The relationship of acculturation and gender to attitudes toward counseling in Italian and Greek American college students

This exploratory study examined attitudes toward professional psychological services and help provider characteristics among 232 self-identified Italian and Greek American college students in 3 Northeast colleges. Regarding general attitudes toward psychological services in the Italian American sample, women had a greater recognition of personal need for help and higher confidence in the ability of mental health professionals to meet these needs than did men. With regard to preferred counselor demographic characteristics, regardless of gender, lower acculturated Italian American students had a stronger preference for seeing an ethnically similar counselor. With the Greek American sample, there was an interaction effect between acculturation level and gender on attitudes toward services. Among the higher acculturated Greek students, women were more open regarding their personal concerns than men; however, within the lower acculturated cohort, no gender differences were found. With regard to counselor characteristic variables, and similar to Italian Americans, regardless of gender, lower acculturated Greek Americans had a stronger preference for seeing an ethnically similar counselor to discuss a personal problem. Limitations and implications for further research are noted.

[Antibiotic treatment of infections in general practice. Effect of audit assessed by prescriptions data from health insurance registry and physicians' own registration]

The aim was to study whether an audit of treatment of infections in general practice resulted in changed prescribing habits. In 1995-1996 forty-six general practitioners (GP's) from the County of Roskilde participated in an audit regarding infectious diseases (incl. course participation and preparation of treatment guidelines). The effect evaluation was done on the basis of 1) two self-registrations of antibiotic prescriptions carried out with one year's interval, and 2) prescribing data from the National Insurance database collected over two periods, before the first and second self-registration respectively. The number of patients not receiving antibiotics increased significantly from 47.2% to 52.4% after intervention. The self-registration did not show any change in choice of antibiotics, while the registry data showed a shift from broad-spectrum to narrow-spectrum penicillin. This change was, however, also found among the GP's, who did not participate in the audit. The study demonstrated that audit can result in changes in prescribing patterns, but at the same time emphasizes the need for inclusion of external data sources and control groups in the evaluation of intervention effects.

The elderly dialysis patient: management of the hospital stay

Our data show that survival times in elderly patients can be achieved, which justify the strain of the therapy on the patient, the medical effort and financial expense. It is therefore not justifiable to withhold dialysis from a person who requires it on the basis of age. It is also wrong to reduce the therapeutic endeavours to a minimum and describe these then as 'kinder' to the patient. It is to be feared that such a treatment regimen leads to a shorter survival time and simultaneously to a decreased quality of life. Particularly in view of the person's advanced age, it would seem that we are obligated to treat them with the highest quality care so that the remaining time is not only extended, but is filled with life.

[Benzodiazepine consumption in Hvalsø. Can it be further reduced in a region in which earlier intervention reduced consumption by 38 per cent?]

Hvalsø is a country town with six general practitioners in five practices. In 1988, as a result of a campaign influencing both doctors and patients, a 38% reduction in the consumption of benzodiazepines, measured as the number of prescribed doses, was achieved. This reduction still persists. We have now attempted to reduce consumption even further by directly influencing the individual users. We gave them written information, insisted on personal attendance for each prescription renewal, and, for use at these consultations, introduced a new benzodiazepine journal for 60% of the users. Registration of the prescribed amounts of benzodiazepines was performed over two three-month periods, before and after the intervention. The final registration was made six months after the intervention period. The number of prescriptions, number of prescriptions per 1000 patients and the number of users remained unchanged. A 20% reduction in the amount of prescribed sedatives (hypnotics) and a 7% reduction in prescribed minor tranquillizers was achieved because of fewer doses per prescription. We conclude, that we did not manage to change the patients' behaviour, expressed as the number of prescriptions per 1000 patients, but the doctors were influenced to write out fewer doses per prescription. Important reductions in consumption may be achieved in primary interventions.

Bone fracture history and prospective bone fracture risk of hemodialysis patients are related to apolipoprotein E genotype

This investigation of 219 hemodialysis patients relates the history and prospective risk of bone fractures to apolipoprotein E (apoE) genotype. A greater percentage of the 41 patients with the E3/4 and E4/4 genotypes than of the 38 patients with the E2/3 and E2/2 genotypes had a history of bone fractures at the time of recruitment (44% versus 16%, P < 0.005). During the 4 years following recruitment, more of the patients with apoE genotypes E3/4 and E4/4 than with apoE genotypes E2/3 and E2/2 suffered bone fractures, but this difference was not statistically significant (17.1 versus 5.3%, P < 0.1). ApoE genotype appears to be an important genetic risk factor for bone fracture, possibly due to its previously reported influence on vitamin K concentrations in blood.

[How can ethical training in a hospital be organized?]

BACKGROUND

Many everyday situations in hospitals that demand professional decisions also contain an ethical dimension. Unfortunately until today there are only a few physicians and nurses who have received a good medical-ethical knowledge during their professional education.

DESCRIPTION

In this text the basic elements and structure of a model dealing with training in clinical ethics are illustrated. The program is dedicated to members of healing professions who work together. Aspects of great importance are the multiprofessional concept and the regard of the particularities of the hospital.

CONCLUSION

Based on the project's experience, it is shown that the participants not only profit by discussing ethical issues of their professional practice, but there is also a positive effect on the cooperation among the employees.

Bone health of adult hemodialysis patients is related to vitamin K status

This investigation of 68 hemodialysis patients (ages 33 to 91) analyzed the association of biochemical indicators of vitamin K nutriture and bone metabolism, and related both to past bone fracture history and prospective bone fracture risk. Phylloquinone concentrations were significantly lower in the 23 patients with previous fractures compared to those without (0.93 vs. 1.50 nmol/liter, P < 0.003) and a smaller percentage of their serum osteocalcin was carboxylated (48.8 vs. 53.6%, P < 0.03). The 41 patients who never had fractures had nearly three times higher phylloquinone concentrations than the nine patients with fractures during a four-year follow-up period (1.59 vs. 0.55 nmol/liter, P < 0.002) and more carboxylated serum osteocalcin (55.2 vs. 42.0%, P < 0.01). None of the patients with phylloquinone concentrations over 2.2 nmol/liter had elevated intact parathyroid hormone (iPTH) concentrations, and only patients with less than 1 nmol/liter phylloquinone had severe hyperparathyroidism (iPTH > 300 ng/liter). Our data thus indicate that suboptimal vitamin K nutriture in hemodialysis patients is associated both with increased bone fracture risk and with a high prevalence of hyperparathyroidism.

Significant reduction of factor D and immunosuppressive complement fragment Ba by hemofiltration

Because of their effect on the immune response, especially in patients with chronic or acute renal failure, factor D (FD) and the immunosuppressive complement fragment Ba are substances which may be important for the immunological status. Since they cannot be eliminated by conventional Cuprophan hemodialysis because of their high molecular weight (24,000 and 33,000 D, respectively), the effect of hemofiltration (HF) on the plasma concentration of both components was tested. It was shown that plasma levels of FD can be lowered by 43.5% during an HF treatment and the plasma concentration of Ba by 30.6%. Moreover, the two substances could be detected in the hemofiltrate. Up to 75 mg FD and up to 37 mg Ba could be eliminated per treatment, depending on the plasma concentrations and the filtration volume. A convective method such as chronic HF is therefore clearly superior to diffusive methods of blood purification when substances with such a high molecular weight have to be eliminated. It has still to be established whether the elimination of FD and Ba by chronic intermittent HF results in a sustained improvement in the immunological status of patients treated in this way.

Is the choice of membrane important for patients with acute renal failure requiring hemodialysis?

It has recently been reported that patients with acute renal failure requiring hemodialysis have an improved recovery of renal function and a higher survival rate when the dialysis treatments are performed with a biocompatible membrane rather than a bioincompatible membrane. Our data, obtained in 57 patients with acute renal failure, do not support these findings since neither the mortality nor the required number of dialysis sessions could be influenced by using a biocompatible membrane. The survival rate was similar in both groups (64 versus 72%), and renal function was regained in both groups after 6 dialysis sessions. We conclude that when reviewing the literature as well as other factors, the underlying clinical condition or the skill of the physicians is probably more important than the theoretical superiority of biocompatible membranes.

Evaluation of the new ophthalmic antihistamine, 0.05% levocabastine, in the clinical allergen challenge model of allergic conjunctivitis

The objective of this study was to evaluate the efficacy of 0.05% levocabastine, a new antihistamine formulated for ophthalmic use, compared with the placebo vehicle for the treatment of allergic conjunctivitis induced by ocular allergen challenge. Subjects who reacted. positively in both eyes on two separate occasions to ocular allergen challenge with grass, ragweed, or cat dander (N = 47) received one dose of 1 to 2 drops of 0.05% levocabastine in one eye and its vehicle in the other eye. After 10 minutes, the predetermined dose of allergen was instilled in both eyes. Signs and symptoms of allergic conjunctivitis were evaluated with biomicroscopy and subjective evaluation of itching after 3, 5, and 10 minutes. Four hours after drug administration, subjects were rechallenged and reevaluated to determine levocabastine's duration of action. Results showed that levocabastine was significantly more effective than placebo in inhibiting itching, hyperemia, eyelid swelling, chemosis, and tearing after the initial challenge and in inhibiting all parameters except eyelid swelling after the rechallenge 4 hours later (p < 0.05). These results demonstrate that levocabastine, currently the only ophthalmic antihistamine available that is not combined with a vasoconstrictor, is efficacious in the inhibition of itching, as well as all of the allergic signs of a vascular origin, with a duration of action of at least 4 hours. Because of its strong effects on itching and hyperemia, chemosis, lid swelling, and tearing, levocabastine would be a valuable therapeutic agent to add to the heterogeneous family of antiallergic compounds presently available for the treatment of seasonal allergic conjunctivitis.

Conjunctivitis of allergic origin: immunologic mechanisms and current approaches to therapy

The pathogenesis of ocular allergy involves multiple mechanisms, which lead to mast cell degranulation and the release of chemical mediators. Mast cell mediators that have been implicated in allergic ocular disease include histamine, eosinophil chemotactic factors, eosinophil granule major basic protein, platelet-activating factor, prostaglandin D2, and several other less well-defined preformed or newly synthesized mediators. The release of these chemical mediators ultimately results in conjunctival vasodilation, increased vascular permeability, leukocyte chemotaxis, and, rarely, ocular surface destruction. Current therapy of ocular allergy involves elimination of the offending allergen, modulation of the immune system, and pharmacologic inhibition of the chemical mediators. The purpose of this article is to provide a better understanding of the pathogenesis and current therapy of ocular allergic disorders and to review the central role of the mast cell and chemical mediators involved in ocular allergy.

Reduced risk of hypercalcemia for hemodialysis patients by administering calcitriol at night

Renal osteodystrophy therapy in dialysis patients with calcitriol and intestinal phosphate binders containing calcium entails the risk of hypercalcemia. A study was performed using 35 hemodialysis patients to see whether the time of day when calcitriol is administered influences the incidence of hypercalcemia. It was shown that simply by administering at night (11:00 PM), the occurrence of hypercalcemia was significantly reduced. While greater than 80% of patients developed hypercalcemia when calcitriol was administered in the morning, when administered at night, this figure was only 50% (P less than 0.013). At the same time, the extent of hypercalcemia when calcitriol was administered at night was significantly lower than when it was administered in the morning. The incidence of hypercalcemia occurred regardless of the type of phosphate binder containing calcium used, whether it was calcium acetate or calcium carbonate. In addition, hypercalcemic episodes were always associated with hyperphosphatemia. On the basis of the above information, it would be expedient to administer calcitriol at night to dialysis patients, in order to reduce the risk of hypercalcemia and to preserve the hypophosphatemic effect of the applied intestinal phosphate binders.

Beta-2-microglobulin-derived amyloidosis: onset, distribution and clinical features in 13 hemodialysed patients

Postmortem examinations were carried out in 13 patients (6 males, 7 females, age 58 +/- 9 years) who had been on regular hemodialysis treatment for 10-90 months using disposable regenerated cellulose membrane dialyzers. The prevalence of beta 2-microglobulin (beta 2m)-derived AB-amyloid deposits in different sites was determined. At autopsy, specimens were obtained from different joints, paravertebral tissue, intervertebral discs and from visceral organs. During life, routine laboratory parameters and radiographic studies had been carried out at 6-month intervals. Serum levels of beta 2m were elevated in all patients (57.5 +/- 13.4 mg/l). Synovial AB-amyloid deposits were shown in different joints of 4 patients, aged between 59 and 73 years, and dialysed for 10-90 months, respectively. All had been unremarkable by X-ray and asymptomatic. No amyloid could be detected in the intervertebral discs of 2 further patients suffering from destructive spondylarthropathy. In 11 of the 13 patients, extracellular beta 2m deposits were observed by immunohistochemistry in different tissues. The results document that (a) AB-amyloidosis may occur in elderly patients even when dialysed for less than 5 years; (b) most cases are completely asymptomatic; the appearance of symptoms must be dependent on additional factors, e.g., site of AB-amyloid deposition and intensity of inflammatory reaction, and (c) AB-amyloid is not the exclusive cause of destructive spondylarthropathy, as 2 typical cases were observed who were devoid of amyloid.

The treatment of uraemic hyperphosphataemia with calcium acetate and calcium carbonate: a comparative study

A comparative study of long-term haemodialysis patients investigated the effects of calcium acetate and calcium carbonate on concentrations of serum phosphate, calcium, and parathyroid hormone. It was demonstrated that both substances led to a significant decrease in phosphate and serum parathyroid hormone. Administration of calcium acetate reduced the serum phosphate concentration in 7 weeks from an initial value of 2.08 +/- 0.53 mmol/l to 1.51 +/- 0.39 mmol/l (P less than 0.01). Following a 1-week wash-out period, calcium carbonate reduced the serum phosphate concentration in the same patients from 1.99 +/- 0.62 mmol/l to 1.34 +/- 0.40 mmol/l (P less than 0.01). Of particular significance, however, is the fact that in relation to daily elementary calcium intake, calcium acetate was a considerably more effective binder of intestinal phosphate than calcium carbonate. During administration of calcium acetate only 1.02 g of elementary calcium were required daily in order to reduce the serum phosphate concentration. The same patients, however, required 1.88 g of elementary calcium during calcium carbonate therapy. Complementary studies investigated the influence of an accompanying calcitriol medication. In this instance, too, calcium acetate was shown to be more effective; although the patients developed hypercalcaemia with calcium acetate, this happened more often with calcium carbonate. In summary it can be said that daily calcium loading of the uraemic organism under calcium acetate therapy is reduced by nearly half as compared to calcium carbonate therapy, and that this can be achieved with the same effective decrease of the serum phosphate concentration.

[Serum level and organ deposits of beta 2-microglobulin in dialysis patients]

In radioimmunological estimation of beta 2-microglobulin (beta 2m) significant higher serum values were found in 36 dialysis patients (44.4 +/- 20.3 mg/l) in comparison with healthy probands (1.5 +/- 0.2 mg/l). A significant relation to the duration of dialysis, diuresis, symptoms of the musculo-skeletal system, but not to radiologic changes or bone biopsy findings could be seen. Post mortem examinations carried out in 21 dialysis patients revealed AB-amyloid deposits in synovial tissue of different joints (particularly shoulder and hip joint) or intervertebral discs in eight patients (age 48 to 73 years, dialysis duration less than four years) without correlation to serum beta 2m level or radiographically suspect areas. In the tissue of cervical spine or intervertebral discs of two patients suffering from destructive spondylarthropathy no amyloid could be detected. These results suggest that AB-amyloid may occur in elderly patients early in the course of hemodialysis and may be asymptomatic in most cases.

[Drug utilization in Hvalsö. An attempt to change the attitude of the population and physicians to drug use]

All of the prescriptions, a total of 1,876, issued by the five practitioners in Hvalsø in four chosen weeks in 1987/88 were copied. The prescribed drugs, a total of 3,177, were calculated for the individual groups of drugs and corrected for the age distribution among the population as a whole and in the individual doctor's practice. The main results from the following groups of drugs are presented here: hypnotics, drugs for neurosis, antibiotics, drugs for cardiac and circulatory disease, drugs for asthma, contraceptive pills and female sex hormones. By and large, considerably more medicine was prescribed for women than for men. For example, twice as much medicine for insomnia was prescribed for women. This is enough for every fourth woman over the age for 70 years to receive a daily dose of hypnotics. Women appear to commence using hypnotics at the age of 40 years and men at 60 years. Marked differences were found in the patterns of prescription between the individual practitioners and thei is apparently greatest as regards prescriptions for men while the more liberal prescription of hypnotics to women was observed for all of the practitioners. Two groups of drugs were, however, prescribed mostly for men, viz, asthma medicine for all age groups and cardiac and circulatory medicine for persons greater than 60 years. Where all of the groups of drugs were concerned, comparisons were undertaken between the prescription habits of the individual practitioners. The results of this investigation are employed in local health work among the population, in study circle work among the practitioners and as basic ideas for the county drug committee activities.

Influence of membranes on generation of beta 2 M and release of leukocyte lysosomal enzymes

Normal leukocyte functional capacity was investigated by evaluation of phagocytosis of opsonised yeast cells in a radiometric test system. After incubation with dialysis membranes (different cellulosic membranes, polysulfon membrane (PS), polymethylmetacrylate membrane (PMMN), the phagocytosis index, expressed as percent decrease with respect to initial values without membrane, decreased by 10%-25%. The most pronounced effect was observed with PS, cuprophane, modified cellulose and PMMA. The results are not related to differences in the viability of PMN during the test procedure; dead PMN amounted to about 4-6.5%. A significant increase in beta-NAG and beta-Gluc activities was released in the supernatants of the phagocytosis suspensions. This increase activity can be explained by the phagocytosis of PMN but it was not influenced by membrane contact. There was no influence of membrane contact or phagocytosis activity of PMN on the beta 2 M concentration in the supernatant demonstrating that no in vitro generation during incubation with either membrane exists.

Calcium salts of ketoacids as a new treatment strategy for uremic hyperphosphatemia

Hyperphosphatemia and secondary hyperparathyroidism are regular complications in patients suffering from end-stage renal failure. Aluminum-containing drugs are widely used to control serum phosphate, but this therapy carries the well-known risk of aluminum toxicity. Previously we demonstrated that a mixture of ketoacids is very effective in lowering increased serum phosphate and serum PTH levels. Recent studies to clarify the underlying mechanisms whereby these compounds lower serum phosphate revealed that ketoacids act as intestinal phosphate binders. In balance studies we demonstrated that intestinal phosphorus uptake decreased in normal subjects (decrease of absorption during ingestion: 0.7-3.14 mmol/day). Additional in vitro studies not only confirmed the in vivo results but also showed that ketoacids are as efficient as calcium carbonate although they provide less calcium. It is of further interest that ketoacids reached their greatest binding efficiency when the pH is 7.0, whereas calcium carbonate binds phosphate predominantly when the pH is 2.0 or 5.0. Ketoacids represent a further therapy to lower serum phosphate in uremia. As they provide less calcium than calcium carbonate, they could be considered as an advantageous, less dangerous alternative.

Visual cerebral lateralization over phases of the menstrual cycle: a preliminary investigation

This study investigated whether visual cerebral asymmetries would change in phase with hormonal variations during the menstrual cycle. Lexical decision and line orientation tasks were administered during follicular, luteal, and menstrual phases of each woman's cycle. These tasks were also administered to a reference group of male subjects. Signal detection analyses indicated an unvarying RVF advantage in word/nonword discriminability (d') throughout the menstrual cycle, but a phase-dependent shift in left hemisphere response criterion (log beta). Gender differences were present for discriminability of line orientation, and female performance on this task varied over the cycle. The results imply that the neural systems subserving some cognitive functions are sensitive to fluctuations in gonadal steroids and suggest a hormonal basis for gender differences in some visual-spatial functions.

Atrial natriuretic peptide plasma levels during hemodialysis and hemofiltration in patients with end-stage renal disease

Using a cross-over protocol we repeatedly measured the plasma levels of alpha-hANP (atrial natriuretic peptide) during one week by radio-immunoassay in eight patients with end-stage renal disease treated with chronic hemodialysis or hemofiltration. Before each hemodialysis or hemofiltration session mean plasma ANP levels (353 +/- 112, and 337 +/- 99 pg.ml-1, respectively) were significantly above normal (50 - 166 pg.ml-1). In all but one patient, the values fell significantly towards but not reaching the normal range. Plasma ANP concentrations returned to normal at the end of the treatment in only two of the eight subjects. There was a positive correlation between the increase in body weight from one treatment to the next and the plasma ANP concentration (r = +0.35, p less than 0.05). The net loss of fluid volume during each treatment did not correlate significantly with the change in plasma ANP levels. There was no difference between hemodialysis and hemofiltration. Plasma ANP measurement may be helpful in the judgement of volume status in patients with end-stage renal disease treated by hemodialysis or hemofiltration.

[Clinical significance of beta 2 microglobulin determination in dialysis patients]

In radioimmunological estimation of beta 2-microglobulin significant higher serum values were found in 36 dialysis patients (44.4 +/- 20.3 mg/l) in comparison with healthy probands (1.5 +/- 0.2 mg/l). A significant relation to the duration of dialysis, rest diuresis and serum level of aluminium was found. Significant higher concentrations were observed in patients suffering from pain in the shoulder-limb-region and with ostealgia in other regions, but not in radiological verified destructive arthropathy and spondylarthropathy. The used dialyzers MLW 1.3/1.8 m2 did not eliminate the beta 2-microglobulin from the blood.

Acute renal failure due to uric acid nephropathy in a patient with renal hypouricemia

This report is about a 23-year-old man who required hemodialysis in connection with an acute renal failure resulting from uric acid nephropathy without hyperuricemia. After recovering renal function he showed extreme hypouricemia (0.1-0.3 mg/dl) and elevated uric acid clearance (100-300 ml/min). The fractional excretion of uric acid (Cua/Ccr) could be suppressed by oral pyrazinamide and enhanced by probenecid. As no other renal tubular or metabolic abnormalities were detected, it is suggested that a markedly increased renal tubular urate secretion was responsible for the hypouricemia and also for the rare side-effect of an uric acid nephropathy in this patient.

Dietary treatment as seen by German nephrologists. Results of a questionnaire

The majority of German nephrologists consider a protein restriction for patients with advanced renal failure as necessary. However, there was no consensus with regard to the diet, which should be finally applied. It was of further interest that the majority of physicians believe that only 50% of their patients adhere consistently to the diet.

The beneficial effect of ketoacids on serum phosphate and parathyroid hormone in patients with chronic uremia

Hyperphosphatemia and secondary hyperparathyroidism are regular complications in patients suffering from advanced renal failure. As aluminum-containing drugs carry the well-known risk of aluminum intoxication, we were interested in testing in a prospective study a mixture of ketoanalogues and amino acids which have been shown to lower the serum phosphate and parathyroid hormone in uremic patients. For 3 months, in addition to their diet, 17 uremic patients and 12 hemodialysis patients received a daily supplement of this mixture. Although no additional phosphate binders were administered, serum phosphate decreased significantly in the former group and was slightly lower in the latter. The serum parathyroid hormone level was consistently lowered when the initial concentration was not higher than 20 times normal.

Easy production of sterile, pyrogen-free dialysate

Hemodialysis (HD) hypotension is frequently encountered during conventional acetate HD. Recently it has been suggested that monocytes that adhere to the dialysis membrane are also stimulated by endotoxins diffusing from the dialysate side. Stimulated monocytes, however, release interleukin-1, which mediates fever and hypotension through its action on the cyclo-oxygenase cascade. To prevent this endotoxin-induced stimulation of monocytes, a hemofilter with a polyamide membrane (FH 88, Gambro, Lund, Sweden, cut-off 20,000 daltons, surface area 2.0 m2) was interposed between the dialysate outlet of the HD machine and the dialyzer. The data obtained clearly show that the filtered dialysate was always pyrogen-free when tested with a limulus-amebocyte-lysate assay. In addition, in 80% of cases no bacteria were detected after the sterilizing filter. Almost no febrile episodes were observed when sterile dialysate was used.

Different handling of beta 2-microglobulin during hemodialysis and hemofiltration

Very recently it was reported that the amyloid associated with chronic hemodialysis contains, as a major component, a new form of amyloid fibril protein which is homologous to beta 2-microglobulin. As beta 2-microglobulin has a molecular weight of 11,600 daltons, investigations were carried out to see whether or not this protein would be handled differently by hemodialysis and hemofiltration, because the latter method especially is capable of eliminating solutes with such a high molecular weight. The results clearly indicate that hemofiltration removes substantial amounts of beta 2-microglobulin (about 190 mg per treatment, which represents 80% of daily production). It remains to be clarified whether or not hemofiltration is therefore superior to hemodialysis with regard to amyloid deposit formation.

Treatment of uremic hyperphosphatemia--is there still a need for aluminum salts?

Aluminum-containing phosphate binders have been widely employed in the past in the management of uremic hyperphosphatemia. However, an increasing number of reports on aluminum toxicity has stimulated efforts to replace this therapy by safer methods. The aim of the present review is to critically evaluate other treatment strategies. It appears that aluminum-containing phosphate binders should no longer be considered the treatment of choice for controlling uremic hyperphosphatemia. Calcium carbonate, calcium citrate, magnesium carbonate and a mixture of ketoanalogues and amino acids present important therapeutical alternatives which could replace aluminum-containing phosphate binders in the majority of patients. However, it is mandatory, as these therapies also carry some risks, that side effects are detected early.

Glomerular filtration rate in response to an acute protein load

The effect of a protein load on the glomerular filtration rate (measured as creatinine clearance) was studied in normal subjects, healthy vegetarians, patients with advanced liver disease, patients with moderate renal failure and in normal volunteers being pretreated with aspirin or sulindac. Only patients with liver disease were not capable of increasing their glomerular filtration rate after the protein challenge, a finding which suggests that the liver might be of importance for the adequate renal reserve. It is of note that neither the application of nonsteroidal anti-inflammatory drugs nor the existence of a moderate renal failure modify the response to a protein load.