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ZusammenfassungEpidemiologische Untersuchungen zeigen, dass etwa 2–3 % aller Österreicher*innen einen Diabetes mellitus mit Nierenbeteiligung aufweisen. Dies betrifft somit in Österreich etwa 250.000 Menschen. Das Risiko des Auftretens und Fortschreitens der diabetischen Nierenerkrankung kann durch Lebensstilinterventionen und Optimierung des arteriellen Blutdrucks, Blutzuckers und spezielle Medikamentenklassen vermindert werden. In diesem gemeinsamen Artikel der Österreichischen Gesellschaften für Nephrologie und Diabetologie werden die entsprechende Diagnostik und therapeutische Strategien bei diabetischer Nierenerkrankung vorgeschlagen.

BackgroundIn renal studies, various outcome endpoints are used with variable definitions, making it nearly impossible to perform meta-analyses and deduce meaningful conclusions. Increasing attention is directed towards standardization of renal outcome reporting.MethodsA working group was formed to produce a unifying definition of renal outcomes that can be used by all investigators. We propose major adverse renal events (MARE) as the term for a standardized composite of hard renal outcomes. We discuss the components for inclusion in MARE from existing evidence.ResultsMARE could include three to five items, considered relevant to patients and regulators. New onset of kidney injury, that is persistent albuminuria/proteinuria and/or decreasing glomerular filtration rate (GFR) ConclusionsMARE as a reporting standard will enhance the ability to compare studies and thus, facilitate meaningful meta-analyses. This will result in standardized endpoints that should result in guideline improvement to better individualize care of patients with kidney disease.

Recent epidemiological investigations have shown that approximately 2-3% of all Austrians suffer from diabetes with renal involvement, i. e. 250,000 people in Austria are affected. The risk of occurrence and progression of this disease can be ameliorated by life style interventions as well as optimization of blood pressure, blood glucose levels and special drug classes. The present article represents the joint recommendations of the Austrian Diabetes Association and the Austrian Society for Nephrology for the diagnostics and treatment strategies of diabetic kidney disease.

Although nephrologists are responsible for the long-term care of dialysis patients, physicians from all disciplines will potentially be involved in the management of patients with kidney failure, including patients on peritoneal dialysis, the major home-based form of kidney-replacement therapy. This review aims to fill knowledge gaps of non-experts in peritoneal dialysis and to highlight key management aspects of in-hospital care of patients on peritoneal dialysis, with a focus on acute scenarios to facilitate prompt decision-making. The clinical pearls provided should enable non-nephrologists to avoid common pitfalls in the initial assessment of peritoneal dialysis-related complications and guide their decision regarding when to refer their patients to a specialist, resulting in improved multidisciplinary patient care.

One of the most critical long-term complications of type 2 diabetes is nephropathy, currently termed diabetic kidney disease. Although the prevalence is increasing, renal outcomes are heterogeneously defined. Intensive glucose control is effective for the prevention of microvascular complications, including kidney disease. However, the impact of specific drugs on renal outcome measures such as the incidence of kidney disease, albuminuria, progression to end-stage kidney disease, or death of renal cause remains unclear. Comparison of agents or drug classes is impossible, as renal outcomes are inconsistently defined in trials. Recent publications include more stringent criteria, but use only composite endpoints, which can reveal significant results driven by a single surrogate marker but not clinical events of true relevance to patients. This review discusses renal outcomes related to antidiabetic agents for type 2 diabetes, in an attempt to determine the influence of specific drugs on the incidence of diabetic kidney disease and various renal outcomes. There are marked differences among the various agents, but direct comparisons are difficult due to heterogeneous measures. Statements from Kidney Disease Improving Global Outcomes (KDIGO) or European Renal Best Practice (ERBP) highlight that “standardized outcome reporting is key to achieving evidence-based guidance and improving clinical care for patients.” Renal outcome studies including a well-defined, standardized core set of patient-relevant outcomes are needed. Here, we propose to define and establish major adverse renal events (MARE) as the outcome measure for future studies.

Elevated blood pressure remains a major cause of cardiovascular disease, disability, and premature death in Austria, with suboptimal rates of detection, treatment and control also in recent years. Management of hypertension is a common challenge for physicians with different spezializations. In an attempt to standardize diagnostic and therapeutic strategies and, ultimately, to increase the rate of patients with controlled blood pressure and to decrease the burden of cardiovascular disease, 13 Austrian medical societies reviewed the evidence regarding prevention, detection, workup, treatment and consequences of high blood pressure in general and in various clinical scenarios. The result is presented as the first national consensus on blood pressure. The authors and societies involved are convinced that a joint national effort is needed to decrease hypertension-related morbidity and mortality in our country.

The term refeeding syndrome (RFS) refers to the metabolic perturbations and its attendant complications in subjects who are refed after fasting. The syndrome is characterized by profound shifts of electrolytes and fluids. Its consequences are widespread and sometimes fatal. Patients with malignancies are especially vulnerable due to the presence of multiple comorbidities. We report the course of four patients with malignant or hematological disorders who developed RFS while being treated for their underlying illness. All physicians caring for susceptible patients should be cognizant of the risks of refeeding and treat RFS appropriately to reduce patient morbidity as well as mortality.

Recent epidemiological investigations have shown that approximately 2-3% of all Austrians suffer from diabetes with renal involvement, i. e. 250,000 people in Austria are affected. The risk of occurrence and progression of this disease can be ameliorated by life style interventions as well as optimization of blood pressure, blood glucose levels and special drug classes. The present article represents the joint recommendations of the Austrian Diabetes Association and the Austrian Society for Nephrology for the diagnostics and treatment strategies of diabetic kidney disease.

Peritoneal transport characteristics and residual renal function require regular control and subsequent adjustment of the peritoneal dialysis (PD) prescription. Prescription models shall facilitate the prediction of the outcome of such adaptations for a given patient. In the present study, the prescription model implemented in the PatientOnLine software was validated in patients requiring a prescription change. This multicenter, international prospective cohort study with the aim to validate a PD prescription model included patients treated with continuous ambulatory peritoneal dialysis. Patients were examined with the peritoneal function test (PFT) to determine the outcome of their current prescription and the necessity for a prescription change. For these patients, a new prescription was modeled using the PatientOnLine software (Fresenius Medical Care, Bad Homburg, Germany). Two to four weeks after implementation of the new PD regimen, a second PFT was performed. The validation of the prescription model included 54 patients. Predicted and measured peritoneal Kt/V were 1.52 ± 0.31 and 1.66 ± 0.35, and total (peritoneal + renal) Kt/V values were 1.96 ± 0.48 and 2.06 ± 0.44, respectively. Predicted and measured peritoneal creatinine clearances were 42.9 ± 8.6 and 43.0 ± 8.8 L/1.73 m2/week and total creatinine clearances were 65.3 ± 26.0 and 63.3 ± 21.8 L/1.73 m2/week, respectively. The analysis revealed a Pearson's correlation coefficient for peritoneal Kt/V of 0.911 and Lin's concordance coefficient of 0.829. The value of both coefficients was 0.853 for peritoneal creatinine clearance. Predicted and measured daily net ultrafiltration was 0.77 ± 0.49 and 1.16 ± 0.63 L/24 h, respectively. Pearson's correlation and Lin's concordance coefficient were 0.518 and 0.402, respectively. Predicted and measured peritoneal glucose absorption was 125.8 ± 38.8 and 79.9 ± 30.7 g/24 h, respectively, and Pearson's correlation and Lin's concordance coefficient were 0.914 and 0.477, respectively. With good predictability of peritoneal Kt/V and creatinine clearance, the present model provides support for individual dialysis prescription in clinical practice. Peritoneal glucose absorption and ultrafiltration are less predictable and are likely to be influenced by additional clinical factors to be taken into consideration.

Diabetische Nephropathie ist die fuhrende Ursache der Nierenersatztherapie und die haufigste Nierenkrankheit geworden. Die Entwicklung und das Fortschreiten kann durch optimierte Therapie beeinflusst werden. Im vorliegenden Artikel werden die gemeinsamen Empfehlungen der Osterreichischen Diabetesgesellschaft und der Osterreichischen Gesellschaft fur Nephrologie dargestellt.

Once long-standing diabetes has involved the kidneys, the process of ongoing damage to predominantly glomerular structures cannot be stopped by currently available therapeutic interventions. Kidney damage is considered to be clinically “silent” (lacking obvious symptoms) and may present in two forms. Most commonly, proteinuria, starting as microalbuminuria, is the leading presentation. However, in approximately one in every seven patients, a reduction in estimated glomerular filtration (eGFR), without any type of albuminuria, is the first sign of kidney involvement in diabetes [1].

BackgroundCatheter-associated infections markedly contribute to treatment failure in peritoneal dialysis (PD) patients. There is much controversy surrounding prophylactic strategies to prevent these infections.MethodsIn this nationwide multicenter study we analyzed strategies to prevent catheter-associated infections as performed in Austrian PD centers in 2006. A questionnaire was sent to all 23 PD centers in Austria.ResultsTen different catheter models were used in the 332 patients being treated in the 23 Austrian PD centers. Systemic antibiotics prior to catheter placement were given by 17 of the 23 PD centers (glycopeptides, n = 7; cephalosporins, n = 10). Nasal swabs were taken preoperatively by 17 PD centers; nasal Staphylococcus aureus carriers were treated prophylactically with mupirocin cream in 15 of these centers. Dressing change was routinely performed in 318 of 332 chronic PD patients (nonocclusive film dressing, n = 58; gauze dressing, n = 260). Disinfectants for chronic exit-site care included povidone iodine ( n = 155), sodium hypochlorite ( n = 31), povidone iodine + sodium hypochlorite together ( n = 102), and octenidine dihydrochloride/phenoxyethanol ( n = 17). Water+non-disinfectant soap or 0.9% sodium chloride was administered as a cleansing agent to the exit site by 27 patients. Routine S. aureus screening (nasal and/or exit-site swabs) in chronic PD patients was performed in 12 PD centers; carriers were treated with mupirocin cream in 11 of these centers. Dialysis staff members were screened for S. aureus in 8 PD centers and spouses were screened for S. aureus in 5 PD centers. The overall exit-site infection rate was 1 episode/43.9 patient-months, tunnel infection rate was 1 episode/88.9 patient-months, and peritonitis rate was 1 episode/51.0 patient-months. Patients of centers that have installed a prophylaxis protocol for treating S. aureus carriers had lower mean infection rates compared with those not using such a protocol.ConclusionVarious individual prophylactic strategies are used to prevent catheter-associated infections in Austrian PD centers. Infection rates are within the range reported in the literature. There is still scope for improvement in some centers ( e.g., by establishing a prophylaxis protocol).

*2nd Department of Medicine⁄Nephrology, General Hospital of Wiener Neustadt, Wiener Neustadt, and†3rd Department of Medicine⁄Nephrology, Klinikum Kreuzschwestern Wels GmbH, Wels, AustriaABSTRACTNephrogenic systemic fibrosis (NSF) is a systemic illness,which only affects patients with kidney failure. NSF riskincreases with progressively lower levels of kidney function. Itis characterized by red skin areas or plaques that develop overseveral weeks to painful thickened skin with a ‘‘woody’’ tex-ture,resembling‘‘peaud’orange.’’Itmayultimatelycauseflex-ion contractures of joints. Skin biopsy reveals thickenedcollagenbundles,mucindeposition,proliferationoffibroblastsand elastic fibers, without inflammation. Originally describedas nephrogenic fibrosing dermopathy (NFD), because of itsprimarily cutaneous manifestation, it was renamed NSFbecause of the involvement of various organs like the lungs,myocardium, or striated muscles. The pathogenesis of the dis-ease is not known yet, but recently we suggested a strong asso-ciation between development of NSF and exposure togadolinium-basedcontrast(GBC)agents,thereafterconfirmedbyotherauthors.Asaconsequenceofourrecentobservations,medical authorities imposed restrictions that exclude patientswith advanced levels of renal insufficiency from potentiallyimportant magnetic resonance imaging studies with gadolin-ium. Unfortunately, the only alternatives in many situations(examination of brain,lungs,vasculature) areimagingmodali-ties using iodinated radiocontrast agents. Thus, clinicians arefacedwithweighingthepotentialriskofNSFfromGBCexpo-sure against the risk of acute kidney injury-associated with ra-diocontrast media. In this dilemma, clinicians must identifypatientsathigh-risktodevelopNSF.Knownriskfactorscriti-cal for the development of NSF after exposure to GBC agents(certain chelates and higher doses) are end-stage renal diseaserequiring dialysis, especially those with little or no residualrenal function, and advanced kidney disease not on dialysis.Other potential risk factors include metabolic acido-sis, iron overload ⁄intravenous iron, divalent ion distur-bances, endothelial ⁄vascular injury, and high erythropoietindoses.Furtherstudiesarerequired.

Peritoneal transport characteristics and residual renal function require regular control and subsequent adjustment of the peritoneal dialysis (PD) prescription. Prescription models shall facilitate the prediction of the outcome of such adaptations for a given patient. In the present study, the prescription model implemented in the PatientOnLine software was validated in patients requiring a prescription change. This multicenter, international prospective cohort study with the aim to validate a PD prescription model included patients treated with continuous ambulatory peritoneal dialysis. Patients were examined with the peritoneal function test (PFT) to determine the outcome of their current prescription and the necessity for a prescription change. For these patients, a new prescription was modeled using the PatientOnLine software (Fresenius Medical Care, Bad Homburg, Germany). Two to four weeks after implementation of the new PD regimen, a second PFT was performed. The validation of the prescription model included 54 patients. Predicted and measured peritoneal Kt/V were 1.52 ± 0.31 and 1.66 ± 0.35, and total (peritoneal + renal) Kt/V values were 1.96 ± 0.48 and 2.06 ± 0.44, respectively. Predicted and measured peritoneal creatinine clearances were 42.9 ± 8.6 and 43.0 ± 8.8 L/1.73 m(2)/week and total creatinine clearances were 65.3 ± 26.0 and 63.3 ± 21.8 L/1.73 m(2) /week, respectively. The analysis revealed a Pearson's correlation coefficient for peritoneal Kt/V of 0.911 and Lin's concordance coefficient of 0.829. The value of both coefficients was 0.853 for peritoneal creatinine clearance. Predicted and measured daily net ultrafiltration was 0.77 ± 0.49 and 1.16 ± 0.63 L/24 h, respectively. Pearson's correlation and Lin's concordance coefficient were 0.518 and 0.402, respectively. Predicted and measured peritoneal glucose absorption was 125.8 ± 38.8 and 79.9 ± 30.7 g/24 h, respectively, and Pearson's correlation and Lin's concordance coefficient were 0.914 and 0.477, respectively. With good predictability of peritoneal Kt/V and creatinine clearance, the present model provides support for individual dialysis prescription in clinical practice. Peritoneal glucose absorption and ultrafiltration are less predictable and are likely to be influenced by additional clinical factors to be taken into consideration.

COL4A5 mutations are a known cause of Alport syndrome, which typically manifests with haematuria, hearing loss and ocular symptoms. Here we report on a 16-year-old male patient with a negative family history who presented with proteinuria, progressive renal failure and haemolysis, but without overt haematuria or hearing loss. A renal biopsy revealed features of atypical IgA nephropathy, while a second biopsy a year later showed features of focal segmental glomerulosclerosis, but was finally diagnosed as chronic thrombotic microangiopathy. Targeted sequencing of candidate genes for steroid-resistant nephrotic syndrome and congenital thrombotic microangiopathy was negative. Despite all therapeutic efforts, including angiotensin-converting enzyme inhibition, immunosuppressive therapy, plasma exchanges and rituximab, the patient progressed to end-stage renal disease. When a male cousin presented with nephrotic syndrome years later, whole-exome sequencing identified a shared disruptive COL4A5 mutation (p.F222C) that showed X-linked segregation. Thus, mutations in COL4A5 give rise to a broader spectrum of clinical presentation than commonly suspected, highlighting the benefits of comprehensive rather than candidate genetic testing in young patients with otherwise unexplained glomerular disease. Our results are in line with an increasing number of atypical presentations of single-gene disorders identified through genome-wide sequencing.

Although a well-known complication after transplantation, multiple non-skin malignancies within a patient are rare. We report on a kidney transplant recipient who over the course of 20 years developed breast cancer twice, a uroepithelial carcinoma, and myelodysplasia transforming into acute leukaemia. Breast cancer was treated as usual. The transitional cell carcinoma was managed with partial cyst ureterectomy with transposition of the native ureter to the graft. Withdrawal of immunosuppression followed under a “watchful waiting” regime. In conclusion, alertness is requested regarding development of malignancies. Creative solutions are necessary in the management of such patients. Under exceptional circumstances, withdrawal of immunosuppression may be an option.

The objectives of this study were to evaluate whether adequate observation of abdominal pathologic features related to peritoneal dialysis (PD) was possible with magnetic resonance imaging (MRI) under routine conditions, i.e., against the background of the dialysate and without contrast medium. For 16 male and seven female patients (mean age, 51.8 +/- 15.0 yr; mean duration of PD, 324 +/- 542 d), 25 peritoneal MRI studies were performed with the intraperitoneal dialysate as usual. Indications were symptoms or combinations of symptoms, such as leakage or abdominal wall edema (n = 3), bloody dialysate (n = 4), suspected herniation (n = 1), suspected ultrafiltration failure (n = 2), and abdominal pain (n = 5), or routine assessment after initiation of PD (n = 12). The MRI protocol, which was performed with a 1.0-T scanner, consisted of breath-hold, coronal and transverse, T2-weighted, half-Fourier single-shot turbo spin-echo sequences, using a standard body-array coil. MRI studies were well tolerated and successfully completed for all except two patients. Results indicated a leak along the catheter (n = 1), a leak in an umbilical hernia (n = 1), suspected leakage (n = 1), hernias (n = 5, in three patients), intraperitoneal adhesions (n = 5, in four patients), a ruptured ovarian cyst (n = 1), and pleural effusions (n = 4). Pathologic findings unrelated to PD or located extra-abdominally were observed in 19 of the 25 studies. The catheter tip position was easily identified for all patients. In conclusion, this first report on peritoneal MRI using only dialysate as the "contrast medium" indicates that MRI permits detailed observation of all relevant, PD-related, abdominal pathologic features against the dialysate background, thus avoiding system contamination (and thus the risk of peritonitis).

BACKGROUND Diabetic kidney disease (DKD) is the leading cause of end-stage renal disease (ESRD) in Austria, accounting for a high burden of morbidity and mortality. In this nationwide study, we aimed to evaluate the incidence and fate of patients with DKD-ESRD over time. METHODS Data (collected annually) from the Austrian Dialysis- and Transplant Registry were analysed for the development of ESRD due to DKD from 1965 to 2013. RESULTS Over 48 years, 8322 and 22 975 patients with ESRD due to diabetes and non-diabetes, respectively, entered dialysis. While DKD-ESRD-patients were not dialysed until 1974, in 1975 seven type 1- and one type 2-diabetics started dialysis (1.06 per million population-PMP). In the mid-eighties, DKD-ESRD-patients increasingly were accepted for dialysis (1986: 14.53 PMP, 1996: 31.16 PMP). After a peak incidence of 415 diabetic ESRD-patients in 2006 (50.19 PMP), numbers decreased continuously thereafter (2013: 299 patients, 35.73 PMP). Mean age at start of dialysis increased over time and was lower in type 1- and higher in type 2- compared with non-diabetic patients. Five-year-survival-probability in two diabetic ESRD-cohorts, starting in 2007/08 and 10 years earlier was calculated. Five-year-survival was 28% in 1997/98 and 37.5% in 2007/08. Adjusted relative risk reduction was 33% (HR 0.67, CI 95% 0.57-0.78; P < 0.001). CONCLUSION Despite a growing prevalence of diabetes, the incidence of diabetic ESRD has decreased after 2006. Five-year-survival-probability has improved over 10 years. Multifactorial therapeutic interventions may have resulted in this improvement.

The objectives of this open non-randomized study were to evaluate the impact of a new peritoneal catheter placement technique on catheter maintenance, and complications possibly related to the access, e.g. leakage, infectious complications, or drainage failure.In a routine clinical setting, a two-cuff swan-neck catheter was implanted surgically, but its external segment was embedded in a subcutaneous pouch initially without exit site to enable uncontaminated wound healing and tight ingrowth of the cuffs. After 4 weeks at the earliest the distal catheter tip was set free by a small incision under local anaesthesia, and CAPD was started.Using this technique, 26 catheters were implanted in 17 males and nine females (mean age 52.3 +/- 17.4, range 19-83 years). The catheters were buried subcutaneously for a median of 79.5 (mean +/- SD 132.2 +/- 157.2, range 28-675) days, and were activated in 21 patients. No leaks were seen, and only one abdominal wall abscess secondary to a haematoma was found. Long-term follow up (mean duration of CAPD 467.0 +/- 338.1, range 32-1320 days) revealed a very low overall incidence of infectious complications, i.e. 0.80 per patient-year (1 episode per 14.9 patient-months), and the incidence of catheter-related peritonitis amounted to 0.036 per patient-year (1 episode per 27.2 patient-years), only. However, the postoperative course was complicated by seromas in two of 26, and subcutaneous haematomas in 12 of 26 patients, five of which were revised surgically. At catheter activation, fibrin thrombi were found in nine of 21 patients and two had to be operated. Omental catheter obstruction was diagnosed in four patients, and followed by omentectomy. No relationship was seen between thrombus formation and omental obstruction and duration of subcutaneous embedment (P = 0.27 and P = 0.5 respectively) or patient age (P = 0.06 and P = 0.13 respectively; Mann-Whitney-test). There was also no relationship with primary omentectomy or haematoma.We conclude that although the very low incidence of infectious episodes favours the new technique, further improvement is necessary to decrease the unacceptable rate of perioperative complications. Subcutaneous embedding of the catheter may then be considered in patients with expected problems of wound healing, and those who wish to be prepared for peritoneal dialysis in time.

Peritonitis is a major complication of peritoneal dialysis (PD) being associated with hospitalization, catheter loss, technique failure, and increased mortality. Data on incidence rates and risk factors for peritonitis episodes vary between centers. In seven Austrian PD units clinical and laboratory data on each peritonitis episode were collected from all patients (n = 726) who performed PD between January 2000 and December 2009. The peritonitis incidence rate was 0.32 episodes/patient-year. In a multivariate analysis the risk of peritonitis was decreased by 57% in patients treated with oral active vitamin D (HR 0.43; 95% CI 0.28-0.64). Renal disease classified as "other or unknown" (HR 1.65; 95% CI 1.08-2.53) and serum albumin

Nephrogenic systemic fibrosis (NSF) is a systemic illness, which only affects patients with kidney failure. NSF risk increases with progressively lower levels of kidney function. It is characterized by red skin areas or plaques that develop over several weeks to painful thickened skin with a "woody" texture, resembling "peau d'orange." It may ultimately cause flexion contractures of joints. Skin biopsy reveals thickened collagen bundles, mucin deposition, proliferation of fibroblasts and elastic fibers, without inflammation. Originally described as nephrogenic fibrosing dermopathy (NFD), because of its primarily cutaneous manifestation, it was renamed NSF because of the involvement of various organs like the lungs, myocardium, or striated muscles. The pathogenesis of the disease is not known yet, but recently we suggested a strong association between development of NSF and exposure to gadolinium-based contrast (GBC) agents, thereafter confirmed by other authors. As a consequence of our recent observations, medical authorities imposed restrictions that exclude patients with advanced levels of renal insufficiency from potentially important magnetic resonance imaging studies with gadolinium. Unfortunately, the only alternatives in many situations (examination of brain, lungs, vasculature) are imaging modalities using iodinated radiocontrast agents. Thus, clinicians are faced with weighing the potential risk of NSF from GBC exposure against the risk of acute kidney injury-associated with radiocontrast media. In this dilemma, clinicians must identify patients at high-risk to develop NSF. Known risk factors critical for the development of NSF after exposure to GBC agents (certain chelates and higher doses) are end-stage renal disease requiring dialysis, especially those with little or no residual renal function, and advanced kidney disease not on dialysis. Other potential risk factors include metabolic acidosis, iron overload/intravenous iron, divalent ion disturbances, endothelial/vascular injury, and high erythropoietin doses. Further studies are required.

Patienten mit Polyzystischer Nierendegeneration und terminaler Niereninsuffizienz werden in Osterreich zu 6 % und somit seltener der Peritonealdialyse (PD) als Nierenersatztherapie zugefuhrt als Patienten mit nicht-zystischen Nierenerkrankungen (ca. 8 %). In den USA praktizieren mehr als ein Funftel der Zystennieren-Patienten PD. Die Grunde fur diese Unterschiede sind unklar. Die bei dieser Erkrankung beschriebenen extrarenalen Manifestationen wie Divertikulose, erhohte Inzidenz der Hernienbildung oder Gefasaneurysmen konnten theoretisch mit erhohten Komplikationsraten an der PD verbunden sein. Entsprechende Untersuchungen weisen aber kein erhohtes Risiko fur Peritonitis durch Divertikulose und auch keine an der PD vermehrten Gefaskomplikationen nach. Hernien durften unabhangig von der Art der Nierenersatztherapie bei Polyzystischer Nierendegeneration gehauft auftreten und werden moglicherweise durch PD weiter gefordert. Die Dauer, wie lange PD durchgefuhrt werden kann, unterscheidet sich bei Zystennieren-Patienten nicht von der Therapiedauer bei Patienten mit nicht-zystischen Nierenerkrankungen. Zystennieren-Patienten mit abdominellen Beschwerden wie Meteorismus, Vollegefuhl oder Kreuzschmerzen verursacht durch die Organvergroserung sollte nicht unbedingt aktiv zur Peritonealdialyse geraten werden, da die Symptome durch die PD weiter verstarkt werden konnen. Gleiches gilt fur Patienten mit rezidivierenden Hernien. Allen anderen Zystennierenpatienten sollte aber sehr wohl die Methode zur Wahl vorgestellt werden, zumal Technikuberleben, Dialysequalitat oder methodenspezifische Komplikationsraten mit jenen bei Patienten mit nicht-zystischen Nierenerkrankungen vergleichbar sind. PD stellt auch fur Patienten mit Polyzystischer Nierendegeneration eine gleichwertige Behandlungsalternative zur Hamodialyse dar.

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

Die spezifische Bindung von Interferon-α 2 an hochgereinigte Plasma-membran-Proteine humaner, lymphoider Zellen wurde mittels Western-Blot-Technik untersucht. An einer humanen Haarzell-Leukamie-Linie

In einer multizentrischen „open label“ Studie mit IFN-α2b wurden 85 Patienten mit Haarzell-Leukamie behandelt und ausgewertet. Die Induktionsbehandlung bestand in 2 × 106 E IFN-α2b/m2, 3 × wochentlich, s.c. Die Ergebnisse zeigen die hohe Effektivitat der Substanz, wobei unter den verwendeten Dosierungen geringe, gut tolerierbare und passagere Nebenwirkungen im Sinne eines grippeahnlichen Syndroms auftraten. Die Prozentzahl der Remissionen (CR + PR + MR) nach sechsmonatiger Behandlungszeit lag bei 89%, der Anteil von CR betrug 4%, von PR 69%. An einer kleinen Gruppe (4 Patienten) wurde nach Erzielen einer CR oder PR der Effekt unterschiedlicher Formen der Erhaltungstherapie getestet. Die bisherigen, statistisch noch nicht auswertbaren Resultate sprechen dafur, das bei Auftreten eines Ruckfalles nach Aussetzen oder Verringerung der IFN-Dosis (3 × 106 I.E., s.c., 1 × wochentlich) durch Wiedereinsetzen oder Erhohung von IFN-α2 neuerlich Remissionen erzielt werden konnen. Zur Erhaltung der Remissionen durfte eine IFN-Dauertherapie notwendig sein. Mittels eines Kurzzeit in vitro Tests werde der Effekt von Interferon α2 auf die Inkorporation von H3-Thymidin und H3-Uridin in Haarzellen bestimmt. Fur beide Prakursoren ergab sich keine Hemmung des Einbaues. Allerdings zeigte eine Langzeitinkubation (48 h) einen signifikant vermehrten H3-Uridin Einbau, wahrend der H3-Thymidin Einbau unbeeinflust blieb. Diese Resultate sprechen gegen einen unmittelbaren antiproliferativen Effekt von IFN-α2 auf Haarzellen, sie weisen aber auf eine Induktion der RNS-Synthese hin. Eine Zellmarker-Analyse der Haarzellen mit monoklonalen Antikorpern vor und wahrend einer 7tagigen in vitro Behandlung mit IFN-α2 ergab keine Anderung des Phanotyps, so das eine differenzierende Wirkung des IFN auf Haarzellen nicht beobachtet werden konnte.

The efficacy of the benzodiazepine-antagonist flumazenil (Ro 15-1788) was evaluated in 26 patients with coma due to benzodiazepine self poisoning, alone or in combination with alcohol or other psychoactive drugs. 77% of the patients responded to the administration of a mean dose of 1.73 mg (range 0.2 to 8 mg) with immediate awakening or an improvement of at least 2 coma grades. In the patients without response (n = 3) or with minor improvement (n = 3) other psychoactive drugs turned out to be predominantly responsible for their comatose state. Adverse effects of flumazenil treatment such as altered blood pressure or increased heart rate were observed, but were generally mild. An acute benzodiazepine withdrawal syndrome was seen in 2 cases. In conclusion, flumazenil proved to be effective in the treatment of severe benzodiazepine intoxication. Beyond that, in cases of mixed overdosage or initially unknown diagnosis the antidote assisted in the clarification of the clinical condition.

We investigated the role of beta 2-microglobulin as a noninvasive parameter to monitor acute rejection and severe infection in 45 consecutive heart transplant recipients. Endomyocardial biopsy revealed moderate (41 patients) or severe (three patients) rejection in 44 patients. Severe infections of bacterial septicemia (11 patients), bronchopneumonia (two patients), and viral infection (seven patients) were detected by a meticulous schedule of various clinical and laboratory tests. beta 2-Microglobulin levels in serum, generally corrected for serum creatinine, were significantly elevated in patients with infections (median, 6.3 mg/l; range Q10-Q90, 3.47-10.27 mg/l) compared with levels in patients with rejection (p less than 0.0001) or in patients in obviously good condition (p less than 0.0001). At the onset of acute rejection, the median corrected beta 2-microglobulin serum level was 1.56 mg/l (range Q10-Q90, -0.05-3.46 mg/l) and was significantly different from the control group (p less than 0.01). In addition, density function and empirical quantile analyses allowed us to define ranges of beta 2-microglobulin levels that would differentiate between rejection (2.05-3.46 mg/l) and infection (greater than 3.46 mg/l). With these values, sensitivity and specificity were 0.9 and 0.938 for detection of infection and 0.23 and 0.925 for detection of rejection, respectively. By means of beta 2-microglobulin, two cases of infection were misinterpreted as rejection (10%), and four of 44 rejections were mistaken for infections (9%). We conclude that measurements of beta 2-microglobulin may improve the management of heart transplant patients.

We present a female patient with a B-immunoblastic lymphoma of the IgM-lambda type arising in angioimmunoblastic lymphadenopathy. An increased ratio of helper/inducer to suppressor/cytotoxic lymphocytes in the lymph node could have triggered the proliferation of B cells. Evolution of IgM cryoglobulinemia was paralleled by malignant transformation in the lymph node. A short-term in vitro chemosensitivity test could predict response to COP combination chemotherapy suggesting that in vitro chemosensitivity testing can be useful for the therapeutic management of angioimmunoblastic lymphadenopathy.

Summary Approximately 31 patients with chronic myelogenous leukaemia (CML) are documented in the literature who survived more than 10 years after diagnosis. We present a CML-patient whose survival of 27 years is probably the longest reported so far. The analysis of the course of disease in these patients revealed that the duration of unmaintained first remission after chemotherapy is of high prognostic significance. In 17 of 24 evaluable patients the remission lasted more than 1 year and in another five at least 6 months (mean 73.8 months, range 0-240 months). In most patients busulfan was used as initial therapy. There was no correlation between the amount of drug given and the duration of remission or survival. Other parameters such as sex, age, initial leucocyte counts, differential count, haemoglobin, platelet count or spleen size seemed to have no prognostic relevance. While approximately 25% of CML patients with typical duration of survival exhibit a -Phl chromosome mosaicism only, this finding was present in nearly half of the long-term survivers.

The objectives of this study were to evaluate whether age, sex, underlying renal disease, or the performing surgeon is of prognostic relevance to the patency of the vascular access. In a routine clinical setting, 139 first and 144 further fistula operations were done in 139 patients during 5 yr and were analyzed in retrospect. Within a group of 108 patients with first Cimino-Brescia fistulae, Cox multivariate regression analysis revealed the surgeon to be the only determinant with a continuous, significant effect on fistula patency throughout the observation period (P(out) < 0.1). The patency rates of the seven surgeons at 1, 2, and 3 yr differed from 34 to 69, 13 to 62, and 13 to 62%, respectively. Hazard ratios among the surgeons varied from 0.65 to 2.21. Additionally, age (P < 0.004) and diabetes mellitus (P < 0.02) were disclosed to be significant risk factors for impaired patency, but later in the course of disease (time dependent). Sex had no influence. After the failure of the first fistula, revisions of or new Cimino-Brescia fistulae (N = 56) were superior to polytetrafluoroethylene grafts (N = 61). The mean patency of the former amounted to 320 +/- 377 versus 156 +/- 281 days in polytetrafluoroethylene grafts (P < 0.05). It was concluded that increasing age and diabetes mellitus are time-dependent risk factors for the shortened patency of arteriovenous fistulae. The operating surgeon, however, seems to be the major determinant for the continuous patency of Cimino-Brescia fistulae.

The effect of human recombinant interferon alpha 2 (IFN alpha 2) on hairy cells obtained from 16 patients was evaluated. All patients promptly responded to induction of remission with 2 X 10(6) U/m2 interferon alpha 2 b, three times a week, sc. In order to achieve a more detailed insight into the mode of action of interferon in this disease, we determined the influence of IFN alpha 2 on the incorporation of radiolabeled thymidine and uridine into hairy cells. While both 3H-thymidine and 3H-uridine incorporation were unaffected by IFN alpha 2 in a 3-hour incubation period, a significant increase in uridine incorporation into hairy cells, but not CLL cells, was observed after 24 h. Cell surface marker analysis performed with monoclonal antibodies did not reveal a quantitative alteration of the immunophenotype of hairy cells in vitro. In addition, natural killer cells, assessed by monoclonal antibodies and a cytotoxicity assay against K 562 cells, were found to be decreased in 9 out of 10 patients prior to therapy. Although IFN alpha 2 could stimulate natural killer cells in vivo, we did not find a consistent correlation between the activation of these cells and the response to therapy. We conclude, therefore, that NK cells play no major role in the regression of hairy cells. Furthermore, IFN alpha 2 does not alter antigenic determinants in vitro, but leads to an enhanced incorporation of 3H-uridine into hairy cells in vitro, thus indicating a possible role for the induction of RNA synthesis in vivo.