Chronic dialysis in patients with multiple myeloma and renal failure: a worthwhile treatment.

Severe renal failure is a life-threatening complication of multiple myeloma. Aggressive treatment can reverse acute renal failure in many cases but the prognosis for those who require chronic renal replacement therapy is not clear. We have reviewed the treatment of these patients in the Brighton, Dulwich and Guy's Hospitals renal units. Twenty-three patients were treated for a total of 385 months. Over half presented with end-stage renal failure and required dialysis immediately. Fifteen patients died during the study period and actuarial survival was 45 per cent at one year; six have survived for longer than two years. No prognostic features at presentation were identified but those who responded to chemotherapy survived significantly longer than those who did not. Haemodialysis and continuous ambulatory peritoneal dialysis (CAPD) appeared to be equally effective treatments. Complications from dialysis were more common than in patients with renal failure from other causes. Infection in those treated by CAPD was a serious problem and may be exacerbated by aggressive chemotherapy. Maintenance dialysis offers some patients with multiple myeloma long-term survival and should be offered to all patients who are considered to warrant continuing treatment for their underlying disease.

A multi-centre, placebo controlled comparative study between 200 mg and 400 mg celiprolol in patients with mild to moderate essential hypertension.

A two-centre, double-blind, placebo controlled, randomized 3-way crossover study was undertaken to assess the efficacy, tolerability and safety of celiprolol in mild to moderate essential hypertension. A 4-week single-blind placebo run-in/screening period, during which no antihypertensive medication was given, was followed by 3 consecutive 4-week treatment periods with placebo or celiprolol (200 mg or 400 mg daily). At the end of the 4-week placebo run-in/screening period, 26 hospital out-patients with a seated mean blood pressure (systolic/diastolic) of 161.4/101.7 mmHg and a mean pulse rate of 75 beats/min entered the double-blind crossover phase of the study. Results showed that there was no significant difference in seated mean systolic or diastolic blood pressure between 200 mg celiprolol daily (149.2/92.3 mmHg) and 400 mg celiprolol daily (149.1/92.5 mmHg). However, mean seated systolic and diastolic blood pressures were significantly (p less than 0.05) lower on celiprolol than on placebo (157.1/98.2 mmHg). Neither dose of celiprolol had a significant effect on seated pulse rate. No patient was withdrawn due to an adverse event and no laboratory assessment outside the normal range was reported to be of any clinical significance. It is concluded that oral celiprolol, 200 mg or 400 mg daily, is effective and well tolerated for controlling mild to moderate essential hypertension. Since both doses had very similar effects on blood pressure there is no advantage in this group of patients for the 400 mg daily dose of celiprolol.

Acetylator phenotype in patients with lung carcinoma--a negative report.

Fractional acetylation of plasma sulphadimidine 6 h after dosing with 40 mg/kg metabolically active mass (p.o.) was measured in 53 patients with primary lung carcinoma and in 31 controls. Sixty percent of all tumour patients and 58% of controls were slow acetylators. There was no statistical evidence (P greater than 0.5) of association between acetylator phenotype and lung carcinoma.

Diabetic ketoacidosis due to insulin resistance treated by haemodialysis.

A 14-year-old female patient with insulin resistance is reported in whom it appeared that initially insulin breakdown was unusually rapid. Subsequently there was in addition evidence of reduced insulin sensitivity. The rapidly increasing requirement of insulin (1600 units daily), given by continuous IV infusion, was dramatically reduced by haemodialysis, and was maintained subsequently. We suggest that insulin aggregates which may have blocked insulin receptor sites, causing insulin resistance, were removed by haemodialysis.

Hypertensive encephalopathy complicating transplant renal artery stenosis.

A 26-year-old female diabetic patient developed hypertensive encephalopathy with gross neurological abnormalities complicating renal artery stenosis of her transplant kidney. The elevated blood pressure was unresponsive to medical treatment. Surgical correction of the stenoses in the renal artery cured the hypertension and renal failure and led to the patient's complete recovery.

A comparative study of dialysis techniques.

Comparative studies were performed on 19 patients who were dialysed initially for a mean of 25 h a week and then for a mean of 11.1 h a week over two 3-year periods. Clinical, biochemical, haematological and neurological valuations were performed, which showed no significant difference. As an adjunct to haemodialysis a perfusion system was added to 12 of these patients already stable on haemodialysis and estimations made of removal of middle molecular weight substances from plasma by a gel filtration method through a Sephadex column. The results of these various techniques are reported and the comparisons between haemodialysis, haemodialysis and ultrafiltration and haemodialysis, perfusion and ultrafiltration are given.

Five year follow-up of effects of treatment of mild and moderate hypertension.

A five-year follow-up study of the effects of treating patients with both mild and moderate hypertension was performed. The patients were identified during a hospital-based community survey of hypertension. A total of 961 patients were divided into four groups. The first group, the controls, were age- and sex-matched normotensive subjects selected sequentially from the same survey. The second group were patients defined as well-controlled hypertensives; the third group were patients whose blood pressures were less well-controlled; and the fourth group consisted of patients who, for various reasons, were not treated and as such acted as an untreated control group. Both mortality and morbidity were considerably greater in the untreated patients than in the normal subjects. The well-controlled hypertensive patients showed no difference in either morbidity or mortality from normal subjects. The less well-controlled patients had a significantly greater cardiovascular morbidity but no excess mortality over groups 1 and 2. This was true for both mild and moderate hypertension and for women as well as men. These findings therefore confirm the conclusions of other recent studies that good control of hypertension at all levels and in both sexes is justified by the reduction in morbidity and that even less than excellent control is of considerable benefit.

The treatment of hypertension with propranolol and bendrofluazide.

In 101 hypertensive patients, the effects of a combination of propranolol and bendrofluazide were compared with those of each drug alone. After an introductory period with a placebo, the patients received, in a double-blind randomized trial, propranolol 80 mg twice a day, bendrofluazide 2.5 mg twice a day, or both drugs together twice daily. The combination produced significantly greater reductions in lying, standing, and post-exercise systolic and diastolic blood pressure than either drug separately. Side-effects were minimal and the combination was well accepted by patients.

Evaluation of ultra-short dialysis.

A study was carried out to compare the effects of three dialysis regimens of different durations. Nineteen patients dialysed over 1975--7 for an average of only 11.2 hours per week were compared with nine dialysed for 24 hours per week (1974--6) and 10 dialysed for 27 hours (1971--3). Clinical, biochemical, and haematological results showed that the short dialysis regimen was as effective as the longer regimens, except that patients had to take a phosphate binder regularly, and that it was considerably cheaper. Short dialysis has social and economic benefits, since patients have more free time and more patients can be treated with the same number of staff and dialysis stations. As in many areas there is a shortage of places for patients needing dialysis, a short regimen is recommended.

Haemoperfusion with R-004 Amberlite resin for treating acute poisoning.

Eleven patients who had taken overdoses of barbiturates, glutethimide, tricyclic antidepressants, and chloroquine were treated by resin haemoperfusion using an R-004 haemoperfusion cartridge containing XAD-4 resin. All but one patient showed rapid clinical recovery and the drugs were cleared rapidly from the plasma. There were few complications. Resin haemoperfusion is more effective than dialysis and other perfusion methods, especially in poisoning with tricyclic antidepressants. Although haemoperfusion is expensive, it greatly reduces the length of the patient's stay in an intensive care unit and hence is cost-effective.

Reduction in incidence of ampicillin rash by purification of ampicillin.

Purification of ampicillin (Penbritin) with respect to protein impurities has been found significantly to reduce the incidence of rashes in treated patients. This may be related to findings in animals that injections of the isolated protein impurity can induce the formation of circulating IgG antibodies and skin-sensitizing antibodies.