Hypertension and diabetic nephropathy: relationship, significance and management - abstract

During the past 10 years, several investigators have accumulated evidence for defining the relationship between systematic blood pressure levels and diabetic nephropathy. Studies showing the presence of insulin resistance in obese normotensive individuals, non-obese hypertensives, and in non-insulin-dependent diabetes mellitus (NIDDM) raise the possibility of shared pathogenic mechanisms in essential hypertension and diabetes mellitus. It is accepted that control of hypertension retards the progress of renal functional impairment in Diabetic Nephropathy (DN); what remains unknown is the class of antihypertensive agent best suited to this clinical situation. A case has been made for the angiotensin-converting enzyme inhibitors (ACE-Is) which have been demonstrated to have a renoprotective effect greater than can be attributed to lowering systemic blood pressure levels alone. Microalbuminuria is accepted as being an index of glomerular damage and a prognostic indicator for the development of DN and dip-stick detectable proteinuria. The ACE-I enalapril was shown to be more effective in reducing proteinuria than metoprolol, although both drugs reduced systemic blood pressure levels to a similar degree in the patients studied. On the other hand, the dihydropyridine calcium channel blocking agent (CCB), nifedipine, increased albuminuria whereas non-dihydropyridine CCBs did not. The animal experimental evidence suggesting glomerular hypertension as the mechanism through which albuminuria and subsequent glomerulosclerosis develop is persuasive. The differential renoprotective effects of the various hypertensive agents have therefore been related to their differing abilities to modulate both afferent and efferent glomerular arteriolar tone in a manner which produces net reduction in intraglomerular pressure. In clinical circumstances, selection of antihypertensive agents will be guided by the metabolic neutrality of the agent among other attributes, and ACE-Is and CCBs appear to have the most favourable profiles. Finally, the questions of how soon and how far to treat systemic hypertension in diabetics remain to be answered. Does one use ACE-iS to treat microalbuminuric and proteinuric patients who are still normotensive? To what level does one reduce the blood pressure in order to achieve optimal renoprotection in DN? There are now several survival studies of hypertensive patients which purport to show declining mortality with reduction of Diastolic Blood Pressure (DBP) levels to certain end-points, with a subsequent rise in mortality when DBP has been further reduced below approximately 85 mm Hg. The caveat of the "J-shaped" curve applies primarily to those patients with associated ischaemic heart disease, a condition which is frequently encountered in diabetes mellitus. Presumably, in those patients with associated left ventricular hypertrophy, reduction of DBP below a critical level compromises the coronary artery reserve and the blood supply to a mismatched ventricular mass. The ideal blood pressure lowering agent in DN is therefore one which reduces intraglomerular as well as systemic blood pressures, reduces albuminuria, is metabolically neutral, and reduces left ventricular mass. The ACE-Is and the CCBs fulfil these requirements but only ACE-Is decrease insulin resistance. Whether this latter "plus" will be shown to be critical is yet to be demonstrated (AU)

Dialysis therapy in the Caribbean - abstract

Long-term haemodialysis at the University Hospital of the West Indies, Jamaica, started in 1971 with the training of patients with end-stage renal failure for self-treatment in their own homes. There was no Government Health Insurance or other third party funding for this treatment and, regrettably, patients whose financial and social circumstances did not allow home-dialysis treatment perished from terminal uraemia. Elsewhere in the Caribbean, notably in San Fernando and Port-of-Spain in Trinidad and Tobago, attempts were also being made to introduce dialysis therapy. Again, there was little encouragement in the way of funding from traditional health care sources. The majority of Jamaicans coming to end-stage renal failure did so as the result of benign or malignant nephrosclerosis and the majority of these were from the lower socioeconomic strata of the society. To overcome their relative disadvantagement, dialysis programmes were initiated, first at the Kingston Public Hospital (circa 1972) and subsequently at the University Hospital (1974), to prepare patients with end-stage renal failure for renal transplantation. By September 1980 twenty-five cadaver renal transplants had been performed on patients from these two sources. All patients transplanted in Jamaica have received cadaver transplants. On June 14, 1987 the first successful living-related donor renal transplant in the Commonwealth Caribbean was performed in Barbados. A few months later four similar operations were performed in San Fernando. Dialysis facilities now exist in the Bahamas, Barbados, Bermuda, Jamaica and Trinidad and Tobago. The future holds the prospect of co-operation between these centres and the provision of renal transplantation services for a greater number of West Indian nationals (AU)

Prognostic indicators of recovery in malignant hypertension - abstract

Experience with renal failure due to malignant hypertension was reviewed for prognostic factors indicative of recovery of self-sustaining renal function (SSRF) and to define an approach to management in the Eastern Caribbean. All patients admitted to the Queen Elizabeth Hospital between March 1979 and March 1985 with malignant hypertension and significant renal failure (plasma creatinine level greater than 176 micromol/l) were studied. The contributions of age, sex, duration of hypertension and of symptoms prior to admission, urine volume and plasma creatinine levels (on admission and one month later), and of renal size were assessed. Only sex, renal size and mean plasma creatinine level (for the group) at one month were predictive of the likelihood of recovery of SSRF. All four female patients recovered SSRF whereas only 2 0f 9 male patients did so, a difference which was statistically significant (p<0.01). Patients recovering SSRF had combined renal lengths greater than 18.0 cm; patients failing to do so had combined renal lengths less than 16.0 cm or shruken kidneys which could not be accurately measured on infusion pyelography. The admission plasma creatinine levels in the 2 males who recovered were lowest (less than 800 micromol/l) among the male patients. Particularly in male patients, then, there is great urgency in the diagnosis and control of malignant hypertension. Patient with renal impairment warrant early referral to specialist units for the aggresive reduction of blood pressure which may frequently require temporary dialysis support. Thereafter, determination of renal size should be followed by renal biopsy in cases with normal or near normal renal size and by prolonged dialysis in those with preservation of glomerular architecture. With minoxidil therapy, 50 percent of patients may be expected to recover SSRF and larger numbers may do so if referral is sufficiently expeditious (AU)

The feasibility of regular haemodialysis in Jamaica - abstract

In February, 1971, a Pilot Home-Dialysis Training Programme was instituted at the University Hospital of the West Indies in order to examine the feasibility of applying this form of therapy in Jamaica. All patients were in terminal renal failure with creatinine clearance below 5 mls/min. Dialysis was performed using traveno recirculating single pass machines and disposable coil dialyzers. Patients received treatment twice or thrice weekly for 6 to 6 1/2 hours on each occasion, and the "disposable" coils were re-used up to 5 times before being discarded. 5 patients were accepted into the Training Programme and 4 were discharged to treatment in their own homes. 1 death occurred after 8 months on dialysis. Of the remaining 4 patients, 3 are fully rehabilitated and are fully employed, and the fourth a retired farmer, enjoys an active retirement. The first patient to be accepted into the programme is now in his third-year on regular dialysis. Serious complications of therapy have been few in over 50 patient-months of therapy involving more than 500 haemodialysis treatment. On the basis of our experience it is concluded that there are no technical or other difficulties which might prevent the wider application of home-dialysis in Jamaica (AU)

Long-term haemodialysis in the home: results of seven years' experience in Jamaica - abstract

The training of a Jamaican patient for self-treatment with the artificial kidney in his own home was first attempted in 1971. By 1973 a home dialysis training programme (HDTP) was firmly established and based in a 3-bed haemodialysis unit intended primarily for acute haemodialysis treatments. This paper reviews the experience of the HDTP up to the end of 1978. Between 1971 and 1978, sixteen patients were accepted into HDTP: they were required to provide their own funding. One patient received a successful renal transplant before being discharged to home-dialysis and is not included in the subsequent analysis. No more than 4 patients were accepted in any one year. Ten of the 15 patients were completely rehabilitated. Nine of the 15 patients had died at the time of this assessment, but only one of the deaths could be attributed to faulty dialysis technique. Calculation of the cumulative patient survival showed a survival rate of 85.2 percent at 12 months and 67.3 percent at 24 months. Thereafter there was a rapid decline in the survival rate to 44.8 percent at 36 months. The causes of death were varied but there is no consistent pattern. Our experience has shown that Long-term haemodialysis is entirely feasible in the Jamaican and, presumably a Caribbean setting. Indeed, one of the patients trained in the HDTP has completed one year of home-dialysis in Barbados. Deficiencies in the programme have been identified and it is hoped that the provision of psychological counselling, the services of a social worker and third party funding will permit the maximum advantage to be gained from HDTP. (AU)

Severe leptospirosis in humans

In spite of major advances in the control of infectious diseases, leptospirosis remains an important cause of morbidity and mortality in the tropics and subtropics. In rural settings, during the wetter months of the year and where there is close contact with domestic livestock, the incidence of severe disease may be particularly high. Acute renal failure is the important, life-threatening complication; its prompt recognition and treatment are the most important aspects of the successful management of severe leptospirosis (AU)

Systematic lupus erythematosus in Barbados

Systematic lupus erythematosus (SLE) is a relatively common disease in the Caribbean. Its demogaphic and clinical features are presented in this review of SLE in Barbados in which 75 consecutive cases were evaluated during the course of prospective analysis. Renal involvement was the most important cause of morbidity and mortality, and the major indication for the use of aggressive immunosuppressive therapy. Renal failure, immunosuppression, and infection combined to provide major risks to survival (AU)

Clinical features in histologically proven primary hepatoma

Clinical, biochemical and pathological features are assessed in 19 cases of histologically-proven primary hepatoma. 47 percent of the patients recalled the use of "bush teas" in childhood, though only one patient gave a history suggestive of acute veno-occlusive disease. An unusually high prevalence of micronodular cirrhosis was reported among the 18 patients coming to autopsy. Previously proposed carcinogenic mechaninsms are reviewed, and a possible role for senecio alkaloids in the genesis of primary hepatoma is considered (AU)

Post-streptococcal glomerulonephritis in adult Jamaicans with and without sickle cell anaemia

Twenty-nine patients with PSGN were admitted to the Adult Medical Wards during a 6-year period. Although the peak incidence occurred in the age range, 10-14 years, 13 patients (45 percent ) were over the age of 15 years. The disease rarely occurred after the age of 35 years in patients with normal haemoglobin, but all 3 patients with homozygous sickle cell disease were over that age. A possible relationship between chronic leg ulceration, recurrent or persistent streptococcal antigenaemia and immunodeficiency in sickle cell anaemia is noted (AU)

A home dialysis training programme in Jamaica

The experience of a small Pilot Home-Dialysis Training Programme in a developing country is reviewed. The recurrent costs of long-term dialysis have been considerably reduced by employing multiple dialyser re-use. Patient survival has been compared with that in major European and American units, and no firm conclusions have been reached concerning the unacceptable mortality rate among Jamaican patients in the third year of home-dialysis. Deficiencies in the programme have been identified and it is hoped that the provision of psychological counselling, the services of a social worker, a patient's association and third party funding will permit the maximum advantage to be gained from the nursing skill and energy applied to H.D.T.P (AU)

Cessation of regular haemodialysis therapy in oliguric malignant hypertension treated with Minoxidil

The clinical course in 3 patients with malignant hypertension and severe functional renal impairment is reviewed. All were presumed to be in end-stage renal failure and represented 14.3 percent of patients admitted to a regular haemodialysis therapy (RHDT) programme during a 5-year period. Recovery of renal function permitted cessation of RHDT after periods of combined periods of combined peritoneal dialysis and RHDT lasting 19, 4 and 2.75 months respectively. Aggressive lowering of the blood pressure is stressed and supportive replacement of renal function by peritioneal or haemodialysis is recommended, particularly if the renal sizes are normal and urine output is maintained (AU)

Systemic lupus erythematosus in Barbados

Systemic lupus erythematosus (SLE) is a relatively common disease in the Caribbean. Its demographic and clinical features are presented in this review of SLE in Barbados in which 75 consecutive cases were evaluated during the course of prospective analysis. Renal involvement was the most important cause of morbidity and mortality, and the major indication for the use of aggressive immunosuppressive therapy. Renal failure, immunosuppression, and infection combined to provide major risks to survival (Summary)

Diabetic nephropathy: new appraoches, new therapies

In the United States and in the industrialised countries of Europe, in Japan, India and Africa, diabetes is the condition most frequently associated with endstage renal disease (ESRD). In those countries where ESRD registries are maintained, diabetic nephropathy has been shown to have a higher prevalence than hypertension and glomerulonephritis among new ESRD patients, and Mauer and Chavers (1985) have described diabetes as"...the most important cause of ESRD in the Western world." In the US and the Caribbean, diabetes is predominantly Type 2 (NIDDM) with fewer than 10 percent of patients with diabetes being insulinopenic or C-peptide negative. Twenty years ago it was a commonly expressed view that diabetic nephropathy was an infrequent complication of Type 2 diabetes. Since that time a number of prospective studies of Type 1 and Type 2 diabetes have shown the diabetic nephropathy at comparable rates in the two groups of patients. The Diabetes Control and Complications Trial (DCCT) unequivocally linked the renal, retinal, and neurological complications of diabetes to hyperglycemia and to the failure to achieve so called "tight" glycemic control. Intensive diabetes therapy delayed the onset and slowed the progression of retinography and, additionally, delayed the development of microalbuminuria (>28 ug/min) and the development of overt nephropathy (albuminuria >208 ug/min) in patients with baseline microalbuminuria (DCCT Research Group, 1993). Whatever may be the mechanism(s) through which hyperglycemia produces micro and macrovasculopathy, indolent and slowly progressive process effect these end-results. Not surprisigly, abnormal glycosylated haemoglobin (HbA) levels best predict the development of the microvascular and marcovascular complications of diabetes (Harris and Eastman, 1996).(Au)

Systemic lupus erythematosus Barbados: the renal complications - abstract

Over the past 10 years, 75 patients with systemic lupus erythematosus (SLE) have been followed, and this paper reports the clinical findings with emphasis on renal complications and mortality. The diagnosis of SLE was based on the presence of 4 or more of the 1982 "revised criteria" of the American Rheumatism Association. The female: male ratio was 14:1 and the mean age of onset was 27.4 years (range 6-54 years). Six patients (5 girls and 1 boy) presented at < 12 years of age. Patients presented most frequently with polyarthalgia/ polyarthritis (59 per cent), skin rashes (57 per cent), fever (55 per cent), anorexia (39 per cent) and weight loss (33 per cent). Eight patients (11 per cent) presented with acute renal failure and 4 of these had associated nephrotic syndrome (NS). Of 8 patients presenting with NS, 4 had normal renal function. During follow-up, 69 per cent of patients developed significant renal involvement (sustained proteinuria >0.5 g/24 hr. and/or cellular urinary casts) and 14 patients had nephrotic range proteinuria (>3 g/24 hr.). All patients received prednisone at some time for vital organ involvement. Some degree of remission of proteinuria usually occurred over the course of several months. Twelve patients (16 per cent) died during the study, 5 from infection with immunosuppression being the major precipitating factor. Infection is of critical importance in this disease, and renal disease can be modified by the aggressive use of immunosuppressive agents which, however, are potentially hazardous (AU)

Renal replacement by regular haemodialysis therapy and renal transplantation in Barbados: 1979 to 1997

We have reviewed our delivery of highly sophisticated medical therapy, haemodialysis and renal transplantation in a Caribbean setting. The purpose has been to reflect local outcomes in relation to mortality and survival, but comparisons with a vastly larger database have been attempted. Such comparisons are extremely difficult due to methodological differences and the fact that facilities contributing to that database vary considerably with regard to patient age, gender, ethnicity and comorbidity. Nonetheless, the crude data available provide important justification for the existence of regular haemodialysis and its adjunctive therapy of renal transplantation in the Caribbean.(AU)

Hypoglycaemia in chronic renal failure

Persistant symptomatic hypoglycaemia developed in a 26-year-old woman with chronic renal failure. Several factors, including the use of sulfametethroxaole, recent peritoneal dialysis, and poor nutrition may have combined with defective glycogenosis and gluconeogenesis present in chronic renal failure to play a role in its aetiology. Increased awareness of this condition is necessary because chronic renal failure is common in the Caribbean. (AU)

Penicillin therapy in icteric leptospirosis - abstract

The efficacy of antibiotic therapy in icteric (severe) human leptospirosis is unknown. We therefore undertook a prospective, randomized, controlled study of penicilin therapy in such patients. All admitted between October 1, 1983 and June 30, 1986 with a history compatible with leptospirosis, were randomized on admission to receive either 2 megaunits of crystalline pencillin intravenously every six hours for five days or intravenous fluids only. The diagnosis of leptospirosis was confirmed by a four-fold rise in titre or an initial titre> 1:1600 in the micoagglutination test, and/or by positive leptospira cultures. One hundred and fifty patients were initiated, and leptospirosis was confirmed in seventy-five of them. Seventy-one (94.7 percent) of these were jaundiced. One died before randomization, while four were allergic to penicillin. Thus, thirty-two patients were assigned to receive penicillin, and thirty-four to the control group. A comparison of the results of laboratory tests made on the day of admission revealed no signifcant differences between the two groups. There was no significant difference in time for defervescence, return of biochemical variables to normal, incidence of iritis, or mortality between the two groups. Three patients (8.8 percent) died in the control and one (3.1 percent) in the treatment group. The mortality rate was 5.1 percent for the study and 7 percent overall. Six patients had positive urine cultures in the controls while no cultures were obtained in the treated patients. Penicillin appears to have little effect in icteric leptospirosis (AU)

Severe leptospirosis in Barbados

Leptospirosis was confirmed in 134 Barbadian patients between November 1979 and December 1982. The average annual number of cases was 42.3 or approximately 17 cases/100,000 population/year. There were 90 males and 44 females (2:1 ration with ages ranging from 9 - 86 years. In 94 cases the infecting leptospiral serogroups could be identified with certainty. They were Autumnalis 68 (72 percent), Icterohaemorrhagiae 18 (19 percent), Ballum 6(6 percent), Canicola 1 (1 percent) and Grippotyphosa 1 (1 percent). A further 25 cases showed mixed infections with Autumnalis/Icterohaemorrhagiae accounting for 14 of them. Eleven of 14 isolates obtained from hospital patients were identified as Autumnalis (7) (new serovar, to be named bim), A. bulgarica (1), Icterohaemorrhagiae copenhageni (2) and Canicola canicola (1). Twenty-five (19 percent) of the patients died (averag 8/year). There were 14 males: 11 females. Just under half of the fatal cases were < 50 years of age, and a quarter of them were between 20 and 39 years. The serogroups found in 16 of the dead patients were Autumnalis (9), Autumnalis/Icterohaemorrhagiae (1), Autumnalis/Ballum (2), Icterohaemorrhagiae (3), and Ballum (1). Thus Autumnalis could have been the infecting group in 12 of 16 (75 percent) of the fatal cases. The majority of Autumnalis infections are probably caused by the new serovar. Although it is antigenicalyy very similar to fort-bragg it appears to cause severer illness than the latter. since Autumnalis infections are responsible for at least (72 percent) of all cases and up to 75 percent of deaths, Autumnalis bim appears to be the major cause of severe human leptospirosis in Barbados (AU)

Renal dialysis in Barbados - part 1: cost of dialysis provision at the Queen Elizabeth Hospital

OBJECTIVE: The purpose of this study was to assess the health service cost of haemodialysis delivered by the Queen Elizabeth Hospital, Barbados. DESIGN AND METHODS: A cost analysis was performed from the viewpoint of the study hospital using the treatment protocols based on current practice. These incorporated procedures to establish dialysis access sites (surgical set up) and dialysis maintenance. Cost and patient data were collected for the period April 1, 1998 to March 31, 1999. Sixty-four patients were studied. Analyzed costs included personnel, drug expenditure, supplies (dialysis and non-dialysis related), inpatient costs, laboratory and other ancillary services, and indirect or overhead costs such as plant, housekeeping, laundry and administration. RESULTS: The final cost per patient year was $37,930.04 in the first year of dialysis and included surgical set-up, and $34,059.08 in the subsequent years (excluding inpatient admissions and treatments for complications). The total cost of dialysis provision for the year excluding surgical set up was $2,178,561.09. The cost per visit was estimated to be $286.95. Direct costs (determined by patient utilization and physician and nurse directives) amounted to 81.8 percent of total cost. The main expenditure sections were dialysis-related supplies, labour and overheads. Cost savings incurred as a result of strict modification of treatment guidelines were estimated. By altering the number of dialysis visits per week and introducing other cost saving measures, such as dialyzer re-use, a savings of $852,176.32 was observed with a full potential savings of $902,218.63. An incremental cost analysis of a service expansion (scenario 1) indicated that the cost savings would be sufficient to provide an additional 3,328 dialysis treatments or visits per year, incorporating 4 additional dialysis machines. CONCLUSIONS: These findings are important in the light of constrained economic resources. However, the outcomes associated with the observed costs must be explored in order to assess the "true value" or cost effectiveness of the current dialysis practice. Therefore, this analysis is but one component of an overall study to review the renal dialysis services in Barbados for the purpose of informing plans for expansion and optimization of services.(Au)

Membranous glomerulonephritis and the nephrotic syndrome in a patient with Landry-Guillain-Barre-Strohl syndrome

Membranous glomerulonephritis and the nephrotic syndrome concurrent with the Miller-Fisher variant of the Landry-Guillain-Barre-Strohl syndrome (LGBS), acute post-infective polyneuritis, is reported in a 49-year-old man. The onset of heavy proteinuria coincided with the development of the neurological disturbance. While immunosuppressive therapy appeared to hasten improvement in the neurological disease, no such improvement occurred in the glomerulopathy (AU)