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Seventeen children with renovascular hypertension were managed at the Royal Children's Hospital, Melbourne, over the 20-year period from 1975 to 1996. The age at presentation ranged from 10 days to 18 years. All children presented with severe hypertension with mean systolic blood pressure 7 standard deviations above age-matched averages and mean diastolic blood pressure 5.5 standard deviations above age-matched averages. Neurofibromatosis was the most common etiology (58% of patients) and there were no cases of Takayasu's arteritis. Patients underwent a variety of biochemical and imaging investigations but in all cases renal angiography was necessary for definitive diagnosis and for planning therapy. Ten of the 17 patients had surgical procedures performed. Percutaneous transluminal angioplasty was performed in four patients but led to cure in only one patient following thrombosis of the affected artery producing segmental renal infarction. Other vascular reconstructive procedures, including the use of autologous or synthetic bypass grafts and autotransplantation, produced cure of hypertension in 50% of children with improvement in a further 30%. The long-term outlook for children treated with surgical reconstructive procedures was excellent. One patient underwent surgery for avulsion of an arterial graft following a pubertal growth spurt. No other patient originally cured by surgery has required reoperation with no cases of restenosis at a mean follow-up of 11 years 3 months.

Infections are an important cause of mortality and morbidity in renal transplant recipients. To study the impact of anti-rejection therapy on the timing of infections, the records of 599 consecutive renal transplants, performed prior to 31 December 1996 at the Royal Melbourne Hospital, were reviewed. Patients were grouped according to acute rejection (AR) episode and treatment during the first 6 months after transplantation. Group 1 [n = 168 (35%)] patients did not experience any episode of AR. Group 2 [n = 169 (35%)] patients had one or more episodes of AR and received high doses of steroids. Group 3 [n = 141 (30%)] patients had more than one episode of AR and received anti-lymphocyte antibodies in addition to high doses of steroids. Infections were more common in Groups 2 and 3 but only cytomegalovirus (CMV) disease occurred earlier in patients treated with lympholytics. Given the high incidence and early onset of CMV disease in patients receiving lympholytics and considering that an effective prophylactic protocol remains undetermined, pre-emptive treatment with ganciclovir in this high risk group appears justified.

Morphometric quantitative analysis of the renal arterioles (arteriole wall thickness and overall vessel size) in renal biopsies from 21 cadaveric renal allograft recipients taken immediately prior to (0 months) and 3 months after transplantation was carried out using a computer-aided image analyzer. Patients (n = 10) who received standard therapy (cyclosporine, azathioprine and prednisolone) showed an increase in arteriole wall thickness at 3 months compared to 0 months (p0.01). Patients (n = 11) who received standard therapy and oral diltiazem (60 mg t.d.s.) showed no such change in the arteriole wall thickness between 0 and 3 months. As cyclosporine toxicity and/or chronic vascular rejection are associated with an increase in arteriole wall thickness, the differences observed in this study may imply a protective role for diltiazem on renal arterioles.

We performed a prospective randomized trial, comparing the incidence of peritonitis between a flush-disconnect (O-System, Baxter, Deerfield, IL) (OS) and a conventional (System II, Baxter) (CS) continuous ambulatory peritoneal dialysis (CAPD) method. Sixty consenting patients with no significant physical disabilities who commenced CAPD after May 1987 were entered and followed for a minimum of 12 months. Thirty were placed on the OS system and 30 were placed on CS. Age, gender, and time for training did not differ significantly. The period of observation for OS was 375 months; CS was observed for 430 months. OS patients experienced 28 episodes of peritonitis (13.4 months/patient/episode) compared with 88 (4.9 months/patient/episode) in CS (p less than 0.005). By 6 months, 32% of OS patients had had at least one episode of peritonitis, compared with 62% of CS patients; at 12 months, these figures rose to 48% for OS and 91% for CS (p less than 0.01) patients (Life Table Analysis). The median survival time to first peritonitis episode was 5.1 months in CS and 9.7 months in OS (p less than 0.01). Exit-site infections occurred in 14/30 (46%) of patients on OS and in 13/30 (43%) of CS patients. We conclude that the OS was associated with a significant reduction in the incidence of peritonitis.

Of 52 patients with mesangial IgA nephropathy, 25 were allocated to treatment with cyclophosphamide (6 months), and dipyridamole and warfarin (2 years) and 27 to no treatment in a randomized prospective 2-year study. At entry, the treated and untreated groups of patients did not differ in mean serum creatinines, urinary protein excretions, quantitative urinary erythrocyte counts or blood pressure readings. At the end of the trial mean (+/- SEM) serum creatinine values had gone from 0.12 +/- 0.01 to 0.13 +/- 0.01 mmol/l (p less than 0.05) in untreated patients and from 0.10 +/- 0.01 to 0.12 +/- 0.01 mmol/l (p less than 0.05) in treated patients. Mean (+/- SEM) log values of urinary erythrocyte (rbc) counts had not changed significantly from 5.47 +/- 0.09 to 5.21 +/- 0.14 log rbc/ml in untreated patients, from 5.45 +/- 0.11 to 5.49 +/- 0.19 log rbc/ml in treated patients. However, in treated patients, mean (+/- SEM) urinary protein excretions decreased from 1.67 +/- 0.35 to 1.15 +/- 0.31 g/24 h (p less than 0.01) whereas in untreated patients urinary protein was unchanged between initial values of 1.76 +/- 0.34 and follow-up at 1.89 +/- 0.45 g/24 h. No significant changes in blood pressure occurred in either group. This study supports the observation that treatment of IgA nephropathy with cyclophosphamide, dipyridamole and warfarin is associated with a reduction of urinary protein excretion but a significant effect on preservation of renal function, at least as determined by serum creatinine values, could not be confirmed over this two-year study.

Twenty-two patients with crescentic anti-GBM nephritis or Goodpasture's syndrome with renal impairment were reviewed. All patients were treated with a combination of plasma exchange and immunosuppression. Sixteen patients (73 per cent) showed improvement in renal function (greater than 30 per cent reduction in serum creatinine level) apparently in response to treatment, and nine patients (41 per cent) made long-term recoveries in renal function. The most important features carrying a bad prognosis were total anuria, and/or a very high percentage of glomeruli showing crescents (greater than 85 per cent) in the initial renal biopsy. Some patients with other so-called 'bad' prognostic features, including severely impaired renal function at presentation, oliguria and the need to institute dialysis had unexpected marked improvement in renal function and/or recovered renal function in the long term provided treatment with plasma exchange was begun promptly and maintained for a sufficient period to allow resolution of the disease process. Renal biopsies at the beginning and later proved to be an extremely valuable guide for the progress and outcome of the disease.

It has recently been proposed that renal cortical interstitial fibrosis is causally related to progressive decreases in glomerular filtration rate in a variety of renal diseases including glomerulonephritis. One hundred and eighty-eight renal biopsies in 81 patients with mesangial IgA nephropathy were analyzed for the percentage of relative interstitial volume by a point-counting technique. These data were correlated with serum creatinine, endogenous creatinine, endogenous creatinine clearance, and from age-matched donors were used as controls for the interstitial volume measurement. There was a negative nonlinear correlation between percentage of interstitial volume measurement. There was a negative nonlinear correlation between percentage of interstitial volume and creatinine clearance (r = 0.601, p less than 0.001). These correlations were not explained by age. However, serial biopsies in 39 patients clearly demonstrated that the percentage of interstitial volume could be dissociated from creatinine clearance. The prognosis in individual patients for progression to chronic renal failure could not be predicted from the relative interstitial volume at initial biopsy. Patients with mesangial IgA nephropathy demonstrated higher interstitial volumes than age-matched cadaver donors (p less than 0.001). Although interstitial volume and creatinine clearance are inversely related, the ability to dissociate these two variables in serial biopsies draws into question the hypothesis that interstitial fibrosis is causally related to changes in creatinine clearance. Studies to validate this hypothesis should involve patients followed with serial biopsies and renal function studies. In mesangial IgA nephropathy, interstitial changes are most likely secondary to the activity of the glomerular process.

To determine the effects of long-term lithium therapy, we have studied the renal histology and the renal function of 47 patients with affective disorders who were either currently receiving or had previously received maintenance lithium therapy (lithium patients), and we have compared the results with those of 32 other psychiatric patients with similar affective illnesses who had never taken lithium (prelithium patients). The renal biopsy samples, analyzed by a point-counting technique for interstitial fibrosis, were not different in degree between the lithium and the prelithium patients. Interstitial fibrosis was also not different between prelithium patients and age-matched transplant donor kidney controls, but it was greater in lithium patients when compared with the donor kidney controls (P less than 0.01). The specific distal tubular lesion associated with lithium therapy was present in all the biopsy samples of the patients who were currently receiving lithium therapy. Marked distal nephron dysfunction, as measured by urinary concentrating ability (P less than 0.0001) and urinary acidification (P less than 0.0001), was evident in lithium patients compared with the prelithium patients. These defects were correlated with the duration of lithium therapy. Serum creatinine estimations (P less than 0.01), serum beta-2 microglobulins (P less than 0.01), and 51Cr-EDTA clearances (P less than 0.01) suggested some impairment of GFR in lithium patients compared with prelithium patients. These defects did not correlate with the duration of lithium therapy. From these studies we concluded that the marked distal nephron dysfunction induced by lithium might produce prerenal impairment of GFR because the renal function abnormalities have no structural basis when the degree of interstitial fibrosis of other psychiatric patients is used as a control. Prospective studies are needed to answer the controversial question of whether stable maintenance lithium therapy produces chronic nephrotoxicity.

Two intersex dogs with various degrees of mosaicism in the somatic tissues are described. Normal female cells as well as Y-bearing cells with aneuploidy and other abnormalities were involved. In the Red setter an ovarian cortex had developed in mosaic gonads with 8 and 10% of Y-bearing cells. Slight masculinization of the medullae corresponded with some external virilization. These observations support the existence of a threshold proportion of Y-bearing cells for testicular differentiation. Fragments of chromatin in 36% or fewer of the cells in the Cocker spaniel may have been translocated Y-chromosome material.

Thirty-seven patients with biopsy proven mesangial IgA nephropathy were prospectively allocated to either two years of treatment with eicosapentanoic acid (EPA) 10 g per day or no treatment. At entry treated and untreated patients with renal dysfunction (Group A) or patients with normal serum creatinine less than 0.12 mmol/l (Group B) did not differ in serum creatinine, creatinine clearance, urinary protein excretion, or quantitative urinary red cell counts. Compliance with EPA therapy was excellent as assessed by plasma fatty acid profiles. At the end of the trial creatinine clearance in treated patients had gone from 80 +/- 16 to 57 +/- 17 ml/min (p less than 0.05) and in untreated patients from 76 +/- 18 to 55 +/- 14 (p less than 0.05). There were no beneficial effects in either Group A or Group B patients. The only two patients who had improvement in renal function were in the EPA treatment group. Although no side effects of treatment were noted, EPA does not alter the course of established mesangial IgA nephropathy.

Our experience of CAPD in 21 patients over a total period of 118 patients months has been evaluated and compared with intermittent peritoneal dialysis (IPD). CAPD was associated with greater clearance of urea creatinine and phosphate, higher concentrations of haemoglobin, improved control of hypertension and saline overload, and better patient acceptance than IPD. It is concluded that CAPD is an effective form of dialysis with many advantages over IPD, although the incidence of peritonitis is still twice that IPD.

The clinical signs and neuropathology are described of five animals which survived cardiac arrest for various periods of time. The pathogenesis and widespread distribution of the lesions in the brain indicate the necessity of initiating treatment as soon as possible. Methods of treatment are discussed. Resume. Description du tableau clinique et des lesions neurologiques de cinq animaux ayant survecu un temps variable a un arret du cœur. La pathogenie et l'etendue des lesions cerebrales prouvent la necessite d'instituer le traitement aussi precocement que possible; les auteurs discutent les modalites therapeutiques. Zusammenfassung. Die klinischen Zeichen und die Neuropathologie von funf Tieren werden beschrieben, die einen Herzstillstand verschieden lange Zeiten uberlebten. Die Pathogenese und die breite Verteilung von Lasionen im Gehirn deuten auf die Notwendigkeit, eine Behandlung so rasch wie moglich einzuleiten. Behandlungsmethoden werden besprochen.