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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.

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 mortality of patients with end-stage renal disease (ESRD) is especially high after the start of dialysis therapy, especially in diabetic patients. A part of these patients die within three months after initiating renal replacement therapy (RRT). In the present retrospective study we evaluated all patients with ESRD requiring RRT who died within 3 months after initiating the first RRT. A total of 42 patients who died such early after the start of dialysis treatment during the years 1995–2001 were included in the study. Of them, 28 subjects (age 66 + 11 years) were diabetics and 14 non-diabetics (age 76 + 10 years). Indications for the start of dialysis were end-stage renal failure (creatinine clearance < 10–12 mL/min or < 12–14 mL/min in diabetic patients) or fluid lung associated with chronic renal failure (creatinine clearance < 20 mL/min). Hyperhydration with fluid lung was the most common indication for dialysis therapy in patients with diabetes (64.3% versus 14.3%, p < 0.05). The vascular risk fac...

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.

Diabetes is known to be a risk factor for the severity of anemia in nondialyzed 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 nondiabetic 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 nondiabetic subjects (244 ± 122 versus 183 ± 118 IU/kg/week; p < 0.05). CRP after 6 months was significantly higher in diabetic than in nondiabetic 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 nondiabetic 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 nondiabetic 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 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.

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.

Bilateral nephrectomy for treatment of refractory hypertension in chronic hemodialyzed patients has been infrequently carried out. We analyzed the benefits of this operation on blood pressure, clinical state, drug treatment, and quality of life. In 10 hemodialyzed patients with refractory hypertension, systolic (SBP) and diastolic (DBP) blood pressure were measured 1 month before nephrectomy bilateral and 3, 6, 9, and 12 months after. In addition, the use of antihypertensive drugs before and after surgery was evaluated. Four patients had SBP and DBP values characteristic of malignant hypertension. In all 10 patients hypertension responded neither to reduction of plasma volume by ultrafiltration nor to multiple antihypertensive drug therapy. Hypertensive crises were associated with cerebral hemorrhage in two patients, severe encephalopathy with persistent neural dysfunction in one patient, and encephalopathy and diplopia in another. Three months after bilateral nephrectomy blood pressure decreased significantly (P < .005) and was normal in nine patients. In one noncompliant patient with intradialytic body weight increases of nearly 10%, blood pressure was still elevated. Malignant or drug-resistant hypertension with hypertensive crises is an indication for bilateral nephrectomy. The clinical state and quality of life improved in all patients in the present study and antihypertensive treatment is no longer necessary.

During pregnancy women with Type 1 diabetes do not differ from normal women with respect to pregnancy-associated changes in serum lipid levels. However influence of diabetic nephropathy on lipoprotein metabolism in pregnancy has not been described previously. Changes in lipids were compared during and after pregnancy in 10 Type 1 diabetic women without macroproteinuria as well as in 5 diabetic women with macroproteinuria due to diabetic nephropathy. In the pregnant women with macroproteinuria, compared to the diabetic women without macroproteinuria, we observed both significantly higher total and percent increases in serum levels of total cholesterol (97% versus 48%) and of LDL-cholesterol (137% versus 50%), which had risen progressively throughout gestation. The percent increases in serum triglycerides (115% versus 128%) were similar in both patient groups. Metabolic control was improved during pregnancy in both groups of women. Renal function remained normal throughout pregnancy in the diabetic women without nephropathy and worsened during pregnancy in the proteinuric women. The mean protein excretion showed a physiological rise from 0.107 +/- 0.040 g 24 h-1 before pregnancy to 0.336 +/- 0.234 g 24 h-1 in the third trimester in the nonproteinuric women, and an increase from 2.2 +/- 1.0 to 7.1 +/- 1.7 g 24 h-1 during the same period in the women with macroproteinuria. Therefore, it is concluded that the greater increase in serum lipid levels during pregnancy in the women with pre-existing diabetic nephropathy can mainly be explained by the concomitant increase in proteinuria associated with development of the nephrotic syndrome in these patients.

In insulin-treated patients with diabetes, kidney transplantation (KTP) may influence glycemic control, insulin requirements, as well as vascular risk profiles, but the data are controversial. In 10 selected insulin-treated diabetic patients with normally functioning kidney transplants, receiving cyclosporine for immunosuppression, we evaluated the fasting blood glucose, HbA1c, lipid levels, blood pressure, and insulin-requirement from 1 year before to 1 year after KTP.There were no significant differences in the mean HbA1c levels 6 and 3 months before transplantation (8.3 +/- 1.7 and 8.0 +/- 1.4%, respectively) and 3 and 12 months after transplantation (8.2 +/- 1.6 and 7.9 +/- 1.5%, respectively). The mean fasting blood glucose levels increased only transiently by 7% during the first week after transplantation (not significant). The insulin requirement was approximately the same at 3 and 6 months before (42 +/- 14 and 42 +/- 13 IU/d, respectively) and at 3 and 12 months after transplantation (44 +/- 13 and 41 +/- 13 IU/mL, respectively). Only 1 week after transplantation did the insulin requirement increase transiently by 14% to 48 +/- 14 IU/d (P.05). The mean levels of cholesterol and triglycerides as well as mean blood pressure were not significantly different before and after transplantation.Only immediately after KTP did mean blood glucose and insulin requirement increase. At least 3 months after transplantation, glycemic control and insulin requirements as well as the vascular risk factors were approximately the same as before the procedure.

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 significant improvements in therapy over the last decade, the prognosis of nephropathic type 2 diabetic patients continues to be poor (1). In recent antihypertensive intervention studies performed in type 2 diabetic patients with overt nephropathy, the mean 5-year mortality rate was ∼20%. In the irbesartan study published by Lewis et al. (2), the mean death rate after 54 months ranged from 15 (irbesartan group) to 16.3% (placebo group). Similar data were obtained in the losartan study published by Brenner et al. (3). These results might lead to false conclusions concerning the overall mortality of all unselected type 2 diabetic patients with overt nephropathy. In the irbesartan study, major excretion criteria were congestive heart failure (New York Heart Association [NYHA] class III or worse) and cardiovascular events within the last 3 months. In accordance with the irbesartan study, in 1996 we recruited all nephropathic type 2 diabetic patients who were treated at that time in our hospital and/or in the outpatient care …

DUE TO ADVANCING AGE the prognosis of renal tranplanted patients is considered to be uncertain since the risk of vascular complications is increased. Nevertheless, renal transplantation has been proposed to provide better survival rates compared to hemodialysis in older patients. However, cardiovascular complications, which are more frequently present in older recipients, are wellknown risk factors for kidney transplantation. Previous studies have reported the association between left ventricular hypertrophy and adverse outcomes following transplantation. Thus, an accurate assessment of the prognosis of patients after kidney transplantation appears to be highly dependent on appropriate preoperative screening for risk factors. In the present study, we evaluated predictors for poor patient survival among renal transplant recipients over age 50 years based upon the risk factors present in patients who survived less than versus more than 2 years.

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) level500 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 to1,000 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.

Aims/hypothesis . The aim of the study was to examine the effect of pancreas-kidney transplantation on the progression of macrovascular diseases in Type I diabetic patients with end-stage renal disease.¶Methods . The progression of cerebrovascular disease, coronary heart disease and peripheral vascular disease in uraemic patients with Type I (insulin-dependent) diabetes mellitus and who had had simultaneous pancreas-kidney transplantation was compared with that of recipients of a kidney transplant alone. Between 1986 and 1998 a total of 11 uraemic diabetic patients received a simultaneous pancreas-kidney transplantation and 10 diabetic patients a kidney transplant alone. All transplants functioned for at least 24 months, the mean observation period was 69 ± 37 compared with 70 ± 33 months in both patient groups. Macroangiopathic diseases were classified in four stages as described earlier.¶Results. In the group with simultaneous pancreas-kidney transplantation progression of cerebrovascular and coronary heart disease was observed in four patients (36 %) and progression of peripheral vascular disease in five subjects (45 %). In the cohort with kidney transplant alone four patients (40 %) showed progression of cerebrovascular and coronary heart disease and five progression of peripheral vascular disease (50 %); the difference is not significant. Mean values of HbA1 c (5.8 ± 0.2 vs 7.5 ± 0.6 %, p < 0.001) and serum triglycerides (1.2 ± 0.4 vs 2.0 ± 1.0 mmol/l, p < 0.05) were significantly lower in the patients with pancreas-kidney transplantation than in the patient group with kidney transplant alone. Serum cholesterol concentrations and blood pressures were similar in both cohorts.¶Conclusion/interpretation. From our results we concluded that pancreas-kidney transplantation reduces risk factors for the development of macroangiopathy but fails to halt progression of macrovascular diseases similar to Type I diabetic patients with kidney transplant alone. [Diabetologia (2000) 43: 231–234]

A 47-year-old woman with poorly controlled diabetes mellitus (HbA1C 9.2%, fasting blood glucose200 mg/dl) had complained of moderately severe stabbing pain in the left abdomen. On admission there were no abnormal findings on abdominal palpation.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.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.Even extensive malakoplakia can be successfully treated with ciprofloxacin. Poorly controlled diabetes together with a weak immune status (CD4/CD8or = 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 (p0.025). 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.

WCN 2013 No: 282 Topic: 1 — Epilepsy Lesionectomy of the contralateral epileptogenic focus may help epilepsy control F. Al Ghamdi. Pediatric Neurology, KFMC, Riyadh, Saudi Arabia Background: Epilepsy is a common exhaustive and strenuous chronic neurological disorder. Epilepsy is usually controlled, but not cured, with medications. However, over 30% of people with epilepsy do not have seizure control with the best medications. Epilepsy surgery is an option for people with focal seizures that remain resistant to treatment. Patient: We report an eight year old girl who had a road accident followed by right frontal encephalomalacia and resistant seizures. The EEGs confirmed contralateral seizures. She had been resistant to all AEDs. VNS did not make a difference. There was no full agreement that she would benefit from a lesionectomy on the other side of the seizure discharges. After the operation and for 18 months, the girl's seizures dropped from 3–6 daily to only 3 brief seizures for the whole post-operative period. Results: Her seizures have been described as two different types, starting while awake with abnormal eye movements to many different directions and screamingwith subsequent forward tonicmovements of upper limbs. Type 2 while awake, her eyes move upwards and to the right. She would be unresponsive. Interictal EEG revealed sharp wave activities on the left frontocentral and centroparietal regionswith phase reversals at C3. Ictal EEG showed evidence of epileptiform activities starting from the frontocentral and centroparietal regionswith fast recruitment of the right hemisphere.MRI revealed right frontal lobe cystic encephalomalaciawith gliosis. Conclusion: Children with intractable epilepsy and focal brain lesions are candidates for surgery even when they have generalized or contralateral epileptiform discharges. doi:10.1016/j.jns.2013.07.185 Abstract — WCN 2013 No: 2651 Topic: 1 — Epilepsy Immunoadsorption and cyclophosphamide in a relapse of an anti-NMDA-receptor-encephalitis WCN 2013 No: 2651 Topic: 1 — Epilepsy Immunoadsorption and cyclophosphamide in a relapse of an anti-NMDA-receptor-encephalitis G. Caravias, M. Stefflbauer, M. Vosko, O. Janko, M. Guger, G. Ransmayr, F. Gruber. Department of Neurology, General Hospital Linz, Linz, Austria; Department of Internal Medicine II, General Hospital Linz

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 (p0.02). This significant difference has been observed in both women (p0.001) and men (p0.01). Serum uric acid level was lower in type-1 diabetics than in healthy controls but only in diabetic men the difference was statistically significant (p0.001). Male type-2 diabetic patients showed serum uric acid levels similar to the controls, but levels were higher in women with type-2 diabetes (p0.001). The results of this study show that in type-1 diabetic patients the serum uric acid levels are lower in normal (creatinine clearanceor = 80 ml/min) as well as in slightly decreased (creatinine clearance80 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 (p0.05).

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 (p0.05). 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.

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.

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 μg·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 μg·min−1 in the microalbuminuric women vs 43±36μg·min−1 in the normoalbuminuric women (p

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 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.

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.