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Purpose: Pulse wave velocity (PWV) is at least partially controlled by vascular tone. Vascular tone and underlying physiological processes such as sympathetic activity, plasma catecholamin, and cortisol levels have been shown to follow diurnal variations., Materials and Methods: Carotid-to-radial PWV was non-invasively assessed by applanation tonometry in 21 young (26.5+/-2.3 years) healthy men at three different time points (8:00 hr, 12:00 hr, 17:00 hr) during a day. Additionally, heart rate, systolic, diastolic and mean blood pressure, and radial pulse pressure were assessed at the same time points., Results: The mean PWV was significantly higher at 8:00 hr compared with the mean PWV assessed at later time points. No significant differences were found between mean PWV at 12:00 hr and at 17:00 hr. When PWV was corrected for blood pressure, the difference between values at 8:00 hr and 12:00 hr was no longer significant. Systolic, diastolic and mean blood pressure were significantly lower at 17:00 hr compared with those at 8:00 hr., Conclusion: A small but significant diurnal variation of PWV was observed in young healthy men, which might have been caused at least partly by variations of blood pressure. This finding could be of value, when PWV is used in human research. Thus, in longitudinal investigations the measurements should be performed at similar time points in the course of a day, in order to obtain comparable data. Additionally, our observations ought to be of assistance to studies in which novel pharmacological compounds with activity on the vasculature are investigated.

Purpose of Review: The mortality of type 2 diabetic patients with renal disease is high during both the pre-dialysis period as well as the period under dialysis therapy. With respect to rare data in the literature it may be assumed that the mortality rate is especially high during the last year before and the first year after start of dialysis therapy., Recent Findings: After reviewing the reports in the literature dealing with survival of diabetic patients with nephropathy it may be concluded that mortality is especially high during the year before and after initiating dialysis. There are exact survival data of type 2 diabetic patients under dialysis therapy but only few data concerning the survival during the last year prior to dialysis treatment. The possible reasons for this higher mortality shortly before and after start of dialysis are discussed in this article., Summary: The mortality in type 2 diabetic patients is especially high during the last year before and the first year after the start of dialysis therapy. However, only the higher mortality during the first year after initiating dialysis is well documented in the literature. Those patients who die early within 90 days of dialysis are not registered in the registries, therefore, the overall mortality during the first dialysis year is at least 5% higher than the registered. During both periods several factors may play a causal role in the high mortality, a higher prevalence of heart failure, and a progression of macroangiopathy with higher incidence of cardiovascular events due to traditional and non-traditional risk factors, especially inflammation and oxidative stress.

Objectives: To review published data on the perioperative management of antirheumatic treatment and perioperative outcome in patients with rheumatoid arthritis (RA)., Methods: The review is based on a MEDLINE (PubMed) search of the English-language literature from 1965 to 2005, using the index keywords "rheumatoid arthritis" and "surgery". As co-indexing terms the different disease-modifying antirheumatic drugs (DMARDs) as well as nonsteroidal anti-inflammatory drugs (NSAIDs) and "glucocorticoids" were used. In addition, citations from retrieved articles were scanned for additional references. Furthermore, because the number of published articles is so limited, relevant abstracts presented at congresses were included in the analysis., Results: Continuation of methotrexate (MTX) appears to be safe in the perioperative period. Only a limited number of studies address the use of leflunomide and the results are conflicting. Because of the very long drug half-life, its discontinuation would need to be of long duration and is probably not necessary. Data on hydroxychloroquine do not show increased risks of infection. Regarding sulfasalazine, there are no studies from which definite answers could be drawn on whether it should be withheld perioperatively. Preliminary data show that the risk of infections during treatment with TNF-blocking agents may be lower than initially expected. The only available recommendation (Club Rhumatismes et Inflammation, CRI) suggests discontinuing the drugs before surgery for several weeks, depending on the risk of infection and the drug used. They should not be restarted until wound healing is complete. To avoid the antiplatelet effect during surgery, NSAIDs other than aspirin should be withheld for a duration of 4 to 5 times the drug half-life. Patients with chronic glucocorticoid therapy and suppressed hypothalamic-pituitary-adrenal (HPA) axis need perioperative supplementation., Conclusions: While continuation of MTX likely is safe, data on other DMARDs are sparse. In particular, more data on the perioperative use of the biologic agents are needed.

Primary hyperparathyroidism (PHP) during pregnancy is a very rare event that increases maternal and perinatal morbidity and mortality. We present a case in which hypocalcemic tetany of the neonatal infant - caused by transient hypoparathyroidism in the child - finally revealed asymptomatic maternal PHP. An apparently healthy 30-year-old woman had an uneventful pregnancy and delivery. On the 15th postpartal day, the newborn developed hypocalcemic tetany. After receiving supplementation of calcium and vitamin D, the child developed without further pathological findings. Laboratory and radiological studies in the mother led to a diagnosis of maternal PHP. An adenoma of the right lower parathyroid gland was subsequently removed. The search for the cause of hypocalcemia in a newborn should not focus on the patient alone. Examining the apparently healthy mother and approaching the case in a multidisciplinary fashion may benefit both the child and the mother.

Background: Arterial stiffness is thought to play a critical role in the pathogenesis of cardiovascular events, and in hyperthyroidism increased cardiovascular event rates have been reported., Aim: To investigate markers of systemic arterial stiffness, volume homeostasis, and subendocardial perfusion and its interrelationship in patients with Graves' disease (GD) in hyperthyroidism and euthyroidism., Method: Aortic augmentation index (AIx@75) as a measure of systemic arterial stiffness and subendocardial viability ratio (SEVR) as a surrogate measure of subendocardial perfusion were assessed by applanation tonometry in 59 patients with GD in hyperthyroidism and euthyroidism, and measurements were compared to plasma levels of NT-pro-B-type natriuretic peptide (NT-ProBNP)., Results: AIx@75 and NT-ProBNP levels were significantly increased in hyperthyroidism compared to euthyroidism and were positively correlated with each other. SEVR was significantly decreased in hyperthyroidism compared to euthyroidism, mainly due to increased heart rates as shown by the heart rate-corrected SEVR75., Conclusions: In hyperthyroidism, patients with GD exhibited increased systemic arterial stiffness, paralleled by increased levels of NT-ProBNP, a marker of volume overload. The decreased subendocardial perfusion in hyperthyroidism seemed to be mainly due to increased heart rates. The observed unfavorable hemodynamic alterations in hyperthyroidism may serve to explain increased cardiovascular event rates in patients with GD.

Introduction: Insulin resistance is a common problem in obese patients with type 2 diabetes. In a prospective randomized study, we investigated the improvement of metabolic control after a 3-5 day period of intravenous insulin infusion in poorly insulin-treated, overweight type 2-diabetic patients with and without additional glitazone therapy., Methods: Twenty-eight overweight patients (BMI > 28) with poorly insulin-treated type 2 diabetes (HbA1c > 8%) requiring > 80 IU insulin/day received a continuous insulin infusion for 3-5 days (initially 4-6 IU insulin/hour). Thereafter, 14 of the patients also received pioglitazone (15 mg/day). The two groups were compared for HbA1c, mean blood glucose (MBG), body weight, cholesterol, triglycerides and insulin requirement (IU/day) three months before insulin infusion, during infusion, and at three and six months after the infusion., Results: Glycemic control was immediately improved under insulin infusion in both groups: MBG was reduced from 188 +/- 32 mg/dl at baseline to 142 +/- 28 mg/dl at the end of insulin infusion (p < 0.05). In the group receiving pioglitazone, the mean HbA1c three months after the insulin infusion was 16% lower and after six months 17% lower than baseline values (p < 0.02). Concomitantly, the required insulin dose decreased significantly by 15% after three months and 18% after six months (p < 0.02). Two patients (14%) were non-responders (< 10% reduction of required insulin dose). In the group without pioglitazone the mean HbA1c level three months after insulin infusion was 10% lower (p < 0.05) than at baseline; at six months the HbA1c value was the same as that before the infusion. The required insulin dose was 10% lower after three months and only 3% lower after six months (NS). Four patients (28%) were non-responders., Discussion: Short-term insulin infusion therapy is effective in improving metabolic control and, concomitantly, in reducing insulin requirement in poorly insulin-treated type 2-diabetic patients; however, these effects are mostly limited to three months. With additional glitazone treatment after the insulin infusion, the improvement in metabolic control and the reduced insulin requirement can be maintained for more than six months.

Background: Prevalence of insulin resistance (IR) is increased in type 2 diabetes and in end-stage renal disease (ESRD). IR is associated with advanced atherosclerosis and is an independent predictor for cardiovascular disease in diabetes and ESRD patients. We investigated prevalence, severity, predictors and relation to vascular diseases by the homeostasis model assessment (HOMA-IR) in diabetic and nondiabetic ESRD patients., Methods: ESRD patients with type 2 diabetes (n = 27) and nondiabetic ESRD patients (n = 35) were included in the study. IR was assessed with the HOMA-IR using fasting glucose and insulin levels. Additionally, serum levels of C-peptide, HbA1c, triglycerides, cholesterol and C-reactive protein and blood pressure were assessed., Results: Median HOMA-IR was significantly higher in the diabetic ESRD patients than in the nondiabetic ESRD patients (6.3 [range 0.7-61.7] vs. 2.4 [range 0.3-5.7]; p < 0.001). Systolic blood pressure and triglycerides were significantly higher in patients with higher HOMA-IR, whereas HDL cholesterol was significantly lower in those patients. Only nondiabetic patients with increased HOMA-IR had significantly higher C-peptide levels than those with lower HOMA-IR (14.9 + 5.7 vs. 9.0 + 4.3, p = 0.004). Vascular disease prevalence was significantly higher in diabetic patients with higher HOMA-IR than in those with lower HOMA-IR., Conclusions: Prevalence and severity of HOMA-IR was greater in diabetic ESRD patients than in those without diabetes. In diabetic patients low HDL cholesterol was the only predictor for higher HOMA-IR, whereas in nondiabetic patients a high C-peptide level was the only predictor for higher HOMA-IR. The prevalence of vascular diseases is associated with higher HOMA-IR in ESRD patients.

A 23-year old woman was admitted to our hospital because of severe edema due to steroid resistant minimal change nephritis (MCN). The diagnosis was proven by renal biopsy nine years ago. At that time, steroid therapy led to a complete remission. Seven years later, patient was 22 years old, a relapse with severe nephrotic syndrome occurred. The diagnosis MCN was confirmed by a second renal biopsy. A combined therapy with prednisolone and cyclosporine A (CSA) led only to a partial reduction of protein excretion, the edema did not disappear. After 3 months, patient declined further therapy with CSA. On admission to our hospital, one year later in December 2000, the woman showed a severe nephrotic syndrome with edema and fluid lung, despite high doses of furosemide. Urinary protein excretion was 12.5 g/day, serum creatinine was increased to 1.4 mg/dl, the serum protein was reduced to 47 g/l. A repeated renal biopsy confirmed again the diagnosis MCN. Once again, a steroid bolus monotherapy over 4 weeks and an immunosuppressive therapy with CSA over 6 weeks had no effect on proteinuria. Further therapy regimes with mofetil mycophenolat, azathioprine, chlorambucil and cyclophosphamide over a period of 6-12 weeks of each regime was not well tolerated, proteinuria remained high with > 10 g/day. Moreover the patient suffered from severe edema despite furosemide infusions. Therefore, an additional mechanical ultrafiltration was performed 2-4 times monthly. Three months after the last immunosuppressive therapy the edema disappeared spontaneously, the diuretic therapy could be stopped. Serum creatinine was 0.8 mg/dl, protein in urine was still high with 9.8 g/day but serum protein for the first time was normal with 65 g/l. Three months later, the protein excretion was reduced to 0.48 g/l, and all other laboratory data were normal. Meanwhile, the woman has now enjoyed a complete second spontaneous remission for a period of three years.

Background: The progression of chronic renal insufficiency depends on the type of primary renal disease and blood pressure (BP) levels. We investigated the rate of decline of glomerular filtration rate (GFR) during 3 years prior to the start of dialysis therapy in type 2 diabetic patients with diabetic nephropathy (dNP) or vascular nephropathy (vNP). The aim of the study was to determine differences in the progression of renal insufficiency and the prevalence of vascular diseases in the two patient groups., Methods: In a retrospective study, we investigated type 2 diabetic patients with chronic renal insufficiency who were undergoing regular controls in our outpatient care unit for at least 3 years prior to the start of dialysis. We evaluated only patients who had already died under chronic dialysis therapy, and whose diagnosis of primary renal disease was histologically conformed at autopsy. A total of 40 type 2 diabetic patients were included in the study. Of these, 28 patients had dNP (age 62 +/- 8 years) and 12 had vNP (age 70 +/- 7 years). The following parameters were determined at 3- to 6-month intervals: body weight, BP, HbA1c, serum creatinine (Cr), Cr clearance (Cockroft formula), cholesterol and triglycerides. The prevalence of vascular disease in the two groups was also assessed., Results: The average decrease in Cr clearance was 7.7 +/- 2.4 ml/min/year in patients with dNP and 7.7 +/- 2.1 ml/min/year in those with vNP (NS). During the entire observation period, mean HbA1c values (7.0 +/- 0.8 vs. 6.8 +/- 0.6%), systolic BP (137 +/- 8 vs. 138 +/- 11 mm Hg) and diastolic BP (86 +/- 4 vs. 87 +/- 7 mm Hg), cholesterol and triglycerides did not differ significantly in the two groups. The prevalence of vascular disease 3 years prior to and at the start of dialysis therapy was similar in patients with dNP and vNP., Conclusion: The progression of dNP and vNP is similar at least during 3 years before the start of dialysis therapy. Vascular risk factors and the prevalence of vascular diseases were not significantly different in the two patient groups. However, diabetic patients with ESRD secondary to dNP were significantly younger than those with vNP.

Background: Hypolactasia and lactose intolerance are common conditions worldwide. Hypolactasia seems to be strongly correlated with genotype C/C of the genetic variant C-->T(-13910) upstream of the lactase phlorizin hydrolase (LPH) gene. We developed a rapid genotyping assay for LPH C-->T(-13910) and investigated the relationship of positive lactose breath hydrogen test (LBHT) results suggesting lactose intolerance with LPH C-->T(-13910) genotype., Methods: Using automated DNA purification on the MagNA Pure LC and real-time PCR on the LightCycler, we examined samples from 220 individuals to estimate genotype frequencies; we then determined LPH C-->T(-13910) genotype in samples from 54 Caucasian patients with a positive LBHT result and symptoms of lactose intolerance., Results: Genotyping of 220 individuals revealed frequencies of 21.4%, 41.8%, and 36.8% for genotypes C/C, C/T, and T/T. Of the patients with positive LBHT results, only 50% had the C/C genotype suggestive of primary adult hypolactasia in our study population. The other patients had various degrees of secondary hypolactasia or symptoms of lactose intolerance. Patients with C/C genotype had a mean (SD) peak H2 increase in the LBHT [108 (58) ppm] that was significantly higher than in patients with the C/T [65 (54) ppm] and T/T [44 (34) ppm] genotypes., Conclusions: The new real-time PCR assay provides a rapid, labor-saving means for the genotyping of LPH C-->T(-13910). Use of the assay may assist in differentiating patients with primary hypolactasia from those with secondary hypolactasia and lactose intolerance, who may need further clinical examinations to diagnose their underlying primary diseases.

The influence of delayed kidney graft function on allograft outcome is described controversially in the literature. The aim of the study was to evaluate possible risk factors for delayed graft function (DGF) and investigate the impact of DGF on short- and long-term renal allograft function. Two groups were formed: the first one consisted of patients who gained immediate graft function (IGF) (n = 64) after transplantation and the second group included patients with DGF (n = 31; with at least one dialysis needed in first week after transplantation). The DGF group had a statistically significant longer duration on dialyses prior to transplantation (DGF 54 vs. IGF 33 months; p < 0.05), on average more frequently a re-transplantation (DGF 1.7 vs. IGF 1.3; p < 0.01), a longer re-anastomosis time (DGF 52.9 vs. 44.2 min; p < 0.01), a lower systolic (DGF 136 +/-24 mmHg vs. IGF 158 +/- 25; p < 0.001) and diastolic blood pressure (DGF 78 +/- 14 vs. IGF 89 +/- 16 mmHg; p < 0.01) at admission to the hospital and a higher serum (S)-creatinine at discharge (DGF 2.5 +/- 1.6 vs. IGF 1.6 +/- 0.4 mg/dL; p < 0.01). Prior to transplantation the DGF group had more often advanced vascular diseases (DGF 29.0 vs. IGF 12.5%; p < 0.01) and these patients incurred more frequently new ones during the next 3 yr after transplantation (DGF 22.6 vs. IGF 6.3%; p < 0.001). After 3 yr the graft survival tended to be lower in the DGF group (DGF 74.2 vs. IGF 84.4%; NS), but this difference was not statistically significant.

Background: Arterial stiffness is at least partially controlled by vascular tone. Vascular tone and underlying physiological processes, e.g. sympathetic activity, have been shown to follow diurnal variations., Methods: This study investigated whether arterial stiffness and perfusion of subendocardial myocardium relative to cardiac workload show diurnal variations under physiological conditions. The aortic augmentation index (AIx) and subendocardial viability ratio (SEVR) were measured noninvasively in 26 healthy young men (27.6 +/- 3.4 years) using applanation tonometry at three different times (8:00, 12:00, 17:00) during one day., Results: Mean AIx was significantly higher and mean SEVR significantly lower at 8:00 than at the later times. No significant differences were found between mean AIx and mean SEVR at 12:00 and at 17:00., Conclusions: The observed diurnal variations of AIx and SEVR will be of value when applanation tonometry is used in human research. In order to arrive at comparable data in longitudinal investigations, measurements should be made at similar times during the course of a day. In addition, our observation should assist in studies in which novel pharmacological compounds with activity on the vasculature are investigated.

A 56-year-old man was admitted due to chronic diarrhea with progressive weight loss (30 kg within 1 year). All results of medical investigations were normal. The suspected diagnosis of a neuroendocrinological neoplasm could not be established; there was also no evidence for a lymphoma or amyloidosis. Chronic diarrhea and weight loss persisted over the ensuing weeks. Additionally, impairment of renal function and heart insufficiency with consecutive pericardial effusion as well as peripheral facial paralysis and peripheral neuropathy could be observed. Six months after hospital admission, the patient died due to progressive multiple organ failure. Postmortem examination revealed normal bone marrow. Only with additional immunohistochemical investigations of all organs could the diagnosis of a systemic Congo red-negative light chain disease be established.

Background: The prevalence of individuals with latent autoimmune diabetes in adults (LADA) among diabetic patients with end-stage renal disease is unknown. Furthermore, there are no references in the literature about the persistence of glutamic acid decarboxylase antibodies (GADA) in uraemic LADA patients. The aim of the study, therefore, was to evaluate the prevalence of LADA, classified according to special features, in diabetic patients undergoing dialysis therapy as well as to find out the frequency of GADA in these patients. In addition, we investigated vascular risk factors and the prevalence of vascular diseases in each type of diabetes., Methods: 538 patients undergoing chronic dialysis therapy from 37 Austrian dialysis centres were analysed in the study. Patients were divided into three groups: patients with type 1 or type 2 diabetes and patients with LADA. The classification of the different types of diabetes was based on the guidelines of the German Diabetes Society. We measured GADA and estimated the baseline data with reference to body mass index (BMI), age at onset of diabetes and at initiating dialysis therapy, the actual values of haemoglobin (Hb) A1c and cholesterol and the prevalence of vascular diseases by using a structured questionnaire., Results: Type 1 diabetes was classified in 52 patients, type 2 diabetes in 434 and LADA in 52 (9.7%). The prevalence of positive GADA was 17.3% in the type 1 diabetic patients and 26.9% in the LADA patients. There was no positive GADA in the type 2 diabetic subjects. Age at the onset of diabetes and age at the start of dialysis were approximately the same in the LADA and the type 2 diabetic patients, while the age of the subjects with type 1 diabetes was significantly lower (P<0.001). BMI was significantly lower (25+/-3 vs 27+/-5 kg/m2) in the LADA patients than in the type 2 diabetic patients. The mean HbA1c value in the LADA patients was significantly higher than in the subjects with type 2 diabetes (P<0.01). Blood pressure (BP) was similar between LADA and type 1 or type 2 diabetes, though diastolic BP tended to be lower in the LADA patients than in the type 1 diabetics. The cholesterol levels were comparably high in each type of diabetes. In the LADA patients, the prevalence of retinopathy was lower than in the type 1 diabetics and the prevalence of stroke and angina pectoris was lower than in the type 2 diabetic patients, but the differences were not significant., Conclusions: The prevalence of LADA in diabetic patients on maintenance dialysis was 9.7%. This value is comparable to the frequency of LADA at onset of diabetes. The frequency of persisting GAD autoantibodies was 27% in the LADA patients and 17% in the type 1 diabetic patients. BMI was significantly lower in the LADA patients than in the type 2 diabetic patients, while diastolic BP only tended to be lower in the LADA patients than in the type 1 diabetics. The prevalence of vascular diseases was not significantly different between LADA and types 1 or 2 diabetes. According to our data it can be assumed that only a few uraemic patients with LADA are suitable for simultaneous pancreas-kidney transplantation.

Unlabelled: There are only a few data in the literature concerning metabolic control in insulin-treated diabetic patients with end stage renal disease (ESRD). The aim of the study was to find out the long-term impact of hemodialysis on glycemic control and lipid values in type 2 diabetic patients. Twenty insulin-treated type 2 diabetic patients (age 62 +/- 9 years, f:m=6:14) were evaluated. We compared HbAlc, fasting blood glucose (FBG), body weight, serum lipids, insulin requirement, and blood-pressure (BP) 12 and 6 months before dialysis, at the start of dialysis, and 6 as well as 12 months after the start., Results: The mean HbA1c- and FBG-values were not significantly different before and after the start of dialysis therapy. The average insulin requirement was 26 +/- 10 IU/day in the predialysis period, 25 +/- 12 IU/day at the start, and 24 +/- 13 as well as 22 +/- 13 IU/day after the start of dialysis. The mean cholesterol level fell significantly from 199 +/- 63 and 190 +/- 49 mg/dL in the predialysis phase to 167 +/- 62 and 157 +/- 38 mg/dL after dialysis began. The triglyceride concentrations decreased only slightly after the start of dialysis. The incidence of hypoglycemia (n/patient/month) was markedly lower in the predialysis phase (0.4 vs. 0.6, NS) than after start of dialysis. In patients with residual diuresis (<500 mL urine/day) the needed insulin doses decreased significantly by 29% compared to patients with higher residual diuresis, whose insulin requirement remained unchanged. In summary, hemodialysis had no significant long-term effect on glycemic control in insulin-treated type 2 diabetic patients, but incidence of hypoglycemia tended to be higher under hemodialysis than in the predialysis period. Lipid levels tended to be lower after the initiation of dialysis therapy. Insulin requirement under hemodialysis decreased only in patients with loss of residual urine volume (below 500 mL urine/day).

Diabetes is known to be a risk factor for the severity of anemia in non-dialyzed patients with renal failure. The aim of this study was to evaluate differences in hemoglobin (Hb) response to erythropoietin (EPO) in diabetic and nondiabetic patients on chronic hemodialysis (CHD). Sixty-four patients on CHD were included in the study: 24 type 2 diabetics (mean age, 59+/-11 years; 10 men, 14 women) and 40 nondiabetics (age, 53+/-14 years; 21 men, 19 women). All patients received a fixed dose of 50 mg ferric saccharate and EPO per week, dosed individually to achieve a target Hb level of 12 g/dl. Hb levels, ferritin, transferrin saturation (TSAT), EPO requirement (IU/kg/week), folic acid, vitamin B12 and C-reactive protein (CRP) were measured every two months. Additionally, the incidence of infectious diseases during the observation period of six months was evaluated, and a univariate correlation analysis of CRP and EPO requirements was performed in both groups. Patients with and without diabetes were divided into two groups each: those with normal CRP and those with elevated CRP. The EPO requirements of these groups were compared. Under identical iron substitution the mean Hb level increased more, but not significantly, in non-diabetic patients than in diabetic patients. After 6 months the mean Hb levels were 12.1+/-1.2 versus 11.5+/-1.2 g/dl (NS), although the actual EPO requirement was higher in diabetic than in non-diabetic subjects (244+/-122 versus 183+/-118 IU/kg/week; p<0.05). CRP after 6 months was significantly higher in diabetic than in non-diabetic patients (2.6+/-2.2 versus 1.5+/-1.3 mg/dl; p<0.05), as was the incidence of infectious disease (n/patient/month) (0.24 versus 0.08; p<0.05). The correlation coefficient between CRP and EPO requirements was statistically significant in both diabetic (r=0.547 p<0.01) and non-diabetic subjects (r=0.577; p<0.001). All other laboratory indices were similar in both groups. In the diabetic patients with normal CRP (n=6) the Hb levels achieved after six months were similar to those of non-diabetic patients (n=10) with normal CRP (11.9+/-1.1 versus 12.1+/-1.2%), and the required EPO was comparable. We conclude that the Hb response to EPO is reduced in diabetic patients on CHD. This elevated EPO requirement may be explained by a greater prevalence of infectious diseases, characterized by a significantly higher CRP level, in these patients. Other causes for the elevated EPO requirement could be excluded.

Despite advanced techniques of renal replacement therapy the overall mortality of patients with ARF is still high. The majority of patients with ARF requiring dialysis are those with nontraumatic ARF. In a retrospective study we compared the causes of nontraumatic ARF, the risk factors for the development of renal failure and the mortality rates in patients with and without diabetes mellitus who received dialysis therapy in the years 1991-2000. A total of 232 patients were included in the study, 34 (14.6%) of them with and 198 patients (85.4%) without diabetes. The predominant causes of nontraumatic ARF like congestive heart failure (26.4 vs. 13.6, p < 0.05) and hypotension/hypovolemia (20.6 vs. 7.6%, p < 0.05) occurred more frequently in diabetic patients. The prevalence of sepsis (8.8 vs. 10.1%, NS), malignancy/ hypercalcemia (5.8 vs. 11.6%, NS) and other causes of nontraumatic ARF were similar in both groups. The prevalence of hepato-renal syndrome (5.8 vs. 13.6%, p < 0.05) and acute kidney graft failure (2.9 vs. 15.1%, p < 0.05) was higher in the nondiabetic individuals. Patients with diabetes showed more often chronic predictors for the onset of ARF like pre-existing hypertension (93.6 vs. 51.0%, p < 0.05), congestive heart failure (44.1 vs. 14.6%, p < 0.005), pre-existing renal insufficiency (76.4 vs. 46.9%, p < 0.05) and ACE-inhibitor therapy (32.3 vs. 9.6%, p < 0.005). Additionally, the prevalence of multiple organ failure (MOF) as prognostic factor was significantly higher in the diabetic patients (47.0 vs. 21.7%, p < 0.05). The mean number of dialyses therapy was 4.7 vs. 4.5 per patient. The overall mortality was 41.1 vs. 44.% (NS). In conclusion, the prevalence of the most common causes of nontraumatic ARF was different between the patients with and without diabetes. The diabetic individuals had more frequently predictors for the onset of ARF. The overall mortality was approximately the same in both groups.

Background: Cardiovascular morbidity and mortality is markedly increased in patients with end-stage renal disease (ESRD) undergoing hemodialysis (HD) and is further pronounced when diabetes mellitus is also present. As atherogenesis is mediated by inflammation of vessel walls and as evidence evolves that atherosclerosis and diabetes mellitus share a common inflammatory basis, we considered whether ESRD patients with additional diabetes mellitus exhibit increased inflammation levels exceeding those of ESRD patients without diabetes mellitus., Methods: The study included 20 ESRD patients with type 2 diabetes mellitus and 16 non-diabetic ESRD patients on long-term HD. The patients' clinical characteristics and serum levels of C-reactive protein (CRP), interleukin 6 (IL-6), soluble tumor necrosis factor receptor I (sTNF-RI), neopterin and fibrinogen were assessed., Results: There were no significant differences in serum levels of CRP, IL-6, neopterin, sTNF-RI and fibrinogen found in ESRD patients with and without diabetes mellitus. HD duration correlated significantly with neopterin (r=0.515, p<0.001) and sTNF-RI (r=0.429, p<0.05) serum levels. HD led to a significant reduction in neopterin levels whereas CRP, IL-6 and sTNF-RI levels did not change significantly., Conclusions: With the inherent limitations of a small number of patients studied, we observed that the presence of type 2 diabetes mellitus in addition to ESRD was not associated with further increased serum levels of the examined inflammatory parameters. Our observations suggest that the worsened prognosis of diabetic ESRD patients is probably not explainable by superimposing inflammatory processes.

Repeated renal transplant calcinosis is a rare event. We report a young woman in whom repeated calcinosis was observed in two consecutive renal transplants. Persistent secondary hyperparathyoidism and hyperphosphatemia due to impaired renal function were assumed as the pathogenic factors for calcinosis. Sub-total parathyroidectomy performed shortly after the third transplantation and good function of the renal graft have prevented calcinosis in the third graft for more than five years.

Despite advanced techniques of renal replacement therapy as well as improved medical care and control over the last decade, the overall mortality of patients with "internal" nontraumatic acute renal failure (ARF) requiring replacement therapy is still high. In a retrospective study we compared causes of nontraumatic ARF, risk factors for the development of renal failure and mortality rates in patients with nontraumatic ARF, who received hemodialysis therapy from 1981 to 1990 and from 1991 to 2000. 510 patients with nontraumatic ANV requiring hemodialysis were evaluated, 278 patients in 1981-1990 and 232 patients in 1991-2000. In both groups the chronic risk factors for ANV such as hypertension, diabetes mellitus, chronic cardiac failure, chronic hepatic failure and pre-existing renal impairment and the causes of a traumatic ARF were compared. In addition, concomitant sepsis and multi-organ failure as prognostic parameters as well as mortality rates dependent on the causes of ARF were evaluated. In the latter period, there was a significant reduction in the prevalence of acute glomerulonephritis (3.0 versus 8.3%, p < 0.05) and acute interstitial nephritis (2.6 versus 7.6%, p < 0.05) as well as acute pancreatitis (1.7 versus 7.6%, p < 0.01) as causes of ARF. On the other hand, the prevalence of drug-induced ARF increased during the latter period (10.8 versus 4.7%, p < 0.05). Other etiologies of nontraumatic ARF did not significantly differ between the two decades. Patients treated from 1991 to 2000 had chronic risk factors for the development of ARF, namely diabetes (14.6 versus 6.8%), coronary artery disease (28.0 versus 9.3%) and pre-existing renal impairment (51.7 versus 17.6%, p < 0.001), more frequently than did patients dialysed from 1981-1990. The prevalence of sepsis and multi-organ failure was approximately the same in both periods. The overall mortality (41.8 versus 44.6%, NS) and mortality secondary to causes of nontraumatic ARF were similar in both periods. In summary: the prevalence of several causes of nontraumatic ARF has changed during the last decades. Furthermore, patients treated in the 90's had chronic risk factors for renal failure, namely diabetes and pre-existing renal impairment as well as coronary artery disease, more frequently than did subjects treated in the preceding time period. The prognosis of the patients has not been significantly improved.

We report on a Mycobacterium marinum infection in a diabetic woman 8 years after undergoing a combined pancreas-kidney transplantation. This is, to our knowledge, the first case report on an isolated skin infection with atypical mycobacteria after simultaneous pancreas-kidney transplantation. A genetic probe categorization revealed an infection with M. marinum. Skin tuberculosis caused by M. marinum is an uncommon complication in kidney or pancreas-kidney transplant recipients, hence the diagnosis can be delayed., (Copyright 2002 S. Karger AG, Basel)

Despite improvements in dialysis therapy, the mortality rate of patients with end stage renal disease (ESRD) has remained high. A relatively high proportion of uremic patients dies within one year after the initiation of dialysis treatment. The aim of this study was to evaluate predictors for this early mortality in patients with ESRD. A total of 66 uremic patients were included in the study. Patients were divided in those who survived < 1 year (n = 17) and those who survived > or = 1 year (n = 49). We compared the prevalence of diabetes and hypertension and of vascular diseases as well as the prevalence of heart insufficiency (EF < 30%) and left ventricular hypertrophy (LVH). Additionally, we estimated the laboratory parameters serum creatinine, creatinine clearance, BUN, cholesterol, triglycerides, fibrinogen, serum protein, serum albumin and hemoglobin, and evaluated the indications for the initiation of dialysis therapy in both patient groups. The patients with survival < 1 year were significantly older (64+/-12 vs. 54+/-14 years, p<0.01) and showed a lower BMI (22+/-3 vs. 25+/-3, p<0.01) than those who survived > 1 year. The prevalence of diabetes (70% vs. 31%, p<0.05), cardiac insufficiency (70% vs. 16%, p<0.025), cardiovascular disease (65% vs. 28%, p<0.05) and peripheral vascular diseases (70% vs. 28%, p<0.05) was significantly higher in the patients with early mortality. The prevalence of hypertension was similar in both groups, however, the prevalence of LVH was significantly higher in the patients who survived < 1 year (88% vs. 37%, p<0.05). Laboratory parameters were not significantly different in the two groups of patients, with the exception of serum albumin, which was significantly lower in the patients with early mortality (3.5+/-0.6 vs. 3.9+/-0.4 g/l, p<0.02). Hyperhydration was the most common indication for the start of dialysis in patients with early mortality (59% vs. 13%, p<0.025). Cardiac insufficiency was the most common cause of death in these subjects (n = 10, 59%). Six individuals (12%) died within four weeks after initiating dialysis therapy. Thus, there are several predictors for early mortality in end-stage renal disease patients, including high age, low BMI, the presence of diabetes, coronary heart disease, heart insufficiency and LVH, as well as low serum albumin levels. A relatively high percentage of patients die shortly after the start of dialysis therapy. Heart insufficiency is the most common cause of early death in these patients.

Background and Objective: The risk for hyperkalaemia during therapy with angiotensin-converting enzyme inhibitors is especially increased in the elderly diabetic because of a decrease in glomerular filtration rate (GFR), as well as the occurrence of hyporeninaemic hypoaldosteronism. We evaluated the risk for hyperkalaemia under long-term angiotensin-converting enyzme inhibition in 86 insulin-dependent type 2 diabetic patients in relation to their GFR., Patients and Methods: We compared the influence of a 3 to 6 months long treatment with angiotensin-converting enzyme inhibitors on the serum potassium levels, the creatinine clearance and the urinary albumin excretion in insulin-dependent type 2 diabetic patients with an initial creatinine clearance < 50 ml/min/1.73m(2) (n = 15, age 66 +/- 6 years) and >/= 50 ml/min/1.73m(2) respectively (n = 71, age 61 +/- 10 years). In addition, we also investigated the influence on the metabolic control and the blood pressure values in both groups of patients., Results: In the patients with creatinine clearance >/= 50 ml/min/1,73m(2) the mean potassium level increased from 4.3 +/- 0.2 to 4.6 +/- 0.4 mmol/l (P < 0,01), while the incidence of a potassium level > 5 mmol/l was 17 %. In the group with a creatinine clearance < 50 ml/min/1.73m(2) the potassium level rose from 4.5 +/- 0.2 to 5.0 +/- 0.4 mmol/l (P < 0.01). The incidence of potassium levels > 5 mmol/l was 66 % (P < 0,01). In both patient groups the creatinine clearances did not change significantly during angiotensin-converting enzyme inhibition, and the urinary albumin excretion as well as the HbA(1c) values and blood pressure showed only a tendency towards a decrease., Conclusion: Long-term treatment with angiotensin-converting enzyme inhibitors in insulin-dependent type 2 diabetic patients leads to a significant increase in serum potassium. The incidence of hyperkalaemia with potassium levels > 5 mmol/l is significantly higher in the patients with initial creatinine clearance < 50 ml/min/1.73m(2). Severe hyperkalaemia with potassium levels > 6 mmol/l was not observed.

We report the rare case of a recurrent hyperparathyroidism after total parathyreoidectomy due to multiple ectopic glands in a patient on long-term haemodialysis. In a today 47 years old man with membranoproliferative glomerulonephritis intermittent haemodialysis therapy was started in 1975. In 1982 an advanced secondary hyperparathyroidism with a parathormone (PTH) level > 500 pg/l was diagnosed; later on PTH concentration increased to 2,550 pg/ml. In 1987 total parathyroidectomy with parathyroid autograft into the left forearm was performed. After parathyroidectomy the PTH level fell to 150 pg/ml. In 1993 PTH concentration increased again to 1,750 pg/ml. There was no evidence for recurrent parathyroid glands in the neck or forearm. Therefore, we investigated the substernal region by 99mTc-tetrofosmin scintigraphy and magnetic resonance imaging. Both investigations showed evidence for two ectopic parathyroid glands in the anterior mediastinum. In June 1999 in an open thoracic surgical procedure only the greater parathyroid gland in the anterior mediastinum was isolated, but a second gland was detected in the posterior mediastinum. Both parathyroid glands were resected (histologically hyperplastic parathyroid gland tissue). After surgery the PTH level decreased to 340 pg/ml, but later on PTH increased again to > 1,000 pg/ml in January 2001. A control 99mTc-tetrofosmin scan showed evidence for a third ectopic parathyroid gland in the anterior mediastinum. Recurrent secondary hyperparathyroidism can rarely be caused by recurrent ectopic parathyroid glands in the mediastinum.

Background: Patients with recurrent glomerulonephritis (RG) after kidney transplantation are at high risk for thromboembolic events but it is unclear when the risk begins to increase., Patients and Methods: We evaluated the risk for thrombovenous and thromboembolic complications in relation to the occurrence of severe proteinuria (> or = 2 g protein in 24-hour urine) in 15 renal allograft recipients with biopsy-proven RG, who had received 20 allografts RG. The total period of observation was 53 (10-91) months. The post-transplant period before the occurrence of severe proteinuria lasted 18 (1-34) months and the subsequent proteinuric period until the end of the study, 35 (9-85) months., Results: The monthly incidence of thrombovenous and thromboembolic complications was only 1/18 in the first period before and in contrast, 11/35 in the subsequent period after the occurrence of severe proteinuria. The mean urinary protein excretion increased from 0.4 +/- 0.1 g/day immediately after transplantation to 6.1 +/- 4.8 g/day at the end of the study (p < 0.001). During the same period there was a 1.2-fold increase of fibrinogen (from 366 +/- 88 to 442 +/- 120 mg/dl, p < 0.025) and a 1.2-fold decrease of antithrombin III (from 110 +/- 12 to 92 +/- 12%, p < 0.001). All thrombotic complications occurred in 6 patients with 9 grafts; at the end of the study this group showed higher fibrinogen concentrations (454 +/- 155 versus 433 +/- 89 mg/dl, NS) m and lower antithrombin III levels (88 +/- 11 versus 97 +/- 11%, p < 0.05) than the group without thrombotic complications., Conclusion: In kidney transplant patients with RG a high risk for thrombovenous and thromboembolic complications can be obs- served after the occurrence of severe proteinuria; this can mainly be explained by high fibrinogen and low antithrombin III levels. Anticoagulation therapy should be started in patients with RG immediately after the occurrence of severe proteinuria.

The objective of the study was to evaluate differences in the perinatal complications and in the 3-year follow up of infants of diabetic mothers with and without diabetic nephropathy stage IV. We compared the fetal and maternal complications and the early postpartal development until 3 years after delivery in 10 children of nephropathic diabetic mothers and 30 children of diabetic mothers without nephropathy. The mean (+/-SD) birthweight of the infants of nephropathic women was 2,250 +/- 496 g versus 3,544 +/- 435 g in the women without nephoropathy (p < 0.01). Births were premature in six pregnancies (60%) of the nephrotic women but in none of the women without nephropathy (p < 0.01). Three infants (30%) of the women with nephropathy showed respiratory distress syndrome in contrast to two babies (6%) of the women without nephropathy. Pre-eclampsia or eclampsia occurred in 6 (60%) pregnant women with and in two women (6%) without diabetic nephropathy (p < 0.01). Nephrotic syndrome was observed in 7 nephrotic women (70%) in contrast to none women without nephropathy. Three years postpartum, six of the children (60%) of nephropathic women had a body weight < the 50th percentile but none of the children of the women without nephropathy did so (p < 0.01). In addition, the children of nephropathic mothers started to speak significantly later (15 +/- 3 versus 12 +/- 13 months postpartum, p < 0.05) and had infectious diseases more commonly (60% versus 6%, p < 0.01) than the children of women without nephropathy. It can be concluded that in pregnancies of diabetic women the birth weights of the infants are significantly smaller and the fetal as well as maternal complication-rates significantly higher than in those of women without nephropathy. Also 3 years after delivery, the body weight of the children of nephropathic diabetic women is significantly lower than that of children of diabetic women without nephropathy. Additionally, children of nephropathic women are retarded in terms of linguistic development and their resistance to infections is reduced.

History and Admission Findings: A 47-year-old woman with poorly controlled diabetes mellitus (HbA1C 9.2%, fasting blood glucose > 200 mg/dl) had complained of moderately severe stabbing pain in the left abdomen. On admission there were no abnormal findings on abdominal palpation., Investigations: Abdominal ultrasound and computed tomography (CT) revealed a partly solid partly cystic well-circumscribed space-occupying lesion, about 15 cm in diameter, in the left abdomen, extending from the lower third of the kidney into the pelvis., Diagnosis, Treatment and Course: Biopsy of the lesion showed chronic granulating inflammation with foamy histiocytes (Hansemann macrophages) as characteristic substrate of extensive malakoplakia. Despite the size of the lesion it was not excised but long-term treatment with ciprofloxacin undertaken. At the same time, the diabetes was carefully controlled with ordinary insulin. Ten months later there was no longer any evidence of the lesion by ultrasound and CT., Conclusions: Even extensive malakoplakia can be successfully treated with ciprofloxacin. Poorly controlled diabetes together with a weak immune status (CD4/CD8 < or = 1) may have favoured the occurrence of malakoplakia.

Pregnancy in type 1 diabetic women with overt nephropathy can lead to a further deterioration in renal function but it is not clear at what level of pre-conceptional GFR the risk for worsening of renal function begins to increase. Therefore we investigated the influence of pregnancy on renal function in 12 women (14 pregnancies) with pre-conceptional macroproteinuria and near-normal creatinine clearance (range 37-93 ml/min/1.73m2). S-creatinine, creatinine clearance (CrCL), HbA1c and blood pressure (BP) were measured before conception, during each trimester (12th and 24th week of gestation and last week before delivery) and three and six months post-partum. In five diabetic women with six pregnancies (group A) there was a physiological increase in CrCl of 36% up until the 24th week of gestation; their pre-conceptional mean CrCl was 80 (range 70-93) ml/min/1.73m2. In seven women with eight pregnancies (group B) CrCl decreased by 16% during the first two trimesters; the mean CrCl before conception was 61 (37-73) ml/min/1.73m2. In the last week before delivery CrCl worsened transiently in three cases in group A and four in group B, due to pre-eclampsia. Three months post-partum the mean CrCl in group A was 78 (70-91) ml/min/1.73m2, approximately the same as before pregnancy. In group B the mean CrCl was 39 (22-68) ml/min/1.73m2 at this same time; this was 36% lower than the pre-conceptional clearance. Mean HbA1c in both groups were approximately the same, but mean BP tended to be higher during pregnancy in group B, especially in the week before delivery (p<0.05). We conclude that in a high percentage of nephropathic diabetic women with significantly low CrCl before conception, renal function worsens during and after pregnancy. Inadequate antihypertensive therapy may contribute to this.

Hypertension is frequently observed in end-stage renal failure. We analysed the incidence and severity of hypertension as well as antihypertensive treatment in a large group of patients on renal replacement therapy (RRT). Questionnaires were sent to all 49 dialysis centers caring for a total of 2090 patients on RRT in Austria. Hypertension was classified as mild, moderate or severe according to WHO criteria. 22 dialysis centers returned completed questionnaires accounting for 1087 patients on RRT. Of these 653 (60%) patients were hypertensive; 425 (39%) patients had mild or moderate, while 228 (21%) patients had severe hypertension. Patients with mild or moderate hypertension need on average 1.5, while those with severe hypertension on average 3.3 antihypertensive drugs. Calcium antagonists were the antihypertensive drugs most frequently administered, in 71% of the patients, followed by ACE inhibitors, alpha- and beta-blockers. Despite multidrug antihypertensive therapy severe hypertension is still a serious problem in patients on RRT. Tassin's center experience showed that longer dialysis time normalizes hypertension and reduces the requirement of antihypertensive treatment in patients on hemodialysis.

Cigarette smoking was known to promote the progression of diabetic nephropathy in patients with type 1 diabetes, but its influence on the course of diabetic nephropathy in patients with type 2 diabetes had not been previously established. In a prospective follow-up study we therefore compared the progression of nephropathy in type 2 diabetic patients with or without tobacco consumption. Initiation of dialysis treatment or death of the patient were the end points of the study. 36 patients with type 2 diabetes complicated with diabetic nephropathy were included in the study, 16 smoked and 20 did not. The main outcome measures were proteinuria, arterial blood pressure, HbAlc, serum-creatinine and creatinine clearance, which were controlled at least every six months. In the smoking diabetic patients the mean (SD) creatinine-clearance decreased from 82 +/- 10 to 10 +/- 6 ml/min/1.73 m2 over a period of 62 +/- 21 months. The rate of decline of the creatinine-clearance was 1.24 +/- 0.34 ml/min/month. In the non-smoking patients the creatinine-clearance decreased from 79 +/- 8 to 9 +/- 3 ml/min/1.73 m2 within 79 +/- 27 months. The rate of decline in the creatinine-clearance was 0.99 +/- 0.35 ml/min/month (p < 0.025). HbAlc, systolic and diastolic blood pressure as well as serum cholesterol and triglycerides were not significantly different in both patient groups. Therefore, we conclude that cigarette smoking promotes the progression of diabetic nephropathy in patients with type 2 diabetes, just as it is known in type 1 diabetic patients.

Cerebrolysin is a peptide solution with free amino acids and biologically active peptides showing neurotrophic efficiency. In a placebo-controlled longitudinal study we investigated the effect of that drug for treatment of painful diabetic neuropathy in 20 type-II diabetic patients (9 women, 11 men, mean age 63 +/- 9 years, duration of diabetes 14 +/- 7 years). Patients received daily a cerebrolysin-infusion (20 ml in 500 ml Ringer) over a period of 10 days. In an age- and diabetes-duration matched placebo group of 10 type-II diabetic patients (7 women, 3 men, age 66 +/- 9 years, duration of diabetes 12 +/- 5 years) vitamin B infusion was administered (5 ml vitamin B complex in 500 ml Ringer) during 10 days. We compared a five-item symptom score scale (FIS) for pain, dysesthesia, paresthesia, nightly exacerbation, and sleep disturbances (grade 0 to 3) and a graphic visual analogue rating scale (VAS) for recording the magnitude of the pains (scale 0 to 100 mm) at the beginning and the end of the infusion therapy as well as 6 weeks later. Cerebrolysin was associated with a significant decrease in total FIS score from 8.7 +/- 1.9 at the start of therapy to 5.1 +/- 2.2 after 6 weeks (p < 0.001), and to a reduction of the VAS score from 4.2 +/- 0.8 to 2.8 +/- 0.9 (p < 0.001) during the same period of observation. In contrast in the placebo group the total FIS score decreased only from 7.9 +/- 1.2 at the beginning to 6.6 +/- 1.1 (p < 0.05) 6 weeks later and the VAS score from 4.5 +/- 0.6 to 4.0 +/- 0.5 (NS). Thus cerebrolysin led to a significant subjective improvement of painful diabetic neuropathy in type-II diabetic patients at least for a period of 6 weeks.

Two hundred eleven patients with acute ischemic stroke, stage III or IV, received daily intravenous infusion of 500-1000 mL low-molecular dextran (dextran 40) over a period of 4 days. In 10 cases (4.7%) acute renal failure, associated with dextran infusion, could be observed; oligoanuria occurred after a mean time of 4 (3-6) days. The incidence of dextran-induced acute renal failure was significantly higher in patients with a preexisting reduction of glomerular filtration rate below 30 mL/min/1.73 m2 (p < 0.005). Five of the patients (50%) with acute renal failure died within 4-12 days after the hemodilution therapy with dextran 40; this high lethality was due to nonrenal complications.

Silicone breast implants have been surgical routine for over 30 years. An association between silicone augmentation and immune related diseases has been reported in approximately 100 cases. In a retrospective single center study we investigated 36 non-selected women with silicone breast implants and 36 sex- and age-matched controls. Autoimmune reactions were evaluated by measuring antinuclear antibodies (ANA), rheumatoid factor (RF) and thyroid gland antibodies (TMS), along with angiotensin-converting enzyme (ACE), C-reactive protein (CRP) and other immunological and laboratory parameters. In the controls only 3 (8%) women had an elevated ANA titer and 1 demonstrated thyroid autoantibodies (microsomal), giving a total of 4 (11%) women with detectable autoantibodies. By contrast, 12 (33%) of the 36 women with silicone augmentation had raised ANA titers (> or = 1 : 80), a significantly higher percentage than in the control group (p < 0.02). Of the 12 women, 1 showed antismooth muscle antibodies (ASMA; titer 1 : 40) and 2 of the patients displayed antineutrophilic cytoplasm antibodies (ANCA; 1 : 320 and 1 : 40, respectively), one of the latter also being positive for rheumatoid factor. 2 further women demonstrated thyroid autoantibodies (microsomal), giving a total of 14 (39%) women in whom significant autoantibodies were detectable. Clinical symptoms (musculoskeletal) were present in 1 patient. Most of the observed autoantibodies were organ-unspecific, with a predominance of elevated ANA titers of the heterogeneous type and not related to a distinct clinical entity. However, none of the investigated women with silicone breast implants showed clinical symptoms or signs of connective tissue disease according to ARA criteria.

Atraumatic rhabdomyolysis with consecutive oliguric renal failure occurred in a 67-year-old man with chronic renal insufficiency in the pre-dialysis phase after four years of therapy with lovastatin without complications. Diuresis remained low after normalization of the muscle enzymes, and the patient required chronic hemodialysis. This case report shows that lovastatin-associated rhabdomyolysis with consecutive myoglobinuric renal failure can be seen also after long-standing lovastatin therapy. In pre-existing renal insufficiency this can lead to earlier requirement of chronic dialysis treatment.

In 50 type-1 and 50 type-2 diabetic patients serum uric acid levels were measured. Type-1 diabetics showed significantly lower serum uric acid levels in comparison to type-2 diabetics (p < 0.02). This significant difference has been observed in both women (p < 0.001) and men (p < 0.01). Serum uric acid level was lower in type-1 diabetics than in healthy controls but only in diabetic men the difference was statistically significant (p < 0.001). Male type-2 diabetic patients showed serum uric acid levels similar to the controls, but levels were higher in women with type-2 diabetes (p < 0.001). The results of this study show that in type-1 diabetic patients the serum uric acid levels are lower in normal (creatinine clearance > or = 80 ml/min) as well as in slightly decreased (creatinine clearance < 80 ml/min) glomerular filtration rate. But in type-2 diabetic patients the serum uric acid levels were significantly higher when glomerular filtration rate was below 80 ml/min in contrast to normal renal function (p < 0.05).

During the past years perinatal mortality in diabetic pregnancy has been lowered significantly, in special collections with highly motivated diabetic women even below 2%. In case of optimal metabolic control and absence of diabetic angiopathy the perinatal survival rate is identical to that in normal pregnancy. But adequate metabolic control cannot be reached in all pregnant women during the whole period of gestation, and pre-existing diabetic angiopathy exists frequently; therefore diabetic pregnancy will be associated with elevated perinatal mortality and morbidity also in the future. In case of pre-existing diabetic nephropathy, especially when GFR is decreased before conception there is a high risk for both progression of nephropathy during pregnancy and increased incidence of gestosis and intrauterine growth retardation which lead to earlier delivery (before the 36th week of gestation) in most cases. Perinatal mortality newborns of diabetic women with nephropathy has been decreased significantly during the past years, but perinatal morbidity in these newborns is still high. Pre-existing proliferative retinopathy can show progressive deterioration during pregnancy, but spontaneous regression post partum is usual. In rare cases progression of retinopathy also after delivery has been described even when laser coagulation was performed. Diabetic women with macroangiopathy, especially with coronary artery disease show a high risk for cardiovascular events during pregnancy. The occurrence of acute myocardial infarction in pregnant diabetic women is associated with elevated fetal and maternal mortality. Though there are case reports in the literature describing a successful fetal and maternal outcome after myocardial infarction during pregnancy.

In recent studies, it has been demonstrated that strict dietary protein restriction has a beneficial effect on renal transplant patients who show chronic rejection, or transplant fibrosis respectively; however, the protein intake in those investigations usually has been below 0.6 g/kg day, and such a strong restriction may be associated with both a negative nitrogen balance, and low patient compliance. Our study was therefore undertaken to investigate whether the same beneficial effect could be attained with a more moderate dietary protein restriction in renal transplant recipients. In a randomized cross-over study, 14 patients with biopsy-proven transplant fibrosis received a mildly protein restricted diet (0.7 g/kg/day), and a normal protein diet (1.2 g/kg/day) respectively during two 3-week periods. In the patients undergoing moderate protein restriction, a significant reduction in urinary albumin, and total protein excretion, as well as a decrease in albumin/creatinine ratio was observed at the end of the 3-week period when compared to the patients on normal protein diet (p < 0.05). The 51Cr-EDTA-clearance did not differ at the end of each of these dietary periods. In contrast to earlier studies with lower protein intake, the moderate protein restriction in our investigation was not associated with a decrease in serum proteins. In conclusion, a mildly restricted protein intake has also proved effective in significantly reducing the urinary protein excretion in patients with renal transplant fibrosis, yet, without causing decreasing serumprotein-concentrations, which are a sign for a negative nitrogen balance.

We compared urinary albumin excretion during and after pregnancy in 30 insulin-dependent diabetic (IDDM) women with normoalbuminuria and in 12 IDDM women with microalbuminuria (> 15 micrograms.min-1) prior to conception. There was a 6.7-fold increase in the urinary albumin excretion up until the third trimester in the women with pre-existing microalbuminuria, compared with a 3.8-fold increase in the normoalbuminuric women. In both groups of patients the urinary albumin excretion reached a peak during the third trimester with 492 +/- 404 micrograms.min-1 in the microalbuminuric women vs 43 +/- 36 micrograms.min-1 in the normoalbuminuric women (p < 0.0005). Two women from each of the groups developed eclampsia with diastolic blood pressure over 90 mm Hg, mild or moderate oedema and macroproteinuria. Four of the pregnant women with pre-existing microalbuminuria showed a transient nephrotic syndrome (33.3%) with protein excretion over 3 g in 24-h urine samples during the third trimester. In contrast, this was not observed in any of the normoalbuminuric women (p < 0.05). Within 12 weeks after delivery the urinary albumin excretion rates dropped to the pre-conception values in both patient groups. Renal function remained normal during pregnancy in both of the groups, with a physiological increase in creatinine clearance up until the third trimester (26% increase in the normoalbuminuric women vs 22% in the microalbuminuric women). In conclusion, the effect of pregnancy on the urinary albumin excretion in diabetic women with pre-existing microalbuminuria is an exaggeration of the increase of albuminuria in diabetic women with normoalbuminuria; normalization occurs within 12 weeks after delivery in all cases.(ABSTRACT TRUNCATED AT 250 WORDS)

In 84 patients with insufficiently treated essential hypertension (systolic blood pressure > or = 160 mmHg and/or diastolic blood pressure > or = 100 mmHg) and normal renal function (creatinine clearance Mean +/- SD = 114 +/- 22 ml/min/1.73 m2) the mean urinary albumin excretion was 39 +/- 19 mg/24h in comparison to 14 +/- 13 mg/24h (p < 0.001) in 10 healthy controls. In 39 of the hypertensive patients albumin excretion was increased (> 30 mg/24h urine) in a subclinical range (microalbuminuria). After 3 days of effective antihypertensive treatment (systolic blood pressure < 150 mmHg and diastolic blood pressure < 90 mmHg) the mean albumin excretion of the microalbuminuric patients decreased from 66 +/- 33 mg/24h to 44 +/- 28 mg/24h (p < 0.01). 27 of these hypertensive patients showed persistent microalbuminuria; in the other 12 patients with primary microalbuminuria the albumin excretion rate was normal now. In the patients with persistent microalbuminuria the prevalence of hypertensive retinopathy was 85% in comparison to only 33% in the patients with reversible microalbuminuria under intensified antihypertensive treatment (p < 0.01) and 31% in the patients with primary normoalbuminuria. The prevalence of coronary heart disease was 11% in the patients with normoalbuminuria and 29% in those with irreversible microalbuminuria (ns). Thus hypertensive patients with persistent but not with reversible microalbuminuria under short intensive antihypertensive therapy show a statistically significant higher prevalence of hypertensive retinopathy and therefore can be considered as an indicator of general microvascular damage in essential hypertension.

We investigated the rate of decline in GFR and the changing prevalences of micro- and macrovascular complications in 20 type II diabetic patients [mean age 58 (46-71) years, female:male = 7:13, duration of diabetes 16 (12-30) years] from the stage of macroproteinuria with GFRs which were still normal until the beginning of dialysis or the time of death. Controls of renal function, proteinuria, HbAlc, serum lipids, and blood pressure were performed every 6 months at the beginning of the study and later on at 3-month intervals. Fundoscopy, electrocardiogram at rest and in case of need a symptom-limited treadmill ECG, a Duplex ultrasound examination of the carotid vessels, and a Doppler sonographic examination of the femoral arteries were repeated each year. The creatinine clearance (mean +/- SD) of the patients was 81 +/- 6 mL/min/1.73 m2 at the beginning of the study. The rate of decline in creatinine clearance was 1.01 +/- 0.38 mL/min/month during the whole period of observation. Twelve patients (group A) required dialysis after a mean time of 74 (40-119) months; their creatinine clearance was 7 +/- 2 mL/min/month at the beginning of renal replacement therapy. Eight patients (group B) died a short time before the beginning of dialysis treatment; their creatinine clearance was 13 +/- 5 mL/min/1.73 m2. The causes of death were sudden death (n = 4), cardiac failure (n = 1), and stroke (n = 2); in one case it was unknown. The two patient groups did not differ in respect to the mean age, duration of diabetes, HbAlc values, serum cholesterol levels, and blood pressure. The decline in the creatinine clearance was also similar in both patient groups, with 1.07 +/- 0.35 versus 0.98 +/- 0.41 mL/min/month. Only the mean serum triglyceride concentration was significantly higher in the patients who died before dialysis. At the start of the study, cerebrovascular disturbances (including plaques in the carotid vessels) were found in 30%, cardiovascular disturbances (including pathologic ECG findings) in 45%, a peripheral vascular disease in 15%, and diabetic retinopathy (grade I and II) in 75%. At the beginning of dialysis treatment or the time of death, respectively, the prevalence of cerebrovascular diseases was increased to 70% and the prevalence of cardiovascular diseases to 90%; peripheral vascular disease was present in 50% and diabetic retinopathy in all of the cases. We conclude that type II diabetic patients show high mortality (40%) and poor quality of life, not only when they require dialysis treatment, but also in the predialysis phase.

The lipid-lowering effect of a new mixture of fiber consisting in guar and apple-pectin in combination with apple-pomaces has been estimated in 15 female type 2-diabetics [age mean = 62 (52-70) yr] with hypercholesterolemia (total-chol > 240 mg/dl and LDL-chol > 130 mg/dl). After a dietetic run-in-phase of 3 weeks the patients received the fiber mixture (1 package of 17 g with about 5.9 g water-soluble fiber) dissolved in 250 ml water for the next 9 weeks: during the first 3 weeks 2 portions per day, the next 3 weeks twice 1/2 portion and the last 3 weeks one 1/2 portion daily. The fiber mixture had to been consumed 30 minutes before taking a main meal. Regular intake of the fiber product led to a significant decrement in blood lipids, and this improvement under 2 portions daily has been maintained for the most part with the reduced dosage. The total-chol levels decreased by 11.3% during the first 3 weeks of fiber intake (p < 0.05) and by -12.6% during the next 3 weeks (p < 0.05), the decrease during the last 3 weeks under the reduced fiber intake was -9.6% (ns). The HDL-chol levels remained approximately the same during the whole period of observation. The triglyceride concentrations in serum could be lowered by -15.5% during the first 3 weeks of fiber intake, and by -19.2% during the next 3 weeks (p < 0.05), finally the decrease was -12.3% (ns). The atherogenic index (Chol-/HDL-chol) could be reduced on an average of 14.3% in relation to the initial value.(ABSTRACT TRUNCATED AT 250 WORDS)

Over a six-week period a 60-year-old patient had several unexplained intoxication-like episodes. He finally had severe abdominal cramps with changes in the level of consciousness and oligoanuric renal failure (creatinine 4.7 mg/dl). The history, marked metabolic acidosis (pH 7.15, HCO3- 2.2 mmol/l, pCO2 6.6 mmHg) as well as raised anion residue (43 mmol/l) and the presence of oxalates in urine suggested poisoning by ethylene glycol contained in antifreeze liquid. Intensive haemodialysis adequately eliminated ethylene glycol and its toxic metabolites (glycol aldehyde, glycolic acid). Renal function returned within 10 days, although the concentrating power of the kidney remained impaired for several weeks because of interstitial nephritis. The intoxication had been caused by a defective heating-pipe system from which the antifreeze had leaked into the hot-water boiler (the patient had habitually prepared hot drinks by using water from the hot-water tap). Gas chromatography demonstrated an ethylene glycol concentration of 21 g per litre of water.

The efficacy and safety of lovastatin, a drug for lowering hypercholesterolemia, have been evaluated in ten adult patients with insulin-dependent diabetes mellitus (IDDM) and nephrotic syndrome due to diabetic nephropathy stage IV or V of Mogensen. For the first 8 weeks the patients received only a sugar-free isocaloric diet of which fats supplied approximately 30% of the total caloric intake and with not more than 300 mg cholesterol daily. After this run-in period patients were treated with 20 mg lovastatin once daily for 12 weeks while receiving the same isocaloric diet as previously. Body weights and glycosylated hemoglobin concentrations (HbAlc) did not change significantly during this period. The baseline plasma cholesterol concentrations (mean +/- SD) decreased only by 2% (from 310 +/- 54 to 303 +/- 46 mg/dl) during the 8 weeks with low cholesterol diet and by 25% (from 303 +/- 46 to 228 +/- 38 mg/dl) during the 12-week period on lovastatin therapy (p less than 0.005). The mean concentrations of low-density lipoprotein (LDL-)-cholesterol decreased by 3% (from 218 +/- 53 to 211 +/- 52 mg/dl) during the diet period and by 35% (from 211 +/- 52 to 137 +/- 38 mg/dl) during the period with lovastatin therapy (p less than 0.001). Concentrations of high-density lipoprotein (HDL) cholesterol increased slightly (11%) during the therapy with lovastatin (NS). Baseline plasma triglycerides fell by 22% (from 188 +/- 97 to 146 +/- 59 mg/dl) during the period with fat-restriction (p less than 0.05) and by 13% (from 146 +/- 59 to 127 +/- 54 mg/dl) during the period of lovastatin therapy (NS).(ABSTRACT TRUNCATED AT 250 WORDS)

In patients with essential hypertension increased albumin excretion in the urine compared to healthy controls is well known. In 38 patients (age: Mean +/- SD = 37 +/- 16 yr, f: m = 19:19) with benign essential hypertension and normal renal function (creatinine clearance: Mean +/- SD = 99 +/- 16 ml/min) we found a mean urinary albumin excretion of 79 +/- 61 mg/24 h in comparison to 14 +/- 13 mg/24 h (p less than 0.01) in 10 healthy controls (age: Mean +/- SD = 35 +/- 14 yr, f: m = 5:5). In 13 patients with hypertension urinary albumin excretion was increased (greater than 25 mg/24 h) in a subclinical range (microalbuminuria), the other 25 hypertensive patients had normoalbuminuria. Comparing the hypertensive patients with and without microalbuminuria, those with elevated albumin excretion were older (age: Mean +/- SD = 42 +/- 12 yr vs. 32 +/- 19 yr), had a longer average duration of hypertension (8 +/- 5 yr vs. 5 +/- 4 yr) and a higher prevalence both of hypertensive retinopathy (77% vs. 28%) and of abnormalities in the electrocardiogram (23% vs. 4%) than those with normal albumin excretion. The difference in the prevalence of hypertensive retinopathy (grade I and II) was statistically significant (p less than 0.05). Furthermore the patients with microalbuminuria required a more intensive antihypertensive therapy than those with normoalbuminuria, 46% requiring triple drug therapy as opposed to 24% in the latter group. Thus the demonstration of microalbuminuria in patients with benign essential hypertension is associated with a higher prevalence of funduscopic and electrocardiographic abnormalities, and therefore can be considered as an indicator of early vascular damage in essential hypertension.

During the Annual Meeting of the Austrian Diabetes Association various diabetic centres presented their success and failure rates with respect to metabolic control and prevention of late complications in diabetic patients on a country-wide basis. The analysis revealed that only 30% of all type I diabetic patients are adequately controlled. Intensive education in diabetes self-management, capable of leading to optimal metabolic control in up to 50% of the instructed patients, is however available only to a small minority of the diabetic patients to date. Despite the enormous improvement which has been achieved in the management of pregnant diabetic women, intensive specialized care is often commenced far too late. In rural areas, in particular, even conventional therapy is not fully implemented and late complications are, thus, inevitable.

Hypercalcemic crisis represents a medical emergency. If conservative treatment is ineffective, low calcium bath or zero calcium bath hemodialysis are good alternatives. We report 4 patients treated with calcium free acetate hemodialysis because of hypercalcemic crisis due to breast cancer, hepatocellular carcinoma, cirrhosis of the liver and immobilisation with hydrochlorothiazids' medication. Following 3 h of hemodialysis, serum calcium concentrations fell from a mean value of 3.96 (range 3.53-4.46) mmol/l to 2.71 (2.28-3.12) mmol/l. In 2 patients rapid clinical improvement was achieved and in one oliguric patient diuresis started spontaneously during hemodialysis. One patient died from gram-negative sepsis. In 3 cases the subsequent conservative treatment was sufficient to maintain serum calcium levels within the normal range. Together with the previously reported cases (5 patients treated by hemodialysis with low dialysate calcium and 3 patients by hemodialysis with calcium free dialysate) our experience indicates that hemodialysis is an effective and safe therapy for hypercalcemic crisis.

Diabetes mellitus is the most frequent endogenous cause of fat metabolism-disorder. In diabetics the risk for arteriosclerosis is significantly higher and the clinical significance of hyperlipidemia should be estimated more serious as in non-diabetics. The predominant abnormality of fat metabolism in diabetes is hypertriglyceridemia due to an increase of triglyceride-carrying lipoproteins, the chylomicrons and the very-low-density lipoproteins. In type I-diabetics the decisive pathogenetic factor for hypertriglyceridemia is the impaired degradation of VLDL and the reduced chylomicron-clearance, caused by decreased activity of the lipoproteinlipase. In ketoacidosis there is an additional increase in hepatic VLDL-triglyceride-production due to increased lipolysis with elevated free-fatty-acid flux. Total cholesterol in type I-diabetics is only significantly elevated when metabolic control is poor, low-density lipoprotein (LDL-)-cholesterol-levels can be increased and high-density lipoprotein (HDL-)cholesterol decreased in dependence on the metabolic control. In type II-diabetics the decisive pathogenetic factor for hypertriglyceridemia is increased VLDL-triglyceride-synthesis in the liver especially due to augmented free-fatty-acid flux. Additionally the activity of the lipoproteinlipase can be reduced. Usually in non-insulin-dependent diabetics LDL-cholesterol-levels can be seen elevated and HDL-cholesterol-concentration decreased in correlation with the metabolic control. Primary hyperlipoproteinemia appears frequently in diabetics, but this can be explained by the association with obesity in type II-diabetics.