Shuntchirurgie bei Hämodialysepatienten: Teil 2: Revisionen

Zusammenfassung: Aufgrund der demografischen Entwicklung und der ansteigenden Prävalenz des Diabetes mellitus steigt die Zahl dialysepflichtiger Patienten stetig an. Bei vielen dieser Erkrankten stellt die Anlage einer autologen arterio-venösen Fistel eine echte Herausforderung dar. Im ersten Teil wurde die Thematik der Neuanlage von Hämodialysezugängen besprochen. Früh- und Spätkomplikationen von Shunts wie Stenosen, Verschlüsse, Aneurysmen, Infekte und Steal-Syndrom sind bei dieser chirurgischen Technik häufig und müssen nach heute gültigen Richtlinien behandelt werden, was in diesem 2. Teil abgehandelt wir

Shuntchirurgie bei Hämodialysepatienten: Teil 1: Die Erstanlage

Zusammenfassung: Aufgrund der demografischen Entwicklung und der ansteigenden Prävalenz des Diabetes mellitus nimmt die Zahl dialysepflichtiger Patienten stetig zu. Bei vielen dieser Erkrankten stellt die Anlage einer autologen arterio-venösen Fistel eine echte Herausforderung dar. Erweist sie sich als unmöglich, muss der Gefäßchirurg mit alternativen Zugängen sowie den Vor- und Nachteilen von alloplastischen und heterologen Prothesen vertraut sein (Teil 1). Früh- und Spätkomplikationen wie Aneurysmen, Stenosen, Verschlüsse, Infekte und Steal-Syndrom sind in der Shuntchirurgie häufig und sollten nach heute gültigen Richtlinien behandelt werden (Teil 2

Does continuous renal replacement therapy favourably influence the outcome of the patients?

Continuous haemodialysis and continuous haemofiltration are efficient and safe techniques for the treatment of acute renal failure. Theoretical advantages are improved haemodynamic stability and easier fluid removal. All 15 available studies comparing intermittent (522 patients) with continuous (651 patients) renal replacement therapy have been reviewed. From these studies it cannot be established, whether the use of a continuous instead of an intermittent treatment modality improves the outcome in patients with acute renal failure. Reviewing all 67 published studies dealing with continuous renal replacement therapy revealed a trend to a decreasing mortality rate (P<0.08) over the last 11 years, whereas the mean age and the severity of illness of the patients, measured by the APACHE II score, did not change. In order to establish whether the quality of treatment has improved as a function of time, two quality factors (QF) were created, i.e. QF for age (mean age/mean mortality rate of the patients treated) and QF for severity of diseases (mean APACHE II/mean mortality rate). Both QF improved from 1984 until 1994, when analyzed for continuous (P<0.001) or intermittent (P<0.001) treatment modality. Thus the quality of treatment of patients with acute renal failure improved during the last decade. However, there is no evidence with respect to survival rate that a continuous renal replacement therapy is superior to an intermittent on

Outcome of home haemodialysis patients: a case-cohort study

Background. Randomized, controlled comparisons between home haemodialysis (HHD) and centre haemodialysis (CHD) have not been performed to date. Reported survival benefits of HHD as compared with CHD from uncontrolled studies have been attributed largely to patient selection. Methods. In order to minimize a selection bias, we have compared the outcome of our HHD and CHD patients with a nested case-cohort study. For each patient trained for HHD at our dialysis centre between 1970 and 1995 (n = 103), a corresponding match was searched from the CHD patients by retrospective chart analysis. The pairs were matched for sex, age (±5 years), time of dialysis therapy onset (±2 years) and renal disease category. For 58 of the 103 HHD patients, a corresponding matched CHD patient was identified. Both treatment groups had the same mean age (50±13 years) at dialysis onset and were comparable with respect to the Khan comorbidity index, prevalence and duration of hypertension, smoking habits, history of myocardial infarction, stroke and peripheral vascular disease. In both groups, ∼50% of the patients were transplanted during the observation period. Results. HHD patients were hospitalized less often and tended to have fewer operations as compared with CHD patients. Survival was significantly longer in HHD as compared with CHD. Five, 10 and 20 year survival rates were 93 (n = 55 patients at risk), 72 (41) and 34% (11) with HHD and 64 (38), 48 (26) and 23% (4) with CHD, respectively. This survival difference persisted after adjusting for predictors of mortality, i.e. age at onset of dialysis, year of start of dialysis therapy and Khan comorbidity index. Conclusions. HHD offers a cheap and valuable alternative to CHD, with no apparent disadvantage

Haemodialysis activates phospholipase A2 enzyme

Background Clinical and experimental evidence suggest that haemodialysis (HD) procedure is an inflammatory process. For the production of proinflammatory lipid mediators in many inflammatory reactions, the release of arachidonic acid by phospholipase A2 (PLA2 enzyme is a prerequisite. Therefore, the purpose of the present investigation was to establish whether the activity of PLA2 increases during HD and whether the increase depends on the type of dialyser used. Methods We performed dialysis in eight chronic HD patients. Blood samples entering and leaving the dialyser were obtained before and at 15, 60, 120 and 180 min after the dialysis was started, on one occasion using a cuprophane and on another occasion a cellulose triacetate dialyser. PLA2 activity was assessed in crude plasma and in plasma extract. Results PLA2 activity in plasma extract exhibited similar biochemical properties to that of inflammatory human synovial fluid PLA2 enzyme which is of group II PLA2. PLA2 activity in crude plasma represents a type of PLA2 other than the synovial type. In HD patients, baseline PLA2 activities in crude plasma and plasma extract were significantly increased when compared to normal subjects. An increase in PLA2 activity was observed in crude plasma with a peak appearing at 15 min when the patients were dialysed with cuprophane and cellulose triacetate membranes. This increase was observed in both arterial and venous blood samples and was more pronounced when the patients were dialysed with cuprophane than with cellulose triacetate membranes. When PLA2 was assessed in plasma extract, the activity increased only with cuprophane but not with cellulose triacetate membranes. Conclusions PLA2 activity in plasma is increased in HD patients and increases during the dialysis procedure to a greater extent with a less biocompatible membrane. Continuous activation of PLA2 might be relevant for long-term deleterious consequences of H

Hemodynamic Modeling of the Intrarenal Circulation

Three dimensional, time dependent numerical simulations of healthy and pathological conditions in a model kidney were performed. Blood flow in a kidney is not commonly investigated by computational approach, in contrast for example, to the flow in a heart. The flow in a kidney is characterized by relatively small Reynolds number (100<Re<0.01—laminar regime). The presented results give insight into the structure of such flow, which is hard to measure in vivo. The simulations have suggested that venous thrombosis is more likely than arterial thrombosis—higher shear rate observed. The obtained maximum velocity, as a result of the simulations, agrees with the observed in vivo measurements. The time dependent simulations show separation regimes present in the vicinity of the maximum pressure value. The pathological constriction introduced to the arterial geometry leads to the changes in separation structures. The constriction of a single vessel affects flow in the whole kidney. Pathology results in different flow rate values in healthy and affected branches, as well as, different pulsate cycle characteristic for the whole syste

Joint field experiments for comparisons of measuring methods of photosynthetic production

During the 1st GAP Workshop at Konstanz in April 1982 comparative measurements of phytoplankton primary production by several techniques were conducted simultaneously at an offshore station in Lake Konstanz and an experimental algal pond. Suspended glass bottle exposure techniques using 14C and 13C uptake gave Pz (mg C m−3 h−1) values which varied considerably near-surface, but estimates of areal rates for the euphotic zone ΣPcu(mg C m−3 h−1) which were reasonably close. In the lake, ΣPz, from a vertical tube exposure (with 14C uptake) was greater than rates derived for integrated bottle samples. The oxygen bottle method permitted a good estimate of compensation depth, corresponding to in situ growth studies. There were difficulties in direct comparison between O2 and carbon methods. Correlation between them for Pz was good in the lake but poor in the pond, both for suspended bottle and vertical tube methods. This series demonstrates that despite reasonable overall estimates, comparatively minor methodological differences in experimental technique can cause large variatio

Comparison of continuous and intermittent renal replacement therapy for acute renal failure

Background. Mortality rates of critically ill patients with acute renal failure (ARF) requiring renal replacement therapy (RRT) are high. Intermittent and continuous RRT are available for these patients on the intensive care units (ICUs). It is unknown which technique is superior with respect to patient outcome. Methods. We randomized 125 patients to treatment with either continuous venovenous haemodiafiltration (CVVHDF) or intermittent haemodialysis (IHD) from a total of 191 patients with ARF in a tertiary-care university hospital ICU. The primary end-point was ICU and in-hospital mortality, while recovery of renal function and hospital length of stay were secondary end-points. Results. During 30 months, no patient escaped randomization for medical reasons. Sixty-six patients were not randomized for non-medical reasons. Of the 125 randomized patients, 70 were treated with CVVHDF and 55 with IHD. The two groups were comparable at the start of RRT with respect to age (62±15 vs 62±15 years, CVVHDF vs IHD), gender (66 vs 73% male sex), number of failed organ systems (2.4±1.5 vs 2.5±1.6), Simplified Acute Physiology Scores (57±17 vs 58±23), septicaemia (43 vs 51%), shock (59 vs 58%) or previous surgery (53 vs 45%). Mortality rates in the hospital (47 vs 51%, CVVHDF vs IHD, P = 0.72) or in the ICU (34 vs 38%, P = 0.71) were independent of the technique of RRT applied. Hospital length of stay in the survivors was comparable in patients on CVVHDF [median (range) 20 (6-71) days, n = 36] and in those on IHD [30 (2-89) days, n = 27, P = 0.25]. The duration of RRT required was the same in both groups. Conclusion. The present investigation provides no evidence for a survival benefit of continuous vs intermittent RRT in ICU patients with AR

Creating, moving and merging Dirac points with a Fermi gas in a tunable honeycomb lattice

Dirac points lie at the heart of many fascinating phenomena in condensed matter physics, from massless electrons in graphene to the emergence of conducting edge states in topological insulators [1, 2]. At a Dirac point, two energy bands intersect linearly and the particles behave as relativistic Dirac fermions. In solids, the rigid structure of the material sets the mass and velocity of the particles, as well as their interactions. A different, highly flexible approach is to create model systems using fermionic atoms trapped in the periodic potential of interfering laser beams, a method which so far has only been applied to explore simple lattice structures [3, 4]. Here we report on the creation of Dirac points with adjustable properties in a tunable honeycomb optical lattice. Using momentum-resolved interband transitions, we observe a minimum band gap inside the Brillouin zone at the position of the Dirac points. We exploit the unique tunability of our lattice potential to adjust the effective mass of the Dirac fermions by breaking inversion symmetry. Moreover, changing the lattice anisotropy allows us to move the position of the Dirac points inside the Brillouin zone. When increasing the anisotropy beyond a critical limit, the two Dirac points merge and annihilate each other - a situation which has recently attracted considerable theoretical interest [5-9], but seems extremely challenging to observe in solids [10]. We map out this topological transition in lattice parameter space and find excellent agreement with ab initio calculations. Our results not only pave the way to model materials where the topology of the band structure plays a crucial role, but also provide an avenue to explore many-body phases resulting from the interplay of complex lattice geometries with interactions [11, 12]

A comparison of benthic macroinvertebrate assemblages among different types of alpine streams

SUMMARY 1. Benthic macroinvertebrate assemblages were compared among a diverse array of firstorder alpine tundra streams of the Swiss Alps. 2. A principal components analysis separated sites into three main groups: rhithral streams, rhithral lake outlets, and kryal sites including outlets and streams. Rhithral streams contained the most diverse and taxon rich assemblages, being colonised by both non-insect taxa and Ephemeroptera, Plecoptera, Trichoptera and Diptera. 3. Rhithral lake outlets supported high densities of non-insect taxa such as Oligochaeta, Nemathelminthes and crustaceans. Despite low taxon richness, kryal sites had high Ephemeroptera and Plecoptera abundances. Chironomidae were most common at all sites. 4. Collector-gatherers were dominant at all sites, whereas filter-feeders were rare. Scrapers and shredders were more common in streams than lake outlets. 5. Water temperature and algal standing crops were higher at rhithral lake outlets than rhithral streams, perhaps providing more favourable habitat for non-insect taxa. Glacial runoff was the dominant factor influencing macroinvertebrate assemblages of kryal streams and kryal lake outlets. Alpine lakes influenced the environmental conditions of their outlets and, consequently, their macroinvertebrate assemblages unless being constrained by a glacial influence