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Current knowledge regarding the concordance and discordance of the eye and kidney complications of diabetes is based on observations by ophthalmoscopy of retinal structural changes, which may be present at [...]

In a cross-sectional study, glomerular basement membrane (GBM) width, the volume fractions of the mesangium ([V.sub.v]Mes), its cell ([V.sub.v]Cell) and matrix ([V.sub.v]Matx) components, and surface density of the peripheral capillary [...]

Eight women with insulin-dependent diabetes mellitus (IDDM) with low creatinine clearance rate (CCR) and normal urinary albumin excretion (UAE) were compared with three other groups of diabetic women: 19 with normal creatinine clearance rate (CCR) and UAE, 7 with normal CCR and microalbuminuria, and 7 with low CCR and microalbuminuria. The four groups were similar in age, duration of diabetes, [HbA.sub.1], incidence of urinary tract infection, prevalence of bladder neuropathy, and urinary urea nitrogen excretion rate. The prevalence of hypertension was similar among the groups, although mean arterial pressure was higher in the low CCR and microalbuminuria group. Renal area index was lower in the low CCR and normal UAE groups than in the other groups of diabetic patients, but was not different from normal. Morphometric measures of mesangial expansion and estimates of arteriolar hyalinosis and global glomerulosclerosis were increased to a similar degree in the low CCR and normal UAE, normal CCR and microalbuminuria, and low CCR and microalbuminuria groups compared with the group without abnormalities of renal function. Therefore, it is likely that diabetic glomerulopathy is, at least in part, responsible for the loss of glomerular filtration rate seen in the low CCR and normal UAE patients. Thus, the definition of incipient nephropathy may have to be expanded beyond the concept of microalbuminuria if longitudinal study of such patients reveals an increased risk of the subsequent development of overt nephropathy. Finally, screening for diabetic kidney disease among IDDM patients should include determination of glomerular filtration rate and measurement of UAE and blood pressure, especially among women. Diabetes 41-581-86, 1992, Overt diabetic nephropathy classically begins with dipstick-positive proteinuria (urinary albumin excretion [UAE] 200 mg/24h) followed or accompanied by the development of hypertension and/or falling glomerular filtration rate (GFR; 1,2). At [...]

Although kidney transplants have been performed for many years, there is controversy over the advisability of this procedure for young children with kidney failure or end-stage renal disease. Kidney failure in infants is associated not only with growth failure, but also with severe central nervous system disorders including progressive encephalopathy (abnormal structure or function of brain tissue), delayed development, microcephaly (small brain size) and seizures. If these infants are to survive and develop, they need early and aggressive intervention. Results are reported from the authors' experience in treating 75 infants less than two years old with kidney transplantation; 79 transplants were performed in these children. In 63 transplant operations, the donor was a living relative of the baby; 1 was not related; and 15 organs were obtained from cadavers (dead bodies). All the infants who received transplants were on or about to begin hemodialysis (a procedure in which wastes are removed from the blood using a machine). The transplants took place between 1965 and 1989, and 64 percent of the patients are alive with functioning kidneys. Since 1983, the one-year patient survival has been 95 percent, and the five-year survival has been 91 percent. Survival of the graft (donated organ) has been 86 percent at one year and 73 percent at five years. Patients who received immunosuppressive therapy with cyclosporine had 100 percent patient survival at one and five years, with graft survival of 96 percent at one year and 82 percent at five years. There was no difference in outcome between infants and older children. The most common cause of graft loss was rejection of the donated organ (15 patients). No graft rejection episode has been experienced by 52 percent of the transplant patients. Following transplantation, infant growth and development improved. It is recommended that living donors be used whenever possible. (Consumer Summary produced by Reliance Medical Information, Inc.)

We investigated the role of the aldose reductase pathway in the pathogenesis of the nephropathy of rats with severe (non-insulin-treated) streptozocin-induced diabetes of 6 mo duration. The initial experiment included [...]

Mean Glomerular Volume and Rate of Development of Diabetic Nephropathy Diabetic nephropathy (defined as urinary protein excretion [is greater than]500 mg/24 h) occurs in |40% of type I (insulin-dependent) subjects [...]

Mesangial Expansion as a Central Mechanism for Loss of Kidney Function in Diabetic Patients Our central postulate is that structural lesions of the glomerulus are the primary cause of the [...]

In arterial hypertension (AH), endothelial dysfunction (ED) is considered to be one of the earliest impairments of target organs. The association between AH and the severity of EDs in involutive altered vessels has been determined. The characteristics of the association between vasotonic bioeffectors—nitric oxide (NO) and endothelin-1(ET-1)—in connection with the results of endothelial vasodilation have been described. A technique that makes it possible to estimate the degree of interaction between NO and ET-1 has been proposed. It has been determined that on the top of passive vasodilation, which develops as a combination of involutive and hypertensive impairments to the endothelium, maintaining adequate blood flow in the vessel after the mechanical stress-induced exposure is accounted for by the increased velocity of systolic and diastolic blood flow, increased endothelium sensitivity to shear stress, and changes in the synthesis and secretion of ET-1 and NO.

Laminin a non-collagenous glycoprotein is a major component of the renal glomerular basement membrane and mesangium. Thus far eleven distinct chains have been described, permutations of which make up 15 laminin isoforms. Laminin molecules interact with cells and other matrix molecules during organ development and differentiation. We studied the distribution of laminin isoforms in patients with type 1 diabetic nephropathy, membranous nephropathy, membranoproliferative glomerulonephritis and IgA nephropathy/ Henoch–Schönlein purpura. Immunofluorescence microscopic studies with laminin-chain-specific antibodies to the α1, α2, α5, β1, β2 and γ1 chains detected α2, β1 and γ1 chain expression in the normal mesangium and α5, β2 and γ1 in normal glomerular basement membrane. Significantly, constituents of the glomerular basement membrane, α5, β2 and γ1 chains were overexpressed in kidneys with diabetic nephropathy. Initially the constituents of the mesangium increased commensurate with the degree of mesangial expansion and degree of diabetic nephropathy. Reduction in α2 chain intensity was observed with severe mesangial expansion and in the areas of nodular glomerulosclerosis. In addition, with late disease aberrant expression of α2 and β2 chains was observed in the mesangium. Glomerular basement membrane in renal disease overexpressed molecules normally present in that location. In summary, the alterations in basement membrane composition in various renal diseases seem to not only reflect the balance between synthesis and degradation of normal basement membrane constituents, but also their aberrant expression.

Abstract: To identify the clinical and instrumental features of the relation of endothelial (ED) and myocardial (MD) dysfunctions in elderly persons with arterial hypertension (AH), 66 patients of 60–74 years of age, suffering from hypertension stage II and 26 of the same age without cardiovascular disease were examined. It is established that the development of hypertension against ED is accompanied by the formation of the concentric hypertrophy and concentric myocardial remodeling, diastolic and systolodiastolic MD, and its severity is conjugated with the severity of endothelial dysfunction. Progression of ED is accompanied by disorders of metabolism of lipids, higher intensity of their peroxidation, and decreasing efficiency of antioxidant protection mechanisms.

Pancreatic tissue fragments from neonatal inbred Lewis rats were distributed throughout the peritoneal cavities of isologous diabetic recipients receiving prednisolone on a schedule similar to that used in clinical transplantation beginning 9–44 days before transplantation. Plasma glucose levels in six of seven diabetic rats receiving prednisolone returned to normal levels 3 weeks after transplantation. Plasma insulin levels in the animals with successful transplants reached, at 1 week after transplantation, levels measured in normal control rats, but never attained the high insulin levels observed in the normal control animals receiving steroids. As with glucose the insulin levels remained in the normal range, and the animals steadily gained weight. During i.v. glucose tolerance tests (IVGTTs) in the rats with successful transplants at 4, 11–14, and 26–29 weeks after transplantation, the glucose levels were similar to those observed during IVGTTs in the control animals before and during corticosteroid therapy. In contrast, insulin levels during the IVGTTs were lower in the rats with successful transplants than in the control rats with or without steroids; however, insulin release during the IVGTTs was rapid in all animals, both with successful transplants and controls. These observations demonstrate that islet tissue implanted in the peritoneal cavities of diabetic rats receiving immunosuppressive chronic corticosteroid therapy can respond with a rapid and sufficient release of insulin to reverse diabetes as documented by normal glucose levels under stimulated and nonstimulated conditions.

The role of cadaver kidney transplantation in the management of end-stage renal disease in young children is controversial. To assess the current risk-benefit ratio of cadaver first and second kidney transplants in recipients under 6 years of age, we compared the outcome of 19 transplants performed between 1984 and 1989 using a quadruple-drug regimen (Minnesota antilymphocyte globulin, azathioprine, prednisone, cyclosporine) with the outcome of 25 transplants performed prior to 1984 without the use of cyclosporine at a single institution. Twenty-five transplants were in children under the age of 3 years. In the last decade patient survival has significantly improved. One-year patient survival improved from 53 before 1979 to 90 since 1979 (P<0.05). The use of the quadruple-drug regimen since 1984 was associated with a significant improvement in one-year cadaver graft function from 40 before 1979 to 78 in recipients under 6 years of age, and from 22 to 82 in recipients under 3 years of age (P<0.05). With the quadruple-drug regimen, one-year and four-year graft function rates for children under 6 years of age were 83 for first cadaver transplants and 72 for second cadaver transplants, which were essentially the same results as in older children and adults. Children who received kidneys from donors over 4 years of age achieved the best result, with 87 one-year graft function compared with 50 for kidneys from donors under 4 years old. In 15 children with successful transplants, 8 (53) showed accelerated growth, 5 (33) had normal-velocity growth, and only 2 children (14) with suboptimal renal function had poor growth following transplantation. Therefore, we believe that with a quadruple-drug immunosuppressive protocol, cadaver renal transplantation using kidneys from adults or pediatric donors over 4 years old is an acceptable form of treatment in young children with end-stage renal disease for whom there are no suitable living-related donors.

Cryostat sections of 11 rejected human renal grafts were selected for positive results in immunofluorescence tests. Immune complexes were detected in glomerular basement membrane (9 cases), tubular basement membrane (3 cases), and vessels (5 cases). Preincubation of the sections with FII of pooled human serum, but not of rabbit serum, prevented the staining of immune complexes for human IgG. These findings were interpreted by the assumption that most complexes under study were produced by reaction of the patient's altered IgG with the rheumatoid-like factor of IgG variety.

The pediatric nephrologist has traditionally not been involved in the care of the diabetic child since diabetic nephropathy presents in adulthood. Recent studies suggest that diabetic kidney disease develops silently during childhood. Measurement of urinary albumin excretion (UAE) allows earlier detection of patients at risk of nephropathy, often in adolescence. In addition to diabetic nephropathy, diabetic children are at risk of urinary tract infections, renal papillary necrosis, and various forms of glomerulonephritis. The role of the pediatric nephrologist in the care of the child with diabetes might include advising on the administration and interpretation of screening for UAE and the measurement and interpretation of glomerular filtration rate, and blood pressure. Children with evidence of renal dysfunction should be evaluated and treated by the pediatric nephrologist. Frequently, renal biopsy will be necessary in these patients. Future research may allow the detection of diabetic kidney disease earlier in childhood, further expanding the role of the pediatric nephrologist. In particular, early renal biopsy may eventually be used to select those patients at risk of diabetic nephropathy for specific treatment alterations.

We were concerned that clinical manifestations of rejection (R) might be subtle in small children transplanted with adult kidneys. We retrospectively analyzed the first rejection episode (biopsy proven) in 22 children (R group) under age 4 years [mean age, 23.7±2.2 months (±SEM); mean weight, 9.4±0.4 kg] receiving an adult-related donor kidney. We matched these patients for age, date of transplant, donor source and immunosuppression with 36 children without R (control or C group). We compared both groups at similar intervals from transplantation, based on the time of R (5.38±1.2 months) in the R group and analyzed the immediate 8-week period prior to R and the corresponding interval in the C group. Hypertension occurred in 82% (18/22) of the R versus 8% (3/36) of the C group (P<0.01). Fever longer than 7 days occurred in 45% (10/22) of the R versus 0% (0/36) of the C group (P<0.01). Increased creatinine occurred in only 45% (10/22) of the R versus 3% (1/30) of the C group (P<0.01). Cyclosporine did not influence these manifestations of R. The clinical manifestations did not predict the R grades on biopsy, which were moderate to severe in 13 and mild in 9 of the R patients. Graft survival was higher at 3 years in the C (95%) than in the R patients (65%), (P<0.004). Thus, clinical manifestations of acute R can be subtle in small children with adult renal allografts. Renal biopsy should not be delayed until the creatinine is elevated in these patients.

The evaluation of renal biopsies from diabetic patients rests upon measurements of many structures in glomeruli, the tubules and the interstitium. These individual values can also be expressed as an index of renal structure. To assess the validity of the individual values versus a published index of renal structure, we evaluated glomerular basement membrane width, mesangial volume fraction, other measures of glomerular structure, and percentage glomerulosclerosis in type 1 diabetic subjects with renal function ranging from normal to marked albuminuria, hypertension, and a falling glomerular filtration rate. For all measured structural parameters and for the index, all groups of diabetic patients, even those who had completely normal renal function, had values different from non-diabetic subjects (P<0.001). Furthermore, there was an excellent correlation between the structural index and a similar functional index (r=0.77).

It is difficult to determine which pediatric hemodialyzer to use in a given clinical situation since there is no comprehensive comparison of pediatric hemodialyzers. We evaluated five currently available disposable pediatric hemodialyzers in vitro and in vivo during treatment of pediatric patients. Two dialyzers, Gambro Mini-Minor and Viva Cell 0.2 are well suited to small pediatric patients weighing less than 10 kg. Three of the dialyzers are well suited to the pediatric patients weighing greater than 10 kg (Gambro Minor, Cordis Dow 0.6, Viva Cell 0.5). By considering the clinical status of the child and the performance characteristics of the dialyzer (solute removal, priming volume, ultrafiltration, etc.) it is possible to employ a hemodialyzer which more precisely meets the needs of the child without increasing risk factors associated with pediatric hemodialysis.

Although chickenpox can cause severe morbidity and mortality in pediatric renal transplant recipients, published reports describing treatment of these patients are few, especially in the cyclosporine era. Sixty-nine episodes of chickenpox occurring in 66 patients were diagnosed in our transplant population between January 1984 and May 1996. Immunosuppression consisted of prednisone and azathioprine (30 cases); prednisone, azathioprine, and cyclosporine (38 cases); or prednisone alone (1 case). Azathioprine was temporarily discontinued in 66 of 68 cases. Cyclosporine was continued at the preexisting dose in 36 of 38 cases. Acyclovir was administered parenterally in 62 of 69 cases. Sixty-five of 66 patients survived. Cyclosporine use did not increase the incidence of severe disease (p > 0.1). Acute allograft rejection occurred in three patients and responded to prednisone. Chickenpox in children with renal transplants can be successfully treated with intravenous acyclovir and temporary withdrawal of azathioprine. Allograft rejection is uncommon with this approach. Patients receiving cyclosporine do not appear to experience increased morbidity or mortality with chickenpox. (J Pediatr 1997;131:874-7)

We used immunogold electron microscopic (IEM) techniques with periodate-lysine-paraformaldehyde-fixed and Lowicryl-embedded or cryopreserved tissues to study the distribution of alpha 1(IV) and alpha 3(IV) chains of Types IV and VI collagen in glomerular basement membrane (GBM) and mesangial matrix of glomeruli in normal human kidneys. Monoclonal antibodies to alpha 1(IV) and alpha 3(IV) collagen chains and Type VI collagen could be detected only with cryoultramicrotomy, whereas polyclonal anti-Type IV collagen antibody was detectable in Lowicryl-embedded tissue. Ultrastructural detail was better preserved in the Lowicryl-embedded tissue. IEM labeling provided more detailed information as to the site-specific array of these extracellular matrix molecules in glomeruli than did immunofluorescent microscopy. The labeling of alpha 1(IV) collagen chain was distributed mainly along the endothelial side of glomerular basement membrane and the mesangial matrix. Mesangial GBM was relatively poorly labeled compared with that of mesangial matrix. In contrast, the alpha 3(IV) chain was detected throughout the thickness of the GBM, but there was no labeling of mesangial matrix. Type VI collagen distribution was identical to that of the alpha 1(IV) chain within the glomerulus but was also associated with interstitial collagen fibrils. This study documents and details the heterogeneous distribution of Type IV and VI collagen chains within the normal human glomerulus and provides the framework for the study of these matrix components in human glomerular diseases.

Renal insufficiency occurs in at least 1.5% of children with anaphylactoid purpura (AP). We reviewed the records of 16 children who developed end-stage renal disease (ESRD group) secondary to AP and matched them for age, era of onset, renal histology, and clinical severity at onset with 16 children who has AP but whose creatinine clearance returned to and remained normal (recovery group). We reviewed creatinine clearances at 1, 3, 5, and 10 years after onset. A creatinine clearance >70 ml/min per 1.73 m2 was present in 50% of the patients in the ESRD group at 3 years and in 25% at 5 years after onset. In contrast, all patients in the recovery group had a creatinine clearance >70 ml/min per 1.73 m2 by 3 years (7 of 16 had a creatinine clearance >125 ml/min per 1.73 m2) and all were normal 95–125 ml/min per 1.73 m2) by 5 years. Thus, the presence of an increased creatinine clearance (>125 ml/min per 1.73 m2) at 3 years predicted recovery, while failure to reach a creatinine clearance of >70 ml/min per 1.73 m2 at 3 years predicted progression to ESRD. There was no evidence of recurrent systemic AP or nephritis in the 14 patients who underwent renal allograft transplantation. We conclude that long-term evaluation of patients over many years is required to identify those who will progress to ESRD from AP and that recurrence of AP in the renal transplant is uncommon.

Fatty acid compositions of phospholipids of heart, liver, kidney, aorta, and serum from rats having streptozotocin-induced diabetes were determined and compared with those of nondiabetic controls. Linoleic and dihomo-gamma-linolenic acids were increased whereas arachidonic acid was decreased in most tissues, suggesting an impairment of delta 5-desaturase activity. Acids derived from linolenic acid were increased in some diabetic tissues from diabetic animals although the linolenic content was normal, indicating less impairment in the desaturation of the omega 3 series of fatty acids. Diabetes suppressed all polyunsaturated acids in the whole animal, but the competition between omega 3 and omega 6 acids favored the excessive suppression of long-chain omega 6 acids and an increase in the proportion of omega 3 acids in lipids of vital tissues. These changes in fatty acid composition of the phospholipids may have significant effects on cellular functions and vasoregulatory control mechanisms in diabetes.

Summary: Two female siblings were treated for acute neonatal hyperammonaemia due to complete carbamyl phosphate synthetase I deficiency. The first child was detected clinically at 65 hours of age and therapy started at 79 hours. The second child was followed from birth and therapy started at 5 hours of age. The extrapolated rate of increase of blood ammonia, in the first hours of life before therapy started, was 19 µmol L–1 h–1 in both babies. Peak blood ammonia level was 2235 µmol/L in the first (clinically detected) child and 271 µmol/L in the second (prospectively followed) child. The second child became symptomatic at 3 hours of age when blood ammonia level was as low as 90 µmol/L, whereas blood ammonia levels above 100 µmol/L caused no symptoms during recovery. The child detected clinically required haemodialysis and peritoneal dialysis to treat the hyperammonaemia. In the prospectively treated child, early therapy with intravenous sodium benzoate and sodium phenylacetate slowed the rate of increase in blood ammonia level, but this therapy did not prevent the need for peritoneal dialysis.

Specific problems discussed include blood access and complications thereof, pediatric dialyzers with reference to priming volumes, efficiency of clearance and dysequilibrium syndrome, ultrafiltration and weight monitoring, and hemodialysis for intoxications.

At our institution, 521 kidney transplants were performed in 429 children (mean age 8.7±5.6-years) between 1969 and 1991. Of these transplants, 408 were primary, 113 were retransplants, 347 were living related, 171 were cadaver, and 3 were living nonrelated. Immunosuppression consisted of prednisone, azathioprine, and Minnesota antilymphocyte globulin (non-CSA) in 339 patients, total lymphoid irradiation in 8, and, more recently, cyclosporine (CSA) in addition in 168 patients. Average followup was 8.8±6.0 years.

A case of steroid-resistant nephrotic syndrome with focal segmental glomerulosclerosis leading to renal failure in a 4-year-old girl is described by her mother, with special emphasis on the problems resulting from recurrence of this disease, with graft loss in three successive kidney transplants. This report chronicles the gradual evolution from a family's initial heavy dependence upon medical solutions to their ultimate primary emphasis upon spiritual values, with medicine seen as the support toward achieving the child's psychological well-being and spiritual growth. The physician's role in balancing medical decision making, non-medical alternatives, and demands on limited and precious resources in such difficult cases is discussed.

Initially, poor long-term prognosis in patients with SLE and fear of recurrent disease dissuaded renal transplantation in this group of patients. However, in 1975 the Advisory Committee to the Renal Transplant Registry reported satisfactory 1–2-year results in 56 patients with SLE from 36 institutions. Subsequently, renal transplantation for SLE patients with end-stage renal disease has become more accepted, though it has been recommended that transplantation be postponed for at least one year after initiating dialysis. Five cases of recurrent lupus nephritis have been reported in the literature. However, since the long-term outcome after transplantation in this group of patients is not well established, we have examined the long-term outcome in SLE patients who underwent renal transplantation at the University of Minnesota.

Transplantation is the treatment of choice for children with end-stage renal disease. However, the long-term quality of life and socioprofessional outcome for those with successful transplants have not previously been reported. We studied these factors in patients transplanted when<18 years old who currently have ≥10 years of graft function. A total of 57 questionnaires were sent out; 57 (100) responded [24 female and 33 male patients; average (±SD) age at tx = 10±5 years (0.9–17.7); average f/u = 15.6±3 years (10–26); current age = 26±5 years (12–38); 26 had < 1 transplant]. Of the 57 respondents, 9 are<18 (all are in school); 48 are ≥18 (7 in school, 37 employed, 4 unemployed); 12 are married, 1 engaged, and 2 divorced; and 9 have children.

Uninephrectomy is known to accelerate the development of both functional and morphological changes seen with experimental diabetic nephropathy in the rat. The present experiments utilized electron and light microscopic morphometric techniques to assess glomerular basement membrane width and the volumes of the total mesangium and its cellular and matrix components of inbred Lewis rats made diabetic at 6 weeks of age and uninephrectomized 9 days later. Immunofluorescent microscopy was used to evaluate IgG and C3in the mesangium. The reversibility of established diabetic glomerular lesions in uninephrectomized diabetic rats after 7 months of diabetes was studied by performing intraportal transplant of neonatal pancreatic tissue. Renal biopsies were taken 2 months later in transplanted and non-transplanted animals. Islet transplantation lowered plasma glucose to normal levels (29.6 to 7.3 mmol/l) and raised plasma insulin values (6.3 to 53 μU/l). Glomerular basement membrane width in transplanted rats (268 nm) still exceeded the same measure (226 nm) in nondiabetic uninephrectomized rats. In transplanted animals volumes of the mesangium (0.51 × 106μm3) and of its cellular (0.27 × 106μm3) and matrix (0.24 × 106μm3) components remained higher than similar measures in control rats (0.32 × 106, 0.17 × 106and 0.15 × 106μm3, respectively). Mesangial IgG in treated animals approached normal, but mesangial C3remained similar to levels in non-transplanted diabetic control animals. These observations in uninephrectomized-diabetic rats contrast with previous observations in intact diabetic rats in which mesangial volumes and localization of immunoglobulins and complement returned to normal levels following islet transplantation.

Immunoglobulins and complement are deposited in the glomerular mesangium of rats with progressive glomerulosclerosis secondary to chemically induced diabetes mellitus. Isotransplantation of a kidney from a rat diabetic for 6 mo into a normal recipient results within 2 mo in the disappearance of IgG, IgM, and ß1C from the mesangium and arrest or reversal of the light microscopic glomerular lesions. Kidneys isotransplanted from normal donors into diabetic rats developed mesangial matrix thickening and deposition of IgG, IgM) and ß1C in the mesangium. No glomerular changes occur upon transplantation of a normal kidney into a normal rat. These findings indicate that diabetic glomerular changes in the rat are reversible and are secondary to the diabetic state rather than to the inducing agent.

This article outlines the current status of pediatric renal transplantation and emphasizes a practical approach to patient management. It discusses two areas of renal transplantation in children in which results differ significantly between children and adults. These areas are renal transplantation in the very young child and transplantation in children with renal failure secondary to urologic disease.

This brief review is designed to summarize the authors’ view of the incidence and natural history of infections in transplant patients, the prophylactic measures, diagnostic problems, and treatment based on an experience with more than 650 renal transplants.

Thirty-five patients with Type 1 (insulin-dependent) diabetes mellitus and 90 normal subjects had renal size (renal area index) determined by X-ray and also had examination of renal biopsies by light and electron microscopy. Renal area index of 206±32 cm2/1.73 m2(mean±SD) in the Type 1 diabetic patients exceeded that in the normal subjects (180±25 cm2/1.73 m2, p<0.001). In the diabetic patients, the renal area index correlated with creatinine clearance (r=+0.43, p<0.05), but did not correlate with urinary albumin excretion, or the electron microscopic measurements of percentage total mesangium and glomerular basement membrane width. In diabetic patients with clinical nephropathy or severe glomerulopathy on biopsy, the kidneys may remain large. Thus, renal size does not indicate the severity of diabetic renal lesions on biopsy.

A 4-kg newborn baby with terminal uremia underwent 28 technically successful hemodialyses over a two-month period. A profunda femoris artery to saphenous vein silastic special pediatric shunt and four different pediatric dialyzer systems were used. Glucose added to the dialysate solution and intravenous mannitol administration prevented significant fluctuations in serum osmolality. Severe hypertension, malnutrition, electrolyte imbalance, and retarded motor development were problems encountered.

A mechanism of immune glomerular injury is described based on the fixation of antibody (Ab) to an antigen (Ag) that has localized in the glomerular mesangium. Rabbits were given, intravenously (i.v.), aggregated human IgG (AHIgG) or albumin (AHSA) and 10 h later, when the Ag by immunofluorescent microscopy was present in the mesangium, a kidney was removed and transplanted into a normal rabbit. The recipient then received, i.v., rabbit anti-HIgG or anti-HSA. Within minutes of Ab infusion, glomeruli of the donor kidney had polymorphonuclear (PMN) infiltration that over the next few hours became marked and was associated with glomerular cell swelling. At 24 h a decrease in PMN's and early mesangial proliferation was seen. By 3 days there was marked mesangial hypercellularity and increased mesangial matrix. Within minutes after Ab administration rabbit IgG, C3, and fibrin were seen in the glomerular mesangium. There was a fall in complement titer by 1 min after Ab infusion that was due to complement consumption by the donor kidney. Complement then returned to normal levels by 48 h. Significant glomerular injury did not occur (a) in the recipient's own kidney, (b) from Ag administration and transplantation without recipient Ab administration, or (c) from transplantation and Ab administration without prior Ag administration. These studies demonstrated that Ag localized in the glomerular mesangium can react with circulating Ab and complement resulting in severe glomerular injury.

The effect of vesical dysfunction on the survival and function of renal transplants was evaluated by a retrospective study in which 18 children with posterior urethral valves and 18 children with vesicoureteral reflux were randomly matched with 36 children used as controls. There was no statistically significant difference in patient survival among the 3 groups. Five years after transplantation 50 per cent of the grafts in children with posterior urethral valves were functioning, while 73 and 75 per cent, respectively, of the grafts were functioning in children with vesicoureteral reflux and in the control group. Renal function during the 5 years was significantly better in children in the control group and in those with vesicoureteral reflux than in children with posterior urethral valves. We believe that the presence of an abnormal bladder may alter graft survival and adversely affect the function of the transplanted kidney.

We report a case of complete recovery of renal function in a patient with de novo hemolytic uremic syndrome (HUS) following renal transplantation. This 3-year-old girl had none of the factors known to contribute to the development of HUS in transplant recipients. This case illustrates the usefulness of renal biopsy in the accurate diagnosis and management of dysfunction in the allograft following renal transplantation.

The natural history of focal segmental glomerulosclerosis in patients retransplanted after loss of a primary allograft is not well established. We studied 14 patients with FSGS who were retransplanted between April 1964 and September 1990 to determine if recurrence in a second or subsequent allograft could be predicted. In this group, 8 of the primary allografts were lost to recurrent disease and 6 to rejection. None of the 6 patients who lost their primary allograft to rejection without evidence of recurrent FSGS suffered recurrent disease after retransplantation.

We examined tissues of seven non-diabetic mongrel dogs and four diabetic beagle dogs treated with constant insulin infusion via totally implantable pumps for from 210 to 880 days. Kidney and skeletal muscle tissue from all dogs were stained with Congo Red and thioflavin-T and appropriately examined. Kidney tissues from the beagle dogs were examined by electron microscopy. No amyloid deposits were found in any of these tissues. Thus, we cannot confirm an earlier report of amyloid occurring in dogs given long-term intravenous insulin. It is concluded that amyloidosis is not a necessary complication of long-term intravenous insulin infusion in dogs.

Several substances are known to have a profound effect on both the kidney and the inner ear. The aminoglycoside antibiotics are toxic to both of these organs. Ethacrinic acid and furosemide affect transport mechanisms in the loop of Henle as well as the inner ear. In addition, studies have suggested antigenic similarities between the stria vascularis of the cochlea and the renal tubules.This report of potassium bromate poisoning and its resultant deafness and renal failure further emphasizes the curious relationship between these two organ systems.