Nephrologe最新文献

The pathogenesis of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides is complex; however, a better understanding in recent years has enabled new therapeutic approaches. In recent years priority was given to the minimization of treatment-associated toxicity. For induction of remission of severe granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA), glucocorticoids are used as well as cyclophosphamide and rituximab. The current recommendations enable a more rapid tapering of steroid dose and advise caution in the use of plasmapheresis. Rituximab and azathioprine are available options for maintenance of remission. The choice of medication and duration of remission maintenance are oriented particularly to the risk of recurrence. The importance of low-dose steroids has not yet been finally clarified. New treatment approaches, such as the C5a receptor inhibitor avacopan could enable a minimized steroid treatment in the future. The treatment of eosinophilic granulomatosis with polyangiitis (EGPA) is less evidence-based and consists of glucocorticoids, immunosuppressive agents depending on the severity and increasingly more biologics, e.g. interleukin‑5 blockade. Supportive measures (e.g. vaccinations, infection prophylaxis, cardiovascular risk management) are increasing in importance. Future treatment strategies must take the individual risk (e.g. ANCA subtype, relapse risk) more into consideration for selection and duration of treatment.

Very old people have a 1‑year mortality on hemodialysis, which in association with comorbidities and a catheter as dialysis access exceeds 30%; however, meta-analyses show that timely preparation and individually selected procedures decisively improve the morbidity and mortality even in old age. With increasing age and frailty the treatment targets shift away from prolongation of the lifespan to improvement of the quality of life. In this way the preference of home dialysis procedures, also as assisted peritoneal dialysis, can also achieve importance just as specialist nephrological treatment without renal replacement therapy with a palliative treatment target. In advanced age comorbidities, cognitive impairment, frailty and the overall prognosis determine the meaningful approach. Even with the placement of a vascular access there are other criteria for making decisions in very old people with respect to the anastomosis site and timing of access placement. Recommendations on the duration and frequency of dialysis follow the quality of life with incremental and at the end of life also with decremental treatment regimens. The demographic development is a special challenge for nephrology with an increase in older patients. Timely clarification of all renal replacement procedures and establishment of individual treatment targets with a careful selection of the dialysis modality and intensity can make a decisive contribution to improvement of the prognosis and particularly to the quality of life even in the very old.

Aspects of palliative medicine such as withholding and withdrawal of dialysis, initiating conservative therapy and cooperative end-of-life care have increasingly become part of standard renal care. The corresponding transfer of knowledge of palliative medicine principles has so far been lacking in training and further education. This consensus paper proposes structured curricular training for the kidney team based on principles of palliative care.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly spread globally since December 2019. A first wave is visible up to the end of June 2020 in many regions. This article presents a review of the current knowledge on the epidemiology and prevention. The SARS-CoV‑2 predominantly replicates in the upper and lower respiratory tracts and is particularly transmitted by droplets and aerosols. The estimate for the basic reproduction number (R₀) is between 2 and 3 and the median incubation period is 6 days (range 2-14 days). As with the related SARS-CoV and Middle East respiratory syndrome (MERS-CoV), superspreading events play an important role in the dissemination. A high proportion of infections are uncomplicated but moderate or severe courses develop in 5-10% of infected persons. Pneumonia, cardiac involvement and thromboembolisms are the most frequent manifestations leading to hospitalization. Risk factors for a complicated course are high age, hypertension, diabetes mellitus and chronic cardiovascular and pulmonary diseases as well as immunodeficiency. Currently, the estimation for the infection fatality rate (IFR) is between 0.5% and 1% across all age groups. Outbreaks were limited in many regions with bundles of various measures for reduction of social contacts. The incidence for the first wave in Germany can be estimated as 0.4-1.8% and excess mortality could not be observed.