Cambrian sea water preserved as inclusions in marine low-magnesium calcite cement.

THE existence of temporal changes in the chemical composition of the oceans, which could provide constraints on the potential variability of the ocean-atmosphere; system, remains an open question. Assessments of the chemistry of ancient oceans have relied largely on analysis of marine precipitates, generally carbonate and evaporite minerals1. These studies suggest that, whereas marine salinity has remained relatively stable over Phanerozoic time1, magnesium, calcium and sulphate concentrations of ancient oceans and CO2 partial pressure of ancient atmospheres may have changed2-4. The ratios of isotopes of carbon, oxygen, sulphur and strontium also appear to have varied3,5,6. Here we present analyses of primary, one-phase fluid inclusions in Cambrian and Ordovician marine cements, which appear to represent aliquots of early Palaeozoic oceans. The cements have trace element, stable isotope and strontium isotope contents that are consistent with their having been precipitated in a Cambrian-Ordovician marine environment, and the fluids have marine salinities. As these (apparently primary) cements are low-magnesium calcite, unlike the predominantly high-magnesium calcite and aragonite of today's carbonate precipitates, the chemistry of the Cambrian ocean-atmosphere system seems to have been different from that of today.

Receptors for maleylated proteins regulate secretion of neutral proteases by murine macrophages.

Receptors for maleylated or acetylated proteins as well as for alpha-2-macroglobulin-protease complexes on macrophages serve as scavengers by mediating the uptake of macromolecules from the extracellular compartment. Described in this report is a novel function of these receptors on macrophages: regulation of neutral protease secretion. The binding of maleylated bovine serum albumin to macrophages triggered secretion of three neutral proteases: neutral caseinases, plasminogen activator, and cytolytic proteinase. Release of acid phosphatase, however, was not induced. An important biological consequence of protease secretion by macrophages, tumor-cytolysis, was also triggered by engagement of the receptor for maleylated bovine serum albumin. By contrast, the binding of alpha-2-macroglobulin-protease complexes to the macrophages suppressed secretion of all three proteases. Thus two receptors heretofore believed to serve principally as scavengers also regulate secretory functions of macrophages.

Differential effects of endocrine dysfunction on the axial and the appendicular skeleton.

In 100 patients with various types of endocrine dysfunction, we measured bone mineral density (BMD) at the midradius (greater than 95% cortical bone) and distal radius (75% cortical and 25% trabecular bone) by single photon absorptiometry and at the lumbar spine (greater than 66% trabecular bone) using the new technique of dual photon absorptiometry. BMD in each endocrine disorder deviated in at least one site from the sex-specific age regression of 187 normal subjects. For patients with primary hyperparathyroidism, hypercortisolism, and hyperthyroidism this deviation was negative (suggesting bone loss), whereas for patients with secondary hyperparathyroidism due to chronic renal failure, acromegaly, and postsurgical hypoparathyroidism it was positive (suggesting bone gain). When all six states of endocrine dysfunction were compared concomitantly by multivariate analysis of variance, the profile of the changes in BMD differed significantly (P less than 0.001), indicating a nonuniform response of bone to the various hormonal alterations. When values for BMD at each of the three scanning sites were compared the midradius and distal radius did not differ significantly; either of the radius measurements, however, differed significantly (P less than 0.001) from the lumbar spine. Thus, the BMD of the axial skeleton cannot be reliably predicted from measurements made in the appendicular skeleton. We conclude that the effects of endocrine dysfunction on bone density are complex and are both disease and site specific.

Etiology of hyperparathyroidism and bone disease during chronic hemodialysis. I. Association of bone disease with potentially etiologic factors.

The present study was prompted by the observation that, in patients with chronic renal failure being followed at this center, renal osteodystrophy developed almost exclusively in those who were treated by chronic hemodialysis at home rather than in our center. A systematic comparison was made between the 10 patients with roentgenographic evidence of the bone disease and 18 patients without demonstrable bone disease. The two groups were similar in age, sex, nature of renal disease, and duration of dialysis. The mean duration of kidney disease was almost 2 yr longer in the patients without bone disease than in those with bone disease. Other significant differences related to where the hemodialysis was performed and to the calcium concentration in the dialysate (6.0-7.4 mg/100 ml in the hospital and 4.9-5.6 mg/100 ml at home). If the unknown factors related to where the dialysis was performed were of no consequence, the major factor contributing to the production of bone disease observed in these patients was the use of a dialysate with a calcium concentration less than 5.7 mg/100 ml.

Etiology of hyperparathyroidism and bone disease during chronic hemodialysis. II. Factors affecting serum immunoreactive parathyroid hormone.

Plasma concentration of immunoreactive parathyroid hormone (IPTH) was measured in 18 patients who had been on a hemodialysis program for longer than 6 months. A negative correlation was found between the predialysis plasma concentration of IPTH and the mean concentration of calcium in the dialysate previously used: plasma concentrations of IPTH were higher in patients dialyzed against a calcium concentration between 4.9 and 5.6 mg/100 ml than in patients dialyzed against a calcium concentration of 6.0 mg/100 ml or more. Plasma concentrations of IPTH also were higher in patients with bone disease than in patients without bone disease. Furthermore, a positive correlation was found between predialysis plasma concentrations of IPTH and calcium, and between mean predialysis concentration of IPTH and phosphate. To obviate the possibility that individual differences in susceptibility could have accounted for the observed effects of plasma phosphate and of dialysate calcium, a 2 x 2 factorial study was conducted in seven of these patients to examine the independent effects of perturbation of each of these factors. It was observed that plasma concentration of IPTH was lowest with the combination of high dialysate calcium and low plasma phosphate, highest with the combination of low dialysate calcium and high plasma phosphate, and intermediate with the two other combinations. It is concluded that both dialysate calcium and plasma phosphate are important determinants of parathyroid function in these patients.

Etiology of hyperparathyroidism and bone disease during chronic hemodialysis. 3. Evaluation of parathyroid suppressibility.

Parathyroid function was assessed by calcium infusions (4-8 h) in 16 patients with chronic renal insufficiency being treated by long-term hemodialysis. The concentrations of two immunoreactive species of parathyroid hormone in plasma (iPTH-9, mol wt 9500; iPTH-7, mol wt 7000) were estimated by radioimmunoassays utilizing two relatively specific antisera. Control values of the smaller species, iPTH-7, were uniformly high, whereas values of iPTH-9 were normal in 12 of 19 studies. Response of iPTH-7 to calcium infusions was variable, with significant decreases occurring only five times in 27 infusions. Concentrations of iPTH-9, however, decreased during every calcium infusion. In contrast to these acute responses, five of six patients studied during periods of dialysis against both low (< 6 mg/100 ml) and high (7-8 mg/100 ml) calcium concentrations in the dialyzate showed a decrease in values of iPTH-7 during the period of dialysis against the higher calcium concentration. It is concluded that plasma concentrations of iPTH-9 reflect primarily the moment-to-moment secretory status of the parathyroid glands, while concentrations of iPTH-7 reflect more closely chronic parathyroid functional status. It is further concluded that the failure of iPTH-7 to decrease during induced hypercalcemia should not be equated with autonomy of parathyroid gland function.

Pancreatic carboxyl ester lipase: a circulating enzyme that modifies normal and oxidized lipoproteins in vitro.

Pancreatic carboxyl ester lipase (CEL) hydrolyzes cholesteryl esters (CE), triglycerides (TG), and lysophospholipids, with CE and TG hydrolysis stimulated by cholate. Originally thought to be confined to the gastrointestinal system, CEL has been reported in the plasma of humans and other mammals, implying its potential in vivo to modify lipids associated with LDL, HDL (CE, TG), and oxidized LDL (lysophosphatidylcholine, lysoPC). We measured the concentration of CEL in human plasma as 1.2+/-0.5 ng/ml (in the range reported for lipoprotein lipase). Human LDL and HDL3 reconstituted with radiolabeled lipids were incubated with purified porcine CEL without or with cholate (10 or 100 microM, concentrations achievable in systemic or portal plasma, respectively). Using a saturating concentration of lipoprotein-associated CE (4 microM), with increasing cholate concentration there was an increase in the hydrolysis of LDL- and HDL3-CE; at 100 microM cholate, the present hydrolysis per hour was 32+/-2 and 1.6+/-0.1, respectively, indicating that CEL interaction varied with lipoprotein class. HDL3-TG hydrolysis was also observed, but was only approximately 5-10% of that for HDL3-CE at either 10 or 100 microM cholate. Oxidized LDL (OxLDL) is enriched with lysoPC, a proatherogenic compound. After a 4-h incubation with CEL, the lysoPC content of OxLDL was depleted 57%. Colocalization of CEL in the vicinity of OxLDL formation was supported by demonstrating in human aortic homogenate a cholate-stimulated cholesteryl ester hydrolytic activity inhibited by anti-human CEL IgG. We conclude that CEL has the capability to modify normal human LDL and HDL composition and structure and to reduce the atherogenicity of OxLDL by decreasing its lysoPC content.

Effect of pyran copolymer on activation of murine macrophages: evidence for incomplete activation by use of functional markers.

The degree of activation of peritoneal macrophages elicited by pyran copolymer (MVE-2) was studied in C57BL/6J mice. When cytotoxicity was examined under endotoxin-free culture conditions, the pyran-elicited macrophages could not complete cytolysis of tumor target cells. The macrophages, however, completed cytolysis when pulsed with endotoxin. These results were obtained when either the interval between injection of the pyran copolymer and harvest of the macrophage or the dose of pyran was varied. The pyran-elicited macrophages expressed five markers considered to be typical of inflammatory macrophages, and bound tumor cells to an augmented degree. The pyran-elicited macrophages were capable of secreting a potent cytolytic proteinase when pulsed with endotoxin, but did not secrete cytolytic proteinase spontaneously. The pyran-elicited macrophages, in contrast to inflammatory macrophages, could effect cytostasis of tumor cells; their cytostatic potential was also augmented by addition of endotoxin. Taken together, the results indicated that pyran copolymer elicits primed but not fully activated murine macrophages.

Differential expression of murine macrophage-mediated tumor cytotoxicity induced by interferons.

The requirements for interferon (IFN)-induced priming of murine peritoneal macrophages for cytolysis of tumor cell lines of distinct histological origin were investigated. Lysis of B16 melanoma targets required exposure of elicited macrophages to recombinant murine gamma interferon plus lipopolysaccharide (LPS) together, while sequential treatment of macrophages with IFN-gamma then LPS resulted in lysis of P815 mastocytoma targets. The kinetics of macrophage activation by IFN-gamma and LPS for lysis of P815 and B16 melanoma targets varied considerably, 8 h being sufficient for P815 targets but 24 h being required for B16 targets. Pretreatment of the macrophages with the antibiotic polymyxin B was able to inhibit completely the induction of tumor lysis of B16 targets but not of P815 targets. In addition, IFN-alpha/beta was able to prime macrophages for lysis of P815 targets but not of B16. Finally, the kinetics of priming macrophages with IFN-gamma for lysis of B16 targets had a profound effect on the subsequent exposure time requirement for LPS. The results indicate that the induction of murine macrophage-mediated tumor cytotoxicity can vary considerably depending on the amount and type of interferon used, the presence of a second signal, and the type of tumor target used.

Cholesterol transport between cells and high-density lipoproteins.

Various types of studies in humans and animals suggest strongly that HDL is anti-atherogenic. The anti-atherogenic potential of HDL is thought to be due to its participation in reverse cholesterol transport, the process by which cholesterol is removed from non-hepatic cells and transported to the liver for elimination from the body. Extensive studies in cell culture systems have demonstrated that HDL is an important mediator of sterol transport between cells and the plasma compartment. The topic of this review is the mechanisms that account for sterol movement between HDL and cells. The most prominent and easily measured aspect of sterol movement between HDL and cells is the rapid bidirectional transfer of cholesterol between the lipoprotein and the plasma membrane. This movement occurs by unmediated diffusion, and in most situations its rate in each direction is limited by the rate of desorption of sterol molecules from the donor surface into the adjacent water phase. The net transfer of sterol mass out of cells occurs when there is either a relative enrichment of sterol within the plasma membrane or a depletion of sterol in HDL. Recent studies suggest that certain minor subfractions of HDL (with pre-beta mobility on agarose gel electrophoresis and containing apoprotein A-I but no apo A-II) are unusually efficient at promoting efflux of cell sterol. To what extent efflux to these HDL fractions is balanced by influx from the lipoprotein has not yet been established clearly. The prevention and reversal of atherosclerosis require the mobilization of cholesterol from internal (non-plasma membrane) cellular locations. To some extent, this may involve the retroendocytosis of HDL. However, most mobilization probably involves the transport of internal sterol to the plasma membrane, followed by desorption to extracellular HDL. Several laboratories are investigating the transport of sterol from intracellular locations to the plasma membrane. Studies on biosynthetic sterol (probably originating mostly in the smooth endoplasmic reticulum) suggest that there is rapid transport to the plasma membrane in lipid-rich vesicles. Important features of this transport are that it bypasses the Golgi apparatus and may be positively regulated by the specific binding of HDL to the plasma membrane.(ABSTRACT TRUNCATED AT 400 WORDS)

Efflux of phospholipid from fibroblasts with normal and elevated levels of cholesterol.

To address the hypothesis that phospholipid efflux from cells contributes to lipoprotein structure, we have examined the efflux of biosynthetically labeled [32P]phospholipid from cells to lipoproteins. With normal human skin fibroblasts in monolayer culture, high density lipoprotein (HDL3) promoted the efflux of phospholipid in a concentration-dependent manner. As analyzed by TLC, the major phospholipids released from fibroblasts were phosphatidylcholine, sphingomyelin, lysophosphatidylcholine and phosphatidylethanolamine. At identical concentrations, HDL3 and dimethylsuberimidate treated-HDL3 promoted similar efflux, suggesting that efflux did not depend on specific binding of HDL3 to the cell surface. When the content of cholesterol in fibroblasts was doubled by pre-incubation with LDL and cholesterol-rich liposomes, the fractional efflux of phospholipid to HDL3 and other acceptors was stimulated about 2-fold. Most of this stimulation was due to enhanced release of phosphatidylcholine. Similar effects of enrichment were found with Fu5AH rat hepatoma cells, but not with J774 mouse macrophages. The results support the hypothesis that the efflux of phospholipid from cells contributes to the phospholipid content of HDL. This may enhance the ability of HDL to remove cholesterol from cells, the initial step in reverse cholesterol transport.

Mechanisms and consequences of cellular cholesterol exchange and transfer.

It is apparent from consideration of the reactions involved in cellular cholesterol homeostasis that passive transfer of unesterified cholesterol molecules plays a role in cholesterol transport in vivo. Studies in model systems have established that free cholesterol molecules can transfer between membranes by diffusion through the intervening aqueous layer. Desorption of free cholesterol molecules from the donor lipid-water interface is rate-limiting for the overall transfer process and the rate of this step is influenced by interactions of free cholesterol molecules with neighboring phospholipid molecules. The influence of phospholipid unsaturation and sphingomyelin content on the rate of free cholesterol exchange are known in pure phospholipid bilayers and similar effects probably occur in cell membranes. The rate of free cholesterol clearance from cells is determined by the structure of the plasma membrane. It follows that the physical state of free cholesterol in the plasma membrane is important for the kinetics of cholesterol clearance and cell cholesterol homeostasis, as well as the structure of the plasma membrane. Bidirectional flux of free cholesterol between cells and lipoproteins occurs and rate constants characteristic of influx and efflux can be measured. The direction of any net transfer of free cholesterol is determined by the relative free cholesterol/phospholipid molar ratios of the donor and acceptor particles. Cholesterol diffuses down its gradient of chemical potential generally partitioning to the phospholipid-rich particle. Such a surface transfer process can lead to delivery of cholesterol to cells. This mechanism operates independently of any lipoprotein internalization by receptor-mediated endocytosis. The influence of enzymes such as lecithin-cholesterol acyltransferase and hepatic lipase on the direction of net transfer of free cholesterol between lipoproteins and cells can be understood in terms of their effects on the pool sizes and the rate constants for influx and efflux. Excess accumulation of free cholesterol in cells stimulates the rate of cholesteryl ester formation and induces deposition of cholesteryl ester inclusions in the cytoplasm similar to the situation in the 'foam' cells of atherosclerotic plaque. Clearance of cellular cholesteryl ester requires initial hydrolysis to free cholesterol followed by efflux of this free cholesterol. The rate of clearance of cholesteryl ester from cytoplasmic droplets is influenced by the physical state of the cholesteryl ester; liquid-crystalline cholesteryl ester is removed more slowly than cholesteryl ester in a liquid state.(ABSTRACT TRUNCATED AT 400 WORDS)

Lipoproteins and cellular cholesterol homeostasis.

Cholesterol homeostasis in peripheral cells involves a balance between the influx and efflux processes. The acquisition of cholesterol by such cells is mediated by a variety of receptor and non-receptor processes involving both normal and modified lipoproteins. The offsetting efflux process is mediated by HDL and especially particles containing only apo A-I. An efficient reverse cholesterol transport by HDL of cholesterol from peripheral cells to the liver protects against the development of atherosclerosis. In cells that do not contain excess cholesterol, the cholesterol is distributed as unesterified cholesterol molecules between the plasma membrane and the membranes of the intracellular organelles. In cholesterol-loaded cells such as macrophage foam cells, the membranes became enriched in unesterified cholesterol and, in addition, cytoplasmic CE droplets and lysosomal cholesterol crystals can form. The ways in which cholesterol molecules move between intracellular sites and the plasma membrane to become available for efflux to extracellular acceptor particles are becoming known. Cholesterol molecules in the plasma membrane can desorb and diffuse through the aqueous phase and be sequestered by HDL particles. The cell cholesterol available for efflux can exist in different kinetic pools, and these pools, such as those in various domains in the plasma membrane, require further definition. The cholesterol molecules present in intracellular pools also efflux with different kinetics and by different pathways. Thus, newly synthesized cholesterol is actively transported by a vesicle system from the ER to the plasma membrane, whereas lysosomal cholesterol seems to be transported to the plasma membrane by a protein-mediated, diffusional process. Clearance of cytoplasmic CE is dependent upon the rate of turnover of the CE cycle and the magnitude of the cholesterol gradient between the plasma membrane and the extracellular acceptor particle. It can be expected that the interdependence of the pathways and the molecular mechanisms underlying the intracellular trafficking of cholesterol will be elucidated in the near future.

Treatment of renal failure associated with multiple myeloma. Plasmapheresis, hemodialysis, and chemotherapy.

The aims of this study were to examine in a prospective, randomized trial the efficacy of plasmapheresis in preventing irreversible renal failure in patients with multiple myeloma and to study the renal biopsy tissues from such patients. Twenty-one patients with active myeloma and progressive renal failure were randomized to one of two groups: group 1, forced diuresis and chemotherapy (10 patients), and group 2, forced diuresis, chemotherapy, and plasmapheresis (11 patients). Plasmapheresis and chemotherapy lowered the serum myeloma protein value much more rapidly than chemotherapy alone. Of 5 patients who were oliguric and undergoing dialysis at presentation, only 3 who were treated by plasmapheresis recovered. Of 16 polyuric patients, 5 in group 1 and 7 in group 2 showed improvement in renal function. The main factor that determined irreversibility of renal failure was the severity of myeloma cast formation.

Cimetidine treatment of azotemic secondary hyperparathyroidism.

Cimetidine, an antagonist to histamine H2-receptors, reportedly lowers serum calcium and/or serum immunoreactive parathyroid hormone (iPTH) concentrations in some patients with primary and secondary (azotemic) hyperparathyroidism. We administered the drug orally (300 mg every 6 h) to five normal volunteers and four azotemic patients with secondary hyperparathyroidism who were not undergoing chronic hemodialysis. The normal persons and one azotemic patient took the drug for 5 weeks, and the remaining azotemic patients took it for 1 week. Before treatment, all patients had elevated levels of serum iPTH (two different assay systems), with or without elevated serum calcium concentrations, and increased urinary excretion of cAMP (per 100 ml glomerular filtrate). Cimetidine treatment caused no changes in serum calcium, phosphorus, or iPTH or in urinary cAMP (expressed as nanomoles per g creatinine). Serum creatinine, however, increased significantly in patients (P less than 0.02) and control subjects (P less than 0.025), which yielded statistically significant but spurious increases of urinary cAMP when expressed per 100 ml glomerular filtrate. We conclude that short term cimetidine administration has no effect on parathyroid function in normal persons or those with azotemic hyperparathyroidism. Because of its confusing effect on serum creatinine and a possible (albeit rare) adverse effect on renal function, the drug should be used with caution in azotemic patients not yet requiring chronic dialysis.

Mechanisms of high density lipoprotein-mediated efflux of cholesterol from cell plasma membranes.

The participation of HDL in the reverse cholesterol transport (RCT) from peripheral cells to the liver is critical for the antiatherogenic properties of this lipoprotein. Experimental results showing that efflux of cholesterol from cells growing in culture is mediated by HDL and lipoprotein particles containing apo A-I, in particular, support this conclusion. A bidirectional flux of unesterified cholesterol molecules between the plasma membrane of cells and HDL particles in the extracellular medium occurs. Net efflux of cholesterol mass from the cells involves passive diffusion of cholesterol molecules through the aqueous phase and down their concentration gradient between the membrane and HDL; the concentration gradient is maintained by LCAT-mediated esterification of cholesterol molecules in the HDL particles. Fully lipidated apo A-I is important in promoting this aqueous diffusion mechanism because it: (1) acts as a cofactor for LCAT; and (2) solubilizes phospholipid into small HDL-sized particles that are efficient at absorbing cholesterol molecules diffusing away from the cell surface. Apo A-I also exists in an incompletely lipidated state in plasma. Apo A-I molecules in this state are able to solubilize phospholipid and cholesterol from the plasma membrane of cells. This membrane-microsolubilization process is enhanced by enrichment of the plasma membrane with cholesterol and is the mechanism by which pre-beta-HDL particles in the extracellular medium remove cholesterol and phospholipid from cells. The relative contributions in vivo of the aqueous diffusion and membrane-microsolubilization mechanisms of apo A-I-mediated cell cholesterol efflux are not predicted readily from cell culture experiments. Confounding issues are the variations with cell type and the dependence on the degree of cholesterol loading of the cell plasma membrane.

Results of subtotal parathyroidectomy in hemodialysis patients.

In 61 hemodialysis patients undergoing subtotal parathyroidectomy, there was a good correlation between the preoperative serum immunoreactive parathyroid hormone value (iPTH) and the weight of parathyroid tissue removed surgically (p less than or equal to 0.001). Postoperatively, iPTH decreased rapidly from an initial mean (+/- SD) of 2,928 +/- 1,600 muleq/ml and remained at 365 +/- 296 muleq/ml at last follow-up of patients still undergoing hemodialysis (normal, less than 50 muleq/ml). Of six patients who had recurrent hyperparathyroidism (10 percent of total), three required a second subtotal parathyroidectomy. Aluminum-related osteomalacia eventually developed in six patients with bone biopsy-proven hyperparathyroidism before parathyroidectomy. Nine patients with severe fracturing bone disease and hypercalcemia preoperatively but without clear evidence of hyperparathyroidism did not show a favorable response to subtotal parathyroidectomy (high mortality within 28 months, persistence of hypercalcemia, and symptomatic bone disease). Thus, subtotal parathyroidectomy can benefit patients with clearly established severe progressive hyperparathyroidism not responsive to medical therapy but is contraindicated in patients with low iPTH values and no bone biopsy evidence of severe hyperparathyroidism.

Pulmonary hypertension and familial Mediterranean fever: a previously unrecognized association.

Familial Mediterranean fever is an autosomal recessive inherited disorder characterized by recurrent episodes of fever accompanied by inflammation of the peritoneum, pleura, synovial membranes, and skin. The disorder predominantly affects persons of Mediterranean origin. The most serious complication of the disease is amyloidosis, which is the cause of death in a substantial proportion of adult patients with the disorder. Only one previous report has described pulmonary hypertension in a patient with systemic amyloidosis associated with multiple myeloma. Herein we describe the first known occurrence of pulmonary hypertension due to pulmonary amyloidosis in a 48-year-old woman with familial Mediterranean fever. Postmortem examination showed extensive deposits of amyloid in the pulmonary vessels, alveolar capillary walls, and myocardium, which explained the hypoxia, hypotension, and terminal cardiac arrhythmias that were the immediate cause of death in this patient.

A four-year comparison of continuous ambulatory peritoneal dialysis and home hemodialysis: a preliminary report.

All patients who received initial dialysis therapy by either continuous ambulatory peritoneal dialysis (CAPD) or home hemodialysis between January 1979 and January 1983 were retrospectively compared for adequacy of dialysis, morbidity, and survival. In this study group, 30 patients had home hemodialysis and 21 patients had CAPD; the mean ages of the patients in these two groups were comparable. Both methods of treatment provided adequate dialysis, as shown by results of serial laboratory studies. The number of days of hospitalization per year at risk was twice as great for the patients on CAPD as for those on home hemodialysis; peritonitis was responsible for this difference. The survival was similar in both groups at 32 months of therapy. Death was clearly related to coexisting morbid events other than dialysis in the home hemodialysis group; however, one of the two deaths in the group on CAPD seemed to be indirectly related to the treatment of peritonitis. These findings suggest that CAPD, when compared with hemodialysis, (1) provides adequate dialysis, (2) is accompanied by greater morbidity (hospitalization), and (3) may introduce a morbid event (peritonitis) that may adversely affect survival.

Chronic gouty nephropathy treated by long-term hemodialysis and allopurinol.

A patient with intractable tophaceous gout and advanced renal failure responded favorably to treatment by long-term hemodialysis and administration of allopurinol. Plasma uric acid levels returned to normal, tophi decreased in size, and the frequency of attacks of gout decreased markedly and permitted the patient to return to full-time employment.