Minimal change nephrotic syndrome presenting after acute decompression

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Clinical and histopathological predictors of progressive disease in IgA nephropathy

The clinical course and biopsy findings of twenty-one patients with IgA nephropathy, followed up for a mean period of 37.4 mth (range 24-54 mth) after diagnosis, were reviewed retrospectively to determine whether the clinical presentations, the laboratory findings or histopathologic changes have prognostic implications. An age of 24 yr or above and a serum creatinine of 0.18 mmol/l or above at diagnosis correlated significantly with renal insufficiency at the end of the follow-up (P = 0.023 & 0.03). Proteinuria of 1.5 g/d or more and hypertension (systolic greater than 150 mmHg or diastolic greater than 100 mmHg) when well controlled, were not found to be significant. Asymptomatic proteinuria and gross hematuria, on the other hand, correlated negatively with renal insufficiency at the end of the follow up (P = 0.034). With respect to histopathological changes, greater than 30% global glomerular sclerosis and moderate or marked tubular atrophy correlated significantly with renal insufficiency (P = 0.005 and 0.005). However, less than 10% glomerular crescents, small amounts of mesangial electron dense deposits or absent ultrastructural peripheral glomerular capillary wall abnormalities correlated negatively with renal insufficiency (P = 0.017, 0.03 & 0.03).

Oliva vidua fulminans, a marine mollusc, responsible for five fatal cases of neurotoxic food poisoning in Sabah, Malaysia

This is the first report in which a marine mollusc, Oliva vidua fulminans (olives), generally not known to be poisonous, was responsible for death in five children after consuming boiled olives with tamarind. The onset of symptoms was rapid 10 to 20 min after consumption of the olives. Signs and symptoms included nausea, vomiting, abdominal pain, tingling sensation around the lips, numbness around the mouth, drowsiness, lethargy and generalized weakness with paraesthesia in the limbs. The five deaths occurred within 3 to 4 hours after eating the poisoned olives and resulted from respiratory failure. Left-over olives from the affected household and freshly collected live olives had a toxicity of 14,200 mouse units (M.U.) and 15,000 M.U. per 100 g meat respectively. No other common chemical poison and organophosphorus insecticides were detected. The neurotoxic agent was acid and heat stable and was toxic at pH less than 4. Its action was similar to that of paralytic shellfish poisoning which was caused by toxins from certain dinoflagellates.

Effects of nadolol and propranolol on renal function in hypertensive patients with moderately impaired renal function

Effects of oral administration of equipotent antihypertensive doses of propranolol and nadolol on renal function were examined in 20 hypertensive patients with moderately impaired renal function. Creatinine clearance increased, and serum beta 2-microglobulin concentrations decreased, when patients were switched from propranolol to nadolol therapy (creatinine clearance = 46.7 +/- 4.9 ml min-1 on propranolol and 52.7 +/- 5.9 on nadolol; beta 2-microglobulin = 6.14 +/- 0.66 mg l-1 on propranolol and 5.62 +/- 0.62 on nadolol). When patients were put back on propranolol, their creatinine clearances (45.9 +/- 5.0 ml min-1) and serum beta 2-microglobulin concentrations (6.51 +/- 0.67 mg l-1) returned to values comparable to those obtained before the change to nadolol was made. Serum beta 2-microglobulin concentrations correlated significantly with creatinine clearance (r = -0.819, P less than 0.001).

Effects of anti-inflammatory and anti-rheumatic drugs on the activities of purified and membrane-bound Na+/K+ adenosine triphosphatase

We have examined the effects of anti-inflammatory and anti-rheumatic drugs on membrane-bound and purified Na+/K+-ATPase activity in vitro. Only the gold-containing compounds (gold sodium thiomalate and auranofin) were found to inhibit the enzyme activity in a dose-dependent manner. Sodium thiomalate and triethylphosphine, the ligand compounds for gold sodium thiomalate and auranofin, respectively, had no effect on ATPase activity. The antagonistic properties was abolished by preincubation of the gold compounds with dithiothreitol. Lineweaver-Burke analysis of the inhibitions of purified ATPase by the gold compounds was found to follow uncompetitive kinetics. Inhibition of ATPase by gold may cause disruption of transmembrane cation transport and thus result in impairment of several metabolic processes and cellular functions.

Acute deterioration in renal function in systemic lupus erythematosus

In a retrospective study of 196 hospital admissions for systemic lupus erythematosus (SLE) over five years acute deterioration in renal function occurred in 36 admissions (18.4 per cent) and was the commonest mode of deterioration of renal function in SLE patients. Active lupus accounted for the majority of cases, with crescentic WHO IV lupus glomerulonephritis (greater than or equal to 50 per cent crescents) the commonest underlying pathology. In 19 per cent of these 36 admissions, it was most likely that concurrent infections at onset precipitated the episodes. Central nervous system lupus and infections were the major causes of death. Recovery of renal function was, however, achieved in 76 per cent using mainly pulse methylprednisolone and immunosuppressives as well as elimination of provoking factors especially infections.

Bancroftian filariasis and malaria in island and hinterland populations in Sabah, Malaysia

An epidemiological survey of filariasis and malaria in Banggi Island and Upper Kinabatangan, Sabah, revealed microfilarial rates of 7.2% and 8.6% respectively and malaria prevalence of 9.7% and 16.9% respectively. Wuchereria bancrofti was a rural nocturnally periodic type with a periodicity index of 137.2 and average peak hour at 01.32 hrs; 9.2% of microfilaremic carriers as compared to 2.4% amicrofilaremic subjects had clinical filariasis. The Plasmodium falciparum: P. vivax: P. malariae ratios were 1:1:0.17 and 1.4:1:0.12 for Banggi and Upper Kinabatangan respectively. Anopheles flavirostris was incriminated as a new malaria vector in Banggi where the well-known primary malaria vector is An. balabacensis. The latter was also found for the first time to be a vector of rural W. bancrofti in Upper Kinabatangan. Experimental feeding also showed that L3 larvae of W. bancrofti were recovered at low rates from An. balabacensis. Aedes togoi appeared to be a suitable laboratory vector for W. bancrofti.

Unusual transformations of renal involvement in systemic lupus erythematosus

The clinical course of a woman with systemic lupus erythematosus demonstrated that renal involvement in this disease can change, both in the predominant site of renal injury and in the pattern of glomerular lesions. Over 50 months she had first tubulo-interstitial lupus nephritis with no glomerular change, then a membranous nephropathy with disappearance of tubulo-interstitial inflammation, and finally crescentic glomerulonephritis. This case emphasizes the need for close follow-up of all lupus patients regardless of their initial renal manifestations and pathology.

Cefuroxime pharmacokinetics in continuous and intermittent peritoneal dialysis

Pharmacokinetics of cefuroxime was studied in patients on continuous ambulatory or intermittent peritoneal dialysis. A single intravenous bolus (15 mg/kg) of cefuroxime provided a mean serum concentration of 86 mg/litre 5 min, 40 mg/litre 1 h, 163 mg/litre 24 h after the injection. The peritoneal clearance of cefuroxime varied widely among different individuals, ranging from 1.45 to 6.17 ml/min with a mean of 3.59 ml/min during 4-hour exchanges, and from 0,52 to 11.3 ml/min during 2-hour exchanges. A single injection (15 mg/kg) of the antibiotic could not provide satisfactory antibiotic concentrations in peritoneal effluent during peritoneal lavage. When cefuroxime had been added to peritoneal dialysis solution before the solution was instilled into the peritoneal cavity, a significant decrease in cefuroxime concentration occurred in the peritoneal effluent even after a short equilibration time. Furthermore, cefuroxime concentrations measured in residual dialysis solutions in the plastic bags ranged from 44.3 to 1,351% of the concentration of cefuroxime calculated from the added doses, indicating that despite great care, mixing of the antibiotic with dialysis solutions in plastic bags was far from uniform.

Post-heparin hepatic and lipoprotein lipase activities in nephrotic syndrome

Lipid metabolism was studied in 18 patients with nephrotic syndrome due to various glomerulonephritides. Nephrotic patients had hypercholesterolemia with or without hypertriglyceridemia. The mean serum high-density lipoprotein cholesterol concentration was not significantly reduced in nephrotic patients. Hepatic lipase and lipoprotein lipase activities were measured selectively in post-heparin plasma from all 18 patients using a substrate-specific method. The mean lipoprotein lipase activity in nephrotic patients was markedly reduced while the mean hepatic lipase activity was not significantly different from that of controls. Lipoprotein lipase activities correlated inversely with serum triglyceride concentrations, but positively with in vivo post-heparin fractional clearance rates of Intralipid and with serum high-density lipoprotein concentrations. Nephrotic serum inhibited lipoprotein lipase activity in normal subjects. The percentage inhibition, however, did not correlate with the degree of hypertriglyceridemia. A relatively weak inverse correlation was shown to exist between plasma albumin concentration and hepatic lipase activities.

Pathogenic roles of post-heparin lipases in lipid abnormalities in hemodialysis patients

The relative roles of hepatic lipase and lipoprotein lipase in the pathogenesis of uremic lipid abnormalities were studied in 92 hemodialysis patients. Fasting serum cholesterol, triglyceride, and HDL-cholesterol concentrations were measured. Plasma lipoprotein electrophoretic patterns were determined in all patients. Hepatic lipase and lipoprotein lipase activities were selectively measured in post-heparin plasma in 59 patients. Hemodialysis patients had higher serum triglyceride and lower HDL-cholesterol concentrations than did their age and sex-matched control subjects. Both hepatic and lipoprotein lipase activities were reduced in hemodialysis patients. An inverse relation between lipoprotein lipase activities and serum triglyceride concentrations emerged. Lipoprotein lipase activities correlated with in vivo post-heparin fractional clearance rates of Intralipid. A positive correlation between lipoprotein lipase activities and HDL-cholesterol concentrations probably reflected impaired catabolism of triglyceride-rich lipoproteins being responsible for the low HDL-cholesterol concentrations. Hemodialysis patients (41.3%) had an abnormal lipoprotein (the 'mid-band'). While hepatic lipase activities did not correlate with any parameters of lipid metabolism, patients with 'low' hepatic lipase activities had a significantly higher prevalence of 'mid-bands' than did those with 'normal' activities. No evidence was developed to prove that the 'mid-band' lipoproteins were remnant particles.

Effects of propranolol and hemodialysis on the response of glucose, insulin, C-peptide and cyclic AMP to glucagon challenge

Hypoglycemia is frequently reported in hemodialysis patients on propranolol. We studied the influence of propranolol on carbohydrate metabolism in sixteen hemodialysis patients (eight on propranolol and eight not) with pre-dialysis oral glucose tolerance tests (OGTT) and pre- and post-dialysis glucagon tests. Propranolol was shown to have significant suppressive effect on the insulin response during OGTT. With glucagon challenge pre- and post-dialysis, despite a similar cAMP response, patients on propranolol had significantly lower glucose response than those not receiving propranolol and it is postulated that this is due to post-receptor post-cAMP inhibition of hepatic glycogenolysis. Moreover, while the glucose response in patients not on propranolol significantly increased after dialysis, no significant change was found in patients on propranolol. The significantly higher C-peptide, insulin and cAMP responses to glucagon challenge in the hemodialysis patients as compared to normal controls may be due to delayed clearance of glucagon, and the further increased responses after dialysis may be due to the removal of a dialyzable factor suppressing these responses.

Captopril in hypertension after renal transplantation

Eight hypertensive renal allograft recipients who had received captopril are presented. Captopril in a maximal daily dose of 250 mg enabled the withdrawal of large doses of beta-blocking agents and vasodilators. Blood pressure was satisfactorily controlled in all except one. No adverse side effects were observed other than the 'first dose' effect which resulted in transient anuria in one patient. Captopril appears to be a useful agent in the management of severe hypertension after renal transplantation.

Lipid nephrotoxicity in chronic progressive glomerular and tubulo-interstitial disease

It is hypothesised that chronic progressive kidney disease may be mediated by abnormalities of lipid metabolism. A series of self-perpetuating secondary events follows an initial glomerular injury. Increased glomerular basement membrane permeability leads to loss of lipoprotein lipase activators, resulting in hyperlipidaemia. Circulating low-density lipoprotein binds with glycosaminoglycans in the glomerular basement membrane and increases its permeability. Filtered lipoprotein accumulates in mesangial cells and stimulates them to proliferate and produce excess basement membrane material. The proximal tubular cells metabolise some of the filtered lipoprotein and the remainder are altered on passage down the nephron. Luminal apoprotein precipitates, initiating or aggravating tubulo-interstitial disease, if the intraluminal pH is close to the isoelectric point of the apoprotein. The hypothesis offers new approaches to the study of chronic progressive kidney disease by proposing a major pathogenetic role for lipid abnormalities.

Plasma LCAT activities in renal allograft recipients

Plasma LCAT activities were measured in 51 renal allograft recipients as well in 18 patients before and after successful renal transplantation. The mean plasma LCAT activity of the 51 patients did not differ significantly from that of 27 normal subjects. When the patients were separated into two groups according to whether they had normal or impaired renal function, there was no significant difference in their mean LCAT activities. Plasma LCAT activities correlated significantly with total cholesterol and total triglyceride concentrations. The sequential study demonstrates that the low plasma LCAT activities in uraemic patients rose towards normal after successful transplantation. At the same time, total cholesterol and HDL-cholesterol concentrations also increased. The increase in LCAT activity after renal transplantation is due to increased concentrations of the enzyme and probably reflects increased turnover of triglyceride-rich lipoproteins.

Hyperlipidemia in patients on maintenance hemo- and peritoneal dialysis: the relative pathogenetic roles of triglyceride production and triglyceride removal

A study was undertaken in 76 patients on maintenance hemodialysis and 26 patients on maintenance peritoneal dialysis to elucidate the pathogenesis of hyperlipidemia in these patients. A high prevalence of hypertriglyceridemia and low concentrations of high density lipoprotein cholesterol was found. Hemodialysis patients had low or normal total cholesterol concentrations which were significantly lower than those on peritoneal dialysis. The length of treatment did not affect the prevalence of the lipid abnormalities. Both pre- and post-heparin fractional clearance rates of Intralipid were markedly reduced in both groups of dialysis patients and were correlated inversely with serum triglyceride concentrations. However, when compared with normal subjects with similar fractional clearance rates of Intralipid, both groups of dialysis patients had higher serum triglyceride concentrations, probably reflecting increased triglyceride production. Serum triglyceride concentrations in both groups of dialysis patients were positively correlated with plasma immunoreactive insulin levels. Furthermore, a significant inverse correlation was observed between plasma immunoreactive insulin levels and post-heparin fractional clearance rates of intralipid. It was concluded that insulin resistance probably caused the defective triglyceride removal, and that both decreased removal and increased production of triglycerides contributed to the hyperlipidemia in dialysis patients.

Plasma lecithin-cholesterol acyltransferase activities in uraemic patients

Plasma lecithin-cholesterol acyltransferase (LCAT) activity was measured in 43 haemodialysis and 15 peritoneal dialysis (CAPD) patients. LCAT activities in both groups of patients were significantly lower than those of normal subjects and did not correlate with any of the other biochemical parameters studied. The effect of intravenous administration of 100 U/kg of heparin on LCAT activity was examined in 21 haemodialysis patients and 19 normal subjects. Heparin inhibited LCAT activity by increasing plasma free fatty acid concentrations. LCAT remained inhibited throughout a dialysis session and returned towards pre-dialysis levels an hour after haemodialysis was discontinued. The cause of the low LCAT activities in the patients was not certain, but did not appear to be due to the presence of inhibitors in the uraemic plasma. The significance of these findings is discussed.

Response patterns to DL-carnitine in patients on maintenance haemodialysis

10 hypertriglyceridaemic hemodialysis patients were given dl-carnitine, 600 mg daily, for 8 weeks and then 1.2 g daily for 12 weeks. Serum total cholesterol, total triglyceride, high-density lipoprotein cholesterol and plasma free fatty acid (FFA), glucose, and immunoreactive insulin concentrations were measured at regular intervals during the treatment. Intravenous fat tolerance tests were performed in 9 patients. Plasma FFA concentrations fell and the post-heparin fractional clearance rate of Intralipid increased significantly after all-carnitine administration. While overall no clear-cut effect of dl-carnitine on serum lipids was found, two patterns of response to dl-carnitine could be distinguished: the 'paradoxic' response with a rise in serum triglyceride concentrations and the dual response to two different dosages of dl-carnitine.

Hyperlipidaemia in untreated nephrotic syndrome, increased production or decreased removal?

The relative importance of increased lipoprotein synthesis and decreased lipoprotein catabolism is examined in 13 patients with untreated nephrotic syndrome by the use of intravenous fat tolerance tests analysed in relation to other parameters of lipid metabolism. Increased lipoprotein synthesis in nephrotic patients was indicated by the fact that at a given fractional clearance rate of Intralipid (K2), nephrotic patients had higher serum TG concentrations than did control subjects. A defect in lipoprotein catabolism was also suggested by the frequent finding of intermediate density lipoproteins on electrophoresis and the marginally low (p = 0.05) mean K2 in nephrotic patients. A highly significant (p less than 0.001) positive correlation between HDL-cholesterol concentrations and postheparin fractional clearance rates (K'2) of Intralipid led to the speculation that in the severe nephrotic state (albumin less than 20 g/l) the loss of high density lipoproteins may contribute to the hyperlipidaemia.

Fat clearances and hyperlipidaemia in renal allograft recipients--the role of insulin resistance

The mechanism of hyperlipidaemia in renal allograft recipients was investigated in 19 patients randomly selected from a cohort of 54 patients with functioning renal allografts. Serum cholesterol, triglyceride and high-density lipoprotein cholesterol concentrations as well as plasma immunoreactive insulin levels were measured in fasting blood samples. Intravenous fat tolerance tests were performed before and 15 min after heparin administration. Renal allograft recipients had reduced fractional clearance rates of Intralipid and a positive correlation was demonstrated between plasma immunoreactive insulin levels and serum triglyceride concentrations. Plasma immunoreactive insulins also correlated inversely with fractional clearance rates of Intralipid. It was concluded that both increased production and decreased removal of lipoproteins contribute to the hyperlipidaemia and that insulin resistance due to corticosteroids was the centre of the problem.

Three years' experience of continuous ambulatory peritoneal dialysis

Patients on continuous ambulatory peritoneal dialysis (CAPD) were studied for three years. 29 of them who had been on CAPD for six months or more were compared with patients on intermittent peritoneal dialysis (IPD) and on haemodialysis (HD). CAPD patients had significantly higher levels of HDL-cholesterol than HD patients. Urea, potassium, phosphate, and urate levels were significantly lower, and haemoglobin levels significantly higher, than in the IPD and HD groups. 43 CAPD patients studied had a peritonitis rate of 2.22 episodes per patient-year. CAPD offers an alternative form of dialysis to those unsuitable for HD, but until peritonitis rates can be reduced CAPD cannot rival HD as a long-term treatment.

The role of multiple pharmaco-therapy in the pathogenesis of hyperlipidemia after renal transplantation

A study was undertaken in 54 renal allograft recipients to evaluate the multiple factors contributing to the pathogenesis of hyperlipidemia after renal transplantation. Serum triglyceride concentrations were found to correlate positively with the cummulative prednisolone dose, and with abdominal skin fold thickness. Serum cholesterol concentrations correlated significantly with serum creatinine concentrations. Patients on beta adrenergic blocking agents had lower plasma free fatty acid concentrations and patients on diuretics had higher serum triglyceride concentrations. The implication of these findings are discussed.

The effects of vitamin A toxicity on calcium and lipid metabolism in chronic renal failure

Serum vitamin A levels were high in haemodialysis patients, and were found to correlate with plasma calcium, triglyceride, cholesterol and insulin levels. Vitamin A containing multivitamin supplements were found to contribute to increased serum vitamin A levels, and their withdrawal in seven patients caused a significant decrease in serum vitamin A and calcium levels, with no effect on lipid levels. Vitamin A containing preparations should therefore be prescribed with caution in these patients.

Hepatitis B and the dialysis and renal transplantation unit

Different facets of hepatitis B infections are encountered in a renal unit. The viral antigens are implicated in the pathogenesis of some cases of glomerulonephritis. Hepatitis B surface (HBs) antigenaemia frequently persists in dialysis patients who contract the virus and presents a significant health hazard to the attendant staff. Persistent HBs antigenaemia does not jeopardise renal allograft survival. The effect of anti-HBs antibodies is not clear. Transplantation can reactivate latent hepatitis B infections and render patients HBs antigen (HBsAg)-positive. Hepatic malignancies have been observed and increased patient mortality reported in HBsAg-positive renal allograft recipients. The effect of immunosuppression and maternal viral infection on the fetus is open to speculation.

Fat clearance before and after heparin in chronic renal failure--haemodialysis reduces post-heparin fractional clearance rates of intralipid

The effect of heparin on the kinetics of fat removal was studied in 15 subjects and it became apparent that the fat tolerance test could be performed after the administration of heparin. Therefore, fractional clearance rates of Intralipid were determined before and after heparin in three groups of patients: 18 in chronic renal failure, 11 on peritoneal dialysis and 17 on haemodialysis. Patients on peritoneal dialysis and on haemodialysis had similar serum triglyceride concentrations and comparable fractional clearance rates of Intralipid before heparin was given. However, the latter had significantly smaller increases in fractional rates of Intralipid clearance after the administration of heparin. Either gradual diminution of releasable releasable enzymes by regular heparinisation or activator concentrations becoming rate-limiting could be responsible for the low post-heparin fractional clearance rates observed in haemodialysis patients.

Comparative clinical features in patients with myasthenia gravis with systemic lupus erythematosus

The occurrence of myasthenia gravis (MG) with systemic lupus erythematosus (SLE) seems to be more common than random association alone would predict. Moreover, both share immunologic aspects, tissue-directed antibodies and T and B cell abnormalities. To our knowledge, 7 cases of MG in association with SLE have been reported in the English literature in the last 15 yr; in 6 of the 7 cases, MG preceded the SLE; in only 1 reported case and in our case, SLE preceded the MG. The disease that develops later predominates in the prognosis for each patient.

Nocturnal polyuria and saluresis in renal allograft recipients

The evolution of nocturnal polyuria and saluresis in renal allograft recipients was studied by comparing the day to night (D:N) ratios of urine volume and sodium excretion in 15 patients who had undergone transplantation less than one year previously (recent-transplant group) with those in 11 patients who had undergone transplantation at least one year previously. Eleven patients with chronic renal failure and 12 normal subjects served as controls. Patients in the recent-transplant group had significantly lower D:N ratios of urine volume and sodium excretion than the patients who had undergone transplantation at least a year before, while the ratios in this last group did not differ significantly from those in the normal subjects. Nocturnal polyuria and saluresis gradually subsided in five patients studied for three months. Chronic renal failure and uraemic autonomic neuropathy were unlikely causes of the nocturia. The patients in the recent-transplant group had significantly lower D:N ratios of urine volume than the controls with chronic renal failure, and the mean Valsalva ratio in eight of them was not significantly different from that in the normal subjects. An undue sensitivity of renal allografts to postural influences was proposed.