The spectrum of renal disease in Laurence-Moon-Biedl syndrome

To determine the nature, extent, and severity of renal involvement in Laurence-Moon-Biedl syndrome (obesity, mental retardation, polydactyly, hypogonadism, and pigmented retinal dystrophy), we evaluated 20 of 30 patients with the disorder identified from ophthalmologic records in Newfoundland. The mean age was 31 years, and seven were male. All 20 patients had structural or functional abnormalities of the kidneys or both. Three had end-stage renal disease, with two requiring maintenance hemodialysis. The remaining 17 patients had normal serum creatinine values and estimated creatinine clearances. Half the subjects had hypertension. Fourteen of 17 patients could not concentrate urine above 750 mOsm per kilogram of body weight even after vasopressin, whereas all 10 normal controls could. Urinary pH decreased below 5.3 after ammonium chloride administration in all 15 normal controls, but in only 13 of 18 patients. Calyceal clubbing or blunting was evident in 18 of 19 patients studied by intravenous pyelography; 13 patients had calyceal cysts or diverticula. Seventeen of 19 patients had lobulated renal outlines of the fetal type. Four patients had diffuse renal cortical loss, but only two of these had renal insufficiency. We conclude that Laurence-Moon-Biedl syndrome includes the presence of renal abnormalities.

Congestive heart failure in dialysis patients

To determine the prevalence of congestive heart failure in dialysis patients and the disorders with which it is associated, 85% of 153 nondiabetic patients who were undergoing maintenance dialysis had echocardiography and gated cardiac scan. Ten percent (n = 15) had congestive heart failure, 53% (n = 8) of whom had dilated cardiomyopathy, and 47% (n = 7) had hypertrophic hyperkinetic cardiomyopathy. Ischemic heart disease was an additional independent risk factor for congestive heart failure. Significantly more of those patients with dilated cardiomyopathy were smokers and none were hypertensive, whereas all those patients with hypertrophic cardiomyopathy were hypertensive. The prevalence of hypertrophic hyperkinetic disease was 11%, of dilated cardiomyopathy 18%, and of symptomatic ischemic heart disease 18%. We concluded that congestive heart failure in dialysis patients is associated not only with dilated cardiomyopathy but also with hypertrophic cardiomyopathy, a disease that requires echocardiography for diagnosis and that has different risk factors and management.

The long-term outcome of hepatitis B infection in hemodialysis patients

Little information on the long-term outcome of hepatitis B virus (HBV) infection in hemodialysis patients is available. We studied 49 hemodialysis patients, seen at three centers between 1969 and 1985, who developed HBV infection. Patients were studied retrospectively and followed for up to 10 years (mean 52 +/- 5 months). Only 20% (n = 10) of patients converted to hepatitis B surface antigen (HBsAg) negative, the majority of whom did so within 6 months of becoming HBsAg positive. Twenty-nine percent (n = 14) of patients developed chronic elevation of liver enzymes which remitted in one patient. Only one patient died from liver disease. We conclude that HBV infection in hemodialysis patients more often results in persistent antigenemia and chronic elevation of liver enzymes than is the case in patients without kidney disease. However, the risk of death from liver disease is low.

Left ventricular hypertrophy in end-stage renal disease

To determine the prevalence of left ventricular hypertrophy (LVH; left ventricular wall thickness greater than or equal to 1-2 cm in diastole) among end-stage renal disease (ESRD) patients and the most important risk factors that independently relate to LVH, 189 non-diabetic ESRD patients without dilated cardiomyopathy in two centres had echocardiography and full clinical review. 104 of 189 (55%) patients had LVH consisting of 52 of 83 (65%) patients on haemodialysis, 18 of 20 (90%) peritoneal dialysis patients and 34 of 86 (40%) transplanted patients. Using multiple logistic regression, the most important factors which independently related to LVH, in all patients studied, were dialysis as current ESRD treatment (p less than 0.001), followed by age (p = 0.008), hypertension as defined by number of blood pressure medications (p = 0.007), followed by high serum alkaline phosphatase which probably reflects hyperparathyroidism (p = 0.03). In a subset of patients with severe LVH (left ventricular wall thickness greater than or equal to 1.4 cm), a high serum alkaline phosphatase level was the best predictor of LVH (p less than 0.001), followed by high diastolic blood pressure (p = 0.004) and age (p = 0.02). In dialysis patients, the most important variable were age (p = 0.009) and high serum alkaline phosphatase (p = 0.03). In the transplant group, patients with LVH were taking significantly more antihypertensive medications than those without LVH (p = 0.002). This variable was the only predictor of LVH in the transplant group.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical features and severity of nonspecific symptoms in dialysis patients

Nonspecific symptoms are common in dialysis patients but few methods are available to measure their severity and their response to alteration in dialysis therapy. To determine the clinical features and measure the severity of the most important symptoms in end-stage renal disease (ESRD) patients, 97 dialysis patients were interviewed, 63 of whom were reinterviewed 1 year later. For comparison 82 transplant recipients were also interviewed. The six most important symptoms in dialysis patients (using the product of the patient's perception of severity and prevalence) were tiredness, cramps, pruritus, dyspnea, headaches and joint pain. The symptoms were long-standing, occurred frequently, with little difference in prevalence between hemo- and peritoneal dialysis patients, and were often unrelated to a hemodialysis session. For each symptom, several dimensions of severity were assessed including frequency, duration, effect on sleep, daily living, activity, subjective quality of life and necessity for drug therapy. Often these dimensions did not correlate with patient's perception of severity. For each symptom these items were combined to give an aggregate score with a range 0-10. Interobserver reproducibility for each symptom score was greater than or equal to 0.7 but intraobserver reproducibility was poor for 3 symptoms, because of the fluctuating nature of the symptoms. Construct validity was demonstrated by finding a significantly worse distribution of aggregate scores for tiredness, cramps, pruritus, dyspnea and nausea/vomiting in dialysis compared to transplant patients. Aggregate scores changed little after 1 year's follow-up in stable dialysis patients but significant improvement in the aggregate scores for tiredness, dyspnea and nausea/vomiting were observed in 14 patients after successful transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Recurrent hemoperitoneum in women receiving continuous ambulatory peritoneal dialysis

Of 27 women in the reproductive age group receiving continuous ambulatory peritoneal dialysis for more than 3 months, 4 of 7 who menstruated developed recurrent hemoperitoneum. Tubal ligation had been done in 3 of these 4 women. There were 37 episodes of hemoperitoneum; 22 occurred at midcycle and 15 with menstruation. One patient required repeated blood transfusion, but after oral anovulant therapy no further bleeding occurred and no transfusion was required. Two patients needed laparotomy: one for heavy intraperitoneal bleeding originating from a luteal cyst, and the other for severe lower abdominal pain from follicular and luteal cysts. Ultrasound examinations suggested the presence of small ovarian cysts in the two remaining patients. Recurrent midcycle hemoperitoneum in women on continuous ambulatory peritoneal dialysis may be triggered by ovulation and associated ovarian cyst formation. Suppression of ovulation should be considered.

Hepatitis B disease in dialysis and transplant patients. Further epidemiologic and serologic studies

As hepatitis B virus (HBV) infection in renal transplant recipients is associated with a high incidence of progressive liver disease it may be inadvisable to transplant hemodialysis patients with hepatitis B antigenemia. To determine the natural history of HBV disease in hemodialysis patients, all 49 patients on hemodialysis treatment for at least 1 year, at 3 centers, who developed circulating hepatitis B surface antigen (HBsAG), were studied. A subgroup of these patients (n = 31) aged less than or equal to 50 years, followed for 55 +/- 6 months after detection of HBsAg was compared with 22 previously studied HBsAg-positive transplant patients followed for 81 +/- 9 months. Significantly more transplant patients developed chronic hepatitis defined biochemically (P less than .001) and none of the transplant patients became HBsAg-negative compared with 19% of the hemodialysis group. Taking difference in follow-up into account, mortality was significantly higher in the transplant recipients (P less than .005) following development of HBsAg antigenemia, and the mortality difference was attributable to deaths from liver disease. A total of 36 serum samples from 14 of the 22 HBsAg-positive renal transplant recipients was analyzed for hepatitis B e antigen (HBeAg), antibody to hepatitis D virus (anti-HD), and hepatitis B virus deoxyribonucleic acid (HBVDNA) concentration. No serum sample was anti-HD-positive. Twelve of the 14 patients were HBeAg-positive. Five patients became HBeAg-negative, 3 of whom developed aggressive liver disease. One HBeAg-negative anti-HBe-positive patient had progression of liver disease from asymptomatic carrier status to chronic active hepatitis (CAH). Of 14 patients, 9 developed progressive CAH. HBVDNA concentration was not diagnostic of disease activity on liver biopsy. However only 1 sample of 10 measured in 5 patients with nonprogressive disease had a level greater than 100 pg/L, compared with 9 of 17 in the group who progressed to CAH. During the interval when the liver histology progressed from asymptomatic carriage or chronic persistent hepatitis (CPH) to CAH, the HBVDNA concentration increased by greater than 10 times baseline in 4 of 5 patients who had serial samples, whereas this did not occur in 4 patients with nonprogressive disease. We conclude that the long-term outcome of hepatitis B infection in transplant recipients is significantly worse than in hemodialysis patients. Therefore it may be inadvisable to transplant HBsAg-positive hemodialysis patients.(ABSTRACT TRUNCATED AT 400 WORDS)

The effect of ethanol on serum cyclosporine A levels in renal transplant recipients

Following an alcohol binge, cyclosporine A (CyA) levels rose by 100% in a 51-year-old transplant recipient treated with CyA. As CyA and ethanol are both metabolized by the cytochrome P-450 enzyme system, ethanol could theoretically interfere with CyA metabolism. Therefore, eight male renal transplant recipients were assessed in a crossover study to determine the effects of acute ethanol ingestion on CyA serum concentrations. CyA serum concentrations did not rise following 50 mL of 100% alcohol. We conclude that heavy alcohol intake may increase CyA levels but that acute moderate intake does not.

Low-output left ventricular failure in end-stage renal disease

To determine the factors associated with low-output left ventricular failure (LVF) in endstage renal disease (ESRD), we performed echocardiography and gated cardiac scan on 217 nondiabetic dialysis and transplant patients. The prevalence of low-output LVF (ejection fraction less than 55% and left ventricular end diastolic diameter greater than or equal to 5.5 cm) in dialysis patients was 18% and in transplant patients 2%. The 26 patients with LVF were compared to 52 controls without LVF, matched by age, sex and year of starting treatment for ESRD, but not for current ESRD therapy. Mean age was 55 +/- (SEM) 14 years; 73% of the patients in both groups were males. Duration of treatment for ESRD was 5.6 +/- 4.3 years in patients, compared to 5.1 +/- 4.1 years in controls. Significant differences between LVF patients and controls included current treatment (73% of cases were on hemodialysis and 8% were transplanted, compared to 48 and 42%; chi 2 = 9.9, p less than 0.01), high serum creatinine, smoking and high serum alkaline phosphatase. There were no differences for current blood pressure, proportion on treatment for hypertension, left ventricular wall thickness, symptomatic ischemic heart disease, proportion with functioning vascular access, degree of weight gain between dialyses, hemoglobin level or high transfusion requirement. Multiple logistic regression demonstrated the most significant and independent variables associated with LVF were high alkaline phosphatase (suggestive of hyperparathyroidism), smoking and high serum creatinine levels (reflecting degree of uremia). Dialysis patients with LVF (n = 23) were compared to dialysis patients who had normal echocardiograms (n = 29).(ABSTRACT TRUNCATED AT 250 WORDS)

Staphylococcal epidermidis infection of a hemodialysis button-graft complex controlled by vancomycin for 11 months

A 54 year old woman had a Bentley DiaTAP button implanted in her thigh for hemodialysis access. She had been started on continuous ambulatory peritoneal dialysis (CAPD) because of intractable vascular access problems. Unfortunately, CAPD had to be discontinued because of fungal peritonitis. Transplantation had not been possible because of circulating cytotoxic antibodies. The prosthetic complex soon became infected with Staphylococcus epidermidis and blood cultures were intermittently positive for 11 months. However, with continuing vancomycin therapy she remained in her usual state of health, without side effects from vancomycin, until venous thrombosis resolved and it became possible to remove the infected prosthetic complex and implant a button in an arm. As a last resort, it may be possible to maintain a patient on dialysis in reasonable health with a DiaTAP button graft complex infected with Staphylococcus epidermidis and intermittent positive blood cultures using long term vancomycin therapy. Such management probably would not be appropriate for any other organism.

Audit of the Medical Audit Committee

We reviewed 39 medical audits started in one institution between 1981 and 1985 to determine whether they monitored the quality of health care in a scientific manner, whether recommendations were made that could improve the quality of health care and, if so, whether the recommendations were acted on. Thirty-three audits (85%) were completed; 21 (64%) failed to state their objectives, 30 (91%) failed to compare their results with those in the literature, 9 (27%) made no recommendations that could improve the quality of health care, and 9 were poorly researched and written. The number of patients in each audit was usually adequate. Feedback was rarely received by the Medical Audit Committee concerning the Medical Advisory Committee's response to the audit. Information concerning the implementation of recommendations was available for 17 of the 24 audits that made recommendations; 7 (41%) had failed to implement half or more of the recommendations. Despite these problems, 8 (24%) of the audits were considered to be of a quality that could improve health care. We present recommendations to improve the audit procedure and foster the growing confidence among doctors in the medical audit.

The decreased incidence of aseptic necrosis in renal transplant recipients--a case control study

Before 1971 the incidence of aseptic necrosis in renal transplant recipients was 29%, and after 1971 it was 5%. To investigate the reasons for this decreased incidence and to elucidate the causes of aseptic necrosis we studied all 26 transplant patients with aseptic necrosis and 42 controls matched for year of transplantation, age, and sex. Development of aseptic necrosis was not related to duration of dialysis before transplant, severity of uremia at the time the patient started dialysis, adequacy of dialysis before transplantation, transplant dysfunction at the time aseptic necrosis was diagnosed, hyperparathyroidism before or after transplantation, lack of Vitamin D supplementation after transplantation, or fatty infiltration of liver. Total steroid dose 1 month after transplantation was actually lower in aseptic necrosis compared with the control group (2.47 +/- 0.3 g vs. 3.6 +/- 0.3 g SEM g) and was similar after 4 months (6.72 +/- 0.55 g vs. 7.14 +/- 0.6 g), as were total numbers of i.v. doses of methylprednisolone or hydrocortisone. However, blood urea nitrogen (BUN) during the dialysis period was significantly higher in the aseptic necrosis group. Of the aseptic necrosis group, 27% had a previous transplant compared with 5% of controls. Half the aseptic necrosis group (5/10) had parenchymal iron on liver biopsy one year after transplant compared with 15% (2/13) of those without aseptic necrosis. Patients transplanted before 1971 (with and without aseptic necrosis) received significantly more i.v. hydrocortisone and less i.v. methylprednisolone, had higher BUN levels at the time of starting dialysis, and had lower serum calcium and higher serum phosphate at transplantation compared with patients transplanted in or after 1971. The incidence of aseptic necrosis following transplantation has decreased during the past 13 years for reasons that are unclear. Risk factors for aseptic necrosis may include previous transplantation, severe iron overload that may lead to marrow fibrosis and osteopenia, and increased protein catabolism/turnover during dialysis.

Reduction of azathioprine in renal transplant patients with chronic hepatitis

To determine whether prolonged reduction of azathioprine in renal transplant recipients with chronic hepatitis affected the progression of liver disease without an adverse effect on graft survival we studied all transplant patients with a raised serum glutamic oxaloacetic transaminase level greater than normal for more than 1 year who had azathioprine reduced below 100 mg/day for longer than 1 year. Six HBsAg-positive patients had chronic hepatitis for 67 +/- 7 (SE) months before reduction of azathioprine and were followed for a further 49 +/- 14 months. None of the six patients remitted, 3 patients died from liver disease, and none returned to dialysis. In the group of 12 patients who did not have azathioprine reduced, none remitted, 4 died from liver disease, and none returned to dialysis during a follow-up of 115 +/- 9 months. Seven HBsAG-negative patients had chronic hepatitis for 32 +/- 11 months before reduction of azathioprine and were followed for a further 46 +/- 8 months. One of the seven remitted, none died from liver disease and one returned to dialysis. In the group of 15 patients who did not have azathioprine reduced 5 patients remitted, none died from liver disease, and none returned to dialysis. We conclude that prolonged reduction of azathioprine does not slow the progression of liver disease in renal transplant recipients with HBsAg-positive or HBsAg-negative chronic hepatitis, nor does it predispose to graft failure. However reduction of immunosuppression early in the course of hepatitis B disease may be necessary to prevent adverse long-term sequelae.

The spectrum of diseases associated with necrotizing glomerulonephritis and its prognosis

Necrotizing glomerulonephritis (NGN) represents small-vessel vasculitis in the kidney. To assess the diseases associated with necrotizing glomerular changes and their prognosis we studied all 32 patients who had this histologic finding on kidney biopsy from 1969 to 1982 and compared them to those patients who had crescentic, diffuse, or focal and segmental glomerulonephritis without necrosis (n = 29). The diseases associated with NGN were systemic lupus erythematosus (n = 6/15), Henoch-Schönlein purpura (n = 3/4) Goodpasture's syndrome (n = 4/7), Wegener's granulomatosis (n = 6/6), polyarteritis (n = 4/5), infective endocarditis (n = 2/3), and idiopathic rapidly progressive glomerulonephritis (n = 7/21). Necrotizing glomerulonephritis occurred significantly more often in the vasculitides than in all the other disorders put together. The most difficult diagnosis problem occurred in patients with renal disease and pulmonary hemorrhage (n = 9), in three of whom diagnosis was uncertain even after autopsy (two autopsies done within one month and one within three months of presentation). A fourth patient had a linear staining for IgG along the glomerular basement membrane (GBM) on kidney biopsy but was subsequently diagnosed as having Wegener's granulomatosis. Comparison of patients with without NGN revealed no difference in outcome (death or dialysis) one year after biopsy (38% v 43%) or in serum creatinine levels one year later (4.6 v 4.8 mg/dL). The prognostic effect of NGN was not obscured by unequal distribution of other adverse prognostic factors in the two groups. The most important prognostic characteristics we identified for outcome were serum creatinine at biopsy (chi 2 = 24.0, P less than .0004) and the sum of activity and chronicity indexes on biopsy (chi 2 = 12.7, P = .0004). These variables were similarly distributed in patients with and without necrosis, mean serum creatinine levels at biopsy being 4.3 v 4.2 mg/dL and sum of indexes 7.8 v 8.0. Other factors such as clinical diagnosis and therapy were not important prognostically and therefore could not explain our results. We conclude that NGN in patients with active proliferative glomerulonephritis has multiple causes. Diagnostic difficulties occurred in those with anti-GBM-negative pulmonary hemorrhage. The appearances of small-vessel vasculitis in the kidney did not appear to have prognostic significance.

Chronic hepatitis in end-stage renal disease: comparison of HBsAg-negative and HBsAg-positive patients

To determine the outcome of chronic hepatitis in ESRD we studied all 358 renal transplant recipients and 295 hemodialysis patients treated for greater than 1 year since 1970. The incidence of chronic hepatitis (elevated SGOT for greater than 1 year) was 15% (N = 54) in transplanted and 3.4% (N = 10) in dialysis patients. Forty-eight percent (26) of transplanted and 50% (5) of dialysis patients were HBsAg positive. In the transplanted group, the clinical outcome of chronic hepatitis was significantly better in HBsAg-negative compared to HBsAg-positive patients; 11% died, none from liver disease, and 32% remitted after a mean follow-up from start of liver disease of 77.3 +/- 8.2 months, whereas in the HBsAg-positive group 54% (14) died, nine from liver disease, and one remitted after a follow-up of 90.2 +/- 8.9 months. Adverse prognostic factors (age, duration of diabetes, and heart disease) present before ESRD treatment began were similar in both groups, as was duration of follow-up. Only 14% (2/14) of HBsAg-negative patients progressed to chronic active hepatitis on liver biopsy compared to 71% (15/21) of HBsAg-positive patients. Histological stability in those with serial biopsies occurred in 66% (4/6) of HBsAg-negative patients, but in only 18% (13/16) of HBsAg-positive patients with a similar duration of follow-up. No dialysis patients died from liver disease. We conclude that chronic hepatitis occurs more frequently in transplanted than dialyzed patients, and that HBsAg-negative chronic hepatitis has a more benign, clinical, and histological outcome than chronic HBsAg-positive hepatitis in renal transplant recipients.

The impact of renal transplantation on the course of hepatitis B liver disease

To establish the impact of transplantation on the course of chronic hepatitis B liver disease we performed a prospective study of the clinical and pathological sequelae of hepatitis B disease in all 22 patients who had renal allografts that functioned for more than 1 year and who were hepatitis B surface antigen (HBsAg)-positive following transplantation. No patient converted to HBsAg-negative. During a mean follow-up of 83 months serial liver biopsies were performed in 20 patients and 1 liver biopsy was available in the remaining 2 patients. Eleven patients died of liver disease, 5 of whom died of hepatic failure, 3 with hepatoma, 2 of gastrointestinal hemorrhage, and 1 of ascites with pleuroperitoneal fistula. Aggressive liver disease was observed in the vast majority of patients: 12 ultimately developed cirrhosis, (mean follow-up 81 months), 6 chronic active hepatitis (mean follow-up 93 months), 3 chronic persistent hepatitis (mean follow-up 89 months), and in 1 patient the presence of HB virus in hepatocytes was the sole morphologic alteration (follow-up 42 months). There was a marked tendency to progression in that 82% of patients with virus only, reactive hepatitis, or chronic persistent hepatitis on initial biopsy subsequently developed chronic active hepatitis or cirrhosis. For comparison, 10 HBsAg-positive patients whose renal failure had been treated by hemodialysis were also studied over a comparable period. Four patients converted to the negative state. Biochemical evidence of persistent liver dysfunction occurred in only 1 patient and no patient has died from complications of liver disease. We conclude that in the immunosuppressed renal transplant patient HB infection often results in the development of cirrhosis, leading to death from hepatoma and hepatic failure. This course is worse than that in dialysis patients. Renal transplantation of HBsAg-positive patients with end-stage renal failure may be inadvisable.

Transplantation versus dialysis in diabetic patients with renal failure

Studies suggesting that transplantation is better than dialysis for diabetic patients with renal failure may be biased by the more favorable pretreatment prognosis of transplanted patients. Therefore, to provide a fairer comparison we controlled for pretreatment clinical state, categorized treatment received, and assessed mortality, major morbid events, and hospitalization in 51 diabetic patients who began therapy between 1970 and 1980. Fourteen patients were treated by transplantation and 37 by dialysis. The mean waiting period for transplantation was 5 months. The average age of transplanted patients was 40.9 years and of dialyzed patients 59.6 years. When we controlled for this age disparity and other factors (duration of diabetes and heart failure) that affect prognosis in end-stage renal disease (ESRD), the mortality with both transplantation and dialysis was similar to that expected from the overall mortality rate of the 51 study patients. Treatment received had no effect on mortality; the observed deaths compared with deaths expected from pretreatment status were 8 and 7.3 for transplantation and 30 and 30.7 for dialysis. We also compared major morbid events (blindness, amputation, stroke, severe heart failure, and myocardial infarction) and hospitalization in transplanted patients with the 24 dialyzed patients who survived long enough (5 months) to be eligible for transplantation. The number of major morbid events was 2.7 per 10 patient-years in the transplanted group and 3.4 in the dialyzed group. Hospitalization was 151.3 d/yr in transplanted patients and 55.6 d/yr in dialyzed patients (P less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The role of azathioprine reduction in late renal allograft failure

A group of 123 patients who had functioning renal transplants for more than 5 years were studied to discover whether prolonged reduction of azathioprine could predispose to late allograft failure. From the point of entry into the study (5 years after transplantation), the 5-year cumulative graft survival among living-related-donor recipients was 91.7%, and among non-living-related-donor recipients it was 84.8%. The azathioprine dose was reduced in 21 patients, for medical reasons, below 100 mg/day for more than one year when serum creatinine was stable and less than 2 mg/dl. Eight patients subsequently required dialysis. In the control group of 35 patients (transplanted in the same years, with serum creatinine that was similar at the same time posttransplantation to that of those who had azathioprine reduced) only 1 patient required dialysis. The likelihood of dialysis was significantly greater in those who had azathioprine reduced compared with those who did not (chi 2 = 12.0, P less than 0.001). No patient who had azathioprine reduced because of low white cell counts or chronic hepatitis subsequently required dialysis. It was concluded that a prolonged reduction of the azathioprine dose may predispose to late allograft failure.

Renal function following infusion of radiologic contrast material. A prospective controlled study

In a prospective, controlled study undertaken to assess renal function following infusion of radiologic contrast material, serum creatinine level was determined before scan and for three days after scan in 193 patients undergoing computed tomographic (CT) brain scan with contrast enhancement (contrast medium volume, 60 to 350 mL) and in 233 controls undergoing CT scan without infusion. Renal failure developed in four patients who had infusion of contrast material and in three patients who had no infusion (greater than or equal to 50% increase in serum creatinine level and above normal). In the high-risk group (serum creatinine level greater than or equal to 1.5 mg/dL or diabetes mellitus), renal failure developed in none of the 19 patients infused and in two of 46 in the noninfused group. It was concluded that previous uncontrolled studies may have overestimated the risk of renal failure induced by contrast material.

The diagnostic and prognostic value of renal allograft biopsy

We prospectively studied 89 patients to assess the diagnostic use of renal allograft biopsy in the first three months after transplantation. These biopsies were done in patients in whom diagnosis was not clear or clinical rejection was deemed to be severe. Clinical diagnosis at initial biopsy was compared with the morphological diagnosis. To determine if morphological data improved the prognostic usefulness of the clinical data, we performed multiple logistic regression relating clinical variables at initial biopsy and histological changes in the transplant to the outcome of 120 patients one year after biopsy. The clinical and morphological diagnosis differed in 41 of 89 patients (46%). Of 120 patients in the prognostic study, 35 returned to dialysis during the first year following transplantation. Using multiple logistic regression, a categorical variable that took into account both the serum creatinine and its rate of change before biopsy was the best clinical predictor of return to dialysis. Further increase in chi 2 occurred with type of donor, number of transfusions, and age. Using the clinical variables we produced an index, from 0 to 1 to predict outcome. Only 8 had index less than 0.2, of whom 7 returned to dialysis. The best morphological predictor of outcome was interstitial hemorrhage. Further increase in chi 2 was obtained with vascular endothelial proliferation, glomerular endothelial swelling, and glomerular necrosis. With an index derived from the morphological variables only 11 had index less than 0.2, of whom 9 returned to dialysis. Combining both clinical and morphological data, the best predictor of return to dialysis was interstitial hemorrhage, followed by creatinine, glomerular endothelial swelling, and type of donor. Using both clinical and morphological variables we produced another index to predict outcome. A group of 65 patients had index greater than 0.8, of whom 63 (94%) did not return to dialysis, and 18 patients had index less than 0.2, 17 of whom returned to dialysis. The remaining 12 patients in the dialysis group and 15 in the nondialysis group had indices greater than 0.2 less than 0.8. We conclude that a transplant biopsy yields important diagnostic and prognostic information. Unexpected diagnoses were made in 46% of cases. The addition of morphological data to the clinical data available at time of biopsy greatly improved the prediction of return to dialysis.

Glomerular sclerosis in a renal isograft and identical twin donor. A family study

Loss of renal mass has been associated with the development of glomerular sclerosis in animals and human beings. The pathophysiology of this renal injury is unknown, but glomerular sclerosis in animals can be aggravated or accelerated following exposure to nephrotoxic antibodies, puromycin aminoglycoside or renal irradiation. We describe here the outcome of the first renal transplant performed in the British Commonwealth. Glomerular sclerosis occurred in identical twins who were kidney donor and recipient, renal failure occurring 14 and 16 years after transplantation, respectively. Examination of these twins and all living immediate family members showed that six of the seven family members (both twins, their mother, and three sisters) had increased concentrations of circulating immune complexes, decreased total hemolytic complement, and low or borderline concentrations of C4. Only twins with single kidneys had detectable renal disease. Other preexisting causes of renal disease in these twins that would account for the glomerular sclerosis could not be identified. We suggest that a familial immune defect contributed to the development of glomerular sclerosis in these twins who were predisposed to renal disease due to loss of renal mass.

The clinical and pathological course of hepatitis B liver disease in renal transplant recipients

A prospective study of the clinical and pathological sequelae of hepatitis B disease in 22 immunosuppressed renal transplant patients is reported. All patients had allografts that functioned for more than 1 year, and all were hepatitis B surface antigen (HBsAg)-positive following transplantation. None of the 18 patients who had serial HBsAg tests converted to HBsAg negative. Serial liver biopsies were performed in 19 patients and one liver biopsy was available in the remaining three patients. Follow-up ranged from 12 to 93 months. Seven patients ultimately developed cirrhosis, 6 developed chronic active hepatitis, 5 developed chronic persistent hepatitis, and in 4 the presence of HB virus in hepatocytes was the sole morphologic alteration. The initial liver biopsy was not an accurate predictor of ultimate severity of liver disease because 5 of the 12 patients with virus only or chronic persistent hepatitis subsequently developed chronic active hepatitis or cirrhosis. Clinical liver dysfunction occurred in 8 patients, all of whom had chronic active hepatitis or cirrhosis. Three patients died with hepatic failure and 2 with hepatoma. The risk of death from liver disease in HBsAg-positive renal transplant patients was 5% per patient-year. For comparison, 10 HBsAg-positive patients whose renal failure had been treated by hemodialysis were also studied over a comparable period. Biochemical evidence of persistent liver dysfunction recurred in 1 patient only; 4 patients converted to the HBsAg-negative state; and no patient has died from complications of liver disease. We conclude that in the immunosuppressed renal transplant patient HB infection often results in the development of chronic active hepatitis, leading to cirrhosis and death from hepatoma and hepatic failure.

Rhabdomyolysis and acute renal failure in chronic alcoholics with myopathy, unrelated to acute alcohol ingestion

Rhabdomyolysis leading to acute renal failure necessitating hemodialysis is described in three chronic alcoholics. In each case an acute medical or surgical event, but not alcoholic intoxication, was implicated. Renal biopsies demonstrated acute tubular necrosis with intraluminal deposits consisting of Tamm-Horsfall protein and myoglobin. After recovery all three patients were demonstrated to have proximal muscle weakness with similar electromyographic abnormalities but nerve-conduction was impaired in only two. Muscle biopsies showed mixed, but predominantly type II fiber atrophy and reduced muscle phosphorylase levels. In the one patient tested the lactate response to forearm muscle ischemia was abnormal. It is postulated that chronic alcoholics may be predisposed to rhabdomyolysis and acute renal failure following acute medical and surgical stress as well as acute alcohol abuse. The muscle damage in these patients may be due to impaired intra cellular glycogen metabolism.

Severe lithium intoxication treated by forced diuresis

In a woman who had been in coma for 4 days because of severe lithium intoxication forced diuresis led to full recovery. Forced diuresis is simpler than hemodialysis and may be as effective in some patients with severe lithium intoxication.

Symptomless abnormalities proteinuria

During the last decade enormous progress has been made in the study of the ultrastructure of the glomerular capillary wall, the mechanism of protein filtration and excretion, and the pathophysiology and biochemistry of proteinuria. However, current knowledge concerning each of these problems is incomplete. Nonetheless the mechanisms of proteinuria can be categorized, using available biochemical measurements of plasma and urinary proteins, into four groups of causes. The mechanism most commonly underlying proteinuria is a defect of glomerular permeability but proteinuria may also result from the presence in the plasma of high concentrations of low molecular weight protein, failure of the proximal tubule to reabsorb protein filtered by the normal glomerulus, and protein derived from the renal parenchyma. Glomerular proteinuria may cause the nephrotic syndrome or may persist without symptoms. Investigation and follow-up of persistent asymptomatic proteinuria is important although the natural history of this condition is still uncertain.

The nephrotic syndrome

In recent years tremendous advances have been made in the clinicohistological correlates of glomerular diseases, as a result of light microscopy and electron microscopy of the kidney, and also immunological evaluation of these diseases. However, current knowledge concerning the immunopathology, pathophysiology, and treatment of most causes of the nephrotic syndrome is inadequate. The prognosis of glomerulonephritis (especially when proliferative disease presents as the nephrotic syndrome) is still uncertain. Consequently most adult patients presenting with the nephrotic syndrome require careful assessment of their kidney and immunological function, as well as accurate monitoring of the effects of treatment in both the short term and the long term.

Iron overload in beta-thalassaemia minor. A family study

23 descendents of a 74--year-old Englishman who had beta-thalassaemia trait, and died of hepatoma, were studied to discover whether thalassaemia minor alone could predispose to iron overload. Serum ferritin and HLA antigens were assessed in all members, and adults underwent radioiron investigations and liver biopsy. 2 members of the second generation and 1 of the third generation, all of whom had thalassaemia trait, had elevated liver iron concentration, indicating preclinical iron overload. This was not associated with any HLA type. None of the subjects had been treated with exogenous iron. The one member of the second generation who had thalassaemia minor but not iron overload was female, and the 5 members of the third generation with the trait, but with normal serum ferritin levels, were all under the age of 15 years. Members of the family without beta-thalassaemia minor had normal iron metabolism. It is possible that the development of iron overload in 4 members of this family was related to the presence of thalassaemia minor, and not to the inheritance of another abnormal gene causing idiopathic haemochromatosis.

Relation between arterial pressure, dietary sodium intake, and renin system in essential hypertension

Forty-one patients with mild essential hypertension, 36 patients with severe hypertension, and 28 normotensive subjects were studied on a high sodium intake of 350 mmol/day for five days and low sodium intake of 10 mmol/day for five days. The fall in mean arterial pressure on changing from the high-sodium to the low-sodium diet was 0.7 +/- 1.7 mm Hg in normotensive subjects, 8 +/- 1.4 mm Hg in patients with mild hypertension, and 14.5 +/- 1.4 mm Hg in patients with severe hypertension. The fall in blood pressure was not correlated with age. Highly significant correlations were obtained for all subjects between the ratio of the fall in mean arterial pressure to the fall in urinary sodium excretion on changing from a high- to a low-sodium diet and (a) the level of supine blood pressure on normal diet, (b) the rise in plasma renin activity, and (c) the rise in plasma aldosterone. In patients with essential hypertension the blood pressure is sensitive to alterations in sodium intake. This may be partly due to some change either produced by or associated directly with the hypertension. A decreased responsiveness of the renin-angiotensin-aldosterone system shown in the patients with essential hypertension could partly account for the results.

Prolonged isometric exercise. Part 2: Effect on circulation and on renal excretion of sodium and potassium in young males genetically predisposed to hypertension

The effect of stress, in the form of prolonged isometric exercise, on the circulation and on the renal excretion of sodium and potassium was studied in 16 male medical students whose parental blood pressure (BP) was less than 140/85 mm Hg, and in 17 male students with one or two parents who had BPs greater than 150/95 mm Hg. After the subjects rested initially for 90 minutes, basal measurements were made of heart rate, BP, and the rates of sodium and potassium excretion. The subjects then underwent a 1-hour period of intermittent isometric exercise involving all four limbs in rotation, during which BP and heart rate were measured. A 5-hour period of rest followed, during which BP, heart rate, and the rate of electrolyte excretion were measured at half-hourly intervals for the first 2 hours and at hourly intervals for the last 3 hours. The precise protocol was repeated on another day in the absence of the period of isometric exercise. The electrolyte excretion responses of each subject were then expressed as the ratio of the changes from basal values observed on exercise and rest days. At no time was there any difference in systolic and diastolic BP, heart rate, and rate of sodium and potassium excretion following exercise when sons of normotensive parents were compared to the sons of hypertensive parent(s). These results indicate that the retention of sodium and potassium following isometric exercise seen in patients with hypertension does not occur in subjects genetically predisposed to hypertension and suggest that the effect is a consequence of, rather than a predisposing factor to, hypertension.

Prolonged isometric exercise. Part 1: Effect on circulation and on renal excretion of sodium and potassium in mild essential hypertension

The effect of stress, in the form of prolonged isometric exercise, on the circulation and on the renal excretion of sodium and potassium was studied in 18 patients with mild essential hypertension. Thirteen men and five women, aged 20 to 50 years with basal diastolic blood pressure (BP) between 90 and 110 mm Hg were matched by age, sex, and race with 18 controls who had basal diastolic BPs less than 85 mm Hg. After the subjects rested for 90 minutes, basal measurements of pulse rate, BP, and rates of sodium and potassium excretion were made. The subjects then underwent a 1-hour period of isometric exercise involving all four limbs in rotation, followed by 5 hours of rest during which the measurements were repeated at half-hourly intervals for the first 2 hours and at hourly intervals for the last 3 hours. On another day, the subjects were again studied after 1 hour of resting instead of exercise. Responses of each subject were then expressed as ratios of changes from the basal values observed on the exercise and rest days. Changes in systolic and diastolic BP and hart rate were not significantly different in the hypertensive and control groups. In hypertensive subjects, the rate of sodium and potassium excretion was decreased after isometric exercise compared with the rest day, whereas in normal subjects this response was reversed. For the first 3 hours after exercise, the cation excretion rate of the hypertensive group was significantly less than that of the control group. These results indicate that isometric exercise in mild hypertension induces prolonged renal retention of both sodium and potassium.

Blood pressure and hormonal changes following alteration in dietary sodium and potassium in young men with and without a familial predisposition to hypertension

The blood pressures (BP) of the parents of a group of students were determined and two subgroups of students were defined, one with (PHT group) and one without (PNT group) a familial predisposition to hypertension. Observations were made in both groups during three periods of modified dietary electrolyte intake: (i) no-added sodium (low Na), (ii) no added sodium with potassium supplementation (low Na/high K), and (iii) sodium supplementation (high Na). The diets were given in random order. At the start of the trial, while the students continued their customary diet, the PHT group had higher systolic and diastolic pressures and plasma noradrenaline levels than the PNT group. At the end of 4 weeks of the high Na diet, the BP levels of both groups were significantly higher than those after the low Na diet. In contrast, when the low Na diet was supplemented for 2 weeks with potassium, BPs of the PHT group fell significantly, while those of the PNT group rose slightly. BP in the PHT group was significantly lower during the low Na/high K than during the high Na diet (systolic 10.5 mm Hg +/- 2.3 SE; diastolic 11.2 +/- 2.5, the changes being significantly different from those in the PNT group. The changes in plasma renin and aldosterone were similar in both groups during the different diets. Plasma noradrenaline fell in the PHT group, but rose in the PNT group when the low Na diet was supplemented with potassium. This fall in plasma noradrenaline in the PHT group during the low Na/high K diet correlated with the falls in systolic and diastolic BP. It is concluded that whereas young adults with a familial predisposition to hypertension behave similarly to those without such a predisposition in having a pressor response to a high sodium intake, they are peculiar in showing a depressor response to a high potassium intake.

Effect of inheritance and stress on the diurnal excretion of sodium and potassium in young people with and without a family history of hypertension

1. The diurnal excretion of sodium and potassium was observed in young people, with and without a genetic predisposition to hypertension, both in the presence and absence of psychological stress. 2. In the absence of stress, the normal day/night sodium excretion ratio was reversed in the children of hypertensive parents. This was significantly less than day/night sodium excretion in children of normotensive parents. A similar finding was observed for day/night potassium excretion. 3. There was a significant negative correlation between systolic blood pressure and day/night sodium excretion in children of hypertensive parents but not in children of normotensive parents. 4. After the mental stress of a University examination day/night sodium reverted to normal in children of hypertensive parents.

Effect of isometric exercise on the renal excretion of sodium and potassium in mild hypertension

1. Basal levels of pulse rate, blood pressure and rates of sodium and potassium excretion were observed in eight white male patients with mild hypertension and eight age-, sex- and colour-matched controls during an initial rest period of 90 min and then for 5 h after a 1 h period of isometric exercise involving all four limbs in rotation. The studies were repeated on another day with the subjects resting instead of exercising for 1 h. 2. Changes in systolic pressure after exercise were similar in the hypertensive and control groups, whereas the rise in diastolic pressure was higher and the rise in pulse rate lower after exercise in the hypertensive group compared with the control group. 3. The changes in the rate of salt excretion were significantly different in the two groups, the hypertensive group retaining proportionately more sodium and potassium over several hours.

Iron overload despite partial gastrectomy

Iron overload was found in 3 patients who had undergone partial gastrectomy: a 61-year-old woman developed iron overload because she may have had idiopathic haemochromatosis and had also been given parenteral iron; in a 62-year-old man with thalassaemia minor, iron overload may have developed because of increased oral iron ingestion, low serum folate, increased, albeit ineffective, erythropoiesis and sideroblastic anaemia; a 74-year-old man with thalassaemia minor developed iron overload without exogenous therapy and died from a hepatoma. These cases illustrate that partial gastrectomy fails to protect patients from developing iron overload, particularly if given uncontrolled iron therapy.