[Diagnostic image (348). A man with peculiar calcifications on an abdominal X-ray]. / Diagnose in beeld (348). Een man met bijzondere verkalkingen op een buikoverzichtsfoto.

An X-ray of the abdomen of a diabetic dialysis patient showed typical signs of extra-skeletal calcification with mediasclerosis and calcification of the vasa deferentia.

[Daily problems involving contact with terminally ill patients with renal failure]. / Alltagsprobleme im Umgang mit terminal niereninsuffizienten Patienten.

Practitioners and physicians working in emergency rooms are often confronted with dialysis patients or patients who have received a kidney transplant. For dialysis patients, the mode of dialysis treatment needs to be assessed and dialysis access should be secured. Furthermore, the indications for the next dialysis treatment need to be determined. Dialysis patients often present themselves because of fluid overload, hypo- or hypertensive episodes, electrolyte disturbances, fever or cardiovascular events. Patients undergoing continuous peritoneal dialysis are at an increased risk of infection of the catheter or of peritonitis. Patients with a renal transplant require continuation of their immunosuppression and the function of the transplant should be monitored. These patients often present with infections in which case the degree of immunosuppression may need to be reduced. Vaccinations as well as an increased risk for malignancies require special attention in these patients.

Adenylate cyclase of gastric mucosa in patients with chronic renal failure.

It has been shown previously that antisecretory response of famotidine is altered in patients with renal failure. To evaluate the underlying mechanism(s) of this clinical observation we obtained biopsy specimens of fundic mucosa from 3 groups of patients with variable renal function (group 1 normal renal function (n = 16); group 2 chronic renal failure (n = 16), CLCR > or = 5 < 90 ml/min; group 3 hemodialysis therapy (n = 16)) (matched for age, sex, and Helicobacter pylori (Hp) status. In the homogenized samples adenylate cyclase (AC) activity was assessed and the influence of uremia on this second messenger system involved in gastric acid secretion was tested. AC activity was measured as the formation of cAMP, which was determined by RIA. The mean basal AC activity was 150 in group 1, 190 in group 2, and 120 pmol cAMP/mg protein/20 min in group 3. There was a dose-dependent stimulation by histamine (1 microM-1 mM). Emax of cAMP formation ranged between 230 and 403 pmol cAMP/mg protein/20 min and EC50 between 5.9 and 20.1 microM histamine, dependent on Hp status. Histamine-stimulated AC activation was reduced to about 50% by 0.1 mM famotidine. The sensitivity of AC to histamine seems to decrease in patients undergoing hemodialysis. Similarly, the colonization with Hp may result in decreased maximal response of the AC system towards histamine.

Influence of recombinant human erythropoietin on hematological and hemostatic parameters with special reference to microhemolysis.

Twenty chronic hemodialysis patients with renal anemia (hematocrit < 25%) received recombinant human erythropoietin (40 IU/kg body weight 3 x weekly) intravenously after each dialysis. Prior to and at 4, 8 and 12 weeks after commencement of erythropoietin therapy, hematocrit together with hemostasis and microhemolysis parameters were determined. There were significant increases in hematocrit, platelet count and platelet retention, but a significant fall in the initial clearly prolonged bleeding time. Free plasma hemoglobin likewise increased. Conversely, lactate dehydrogenase, prothrombin time, fibrinogen, antithrombin III activity, protein C activity and protein S concentration were all unaltered. The positive effect on bleeding time and platelet retention is most probably caused by an increase in adenosine diphosphate due to the hematocrit-dependent rise in the blood shear stress via physiologic microhemolysis (raised free plasma hemoglobin).

Diagnosis and treatment of a solitary infected hepatic cyst in two patients with adult polycystic kidney disease.

We report on two women (one 52-year-old who underwent kidney transplantation 15 months ago and the other, 71-year-old, undergoing hemodialysis) both with adult polycystic kidney disease who had to be hospitalized because of recurrent fever attacks up to 40 degrees C without any remarkable abdominal symptoms. Staphylococcus hominis and E. coli were recovered respectively from blood cultures of both patients. Evidence for the presence of a solitary infected cyst in the liver could only be obtained by computed tomography (CT) with i.v. administration of a contrast medium. In both cases the infected liver cyst was non-operatively drained with a CT-guided percutaneous catheter and therefore the necessity of laparotomy was avoided.

Response of vasoactive substances to intermittent ultrafiltration in normotensive hemodialysis patients.

The changes in blood volume (BV), atrial natriuretic peptide (ANP), plasma renin activity (PRA), aldosterone (Aldo), norepinephrine (NE), epinephrine (Epi), parathyroid hormone (PTH), arginine vasopressin (AVP) and the cyclic nucleotides cAMP and cGMP were measured during a fluctuating BV cycle in 15 patients with end-stage renal failure maintained on chronic hemodialysis (HD). HD consisted of 4 periods of about 60 min each. The first half of each HD period consisted of ultrafiltration (UF) greater than 1,000 ml/h, and the second half consisted of no UF. Changes in relative BV were measured using continuous hemoglobinometry. Total BV at the end of treatment was 74.3 +/- 6.9% of the pretreatment volume. A significant positive correlation between BV and the levels of ANP, PTH, Epi and cGMP and an inverse correlation between BV and PRA, Aldo, AVP and NE were demonstrated. While mean values of NE and AVP levels were directly related to actual changes in BV, individual values did not homogeneously reflect this relationship. The cyclic nucleotides cGMP and cAMP did not follow immediate BV changes, but showed a significant decrease correlated with diminished BV. Based on a pre-postdialysis analysis, significant changes in PRA and Aldo were missing. It seems possible that vascular stability in dialysis patients may be maintained by the response of NE and AVP, and not by the renin-aldosterone system. The changes in ANP and cGMP values correlated most significantly (r = 0.38 and r = 0.51, p < 0.005) with the changes in BV, but no single variable could explain the blood pressure regulation during HD with intermittent rapid UF.

[The signal behavior of parathyroid adenomas in MRT--the contrast ratio of the thyroid and fatty tissue]. / Das Signalverhalten von Nebenschilddrüsenadenomen in der MRT--Kontrastverhalten zu Schilddrüse und Fettgewebe.

A quantitative analysis of signal relationships using T1, proton and T2 weighted spin echo sequences was carried out using 20 parathyroid adenomas demonstrated by MRI. T1 weighted sequences from 15 adenomas were also examined following intravenous injection of Gd-DTPA. No typical signal relationship could be defined. In 4 cases the administration of contrast medium markedly increased the contrast between the adenoma and the thyroid gland. In 12 cases the tumour could be examined histologically following removal. In 2 cases there was oedema of the tumour and corresponding increased intensity of the T2 weighted sequences; in none of the other cases was there any clear correlation between the signals and the histology.

Vasoactive hormones during hemodialysis with intermittent ultrafiltration.

The correlations between actual blood volume (BV), blood pressure (BP), heart rate, and plasma levels of renin activity (PRA), serum aldosterone (ALD), antidiuretic hormone (ADH), epinephrine (E), norepinephrine (NE), atrial natriuretic factor (ANF), cGMP, and cAMP were investigated in 10 stable patients during HD. HD consisted of four periods of about 60 min each. One half with an UF rate greater than 1,000 ml/h, followed by a time interval of 30 min without UF resulting in a "saw tooth" profile of BV. Decrease in BV was measured by continuous hemoglobinometry. Average total decrease in BV was 25%, while BP and HR did not change significantly. E, NE, ANF and ADH levels were directly related to actual changes in BV, suggesting that BP regulation in this special mode of HD is mainly supported by endogenous catecholamine and ADH secretion. The second messenger cGMP did not follow actual BV changes, but showed a significant decrease correlated with diminished BV. A significant change in PRA and ALD was missing. It is concluded that vascular stability in these patients is maintained by the response of catecholamins and ADH to decrease in blood volume, and not by the renin-aldosterone system.

[Transfusion malaria in promyelocytic leukemia]. / Transfusionsmalaria bei Promyelozytenleukämie.

Five weeks after re-induction treatment and nine days after discharge from hospital, remittent fever occurred in a 34-year-old woman with promyelocytic leukaemia in full remission. She also had haemolytic anaemia and thrombocytopenia, as well as a reduced creatinine clearance. Findings on physical examination were unremarkable, but Falciparum malaria was found in the blood smear. Infusion of erythrocyte or platelet concentrates, administered in treating the leukaemia, was the probable source of the infection. Ten days after starting the administration of chloroquine and sulfadoxine-pyrimethamine she was discharged from hospital, cured of the malaria.

Adrenaline sensitive adenylate cyclase in human gastric mucosa.

Basal and adrenaline-stimulated adenylate cyclase (AC) was studied in biopsy specimens of the gastric and duodenal mucosa from 112 individuals. AC activities were log normally distributed. AC of fundic and antral gastric mucosa responded to adrenaline in a concentration-dependent manner, that of the duodenal mucosa did not respond to adrenaline. The degree of activation in biopsies of normal gastric mucosa was similar to that of patients with chronic atrophic gastritis or patients antrectomized according to the Billroth method. AC in biopsies from cimetidine-treated peptic ulcer patients was less sensitive to adrenaline than AC in biopsies from untreated patients. The threshold concentration of cimetidine to inhibit adrenaline-stimulated AC in vitro was 10(-6) mol/l. The data provide evidence of an adrenaline-sensitive AC in cells other than parietal cells and show an inhibitory action of cimetidine on the catecholamine-sensitive AC in the human gastric mucosa.