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Metabolic and nutritional care implies procedures which involve normalization or improvement of metabolic deviations in chronic renal insufficiency and failure by dietary and medicamentous means. The therapeutic procedure not only improves some metabolic disorders associated with a decline of the excretory and metabolic endocrinological renal function but can have a positive impact also on progression of renal insufficiency. Conservative treatment thus involves low protein diets, modification of electrolyte and water intake, adjustment of the acid-base balance, Ca, P metabolism, haemogram, hypertension, proteinuria and hyperlipidaemia. In non-diabetic subjects it is sufficient to achieve a glomerular filtration of 0.2 ml/sec. and serum creatinine of 500-600 mumol/l.

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In a group of patients after transplantation of the kidney with stabilized graft function treated by Consupren sol. combined with prednisone and azathioprin in 20 patients (group A) Consupren sol. was replaced by Consupren S capsules, in 17 patients (group B) Consupren sol. therapy proceeded without any change. To maintain the cyclosporin blood concentration within the therapeutic range it was necessary after the change of drug form in group A to adjust the dosage of the drug in 12 patients of group A while in group B only in one patient (p<0.01). The mean doses and levels of Cy-A however did not change significantly during the three-month investigation period in the two groups and and the bioequivalence of the two preparations was evident. Conversion from Consupren sol. to Consupren S capsules is not associated with the risk of rejection or undesirable effects. It can be implemented at a ratio of 1:1 or 1: the closest dose divisible by 25 (the smallest capsules are 25 mg) and after conversion a check-up or possible modification of the dose is necessary.

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Severe gastroduodenal bleeding after renal transplantation is effectively prevented by H2 receptor blockers. New drugs for prophylaxis include proton pump inhibitors. The aim of the present study was to compare the effects of prophylaxis with the H2 blocker ranitidine and with the proton pump inhibitor omeprazole. One hundred seventy-seven consecutive patients were included in a controlled, prospective, randomized study after cadaveric renal transplantation. In one case, ranitidine failed to prevent exsanguination due to duodenal peptic ulcer bleeding. No bleeding was noted in the omeprazole group. There were no significant differences between the groups in hospitalization time, development of renal function, amount of cyclosporin A, prednisone, azathioprine, or methylprednisoline ingested, or laboratory biochemical parameters. We conclude that prophylaxis of severe gastroduodenal bleeding after renal transplantation with omeprazole is effective. Omeprazole is certainly as good as ranitidine; its advantages are a prolonged effect and a simple dosage, independent of graft function development.

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BACKGROUND: For patients having regular haemodialysis there are no suitable complete preparations for general use in case intensive treatment is needed. Nutrilac renal is a new preparation of a nutritionally defined liquid diet corresponding as to its composition to the needs of haemodialyzed patients. The purpose of the present work was to assess whether this preparation when administered as a supplement will have a favourable effect on the nutritional parameters of haemodialyzed patients. METHODS AND RESULTS: Nutrilac renal was administered to haemodialyzed patients for a period of three weeks as a supplement meeting 20% of the energy requirements. The protein intake rose from 0.87 to 0.95 g/kg body weight (p < 0.05), the energy intake from 109 to 126 kJ/kg body weight (p < 0.05). As to nutritional parameters, the serum albumin values improved (from 25.0 to 29.4 g/l, p < 0.05) and Whitehead's quotient from 1.8 to 1.5, p < 0.05). The favourable effect on the amino acid spectrum was manifested by a significant rise of essential amino acids and those with branched side chains (p < 0.01). The preparation did not lead to a rise of potassium, ura and vitamin A levels. CONCLUSIONS: The newly developed preparation Nutrilac renal exerts a favourable effect on nutritional parameters. Changes in the aminogram characterized by an increase of essential amino acids, in particular threonine, valine, leucine and isoleucine indicate the high biological value of the protein component of the preparation for patients with chronic renal failure.

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In bioptic specimens of the gastric mucosa of 57 patients with dyspeptic complaints and/or a duodenal ulcer Helicobacter pylori was detected under the microscope in 82,4% of chronic active gastritis and in 28,6% and 61,5% resp. of chronic gastritis grade I and II. The finding of helicobacteria depended on the number of collected specimens. They were never found at sites with intestinal metaplasia and their numbers did not correspond to the intensity and character of the inflammatory changes. As compared with the antrum, in the corpus of the stomach helicobacteria were found more frequently not only in mild forms of the inflammation but also in the normal mucosa. In the duodenum the finding was negative and the inflammatory changes were only mild. In all patients with a duodenal ulcer and a scar after ulceration in the antrum chronic active or inactive gastritis grade II was found with helicobacteria in 84,6% of the observations. Cultivation was consistent with microscopic evidence in 50 patients (87,7%).

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Residual kidney function was examined in 10 patients with chronic renal insufficiency under balance conditions and in 30 outpatients on the basis of urea clearance (Curea) and potassium clearance (CK). Protein intake was 35-40 g/day (0.5 g/kg/day) and potassium intake was 30-40 mmol/day. Under these conditions the critical values of residual kidney function were as follows: 1) plasma urea concentration (Purea) did not exceed 30 mmol/l if Curea did not drop below 3.8 ml/min; 2) plasma potassium concentration (PK) did not exceed 5 mmol/l if CK did not decrease below 4.1 ml/min. Clinical examination of Curea and CK provides additional information to the examination of creatinine clearance (Ccr) or its plasma concentration (Pcr). Our results suggest that the critical value of residual kidney function cannot be defined only on the basis of examination of Ccr or Pcr. Examination of Curea and CK can help in the interpretation of very high Purea and hyperkalemia in patients with chronic renal insufficiency.

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Very little is known about bile composition in the end stage of chronic renal sufficiency. Patients with this condition are either assigned to a dialysis-transplantation programme, or are treated temporarily with a low-protein diet. Our study was designed to determine bile composition both in a group of ten patients treated with a low-protein diet over a long period of time, and in 11 patients on regular haemodialysis. The patients on haemodialysis were found to have increased bile cholesterol and an increased saturation index in the bile, i.e. changes implying increased risk of cholecystolithiasis. These changes were further enhanced by the effect of a low-protein diet with subsequent increases in cholesterol values and the bile saturation index, as well as a decrease in primary and an increase in secondary bile acids in the bile, i.e. a change in the spectrum of bile acid characteristic for cholecystolithiasis.

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The relationships between the plasma levels of urea (P(urea)), renal clearance of urea (C(urea)) and creatinine (Ccr) at an intake of 0.5 g protein/kg body weight/day were followed in 10 patients with chronic renal failure (CRF) under balance conditions. Under these conditions, P(urea) attained a value of 30 mmol/l when C(urea) had decreased below 3.8 ml/min. By contrast, no correlation could be demonstrated between P(urea) and Ccr under these conditions. The same relationships were followed in another group of 30 outpatients with CRF. Even in patients not followed under balance conditions, C(urea) determination makes it possible to establish whether the high increase in P(urea) is due to the decrease in residual renal function below the critical level or whether extrarenal factors are involved. Likewise, no significant correlation between P(urea) and Ccr could be demonstrated under these conditions. The findings suggest that C(urea) measurement in CRF patients helps to assess residual renal function in terms of P(urea) regulation and provides information that cannot be obtained by Ccr measurement.

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When following the spectrum of plasmatic amino acids in patients with chronic renal failure in course of a six-week treatment with low-protein diets, an increase of non-essential amino acids, glycine and alanine, was observed in the case of a diet containing 20 g of proteins. A further decrease of tyrosine and threonine, which were decreased already before the therapy, suggests the presence of an effect of the reduced intake of proteins on the levels of these amino acids. High levels of methionine occurring in the case of the diet containing 20 g of proteins a day, supplemented by methionine to a minimally necessary requirement according to Rose, show different requirements) for this amino acid in patients with the chronic renal failure. A significant drop of the histidine and arginine as compared to the values before the treatment demonstrated that it is also necessary to take into account these amino acids when composing optimal amino acid formulation for uremics. A preliminary proposal is presented of a composition of amino acid mixture suitable for patients with chronic renal failure which differs essentially from the Rose formulation developed for a healthy organism. Different requirements for arginine are also considered in addition to the essential amino acids and histidine.

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