A prospective randomized trial of low-dose versus high-dose steroids in cadaveric renal transplantation.

Low-dose steroid regimens, in combination with azathioprine, have become increasingly common for immunosuppression of renal transplant recipients. The change from conventional high-dose steroid regimens was prompted by the results of several prospective trials that showed similar graft survivals with high-dose and low-dose steroids, but a lower incidence of steroid-induced complications in low-dose-steroid--treated patients. However, the number of patients entered into the trials was small, and consequently there remained a possibility that a clinically relevant difference in graft survival could have remained undetected. A multi-center prospective trial was performed to compare graft survival with high-dose (91 patients) and low-dose (98 patients) oral steroids in combination with azathioprine. There was significantly worse graft survival in the low-dose group. The difference was largely due to a poor graft survival in patients receiving low-dose steroids and azathioprine less than 1.75 mg/kg/day. Graft survivals were similar in the high-dose and low-dose steroid patients who received azathioprine doses of greater than 1.75 mg/kg/day. The results indicate that the combination of low doses of both steroids and azathioprine provides inadequate immunosuppression in renal transplantation, although higher doses of azathioprine allow the use of low-dose steroids without significantly more graft losses than with high-dose steroids.

Presentation and detection of chronic renal disease in children and adults.

Chronic renal failure develops slowly and insidiously in most patients. Prevention depends on the early detection and full assessment of the patient at risk. Indications for investigation in children and adults with glomerulonephritis and urinary infection are outlined.

Investigation of urinary infection in childhood.

The first proven urinary infection in both girls and boys should be investigated with an IVP and micturating cystourethrogram. If both investigations are normal, recurrent infections will not produce renal scars. Renal scars will develop in 10 per cent of children with reflux, unless renal infections are prevented by appropriate drug or surgical treatment.

Glomerulonephritis in children and adults.

Glomerular disease is associated with a limited number of signs which are easily detected by routine clinical examination and urine tests. Haematuria, proteinuria, oedema, hypertension and renal impairment occur in various combinations including classical and predictable syndromes such as acute post streptococcal nephritis and the nephrotic syndrome in children. Apart from these classical syndromes clinico-pathological correlations in glomerular disease are poor. Early renal biopsy is required to determine the extent of the glomerular disease and the long term prognosis in most patients with prolonged proteinuria and haematuria.

Hereditary vesicoureteric reflux: phenotypic variation and family screening.

Family screening programs offer the prospect of detecting hereditary vesicoureteric reflux before scars develop with urinary infections. This review describes minor to severe reflux and reflux nephropathy (RN) in five families where a member developed renal failure, including 3 children who developed both scars and renal failure. Analysis of families in the literature demonstrated similar phenotypic variation and the regular detection of both sterile reflux and RN by screening. Future systematic family studies could evaluate the predictive value of ultrasound in detecting significant reflux, assess the severity of congenital RN found in infants, and compare prophylactic regimes with historic controls.

Dialysis in the home.

Patients with impaired renal function require thorough evaluation at the time of diagnosis and careful supervision thereafter. If renal failure ensues, both dialysis and renal transplantation can be used to provide integrated and total care. The family physician has an important role to play in medical supervision of patients undertaking dialysis at home. Discussion and careful examination during routine visits can forestall complications and contribute to the patient's confidence and independence. There are few problems that cannot be sorted out by an interested family physician with support from the parent renal unit.

The Renal Handling of Dextran 40 by Surgical Patients.

A study has been made of the renal handling of low molecular weight dextran (dextran 40) by surgical patients. In spite of the usual fall in glomerular filtration rate during surgery, high urine dextran concentrations may occur, with the formatin of highly viscous urine. In view of the possible association between high dextron concentrations and oliguric renal failure, precautions in its administration are suggested with particular emphasis on the maintenance of urine flow rates.

Physical, emotional and social adjustments to home dialysis.

Forty home dialysis patients and their families were interviewed by means of a standard questionnaire to determine their physical, emotional, and social adjustment to treatment. The results indicated a reasonable level of health, particularly in patients under the age of 50 years. However, home dialysis produced considerable strain in the family, particularly in the dialysis partners. Home training programmes should provide appropriate learning and technical experience for the dialysis partners and continued support, including integrated medical and paramedical services, domiciliary visiting, and regular holidays. Limited-care dialysis facilities should be provided where home dialysis is impractical or becomes intolerable.

Parathyroidectomy in chronic renal failure.

Parathyroidectomy was carried out in 26 patients over a 14-year period. Excellent results were obtained in patients with severe hyperparathyroidism. Vascular calcification, hypercalcaemia and pruritus did not justify surgery unless associated with unequivocal hyperparathyroidism. 13 patients required intravenous calcium infusion for up to 2 weeks to control post-operative hypocalcaemia. Calcium requirements could be predicted from the pre-operative plasma alkaline phosphatase level. Following operation continued treatment with vitamin D was necessary to prevent hypocalcaemia. Hyperparathyroidism recurred in 1 patient after 8 years and 4 patients developed osteomalacia. Since parathyroid hormone may have toxic effects other than those on bone, maintenance of normal levels should be a long-term objective in the treatment of patients with chronic renal failure. Where large parathyroid glands are present, surgical reduction in gland mass is a logical prelude to long-term suppression of parathyroid hormone with vitamin D and phosphate-binding agents.