Anticardiolipin antibodies in South African patients with lupus nephritis: a clinical and renal pathological study.

AIMS: This study was conducted prospectively to ascertain the prevalence of anticardiolipin antibodies (ACAs) in patients with lupus nephritis and to determine whether this subgroup of patients differed clinically and histologically from patients without the antibody. PATIENTS AND METHODS: 40 SLE patients (26 Blacks, 14 Indians, 37 females, 3 males) with evidence of renal involvement underwent clinical assessment and percutaneous renal biopsy. Special investigations included: urinary protein quantitation; radioisotope glomerular filtration rate (GFR); complement levels, and antinuclear antibodies and ACAs. Histology was reviewed by a single senior pathologist blinded to the ACA results. In addition to the standard WHO classification, specimens were examined for intrarenal thrombosis. RESULTS: The prevalence of ACA was 45% (18 of 40 patients). Thrombocytopenia was more frequent in patients with ACA (33 vs. 13.6%, p = 0.015). Patients with ACA did not differ from controls with regard to the incidence of thrombosis, neurological disorders, recurrent fetal loss, active disease and hypertension. Mean GFR and 24-hour urine protein (ACA vs. controls) were 51.3 versus 67 ml/min (NS) and 2.4 versus 3.7 g (NS), respectively. Intrarenal microvascular thrombosis (glomerular and arteriolar) occurred in 27.7% of ACA patients versus 9% of controls (p = 0.025). Apart from a higher incidence of class-III nephritis in the controls, standard histology (WHO classification) did not differ between the 2 groups. CONCLUSION: The prevalence of ACA in our patients with lupus nephritis was 45%. This subgroup did not differ from patients without the antibody apart from a higher incidence of thrombocytopenia and intrarenal microvascular thrombosis.

The significance of arterial hypertension at the onset of clinical lupus nephritis.

The prognostic importance of hypertension at the onset of clinical lupus nephritis is not well established. We studied retrospectively 44 patients with lupus nephritis in order to ascertain the prevalence of hypertension at presentation and to investigate a possible association between hypertension and renal functional impairment. A correlation was also sought between hypertension and histological class of lupus nephritis. Hypertension was graded as mild (diastolic 95-99 mmHg), moderate (100-114) or severe (> 115). Impaired renal function (creatinine > 120 mumol/l) was graded as mild (120-200 mumol/l), moderate (200-350 mumol/l), or severe (> 350 mumol/l). Histological class and the presence of hypertensive renal vascular lesions was recorded. The prevalence of hypertension was 38%. There were 17 hypertensives and 27 normotensives. The incidence of renal impairment was greater in the hypertensives, 47% vs 18.5% (p = 0.04). Mean serum creatinine was also higher higher in this group (p = 0.02). The presence of hypertensive renal vascular lesions identified a high-risk subgroup who had a higher incidence of renal functional impairment and worse renal function than the hypertensive group as a whole. Even at an early stage, hypertension and hypertensive renal vascular lesions correlated well with renal functional impairment. Aggressive treatment of hypertension is therefore essential in early lupus nephritis in order to prevent further deterioration of renal function as the disease evolves.

Leukocyte analysis of tubulointerstitial nephritis in primary membranoproliferative glomerulonephritis.

Cellular immune mechanisms may be involved in the pathogenesis of tubulointerstitial nephritis associated with several forms of primary glomerulonephritis. This study aims to characterize the mononuclear leukocytes infiltrating the interstitium in patients with primary membranoproliferative glomerulonephritis (MPGN) and correlates the degree and nature of the infiltrate with renal function. Cellular identification using monoclonal antibodies to leukocyte cell-surface antigens was conducted on renal biopsy specimens from 17 patients with type I primary MPGN (group 1) and 10 controls with various forms of nonproliferative glomerulonephritis (group 2). The majority (14) of the 17 patients in group 1 were black South Africans. Renal function was assessed at the time of renal biopsy. Patients with MPGN had a significant increase in the number of interstitial total leukocytes (LCA), T lymphocytes (T), and B lymphocytes (B) compared with controls. Although the interstitial monocyte (KP(1)) count was also increased in MPGN patients, the difference was not significant. Recorded numbers of cells per square millimeter in group 1 versus group 2 are as follows: LCA, 1306 +/- 1254 versus 138 +/- 91 (P<0.001); T, 638 +/- 547 versus 42 +/- 60 (P.0.01); B, 161 +/- 165 versus 57 +/- 50 (P=0.02); and KP(1), 125 +/- 153 versus 54 +/- 59 (P=0.17). As noted in previous studies, the T lymphocyte was the dominant cell, comprising 48.8% of the total count. However, the combined number of T lymphocytes, B lymphocytes, and monocytes accounted for only 70.6% of the total leukocytic interstitial count, implying that the majority of the remaining 29.4% of the cells were mononuclear leukocytes that did not express the antigens we stained for. There was a moderate correlation between the number of interstitial total leukocytes, and impairment of renal function as measured by both the serum creatinine (r = 0.43) and creatinine clearance (r = -0.41). This correlation also existed for the individual cells comprising the infiltrate and was strongest for T lymphocytes (r = 0.63) followed by monocytes (r =0.46) and B lymphocytes (r = 0.41). In conclusion, we have demonstrated a significant mononuclear leukocytic interstitial infiltrate in our patients with type I MPGN and a correlation between all cells of this infiltrate with impaired renal function. This correlation was strongest for the most frequently observed cell, the T lymphocyte.

Acute renal failure in pregnancy in South Africa.

This study compares our experiences of the incidence and etiology of acute renal failure in pregnancy (ARF-P) in patients requiring hemodialysis, a decade after a previous publication from our institution. A retrospective analysis of the hospital records of 42 patients with a diagnosis of ARF-P during a 3-year period from 1990 to 1992 was undertaken [16% of the total number of acute renal failure (ARF) patients needing hemodialysis]. The incidence of ARF-P (expressed relative to all cases of acute renal failure requiring hemodialysis) decreased from 24.6% (1978) to 16% (1992: p = 0.03). Preeclampsia-eclampsia (PE:E) replaced septic abortion as the principal cause of ARF-P. In those patients with PE:E, thrombocytopenia (platelet count < 150 x 10(9)/L) occurred in all, while 33% developed the HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). Ingestion of herbal toxins was noted mostly in patients with septic abortion. Maternal mortality was 5% and was due to multiorgan failure complicating septic abortion. The perinatal mortality of 55% occurred in women with early gestation, thrombocytopenia, and high serum creatinine levels. Acute renal failure in pregnancy continues to present a challenge in South Africa, a developing country. There were significantly more obstetric than gynecological causes in 1992 (p = 0.0003). This could be attributed to the steady decline in septic abortion since 1978. The main contributor to obstetric-related causes was PE:E. Greater emphasis should therefore be placed on detecting hypertension at antenatal visits.(ABSTRACT TRUNCATED AT 250 WORDS)

Avascular necrosis of bone following renal transplantation.

This study was undertaken to determine the incidence and clinical features of avascular necrosis of bone in 69 transplant recipients all of whom had a functioning allograft for at least 12 months. An attempt was also made to identify any potential predisposing factors. The patients were assessed by an orthopaedic surgeon. The diagnosis of avascular necrosis was made on the basis of radiographs and isotope bone scans. Fourteen patients (20.2%) developed avascular necrosis with a mean onset of 19 months post-transplantation. The hip joint was most commonly affected. The isotope bone scan was the most sensitive diagnostic tool; abnormalities were detected before the onset of symptoms in 4 patients. Avascular necrosis was more common in Indian transplant recipients and was also associated with: (i) cadaver transplants; (ii) more frequent bouts of acute rejection (P < 0.05); and (iii) a greater incidence of other steroid-associated side-effects (P < 0.05). Alcohol consumption and radiological evidence of osteoporosis were more prevalent in the avascular necrosis group (42.8% v. 29.0% and 28.5% v. 7.2% respectively). Avascular necrosis did not correlate with age, sex, renal function at 1 year or severe secondary hyperparathyroidism. This study suggests that corticosteroid therapy plays an important role in the pathogenesis of avascular necrosis. Excessive alcohol consumption and osteoporosis also appear to be risk factors.

Circulating auto-antibodies to neutrophil cytoplasmic antigens in vasculitis. A report of 3 cases.

Three patients are described who presented with symptoms and signs of a vasculitic illness but in whom a definite diagnosis was not made until the application of a test to detect auto-antibodies to neutrophil cytoplasmic antigens. There has long been a need for a diagnostic marker for the groups of diseases which fall into the broad classification of systemic vasculitides. Diagnosis of the patients as having either Wegener's granulomatosis or microscopic polyarteritis by the finding of this auto-antibody enabled a positive approach to treatment with combinations of immunosuppressive agents. In addition, serial measurement of the auto-antibody titres enabled monitoring of disease activity.

Profile of crescentic glomerulonephritis in Natal--a clinicopathological assessment.

Crescentic glomerulonephritis is invariably associated with a fulminant syndrome of rapidly progressive renal failure which generally progresses to end-stage renal failure within weeks or months of onset. A widely differing aetiological background has been reported from Western countries. Work from the African continent is sparse. In a study from the province of Natal in South Africa between 1981 and 1987, 27 cases of crescentic nephritis were identified from a total of 458 patients who underwent renal biopsy at King Edward VIII and Addington hospitals. Poststreptococcal nephritis was the commonest aetiological factor (n = 8). There were six black patients in this group. Nine patients were classified as idiopathic and of these five were black. Four patients (one black) had antiglomerular basement membrane disease. Of the 24 patients subjected to variable combinations of immunosuppression, antiplatelet agents, dialysis and plasmapheresis, 11 improved, observed over four months to four years. Oliguria and severe renal failure at presentation signified a poor prognosis.

IgA nephropathy in blacks and Indians of Natal.

IgA nephropathy besides exhibiting a characteristic geographical distribution has been noted to have a low incidence in the blacks of the USA. There is a paucity of data on IgA nephropathy in the blacks of Africa. We report our findings among the blacks and compare these with Indians. An analysis of the primary glomerular diseases of 252 blacks and 75 Indians over 6 years (1981-1986) was done. Mesangiocapillary glomerulonephritis was the commonest type in the black (35.7%), whereas mesangial proliferative glomerulonephritis was the commonest in Indians (26.7%). IgA nephropathy occurred in 2 blacks (1 male, 1 female), whereas there were 10 Indians (8 males, 2 females). Available data among whites in Natal show that IgA nephropathy is not uncommon. HLA studies done in blacks with IgA nephropathy did not reveal the HLAB35 or the DR4 antigen. HLAB35 in our blacks is less common compared to Indians and whites of Durban. Thus, although glomerulonephritis is common in blacks, IgA nephropathy is rare. This suggests that infection which is common in our black population may not be responsible for the aetiology of IgA nephropathy. A dietary factor in the form of a high-fibre diet may protect the black population from IgA nephropathy. However, a genetic factor cannot be excluded.

Myocardial infarction after probable black mamba envenomation. A case report.

A probable direct toxic effect of elapid venom on the myocardium as evidenced by transient ECG changes and transiently elevated cardiac enzyme levels is described. The patient made good recovery with no residual cardiac damage.

Comparison of haemoglobin levels and blood-transfusion requirements in patients on haemodialysis and on chronic ambulatory peritoneal dialysis.

Comparison of haemoglobin (Hb) and haematocrit (HCT) levels and blood-transfusion requirements in two groups of patients with end-stage renal disease, one on haemodialysis and the other on continuous ambulatory peritoneal dialysis (CAPD), revealed that patients on CAPD had significantly higher Hb and HCT levels than their counterparts on haemodialysis. Blood-transfusion requirements were significantly lower in the CAPD group. There was no correlation between Hb levels and serum creatinine or albumin levels. Two anephric patients on haemodialysis had relatively high transfusion requirements, and this may have had an influence on the results. An analysis of 10 individual patients who were transferred from haemodialysis to CAPD revealed that half of them experienced a significant increase in Hb and HCT levels after having been on CAPD for 12 months. The Hb/HCT response of individual patients was extremely variable, and did not correlate with the number of blood transfusions. There was no significant change in transfusion requirements during the period on CAPD.