Douglas R. Maxwell

Primary glomerulonephritis complicating diabetic nephropathy: report of seven cases and review of the literature

Glomerulonephritis has been recognized as a rare complication of diabetes mellitus. The clinical, pathologic, and laboratory findings for 18 diabetic patients were reviewed. Eight of these patients (44 per cent) were found to have primary glomerulonephritis in addition to diabetic nephropathy. Although this series may not represent the true incidence of complicating glomerulonephritis in diabetes, it is probable that the incidence of this condition has been underestimated. An additional 26 previously reported cases are reviewed.

Protection from Gentamicin Nephrotoxicity by Cephalothin and Carbenicillin

In rats, cephalothin exerts a protective effect upon the nephrotoxicity of gentamicin. To examine the possibility that this effect is also observed with carbenicillin, we gave the following (milligrams per kilogram) to rats daily for 14 days: gentamicin alone, 60; gentamicin plus cephalothin, 100, 500, or 1,000; gentamicin plus carbenicillin, 50, 100, 250, 500, or 1,000. A 500-mg/kg dose of cephalothin afforded significant partial protection from gentamicin nephrotoxicity, as did a 100-mg/kg dose of carbenicillin. Increasing doses of either drug failed to increase protection. The data suggest that in rats not only does carbenicillin afford some protection from gentamicin nephrotoxicity, but also that it does so at a lower dose than cephalothin. These findings may in part explain the divergent observations regarding the nephrotoxicity of cephalothin-gentamicin combination therapy in rats and humans.

Pharmacokinetics of Netilmicin in Patients with Renal Impairment and in Patients on Dialysis

The pharmacokinetics of netilmicin were examined in 25 adult subjects, 7 normal subjects, and 18 patients with renal impairment. Five were dialysis patients who were studied on and off dialysis. Netilmicin, 2 mg/kg, was infused intravenously over 1 h. The peak serum concentration ranged from 9 to 11 μg/ml. The mean biological half-life of netilmicin for subjects with a creatinine clearance (Ccr) > 70 ml/min was 2.7 h, for those with Ccr > 25 < 70 ml/min it was 10 h, for those with Ccr > 4 < 25 ml/min it was 32 h, and for those who were anephric it was 42 h. Ccr was correlated positively with the elimination constant and the drugs serum clearance. It was negatively correlated with the drugs volume of distribution. The dialyzer clearance of netilmicin was positively correlated with plasma flow rate and was similar to values previously reported for gentamicin. Netilmicin behaves in a fashion similar to other aminoglycosides. Therapeutic guidelines are suggested.

Roentgenographic manifestations of maxillomandibular renal osteodystrophy

We examined 30 male chronic hemodialysis patients and 18 male controls without known bone or renal disease to determine the utility of maxillomandibular, non-dominant hand, shoulder and pelvis films in the evaluation of renal osteodystrophy. We used panoramic periapical radiographs to examine the maxilla and mandible and sensitive rapid processing films for the hand, shoulder and pelvis. Films were evaluated by experienced personnel without knowledge of the patients. There were significant differences between patients and controls in creatinine, urea nitrogen, total protein, albumin, alkaline phosphatase and phosphorus. Twenty-three patients had abnormal hand radiographs and 22 patients had abnormal jaw radiographs (p less than 0.05 vs. controls). Four patients had changes in the hands, but not in the jaw; 4 had opposite findings. Changes in the jaw tended to be more severe than in the hands in those with involvement of both. We concluded that dental and hand radiography are good screening techniques for evaluating bone disease. They may be useful in evaluating treatment for renal osteodystrophy.

Calcitriol in dialysis patients.

We conducted a 7‐month randomized, single, double, single‐blind comparison of calcitriol (1,25(OH)2D3) with vitamin D3 in 22 hemodialysis patients to study the effects on the biochemical abnormalities associated with osteodystrophy. Calcitriol was given for 3 mo. All patients had initial pre study calcium values ≤9.5 mg/100 ml, and phosphate values ≤4.5 mg/100 ml. Data were analyzed using the Normalized Trend Index (NTI). Calcitriol induced a rise in calcium (8.7 to 10.25 mg/100 ml) (p < 0.001) and a fall in alkaline phosphatase (p < 0.005), while D3 had no appreciable effect. The mean dose of calcitriol during treatment was 0.579 µg/day while that for D3 was 706 IU/day. The effect on serum phosphate concentration was variable. Hypercalcemia as high as 13.2 mg/100 ml occurred in 2 of 13 patients on 1,25(OH)2D3, but in every instance promptly returned to normal with dose reduction. No other adverse effects were noted with therapy. We conclude that calcitriol reverses the biochemical abnormalities of osteodystrophy. Since its effects are rapidly reversed with discontinuation, the drug is probably safe as well as effective.

Nephrotoxicity of netilmicin in combination with non-aminoglycoside antibiotics.

To assess the possibility that non-aminoglycoside antibiotics may adversely affect the nephrotoxicity of the new semisynthetic aminoglycoside netilmicin, we gave ampicillin, carbenicillin, methicillin, cefamandole, and clindamycin, either singly or in combination with netilmicin, at two dose concentrations in rats. Results were compared as to the effect of netilmicin given singly and to saline-injected and noninjected controls. Antibiotic combinations resulted in no greater nephrotoxicity than did netilmicin alone. Netilmicin concentrations in renal tissue were high, and these levels were not consistently affected by the other drugs. The data suggest that in rats the nephrotoxicity of netilmicin is not affected adversely by the presence of non-aminoglycoside antibiotics.

Hepatitis B Virus Vaccine: A Randomized Trial of a Reduced Dose Regimen in Hemodialysis Patients

To test the hypothesis that increasing the dose enhances response to hepatitis B virus vaccine in hemodialysis patients, we performed a randomized, double blind, controlled clinical trial. Twenty-four hemodialysis patients were randomly assigned to receive either three 20 mcg or the recommended three 40 mcg intramuscular injections over 6 months. In addition, 19 normal volunteers also received three 20 mcg doses of the vaccine. The presence of Anti-HBs was determined qualitatively and quantitatively. Non-uremic subjects seroconverted more frequently than did either of the dialysis patient groups. Doubling the individual doses of vaccine did not improve the response of the dialysis patients. We conclude that the response to the vaccine is not diminished when dialysis patients are given half the recommended dose of the vaccine and that the cost of vaccinating this high-risk population could be substantially reduced.

Mezlocillin pharmacokinetics in renal impairment

Mezlocillin kinetics was examined in 28 adult subjects with varying renal function. Mezlocillin, 3 gm, was infused over 30 min. Mean peak plasma concentrations ranged from 204 to 253 mg/l. When the area under the curve (AUC) was plotted against creatinine clearance (CCr), the relationship found was expressed by the equation . From this relationship a dosage nomogram was derived describing a power function with the following equation: Dose fraction . Therapeutic guidelines are suggested.

BLOOD GLUCOSE CONTROL IN DIABETICS: III

to individualized care, the end result can be rewarding both for the patient and the caregivers. these patients, ESRD is the culmination of a lifetime of diabetic complications, and tremendous support is required from the nephrology team, in order to cope with adjustment to dialytic therapy. Acknowledgment *lthough the care Of diabetic patients can be frustrating, with a team approach and attention The authors thank CAPD nurse, Marcia Joseph, RN, for giving of her time and expertise in the management of the diabetic CAPD patient.