Renal outcome of type 2 diabetes in South Africa--a 12-year follow-up study

AIMS

Previous studies of type 2 diabetes mellitus have indicated a benign renal outcome after long-term follow-up. The aim of this study was to determine how often renal failure due to diabetic nephropathy was a cause of death in patients with type 2 diabetes.

METHODS

Prospective observational study of 59 South African patients with type 2 diabetes over a 12-year period. During the study repeated clinical evaluations were accompanied by measurements of serum creatinine, serum cholesterol, random blood sugar, and urine protein/creatinine ratios.

RESULTS

The mean duration of diabetes at the end of the study was 17.8 years. There was a wide variation in the time from clinical diagnosis of diabetes to macroproteinuria (mean 9.7 years, SD 5.9, range 0 - 21) and the rate of deterioration of renal function. This rate correlated with poor control of blood pressure, a glucose level of > 14 mmol/l, heavy proteinuria, a high retinopathy score, a body mass index of < 28 and the number of pack years of smoking. At the end of the study 47 patients (79.7%) had died. Of these deaths 17 (28.8%) were due to chronic renal failure.

CONCLUSIONS

In contrast to other studies we have shown that in a developing country renal failure in type 2 diabetic patients is a major cause of death. Determining the prognosis for an individual patient is difficult as there are wide ranges in the time of onset of proteinuria, the rise in serum creatinine and the time to ultimate progression to end-stage renal failure.

Pacemaker induced superior vena cava obstruction: management by spiral vein graft

A 35-year-old male developed superior vena cava (SVC) obstruction due to multiple retained pacemaker leads. This caused cyanosis and suffusion of the head and neck during arm exercise, with desaturation from 99%-90% demonstrated by ear oximetry. The SVC was bypassed using a spiral vein graft because of worsening symptoms. Dramatic improvement resulted, with desaturation no longer demonstrable.

Significant cost-saving with modification of antihypertensive therapy

Thirty patients attending Somerset Hospital Outpatient Department, Cape Town, who were on nifedipine for hypertension or chest pain, were followed up for 6 months after alternative therapy was instituted. After the change of treatment, blood pressure control improved and no serious side-effects were encountered. Reserpine combined with a thiazide was a major component of the new regimen which reduced the monthly cost per patient from R54 to R14, a saving of 73%. If this saving was extended to 5% of the potential hypertensive patients in the RSA it would amount to R8 million per month. Although a self-assessment depression inventory was completed by 21 patients, our study does not fully evaluate the impact on quality of life. The likelihood of side-effects is, however, small--provided that the maximum daily dose of reserpine does not exceed 0.1 mg. We feel that a more considered approach is needed in the choice of antihypertensive agents.

Diagnostic role of intravenous urography in acute and chronic renal failure

High-dose intravenous urography (IVU) was performed 62 times in 59 patients with acute (ARF) and chronic (CRF) renal failure. The major diagnostic categories were chronic glomerulonephritis, malignant hypertension, acute tubular necrosis (ATN), and acute glomerulonephritis. The cause of the renal failure, whether CRF or ARF, oliguric or nonoliguric, could not be reliably determined by either the evolving pattern or density of nephrogram, or the size of the kidneys. Although a persistent dense nephrogram favored the diagnosis of ATN, the major correlate was a decreasing density of nephrogram as the serum creatinine level increased (P less than 0.005).

Elevated plasma renin activity associated with renal dysfunction

Elevated plasma renin activity (PRA) has been documented in patients with established acute renal failure. To study the association of PRA and renal dysfunction, 53 patients who were at risk of developing acute renal failure had serial measurements of PRA, renal function, and urinary beta 2-microglobulin. Those entered for study had pneumonia, septicaemia, volume loss with hypotension, or major surgical procedures with complications. Patients were divided into groups of abnormal or normal renal function. Abnormal renal function was defined by an elevated plasma urea and/or creatinine level with a submaximal urine urea to plasma urea ratio. The mean values of PRA for the abnormal and normal renal function groups, respectively, were 29 and 5.2 ng/ml/h (p less than 0.0001) and for beta 2-microglobulin 16.2 and 6.4 micrograms/l X 10(3) (p less than 0.0005). A linear regression of the logs of PRA to beta 2-microglobulin for the total group of patients gave an r value of 0.526 (p less than 0.001). These data show an association of PRA to renal dysfunction and tubular injury/dysfunction in the prerenal phase of renal failure, suggesting an effect of the renin-angiotensin system at this phase. It is not possible, however, to conclude from our study that the renin-angiotensin system has a direct role in the development of established acute tubular necrosis, since only 3 patients fell within this category.

Systemic lupus erythematosus in 3 black South African men. Case reports

Only 1 case of systemic lupus erythematosus (SLE) has been documented in a South African Black man. We report 3 further patients, 1 each from Cape Town, Durban and East London, diagnosed between 1978 and 1982. All 3 patients fulfilled the revised American Rheumatism Association criteria for the classification of SLE.

Haemorrhagic right pleural effusion complicating acute-on-chronic pancreatitis. A case report

A 40-year old man presented with pulmonary symptoms and a right-sided haemorrhagic pleural effusion. Tuberculosis and carcinoma, both primary and secondary, were excluded as a cause. Chronic pancreatitis was diagnosed on the basis of a 5-year history of repeated episodes of alcohol-induced epigastric pain and suggestive findings on endoscopic retrograde cholangiopancreatography. The chronic pancreatitis became acute during hospitalization. The disproportionate elevation of the pleural fluid amylase level in comparison with the serum amylase level provided definitive evidence that the pleural effusion was a complication of pancreatitis.

Ceftazidime and cefamandole in the treatment of pneumonia

Fifty-nine community-acquired pneumonias were treated in a randomized double blind trial with cefamandole or ceftazidime. A prospective scoring system was used to define severity. This made use of basic clinical data, associated diseases, white blood count, blood gases and chest radiographs. There were no serious side-effects from the drugs. There were two deaths and six failed treatment. The scoring system which defined an 'ill group' showed as good a response of these ill patients to the new cephalosporin, ceftazidime as to cefamandole.

Pharmacokinetics of ranitidine in patients with chronic renal failure

The pharmacokinetic behaviour of a single oral 150 mg ranitidine dose was studied in six patients with severe chronic renal failure (CRF) (creatinine clearance 2-18 ml/min) and compared to that in ten patients with duodenal ulceration but normal renal function (N) (creatinine clearance 69-125 ml/min). Although the maximum concentrations (Cmax) were significantly higher in CRF group when compared to N group (p less than 0.025) there was no difference in the time taken to reach Cmax (tmax). The area under the curve (AUC) was also significantly larger in the CRF group (p less than 0.001) than in the N group. Within the CRF group there was a large variation in Cmax (CV = 38%) and AUC (46%) which may reflect variable bioavailability of ranitidine. The terminal elimination rate constant (beta) was significantly smaller (p less than 0.001) in CRF group when compared with N group resulting in a median t1/2 for the CRF group of 7.3 h, 2.4 times that of N group. The recovery of unchanged ranitidine in the urine was significantly less in CRF group (p less than 0.001) despite a great interindividual variation in both groups. A significant linear relationship between beta and creatinine clearance was shown (r = 0.81 p less than 0.001). The results indicate that ranitidine elimination is appreciably reduced in renal failure. It is tentatively suggested that the standard 150 mg dose should be halved while keeping the dose interval unchanged at twelve hours in patients with severe renal failure (creatinine clearance less than 30 ml/min).

The effect of beta-blockers on ventilatory function in chronic bronchitis

The effect of propranolol and atenolol on air-flow obstruction in patients with chronic bronchitis was evaluated by means of a double-blind, placebo-controlled cross-over trial. Fifteen patients with chronic bronchitis and mild air-flow obstruction, in whom there was no clinical suggestion of asthma, were studied. Two patients developed symptomatic increases in air-flow obstruction on propranolol and were withdrawn from the study. A symptomatically insignificant but statistically significant increase in air-flow obstruction was observed during treatment with both propranolol and atenolol.

Effects of frusemide in chronic renal failure

The present study was designed to refute or confirm the postulate that the use of high dose frusemide in chronic renal failure will increase the glomerular filtration rate (GFR). 7 patients in stable chronic renal failure were admitted to hospital for 20 days. For 10 days fluid balance was maintained and no diuretics given. During the next 10 days, a gram of frusemide was given orally, with fluid and electrolyte replacement based on the 24-hour urine collections which were made throughout the 20-day period. Daily estimations of sodium, potassium, urea, creatinine and osmolality were made on plasma and urine. The excretion of water (p less than 0.01), sodium (p less than 0.01) and potassium (p less than 0.05) increased significantly during the treatment period. There was no significant change in blood pressure, weight, creatinine clearance (C/CR), clearance of urea (C/Urea), total urea and creatinine excretion, serum sodium, potassium or osmolality. The results demonstrate that a gram of frusemide, administered to patients in stable chronic renal failure, does not have any effect on intrinsic renal function. However, there was a significant increase in urine volume, as well as sodium and potassium excretion.

Diagnostic and therapeutic problems of polyarteritis nodosa

Eleven patients with a diagnosis of polyarteritis nodosa were seen over an 8-year period in Cape Town, and evaluated as to clinical presentation, the most effective diagnostic approach, and the response to therapy. The major features of fever, abdominal pain, peripheral neuritis, myalgia/arthralgia, weight loss, proteinuria, positive urinary sediment and high white blood cell count should readily lead to the diagnosis which can be confirmed by multiple muscle biopsies. At the same time an ellipse of skin and subcutaneous fat can be taken. If the diagnosis is made early enough, an aggressive approach to therapy with steroid and immunosuppressive drugs can induce a response even in those patients who already have renal failure.

Viral hepatitis

The natural history of and biochemical changes in 27 patients with viral hepatitis are outlined. Analysis is made of the symptomatology and physical signs at the time of presentation as well as a comparison between hepatitis B surface antigen-positive and negative patients. In general, hepatitis B surface antigen-positive patients have a more severe clinical illness as well as greater biochemical derangement and a longer duration of disease.

Lymphoid interstitial pneumonia with associated chronic active hepatitis and renal tubular acidosis

Various combinations of diffuse interstitial fibrosis, chronic liver disease, and renal tubular acidosis have been recorded. The patient we report is unique in that the features of chronic liver disease and renal tubular acidosis were discovered while the patient was being treated for lymphoid interstitial pneumonia. This sequence of events has not been previously described.

Carbenicillin in acute renal failure

Three septicaemic patients with acute renal failure required carbenicillin. Septicaemia was caused by Pseudomonas in 2 patients and by Serratia marcescens in the third. Therapy in the first 2 patients was complicated by massive gastro-intestinal and uterine bleeding. Septicaemia in the third patient was initially uncontrolled owing to inadequate serum levels of carbenicillin, despite increased dosage as renal function improved. The problems and indications for the use of carbenicillin in renal failure are discussed and the possible relationship to bleeding diathesis is considered.

Leukaemoid reaction and disseminated tuberculosis. A case report

Four cases of leukaemoid reactions to tuberculosis, notwithstanding the presence of Auer's rods in the myeloblasts, have previously been reported. A fifth case of disseminated tuberculosis in which Auer's rods were similarly observed, is described. However, we believe that this association does not mean that Auer's rods occur as part of a leukaemoid response, but rather that it indicates the simultaneous presence of acute leukaemia and tuberculosis.

Isolated partial deficiency of adrenocorticotrophic hormone

A patient with tuberculous empyema who presented with severe hyponatraemia, is described. In the course of investigation, he was discovered to be suffering from isolated adrenocorticotrophic hormone deficiency.