[Kidney diseases in the elderly from the internal medicine viewpoint. Diagnosis and therapy]. / Renale Erkrankungen im Alter aus internistischer Sicht. Diagnostik und Therapie.

In the conservative and dialysis treatment of renal disease in the elderly, the methods employed are the same as those applied in the young patient. The various procedures for the qualitative and quantitative determination of protein in the urine are non-stressful and therefore of special value in the old patient. The diagnostic usefulness, in particular for follow-up observation of renal disease, is very high. With respect to the use of dialysis in the elderly, the various methods of peritoneal dialysis-CAPD, IPD and CCPD-have all proved beneficial. Since they do not particularly stress the circulatory system, they can be used in patients with coronary heart disease, arterial occlusive disease, or hypertension. For the choice of therapeutic procedure, the individual assessment of his life situation by the patient himself is of major importance.

[Involvement of the pericardium in Churg-Strauss syndrome]. / Beteiligung des Perikards bei Churg-Strauss-Syndrom.

In two patients (24 and 26 years old) with chronic bronchial asthma, allergic rhinitis, peripheral blood eosinophilia of 48% and 51%, respectively, mononeuritis multiplex and abnormal erythrocyte sedimentation rate, Churg-Strauss syndrome was diagnosed. Acute pericarditis with abnormal ECGs and compensatory sinus tachycardia was documented in both cases as a sign of systemic vasculitis. Echocardiography revealed hemodynamically relevant pericardial effusions of 1.3 cm and 2.7-3.2 cm leading in one case to slightly diastolic compression of the right ventricle. The pericardial lesions showed good response to diuretic therapy with furosemide and administration of immunosuppressive agents like cyclophosphamide and azathioprine in combination with corticosteroids. The two presented cases underline that pericardial effusions of hemodynamic significance can be prominent clinical features of Churg-Strauss syndrome.

Plasma lipids are not oxidized during hemodialysis.

Lipid peroxidation products, both lipid hydroperoxides and thiobarbituric acid reactive substances (TBARS) were determined in the plasma of 31 uremic patients treated with maintenance hemodialysis. Whereas patients had significantly elevated TBARS compared to 93 healthy controls (4.25 +/- 1.53 vs. 1.66 +/- 0.50 mumol/l; p < 0.01) lipid hydroperoxides were not detected in the plasma of patients before dialysis. After hemodialysis, a slight increase in TBARS was observed (4.50 +/- 1.97 mumol/l, p > 0.01). However, when the TBARS were corrected for hemoconcentration by relating TBARS to the plasma cholesterol concentrations a statistically significant decrease of TBARS was observed (1.02 +/- 0.63 mumol TBARS/mmol cholesterol vs. 0.84 +/- 0.60 mumol TBARS/mmol cholesterol; p < 0.01) after 240 min of hemodialysis. There was no evidence for the formation of plasma lipid hydroperoxides in the extracorporeal circulation. It is therefore suggested that elevated TBARS in chronic renal failure are not caused by the dialysis therapy.

Alpha 1-microglobulin (protein HC): features of a promising indicator of proximal tubular dysfunction.

alpha 1-Microglobulin (protein HC) is a stable urinary indicator protein which reflects acute and chronic dysfunctions of the proximal renal tubule. High urinary concentrations were found to be indicative of tubular drug toxicity, interstitial nephritis or chronic renal failure. The protein is synthesized by liver cells and readily associates with serum immunoglobulin A. Only the free form is filtered through the glomerulus and is reabsorbed by proximal tubular cells. The exact physiological function of this member of the new superfamily of lipocalins is still unknown, but there are indications that alpha 1-microglobulin (protein HC) may serve as an excretion vehicle for fluorescent, charge-heterogeneous substances of unknown nature. Additionally, it seems to be associated with the humoral and cellular immune response.

[Localization and extent of tissue damage caused by extracorporeal lithotripsy (ESWL)]. / Lokalisation und Ausmass einer Gewebeschädigung durch die extrakorporale Lithotrypsie (ESWL).

Extracorporeal shock wave lithotripsy (ESWL) causes proteinuria. In our study we investigated the protein fractions and the electrolyte composition of the urine in patients who had been treated with ESWL. The aim was to obtain information on the degree and the localisation of the glomerular, tubular or vascular destruction caused by ESWL in humans. A total of 34 patients with stones had been treated with ESWL. As parameters we used: urine output, creatinine clearance, total protein, albumin, immunoglobulin G, N-acetyl-beta-D-glucosaminidase (beta-NAG), alpha-1-microglobulin, the fractional excretion of Na+ and apolipoprotein-A-1. After ESWL treatment proteinuria and albuminuria are found. Our parameters show no deterioration of the glomerula or the tubulus. The increase in apolipoprotein-A-1, a postglomerular parameter, however, is interpreted as a manifestation of vascular destruction after ESWL; this is normally temporary, leaving no permanent damage.

[Hemolytic-uremic syndrome in an adult with T-cryptantigen liberation]. / Hämolytisch-urämisches Syndrom des Erwachsenen mit T-Kryptantigen-Freilegung.

Haemolytic uraemic syndrome was diagnosed in a 36-year-old woman with acute renal failure (creatinine 10.5 mg/dl), haemolytic anaemia (haemoglobin 9.7 g/dl, lactate dehydrogenase 1926 U/l) and thrombopenia (98,000/microliters). After initial plasmaphereses and high doses of furosemide all symptoms disappeared within three weeks. The lectin tests demonstrated that the illness was connected with the liberation of T-crypt-antigen (Thomsen-Friedenreich antigen) on the erythrocytes. This special form of the haemolytic uraemic syndrome (neuraminidase-induced haemolytic uraemic syndrome) has previously been observed almost exclusively in children. However, for diagnosis and differentiation of haemolytic uraemic syndromes the presence of liberated T-antigen on erythrocytes should also be tested for in adults.

Application of urinary indicator proteins in the non-invasive assessment of glomerulo-tubular lesions in patients with chronic glomerulonephritis and rheumatoid arthritis.

As the semiautomated electrophoretic analysis of proteinuria still needs technical experience, interest was focused on easy-to-perform methods of urinary protein measurement. SRID-tests for albumin, transferrin, IgG, alpha-1-microglobulin and a spectrophotometrical test for beta-NAG were carried out in 50 normal controls and compared to PCI/ECI-values of patients suffering from rheumatoid arthritis (n = 52) and various types of chronic glomerulonephritis (n = 41). Elevated levels of alpha-1-M and beta-NAG in chronic glomerulonephritis were interpreted as indicative for tubulointerstitial involvement in the chronic inflammatory process. PCI/ECI elevation in individual RA-samples may be caused by functional impairment of tubular protein handling due to chronic ingestion of non-steroid analgesics. The serum assays for transferrin (TF) and IgG based on SRID technique turned out to be too insensitive for the application on unconcentrated urine of normal control persons. In renal patients, however, TF-PCI values above 30 mg/g crea and IgG-PCI values above 50 mg/g crea have to be interpreted as pathologic indicating damage of the glomerular basement membrane. To elucidate TF- and IgG-values in urines with low protein content, highly sensitive nephelometric methods should be used. Concentration of urinary proteins using membrane filters may lead to protein losses, resulting in miscalculation of PC-indices.