[Skin necrosis in the front foot area during anticoagulation with phenprocoumon]

HISTORY AND ADMISSION FINDINGS

A 52-year-old woman was admitted because of pain for several days in the lower left leg and increasing pretibial swelling with livid discoloration. Six months before she had undergone a bilateral adnexectomy with removal of the omentum and subsequent chemotherapy for ovarian cancer.

INVESTIGATIONS

Duplex sonography on the day of admission revealed thrombosis of the left popliteal vein with an unobstructed femoral vein. Both the quick value (89%) and partial thromboplastin time (PTT, 35.9 s) were within normal limits. Computed tomography and sonography were highly suspicious of a local recurrence of the ovarian cancer with peritoneal carcinomatosis.

TREATMENT AND COURSE

PTT-effective heparinization (heparin-Na) was initiated together with overlapping anticoagulation with phenprocoumon (thromboplastin time 20-30%). On the 9th day after starting phenprocoumon painful, black necrotic changes began to appear on the skin of the left first to fourth toes. Assuming these to be due to phenprocoumon, anticoagulation was switched to low-molecular heparin (Enoxaparin), and antithrombin III and protein C were administered. A few days later thrombosis of the right iliac vein occurred, probably caused by local recurrence of the ovarian cancer. No palliative chemotherapy was undertaken in view of the thrombotic complications. The patient died a few months later from the cancer.

CONCLUSION

If there is an underlying malignancy, chemotherapy and therapeutic vitamin-K antagonism in the presence of thromboembolic complications increases the risk of lowering protein C activity and may cause the rare complication of skin necrosis, induced by phenprocoumon.

Contact allergy to cosmetics: testing with patients' own products

In a 2-year period, 1527 patients with contact dermatitis were investigated in the patch-test clinic. In 531 patients, allergy to cosmetics was suspected from the history and they were tested with their own cosmetic products. 40 (7.5%) (of the 531 patients) had 1 or more positive reactions, 82 (15.4%) had doubtfully positive reaction(s) and 31 (5.8%) had irritant reaction(s). Skin-care products were tested most frequently and were also found to cause most positive, doubtfully positive and irritant reactions, 80% of the patients with positive reactions to their own products had no history of contact dermatitis prior to the presenting attack, and in 92.5% of the cases, the positive reaction was considered relevant or partly relevant. In patients with a positive reaction, ingredients that could be responsible were found in 60% of the cases by testing with the European standard series and a series of common cosmetic ingredients. Fragrance mix and formaldehyde were found to be the ingredients most often responsible and were significantly more frequent in patients with positive reactions to their own products, compared to a control group of eczema patients also seen in the patch-test clinic.

Comparison between 2 test models in evaluating the effect of a moisturizer on irritated human skin

The purpose of the present study was to compare 2 experimental models of moisturizer efficacy on the recovery of irritated skin on the hands and the volar forearms. 12 healthy volunteers had their hands immersed in sodium lauryl sulfate (SLS) 10 min 2x daily for 2 days, and at the same time the volunteers had patch tests with SLS (0.125%, 0.25% and 0.5%) applied on their forearms for 24 h. After irritation of the skin, the volunteers had a moisturizer applied on one arm/hand 3x daily for the following 9 days. The other arm/hand served as untreated control. Evaluation was done on days (D) 1, 3, 5, 8 and 12 by transepidermal water loss, electrical capacitance, laser Doppler flowmetry and DermaSpectrometry. Both models were found useful, and the moisturizer was found to accelerate regeneration of the skin barrier function in both the hands (D8, p<0.05) and the volar forearms (0.5% SLS, D5 and D8, p<0.01). When the forearm model is used in the present set-up, a relatively high concentration of SLS (>0.25%) should be used and evaluation measurements are best performed on D5-D8. The forearm model proved reliable and easy to handle and we suggest that this model is used in future studies on moisturizer evaluation.

[Investigation of malignant melanoma in an "open house" setting]

Individuals with a self-evaluated risk of malignant melanoma were invited to an "open house" where trained dermatologists examined suspected lesions. The attendants filled in a short questionnaire relating to skin cancer risk factors. Persons with skin changes suspected for malignancy were referred for excision in the dermatological department. The clinical evaluation included dermatoscopy. Nine hundred and eleven individuals attended. Among 16 individuals referred for excision one malignant melanoma, one lentigo maligna melanoma and two in situ melanomas were histologically verified. Furthermore, 21 basal cell carcinomas were identified clinically. The most frequent clinical diagnoses were melanocytic naevi and seborrhoic keratoses.

Paraneoplastic pemphigus with fatal pulmonary involvement in a woman with a mesenteric Castleman tumour

A 42-year-old woman presented with oral and labial erosions, conjunctivitis, facial rash and lichenoid erythematous papules on the trunk. Paraneoplastic pemphigus (PNP) was suspected, and a search for a neoplasm revealed an intra-abdominal Castleman tumour sized 7 x 5 x 6 cm. After removal of the Castleman tumour, the skin and mucosal inflammation gradually subsided over the next 12 months. However, due to irreversible pulmonary involvement the patient died of intractable respiratory distress 2 years after the onset of the disease. Systemic corticosteroids, azathioprine, cyclophosphamide, high-dose intravenous immunoglobulins and thalidomide were ineffective. The diagnosis of PNP was confirmed by keratinocyte antigen immunoprecipitation with the patient's serum.

Effect of long-term use of moisturizer on skin hydration, barrier function and susceptibility to irritants

Moisturizers are often used in the prevention and treatment of irritant contact dermatitis. The present study was to determine whether long-term daily use of a moisturizer on normal skin would affect skin barrier function, hydration state, or susceptibility to sodium lauryl sulphate. Healthy volunteers used a moisturizer on one forearm 3 times daily for 4 weeks. The other forearm served as a control. Afterwards both forearms were challenged with a patch-test of sodium lauryl sulphate. Skin barrier function was evaluated by measuring trans-epidermal water loss and skin hydration by measuring electrical capacitance. Electrical capacitance was significantly increased on the treated arm during the treatment period. After challenge with sodium lauryl sulphate, transepidermal water loss was significantly higher on the arm treated with moisturizer than on the control arm. The results suggest that long-term treatment with moisturizers on normal skin may increase skin susceptibility to irritants.

High glucose increases prostaglandin E2 synthesis in human peritoneal mesothelial cells: role of hyperosmolarity

Peritoneal mesothelial cells are considered the predominant source of peritoneal prostanoid formation because they represent the largest resident cell population in the peritoneal cavity. The present study was designed to evaluate the effect of D-glucose, which is widely used in commercially available peritoneal dialysis fluids as an osmotic compound, on the synthesis of prostaglandins in cultured human mesothelial cells (HMC). Analysis of eicosanoid synthesis in HMC by reversed-phase HPLC revealed that 6-keto-PGF1alpha, the spontaneous hydrolysis product of prostacyclin (PGI2), and prostaglandin E2 (PGE2) were the main eicosanoids produced. Addition of D-glucose resulted in a time- and concentration-dependent (30 to 120 mM) increase in PGE2 production in HMC (24 h, 90 mM: 3.9+/-0.5 ng/10(5) cells versus 2.3+/-0.3 in untreated cells; P < 0.05). Mannitol (90 mM) or L-glucose (90 mM). nonmetabolizable osmotic compounds, also led to a significant (P < 0.05) but less intense increase in PGE2 synthesis (3.3+/-0.4 and 3.2+/-0.5 ng/10(5) cells, respectively). Increased PGE2 synthesis was completely blunted by coincubation with the specific protein kinase C (PKC) inhibitor Ro 31-8220 or downregulation of PKC activity by preincubation with phorbol myristate acetate for 16 h. Furthermore, coincubation with PD 98059, an inhibitor of the mitogen-activated protein kinase/extracellular signal-regulated kinase pathway, also inhibited increased PGE2 synthesis by D-glucose or mannitol. In contrast, the iso-osmolar glucose polymer icodextrin, which is used as an alternative to D-glucose in peritoneal dialysis solutions, had no effect on PGE2 synthesis. These data indicate that D-glucose and metabolically inert sugars increase PGE2 synthesis in HMC at least in part by hyperosmolarity and that this effect requires activation of PKC and the mitogen-activated protein kinase/extracellular signal-regulated kinase pathway of intracellular signaling.

Inflammatory demyelinating neuropathy in patients with end-stage renal disease receiving continuous ambulatory peritoneal dialysis (CAPD)

OBJECTIVE

To report on 3 patients with inflammatory demyelinating peripheral neuropathy in strong temporal coincidence with the initiation of peritoneal dialysis (PD) therapy.

SETTING

Nephrology and Neurology Department of the University Hospital, Munich, Germany.

PATIENTS

Three patients with end-stage renal failure presented with the clinical picture of inflammatory demyelinating peripheral neuropathy within 4 to 10 weeks after start of continuous ambulatory peritoneal dialysis (CAPD). They had acute or subacute onset of lower extremity or generalized weakness, diminished reflexes, elevated spinal fluid protein levels, and signs of demyelinating neuropathy on electrophysiological testing.

MEASURES

Clinical follow-up, nerve conduction studies, cerebral spinal fluid (CSF).

RESULTS

All patients did not improve under intensified PD therapy but took profit from immunomodulatory therapy. One bed-bound patient improved after change to hemodialysis and showed complete remission after renal transplantation.

CONCLUSION

Because of strong temporal coincidence, a causal relationship between CAPD and inflammatory demyelinating peripheral neuropathies can be suspected in these 3 patients.

[Fibrillary glomerulonephritis. Case report for differential nephrotic syndrome diagnosis]

A 67-year-old male patient presented with a nephrotic syndrome. Biopsy of the kidney revealed the characteristic of fibrillary glomerulopathy on light and electron microscopy. Other non-nephritic causes of a nephrotic syndrome (e.g. amyloidosis, immunotactoid glomerulopathy, light-chain glomerulopathy, cryoglobulinaemia, collagen-III glomerulopathy, fibronectin glomerulopathy) could be excluded. Besides the case report, differential diagnosis of fibrillary glomerulopathies is presented.

[Perioral dermatitis in children under steroid inhalation therapy]

Topically applied corticosteroid is a known provoking factor in perioral dermatitis. In recent years inhaled corticosteroids have become first line therapy for asthma in children. We present two characteristic cases of perioral dermatitis that developed during asthma treatment with budesonide using either a nebulizer or a spacer connected with a mask. In severe cases treatment with oral erythromycin or topical metronidazole gel may be considered. The eruption should not be confused with atopic eczema.

[Mycoplasma hominis. A rare causative agent of acute pyelonephritis]

HISTORY AND CLINICAL FINDINGS

A 23-year-old woman was admitted with typical signs of an acute urinary tract infection: fever, pain on tapping over both renal areas and in both flanks, urgency and dysuria. She had a history of renal colic with spontaneous passage of a renal stone.

INVESTIGATIONS

There was marked leukocytosis and raised C-reactive protein, leukocyturia and haematuria, but no nitrites or protein in the urine. All blood and urine cultures were sterile and renal ultrasound was unremarkable.

DIAGNOSIS, TREATMENT AND COURSE

As signs and laboratory data indicated acute pyelonephritis (PN) she was treated with gyrase inhibiting antibiotics. But while symptoms improved, fever, leukocyturia and haematuria continued; no micro-organism could be demonstrated. Mycoplasma was therefore considered as a rare cause of PN. Special urine cultures then grew M. hominis, > 10(5) organisms/ml. On the basis of sensitivity tests doxycycline was administered. All symptoms quickly improved and all inflammation parameters and urine sediments became normal.

CONCLUSION

In rare instances M. hominis may be isolated as the causative organism of PN. If, in cases with appropriate symptoms, routine tests fail to demonstrate the causative agent, M. hominis should be included in the differential diagnosis.

[Porphyria cutanea tarda and hepatitis C virus infection]

Porphyria cutanea tarda (PCT) is a rare metabolic disorder characterized by an abnormal porphyrin metabolism and typical cutaneous lesions. Recently a strong association between PCT and hepatitis C virus (HCV) has been proposed. Studies in the south of Europe have shown high prevalences (53 to 91%) of HCV markers in patients with sporadic PCT. Six characteristic case stories are presented. We suggest routine hepatitis C serological testing in all patients with PCT, as HCV infection is a major predisposing factor for the disease.

[Patient survival, a change in methods, and hospitalization in CAPD abd hemodialysis]

BACKGROUND AND OBJECTIVE OF STUDY: Continuous ambulatory peritoneal dialysis (CAPD) still plays a minor role in Germany compared with haemodialysis (HD) in the management of terminal renal failure. An investigation was undertaken to compare mortality rate, change of dialysing method as well as number and duration of hospital stays of patient undergoing CAPD or HD at a nephrological centre.

PATIENTS AND METHODS

All 166 patients in terminal renal failure (except those with a malignancy) admitted between January 1987 and December 1992 were included (63 women and 103 men, aged 19-84 years). The choice between the two dialysis methods was made by the patients after detailed information had been given. Taking into account basic disease and any secondary illness as well as age and sex, survival time, any change of dialysing method and hospitalisation details were prospectively analysed for the two dialysing methods.

RESULTS

After 4 years there were no significant differences in mortality rate between the two methods (HD 37%, CAPD 29%). The Cox model revealed no influence of various parameters on the mortality rate of the two methods. However, cumulative patients survival was significantly decreased by arterio-sclerotic disease (P < 0.05; probability of survival after 4 years was 53% and 73%, respectively, for HD and 57% and 77% for CAPD). Similarly, age > or = 60 years at onset of dialysis significantly lowered probability of survival (after 4 years of dialysis, 53% vs 70% for HD, 45% vs 80% for CAPD: P < 0.05). But there were no significant differences between the two methods with respect to these two factors. After 4 years, "method survival" was more common with HD (94%) than CAPD (64%), P < 0.05). In particular diabetics had a significantly lower "method survival" after 4 years than non-diabetics (29% vs 74%). There was no significant difference between the two methods regarding number and duration of hospital stays.

CONCLUSIONS

These data show that, in a nephrological centre with long experience in both methods of dialysis, CAPD is an equal alternative to HD.

Modulation of procoagulant and fibrinolytic system components of mesothelial cells by inflammatory mediators

Human peritoneal mesothelial cells (HMC) play a critical role in maintaining the intraperitoneal balance between fibrinolysis and coagulation by expressing the fibrinolytic enzyme tissue-type plasminogen activator (t-PA) as well as a specific plasminogen activator inhibitor, PAI-1, and the procoagulant protein tissue factor (TF). Of three compounds known to stimulate t-PA synthesis in cultured human endothelial cells, i.e., retinoic acid, the protein kinase C activator 4 beta-phorbol 12-myristate 13-acetate (PMA), and sodium butyrate, only butyrate (1 mM) caused about a threefold increase in t-PA synthesis and mRNA expression in HMC after 24 h of incubation, without markedly affecting PAI-1 synthesis. PMA (10 nM) induced a threefold increase in urokinase-type plasminogen activator (u-PA) mRNA, but u-PA antigen levels in the HMC conditioned media remained below the detection level (0.5 ng/ml), possibly as a result of rapid uptake and degradation by the u-PA receptor. The u-PA receptor mRNA levels were about fivefold enhanced above control levels after PMA treatment of the cells. An increase in intracellular adenosine 3',5'-cyclic monophosphate levels by forskolin (10 microM) diminished t-PA and PAI-1 levels 43 and 17%, respectively. Among the inflammatory mediators tested [tumor necrosis factor-alpha (TNF-alpha), interleukin-1 alpha, and bacterial lipopolysaccharide], TNF-alpha (10-1,000 U/ml) showed the strongest procoagulant effects. We found that the isoflavone compound genistein (25 micrograms/ml) prevented the TNF-alpha-induced expression of PAI-1 and TF while also slightly counteracting the decrease in t-PA synthesis. The protein kinase C inhibitor R0-318220 (3 microM) only moderately opposed the TNF-alpha-induced changes in t-PA and PAI-1 synthesis but completely prevented the induction of TF mRNA. In summary, our results demonstrate that t-PA synthesis in HMC is relatively insensitive to pharmacological stimulation. To restore the balance between fibrinolysis and coagulation under inflammatory conditions, attempts to interfere with the TNF-alpha-signaling pathway were more successful.

High-flux hemodialysis postpones clinical manifestation of dialysis-related amyloidosis

Amyloidosis due to the retention of beta 2-microglobulin (beta 2-MG) is a frequent complication of hemodialysis (HD). Significant amounts of beta 2-MG can be removed from the body by highly permeable HD membranes, whereas conventional low-flux membranes are impermeable for the molecule. In a prospective and controlled study we investigated whether high-flux HD could delay the onset of dialysis-related amyloidosis (DRA). Twenty patients treated with cuprophane low-flux HD membranes were matched for age and previous time on HD either to continue their HD regimen or to receive HD treatment with high-flux polysulfone membranes. For 6 years each patient was examined for manifestations of DRA once a year or upon individual needs, additionally, serum beta 2-MG levels were monitored. After 6 years of follow-up no clinical signs of DRA were found in any of the patients dialyzed with high-flux polysulfone membranes, whereas 8/10 of the conventionally dialyzed patients had CTS and/or osteoarticular lesions. Serum levels of beta 2-MG were significantly reduced in patients treated with high-flux polysulfone membranes.

Bioincompatible membranes place patients with acute renal failure at increased risk of infection

The mortality of critically ill patients with acute renal failure (ARF) requiring hemodialysis remains high (> 50%), even though major improvements in the management of this disorder have been made. Sepsis has been identified as a major cause of death in ARF. Experimental data have suggested that bioincompatible membranes aggravate uremia induced neutrophil dysfunction. In the following two combined prospective, randomized, clinical studies, the effects of the biocompatibility of dialysis membranes on the susceptibility to infection were compared in 72 surgical and medical patients with ARF. The group of patients treated with biocompatible polyacrylonitrile membranes had a significantly lower incidence of bacterial infections and a lower relative and absolute mortality rate due to sepsis, compared to patients treated with bioincompatible cuprophane membranes. These investigations identified bioincompatibility as a factor that adversely affects the prognosis of critically ill patients with ARF.

Limitations of pulse oral calcitriol therapy in continuous ambulatory peritoneal dialysis patients

Calcitriol is increasingly used for therapy of secondary hyperparathyroidism in patients with end-stage renal disease. Its therapeutic efficacy, however, often has been limited by the associated increase in intestinal calcium and phosphorus absorption. Previous studies reported that these side effects could be avoided by intermittent administration of calcitriol in high doses, subsequently referred to as pulse therapy. The present study was designed to investigate pulse oral calcitriol therapy in a patient subgroup especially susceptible to the development of hypercalcemia and hyperphosphatemia under standard continuous calcitriol treatment. We examined 15 peritoneal dialysis patients with moderate degrees of hyperparathyroidism (intact parathyroid hormone [iPTH] levels, 150 to 903 pg/mL) ingesting between 1.5 and 6 g of calcium salts as the sole phosphate binders. Treatment consisted of 0.5 microgram calcitriol twice weekly. Eight of these patients had been previously converted to low calcium dialysate to tolerate the necessary doses of phosphate-binding calcium salts. During the study period, comprising 8 pretreatment weeks and 8 weeks of therapy, dialysates and doses of calcium salts were not changed, so that only calcitriol influenced the determined parameters. As expected, iPTH levels decreased rapidly in all patients (P < 0.0001). However, within 4 weeks of treatment a marked increase in calcium phosphorus products was observed (P < 0.0001). Overt hypercalcemia developed in five patients. We concluded that pulse oral calcitriol has to be carefully monitored in peritoneal dialysis patients receiving high doses of calcium salts because of the increased risk for hypercalcemia and hyperphosphatemia.

Biocompatible membranes in acute renal failure: prospective case-controlled study

The mortality of critically ill patients with acute renal failure has been halved through intervention by haemodialysis. However, several reports suggest that the course of the disorder may be prolonged by this procedure. Our prospective randomised study was done to see whether the generation of inflammatory mediators by bio-compatible membranes has an adverse effect on the outcome of acute renal failure. 52 patients, similar in age, severity of acute renal failure, general disease status (APACHE II), and management of acute renal failure or its related conditions, were divided into two groups. Haemodialysis was done with cuprophane or polyacrylonitrile membranes. Cuprophane membranes induced intense activation of the complement system (as judged by measurement of C3a) and lipooxygenase pathway (leukotriene B4) resulting in alterations of neutrophil kinetics and function. The cuprophane group had a lower survival rate (38 vs 65%), a higher proportion of patients dying from sepsis (71 vs 40%), required more haemodialysis sessions (12 vs 9), and demonstrated delayed resolution and recovery from acute renal failure than the polyacrylonitrile group. The difference in mortality regarding lethal sepsis as cause of death was statistically significant. Our observations indicate that the outcome of critically ill patients with acute renal failure may be influenced by bio-incompatibility reactions to the dialysis membrane. These results have direct implications for such patients on haemodialysis.

Assessment of acute parathyroid responsiveness to high calcium dialysate in uremic patients

The response of the parathyroid glands to dialysis-induced changes in calcium has been studied in 83 normocalcemic patients receiving maintenance hemodialysis. Predialysis concentrations of intact parathyroid hormone (iPTH) were normal in 13 patients; 70 patients had increased iPTH levels of different degrees. All patients had analytically significant changes in total serum calcium (2.3 +/- 0.2 vs 2.8 +/- 0.2 mmol/l) without additional parenteral calcium loading during a standard dialysis session with a dialysis solution of 1.75 mmol calcium chloride. During hemodialysis the concentration of iPTH fell in 77 patients and was normalized in 48 of these patients. The remaining 6 patients showed no or an inadequate response (less than 30% suppression of predialysis iPTH) to the increase in Ca. Parathyroidectomy was performed in patients with refractory iPTH secretion. Histological evidence of marked parathyroid hyperplasia was obtained in all these patients. All patients with normal or partial responsiveness of the parathyroids tolerated at least small doses of 1.25 (OH)2-vitamin D3. Quantification of predialysis and postdialysis iPTH concentrations is a useful and simple method for identifying those uremic patients with true autonomy of the parathyroid glands at an early stage.

Assessment of Acute Parathyroid Responsiveness to High Calcium Dialysate in Uremic Patients

The response of the parathyroid glands to dialysis-induced changes in calcium has been studied in 83 normocalcemic patients receiving maintenance hemodialysis. Predialysis concentrations of intact parathyroid hormone (iPTH) were normal in 13 patients; 70 patients had increased iPTH levels of different degrees. All patients had analytically significant changes in total serum calcium (2.3 ± 0.2 vs 2.8 ± 0.2 mmol/l) without additional parenteral calcium loading during a standard dialysis session with a dialysis solution of 1.75 mmol calcium chloride. During hemodialysis the concentration of iPTH fell in 77 patients and was normalized in 48 of these patients. The remaining 6 patients showed no or an inadequate response (less than 30% suppression of predialysis iPTH) to the increase in Ca. Parathyroidectomy was performed in patients with refractory iPTH secretion. Histological evidence of marked parathyroid hyperplasia was obtained in all these patients. All patients with normal or partial responsiveness of the parathyroids tolerated at least small doses of 1.25 (OH)2-vitamin D3. Quantification of predialysis and postdialysis iPTH concentrations is a useful and simple method for identifying those uremic patients with true autonomy of the parathyroid glands at an early stage.

[Acute aortic insufficiency following endocarditis due to infection with Campylobacter fetus subspecies fetus]

A 50-year-old male alcoholic addict, examined because of diarrhoea with fever was found to have Campylobacter jejuni in blood and stool cultures. After administration of broad-spectrum penicillin all acute symptoms disappeared but he lost 8 kg within 3 months and his general state health gradually deteriorated. After 3 months he suddenly developed leg oedema, dyspnoea and bouts of fever up to 38.8 degrees C. A loud cardiac murmur was now heard. Echocardiography demonstrated vegetations on the regurgitant aortic valve. Endocarditis being suspected he was at first treated with penicillin G (15 mega IU/d) and gentamycin (160 mg/d). The fever regressed, but after 8 days the blood culture grew Campylobacter fetus subspecies fetus. Antibiotic treatment was switched to imipenem, twice daily 500 mg, in accordance with sensitivity test results. Further blood cultures were sterile. Despite this the cardiac status deteriorated, the aortic regurgitation reaching grade IV. The valve was replaced with a bioprosthesis and the patient quickly improved postoperatively. Antibiotic treatment was stopped and the cardiovascular status became normal. The patient has now been free of symptoms and recurrence for 7 months.

[Fasciola hepatic infection in a family: diagnosis and therapy]

A 39-year-old man was hospitalized because of a 5-week history of feeling very ill, with fever up to 39 degrees C and nonspecific upper abdominal pain. He looked very pale and his spleen was painful on palpation. There was a blood eosinophilia of over 50% and computed tomography demonstrated hypodense areas in the liver, suggesting a parasitic infection with liver involvement. An ELISA factor of over 100 and the finding of liver fluke eggs in bile confirmed the diagnosis of Fasciola hepatica infection, which was probably acquired by eating wild watercress when visiting in the Allgäu. A fasciola infection was also proven in his 37-year-old sister who for some time had complained of colicky right-sided upper abdominal pain, her 40-year-old husband with similar symptoms and their 10-year-old daughter. All four were successfully treated for two days with 10 mg/kg triclabendazole daily by mouth. Persons eating raw vegetables and salads of wild-growing plants are at risk of being infected with Fasciola hepatica.

Removal of beta 2-microglobulin by hemodialysis and hemofiltration: a four year follow up

Efficient removal of total body burden beta 2-Microglobulin (beta 2-M) in uremia is a continuing challenge, as dialysis-related amyloidosis represents a major complication of chronic renal replacement therapy. To investigate long-term beta 2-M removal we studied 3 groups of stable end-staged renal failure patients over a period of 4 years; we compared low flux (cuprophane) hemodialysis (n = 12), high flux (polysulfone) hemodialysis (n = 12) and hemofiltration using high flux polysulfone (n = 8). In contrast to the cuprophane membrane, the polysulfone membrane eliminated considerable amounts of beta 2-M. This was associated with a sustained reduction of predialysis serum beta 2-M-levels (by 20%). Compared with high flux hemodialysis, hemofiltration provided a 50% higher elimination of beta 2-M. Thus, our long-term evaluation of beta 2-M removal suggests that hemofiltration rather than hemodialysis may be the treatment of choice for delaying the incidence of dialysis-related amyloidosis.

Vascular deposition of complement-split products in kidney allografts with cell-mediated rejection

Complement activation in 73 renal transplant biopsies was investigated by indirect immunoperoxidase staining using MoAbs reactive with complement-split products. Intense deposition of complement fragments C4d and C3d in peritubular capillaries, indicating activation of the classical pathway, could be detected in the majority of transplanted kidneys with cell-mediated rejections. Abundant deposition of complement-split products was observed in 22 early biopsies from patients with high 'immunological risk' (i.e. previous, rejected transplants and/or circulating antibodies against HLA-antigens). Despite negative results in the crossmatch before transplantation and paucity of immunoglobulins in transplant biopsies, antibodies directed against endothelial cell antigens should be considered as a possible cause of classical complement activation.

Expression of the Fc-receptor for IgE (Fc epsilon RII, CD23) on alveolar macrophages in extrinsic allergic alveolitis

Expression of the Fc receptor for IgE (Fc epsilon R) was analyzed on alveolar macrophages (AM) in 10 patients with extrinsic allergic alveolitis (EAA) compared with 10 patients with sarcoidosis and to 6 apparently healthy controls. By using the anti-Fc epsilon RII mAb M-L25 in immunocytochemistry experiments, we found that greater than 60% of AM in 10 of 10 patients with EAA were strongly positive, as evidenced by visual analysis in light microscopy and by cytometry. By contrast, no significant staining was detected in sarcoidosis or in controls with either method. Similar results were obtained when Fc epsilon R were identified with preformed immune complexes consisting of NIP-specific human/mouse chimeric IgE antibody plus NIP-ovalbumin. Furthermore, greater than 60% of AM in patients with EAA stained positive for IgE, demonstrating that endogenous IgE is bound to the AM. Our data suggest that IgE antibodies bound to Fc epsilon RII on AM may be involved in pathophysiology of extrinsic allergic alveolitis by activation of the AM after binding of allergen to the cell surface IgE. Furthermore, with the clearcut pattern of Fc epsilon RII expression in extrinsic allergic alveolitis it may be possible to use CD23 antibodies for differential diagnosis of inflammatory lung disease.

[What is established in the therapy of kidney diseases?]

The established therapy for glomerular disorders of the kidney is outlined in a short review. Before initiating therapy, the physician must decide if the underlying disease is of primary or secondary type. The nephrotic syndrome and progressive renal insufficiency can result in both conditions. The necessary dietary and pharmacological principles in the therapy of these syndromes are discussed. Finally, the clinical and therapeutic aspects of secondary glomerulopathy are described with selected examples.

Detection of both isotypes of complement C4, C4A and C4B, in normal human glomeruli

Monoclonal antibodies reactive against the complement C4A and C4B isotypic components were used in an immunoperoxidase technique for the histological study of normal human renal tissue. Prominent staining with both antibodies was seen in the mesangial areas of all normal kidney sections investigated. Occasional staining of arteriolar walls of the same tissues, however, was also observed. In contrast, no mesangial staining was seen using monoclonal antibodies reactive against other 'early' complement components, such as C1q and C3. Specificity of the glomerular staining with the anti-C4 reagents was demonstrated in two patients possessing only the C4A serum component but lacking genetically the C4B locus products. As would be predicted, glomerular staining with the anti-C4A reagent, but not anti-C4B, was clearly demonstrable. It is concluded that both isotypes of complement C4 are present in normal human glomeruli and thus might be operative for normal mesangial function.

[Recurrent pulmonary hemorrhage with normal kidney function]

A case of Goodpasture's syndrome with normal renal function is described. Clinical, morphological and prognostic features of the diagnosis are compared with the findings in Goodpasture's syndrome with progressive renal failure and with the findings in idiopathic pulmonary hemosiderosis.

Rare variant of complement C4 is seen in high frequency in patients with primary glomerulonephritis

59 unselected patients with primary glomerulonephritis were phenotyped for alleles of the MHC-linked complement genes, C4A, C4B, and BF. A rare variant of the C4B locus, C4B*2.9, was found in 25% of these patients compared with only 2% of the normal population--a relative risk of 22.1 for glomerulonephritis in individuals with this variant. Subdivision of patients by histological classification of glomerulonephritis revealed a significant association of C4B*2.9 with the membranoproliferative form. There were no significant associations between primary glomerulonephritis or its subtypes and the other HLA markers tested.

Endobronchial laser therapy--differential therapeutic use and clinical value

Endobronchial laser irradiation was performed on 27 patients with inoperable malignant (n = 23) and benign (n = 4) disease of the bronchial system for the treatment of recurrent pulmonary bleeding and recanalization of centrally obstructed or stenosed airways. The essentially palliative measure led in more than half the patients with hemoptysis to immediate and lasting hemostasis, in all patients with stenosis to complete or partial restoration of airway patency, and in 7 of 11 patients with total obstruction to a radiologically verifiable re-expansion of atelectasis. In the total of 58 laser treatments performed, complications occurred in three cases and were managed by conventional clinical measures. Successful recanalization in patients with pre-existing bronchial obstruction presupposes a short-segment, polypous tumor growth, intact bronchial wall structures, and short occlusion time. In addition to the treatment and prophylaxis of recurrent pulmonary bleeding, the principal use of endobronchial laser treatment in the future will probably concentrate on the palliative therapy of preocclusive stenoses of the trachea and main bronchi.

Arachidonic acid metabolites, hypertension and arteriosclerosis

The level of arterial blood pressure is set by complete interactions of several mechanisms which influence both blood flow in and resistance of the vascular system. An imbalance favouring elevation of vascular resistance or extracellular volume will result in hypertension. Such alterations may include increased activity of the sympathetic nervous system, of the renin-angiotensin system, or excessive secretion of mineralocorticoids. Of equal importance may be a reduced activity of blood pressure-lowering factors such as prostaglandins and the kallikrein-kinin system. This paper describes the possible significance of prostaglandins in the pathophysiology of hypertension and in degenerative vascular disease, based on their involvement in the control of vascular resistance, renal regulation of extracellular volume and platelet-vessel wall interactions. An abnormality in the biosyn-thesis of certain prostaglandin endoperoxide metabolites may lead to hypertension even without an increase in the activity of the classic blood-pressure-elevating systems. The contribution of prostaglandins for the development of hypertension and degenerative vascular disease may be based on an inherent abnormality of the prostaglandin system, as well as on the effects of major risk factors such as dietary intake of sodium and fat on prostaglandin synthesis. Specific blockade or stimulation of distinct biosynthetic pathways leading to antagonistically acting prostaglandins and nutritional manipulation of precursor fatty acids should lead to a better understanding of the pathomechanisms involved and may offer new strategies for therapy or prevention of these cardiovascular disorders.

Urinary prostaglandins and kallikrein in essential hypertension

1. Urinary prostaglandins (PG), kallikrein and plasma renin activity (PRA) were measured in 35 patients with essential hypertension and 22 normotensive controls before and 15 min after frusemide (40 mg intravenously). 2. PGE2 and kallikrein excretion rates were lower in hypertensive subjects, and failed to rise to the same extent after frusemide. PGF2 alpha excretion was not significantly different in the two groups of patients either before or after frusemide. PRA rose less in the hypertensive subjects after frusemide. 3. These findings support the view that there is an abnormality of renal vasodilator systems (PGE2 and kallikrein) in essential hypertension.

Formation and action of prostaglandins in the kidney

The kidney has a high capacity to produce a spectrum of different acting prostaglandins (PG). In vivo and in vitro studies have shown that renal formation of PG's, possibly in the vasculature of the cortex represents an essential step in the mechanisms regulating the secretion of renin. PG's formed in the cortex seem to participate also in the control of renal vascular resistance and glomerular filtration rate. PGE2 formed in the medulla modulates the hydroosmotic action of antidiuretic hormone and influences the kidney's capacity for urine concentration. Renal PG formation is reduced by high NaCl intake and enhanced by low NaCl intake and in hypokalemic states. These findings make renal PG's good candidates for participation in the regulation of salt and water balance and in the control of blood pressure. Due to the close connection with the renin angiotensin system, alterations in renal PG formation might be involved in the etiology of high and low renin states. Thus, an impairment in the renal cortical production of vasodilating and renin-stimulating PG's could constitute the common denominator for both the reduced renin secretion and the increased vascular resistance which have been reported to be associated in essential hypertension.

[Reduced urinary prostaglandin E2-excretion and diminished responsiveness of plasma renin activity in patients with essential hypertension (author's transl)]

Under basal conditions prostaglandin (PG) E2-excretion was significantly lower in 35 patients with essential hypertension studied than in 22 age- and sex-matched controls (p less than 0.02). PGF 2 alpha--excretion was similar in both groups. Within the first 15 minutes after furosemide i.v., PGE2-excretion rose substantially less in the patients than in the controls (p less than 0.001), while the increase in PGF 2 alpha-excretion was not different for both groups. The coincident rise of plasma renin activity was significantly lower in the hypertensive (167% +/- 11, SEM) than in the normotensive (386% +/- 46) group (p less than 0.001). Our results support the assumption that a decrease in renal cortical (vascular?) synthesis of vasodilatating PG's may be the cause for both, the diminished secretion of renin and the increase of vascular resistance in the kidney, which are often associated in essential hypertension.