Low body mass index in kidney transplant recipients: risk or advantage for long-term graft function?

OBJECTIVES: Nutritional status is known to be a marker of overall health status and a strong predictor of patient survival in several diseases. Whereas obesity is suspected to have a negative influence on general renal transplantation outcomes, the relationship between impaired nutritional status and long-term kidney graft survival is not yet clear. METHODS: We retrospectively analyzed graft survival with a follow-up time of 5 to 12.5 years among 224 kidney transplantations. A Cox proportional hazards model was applied to estimate risk factors for loss of graft function. RESULTS: The Cox model initially showed no significant influence of the body mass index (BMI) at 1 year after transplantation on the risk of transplant failure (relative risk 0.97 per BMI unit, P = .34). When the patients were divided into two groups according to BMI, a clear disadvantage was shown in terms of long-term graft survival for the groups with a low BMI. The risk of loss of transplant function increased by a factor of 1.85 (relative risk) if the BMI 1 year after kidney transplantation was less than 23 (P = .035). CONCLUSIONS: These findings suggested impaired long-term kidney graft survival among patients with reduced nutritional status. This result is assumed to reflect improved immune function due to reduced nutrient availability, thus leading to reinforcement of chronic rejection processes. This assumption is consistent with the already known immunomodulatory effect of caloric restriction to mitigate T-cell activation.

Ten years of laparoscopic living donor nephrectomy: retrospect and prospect from the nephrologist's point of view.

The laparoscopic living kidney donor nephrectomy introduced in 1995 has become an accepted method of kidney harvest for transplantation. The method has proven its usefulness as well as its superiority compared to open donor nephrectomy. Based on the results of a decade, an overview from a nephrologist's point of view is presented here in; a view that is known to be quite different from (and sometimes contrary to) the surgeon's approach. While urologists and surgeons focus more on the technique and complication rates, the nephrologist tends to estimate the new procedure with regard to his dialysis patients' outcomes (ie, whether it will result in an increased number of kidney transplantations in the long term). The latter aspect has to be the benchmark in the estimation of the effects of this procedure; it is the ultimate goal of every surgery in kidney transplantation. The 10-year results are more than encouraging, but nevertheless it will take at least one more decade for a valid evaluation.

Cardiac beta-adrenoceptors in chronic uremia: studies in humans and rats.

OBJECTIVES: The purpose of this study was to elucidate whether cardiac beta-adrenergic effects may be blunted in patients on maintenance hemodialysis (HD) and may help to explain autonomic dysfunction. BACKGROUND: Patients on HD often suffer from autonomic dysfunction. METHODS: We investigated the cardiovascular response of five HD patients (age: 46.1+/-7.9 years) and six healthy volunteers (age: 48.2+/-7.5 years) to isoprenaline, pirenzepine and phenylephrine. For analysis of underlying mechanisms of beta-adrenoceptor hyporesponsiveness, six-week-old male Wistar rats were rendered uremic by 5/6-nephrectomy (n = 9; SNX) and were killed for removal of the heart after six to seven weeks. Sham-operated rats (n = 15) served as controls. RESULTS: In the patient study, isoprenaline (3.5, 7, 17, 35 ng/kg/min, i.v.) led to an increase in heart rate, and shortening of the heart rate corrected duration of the electromechanical systole (QS2c), both of which were significantly reduced in HD patients. Baroreflex sensitivity was significantly reduced in HD patients. The response to low parasympathomimetic doses of pirenzepine was unchanged. In the rat study, left ventricular strips were placed in an organ bath, electrically driven and exposed to isoprenaline (10(-11) to 10(-6) mol/liter). While pD2 values were unchanged, maximum effect at the highest concentration was significantly reduced in SNX rats. The response to carbachol was not altered, nor was the M2-cholinoceptor density. There was no difference in beta-adrenoceptor density, or in immunodetectable amount of Gs and Gi protein. Activation of adenylyl cyclase evoked by isoprenaline was significantly reduced in left ventricular membranes of SNX rats, whereas effects of 10 micromol/liter GTP, 10 mmol/liter NaF, 10 micromol/liter forskolin and 10 mmol/liter Mn2+ were not altered. CONCLUSIONS: Cardiac beta-adrenergic responses are blunted in chronic uremia due to reduced isoprenaline-dependent activation of adenylyl cyclase. This might be caused by an "uncoupling" of the receptor or by an inhibition of the receptor by uremic toxins.

FP-receptor mediated trophic effects of prostanoids in rat ventricular cardiomyocytes.

The aim of this study was to characterize the receptor subtype involved in cardiac effects of prostanoids. For this purpose we determined in neonatal and adult rat cardiomyocytes effects of prostanoids on inositol phosphate (InsP)-formation (assessed as accumulation of total [(3)H]-InsP's in myo-[(3)H]-inositol pre-labelled cells) and on rate of protein synthesis (assessed as [(3)H]-phenylalanine incorporation), and on contractile force in left ventricular strips of the rat heart. For comparison, effects of prostanoids on InsP-formation and contractile force were determined in rat thoracic aorta, a classical TP-receptor containing tissue. Prostanoid increased InsP-formation and rate of protein synthesis in neonatal as well as adult rat cardiomyocytes; the order of potency was in neonatal (PGF(2alpha)>PGD(2)> or =PGE(2)> or =U 46619>PGE(1)) and adult (PGF(2alpha)>PGD(2)> or =PGE(2)>U 46619) rat cardiomyocytes well comparable. Moreover, in electrically driven left ventricular strips PGF(2alpha) caused positive inotropic effects (pD(2) 7.5) whereas U 46619 (up to 1 microM) was uneffective. In contrast, in rat thoracic aorta U 46619 was about 100 times more potent than PGF(2alpha) in increasing InsP-formation and contractile force. The TP-receptor antagonist SQ 29548 only weakly antagonized prostanoid-induced increases in rate of protein synthesis (pK(B) about 6) in rat cardiomyocytes but was very potent (pK(B) about 8-9) in antagonizing prostanoid-induced increases in InsP-formation and contractile force in rat aorta. We conclude that, in cardiomyocytes of neonatal and adult rats, the prostanoid-receptor mediating increases in InsP-formation and rate of protein synthesis is a FP-receptor. Moreover, stimulation of these cardiac FP-receptors can mediate increases in contractile force.

Effect of a silver device in preventing catheter-related infections in peritoneal dialysis patients: silver ring prophylaxis at the catheter exit study.

Catheter-related infections remain a significant cause of method failure in chronic peritoneal dialysis (PD) therapy. Given the increasing antibiotic resistance, such nonpharmacological strategies as local silver devices attract more interest. To establish whether a silver ring device (designed by Grosse-Siestrup in 1992) mounted onto the PD catheter and placed at the exit site at skin level is effective in preventing exit-site and other catheter-related infections, a prospective 12-month, multicenter, controlled study stratified by diabetes status was conducted. The study subjects were assessed by an extensive structured inventory, including a broad spectrum of control variables, such as age, body mass index (BMI), Staphylococcus aureus carrier status, catheter features, mode and quality of PD therapy, comorbidity, and psychosocial rehabilitation. Ten experienced German outpatient dialysis centers (seven adult, three pediatric) participated in the trial. All eligible patients (n=195) from the study area without catheter-related infections during the ascertainment period were included (incidental subjects undergoing PD therapy for at least 3 months). The main outcome measures were the occurrence of first exit-site infections (primary study end point), sinus tract/tunnel infection, and peritonitis. Ninety-seven patients were assigned to the silver ring and 98 patients to the control group. Baseline characteristics of age, sex, proportion of pediatric and incidental patients, S aureus carrier status, and other variables were similar in both groups. The incidence of infections in the silver ring group versus the control group was as follows: 23 of 97 versus 16 of 98 patients had exit-site infections, 12 of 97 versus 12 of 98 patients had sinus tract/tunnel infections, 16 of 97 versus 18 of 98 patients had peritonitis, respectively. Kaplan-Meier analysis for the probability of an infection-free interval showed no statistical difference (log-rank test) between the two groups. Displacement of the silver ring contributed to study termination in 6% of the study group patients, including two patients with catheter loss. Univariate analysis and multiple logistic regression identified younger age (<50 years), low serum albumin level (<35 g/L), number of previously placed PD catheters, short cuff-exit distance (<2 cm), and S aureus nasal carriage as risk factors for the development of exit-site infections. In conclusion, our study does not show any benefit of the silver ring in preventing catheter-related infections in PD patients. Thus, prevention of infection-related method failure in PD still has to rely on conventional antibiotic treatment strategies and less so on alternative methods.

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.

ET-receptor function in relation to blood pressure in spontaneously hypertensive and aortic-banded rats.

Endothelin-1 (ET-1), a potent endogenous vasoconstrictor, has been proposed to play a pathophysiologic role in hypertension. The aim of this study was to find out whether changes in ET-receptor function are cause or consequence of blood pressure elevation in hypertension. For this purpose, we assessed ET-receptor function [as ET-1-induced [3H]inositol phosphate (IP) accumulation] in slices of left ventricle and renal cortex and in rings of thoracic and abdominal aorta from spontaneously hypertensive rats (SHR) at the age of 8 weeks (i.e. developing hypertension), 12 and 24 weeks (established hypertension) vs. normotensive age-matched Wistar-Kyoto (WKY) rats, and from supra-renal aortic-banded (AOB) rats at the age of 8, 12 and 24 weeks (i.e. 4, 8 and 20 weeks after AOB) vs. sham-operated (SOP) age-matched WKY rats. In the SHR with established hypertension ET-1-induced IP formation was altered in all tissues investigated: it was significantly increased vs. WKY rats in left ventricle, and significantly decreased in renal and aortic tissues. Similarly, in AOB rats at all ages ET-1-induced IP formation was changed in those tissues that were under pressure load [heart (increase) and thoracic aorta (decrease)] vs. SOP rats, whereas in those tissues not under pressure load (kidney and abdominal aorta) ET-1-induced IP formation was not different between AOB and SOP rats. Moreover, in 8-week-old SHR (where hypertension is not yet established) ET-1-induced IP formation was not significantly different compared to WKY rats (with the exception of thoracic aorta). We conclude that, at least in SHR and AOB rats, changes in ET-1 signalling are secondary to the elevation in blood pressure.

Theophylline kinetics in peripheral tissues in vivo in humans.

Several biochemical and cellular effects have been described for methylxanthines under in vitro conditions. However, it is unknown, whether threshold concentrations required to exert these effects are attained in target tissues in vivo. We therefore employed the microdialysis technique for measuring theophylline concentrations in peripheral tissues under in vivo conditions. Following in vitro and in vivo calibration, microdialysis probes were inserted into the medial vastus muscle and into the periumbilical subcutaneous adipose layer of healthy volunteers. Following single oral dose administration of 300 mg or i.v. infusion of 240 mg theophylline, in vivo time courses of theophylline concentrations were monitored in tissues and plasma. Major pharmacokinetic parameters (cmax, tmax, AUC) were calculated for plasma and tissue time courses. The mean AUCtissue/AUCplasma-ratio was 0.56 (p.o.) and 0.55 (i.v.) for muscle and 0.55 (p.o.) and 0.72 (i.v.) for subcutaneous adipose tissue. We conclude that microdialysis provides important information on the distribution and the tissue pharmacokinetics of theophylline.

Gq/11-coupled receptors and protein synthesis in rat cardiomyocytes: role of Gi-proteins and protein kinase C-isozymes.

Our recent findings indicate that, in rat neonatal ventricular cardiomyocytes, endothelin-1 (ET-1) induces increases in the rate of protein synthesis in a partly pertussis toxin (PTX)-sensitive manner, and that angiotensin II-evoked increases in the rate of protein synthesis are brought about via local secretion of ET-1. The aim of this study was to find out: (1) whether noradrenaline (NA) and the thromboxane A2 (TXA2)-mimetic U 46619-induced increases in the rate of protein synthesis may be also partly PTX-sensitive and/or mediated by ET-1, and (2) whether the growth-promoting effects of NA and U 46619 as well as ET-1 might involve activation of the same set of protein kinase C (PKC) isozymes. For this purpose we first studied the effects of NA and U 46619 on inositol phosphate (IP)-formation (assessed as accumulation of total [3H]IPs in myo-[3H]inositol prelabelled cells) and on the rate of protein synthesis (assessed as [3H]phenylalanine incorporation) (1) in the presence and absence of the ET(A)-receptor antagonist BQ-123, and (2) in nontreated and PTX-pretreated cells. Second, we assessed the effects of the PKC-inhibitors bisindolylmaleimide I and Gö 6976 and of phorbol-12-myristate-13-acetate (PMA; 1 microM overnight)-pretreatment on U 46619-, NA- and ET-1-induced increases in the rate of protein synthesis. NA (0.01-10 microM) concentration-dependently increased IP-formation (maximum increase: 115-/+23% above basal, n=4) and [3H]phenylalanine incorporation (maximum increase: 40+/-3% above basal, n=20). Both responses were antagonized by the alpha1-adrenoceptor antagonist prazosin (1 microM), but were not significantly affected by BQ-123 (1 microM). U 46619 (0.01-100 microM) concentration-dependently increased IP-formation (maximum increase: 89+/-12% above basal, n=8) and [3H]phenylalanine incorporation (maximum increase: 33+/-4% above basal, n=16). Both responses were slightly but significantly antagonized by the TP-receptor antagonist SQ 29548 (1 microM), but were not affected by BQ-123 (1 microM). Pretreatment of the cardiomyocytes with 250 ng ml(-1) PTX overnight did not significantly affect NA- and U 46619-evoked increases in IP-formation and [3H]phenylalanine incorporation. The PKC-inhibitor bisindolylmaleimide I (5 microM) as well as pretreatment of the cells with PMA (1 microM) significantly reduced the effects of NA, U 46619 and ET- I on the rate of protein synthesis; in contrast, the PKC-inhibitor Gö 6976 (5 microM) was without any effects. We conclude that, in rat neonatal ventricular cardiomyocytes, stimulation of Gq/11-coupled receptors increases the rate of protein synthesis; this involves activation of the same PKC-isozymes (very likely PKC-delta and/or -epsilon). NA and U 46619 cause their growth-promoting effects in a PTX-insensitive manner; ET-1 is not involved in their effects.

Nitric oxide inhibits isoprenaline-induced positive inotropic effects in normal, but not in hypertrophied rat heart.

Evidence has accumulated that, in the rat heart, nitric oxide (NO) inhibits beta-adrenoceptor-mediated positive inotropic effects. The aim of this study was to investigate whether this effect of NO may be altered in cardiac hypertrophy. For this purpose we studied the effects of the NO-donor SNAP (S-nitroso-N-acetyl-D,L-penicillamine) on isoprenaline-induced positive inotropic effects in left ventricular strips from three models of cardiac hypertrophy: a) 12-16 weeks old male spontaneously hypertensive rats (SHR) vs. age-matched normotensive Wistar-Kyoto (WKY) rats, b) six weeks old male Wistar WKY-rats sub-totally nephrectomized (SNX) 7 weeks after SNX vs. sham-operated rats (SOP) and c) four weeks old male Wistar WKY-rats supra-renal aortic-banded (AOB, band diameter 1.0 mm) 8 weeks after AOB vs. SOP. In all three models of cardiac hypertrophy the heart weight/body weight ratio was significantly higher than in their respective controls. On isolated electrically driven ventricular strips isoprenaline (10(-10)-10(-5) M) caused concentration-dependent increases in force of contraction. Maximal increases (Emax) were similar in SHR vs. WKY-rats, but reduced in SNX- (2.9+/-0.29 vs. 5.1+/-0.34 mN, p<0.01) and AOB-rats (2.3+/-0.37 vs. 4.2+/-0.33 mN, p<0.01). In control rats (WKY and the respective SOP) the NO-donor SNAP (10(-5) M) caused a significant rightward-shift of the concentration-response curve for isoprenalinel; this rightward-shift could be inhibited by methylene blue (10(-5) M). In ventricular strips of SHR, SNX- and AOB-rats, however, 10(-5) M SNAP failed to significantly affect isoprenaline-induced positive inotropic effect. We conclude that in cardiac hypertrophy effects of NO are attenuated. Such an impairement of the NO-system could contribute to the development and/or maintenance of cardiac hypertrophy.

Noradrenaline-induced increase in protein synthesis in adult rat cardiomyocytes: involvement of only alpha1A-adrenoceptors.

Adult rat ventricular cardiomyocytes contain alpha1A- and alpha1B-adrenoceptors (ARs, 20%:80%, assessed by [3H]prazosin binding). We studied which alpha1-AR subtype mediates noradrenaline (NA)-induced increase in rate of protein synthesis, and which signalling pathway is involved. NA (10-9-10-4 M) concentration-dependently increased inositol phosphate (IP) formation (pEC50-value=6.1+/-0.1, n=5) and protein synthesis (assessed as [3H]phenylalanine incorporation; pEC50-value=6.6+/-0.1, n=6). NA-induced IP-formation was partly inhibited by the alpha1B-AR antagonist chloroethylclonidine (CEC, 30 microM; 33+/-9% inhibition, n=5); following CEC-treatment the alpha1A-AR-selective 5-methyl-urapidil (5-MU) inhibited NA-induced IP-formation with a pKi-value of 9.2+/-0.2 (n=6); the alpha1D-AR-selective BMY 7378 was only a weak antagonist (pKi-value <7). NA-induced increase in protein synthesis was insensitive to CEC whereas 5-MU inhibited it with a pKi-value of 9.1+/-0.2 (n=6). NA (1 microM)-induced increase in protein synthesis was inhibited by the protein kinase C (PKC) inhibitor bisindolylmaleimide (IC50-value: 206 nM), the PI 3-kinase inhibitors wortmannin (IC50=3.4 nM) and LY 294002 (IC50=10 microM), and p70s6-kinase inhibitor rapamycin (IC50=123 pM) but not by the p38 MAP-kinase inhibitor SB 203580 (10 microM) or the MEK-inhibitor PD 98059 (25 microM). Moreover, 5-MU (30 nM) but not CEC inhibited NA-induced activation of p70s6-kinase. We conclude that, in adult rat cardiomyocytes, alpha1A- and alpha1B-AR mediate NA-induced IP-formation but only alpha1A-ARs mediate increase in protein synthesis. Alpha1A-AR-mediated increase in protein synthesis involves activation of a PKC, PI 3-kinase and p70s6-kinase but not of ERK- or p38 MAP-kinase.

Further advances of chronic renal replacement therapy in eastern Germany, 1994 versus 1989.

Unlike the other former Soviet-block countries, Eastern Germany/the "GDR", had the opportunity to the re-unification with a highly developed western country, the Federal Republic of (West) Germany in 1990. In order to record the following rapid improvements in renal replacement therapy, we performed our own survey in Eastern Germany--excluding Eastern Berlin--by questionnaire, comparing the years 1989/December, and 1994/December. 112 of the 113 dialysis facilities for adult regular dialysis patients replied to our questionnaire (99%). From 1989 to 1994, the number of dialysis centers increased from 53 to 113 (-->213%), reaching 7.9 centres p.m.p. Of these facilities, 29% were hospital centers, 48% were private dialysis units, and 23% were run by nonprofit dialysis organizations. The number of dialysis stations increased from 602 to 1,719 (-->286%), i.e. 120 stations p.m.p. The number of patients in regular dialysis treatment rose from 2,127 to 5,335 (-->251%), that means a prevalence of 373 patients p.m.p. In 1989, 67 new patients (p.m.p.) had been accepted for maintenance treatment (incidence), in contrast to 130 new patients p.m.p. in 1994 (-->194%), now under the conditions of unlimited accessibility to dialysis treatment. Questions referring to this point--the incidence of new patients--were only asked in Thüringen (2.5 mio. inhabitants). Alternative treatment modalities became feasible under the new conditions in Eastern Germany. In contrast to 99% hemodialysis patients in December 1989, at the end of 1994 92.8% of the patients were treated by hemodialysis, 2.0% by hemofiltration, and 5.2% by peritoneal dialysis, predominantly CAPD.(ABSTRACT TRUNCATED AT 250 WORDS)

Is interleukin-6 concentration in the dialysate of continuous ambulatory peritoneal dialysis patients a prognostic parameter in peritonitis?

In continuous ambulatory peritoneal dialysis (CAPD) patients, peritonitis is a dangerous complication. Chemical examinations in the dialysate can be successfully used to assess permeability disturbances, hemostatic balance, and (for early detection and follow-up) cellular inflammatory reaction. In 7 CAPD patients (age: 50 +/- 15 years; dialysis duration: 40 +/- 24 months) with peritonitis episodes, and in 17 age-matched CAPD patients (age: 50 +/- 13 years; dialysis duration: 29 +/- 18 months) without peritonitis, we examined daily dialysate cell count (CC) and concentrations of albumin (ALB), immunoglobulin G (IgG), thrombin-antithrombin III complex (TAT), D-dimer (DD), and interleukin-6 (IL-6) after the long dwell (8-10 hours) over an interval of at least 14 days. In CAPD patients with peritonitis episodes, all parameters (CC, ALB, IgG, TAT, DD, IL-6) were significantly increased in the first days [IL-6 mean: 25,190 pg/mL (range: 2560-52,708 pg/mL) vs 66 pg/mL (range: 21-163 pg/mL)]; then, up to day 14 after successful therapy with antibiotics, the levels showed no differences as compared with CAPD patients without peritonitis. In the case of relapse of peritonitis (4 cases), concentration of IL-6 rose again on day 14, 1 day earlier than did the other parameters. Determination of IL-6 in the dialysate is a reliable prognostic parameter for the course of peritonitis (start, end, relapse) in CAPD patients.

[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.

[Living donor and kidney transplantation]. / Lebendspende für die Nierentransplantation.

The medical, immunological and surgical histories of the transplantation of kidneys from a living donor have been developed differently. Living kidney transplantation involves better organ quality and also better kidney function than postmortem kidney transplantation. In Germany, living kidney transplantation is legally based on the transplantation statute of 1997. Traditionally, retroperitoneoscopic open nephrectomy is the gold standard used by most transplantation centers in Germany. The laparoscopic hand-assisted nephrectomy is a very good alternative to other surgical methods, but must be applied by experience surgeons. Digital subtraction angiography gives the best information on the maintenance of the vessels of the kidney, the vessels to the upper or lower poles and the retrocaval course of the venous vessels. The rate of postoperative complications for transplantation from a living kidney donor is lower than that for postmortem kidney transplantation. The formation of a donor organ registry can be very helpful in the evaluation and handling of information on organ donation.

[Determination of renal function in clinical routine: which is the best method?]. / Bestimmung der Nierenfunktion im klinischen Alltag--welche Methode ist die beste?

BACKGROUND AND OBJECTIVE: Accurate quantification of renal function is important for diagnosing and monitoring progression of renal diseases and for calculating adequate doses of drugs that are excreted by the kidneys. Gold-standard procedures are too complex for routine clinical use. At the moment there are several formulae to choose from, all said to estimate renal function precisely enough for clinical purposes. It was the aim of this study to compare the accuracy of several of these in clinical routine. PATIENTS AND METHODS: The results of inulin clearance were compared with those calculated by the Cockcroft-Gault formula (CGF), abbreviated diet modification of renal disease (MDRD) formula, the Mayo formula and the cystatin C-based formula as proposed by Larsson et al. Included were 189 in-patients (aged 20-87, 40% of them women, range of inulin clearance 8-244 ml/min/1,73m). In addition, inulin clearance was compared with creatinine clearance in 142 patients (aged 20-87 years, 42% women. Inulin clearance 13-244 ml/min/1,73m). Bland-Altman diagrams were drawn and mean bias and standard deviation of the formulae were compared with inulin clearance, as were sensitivity and specifity for diagnosing reduced renal function. RESULTS: All formulae underestimated glomerular filtration rate (GFR), with CGF and MDRD formulas giving the best results. These formulae had a mean bias of -16.2 (SD 24.8) and -18.2 (SD 25.6) ml/min/1,73m (2) , respectively. All creatinine-based formulae showed a high sensitivity and specifity for diagnosing a GFR below 60 ml/min/1,73m (2). CONCLUSION: None of the estimating formulae can replace inulin clearance with adequate accuracy. In our patients the cystatin C formula of Larsson et al showed no advantage. But the MDRD formula, which can be calculated without knowing body weight, is as accurate and precise as CGF.

[Abscettic pneumonia in a renal transplantation female patient]. / Abszedierende Pneumonie bei einer nierentransplantierten Patientin.

A 39-year old female patient who was kidney transplanted three years ago was admitted to hospital with fever of unknown origin for several days. Blood samples revealed decreased renal function and increased inflammation parameters. Chest X-ray and CT scan showed multiple cavernous structures, some with liquid. Staphylococcus aureus was detected in blood culture samples. With the aid of these results Staphylococcus pneumonia with multiple abscesses was diagnosed. The treatment consisted of removal of the infectious focus and a systemic antibiotic therapy corresponding to the microbiologic results. We describe a case of Staphylococcus pneumonia caused by a infected vascular prosthesis under consideration of immunosuppression in a renal transplanted patient.

[Clinical aspects of the use of the artificial kidney]. / Klinische Aspekte beim Einsatz der künstlichen Niere.

During the last years the haemodialysis treatment in chronic uraemia has been admirably developed and improved. At now as ever high expenditure for the chronic dialysis programme the capacity at our disposal must optimally be used. For this it is necessary to detoxicate the patients in relatively short times of treatment as effective as possible. But the increase of the efficacy of the haemodialysis is limited, which is revealed in the fact that the patient under the highly effective treatment shows complications such as decrease of blood pressure, muscle spasms, nausea and vomiting as well as headache. The clinical findings of the patient may further depend on the age, on the dialysis technique being at our disposal, on the composition of the dialysis solution, the biocompatibility of the dialysis membrane, the level of the retention values as well as on nutrition, training condition of the patient, psychic factors and others. The scientific efforts for optimization of the haemodialysis treatment have the aim to realize a haemodialysis treatment adapted individually to each patient, in order to treat the individual patient as effective as possible, however, without complications.

[Incidence of bacterial infections during hemodialysis treatment]. / Zur Häufigkeit bakterieller Infektionen unter chronischer Hämodialysebehandlung.

44 chronic hemodialysis patients were evaluated over a period of 24 months regarding location and kind of bacterial infection, hospitalization, influence on rehabilitation and the course of infection episodes (IE). During 409,5 dialysis patients months (DPM) we observed 61 IE's, i.e. 14,9 IE per 100 DPM. Out of 59 hospitalization episodes 33 (56%) were due to bacterial infections. 774 from 1559 hospital days were caused by infections. In 6 cases IE was the cause of death. It could be excluded that duration of dialysis treatment, renal disease or uremic complications are correlating with bacterial infections.