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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.

In a retrospective study the course of acute myocardial infarction was investigated in 1840 patients treated in 1980 in eleven Hamburg hospitals (90% of hospitals admitting emergencies). 71% of patients were over 60 years of age, infarction frequency reached its peak in the eighth decade. Compared to prior investigations the percentage of women was higher both as a whole and in patients over 70 years of age (ratio men to women = 1.8 : 1). In comparison with the overall population of Hamburg, infarction rate was not increased in certain social classes. Frequency of "silent" infarctions was 4 to 5 times higher in patients of 70 years of age than in younger ones. Left ventricular failure and conduction disturbances increased with age, while extrasystoles occurred at all ages without difference. Hospital mortality of acute infarction was 29% for men and 37% for women. Striking results are the higher mortality of younger women and the considerable increase of mortality in patients over 70 years of age, probably due to change of age structure, the large number of acute reinfarctions (29%), and the short admission time. 40% of patients of all age-groups were admitted within 3 hours after onset of infarction.

OBJECTIVE To determine retrospectively the complications and long-term results of aortocoronary bypass grafting in patients with end-stage renal disease. PATIENTS AND METHODS 65 patients with coronary heart disease (CHD) and on dialysis (54 men, 11 women; average age 56.9 +/- 8.1 years) underwent aortocoronary bypass grafting between 1982 and 1992. Mean duration of dialysis (haemo- or peritoneal) was 41.1 +/- 45.0 (1-215) months. All patients had had haemofiltration treatment in conjunction with the bypass operation. RESULTS Coronary angiography demonstrated triple-vessel disease in 40 patients (62%). Average number of bypasses was 2.8 per patient. Perioperative death rate was 4.6%. 95% of survivors were free of symptoms 6 months postoperatively. Long-term survival rate was 71% after 3 years and 55% after 5 years. CONCLUSION Aortocoronary bypass grafting for CHD in patients with end-stage renal disease can be performed with a low perioperative mortality rate and significantly improves symptoms.

Hintergrund Die anatomische Darstellung und Erfassung moglicher Anomalien der Nierengefase und Ureteren ist fur die Planung einer Lebendnierenspende von essenzieller Bedeutung. Die vorliegende Untersuchung soll die Wertigkeit der nichtinvasiven Evaluation mit der 64-Zeilen-Multidetektor-CT untersuchen.

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.

Conversion from mycophenolate mofetil (MMF, CellCept) to enteric-coated mycophenolate sodium (EC-MPS, myfortic) is safe and effective in renal transplant patients treated with the standard dose of 2 g MMF. In this 6-month, international, multicenter, open-label, single-arm trial, a large cohort of maintenance renal transplant patients receiving different doses of MMF were converted under normal clinical conditions to equimolar doses of EC-MPS. Mean calculated creatinine clearance remained stable from the time of study entry (59.6 +/- 19.7 mL/min) to the end of the study (58.3 +/- 19.8 mL/min). Adverse events were reported by 152 patients (67%), with gastrointestinal complications being observed in 45 patients (20%). Thirty-three patients (15%) experienced adverse events or infections with a suspected relation to EC-MPS, including one case of anemia and two cases of leukopenia. Eleven patients (4.9%) required a reduction in EC-MPS dose and seven patients (3.1%) permanently discontinued EC-MPS owing to adverse events. At month 6 after conversion, five patients (2.2%) experienced biopsy-proven acute rejection. There were no graft losses or deaths. These data support earlier findings that stable maintenance renal transplant patients receiving MMF with cyclosporine with or without corticosteroids can be converted to EC-MPS with no compromise in efficacy and tolerability, and no adverse effect on renal function.

Mycophenolate mofetil (MMF), in combination with cyclosporine and corticosteroids, improves long-term graft survival in renal transplant recipients. However, optimal MMF therapy may be limited by gastrointestinal (GI) intolerance, which may result in the need for MMF dose reduction, interruption, or discontinuation, leading to increased risk of acute rejection. Enteric-coated mycophenolate sodium (EC-MPS) is a new formulation delivering mycophenolic acid developed with the aim of improving upper GI tolerability. A large prospective, open-label, multicenter program (myPROMS: myfortic PROspective Multicenter Study) is underway to determine the efficacy and safety of EC-MPS, in combination with cyclosporine microemulsion (CsA; Neoral) in a large population of de novo and maintenance renal transplant recipients. myPROMS consists of one global protocol with 14 subprotocols. Each subprotocol is designed to address further specific objectives, such as specific patient populations, steroid regimens, and various CsA C2 targets. The preliminary data summarized here are from two subprotocols, which investigated the benefits of converting maintenance renal transplant patients receiving MMF to EC-MPS. The 3-month interim analyses suggest that the conversion from MMF to EC-MPS is well tolerated in maintenance renal transplant recipients.

Anatomical imaging and the ascertainment of any anomalies in the renal vessels and the ureters are essential in the planning of a kidney donation. The aim of the present study was to assess the value of 64-row multidetector CT in noninvasive examination of the renal vessels and ureters of potential living kidney donors.The evaluation embraced 63 living renal donors (LNS) who underwent preoperative CT examination from December 2004 to January 2007. The examinations were all carried out using a Somatom Sensation -Cardiac 64 (Siemens Medical Solutions, Germany). As well as CT angiography (CTA), a venous phase of the abdomen and a late phase after 15 min using low-dose technique were performed for CT urography (CTU). The radiological findings were compared with the surgical results, or with the angiograms in 2 cases. Sensitivity, specificity and both negative and positive predictive value were calculated.In the 63 (31 female, 32 male) donors CTA had a sensitivity of 100% in examination of the main and accessory renal arteries and of 98.3% when the venous and ureteric anatomy were assessed. The sensitivity of low-dose CTU was also 100%.The findings recorded in this study indicate that noninvasive preoperative planning with 64-row multidetector CTA and CTU is a reliable "one-stop shopping" method of examination for potential living kidney donors.

After renal transplantation immunosuppressive drugs-like cyclosporin A (CsA) and FK506 induce either hypoaldosteronism or pseudo-hypoaldosteronism presenting with hyperkalemia and metabolic acidosis. We investigated the relationship between renal allograft function under CsA therapy and plasma aldosterone concentration, potassium- and water homeostasis and mineralocorticoid receptor (MR) expression level in peripheral leukocytes.We studied 21 renal transplant patients under CsA therapy and 12 healthy controls. Transplant recipients were studied before and under fludrocortisone treatment. Using quantitative reverse-phase polymerase chain reaction (RT-PCR) specific for the MR, we analyzed the level of expression of MR in peripheral leukocytes.In acidotic transplant recipients (HCO(3) 18.5 +/- 1.2 mM) renal function was only slightly impaired with 2.0 +/- 0.2 mg creatinine/dL when compared with 1.8 +/- 0.3 mg/dL (ns) in non-acidotic patients (HCO(3) 23.0 +/- 2.8 mM). Mean plasma aldosterone levels in renal transplant recipients did not differ from control levels (150 +/- 33 pg/mL vs. 148 +/- 33 pg/mL, ns). In contrast, the expression level of MR in peripheral leukocytes of renal transplant recipients treated with CsA was significantly decreased when compared with healthy controls without renal disease (120 +/- 78 vs. 423 +/- 73 RNA molecules/0.5 microg total RNA, p0.01). The level of expression of MR in renal transplant recipients did not differ between acidotic patients and non-acidotic patients (ns). The application of fludrocortisone reversed hyperkalemia and metabolic acidosis without significant effect on MR expression.The present data demonstrate that hyperkalemia and metabolic acidosis following CsA treatment in kidney transplantation might be associated with a down-regulation of MR expression on peripheral leukocytes. Electrolyte imbalance is reversible on application of fludrocortisone. This observation supports fludrocortisone treatment in transplant patients with severe electrolyte disturbances.

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.

More frequently there is the need for renal transplantation of older patients. Against the background of an increasing number of old donors and recipients, Eurotransplant Leiden started the Eurotransplant Senior Program (ESP) 'old for old' in 1999. The ESP works with donors and recipients both over 65 yr. The kidneys are transplanted with short cold ischaemia time regardless of the human leukocyte antigen (HLA) compatibility. Compatibility of blood groups, negative crossmatch and less than 5% cytotoxic antibodies are required. First experiences from 10 patients at Heinrich Heine University hospital are reported here. The course of 10 transplanted patients is described from January 1999 until November 1999 (28.4+/-15.8 wk). Age of donor and recipient, cause of dialysis and concomitant diseases from recipients, function of the transplanted kidney and complications are analysed. Immunosuppression consisted initially of cyclosporin A, mycophenolic acid and steroids. The results of these 10 patients were compared to 14 patients who were transplanted according to the ordinary Eurotransplant criteria (Eurotransplant Kidney Allocation System) in the same period of time. Kidneys from six donors (70.5+/-3.3 yr) were transplanted to 10 different recipients (66.9+/-2.2 yr). The control group consisted of 14 patients (47.6+/-14.4 yr) who received kidneys from 14 donors (48.3+/-10.1 yr). One double kidney transplantation was performed in the senior group, i.e. two kidneys from a marginal donor were transplanted to one recipient ('two in one'). In the ESP group, cold ischaemia time was reduced by 5 h and mean of HLA mismatches was more than doubled. Mean length of hospitalisation of ESP and control groups was 47.2+/-28.2 and 34.2+/-11.6 d, respectively. Intraoperatively, no complications were seen, post-operative care was performed on a normal ward. ESP patients suffered more often from delayed graft function, which led to further need for haemodialysis for 11.2 d. Finally, 9 of 10 patients acquired a satisfactory renal graft function. A total of 13 biopsies were performed in eight cases. Altogether seven acute rejections in 6 patients were found (four interstitial, one vascular, one interstitial+vascular, one clinical). The 9 patients with sufficient renal graft function were discharged with a mean serum creatinine level of 2.3+/-0.5 mg/dL (control: 1.9+/-0.8 mg/dL). Comparing these 10 recipients to a control group consisting of 14 patients, the results are comparable and encouraging. In conclusion, the short-term results of the ESP are promising. Nevertheless, the post-operative care requires more attention due to several complications. Though the HLA compatibility was not considered, all rejections were coped with effectively. Quality of life was improved.

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.

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.

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.

Patients with end-stage renal disease (ESRD) have a high incidence of coronary artery disease. In 30-60% of these patients coronary artery disease can be demonstrated by coronary angiography often prompting myocardial revascularization. Previous studies on PTCA in patients with ESRD have suggested a high rate of procedural complications and restenosis. We studied the rate of restenosis after PTCA in 23 patients with chronic renal failure (17 males, 6 females, age: 52.5 +/- 18.3 years). After primarily successful PTCA all patients were restudied angiographically within 6-12 months. Using quantitative coronary angiography 13 patients (56%) demonstrated restenosis (stenosis50% luminal diameter). In 11 of these patients further revascularization therapy was indicated (6 x PTCA, 5 x CABG). Before follow-up angiography 12 patients demonstrated recurrence of angina pectoris, the sensitivity of clinical symptoms for angiographic restenosis was 69%. High concentrations of triglycerides (265 +/- 160 mg/dl), total cholesterol (258 +/- 53 mg/dl) with low HDL-levels (34 +/- 14 mg/dl) as well as elevated plasma levels of fibrinogen (481 +/- 114 mg/dl) were measured before PTCA. The mechanisms contributing to the high rate of coronary restenosis in patients with ESRD remain unclear, influence of lipid abnormalities, hemostatic factors and fibrinolytic state as well as primarily uremic factors have to be discussed. Prospective interventional studies are needed to address the relevance of PTCA for myocardial revascularization in this patient group.

Over the past 3 years, 35 newborn infants have been referred for surgical management of hypoplastic left heart syndrome. Surgical palliation (first-stage Norwood) or cardiac transplantation was offered. Twenty-four families (68%) chose palliation and 11 families (32%) chose cardiac transplantation. Of the 11 infants listed for cardiac transplantation, five underwent transplantation. Because of a lack of donors after an average wait of 25 days (19 to 31), the remaining six infants underwent palliation, with no perioperative deaths. Of the 30 infants undergoing palliation, including crossovers, 20 (67%) survived the first operative stage. Among the last 19 infants undergoing palliation in 1990, the early survival was 84%. Risk factors determined for poor outcome were year of operation (p less than 0.001) and circulatory arrest time greater than 50 minutes (p less than 0.001). Among the 13 infants undergoing palliation with a circulatory arrest time of less than 50 minutes, there were 12 survivors (92%); among 12 having a circulatory arrest time of more than 50 minutes, there were four survivors (33%). At intermediate follow-up, six infants have undergone second-stage procedures (Glenn), with five survivors. There were eight late deaths, four caused by respiratory infections and four caused by cardiac problems, including a thrombosed shunt in one infant. Three of five infants are alive and doing well after cardiac transplantation. Size of aorta, tricuspid regurgitation, and ventricular wall thickness did not prove to be risk factors. Given the existing data, we believe these infants should be managed selectively on the basis of donor availability and family wishes.

New monoclonal antibodies directed to membrane molecules unique to lymphocyte subsets have provided the means to alter the immune response to alloantigens in a more selective fashion. This investigation demonstrates that monoclonal antibody-induced depletion of CD4 helper/inducer T lymphocytes before transplantation of a fully mismatched heart allograft allows permanent engraftment in rats without further immunosuppression. Five adult male ACI (RT1a) rats received cell-depleting doses of the mouse anti-rat CD4 monoclonal antibody, MRC Ox-38, for 1 month before undergoing heterotopic abdominal heart transplantation. No other immunosuppression was administered, and immunotherapy was discontinued the day of transplantation. After all five Lewis rat (RT1(1)) hearts were maintained free of rejection for more than 3 months, a second heterotopic transplant was performed, this time to the femoral vessels, using either fresh Lewis heart allografts (n = 3) or third-party, Brown-Norway (RT1n) hearts (n = 2). Histologic evaluation was performed 3 weeks later and revealed severe rejection of the femoral Brown-Norway grafts with no evidence of rejection in any of the femoral or original abdominal Lewis grafts. These results suggested that limited, pretransplant anti-CD4 immunotherapy allowed permanent engraftment of fully mismatched cardiac allografts in rats and conferred donor-specific unresponsiveness.

The structure of rat intestinal cell receptors for Escherichia coli heat-stable enterotoxin (ST) was investigated by affinity cross-linking to 125I-ST and analysis by denaturing gel electrophoresis. Cross-linking of labeled toxin to intestinal membranes and analysis by nonreducing sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) revealed five specifically labeled proteins with molecular masses of 160, 136, 78, 71, and 56 (kilodaltons) kDa. Exhaustive reduction of these samples resulted in a similar pattern of labeling. Affinity-labeled proteins were further analyzed by nonreducing SDS-PAGE, reduction of the resulting separated proteins, and further separation by SDS-PAGE in the presence of beta-mercaptoethanol. Thus, the 160-kDa band on nonreducing gels consisted of two different receptors: a 160-kDa polypeptide not further reducible and one composed of at least two subunits, one of which was the 78-kDa subunit. Similarly, the 136-kDa band on nonreducing gels consisted of a 136-kDa polypeptide not further reducible and one composed of at least two subunits, one of which was the 71-kDa subunit. The 78-, 71-, and 56-kDa subunits were not further reducible. These data suggest heterogeneity of the ST receptor subunit structure and organization in rat intestinal epithelia.

There have been only a few investigations that have considered renal disease or any disturbance of renal function in the calculation of risk in cardiac surgery. Risks of cardiac surgery have to be considered for renal disease without direct connection to heart disease (e.g., infections of the kidney and of the urinary tract, primary and secondary glomerulonephritis, parenchymal renal disease, and impaired renal function of unknown origin), as well as in renal disease with concomitant influence on heart and kidney (e.g., infective endocarditis, arterial hypertension, systemic disease of heart and kidney such as with diabetes mellitus, disturbance of kidney function or electrolyte balance due to heart failure). In most cases, the problem is solved by therapeutic intervention and postponement of cardiac surgery. A limited or negative operative indication is found with untreatable infection of the kidney or urinary tract, with untreatable nephrotic syndrome, in advanced renal disease with heart transplantation, as well as in case of severe arterial hypertension with possible organ complications, and in advanced diabetes mellitus with ESRD and multiorgan involvement. After cardiac surgery, acute renal failure represents a critically important complication. Primary therapeutic procedures must include prophylaxis of hemodynamic unstable situations, as well as prophylaxis of infectious complications. Cardiac surgery in dialysis patients and post-transplant patients is basically possible and only has a slightly increased risk compared to patients with normal renal function. Seventy-seven dialysis patients were operated (49 aorto-coronary bypass operations, 19 single-valve and multiple-valve replacements, five patients with valve replacement and aorto-coronary bypass, and four other cardiac surgical operations). Only in valve replacement, was mortality significantly higher than in renal healthy persons, the main causes of death being cerebrovascular complications and septicemia.

The chronic effect of the calcium antagonist nitrendipine was investigated on blood pressure (BP), plasma aldosterone concentration (PAC), plasma renin activity (PRA), and serum potassium in six patients with primary aldosteronism, either due to an (unilateral) aldosterone-producing adenoma (APA;n=3; age, 44±4 years; PAC, 312±96 pg/ml; PRA

1158 patients with acute myocardial infarction hospitalized in 6 clinics at Hamburg were analyzed retrospectively with special regard to older patients. 46% of all patients were older than 70 years. In contrast to former investigations the rate of myocardial infarction of women over 70 is arised. The reason of admission was reinfarction in 39%. The most frequent risk factors were hypertension and diabetes mellitus; but hypertension is not more frequent than in this age-group of the whole population. A so-called "silent" myocardial infarction occurred in 10-15% of patients over 70 years. The clinical course of acute myocardial infarction was injured by hemodynamic complications in 66%. Ventricular fibrillation was more frequent in younger than in older patients. The reanimation of older patients was successful in 25% primary, but the inhospital mortality was unchanged high (50%). In contrast to younger patients 40% of cases of death occurred after the acute phase in the 2.-4. week of hospital treatment.

The chronic effect of the calcium antagonist nitrendipine, a 1,4-dihydropyridine derivative, on blood pressure (BP), plasma aldosterone concentration (PAC), plasma renin activity (PRA), and serum potassium was investigated in six patients with primary aldosteronism, either due to an (unilateral) aldosterone-producing adenoma (APA) (n = 3; age 44 +/- 4 years; PAC: 312 +/- 96 pg/ml; PRA: less than 0.1 ng/L/h; serum potassium: 2.8 +/- 0.3 mmol/L) or to bilateral idiopathic hyperaldosteronism (IHA): (n = 3; age 49 +/- 1 years; PAC: 212 +/- 32 pg/ml; PRA: 0.1 +/- 0.1 ng/L/h; serum potassium: 3.3 +/- 0.2 mmol/L). After withdrawal of antihypertensive medications 2 weeks prior to the study, nitrendipine was given orally in a daily dosage of 40-60 mg. BP, PAC, PRA, and serum potassium were determined before and after 4 weeks of nitrendipine therapy. After 4 weeks, blood pressure was significantly reduced (178 +/- 10 to 165 +/- 6 mm Hg systolic, 109 +/- 7 to 101 +/- 6 mm Hg diastolic) in three patients with APA and in two with IHA. No significant changes of PAC, PRA, and serum potassium were observed in these patients. However, one patient with clinical characteristics of IHA and a long-term history of diuretic therapy showed a complete normalization of BP, PAC, PRA, and serum potassium, suggesting that the etiology of autonomous hyperaldosteronism in this patient might differ from typical primary aldosteronism. From these findings, we follow that calcium antagonists do not normalize BP, PAC, PRA, and serum potassium in patients with APA.(ABSTRACT TRUNCATED AT 250 WORDS)

In a retrospective study the course of acute myocardial infarction was investigated in 1840 patients treated in 1980 in eleven Hamburg hospitals (90% of hospitals admitting emergencies). 71% of patients were over 60 years of age, infarction frequency reached its peak in the eighth decade. Compared to prior investigations the percentage of women was higher both as a whole and in patients over 70 years of age (ratio men to women = 1.8 : 1). In comparison with the overall population of Hamburg, infarction rate was not increased in certain social classes. Frequency of "silent" infarctions was 4 to 5 times higher in patients of 70 years of age than in younger ones. Left ventricular failure and conduction disturbances increased with age, while extrasystoles occurred at all ages without difference. Hospital mortality of acute infarction was 29% for men and 37% for women. Striking results are the higher mortality of younger women and the considerable increase of mortality in patients over 70 years of age, probably due to change of age structure, the large number of acute reinfarctions (29%), and the short admission time. 40% of patients of all age-groups were admitted within 3 hours after onset of infarction.

A clonidine suppression test and the measurement of the catecholamine (noradrenaline and adrenaline) concentration in 24-hour urine were undertaken on 13 patients with benign phaeochromocytoma (PCC), 30 patients with benign hypertension (BHT) and ten healthy, normotensive volunteers. In 11 patients with PCC (85%) the clonidine suppression test gave true-positive results (no significant suppression of initially raised plasma-catecholamine concentration after oral intake of 300 micrograms clonidine). Continuous fall in plasma-catecholamine level after clonidine occurred in two patients with PCC and only moderately elevated initial levels (false-negative results, 15%), as well as in all patients with BHT and all normal controls (true-positive, 100% each). A false-negative result for catecholamine concentration in 24-hour urine was obtained in only one patient (8%). In all others there were either true-positive results (urine concentration greater than 200 micrograms/24 h in 12 patients with PCC, 92%) or true-negative results (urine concentration less than 150 micrograms/24 h in all patients with BHT, 100% each). Compared with direct catecholamine measurement in 24-hour urine, the clonidine suppression test did not fulfil the criteria for further investigations in those patients who had moderately raised plasma-catecholamine levels.

Retrospectively the clinical course of acute myocardial infarction (MI) was investigated in 1840 patients (1211 men and 629 women of all ages) treated in 11 hospitals (90% of emergency capacity) at Hamburg in 1980. 71% were older than 60 years, the average age was 69,3. 1237 patients had the first MI. There were no differences in frequency of MI in the different social classes (self-employed, employees or officials, workers) compared to the population of Hamburg. The in-hospital mortality of first MI was 23%, mortality of reinfarction was 43% (p< 0.05).