Failure of cimetidine to prevent gastroduodenal ulceration and bleeding after renal transplantation.

Treatment of renal transplant patients with the H2-antagonist cimetidine has previously been assumed to be of reasonable prophylactic value in controlling the incidence of the postoperative complications of gastric or duodenal ulceration. We attempted to evaluate the performance of the drug in a controlled trial by treating transplant patients with either cimetidine or a placebo. Of the 59 patients accepted for the trial, four had to be excluded eventually because of irregularities in the administration of the drug and, in on case, nonfatal respiratory failure. Six of 27 from the cimetidine group had erosions or ulcers by the third day after surgery and two more had them by the end of the fourth week. Three of 28 placebo patients developed lesions after 3 days and three more developed them after 7 weeks. In the months after transplantation, one cimetidine and two placebo patients developed ulcers. Bleeding occurred three times with cimetidine and twice with the placebo. Renal function was similar in both groups as was the necessity of transplantectomy because of irreversible rejection. We conclude that cimetidine does not lower the incidence of gastroduodenal mucosal lesions and upper gastrointestinal bleeding after renal transplantation, nor does it influence rejection of the allograft.

Glucose metabolism and insulin sensitivity in patients on chronic hemodialysis.

In order to evaluate the potential role of parathyroid hormone on glucose metabolism in patients on chronic hemodialysis hyperglycemic clamp studies were performed in 7 parathyroidectomized and 11 nonparathyroidectomized patients on chronic hemodialysis and in healthy controls. There were no significant differences in the peripheral glucose uptake of the 3 groups. The beta cell response to hyperglycemia during the early phase as well as during the steady state was almost identical in controls and in nonparathyroidectomized uremics, whereas in the parathyroidectomized group a markedly enhanced insulin secretion was found. Calculated tissue sensitivity to insulin therefore was equal in controls and in nonparathyroidectomized uremics, whereas patients after parathyroidectomy had peripheral insulin resistance. Our results demonstrate that patients on chronic hemodialysis apparently have normal peripheral glucose uptake. The subgroup of patients who have undergone parathyroidectomy, however, show an enhanced insulin response to hyperglycemia suggesting peripheral insulin resistance. We conclude that longstanding and severe secondary hyperparathyroidism--the usual cause for parathyroidectomy in these patients--results in irreversible insulin resistance with a compensatory increase of insulin secretion.

[Efficacy and tolerance of hepatitis B vaccination in medical personnel and hemodialysis patients]. / Zur Wirksamkeit und Verträglichkeit der Hepatitis-B-Impfung bei medizinischem Personal und bei Hämodialysepatienten.

The efficacy and safety of a hepatitis B vaccine (Pasteur Institute) has been evaluated in 93 healthy members of the medical staff and in 28 patients undergoing chronic haemodialysis. Following 3 injections of vaccine (each 5 micrograms) at monthly intervals, 94% of the healthy subjects and 61% of the patients were already successfully immunized 4 months after commencement of the vaccination course. Those who did not respond initially received an additional dose at 6 months, which induced seroconversion in several more cases, resulting in the successful immunization of 98% of healthy subjects and 75% of haemodialysis patients. Immune response was sex- and age-dependent. Peak anti-HBs concentrations in responders at 6 months were 643, 325, and 194 mU/ml in healthy women, healthy men, and in patients, respectively. None of the staff members developed clinical or biochemical signs of hepatitis or of any other disease. Markers of hepatitis B virus infection were detected in 3 healthy subjects and in 6 dialysis patients.

[Interference of reticulocyte metabolism with enzyme activity analyses in haemolytic anaemias (author's transl)]. / Einfluss der Retikulozyten auf die Bestimmung von Enzymaktivitäten bei hämolytischen Anämien.

This paper outlines the procedure for the preparation of leucocyte-free reticulocytes and normocytes and details the activities of the key enzymes in reticulocytes, normocytes and leucocytes. An assesment of the error in normocyte enzyme analyses due to contamination with reticulocytes and leucocytes is enabled by these means.

[Haemodialysis in children (author's transl)]. / Hämodialyse bei Kindern.

Thirty four children, aged 2 to 15 years, were treated by haemodialysis between 1967 and 1978. Eleven children suffered from acute renal failure. Twenty three children with end-stage chronic renal disease were treated over periods ranging from 1 week to 19 months. All children were dialysed in a renal unit for adult patients awaiting renal transplantation. Our results refer especially to the technical equipment for paediatric dialysis and to the problems of blood access. The medical problems of chronic uraemia and chronic intermittent haemodialysis in children are discussed. From our experience we conclude that a sufficient degree of rehabilitation can be reached only in a paediatric dialysis unit.

[Calcium and phosphorus metabolism in patients on chronic intermittent haemodialysis with different calcium concentrations in the dialysate (author's transl)]. / Kalzium-Phosphat-Stoffwechsel chronisch hämodialysierter Patienten bei verschiedenen Kalziumkonzentrationen der Dialysatflüssigkeit.

A study was carried out in 25 patients on chronic intermittent haemodialysis on the effect of increasing the dialysate calcium concentration from 1.5 to 1.75 mMol/l on calcium and phosphorus metabolism. In 16 patients the increase in the dialysate calcium resulted in a sufficiently large increase in the plasma Ca level to suppress the parathyroid glands. The calcium influx during dialysis in these patients was sufficient to abolish the effects of diminished calcium absorption from the intestine due to loss of endocrine renal function. The remaining 9 patients showed no suppression of parathyroid gland activity and could be separated into two different groups, one requiring calcium supplementation and the other group manifesting signs of autonomic hyperparathyroidism. The five patients showing a higher calcium requirement were started on active vitamin D metabolites. In the remaining 4 patients parathyroidectomy will probably be inevitable if progression of the clinical manifestations of hyperparathyroidism occurs. Close control of plasma phosphorus levels is mandatory to avoid an increase in the calcium phosphate product or the danger of hypophosphataemic osteomalacia.

[Aluminum-balance during haemodialysis (author's transl)]. / Aluminiumkinetik während Hämodialyse.

Aluminium kinetics in patients with endstage renal failure and chronic intermittent haemodialysis have been studied. All patients revealed elevated predialytic serum aluminum levels. Because of a significant correlation between daily intake of aluminiumhydroxyd and serum aluminium levels it is concluded that the intestinal aluminium absorption plays an etiological role in the development of hyperaluminaemia. Plasma aluminium levels at the end of a regular dialysis procedure are significant lower compared to predialytic values. Similarly a significant decrease of aluminium concentration was observed in the plasma after passage through the dialyzer. This is due to the fact that the aluminium content of the dialysate used in our unit (0.1-0.3 mumol/l) is lower than the ultrafiltrable fraction of the plasma aluminium measured in vivo. Therefore a negative aluminium-balance during haemodialysis has to be assumed in our patients. Extreme aluminium-accummulation seems to be avoided and we therefore never experienced aluminium intoxication and dialysis dementia in our center. To assess a negative aluminium balance during haemodialysis, because of high protein binding of aluminium, a dialysate with an extreme low aluminium content has to be recommended.

[Renal failure and carbon monoxide diffusing capacity of the lung (author's transl)]. / Niereninsuffizienz und CO-Diffusion der Lunge.

Reduced carbon monoxide diffusing capacity of the lung (DLCO) is reported in patients with impaired renal function. Since DLCO also depends on the pulmonary capillary blood volume the role of renal anaemia was evaluated. Measurements were carried out in 43 azotaemic patients [serum creatinine (SKr) 1.5 to 14.0 mg/100 ml], without evidence of cardiovascular or pulmonary complications of uraemia, of SKr, haemoglobin concentration (Hb) and steady state DLCO. In the case of DLCO values allowance was made for body surface area and thoracic gas volume. The relation was studied of the corrected DLCO to SKr and to Hb. There was a higher statistical correlation between DLCO and Hb than between DLCO and SKr. After additional correction of DLCO for Hb, no correlation to SKr was found. It is concluded that the reduction in DLCO in uraemia is due largely to a low Hb and, hence, to renal anaemia rather than to uraemic damage of interstitial lung tissue.

[Renal transplantation in children (author's transl)]. / Nierentransplantation bei Kindern

During the past 2 years 7 children received kidneys from cadaveric donors. 2 transplants had to be removed because of irreversible chronic rejection and 1 recipient died on the 4th day after surgery. The remaining 4 recipients are doing well. In the evaluation of the results special emphasis is placed on the normalization of growth and puberty. The difficulties of psychosocial rehabilitation are stressed.

[Spontaneous rupture of renal allografts (author's transl)]. / Spontane Parenchymruptur allotransplantierter Nieren.

Spontaneous rupture of an allografted kidney is not such a rare complication of kidney transplantation. In our series 5.2% of the transplanted kidneys ruptured spontaneously. The condition is an acute emergency characterized by the triad, acute abdomen, swelling in the region of the transplant and haemorrhagic shock. The aetiology of transplant rupture seems to be multifactorial, but the superimposition of an acute rejection episode on ischaemic tubular damage with acute renal failure was found to be the most important combination of events leading to transplant rupture in our patients. Exceptionally precise immunological monitoring in the early phases following transplantation and early aggressive therapy of an acute rejection crisis associated with acute renal failure should prevent allograft rupture.

[Interaction between blood platelets and capillary kidney in haemodialysis (author's transl)]. / Die Interaktion zwischen Thrombozyten und Kapillarniere im Rahmen der Hämodialyse.

In haemodialysis an interaction between platelets and the dialysator membrane occurs, which is not prevented by heparin. This can be demonstrated by parietal depositions of platelets in the capillaries of the artificial kidney by scanning electron microscopy, as well as in a marked increase of reversible platelet microaggregates during the first phase of dialysis. Some patients are prone to develop thrombosis of the capillary kidneys in spite of a high-dose heparinization. In these cases the use of diclofenac, a cyclooxygenase inhibitor, prevents these adverse platelet reactions.

[Neuropathology of renal transplantation (author's transl)]. / Neuropathologische Befunde nach Nierentransplantation

The neuropathological features are presented of an autopsy series of 43 renal transplant recipients. Inflammatory CNS lesions were found in 18 cases and were attributable to secondary CNS involvement in bacterial or fungal septicaemia (8 cases) or in localized extraneural infections (5 cases). Mixed bacterial-fungal infection and bacterial-fungal-viral triple infection were seen in one case each. Isolated toxoplasmic granulomas were observed in two cases. No tissue changes typical of CNS viral infections, including cytomegaly, were found except for small glial nodules in the brain stem in 7 cases. Massive intracerebral haemorrhages were seen in 2 cases after haemodialysis; subdural haematoma occurred once. Non-specific changes including brain oedema and diffuse glial poliodystrophy were found in many cases; vascular lesions and purpura occurred only seldom. A meningocerebellar malignant lymphoma, probably of metastatic origin was found in one case. Clinico-pathological correlation was poor in 5 cases; this is considered to be due to immunosuppressive therapy, which may mask either clinical expression of severe CNS lesions or morphological expression of viral encephalitis.

[Hyperparathyroidism in chronic renal insufficiency new clinical and surgical aspects (author's transl)]. / Hyperparathyreoidismus bei Niereninsuffizienz.

The therapy of secondary hyperparathyroidism in chronic renal disease has been improved by the availability of active 1-alpha-hydroxylated vitamin D derivatives. However, in cases with progressive secondary hyperparathyroidism which have not been brought under control conservatively, surgical intervention is still required. Total parathyroidectomy with autologous transplantation of parathyroid tissue in the forearm has recently been recommended as the optimum surgical approach to secondary hyperparathyroidism. Recent literature is reviewed and personal clinical experience is reported in this paper, followed by a presentation and discussion of the pathophysiology of hyperparathyroidism in chronic renal failure, various means of conservative treatment, indications for parathyroidectomy, surgical aspects and technique of cryopreservation, as well as a standardized therapeutic regimen for pre- and postoperative treatment with calcium and 1-alpha-hydroxylated vitamin D analogues.

Reversible acute tubular necrosis following severe acute renal rejection.

The clinical observation of 6 out of 250 renal transplant patients showed that acute renal rejection may lead to reversible acute tubular necrosis (ATN) necessitating intermittent haemodialysis treatment. Despite missing early response to high-dose (methyl-) prednisolone therapy (during a mean period of 4.7 days) all 6 patients developed spontaneous diuresis 14.5 days on average after onset of rejection while on maintenance immunosuppressive therapy. From the clinical course the conclusion was drawn that in severe cases of renal rejection with arteriographic and histological findings consistent with acute tubular necrosis, prolonged therapy with high doses of (methyl-) prednisolone is not desirable, since after reversal of immunological rejection the onset of spontaneous diuresis will be determined mainly by the duration of the healing and recovery phase of acute tubular necrosis.

[Urinary enzymes in the early detection of rejection reactions after renal transplantation (author's transl)]. / Harnenzyme zur Frühdiagnose von Abstossungsreaktionen nach Nierentransplantation

Urinary enzymes were studied in 15 patients subjected to kidney transplantation. The investigation was initiated immediately after operation and was continued for a period of between 2 and 8 weeks. There was a significant increase in urinary MDH activity in 94.2% of cases, of LDH activity in 95,65% and of gamma-GT activity in 95,17% of the cases. This detected increase in urinary enzyme activities preceded the clinical diagnosis of rejection by activities preceded the clinical diagnosis of rejection by at least 24 hours. Determination of these enzymes provides a reliable tool for the early detection of rejection crises.