OPG cumulation was registered.

[Enzyme determination in the urine for the evaluation of kidney tolerance of the water-soluble roentgen contrast medium iopamidol]. / Enzymbestimmungen im Harn zur Beurteilung der Nierenverträglichkeit des wasserlöslichen Röntgen-Kontrastmittels Iopamidol.

The renal toxicity of the ionic, very hyperosmolaric megluminamidotrizoate was compared with the toxicity of the non-ionic, slightly hypertonic iopamidol after intravenous injection of 0.7 ml/kg body weight (i.e. about 300 mg iodine/ml) in a randomized study of 20 individuals with normal kidneys. Quantitative measurements of the excretion of the enzymes, lactate dehydrogenase (LDH), alkaline phosphatase (AP), and N-acetylglucosaminidase (NAG) in 24-h urine samples, serum creatinine, and the endogeneous creatine clearance were conducted to determine the possible renal damage. All 20 subjects tolerated both contrast mediums well. Reduced renal function as measured by the creatinine blood level and the endogeneous clearance did not occur. The ionic, hyperosmolaric megluminamidotrizoate++ caused significantly elevated enzymuria of NAG, AP, and LDH (P less than 0.01) following tubular irrigation, whereas iopamidol showed no significant enzymuria. Therefore, it appears that the non-ionic contrast medium, iopamidol, is less toxic for kidneys than the ionic megluminamidotrizoate.

Subcutaneous injection of desmopressin (DDAVP): evaluation of a new, more concentrated preparation.

A more concentrated desmopressin (DDAVP) preparation (40 micrograms/ml), which required small injection volumes (less than 1 ml), was studied in a double-blind trial in 10 healthy volunteers, 12 patients with haemophilia A, and 8 patients with uraemic bleeding. DDAVP was administered by subcutaneous injection at a dose of 0.4 micrograms/kg body weight. In healthy subjects, peak levels of DDAVP ranging from 480 to 638 pg/ml were reached 1 h after the subcutaneous injection and DDAVP was eliminated with a mean half-life of 3.1 h. DDAVP produced a 2.5-fold (3.0-fold) increase of factor VIII:C (factor VIII:Ag) and a 1.9-fold (2.2-fold) increase of von Willebrand factor:Ag (ristocetin cofactor) over baseline levels. Additionally, a 2.1-fold increase of tissue-type plasminogen activator antigen was observed. Factor VIII and von Willebrand factor were rapidly eliminated with a half-life ranging from 1.3 to 5.7 h and from 1.1 to 11.4 h, respectively. In haemophilia A patients, DDAVP produced a 2.3-fold increase of factor VIII:C 1 h after the injection. DDAVP was given on 8 occasions for management of bleeding, and only in 1 patient did a wound haematoma (after herniotomia) occur. In 7 of the 8 patients with uraemia the bleeding time shortened, and in all patients an increase of platelet retention and a decrease of platelet count was observed (p less than 0.05). No serious local or systemic untoward side effects were observed.

Ultrafiltration of dialysis fluid for hemodialysis.

Since the quality of water in dialysis fluid varies considerably, and, in view of the fact that endotoxin or active derivatives can cause acute side effects in patients, the dialysis fluid must be sterile. The predialyzer fluid in 20 hemodialysis patients was investigated. Bacterial loading was between 5/ml and 5,000/ml, and the endotoxin concentration was high and extremely variable. After ultrafiltration of the dialysis fluid by a polyamide hollow fiber membrane, all samples were free of bacteria, and the concentration of endotoxin was lower than the detectable limit. With this procedure we can obtain sterile dialysis fluid, which is endotoxin free.

Comparative investigation of the microcirculation in patients with hypertension and healthy adults.

A total of 51 patients with arterial hypertension, 29 of which have renal dysfunction, were examined with regard to patient history, clinically, laboratory analysis and capillary microscopy. Compared to healthy adult patients with hypertension demonstrated a significant increase in the number of capillaries per millimeter of epidermis, while at the same time showing a significantly decreased erythrocyte column diameter. This observation was more pronounced the greater the degree of retinal vascular alteration (fundus hypertonicus). The duration of reactive hyperemia in response to three minutes of ischemia with a spygmonometer cuff was considerably shortened in patients with hypertension. Here as well, an increasing degree of retinal vascular alteration correlated with a decrease in reactive hyperemia to the point of no response at all. The blood fluidity of patients with arterial hypertension was significantly limited. The plasma viscosity as well as the erythrocyte aggregation were significantly elevated. Patients suffering from additional kidney dysfunction had even higher viscosities. There also appeared to be a correlation to the degree of fundus hypertonicus in which the plasma viscosity increased in relation to an increasing degree of retinal vascular alteration.

[Recombinant human erythropoietin (rh-EPO) in chronic, dialysis-dependent renal failure: effects on macro- and microcirculation and hematologic parameters]. / Rekombinates humanes Erythropoietin (rh-EPO) bei chronischer, dialysepflichtiger Niereninsuffizienz: Auswirkungen auf die Makro- und Mikrozirkulation und hämatologische Parameter.

Recombinant human erythropoietin (rh-EPO) has been shown to be effective in the treatment of renal anemia. Additionally, rh-EPO improves the hemostatic defect of uremia. On the other hand, a hypertensinogen effect and an increased risk for thrombosis have been reported in hemodialysis (HD) patients with rh-EPO. 20 HD patients in Homburg were recruited for a multicenter, placebo-controlled study (MF 3981), aiming to assess the risk of rh-EPO. Initially, 10 patients received rh-EPO at a dose of 3 x 80 U/kg body weight and week which was subsequently adjusted according to the hematocrit. After 6 months, the patients receiving placebo were changed to rh-EPO therapy. Clinical and laboratory data were obtained before, as well as 1, 3, 6 and 12 months after beginning of the study. Erythrocyte counts increased significantly in the rh-EPO group. Also, an increase of platelet count, fibrinogen and plasma viscosity was observed during rh-EPO. Tissue type plasminogen activator and plasminogen activator inhibitor as well as von-Willebrand-factor remained unchanged, although a shortening of the bleeding time was observed. Blood pressure and arterial blood flow were not influenced by rh-EPO.

Hemofiltration and plasmapheresis in premature infants and newborns.

Extracorporal detoxication methods in newborns are most unavailable, contraindicated because of technical problems. Herein are reported the experiences with a blood pump unit that was miniaturized for hemodialysis, hemofiltration, and plasmapheresis in newborns. In three premature infants with acute renal failure of different etiology (two newborns with severe Rh-erythroblastosis, 1 premature infant with hypoproteinemia) 13 single-needle hemofiltrations and 6 single-needle plasmaphereses were performed with double head pump, special tube systems, and small modules. The age of the patients ranged from 1 to 14 days, body weight was between 800 and 2,800 g. Four umbilical veins and two femoral veins were used as vascular access. The ultrafiltration rate during the treatment averaged 0.3 ml/min in single-needle hemofiltration and the plasma filtrate flow rate 1.3 ml/min in single-needle plasmapheresis. All treatments were well tolerated. Four patients died due to complications unrelated to the treatment, two patients recovered. These preliminary results show that both hemofiltration and plasmapheresis may be carried out without major problems in premature infants and newborns.

[Coincidence of hypertensive changes of the eye fundus and regulation disorders of peripheral microcirculation: I--Skin]. / Koinzidenz zwischen hypertensiven Augenhintergrundsveränderungen und Regulationsstörungen der peripheren Mikrozirkulation: Teil I--Haut.

In cases of arterial hypertension, funduscopy is an established method of estimating systemic vascular lesions. In this study the relation between the extent of retinal vascular changes and dynamic processes in the microcirculation of the skin was investigated by nailfold capillaroscopy in 88 patients. With increasing vascular changes a progressive loss of vasodilator reserve and transcutaneous partial pressure was observed (no morphologic changes--fundus hypertonicus II--fundus hypertonicus III). It thus appears possible to evaluate the functional state of the macro- and microcirculation by funduscopy.

Hemofiltration and plasmapheresis in newborns using a small blood pump system.

Extracorporeal detoxification methods in newborns and premature infants are unavailable and contraindicated because of technical problems. The authors' experiences with a blood pump unit that was miniaturized for hemodialysis, hemofiltration, and plasmapheresis in newborns are reported. In 28 newborns and premature infants, 32 hemofiltrations, 3 hemodialyses, and 57 plasmaphereses were carried out for different diseases. Thirteen of 28 patients died despite hemofiltration and/or plasmapheresis as a result of their primary disease and/or immaturity, and 15 patients improved.