J. B. Eastwood

VITAMIN-D DEFICIENCY IN THE OSTEOMALACIA OF CHRONIC RENAL FAILURE

The plasma level of 25-hydroxy-vitamin D (25-OHD) has been measured and the histological appearances of bone examined in 22 patients with stable chronic renal failure. The results show that osteomalacia occurred only in those patients with relatively low levels of 25-OHD. It is concluded that the osteomalacia of chronic renal failure results from a lack of 25-hydroxy-vitamin D3 superimposed on an existing deficiency of 1,25-dihydroxy-vitamin D3 (1,25-(OH)2D3) rather than from lack of 1,25-(OH)2D3 alone.

NORMAL PLASMA-1,25-(OH)2-VITAMIN-D CONCENTRATIONS IN NUTRITIONAL OSTEOMALACIA

Three patients with advanced untreated nutritional osteomalacia had low plasma concentrations of 25-OHD and 24, 25-(OH)2D, and a raised concentration of immuno-assayable parathyroid hormone. The plasma concentration of 1, 25-(OH)2D was normal in all 3 patients.

Double-blind trial of oral 1,25-dihydroxy vitamin D3 versus placebo in asymptomatic hyperparathyroidism in patients receiving maintenance haemodialysis.

Fifty-seven patients who had been receiving maintenance haemodialysis for a mean of 4.6 years were given 0.25-0.5 microgram oral 1,25-dihydroxy (1,25-(OH)2) vitamin D3 or a placebo in a double-blind manner for one to two years. In patients with normal radiographs (mean plasma parathyroid hormone concentration 205 microliterEq/ml) 1,25-(OH)2 vitamin D3 prevented the development of the radiological appearances of hyperparathyroidism. In patients with abnormal radiographs (mean plasma parathyroid concentration 709 microliterEq/ml) 1,25-(OH)2 vitamin D3 arrested or reversed the radiological changes of hyperparathyroidism. Nevertheless, the response was slow and the concentration of the hormone remained considerably raised (mean 445 microliterEq/ml). It is concluded from these results that giving 1,25-(OH)2 vitamin D3 to patients receiving maintenance haemodialysis who have normal hand radiographs or minimal erosions is beneficial. In patients with more advanced hyperparathyroidism parathyroidectomy should be considered unless there is a rapid response.

Tetracycline Poisoning in Renal Failure

Seven cases are reported in which drugs of the tetracycline group produced a fall in the glomerular filtration rate. In six patients there was a primary underlying renal disease and renal impairment. All seven patients were made seriously ill by the antibiotic. Two patients required immediate haemodialysis; one died and the other continued on dialysis until transplanted. Another patient initially responded to intravenous fluids and protein restriction but his renal function deteriorated and four months later he began maintenance haemodialysis. Three patients required peritoneal dialysis. The seventh patient responded satisfactorily to conservative management. The medical and medicolegal complications arising from the use of tetracycline in patients with renal disease are discussed. Yet another plea is made that drugs of the tetracycline group other than doxycycline should not be given to patients with chronic renal failure.

Hepatitis in a Maintenance Hemodialysis Unit

Abstract Fourteen of 27 patients being treated with maintenance hemodialysis and 1 staff nurse from the general wards developed hepatitis between August 1966 and April 1967; 1 patient died. Eight o...

Survival in 200 patients treated by haemodialysis and renal transplantation.

The survival rates in 200 patients with terminal renal failure treated by maintenance haemodialysis and renal transplantation were analysed. The overall survival rate (+/- SE) was 81-4 +/- 3% at two years, 68-4 +/- 4% at five years, and 60-8 +/- 4-8% at eight years. Survival was inversely related to age: in those aged 15-34 years overall survival was 89-7 +/- 3-7% at two years, 87-8 +/- 4-1% at five years, and 83-9 +/- 5-5% at eight years. Eighty per cent of the surviving patients were able to work full time. The survival rate in patients returned to dialysis after graft rejection was 87-5% +/- 8-3 at three years.

The Role of Parathyroidectomy in the Management of Hyperparathyroidism in Patients on Maintenance Haemodialysis and After Renal Transplantation

Between March 1964 and March 1980, 36 (34 dialysis, 2 transplant) of 327 patients accepted for the maintenance dialysis/transplantation programme at Charing Cross Hospital were submitted to parathyroidectomy. There were four main indications: persistent hypercalcaemia, progressive phalangeal erosions, aseptic necrosis of the femoral head and height loss with abnormal bone biopsy despite normal hand radiographs. At parathyroidectomy, 4 glands were removed in 1 patient, 3 1/2 glands in 24, 3 glands in 7, 2 glands in 3 and a single large gland in 1 patient. The operation was followed by improvement in 28 patients, no change in 5, and progression of hyperparathyroidism in 3.2 of the 28 patients who improved later relapsed and were treated with 1,25-(OH)2 vitamin D3. 4 patients were submitted to a further parathyroidectomy and improved considerably. We would conclude that, although parathyroidectomy is an effective and safe procedure, it is to be hoped that careful monitoring of bone state and early administration of 1,25-(OH)2 vitamin D3 may reduce the need for parathyroidectomy.

SHEDDING OF NAILS APPARENTLY INDUCED BY THE ADMINISTRATION OF LARGE AMOUNTS OF CEPHALORIDINE AND CLOXACILLIN IN TWO ANEPHRIC PATIENTS

SUMMARY.— Two anephric patients on twice weekly maintenance haemodi‐alysis developed staphylococcal infections of their Scribner Teflon‐silastic arteriovenous shunts. Both patients were treated with very large doses of cephaloridine and cloxacillin in an attempt to preserve the shunts.

Serum and plasma concentrations of clindamycin following a single intramuscular injection of clindamycin phosphate in maintenance haemodialysis patients and normal subjects

SummarySerum levels of clindamycin bioactivity and total clindamycin were studied after single intramuscular injections of 300 mg of clindamycin phosphate in a group of 6 normal subjects and a group of 6 maintenance haemodialysis patients. The patients were studied during a non-dialysis period and then again during haemodialysis. Peak levels tended to be higher and elimination half-lives shorter in the patients than in the normal subjects. Possible reasons for these differences are discussed. There was no evidence that haemodialysis per se influenced the pharmacokinetics of clindamycin phosphate. The proportion of unhydrolysed clindamycin phosphate tended to be higher in the renal failure patients and the reason for this is not apparent. Little, if any, dosage modification is necessary in severe renal failure although there is probably little point in exceeding a dose of 300 mg intramuscularly every 8 h even in severe infections in patients with severe renal failure. The higher peak levels in patients with advanced renal failure indicate the need for further studies with repeated doses.

The ‘Shrinking Man’ Syndrome

3 men presented with loss of height. Quantitative bone histology revealed all the features of hyperparathyroidism, yet the plasma calcium and hand radiographs were normal. 2 of the patients had been on maintenance haemodialysis for over 10 years (a group in whom osteopenia is described) and the third was elderly. It is probable that in these 3 patients the loss of height was due to wedging of vertebrae as a result of the hyperparathyroidism. It is suggested that in all 3 the disease became manifest clinically because the vertebrae may have been osteopenic for other reasons.