Hypocalcemic heart failure in end-stage renal disease

A 37-year-old woman presented with hypocalcemic heart failure complicating end-stage renal disease. Heart failure persisted despite conventional therapy but improved after correction of hypocalcemia. Continuous monitoring of left ventricular function by radionuclide study during calcium replacement showed dramatic improvement. Our case showed that hypocalcemia could be a rare but reversible cause of frank heart failure in uremic patients.

The effect of fish-oil dietary supplement on the progression of mesangial IgA glomerulonephritis

The effect of fish-oil dietary supplement on the rate of progression of renal failure in 11 patients with IgA nephropathy was investigated by comparing the slope of the plot of reciprocal serum creatinine versus time before and after supplement. After supplement, the slope significantly decreased in two patients, increased in two, and was not significantly altered in the remainder. Before supplement, serum IgA, IgA circulating immune complexes, and in-vitro Ig production were not significantly different from normal controls. After supplement, urinary protein transiently increased, serum IgA circulating immune complexes decreased, and serum triglyceride and in-vitro platelet aggregation tended to decrease. Only the change in serum IgG and spontaneous in-vitro IgG production correlated with the change in the rate of renal functional deterioration. No clinical or biochemical parameters before supplement predicted the subsequent response. In patients with IgA nephropathy, non-immune factors probably contribute to progression of renal failure, and in these patients fish-oil dietary supplement has either no demonstrable or an unpredictable effect.

Lupus nephritis patients on maintenance dialysis in Hong Kong

Eleven patients with lupus nephritis required maintenance dialysis. Two were on haemodialysis (HD), 9 on continuous ambulatory peritoneal dialysis (CAPD). One was subsequently transplanted and recurrence of lupus nephritis occurred at 9 months posttransplant. One discontinued CAPD after 6 months; 4 died and the remaining 7 were fully rehabilitated. There was marked regression of extra-renal lupus activity post-dialysis.

Mesangial IgA nephropathy with steroid-responsive nephrotic syndrome: disappearance of mesangial IgA deposits following steroid-induced remission

This report describes the clinical features and renal biopsy pathology in two patients with immunoglobulin A (IgA) nephropathy and nephrotic syndrome before and after steroid-induced remission. Apart from confirming the frequently relapsing course and mild glomerular changes observed in patients with IgA nephropathy and steroid-responsive nephrotic syndrome (SRNS), we were able to show that mesangial expansion and mesangial IgA deposits disappeared or were greatly reduced in repeat renal biopsies following steroid-induced remission. Because mesangial IgA deposits usually persist in repeat biopsies obtained from patients with typical IgA nephropathy, their resolution in our patients following steroid remission would support the proposal that the association of IgA nephropathy and SRNS may represent a distinct clinical syndrome. It is postulated that the presence of mesangial IgA deposits during nephrotic presentation and their disappearance following steroid-induced remission may result from increased mesangial sequestration of IgA circulating immune complexes (CIC) during the period of enhanced glomerular permeability and that the increased load of IgA CICs may reflect a common defect in mucosal immunity or immunoregulation in these patients.

Gemfibrozil improves abnormalities of lipid metabolism in patients on continuous ambulatory peritoneal dialysis: the role of postheparin lipases in the metabolism of high-density lipoprotein subfractions

Twenty-five CAPD patients were given gemfibrozil in increasing doses for a total of 14 weeks. Parameters of lipid metabolism including serum total cholesterol, LDL cholesterol, HDL cholesterol, HDL2 cholesterol, HDL3 cholesterol triglyceride, apolipoprotein A-1, apolipoprotein B, postheparin lipoprotein lipase, and hepatic lipase activities were measured before the commencement, at every increment in the dose of gemfibrozil and 4 weeks after discontinuation of therapy. Gemfibrozil normalized the deranged parameters of lipid metabolism. Thus, with treatment, serum triglyceride, and total cholesterol, LDL cholesterol and apo B decreased, whereas serum HDL cholesterol, HDL2, and HDL3 (predominantly the latter subfraction), hepatic lipoprotein lipase activities increased. Apo A-1 did not change significantly. Even in normotriglyceridemic patients serum HDL cholesterol increased. The side effects consisted of muscle aches and a significant rise in serum CPK. Gemfibrozil produced a significant decrease in gamma-GT activities. A possible mechanism for the interconversion between HDL2 and HDL3 that resulted in a preferential increase in the latter was discussed. It was concluded that gemfibrozil, in a dose not exceeding 300 mg twice a day favorably improved the risk factor for ischemic heart disease in CAPD patients.

The role of soluble immune response suppressor lymphokine in the prediction of steroid responsiveness in idiopathic nephrotic syndrome

The role of serum soluble immune response suppressor (SIRS) lymphokine in the prediction of steroid responsiveness in idiopathic nephrotic syndrome was investigated. Serum SIRS was detected by its capacity to suppress the induction of plaque forming cells in pokeweed mitogen-stimulated in vitro lymphocyte culture in a dose dependent manner, and specificity was determined by the ability of monoclonal anti-SIRS coated beads to specifically absorb the suppressor activity. Serum SIRS was present in 7 of 18 patients with steroid responsive nephrotic syndrome and in 1 of 6 patients with nephrotic syndrome who were resistant to steroid treatment. It was also found in 2 of 4 patients with nephrotic syndrome which would be expected to be resistant to steroid treatment, in 2 of 10 patients with steroid responsive nephrotic syndrome in remission and in 2 of 8 normal healthy controls but was absent in 8 patients with non-nephrotic proteinuria secondary to a variety of renal disease. It was concluded that, although serum SIRS was present more often in patients with steroid responsive nephrotic syndrome, it is not a sensitive enough assay for predicting the response to treatment.

Adult-onset mesangiocapillary glomerulonephritis: a disease with a poor prognosis

A retrospective analysis of the records of 46 patients with adult-onset mesangiocapillary glomerulonephritis seen over a period of 15 years is reported. There were 28 males and 18 females with a mean age of 34 years. Mean observation period was 60 months. All patients had renal biopsies and characteristic changes, but no dense deposit variant was seen. HBsAg was positive in 20 per cent of the patients tested whereas in the general population it was about 10 per cent. Nephrotic syndrome was the commonest presentation. There was a mean delay of 8.5 months between the onset of symptoms and renal biopsy. Nineteen patients were given steroid/immunosuppressive therapy while 27 received no specific treatment. At the time of review, renal function was stable in 13 patients but progressively deteriorating in 33. In the latter, the slope of the graph of reciprocal of creatinine versus time could be accurately determined. Steroid/immunosuppressive therapy did not influence the rate of progression of renal failure but appeared to hasten and induce more partial remissions of the nephrotic state. There was no difference in cumulative renal survival between treated and untreated patients, and between HBsAg-positive and negative patients. Overall, 23 patients required dialysis/renal transplantation and an additional four had died of end-stage renal failure at the time of this review.

Climatic factors and peritonitis in CAPD patients

From March 1983 to December 1987 the relation of the occurrence of all episodes of peritonitis in CAPD patients to climatic factors, such as temperature and relative humidity was examined. Altogether 389 episodes were recorded in 239 patients. Peritonitis due to Staphylococcus epidermidis, Gram-negative organisms and culture-negative episodes was most frequent during the hot months of the year, June to October. The occurrence of peritonitis due to Staphylococcus aureus was uniformly distributed throughout the year. Relative humidity did not seem to affect the frequency of peritonitis.

Fine needle aspiration cytodiagnosis of nasopharyngeal carcinoma in cervical lymph nodes. A study of 40 cases

The cytologic features of fine needle aspiration (FNA) samples of 40 metastatic nasopharyngeal carcinomas in cervical lymph nodes were reviewed. FNA was performed with 21-gauge or 23-gauge needles; the FNA smears were stained with the Papanicolaou stain or with hematoxylin and eosin. Several typical cytologic features were noted. All cases showed the presence of clusters of cohesive tumor cells, most of which were undifferentiated. Medium-sized oval vesicular nuclei were present in 85% of the cases; all cases had prominent nucleoli. The cytoplasm was generally pale, with ill-defined boundaries in 87.5% of the cases. Mitoses were present in 75% of the cases. Mature lymphocytes were intermingled with tumor cells in all cases. The cytologic features correlated with the histologic features in surgical biopsies of the nasopharynx and lymph nodes. The results show that FNA of cervical lymph nodes can aid in the diagnosis of otherwise occult nasopharyngeal carcinoma and in detecting residual or recurrent nodal disease in patients with nasopharyngeal carcinoma who had undergone treatment.

Fungal peritonitis complicating peritoneal dialysis: report of 27 cases and review of treatment

The clinical features, treatment and outcome of 27 cases of fungal peritonitis were studied. Twenty-one cases occurred in patients receiving CAPD and six in patients on intermittent peritoneal dialysis. Twenty-five cases were due to Candida spp., one was due to Trichosporon spp. and in one, both Candida and Trichosporon and an unidentified acid-fast bacillus were isolated. Clinical features of fungal peritonitis and bacterial peritonitis were the same. A direct comparison with patients without fungal peritonitis failed to reveal an increased incidence of diabetes mellitus. However, a history of recent bacterial peritonitis and antibiotic treatment was frequently obtained. We found that the combination of oral ketoconazole and intraperitoneal miconazole is successful in treating fungal peritonitis complicating peritoneal dialysis but catheter removal and replacement is often necessary. Analysis of the relationship between clinical outcome and various treatment strategies in cases reported in the literature and in our own showed that an initial trial of antifungal drugs consisting of oral ketoconazole and i.p. 5-fluorocytosine or miconazole is warranted in most cases before contemplating catheter removal.

Detection of Epstein-Barr virus-associated antigen in fine needle aspiration smears from cervical lymph nodes in the diagnosis of nasopharyngeal carcinoma

Epstein-Barr virus (EBV) has consistently been shown to be associated with undifferentiated nasopharyngeal carcinoma, and an EBV-associated nuclear antigen (EBNA) has been detected in the cells of nasopharyngeal carcinoma. A study on the applicability of EBNA detection in fine needle aspiration (FNA) smears from cervical lymph nodes in the diagnosis of metastatic nasopharyngeal carcinoma was performed. All 11 cases (100%) with metastatic nasopharyngeal carcinoma showed EBNA-positive tumor cells, characterized by bright, granulated nuclear fluorescence. Three (50%) of six cases with other metastatic head and neck carcinomas also showed EBNA-positive tumor cells. These findings suggest that the presence of EBNA-positive tumor cells in FNA smears from cervical lymph nodes is not specific for metastatic nasopharyngeal carcinoma. On the other hand, a negative result in the presence of tumor cells may help to exclude it. A larger study is required to verify these preliminary findings.

Optimal reuse of cuprammonium rayon hollow-fibre dialyzers

The optimal number of times a hollow-fibre cuprammonium rayon (Terumo TAF) dialyzer could be used was determined in twelve patients. Each dialyzer was reused six times. There was a highly significant decrease in neutrophil count (46.9 +/- 6.9%, mean +/- s.e.m.), platelet count (9.6 +/- 3.8%, mean +/- s.e.m.) and serum C3 concentration (10.25 +/- 2.4%, mean +/- s.e.m.) 30 minutes after the commencement of dialysis The intensity of these changes decreased with the re-use of the dialyzers up to the fourth time. There was a small, but significant increase in serum beta 2-microglobulin concentrations after a 6-hour dialysis. The difference between pre- and post-dialysis serum beta 2-microglobulin concentrations appeared to be greater during the 5th and the 6th use (18.8% and 20.5% vs 5.0% during the first use). The clearance rates of urea and creatinine showed a trend to decrease from the fourth use onwards and the ultrafiltration coefficient was significantly reduced from the third use (8.5 +/- 4.0 mean +/- s.e.m.) onwards so that at the sixth use it was only 75.8 +/- 4.8%, (mean +/- s.e.m.) of the value at the first use. It is concluded that the optimal number of uses a cuprammonium rayon hollow-fibre dialyzer can be put to is four.

A double-blind controlled trial of norfloxacin versus cotrimoxazole in the treatment of urinary tract infections

A double-blind controlled trial of norfloxacin versus cotrimoxazole in the treatment of urinary tract infections was conducted. Eighty-eight patients were recruited but data from 80 patients were analysed. Norfloxacin cured 93 per cent of the infections while the cure rate achieved by cotrimoxazole was only 70 per cent (p = 0.03, Fisher's exact test). The difference was attributable to a higher incidence of resistance to cotrimoxazole among the bacterial isolates. Escheria coli was the commonest pathogen and together with klebsiella accounted for 78 per cent of all isolates. Fifteen per cent of E coli and 15 per cent of klebsiella isolates were resistant to cotrimoxazole while all were sensitive to norfloxacin. Side effects were minimal and consisted mainly of nausea and non-specific dizziness.

Hepatitis B infection and renal transplantation: the absence of anti-delta antibodies and the possible beneficial effect of silymarin during acute episodes of hepatic dysfunction

The incidence of hepatitis B infection among renal transplant recipients was reviewed. Among 90 patients, 13 were HBsAg positive prior to renal transplantation. Episodes of hepatic dysfunction were seen in eight and one died of fulminating hepatitis and disseminated tuberculosis. Silymarin, a herbal extract, appears to confer some benefits in ameliorating hepatic dysfunction. Antibodies to the delta agent were not detected during any of these episodes. One patient contracted hepatitis B after transplantation and rapid reduction in steroid dose was associated with deterioration of liver function. He developed antibodies and cleared the virus. Four HBsAg-negative patients received kidneys from HBsAg positive donors without becoming HBsAg positive.

Tuberculous peritonitis complicating long-term peritoneal dialysis. Report of 5 cases and review of the literature

The characteristics of 5 patients who developed tuberculous peritonitis while receiving long-term peritoneal dialysis (PD) are presented. There were 2 males and 3 females. 3 patients were on intermittent and 2 were on continuous ambulatory peritoneal dialysis when tuberculous peritonitis was first diagnosed. None of the patients had recently received immunosuppression therapy or were diabetics. The clinical presentations were similar to other forms of peritonitis complicating PD except for a more insidious onset. As extraperitoneal involvement and peritoneal lymphocytosis were rarely present, the diagnosis was mainly dependent on the direct demonstration of Mycobacterium tuberculosis with smear (1 patient) and culture (4 patients). In 1 patient with a pleuroperitoneal communication, the diagnosis was made by pleural biopsy and a positive response to antituberculous therapy. All patients responded to treatment with a combination of three antituberculous drugs which included streptomycin, isoniazid, rifampicin and pyrazinamide. Two patients were transferred to hemodialysis. In 3 patients, peritoneal dialysis was continued. Peritoneal clearance and ultrafiltration capacity were unchanged for up to 16 months after treatment in 2 patients who continued peritoneal dialysis but was reduced by 30 and 50%, respectively, in the remaining patient. Only 1 patient died, but her death was not directly related to tuberculous peritonitis. It was concluded that with a high index of suspicion and early institution of treatment, tuberculous peritonitis complicating PD can be successfully treated with low mortality and without compromising the dialysis capacity of the peritoneal membrane.

Oral treatment of peritonitis in CAPD patients with two dosage regimens of ofloxacin

Two open studies of oral treatment of peritonitis in CAPD patients with ofloxacin are described. The first study included 10 episodes of peritonitis treated with ofloxacin 400 mg followed by 200 mg daily for a total of seven days. In the second study of 18 peritonitis episodes, the treatment was ofloxacin 400 mg followed by 300 mg daily for a total of ten days. The cure rate was 50% in the first study and 83% in the second. There was significant accumulation of ofloxacin in the serum but the mean serum trough level with the second treatment regimen plateaued at 6 mg/l on day 10. Peritoneal effluent ofloxacin levels correlated well with the prevailing serum concentrations of the antibiotic and, except on day 1, the mean peritoneal effluent ofloxacin levels all exceeded 3 mg/l with the second dosing scheme. Side effects were mainly nausea and dizziness.

Glomerulonephropathy of Laurence-Moon-Biedl syndrome

A patient with Laurence-Moon-Biedl syndrome and nephrotic range proteinuria is presented. Radiological investigation of the urinary tract revealed clubbed calyces but no evidence of obstruction or vesicoureteric reflux. Renal biopsy revealed occasional sclerotic glomeruli, extensive foot-process fusion and segmental glomerular basement membrane abnormalities with negative immunofluorescence for immunoglobulins and complement. Nephrotic proteinuria responded to steroid therapy but mild proteinuria persisted. The findings were consistent with minimal change nephropathy superimposed on the glomerular lesions of Lawrence-Moon-Biedl syndrome.

Primary glomerulonephritis in Hong Kong

The clinical presentation and natural history of 428 patients with biopsy-proven primary glomerulonephritis were reviewed. Minimal change glomerulonephritis presented with the nephrotic syndrome and followed a benign course. Membranous glomerulonephritis took a slow downhill course. HBs antigenaemia was present in 30% of patients with membranous glomerulonephritis. Mesangiocapillary glomerulonephritis often presented with mixed nephritic-nephrotic syndrome and had a bad prognosis. No type II variant was detected. Mesangial IgA glomerulonephritis commonly presented with abnormal urinary sediments although 2.5% of adults presenting with the nephrotic syndrome without glomerular insufficiency had mesangial IgA disease. Mesangial IgA glomerulonephritis was an important cause of end-stage renal failure in Hong Kong.

The effect of diethylcarbamazine citrate on incidence and recovery rates of Brugia malayi microfilaremia in Sabah, Malaysia

Mass drug administration via 3 modes of delivery reduced the incidence and prevalence rates and intensity of Brugia malayi infection in 3 rural villages in the Bengkoka Peninsula, Sabah, in 1982-1983. A dosage of 6 mg diethylcarbamazine citrate (DEC-C)/kg body weight was administered either daily or weekly (total of 6 doses, 36 mg/kg body weight), and impact on B. malayi cases were comparable in the 3 villages. A total of 384 people participated in the DEC-C regimens, and all pregnant women and children under 2 years were excluded from the study. Bekessy's method of estimation of incidence and recovery rates was applied to data on B. malayi microfilaremia before drug administration. Treatment with DEC-C by any of the 3 modes of delivery drastically reduced the number of episodes of patent microfilaremia, incidence and prevalence, and median microfilarial density. Reduction was sustained for at least 18 to 24 months after treatment.

Peritoneal eosinophilia in patients on continuous ambulatory peritoneal dialysis: a prospective study

A prospective study on peritoneal eosinophilia was conducted in 23 continuous ambulatory peritoneal dialysis (CAPD) patients for a mean period of 7.9 months. Peritoneal eosinophilia as defined by peritoneal eosinophil count exceeding 100/mm3 was found in 60.8% of patients. Most developed peritoneal eosinophilia within 3 months of the initiation of dialysis, although the phenomenon could occur as early as one day or as late as 6 months after dialysis. Fifty-seven percent of those with peritoneal eosinophilia also had peripheral blood eosinophilia. Although most peritoneal eosinophilic episodes subsided in a month, in one patient the process grumbled on for 150 days. The number of peritonitis episodes was not significantly different between patients with peritoneal eosinophilia and those without. The only distinction between the two groups of patients was that those who developed peritoneal eosinophilia had a significantly (P = .002) higher serum IgE concentration initially as well as throughout the period of observation.

Transmission dynamics and estimates of malaria vectorial capacity for Anopheles balabacensis and An. flavirostris (Diptera: Culicidae) on Banggi island, Sabah, Malaysia

Holoendemic malaria transmission in two small isolated forest communities and a coastal village was studied by (1) all night human bait collections of Anopheles species from inside and outside houses and (2) buffalo-biting and CDC light-trapping catches during March and November 1984. During the same period thick and thin blood films were collected from the human population, and spleen rates were determined in children from two to nine years of age. Using both the immunoradiometric assay (IRMA) and the dissection technique, more sporozoite-positive infections were detected in An. balabacensis and An. flavirostris in November than in March. IRMA confirmed the presence of Plasmodium falciparum sporozoites. An average of 76.2% of the An. balabacensis population lived long enough to have reached a point where infectivity with P. falciparum was possible in November. Although fewer than five adult females bit humans per night at any time, a resident could theoretically have received more than 160 infective bites in one year. A high frequency of feeding on humans, coupled with increased anopheline life expectancy, contributed to high estimates of falciparum malaria vectorial capacity (number of infections distributed per case per day); for An. balabacensis (1.44-7.44 in March and 9.97-19.7 in November) and for An. flavirostris (0.19-5.14 in March and 6.27-15.8 in November). These high values may explain the increased malaria parasite rates obtained from at least two forest communities. Correlation between actual and calculated rates of gametocytaemia was poorest in Kapitangan due to inadequate sampling of the human population. In Banggi island, malaria is stable and holoendemic, and the population enjoys a high degree of immunity.

Living-related renal transplantation in a patient with nail-patella syndrome

Living-related renal transplantation was performed successfully in a patient with nail-patella syndrome. Graft biopsy 18 months post-transplantation showed normal glomerular basement membrane by electron microscopy. Dystrophic nails of both index fingers had also regrown, suggesting the donor kidney might replenish deficient factors.

Ofloxacin pharmacokinetics in patients on continuous ambulatory peritoneal dialysis

Pharmacokinetics of ofloxacin (OFX) was studied in patients on continuous ambulatory peritoneal dialysis (CAPD) carrying out three exchanges per day. In 11 patients given 300 mg of OFX orally, serum OFX concentration peaked at 2.44 mg/l 3.7 hours after administration and the mean elimination half-life of OFX was 25 hours. OFX concentrations in peritoneal fluid underwent cyclical changes with each change of solutions, reaching beyond 0.5 mg/l after 2 hours of equilibration. There was a highly significant correlation between corresponding serum and peritoneal fluid concentrations of OFX after an 8 h equilibration (r = 0.85, p less than 0.001). In 5 patients given a 400 mg loading dose followed by 200 mg of OFX per day for 7 days, trough serum OFX concentrations ranged from 1.35 to 7.00 mg/l and no adverse effects were noticed. CAPD per exchange removed less than 2% of the total dose of OFX given.

Nephrotic syndrome associated with angiofollicular lymph node hyperplasia

A women presented at the age of 22 with anemia, hepatosplenomegaly, polyclonal hypergammaglobulinemia and a mediastinal shadow. At thoracotomy she had enlarged mediastinal lymph nodes which displayed histological features typical of angiofollicular hyperplasia. Marrow plasmacytosis was present. She developed diabetes mellitus at the age of 29 yrs after she had received oral steroid treatment for one year. The nephrotic syndrome supervened another year later. Her kidneys were enlarged before the onset of diabetes. The glomerular changes included a marked increase of mesangial matrix and segmental hypercellularity. The association of the nephrotic syndrome and angiofollicular lymph node hyperplasia is extremely rare and their interrelation remains enigmatic.

Cyclosporin A in steroid-sensitive nephrotic syndrome with frequent relapses

Eight patients with steroid-sensitive nephrotic syndrome which frequently relapsed despite cyclophosphamide treatment were given cyclosporin A (7.5 mg/kg/day to 10 mg/kg/day) for 8 to 12 weeks. Six had minimal change glomerulonephritis and two had focal segmental glomerulonephritis. Cyclosporin A was given to 5 patients when their nephrotic syndrome was in relapse and to 3 patients when the nephrotic syndrome was in remission. Cyclosporin A induced a transient remission in only one patient.

Controlled trial of antiplatelet agents in mesangial IgA glomerulonephritis

A trial of antiplatelet therapy (slow-release aspirin and dipyridamole) in mesangial IgA glomerulonephritis was conducted. Vitamin B was given to the control group. Altogether, 38 patients were observed for a mean of 33.2 months. Antiplatelet therapy did not favorably modify the course of mesangial IgA glomerulonephritis. The rate of progression of the disease, measured by the slope of reciprocals of serum creatinine v time plots, correlated significantly with the severity of tissue damage as assessed by an arbitrary morphologic score from renal biopsy specimens.

Continuous ambulatory peritoneal dialysis (CAPD): experience with the first 100 patients in a Hong Kong centre

We treated 100 Chinese patients age 16 to 83 years by CAPD, using three 2-litre exchanges per day. The treatment was self-financed in 69 patients, by charitable organisations in 25 patients, and by government funds in 6 patients. Satisfactory biochemistry was maintained and there was no gross hyperlipidaemia, renal osteodystrophy, or loss of ultrafiltration capacity of the peritoneum. Rehabilitation was good and 62% of patients returned to full-time employment. The average duration of hospitalization was 11.3 days per patient year. Peritonitis usually due to Staphylococcus pyogenes occurred at a frequency of one episode per 12.3 patient-months. Sixteen patients were transplanted and had a 2-year graft survival of 78.5%. The cumulative patient survival was 97% at 1 year and 84% at 2 years. The corresponding technique survival rates were 87% and 76% respectively.

Acute post-streptococcal glomerulonephritis followed shortly by acute rheumatic fever

A 16 year old girl with post-streptococcal glomerulonephritis developed acute rheumatic fever 19 days afterwards. Previous publications on concurrent post-streptococcal glomerulonephritis and acute rheumatic fever are reviewed.

Adult Fanconi syndrome in kappa light chain myeloma

Distinctive morphological features in both the marrow infiltrate and the kidney were seen in a 52-year-old woman with kappa light chain-producing plasma cell myeloma, diagnosed on the basis of multiple osteolytic lesions, the presence of atypical plasma cells in the bone marrow, and monoclonal immunoglobulin production as demonstrated by immunoperoxidase staining on marrow sections. Large focal collections of histiocytes in the bone marrow and the renal proximal tubular epithelium had abundant glassy cytoplasm. Characteristic crystalline inclusions were seen ultrastructurally in both types of cells. It is believed that these crystalline deposits are lysosomal inclusions composed of altered kappa light chains taken up by these cells. The renal changes were entirely different from those of myeloma kidneys and were associated with proximal tubular dysfunction of adult Fanconi syndrome without distal tubule abnormality.

Acute inflammation in gram-negative infection: endotoxin, interleukin 1, tumor necrosis factor, and neutrophils

Experimental bacterial infection of the dermis induced with gram-negative microorganisms is associated with an acute inflammatory reaction, which represents the principal local defense against spread of the infection. When the inflammatory reaction is quantitated with radiolabeled cells and proteins, the kinetics resemble acute inflammation induced with other agents, such as immune complexes or chemotaxins. There is an interrelationship between the components or events of the inflammatory reaction; inasmuch as vascular injury is neutrophil-dependent, neutrophils must migrate to the site where the bacteria multiply. In neutropenic animals there is no such emigration and bacterial multiplication is not inhibited. The microorganisms shed endotoxin, which in turn induces secretion of interleukin 1 (IL 1) and probably tumor necrosis factor. Endotoxin is the most potent agent (10(-15) mol vs. 10(-12) mol of C5ades Arg) capable of inducing a neutrophil influx. Desensitization or tachyphylaxis of the tissues (probably of postcapillary venular endothelium) to IL 1 seems to control cessation of the neutrophil influx (also in vitro evidence). Phagocytosis of the bacteria by neutrophils is associated with release of oxygen radicals and lysosomal proteases from the neutrophils. These are instrumental in eliciting microvascular injury, which is characterized by enhanced vasopermeability, hemorrhage, and thrombosis.

Continuous ambulatory peritoneal dialysis (CAPD) in diabetic patients with end-stage renal failure in Hong Kong

The authors' experience in managing 17 diabetic patients among their first 100 consecutive patients treated with continuous ambulatory peritoneal dialysis (CAPD) was reviewed. The diabetics were significantly older than the non-diabetics, but their biochemistry was comparable to that of the non-diabetics. With three exchanges a day, the requirement for antihypertensives was high (60%). Exit-site infection occurred at a rate of one episode per 9.7 patient-months, and the frequency of peritonitis averaged one episode per 9.4 patient-months; the main culprit was Staphylococcus pyogenes. Rehabilitation was good because the patients had to finance their treatment. In spite of old age, 23% worked full-time. There was no progressive increase in serum cholesterol or triglycerides. Glycemic control was good and was comparable whether the patients were given insulin subcutaneously or intraperitoneally. There was a highly significant (p less than 0.001) positive correlation between fasting blood glucose levels and HbA1 concentrations. Fasting blood glucose concentrations did not correlate with either serum cholesterol or triglyceride concentrations. Diabetic retinopathy progressed in five patients, to the point that their vision was severely impaired. There was no relationship between the degree of glycemic control and progression of diabetic retinopathy. Two patients died of cardiovascular causes, but there were no peritonitis-related deaths. Cummulative patient survival at 2 years was 86%, and the corresponding technique survival, 100%.

Immunoglobulins (IgG, IgA, IgM, IgE) and complement components (C3, C4) in nephrotic syndrome due to minimal change and other forms of glomerulonephritis, a clue for steroid therapy?

Serum IgG, IgA, IgM, IgE, C3 and C4 were measured in 13 patients with minimal change (MC) glomerulonephritis and 10 with the nephrotic syndrome (NS) due to other forms of glomerulonephritis. The tests were repeated in all patients with MC glomerulonephritis when they went into remission. Serum IgG was reduced, IgM, IgE and C3 were raised while serum IgA was within the normal range when the patients were nephrotic. Changes in serum immunoglobulins and complement components were not specific to MC glomerulonephritis and these parameters reverted towards normal when the NS went into remission. Elevated C3 levels probably reflected increased hepatic protein synthesis since C3 correlated significantly with serum cholesterol. There was a tendency for serum IgE concentrations to positively correlate with the total dose of prednisolone required to bring the NS to remission.

Effects of selective and non-selective beta-blockers on the alanine and free fatty acid responses to glucagon challenge in hemodialysis patients

Hypoglycemia is frequently reported in hemodialysis patients on propranolol. The effects of beta-blockers on the glucose, alanine and free fatty acid responses to glucagon challenge (2 mg) in fourteen hemodialysis patients were studied. Patients on propranolol had impaired glycemic response while those on metoprolol had decreased response only before dialysis. There was a significant negative correlation between propranolol level (log-transformed) and glycemic responses, suggesting that propranolol has direct effect on the latter. Hemodialysis patients had fasting alanine levels comparable to those of normal subjects. After glucagon challenge, the decrements in alanine level had no consistent relationship to the impaired glycemic response. Thus suppression of gluconeogenesis is unlikely to be the prime cause of propranolol-induced hypoglycemia. The basal free fatty acid levels were significantly lower among hemodialysis patients on propranolol. This limited availability of free fatty acid as well as the inhibitory effect on hepatic glucagon-stimulated glucose output may contribute to the predisposition to hypoglycemia in dialysis patients given propranolol. The results suggest that metoprolol has less interference on energy substrate supply in hemodialysis patients under fasting conditions.

Disseminated zygomycosis masquerading as cerebral lupus erythematosus

Zygomycosis often occurs in patients with an underlying disease, e.g., diabetes mellitus, leukemia, and lymphoma, or an immunocompromised state. This report discusses a case of a 21-year-old woman with systemic lupus erythematosus complicated by uremia, acidosis, steroid therapy, prolonged antimicrobial therapy, and disseminated zygomycosis.