Recovery of pure red-cell aplasia secondary to antierythropoietin antibodies after cessation of recombinant human erythropoietin.

We describe a patient with end-stage renal failure (ESRF) who developed anti-erythropoietin (anti-EPO) antibodies and pure red-cell aplasia (PRCA) after using Eprex (Janssen-Cilag, Sydney). Anti-EPO antibodies were detected with an immunoprecipitation technique and were shown to inhibit erythropoiesis in vitro. Antibody levels waned upon ceasing Eprex. The patient required transfusions for 21 months then recovered after immunosuppression.

Sarcoidosis with prominent giant cells.

A 31-year-old man presented with a widespread papular eruption and systemic symptoms including renal colic and decreased exercise tolerance. The combination of clinical features and laboratory investigations that revealed an elevated angiotensin converting enzyme level and hypercalcaemia enabled a diagnosis of sarcoidosis to be made. Multiple skin biopsies showed prominent Touton-like giant cells which delayed the diagnosis. Giant cells are frequently seen in sarcoidal granulomas but in some cases their prominence and Touton-like appearance may suggest alternative diagnoses such as xanthogranulomas.

Acute renal impairment after immersion and near-drowning.

Acute renal impairment (ARI) secondary to immersion and near-drowning is rarely described and poorly understood. A retrospective case-control study was performed: (1) to determine the incidence of ARI associated with near-drowning or immersion and (2) to define the clinical syndrome and to assess clinical predictors of ARI. Of 30 patients presenting after immersion or near-drowning, 50% were identified with ARI, with a mean admission serum creatinine of 0.24 +/- 0.33 mmol/L (2.7 +/- 3.7 mg/dl). These patients were a heterogeneous group: Eight had mild reversible ARI, three had ARI related to shock and multisystem failure, two had rhabdomyolysis-related ARI, and two had severe isolated ARI. Two patients required supportive hemodialysis and two died. Patients with ARI experienced more marked acidosis than control patients, as measured by serum bicarbonate (P < 0.001), pH (P < 0.001), and base excess (P < 0.001). There was also a higher admission lymphocyte count in the ARI group (P = 0.056). Dipstick hematuria on admission was significantly more common in patients with ARI (P = 0.016), and patients with 2 to 3+ of admission dipstick proteinuria had a higher peak serum creatinine than patients with less proteinuria (P < 0.05). Admission predictors of ARI by univariate logistic regression analysis included reduced serum bicarbonate (P = 0.002), pH (P = 0.001), and base excess (P < 0.001). The best predictor of ARI on multivariate analysis was a negative base excess (P = 0.01). In summary, acute renal impairment commonly occurs after immersion and near-drowning and is a heterogeneous condition. Although mild reversible renal impairment (serum creatinine < 0.30 mmol/L) (3.4 mg/dl) is usual, severe acute renal failure requiring dialysis can occur. It is recommended that any patient who presents after near-drowning or immersion should be assessed for potential ARI by serial estimations of serum creatinine, particularly when there is an increase in the initial serum creatinine, marked metabolic acidosis, an abnormal urinalysis, or a significant lymphocytosis.

Managing HIV. Part 5: Treating secondary outcomes. 5.10 HIV and renal disease.

Renal parenchymal and fluid and electrolyte abnormalities may complicate hospitalisation in 20% of patients. HIV-specific renal abnormalities are being defined, but most follow opportunistic infection or drug nephrotoxicity. Principles of treatment are largely the same as for patients without HIV.

Simultaneous transplantation of the heart and kidney.

BACKGROUND: Multiple organ transplants have become frequent. Combined heart-and-kidney grafting has been reported recently and we have pursued this in selected cases. AIMS: To devise a protocol for simultaneous heart-and-kidney transplantation, review our clinical experience with the procedure and the causes of cardiac and renal disease in this group. METHODS: Seven patients with advanced cardiac failure (LV ejection fraction < 0.29 units; five with IDCM), and chronic renal failure (serum creatinine > 375 mumol/L) due to a variety of causes, were accepted for combined heart-and-kidney transplantation. Four males, of mean age 33 years, underwent the procedure. Each received his organs from a single cadaveric donor with ABO blood group compatibility and a negative 'current' lymphocytotoxic cross-match, but without regard to HLA-antigen matching. Cardiac ischaemic time averaged 3 hours 40 minutes, the renal first warm time was 0 minutes in all cases, and renal cold and second warm ischaemic times averaged 5 hours 17 minutes and 52 minutes respectively. The heart was grafted first and the kidney second in a procedure which averaged seven hours. Immunosuppression was achieved by induction with antithymocyte globulin, thence steroids, azathioprine and cyclosporin A. RESULTS: No patient required post-operative dialysis. One patient had early urological complications requiring operative correction, but no serious opportunistic infections were observed. Early cardiac rejection on biopsy (ISHT grade 3a) was seen in three patients at four-ten weeks and responded promptly to increased steroids, but severe steroid-resistant rejection of both heart and kidney contemporaneously occurred in one of these three at 19 months and required a course of muromonab-CD3. All four patients developed hypertension. Mean creatinine clearance was 1.23 +/- 0.22 mL/second (74 +/- 13 mL/minute) at last follow-up. All four recipients were alive, well and rehabilitated 5, 20, 28 and 35 months after grafting. Two patients died while waiting for the double procedure and another patient eventually died after being taken off the dual waiting list and receiving a renal transplant only. CONCLUSIONS: In experienced hands, combined heart-and-kidney transplantation is feasible and offers a compelling therapeutic solution in the treatment of advanced cardiac and renal failure. IDCM is a frequent cause of the heart failure in this group.

Lipoprotein(a) levels in chronic renal disease states, dialysis and transplantation.

Lipoprotein(a) is an independent risk factor for cardiovascular disease. Lipoprotein(a) levels were measured in 196 patients (103 Male [M]: 93 Female [F]) with chronic renal diseases and in 116 controls. Median levels of Lipoprotein(a) [Lp(a)] were found to be significantly elevated in patients with untreated chronic renal disease (285,285 mg/L; M,F; range 30-1675 mg/L) and in those treated with continuous ambulatory peritoneal dialysis (320, 603; M,F; range 50-1450) compared with controls (70,51; M,F; range 1-750; p less than 0.01 Males, p less than 0.001 Females). Lp(a) levels in patients treated by haemodialysis (133,35; M,F; range 5-685) and renal transplantation (100,95; M,F; range 10-1700) were not significantly different from controls. Lipoprotein(a) levels correlated inversely with serum albumin in the combined dialysis group (r = -0.34, p less than 0.001), and with urinary protein loss in the combined transplant and chronic renal diseases groups (r = 0.29, p less than 0.01). This correlation of Lp(a) with protein metabolism suggests a similarity with changes in other apolipoprotein-B containing lipoproteins in nephrosis. These findings may be relevant to the increased risk of atherosclerosis in patients with chronic renal disease and to their optimum mode of renal replacement therapy.

Heat stroke following Rugby League football.

OBJECTIVE: To present a case of severe heat stroke after Rugby League football. CLINICAL FEATURES: A 29-year-old Rugby League forward with a mild infection of the upper respiratory tract collapsed while playing football in late March, when the ambient temperature was 24.1 degrees C and the relative humidity up to 73%. He was initially thought to have sustained a head injury and was markedly dehydrated. He suffered severe disseminated intravascular coagulation and gross neurological, renal and hepatic disturbances. INTERVENTION AND OUTCOME: He required repeated haemodialysis, assisted ventilation and supportive therapy and remained unconscious for 10 days. He then recovered fully. CONCLUSION: Heat stroke is potentially fatal and can be easily mistaken for head injury in contact sports. When players are dehydrated, have febrile illness and play in warm conditions, they may succumb to heat stroke.

Allopurinol dosage selection: relationships between dose and plasma oxipurinol and urate concentrations and urinary urate excretion.

1. Allopurinol usage in 50 patients of a city teaching hospital was surveyed. 2. The plasma concentrations of oxipurinol and uric acid and the urinary production of uric acid were examined. 3. The daily doses of allopurinol ranged from 50 to 1200 mg but 83% of patients were taking 300 mg daily. 4. A wide range of plasma oxipurinol concentrations was observed from 2.8 to 55.8 mg l-1 with a mean +/- s.d. of 15.2 +/- 11.7 mg l-1. 5. The population studied included a high proportion of patients with renal impairment and creatinine clearance was a significant determinant of oxipurinol concentrations (P less than 0.005). 6. There was no significant correlation between plasma urate and plasma oxipurinol concentrations and only a few plasma urates were above the upper limit of the reference range of the laboratory. 7. It was apparent that many patients were taking unnecessarily high daily doses of allopurinol and that renal status was not always considered when deciding dosage regimens of allopurinol.

The effect of metabolic acidosis on vitamin D metabolites and bone histology in uremic rats.

Biochemical data and skeletal histomorphometric measurements are presented for normal rats and for two groups of rats rendered uremic by partial nephrectomy. In one of these groups chronic acidosis was induced by the oral administration of hydrochloric acid. Uremic animals had higher urine calcium excretion rates and lower serum concentrations of vitamin D metabolites than normal rats. Chronic acid loading of uremic rats resulted in hypercalcemia, elevated serum parathyroid hormone concentrations, and a significant loss of trabecular bone in addition to the above changes. greater osteoclast densities and higher resorption surfaces wee seen in the uremic acidotic animals than in the other two groups. The acidotic uremic state induced more potent changes in calcium metabolism and bone structure than uremia alone.

Relation of alcohol and cigarette consumption to blood pressure and serum creatinine levels.

From the records of an automated multi-phasic health testing centre, daily drinkers in four alcohol consumption groups were each separately matched for sex, age and obesity to a single non-drinker control. All subjects satisfied strict eligibility criteria selected to exclude the effects of other factors known to influence blood pressure or renal function or both. The 5500 pairs of subjects were compared for systolic and diastolic blood pressure and serum creatinine. After allowing for smoking, drinkers had significantly elevated blood pressure compared with their controls, and the elevation was greater the heavier the alcohol intake, except for the heaviest drinking females. This result was more pronounced in males than females, and for systolic than diastolic blood pressure. By contrast, smoking cigarettes was shown to be associated with lower blood pressure, independent of sex and drinking history. Smoking was also associated with a decreased serum creatinine concentration as was drinking three or more drinks per day. However, drinkers of two or fewer drinks daily had higher serum creatinine concentrations than their non-drinker controls.

Vitamin D metabolism in nephrotic rats.

Vitamin D metabolites were measured in sera of normal, vitamin D deficient and nonazotemic nephrotic rats. The concentrations of all metabolites were reduced in nephrotic and vitamin D deficient animals although 1,25-dihydroxyvitamin D values remained relatively normal in the nephrotic group. Twenty-four hours after the intravenous injection of tritiated 25-hydroxycholecalciferol, approximately 34% of the injected radioactivity appeared in the urine of the nephrotic animals compared with 0.4% in the controls. In extracts from nephrotic sera subjected to high performance liquid chromatography, the percentage of radioactive counts comigrating with 1,25-dihydroxycholecalciferol and 24,25-dihydroxycholecalciferol was significantly increased. The various metabolites were present in urine in approximately the same ratios as in serum. Dynamic histomorphometry of tibial metaphyses showed no abnormality. Urinary losses of vitamin D metabolites constitute the major cause for low serum values in nephrotic rats. The apparent synthetic rates are not impaired.

Total parathyroidectomy and renal function in patients with chronic renal failure.

5 patients with nonterminal renal failure who underwent total parathyroidectomy at Sydney Hospital over a 4-year period showed significant postoperative deterioration in renal function. In 4 of these patients, this deterioration occurred at a time when they were receiving supplements of calcium and 1,25-dihydroxyvitamin D3 but when close monitoring failed to show any evidence of hypercalcemia. In 1 patient the deterioration in renal function was clearly associated with hypercalcemia. We suggest that parathyroidectomy in nondialyzed patients be reserved for those with severe symptomatic hyperparathyroidism and that wherever possible the need for large doses of calcium and vitamin D be avoided.

Long-term survival after cadaveric renal transplantation.

In a series of 404 consecutive first cadaver kidney transplants performed since 1967 the actuarial five- and 10-year survival of patients were 61% and 47% respectively and of grafts 46% and 36%. In more than four-fifths of the patients surviving these intervals the original cadaveric grafts were functioning at these times, and most of the remainder were sustained by subsequent grafts. Although graft survival has remained static since 1967, patient survival improved. Results for 43 consecutive second cadaver transplants were similar after five years to those of first grafts. These results promote the acceptability of cadaveric transplantation as a long-term treatment for chronic renal failure.

Heinz-body haemolysis in haemodialysed patients caused by chloramines in Sydney tap water.

In August 1981, there was an outbreak of Heinz-body-positive haemolytic anaemia among patients who were undergoing dialysis in Sydney Hospital. This appeared to be due to excessive chloramines in and inadequate carbon filtration of, the water used for haemodialysis. After improvement of the carbon filtration system, there have been no further cases of anaemia.

Treatment of renal transplant artery stenosis by percutaneous transluminal dilatation.

Transluminal arterial dilatation using a balloon catheter was performed in four patients with renal allografts and transplant artery stenosis. In three patients the procedure was uncomplicated and resulted in reduction in mean blood pressure from 180/100 mm Hg to 135/85 mm Hg immediately after and 135/90 mm Hg at a mean of eight months after angioplasty; renal function remained stable. In one patient with two stenoses the procedure was abandoned because of inaccessibility of the stenotic sites to the dilatation catheter; however, reversible acute renal failure ensued. Percutaneous transluminal angioplasty may thus offer a successful alternative to conventional surgical techniques in renal transplant artery stenosis in suitable patients.