High mortality with systemic lupus erythematosus in hospitalized African blacks.

This survey was undertaken to determine the clinical spectrum and outcome of SLE in hospitalized African blacks in Durban, South Africa. We reviewed the hospital records of all patients with SLE who were seen during 1984 and 1990. Eighty-five patients were seen and their mean age at diagnosis was 33.3 years. The prevalence of the various diagnostic criteria was as follows: cutaneous, 68%; arthritis, 66%; renal, 65%; serositis, 29%; neuropsychiatric, 21%; haematological, 71%; immunological, 49%; anti-nuclear factor, 98%. Follow up data were not available in many patients but 25 (29%) are known to have died. The commonest causes of death were renal, infection, neurological and cardiac. This survey shows that SLE is being recognized more frequently in African Blacks and is associated with a high mortality.

Systemic lupus erythematosus and renal involvement. A South African experience.

Renal involvement in systemic lupus erythematosus (SLE) often signifies a poor prognosis. Whilst SLE appears to be not uncommon in the racial groups of South Africa, there are few reports in the literature. Between 1984 and 1987, 43 patients with SLE and nephritis were analyzed. Clinical and biochemical manifestations are described. The histological types (WHO classification) were mainly class II (15 cases) and class IV (17 cases). The ratio of black to Indian patients was 26.4% in class II and 43.4% in class IV to 42% each in class II and class IV respectively. Immunofluorescence showed a predominantly granular pattern of IgG, C1 and C3. Treatment was with combinations of prednisone and cyclophosphamide (14 cases), prednisone and azathioprine (21 cases) or pulse methylprednisolone (6 cases; total 41 cases). Two patients were not treated. There was no difference between cyclophosphamide and prednisone (14 cases) and prednisone with azathioprine (21 cases) treatment groups. The follow-up period was for 4 years. Mortality occurred in 15 patients (35%). The main cause of death was renal failure in 10 patients, infection in 1 patient and central nervous system involvement in 1 patient. The prognosis was worse in the Indian compared with the black patients. The WHO classification did not give an accurate prognosis regarding mortality in our study. Because of limited resources for the treatment of chronic renal failure in developing countries, we feel that patients with lupus nephritis should be treated with improved ancillary medical therapies and more effective immunosuppressive regimens.

Arterial thrombosis in nephrotic syndrome.

The nephrotic syndrome is characterized by profound changes in the turnover and concentration of most plasma proteins, including those involved in the coagulation pathways. Thromboembolic complications, especially venous, have been widely reported. Arterial thrombosis is a relatively rare complication and has been reported mainly in nephrotic children. In this report, an adult nephrotic patient who developed thromboses of his right middle cerebral and left femoral arteries is described. The patient died, and at postmortem no underlying arterial disease was found. Histology of the kidneys showed minimal change disease.

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.

A comparison of lisinopril and atenolol in black and Indian patients with mild-to-moderate essential hypertension.

The effects of lisinopril (MK-521; MSD) and atenolol in the treatment of mild-to-moderate essential hypertension were compared in a double-blind, parallel, controlled study, with 24 patients randomly assigned to lisinopril and 12 to atenolol. Patients in both groups whose blood pressure did not respond satisfactorily were given hydrochlorothiazide (HCTZ). The groups were matched for age, race and pretreatment blood pressure. Response to therapy was similar in the atenolol and lisinopril groups, but the combination of lisinopril and HCTZ produced a better response than atenolol plus HCTZ. Indian patients appeared to respond better to lisinopril than black patients, but the hypotensive response to lisinopril plus HCTZ was similar. Plasma renin activity rose and the plasma aldosterone level fell after taking lisinopril. Adverse effects did not occur and only 1 patient on lisinopril 20 mg/d was withdrawn from the study because of postural hypotension. Lisinopril alone and combined with HCTZ in Indian patients and lisinopril combined with HCTZ in black patients produced a satisfactory fall in blood pressure.

The protein/creatinine index. A semiquantitative assessment of 24-hour protein excretion.

The 24-hour protein excretion is important in estimating the severity of a renal lesion and is used extensively for diagnostic and prognostic purposes and also to follow the response of patients to treatment. The disadvantages of timed 24-hour collections are that they are cumbersome, inconvenient, expensive, and unreliable in up to one-third of cases. The aim of this study was to correlate the protein/creatinine (P/cr) index in a random spot urine sample and protein excretion in a 24-hour urine sample from the same patient. The P/cr index was derived as follows: (Formula: see text). In the 34 patients investigated there was a highly significant correlation (r = 0.9017) between the P/cr index and 24-protein excretion. The P/cr index is a useful and quick method of assessing proteinuria in most patients with renal disease.

A comparative study of ketanserin and metoprolol in essential hypertension.

The role of serotonin in the pathogenesis of hypertension is interesting, and its investigation is much in vogue at present. This study compared the hypotensive effect of ketanserin, a specific 5-hydroxytryptamine receptor antagonist, with metoprolol in essential hypertension. On a double-blind basis, one treatment group (19 patients on ketanserin) was compared with another (21 patients on metoprolol). There was a significant reduction in diastolic blood pressure with both ketanserin and metoprolol (P less than 0,001). Side-effects were insignificant. One patient on metoprolol and 2 on ketanserin complained of dizziness. The dose of ketanserin was 40 mg twice a day and that of metoprolol 100 mg twice a day. Ketanserin does not appear to cause abnormal haematological values or biochemical adverse effects. It can be given to hypertensive patients with cardiac failure or bronchial asthma without adverse effects and may improve the peripheral vascular status of a hypertensive patient.