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Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht.

Background and Objective: Diuretics are key elements of the pharmacotherapy of diseases in internal medicine. Currently, they are particularly used in the treatment of edema and hypertension. For the treatment with diuretics some rules exist that help to improve the effectiveness and success. The article explains these rules, especially regarding combination treatment and meaningful dose escalation. Additionally, the side effects of treatment are critically discussed., Results and Conclusion: There is little evidence for the influence of diuretics in the treatment of edema on prognostic factors, such as mortality and comorbidities. For an improvement of the prognosis other substances are more important, e.g. angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers; however, diuretics in the treatment of hypertension show clear positive effects on the endpoints. In recent years a problem of side effects was demonstrated (skin cancer). Comparing the benefits regarding prognosis in the treatment of hypertension with the side effects, the administration but with appropriate protective measures seems to be warranted.

Acid-base disorders and in particular metabolic acidosis are very common in critically ill patients and contribute significantly to morbidity and mortality. We shed light on the most common causes, the pathophysiology and treatments. Particular attention will be paid to the common practice of substituting sodium bicarbonate in the light of recent study results.

The examination of the urine is the oldest and a very basic technique for every nephrologist. It helps to detect, diagnose and classify diseases of the kidneys and the urinary tract. Proteinuria is an important sign of kidney disease and an own factor in the pathophysiology of renal progression. Acanthocytes in the urine (> 5 %) have a high specifity (98 - 100 %) for diagnosing a glomerular hematuria., Competing Interests: Priv.-Doz. Dr. M. Kimmel hat Forschungsunterstützung und Vortragshonorare von Astute Medical erhalten. D. Biegger und Prof. Dr. M. D. Alscher geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

The estimation of potassium in the serum is basis for the diagnosis of potassium disturbances. The value is a result of intake, excretion and internal distribution of potassium between intra- and extracellular compartments of the body. Clinically, we often see disturbances of potassium. The causes are explained by an aging population with morbidities that warrant diuretic treatment on the one side, and chronic kidney diseases on the other. In the first cases, we see hypokalaemia, in the latter hyperkalaemia. Both can lead to increased mortalities which are often labelled as "sudden heart death" without finding the underlying mechanism to be potassium driven. This is due to the fact that cardiac arrhythmias (ventricular fibrillation, heart block) lead to cardiac arrest. The pathophysiological understanding of the principles is the key for the guidance of diagnosis and therapy of the disturbances of potassium metabolism. Only by that, a decrease in mortality can be accomplished., (© Georg Thieme Verlag KG Stuttgart · New York.)

The regulation of the acid-base balance and pH is critical for the organism. The most important buffer system is CO 2 / HCO 3 - . The kidney controls systemic bicarbonate and therefore the metabolic regulation and the lung is relevant for respiratory regulation by an effective CO 2 elimination. There are four acid-base disorders with two metabolic and two respiratory disorders (acidosis and alkalosis). The anion gap enables a further workup of metabolic acidosis., (© Georg Thieme Verlag KG Stuttgart · New York.)

The proposals by health care providers to impose drastic limits on chronic dialysis in hospitals to the extent that it can only be provided on loss-making terms, will jeopardize the cost efficiency of nephrological departments in hospitals and hence their continued existence. Such departments play a key role within the discipline, however, as the training of nephrologists is tied to them by further training regulations. The authors take the view that the proposals by health care providers are short-sighted with regard to the quality of care and the safeguarding of care in the future, and that they counteract the goals of quality assurance currently dominating the health policy agenda., (© Georg Thieme Verlag KG Stuttgart · New York.)

The cardiorenal syndrome describes the frequent clinical situation in which therapy of a patient with acute cardiac decompensation is limited by a decline of renal function. This is frequently associated with preexisting chronic renal insufficiency. It is important to be aware of this potentially fatal constellation and perform diuretic therapy slowly and carefully in order to avoid inadequate volume depletion. This may require surveillance in an intensive care unit. Ultrafiltration is an alternative to diuretic therapy which may permit greater fluid loss when beginning therapy and better control of volume reduction once heart failure symptoms improve. The individual treatment of patients with cardiorenal syndrome requires a close cooperation between cardiologists and nephrologists.

Hypokalemia is a common finding. The clinical presentation can be paralyses and cardiac arrhythmias. We present a normotensive young woman with salt appetite, cramps and palpitations. In our case report the patient shows a positive family history for hypopotassemia, a metabolic alkalosis with hypotension, and hypocalciuria with an increased urinary potassium loss. The levels of renin and aldosterone were elevated. After a negative testing for metabolites of diuretics, we obtained a positive result of the suspected SLC12A3 genetic test. This mutation leads to a failure of the thiazide-sensitive sodium-2-chloride-cotransporter, the so called Gitelman syndrome, which presents similar to a chronic thiazide therapy. The Gitelman syndrome is a rare disease with renal potassium loss and hypotension. Especially in young patients around the age of twenty or in patients with chronic intractable hypopotassemia a Gitelman syndrome should be considered.

History and Findings: A 30-year-old woman presented to our emergency department with severe headaches, dizziness and uncontrolled hypertension. She had arterial hypertension and a known heart murmur since adolescence. Previous medical work up did not reveal any cause for secondary hypertension. Recently her blood pressure had been difficult to control. A systolic murmur as well as absent inguinal and feet pulses were notable at the physical examination., Investigations: When performing doppler ultrasound the closing pressures of the dorsalis pedis arteries were only 70 mm Hg compared to a blood pressure reading of 160 mm Hg on the upper arms. Thoracic magnetic resonance imaging showed subtotal aortic coarctation causing the differences in blood pressures. Echocardiography and cardiac catheterization additionally revealed a moderately stenosed bicuspid aortic valve, the pressure gradient across the coarctation was 30 mm Hg., Therapy and Course: Despite the severity of the coarctation an interventional approach was favoured instead of a classical operative therapy. Balloon dilatation with stent implantation was performed without complications. Since the intervention blood pressure have remained normotensive, the coarctation gradient being markedly reduced., Conclusions: In young patients with arterial hypertension, as well as in cases of severe and refractory hypertension, causes of secondary hypertension must be looked for and excluded. Especially when hypertension occurs in adolescence, aortic coarctation should be taken into account, in addition to renal or endocrine causes. A thorough physical examination with cardiac auscultation and checking of all peripheral pulses is the crucial step to the diagnosis., (© Georg Thieme Verlag KG Stuttgart · New York.)

History and Admission Findings: A 65-year-old man was admitted with history of claudication symptoms and painful skin lesions of the lower legs. Physical examination showed palpable purpura of the lower legs and livedo reticularis, most marked at the forefoot and toes., Investigations: Computed tomography (CT) showed an aortic mass 2 cm above the bifurcation. This was treated after angiography with a covered stent. Biopsy of the skin lesions showed no sign of vasculitis and no cholesterol crystals., Treatment and Course: The patient was discharged and remained symptom-free for 9 months. He was readmitted at that time with recurrent complaints. CT revealed a subtotal stenosis of the aortic stent. A skin biopsy showed CD31-positive tumor cells in small arteries. Biopsy of a new osteolytic lesion in the ileum confirmed the diagnosis of angiosarcoma of the aorta. The patient decided in favor of palliative care and was discharged from the hospital., Conclusion: Primary tumors of the aorta, although they are rare, should be considered in the presence of an intravascular mass with stenosis to blood flow. A skin biopsy is easy to conduct and often leads to the final diagnosis., (Georg Thieme Verlag KG Stuttgart. New York.)