High mortality with systemic lupus erythematosus in hospitalized African blacks.

This survey was undertaken to determine the clinical spectrum and outcome of SLE in hospitalized African blacks in Durban, South Africa. We reviewed the hospital records of all patients with SLE who were seen during 1984 and 1990. Eighty-five patients were seen and their mean age at diagnosis was 33.3 years. The prevalence of the various diagnostic criteria was as follows: cutaneous, 68%; arthritis, 66%; renal, 65%; serositis, 29%; neuropsychiatric, 21%; haematological, 71%; immunological, 49%; anti-nuclear factor, 98%. Follow up data were not available in many patients but 25 (29%) are known to have died. The commonest causes of death were renal, infection, neurological and cardiac. This survey shows that SLE is being recognized more frequently in African Blacks and is associated with a high mortality.

Acute renal failure in blacks and Indians in South Africa--comparison after 10 years.

Acute renal failure (ARF) has changed in its aetiology in developed Western countries. This study compares our experiences of the aetiology and incidence of ARF a decade after a previously recorded paper in the literature. The data of 226 patients with a diagnosis of ARF during a 3-year period from 1986 to 1988 was analysed. ARF in our study occurred at a younger age. Medical causes of ARF remain the dominant subgroup. There were female patients presenting with ARF associated with self-induced abortions. Toxins of a herbal variety and infections remain the commonest aetiological factors in the medical subgroup. Infections have replaced nephrotoxins as being the principal medical cause. There has been no major change in the incidence or aetiology of ARF over a decade. The prevention of ARF in blacks in sub-Saharan Africa is primarily concerned with the eradication of nephrotoxins and infections and a laxity in the abortion laws of the country. Only by an improvement in education, nutrition, socio-economic status and sanitation can one eradicate or diminish ARF in developing countries.

Light-chain nephropathy. A report of 2 cases.

Two cases of renal impairment caused by the deposition of monoclonal immunoglobulin light-chain determinants in the glomerular mesangium and basement membranes as well as in the tubular basement membranes of the kidney are described (light-chain nephropathy). Both cases were associated with myeloma. Examinations by light microscopy, immunohistochemistry and electron microscopy are also described. Differential diagnoses on light microscopy include diabetic glomerulosclerosis (Kimmelstiel-Wilson lesions), amyloidosis and mesangiocapillary glomerulonephritis type 1.

Circulating auto-antibodies to neutrophil cytoplasmic antigens in vasculitis. A report of 3 cases.

Three patients are described who presented with symptoms and signs of a vasculitic illness but in whom a definite diagnosis was not made until the application of a test to detect auto-antibodies to neutrophil cytoplasmic antigens. There has long been a need for a diagnostic marker for the groups of diseases which fall into the broad classification of systemic vasculitides. Diagnosis of the patients as having either Wegener's granulomatosis or microscopic polyarteritis by the finding of this auto-antibody enabled a positive approach to treatment with combinations of immunosuppressive agents. In addition, serial measurement of the auto-antibody titres enabled monitoring of disease activity.

Profile of crescentic glomerulonephritis in Natal--a clinicopathological assessment.

Crescentic glomerulonephritis is invariably associated with a fulminant syndrome of rapidly progressive renal failure which generally progresses to end-stage renal failure within weeks or months of onset. A widely differing aetiological background has been reported from Western countries. Work from the African continent is sparse. In a study from the province of Natal in South Africa between 1981 and 1987, 27 cases of crescentic nephritis were identified from a total of 458 patients who underwent renal biopsy at King Edward VIII and Addington hospitals. Poststreptococcal nephritis was the commonest aetiological factor (n = 8). There were six black patients in this group. Nine patients were classified as idiopathic and of these five were black. Four patients (one black) had antiglomerular basement membrane disease. Of the 24 patients subjected to variable combinations of immunosuppression, antiplatelet agents, dialysis and plasmapheresis, 11 improved, observed over four months to four years. Oliguria and severe renal failure at presentation signified a poor prognosis.

IgA nephropathy in blacks and Indians of Natal.

IgA nephropathy besides exhibiting a characteristic geographical distribution has been noted to have a low incidence in the blacks of the USA. There is a paucity of data on IgA nephropathy in the blacks of Africa. We report our findings among the blacks and compare these with Indians. An analysis of the primary glomerular diseases of 252 blacks and 75 Indians over 6 years (1981-1986) was done. Mesangiocapillary glomerulonephritis was the commonest type in the black (35.7%), whereas mesangial proliferative glomerulonephritis was the commonest in Indians (26.7%). IgA nephropathy occurred in 2 blacks (1 male, 1 female), whereas there were 10 Indians (8 males, 2 females). Available data among whites in Natal show that IgA nephropathy is not uncommon. HLA studies done in blacks with IgA nephropathy did not reveal the HLAB35 or the DR4 antigen. HLAB35 in our blacks is less common compared to Indians and whites of Durban. Thus, although glomerulonephritis is common in blacks, IgA nephropathy is rare. This suggests that infection which is common in our black population may not be responsible for the aetiology of IgA nephropathy. A dietary factor in the form of a high-fibre diet may protect the black population from IgA nephropathy. However, a genetic factor cannot be excluded.

The growth hormone responses to L-dopa and TRH in acromegaly.

The GH responses to TRH and L-dopa were investigated in 14 Indian and African patients with untreated acromegaly. A positive response to L-dopa (greater than 50% change from basal) was obtained in 6 of the 14 patients tested while a positive response to TRH (greater than 100% change from basal) was found in 5 of 12 patients tested. While 9 patients responded to at least one agent, only 2 had a positive response to both agents. Positive responders appeared to be hyper-prolactinemic and have evidence of abnormal glucose tolerance as compared to nonresponders.

Serum beta-2-microglobulin estimation as an indicator of the glomerular filtration rate.

In 56 patients in whom the glomerular filtration rate (GFR) was estimated by the 51Cr-EDTA technique, serum creatinine and beta 2-microglobulin levels were also measured. In the 15 patients with a GFR of greater than or equal to 80 ml/min, both serum creatinine and beta 2-microglobulin levels were within the reference range. However, the beta 2-microglobulin level was elevated (greater than 2,3 mg/l) in all 41 patients with a GFR of less than 80 ml/min, while the serum creatinine level was increased (greater than 133 mumol/l) in only 35 patients. In the remaining 6 patients, the creatinine values ranged from 75 to 125 mumol/l. It would therefore seem that serum beta 2-microglobulin assay is a more sensitive test than creatinine assay for detecting impaired renal function.

The clinical presentation and biochemical diagnosis of acromegaly and gigantism.

Over a 5-year period 14 patients with acromegaly and gigantism were seen at the endocrine clinic of King Edward VIII Hospital: 9 were Blacks and 5 Indians; 8 of the patients were women. The mean age of the patients was 46 years. Surprisingly, only 2 patients complained of acral overgrowth. Symptomatology was varied and not characteristic of the condition. On examination all patients had unequivocal signs of soft-tissue and bony overgrowth, 64% had visual abnormalities and 50% hypertension. Radiologically, 88% showed an enlarged pituitary fossa. On biochemical investigation, the fasting levels of growth hormone (GH) were increased in 12 patients and during oral glucose tolerance tests, the GH levels in these 12 patients were not suppressed. One patient in whom the fasting GH level was not increased had progressed to the stage of panhypopituitarism, in the remaining patient challenge with thyrotrophin-releasing hormone (TRH) led to increased GH levels and L-dopa challenge resulted in a paradoxical decrease in GH levels. Seven patients with increased GH levels who were challenged with L-dopa showed the typical decrease in GH levels found in this condition; in 5 of these patients, challenged with TRH, GH levels increased. The findings emphasize that despite the ease of clinical diagnosis, appropriate biochemical investigations are necessary to confirm the exact status of the disease, which is rare in the population studied.