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Ureteritis cystica is a rare benign condition. In this report, we have presented the case of a patient with a left upper back pain. The CT scan showed multiple irregular filling defects in the upper left ureter and the left renal pelvis. During the ureteroscopy, multiple yellow cystic lesions were seen in the proximal part of the left ureter and in the renal pelvis.The pathology report described cystic structures coated with single line cubic metaplastic epithelium. Ureteritis cystica should be considered in a differential diagnosis, in case of atypical radiological findings. No active treatment is required when confirmed. Keywords: Ureteritis cystica, Cystitis cystica, Ureter

Background: In the Eurotransplant Kidney Allocation System (ETKAS), transplant candidates can be considered for high-urgency (HU) status in case of life-threatening inability to undergo renal replacement therapy. Data on the outcomes of HU transplantation are sparse and the benefit is controversial., Methods: We systematically analysed data from 898 ET HU kidney transplant recipients from 61 transplant centres between 1996 and 2010 and investigated the 5-year patient and graft outcomes and differences between relevant subgroups., Results: Kidney recipients with an HU status were younger (median 43 versus 55 years) and spent less time on the waiting list compared with non-HU recipients (34 versus 54 months). They received grafts with significantly more mismatches (mean 3.79 versus 2.42; P < 0.001) and the percentage of retransplantations was remarkably higher (37.5 versus 16.7%). Patient survival (P = 0.0053) and death with a functioning graft (DwFG; P < 0.0001) after HU transplantation were significantly worse than in non-HU recipients, whereas graft outcome was comparable (P = 0.094). Analysis according to the different HU indications revealed that recipients listed HU because of an imminent lack of access for dialysis had a significantly worse patient survival (P = 0.0053) and DwFG (P = 0.0462) compared with recipients with psychological problems and suicidality because of dialysis. In addition, retransplantation had a negative impact on patient and graft outcome., Conclusions: Facing organ shortages, increasing wait times and considerable mortality on dialysis, we question the current policy of HU allocation and propose more restrictive criteria with regard to individuals with vascular complications or repeated retransplantations in order to support patients on the non-HU waiting list with a much better long-term prognosis., (© The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

We evaluated the impact of smoking on the progression of macro-angiopathy as well as patient and graft survival in 35 type-1 diabetic patients with simultaneous kidney-pancreas transplantation (SKPT). According to their smoking history, the patients were divided into smokers (n = 12) and nonsmokers (n = 23). Mean observation period was 80 (12-168) vs. 84 (12-228) months. The prevalence of vascular diseases as well as the incidence of vascular complications during the observation period was evaluated in each group. Graft- and patient survival were calculated. The prevalence of all vascular diseases was higher in the smokers with prior SKPT at the start as also at the end of study; however, the differences were not significant. In addition, the incidence of vascular complications (stroke, myocardial infarction and amputation) during the follow-up period was higher in the smoking group. Taking all vascular complications together (events/patient/year) the difference was significant (0.105 vs. 0.066, P < 0.05). One- and 5-year patient survival was 100% and 75% for smokers vs. 100% and 91% for nonsmokers. One- and 5-year pancreas graft survival at the same time was 100% and 75% in living smokers as well as 100% and 83% in the nonsmokers: We conclude that smoking after SKPT is associated with a progression of macro-angiopathy. Additionally, mortality after SKPT tends to be higher in smoking patients.

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.

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.

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.

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.

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.

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).

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.

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.

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.

In a retrospective study the frequency of hypokalemia was investigated in a large group of hospitalized patients. In a period of 1 year 33,426 patients were hospitalized, of these 1,177 (3.52%) revealed serum potassium level of less than or equal to 3.0 mmol/l. On admission to the hospital 592 (50.3%) showed serum potassium levels within normal range and developed their hypokalemia in the hospital. A severe hypokalemia equal or lower 2.5 mmol/l was observed only in 0.54% of the patients. Hypokalemia was frequently associated with cardiovascular, gastrointestinal and urogenital diseases following by diabetes mellitus and polytraumas. The main causes of hypokalemia were diuretics and gastrointestinal potassium loss. Severe hypokalemia (less than or equal to 2.5 mmol/l) is a predisposing factor for the occurrence of ectopic ventricular activity in patients with preexisting myocardial lesions like left ventricular hypertrophy or after myocardial infarction. Therefore in patients with preexisting myocardial lesions and severe hypokalemia potassium replacement therapy may be needed.