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Glomerular filtration rate (GFR) was measured in 9 voluntary male kidney donors by scintigraphy. In the basal state, the mean GFR was 96.1 +/- 22 ml/min/1.73 m2. Four weeks after donor nephrectomy, the GFR of the remaining kidney had increased by 22.8 +/- 20.7% (p0.05). A protein meal given at this time failed to significantly augment the GFR. The GFR of the grafted kidney increased by 59.7 +/- 24.4% after 6 months (p0.01). Renal functional reserve was thus demonstrated in the remaining kidney and the allograft, though a further reserve could not be elicited in the remaining kidney.

Summary: Impaired allograft function is an important cause of hypertension in cadaveric renal transplant recipients. the risk factors for post-tranplant hypertension in living related transplant recipients with inherent good graft functions are likely to be different and have not been studied. In addition, controversy surrounds any independent effect hypertension might have on renal allograft functions. Four hundred and seventy three living related renal allograft recipients were retrospectively analysed to study the risk factors for development of post-transplant hypertension and its effect on graft outcome. Prevalence of hypertension was 76.1%. the presence of pre-transplantation hypertension was the most important independent risk factor for development of hypertension after transplantation. This suggests an important role of retained native diseased kidneys as a cause of hypertension. Other risk factors included: cyclosporin A immunosuppression, patient age less than 40 years and the presence of renal insufficiency at last follow up. Hypertension did not have any effect on patient or graft survival during the mean follow-up period of 20.1 ± 13.7 months; however, it was associated with an independent risk for the presence of renal insufficiency in the post-transplant period.

Summary: Data on zinc status in Indian patients with chronic renal failure is lacking. There are conflicting data in the literature on plasma and erythrocyte zinc levels in renal failure patients and the effect of haemodialysis on zinc status. of the multiple factors believed to be involved in the pathogenesis of uraemic impotence, attention has been focused on the possible role of zinc depletion and hyperprolactinaemia. We report a longitudinal study on 27 patients with end-stage renal disease (ESRD). Plasma and erythrocyte zinc, serum prolactin and serum total testosterone were studied at diagnosis, 4 weeks after haemodialysis, and 3 and 6 months after successful renal transplantation. Zinc status and hyperprolactinaemia are both normalized within 6 months after renal transplantation. While there was a significant positive correlation between plasma zinc and serum testosterone, there was no correlation between serum prolactin and testosterone. This observation suggests that plasma zinc may be a more important determinant of normal gonadal function than prolactin in renal transplant recipients.

Summary: The aim of this study was to compare the alimentary phosphate-binding capacity of calcium acetate to calcium carbonate in stable chronic renal failure patients who were not on haemodialysis. Intestinal absorption of phosphate and calcium was measured on three occasions in five patients with chronic renal failure who were not on maintenance haemodialysis. During each test period they received either no drug, calcium carbonate or calcium acetate (both containing 1g elemental calcium) in a randomized manner, along with a standardized meal. Intestinal contents were recovered after 10h by whole gut lavage, and phosphorus and calcium measured in meal and intestinal contents. Faecal excretion of ingested phosphorus increased from 13.85% in the absence of drug to 29.91% after calcium carbonate administration. Phosphorus excretion was significantly higher after calcium acetate (43.92%) compared to calcium carbonate (P

Summary— A retrospective study of 1000 live renal transplants was performed in order to assess the factors associated with hypertension in renal transplant recipients. The prevalence of hypertension prior to transplantation was 48%. The need for antihypertensive drugs decreased in 43%, increased in 31% and remained the same in 26%. The presence of hypertension before transplantation, rejection episodes, transplant renal artery stenosis and native kidney disease were the main factors associated with post-transplant hypertension. An algorithm for the management of post-transplant hypertension is suggested.

Delay in reporting the immunofluorescence findings on renal biopsies, owing to an interruption in supply of reagents, made possible a retrospective analysis of the effect of the lack of this information on patient management. Hospital case records of the 39 patients so affected were reviewed to determine what changes in their management took place after the immunofluorescence findings became available. The clinical, laboratory, and light microscopic findings in all except a case of pauci-immune crescentic glomerulonephritis allowed management decisions to be made that were not influenced by immunofluorescence findings. This was owing to correct prediction of the immunofluorescence findings, as in cases of IgA nephropathy presenting with recurrent haematuria; the adequacy of light microscopy in the interpretation of graft biopsies, in classifying lupus nephritis and in most cases of nephrotic syndrome; and the absence of entities identifiable only by immunofluorescence among these patients.

Eighty patients with non-insulin-dependent diabetes mellitus being treated in a south Indian hospital were biopsied to confirm suspected nondiabetic renal disease (NDRD). The positive predictive value of the standard clinical indicators for NDRD in the presence or absence of diabetic retinopathy was 54 and 87%, respectively. These values are higher than those given by comparable studies in Western populations. This is probably due to a higher prevalence of NDRD in the population of south India, and especially of proliferative glomerulonephritis, which was found in 21.5% of the patients studied. Standard clinical predictors of NDRD in diabetics have a high predictive value in the tropics where there is a high prevalence of proliferative glomerulonephritis.

A randomized, controlled trial was conducted in a pediatric unit in a teaching hospital in India to assess the efficacy of levamisole in maintaining remission in children with steroid-sensitive nephrotic syndrome. Sixty-one children with steroid-sensitive nephrotic syndrome, who had achieved remission with corticosteroids, were allocated to a treatment group (33 patients) receiving levamisole (2-3 mg/kg/day) twice a week for 12 months or to a control group (28 patients) receiving no treatment. The main outcome measure was duration of remission. Thirty months later, in the levamisole group, 21 of 33 patients were in remission as against 12 of 28 patients in the control group (chi 2 = 2.54, p = 0.11, NS). The median duration of remission maintenance was 12 months in the levamisole group as compared with 10.5 months in the control group. On survival analysis, the difference in duration of remission maintenance between the two groups was not significant (p = 0.10), though there was a trend in favor of the treatment group. On stratified survival analysis, multiple relapsers in the levamisole group had longer remission maintenance than the control group though this did not reach statistical significance (p = 0.08). The clinically significant trend towards increased duration of remission maintenance in steroid-sensitive nephrotic syndrome observed with levamisole therapy, especially in patients with multiple relapses, may require a larger study with a longer follow-up for definitive confirmation.

The prevalence of post-transplant diabetes mellitus in 222 consecutive live related renal allograft recipients over a 3-year period was found to be 11.7%. Most of them (20 of 26) developed diabetes mellitus within the first 4 months of transplantation. Post-transplant diabetic patients were older, and had a significantly greater incidence of avascular necrosis of bone. An assessment of risk factors showed that abnormal postprandial blood sugar pretransplant was a significant predictor for development of post-transplant diabetes, whereas cumulative oral steroid dose, weight gain after transplant, type of immunosuppression employed, and graft function were not important. We conclude that post-transplant diabetes mellitus frequently develops in patients with a predisposition by virtue of older age and pretransplant postprandial hyperglycaemia. While steroids are important in the pathogenesis, there was no demonstrable dose-response relationship; post-transplant diabetic patients may be a group with a greater propensity to steroid-induced complications.

Of 213 renal allgraft recipients suspected to have had pulmonary tuberculosis, 132 had sputum examinations and 14 showed acid-fast bacilli. Of the remaining 118 patients, 25 had gastric aspirations, 18 had bronchoalveolar lavage, and 75 did not require further investigation because of spontaneous improvement or confirmation of an alternative diagnosis. While 9 of the 25 patients' gastric aspirate examination was positive, all the 18 who had bronchoalveolar lavage were negative for acid-fast bacilli. Eighty-one patients without expectoration had gastric aspiration directly and 14 showed acid-fast bacilli. Of the remaining 67 patients only 17 had bronchoalveolar lavage, of which three were positive for AFB and the rest did not require further testing for tuberculosis. A total of 106 patients had gastric aspiration. Acid-fast bacillus positivity was significantly more (P

Forty-six patients from 23 Indian families with hereditary chronic nephritis (HCN) with or without Alport's syndrome are presented. The occurrence of this disease in diverse Indian races, communities and castes is now documented. Clinical and laboratory findings in these patients are similar to those reported from temperate regions.

A 32-year-old male patient developed headaches, vomiting, blurring of vision, and focal seizures of the left side of the face 2 months after a renal transplant. He developed a brain abscess and died. Direct KOH examination of the brain tissue demonstrated hyaline as well as dematiaceous, septate hyphae. Histologic examination of brain sections revealed polymorphous fungal elements consisting of septate, dark-pigmented hyphae, intercalary and terminal swollen fungal cells, and budding yeastlike cells characteristic of phaeohyphomycosis. Chaetomium globosum was isolated from the brain tissue on all of the fungal media used. This case represents the first histologically and culturally documented phaeohyphomycotic brain infection caused by C. globosum.

The clinical pattern of nephropathy was studied in 498 diabetic patients who were hospitalized during the period 1980-1985 at the Christian Medical College Hospital, Vellore, India. The diagnosis of nephropathy was confirmed in the presence of persistent proteinuria of 500 mg or more in any 24 hour urine sample in the absence of urinary infection and congestive failure. Only four patients had Type I diabetes, all the rest being non-insulin-dependent (Type II). There was significant male preponderance, and the largest number of patients were in the fifth and sixth decades. The age of onset in Type II diabetics was between 30 to 50 years in 74%; 55% of the patients were known to have diabetes for less than 10 years, and in only 6% was the duration greater than 20 years. The degree of renal failure and proteinuria showed a variable pattern in relation to the duration of diabetes. Arterial hypertension was present in 80% of the patients and coronary artery disease in 33.5%, while cerebrovascular disease and peripheral vascular disease were evident in 7.4 and 4.8%, respectively. Fundoscopic examination showed evidence of retinopathy in 278 patients (53%), with proliferative changes in 17%. Clinical evidence of retinopathy was absent in 110 patients (22%), and in the rest the results of fundus examination was not documented; thus, the incidence of clinical retinopathy in this review was 72% (278/388). It is concluded that contrary to what has been observed in Type I diabetes, the progression of nephropathy in Type II bears no relationship to the duration of disease, nor is retinopathy a constant feature.

SUMMARYSeventy-eight children were treated for the haemolytic-uraemic syndrome complicating bacillary dysentery over a ten-year period. Early dialysis favoured survival significantly. The renal status of 22 of the 28 survivors was re-evaluated 18–84 months after initial hospitalization. Complete recovery was found in all except two patients; one of them had neurological sequelae and the other a glomerulonephritic disease.

Cryptococcus coagglutination (COA) test reagent was prepared locally and showed no cross reactions with different species of bacteria or yeasts or with 75 control sera including 25 that gave positive results for RA factor. We used the COA test to detect cryptococcus antigen in the CSF and we could confirm the diagnosis of 11 out of 115 suspected cases of fungal meningitis; the titre varied from 4 to 128. A four-fold rise in titre confirmed the diagnostic value and a steady fall in titre in three patients on therapy indicated the prognostic value of the test. The earliest confirmation was in a renal transplant patient on the eighth day after onset of symptoms. The COA test was negative with the CSF of 118 patients with chronic meningitis. Cryptococcal colony forming units (cfu) in CSF varied from 100 to greater than 100,000/ml and correlated well with microscopy and with the COA antigen titre in CSF. Four out of the 11 patients who had cryptococcaemia, had 50,000-100,000 cfu/ml in the CSF. Cryptococcus antigen was detected by COA in the serum of all 11 patients, even in those with only 100 cfu/ml in CSF. In the three post-renal transplant patients, who were being monitored regularly, the diagnosis was made early and all three recovered on antifungal therapy with no relapse to date (1-2 years). All the others, including the two primary CNS infections, succumbed to the disease because they presented late for diagnosis and therapy. The cryptococcus COA test is a simple and specific test that can be used as a rapid test to confirm early diagnosis and permit prompt therapy, which should improve the prognosis in CNS and other forms of systemic cryptococcosis. Moreover, it is reproducible and cost-effective, particularly in countries where the latex and other expensive test reagents are not generally available.

A case is reported of Bancroftian filariasis and acute immune complex glomerulonephritis in a 44-year-old man. Renal biopsy showed microfilariae and large numbers of eosinophils in the glomeruli (eosinophilic glomerulonephritis). The absence of other aetiological factors suggests that the glomerulonephritis may have been of filarial origin.

Paraffin-embedded renal biopsy material from 50 cases of membranoproliferative glomerulonephritis (MPGN) was studied by thioflavin T staining and electron microscopy. Glomerular capillaries showed bright diffuse linear thioflavin T fluorescence in all cases of MPGN type 2 and also in some cases of MPGN types 1 and 3. This pattern of fluorescence appears to be related to the extent of intraglomerular deposits, rather than their location or nature.

Electron microscopic examination of renal biopsies from nine patients who developed renal failure after Russell's viper bite showed glomerular mesangial hypercellularity, vascular endothelial swelling, tubular epithelial necrosis and shedding, acellular segments of tubular basement membrane and an interstitial infiltrate composed of mast cells, eosinophils, lymphocytes and plasma cells. These cells showed many close contacts with each other and with fibroblasts. Severe vascular and tubular lesions were also present in the medulla. These abnormalities and other reported clinical and laboratory investigations in this condition, suggest that the primary lesion is a reversible intravascular coagulation with secondary ischaemic tubular damage. The inflammatory response in the interstitium is probably initiated by a release of antigens from damaged tubules.

SUMMARYAn analysis of hospital case records showed that haemolytic-uraemic syndrome complicating bacillary dysentery was the most important cause of acute renal failure in south Indian children. It was present in 39% of 179 children treated for acute renal failure in this hospital during the decade 1969–1978. This condition was first diagnosed in 1971 and its prevalence was highest in 1977. Other causes of acute renal failure of geographical interest, encountered in this study, included cholera and snakebite.

A review of 85 patients aged 60 years or more, treated in a southern Indian hospital for conditions requiring renal biopsy, showed that diffuse poliferative glomerulonephritis was the most frequent diagnosis, being present in 24 cases of whom 11 had elevated serum streptococcal antibody titres. Infections were also important in 2 patients with amyloidosis secondary to tuberculosis, in 3 patients with acute tubular necrosis following infectious gastroenteritis and in a patient with acute pyaemic interstitial nephritis with septicaemia. Drugs including indigenous medicines were the other important cause of renal disease, being implicated in 11 cases.

Nephrotic syndrome was the commonest clinical presentation among 2827 consecutive adult Indian patients from whom adequate kidney diopsies were obtained for suspected renal disease. In 83 per cent of cases the nephrotic syndrome was due to minimal change disease, focal segmental glomerulosclerosis, mesangiocapillary glomerulonephritis, membranous glomerulonephritis, lupus glomerulonephritis or diabetic glomerulosclerosis. Amyloidosis, usually secondary to tuberculosis or leprosy, was present in only 34 patients. Acute nephritis, the next most frequent clinical presentation, was due to diffuse endocapillary proliferative, crescen-tic or mesangial proliferative glomerulonephritis in 88 per cent of cases, almost half of whom had elevated serum streptococcal antibody titres. Eosinophilia showed a highly significant association with diffuse endocapillary proliferative and mesangiocapillary glomerulonephritis. Idiopathic IgA nephropathy was present in only 10, and antiglomerular basement membrane antibody disease in only one, of the 238 patients whose biopsies were studied by immunofluorescence. Complications of pregnancy accounted for 70 per cent of cases of cortical necrosis. Acute gastroenteritis, septicaemia, abortions, snake bite and allopathic and indigenous medicines were important causes of acute tubular necrosis.

We studied the clinical profile of 296 non-insulin-dependent diabetic (NIDDM) patients with nephropathy and renal failure. Male preponderance was striking in this group and the age of onset of diabetes was between 30 and 50 years in 75%. Retinopathy was present in 86% with proliferative changes in 20% and coronary artery disease was evident in 40% of the patients. The incidence of retinopathy and coronary artery disease was significantly higher in this group than in a group of non-insulin-dependent diabetics without nephropathy (86% vs. 18.5%; 40% vs. 30% respectively, P less than 0.01). It is our observation that patients with NIDDM developing nephropathy and renal failure have had an early onset of disease and are significantly more often male. There is also a greater incidence of elevated blood pressure, coronary artery disease and retinopathy in this group.

Infections were a major cause of death in 84% of 38 autopsied renal allograft recipients in a south Indian hospital. Pyogenic bacteria and fungi were the most common etiological agents encountered, being present in 50 and 47% of cases, respectively. Tuberculosis and hepatitis B virus infection were more prevalent and Pneumocystis carinii and cytomegalovirus disease rarer than in comparable series from non-tropical countries. 1 case each of amoebiasis, strong-yloidiasis and filariasis were the parasitic infections encountered.

Electron microscopy of renal biopsy material from 50 patients with membranoproliferative glomerulonephritis treated in a southern Indian hospital, showed a low prevalence of type 2 (dense deposit) disease. Eosinophilia was seen in more than one-third of the 41 patients with type 1 disease. Associated diseases and possible sources of chronic antigenaemia found in some patients included: streptococcal infection, Bancroftian filariasis, tropical pulmonary eosinophilia, hepatitis B surface antigenaemia and lepromatous leprosy.

L'utilisation preventive de dipyridamole n'a pas influence le fonctionnement de la greffe et n'a pas eu d'effet benefique sur la fonction renale pendant 1 an apres la transplantation

Prednisolone pharmacokinetics and protein binding characteristics were studied in 10 renal transplant patients with various degrees of renal function (serum creatinine: 80-380 mumol/l) who received their usual oral maintenance dose of prednisolone (0.18 +/- 0.04 mg/kg). Plasma was assayed for prednisolone and hydrocortisone by h.p.l.c. and free prednisolone concentrations were determined in each sample by a rapid ultrafiltration technique. Free prednisolone area under curve (AUCu) ranged from 101 to 436 ng ml-1 h and was 6.3 to 15.0% of total prednisolone AUC. The fraction AUCu/AUC was closely related to serum albumin and creatinine concentrations determined at the time of study (multilinear regression correlation coefficient r2 = 0.830, P less than 0.0001); elevated serum creatinine and low albumin concentrations were associated with a higher % free. These results suggest that much of the variability in prednisolone protein binding could be attributed to inter-patient variability in serum albumin and creatinine concentrations. Total prednisolone concentrations would be potentially misleading in any comparisons made between patient groups with different renal function.

The electron microscopic appearances of renal biopsy material from four children who developed the haemolytic-uraemic syndrome as a complication of bacillary dysentery are described. Glomerular lesions present included deposits of fibrin and platelets, subendothelial rarefaction and lysis of endocapillary cells with or without necrosis of glomerular epithelial cells and periglomerular tissue. Tubular epithelial necrosis and cytoplasmic degeneration with an infiltrate of lymphocytes and plasma cells were also seen. It is likely that the different glomerular lesions result from thrombosis and obstruction of blood vessels at various levels of the intrarenal circulation. The tubulo-interstitial changes appear to be secondary to glomerular lesions.

Complement components were detected in the urine of patients with filarial chyluria. Their presence probably resulted from the escape of lymph into the urinary tract. Serum C4 was in the low normal range, whereas serum C3c was increased, probably in response to inflammation.

Fifty-eight previously untreated adults with minimal-change nephrotic syndrome (MCNS), who had a mean follow-up period of 35.8 months, were studied with regard to their response to alternate-day steroid therapy. The nephrotic syndrome in 54 patients (93%) remitted by 12 weeks and patients continued to be in remission at 16 weeks. Of the 54 patients, 8 (14.8%) had frequent relapses and 9 (16.6%) had infrequent relapses. No serious complications as a result of steroid therapy were encountered.

Toutes les greffes rejetees ne doivent pas etre enlevees avant la retransplantation. L'immunodepression peut etre progressivement reduite et arretee en cas d'indication chez certains malades sans effets nefastes sur la greffe rejetee ou sur les greffes ulterieures