Loa loa: the use of a blood cell separator to reduce microfilaraemia before specific chemotherapy

Three years after returning to the U.K. a 58-year-old British engineer, who had worked in the Nigerian oilfields for 24 years, was found to have Loa loa. His midday microfilarial count ranged between 12 X 10(6) and 16 X 10(6) parasites per litre. Before starting treatment, I litre of leucocyte/platelet-rich plasma was removed by means of a blood cell separator. Six intermittent cycles of blood separation were performed during a single 4-h session around midday in order to coincide with the period of maximum microfilarial presence in the peripheral circulation. This resulted in a 50% reduction of the microfilaraemia. Where facilities for blood cell separation are available, this procedure, together with appropriate chemotherapy, should be particularly beneficial in the management of heavy filarial infections.

The effect of probucol and cholestyramine combination therapy in severe familial hypercholesterolaemia

The relative effects of cholestyramine and probucol, alone and in combination, on serum total cholesterol (TC), high density lipoprotein cholesterol (HDL-C) and the ratio of TC to HDL-C (T/HDL-C) have been studied in a group of 10 subjects with severe familial hypercholesterolaemia. The combination of cholestyramine plus probucol was more potent than either agent alone in reducing TC. The use of probucol either alone or in combination reduced the HDL-C concentrations, but the ratio of T/HDL-C was not consistently affected. The effect of the combination therapy did not diminish after periods of at least 6 months and in some cases led to partial regression of long-standing xanthomata. The combination of probucol with cholestyramine did not give rise to additional side effects and it is considered to be a valuable addition to the regimens available for the treatment of severe familial hypercholesterolaemia.

Plasma exchange in acute renal allograft rejection. A controlled trial

A controlled trial was carried out to assess the value of intensive plasma exchange in 27 renal transplant recipients with clinical and histological evidence of acute vascular rejection. In addition to standard immunosuppression, 13 patients received plasma exchange on six consecutive days at a mean exchange volume of 40.6 ml/kg of body weight each day using an intermittent cell separator. A further 14 patients received standard immunosuppression only. In addition, 10 patients exchanged prior to the controlled trial have been studied. Analysis of short-term benefit, as evidenced by a reduction in serum creatinine, and by subsequent graft survival revealed no significant difference in these parameters between the two groups in the controlled trial. This regimen of plasma exchange has not, therefore, been shown to modify acute renal allograft rejection.

Metabolic studies with 'Nutrauxil', an enteral feed preparation

A metabolic study was carried out in 6 patients requiring enteral feeding to investigate the effectiveness and tolerance of 'Nutrauxil', a ready-made liquid nutritional preparation, over a period of 8 days. The results of anthropometric and laboratory measurements, made initially and at the end of two 4-day periods, showed that the basic provision of 2000 kcal and 60 g protein per day with 'Nutrauxil' maintained patients in metabolic, electrolyte and nitrogen balance. No adverse effects were noted and the preparation was easy to administer. It was concluded that 'Nutrauxil' compared favourably with other enteral feed preparations with respect to its nutritional effectiveness on clinical, biochemical and economic grounds.

Ventriculo-atrial shunt nephritis

A case of immune complex glomerulonephritis with reversible renal insufficiency following ventriculoatrial shunting is described and the English language literature is reviewed. The importance of recognizing this reversible glomerulonephritic lesion is emphasized.

The role of propranolol therapy and proteinuria in the etiology of post renal transplantation hyperlipidemia

The effects of propranolol and proteinuria on the fasting lipoprotein profiles of 33 male renal allograft recipients have been studied. By isolating the two variables by division of the patients into four groups according to propranolol dose and proteinuria, i.e. 1. propranolol = 0 mg/24 hr, proteinuria; less than 0.5 g/24 hr; 2. propranolol less than 0 mg/24 hr, proteinuria; less than 0.5 g/24 hr; 3. propranolol = 0 mg/24 hr, proteinuria; less than 0.5 g/24 hr; and 4. propranolol greater than 0 mg/24 hr, proteinuria; greater than 0.5 g/24 hr, it has been shown that propranolol treatment elevates the very low density lipoprotein triglyceride and decreases the high density lipoprotein cholesterol and that proteinuria (greater than 0.5 g/24 hr) increases low density lipoprotein cholesterol. The possible significance of these results in terms of transplantee management is discussed.

Effect of xipamide in oedema of renal disease with varying degrees of renal insufficiency: a comparative trial with frusemide

In an open crossover trial, 15 patients with evidence of renal impairment, defined by proteinuria, raised serum creatinine or impaired creatinine clearance, were randomly allocated to treatment with either 40 mg frusemide or 40 mg xipamide daily for 7 days. After a 3-day mid-point wash-out period, patients were changed the alternative drug for a further 7 days. Assessment measures involved a wide range of clinical and biochemical parameters. Whilst both drugs significantly reduced oedema, xipamide was more effective than frusemide, and this was associated with a significantly greater effect on sodium excretion with xipamide. With the exception of standing systolic blood pressure where the reduction was significantly more pronounced with xipamide, no significant changes in resting systolic, resting diastolic or standing diastolic pressure were observed to be associated with change of treatment. Three patients noticed minor side-effects during xipamide therapy. There were no adverse reactions inpatients taking frusemide.

Renal transplant in a patient with major donor-recipient blood group incompatibility: reversal of acute rejection by the use of modified plasmapheresis

A 47-year-old patient with blood group O inadvertently received a mismatched kidney from a donor of blood group A. Two days after transplantation, the clinical, biochemical manifestation of an intrarenal, intravascular coagulation was seen. This was treated by plasma exchange with the rapid reversal of all parameters, and reduction of both the IgG and IgM component of the circulating anti-A antibody. The patient, 20 months after transplantation, has normal renal function. Subsequent repeated biopsies have shown no recurrence or manifestation of the effects of the intravascular coagulopathy. This case report documents, for the first time, the reversal of the known deleterious effects of major blood group incompatibility on renal transplantation by the use of a new technique, modified plasmapheresis. Furthermore, it implies that the limitation of transplantation of kidneys on the basis of major ABO blood groups may not be justifiable in all instances.

Changes in serum calcium caused by supplementation of low protein diets with keto-acid analogues in patients with chronic renal failure

Six patients with stable end stage chronic renal failure have been studied while receiving keto-acid supplements that provided a daily calcium load of 42 +/- 2 mM. None of the patients had intercurrent illness. All patients showed elevated serum calcium concentration levels while on keto-acid supplements, reaching significance on 5 occasions. Reciprocal falls in serum phosphate concentrations were noted in all patients, and this observation was not due to an anabolic effect of the keto-acids. In 3 patients, the rise in serum calcium concentration was associated with marked clinical manifestations that required curtailment of treatment. The risk of hypercalcemia occurs early and certain high risk categories can be identified. Recommendations about the use of calcium salts of alpha-keto-acid analogues are given and it is suggested that a choice should be made available between calcium and sodium salt analogues.

Hypokalaemic hyperchloraemic metabolic acidosis and vesical stone complicating appendicovesical fistulae

Two patients with appendicovesical fistulae are described. Both presented with gastrointestinal and urinary symptoms. Biochemical examination showed hypokalaemic hyperchloraemic metabolic acidosis; radiographic investigations showed a vesical stone and a communication between the bladder and the bowel. The findings at operation suggested that the fistulae may have arisen as complications of previous appendicitis. The diagnosis of appendicovesical fistulae may be difficult but should be considered in the presence of hypokalaemic hyperchloraemic metabolic acidosis and vesical stones.

Serious renal transplant rejection and adrenal hypofunction after gradual withdrawal of prednisolone two years after transplantation

Ten patients with stable renal function two years after transplantation had their sole immunosuppressive treatment (oral prednisolone 10 mg daily) withdrawn by reducing the daily dose by 1 mg at monthly intervals. Plasma prednisolone concentration, cortisol concentration, creatinine clearance, and serum creatinine concentration were measured in all patients, and the adrenal response to corticotrophin was determined in five by measuring plasma cortisol concentrations before and after tetracosactrin injection. No episodes of rejection occurred in patients taking over 7 mg prednisolone daily. Although three patients apparently required only minimal immunosuppressive treatment (less than 5 mg daily) the remainder suffered episodes of rejection at daily doses below 7 mg. There was a tenuous association between rejection and low plasma cortisol concentration, but neither the pattern of plasma prednisolone concentrations nor the response to tetracosactrin were related to episodes of rejection. Reducing the daily dose of oral prednisolone to under 7 mg should not be attempted in patients with renal transplants unless there are extenuating circumstances.

Ingestion of formic acid-containing agents--report of three fatal cases

Three patients were treated after they had deliberately ingested domestic agents containing formic acid. The major complications included the local effects on the oropharynx, oesophagus and stomach, metabolic acidosis, derangement of clotting mechanisms with haemorrhage and shock, widespread intravascular haemolysis, disseminated intravascular coagulation and the acute onset of respiratory and renal failure. All 3 patients died between 2 and 14 days after admission. It is the authors' belief that intensive therapy from the outset to include exchange transfusion, infusion of clotting factors, high dose steroids, ventilatory support and peritoneal or haemodialysis with parenteral nutrition may perhaps offer a better chance for survival.

Dietary management of chronic renal failure with oral amino acids

6 patients in end-stage renal failure of varying aetiologies have been studied on low protein dietary regiments according to a P 6 formulation. All patients had part of their daily protein allowance substituted by an essential amino acid capsule also containing histidine and glutamic acid. All patients were maintained in nutritional balance as a result of the regiments prescribed. No toxic effects were noted and patient compliance was good. Our studies suggest the amino acid formulation given is safe and did not cause any fluctuations in patient plasma amino acid profiles. Our studies suggest an improved method of low protein dietary management for chronic renal failure patients together with a greater flexibility and wider range of prescribing possibilities. It is recommended that amino acid supplements according to the formula produced here constitute an improvement on currently prescribed Giovannetti regimens.

Prevention of amino acid losses during peritoneal dialysis

The addition of amino acid supplements to peritoneal dialysis fluid has been studied in 8 patients with compromised renal function requiring peritoneal dialysis. By the addition of 10 ml of Vamin-glucose solution to each one litre of peritoneal dialysate, amino acid losses were curtailed, no significant alterations occurred in the plasma amino acid concentrations, there were no local complications and no infections were seen. This procedure is recommended as a safe, simple way of keeping a patient in positive amino acid balance during peritoneal dialysis.

The role of plasmapheresis in renal transplantation

Plasmapheresis has been studied in ten patients who received cadaveric renal allografts. In six patients (group A), plasma was carried out on the first post-operative day and then on alternate days until six treatments had been completed. No beneficial effect was observed but treatment was well tolerated and there were no complications. One patient retains a functioning graft. Plasma exchange was carried out on six consecutive days in five patients (group B) who were actively rejecting their grafts and in whom conventional methods of treatment had failed. All five patients showed improvement in graft function. Rejection was reversed in four patients and was contained in one patient. Subsequently rapid recrudescence of graft rejection occurred in one patient, extended graft survival was seen in two patients, and the other two patients have retained life supporting grafts. Plasmapheresis may have a part to play in the treatment of renal allograft rejection and further evaluation of this treatment is indicated.