Renin and the juxtaglomerular apparatus in diabetic nephropathy

In order to study the role of the renin-angiotensin system in patients with diabetic nephropathy, renin release and the juxtaglomerular apparatus were studied in 17 diabetic patients with proteinuria and in 23 without proteinuria; 8 normal subjects were used for conctrls. Despite hypertension and marked arteriosclerosis, plasma renin activity (supine posture) was normal; however, the renin response to salt restriction and upright posture was less in the diabetic patients with proteinuria than in the controls. Renal renin content, determined at autopsy, was also normal. Examination of the juxtaglomerular apparatus in the diabetic patients with proteinuria revealed hyalinization of the afferent and efferent arterioles in most of the glomeruli and various degrees of destruction of the juxtaglomerular cells. The findings suggest that renin production is not increased in diabetic patients with proteinuria plus marked vascular damage, and that the renin-angiotensin system in patients with diabetic nephropathy apparently does not play an important role in the exacerbation of hypertension or the degree of vascular damage.

Subarachnoid hemorrhage in children

45 cases of subarachnoid hemorrhage in children were surveyed. 73 percent of the causes were arteriovenous malformations and spontaneous intracerebral hematomata. Arteriovenous malformations in children may grow in size which may be due to the fact that besides the nidus demonstrated by angiography there are surrounding abnormal vascular groups, the reserved nidus. If one fails to extirpate this reserve nidus at the time of surgical excision of the arteriovenous malformation, it may become nidus several years later and may bleed again. The follow-up results of surgery in subarachnoid hemorrhage cases were fairly good.

A case of 17alpha-hydroxylase deficiency with symptoms mimicking testicular feminization

A case of 17alpha-hydroxylase deficiency mimicking testicular feminization is reported. Different from the complete form of testicular feminization in which androgens are normal or elevated and end-organ insensitivity to androgens is supposed, this case had a negligible amount of androgens and responded to the injection of testosterone propionate with a positive nitrogen and phosphate balance.

Significance of vasospasm in the treatment of ruptured intracranial aneurysms

The authors have analyzed a total of 96 consecutive cases in which vasospasm followed subarachnoid hemorrhage (SAH). The SAH was caused by ruptured intracranial aneurysm or developed after aneurysm surgery. Usually at least 4 days elapsed between SAH and the onset of vasospasm. Vasospasm subsided an average of 2 weeks after onset. Of 68 patients with preoperative vasospasm, eight died due to cerebral edema resulting from ischemia, and 49% of survivors had neurological deficits. Preoperative vasospasm was not aggravated by surgical intervention when operations were carried out more than 7 days after the onset of vasospasm. Postoperative vasospasm was found in 25 of 52 patients who underwent operation within 1 week after SAH (excluding cases in Grade V). Five of these patients died, all of whom underwent surgery between the fourth and seventh day after SAH (the day of SAH was counted as the first day). There were no deaths among 20 patients operated on within the first 3 days after SAH. Postoperative vasospasm was always mild in these cases, when it occurred, probably because blood clot or blood-stained cerebrospinal fluid was removed by operative procedures. In all cases, 4 to 11 days elapsed between the last SAH and the onset of postoperative vasospasm regardless of the timing of surgery.

[Follow-up results of microsurgery of intracranial aneurysms (author's transl)]

In the past 7 years, 403 cases of intracranial aneurysms were submitted to microsurgical operations. The operative mortality was 5.4%, and in the follow-up, 82.4% are working, 6.2% are caring for self and 5.9% are either bed-ridden or dead from other causes after discharge. If 6 cases of Grade V are excluded from the statistics and the day of subarachnoid hemorrhage (SAH) is counted as the 1st day, cases submitted to microsurgery on the 1st, the 2nd and the 3rd days showed no mortality and 72.7% of them are working in the follow-up. Cases undergone micro-surgery on the 4th through the 8th day showed a high mortality of 15.2% due to postoperative vasospasm, whereas in cases submitted to micro-surgery in the 2nd week after SAH the operative mortality was 6% and in cases submitted to micro-surgery later than the 2nd week it was 3%. In the follow-up 84% and 85.6% are working in the latter two respectively. These results seem to encourage ultra-early surgery for ruptured aneurysm cases. However, one should always bear in mind that the acute stage of SAH should be regarded as a "systemic disease", not as a "local disease", and only those who have ability and facility to manage this systemic disease may be qualified to perform early surgery for ruptured aneurysms.

Effects of angiotensin III (DES-1-asp-angiotensin II) and angiotensin III analogue (DES-1-asp-8-ile-angiotensin II) upon adrenal steroidogenesis and blood pressure

Effects of angiotensin III and angiotensin III analogue upon adrenal steroidogenesis and blood pressure were studied in rats, rabbits and a man. Pressor effect of angiotensin III was about one fifth of that of angiotensin II in all the species. Degradation rate of pressor effect of angiotensin III in plasma was more rapid than that of angiotensin II. Different from the effects of angiotensin III upon blood pressure, its effect upon aldosterone was similar to that of angiotensin II. The effect of angiotensin III upon other adrenal steroids, such as DOC and cortisol, however, seemed to be slightly less than that of angiotensin II. Angiotensin III producted an additive effect to that of ACTH, but it didn't produce an additive effect to that of angiotensin II. Angiotensin III analogue, itself, stimulated adrenal steroidogenesis, but it inhibited the effects of angiotensin III and angiotensin II upon aldosterone. Effects of ACTH upon plasma DOC and cortisol were not inhibited by angiotenesin III analogue, but the effect of ACTH upon aldosterone was blunted slightly.

The renal lesion associated with total lipodystrophy

This report concerns a 41-year-old man with total lipodystrophy associated with a specific renal disorder. He had massive proteinuria, mild azotemia and a normal level of serum complement in addition to the generalized loss of subcutaneous fatty tissue. Results of 1 50-gm glucose tolerance test indicated a high fasting insulin level with an exaggerated response to glucose. Hypoglycemic responses to exogenous insulin were reduced. Renal biopsy revealed changes consistent with glomerular lipidosis. This case is unique in that the renal lesion was not the Kimmelstiel-Wilson pathologic change atributable to abnormal glucose metabolism.

[Spinal arteriovenous malformation fed by branches of the internal iliac artery (author's transl)]

A 51-year-old male had lumbago and intermittent progressive gait disturbance for 2 years. Finally, he could not walk due to paraparesis. Neurological examination revealed flaccid paraparesis, dysuria, constipation and sensory disturbance below the L-4 dermatome. Myelogram showed serpiginous filling defects from sacral to thoracic region suggesting spinal arteriovenous malformation. Angiogram performed by conventional selective injections into the subclavian, intercostal, and lumbar arteries demonstrated no abnormal lesions but abdominal aortogram carried out at the aortic bifurcation revealed spinal arteriovenous malformation fed by branches of the right internal iliac artery. The angiographic findings may be identified at the single coiled vessel type of Doppamn's or A-V shunt type of Saito's classification. Laminectomies were performed from Th-8 to Th-9 and Th-12 to L-2. Feeder was clipped and the drainers were partially removed. No intramedulllary extension was recognized. After one month postperatively, the patient could walk with support. Postoperative angiographic control performed by selective injections into four iliac arteries disclosed no abnormal vessels. Angiographic examinations of the spinal arteriovenous malformations are usually limited to branches of the subclavian, intercostal and lumbar arteries. But at the cauda equina or conus medullaris, anterior and posterior spinal arteries are sometimes anastomosed with medullary feeders from lateral sacral or other hypogastric arteries. Therefore, it is possible that these branches of iliac arteries may feed spinal arteriovenous malformations as seen also in the cases reported by Picard, Stein and Heindel. This report emphasizes the importance of selective iliac angiogram to demonstrate spinal arteriorvenous malformations when conventional methods fail to show lesions.

[Application of parenteral cephradine in urinary tract infections (author's transl)]

A new antibiotic cephradine was administered intravenously for 3 approximately 7 days at daily doses of 1.0 approximately 2.0 g to 56 patients, including 39 cases of acute urinary tract infections, 13 of chronic urinary tract infections and 4 for postoperative prophylaxis. Of 39 cases with acute urinary infections, definite response was seen in 35 cases and no definite response in 4 cases. Of 13 cases with chronic urinary tract infections, definite response was seen in 7 cases and no definite response in 6 cases. Good results were obtained clinically in 4 cases for prophylaxis of postoperative infections. No side effect was observed with cephradine with cephradine throughout the experiment.

Benign desoxycorticosterone-producing adrenal tumor

A woman with a benign tumor of the left adrenal cortex had a six-year history of hypertension. Serum potassium level and plasma renin activity were low. Plasma aldosterone and cortisol levels were low normal, and plasma desoxycorticosterone (DOC) level was extremely high. Iodine 131-labeled cholesterol accumulated in the tumor in the left upper quadrant of the abdomen. At laparotomy, a benign adrenal tumor was excised; thereafter, the blood pressure and plasma DOC levels returned to normal. We believe that this is the first case of a benign DOC-producing adrenal tumor.

The mechanism of low-renin hypertension: aldosterone response to sodium restriction and upright posture, angiotensin II, ACTH and potassium in patients with hypertension

Plasma renin activity and aldosterone were measured simultaneously in 67 out-patients with essential hypertension. High aldosterone was more often in patients with high renin, and low levels of aldosterone were usual in those with low and normal renin. In order to study the mechanism by which aldosterone and renin acitvity are suppressed in low-renin hypertension, 25 patients (13 normal-renin hypertensives, 10 low-renin patients including 4 non-responders and two DOC excess hypertensives) were investigated as inpatients. Plasma renin activity, aldosterone and cortisol were determined by the following stimualtions with 3 days of sodium restriction and 2 hours of upright posture, angiotensin II infusion (at a dose which increased 20mmHg of diastolic blood pressure), ACTH administration (rapid i.m. injection of 0.25 mg of alpha 1-24 preparation) and potassium infusion (30 meq of potassium i.v.). Responses of aldosterone in normal-renin hypertensives to all stimulations were 3-5 fold increases from bases line values. Low-renin hypertensives except two of four non-responders showed the responses similar to those in normal-renin patients. The responses of two of the non-responders were similar to those in DOC excess hypertensives who showed reduced responses of aldosterone to some of these stimulations. Thus, it seems that low-renin hypertension is a clinical entity caused by a variety of mechanisms, and the mechanism by which low-renin hypertension is induced is not explained by one factor such as an unknown mineralocorticoid.

Effects of furosemide and chlorothiazide on blood pressure and plasma renin activity

Short (2 weeks) and long (12 weeks) term effects of furosemide and chlorothiazide on blood pressure, plasma renin activity, and uric acid concentration were studied in 69 hypertensive patients. Both treatments caused significant reductions in blood pressure and increases in plasma renin activity and uric acid at 2 and 12 weeks in 6) normal renin patients; there was no difference between the effects of furosemide and that of chlorothiazide. Reduction in blood pressure in eight low renin patients who showed smaller changes in plasma renin activity and uric acid was not significant at 2 weeks but significant after 12 weeks of treatment.

[Effects of low salt plus upright posture, angiotensin II, ACTH, and potassium upon plasma renin activity, aldosterone, and cortisol (author's transl)]

In order to study the control system of plasma aldosterone in human, we examined the effects of low salt plus upright posture, angiotensin II, ACTH and potassium upon plasma renin activity, aldosterone and cortisol in five subjects who were supposed to be normal. All of the procedures, low salt diet with below 3 g of salt and 2 hr-upright posture, 0.25 mg of Cortrosyn, angiotensin infusion to increase 20mmHG of diastolic pressure for an hour, and 30 mEq of potassium infusion stimulated plasma aldosterone significantly. Furthermore, in each subject the degrees of response to each of these stimulations were almost same. In an old woman aged 68, responses to all of stimulations were significantly lower than those in other subjects. Plasma cortisol was significantly stimulated by ACTH, but slightly reduced by potassium infusion. From these results, it is certain that plasma aldosteron levels are easily affected by a small amount of changes in angiotensin, ACTH, potassium and sodium. However, responses of aldosterone to these changes seem to be decreased in old subjects.

[Two cases of the traumatic rupture of the diaphragm (author's transl)]

Recently, the cases of traumatic rupture of the diaphragm increased due to traffic accidents increasing. We experienced two cases of this type of trauma in short breathing after traffic accidents. The chest roentgenograms on admission revealed multiple fractured ribs, homogenous density in the left thorax and mediastinal shift to the right side with the elevation of the left diaphragm, and the stomach were demonstrated in the left thoracic cavity by the method of nasogastric tube barium study. The transthoracic operation were performed following 7 hours after an accident on the first case. The omentum, splenic flexura of colon, stomach, small bowel, and spleen were herniated to the left thoracic cavity and the spleen was ruptured. The spleen was resected in the same field and the diaphragm rupture was closed with 8 figure stitch sutures. On the second case, also, the transthoracic operation were performed seven days after admission because of misdiagnosis for left hemothorax. Herniated stomach, colon, small bowel, omentum, and spleen were repositioned and diaphragm rupture was closed with 8 figure stitch sutures. Covalescence were smooth and the patients were discharged from the hospital on the 28th post operative days.

Oestrogen hypertension in rats

1. A large dose of oestrogen elevated the blood pressure in male Westar rats. 2. Plasma renin substrate and renin activity increased significantly but plasma renin concentration was unchanged. 3. The increase in blood pressure induced by oestrogen was significantly reduced by salt loading, plasma renin concentration was suppressed and the increase in plasma renin activity was reduced. 4. The increase in plasma renin activity induced by the increase of plasma renin substrate concentration may play a role in oestrogen-induced elevation of blood pressure.