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End Stage Renal Disease affects many people in the world. There are three methods of renal replacement therapy available to patients: Continuous ambulatory peritoneal dialysis, haemodialysis and transplantation. Transplantation is the most viable and cost effective form of renal replacement therapy that is available for these patients. There are 3 factors required to help ensure a successful renal transplantation program: A well legislated donor and recipient program, Human Leukocyte Antigen testing (pre and post transplant), as well as a post transplant follow up program. Keywords: Renal Transplant; South Asia; Nepal; Human Leukocyte Antigen DOI: 10.3126/jpn.v1i1.4453 Journal of Pathology of Nepal (2011) Vol.1, 52-55

Background Diabetes mellitus is a well recognized public health concern and projections of its future effect are alarming. It is one of the leading causes of end stage renal disease in both developed and emerging nations. The objective of the present study was to assess the progressive deterioration of renal function in Diabetes mellitus among Nepalese. Materials and Methods It was a hospital based case control study carried out in the Department of Biochemistry of Manipal Teaching Hospital, Pokhara, Nepal between 1st January 2010 and 31st August 2010. The variables collected were age, gender, random blood glucose, serum urea and creatinine levels of the patients. Results Out of 440 patients, there was a slight predominance of males (54.1%) as compared to females (45.8%). Patients in between 41-100 years were 2.8 times more at risk of developing kidney disease as compared to age group (0-40 years)(Odds Ratio=2.8, p=0.0001). Diabetic patients were twice at risk of developing kidney disease than non diabetics (Odds Ratio=1.97, p=0.001). There was a significant increase in mean values of serum creatinine (CI 4.3 to 4.8) and urea (CI 118.55 to 153.50) in kidney disease patients with Diabetes mellitus. In non diabetic kidney disease patients, mean values of serum creatinine (CI 3.29 to 3.70) and urea (CI 98.88 to 116.92) were also moderately raised as compared to controls. Conclusion Diabetic renal lesions are not only preventable but also reversible. In summary, glycemic control significantly influences the rate of progression from microalbuminuria to proteinuria and from overt nephropathy to end stage renal disease. The best modality of treatment includes strict control over blood glucose levels and its evaluation at frequent intervals. Key Words : Diabetic Mellitus; Kidney Disease; Case Control Study; Nepal DOI: 10.3126/nje.v1i1.4108 Nepal Journal of Epidemiology 2010;1 (1):22-25

Introduction: Chronic renal failure is a pathophysiologic process with multiple etiologies, resulting in the inexorable attrition of nephron number and function, and frequently leading to end stage renal disease. There are various cutaneous changes in chronic renal failure. Objectives: To observe the cutaneous manifestations in chronic renal falure and find out any difference in occurrence of cutaneous manifestation with modality of treatment of CRF. Methods: The study was conducted in 50 (fifty) adult patients with chronic renal failure and another 50 (fifty) patients with similar age admitted with other renal diseases but not suffering from chronic renal failure as control to facilitate comparison were considered in the Department of Dermatology and Venereology and the Department of Medicine, Shree Birendra Hospital, Chhauni from September 2008 to June 2010. Results: A significant occurrence of pruritus, xerosis and pallor in CRF patients: the highest being pruritus followed by xerosis and pallor. Occurrence of pruritus was found to be more in HD patients (68%) than in IPD patients (38%). No correlation was found between ages, sex, and duration of dialysis with complaint of pruritus. Skin xerosis is considered an important factor contributing or initiating pruritus. Conclusion: Pruritus is the commonest cutaneous manifestation of chronic renal failure. DOI: http://dx.doi.org/10.3126/mjsbh.v9i2.5020 Medical Journal of Shree Birendra Hospital Vol.9(2) 2010: 13-16

mother 11.6568 Normal 0 false false false MicrosoftInternetExplorer4 st1\:*{behavior:url(#ieooui) } /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-parent:""; mso-padding-alt:0cm 5.4pt 0cm 5.4pt; mso-para-margin:0cm; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman"; mso-ansi-language:#0400; mso-fareast-language:#0400; mso-bidi-language:#0400;} Objective: To determine the current pattern and prevalence of renal diseases in childhood in this region of Nepal. Material and Methods: A retrospective study of the renal diseases in children attending the Pediatric OPD and those hospitalised in Manipal Teaching Hospital, Pokhara was done over a period of 6 years (September 2000- September 2006). A detailed clinical and laboratory evaluation was performed at baseline. The children were managed according to disease diagnosed. These cases are under follow up and some have undergone surgical treatment. Results: 228 children (123 boys & 105girls) were diagnosed to have renal disease. Among them 39.5% had urinary tract infection (UTI), 30.7 % were suffering from acute glomerulonephritis (AGN), 17.5% were cases of nephrotic syndrome (NS) and 12 % had some other problems for example, 6.14% had genetic defects, 2.63% had renal Stone, 2.2% had pre-renal acute renal failure, unexplained recurrent hematuria in 1.3%. All the cases of UTI underwent through investigation and were treated accordingly. All cases of AGN are planned for follow up for 1½ yrs and among them 3 required biopsy till date. All cases of NS are under regular follow-ups and 2 have undergone biopsy. Renal stone was operated successfully. All cases of acute and chronic renal failures had required dialysis. Out of 5 (2.5%) chronic renal failures, 2 with end stage renal disease expired after repeated hemodialysis and three are still requiring dialysis. Among the obstructive uropathies, 43 % had renal stone, 36 % had posterior urethral valve and 21% VUR. Conclusion: It can be concluded that renal disease is not uncommon in children. It can be completely cured with proper and adequate treatment. Sometimes it has a bad prognosis when it reaches end stage renal disease. Early recognition, timely treatment and regular follow up are mandatory in management of children with renal diseases. Key words: Renal disease pattern, UTI, AGN, NS, Obstructive Uropathy, Renal failure doi:10.3126/jnps.v27i2.1414 J. Nepal Paediatr. Soc. Vol.27(2) p.75-78

Background: Renal allograft biopsy remains the gold standard for the diagnosis of graft dysfunction. Protocol renal allograft biopsies have provided insights into pathogenesis of early and late allograft injury and guided clinical management. The aim of this study was to find out the causes of early and late graft dysfunction in renal allograft biopsies taken at different time points after transplantation. Materials and Methods: Between August 2008 and February 2011, a total of 98 renal allograft biopsies from 62 kidney transplants recipients were received in the department of Pathology, KIST Medical College and Teaching Hospital. Renal allograft biopsies were interpreted according to the Schemes of Banff ’09 update. Results: The maximum numbers of recipients were in the age group of 31-40 years. Age ranges from 16 to 61 years. Out of 62 recipients, there were 47(75.8%) males and 15 (24.2%) females. The time of biopsy ranges from 0 hour to 6 years after transplantation. There were 9 (9.18%) cases of acute T cell-mediated rejection, 8 (8.16%) cases of acute antibody-mediated rejection, 6 (6.12%) cases of acute ischemic injury, 6 (6.12%) cases of borderline lesions and 4 (4.08%) cases of chronic calcineurin inhibitor toxicity. Conclusion: In the early post-transplant period (0-6 months), acute antibody-mediated rejection, acute ischemic injury and T cell-mediated rejection are the major causes for graft dysfunction. In the late post transplant period (> 6 months after transplant), transplant glomerulopathy, chronic calcineurin inhibitor toxicity, viral infections and graft senescence including donor derived disease result in poor late graft survival.DOI: http://dx.doi.org/10.3126/jpn.v2i3.6016 JPN 2012; 2(3): 172-179

An inhibitor of transepithelial sodium transport was found in a low molecular weight fraction obtained from serum of patients with far advanced chronic renal disease. In 18 nondialyzed patients, the mean inhibition of short circuit current (SCC) was 24.9 +/-2.2% (SE). With a comparable fraction from 11 normal subjects. SCC decreased by only 5.3 +/-1.5%. There was significantly greater inhibition with the serum fractions of patients with end stage renal disease being maintained on chronic hemodialysis than in the normal control group; but the degree of inhibition in the dialyzed population was significantly less than that observed in the nondialyzed chronically uremic patients. The inhibition of SCC produced by the serum fractions of a group of seven patients with acute renal failure was not significantly different from the control group despite the presence of high grade uremia in the former. The inhibitory fraction has characteristics identical with the uremic serum fraction which previously has been shown to inhibit p-aminohippurate (PAH) uptake by rabbit kidney cortical slices. With gel filtration through Sephadex G-25, the active fraction appears after the major peaks of substances as small as urea and sodium; hence it may have been retarded on the column. But its ultrafiltration characteristics suggest that its molecular weight may be less than 1000. The inhibitory capability was not destroyed by boiling, freezing, or digestion with chymotrypsin or pronase. Neither methylguanidine nor guanidinosuccinic acid in concentrations well above those present in the serum of uremic patients inhibited sodium transport in the frog skin. The data suggest that there is an inhibitor of sodium transport in the serum of patients with chronic uremia. The role of this material in the regulation of sodium excretion in uremia as well as its possible role as a uremic toxin are subjects of both theoretical and practical interest.

Objectives: To assess the serum creatinine and creatinine clearance values in hypertensive patients for providing information to the health-policy planners, clinical practitioners about the importance of routine monitoring of serum creatinine and creatinine clearance in hypertensive patients for prevention of ESRD and other consequences to combat morbidity and mortality and to reinforce the need to consider these parameters in daily clinical practice. Study design: It was a cross-sectional study. Setting: The study was conducted at Department of Physiology and Biochemistry of Mymensingh Medical College, Medicine Unit of Mymensingh Medical College Hospital. Study period: The period of the study was January 2005 to December 2005. Participants: A total number of seventy subjects were included in this study. Out of 70 subjects, 40 (forty) were hypertensive patients and 30 (thirty) were normotensive & healthy controls. Intervention: The subjects were selected on the basis of history and clinical examination. Convenient sampling technique was applied. During visit the available hypertensive patients and controls (normotensive & healthy) those who were present were selected. Having received their written consent they were interviewed & examined by prepared personal data sheet and sample of blood (after overnight fasting) was drawn for biochemical examination. Main outcome measure: Mean values of serum creatinine and creatinine clearance. Result: Serum creatinine was greater in hypertensive than those of normotensive. Creatinine clearance was less in hypertensive than those of normotensive. Serum creatinine & creatinine clearance in between males hypertensive & control shows that CrCl were statistically significant but not the serum creatinine. In females of hypertensive & control shows no differences in case of SCr & CrCl. Among 40 hypertensive the number of “Getting treatment - regular” & “ Getting treatment-irregular” was 14 (35%) & 26 (65%) respectively. Similarly in patients “suffering less than 5 yrs” and “suffering 5 yrs & above” the differences are also not statistically significant. Conclusion: The observations of this study revealed that most of the hypertensive patients were taking treatment irregularly and there was significant alteration of biochemical parameters in hypertensive patients. Therefore, for routine monitoring of hypertensive patients to prevent the end stage renal disease (ESRD) and other consequences, the reinforcement of the investigations of these parameters may be recommended in daily clinical practice. Key Words: Hypertension, creatinine, creatinine clearance, Cockcroft-Gault formula J Bangladesh Soc Physiol. 2006 Dec;(1):19-26.

Ten diabetics, nine requiring insulin, were kept alive on peritoneal dialysis and haemodialysis for varying periods of time, with a mean suvival rate of 7 months only per patient. The management of the cardiovascular problems affecting the brain, eye, heart, and peripheral vessels far exceeded the difficulties in managing their diabetic state. Two patients were maintained on home dialysis, one with full sight, the other with partial sight. One patient received a combined renal and pancreatic transplant and required no insulin for 8 days, succumbing from a pulmonary embolus. Patients with diabetes will be accepted in the future for regular dialysis, particularly before severe protein restriction has taken place, and before hypertension has complicated their retinal problems.

Glomerulonephritis (GN) is a common renal disease and common cause of chronic renal failure (CRF) accounts for more than one-third of patients of end stage renal disease (ESRD) requiring either dialysis or transplantation. In our country, early diagnosis and treatment of GN depends on routine urine and blood examination and using light and immunofluorescent microscopic study of renal biopsy. The purpose of this study was to demonstrate the frequency, type, intensity, pattern and site of deposition of immunoglobulin IgG, IgA, IgM and C3 by direct immunofluorescence microscopic technique (DIF) in various pattern of GN and to correlate with clinical and histopathological findings. Among 120 cases of renal biopsy, 110 cases (91.67%; n=120) were adequate for histopathologic study only and 98 cases (81.67%; n=120) were adequate for both histopathologic and direct immunofluorescence microscopic study. In this series, maximum numbers of cases were found in 21-30 age group (27.27%). Most frequent clinical presentation and pattern of glomerulonephritis were nephrotic syndrome (61.22%; n=98) and mesangioproliferative GN (40.81%) respectively. Among 98 cases of study group, 49 cases (50%; n=98) were DIF positive. The most frequent type of depositions were C3 (type) in various combinations (98%; n=49) followed by IgG (67.35%) and IgA (40%). Mesangium followed by glomerular basement membrane were the most frequent site and granular pattern was the most frequent pattern of deposition. The frequent combination of depositions in various pattern of GN were C3 + IgG (36.73%; n=49) followed by C3 + IgA (20.41%). There was a correlation between histopathologic pattern of GN and type-site-pattern of deposition in the glomeruli. Immune-depositions were cent percent in IgA nephropathy, membranous GN (MGN), diffuse proliferative GN and membranoproliferative GN. Among 15 cases of IgA neph.ropathy (15.31%; n=98), most frequent pattern and clinical presentation of GN was mesangioproliferative GN (60%; n=15) and haematuria (46.67; n=15) respectively. In this study, DIF was proved to be essential, sensitive and specific diagnostic tool in the evaluation of glomerular diseases. However, DIF study is no substitute of light microscopy but both provide information which when taken as a whole contributes to better understanding of GN. Key words: DIF; GN; CRF; ESRD DOI: http://dx.doi.org/10.3329/bjpath.v26i1.9129 BJPATH 2011; 26(1): 14-19

Background: Compared with general population mortality rates are 10-20 times higher among patients with end stage renal disease, with 50% of this excess burden being attributable to cardiovascular disease. This excess risk is not entirely explained by elevation of traditional risk factors. Elevation of several Non-traditional risk factors associated with an increased risk for cardiovascular disease in CKD and haemodialysis dependent patients. Methods: It was a case control study which included total 96 subjects, 48 were non-dialysis CKD patients, 22 Heamodialysis dependent patients and 26 healthy controls. Non-traditional risk factors homocysteine, fibrinogen, CRP, factor VII activity and haemoglobin estimated and compared with normal control population. Results: The study revealed that homocysteine , fibrinogen , CRP, factor VII significantly increased and haemoglobin was significantly low in both non-dialysis CKD and haemodialysis dependent patients in comparison to control group. Mean homocysteine 15.38, 27.30, 23.76 μmol/L in control, non-dialysis CKD and haemodialysis dependent patient respectively. Fibrinogen in control , non-dialysis CKD and haemodialysis dependent patient were 180.25 , 264.10 , 259.59 mg/dl respectively. CRP level in control, non-dialysis CKD and haemodialysis dependent patient were 3.90, 52.59, 17.31 mg/L respectively. Factor VII activity in control was 94.18%, whereas in non-dialysis CKD it was 103.97%, and 106.18 % in haemodialysis dependent patient. haemoglobin was 13.85 gm/dl in control , but in nondialysis CKD it was 8.08 gm/dl, and in haemodialysis dependent patients 9.46 gm/dl .cardiovascular disease in nondialysis CKD 54.56% and haemodialysis dependent patients 59.4% Conclusion: Haemoglobin is low and levels of homocysteine, fibrinogen, CRP, factor-VII activity are increased among the patients with CKD and haemodialysis dependent patients. Key words: Non-traditional; Cardiovascular; Chronic Kidney Disease DOI: 10.3329/jom.v11i2.5450 J MEDICINE 2010; 11 : 108-114

The study was carried out with an aim to make a correlation between radionuclide renographyand biochemical test in the evaluation of renal diseases. A total of 275 patients with a history oflow back pain were included in the study. Radionuclide renography and biochemical test weredone in most of them in consecutive days. Among them, 241 patients were finally found to bepositive. Available USG, X-ray, IVU, TC, DC, ESR and Hb% findings were also correlated wellwith renogram. Renal diseases like renal stone, acute glomerulonephritis (AGN), ureteric stone,enal abscess, chronic renal failure, end stage renal disease (ESRD) and renal trauma wereound in most of the cases. In case of radionuclide renography, mild to severe renalnsufficiency found in 87.64% cases (single & bilateral) in contrast to biochemical test wherencreased blood urea/ serum creatinine found in 30.91% cases. Our study focuses themportance of renogram technique over biochemical test for precise evaluation of differentialrenal function.doi: 10.3329/taj.v16i2.3885TAJ December 2003; Vol.16(2): 65-67

End stage renal disease (ESRD) patients receiving haemodialysis (HD) are frequently associatedwith anaemia. Zinc, being an important nutrient for haemoglobin synthesis, was studied for it'seffect, if any, on renal disease associated anaemia among patients in the HD unit of BSMMU(formerly IPGMR), Dhaka. Surprisingly, a tow plasma zinc level and a high corpuscular (RBC)zinc level was observed. All of our subjects were found anaemic. A significant correlation wasobserved between plasma zinc level on one hand and haemoglobin level as well as RBC countson the other hand. There are several suggestions for this low plasma and high corpuscular zinclevel. However, this altered zinc level in plasma and red blood corpuscles might interfere withhaemoglobin synthesis and might be one of the factors for renal disease associated anaemia.doi: 10.3329/taj.v16i1.3895TAJ June 2003; Vol.16(1): 12-14

Extract: Hormonal and metabolic factors which influence growth were studied in nine growth-retarded uremic children who received renal homografts. Post-transplant growth velocity based on bone age (GVBA) became normal in four (88–103%), accelerated in two (127–139%), and remained subnormal in three (18–50%). Serum somatomedin (SM), was very low in all children before transplant (0.39 ± 0.10 U/ml), but rose in each child after transplantation. Post-transplant somatomedin (0.84 ± 0.14 U/ml) was not significantly different from the somatomedin of eight healthy male control subjects matched for bone age (1.03 ± 0.16). Post-transplant GVBA was directly correlated (P 9.1 mg/m2/24 hr). Speculation: If low serum somatomedin activity develops in the course of end stage renal disease in children, growth retardation may be the consequence. After renal transplantation normalization of serum somatomedin activity may be a necessary although not sufficient condition for the resumption of growth.

Objective This study was cross sectional survey conducted to find the prevalence of Restless legs syndrome (RLS) in end stage renal disease (ESRD) patients on haemodialysis (HD). Methods Data were obtained from 250 patients on chronic maintenance HD. To assess the prevalence of RLS, Clinical diagnostic criteria for RLS was used which is established by the International RLS Study Group. Results Total 250 patients were included in this study. 153 (61.2%) patients were male and 97 (38.8%) were females. Mean age of the patients was 45.27 years. Mean duration of HD was 26.10 months. Total162 (64.8%) patients were found to be suffering from RLS. Out of 153 males, 87(56%) were suffering from RLS and among 97 females, 75(77.3%) were suffering from RLS. In our study, gender was statistically significantly associated with RLS (p-value 0.001). In age groups 159(63.6%) patients were below 51 years; among them 102(64.1%) were suffering from RLS; whereas 91(36.4%) patients were equal or above 51 years of age and among this group 60(65.9%) patients were suffering from RLS. There was no statistically significant association between RLS and age groups (p-value 0.776). Conclusions RLS is common in patients undergoing regular HD. It is more commonly seen in females.

From 1964 through 1971, sixty-three transplantations were performed in fifty-four children under the age of eighteen at the University of California Medical Center, San Francisco. Thirty-two of the children received their first renal graft from a related donor and twenty-one from a cadaver donor. In the living related donor group, survival of first grafts was 90 per cent at one year, and in the cadaver donor group it was 67 per cent at one year. Ten patients died during the eight year period. Linear growth of children who had reached their adult height prior to transplantation was favorably influenced by changing the prednisone schedule from daily doses to doses every other day. By performing retransplantation if graft failure occurred, 80 per cent of the fifty-four patients now have functioning grafts up to eight years postoperatively. These results show that children with end stage renal disease are favorable candidates for renal transplantation.

Objective: Critically ill patients with acute kidney injury (AKI) frequently need acute renal replacement therapy (aRRT). We evaluated an inexpensive, rapid quantitative and qualitative analysis of proteinuria on the course of AKI patients requiring aRRT in intensive care. Method: This was a prospective, observational study of critically ill patients with severe established AKI or Acute on Chronic Kidney Injury (AoCKI) requiring aRRT. Urine samples were analyzed using Sodium-Dodecyl-Sulphate-Polyacryamide Gel Electrophoresis (SDS-PAGE). Results: A total of 30 critically ill patients were studied. Those who died have higher APACHE II (29 ± 6 vs. 20 ± 5, p

Background and Objective: Hand ulcers are seen in a small percentage of patients with diabetes. The predisposing factors of diabetic hand varies between different countries. However, the effects of predisposing factors on prognosis are not clear in diabetic hand infections. In this study, our aim was to determine the effects of predisposing factors on poor prognostic outcomes in patients with diabetes mellitus. Methods: Thirty-four patients with diabetes mellitus who were treated and followed up for a hand infection in between 2008 and 2014 were investigated retrospectively. Patients were evaluated according to predisposing factors defined in the literature that included disease period, age, gender, admission time, presence of neuropathy, smoking habits, HbA1c levels at admission time, peripheral vascular disease, end-stage renal disease (ESRD), and trauma. Death and minor/major amputation cases during treatment were defined as poor prognosis. Results: Patients who had ESRD, peripheral neuropathy, or an HbA1c level greater than 10% had significantly higher amputation rates. Conclusions: Peripheral neuropathy, ESRD, and HbA1c levels greater than 10% at the time of admission were determined as poor prognosis criteria for diabetic hand treatment.

Background: Hypertension is commonly found in patients with Diabetic Kidney Disease (DKD). Microalbuminuria is the first clinical sign of involvement of kidneys in patients with type 2 diabetes. Uncontrolled hypertension induces a higher risk of cardiovascular events, including death, increasing proteinuria and progression to kidney disease. Objectives: To determine the correlation between microalbuminuria and hypertension and their association with other risk factors in type 2 diabetic patients. Methods: One hundred and thirteen type 2 diabetic patients attending the diabetic clinic of Shaikh Zayed Postgraduate Medical Institute, Lahore, Pakistan were screened for microalbuminuria and raised blood pressure. The study was conducted from November 2012 to June 2013. Results: Patients were divided into two groups. Group 1, those with normoalbuminuria (n=63) and Group 2, those having microalbuminuria (n=50). Group 2 patients showed higher blood pressure values as compared to Group 1. The results were statistically significant and showed poor glycemic control as a contributing risk factor. Conclusion: The study concluded that there is high frequency of hypertension among type 2 diabetics but still much higher among those having microalbuminuria. So, early recognition of renal dysfunction through detection of microalbuminuria and to start treatment without any delay will confer future protection from end stage renal disease as well as hypertension and its complications in type 2 diabetic patients.

This study was undertaken to define the hemodynamic changes in hypertension of chronic end-stage renal disease. Mean cardiac index in 75 uremic patients was higher ( P < 0.001) than that of 42 normal volunteers while stroke index was not different from normals. The higher cardiac indices of uremic patients were accounted for by increased heart rates. Despite the significantly higher blood pressure in the uremics, their mean total peripheral resistance index was not different from that of normals. The total group of 75 patients included 52 hypertensive and 23 normotensive uremics. Cardiac index, heart rate, and stroke index were the same in 52 hypertensive and 23 normotensive uremics while mean total peripheral resistance index of hypertensive uremics was higher ( P < 0.001) than normotensive uremics. Therefore, the hypertension in end-stage renal disease is sustained by a high total peripheral resistance. Bilateral nephrectomy in 12 hypertensive uremics resulted in no changes in cardiac index; a consistent decrease in blood pressure ( P < 0.001) and a decrease in total peripheral resistance index ( P < 0.001) occurred. Bilateral nephrectomy in eight additional uremics with malignant hypertension resulted in an actual increase in cardiac index ( P < 0.001) with a consistent reduction in blood pressures ( P < 0.001) and an even more dramatic decrease in total peripheral resistance ( P < 0.001). These findings imply that a vasopressor substance of renal origin increasing peripheral resistance is the major factor in the pathophysiology of renal hypertension in the late stage of its natural history.

Wegener's granulomatosis, a disease of multi-system involvement, has been uniformly fatal until antimetabolite drugs were introduced into its management. Effective control of the systemic manifestations by immunosuppression justifies renal transplantation as a logical extension of therapy in a select group of patients with end stage renal disease.

Eighteen patients with end-stage renal failure secondary to primary bilateral vesicoureteral reflux are presented. These cases document a potential terminal phase in the natural history of vesicoureteral reflux. Five patients had sterile reflux alone, and four patients probably had sterile reflux until urinary tract infection occurred at our near endstage renal failure. The remaining patients had reflux associated with recurring urinary tract infection. Early diagnosis and proper management are important in vesicoureteral reflux.

Although it is well known that hypertension is often associated with renal parenchymal disease, especially in its terminal phases, the nature of this relation has not been defined. Efforts to study this problem in animals have not proved fruitful. Renal disease as produced in animals only irregularly results in hypertension, and no satisfactory model for this form of hypertension has yet emerged. Contradictory and confusing results have also occurred in the accumulated experience with patients studied during dialysis and in transplantation programs. In recent years, it has become evident that blood pressure in anephric patients is sensitive to changes in . . .