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Von der MDCT-Technik und ihrer mittlerweile weiten Verfugbarkeit hat auch die Bildgebung bei Nieren- und Hochdruckkrankheiten profitiert. In zunehmendem Mase kann die MDCT Indikationen der (invasiven) konventionellen Angiographie ubernehmen und die i.v.-Urographie vollstandig ersetzen. Zur Minimierung der Gesamtstrahlendosis ist fur jede Fragestellung ein masgeschneidertes Untersuchungsprotokoll anzuwenden. Soweit sinnvoll sollten Niedrigdosisprotokolle (z. B. zur Diagnostik der Urolithiasis) zur Anwendung kommen. Durch die Verbesserung der longitudinalen Auflosung (z-Achse) und der resultierenden isotropen Voxel stehen vielfaltige Moglichkeiten der Bildrekonstruktion zur Verfugung. Die Anfertigung von multiplanaren Rekonstruktionen, dunneren Schichten und/oder 3D-Rekonstruktionen kann in vielen Fallen hilfreich bei der Diagnosefindung sein. Grundlage einer aussagekraftigen Untersuchung ist nicht zuletzt eine gute Kommunikation zwischen klinisch tatigen Arzten und Radiologen.

BACKGROUND: 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 Dusseldorf had acted in conformity with the established case law in Germany. METHODS: Between April and August 2006 doctors at the university medical center in Dusseldorf filled in a standardized questionnaire about the decisions they had taken to withdraw life-support treatment. RESULTS: 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. CONCLUSION: 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.

A 49-year-old previously healthy man fell gravely ill after repeatedly eating the mushroom Paxillus involutus. Haemolysis and circulatory shock caused acute renal failure, acute respiratory failure and disseminated intravascular coagulation. The patient died three-and-a-half days after the mushroom meal in protracted shock. In addition to the signs of haemolysis, post-mortem examination revealed signs of intravascular coagulopathy in lungs, kidneys, adrenals, myocardium, liver and spleen. There were also extensive fat emboli to both lungs. An IgG antibody against paxillus involutus extract was demonstrated in the patient's serum. The immunological reaction pattern suggests primarily the formation of an immune complex, which secondarily attaches itself to the erythrocyte surface and causes intravascular haemolysis by activation of the complement chain. In the first instance the diagnosis is made from anamnestic data. In addition to adequate treatment of circulatory shock, immediate plasma separation could provide a chance of effective treatment.

A 49-year-old woman took about 12.5 mg digoxin with suicidal intent. Severe arrhythmias, including recurrent ventricular fibrillation, occurred. Sheep Fab fragments of digoxin-specific antibodies were administered i. v. at a dose of 480 mg. Serum free-digoxin concentration fell within half an hour to 0, with simultaneous rise of total digoxin from 13 micrograms/l to a maximum of 176 micrograms/l after 2 hours. At the same time there was marked improvement in the clinical condition with restoration of a stable sinus rhythm. There were no side effects to the Fab fragment administration.

An 18-year-old woman developed an acute haemolytic anaemia, acute transient renal failure and progressive hepatic failure. Coeruloplasmin and serum copper concentration were normal; a Kayser-Fleischer ring and any neurological symptoms were absent initially. Liver biopsy was contraindicated because of increased bleeding tendency. Wilson's disease was diagnosed only after the acute renal failure had regressed, on the basis of the urinary copper excretion (2890 micrograms/d, rising to 7330 micrograms/d after D-penicillamine administration). Progressive liver failure required transplantation. After it the patient quickly recovered and is now, two years later, free of disease. -This case demonstrates that Wilson's disease may be difficult to diagnose at the time of initial acute manifestation. But it can be recognized early from the pathognomonic low alkaline phosphatase and by calculation of free serum copper.

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.

Patienten mit chronischer Niereninsuffizienz weisen eine vielfach erhohte kardiovaskulare Morbiditat und Mortalitat auf. Der akzelerierten Atherosklerose liegt ein chronisch inflammatorischer Prozess zugrunde, der durch zahlreiche mit der Niereninsuffizienz assoziierte Faktoren (z. B. oxidativer Stress, gestorter Ca2+/PO4-Stoffwechsel, aktiviertes RAA-System) verstarkt wird. Entscheidende Progressionsfaktoren sind Hypertonie und Proteinurie, die fruh und konsequent behandelt werden mussen, um auch kardiovaskulare Komplikationen zu reduzieren. Die Diagnostik kardialer Erkrankungen bei Niereninsuffizienz kann bei fehlenden klassischen Symptomen (z. B. Angina pectoris) erschwert sein, deshalb sollte die Indikation zur kardialen Diagnostik groszugig gestellt werden. Neben der medikamentosen Therapie kardialer Erkrankungen kommen bei Patienten mit Niereninsuffizienz auch interventionelle oder operative Therapien zum Einsatz, sowohl Kurzzeit- als auch Langzeiterfolge sind vom Ausmas der Nierenfunktionseinschrankung abhangig.

AIMS Although on account of their nephroprotective effects, ACE inhibitors and angiotensin receptor antagonists appear to be advantageous for patients after renal transplantation, their use in these patients has been limited up to now. This is in part due to the risk of inducing a decrease in the glomerular filtration pressure gradient with subsequent impairment of allograft function. The aim of the present study was to investigate the effects of ACE inhibitors and angiotensin receptor antagonists on renal function, excretion of prostaglandins as a parameter of glomerular hemodynamics and TGF-beta1 plasma levels during an 8-week withdrawal phase in pretreated patients. PATIENTS AND METHODS Sixteen patients with stable long-term allograft function undergoing therapy with candesartan (group 1) and 16 patients with stable long-term allograft function undergoing therapy with perindopril (group 2) were included in the study. Any signs of chronic allograft dysfunction were defined as exclusion criteria. Renal function, albuminuria, TGF-beta1 plasma levels as well as the excretion of thromboxane B2 and 6-keto-prostaglandin-F-1alpha were monitored during an 8-week withdrawal phase of the angiotensin receptor antagonist or ACE inhibitor, respectively. Normotension was maintained throughout the study period through adjustment of other anti-hypertensive drugs. RESULTS Creatinine clearance as well as TGF-beta1 plasma levels and the excretion of prostaglandins remained unchanged after discontinuation of candesartan or perindopril. However, after withdrawal of the substances a significant increase in albuminuria was noted in both patient groups throughout the observation period. After 8 weeks, median albuminuria had increased by 63% in group 1 and by 163% in group 2. CONCLUSIONS We were able to demonstrate that the use of ACE inhibitors and angiotensin receptor antagonists in patients after renal transplantation is safe. Favorable effects of both substances on albuminuria were detectable in patients who showed no signs of chronic allograft dysfunction according to the usual criteria. Therefore, a nephroprotective effect of candesartan as well as of perindopril, is highly probable in patients after renal transplantation. Further investigations regarding routine use in these patients are therefore mandatory.

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.

Anamnese und klinischer Befund: Ein 39-jahriger Patient wurde zur Abklarung eines nephrotischen Syndroms vorgestellt. In der aktuellen Anamnese gab der Patient eine Verschlechterung des Allgemeinbefindens mit rezidivierenden Fieberschuben und einer seit einem Jahr bestehenden Mikrohamaturie und Proteinurie an. Daruber hinaus berichtete der Patient uber eine ventrikuloatriale Shuntimplantation im Alter von 24 Jahren aufgrund eines Hydrocephalus internus. In einer auswartigen Klinik wurde wegen eines nephrotischen Syndroms bei der Verdachtsdiagnose einer membranoproliferativen Glomerulonephritis eine Steroidbehandlung eingeleitet, unter der eine weitere Progression der Erkrankung verzeichnet worden war. Bei Aufnahme waren ausgepragte Odeme sowie erhohte Temperaturen von 38,5 ˚C nachweisbar. Der Allgemeinzustand des Patienten war reduziert. Eine Nackensteifigkeit bestand nicht. Untersuchungen: Laborchemisch fanden sich erhohte Entzundungsparameter. Die Nierenfunktion gemessen am Serumkreatinin und der Kreatininclearance waren normal. Die Komplementfaktoren C3 und C4 waren vermindert. Die Proteinurie betrug 9 g/24 h. Die durchgefuhrte Nierenbiopsie ergab den Befund einer membranoproliferativen Glomerulonephritis Typ I. In der aeroben Blutkultur wurde mehrfach Micrococcus roseus/varians nachgewiesen. Therapie und Verlauf: Aufgrund der Untersuchungsergebnisse bestand der Verdacht auf eine durch den ventrikuloatrialen Shunt verursachte chronische Infektion mit sekundarer Glomerulonephritis. Als therapeutische Masnahme erfolgte daher die Explantation des Shuntsystems. Die Untersuchung des explantierten Shuntsystems erbrachte den Nachweis des selben Erregers wie in der Blutkultur. 6 Monate nach Shuntwechsel und Behandlung der Infektion und betrug die Proteinurie 0,450 mg/24 h bei einem Serumkreatinin von 1,0 mg/dl. Folgerung: Bei Nachweis einer membranoproliferativen Glomerulonephritis mussen auch die sekundaren Formen in die differentialdiagnostischen Uberlegungen einbezogen werden. Bei gezielter Therapie wird in den meisten Fallen eine weitere Progression der Nierenerkrankung verhindert werden konnen. History and admission findings: 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. Investigations: 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. Treatment and course: 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. Conclusion: 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.

Plasma-ANP- (pg/ml; Radioimmunassay) als Parameter einer postischamischen Dysfunktion und Troponin-T-Spiegel (TnT) (ng/ml; ELISA) als Indikator eines ischamischen Zellschadens wurden vor, wahrend und nach der extrakorporalen Zirkulation (EKZ) bei 15 Patienten mit koronarer Herzerkrankung (KHK) (mittleres Alter: 58±6,1 Jahre; 13m, 2w; alle ohne eingeschrankte linksventrikulare Funktion und Zeichen einer kongestiven Herzerkrankung) untersucht. Unter standardisierten Bedingungen bei der EKZ wurden Basisdaten bezuglich der kardialen Hamodynamik (Herzfrequenz (HF); systolischer (RR sys,mmHg), diastolischer Druck (RR dia,mmHg); zentralvenoser Druck (ZVD,mmHg); linksatrialer Druck (LAP,mmHg); linksventrikularer, enddiastolischer Druck (LVEDP,mmHg)) dokumentiert und unter Elektrokardiographie (EKG) – Monitoring wurden Blutproben entnommen: 1) 10 min vor Anasthesiebeginn; 2) vor EKZ; 3) nach 1h EKZ; 4) 5min nach EKZ-Ende; 5) 1h nach EKZ-Ende; 6) 6h postoperativ (postop); 7) 24h postop; 8) 48h postop; 9) 10 Tage postop. Zusatzlich wurden mit Hilfe der ¶M-Mode Echokardiographie (Echo) pra- und am 10. postoperativen Tag der linksatriale Durchmesser (LAD, mm), der linksventrikulare enddiastolische Durchmesser bei Q (LVEDD, mm) gemessen und die Ejektionsfraktion (EF, %) berechnet.¶ Die Bestimmung der ANP- bzw. TnT-Konzentrationen im Plasma des arteriellen und venosen Blutes erfolgte mittels eines Doppel-Antikorpers (AK)-Radioimmunoassay bzw. ELISA-Tests.¶ Bei dem Kollektiv der KHK-Patienten fand sich ein Konzentrationsanstieg des ANPs von 90±10 (M±SEM)pg/ml (p

Die Plasma-ANP-Spiegel vor, wahrend und nach der extrakorporalen Zirkulation (EKZ) bei 20 Patienten mit koronarer Herzerkrankung (KHK) (mittleres Alter: 57 Jahre; 18 m, 2 w; alle mit nicht eingeschrankter linksventrikularer Funktion) und 20 Patienten mit Mitralvitien (MV) (mittleres Alter: 68 Jahre; 7 m, 13 w; 10 im Sinusrhythmus (SR), 10 mit Vorhofflimmern (Vhfli)) wurden untersucht. Unter standardisierten Bedingungen bei der EKZ wurden Basisdaten bezuglich der kardialen Hamodynamik (zentralvenoser Druck (ZVD); linksatrialer Druck (LAP); linksventrikularer, enddiastolischer Druck (LVEDP); linksventrikularer enddiastolischer Durchmesser (LVEDD)) der untersuchten Patientenkollektive erhoben und mit den Plasmakonzentrationen des atrialen natriuretischen Peptids (ANP) in Beziehung gesetzt.

64 percutaneous renal biopsies were done on 60 patients with renal impairment (serum creatinine level more than 1.5 mg%) under sonographic guidance. In 62 biopsies (96.8%), more than 3 glomeruli were seen, in 45 biopsies (70.3%) the amount of at least 10 glomeruli could be obtained, this being the amount desirable for a good histological diagnosis; 8 cases (12.5%) presented with minor complications after the biopsies. All of them resolved spontaneously. Ultrasound-guided percutaneous renal biopsy is a safe procedure for rapid diagnosis and induction of a specific therapy in patients with renal impairment.

The efficacy and safety of tacrolimus- and cyclosporine-based immunosuppressive regimens were compared in a prospectively defined subgroup of kidney transplant recipients from the European, open, multicentre, 2:1 randomised, parallel group study. Patients were stratified as high risk for immunological events if they had a panel-reactive antibodies grade greater than 80% and/or a previous transplant functional for less than 1 year. The primary efficacy variables evaluated were the incidence of acute rejection, steroid usage and patient and graft survival. Safety was assessed based on adverse events and laboratory evaluations. At 1 year, the tacrolimus group (n = 22) had a lower incidence of biopsy-proven acute rejection (31.8%) and a higher graft survival (86.0%) than the 11 patients in the cyclosporine group (54.5% and 72.0%, respectively). The frequencies of adverse events were similar between the two groups. The tacrolimus regimen appears more beneficial for high risk patients than cyclosporine.

Bei den uberwiegend immunpathogenetisch bedingten Glomerulonephritiden (GN) unterscheidet man primare und sekundare Formen. Die primaren Formen sind durch fehlende, die sekundaren durch vorhandene andere Systemerkrankungen definiert. Durch ihre Immunpathogenese sind die Glomerulonephritiden pradestiniert fur eine immunsuppressive bzw. - modulierende Therapie. Daruber gibt die vorliegende Arbeit einen Uberblick. Sie enthalt gleichzeitig eine Klassifikation der GN unter klinischen und der rasch progressiven GN unter immunpathogenetischen Gesichtspunkten und beschaftigt sich auserdem mit den Ursachen des nephrotischen Syndroms.

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.

Lipoprotein patterns in renal transplant patients: a comparison between FK 506 and cyclosporine A patients.

The clinical importance of renovascular disease, atherosclerotic or of other origin, arises from the fact, that renal artery stenosis (RAS), if hemodynamically significant (70% diameter reduction), induces arterial hypertension, renal insufficiency or both. The prevalence of RAS rises with increasing age and with the presence of atherosclerosis of the aorta, carotid, coronary and peripheral arteries. Typical clinical symptoms, as uncontrolled hypertension or renal dysfunction in the absence of pathological urinary findings, are helpful to select patients for further screening methods: We see a prominent role of color duplex sonography as a screening procedure. Intra-arterial angiography remains gold standard for the diagnosis of RAS. The major problem in daily clinical practice is the differentiation between patients in which hypertension and kidney function can be improved or normalized by removal of RAS and those with ''fixed'' hypertension and irreversible kidney dysfunction and therefore to decide if it is worth while to perform invasive treatment as angioplasty or surgery. In this setting, the proof of hemodynamic significance is essential and is indicated especially when the stenosis has a diameter reduction of50-70% only. Methods proving a critical stenosis are intra-arterial measurement of the pressure gradient, measurement of differential renal vein renin and duplex sonography. In addition, predictors of treatment outcome should be considered. Studies analyzing if patients improve with blood pressure and kidney function after removal of RAS have shown that high grade stenosis and/or very high blood pressure indicate a good outcome. Further prognostic factors are the absence of parenchymal disease and/or positive functional test. In the presence of a critical stenosis in a patient with a clear clinical problem with hypertension and/or renal dysfunction a positive effect of invasive treatment seems warranted despite the risks that must be considered as well in angioplasty as in surgery. The selection for the type of invasive treatment requires a clarification of the treatment goals in the individual patient, the evaluation of the morphology and localization of the stenosis as the presence of other vascular disease (aortic aneurysm, peripheral artery disease etc.) and the assessment of the risk according to the type of intervention.

A 26-year-old woman presented with fatigue, muscle cramps and weakness. Since the age of 8 years she had moderate hypokalemia of unknown origin that was confirmed on multiple occasions. There was no family history of disease.Laboratory tests showed moderate to severe hypokalemia with a serum potassium concentration of 2.7 to 3.0 mmol/l, hypomagnesemia, metabolic alkalosis and pronounced stimulation of the renin-angiotensin-aldosterone system. Despite normal serum calcium levels, urinary calcium excretion was below the detection threshold. Increased natriuresis was observed after administration of furosemide, but not after administration of hydrochlorothiazide. This finding pointed to the presence of a non-functional thiazide-sensitive sodium/chloride cotransporter in the distal convoluted tubule, characteristic for Gitelman's syndrome. Genetic analysis confirmed the diagnosis of Gitelman's syndrome and documented two heterozygous mutations in the gene encoding the sodium/chloride cotransporter.The patient was treated with 160 mmol potassium and 30 mmol magnesium supplementation per day. Serum potassium was normalized and magnesium serum levels increased. Weakness and fatigue improved markedly.Gitelman's syndrome is an important differential diagnosis in the evaluation of the normotensive patient with hypokalemia.

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.