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Listing a patient on the Eurotransplant waiting list for a kidney transplantation obliges transplant centers to ensure that an allocated organ can also be transplanted, as long as there are no acute recipient-specific medical or personal contraindications. Assessing the ability for transplantation over a period of up to 10 years between initiation of dialysis and an organ offer represents a major challenge in manpower and logistic efforts. The present article reviews specific aspects regarding waiting list management on the basis of current guideline recommendations and literature data.

Chronic kidney disease is defined by decreased glomerular filtration rate or proteinuria. Diabetic nephropathy and hypertensive renal damage are responsible for the majority of cases. The initiation of therapy has to consider if causal treatment of the underlying disease is possible and indicated. In all patients, even if specific treatment is not possible, therapy should aim at reducing progression of kidney failure. Chronic kidney diseases tend to intrinsic deterioration that persists after cessation of the causative damaging pathomechanism. Progression of disease can be delayed; the most important measures include strict blood pressure control, reduction of proteinuria, and avoidance of further renal harm. Kidney disease induces typical sequelae such as left ventricular hypertrophy, vascular calcification, anemia, and renal osteodystrophy. While these are well understood nowadays therapeutic options are limited. The uremic syndrome is to be avoided by renal replacement therapy.

Hintergrund Im Rahmen der vorliegenden Studie sollte untersucht werden, ob bei Patienten in der Fruhphase einer ambulant erworbenen Sepsis („community-acquired sepsis“, CAS) ein Zusammenhang zwischen der Leberfunktion, gemessen uber die Indocyaningrun(ICG)-Elimination, und dem klinischen Verlauf existiert.

Systemic steroids are widely used worldwide as a standard of care for primary therapy of idiopathic sudden sensorineural hearing loss (ISSHL). The German ISSHL guideline recommends high-dose steroids for primary therapy of ISSHL, without evidence from randomized controlled trials (RCTs). The rationale for the treatment of ISSHL using high dose steroids is only based on retrospective cohort studies.This article describes the planning and initiation of a multicenter, national, randomized, controlled clinical trial entitled Efficacy and safety of high dose glucocorticosteroid treatment for idiopathic sudden sensorineural hearing loss - a three-armed, randomized, triple-blind, multicenter trial (HODOKORT). This clinical trial aims to compare standard dose with two types of high-dose steroids for primary systemic therapy with respect to their efficacy in improving hearing, and thus communication ability, in patients with idiopathic sudden sensorineural hearing loss.This study is funded by the "Clinical Trials with High Patient Relevance" research program in the health research framework of the German Federal Ministry of Education and Research. It is one of two studies by the German Study Center of Clinical Trials of the German Society of Otorhinolaryngology, Head and Neck Surgery (DSZ-HNO). Planning and initiation was done in cooperation with the DSZ-HNO, the Coordination Center of Clinical Trials of the Martin-Luther-University Halle-Wittenberg, and the Study Center of the University Hospital Freiburg.

Zusammenfassung Bei der Hamodialysebehandlung wird Blut extrakorporal unter Verwendung von Dialysemaschinen gereinigt. Verfahrensbedingt ist eine nosokomiale Transmission von hamatogen ubertragbaren Erregern dabei moglich. Die entscheidende Frage ist, ob sich aus dieser Situation ein Risiko fur den nachsten Patienten ergibt und wie mit einem Dialysegerat umgegangen werden muss, das bei einem Patienten mit bekannter Prionen-Erkrankung eingesetzt wurde. Die Verfahren zur Inaktivierung von Prionen sind im Vergleich zu den ublichen Desinfektions-Verfahren fur Dialysegerate sehr aufwandig. Da keine wirksame Methode zur Inaktivierung von Prionen zur Desinfektion von Dialysegeraten angewendet werden kann, muss eine andere Strategie fur den Umgang mit Dialysegeraten, die in Kontakt mit an Prionen erkrankten Patienten gekommen sind, zur Anwendung kommen. Dialyse-Einrichtungen sollten eine Verfahrensanweisung zur Risikoanalyse in einer „Prionen-Situation“ in ihrem Hygieneplan vorhalten. Der Umgang mit Dialysegeraten kann entweder konservativ (Verwerfen des Gerates) oder differenziert (Anwendung verfugbarer Informationen und Durchfuhrung einer individuellen Risikobewertung) sein. Diese beiden Alternativen werden als Empfehlungen vorgestellt.

Die Festlegung des Optimalgewichts bei Dialysepatienten ist noch immer ein substanzielles Problem. Die rein klinische Einschatzung ist meist zu unprazise und wenig reproduzierbar. Verschiedene technische Hilfsmittel werden in diesem Artikel erlautert und miteinander verglichen. Insbesondere das Blutvolumenmonitoring zur Reduktion intradialytischer Komplikationen und die Bioimpedanzverfahren zur Festlegung des Optimalgewichts erscheinen als vielversprechende Technologien. Zukunftig konnte durch eine Kombination von Blutvolumenmonitoring und Unterschenkel-Bioimpedanzspektroskopie eine automatisierte Ultrafiltration Realitat werden.

Die CMV-Infektion gehort zu den haufigsten und am meisten Ressourcen verbrauchenden Infektionskomplikationen nach Nierentransplantation. Die Durchseuchung ist hoch, das Virus persistiert lebenslang. Unter Immunsuppression kann es zur Reaktivierung kommen, seronegative Empfanger konnen durch das Transplantat neu infiziert werden. Goldstandard der Diagnostik ist der Nachweis von pp65 in Leukozyten oder der Virus-DNA im Blut, die Serologie dient ausschlieslich der Risikostratifizierung des Patienten vor Transplantation. Die CMV-Erkrankung kann heute uberwiegend verhindert werden: Die „Prophylaxestrategie“ besteht aus Ganciclovir oder Valganciclovir uber 90 bis 100 Tage, bei der „praemptiven Therapie“ (Voraussetzung: engmaschiges CMV-DNA-Monitoring) wird erst bei nachgewiesener Replikation behandelt, vor Auftreten von Symptomen. Eine CMV-Erkrankung kommt nur noch selten vor und muss rasch antiviral, ggf. auch mit Hyperimmunglobulinen behandelt werden.

Am 01.05.2017 wurde Univ.-Prof. Jürgen Floege, Aachen, in den 6-köpfigen Vorstand der Deutschen Gesellschaft für Innere Medizin gewählt und gleichzeitig als Präsident für die Amtsperiode 2019/2020 berufen. 2020 wird er dann Kongress-Präsident des DGIM-Kongresses in Wiesbaden sein. Die Wahl von Prof. Floege stärkt den Stellenwert der Nephrologie als wichtiges Kernfach der Inneren Medizin.

The aim of our clinical study was to correlate liver function measured by indocyanine green (ICG) elimination and clinical outcomes in patients with an early stage of community-acquired sepsis (CAS).A total of 341 patients (≥ 18 years) presenting with suspicion of CAS or evidence of an infection and fulfillment of ≥ 2 systemic inflammatory response syndrome (SIRS) criteria were included in the observational study"Prognosis of early sepsis 2" (Prognose der frühen Sepsis 2, ProFS 2). Patients who had been hospitalized within the last 7 days were excluded. In a subgroup of these patients (n = 72) who were transferred to an intensive or intermediate care unit according to the clinical judgment of the treating physicians, ICG elimination (plasma disappearance rate, ICG-PDR; 15 min retention rate, ICG-R15) was assessed by using a noninvasive monitoring system (LiMON, PULSION Medical Systems, Germany). ICG-PDR and -R15 were determined on the day of admission (n = 72) and after 96 h (n = 34). The primary end point of the study was defined as death within 30 days. Secondary endpoints were need for renal replacement therapy, requirement for invasive mechanical ventilation, and length of stay in an intermediate or intensive care unit.In contrast to patients with sepsis or severe sepsis, ICG elimination was found to be significantly impaired in patients with septic shock. Furthermore, a significant predictive value of ICG-PDR and -R15 on the day of admission for the need for subsequent renal replacement therapy (n = 12) was observed. In addition, reduced ICG elimination was associated with a longer stay in an intermediate or intensive care unit. However, ICG elimination on admission could not predict 30-day mortality (n = 14) or requirement of mechanical ventilation (n = 20).

Uremia describes the consequences of intoxication in chronic renal failure with substances that are renally cleared in healthy individuals. Acute uremia is a syndrome of gastrointestinal symptoms, pericarditis, pleuritis, and central nervous system alterations ending with coma. These symptoms can be resolved by renal replacement therapy. In addition, chronic uremia can result in damage of multiple organ systems, which continues to advance despite dialysis therapy. This is caused by retention of toxins that cannot be adequately removed due to insufficient treatment time or a molecular weight range hampering elimination. Uremic toxins can be generated by the energy or nucleic acid metabolism, they can be proteins or large molecules that are altered chemically by the uremic milieu. Chronic uremia can influence the majority of long-term complications of chronic renal failure: systemic microinflammation, cardiovascular disease, immunodeficiency, malnutrition, anemia, bone metabolism, and polyneuropathy. There are few therapeutic options other than kidney transplantation.

Disorders of electrolyte balance are frequent and pathophysiologically complex. Sodium is responsible for a large part of the osmolarity of extracellular fluids. Therefore, pathological concentrations of serum sodium reflect the relation between sodium and water in the extracellular compartment rather than the total body sodium content. The causes of hypo- or hypernatremia can only be deduced if total body volume status is considered. Patients with hyponatremia and volume deficit should receive sodium chloride solution while patients with this disorder in the presence of volume overload need strict water restriction. In certain cases additional specific pharmacotherapy directed at the effects of antidiuretic hormone may be considered. Potassium and calcium are extracellular regulatory ions; their concentrations do not relevantly contribute to osmolarity and water distribution but to electrophysiologically relevant transmembrane potentials. These ions are influenced by active membrane transporters and regulated by several hormones. The rather small extracellular pools are overfilled or depleted by alterations of intake and excretion. In addition, several inborn or acquired defects of transmembrane transporters may severely alter their extracellular concentrations. Therapy needs to consider the specific mechanisms that led to the electrolyte disorder including modification of intake, excretion or extra-intracellular distribution.

Die Lebenserwartung uramischer Patienten ist deutlich reduziert, wobei kardiovaskulare Erkrankungen und Ereignisse mehr als 50% der Todesfalle in dieser Patientenpopulation ausmachen. Das 5-Jahres-Uberleben von Dialysepatienten ist mitunter schlechter als bei Patienten mit soliden Tumoren. In den letzten Jahren ist auserdem realisiert worden, dass bereits eine leichte Einschrankung der Nierenfunktion einem releventen und unabhangigen Mortalitatsrisikofaktor entspricht. Letztlich stellt eine akzeleriert ablaufende Athero- und Arteriosklerose das hauptsachliche morphologische Korrelat dieser insbesondere kardiovaskularen Ubersterblichkeit in der Uramie dar, zusatzlich findet sich aber auch eine hohe Pravalenz von arterieller Hypertonie im Kontext mit Volumenuberladung und linksventrikularer Hypertrophie. Fur Shuntplanung und-chirurgie spielen insofern die haufig schwerwiegend vorgeschadigten Gefase und die potenziell vorbestehende Herzinsuffizienz eine relevante Rolle.

Immunosuppressive treatment in transplant patients frequently causes infectious complications with cytomegalovirus (CMV). The extent of CMV replication can be followed by a number of diagnostic methods. There is, however, no simple diagnostic tool to assess the quality of the cellular antiviral immune response of an individual patient. This would be of particular importance for therapy decisions, as patients with detectable virus load do not necessarily develop CMV-related disease. Using a rapid whole blood assay, the frequencies of CMV-reactive CD4 and CD8 T cells were followed after renal transplantation to characterize their relative contribution in the containment of CMV infection.T cells from transplant patients ands healthy control persons were stimulated with CMV antigen in vitro. Based on specific cellular activation and induction of intracellular cytokines, the frequency of CMV-reactive CD4 and CD8 T cells was determined using flow cytometry. Viral load quantified using the "hybrid-capture" assay.The absence of CMV complications in long-term transplant recipients is reflected by stable virus-specific T-cell frequencies, which do not differ from healthy CMV-positive controls. In contrast, during the first months after transplantation, clinical symptoms are preceded by a decrease in CMV-reactive CD4 T-cell frequencies and an increase in CMV load.The individual immune response and CMV replication are critically balanced and can be characterized by assesing both viral load and antiviral T cells. Our experimental design allows the identification of patients with sufficient, insufficient, or absent T-cell activity and can serve as diagnostic tool to facilitate decisions on antiviral therapy.

Glucocorticoids act as immunosuppressive drugs mainly via their effects on antigen-presenting cells. They are known to influence production of cytokines as well as expression of cell surface molecules. B7 molecules belong to the most important costimulatory signals for T-cell activation during transplant rejection. They are expressed on antigen-presenting cells and up-regulated during the immune response. We studied the influence of glucocorticoids on the regulation of these accessory signals.Human monocytes were purified from peripheral blood of healthy volunteers by centrifugal counterflow elutriation. Activation-dependent transcription and expression of B7-1 (CD80) and B7-2 (CD86) were detected by reverse transcription-polymerase chain reaction and flow cytometry in the absence or presence of glucocorticoids.The expression pattern of B7-1 and B7-2 on monocytes depends on the type of stimulation. Activation by interferon-gamma induces both B7-1 and B7-2, whereas cAMP exclusively up-regulates B7-2. Glucocorticoids selectively inhibit the expression of B7-1 while leaving B7-2 unaffected. The effect occurs at concentrations that are reached during therapeutical application of the substances in humans. It is mediated via the cytoplasmic glucocorticoid receptor, as it can be abrogated by the glucocorticoid receptor antagonist RU38486. Inhibition of B7-1 occurs at the transcriptional level. Up-regulation of the molecule can similarly be inhibited by hydrocortisone, prednisolone, and dexamethasone at equipotent doses.Inhibition of the up-regulation of B7-1 by glucocorticoids is a previously unknown mechanism of action of these substances and may relevantly contribute to their effects as immunosuppressive drugs.