Important causes of chronic kidney disease in South Africa.

In hypertensive patients without chronic kidney disease (CKD) the goal is to keep blood pressure (BP) at ≤140/90 mmHg. When CKD ispresent, especially where there is proteinuria of ≥0.5 g/day, the goal is a BP of ≤130/80 mmHg. Lifestyle measures are mandatory, especiallylimitation of salt intake, ingestion of adequate quantities of potassium, and weight control. Patients with stages 4 - 5 CKD must be carefullymonitored for hyperkalaemia and deteriorating kidney function if angiotensin-converting enzyme (ACE) inhibitors or angiotensin IIreceptor blockers (ARBs) are used, especially in patients >60 years of age with diabetes or atherosclerosis. BP should be regularly monitoredand, where possible, home BP-measuring devices are recommended for optimal control.Guidelines on the use of antidiabetic agents in CKD are presented, with the warning that metformin is contraindicated in patients withstages 4 - 5 CKD.There is a wide clinical spectrum of renal disease in the course of HIV infection, including acute kidney injury, electrolyte and acid-basedisturbances, HIV-associated glomerular disease, acute-on-chronic renal disease and side-effects related to the treatment of HIV.

Important complications of chronic kidney disease.

The complications of chronic kidney disease (CKD) are dyslipidaemia, hyperkalaemia, metabolic acidosis, anaemia, and bone and mineraldisorders. Dyslipidaemia may be treated with low-density lipoprotein-lowering agents. Statins are ineffective in stages 4 and 5 CKD, but areindicated for preventing the progression of disease in the earlier stages. Chronic acidosis has recently been shown to be a risk factor in theprogression of CKD renal dysfunction. Therefore, treatment is mandatory. Practically, this should consist of 1 - 2 heaped teaspoons of sodiumbicarbonate 2 - 3 times per day, which is an inexpensive and safe therapy that does not raise the blood pressure in spite of the increased sodiumlevel. Target levels of haemoglobin, according to international guidelines, are between 10 g/dL and 12 g/dL. The serum phosphate level is raisedin stage 4 CKD, and especially in stage 5 CKD, which is associated with coronary carotid and other vascular calcifications and may result inischaemic heart disease, myocardial infarction and stroke. A raised parathyroid hormone level (secondary hyperparathyroidism) is also a majorrisk factor for cardiovascular disease and is associated with increased hypertension and resistance to the treatment of CKD-associated anaemia.

Mononuclear and polymorphonuclear leucocyte dysfunction in male homosexuals with the acquired immunodeficiency syndrome (AIDS).

In addition to the well-documented abnormalities of cell-mediated immunity we have observed that both polymorphonuclear leucocytes (PMNLs) and mononuclear leucocytes (MNLs) from 3 patients with the acquired immunodeficiency syndrome (AIDS) showed markedly defective migratory responsiveness to leuko-attractants in vitro. Reduced PMNL and MNL chemotaxis is attributable, at least in part, to a serum inhibitor of leucocyte migration, since co-incubation of PMNLs from healthy control subjects with 10% AIDS serum inhibited the migration to leuko-attractants of these cells. This serum-inhibitory effect on leucocyte migration was not due to the presence in AIDS serum of increased levels of prostaglandin E2, cytomegalo-virus or anti-leukocyte antibodies. However, elevated serum immunoglobulin A (IgA) levels were observed in all 3 patients. IgA is a potent inhibitor of PMNL and MNL migration. It is possible that serum inhibitors of leucocyte migration perpetuate the profound immunosuppression characteristic of AIDS.