Wolfgang Pommer

Regular Analgesic Intake and the Risk of End-Stage Renal Failure

The strength of the association between regular analgesic intake (RAI) and end-stage renal failure (EF) has been insufficiently established until now. A case-control study was conducted to estimate the relative risks (RR) of EF after RAI (defined as consumption of 15 or more analgesic doses per month for a continuous period of at least 1 year) for cumulative drug intake, single-ingredient analgesics, combinations, and specific compounds. The case group included all patients with EF undergoing renal replacement therapy in the area of West Berlin (1984-1986, n = 921). Control subjects, matched to cases by sex, age, and nationality, were selected from a group of patients in outpatient clinics. Matching was possible for 517 cases. The RR of EF after RAI of any analgesic was 2.44 (95% confidence interval: 1.77-3.39) and after RAI of combination drugs 2.65 (95% confidence interval 1.91-3.67). No significant increase was found, however, after RAI of single-ingredient analgesics. The RR after RAI of combination drugs and for the most preferred analgesic ingredients (phenacetin, paracetamol, acetylsalicylic acid, phenazones, caffeine) increased with dose. Furthermore, a dose-time-related RR after RAI of the longest used preparation was found. Thus, the results clearly show an increased RR of EF after RAI related to both dose and exposure time of mixed analgesic compounds, but not for the use of only single-ingredient analgesics.

Outcome of patients with ventricular assist devices and acute renal failure requiring renal replacement therapy.

The significance of acute renal failure (ARF) for patients treated with a ventricular assist device (VAD) is uncertain. There is little information on the outcome of patients who require renal replacement therapy during treatment with a VAD. A retrospective review was undertaken to evaluate the impact of renal failure requiring renal replacement therapy on such patients. Studied were 227 patients who were supplied with a VAD at the German Heart Institute Berlin. Fifty-five patients required renal replacement therapy during treatment with a VAD. These were compared with patients not needing renal replacement therapy (ARF and non-ARF groups). Significant differences for the end points of survival, heart transplantation, and discharge from hospital were observed in patients with ARF (p < 0.01). Survival was then analyzed according to indications for treatment with a VAD (bridge to transplantation or cardiac recovery after cardiotomy, transplantation, myocardial infarction, myocarditis, and endocarditis). Survival for bridge-to-transplantation patients was clearly influenced in a negative way by ARF (p < 0.01). For cardiac recovery patients, only a small difference in survival was observed (p = 0.05). We conclude that ARF is a negative predictor for bridge-to-transplantation patients. For cardiac recovery patients the impact of ARF on survival is marginally significant.

Membrane plasma exchange in Goodpasture's syndrome.

We report two cases with Goodpastures syndrome successfully treated by membrane plasma exchange. In both patients, pulmonary infiltrations and hemoptysis had already resolved after the first pulse methylprednisolone dose (1000 mg IV). Following plasma exchange, renal function did not further deteriorate in one patient and returned to normal in the other patient. From the clinical course of our patients and a review of the literature, we conclude that membrane plasma exchange is effective in preventing deterioration of renal function in Goodpastures syndrome. Analysis of the literature shows that patients who respond to plasma exchange have significantly fewer crescents and lower plasma creatinine, while non-responders are more often oliguric or anuric and require dialysis at the time of plasma exchange.

Acute interstitial nephritis and non-oliguric renal failure after cefaclor treatment

SummaryA case of acute interstitial nephritis (AIN) developing after cefaclor treatment is reported. Diagnosis was proofed by kidney biopsy and lymphocyte transformation test. The clinical course of the patient with non-oliguric renal failure was favourable. Four weeks after discontinuation of cefaclor treatment the renal function was completely restored and remained stable over the ten-month follow-up period. It is concluded that cefaclor can cause hyperallergic AIN and acute renal failure.

Mortality risk in hemodialysis patients with increased arterial stiffness is reduced by attainment of classical clinical performance measures.

Background: We determined whether attainment of classical clinical performance measures for hemodialysis care improves survival in hemodialysis patients with increased arterial stiffness. Methods: We performed a prospective cohort study of 538 hemodialysis patients with a median follow-up of 19 months (interquartile range 8–30). Arterial stiffness was measured using applanation tonometry. Clinical performance measure targets were hemoglobin value ≥110 g/l, serum albumin value ≥37 g/l and measured single-pool Kt/V urea value ≥1.2. Results: During follow-up, 217 patients (40%) died. In non-survivors, arterial stiffness of large arteries (S1) was significantly higher compared with survivors (p = 0.0002). An analysis of hemodialysis patients who were alive 18 months after inclusion into the study showed that survival was significantly longer in those patients that met ≥2 clinical performance measure targets compared with patients that met ≤1 target (χ2 4.13; p = 0.04). Better attainment of classical clinical performance measures showed a 54% mortality risk reduction. Conclusion: S1 predicted mortality in hemodialysis patients. However, better attainment of classical clinical performance measures significantly improved long-term outcome in hemodialysis patients despite their pronounced increase in arterial stiffness.

Akutes Nierenversagen bei sekundärer renaler Oxalose

Bei einer 35jahrigen Patientin entwickelte sich nach der chirurgischen Behandlung eines Pankreasabszesses ein langsam progredientes akutes Nierenversagen. Wegen des untypischen Verlaufs wurde eine Nierenbiopsie vorgenommen; es fand sich eine schwere obstruktive renale Oxalose mit begleitender interstitieller Nephritis. Eine primare Oxalose wurde durch Bestimmung von Glycerat und Glycolat im Urin ausgeschlossen. Da andere Ursachen fur eine gesteigerte Oxalatbildung nicht vorlagen, wurde ein ursachlicher Zusammenhang mit der parenteralen Zufuhr von Xylit angenommen. Diesen Glukoseaustauschstoff hatte die Patientin wahrend einer totalen parenteralen Ernahrung uber 4 Wochen in einer Dosis von 3,0 g/kg/Tag (Gesamtdosis 4480 g) erhalten. Unter Hinweis auf vorangegangene autoptische Untersuchungen und jungste experimentelle Untersuchungen uber die metabolischen Schritte vom Xylit zum Oxalat werden die Moglichkeiten und Bedingungen fur eine vermehrte Bildung und Ablagerung von Oxalat nach Zufuhr von Xylit diskutiert.

Das akute Nierenversagen bei älteren Patienten – entscheidend für die Gesamtmortalität?

Acute kidney injury (AKI) in the elderly is associated with high risks of chronic kidney disease (CKD), hospital- and all-cause mortality. Based on the decreased renal function in older age groups and age-specific co-morbidity as hypertension, cardiovascular complications, and diabetes mellitus, the risk for AKI is increased. In outpatients inadequate pharmacotherapy and self-medication contribute to increased risk of AKI while in hospital settings severe infection, cardiovascular interventions with contrast media and major surgery may result in higher rates of AKI. Every fourth case is on risk for recurrent AKI followed by advanced CKD and renal replacement therapy. In the oldest old with high co-morbidity condition indication of renal replacement in AKI should be processed by shared-decision making. In many cases palliative care in this setting may be appropriate.

Der Wert der Nierenbiopsie in der primären anurischen Phase bei allogenen Nierentransplantaten

Die primare Anurie in der fruhen postoperativen Phase nach Nierentransplantation ist eine relativ haufige Komplikation. Die Ursachen dafur konnen prarenal (Nierenarterien/-venenthrombose), intrarenal (akutes Nierenversagen, akute oder perakute Abstosung, Spontanruptur) oder post renal (Abflushindernisse unterschiedlicher Art) liegen.