Otmar Janko

Bilateral Nephrectomy: the Best, but Often Overlooked, Treatment for Refractory Hypertension in Hemodialysis Patients

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.

Impact of smoking on progression of vascular diseases and patient survival in type-1 diabetic patients after simultaneous kidney–pancreas transplantation in a single centre

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.

Recurrent calcinosis in consecutively transplanted kidney grafts.

ZusammenfassungEine wiederholt auftretende Nierentransplantat-Kalzinose ist ein seltenes Ereignis. Wir berichten über eine junge Frau, bei der eine wiederholt in zwei konsekutiv transplantierten Leichennieren aufgetretene Kalzinose beobachtet wurde.Als Ursache der Kalzinose wurden ein persistierender sekundärer Hyperparathyreoidismus und eine Hyperphosphatämie im Rahmen einer zunehmenden Nierenfunktionseinschränkung angenommen. Durch eine subtotale Parathyreoidektomie, durchgeführt kurz nach der dritten Nierentransplantation, sowie durch eine gute Funktion des Nierentransplantats konnte seit über 5 Jahren eine neuerliche Kalzinose im 3. Transplantat verhindert werden.SummaryRepeated 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. Subtotal 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.

Rate of Decline of GFR and Progression of Vascular Disease in Type 2 Diabetic Patients with Diabetic or Vascular Nephropathy during the Last Three Years before Starting Dialysis Therapy

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.

Different Risk Factors and Causes for Early Death after Initiating Dialysis in Diabetic and Non-Diabetic Patients

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 factors blood pressure and serum-lipids were similar in both groups; however, diabetic patients were younger than non-diabetic subjects. The prevalence of vascular diseases tended to be higher in the diabetic group, but difference was not significant (see ). Severe heart failure (NYHA stage III-IV) was more common among diabetics (42.8% versus 14.3%, p < 0.05). The incidence of sepsis (17.9% versus 14.3%) did not significantly differ between the groups. The most common cause of death was cardiovascular events in both diabetic and non-diabetic patients (71.5% and 64.2%, respectively). Heart failure was a more common cause of death in diabetic patients (39.2% versus 21.4%, NS). In conclusion, early death after the initiation of dialysis treatment was more common in patients with type 2 diabetes, though, the diabetic patients were less old. In the diabetic group fluid lung was more often indication for initiating dialysis therapy than in the non-diabetic group. In both, diabetic and non-diabetic patients, the most common causes of death are cardiovascular events.