[Risk factors for pneumonia in patients with cardiovascular diseases]. / Risikofaktoren für Pneumonien bei Patienten mit kardiovaskulären Grunderkrankungen.

A case-control-study was performed to identify patients at particularly high risk of community-acquired pneumonia and nosocomial pneumonia with a special focus on cardiovascular diseases as potential risk factors. Thirty-six consecutive hospitalized patients with cardiovascular diseases and pneumonia were matched with 36 controls also suffering from cardiovascular diseases but without pneumonia. From all cardiovascular diseases only heart failure proved to be an independent risk factor for pneumonia (OR 5.69, 95 % KI 1.69 - 19.04, p = 0.0048). Both chronic (p = 0.009) and acute heart failure (p = 0.028) were associated with an increased risk of pneumonia. The risk of pneumonia was closely related to the degree of ventricular function impairment. Coronary heart disease, valvular disease, arrythmia, myocarditis, endocarditis and cardiomyopathy did not increase the risk for pneumonia unless accompanied by heart failure. Pulmonary (OR 9.24, 95 % KI 1.48 - 57.74, p = 0.00174) and renal diseases (OR 7.49, 95 % KI 1.38 - 40.76, p = 0.0197) were validated as additional independent risk factors. A history of smoking was also associated with an increased risk of pneumonia (p = 0,023). This study supports the hypothesis that heart failure resulting from cardiovascular disease and not cardiovascular disease itself mounts the risk for pneumonia.

Inflammatory and immunological parameters in children with haemolytic uremic syndrome (HUS) and gastroenteritis-pathophysiological and diagnostic clues.

The objective of this study was to identify parameters indicating a risk for developing typical haemolytic uremic syndrome (D+HUS) during the prodromal phase of diarrhea caused by enterohaemorrhagic Escherichia coli (EHEC). Forty-eight children were studied prospectively with regard to inflammatory serum factors on admission to hospital. Ten patients developed D+HUS (group I), 15 suffered from viral-gastroenteritis (group IIa) and 23 from other types of bacterial gastroenteritis (group IIb). Mean levels of IL-8 tended to be elevated in group I compared to groups IIa and IIb. Neopterin and IL-10 levels particularly were significantly decreased in HUS in comparison to both gastroenteritis groups. Low IL-10 levels indicate a substantial disregulation of the immune response in HUS, as IL-10 downregulates the pro-inflammatory response and suppresses pro-coagulant activity in experimental endotoxemia. Our results suggest low neopterin, high IL-8 and especially low IL-10 levels are indicators of a high risk for developing HUS.

Hemolytic-uremic syndrome with involvement of basal ganglia and cerebellum.

Hemolytic-uremic syndrome is a microangiopathy often associated with neurologic symptoms. Several patients with persistent lesions in cerebrum and basal ganglia have been reported. We present two children with bilateral basal ganglia and additional unilateral cerebellar lesions in magnetic resonance imaging. These resolved completely in one child. In the other child there were still residuals after 11 weeks. The neurologic symptoms of both improved after several therapeutic plasma exchanges and disappeared after months.

Renal function in predialysis children with chronic renal failure treated with erythropoietin.

To assess the effect of long-term administration of human recombinant erythropoietin (EPO) on renal function, 11 anemic children aged 1.4-17.2 years were followed for 10-61 (mean 31) months on treatment. During EPO therapy the mean hemoglobin rose from 8.1 to 11.1 g/dl at the last observation. The final maintenance dose ranged between 70 and 300 U/kg per week. The rate of deterioration of renal function was calculated by comparing the slope of the regression lines of reciprocal serum creatinine values (SCr) derived from a mean of 20 values per patient obtained over 8-50 (mean 29) months before and a mean of 24 SCR values during EPO therapy. The individual slopes improved after initiation of EPO therapy in all but 3 patients, but the mean change of slope (from -0.0521 to -0.0299) was not significant. The study suggests that in most children with predialysis chronic renal failure long-term administration of EPO is not associated with accelerated deterioration but rather with delayed deterioration of renal function.

[Internal medicine complications of ventriculoatrial shunt]. / Internistische Komplikationen ventrikuloatrialer Shunts.

BACKGROUND: Ventriculo-atrial shunts (VASs) and ventriculo-peritoneal shunts (VPSs) are the symptomatic treatment of choice for hydrocephalus. Bacterial contamination of the atrial part of VASs (usually with Staphylococcus epidermidis) can result in further organ complications, in most instances immune complex mediated glomerulonephritis ("shunt-nephritis") or direct microbial heart valve destruction. PATIENTS AND METHODS: In a retrospective study, we analyzed clinical and laboratory data of 11 patients with VAS associated complications as well as the course of the disease. RESULTS: The following complications were observed: glomerulonephritis (n = 9), glomerulonephritis and aortic valve destruction (n = 1), pulmonary embolism, pulmonary hypertension and tricuspid valve insufficiency (n = 1). Out of the 11 patients, 8 suffered from unexplained fever. All 11 patients had elevated circulating immune complexes. In 3 of 4 patients initially requiring dialysis, renal function improved which allowed to stop hemodialysis. Renal function also improved in 3 of 5 patients who presented with elevated serum creatinine. Unfortunately, the patient with multiple pulmonary embolisms and tricuspid valve insufficiency died of progressive pulmonary hypertension. CONCLUSION: The prognosis for impaired renal function is good only if the VAS infection is diagnosed early and an immediate surgical and antibiotic treatment leads to an eradication of the underlying chronic infection.

Treatment of renal anemia by subcutaneous erythropoietin in children with preterminal chronic renal failure.

Eleven children aged 0.6-17 years with preterminal chronic renal failure and anemia (mean serum creatinine concentration 4.8 mg/dl; mean hemoglobin concentration 7.9 g/dl) were treated with sc injections of recombinant human erythropoietin (EPO, initial dose 150 U/kg/week) over a mean period of 13 months. When a target hemoglobin concentration of 11.5-13.5 g/dl was reached, the dose was adapted. Iron deficiency was corrected. Hemoglobin concentration increased by > 2 g/dl in all patients within 14-119 (mean 45) days. The last maintenance dose ranged between 75 and 300 (mean 133) U/kg/week. No major adverse effects were observed, except for hypertension which occurred in about half of the patients and necessitated interruption of EPO in one child with advanced renal failure. Additional antihypertensive drugs were given to five patients. Body height increased in two patients by 0.6 and 1.3 SDS/year, respectively. In six patients with a mean observation period of 14 months before and 16 months after the start of EPO, the mean slope of the reciprocal serum creatinine concentration curve improved slightly (p = 0.05). The proposed schedule appears to be safe for the treatment of renal anemia in most pre-dialysis patients. Frequent monitoring of hemoglobin, blood pressure, serum creatinine and ferritin is required.

Renal complications of infected ventriculoatrial shunts.

Contamination of a ventriculoatrial shunt (VAS) with skin organisms that are usually nonpathogenic may be followed by an immunologically mediated renal injury. The bacteria characteristically involved are coagulase-negative Staphylococci (e.g., Staphylococcus epidermidis), which strongly adhere to the plastic surface of the VAS. These bacteria are protected from the body's natural defense mechanisms and respond only poorly to antibiotics. As a result, their growth persists and produces a continuous antigenic stimulation. Circulating immune complexes (CIC) are an appropriate tool to screen for chronically infected VASs. We followed CIC in 138 VAS patients. An infected VAS was seen in 20 of the 24 patients with highly elevated CIC and in 1 of the 19 patients with moderately elevated CIC, but none of the 95 patients with normal CIC had evidence of shunt infection. Of the 21 patients with shunt infections, 8 had renal involvement (4 requiring dialysis, and 4 with proteinuria, hematuria, and/or elevated creatinine). Results from kidney biopsy specimens available from 4 patients confirmed glomerulonephritis. Of the 4 patients requiring dialysis at diagnosis, renal function recovered sufficiently to stop dialysis after successful VAS exchange in all but 1. In the other 4 patients, renal symptoms (proteinuria, creatinine) also improved after VAS revision. Chronic infection with S. epidermidis or other bacteria is a continuing problem in patients with VASs and can lead to an immune-mediated renal injury. However, the prognosis for reversal of the renal injury is relatively good if the VAS infection is treated promptly.

Survival time in cystinosis. A collaborative study.

In a retrospective study the overall survival time of 205 cystinotic patients of six countries was determined. The median survival time was 8.5 years. The median time for 'renal death' (age at death due to uraemia or age at starting renal replacement therapy) was 9.2 years. The youngest patient dying of renal death was 5.2 years. No sex difference in survival time was noticed. Furthermore no difference in survival time was noted between the different countries. The analysis of the overall survival curve indicates no clear differences between the infantile and adolescent types of cystinosis.

[Initial experiences with a new painless vascular approach in hemodialysis in children]. / Erste Erfahrung mit einem neuen schmerzfreien Gefässzugang für die Hämodialyse bei Kindern.

The necessity of hemodialysis in children is pointed out to be treated at specialized pediatric dialysis centers. In this connection a new vascular access is presented. The device is made from vitreous carbon and is mounted on a PTFE vascular prosthesis. By means of disposable connectors it can be dialysed without puncturing the implant. The device was implanted for the first time in the world in a small boy of 19 kg bodyweight. Our conclusion is that the biocarbon device is a welcome alleviation and an alternative for angio-access in children.

[Treatment and prognosis of segmental renal hypoplasia]. / Therapie und Prognose der segmentalen Nierenhypoplasie.

Among 140 children with vesicorenal reflux 14 patients were found to be suffering from renal insufficiency. Seven of these patients had histologically proven bilateral segmental renal hypoplasia. Thanks to early commencement and sustainment of antihypertensive therapy, the prognosis of the condition was decisively improved. It does not appear to be worse than in other forms of reflux nephropathy at the renal insufficiency stage. Clinical courses in which there is no deterioration in renal function for more than 10 years are not uncommon. It is also possible to perform an anti-reflux plasty at the renal insufficiency stage. It is thus possible to permanently eliminate feverish infections of the urinary tract.

Plasma inorganic sulfate in children with chronic renal failure.

Plasma sulfate concentration (SO4) was determined in 38 non-dialyzed children with chronic kidney disease and compared to inulin clearance and to other parameters of renal function. SO4 was measured by atomic absorption spectrophotometry. Plasma SO4 was inversely correlated with GFR and effective renal plasma flow. Positive correlations were found between plasma SO4, BUN, serum creatinine and serum phosphate levels. The highest levels of plasma SO4 were observed in 15 children undergoing regular dialysis. It is suggested that sulfate retention might be involved in the pathogenesis of uremic acidosis and bone disease.

[Haemofiltration in children. First experiences (author's transl)]. / Erste Erfahrungen mit der Hämofiltration--einem neuen Blutreinigungsverfahren--im Kindesalter.

Haemofiltration was used in 12 children with terminal chronic renal failure. This method is an alternative for short-term treatment of renal failure by haemodialysis and can be combined with the single-needle-technique. It was also used in a 2 years old girl with acute renal failure. The main advantages of haemofiltration versus haemodialysis are a more rapid removal of fluid in the presence of stable blood pressure readings and a good tolerance by the patient. The primary indication for haemofiltration is hypervolaemia. The high water and salt losses during the procedure have to be exactly calculated and substituted. According to our current experience the volume needed for substitution of filtrate by fluid to be infused i.v. has to be in the range of 50% of body weight.

Radiological kidney size in childhood.

Kidney length (KL), renal area and renal parenchymal area were measured on i.v. urograms of 255 children without apparent kidney disease age 0 to 14 years. These parameters were compared with age, body height, body surface area and the distance between the 1st and 4th lumbar vertebral body. In addition, renal parenchymal thickness was determined at the upper and lower poles. Mean values for normal KL were significantly greater on the left side than on the right side requiring separate growth charts. A mean increase in KL of 6.3 mm for the left and 6.0 mm for the right kidney was calculated for a change of 10 cm body height. A small kidney is defined by a KL below--2 SD for the corresponding body height and/or a quotient of right KL/left KL outside +/- 2 SD from the mean value. Localised loss of renal parenchyma is reflected by an increased or decreased quotient of the upper to the lower polar thickness and reduction of total kidney mass by a diminished bipolar parenchymal thickness related to body height.