Long-term morbidity: hemofiltration vs. hemodialysis.
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Biomedical subjects
Publications and source records attributed to U Hildebrand.
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A 59-year-old white man presented with painless scrotal swelling, a symptom he stated he had had for "several decades." Pathologic examination (conventional stainings, immunohistochemistry, and electron microscopy) revealed a cystic papillary tumor that was classified as a serous papillary cystadenoma, ovarian type, of borderline malignancy, with focal transition into invasive cancer. This appears to be the ninth reported case of testicular tumors of the serous or mucinous ovarian type and the first reported case with development of a circumscribed carcinoma from serous cystadenoma of borderline malignancy.
Reference values for fructosamine and glycated haemoglobin in children are still lacking. Using samples from 522 children (age range 1 day to 9 years), plasma electrophoresis was performed, fructosamine and total protein were determined in EDTA-plasma, and glucose and the fraction of glycated haemoglobin (HbA1c) were determined in EDTA blood. The results were grouped according to age (1, 3 and 5 days, 6-28 days, 2-12 months, 2-3 years, 4-6 years, and 7-9 years). Differences between the age groups were determined using the Mann-Whitney-U-test, and the values in each group were summarized where possible. The 95%-interval was calculated for fructosamine, protein-corrected fructosamine, and HbA1c.
The present study performed on a total of 567 cases of human female breast cancer compares the results of the biochemical assay (dextran-coated charcoal assay = DCC) for oestrogen receptor (ER) with those of several morphological methods developed for the detection of the ER or for the prediction of prognosis by use of other systems (FSA = fluorescent ligand binding assay, ER-ICA = monoclonal antibody assay for ER, LRA = lectin receptor assay using peanut agglutinin, and Barr body estimation). Whereas no correlation at all was observed among the results of the DCC and those of the FSA and Barr body estimation, the ER-ICA and the LRA showed an unanimous tendency towards higher values of ER with increasing intensity of the staining product. The results of the ER-ICA may be expressed by an immuno-reactive score (IRS) calculated from the staining intensity (SI) and the percentage of positive cells (PP). The morphological methods are evaluated with special regard to their correlation with the DCC, their theoretical basis, and their practical application. In summary, the ER-ICA appears to be the sole method directly visualizing the ER protein and--in contrast to the DCC--is therefore completely independent of the content of endogenous or exogenous oestrogens in the tumor tissue. The LRA provides valuable additional information concerning tumour differentiation and possible response to endocrine therapy, whereas the FSA and Barr body estimation should be considered as obsolete and should therefore be abandoned.
Low molecular weight (LMW)-heparin was used as the sole anticoagulant during hemodialysis and hemofiltration in a pilot study on 32 patients. A LMW-heparin dose corresponding to 50% of the patients usual unfractionated, standard (UF)-heparin dose was found to produce comparable plasma heparin levels (anti-FXa-activity). No thrombosis of the extracorporal system and no bleeding complications occurred at this LMW-heparin dose. In contrast to UF-heparin, LMW-heparin produced only slight increases in PTT and thrombin time in all patients. Lipoprotein lipase was stimulated only marginally by LMW-heparin, with a correspondingly reduced release of free fatty acids. Both heparin species caused similar elevations in factor VIII and fibrin monomers, thus excluding a difference in coagulation activation. On the basis of these results, long-term studies have been started at four nephrology centers. To date, 26 patients have been treated with LMW-heparin for 6 months. A LMW-heparin dose was used that produced plasma anti-FXa-activity of 0.5 to 0.9 U/ml (initial dose: 30 to 40; dose/hr: 8 to 15 anti-FXa-units/kg body wt). PTT and thrombin time were only increased by 5 sec on average. Surprisingly, the elevated pre-dialysis levels of factor VIII and fibrin monomers decreased during this 6-month period. Bleeding complications did not occur and thrombotic complications were not observed when the anti-FXa levels were above 0.5 U/ml. LMW-heparin, therefore, appears to be a good alternative to UF-heparin for dialysis patients and may present less risk of bleeding because of its reduced effect on PTT, thrombin time, and thrombocytes.
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Most investigators agree that the remarkable tolerance of the vascular system to fluid withdrawal by haemofiltration is one of the most important advantages of this method. On the other hand it has been shown that blood pressure can be normalised in patients with dialysis-resistant hypertension by applying haemofiltration. The preservation of extracellular osmotic pressure during haemofiltration, obviously caused by the maintenance of a relatively high extracellular Na+ concentration, may induce a rapid and effective refilling of this compartment thus preventing vascular instability. A concept which may explain the apparently contradictory effect of haemofiltration on hypo- and hypertension, is proposed.
The area of contact between the macula densa and the terminal vascular components, the vas afferens, the vas efferens and the mesangium (Goormaghtigh cells) of five glomeruli of the rat has been determined morphometrically using serial sections. The surface, the filtration area, the volume and the total length of the capillaries of each glomeruli has been estimated, and these data have been correlated. There is evidence, that a contact between the macula densa and the mesangium always exists, a contact to the vas afferens is not obligatory.
In order to evaluate the reasons for the better tolerance of the cardiovascular system to body fluid removal in HF, different modifications of single-pass and recirculation HD as well as post-dilution HF were applied in 6 patients with stable chronic renal insufficiency under identical conditions of fluid removal, Curea and use of dialysers. A remarkable tolerance of the vascular system could be observed in HF as in HD when the Na+ concentration in the dialysis or diluting fluid was raised from 130 to 150mEq/L or when plasma osmotic pressure was stabilised by i.v. infusion of mannitol. The different buffers acetate and lactate did not influence the results specifically. Total peripheral resistance and plasma noradrenaline levels increased in HF but showed no changes in HD. Important factors causing the greater tolerance of the cardiovascular system in HF may be a more stable extracellular osmotic pressure, inducing a rapid refilling of the extracellular space, combined with an increasing total peripheral resistance.
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