Pharmacology of r-hirudin in renal impairment.

The pharmacokinetic properties of r-hirudin were studied in nine patients suffering from different degrees of renal insufficiency. To this end, r-hirudin was administered intravenously at dosages of 0.1 mg/kg. The elimination half-life t1/2 beta was determined in blood plasma and the cumulative r-hirudin excretion in urine was measured over 48 h. In healthy volunteers t1/2 beta was 0.9 +/- 0.2 h; the cumulative r-hirudin excretion in urine after 48 h amounted to 38 +/- 10% of the dose administered, most of this quantity was excreted during the first hours. In seven patients with chronic renal failure, t1/2 beta was 15 to 41 h; in three of these patients cumulative urinary r-hirudin excretion was increased to 70-80%, in four patients cumulative r-hirudin excretion in urine within 48 h amounted to 39 +/- 8%, but was delayed in time. In 2 bilaterally nephrectomized patients, t1/2 beta was 168 and 316 h, resp. The renal clearance of hirudin was significantly and linearly correlated with the creatinine clearance (r = 0.872). In all patients aPTT and bleeding time were only moderately prolonged. Because of the modified pharmacokinetic behaviour the administration of hirudin in patients with impaired renal function requires individually adjusted dosages or prolonged administration intervals.

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)

R-hirudin as anticoagulant in regular hemodialysis therapy: finding of therapeutic R-hirudin blood/plasma concentrations and respective dosages.

Recently heparin-induced thrombocytopenia type II has been diagnosed more frequently and does not exclude hemodialysis patients. Up to now, recombinant hirudin is the only available anticoagulant showing no immunologic cross reactions with heparin. However, the use of r-hirudin in hemodialysis patients with different degrees of residual renal functions is impossible using standard dosages because elimination of r-hirudin varies depending on the degree of residual renal function. Therefore the first study was carried out using consecutive r-hirudin anticoagulated hemodialyses to determine the appropriate dose of r-hirudin. Ten hemodialysis patients with creatinine clearance values ranging between 0 and 13 mL/min/1.73m2 were anticoagulated with r-hirudin. An initial bolus of 0.1 mg/kg bwt before the first hemodialysis, resulted in an average r-hirudin blood concentration of 305 ng/mL at the end of treatment. The dose for each of the following four hemodialyses was adjusted individually to reach the minimum therapeutic r-hirudin blood concentration. At the end of these treatments the mean blood r-hirudin concentration was 422 ng/mL. The necessary mean doses ranged between 0.008 and 0.125 mg/kg bwt correlating to the creatinine clearance values of the patients. All hemodialyses of the study were effective and safe. Bleeding times determined during r-hirudin anticoagulation were significantly lower than control values measured 2 days after a heparin administration. The study proved that r-hirudin may be an efficient and safe heparin alternative as a hemodialysis anticoagulant when the individual's residual renal function is noted for dosage and dose adjustment and is controlled by drug monitoring using the ecarin clotting time.

[Stent PTA in secondary symptomatic proximal subclavian artery obstruction]. / Stent-PTA bei sekundär symptomatischen proximalen Subclaviaobstruktionen.

Stent-PTA of secondary symptomatic proximal subclavian artery stenosis In comparison with conventional surgical revascularisation, percutaneous transluminal angioplasty (PTA) is an alternative treatment for short stenoses or occlusions involving the origin of the subclavian artery. If there is clinical suspicion of subclavian artery obstruction (e.g. blood pressure difference in both arms), digital subtraction angiography of the aortic arch and upper limb should be performed prior to creating radial haemodialysis shunts or coronary bypass crafting involving the internal mammary artery. PTA and stenting can be successfully carried out in symptomatic secondary proximal subclavian artery stenosis, e.g. in radial haemodialysis fistulas with distal ischaemia.

[Hepatitis prophylaxis in dialysis centers. A list of recommendations and tips. I]. / Hepatitis-Prophylaxe in Dialysezentren. Ein Katalog von Empfehlungen und Hinweisen I. Mitteilung.

From the standpoint of prevention of hepatitis in this first report references are given to the construction of dialysis centres, to their apparative equipment with special regard to the artificial kidneys, to the dialysators and to the blood-leading systems. Finally the author deals with the technique of punctures and to the possibilities for avoiding too large blood losses in patients undergoing a chronic dialysis.

[Prevention of hepatitis in dialysis centers. A catalog of recommendations and directions. 2]. / Hepatitisprophylaxe in Dialysezentren. Ein Katalog von Empfehlungen und Hinweisen. 2. Mitteilung.

On 33 patients who underwent a lung resection under conditions of stress in the majority of cases also after parenchyma-sparing operation a pulmonary hypertension, in about 50% already a slight hypertension in rest could be proved. The increase of the pulmonary pressure correlated with an increase of the resistance of the pulmonary vascular system, of resistance and age and showed tendencies to the increasing postoperative interval.

[Dialysis treatment of chronic renal failure]. / Die Dialysebehandlung bei chronischer Niereninsuffizienz.

Of the patients with chronic renal replacement therapy in Germany, only 27% are living with a functioning graft, while the other 73% are dialysis patients. At the end of 1990, there were about 30,000 patients on regular dialysis treatment in Germany. Without selection for chronic dialysis, the average age of newly accepted patients is 61 years. More than 30% of the new dialysis patients are diabetics. Intermittent haemodialysis (89.5%), intermittent haemofiltration (4.5%), and peritoneal dialysis (6%) are the different methods of chronic dialysis treatment in Germany. The 5-year-survival rate with regular haemodialysis treatment is 67%, for 50 years old patients without diabetic nephropathy (EDTA, Europe).

[Prevention of hepatitis in dialysis centers. A catalog of recommendations and suggestions. 3]. / Hepatitisprophylaxe in Dialysezentren. Ein Katalog von Empfehlungen und Hinweisen 3. Mitteilung.

This last of three reports on the prevention of hepatitis in dialysis centres deals with the kind and frequency of desinfection measures in the dialysis area, contains advices to the mode of transfer of patients between dialysis centres and makes demands to the tests of hepatitis-B-antigen and antibodies. Finally proposals concerning the frequency of controls for HBs-antigen and anti-HBs and for the passive immunisation with anti-HBs-enriched immunoglobulin are rendered.

[The diagnosis of analgesic nephropathy]. / Zur Diagnostik der Analgetika-Nephropathie.

Inspired by the large proportion of at least 17% of nephropathy due to analgesics as the basic disease among the patients undergoing chronic dialysis in Erfurt and under the impression of a greatly distributed "underdiagnosis" of this avoidable disease the actual diagnostic possibilities for recognition are demonstrated. Above all, in analgesic syndrome the thinking-of is of greatest importance, and the sensible making of the patient's analgesics history. The presumable diagnosis analgesic nephropathy is than made secure by means of imaging methods, with the help of which the almost pathognomonic papillary necroses can be demonstrated. Finally, the reasons are given for the importance of the exact diagnosis analgesic nephropathy, even in the stage of nephrocirrhosis.

[Bacteriologic studies of bicarbonate dialysate and suitable initial solutions]. / Bakteriologische Untersuchungen von Bicarbonatdialysat und entsprechenden Ausgangslösungen.

Dialysates for the haemodialysis are produced unsterile and usually contain bacteria. Own investigations of bicarbonate dialysate and adequate initial solutions comprised sterility tests, determinations of the germ count and germ tolerance experiments. Only the "acid concentrate" was sterile. In the other solutions Corynebacteria, Acinetobacter and Pseudomonas bacteria dominated as typical water germs. In the fresh reverse osmosis water and the bicarbonate dialysate as well as in the recently produced 35-mmolar and 1-molar NaHCO3-solution the germ count was in each case about 10(5)/l and did not change itself essentially at room temperature within 6 hours. The "acid concentrate" and at a lower level also the 1-molar NaHCO3-concentrate have an antibacterial effect. The reverse osmosis water is the main contamination source for the bicarbonate dialysate, the application of which within 6 hours seems worth being used on account of the low germ count.

[Highly effective short-term dialysis with two parallel-connected capillary dialysators type C-DAK4. 2. Clinical parameter, subjective symptoms and performance control of patients compared to conventional dialyses]. / Hocheffektive Kurzzeitdialysen mit zwei parallelgeschalteten Kapillardialysatoren vom Typ C-DAK 4). 2. (Mitteilung:) Klinische Parameter, subjektive Symptomatik und Leistungskontrolle der Patienten im Vergleich zu konventionellen Dialysen).

8 male patients with chronic dialysis (5 of them with binephrectomy) were thrice a week dialysed in 2 groups alternately 2 months conventionally for 6 hours with a capillary dialysator C-DAK mod. 4 and 2 months for 3 hours with 2 parallel connected C-DAK 4. In a constant square metre-hour-product (23.4 m2h/week), homogeneous criteria of treatment and, as a rule, four times repeated use of the C-DAK 4 clinical parameters, subjective complaints and efficiency of the same patients were compared.

[Comparison of repeated use of capillary dialysators model C-DAK 4 and C-DAK 5]. / Vergleich der Wiederverwendbarkeit von Kapillardialysatoren der Modelle C-DAK 4 and C-DAK 5.

18 dialysators C-DAK 5 and 4 each were again used in the same patients with chronic dialysis under the same conditions of dialysis and regeneration (short-acting dialyses of more than 3.5 h with 1 C-DAK 5 or 2 parallel acting C-DAK 4, respectively). A volume of the blood compartment of more than 70% of the initial value was regarded as criterion for the further usability. Thus, model 5 could be used on an average 3.7 times, model 4, however, 6.3 times (p less than 0.0001). Already at the end of the 3rd use in model 5 the capillary volume decreased below 63%, in model 4 only below 88%. The volumetrically determined ultrafiltration showed a decrease parallel to the volume of the blood compartment -- with the same differences between the two models of the C-DAK. In model 15 the effectiveness concerning the elimination of creatinine and urea clearly decreased after the 2nd use, whereas it did not reveal a change also in an application four times repeated. The larger coagulation processes in a more than once repeated use of the C-DAK 5 -- with adequate losses of blood -- are explained with the large length of the capillary and the other distribution of blood with regard to the cross section of the capillary. Summarizing we can say that in chronic routine dialyses -- without testing the individual exemplars -- model 5 of the C-DAK can be used twice, model 4, however, four times.

[Embolism in a left atrial myxoma--case contribution to its diagnosis and differential diagnosis]. / Morbus embolicus beim Vorhofmyxom links--kasuistischer Beitrag zur Diagnose und Differentialdiagnose.

It is reported on a left-atrial myxoma in a 20-year-old patient with atypical symptomatology of the mitral stenosis, unspecific general symptoms and lethally finishing embolisms and on the basis of the course the problems of the differential diagnosis and of the complications are shown.

[Peritoneal dialysis therapy in psoriasis]. / Peritonealdialysebehandlung bei Psoriasis vulgaris.

Report about three patients suffering from psoriasis vulgaris, who were not responsive to common dermatological treatment for many years. After peritoneal dialysis the psoriasis cleared and has not recurred for three to six months. Immunological investigations before and after peritoneal dialysis showed an increasing number of E-rosettes and a decrease of the concentration of soluble immune complexes of the serum.

[Basic disturbances and extra-renal complications - prognosis determining factors in acute renal failure]. / Grundleiden und extrarenale Komplikationen -- prognosebestimmende Faktoren des akuten Nierenversagens.

The author adopts a definite attitude to the prognosis of acute renal failure, based on the experiences of 410 peritoneal dialyses and 168 haemodialyses in 165 patients. In a total lethality of 51% there is no relation between the choice of the technique of dialysis and lethality. The changes of survival are mainly determined by the causal disease and its extrarenal complications. The worst prognosis have patients with a breakdown of other vital functions besides renal failure. The possibility of the alternative treatment haemodialysis/peritoneal dialysis should always be given.