Anaphylactoid reactions to paracetamol.

The toxic effects of paracetamol in overdose quantities are well recognised but the occurrence of anaphylactoid reactions to paracetamol is infrequently identified by consumers and health care professionals. Nevertheless adverse reactions to this drug, even in therapeutic doses, can have fatal or near fatal consequences. A case of an anaphylactoid reaction to paracetamol is described.

Nephrotic syndrome in a patient with IgA deficiency-associated mesangioproliferative glomerulonephritis.

A case of mesangioproliferative glomerulonephritis in a 55-year-old woman with selective IgA deficiency and serum antinuclear antibodies who presented with nephrotic syndrome is described. The patient did not have clinical or laboratory features of systemic lupus erythematosus (SLE) other than antinuclear antibodies. Histology of the patient's renal biopsy revealed a mesangioproliferative glomerulonephritis and direct immunofluorescence showed that paramesangial deposits contained predominant IgM with lesser IgG, C3 and C1q. These findings are identical to those previously described in a form of glomerulonephritis associated with IgA deficiency and would be atypical for lupus nephritis. Glomerulonephritis is not a well recognized complication of IgA deficiency, though it has been rarely reported in the literature. This case provides further evidence that IgA deficiency is associated with a unique immune complex-mediated glomerulopathy with characteristic immunopathological and ultrastructural features. It is the first reported case to present with nephrotic syndrome.

Primary varicella in adult renal transplant recipients: a report of three cases plus a review of the literature.

Disseminated primary varicella zoster infection in renal transplant patients can result in severe and often fatal illness. The disease tends to be much more severe in adults with an 80% mortality in the only reported series (1). We report 3 cases of severe disseminated varicella zoster in adult renal transplant patients who all survived. Early diagnosis, institution of intravenous acyclovir 10 mg/kg tds, zoster immunoglobulin, cessation of azathioprine treatment and aggressive supportive care may improve an otherwise bleak prognosis.

Herpes simplex virus interstitial nephritis in a renal allograft.

We report a 35-year-old woman who developed herpes simplex virus (HSV) type 1 interstitial nephritis following a cadaveric renal transplant. Transplant function was poor and a transplant nephrectomy was performed 23 days post-transplant. Histological changes characteristic of herpes virus infection were seen on the renal biopsy with positive immunoperoxidase staining for HSV. HSV 1 was cultured from the transplant nephrectomy specimen.

Peliosis hepatis in a renal transplant recipient and in a haemodialysis patient.

Peliosis hepatis is described in a renal transplant recipient and in a patient who was receiving long-term haemodialysis. This uncommon liver lesion has been reported in a number of patients, including 18 renal transplant recipients and two patients with chronic renal failure. However, its cause, clinical features, natural history and clinical significance remain to be determined. We emphasize that, although it is rare, peliosis hepatis should be considered in long-term haemodialysis and renal transplant patients who exhibit hepatomegaly and/or splenomegaly and/or disordered liver function (in particular, elevation of hepatic alkaline phosphatase levels).

Parathyroidectomy in chronic renal failure.

Between 1978 and 1984, 19 patients at Royal Perth Hospital (RPH) underwent parathyroidectomy for secondary (renal) hyperparathyroidism. This represented 6.0% of the overall dialysis population treated at RPH during this period of time. The mean duration of pre-operative dialysis for these 19 patients was 48 months, compared with a mean duration of 30 months for the overall dialysis population. The principal indications for parathyroidectomy were symptomatic hyperparathyroid bone disease (10), hypercalcaemia (six), progressive lower limb ischaemia (two) and painful peri-articular calcification (one). The complications of chronic renal failure that were most consistently improved by parathyroidectomy were the clinical, radiological and biochemical manifestations of hyperparathyroid bone disease and hypercalcaemia. Features such as pruritus, soft tissue calcification, vessel wall calcification and peripheral ischaemia responded less predictably. Hyperparathyroid bone disease and hypercalcaemia remain the principal indications for parathyroidectomy in chronic renal failure. Profound postoperative hypocalcaemia was the major early postoperative management problem (seven patients) and was closely linked with the severity of pre-operative hyperparathyroid bone disease. It was also seen more frequently in those patients undergoing total parathyroidectomy with immediate autotransplantation of parathyroid tissue (TP-A), than in those in whom residual parathyroid tissue was left in situ (subtotal parathyroidectomy or STP). Recurrent hyperparathyroidism (four patients) was the major late postoperative complication, but was more frequently the result of a supernumerary or previously overlooked fourth parathyroid gland (three), than due to hyperplasia of residual parathyroid tissue (one). STP and TP-A were equally effective in controlling or reversing renal hyperparathyroidism, but the former was associated with a lower incidence of postoperative management problems and should be the preferred operation in this group of patients.

Renal failure and upper urinary tract obstruction after retrograde pyelography with potassium bromide solution.

Two iodine-sensitive women in whom potassium bromide solution was used as a radiocontrast agent for retrograde pyelography developed similar clinical conditions culminating in renal failure. Renal failure was due to upper urinary tract obstruction from fibrosis and fat necrosis in each case. Similar histological findings have been described in rabbit bladder exposed to sodium bromide solution. Different patterns of exposure corresponded with different sites of major damage in the two cases. One patient, who had repeated studies of the pelvicalyceal system with potassium bromide developed papillary necrosis. Systemic exposure to bromide-releasing compounds (in animals) and to bromides (in humans) has also been associated with papillary necrosis.

Acute haemorrhagic cystitis caused by adenovirus type 11 in a recipient of a transplanted kidney.

A case of haemorrhagic cystitis caused by adenovirus type 11, which occurred in a female patient 13 weeks after renal transplantation is described. The patient lacked neutralising antibody to adenovirus type 11 before transplantation, but this antibody was present in the serum of the kidney donor. The patient developed antibody to adenovirus type 11, and this virus was isolated from her throat and urine. The data suggest that the infection was transmitted by the kidney graft.

Renal transplantation. 12-Year experience.

The results of cadaveric renal transplantation in one centre over 12 years are reviewed. One hundred and sixty-eight grafts have been performed in 147 recipients. At one year after transplantation, patient survival rate was 86%, and graft survival rate was 63%. Analysis of factors influencing graft survival show that the age of recipients, the lack of blood transfusions, and the use of poorly matched grafts (three to four HLA mismatches against 0 to two mismatches), all had adverse effect on survival. Death was a significant cause of graft loss in patients over the age of 45 years. Patients who had not received blood transfusions, and who received grafts which were mismatched for three to four HLA antigens, did especially badly, graft survival rate at six months being only 24% compared with that of 70% in patients who received blood transfusions.

Ureteric stricture associated with analgesic nephropathy.

A case of localized ureteric stricture in a woman with analgesic nephropathy is reported. The problems of diagnosis and management are briefly discussed.

Effect of exogenous and endogenous angiotensin II in the isolated perfused rat kidney.

Rat kidneys were perfused with an artificial solution at constant pressure. The infusion of angiotensin II (AII) (1.5--6 ng min-1) reduced renal perfusate flow (RPF) from 36.6 +/- 2.4 to 19.3 +/- 1.4 ml min-1 (P less than 0.001) (n = 13); GFR rose from 0.48 +/- 0.06 to 0.63 +/- 0.04 ml min-1 (P less than 0.05), and filtration fraction (FF) rose accordingly from 0.015 +/- 0.002 to 0.033 +/- 0.003 (P greater than 0.01). The same results were obtained with purified renin substrate (synthetic tetradecapeptide, 100 ng min-1, n = 8); RPF fell from 31.5 +/- 2.9 to 17.2 +/- 2 ml min-1 (P less than 0.001), GFR rose from 0.36 +/- 0.05 to 0.51 +/- 0.04 ml min-1 (P less than 0.05), and FF increased from 0.021 +/- 0.002 to 0.034 +/- 0.006 (P less than 0.01). The effects of renin substrate were completely prevented by the converting enzyme inhibitor SQ 20,881 (3 X 10(-5) M). In another six experiments the effects of renin substrate at the same dose were fully reversed by addition of the analogue [Sar1,Ala8]AII. We interpret these findings to indicate that both exogenous and endogenous AII produce preferential vasoconstriction of the efferent arteriole, increasing the driving force for ultrafiltration and thereby maintaining or increasing GFR in the face of a reduced plasma flow.

The diagnosis and treatment of lymphocoeles associated with renal transplantation. A report of 6 cases and a review of the literature.

Six patients have developed a lymphocoele after renal transplantation, an incidence of 4%. A lymphocoele should be suspected in a patient who develops a rising creatinine with a pelvic mass or pressure effects on the pelvic veins 1 or more months after operation. The diagnosis is confirmed by intravenous urography, venography and ultrasonography: the use of the latter as a diagnostic measure is recommended. Treatment is by marsupialisation into the peritoneum or external drainage with breakdown of all loculi. Aspiration is unsatisfactory.

Renal failure after snake bite.

Three cases of acute renal failure after snake bite are presented. All required dialysis and the recovery phase was prolonged in each case. Investigations show that microangiopathic haemolytic anaemia was associated with the acute renal failure.

The management of urinary fistulae following cadaveric renal transplantation.

Vesicoureteric, ureteric and calyceal fistulae in cadaver transplants may be successfully treated by early exploration and nephrostomy splintage with silastic tubing for a period of not less than 6 weeks.