Treatment of renal failure in idiopathic membranous nephropathy with azathioprine and prednisolone.

BACKGROUND: Progressive deterioration in renal function occurs in 20-50% of patients with idiopathic membranous nephropathy (IMN). Several treatment regimens have been used to reverse this with varying effect and toxicity. METHODS: Thirteen patients (10 males, 3 females, median age 56 years) with IMN and progressive renal failure were treated with oral prednisolone 20-60 mg/day and azathioprine 1.3-2.7 mg/kgBW/day. All patients were followed up for a minimum of 2 years with a median follow-up of 73 months (range 24-103 months). RESULTS: Ten patients responded to treatment with a fall in serum creatinine and renal function stabilized in the remainder. Two patients relapsed, one of whom responded to an increase in immunosuppression, the other is now on dialysis. Proteinuria has significantly reduced in 10 patients, and only four patients still have nephrotic-range proteinuria. Mean (+/- SE) peak pretreatment serum creatinine of 229 (+/- 161) mumol/l and urinary protein of 11.8 (+/- 1.8) g/24 have fallen to 163 (+/- 65) mumol/l and 3.25 (+/- 1.0) g/24 h after 12 months treatment (P < 0.005, Wilcoxon matched pairs test). Immunosuppressive treatment has been successfully withdrawn in four patients after intervals ranging from 12 to 60 months. Adverse effects, which occurred in 10 patients, have been mild and have not led to treatment withdrawal though dose reductions have been necessary in some patients. CONCLUSIONS: Oral prednisolone and low-dose azathioprine is an effective therapy for progressing renal failure due to IMN, and induces remission of nephrotic syndrome. Side-effects are less than other immunosuppressive regimens.

Isokinetic strength following knee arthroscopy.

This study objectively evaluates recovery of quadriceps and hamstring strength following knee arthroscopy in a group of 43 patients given rehabilitation instructions, but limited supervised rehabilitation. Although the patients did not complain of weakness or functional limitation, isokinetic testing 1, 3, and 8 weeks following surgery revealed persistent weakness in many patients. Incomplete recovery was most apparent when patients were categorized by the degree to which they had recovered normal strength. Results expressed as a mean for the entire group indicated reasonably good recovery and obscured the significant weakness persisting in some patients. Knee extension strength tested at 60 degrees/sec had returned to normal 8 weeks after arthroscopy in only 32% of the subjects. Hamstring strength recovery was better, with 71% having normal strength. Patients may not recognize or report muscular weakness following arthroscopy, yet following 8 weeks of self-supervised rehabilitation many will have objective evidence of persistent weakness. In asymptomatic patients the clinical significance of this weakness is unknown.

Increased renal allograft thrombosis in CAPD patients.

In a retrospective analysis of 202 renal transplant procedures in the years 1989-1992 we identified an excess of grafts lost from primary renovascular thrombosis in patients receiving continuous ambulatory peritoneal dialysis (CAPD) compared to haemodialysis (HD) patients (9 CAPD versus 0 HD, Chi-squared = 9.63; P < 0.01). All graft losses from thrombosis occurred within 16 days of surgery. Possible predisposing causes were identified in three patients. Donor age was greater in CAPD patients losing their kidneys from thrombosis compared to the overall CAPD group [mean (SD) years, 43.0(12.9) versus 29.1(15.8); P = 0.01] whereas no significant difference in haematocrit, platelet count, antibody status, cyclosporin use, peroperative hypotension, primary diagnosis, smoking, or diabetes mellitus was found. Data from the EDTA registry for 1990-91 show that graft loss from primary renovascular thrombosis in UK-treated patients was reported in 7.1% of CAPD recipients compared with 1.8% in haemodialysis. We suggest that CAPD patients are at greater risk of graft loss from renovascular thrombosis than HD patients and may require more intensive fluid and anticoagulant treatment in the perioperative period.

An evaluation of pre- and postoperative nonsteroidal antiinflammatory drugs in patients undergoing knee arthroscopy. A prospective, randomized, double-blinded study.

The potential benefits of a nonsteroidal antiinflammatory drug to 67 patients undergoing knee arthroscopy were evaluated in a prospective, randomized, placebo-controlled, double-blinded study. Group A received the drug (diclofenac, 75 mg twice daily) for 3 to 5 days before and for 7 days after surgery. Group B received a placebo preoperatively and the drug postoperatively. Group C received a placebo at both times. Codeine was available postoperatively for all patients if needed. Outcomes reported by the subjects included pain, crutch use, and return to activities. Outcomes assessed by physicians included knee effusion, range of motion, and gait. Knee flexion and extension strengths were measured isokinetically pre- and postoperatively. Pain scores on the 1st postoperative day were higher in Group C than in Group A. Pain scores at all other time points were not significantly different in the three treatment groups. Groups A and B required less codeine during the first 72 hours after surgery than Group C (mean, 2.9 +/- 1.0 versus 6.8 +/- 1.0 pills). Recovery of function, recovery of strength, and physical examination parameters were not significantly different in the three treatment groups. Diclofenac was an effective analgesic in the immediate postoperative period. Recovery from arthroscopy, however, was not enhanced by taking the drug.

Ulnar Collateral Ligament Injuries of the Thumb.

In brief Many sports, most commonly brief football and skiing, can result in injury to the ulnar collateral ligament of the thumb or its attachment sites. Abduction stress testing and radiographs can determine injury severity. Conservative measures can be used to treat incomplete ligament injuries and nondisplaced fractures; however, surgery is generally needed to repair complete ligament tears and displaced fractures. After adequate immobilization and physical therapy, patients can return to play if the ligament is protected with splinting or taping.

Renal replacement treatment for diabetic nephropathy in Northern Ireland 1979-1987.

Twenty-three patients with end-stage renal failure due to diabetic nephropathy received renal replacement treatment. All patients had insulin-dependent diabetes mellitus. Nineteen transplants were performed in seventeen patients. Two-year graft survival for all transplants was 74% with a two-year patient survival post-transplantation of 81%. Overall two-year patient survival was 73%, compared with 82% in non-diabetic patients receiving renal replacement treatment. In diabetic patients accepted for treatment there was a high incidence of non-renal complications, particularly vascular disease. An aggressive approach to the treatment of vascular disease in these patients may improve overall survival rates.

University of Virginia prospective study of football-induced minor head injury: status report.

We have recently completed the field work phase of a 4-year prospective study of football-induced minor head injuries. Players from 10 University football teams were monitored up to 4 years, and a brief neuropsychological and psychosocial assessment battery was administered to them up to five times before and after injury. Objectives of this project focus on the frequency of head injuries in college football, the impairments that might result from such injury, the duration of impairments, the time course of their recovery, and the possibility of cumulative effects of multiple injuries during the player's college career. Approximately 2500 players were monitored during the study, and nearly 200 players were restudied following minor head injuries. A series of nearly 60 players with orthopedic injuries were tested using the same protocol, and a college student control series of 50 patients were similarly studied. Data analyses are currently underway, and the first report of the findings of this study will be available soon. This article has described the objectives and design of this study, outlined the neuropsychological and psychosocial assessment protocol, and discussed some of the issues related to project implementation. Current data analyses focus on the size of the effects of minor head injury on cognitive and psychosocial performance observed following minor head injury. Upon completion of the initial data analyses, our analysis plan includes having at least two neuropsychologists make independent assessments of the clinical significance of the findings. Similar assessments will be made of the neurophysical symptoms and complaints and psychosocial performance of players after injury.

Plasma prednisolone concentrations and kinetics in renal transplant patients.

Plasma prednisolone concentrations were measured in 26 renal transplant (RT) patients and five control subjects. A linear relationship was found between prednisolone dosage in mg/kg and area under the plasma concentration time curve in seven stable RT patients (r = 0.98) and in all subjects (n = 19) with estimated prednisolone clearance rates (CLp) between 0.075 and 0.11 L/kg/hr (r = 0.96). The greatest deviation from this occurred in five patients having reduced CLp with prolonged prednisolone half life (t1/2p) and in one having increased CLp while taking phenytoin. Three of the five with reduced clearance had steroid induced diabetes and one a Cushingoid appearance. There was some correlation between peak plasma prednisolone and dosage (r = 0.77) in all subjects, but none between creatinine clearance and t1/2p or CLp.

Epidural Hematoma in Lacrosse.

In brief: Several hours after being hit by a lacrosse stick in the left temporoparietal area slightly anterior to the ear, a lacrosse player was found unresponsive and wrapped in a blanket in his dormitory room. He had not lost consciousness during the game, sat out only five minutes, and completed the game. His Glasgow Coma Scale score was 12 of a possible 15. A CT scan showed an epidural hematoma and a skull fracture. He underwent an immediate left temporoparietal craniotomy and evacuation of the epidural hematoma. He recovered fully and requested permission to return to play six months after the injury. The authors think that an improved lacrosse helmet design would help prevent this type of injury.

Intercollegiate Lacrosse Injuries.

In brief:Injury data for an intercollegiate lacrosse team were collected after one season of practices and games and compared with injury data from a summer league team. Only five players (15%) completed the season without injury, and there were 78 total injuries to the 34 players. The most frequent injury was ankle sprain. The experience, skills, and age of collegiate athletes are more homogeneous and they often have superior equipment and playing surfaces, which suggests that they should have fewer injuries. However, the authors believe that the competitiveness of collegiate lacrosse results in higher frequency of injury.

Syncope, Bradycardia, and Hypotension After a Lacrosse Shot to the Neck.

In brief: A lacrosse goalie was hit in the right neck lateral to the cricoid cartilage. He fainted, but responded to conservative measures of supine rest, elevated legs, and close observation. He now wears a neck protector similar to those worn by baseball catchers. This case report emphasizes that someone who is trained in basic life support and understands cardiovascular physiology should attend practices and games.