Sendogan Aker

CARDIOVASCULAR RISK FACTORS AND DISEASES AFTER RENAL TRANSPLANTATION

Cardiovascular disease is a leading cause of death after renal tranpslantation (tpx), and the incidence is considerably higher than in the general population.ObjectiveTo evaluate the incidence of atherosclerotic cardiovascular complications after tpx, the prevalence of cardiovascular risk factors, prior to and following tpx, and the association between the risk factors and complications.Patients and methodsAnalysis of atherosclerotic cardiovascular diseases (coronary artery disease, cerebral and peripheral vascular disease) and cardiovascular risk factors before and after transplantation in 427 renal transplant recipients between 1987 and 1992 (mean age at transplantation 45±12 years, 58% male, 7% diabetics) with a mean post-transplant follow-up of 29±20 months.ResultsFollowing tpx 11.7% developed atherosclerotic cardiovascular diseases, the majority coronary artery disease (9.8%). The comparison of risk factors 12 months before and 24 months following transplantation showed: prevalence of systemic hypertension (from 73% to 85%), diabetes mellitus (from 7% to 16%) and obesity with a body mass index >25 kg/m2 (from 26% to 48%) had increased significantly whereas the number of smokers halved to 20%. Triglycerides decreased significantly (from235 mg/dl to 217 mg/dl). Totaland HDL cholesterol rose significantly (from 232 mg/dl to 273 mg/dl and from 47 mg/dl to 56 mg/dl, respectively). LDL cholesterol increase was significant (from 180 mg/dl to 189 mg/dl). In the univariate analysis, cardiovascular diseases were significantly associated with male gender, age over 50 years, diabetes mellitus (DM), smoking, total cholesterol ≥200 mg/dl, LDL cholesterol>180 mg/dl, HDL cholesterol ≤55 mg/dl, fibrinogen ≥350 mg/dl, body mass index>25 kg/m2, serum uric acid >6.5 mg/dl and with more than two antihypertensive agents per day. The Cox proportional hazards model revealed DM with a relative risk (RR) of 4.3, age>50 years (RR=2.7), body mass index>25kg/m2 (RR=2.6), smoking (RR=2.5), LDL cholesterol>180 mg/dl (RR=2.3) and uric acid>6.5 mg/dl as independent risk factors.ConclusionsThe high incidence of cardiovascular disease following renal transplantation is mianly due to a high prevalence and accumulation of classical risk factors before and following transplantation. Future prospective studies should evaluate the success of treatment regarding reduction of cardiovascular morbidity and mortality in this high risk population.

Comparable outcome of acute unplanned peritoneal dialysis and haemodialysis

BACKGROUND The impact of dialysis modality on outcome, especially on infection early in the course of dialysis, in unplanned acute dialysis initiation has not been well evaluated. The aim of the study was to compare the rates and causes of mortality and morbidity in incident dialysis patients started unplanned acute peritoneal dialysis (PD) or haemodialysis (HD). PATIENTS AND METHODS In this observational cohort study, incident dialysis patients with initiation of unplanned and acute PD (n = 66) or HD (n = 57) at a single centre from March 2005 to June 2010 were included and followed up for 6 months (0-183 days, mean follow-up time 4.72 months). For PD, surgically placed Tenckhoff catheters were used. All HD patients were dialysed with a central venous catheter (non-tunnelled or tunnelled). There were no significant differences in terms of gender, age and prevalence of diabetes mellitus in either group. The prevalence of heart failure [New York Heart Association (NYHA) Stage III-IV] was significantly higher in the PD group (73 versus 46% in HD group, P < 0.01). The population was stratified to PD and HD comparing mortality, infection, bacteraemia and hospitalization. RESULTS Of the 123 patients who commenced acute and unplanned dialysis, n = 44 (35.8%) died during the follow-up period of 0-183 days. There were no significant difference in half-year mortality in n = 20 PD patients (30.3%) versus n = 24 HD patients (42.1%) (P = 0.19). The cardiovascular mortality in PD and HD patients were 9.1 and 10.5%, respectively (P = 1.00). Overall mortality due to infection was higher in the HD (17.5%) versus in the PD group (9.1%), however, not significant (P = 0.19). HD patients had significantly higher probability of bacteraemia in the first 183 days compared to PD patients (21.1 versus 3.0%, P < 0.01). Group comparison by Poisson regression analyses showed that the relative risk of bacteraemia in the PD group versus HD group was 0.16 (95% confidence interval, 0.05-0.57, P = 0.005). The significant difference was not affected by the confounders patient age at time of dialysis, male sex, heart failure (NYHA III-IV), diabetes, malignancy and peripheral arterial occlusive disease Stage IV. There were high proportions of hospitalization after the initiation of dialysis in both groups (PD 75.0% and HD 67.3%, P = 0.40). Univariate and multiple regression analyses revealed only age at initiation of dialysis to be significantly associated with overall mortality (P < 0.05). CONCLUSIONS Dialysis modality (PD versus HD) in an acute unplanned dialysis setting showed, in our population, no significant influence on survival. HD patients had a significantly higher risk of bacteraemia, perhaps due to central venous dialysis catheter. PD seems to be a safe and efficient, at least comparable, alternative to HD in acute unplanned dialysis settings.

Peritoneal dialysis relieves clinical symptoms and is well tolerated in patients with refractory heart failure and chronic kidney disease

The aim of the study was to evaluate the efficacy and clinical outcome of peritoneal dialysis (PD) treatment in patients with severe refractory heart failure (HF) and chronic kidney disease (CKD).

Tumor Necrosis Factor-α Gene G-308A Polymorphism Is a Risk Factor for the Development of Membranous Glomerulonephritis

Background: Tumor necrosis factor-α (TNF-α) is a major pro-inflammatory cytokine. Recently, the G-308A polymorphism of the TNF-α gene has been associated with modified gene expression and increased TNF-α production in the -308A allele. We evaluated its influence on the incidence and clinical course of membranous glomerulonephritis. Methods: We studied 53 patients with biopsy-proven primary membranous glomerulonephritis followed up for 5.7 ± 4.9 years. 100 volunteers were analyzed as controls. According to the slope of the curve of reciprocal serum creatinine against time, group A (slow progressors, n = 35) and group B (fast progressors, n = 18) were defined. TNF-α G-308A polymorphism was determined by polymerase chain reaction amplification. Results: The frequency of the A-allele (associated with higher TNF-α levels) was significantly higher in patients than control subjects (patients: G-allele: 0.66, A-allele: 0.34; controls: G-allele 0.85, A-allele 0.15, p < 0.001). Similarly, the genotype distribution differed significantly between our study and control populations (patients: GG-genotype: 41.5%, GA: 49.1%, AA 9.4%; controls: GG: 71%, GA: 27%, AA 2%, p = 0.001). Age, renal function, proteinuria and blood pressure were similar at the time of renal biopsy between patients with different genotypes (NS). There was also a tendency towards an overpresentation of the A-allele in group B indicating a possible impact on the progression of membranous nephropathy, but a significance was not reached. Furthermore, no impact on renal survival in the Kaplan- Meier analysis was detected (NS). Conclusion: Our results suggest that TNF-α gene G-308A polymorphism is a risk factor for the development of membranous glomerulonephritis.

Different Effects of Cyclosporine A and FK506 on Potassium Transport Systems in MDCK Cells

Background: Hyperkalemia and metabolic acidosis are common manifestations in patients receiving the immunosuppressive agent cyclosporine A (CsA) and the recently introduced FK506. We compared the acute toxic and antiproliferative effects as well as the effects on the transport activity of Na⁺/K⁺-ATPase and Na⁺/K⁺/2Cl^– cotransporter of CsA and FK506 in an established cell line of distal/collecting tubule origin (MDCK cells). Methods: MDCK cells were exposed to various concentrations of CsA or FK506 and the effects on cell viability (MTT test and neutral red uptake), plasma membrane integrity (lactate dehydrogenase (LDH) release) and cell proliferation (bromodeoxyuridine (BrdU) incorporation) were compared. For transport studies, after confluence, MDCK cells were exposed to CsA or FK506 for 48 h in the presence and absence of aldosterone. Ouabain- and bumetanide-sensitive ⁸⁶Rubidium uptake measurements were used to study the activity of the Na⁺/K⁺-ATPase and Na⁺/K⁺/2Cl^– cotransporter at the surface of intact cells. Results: After 24 h of exposure CsA reduced the number of viable cells to 50% at 30 µM, whereas for FK506 2–3 times higher concentrations had to be employed. Similarly, LDH release was stimulated tenfold by 30 µM CsA but only fourfold by 70 µM FK506. In contrast, DNA synthesis was affected at lower concentrations of FK506 than of CsA. In cells treated for 24 h BrdU incorporation was significantly inhibited by 3 µM FK506, whereas a similar inhibition required 10 µM CsA. The transport activity of Na⁺/K⁺-ATPase and of Na⁺/K⁺/2Cl^– cotransporter were significantly decreased (37 and 63%, respectively) on CsA administration (8 µM). In CsA-treated cells the K⁺ channel blockers barium (1 mM), TEA (10 mM) and quinine (1 mM) did not further inhibit the transport activities suggesting that CsA might also act via inhibition of K⁺ channels. FK506 at 8 µM had no effect on Na⁺/K⁺-ATPase transport activity but stimulated Na⁺/K⁺/2Cl^– cotransporter activity by 59%. The stimulatory effect was abolished by K⁺ channel blockers indicating that recycling of K⁺ might increase by FK506. The simultaneous presence of aldosterone (5 µM) protected the cells from the inhibitory effect of CsA on Na⁺/K⁺-ATPase and Na⁺/K⁺/2Cl^– cotransporter activity. The stimulatory effect of FK506 on the Na⁺/K⁺/2Cl^–cotransporter activity was completely abolished in the presence of aldosterone. Conclusions: Both CsA and FK506 showed acute toxicity in MDCK cells in vitro with the effects of FK506 being less pronounced. CsA and FK506 had different effects on the in vivo transport rates of the Na⁺/K⁺-ATPase and the Na⁺/K⁺/2Cl^– cotransporter; CsA inhibited the activity of the Na⁺/K⁺-ATPase and the Na⁺/K⁺/2Cl^– cotransporter whereas FK506 stimulated the activity of Na⁺/K⁺/2Cl^– cotransporter. These effects were abolished by the application of aldosterone.

Influence of cytokine genes polymorphisms on long-term outcome in renal transplantation

Abstract:  Background:  Recently, polymorphisms of cytokine genes have been associated with modified gene expression and increased cytokine production. We evaluated the influence of interleukin‐10 (IL‐10) gene G‐1082A, tumour necrosis factor alpha (TNFα) gene G‐308A and IL‐6 gene G‐174C polymorphisms on the rejection rate, renal function and long‐term outcome in renal transplantation.

Influence of interleukin-6 G-174C gene polymorphism on coronary artery disease, cardiovascular complications and mortality in dialysis patients

BACKGROUND Inflammation is a well recognized central component of atherosclerotic processes in chronic kidney disease. Interleukin-6 (IL-6) levels are a strong determinant of cardiovascular mortality in dialysis patients. We evaluated the impact of IL-6 gene G-174C polymorphism associated with modified IL-6 production on the development of coronary artery disease (CAD), cardiovascular events and mortality in chronic dialysis patients. METHODS We studied n = 463 patients on chronic dialysis with angiographically confirmed (n = 218) or excluded (n = 245) CAD followed up for 65 months after initiation of dialysis. Monitored were arterial hypertension, diabetes mellitus, hyperlipidemia, smoking, CRP and fibrinogen. IL-6 gene G-174C polymorphism was determined by PCR amplification. RESULTS The CC genotype was associated with an impaired patient survival (p < 0.05) remaining an independent risk factor for death in multivariate analysis (HR for CC genotype: 3.58, CI: 1.41-9.07, p < 0.01). CC genotype carrying CAD patients suffered significant frequently cardiovascular events (revascularization, myocardial infarction, death) compared to GG/GC genotype carriers (85.2% vs. 66.5, p < 0.05). However, the IL-6 gene G-174C polymorphism was not related to the onset and development of CAD itself (ns) and the inflammation parameters CRP and fibrinogen did not differ between the genotypes under investigation (ns). CONCLUSIONS Our results suggest that IL-6 gene G-174C polymorphism is associated with the incidence of cardiovascular events and mortality in chronic dialysis patients.

Influence of Cytokine Gene Polymorphisms on Focal Segmental Glomerulosclerosis

Background: Recently, polymorphisms of cytokine genes have been associated with modified gene expression and increased cytokine production. We evaluated the influence of TGF-β1 gene Arg25→Pro, TNFα gene G-308A and IL-6 gene G-174C polymorphisms on the clinical manifestations of focal segmental glomerulosclerosis (FSGS). Methods: The clinical course of 71 patients with biopsy-proven primary FSGS followed up for 6.0 ± 4.4 years was studied. Patients were classified according to the slope of reciprocal serum creatinine into slow (n = 49) and fast (n = 22) progressors. One hundred healthy volunteers were analysed as controls. Genetic polymorphisms were determined by PCR amplification. Results: The genotype distribution of the studied polymorphisms was similar in patients and controls (n.s.). Age, initial renal function, proteinuria and blood pressure did not differ significantly between patients with different genotypes (n.s.). The investigated polymorphisms were not associated with the progression of FSGS as shown by the similar genotype frequencies among slow and fast progressors (n.s.) and the renal survival in the Kaplan-Meier analysis (n.s.). Conclusion: Our results indicate that TGF-β1 gene Arg25→Pro, TNFα gene G-308A and IL-6 gene G-174C polymorphisms are not risk factors or markers of progression in focal segmental glomerulosclerosis.

Inzidenz von Risikofaktoren und kardiovaskulären Komplikationen bei Patienten nach Nierentransplantation

Zusammenfassung□ HintergrundKardiovaskuläre Erkrankungen sind die häufigste Todesursache bei Patienten mit terminaler Niereninsuffizienz und nach Nierentransplantation. Ziel dieser Untersuchung war es, die Inzidenz kardiovaskulärer Risikofaktoren und Erkrankungen nach Nierentransplantation zu ermitteln.□ Patienten und MethodenWir untersuchten bei 427 Patienten (Durchschnittsalter 45±12 Jahre, 58% Männer, 7% Diabetiker) die kardiovaskulären Risikofaktoren (Hypertonie, Hyperlipidämie, Nikotinabusus) und kardiovaskuläre Komplikationen (koronare Herzerkrankung, periphere arterielle Verschlußkrankheit, zerebrovakuläre Ischämie) über einen mittleren Nachbeobachtungszeitraum von 28±20 Monaten.□ ErgebnisseDie Prävalenz der arteriellen Hypertonie und des Diabetes mellitus stieg 24 Monate nach Nierentransplantation hochsignifikant an (von 67% vor Nierentransplantation auf 87% nach Nierentransplantation bzw. von 7% auf 16%, jeweils p<0,001). Dagegen reduzierte sich der Prozentsatz der Raucher 24 Monate nach Nierentransplantation um die Hälfte auf 20% (p<0,001). Die Triglyceride fielen nach Nierentransplantation signifikant ab (von 235±144 mg/dl vor Nierentransplantation auf 217±122 mg/dl nach Nierentransplantation, p<0,05). Das Gesamtcholesterin und HDL-Cholesterin stiegen signifikant an (von 235±65 mg/dl vor Nierentransplantation auf 273±62 mg/dl nach Nierentransplantation bzw. 47±29 mg/dl vor Nierentransplantation auf 56±21 mg/dl nach Nierentransplantation, p<0,05). Es kam zu einem geringfügigen Anstieg des LDL-Cholesterins von 180±62 mg/dl vor Nierentransplantation auf 189±53 mg/dl nach Nierentransplantation (nicht signifikant). Nach Nierentransplantation entwickelten 11,7% der Patienten kardiovaskuläre Komplikationen (hauptsächlich koronare Herzerkrankung mit 9,8%). Diese waren in der univariaten Analyse signifikant assoziiert mit männlichem Geschlecht (p<0,05), Alter über 50 Jahre (p<0,001), Diabetes mellitus (p<0,001), Nikotinkonsum (p<0,05), Gesamtcholesterin > 200 mg/dl (p <0,05), LDL-Cholesterin >180 mg/dl (p<0,01), HDL<55 mg/dl (p<0,05), Fibrinogenspiegel > 350 mg/dl (p<0,05) und Körpermasseindex >25 kg/m2 (p<0,01). In der Proportional-Hazards-Regressionsanalyse nach Cox erwiesen sich Diabetes mellitus (relatives Risiko [RR]=4,3), Lebensalter über 50 Jahre (RR=2,7), Körpermasseindex über 25 kg/m2 (RR=2,6), Nikotinkonsum (RR=2,5) und LDL-Cholesterin über 180 mg/dl (RR=2,3) als signifikante eigenständige Risikoprädiktoren für kardiovaskuläre Erkrankungen nach Nierentransplantation.□ SchlußfolgerungKardiovaskuläre Komplikationen nach Nierentransplantation waren signifikant mit dem kardiovaskulären Risikoprofil und dem Alter > 50 Jahre assoziiert. Zukünftige prospektive Studien müssen den Erfolg einer frühzeitigen Behandlung der kardiovaskulären Risikofaktoren (optimale Blutdruckeinstellung, Therapie der Hypercholesterinämie, Nikotinabstinenz) bei Patienten mit chronischer Niereninsuffizienz auf die kardiovaskuläre Morbidität und Mortalität untersuchen.Abstract□ BackgroundCardiovascular disease is a leading cause of death after renal transplantation (RTx), and the incidence is considerably higher than in the general population. Aim of this study was to evaluate the incidence of atherosclerotic cardiovascular complications after RTx, the prevalence of cardiovascular risk factors, prior to and following RTx, and the association between the risk factors and complications.□ Patients and MethodsAnalysis of atherosclerotic cardiovascular diseases (coronary artery disease, cerebral and peripheral vascular disease) and cardiovascular risk factors before and after transplantation in 427 renal transplant recipients between 1987 and 1992 (mean age at transplantation 45±12 years, 58% male, 7% diabetics) with a mean posttransplant follow-up of 28±20 months.□ ResultsFollowing RTx11.7% developed atherosclerotic cardiovascular diseases, the majority coronary artery disease (9.8%). The comparison of risk factors 12 months before and 24 months following transplantation showed: The prevalence of systemic hypertension (from 67% to 86%), diabetes mellitus (from 7% to 16%) and obesity with a body mass index > 25 kg/m2 (from 26% to 48%) had increased significantly whereas the number of smokers halved to 20%. The triglycerides decreased significantly (from 235±144 mg/dl to 217±122 mg/dl). The total and HDL cholesterol rose significantly (from 232±65 mg/dl to 273±62 mg/dl and from 47±29 mg/dl to 56±21 mg/dl, respectively). The LDL cholesterol increase was insignificant (from 180±62 mg/dl to 189±53 mg/dl). In the univariate analysis, cardiovascular diseases were significantly associated with male gender, age over 50 years, diabetes mellitus (DM), smoking, total cholesterol > 200 mg/dl, LDL cholesterol > 180 mg/dl, HDL cholesterol < 55 mg/dl, fibrinogen > 350 mg/dl, body mass index > 25 kg/m2, and more than 2 antihypertensive agents per day. The Cox proportional hazards model revealed DM with a relative risk (RR) of 4.3, age > 50 years (RR=2.7), body mass index > 25 kg/m2 (RR=2.6), smoking (RR=2.5), and LDL cholesterol > 180 mg/dl (RR=2.3) as independent risk factors.□ ConclusionsThe high incidence of cardiovascular disease following renal transplantation is mainly due to a high prevalence and accumulation of classical risk factors before and following transplantation. The treatment of the risk factors must be effective and introduced early in the course of renal failure, further, they must be continued following transplantation. Future prospective studies should evaluate the success of treatment regarding reduction of cardiovascular morbidity and mortality in this high risk population.BACKGROUND Cardiovascular disease is a leading cause of death after renal transplantation (RTx), and the incidence is considerably higher than in the general population. Aim of this study was to evaluate the incidence of atherosclerotic cardiovascular complications after RTx, the prevalence of cardiovascular risk factors, prior to and following RTx, and the association between the risk factors and complications. PATIENTS AND METHODS Analysis of atherosclerotic cardiovascular diseases (coronary artery disease, cerebral and peripheral vascular disease) and cardiovascular risk factors before and after transplantation in 427 renal transplant recipients between 1987 and 1992 (mean age at transplantation 45 +/- 12 years, 58% male, 7% diabetics) with a mean posttransplant follow-up of 28 +/- 20 months. RESULTS Following RTx 11.7% developed atherosclerotic cardiovascular diseases, the majority coronary artery disease (9.8%). The comparison of risk factors 12 months before and 24 months following transplantation showed: The prevalence of systemic hypertension (from 67% to 86%), diabetes mellitus (from 7% to 16%) and obesity with a body mass index > 25 kg/m2 (from 26% to 48%) had increased significantly whereas the number of smokers halved to 20%. The triglycerides decreased significantly (from 235 +/- 144 mg/dl to 217 +/- 122 mg/dl). The total and HDL cholesterol rose significantly (from 232 +/- 65 mg/dl to 273 +/- 62 mg/dl and from 47 +/- 29 mg/dl to 56 +/- 21 mg/dl, respectively). The LDL cholesterol increase was insignificant (from 180 +/- 62 mg/dl to 189 +/- 53 mg/dl). In the univariate analysis, cardiovascular diseases were significantly associated with male gender, age over 50 years, diabetes mellitus (DM), smoking, total cholesterol > 200 mg/dl, LDL cholesterol > 180 mg/dl, HDL cholesterol < 55 mg/dl, fibrinogen > 350 mg/dl, body mass index > 25 kg/m2, and more than 2 antihypertensive agents per day. The Cox proportional hazards model revealed DM with a relative risk (RR) of 4.3, age > 50 years (RR = 2.7), body mass index > 25 kg/m2 (RR = 2.6), smoking (RR = 2.5), and LDL cholesterol > 180 mg/dl (RR = 2.3) as independent risk factors. CONCLUSIONS The high incidence of cardiovascular disease following renal transplantation is mainly due to a high prevalence and accumulation of classical risk factors before and following transplantation. The treatment of the risk factors must be effective and introduced early in the course of renal failure, further, they must be continued following transplantation. Future prospective studies should evaluate the success of treatment regarding reduction of cardiovascular morbidity and mortality in this high risk population.

Akutes Nierenversagen bei Hantavirusinfektionen

ZusammenfassungHintergrund: Das akute Nierenversagen bleibt in der Klinik eine differentialdiagnostische Herausforderung. Falldarstellungen: Zwischen 1991 und 1996 konnte bei vier vormals gesunden männlichen Patienten im Alter von 29 bis 50 Jahren immunserologisch eine Hantavirusinfektion als Ursache des akuten Nierenversagens gesichert werden. Leitsymptome der Patienten bestanden aus Fieber, Kopfschmerzen, Arthralgien, lumbalen und abdominellen Schmerzen sowie Diureserückgang bis Anurie. Sonographisch zeigte sich bei zwei Patienten eine diskrete Splenomegalie. Klinisch-chemisch bestanden erhöhte Nierenretentionswerte (Kreatinin von 2,2 mg/dl bis 6,7 mg/dl) und eine Thrombozytopenie von 4000 bis 150 000/μl. Die Urinuntersuchung ergab eine milde Proteinurie und Mikrohämaturie. Bioptisch zeigte sich bei einem Patienten ein diffuser Tubulusschaden der Nierenrinde. Bei drei Patienten normalisierten sich die pathologischen Befunde innerhalb von etwa drei Wochen ohne Dialysepflichtigkeit. Ein Patient entwickelte einen schweren Krankheitsverlauf mit akutem Nierenversagen und Lungenödem mit Dialysepflichtigkeit für drei Wochen. In allen Fällen kam es zu einer Verbesserung der Nierenfunktion. Schlußfolgerung: Bei akutem Nierenversagen unbekannter Ätiologie, das mit Fieber, Arthralgien, transienter Oligurie, Proteinurie, Mikrohämaturie und insbesondere zusätzlichen lumbalen und abdominellen Schmerzen sowie Thrombopenie einhergeht, muß differentialdiagnostisch eine Hantavirusinfektion berücksichtigt werden.AbstractBackground: The acute renal failure remains a diagnostic challenge for the clinician. Case Reports: Between 1991 and 1996, acute renal failure caused by hantavirus infection was diagnosed in 4 previously healthy male patients. Main symptoms consisted of fever, headache, arthralgia, lumbar and abdominal pain as well as a decline in diuresis. The ultrasonography showed a slight splenomegaly in 2 patients. The clinical chemistry showed elevated serum creatinine from 2.2 mg/dl to 6.7 mg/dl and thrombocytopenia from 4000 to 150 000/μl. The examination of the urine showed slight proteinuria and microhematuria. The kidney biopsy of 1 patient showed a reversible damage of the tubuli. The pathologic findings normalized within 3 weeks in 3 patients without need for dialysis. One patient developed a severe clinical course with acute renal failure and pulmonary edema requiring dialysis. In all patients, the renal function improved. Conclusion: Hantavirus infection should be considered in acute renal failure of unknown origin accompanied by fever, arthralgia, lumbar and abdominal pain and thrombocytopenia.