Resistant hypertension is still a challenge and reserve antihypertensive agents are often necessary to achieve blood pressure control. One reserve antihypertensive is minoxidil, a direct vasodilator that is known for its strong blood pressure–lowering effect, but contemporary studies are sparse. The authors retrospectively analyzed 54 inpatients with uncontrolled hypertension despite the combined use of current antihypertensive agents. To investigate the effect of minoxidil when added to other antihypertensive agents, blood pressure was evaluated at the time minoxidil treatment was initiated and at discharge. Minoxidil treatment was associated with a significant reduction in blood pressure from 162.4±15.1/83.2±12.7 mm Hg to 135.8±12.2/72.8±6.9 mm Hg ( P <.0001). This effect was sustained across all analyzed subgroups. Although the well‐known adverse events of minoxidil limit its widespread use, these data show that minoxidil as a reserve antihypertensive agent still has a niche indication in the particular subgroup of patients with treatment‐resistant or uncontrolled hypertension.

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

To analyze the performance of the 1 mg dexamethasone suppression test (DST) in patients with obesity. Special attention was paid to the influence of interfering medication on DST.

Cranberry ( Vaccinium macrocarpon ) juice and extracts are widely used and recommended as folk remedy for prophylaxis of urinary tract infections (UTIs). Its putative mechanism is an anti-adhesive effect that prevents docking of bacteria on host tissues. The anti-adhesion quality is attributed to A-type proanthocyanidins (PACs), a group of polyphenols that has a restricted occurrence in cranberries and a few related plants. Clinical trials with cranberry have provided a mixed evidence on behalf of UTI prophylaxis. In some trials, a benefit could not be detected due to lower than calculated UTI recurrence rates, in others failure had retrospectively been blamed on underdosing of cranberry products. To circumvent such problems, cranberry products need to be standardized for the bioactive principle of PAC and administered at a sufficient dose. Further characterization of PAC bioavailability, improvement of the currently inconvenient prescriptions, and above all of the palatability for patients is strongly recommended. Larger staged trials should then be carried out in patients with relevant UTI risks. Keywords: cranberry ( Vaccinium macrocarpon Aiton), urinary tract infection, proanthocyanidins, anti-adhesion, p-fimbriae

Whether organs from donors after brain death (DBD) with acute kidney injury (AKI) should be accepted for transplantation is still a matter of debate.

Objective: With the pandemic of obesity the identification of individuals with hypercortisolism gets more difficult. We analyzed the performance of the 1 mg dexamethasone suppression test (DST) in patients with obesity in a clinical setting. Design and method: We conducted a prospective cohort study in patients with obesity (MOS, NCT00770276). Patients presented in our outpatient department for metabolic and cardiovascular evaluation. After obtaining medical history patients were analysed for anthropometry, metabolism, and cardiovascular risk factors. For evaluation of hypercortisolism we performed a 1 mg dexamethasone-suppression test (DST) in all subjects as screening. In case of insufficient suppression of cortisol (>50nmol/l) further diagnostic assessment was performed: repeat DST, salivary midnight cortisol (SMC) and/or 24 h urine free cortisol (UFC). Medication was assessed for drugs with possibly interfering effects on DST and hypothalamic-pituitary-adrenal axis (e.g. CYP3A4 inducers, estrogen therapy, antidepressants and opiates). Results: A total of 278 patients with a mean age of 42.3years with a female predominance (68.8% women) were screened by DST. Anthropometrical data revealed a mean BMI of 47.9 ± 8.4 kg/m2 and a waist circumference of 137 ± 17.6 cm representing truncal obesity. Insufficient suppression of cortisol after DST was found in 24 patients (8.6%). In 2 patients hypercortisolism was confirmed by UFC. The specificity for DST was calculated with 92.0%. 45.0% of the cohort received confounding medication. Only CYP 3A4 inducers (n = 22, 7.9%) and estrogen therapy (n = 17, 6.1%) were significantly associated with pathological DST. After elimination of all patients with interfering medication specificity slightly increased to 94.9%. Regression analysis revealed no interrelation between DST and anthropometry. Conclusions: In obese patients presenting for bariatric therapy in a tertiary care center we found low prevalence of hypercortisolism (0.7 or < 1.8%). Specificity of DST in this cohort typically screened for hypercortisolism was 92.0% (<51nmol/l), which represents adequate performance. After elimination of interfering medication (CYP3A4 inducers and estrogen therapy) specificity increased only slightly. Furthermore, regression-analysis revealed no association with anthropometrical data, even though we studied patients with extreme measures. In summary DST is an adequate test for screening for hypercortisolism in a real clinical setting.

Mit der renalen Sympathikusdenervation steht seit 2009 ein neues interventionelles minimal-invasives Verfahren zur Behandlung von therapieresistenten Hypertonikern zur Verfügung. Die bisherigen Follow-up-Untersuchungen bis 3 Jahre nach Intervention zeigen anhaltende relevante Blutdrucksenkungen, positive Auswirkungen auf hypertensive Zielorganschäden sind ebenso zwischenzeitlich beschrieben. Bei hoher prozeduraler Sicherheit sind die Langzeitauswirkungen der Ablation auf die Nierengefäße noch nicht hinreichend geklärt. Ebenso besteht weiterhin Optimierungsbedarf hinsichtlich der Auswahl der am besten für dieses Verfahren geeigneten Patienten, hier müssen insbesondere sekundäre Hypertonieformen bzw. Patienten mit Pseudoresistenz vor Intervention identifiziert werden, um unnötige Interventionen zu vermeiden.

IgA-Nephropathie ▼ Die IgA-Nephropathie ist die häufigste Form einer primären Glomerulonephritis in Deutschland. Histologisch ist neben einer glomerulären Ablagerung von IgA-Molekülen eine Proliferation der Mesangialzellen charakteristisch. In den letzten Jahren wurde die Pathogenese der IgA-Nephropathie in wesentlichen Aspekten neu verstanden. Eine Aktivierung des mukosalen Immunsystems hat eine Synthese von polymerem IgA zur Folge, und die entsprechenden Personen zeigen erhöhte Spiegel zirkulierender Immunkomplexe, vornehmlich der Subklasse IgA1. Bei Patienten, bei denen sich in der Folge eine IgA-Nephropathie entwickelt, konnte eine fehlerhafte Glykosylierung des IgA-Moleküls ausgemacht werden. Diese spielt eine zentrale Rolle für eine verminderte Entfernung der deponierten Immunkomplexe und eine Auslösung einer nachfolgenden Autoimmunreaktion.

Introduction Central vein stenosis is not a rare problem in patients on dialysis. Placement of a central vein catheter for dialysis access substantially increases the risk of central vein stenosis. However, even in patients without a previous history of central vein catheter placement, a stenosis can be found in up to 40% of patients. Case presentation We report the case of a 60-year-old male Caucasian German dialysis patient who complained of dry cough, swelling of his right arm and facial edema. Computed tomography venography showed a near-total stenosis of his brachiocephalic vein. We discuss the incidence and risk of central vein stenosis in patients on dialysis and report on a successful minimally invasive interventional treatment. Conclusion Central vein stenosis is not a rare problem in patients on hemodialysis and can even occur without previous placement of central venous catheters. High shunt volumes seem to increase the risk associated with central vein catheters.

Neuro-endocrine deficiencies have been argued to be common sequelae after aneurysmal subarachnoid hemorrhage (aSAH). As this, however, does not resemble our clinical experience, we studied the incidence of neuro-endocrine and neuropsychological deficits after aSAH. Twenty-six patients (20 females) were prospectively screened for neuro-endocrine and neuropsychological deficits 3, 6 and 12 months after aSAH. GH, IGF-1, prolactin, LH, FSH, estradiol, testosterone, ACTH as well as cortisol during ACTH-stimulation were assessed. Neuropsychological analysis covered verbal comprehension, short term and working memory, visuospatial construction, figural memory, psychomotor speed, attention, and concentration. During the study period 5 individuals demonstrated neuro-endocrine dysfunction. Hypogonadotrophic hypogonadism resolved spontaneously in 2 patients and central hypothyroidism in one of these patients during the study. After 12 months three patients presented low IGF-1 levels. 73.9% of our cohort was affected by neuropsychological deficits during follow-up. At 3, 6 and 12 months the prevalences were 56.5, 52.6 and 42.1%, respectively. Interestingly, all patients with neuro-endocrine dysfunction presented impaired clinical outcome with a GOS 4 at some time point of the study (GOS 4 vs. 5, 45.5% vs. 0, P = 0.007). We found a low prevalence of neuro-endocrine and a high prevalence of neuropsychological deficits in patients 3, 6 and 12 months after aSAH without significant interrelation. Spontaneous recovery of neuro-endocrine alterations most likely presents an adaption to or dysfunction after severe illness. This hypothesis is strengthened by the fact that only patients with inferior clinical outcome after aSAH as assessed by GOS demonstrated neuro-endocrine dysfunction.

Primäre systemische Vaskulitiden benötigen in der Regel eine immunsuppressive Behandlung. Mycophenolat-Mofetil (MMF) als lymphozytenselektives Immunsuppressivum mit nachgewiesener Wirksamkeit und guter Verträglichkeit im Bereich der Organtransplantation erscheint hier als Behandlungsansatz vielversprechend. In den letzten Jahren sind diesbezüglich mehrere Studien erschienen, die unter Berücksichtigung besonderer Aspekte der Pharmakokinetik des MMF bei Autoimmunerkrankungen diskutiert werden.

Background: Organ shortage remains the leading obstacle in kidney transplantation. Whether organs from brain-dead donors with acute kidney injury (AKI) should be accepted for transplantation is still a matter of debate. Methods: Centre-based, matched cohort study of 33 renal transplant patients who had received a renal allograft by way of rescue allocation from a donor with AKI prior to organ procurement. 65 kidney transplants devoid of AKI in the donor and performed in each case directly beforehand and thereafter served as controls. Results: All donors with AKI were classified according to the RIFLE criteria: Of these, 3 donors (9.1%) fulfilled level “Risk”, 18 (54.6%) level “Injury”, and 12 (36.4%) level “Failure”. Mean serum-creatinine was 2.41±0.88 mg/dL at time of procurement and 1.06±0.32 mg/dL on admission, respectively. AKI donors had a lower 24hr urine production (3.6 L [IQR 1.2-4.1 L] vs. 4.1 L, [IQR 3.1-5.3 L], P=0.009), were many times exposed to noradrenaline (31/33 [93.9%] vs. 47/65 [72.3%], P=0.02) and/or adrenaline (5/33 [15.2%] vs. 1/65 [1.5%], P=0.02), and had more often undergone cardio-pulmonary resuscitation (11/33 [33.3%] vs. 7/65 [10.8%] P=0.01). Recipient and transplant characteristics, including age, gender, waiting-time, cold ischemia, and immunosuppressive therapy were very similar excepting a more favourable HLA-match in control patients (P=0.01). Hemodialysis posttransplant was more frequently used in AKI recipients (14/33 [42.4%] vs. 18/65 [27.7%], P=0.17). While significant elevations in serum creatinine were noted in these patients until 10 days after transplantation, this difference lost statistical significance by day 14. One year graft survival was very similar comparing the groups (93.6% [95%CI 76.8%-98.4%] vs. 90.3% [95%CI 0.79.6%-95.5%], log rank P=0.58).Figure: [Trajectories of serum creatinine levels]Conclusions: Kidneys from donors with AKI can be transplanted with an excellent intermediate prognosis and should not be discarded.

BACKGROUND:N-acetylcysteine (NAC) has been proposed to prevent radiocontrast nephropathy in high-risk patients.METHODS:The effect of single-dose and prolonged administration of NAC before application of either the ionic, high-osmolar radiocontrast agent diatrizoate sodium (DTZ) or the nonionic, low-osmolar radiocontrast agent iohexol (IOH) in a rat model combining uninephrectomy, salt depletion, and administration of indomethacin was explored. Arterial blood pressure and total, cortical, and medullary blood flow were continuously recorded in anesthetized Sprague-Dawley rats.RESULTS:NAC had no effect on renal hemodynamics in control rats. Both DTZ and IOH induced biphasic changes in renal blood flow and cortical renal blood flux and persistently reduced medullary blood flux. Neither single-dose nor prolonged administration of NAC prevented the hemodynamic changes following administration of DTZ or IOH, respectively. Acute prophylactic administration of NAC prevented increased urinary ET excretion after injection of IOH and, to a smaller degree, of DTZ. Both an ionic, high-osmolar (DTZ) and a nonionic, low-osmolar (IOH) radiocontrast agent induce marked changes in renal hemodynamics in salt-depleted rats treated with indomethacin.CONCLUSIONS:Renal perfusion is not affected by NAC application in a model of experimental contrast nephropathy in rats. Other effects of NAC might thus account for the presumed renoprotective properties.

Commentary on: Akyol AD, Yildirim Y, Toker E, et al. The use of complementary and alternative medicine among chronic renal failure patients. J Clin Nurs 2011;20:1035–43.[OpenUrl][1][CrossRef][2][PubMed][3] A substantial subset of patients with chronic renal failure (CRF) has to accept that their disease will progress to end-stage renal disease (ESRD) despite modern evidence-based therapy. Dialysis-dependency is a bitter burden and patients fear the … [1]: {openurl}?query=rft.jtitle%253DJournal%2Bof%2Bclinical%2Bnursing%26rft.stitle%253DJ%2BClin%2BNurs%26rft.aulast%253DAkyol%26rft.auinit1%253DA.%2BD.%26rft.volume%253D20%26rft.issue%253D7-8%26rft.spage%253D1035%26rft.epage%253D1043%26rft.atitle%253DThe%2Buse%2Bof%2Bcomplementary%2Band%2Balternative%2Bmedicine%2Bamong%2Bchronic%2Brenal%2Bfailure%2Bpatients.%26rft_id%253Dinfo%253Adoi%252F10.1111%252Fj.1365-2702.2010.03498.x%26rft_id%253Dinfo%253Apmid%252F21320219%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1111/j.1365-2702.2010.03498.x&link_type=DOI [3]: /lookup/external-ref?access_num=21320219&link_type=MED&atom=%2Febnurs%2F15%2F1%2F29.atom

OBJECTIVE:Neuropsychological sequelae are common after aneurysmal subarachnoid hemorrhage (aSAH) and may be associated with or caused by supposed hypothalamic-pituitary dysfunction. We evaluated the incidence of neuro-endocrine and neuropsychological deficits after aSAH and their interrelations in a standardized manner.METHODS:26 patients (20 females) were prospectively screened for neuro-endocrine and neuropsychological deficits 3 and 6 months after aSAH. We measured GH, IGF-1, prolactin, LH, FSH, estradiol, TSH, fT4, total T3, testosterone, ACTH as well as cortisol before and after ACTH-stimulation. Neuropsychological analysis covered verbal comprehension, short term and working memory, visuospatial construction, figural memory, psychomotor speed, attention, and concentration.RESULTS:After 3 months central hypogonadism was observed in 2 patients accompanied by central hypothyroidism in 1 male subject. Central hypogonadism resolved spontaneously after 6 months in both. After 3 months, neuropsychological deficits were detected in 57% of the examined patients (44% attention deficits, 38% memory impairment, 12% psychomotor deficits). Neuropsychological deficits were still present in 53% after 6 months.CONCLUSION:We found a low prevalence of neuro-endocrine and a high prevalence of neuropsychological deficits in patients 3 and 6 months after aSAH. Thus, the absent co-incidence of central hormonal and psychological dysfunction leaves a causal association questionable.

Remissions of nephrotic syndrome due to membranous nephropathy (MN) induced byAstragalus membranaceus have drawn nephrologists attention to medicinal herbs as alternative treatments of glomerulonephritis. MN stands for a group of chronic glomerulonephritides that are routinely treated with corticosteroids and cytotoxic drugs, although treatment responses are unsatisfactory and the toxic burden significant. The investigational status of Astragalus and other medicinal herbs like Angelica sinensis, Tripterygium wilfordii, Rheum palmatum, Ligusticum wallichii, Perilla frutescens, Salvia miltiorrhiza, Arctium lappa with respect to their use as treatments of chronic renal disease and specifically of glomerulonephritis is reviewed. Most of these herbs are in current clinical use in China and appear to have promising constituents capable of modifying immune processes in glomerulonephritis. Nevertheless, their application in patients can still not be advocated as clinical studies meeting international quality standards have not been performed and toxic risks had not been excluded with adequate scrutiny. Key words: Glomerulonephritis, medicinal herbs, triptolide, astragalus, perilla, rhubarb.

Objectives We determined the outcome of cardiac allografts from multiorgan donors enrolled in a randomized trial of donor pre-treatment with dopamine.Background Treatment of the brain-dead donor with low-dose dopamine improves immediate graft function after kidney transplantation.Methods A cohort study of 93 heart transplants from 21 European centers was undertaken between March 2004 and August 2007. We assessed post-transplant left ventricular function (LVF), requirement of a left ventricular assist device (LVAD) or biventricular assist device (BVAD), need for hemofiltration, acute rejection, and survival of recipients of a dopamine-treated versus untreated graft.Results Donor dopamine was associated with improved survival 3 years after transplantation (87.0% vs. 67.8%, p = 0.03). Fewer recipients of a pre-treated graft required hemofiltration after transplant (21.7% vs. 40.4%, p = 0.05). Impaired LVF (15.2% vs. 21.3%, p = 0.59), requirement of a LVAD (4.4% vs. 10.6%, p = 0.44), and biopsy-proven acute rejection (19.6% vs. 14.9%, p = 0.59) were not statistically different between groups. Post-transplant impaired LVF (hazard ratio [HR]: 4.95; 95% confidence interval [CI]: 2.08 to 11.79; p < 0.001), requirement of LVAD (HR: 6.65; 95% CI: 2.40 to 18.45; p < 0.001), and hemofiltration (HR: 2.83; 95% CI: 1.20 to 6.69; p = 0.02) were predictive of death. The survival benefit remained (HR: 0.33; 95% CI: 0.12 to 0.89; p = 0.03) after adjustment for various risks affecting mortality, including pre-transplant LVAD/BVAD, inotropic support, and impaired kidney function.Conclusions Treatment of brain-dead donors with dopamine of 4 mu g/kg/min will not harm cardiac allografts but appears to improve the clinical course of the heart allograft recipient. (Prospective Randomized Trial to Evaluate the Efficacy of Donor Preconditioning With Dopamine on Initial Graft Function After Kidney Transplantation; NCT00115115) (J Am Coll Cardiol 2011;58:1768-77) (C) 2011 by the American College of Cardiology Foundation

Background. A recent randomized trial showed that pretreatment of the brain-dead donor with low-dose dopamine improves immediate kidney graft function, by limiting injury from cold storage (ClinicalTrials.gov Identifier: NCT00115115). This study determines whether donor exposure to desmopressin (1-deamino-8-D-arginine-vasopressin [DDAVP]) before organ retrieval affects renal transplant outcome.Methods. This retrospective multicenter cohort study, nested in the database of the dopamine trial, includes 264 deceased heart-beating donors with confirmed brain death and corresponding 487 renal allograft recipients transplanted at 60 European centers between March 2004 and August 2007. We assessed differences in delayed graft function, biopsy-proven acute rejections, and 2-year kidney graft survival in recipients of a DDAVP-exposed versus unexposed graft.Results. DDAVP was associated with improved graft survival (85.4% vs. 73.6%, P = 0.003). This survival benefit persisted after censoring for death with functioning graft (91.1% vs. 82.0%, P = 0.01) and after adjustment for confounders including covariate adjustment from propensity scoring (hazard ratio 0.40, 95% confidence interval [CI] 0.21-0.77; P = 0.006). Delayed graft function (odds ratio 0.97, 95% CI 0.57-1.65; P = 0.92) and biopsy-proven acute rejections (odds ratio 1.32, 95% CI 0.70 -2.49; P = 0.40) were unaffected. The survival effect was enhanced after a shorter cold ischemic time less than 14 hr (91.3% vs. 77.8%, P = 0.008) and after dopamine pretreatment (92.7% vs. 78.6%, P = 0.006). By contrast, prolonged cold ischemic time more than or equal to 14 hr (91.2% vs. 86.5%, P = 0.39) and assignment to the nondopamine group (89.7% vs. 84.8%, P = 0.37) abrogated the survival advantage.Conclusions. Donor DDAVP seems to improve renal allograft survival. Combined use of donor DDAVP and low-dose dopamine should receive further evaluation.