Drug trials: treatment of urinary tract infection with multiple-dose intramuscular administration of cephamandole

Therapy with cephamandole (1.0 g, every eight hours) for five days was effective in eliminating cephamandole-sensitive microorganisms from the urinary tract. A 75% cure rate was achieved in a group of 20 patients, 45% of whom had abnormalities of the urinary tract. Local pain (despite addition of lignocaine) was sufficiently prolonged and severe to make multiple-dose intramuscular administration unacceptable. No other toxic effects were encountered.

Use of labetalol in moderate to severe hypertension

An open study was undertaken in 31 patients with moderate to severe hypertension to compare labetalol (a competitive antagonist of both alpha-adrenoreceptors and beta-adrenoreceptors) alone and in combination with a thiazide diuretic, with a combination of thiazide, beta-adrenergic blocking agent and the alpha-adrenoreceptor blocker prazosin. After introduction of labetalol, six patients withdrew because of intolerable side effects. All 25 remaining patients were controlled on diuretic and labetalol. On labetalol alone, 14 patients were controlled, two withdrew because of side effects and nine had inadequate blood pressure control. Labetalol is an effective antihypertensive agent, but side effects are common and it has few advantages over drugs presently available.

Acebutolol in mild to moderate hypertension: a double-blind crossover study

The effect of acebutolol (Sectral) was compared with that of placebo in 30 patients with mild to moderate hypertension who were receiving a thiazide diuretic. Ten patients did not complete the study. In the remaining 20 patients, acebutolol (mean dose, 910 +/- 408 mg/day) produced significantly greater reduction both in supine and in erect systolic and diastolic blood pressure over 16 weeks than placebo plus chlorothiazide P less than 0.005). Pulse rate also fell significantly. Four patients did not have a consistent reduction in blood pressure. Acebutolol was found to be an effective hypotensive agent with relatively few side effects.

Thrombotic thrombocytopaenic purpura and anuria: response to plasma exchange

This report discusses the treatment and recovery of a 29-year-old woman with thrombotic thrombocytopaenic purpura complicated by servere renal failure. The case is reported because of the rarity of recovery from anuric renal failure in this disease and the probable contribution of plasma exchange to this recovery.

Mesangial IgA nephropathy in pregnancy

The clinical and renal biopsy findings in a group of 12 patients with mesangial IgA nephropathy who had 22 pregnancies are recorded. Seventeen pregnancies were successful. Hypertension was noted in 9 pregnancies and in 12, features of pre-eclamptic toxaemia developed. One patient had post-partum eclampsia. Proteinuria tended to increase during pregnancy and one patient developed nephrotic syndrome which resolved after delivery. Glomerular lesions in these women differed from those in non-pregnant patients with mesangial IgA nephropathy. Focal and segmental proliferative and hyalinosis-sclerosis changes were seen far more frequently than is usual in biopsies from patients with mesangial IgA nephropathy, suggesting that focal and segmental lesions develop during pregnancy.

Haemodynamics of ACTH-induced hypertension in sheep

1. Administration of adrenocorticotropic hormone (ACTH) to sheep produced increases in mean arterial pressure within 24 h associated with an increase in cardiac output and cardiac rate. Both cardiac output and blood pressure remained elevated over the 5 days of ACTH treatment. 2. Administration of ACTH during beta-adrenoreceptor blockade resulted in an increase in blood pressure without changes in cardiac output at 24 h. 3. Administration of a combined steroid infusion over 5 days produced increases in cardiac output identical with the effects of ACTH but with a substantially smaller effect on blood pressure. 4. These data suggest that the observed changes in cardiac output produced by ACTH treatment may be associated with high blood concentrations of adrenocortical steroids rather than being necessary for the development of the hypertension.

Comparison of labetalol, clonidine and diazoxide intravenously administered in severe hypertension

Diazoxide, clonidine and labetalol, administered intravenously in fixed doses, were used to treat 30 episodes of severe hypertension in 27 patients. Labetalol in a fixed dose of 100 mg proved ineffective treatment. Diazoxide 300 mg and clonidine 300 micrograms were comparable in effectiveness. Drowsiness was a common side effect with administration of clonidine (in six of 10 patients) and severe hypotension occurred in one patient who was given diazoxide.

Hydrallazine with beta-blocker and diuretic in the treatment of hypertension. A double-blind crossover study

Thirty-seven hypertensive patients were treated with cyclopenthiazide, oxprenolol and hydrallazine. Blood pressure was controlled in 31 patients and a subsequent double-blind crossover study in 27 patients comparing hydrallazine with placebo confirmed the efficacy of hydrallazine in combination with diuretic and beta-adrenergic-blocking agent. The combination was effective in patients with renal hypertension and renal impairment. No adverse effects on renal function were observed. Patients who were slow acetylators had significantly better blood pressure control and more side effects. In view of the frequency of hydrallazine related side effects, prior institution of beta-adrenergic blocking drugs is desirable.

Abnormal factor VIII in chronic renal failure

Factor VIII procoagulant activity (VIII-C), related antigen (VIII-AG), and von Willebrand factor (VIII-vWf) were measured in 38 patients with chronic renal failure (CRF), in 19 patients with normal renal function from a general medical ward, and in 17 normal subjects. Wide variation in the levels of factor VIII (FVIII) functions were found in the group of CRF patients. There was no correlation between the levels of the three individual activities of FVIII in renal disease. The levels of the three functions were elevated in the patient controls and no significant differences were found between the two groups of patients, although both groups were significantly different from the normal subjects. Increased electrophoretic mobility (EM) was detected in 22 of the 38 patients with CRF (58%) compared to seven of the 19 patients controls (37%). These studies suggest caution in interpretation of changes in FVIII status in patients with other clinical disorders, such as liver disease.

Blood pressure and metabolic effects of 9-alpha-fluoro-hydrocortisone in sheep

9 alphafluorohydrocortisone (9 alphaFF) is an analogue of hydrocortisone with both 'mineralocorticoid' and 'glucocorticoid' activity. 9 alphaFF was infused at 0.2, 0.63 and 2.0 mg/day for 5 days to intact conscious trained sheep. At high dose (0.63 and 2 mg/day) 9 alphaFF raises blood pressure in sheep, (mean arterial pressure rise 32 and 29 mm Hg respectively on the fifth day), lowers plasma [K], raises plasma [Na] and produces initial urinary sodium retention. At low dose (0.2 mg/day) blood pressure is raised (+16 mm Hg on day 5) but plasma and urinary electrolytes are unaltered. 9 alphaFF had no effect on water intake or urine output at any dose. In all animals withdrawal of 9 alphaFF was associated with a natriuresis. On the basis of its affinity for 'mineralocorticoid' and 'glucocorticoid' ovine renal receptors, 9 alphaFF at low dose may raise blood pressure by mechanisms not simply related to its 'glucocorticoid' and/or 'mineralocorticoid' action.

Comparison of the effects of 'glucocorticoid' and 'mineralocortocoid' infusions on blood pressure in sheep

It is generally believed that adrenal steroid hypertension is due to the 'mineralocorticoid' and/or 'glucocorticoid' activities of the steroid(s). The present study examines the blood pressure and metabolic effects of steroid hormone infusion in intact conscious sheep to assess the relative contributions of 'glucocorticoid' and 'mineralocorticoid' activity. Cortisol at 5 mg/h increased mean arterial pressure (MAP) but the effect was small (MAP + 10 mm Hg on day 5). This rate of infusion produces blood cortisol levels appropriate for maximal ACTH stimulation. Cortisol at 20 mg/hr produced hypertension (MAP + 25 mm Hg on day 5, p less than 0.01) but also produced the 'mineralocorticoid' effect of severe hypokalaemia. Dexamethasone at 1 mg/hr produced small increases in MAP but a profound fall in plasma [K]. Aldosterone at 80 microgram/hr (a pharmacological rate) produced hypokalaemia, urinary Na retention but no effect on MAP over 5 days. Thus, in short term infusion experiments, 'mineralocorticoid' effects are not associated with hypertension. Pharmacological concentrations of predominantly 'gluc-corticoid' steroid hormones produced hypertension but also exhibited substantial 'mineralocorticoid' activity. At levels approximating maximal physiological secretion, the rise in blood pressure was small. These results supported the contention that ACTH induced hypertension in sheep represents a mechanism different from a simple 'mineralocorticoid' or 'glucocorticoid' action.

Effect of sodium loading and ACTH on blood pressure of sheep with reduced renal mass

Sodium chloride loading produced a rise in blood pressure in intact sheep which was potentiated by reduction in renal mass. ACTH induced hypertension was also potentiated by reduced renal mass, suggesting a volume component for the hypertension when renal excretory capacity for salt and water is reduced.

Blood pressure and metabolic effects of ACTH in anephric sheep

1. ACTH (80--100 iu/day) was administered to seven sheep for 3--5 days following bilateral nephrectomy. 2. ACTH treatment produced rises in mean arterial pressure in anephric sheep similar to those observed in intact animals. Following withdrawal of ACTH, blood pressure declined over the following 72 h. 3. ACTH produced a transient fall in plasma potassium and anephric sheep, suggesting an internal redistribution mechanism for this ion. 4. These studies demonstrate that adrenal steroid hormones can modify blood pressure in the absence of the kidney.

The effect of corticotrophin (ACTH) administration on the pressor action of angiotensin II, noradrenaline and tyramine in sheep

1. Pressor responses to angiotensin II, noradrenaline and tyramine were examined in sheep prior to and during the development of corticotrophin-induced hypertension. 2. Pressor responses to angiotensin II amide did not change with corticotrophin (ACTH) administration. Small significant increases in pressor responses to noradrenaline occurred at low doses only (0.27 and 1.06 mumol/h). Significant increases in response to tyramine occurred after 24h of ACTH administration, but were not maintained after 6 days of ACTH. These changes are quantitatively small and do not suggest that changes in pressor sensitivity contribute significantly to the rise in blood pressure following ACTH administration. 3. Sodium depletion significantly reduced the pressor responses to angiotensin II amide at all doses and to tyramine in the middle range only, but did not affect the responses to noradrenaline.

Single-dose therapy in management of urinary tract infection

A study was undertaken to determine whether single dose therapy for urinary infection can identify those patients who are likely to have underlying pathological changes of the renal tract, and, thus, those patients who need further investigation. Fifty-three patients (50 females, three males) with documented recurrent urinary tract infection, in whom the present infection was confirmed in two consecutive urine specimens, were studied. Patients received a single dose of 0.5 g kanamycin intramuscularly (or another antibiotic for kanamycin-resistant organisms), and urine was cultured daily over the following week. The original infecting organism was eradicated in 22 of the 37 patients (60%) who completed the study (urine clear at one week), but persisted or relapsed in 15. Bacteriuria disappeared within 24 hours in all but four patients, but both relapses and new infections were seen as early as 48 hours after treatment. Fifteen of 18 patients (83%) with radiologically normal renal tracts were successfully treated compared with only 6 of 16 patients (37%) with a radiological abnormality. Failure of single dose therapy to eradicate urinary infection is thus an indication for further investigation.

Focal segmental sclerosis or scarred focal proliferative glomerulonephritis?

We have made a blind retrospective analysis of 334 renal biopsies, each containing more than 10 glomeruli, from adults and children with glomerulonephritis, in order to assess the clinicopathological significance of segmental lesions. These were defined as endocapillary proliferation and/or sclerosis involving capillary loops, and a less than half the glomerular tufts. On optical microscopy of paraffin-embedded material, 57 biopsies containing segmental lesions were independently classified by two observes as "focal proliferative glomerulonephritis" or "focal segmental glomerulosclerosis". These results were then reviewed with immunofluorescence, electron microscopic and clinical data and an "executive" diagnosis reached. Scarred focal proliferative glomerulonephritis could not be reliably distinguished from focal segmental glomerulosclerosis by optical microscopy alone. Some cases of focal proliferative glomerulonephritis are not associated with systemic disease and may have negative immunofluorescence findings, and we were unable to distinguish scarring in these patients from the lesion of focal segmental glomerulosclerosis with any of the tools at our disposal. Some patients with scarred focal proliferative glomerulonephritis showed profuse proteinuria, a nephrotic syndrome and progression to renal insufficiency. These cases cannot therefore be differentiated from focal segmental glomerulosclerosis by their clinical features. It would seem that the morphological lesion of focal segmental glomerulosclerosis should be regarded as focal segmental glomerular scarring from a variety of insults, rather than a distinct disease entity.

Exaggerated natriuresis in ACTH hypertension in sheep

Adrenocorticotrophic hormone (ACTH) administration to sheep (100 IU/day) produces a sustained increase in arterial pressure within 24 h. The effect of ACTH on excretion of an intravenous saline load was tested in 8 adult cross-bred Merino ewes. A significant diuretic response to saline loading was found after 24 h but no increased natriuresis. On days 3 and 6, diuretic and natriuretic responses were both significantly increased. Steroid-induced sodium retention may have abolished the natriuretic effect on day 1.

Absence of glomerular renal tubular epithelial antigen in membranous glomerulonephritis

Renal biopsies from 24 patients with membranous glomerulonephritis were examined by indirect immunofluorescence for the presence of autologous renal tubular epithelial antigen (RTE). Staining of the luminal layer of proximal tubular epithelium was found in all cases, as with normal human kidney, but granular staining along glomerular capillary walls was not observed. The role of RTE in the genesis of human membranous glomerulonephritis has not been confirmed.

The significance of extracapillary proliferation. Clinicopathological review of 60 patients

Renal biopsy and clinical data from 60 patients with extracapillary proliferation (crescent formation) in greater than or equal to 50% of glomeruli were correlated. Nephropathy was related to infection (15 cases) malignancy (4 cases) and trichlorethylene exposure (2 cases). Isolated proteinuria was found 0.5-20 years before biopsy in 16 patients. Outcome was significantly related to percentage of crescentic involvement. Oligoanuria and impaired function at presentation were bad prognostic signs but preceding infection was favourable. Diverse histological and immunofluorescent findings indicate that extracapillary glomerulonephritis is not a single entity. The clinical course is not always rapidly progressive.

IgA and glomerular disease

Serum IgA levels are raised in a proportion of children with Henoch-Schönlein disease (H. S. P.), patients with Berger's mesangial IgA disease, and in patients with glomerular lesions in association with hepatic cirrhosis. These conditions are all characterized by mesangial staining with anti-IgA antisera on immunofluorescence. It has been suggested that elevated serum IgA levels are of value in the diagnosis of these diseases. We have measured serum IgA levels by radial immunodiffusion in a variety of primary and secondary glomerular diseases. High serum IgA levels were confined to patients with glomerular IgA deposition, but were not restricted to H. S. P. and Berger's disease, nor to patients with deposition of IgA only in a mesangial pattern. Elevated salivary IgA levels were found in 3/4 patients with high serum IgA levels but we found no evidence for involvement of the secretory system in glomerular mesangial IgA deposition.

Senior-Loken syndrome (nephronophthisis and tapeto-retinal degeneration): a study of 8 cases from 5 families

The association of nephronophthisis and tapeto-retional degeneration was described by both Senior and Loken in 1961, but prior to 1974 only 28 cases had been published. This report describes 8 new cases in 27 members of 5 families. The severe juvenile type produces blindness in infancy and death from renal failure before the age of ten. The adult type is characterized by later onset, slower progression of the renal disease and milder ocular manifestations. The eye disease may be congenital amaurosis of Leber type, pigmentary retinal degeneration or retinitis punctata albescens and the electroretinogram (ERG) is of value in the diagnosis of these varieties of hereditary tapeto-retinal degeneration. Renal involvement is often asymptomatic. Defective urinary concentration leading to polyuria and polydipsia is the earliest sign. Proteinuria is inconstant and urinary sediment is often normal. Two patients had aminoaciduria. The disease progresses inexorably to chronic renal failure. One patient has been successfully transplanted and two others are on chronic hemodialysis. Renal histological changes are those of nephronophthisis with tubulointerstitial lesions and multiple cysts. Senior-Loken syndrome appears to be transmitted by a single autosomal recessive pleotropic gene of variable expression. Degeneration of neuroepithelium and renal tubular epithelium, both tissues of ectodermal origin, may represent a genetically determined enzyme abnormality.

Immunogenicity of Escherichia coli O antigen in upper urinary tract infection

The role of immunogenicity of the infecting organism (Escherichia coli) in the antibody response to O antigen in upper urinary tract infection was investigated. Heat-killed vaccines were prepared from "immunogenic" organisms which had produced upper urinary tract infection associated with high titers of hemagglutinating antibody to O antigen and "nonimmunogenic" organisms which had produced upper urinary tract infection without a rise in antibody titer. "Immunogenic" 06 vaccine produced high titers of antibody in patients regarded as possibly "poor producers" of antibody, but "nonimmunogenic" 011 vaccine was not associated with a rise in titer in patients previously regarded as "good producers". These vaccines were significantly different in immunogenicity (P less than 0.05). Five vaccines were tested in 50 rats. The difference in hemagglutinating titers to O antigen between 06 and 011 was highly significant (P less than 0.001). Immunogenicity of the infecting organism appears to be a significant factor in determining antibody response to O antigen in upper tract infection.

Papillary necrosis in renal allografts--report of 2 cases

Two patients are reported in whom early and irreversible renal allograft rejection was associated with passage of necrotic papillary material in the urine. Evidence is presented for a causal relationship between rejection and medullary necrosis. Passage of a papilla is regarded as a definite indication for graft exploration.