In 19 chronic alcoholics with rhabdomyolysis the clinical picture demonstrated markedly different degrees of severity of myolysis. Muscle pain, muscle swellings and brown-coloured urine were rare. But symptoms of delirium, at times with cerebral seizures, were frequent at the onset. Renal failure of different degrees was common; five patients had to be dialysed. Two patients died in irreversible shock. Respiratory insufficiency and hypercalcaemia were other complications. Early recognition of the disease is important, because early treatment can prevent acute "myoglobinuric" renal failure.

Drug Prescribing for Patients with Chronic Kidney Disease in General Practice: a Cross-Sectional Study

Haemodialysis had become impossible or possible only using high doses of heparin in 20 patients with dialysis-dependent renal insufficiency due to lowering of antithrombin III (AT III). In order to assess the value of AT III substitution for effective heparin treatment and concomitant diminution of the danger of haemorrhage AT III substitution was done in these patients. Six patients. Six patients with acute renal failure and disseminated intravascular coagulation were able to undergo dialysis using only 750-1000 IU heparin/h after normalisation of AT III without complications. In 3 patients thrombosing of the extracorporeal system had occurred despite increasing doses of heparin; only after 1500 U AT III subsequent haemodialysis could be performed without thromboses. Dialysis was performed with continuous substitution of the AT III-heparin-complex in 6 patients prone to haemorrhage. 250-500 U of AT III-heparin-complex were sufficient and proved as safe and well manageable possibility of minimal anticoagulation. In 5 patients repeated thrombosing of the haemofilter per day had occurred during continuous arteriovenous haemofiltration. After AT III administration haemofilters could be left in situ for 18-46 hours.

Continuous ambulatory peritoneal diaglysis (CAPD) represents a new method for treatment of chronic renal failure whereby patients carry two litres of dialysate with them permanently and are freely mobile. Dialysis is only interrupted by exchange of dialysate in approximately 6-hourly intervals. Due to the long presence of the dialysate in the peritoneal cavity clearance values are superior to intermittent peritoneal dialysis for small-molecular substances and reach elimination values of haemofiltration for medium-molecular substances. The main technical requirements consist of a permanent peritoneal dialysis catheter linked to a plastic dialysate bag by way of a connecting tube. In order to avoid frequent change of bag and thus increased risk of peritonitis bags are folded and carried on the body of the patient during the interval. Thereafter the bag is unfolded, filled with used dialysate and exchanged for a new bag. Six patients were thus treated for over 34 patient-months so far. Changes of chemical pathology were readily acceptable. Even though CAPD has several advantages over conventional dialysis as they are mainly founded on the high degree of rehabilitation of patients, risk of peritonitis is still a considerable factor of uncertainty.

During her second pregnancy a 27-year-old woman had recurrent acute pancreatitis, in the course of which primary hyperparathyroidism was diagnosed. After regression of the acute signs and under conservative treatment a parathyroid tumour was removed in the 26th week of pregnancy. Comparison of surgical and conservative treatment of primary hyperparathyroidism during pregnancy has indicated that the risk of complications in the neonate is much lower after surgical removal of the adenoma than with an attempt to postpone by symptomatic drug treatment the parathyroidectomy until after delivery.

Lipid peroxidation products, both lipid hydroperoxides and thiobarbituric acid reactive substances (TBARS) were determined in the plasma of 31 uremic patients treated with maintenance hemodialysis. Whereas patients had significantly elevated TBARS compared to 93 healthy controls (4.25+/-1.53 vs. 1.66+/-0.50 mu mol/l; p<0.01) lipid hydroperoxides were not detected in the plasma of patients before dialysis. After hemodialysis, a slight increase in TBARS was observed (4.50+/-1.97 mu mol/l, p>0.01). However, when the TBARS were corrected for hemoconcentration by relating TBARS to the plasma cholesterol concentrations a statistically significant decrease of TBARS was observed (1.02+/-0.63 mu mol TBARS/mmol cholesterol vs. 0.84+/-0.60 mu mol TBARS/mmol cholesterol; p<0.01) after 240 min of hemodialysis. There was no evidence for the formation of plasma lipid hydroperoxides in the extracorporeal circulation. It is therefore suggested that elevated TBARS in chronic renal failure are not caused by the dialysis therapy.

Digital subtraction angiography (DSA) and recently developed digital spot imaging (DSI) are modern radiologic techniques in the angiologic diagnosis of hemodialysis fistulas. Main advantage of these methods is their high sensitivity for contrast media allowing transvenous investigation of arterial vessels without direct punction. This unique feature combined with the possibility of post-investigational digital processing makes digital angiography superior to conventional radiologic investigation Color-Doppler sonography can be used alternatively to DSA/DSI in selected patients especially for >>bed-side diagnosis<< of hemodialysis vascular access.

Patients (pts) with essential hypertension normally exhibit a typical diurnal variation with a nocturnal blood-pressure (BP) decreased. A lack of this periodicity is often reported in pts with secondary hypertension. 24-h BP measurement was therefore performed in 308 pts with essential hypertension, and in 172 pts with secondary hypertension, in order to evaluate the diagnostic value of nocturnal BP decrease. Diagnoses of the secondary hypertensives were: renoparenchymatous hypertension (n = 29), diabetic nephropathy (n = 24), morbus Conn (n = 6), renal artery stenosis (n = 32), pheochromocytoma (n = 5), hemodialysis pts (n = 30), and kidney transplantation (n = 44). Pts with essential hypertension showed a mean systolic and diastolic BP decrease during the nighttime period of 22 +/- 7 mmHg and 17 +/- 5 mmHg, respectively. In contrast, the corresponding values in secondary hypertension were 5.7 +/- 9.2 mmHg (systolic decrease) and 5.2 +/- 5.9 (diastolic decrease). Pts with pheochromocytoma who had a nighttime increase in BP demonstrated the greatest difference from the essential hypertensives, followed by pts with either diabetic nephropathy or after kidney transplantation. A lack of nocturnal BP decline (less than 10% of the daytime values) was detected in 69.8% of pts with secondary hypertension, but only in 5.2% of pts with essential hypertension. In summary, these results suggest that the absence of a nighttime decline in BP during 24-h ambulatory monitoring is an indication of secondary hypertension and should lead to further investigations. Furthermore, a nightly hypertension is associated with a higher risk of complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Noninvasive 24-hour ambulatory blood pressure measurement was performed in 17 normotensive and 19 preeclamptic pregnant women. The normotensive women showed a significant decline of systolic and diastolic blood pressure in the night. In contrast, preeclamptic women demonstrated an attenuated circadian rhythm or no circadian rhythm at all. This result was even more pronounced in patients with severe hypertension, some of whom had a nocturnal increase in blood pressure despite antihypertensive drugs given in an evening dose. The lack of nocturnal blood pressure decrease was still detectable 24 hours post partum. These results reveal that preeclamptic women are endangered by hypertensive emergencies mostly during the night. As a result of this, blood pressure controls should be extended into the night, and antihypertensive drugs should also be given in a sufficient evening dose.

The antihypertensive effects of the alpha1-adrenergic inhibitors prazosin and doxazosin and the beta-adrenergic inhibitors metoprolol and metoprolol-zok (zero order kinetics) were compared in a randomized cross-over study in 15 patients (each group) with mild and moderate hypertension. Treatment period lasted 4 weeks per each medication. Both beta-adrenergic inhibitors showed antihypertensive effects, but metoprolol-zok (95 mg/day) was slightly, but significant superior to conventional metoprolol (100 mg/day) during the day-, the night- and the 24-hour period. The second question was the comparison of prazosin (1 mg/day) and doxazosin (2 mg/day). Doxazosin reduced the blood pressure during the day- and the night-time, while prazosin had only an antihypertensive effect for the day-time period. In the night-time period there was no antihypertensive effect. The maximal antihypertensive effect was found 2 hours (prazosin) and 8 hours (doxazosin) after administration of the drugs.

20 patients with hypertension in 24-hours blood pressure measurements in spite of 4 weeks therapy with the ACE inhibitor ramipril (2.5 mg/d), recieved a combination with metoprolol (100 mg/d). After 4 weeks 15 patients became normotensive, 5 needed diuretics additionally to become normotensive during the next 4 weeks. The antihypertensive effect could be demonstrated during the whole 24 hour-period. The percentage of elevated values during 24-hours blood pressure measurement and of blood pressure-peaks above 180 mmHg were significantly reduced by this combination treatment. Patients reported an improvement of subjective complaints such as palpitation of the heart, headache or internal unrest which had still existed during ACE-inhibitor monotherapy. Typical side-effects of the beta-blocker (tiredness; cold extremities) did not occur. The combination of ACE-inhibitor and beta-blocker seems to be useful especially for young patients with increased sympathicotonus and patients with coronary heart disease.

24-h-Ambulatory blood pressure monitoring and bicycle ergometry were compared in 112 patients with untreated mild to moderate essential hypertension. Patients with high blood-pressure values above 220 mmHg during ergometry showed a significantly higher number of blood-pressure peaks above 180 mmHg.There was no significant correlation between the level of the blood-pressure rise during ergometry and the mean values of blood pressure during the 24-h period neither in the night- or the daytime period, nor of the peak values of the 24-h profile. Blood-pressure values during ergometry in patients with high numbers of systolic blood-pressure peaks above 180 mmHg during ambulatory monitoring did not differ significantly from patients with blood-pressure peaks above 180 mmHg during ambulatory monitoring. Patients with marked blood-pressure rise during ergometry seem to demonstrate a higher number of blood-pressure peaks during daytime. On the other hand, patients with an elevated number of blood-pressure peaks do not necessarily show a high blood-pressure rise during ergometry.

First-dose-response of captopril 1 x 25 mg (no prodrug) and ramipril 1 x 2.5 mg (prodrug) were compared in two groups of 17 patients with moderate or severe hypertension and stimulated renin-angiotensin system (because of continous diuretic therapy) by means of 24-h blood-pressure measurement at the lst and 7th day of therapy. In the ramipril-group the antihypertensive effect started after 2 h, had its maximum (mean: -13/-8 mmHg) after 4 h and remained unchanged for 8 h. The antihypertensive effect was significant for 24 h. There was a slightly but not significant improved blood-pressure reduction at the 7th day compared to the 1 st. The captopril-group showed a f ast and marked decrease of blood pressure within the first hour, and reached its maximum (mean: -18/-10 mmHg) after 2 h. After 7 h there was no antihypertensive effect detectable. At the 7th day blood-pressure reduction was less pronounced compared to the 1 st day. The results show that initial decrease of blood pressure in risk-patients is less severe with prodrug-ACE-inhibitors with slow onset of action so that counterregulation can be activated and prevent severe, fast, ACE-inhibitor-induced hypotension. 24-h-blood-pressure measurement is a sufficient method to evaluate first-dose-response of ACE-inhibitors.