Survival in dialysis patients is different between patients with diabetes as primary renal disease and patients with diabetes as a co-morbid condition.

AIMS/HYPOTHESIS: A previous study in Dutch dialysis patients showed no survival difference between patients with diabetes as primary renal disease and those with diabetes as a co-morbid condition. As this was not in line with our hypothesis, we aimed to verify these results in a larger international cohort of dialysis patients. METHODS: For the present prospective study, we used data from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry. Incident dialysis patients with data on co-morbidities (n = 15,419) were monitored until kidney transplantation, death or end of the study period (5 years). Cox regression was performed to compare survival for patients with diabetes as primary renal disease, patients with diabetes as a co-morbid condition and non-diabetic patients. RESULTS: Of the study population, 3,624 patients (24%) had diabetes as primary renal disease and 1,193 (11%) had diabetes as a co-morbid condition whereas the majority had no diabetes (n = 10,602). During follow-up, 7,584 (49%) patients died. In both groups of diabetic patients mortality was higher compared with the non-diabetic patients. Mortality was higher in patients with diabetes as primary renal disease than in patients with diabetes as a co-morbid condition, adjusted for age, sex, country and malignancy (HR 1.20, 95% CI 1.10, 1.30). An analysis stratified by dialysis modality yielded similar results. CONCLUSIONS/INTERPRETATION: Overall mortality was significantly higher in patients with diabetes as primary renal disease compared with those with diabetes as a co-morbid condition. This suggests that survival in diabetic dialysis patients is affected by the extent to which diabetes has induced organ damage.

Gadolinium and nephrogenic systemic fibrosis.

Nephrogenic systemic fibrosis (NSF) is characterized by red skin areas or plaques that over several weeks successively develop to painful thickened skin with a 'woody' texture, resembling 'peau d'orange'. Starting at the extremities, it may spread to the trunk, and may progressively inhibit flexion of adjacent joints. In skin biopsies of affected areas, thickened collagen bundles, mucin deposition, and proliferation of fibroblasts and elastic fibers are seen. Originally described as nephrogenic fibrosing dermopathy (NFD) because of its primarily cutaneous manifestation, this entity was then named NSF because of systemic involvement of other organs like lungs, myocardium, or striated muscles. The pathogenesis of the disease is not yet known, but our observations suggest a close association between development of NSF and exposure to gadolinium-containing contrast agents, thereafter confirmed by other authors. Recently, gadolinium was demonstrated to be detectable in skin tissue samples of affected patients. In this short review, the development of NSF and its sequential association with the exposure to gadolinium-containing contrast agents is presented. The mechanisms likely to cause NFD/NSF are discussed.

Initial subcutaneous embedding of the peritoneal dialysis catheter--a critical appraisal of this new implantation technique.

BACKGROUND: The objectives of this open non-randomized study were to evaluate the impact of a new peritoneal catheter placement technique on catheter maintenance, and complications possibly related to the access, e.g. leakage, infectious complications, or drainage failure. METHOD: In a routine clinical setting, a two-cuff swan-neck catheter was implanted surgically, but its external segment was embedded in a subcutaneous pouch initially without exit site to enable uncontaminated wound healing and tight ingrowth of the cuffs. After 4 weeks at the earliest the distal catheter tip was set free by a small incision under local anaesthesia, and CAPD was started. RESULTS: Using this technique, 26 catheters were implanted in 17 males and nine females (mean age 52.3 +/- 17.4, range 19-83 years). The catheters were buried subcutaneously for a median of 79.5 (mean +/- SD 132.2 +/- 157.2, range 28-675) days, and were activated in 21 patients. No leaks were seen, and only one abdominal wall abscess secondary to a haematoma was found. Long-term follow up (mean duration of CAPD 467.0 +/- 338.1, range 32-1320 days) revealed a very low overall incidence of infectious complications, i.e. 0.80 per patient-year (1 episode per 14.9 patient-months), and the incidence of catheter-related peritonitis amounted to 0.036 per patient-year (1 episode per 27.2 patient-years), only. However, the postoperative course was complicated by seromas in two of 26, and subcutaneous haematomas in 12 of 26 patients, five of which were revised surgically. At catheter activation, fibrin thrombi were found in nine of 21 patients and two had to be operated. Omental catheter obstruction was diagnosed in four patients, and followed by omentectomy. No relationship was seen between thrombus formation and omental obstruction and duration of subcutaneous embedment (P = 0.27 and P = 0.5 respectively) or patient age (P = 0.06 and P = 0.13 respectively; Mann-Whitney-test). There was also no relationship with primary omentectomy or haematoma. CONCLUSION: We conclude that although the very low incidence of infectious episodes favours the new technique, further improvement is necessary to decrease the unacceptable rate of perioperative complications. Subcutaneous embedding of the catheter may then be considered in patients with expected problems of wound healing, and those who wish to be prepared for peritoneal dialysis in time.

[Comparison between ambulatory 24-hour blood pressure measurement and occasional blood pressure measurement in hemodialysis patients with left heart hypertrophy]. / Vergleich zwischen ambulanter 24-h-Blutdruckmessung und Gelegenheitsblutdruckmessung bei Hämodialysepatienten mit Linksherzhypertrophie.

Since 24-hour blood pressure monitoring seems to be superior to occasional blood pressure measurement as far as risk stratification is concerned, we compared the two methods in patients with secondary hypertension and left ventricular hypertrophy. In 26 haemodialysis patients (12 male, mean age 54 +/- 13 years), the mean occasional blood pressure values during haemodialysis were 147 +/- 18/82 +/- 9 mmHg, the mean 24-hour blood pressure values were 145 +/- 21/ 85 +/- 13 mmHg, during the day 145 +/- 23/86 +/- 13, during the night 143 +/- 25/81 +/- 13 mmHg. The nocturnal reduction of mean blood pressure was -3.6 +/- 7%. Both methods of blood pressure monitoring showed a significant correlation with the relevant echocardiographic parameters of left ventricular hypertrophy, cardiac mass and interventricular septum diameter. Patients with and without a nocturnal reduction in blood pressure could not be differentiated by the mean occasional blood pressure values. Therefore, 24 h ambulatory blood pressure monitoring seems warranted in this high risk group, especially to monitor antihypertensive drug therapy.

Parameters of prognostic relevance to the patency of vascular access in hemodialysis patients.

The objectives of this study were to evaluate whether age, sex, underlying renal disease, or the performing surgeon is of prognostic relevance to the patency of the vascular access. In a routine clinical setting, 139 first and 144 further fistula operations were done in 139 patients during 5 yr and were analyzed in retrospect. Within a group of 108 patients with first Cimino-Brescia fistulae, Cox multivariate regression analysis revealed the surgeon to be the only determinant with a continuous, significant effect on fistula patency throughout the observation period (P(out) < 0.1). The patency rates of the seven surgeons at 1, 2, and 3 yr differed from 34 to 69, 13 to 62, and 13 to 62%, respectively. Hazard ratios among the surgeons varied from 0.65 to 2.21. Additionally, age (P < 0.004) and diabetes mellitus (P < 0.02) were disclosed to be significant risk factors for impaired patency, but later in the course of disease (time dependent). Sex had no influence. After the failure of the first fistula, revisions of or new Cimino-Brescia fistulae (N = 56) were superior to polytetrafluoroethylene grafts (N = 61). The mean patency of the former amounted to 320 +/- 377 versus 156 +/- 281 days in polytetrafluoroethylene grafts (P < 0.05). It was concluded that increasing age and diabetes mellitus are time-dependent risk factors for the shortened patency of arteriovenous fistulae. The operating surgeon, however, seems to be the major determinant for the continuous patency of Cimino-Brescia fistulae.

[Spontaneous regression of a small cell bronchial carcinoma]. / Spontanregression eines kleinzelligen Bronchuskarzinoms.

A circular focus of 1 cm diameter was discovered by chance on a thoracic x-ray of a female patient of 66 years of age suffering from chronic interstitial nephritis due to analgesics. Bronchoscopic suction revealed histologically a small-cell carcinoma of the lung but there was no indication of formation of metastases. The patient refused any tumor-specific treatment. In the further course of the disease the focus showed up radiologically for seven months and was then no longer visible throughout the following 14 months. The patient finally died subsequent to an extensive posterior myocardial infarction. Postmortem examination excluded the presence of a primary tumor of the lung or metastases. Our case suggests the rare occurrence of a spontaneous regression of a small-cell bronchial carcinoma. Although spontaneous regression of malignant diseases is ascribed to immunological factors, such regression can also occur if the immunological system is impaired, as had been the case in this particular patient with chronic renal insufficiency.

The influence of ACE-inhibition on myocardial mass and diastolic function in chronic hemodialysis patients with adequate control of blood pressure.

The objectives of this study were to evaluate the specific effect of the ACE-inhibitor lisinopril on myocardial mass and diastolic function in uremic patients using a protocol designed to leave blood pressure unchanged. Nineteen hemodialysis patients (7 males; mean age: 55 +/- 13 years; mean time on dialysis: 44 +/- 35 months) received lisinopril for 6 months in addition to their preexistent antihypertensive treatment regimens (mean: 1.4 +/- 0.8 drugs). Doses of antihypertensive drugs were adjusted to keep both systolic and diastolic blood pressure stable. Nine patients were withdrawn from lisinopril treatment after 43 +/- 33 days because of hypotension (n = 4), withdrawn consent (n = 3), stroke (n = 1) and cough (n = 1). Seven of them were further studied as controls. Ten patients received 6.4 +/- 4 mg lisinopril as a mean for 6 months. Mean myocardial mass, calculated by M-mode echocardiography, was 324 +/- 103 g before, and 313 +/- 79 g after 6 months of lisinopril treatment. In the control patients, myocardial mass was 318 +/- 110 g initially, and after 6 months, it was 334 +/- 159 g. Early and late transmitral diastolic flow velocities were not significantly influenced by lisinopril. Throughout the study, both the systolic and diastolic 24-h mean blood pressure levels remained stable (systolic: before: 145 +/- 19 mmHg, at 6 months: 147 +/- 17 mmHg; diastolic: before: 87 +/- 12 mmHg, at 6 months 87 +/- 10 mmHg). Thus, no specific effect of lisinopril on regression of myocardial hypertrophy or improvement of diastolic function could be observed within a 6-month period in this small group of hemodialysis patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Sudden onset of paralysis in a twenty year-old male patient.

We report on a twenty year-old male patient who presented with sudden onset of flaccid paralysis. After exclusion of central nervous system involvement, marked hypokalemia pointed to the diagnosis of hypokalemic periodic paralysis, which was completely reversible on oral and parenteral potassium substitution. A provocation test with glucose and insulin administration leading to hypokalemia and incipient paralysis of the limbs confirmed the diagnosis. Pathogenetically, this syndrome is characterized by an excessive shift of potassium ions into the muscle cells. Therapeutic measures include potassium-sparing diuretics, beta blockers, acetazolamide or diclofenamide. In less severe cases, oral potassium may be sufficient to reverse the symptoms.

Ventricular late potentials in haemodialysis patients and the risk of sudden death.

Cardiovascular diseases account for approximately 50% of deaths in patients on chronic haemodialysis. Therefore we prospectively studied 54 consecutive patients on dialysis for the presence or absence of ventricular late potentials (LP). LP, i.e. low-amplitude potentials in the terminal part of the QRS complex, have been shown to be highly indicative of life-threatening arrhythmias and sudden death. The results were correlated with echocardiographic studies and the clinical outcome during a follow-up period of 18 months. Fifty patients were suitable for evaluation (29 males, 21 females; mean age 55 years; mean time on dialysis 32 months; coronary artery disease present in 5) Our analysis revealed LP in seven of 50 patients only. Left ventricular hypertrophy, i.e. mean wall diameter > 12 mm, was present in 78%, a compromised left ventricular function, i.e. shortening fraction < 28%, was found in 28% of the patients. With respect to echocardiographic parameters, patients with and without LP were similar. During follow-up, sudden cardiac death was observed in three of 11 patients deceased. LP were detectable in one of the three only. From the remaining six patients with LP, four are still alive, and two patients died due to atherosclerosis and pulmonary embolism. Our data underline the crucial role of sudden cardiac death in dialysis patients. Ventricular late potentials, however, are of no prognostic relevance with respect to identification of dialysis patients at risk of sudden death.

Beta 2-microglobulin. A reliable parameter for differentiating between graft rejection and severe infection after cardiac transplantation.

We investigated the role of beta 2-microglobulin as a noninvasive parameter to monitor acute rejection and severe infection in 45 consecutive heart transplant recipients. Endomyocardial biopsy revealed moderate (41 patients) or severe (three patients) rejection in 44 patients. Severe infections of bacterial septicemia (11 patients), bronchopneumonia (two patients), and viral infection (seven patients) were detected by a meticulous schedule of various clinical and laboratory tests. beta 2-Microglobulin levels in serum, generally corrected for serum creatinine, were significantly elevated in patients with infections (median, 6.3 mg/l; range Q10-Q90, 3.47-10.27 mg/l) compared with levels in patients with rejection (p less than 0.0001) or in patients in obviously good condition (p less than 0.0001). At the onset of acute rejection, the median corrected beta 2-microglobulin serum level was 1.56 mg/l (range Q10-Q90, -0.05-3.46 mg/l) and was significantly different from the control group (p less than 0.01). In addition, density function and empirical quantile analyses allowed us to define ranges of beta 2-microglobulin levels that would differentiate between rejection (2.05-3.46 mg/l) and infection (greater than 3.46 mg/l). With these values, sensitivity and specificity were 0.9 and 0.938 for detection of infection and 0.23 and 0.925 for detection of rejection, respectively. By means of beta 2-microglobulin, two cases of infection were misinterpreted as rejection (10%), and four of 44 rejections were mistaken for infections (9%). We conclude that measurements of beta 2-microglobulin may improve the management of heart transplant patients.

Duration of first remission as an indicator of long-term survival in chronic myelogenous leukaemia.

Approximately 31 patients with chronic myelogenous leukaemia (CML) are documented in the literature who survived more than 10 years after diagnosis. We present a CML-patient whose survival of 27 years is probably the longest reported so far. The analysis of the course of disease in these patients revealed that the duration of unmaintained first remission after chemotherapy is of high prognostic significance. In 17 of 24 evaluable patients the remission lasted more than 1 year and in another five at least 6 months (mean 73.8 months, range 0-240 months). In most patients busulfan was used as initial therapy. There was no correlation between the amount of drug given and the duration of remission or survival. Other parameters such as sex, age, initial leucocyte counts, differential count, haemoglobin, platelet count or spleen size seemed to have no prognostic relevance. While approximately 25% of CML patients with typical duration of survival exhibit a Ph1 chromosome mosaicism only, this finding was present in nearly half of the long-term survivers.