Increased mortality due to cardiovascular disease in type 1 diabetic patients transplanted for end-stage renal failure.

The graft and patient survivals following renal transplantation in all Type 1 diabetic patients transplanted within the North-West of England between 1981 and 1990 at Manchester Royal Infirmary were studied. Fifty-two Type 1 (insulin-dependent) diabetic patients with end-stage renal failure due to diabetic nephropathy were transplanted during this period. They were compared to controls matched for age, sex, and year of transplantation and also to all 904 patients transplanted during the same period. Graft survival rates at 1 and 5 years in the diabetic patients were lower (80.8% and 62.1%, respectively), compared to controls (88.9% and 77.9%, respectively, p = 0.02) but were similar to those seen in all grafts (80.4% and 59.0%, respectively, p = NS). Actuarial patient survival rate at 5 years was lower in diabetic patients (76.3%) compared to the control group (94.2%, p = 0.003). Myocardial infarction was the main cause (60%) of death in diabetic patients. The results of this large recent series indicate that good graft and patient survival rates can be obtained in Type 1 diabetic patients, although they remain poorer than those of patients with non-diabetic renal disease. More rigorous pretransplantation cardiac assessment and treatment before acceptance of Type 1 diabetic patients for renal transplantation may help to improve patient survival.

Imipenem versus netilmicin and vancomycin in the treatment of CAPD peritonitis.

Imipenem/cilastatin is a new thienamycin antibiotic with a broad bactericidal spectrum. We undertook a prospective randomised study to compare the safety and efficacy of intraperitoneal (IP) imipenem/cilastatin (2 gm daily) [group A; 21 patients, mean age 49.2 years] with a combination of IP netilmicin and vancomycin (500 and 60-100 mg daily resp.) [group B; 20 patients, mean age 55.2 years] in CAPD peritonitis. Each patient underwent 4 daily CAPD exchanges with antibiotics in alternate exchanges. The causative organisms were similar in both the groups as was the duration of therapy (gr.A: 6.8 +/- 0.27 days; gr.B: 7.2 +/- 0.51 days; p = NS). Complete cure was marginally better with imipenem/cilastatin (gr.A; 94.1%, gr.B: 83.3%) with less relapses (gr.A: 1 episode; gr.B: 3 episodes). One episode in gr.A (S. aureus) and 2 in gr.B (Yeast & Proteus) failed to resolve and required catheter removal. Two gr. A patients developed generalised convulsions which settled after discontinuation of the drug. Whilst the results show no significant difference in the outcome in the two groups, the use of IP imipenem would offer a possible advantage as a single antibiotic. Larger experience is needed before imipenem can be recommended as a 'blind' first line agent for CAPD peritonitis.

Calcium, magnesium mass transfer and lactate balance study in CAPD patients with reduced calcium/magnesium and high lactate dialysis fluid.

We studied calcium (Ca), magnesium (Mg) mass transfer (MT) in 10 and lactate balance in 5 CAPD patients using standard dialysis solution [(ST) (Ca 1.75 mmol/l; Mg 0.75 mmol/l; lactate 35 mmol/l)] and with reduced Ca/Mg, high lactate solution [(LC) (1.25 mmol/l; 0.25 mmol/l; 40 mmol/l respectively)]. Exchanges were performed with 1.36% and 3.86% glucose solutions. MT was calculated as mmol/exchange. Ca MT was +0.96 and +0.39 with ST 1.36% and 3.86% glucose respectively. Serum ionised Ca (iCa++) levels were less than fluid Ca during these exchanges. With LC 1.36% glucose it was -0.66 when ICa++ was more than dialysate Ca, but +0.66 when iCa++ was less than dialysate Ca. Ca MT was negative with LC 3.86% glucose irrespective of iCa++ levels. All patients were hypermagnesaemic (mean 1.24 mmol/l. Mg MT was +0.21 and -0.04 with ST 1.36% and 3.86% glucose respectively and -0.62 and -1.13 with LC 1.36% and 3.86% glucose respectively. The difference between mean lactate gain and bicarbonate loss was less (-0.4) during exchange with LC 1.36% glucose. Mean plasma TCo2 and plasma pH did not differ between ST and LC solutions. We conclude that reduced Ca/Mg, high lactate solutions should reduce hypercalcaemia/magnesaemia and maintain a better acid base balance in CAPD patients who may require Ca/Mg containing phosphate binders.

Pattern of renal amyloidosis in western India. A study of 104 cases.

A total of 31,266 autopsies and 1556 renal biopsies were scrutinised over a period of 19 years (1968-1986) retrospectively and prospectively, with an aim to study the incidence and pattern of renal amyloidosis in western India. A total of 104 cases with amyloidosis were detected, 41 from the autopsy series (0.1%) and 63 from biopsies (4%). Secondary amyloidosis was seen in 83.7% and primary amyloidosis in 11.5%. The interval between the onset of predisposing disease and first evidence of amyloidosis varied from 2 months to 31 years. Tuberculosis of various organs was the main cause of secondary amyloidosis (72.4%). Nephrotic syndrome was a common mode of presentation (71.4%). Besides kidneys, which were involved in all cases, the liver, spleen and adrenals were other commonly involved organs at autopsy. Renal failure was the leading cause of death (34.1%).

Clinicopathological study of acute renal failure following viperine snake bite.

Fifty patients of acute renal failure following Viperine snake bite were studied. Oliguria (100%), local swelling (48%) and bleeding tendencies (42%) were the predominant clinical features encountered. Of the 25 patients in whom detailed coagulation studies were done, 24 patients had disseminated intravascular coagulation (DIC) and 1 had primary fibrinolysis. DIC was commoner with Russell's viper bite (62%) in comparison to Echis carinatus bites (40%). Renal histology obtained in 29 cases revealed tubular necrosis (35%), cortical necrosis (24%) tubular degeneration (17%) and glomerular changes (17%). Ballooning of glomerular capillaries (59%), splitting of glomerular basement membrane (40.7%), swelling of endothelial cells (29.6%), and focal proliferation of mesangial cells (17%) were the significant glomerular changes encountered. 20 (40%) patients succumbed, DIC (50%), irreversible shock (30%) and septicaemia (20%) being the immediate causes of death. Development of oliguria within 24 hours of snake bite and cortical necrosis were associated with higher mortality.

Acute renal failure due to viperine snake bite as seen in tropical western India.

A wide spectrum of clinicopathological changes have been described in 50 cases of ARF following viperine snake bite studied prospectively over a 15-year period. Disseminated intravascular coagulation (DIC) was seen in 24/50 cases (Russel's viper bite in 62% and Ecchis carinatus bite in 42% of subjects). Histological examination of renal tissue obtained 1.5 days to 8 weeks after the bite revealed proliferative glomerular changes in 17 cases. These were characterized by ballooning of the capillaries, thickening and splitting of glomerular basement membrane (GMB), fibrin thrombi in the capillaries, and mesangial cell proliferation most prominently seen in Ecchis carinatus bites resulting in ARF.