The diabetic kidney in pregnancy

During normal pregnancy the functions of the kidneys increase; renal plasma flow (RPF) and glomerular filtration rate (GFR) increase by 30-50 percent . The upper limits of blood urea and plasma creatinine will fall to 2.8 mmol/l and 80 micromol/l respectively. Therefore what might be considered normal in non-pregnant females may actually represent significant renal impairment in the pregnant female. Urinary protein excretion also increases during pregnancy and values up to 250-300 mg per day may be normal. In the diabetic patient, with diabetes mellitus and no clinical evidence of renal involvement there is no evidence that pregnancy has any harmful effect on the kidneys. In cases of pregnancies complicated by diabetic nephropathy there is a significant increase in maternal blood pressure and proteinuria. The nephrotic syndrome will develop in the vast majority of patients. After birth, however, the levels of proteinuria will return to levels not significantly different from those prior to pregnancy. There is no significant decrease in creatinine clearance and there does not appear to be any worsening of diabetic nephropathy. The majority of the foetuses will be normal and about 15 percent will be small for gestational age; birthweight is best correlated with creatinine clearance. Although one-fifth of the infants will develop respiratory distress syndrome and one-quarter will have hyperbilirubinaemia, perinatal survival is over ninety percent. The incidence of pre-term delivery and hydramnios is increased. Macrosomia and major congenital defect are also increased. However, these complications can be reduced by very strict control of the blood glucose (AU)

Idiopathic foca and segmental glomerulosclerosis in Jamaica: a 10 year review

Idiopathic focal and segmental glomerulosclerosis (IFSGS) in a predominantly black population does not appear to behave any differently than in Caucasian patients. Response to steroid therapy and cyclophosphamide had favourable prognostic significance. There may be a subgroup of IFSGS which responds more slowly to steroids. The duration of steroid therapy should extend beyond four months (AU)

Idiopathic foca and segmental glomerulosclerosis in Jamaica: a 10 year review

Idiopathic focal and segmental glomerulosclerosis (IFSGS) in a predominantly black population does not appear to behave any differently than in Caucasian patients. Response to steroid therapy and cyclophosphamide had favourable prognostic significance. There may be a subgroup of IFSGS which responds more slowly to steroids. The duration of steroid therapy should extend beyond four months

Glomerulonephritis after human parvovirus infection in homozygous sickle-cell disease

Glomerulonephritis with proteinuria of sufficient degree to manifest the nephrotic syndrome followed aplastic crises induced by human parvovirus (B19) in seven patients with homozygous sickle-cell disease, within 7 days in five patients and 6-7 weeks in two. Segmental proliferative glomerulonephritis was found in all four patients who underwent acute renal biopsies and focal segmental glomerulosclerosis was found in the fifth patient who had a biopsy 4 months later. One patient recovered completely, one died in chronic renal failure after 3 months, and the others had impaired creatinine clearance, four with continuing proteinuria (AU)

Haemodialysis at University Hospital, Mona

Haemodialysis at University Hospital commenced in 1970. One hundred and twenty six patients have been accepted for regular dialysis. Hypertension and chronic glomerulonephritis accounted for 117 patients (93 percent) while 4 patients (3 percent) had polycystic kidneys and 5 patients (4 percent) had diabetes mellitus. Twenty-nine (23 percent) patients received a cadavericrenal transplant. There were eighty-five (68 percent) deaths. Twenty-five patients (30 percent) died in less than one year, twenty-two (25 percent) died between one and two years. Seventeen patients (20 percent) survived over five years before death, and three patients surviving over 10 years. There are twenty patients on regular hospital dialysis at present in the University Hospital, twelve patients have been on dialysis less than 3 years, three patients have been on 3-5 years, and five patients have been on for greater than 5 years and two patients greater than 10 years

Adult T-cell leukemia/lymphoma in a renal transplant recipient

A 42 year old man with chronic renal failure and homograft transplantation developed adult T-cell lymphoma in one native kidney. The role of transfusion in the acquisition of human T-lymphotropic virus type 1 and its role in the early development of adult T cell lymphoma, particularly on the background of chronic immunosuppression, are discussed. To our knowledge, this is the first such case. (AU)

Thyroid-Gonad relationship in systemic lupus erythematosus

Thirty women with systemic lupus erythematosus (SLE) were examined to assess the thyroid-gonad relationship. Significant decreases in mean serum tri-iodo-thyronine and testerone levels and increases in mean serum estradiol and luteinizing hormone levels were observed in SLE patients as compared to control subjects. The serum levels of thyroxine, thyrotropin, tri-iodo-thyronine uptake, free thyroxine index and prolactin were, however, not significantly different in both groups. The interpretation of these findings is unclear but SLE could be regarded as one of the nonthyroidal systematic illness since low serum tri-iodo-thyrotropin levels were observed in our patients. Furthermore, high levels of estradiol and low levels of testosterone in our female patients may indicate involvement of sex steroids in the pathogenesis of SLE. (AU)

Peritonitis in acute peritoneal dialysis at the University Hospital of the West Indies: a five-year review

The records of patients receiving acute peritoneal dialysis during the 1983 - 1987 were retrospectively evaluated. Of a total of 59 patients receiving dialysis, 10 developed peritonitis. Staphylococcus aureus was the single most frequently isolated organism. However, gram-negative bacilli as a group were more common. We recommend the use of cloxacillin orally and gentamicin intra-peritoneally as empiric antibiotic coverage until results of culture reports are available (AU)

Polyarteritis nodosa in Jamaicans

This report describes the main features of the 5 cases of polyarteritis nodosa seen at the University Hospital of the West Indies over a 10-year period. The disease manifestations are protein and only 2 of the 5 patients were diagnosed antemortem, indicating the need to increase physician awareness, especially since response to therapy has improved significantly in recent years. (AU)

Renal pathology in adults over 40 with sickle-cell disease

In a retrospective study of hospital necropsies, we examined the kidneys of 21 patients with homozygous sickle-cell disease who died at the age of 40 or over. Renal failure had caused or contributed to death in ten cases. All kidneys showed changes of papillary damage to a variable extent. In three cases, there was mild cortical irregularity, and in thirteen, there was moderate to severe cortical irregularity, including scarring in some with obvious loss of functioning tissue. Light microscopic examination revealed hypertrophic glomeruli with increased cellularity, lobulation and capillary basement membrane splitting. Glomeruloscelerosis was common, and patchy deposists of fabrin were present in glomerular capillaries in four cases. Though factors contributing to these changes could include papillary necrosis and immune-complex glomerulonephritis, we suggest that sclerosis consequent upon longstanding hyperfiltration may be more important. Glomerular filtration rate is abnormally high in children with sickle-cell disease but in later childhood renal insufficiency, proteinuria and eventually death from renal failure become common (AU)

Thyroid-gonad relationship in chronic renal failure

Thirty-four men of African origin suffering from chronic renal failure, (CRF) were studied to assess thyroid functions and their relationships to serum testosterone. Significantly lower mean values of T4, T3, testosterone, FT4I and FT3I were observed in CRF patients as compared to those in 23 healthy control subjects. Serum TSH, LH and TBG did not differ significantly whereas T3U and PRL were higher in CRF patients. Mean serum T4, T3U and FT4I values were further reduced in haemodialysed than in nonhaemodialysed patients. Significant positive coefficients of correlation between thyroid hormones and testosterone were observed in CRF patients. Simultaneous decreases in both serum and testosterone in the presence of normal serum TSH, LH and TBG levels suggest dysfunction of the pituitary-thyroid-gonad axis (AU)

Membranous glomerulonephropathy with crescents in systemic lupus erythematosus

Over a 2-year period percutaneous renal biopsies were carried out on 23 patients with systematic lupus nephritis. When classified by immunofluorescence, and light and electron microscopy, 4 patients had mesangial disease, 1 had focal and segmental proliferation, 5 had diffuse proliferation and 5 had membranous changes. 3 biopsies were unclassified with end-stage changes and 5 showed an unusual combination of pure membranous changes in association with significant crescent formation. The outcome of the latter group of patients was uniformly poor. We think that this group represents a distinct histological entity with a poor prognosis (AU)

Long-term plasma exchange in patients with systemic lupus erythematosus and diffuse proliferative glomerulonephritis

Thirty-nine patients with systemic lupus erythematosus and diffuse proliferative nephritis were enrolled in a randomized controlled trial of long term plasma exchange therapy. All patients received conventional therapy, and in addition, 20 were exchanged with albumin or plasma. The 20 exchange patients did not show a better preservation in renal function. However, a significant difference in renal function was observed in the 16 exchange patients who were replaced with albumin. This finding was underscored by two-way analysis of variance and convariance, which revealed that background variables favored a better prognosis for the nonexchanged patients.(AU)

Clinico-pathological study on the nephrotic syndrome in Jamaican children

A review of eleven years of hospital admission for childhood nephrotic syndrome is presented. Forty-two children were studied between January 1971 and December 1981. There were no significant sex differences, but 28 of the 42 children (67 percent) were 6 years of age or less, with a peak age incidence in the 2-3 years group. Children aged 6 years or under were significantly associated with responsiveness to corticosteroids, while more none-responders were over 6 years of age (P<0.0001). Seventy-five per cent of those treated with a 2-month course of corticosteroids responded within one month of treatment. Five children had a spontaneous remission of symptoms, at least 3 of whom may have had a resolving post-streptococcal glomerulonephritis (PSGN). Selective renal biopsies were performed in 24/42 (57 percent). Of these 24, minimal change disease (MCD) was present in 6, mesangial proliferative glomerulonephritis (MPGN) in 6, focal glomerulosclerosis (FGS) in 4, diffuse proliferative glomerulonephritis (DPGN) in 3 and one each of focal proliferation, membranous glomerulopathy and mesangio-capillary glomerulonephritis MCGN). As expected, biopsied children had more relapses and were more often treated with cytotoxic drugs (AU)

Conn's syndrome: case report and a review of the syndrome of primary aldosteronism (SOPA)

This report describes the investigation and treatment of a 30-year-old woman with Conn's Syndrome caused by an aldosterone-producing right adrenocortical adenoma associated with the classic triad of hypertension, hypokalaemia, and metabolic alkalosis. Removal of the tumour resulted in the reversal of these abnormalities. To the best of our knowledge, this is the first case of Conn's Syndrome in the West Indies. It is hoped that, with the presently improved diagnostic facilities in the region, this report will stimulate interest in finding other cases of this rare but important and treatable cause of secondary hypertension (AU)

Lupus nephritis in Jamaica (1973-1983) - abstract

The case records of seventy-five patients who had systemic lupus erythematosus (SLE) and renal involvement confirmed histologically were reviewed. There were 70 women and 5 men and the majority of patients were in their second and third decades of life. Lupus nephritis was distinctly uncommon in patients below 10 years of age and above 50 years of age. Over 80 percent of the patients developed renal involvement within one year of diagnosis of SLE. The commonest presenting features were arthritis (78 percent) and rash (48 percent). The least common presenting renal features were proteinuria and renal failure - 60 percent and 55 percent respectively. When classified according to the WHO classification, 20 percent had Class II, 12 percent had Class III, 48 percent had Class IV, and 17 percent had Class V disease. Three per cent had glomerular sclerosis and were thus unclassifiable. The acute nephritic syndrome was seen in 83 percent of Class IV cases, while renal failure was seen in 61 percent of Class IV cases. However, no patient had the acute nephritic syndrome in Class V, whereas the nephritic syndrome and renal failure were seen with the same frequency (62 percent) in Class V cases. The mortality was 6 percent for Class II, 22 percent for Class III, 22 percent for Class IV and 38 percent for Class V cases (AU)