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Different methods of regional anticoagulation using citrate in continuous renal replacement therapy have been described in the past. However, these procedures were usually very complex or did not reach modern requirements for effective continuous renal replacement therapy. Furthermore, little is known about long-term acid-base stability and citrate levels during the treatment. We describe a system in which citrate is used both as anticoagulant and as the sole buffer substance in continuous venovenous haemofiltration. Our citrate-containing, calcium-free substitution fluid was used in predilution mode with a constant ratio between blood flow (120 to 150 ml/min) and substitution flow (2400 to 3000 ml/hour). Anticoagulation was limited to the extracorporeal circuit. Twenty patients with acute renal failure on mechanical ventilation were treated, four for eight hours, four for 24 hours and 12 as long they needed continuous renal replacement therapy (9.6 ± 5.0 days, range 4.0 to 39.3 days). We achieved stable acid-base and electrolyte balance in all patients. We observed no bleeding complications (patient activated clotting time 112.4±17.1 s, post-filter circuit activated clotting time 270.5 ± 80.3 s) and achieved appropriate filter life times (48.6 ± 13.2 h). Predilution, citrate-based substitution fluid provides both anticoagulation within the extracorporeal circuit and control of acid-base balance in critically ill patients at risk of bleeding in acute renal failure. It is easy to apply and safe. Clearance can be varied as long as a constant ratio between blood and substitution flow is maintained.

Objectives: Investigation of the main factors determining the concentration-time course of amino acids and biological molecules in serum and dialysates. Methods: In a randomized, 3-period cross-over study, 11 patients were treated once with each of 3 peritoneal dialysis solutions, 1 containing amino acids and bicarbonate, 1 containing glucose and bicarbonate and I containing glucose and lactate. Nineteen amino acids, 3 proteins, 2 metabolites and 2 ions were measured in serum and dialysate. A standard compartment model was fitted to the data. Results: The amino acids differed significantly in their kinetic characteristics (p < 0.001), mainly volume of distribution and elimination rate. Differences in absorption were small compared to the interpatient variation. The average transport rate from serum to dialysate was 0.50.1.14 h -1 , from dialysate to serum 0.33 - 0.41 h -1 , for elimination from the central compartment 0.35 to 2.27 h -1 , for volume of distribution 0.29 to 0.83 l/kg, for serum protein binding 19.47%, for amount in tissue 82 - 95%, for endogenous metabolic rate 16 - 151 μmol×kg 1 ×h 1 . The volume of distribution correlated with the R group (polar positive < aliphatic < polar uncharged). For the various proteins, the 2 bicarbonate solutions had higher serum-to-dialysate transport rates than the lactate solution (p = 0.018 - 0.601). Conclusion: The compartment model demonstrated its usefulness Accordance with literature data for healthy volunteers indicated the validity of the estimates.

If non-treated or misdiagnosed, acute crescentic glomerulonephritis, clinically defined as rapidly progressive glomerulonephritis (RPGN), may lead to end-stage renal failure (ESRD) within a short time. Histologically, it is characterized by accumulation of inflammatory cells in combination with proliferation of epithelial cells in the glomerulus. According to the proposed immunopathogenic classification by Couser [7], predominantly the immunopathogenic type III without immune deposits often represents the renal manifestation of a systemic vasculitic disease, e.g. polyarteriitis or Wegener's granulomatosis. Having investigated 75 patients with acute crescentic glomerulonephritis for long-term results, we concluded that early histopathologic diagnosis by using an activity and chronicity score system may be not only a predictor for renal prognosis but also a valid supposition for differentiated immunosuppressive therapy in supplement to the clinical data on renal function. The therapeutic advantage of plasmapheresis therapy in addition to immunosuppressive therapy could not be proven.

Factors related to atrial natriuretic peptide (alpha-ANP) regulation and its potential impact on excretory transplant function were examined in a prospective cohort study of 20 patients with end-stage renal disease over 21 days after allogenic kidney transplantation. Depending on posttransplant graft function, patients were separated into those with primary renal function (PF group, n = 10) and posttransplant acute renal failure (ARF group, n = 10). ANP concentrations were markedly elevated in both PF and ARF immediately after renal transplantation, even when compared with the pretransplant dialysis phase (PF group: 939 +/- 467 pg/ml; ARF group: 648 +/- 306 pg/ml, on 3rd postoperative day; "normals': 72 +/- 35 pg/ml). Whilst ANP levels were persistently elevated in patients with acute renal failure, there was a steady decrease in plasma concentrations in patients with primary renal function (PF: 270 +/- 122 pg/ml on 21st day). ANP concentration correlated with endogenous creatinine clearance (rz = 0.56, p0.01, PF group). Moreover, there was a greater correlation between ANP levels and postoperative hydration status, measured as central venous pressure or the difference from predialysis dry weight (rz = 0.79 and rz = 0.74, p0.01, PF group). Systolic blood pressure was also positively correlated with ANP concentrations. Together, these factors accounted for a total correlation coefficient of r = 0.87 (p0.001) in multiple regression analysis. No significant relation was found between plasma ANP levels and total or fractional sodium excretion or free water clearance. With the restoration of renal function most vasoactive hormones (renin-aldosterone system, catecholamines, vasopressin) decreased towards normal values, whilst ANP plasma concentrations remained elevated.

Doctors are often confronted with end-of-life decisions. When deciding on the withdrawal of medical treatment physicians have to consider the legal position. This study was done to evaluated how far doctors at the university medical center in Düsseldorf had acted in conformity with the established case law in Germany.Between April and August 2006 doctors at the university medical center in Düsseldorf filled in a standardized questionnaire about the decisions they had taken to withdraw life-support treatment.128 of a total of 512 doctors questioned replied (25 %; 32,8 % females and 67,2 % males) . The survey showed that the judicial decision (that it is not necessary to provide treatment if life-support measures are not indicated) is largely determined by non-medical criteria. The clinical decision by doctors depended mainly on his personal opinion. Furthermore the survey showed that only a few doctors made use of the - lawful - option to withdraw medical treatment when this was not indicated. Finally the survey revealed that, in case of conflict between indication and perceived patients' wishes, the vast majority of doctors behaved in contravention of the decisions established by case law.There is the need to discuss what non-medical issues should be taken into account when determining the indication of withdrawal of life-support measures. The results also highlighted the uncertainties that exist regarding a doctor's decisions about it. Not only should legislation clarify whether "passive euthanasia" is allowed, but it would also be useful to delegate end-of-life decisions to a review board.

increased ANP levels after uncomplicated coronary artery surgery (CAS) indicate functional reduction.prospective, randomized. Preoperative upto the 12 week postoperative.Thoracic and Cardiovascular Surgery, University of Düsseldorf.15 patients (mean age: 58+/-6.1 years; 13 months, 2 weeks; no myocardial infarction, no congestive heart failure) with 3 vessel disease.levels of atrial natriuretic peptide (ANP) (pg/ml; radioimmunoassay), Troponin T (TnT) (ng/ml; ELISA test), haemodynamic parameters, ECG monitoring, m-mode echocardiography (Echo).increase of ANP, TnT levels during extracorporeal circulation (ECC), decrease after operation.Maximal increase of ANP from preoperative 90+/-10 (M+/-SEM) pg/ml (p0.05) up to intraoperative 380+/-38 pg/ml. Ten days postoperative ANP (26+/-33 pg/ml) still threefold increased compared to preoperative level. Increasement of TnT from preoperative 0.02+/-0.01 ng/ml upto intraoperative 3.44+/-0.47 ng/ml. Ten days postoperative TnT concentration normal (0.13+/-0.11 ng/ml). Correlation of ANP and TnT five min after bypass up to 6 hrs postoperative (p0.05, r =3.4). Increase of left atrial diameter preoperative 42.2+/-1.1 mm up to 46.8+/-1.2 mm (p0.05) 10 days postoperative. LVEDD, EF changed from preoperative 51.1+/-0.9 mm, 73+/-2% to 54.5+/-1.2 mm, 65+/-4% 10 days postoperative.Threefold increase of ANP 10 days postoperative and return of TnT levels to normal under consideration of datas of echo show, that ANP is suitable to indicate the meanterm, functional, myocardial reduction. Increased ANP levels, atrial dilatation and dysfunction are important signs of cardial functional reduction after CAS.

Ischemic heart disease is the major cause of death in patients with end-stage renal disease. The high prevalence of coronary artery disease results in a rising number of dialysis patients requiring myocardial revascularisation.The objective of this study was to compare the outcomes of recurrent angina, myocardial infarction, rate of reinterventions and cardiovascular death following percutaneous coronary angioplasty (PTCA) or coronary artery bypass grafting (CABG) in patients with end-stage renal disease.In a retrospective investigation 40 patients with chronic renal failure undergoing primarily PTCA and 65 patients undergoing CABG were included. Both groups were comparable for gender, duration on dialysis and the number of cardiovascular risk factors per patient. Patients undergoing PTCA were younger (53 +/- 12 years vs. 57 + 8 years; p0.05) and more often diabetics (30% vs. 14%; p0.05).Most patients in both groups had a multi-vessel disease (95% in the CABG group vs. 74% in the PTCA group), in the CABG group there were significantly more patients with a triple-vessel disease (62% with vs. 40% in the PTCA group; p0.01), PTCA was primarily successful in 95% of the patients while complete revascularization was achieved in 88% of patients undergoing CABG. The perioperative mortality after CABG was 4.8% as compared to none after interventional revascularisation. The cumulative freedom of angina after 6, 12 and 24 months after intervention was significantly lower after PTCA (54%, 40%, 29%) than after bypass grafting (97%, 94%, 90%, p0.001). The frequency of reinterventions following PTCA was significantly higher compared to patients following CABG (p0.001). After PTCA 15 patients needed further revascularisations, 8 of them underwent CABG, whereas after CABG only two patients required additional myocardial revascularisation. There was no significant difference in the overall mortality between both groups; the survival rate after 12 and 24 months was 95% and 82% after PTCA and 93% and 86% after CABG, respectively.Although patients receiving CABG had a more severe coronary artery disease the overall mortality was comparable and clinical and functional outcome was improved compared to patients after coronary angioplasty.

The rising life expectancy of patients undergoing kidney transplantation and the improvement in the function rate of the allografts have led to an increasing number of patients suffering from arteriosclerosis-related diseases of the aortoiliac arteries. In these particular cases, an interruption of the blood supply of the allograft is always necessary for operative repair of the aortic and iliac arteries. This means a high risk of ischemic damage to the transplanted kidney.Between 1987 and 2000, 1,076 kidney transplantations were performed in our department. During this time, 14 reconstructive operations of the aortoiliac arteries were performed in 12 patients (6 women, 6 men, average age 55.2 (45-71) years). Operations were indicated in patients suffering from occlusive disease with imminent extremity or allograft loss, and symptomatic or asymptomatic aneurysms with a maximum diameter of more than 4 cm. In patients presenting with thoracoabdominal (1) and abdominal aortic aneurysms (3), protection of the transplanted kidney was performed by axilloiliac or axillofemoral bypass. Hypothermic flush-perfusion of the allograft containing PGE1 and heparin was performed in seven of nine operations for occlusive disease.None of the patients presented with a permanent decrease in kidney function, six patients showed temporary creatinine elevation, and in nine patients creatinine levels at discharge were lower than they were preoperatively. None of the patients died.Reviewing all reported methods of allograft protection, we recommend a three-step strategy including sequential clamp technique (ischemia30 min.), hypothermic flush-perfusion (ischemiaor = 60 min.), and temporary axilloiliac/femoral shunt (ischemia60 min), depending on the expected renal ischemia time.

A 39-year-old man was referred for assessment of a nephrotic syndrome. He reported deteriorating health with bouts of fever and microhaematuria and proteinuria in the past year. At the age of 24 years a ventriculoatrial shunt had been inserted for an internal hydrocephalus. At another hospital he was given steroids for a nephrotic syndrome suspected of being associated with membranoproliferative glomerulitis, but the disease progressed. On admission he had severe generalised oedema with a temperature of 38,5;C. His general condition was poor. He had no neck stiffness.Parameters of inflammation were raised. Serum creatinine and creatinine clearance were normal. Levels of complements C3 and C4 were reduced. The proteinuria was 9g/24h. Renal biopsy revealed type 1 membranoproliferative glomerulonephritis. Micrococcus roseus/varians was demonstrated several times by aerobic blood cultures.The findings suggested chronically infected ventriculoatrial shunt as cause of the glomerulonephritis. The shunt was, therefore, removed. The same pathogens were grown from it on aerobic culture medium. Six months after removal and replacement of the shunt and treatment of the infection the proteinuria had fallen to 0.45 mg/h; serum creatinine was 1.0 mg/dl.When membranoproliferative glomerulonephritis has been demonstrated, secondary forms should be considered in the differential diagnosis. In most cases specific treatment can prevent progression of the renal disease.

Cyclosporin A ( CsA) plays a confounding part in the treatment of nephrotic syndrome. Renal hemodynamics and glomerular permselectivity were investigated in patients with glomerulonephritis to analyse the antiproteinuric action of CsA and to differentiate between nephrotoxic and immunosuppressive effects.We studied 19 patients with nephrotic syndrome after 6 months of treatment with CsA (membranous glomerulonephritis-MGN, n = 10; focal segmental sclerosing glomerulonephritis - FSGN, n = 5; minimal changes glomerulonephritis - MCGN, n = 4). Patients were studied three times within 3 weeks with (A) and without (B) CsA treatment (A-B-A'). Blood pressure, creatinine, proteinuria, C(In), C(PAH), C(Dex) were measured (analysis according to the model of Deen et al., Am J Physiol. 1985; 249 : 374).GFR (C (In)) increased significantly after withdrawal of CsA from 54 +/- 7.3 to 64 +/- 8.5 ml/min (p0.01). Proteinuria increased after withdrawal of cyclosporin (B) between 21 % (MGN) and 45 % (FSGN). After withdrawal of CsA (B) there was no change of FC(dex) in patients with MGN and FSGN. Withdrawal of CsA in patients with MCGN induced a significant decrease in glomerular selectivity in the high molecular range.These data demonstrate that CsA is able to induce even in the short term a significant increase in glomerular permselectivity in MCGN. The acute effects on GFR predominantly determined the acute antiproteinuric effects in patients with MGN and FSGN.

Plasma levels of ANP (pg/ml; radioimmunoassay) as a parameter for postischemic dysfunction and levels of Troponin T (TnT) (ng/ml; ELISA test) as a parameter for postischemic cellular damage were determined in 15 patients with coronary artery disease (CAD) (mean age: 58 +/- 6.1 years; 13 m, 2 w; with no history of myocardial infarction and no signs for congestive heart failure) prior to, during and after extracorporal circulation (ECC). Under standardized conditions during the ECC basic parameters concerning the cardial hemodynamic (heart rate (HR); systolic (RRsys, mmHg), diastolic pressure (RR dia, mmHg) central venous pressure (CVP, mmHg); left atrial pressure (LAP, mmHg); left ventricular enddiastolic pressure (LVEDP, mmHg)) and ECG monitoring blood samples were performed: 1) prior to operation (op); 2) prior to CPB; 3) 1 h CPB; 4) 5 min after CPB; 5) 1 h after CPB; 6) 6 h postoperative (postop); 7) 24 h postop; 8) 48 h postop; 9) 10 days postop. Also the left atrial diameter (LAD, mm) and the left ventricular enddiastolic diameter at Q (LVEDD, mm) pre- and postop were documented with m-mode echocardiography (Echo) and ejection fraction (EF, %) was calculated. The bypass operations were performed with intermittent aortic cross-clamping with open venae cavae (CVP: 0-5 mmHg) and moderate hypothermia. For the determination of ANP levels and TnT levels in arterial and venous blood, a double-antibody (AB) radioimmunoassay and an ELISA test were used. Concerning the patients with CAD there was a maximal increase of ANP from preoperative 90 +/- 10 (M +/- SEM) pg/ml (p0.05) up to intraoperative 380 +/- 38 pg/ml. Ten days postop, the ANP level was with 262 +/- 33 pg/ml still increased threefold in comparison to the preoperative level. TnT showed an increase from preoperative 0.02 +/- 0.01 ng/ml up to intraoperative 3.44 +/- 0.47 ng/ml. Ten days postop the TnT concentration was at the preoperative level with 0.13 +/- 0.11 ng/ml. Five minutes after bypass up to 48 h postop, ANP and TnT levels were correlated (p0.05, r = 3.4). There was an increase of the LAD from preoperative 42.2 +/- 1.1 mm up to 46.8 +/- 1.2 mm (p0.05) 10 days postop as determined by m-mode echo. LVEDD and EF changed from preoperative 51.1 +/- 0.9 mm and 73 +/- 2% to 54.5 +/- 1.2 mm and 65 +/- 4% 10 days postop. The significant increase of TnT (172-fold) indicates the cellular, myocardial injury, caused by the operation without signs in ECG recordings and no signs of congestive heart failure. The significantly increased ANP level up to the 10th day postop indicate sa very sensitive prolonged, postischemic dysfunction, which is not compensated 10 days postop.

Despite significant efficacy of melphalan and prednisone in the therapy of systemic AL(light chain amyloid)amyloidosis the prognosis of the disease is poor. In patients with severe renal manifestation the reported results of low-dose melphalan therapy are inconclusive with respect to relief of clinical symptoms and overall prognosis.We report our results of therapy in a group of 22 patients (8 women, 14 men, mean age 60 years) with renal involvement as the main manifestation of systemic AL-amyloidosis without overt myeloma.Ten patients were treated with low doses of melphalan and prednisone. No significant clinical improvement was observed in any case: the patients died an average of 12 months after diagnosis of the disease. Three patients were treated with high doses of melphalan followed by autologous stem cell transplantation. One patient died due to septicaemia after high-dose chemotherapy. Two of the patients experienced significant remission and live virtually free of clinical symptoms 12 and 18 months after therapy. Nine patients were treated only symptomatically: four of them were alive an average of 30 months after diagnosis of systemic AL-amyloidosis.Only high-dose melphalan therapy offered a realistic chance of amelioration of clinical symptoms in our group of patients, although therapy-associated risks seem to be high. In patients with severe renal amyloidosis, who are not considered for high-dose therapy, particularly careful consideration of potential benefits and possible risks of conventional melphalan therapy is necessary, because the results of this approach are in doubt.

Cardiovascular disease is a major cause of mortality in chronic uremic patients. We studied whether homocysteine is an independent cardiovascular risk factor for patients with end-stage renal disease (ESRD).The study included 163 patients and controls (Group 1: healthy controls, n = 20; Group 2: patients with chronic renal failure, serum creatinineor = 4 mg/dl, n = 23; Group 3: patients with ESRD, n = 91; Group 4: renal transplant recipients, serum creatinineor = 2.5 mg/dl, n = 29). We registered patients for the following factors: age, diabetes, smoking, lipids, vitamin B12, folic acid and homocysteine. The coronary heart disease was diagnosed by coronary angiography.The cardiovascular risk profile (hypertension, diabetes, smoking, hyperlipidemia) among uremic patients was significantly increased compared to the healthy controls. There was a significant correlation between the impairment of renal function and the increase of the homocysteine concentration (Group 1: 12 +/- 4.3 mumol/l vs Group 3: 27.8 +/- 15.8 mumol/l; p0.001). There was no significant difference of homocysteine between the patients with coronary heart disease and those without (29.9 +/- 18.1 mumol/l vs 26.6 +/- 14.4 mumol/l, not significant).In this study a significant correlation between the number of cardiovascular risk factors and the incidence of cardiovascular disease was proven. Although homocysteine was increased among patients with impaired renal function, hyperhomocysteinemia could not be identified as a significant risk factor for coronary heart disease in patients with ESRD. It is assumable that the pathogenesis of coronary heart disease in patients with ESRD is of multifactorial origin.

The acute renal failure remains a diagnostic challenge for the clinician.Between 1991 and 1996, acute renal failure caused by hantavirus infection was diagnosed in 4 previously healthy male patients. Main symptoms consisted of fever, headache, arthralgia, lumbar and abdominal pain as well as a decline in diuresis. The ultrasonography showed a slight splenomegaly in 2 patients. The clinical chemistry showed elevated serum creatinine from 2.2 mg/dl to 6.7 mg/dl and thrombocytopenia from 4000 to 150,000/microliter. The examination of the urine showed slight proteinuria and microhematuria. The kidney biopsy of 1 patient showed a reversible damage of the tubuli. The pathologic findings normalized within 3 weeks in 3 patients without need for dialysis. One patient developed a severe clinical course with acute renal failure and pulmonary edema requiring dialysis. In all patients, the renal function improved.

Acute renal failure following the administration of radiocontrast media (RCM) is a complication found especially in patients with impaired renal function. Within the limits of a pilot study, the objective was to (a) show the effectiveness and compatibility of prostaglandin E(1) (PGE(1)=Alprostadil) in preventing acute renal failure in patients with elevated levels of serum creatinine and (b) to identify the most appropriate PGE(1)-dose.130 patients with renal impairment (serum creatinine/=1.5 mg/dl) were included in the study prior to intravascular RCM injection. The patients received one of three different doses of PGE(1) (10, 20, or 40 ng/kg bodyweight/min) or placebo (physiologic sodium chloride solution) intravenously over a time period of 6 h (beginning 1 h prior to RCM application). Serum creatinine was measured 12, 24, and 48 h post RCM-application and creatinine clearance was determined with two 12 h collection periods, as well as one 24 h collection within 48 h post RCM administration. Adverse events during PGE(1) administration were recorded.In the placebo group, the mean elevation of serum creatinine was markedly higher (0.72 mg/dl) 48 h after RCM administration compared with the three PGE(1) groups (0.3 mg/dl in the 10 ng/kg/min group, 0. 12 mg in the 20 ng/kg/min group, and 0.29 mg/dl in the 40 ng/kg/min group). No clinically relevant changes were seen regarding the creatinine clearance in the four groups examined.Results from this pilot-study suggest that intravenous PGE(1) may be used efficaciously and safely to prevent RCM-induced renal dysfunction in patients with pre-existing impaired renal function.

Based on the observation of 7 patients with chronic IgA nephritis and on a course to end-stage renal failure after several years, D'Amico et al. [1993] reported on a "point of no return" at 2.5 to 3 mg/dl serum creatinine. After exceeding this limit all 7 patients exhibited an irreversible progressive renal failure.Therefore, 115 patients with IgA nephritis from the "German Glomerulonephritis Therapy Study" were examined in order to look for the existence of such a "point of no return".Three different courses could be distinguished: a stable chronic course with constantly normal or only minor elevated serum creatinine lasting for years (91 patients), a progressive course with continuously increasing serum creatinine (22 patients), and a rare (only 2 patients) early acute course with a short-term increase of serum creatinine followed by a rapid return to the normal range. After exceeding 3 mg/dl serum creatinine no remissions were observed in the progressive cases. Sixteen patients showed a rapid, continuously progressive course until end-stage renal failure with exactly the same progression as the 7 patients of D'Amico et al. Six patients of the 22 progressors were not observed long enough. The serum creatinine level doubled on average from 3 to 6 mg/dl within 10 months.Our study confirmed the existence of a "point of no return" at 3 mg/dl (265 micromol/l) during the natural course of chronic IgA nephritis.

Continuous venovenous hemofiltration (CVVH) is the most widely used renal replacement therapy for the treatment of critically ill patients with acute renal failure on the intensive care unit. Whether or not congestive heart failure is an indication for CVVH is controversial and needs to be discussed. Therefore, we present a patient with congestive heart failure who was treated successfully with CVVH.

Despite significant effects of melphalan and prednisone in the therapy of systemic AL-amyloidosis, overall prognosis is poor and remission of clinical symptoms cannot generally be expected. The course of the disease and results of therapy are possibly influenced by the degree and distribution of organ manifestation at the time of diagnosis. We report a group of patients with renal involvement as the main manifestation of disease.Fifteen patients with systemic Al-amyloidosis without symptomatic myeloma (4 women, 11 men, median age 61 [34 to 71] years) have been attended to at our department and were treated throughout the course of the disease.Since primary symptoms were frequently unspecific, the maximum time to diagnosis came to 28 months. Renal involvement was primarily evident at the time of diagnosis when all patients manifested proteinuria or renal insufficiency. Ten patients were treated with a melphalan and prednisone containing chemotherapeutic protocol. A significant clinical improvement was observed in no case. One patient in an advanced stage of disease died after the administration of a high-dose regimen of melphalan with blood stem-cell support subsequent to sepsis.We do not see an absolute indication for chemotherapy. The unfavorable prognosis--14 patients died an average of 13 months after diagnosis--requires a particularly careful consideration of potential benefits and possible risks accompanying cytostatic therapy.

Cardiovascular disease is a leading cause of death after renal transplantation (RTx), and the incidence is considerably higher than in the general population. Aim of this study was to evaluate the incidence of atherosclerotic cardiovascular complications after RTx, the prevalence of cardiovascular risk factors, prior to and following RTx, and the association between the risk factors and complications.Analysis of atherosclerotic cardiovascular diseases (coronary artery disease, cerebral and peripheral vascular disease) and cardiovascular risk factors before and after transplantation in 427 renal transplant recipients between 1987 and 1992 (mean age at transplantation 45 +/- 12 years, 58% male, 7% diabetics) with a mean posttransplant follow-up of 28 +/- 20 months.Following RTx 11.7% developed atherosclerotic cardiovascular diseases, the majority coronary artery disease (9.8%). The comparison of risk factors 12 months before and 24 months following transplantation showed: The prevalence of systemic hypertension (from 67% to 86%), diabetes mellitus (from 7% to 16%) and obesity with a body mass index25 kg/m2 (from 26% to 48%) had increased significantly whereas the number of smokers halved to 20%. The triglycerides decreased significantly (from 235 +/- 144 mg/dl to 217 +/- 122 mg/dl). The total and HDL cholesterol rose significantly (from 232 +/- 65 mg/dl to 273 +/- 62 mg/dl and from 47 +/- 29 mg/dl to 56 +/- 21 mg/dl, respectively). The LDL cholesterol increase was insignificant (from 180 +/- 62 mg/dl to 189 +/- 53 mg/dl). In the univariate analysis, cardiovascular diseases were significantly associated with male gender, age over 50 years, diabetes mellitus (DM), smoking, total cholesterol200 mg/dl, LDL cholesterol180 mg/dl, HDL cholesterol55 mg/dl, fibrinogen350 mg/dl, body mass index25 kg/m2, and more than 2 antihypertensive agents per day. The Cox proportional hazards model revealed DM with a relative risk (RR) of 4.3, age50 years (RR = 2.7), body mass index25 kg/m2 (RR = 2.6), smoking (RR = 2.5), and LDL cholesterol180 mg/dl (RR = 2.3) as independent risk factors.The high incidence of cardiovascular disease following renal transplantation is mainly due to a high prevalence and accumulation of classical risk factors before and following transplantation. The treatment of the risk factors must be effective and introduced early in the course of renal failure, further, they must be continued following transplantation. Future prospective studies should evaluate the success of treatment regarding reduction of cardiovascular morbidity and mortality in this high risk population.

From 1.1.1993 to 12.31.1995 we performed 761 consecutive biopsies on 509 non-selected patients. The most frequent diagnoses in 351 biopsies (39.4%) on native kidneys were 262 cases of glomerulonephritis (74.6%) and 167 of so-called benign nephrosclerosis (47.6%). With 410 biopsies (60.6%) on allograft kidneys 219 cases (78%) showed signs of interstitial rejection, 14 cases (5%) vascular and 49 cases (17%) interstitial as well as vascular rejection. Only after 5 biopsies (0.66%) clinical relevant complications (3 perirenal haematomas, 1 AV fistula, 1 vesical tamponade) appeared. Again percutaneous renal biopsy is proven to be a diagnostically efficient and safe tool at the same time even when used in a large number of non-selected patients, so that an ambulant performance may be discussed. The relatively frequent diagnosis of a so-called benign nephrosclerosis seems to indicate the need for an intensified examination of this disease.

In the tropic sea there are carnivore fishes, e.g. the "peak bass", that incorporate toxin producing seaweed and can cause the ciguatera intoxication. Due to the frequent tourism to tropic regions even more cases of ciguatera intoxication can be seen in Europe. The late phase of ciguatera intoxication has hardly been recognized due to its different unspecific symptoms. In some cases ciguatera intoxication can even grow a vital threatening.Four patients from a travel group addressed us 4 and 14 days after breaking off their holidays in the Dominican republic. They presented complex neurological symptoms including paraesthesia, nervousness, inverse temperature perception, muscle cramps, headache and dizziness. The physical and apparative investigation of the patients, whose age ranked between 22 and 31 years, was totally unobtrusive. Essential for the diagnosis of ciguatera intoxication was the clue to the symptom causing dinner at their holiday location existing of "peak bass and lemon sauce". First symptoms in all members of the travel group were diarrhea, sickness and sweating. In this late phase only a symptomatic therapy could be offered.The here described cases show the importance of a comprehensive information for tropic travellers as for physicians accounted to in the acute phase of ciguatera intoxication, because recognized early enough (within the first 24 hours) the total symptomatology of ciguatera intoxication can be prevented effectively by intravenous infusions of mannitol.

A nonrandomized, prospective, interdisciplinary pilot study of 102 patients with noncompressive optic disc swelling with visual loss (ODSWVL) was performed in order to investigate etiologic and pathogenetic mechanisms. Forty-six patients suffered from underlying inflammatory disease. Seventeen patients suffered from highly probable cardiogenic embolization, 16 patients from multiple vascular risk factors. The remaining patients of the noninflammatory disease group suffered from leukemia, previously unknown or severely decompensated diabetes mellitus, acute arterial hypertension, different kinds of coagulopathies and others. Ninety-six of the 102 patients required medical treatment according to general medical standards. Inhomogeneity of the underlying disease processes explains the ineffectiveness of different monotherapies in previous studies. Interdisciplinary search for the underlying causes allows causative treatment. ODSWVL and anterior ischemic optic neuropathy in particular seem to be a common final pathway of various pathogenetic mechanisms due to different etiologies rather than a disease entity by itself.

When renal amyloidosis has progressed to end-stage renal failure, most patients are severely affected by systemic amyloidosis and nephropathy. An alternative to chronic dialysis is renal transplantation. We present a patient with amyloid nephropathy who developed recurrent transplant amyloidosis. Renal transplantation was performed in 1985 with a living related donor. In 1990 the patient developed amyloidosis of the graft with membranous nephropathy and tubular acidosis due to hyporeninemic hypoaldosteronism. Secondary amyloidosis has been reported to involve glandular organs inducing hypothyroidism, hypocortisolism and hypoaldosteronism. Cyclosporine has been reported to induce hyporeninemic hypoaldosteronism and tubular acidosis, but not hypocortisolism and hypothyroidism. Progression of the amyloidosis of the graft was confirmed by a renal biopsy in 1993. Data published in the literature indicate that the survival rate of amyloidotic graft recipients is worse than those of non-amyloidotic graft recipients. This was confirmed in an analysis of the current CTS data which showed an impaired survival rate at 5-yr of 66 +/- 4% (+/- SE) for patients with amyloidosis (n = 413) as compared with 86 +/- 1% (p0.0001) for patients with glomerulonephritis and 84 +/- 1 (p0.01) for patients with polycystic kidney disease. Graft survival after 5 years was 55 +/- 4% in patients with amyloidosis as compared with 63 +/- 1% (p = 0.02) in patients with glomerulonephritis and 68 +/- 1% in patients with polycystic kidney disease. Graft survival was improved in amyloidotic patients treated with cylosporine as compared with patients on steroids and azathioprine (55 +/- 4% vs. 38 +/- 8%, p0.05). It is concluded that renal transplantation is the renal replacement therapy of choice for patients with AA-type amyloidosis although the overall patient survival is impaired in comparison with patients with other diseases.

The association of non-Hodgkin's lymphoma with different types of glomerulonephritis is well-known for many years. Whereas in Hodgkin's disease, minimal change glomerulonephritis is mainly observed, in non-Hodgkin's lymphoma various forms of glomerulonephritis are found.We describe 3 cases of non-Hodgkin's lymphoma, which were associated with glomerulonephritis. Two cases of glomerulonephritis showed nephrotic syndromes, which improved by medicinal treatment. In 2 cases glomerulonephritis and non-Hodgkin's lymphoma developed simultaneously. In a third lymphoma was followed by glomerulonephritis after 3 years.Although the pathogenetic relationship between non-Hodgkin's lymphoma and glomerulonephritis is not fully understood, the high number of reported cases yield interdependence. Lymphoma associated glomerulonephritis is found more often in men than in women. Low-grade non-Hodgkin's lymphomas--especially chronic lymphatic leukemias--seem to develop glomerulonephritis more frequently than high-grade. The majority of non-Hodgkin's lymphoma do not show any predisposition to a special type of glomerulonephritis, only in cutaneous lymphoma IgA-nephropathy predominates.

To confirm the results of a number of studies conducted in Europe, the United States, and Japan, this multicenter, randomized trial compared the 12-month efficacy and safety of tacrolimus- and cyclosporine-based immunosuppressive regimens in the prevention of renal allograft rejection.A total of 448 renal transplant recipients were recruited from 15 centers and assigned to receive triple-drug therapy consisting of tacrolimus (n=303) or cyclosporine (n=145) in conjunction with azathioprine and low-dose corticosteroids.At 12 months after transplantation, tacrolimus therapy was associated with a significant reduction in the frequency of both acute (tacrolimus 25.9% vs. cyclosporine 45.7%; P0.001 [absolute difference: 19.8%, 95% confidence interval: 10.0-29.6%]) and corticosteroid-resistant rejection (11.3% vs. 21.6%; P=0.001 [absolute difference: 10.3%, 95% confidence interval: 2.5-18.2%]). Actuarial 1-year patient (tacrolimus 93.0% vs. cyclosporine 96.5%; P=0.140) and graft survival rates (82.5% vs. 86.2%; P=0.380) did not differ significantly between the two treatment groups. Overall, the safety profiles of the tacrolimus- and cyclosporine-based regimens were quite comparable. Infections, renal impairment, neurological complications, and gastrointestinal complaints were frequently reported but were mostly reversible in both groups. Higher incidences of elevated serum creatinine, tremor, diarrhea, hyperglycemia, diabetes mellitus, and angina pectoris were reported in the tacrolimus treatment group, whereas acne, arrhythmia, gingival hyperplasia, and hirsutism were more frequent with cyclosporine treatment.The significant reduction in the incidence of episodes of allograft rejection observed with tacrolimus therapy may have important long-term implications given the prognostic influence of rejection on graft survival.

To determine whether (1) the recently developed pneumatic cycler for automatic peritoneal dialysis (APD) achieves individually adjustable adequate dialysis efficacy, and (2) changing from continuous ambulatory peritoneal dialysis (CAPD) to APD results in an appropriate increase of dialysis efficacy.Between July 1994 and August 1995 dialysis treatment for chronic renal failure was performed in 17 patients (four women, 13 men: mean age 42.9 +/- 11.6 years). Ten patients decided primarily on APD, seven changed over from CAPD to APD because of inadequate dialysis efficacy. Adequacy of dialysis was judged by clinical criteria, weekly creatinine clearances (wCcr) and urea levels (urea elimination related to distribution volume [wKT/V]).Mean treatment period with APD was 7.9 +/- 0.3 hours, dialysate volume 19.4 +/- 2.3 1. An ultrafiltration of 1253 +/- 643 ml was achieved. Mean serum creatinine was 13.1 +/- 3.5 mg/dl, mean serum urea-nitrogen 61 +/- 15 mg/dl. wCcr was 78.6 +/- 27.2 1, wKT/V 2.21 +/- 0.33. All patients were adequately dialysed with various forms of APD. In those patients who changed from CAPD the dialysis efficacy, judged by weekly urea-nitrogen elimination, increased by 50% from 1.42 +/- 0.29 to 2.14 +/- 0.20 (P0.05). With the pneumatic cycler the different dialysis modes were achieved without problem.APD with the new pneumatic cycler provided an adequate and attractive option, from both medical and psychosocial aspects, in the dialysis of patients in chronic renal failure. Changing from CAPD to APD in certain patient groups clearly increased dialysis efficacy so that changing over to haemodialysis can often be avoided.

Data on 64 rejection reactions in 108 consecutive patients after renal transplantation (61 males, 47 females; mean age 42.8 +/- 12.9 years) were analysed to test what Doppler sonographic measurements can be used to predict whether a given drug regimen is able to suppress rejection. Results were compared with renal function and histological evidence of rejection. Thepulsatility index(PI), which is dependent on flow resistance, was determined by Doppler echocardiography: it increases on rejection (measurements made 2.0 +/- 1.1 days apart). The rejection reaction was successfully controlled by drugs (methylprednisolone, azathioprine and cyclosporin) in 44 patients (group 1), but not in 20 patients (group 2). PI before rejection (group 1: 1.8 +/- 0.5; group 2: 1.7 +/- 0.6), PI during histologically confirmed rejection (2.6 +/- 1.2 and 3.1 +/- 1.4, respectively), the size of difference between these values, and parameters of renal function provided no pointers to any drug efficacy in suppressing rejection. But individual changes in PI during suppression treatment proved to be of outstanding value (P0.00005). Signs of florid rejection at the end of treatment period correlated with a rising PI in 13 of 17 rejection episodes, while PI fell in only 7 of 47 episodes. Vascular signs of rejection tended to be poor predictors of rejection (P .028). - These findings indicate that serial Doppler sonography can be helpful in monitoring antirejection treatment.

The urinary excretion of pyridinium cross-links was measured in 70 second morning urine samples from 49 patients following renal transplantation. One and three months after renal transplantation, the urinary excretion of pyridinium cross-links was higher (p0.05) than at one week after transplantation. At all times after transplantation, the values for the excretion of pyridinium cross-links were correlated with the bone alkaline phosphatase concentrations (p0.001). However, there was no correlation between parathyrin concentrations and the values for the excretion of pyridinium cross-links (p0.05). This rise in the excretion of pyridinium cross-links is probably due to an increase of bone resorption caused by cyclosporin A and/or glucocorticoids. In the case of 17 urines with excretion values of pyridinium cross-links above the upper reference limit (pyridinoline equivalents, 93 mumol/mol creatinine), only 2 (12%) of the corresponding sera showed increased bone alkaline phosphatase values. In patients following renal transplantation simultaneous assessment of bone formation and bone resorption (determined from bone alkaline phosphatase serum concentrations and the excretion of pyridinium cross-links) may therefore enhance the diagnostic sensitivity for detecting effects on bone metabolism.

The validity of colour Doppler ultrasound (CDU) in the detection of transplant renal artery stenosis (TRAS) was investigated. 93 patients presenting with deteriorating hypertension underwent CDU. Seven out of 93 patients (8%) were excluded from the study because of incomplete visualization of the transplant vessels. The CDU diagnosis of TRAS was made when all of the following criteria were present: 1. local increase in flow velocity exceeding 150% of the values found in other sections of the transplant artery and 2. marked turbulences in the artery distally of a region with local flow increase. 86 CDU examinations obtained in 86 patients [52 male, 34 female; mean age 45.7 +/- 12.6 years; examined on average 28.8 months (1-156) after transplantation] were compared with 40 angiographies. Patients showing stenosis in the CDU (n = 12) or receiving combined antihypertensive therapy with 3 or more drugs (n = 28) had an angiography performed. Angiography confirmed 11 out of the 12 arterial stenoses that had been found with CDU and detected one segment artery stenosis of 30-50% that was not detected by CDU. In 4 stenosed arteries, peak velocities were higher than the maximum velocity measurable with the pw-Doppler (higher than 350 cm/s). Peak velocities measured by CDU within 8 stenoses exceeded the flow speeds obtained elsewhere in the artery by 193 +/- 35% (286 +/- 82 cm/s). Using the criteria of stenosis as defined in this paper, CDU may be employed as screening method to detect TRAS with a sensitivity of 92% and a specificity of 96%.

A retrospective analysis of 21 male and 82 female patients with systemic lupus erythematosus (SLE) was performed in order to identify sex-linked differences in disease manifestations. As organ manifestation, cardiac involvement was assessed in 12 of 21 male patients (57%) and in 18 of 82 females (22%; p0.05). Renal involvement occurred in 16 male (76%) vs 26 female patients (32%; p0.05). Endstage renal disease developed in 5 of the 21 men (24%), but only in 6 of the 82 women (7%) with SLE. The most striking clinical result was the high frequency of thrombembolic complications in male SLE-patients. Twelve out of 21 males (57%) experienced more than 30 thrombembolic events in contrast to 9 events in 5 out of 82 females (6%; p0.0001). Persisting elevated IgG-anti-cardiolipin antibodies were found in 48% of male and only 16% of female patients (p0.05). In conclusion, these data suggest that SLE in males is characterized by more frequent and severe organ involvement and especially by striking prevalence of partly life-threatening thrombembolic complications.

In a prospective randomized open multicenter study, 107 anemic (Hct= 28%) peritoneal dialysis (PD) patients were treated with s.c. rhEPO daily. The mean observation period was 299 days (range 14-479 days). Patients were randomly assigned to 3 groups with different initial doses: 5 U/kg (G5), 10 U/kg (G10), 20 U/kg (G20). Initial doses were maintained for at least 8 weeks unless the target Hct (30-35%) was achieved earlier. The weekly increase of Hct was significantly (p0.05) dose-dependent: 0.19% in G5, 0.5% in G10 and 0.94% in G20. In case of insufficient response (0.5% per week), the dose was doubled every 4 weeks. Final doses on achieving the target Hct ranged from 5 to 40 U/kg (median 20 U/kg). The dose was then reduced to 50% and adjusted individually. The median maintenance dose was 9.9 U/kg/day. No tendency towards higher blood pressure or intensification of antihypertensive treatment was observed. When rhEPO is administered daily, 10 U/kg/day (70 U/kg weekly) is the recommended starting dose. The need for higher doses used in unsatisfactory response, should lead to further examination to rule out iron deficiency and other reasons for non-response. The median maintenance dose reported here is the lowest published in the literature for PD patients and seems to be linked to the daily injections.

30 patients with an acute build-up of renal transplant were examined comparatively via antegrade pyelography (AP), computed tomography (CT) and sonography (SONO). In the proof of obstructions and compressions of the ureter of renal transplant, antegrade pyelography was superior to sonography and computed tomography. Perirenal collections of fluids were recognised correctly via sonography by 73% (11/15) and computed tomography by 87% (13/15). The computer tomogram is superior in the differentiation of perirenal collection of fluids. In establishing proof of the cause of an acute build-up of renal transplant it was evident that computed tomography with a sensitivity of 64% and a specificity of 94% was slightly superior.

The clinical clues of sudden arterial hypertension, acute pain in the side, proteinuria, hematuria, abdominal bruits and renal failure are suspicious for spontaneous dissection of the renal arteries, even in the absence of one or more of the above-mentioned symptoms. To confirm the diagnosis and to provide appropriate therapy, immediate renal arteriography is mandatory, otherwise acute loss of renal tissue may occur. We report on one patient with spontaneous dissection of the renal arteries.

Long-term administration of ciclosporin has been complicated by side-effects, the predominant being nephrotoxicity. We performed renal function studies on 20 patients treated with ciclosporin (group 1) and on 12 patients serving as controls (group 2). Only patients with serum creatinine less than 1.3 mg/dl entered the study. The renal function studies consisted of: Inulin clearance, PAH clearance, sodium sulphate loading, sodium bicarbonate loading. Plasma renin activity (PRA), inactive renin (IR) and aldosterone (ALDO) were measured basally and after stimulation with 40 mg furosemide i.v. Serum creatinine was not significantly impaired under ciclosporin with 1.1 +/- 0.1 mg/dl vs 0.9 +/- 0.1 mg/dl in the control group (ns). Glomerular filtration rates as measured by creatinine and inulin clearance were significantly impaired in group 1 as compared to group 2. Inulin clearance was impaired by ciclosporin with 93.5 +/- 4.4 ml/min/1.73 m2 as compared to 121 +/- 6.6 ml/min/1.73 m2 (p less than 0.05) in patients of group 2. The PAH clearance in ciclosporin treated patients was impaired, with 379 +/- 22.1 ml/min/1.73 m2 in group 1 as compared to 605 +/- 39 ml/min/1.73 m2 (p less than 0.001) in group 2. Mean arterial pressure and renovascular resistance were significantly increased in ciclosporin treated patients. We demonstrated, by means of sodium sulphate and bicarbonate loading, incomplete distal tubular acidosis in 3 patients from group 1 but in none of group 2. There was no difference in basal plasma renin activity (PRA), but during volume contraction induced by furosemide there was only blunted response by PRA in patients receiving ciclosporin with 2.7 +/- 0.3 ng/ml/h as compared to 7.7 +/- 0.5 ng/ml/h in controls.(ABSTRACT TRUNCATED AT 250 WORDS)

A patient, born in 1968, was found at the age of 9 years to have Alport's syndrome. In his 20th year, when in terminal renal failure, his father's kidney was transplanted into him. 14 months later there was a sudden worsening of his renal function after a varicella infection; for the first time antibodies against the glomerular basal membrane (GBM) were detected. Despite an increase in prednisolone dosage and 6 plasmaphereses chronic haemodialysis again became necessary. Renal biopsy revealed necrotizing intra- and extracapillary glomerulonephritis. Simultaneously there was a raised anti-NC-1-antibody titre (1:80) in the serum. After removal of the transplant the titre fell to normal. The NC-1 antigen, a component of the GBM in healthy persons, may be absent in Alport's syndrome. An analysis of the few cases of anti-GBM glomerulonephritis in renal transplants of patients with Alport's syndrome may make it possible to recognize factors which precipitate or favour this form of glomerulonephritis.

12 patients with the nephrotic syndrome (N.S.) and normal serum creatinine (less than 1.5 mg/dl) were investigated in a follow-up study over 10 days under diuretic treatment with piretanide (29 +/- 24 pg/ml). Clinical effects, parameters of renal clearance and hemodynamics, metabolic changes and the influence on vasoactive and volume dependent hormonal systems were studied. Piretanide markedly increased urine volume and electrolyte excretion (Vu +53%, UNa +24%, p less than 0.05, after 10 days treatment) but did not significantly alter glomerular filtration rate or renal blood flow. While baseline plasma renin activity was in the normal range and regularly stimulated (2.55 ng/ml x h to 7.7 ng/ml x h) plasma ANP values were elevated (152 +/- 107 pg/ml) at the start of the study and did not significantly change under piretanide treatment. This may be an indicator of sodium retention and a high plasma volume in the primary form of the nephrotic syndrome. Thereby piretanide did not significantly alter the intravascular space.

A prospective study of 45 consecutive patients (27 men, 18 women, mean age 42 [22-64] years) who had undergone allogeneic renal transplantation was carried out to ascertain whether rejection of the graft can be detected by routine follow up with colour-coded Doppler ultrasonography even in the presence of acute renal failure requiring dialysis. Conventional diagnostic methods detected 44 episodes of rejection in 33 patients: 26 of these arose in 18 patients with acute renal failure requiring dialysis and 18 in 15 patients who did not require dialysis. Colour-coded Doppler ultrasonography was used to determine the "pulsatility index" (PI) at intervals of 3 to 6 days. 17 of the 18 episodes of rejection occurring in transplant patients with stable serum creatinine levels (3.41 +/- 1.48 mg/dl) were detected by colour-coded Doppler ultrasonography 3.8 +/- 5.6 days earlier than by conventional diagnostic methods, the indicator being the rise in PI (sensitivity 93.8%). 25 of the 26 rejection reactions which arose in patients with oligo-anuria due to post-operative renal failure were detected 2.0 +/- 2.7 days earlier (sensitivity 96%). The rise in PI was greater in episodes of vascular rejection than in purely interstitial rejection episodes (40.9 +/- 73.9% versus 10.0 +/- 8.8% per day). Colour-coded Doppler ultrasonography ia a new, highly sensitive, noninvasive method for the early detection of rejection reactions after renal transplantation. Acute postischaemic renal failure does not reduce its sensitivity.

Atrial natriuretic peptide (ANP) and plasma renin activity (PRA) were studied in 19 patients with end-stage renal disease (ESRD) under haemodialysis (HD). On the basis of clinical findings, patients were divided into three groups: group A, 6 patients, of mean age 41 +/- 15 years, without heart failure and in need of ultrafiltration (658 +/- 282 ml h-1); group B, 6 patients, of mean age 54 +/- 15 years, without heart failure under isovolaemic HD; group C, 7 patients, of mean age 60 +/- 3 years, with heart failure (NYHA III-IV) and in need of ultrafiltration (607 +/- 120 ml h-1). The highest predialysis ANP levels were found in group C (1534 +/- 471 pg ml-1) followed by group A (476 +/- 168 pg ml-1) and group B (236 +/- 138 pg ml-1) (normal range 62 +/- 27 pg ml-1). Systolic and diastolic blood pressure and heart rate did not correlate with ANP levels in either of the groups. However, iso-osmotic reduction of the body weight by ultrafiltration was correlated with decreasing ANP levels during HD (for groups A and C, r = 0.88 and 0.98, respectively). Isovolaemic HD did not alter ANP concentrations (group B). All patients received a volume bolus at the end of HD, and they responded with an instant increase in ANP concentration, which was most pronounced in patients with concomitant heart failure. PRA was not significantly correlated with ANP levels during HD. In conclusion, the results of this study indicate that there is a sensitive response of ANP levels to changes in body fluid status in ESRD.

Three patients with solar urticaria were treated with plasmapheresis. By intradermal injection of in vitro irradiated serum the existence of a circulating photoallergen was demonstrated in cases 1 and 2 but not in case 3. Plasmapheresis induced complete remission of solar urticaria in case 1 and transient improvement in case 2. In case 3, however, no beneficial effect was observed. It is suggested that some patients with solar urticaria, probably those with a circulating photoallergen, may benefit from plasmapheresis.

There are typical morphological indicators of tubular defects during the administration of ciclosporin A (CSA). Distal tubular function remains unclear although hyperkalemia is a common clinical feature in these patients. We performed renal function studies 3 months after renal transplantation on 35 patients (group 1) treated with CSA. The results were compared to those of a control group consisting of 15 patients transplanted earlier and treated with azathioprine (group 2). Only patients with stable renal function (creatinine less than or equal to 2.0 mg/dl) entered the investigation consisting of: inulin (In) clearance; p-aminohippuric acid (PAH) clearance; ammonium chloride loading; sodium sulfate loading, and sodium bicarbonate loading. Plasma renin activity and aldosterone were measured basally and after stimulation with 40 mg i.v. furosemide. Clearances of In and PAH were significantly impaired during the administration of CSA. Group 1: CIn 73.3 +/- 8.7 ml/min/1.73 m2 (p less than 0.01), CPAH 263 +/- 58.3 ml/min/1.73 m2 (p less than 0.01); group 2: CIn 89.6 +/- 19.1 ml/min/1.73 m2, CPAH 338.7 +/- 63.5 ml/min/1.73 m2. Incomplete distal tubular acidosis could be demonstrated in 8 patients from group 1 but none of group 2. Hyporeninemic hypoaldosteronism could be demonstrated in 4 patients during the administration of CSA. CSA in therapeutic doses significantly impairs renal perfusion, glomerular filtration, distal acidification and the renin-aldosterone axis.

In order to investigate the behaviour of atrial natriuretic peptide (ANP) in untreated mild to moderate essential hypertension and the influence of blood pressure normalisation by a beta 1-receptor blocker a study was conducted in groups of normotensive and hypertensive middle aged subjects. 10 normal subjects and 10 patients with essential hypertension (WHO I-II) without any medication and on betaxolol monotherapy were studied at rest and during graded exercise. In addition the response of ANP, cyclic guanosine monophosphate (cGMP) and the renin-aldosterone-system was investigated. Normal subjects and hypertensive patients did not differ in ANP levels at rest and also responded with a comparable exercise dependent increase at all workload levels. A steady decrease of ANP was noticed during the recovery period in both groups. After beta-blocker treatment in the hypertensive patients ANP concentrations significantly rose, both at rest and more pronounced during exercise. cGMP reacted in a similar way but showed a more inert response. A counter-regulatory behaviour between ANP and PRA or aldosterone, as seen under volume shifts, could not be detected. These findings demonstrate that plasma ANP is not altered in untreated essential hypertension. Increased ANP levels in beta 1-blocker treatment may contribute to its blood lowering effect.