The effect of extracorporeal albumin dialysis on plasma phospholipid fatty acids in patients with end-stage liver disease

The effect of extracorporeal albumin dialysis (ECAD) using the MARS device on plasma phospholipid fatty acids (PLFA) in patients with end-stage liver disease (ESLD) was examined. Phospholipids were isolated from plasma and the fatty acid (FA) composition of non-sphingomyelin PL determined using capillary gas chromatography (GC). Plasma samples were also obtained from six patients with ESLD undergoing ECAD and from five patients with similar ESLD who were not treated, as well as from non-fasting healthy subjects. PLFA were much lower [506 +/- 62 microg/mL (M +/- SD)] in patients with ESLD than in healthy subjects (2709 +/- 688 microg/mL). In addition, the proportion of n3 and n6 polyunsaturated FA was much lower in patients with ESLD (n3, 1.7 +/- 0.1%, n6, 19.6 +/- 1.4%) than in healthy controls (n3, 4.1 +/- 2.4%, n6, 31.9 +/- 6.2%) ECAD caused an immediate increase in PLFA, averaging 56% in all patients, but PLFA levels decreased some hours later after treatment. ECAD also caused a small increase in the proportion of n3 and n6 of PLFA. During the 5 days of the study, PLFA rose in both ECAD-treated and untreated patients, but the increase was significantly greater in ECAD treated patient. It is concluded that patients with ESLD have markedly decreased PLFA; these PLFA have a lower proportion of the polyunsaturated n3 and n6 FA with the result that the plasma level of these essential polyunsaturated PLFA is extremely low compared to that of healthy subjects. ECAD causes a transient increase in PLFA toward normal levels and also increases the proportion of n3 and n6 FA.

Hyperlipidemia in pediatric kidney transplant recipients treated with cyclosporine

Hyperlipidemia is a risk factor for cardiovascular disease in adult kidney transplant (Tx) recipients. We sought to determine the prevalence of, and the risk factors associated with, hyperlipidemia in pediatric kidney Tx recipients on cyclosporine (CsA). We identified 59 patients (mean age 8.2+/-5.7 years) transplanted between 1 January 1991 and 31 December 1993. Pre Tx, 34% had elevated total cholesterol [TC >200 mg/dl (5.17 mmol/l)]; 54% had elevated triglycerides [TG >200 mg/dl (2.26 mmol/L)]. Mean TG was higher pre Tx in dialysis (versus nondialysis) patients: 306 mg/dl (3.46 mmol/l) versus 228 mg/dl (2.58 mmol/l) ( P=0.04). Mean TC was higher in peritoneal dialysis than hemodialysis patients: 222 mg/dl (5.74 mmol/l) versus 169 mg/dl (4.37 mmol/l) ( P=0.03). Pre Tx and 3-year values correlated (TC, r=0.49, P=0.0008; TG, r=0.41, P=0.001); 3- and 5-year TC values correlated ( r=0.57, P=0.003). At 5 years post Tx, 41% of the recipients had elevated TC; 14% had elevated TG. Recipients with elevated TC had higher mean CsA concentrations at 1 year post Tx ( P=0.03). Recipients with elevated TG tended to receive more prednisone ( P=0.06). At 5 years post Tx, recipients had a high prevalence of hyperlipidemia. The identification and treatment of hyperlipidemia should be included in pediatric kidney Tx protocols.

The effect of pregnancy on the renal handling of glucose

Tubular reabsorption of glucose has been measured during glucose infusion in 29 healthy women during and after pregnancy. All the women had normal glucose tolerance to an oral load, and normal glucose excretion when not pregnant, but exhibited a wide range of daily glucose excretion in pregnancy. Throughout pregnancy the renal reabsorption of glucose is less effective than in the non-pregnant state and, in general, the greater the amount fo glycosuria which develops in pregnancy, the less effective is the reabsorption during infusion. Post partum, women with minor degrees of glycosuria during the preceding pregnancy return to a normal highly efficient reabsorption performance during infusion, but women who exhibit greater degrees of glycosuria have a reduced capacity to reabsorb even though they are no longer glycosuric after the pregnancy. It is concluded that pregnancy imposes some specific change in the glucose reabsorptive capacity of the proximal tubule and that women with more than usual degrees of glycosuria in pregnancy may, in addition, have an element of tubular damage. This is discussed in relation to other renal function changes in pregnancy in an attempt to explain the characteristic intermittency of clinical glycosuria in pregnancy.

Insulin-resistant diabetes with autoantibodies induced by exogenous insulin. Successful treatment by insulin withdrawal

An obese woman was studied over a five-year period, during which time she had three episodes of severe insulinresistant diabetes, associated with a high level of insulin antibodies.

During her second hospitalization, there was no evidence of acute stress, suggesting that in addition to obesity, her extremely high levels of antibodies were interfering with the effectiveness of the administered insulin. These antibodies were shown by immunologic methods to bind both circulating exogenous (bovine) and endogenous (human) insulins. With no other specific therapy except the abrupt halt of insulin, her diabetes improved, her antibody liters declined with a half-life of about twenty days, and the capacity of her plasma to bind both exogenous and endogenous insulin decreased. Antibody levels, although much lower, were still detectable more than eighteen months after discontinuing insulin therapy.

The patient's marked clinical improvement on stopping insulin, suggested that the high levels of circulating antibodies were a factor in maintaining her severe insulin resistance. Treatment with insulin in this patient was not only ineffective but apparently had worsened her diabetes. The excellent results obtained during her third hospitalization emphasize the superiority of supervised diet and enforced weight reduction over insulin as a choice of treatment in this type of patient.

The safety of drivers with chronic disease

Six hundred and twelve drivers with chronic disease, mainly diabetes, cardiovascular disease, renal disorders, and diseases of the sense organs, were investigated with regard to the frequency of road accidents and serious driving offences during a 10-year period. Road accidents directly caused by the disease or its treatment occurred in four (0·8%) cases, all due to hypoglycaemic attacks in insulin-treated diabetics. A comparison was made between the investigation series and a control series identical with regard to number, sex, age, and duration of licence-holding. About 50% of the drivers in each series were asked about their exposure to traffic; this proved to be similar in both series. The percentages of drivers experiencing road accidents were 4·1 in the investigation series and 7·7 in the control series. The corresponding figures for road accidents and serious driving offences taken together were 9·8% and 15·3%. The conclusion is drawn that any increased risk to road safety constituted by drivers with the specified chronic diseases may be satisfactorily offset by the restrictions applied in Sweden in the granting of licences to these drivers.

CASE OF RENAL TUBULAR OSTEOMALACIA (DENT TYPE 2) WITH LATER DEVELOPMENT OF AUTONOMOUS PARATHYROID TUMOURS

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