Strategien der altersadäquaten Pharmakotherapie bei Niereninsuffizienz

Many geriatric patients with multimorbidities have an increased risk for impaired renal function due to age and often the presence of comorbidities, such as diabetes mellitus, hypertension and heart failure. This impairment in kidney function in turn necessitates adjustments in drug therapy. A successful strategy for treating these patients includes treatment of the underlying diseases, a comprehensive review of the indications, selection of appropriate pharmacotherapeutic alternatives and for some drugs dose adjustment to the renal function. To achieve therapeutic success many patient individual factors, such as potentially complex medication regimens, polypharmacy, cognitive function and functional disabilities need to be considered when prescribing medications. This article describes the problems associated with drug therapy that is not adjusted to renal function and provides guidelines for assessment of the benefits and risks in patients with kidney failure. The characteristic features of geriatric patients in particular are considered and discussed.     

Sekund?re Pr?vention bei fortgeschrittener Niereninsuffizienz

Dialysis treatment within the framework of the statutory healthcare insurance also encompasses medical measures for prevention of terminal or chronic renal failure. In patients who have an increased risk for development of chronic progressive renal disease, terminal renal failure can be avoided or at least delayed for as long as possible by a so-called consultative cooperation between the treating (general) physician and a qualified nephrologist. In the Federal covering agreement the definition of affected patient groups and the structuring of medical measures for prevention of terminal renal failure could be specified.     

Therapie der Hyperkalzämie mit Ibandronat bei akuter Niereninsuffizienz

Hypercalcaemia is a common complication of malignancies associated with bone destruction. Besides, benign diseases as sarcoidosis or hyperparathyroidism may lead to hypercalcaemia. The main principles of modern therapy contain a forced diuresis as well as the application of bisphosphonates. Latter substances bear the danger of developing a renal insufficiency. Here, we report the case of a female patient, suffering from primary hyperparathyroidism with severe hypercalcaemia and calcium levels up to 6 mmol/l, who developed acute renal failure. We treated the patient with forced diuresis and repeated infusions of ibandronate (5 x 6 mg ibandronate). Even if lowering the serum levels of calcium only for a short time after each application, yet we could improve renal function by these means. Only after performing a parathyroidectomy, we could see a sustained decline of calcium levels. This case report supports the results of other publications, that have reported the missing nephrotoxic effect of ibandronate compared to other bisphosphonates.     

Schulterendoprothetik bei prim?ren Synovialkrankheiten

Shoulder arthroplasty has become an essential component of the standard surgical repertoire for the treatment of severe primary and secondary glenohumeral arthritis and has been shown to provide reliable long-term pain relief with satisfactory functional results. In most cases, in particular in patients with rheumatoid arthritis (RA), the indications for arthroplasty are primarily based on pain, which often includes severe pain at rest. Despite poor bone stock and impaired soft tissue quality in RA which frequently results in massive, irreparable rotator cuff tears, shoulder arthroplasty has been shown to be an effective means of improving shoulder function. Several different types of prostheses are now available for different indications determined by age, functional demand, etiology and structural deficits. For optimal outcome, the most suitable type of prosthesis needs to be selected by an experienced shoulder surgeon who is familiar with the entire spectrum of treatment options.     

Kardiovaskuläre Kalzifikationen bei Niereninsuffizienz

Uremic vascular calcification is still a major challenge in nephrology. Cardiovascular complications contribute substantially to morbidity and mortality of patients with renal replacement therapy. Understanding the development of vascular calcification and enabling the reliable identification of patients at high risk for cardiovascular complications as well as the development of new therapeutic options are of utmost importance. The traditional view of the development of vascular calcification as a passive process has been challenged since results emerged supporting an active, cell-driven pathomechanistic process instead. This review gives an update on the current hypotheses on the development of vascular calcification and a summary of the latest results. In addition new therapeutic strategies for tackling vascular calcification will be discussed.     

Hyperkalz?mie und Niereninsuffizienz bei einem 52-j?hrigem Mann

We report a 52-year-old patient admitted with a diagnosis of renal impairment and hypercalcaemia. The parathyroid hormone (PTH) was suppressed, PTH-related peptide levels not elevated, and 1.25 vitamin D3 was within normal range. Levels of angiotensin-converting enzyme and soluble interleukin-2 receptor were significantly raised. Extensive diagnostic workup did not yield results satisfactory for a definite diagnosis. Finally a renal biopsy showed epithelioid cell granuloma and light-to-moderate nephrocalcinosis. We made the diagnosis of isolated renal sarcoidosis. Therapy with systemic steroids was followed by rapid normalisation of serum calcium and renal function. Unusual in this case was the diagnosis of isolated renal sarcoidosis combined with normal levels of 1.25 vitamin D3 in the presence of severe hypercalcaemia.     

Echokardiographische On-line-Quantifizierung der linksventrikul?ren systolischen Funktion bei Kindern: Vergleich mit der konventionellen off-line-Bestimmung

In einer prospektiven Studie wurde der klinische Stellenwert der auf automatischer Konturerkennung beruhenden Methode der „Akustischen Quantifizierung“ (AQ) untersucht. Dazu wurden echokardiographisch linksventrikul?re Volumina und Ejektionsfraktion on-line bestimmt und mit den entsprechenden konventionell (manuell) off-line ermittelten Daten verglichen.    107 S?uglinge, Kinder und Jugendliche zwischen 0,1 und 18 Jahren wurden in die Studie einbezogen. Sowohl für AQ als auch für die manuelle off-line-Bestimmung wurde im apikalen Vierkammerblick untersucht. Die linksventrikul?ren Volumina wurden monoplan mit der „Method of discs“ (SIMPSON-Regel) bestimmt. Obwohl niedriger bestimmt, korrelierten die mit der AQ-Methode ermittelten enddiastolischen Volumina mit den manuell bestimmten Volumina (r=0,99). Die mit den beiden Methoden ermittelten endsystolischen Volumina (ESV) des linken Ventrikels wiesen ebenfalls eine gute Korrelation (r=0,98) auf, wobei das mit AQ bestimmte ESV etwas niedriger war. Die mittlere Ejektionsfraktion wurde mit 61,1±6,8% durch AQ und mit 61,5±5,9% manuell bestimmt; lineare Regressionen erbrachten eine gute Korrelation: y=0,77 x±14,1; r=0,89; p<0,001.    Die Bestimmung linksventrikul?rer Volumina und der aus den Volumina abgeleiteten Ejektionsfraktion durch AQ führt zu Ergebnissen, die mit den manuell bestimmten Parametern durchaus vergleichbar sind. Allerdings führt die AQ-Methode zu einer gewissen Untersch?tzung. Die für die Datenacquisition erforderliche Zeit ist bei beiden Methoden nahezu gleich. AQ stellt sich auch für die P?diatrie als eine prinzipiell funktionierende Methode bei der real-time-Bestimmung linksventrikul?rer Volumina dar.     

Die Bedeutung der alkalischen Leukozytenphosphatase bei retikulären und lymphatischen Systemkrankheiten und bei der Lymphogranulomatose

Zusammenfassung An 29 Patienten mit Lymphogranulomatose, 16 Kranken mit malignem Wachstum des Retikuloendothels und 9 an chronischer Lymphadenose Erkrankten wurden Bestimmungen der alkalischen Leukozytenphosphatase unter Verwendung der Azo-Kupplungsmethode vorgenommen.Wegen der starken Streuung der alkalischen Leukozytenphosphatase bei der Lymphogranulomatose und bei den retikulären Systemkrankheiten ist differentialdiagnostisch eine Abgrenzung von der chronischen Lymphadenose und wahrscheinlich auch vom Lymphosarkom nur bedingt möglich. Bei einer niedrigen Fermentaktivität kann zwischen einer chronischen Lymphadenose, dem Lymphosarkom, dem Morbus Hodgkin und einer malignen Retikulose im weiteren Sinne nicht unterschieden werden. Andererseits muß beim Vorliegen eines hohen Phosphatasegehaltes die Diagnose zwischen einer Lymphogranulomatose und einer essentiellen Proliferation des Retikuloendothels offen bleiben. Innerhalb der, Gruppe der retikulären Systemkrankheiten zeigen die eigentliche maligne Retikulose und das Plasmozytom, möglicherweise auch das Retothelsarkom, erhebliche Schwankungen des Phosphatasetests. Ist die Differentialdiagnose eingeengt auf eine akute Myelose oder eine maligne leukaemische Retikulose, so rechtfertigt ein hoher Gehalt der neutrophilen Granulozyten an alkalischer Phosphatase die Entscheidung zugunsten der Retikulose.Vergleichende Untersuchungen der alkalischen Leukozytenphosphatase mit dem Absolutwert der Neutrophilen im peripheren Blut und der Blutsenkung eröffnen Einblicke in die Leukozytenfunktion. Die sich hieraus ergebenden Konsequenzen werden diskutiert.

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Summary Using the azo-coupling method, alkaline leucocyte phosphatase has been measured in 29 patients with lymphogranuloma, 16 with malignant growth of the reticulo-endothelial system and 9 with lymphadenosis.Because of the wide scatter of alkaline leucocyte phosphatase values in lymphogranuloma and diseases of the reticular system, it is possible to diagnostically differentiate between these and lymphadenosis and probably also lymphosarcoma only under, certain conditions. At low enzymic activities, it is not possible to distinguish between chronic lymphadenosis, lymphosarcoma, lymphogranuloma and general malignant reticuloma. On the other hand, at high phosphatase levels, diagnosis between lymphogranuloma and an essential proliferation of the reticulo-endothelial system is certain. Within the family of diseases of the reticulo-endothelial system, the phosphatase test shows large variations in activity between malignant reticuloma and plasmacytoma and possibly reticulosarcoma. If the differential diagnosis is narrowed down to acute myeloma or a malignant reticuloma, a higher alkaline phosphatase content in the neutrophilic granulocytes confirms the reticuloma.Comparison of the alkaline leucocyte phosphatase with the absolute value for neutrophils in peripheral blood and during hypostasis, gives an indication of leucocyte function. The consequences of this are discussed.

     

Dialysebedürftige Niereninsuffizienz bei alten Patienten

The initiation of dialysis is often not reasonable in very old patients with high comorbidities. This is especially true for patients who are geriatrically described as frail and show cognitive and executive function deficits. For estimation of the impairments, scores and standardized tests are more suitable than clinical experience or the surprise question. During the clarification for geriatric patients about the imminent need for dialysis, in addition to the options of various dialysis procedures the option of conservative treatment should also be discussed. In no way should all geriatric patients be given false hopes and the prospect that after beginning dialysis the health-related problems will be drastically improved. This is only the case with very few patients. Often only a stabilization of the condition can be achieved. In the case of conservative treatment an intensive orientation to the symptoms is more important than treatment to avoid delayed sequelae of dialysis. Inclusion in the palliative medicine network seems to be advisable. Initiation of dialysis treatment should be carried out by onset of uremia or other complications. A premature initiation of dialysis treatment is not meaningful in geriatric patients; however, there seems to be no doubt that dialysis in relatively healthy geriatric patients increases the survival rate. Focusing on symptom control and quality of life should be given priority in geriatric patients. A rehabilitation treatment before or after starting dialysis can possibly contribute to stabilization.     

Das Verhalten der Elektrolyte im extrazellulären Medium bei der Stauungsherzinsuffizienz

Ohne ZusammenfassungMit 5 Tabellen     

Progrediente Niereninsuffizienz und Proteinurie bei einem 74-j?hrigen Patienten

This case example of a 74-year-old patient with limited kidney function in stage 3 according to KDOQI (Kidney Disease Outcomes Quality Initiative) and proteinuria admitted for in-patient renal biopsy, describes the anamnesis, the clinical findings and the primary diagnostics. In the subsequent diagnostics the kidney biopsy supplied the first evidence of the presence of infiltration of the kidneys by a low malignancy non-Hodgkin B-cell lymphoma which was confirmed by iliac crest biopsy, computed tomography and hematological tests.     

Pr?vention der vaskul?ren Demenz

During recent years, increasing knowledge has been obtained from clinical studies about the impact that vascular factors have on cognitive function and dementia. Due to demographic reasons and still insufficient control of all vascular risk factors, dementia and associated problems are of increasing importance and will have impact on economical and social development in most countries. The incidence of cognitive impairment and dementia will increase exponentially. As long as no causal therapy for dementia exists, diagnosis and control of risk factors for dementia will need much more attention. Hypertension is not only the most important risk factor for stroke that often leads to dementia but also for silent brain infarcts, which are also associated with onset of dementia. Uncontrolled hypertension is associated with cognitive impairment and sufficient control of hypertension in middle-aged patients can reduce the risk of dementia in older ages. Nevertheless, treatment of all other risk factors (e.g., diabetes mellitus, hyperlipidemia, atrial fibrillation) is important to reduce the onset of not only vascular but also Alzheimer dementia.