K. F. Fairley

ANTICOAGULANTS IN "IRREVERSIBLE" ACUTE RENAL FAILURE

Abstract 6 consecutive cases of oliguric renal failure shown histologically to be due to glomerulonephritis or obstructive lesions in arterioles and glomeruli improved considerably following continuous high-dose infusion of heparin, which was given in addition to steroids and immunosuppressive drugs. The prompt improvement in renal function which followed heparin infusion suggests that this method of treatment may have some direct effect on the underlying lesion as has been demonstrated in animals. 2 patients died from diffuse vascular lesions in other organs, but 4 were well at two to nine months after the onset of the renal failure, with blood-urea levels between 23 and 40 mg. per 100 ml.

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.

LEUCOCYTE-EXCRETION RATE AS A SCREENING TEST FOR BACTERIURIA

Abstract A raised leucocyte-excretion rate was present in 92% of urines containing more than 100,000 bacteria per ml. The rate is not a suitable screening test for bacteriuria, because in 26% of urines tested, despite insignificant bacteriuria, the excretion-rate was high. It is a good screening test, however, for urinary-tract disease; in only 6% of high counts could no explanation for this be found in the urinary tract.

Renal Papillary Necrosis with a Normal Pyelogram

discharging the larvae by a mature worm. Guinea-worms are known to discharge larvae in abnormal sites such as the extradural space (Reddy and Valli, 1967). The arthritis is not due to secondary infection, as in all the cases the culture was sterile. It is due to the products of parturition of the worm discharged into the joint. It is not due to the breaking up and crushing of the worm between the opposing bones during walking, for in every case the worm was entire without any break. In the last case operation was carried out on the third day after the onset of pain and swelling, and the worm was alive and moving. This again shows that it is the discharge of the larvae in an abnormal site which is responsible for the synovitis. Gandhi (1962) treated his case by rest and antibiotics only after the chance removal of the worm (which got caught in the aspirating ncedle) and aspiration of the fluid. No mention of seeing the larvae was made in the report nor was a follow-up noted. As a rule surgical procedures are carried out after the active stage of synovitis has been arrested, and conservative treatment should be given an adequate trial before surgery is undertaken. Conservative treatment in several cases of acute synovitis of the knee with a history of guinea-worm infection during the past few years was not successful. Entry of the worm into the joint cavity and liberation of its products of conception, giving rise to acute synovitis, was not thought of. So repeated aspirations with instillation of penicillin were given. Culture examination was always sterile and no definite diagnosis was made. Simple microscopical examination of the fluid was not made, as the finding of larvae in the fluid was not expected. Many cases ended up with chronic synovitis and involvement of cartilaginous and osseous portions of the joint, and were mistaken for gonococcal or tuberculous arthritis. Fluid in the joint with chronic proliferation of the synovial membrane persisted for months. Surgery was undertaken late in these cases in the form of synovectomy or arthrodesis, with consequent partial or complete stiffness of the knee after months of suffering. Routine microscopy of the joint fluid in cases of acute synovitis disclosed larvae, and since larvae could not be seen without the presence of the adult worm immediate removal of the worm and its extruded products from the joinlt was thought to be imperative. So arthrotomy in the acute stages wvas felt to be necessary for the removal of the offending worm and products, with irrigation of the joint cavity. In our limited experience of this not so unusual but definitely unsuspected lesion we found that if the patient reported early, wvhen the larvae could be seen in the fluid, the diagnosis was easy. In such cases arthrotomy for removal of the worm should be done. Removal of the worm and cleaning of the joint cavity was sufficient to restore a joint to normal use.

URINARY FIBRIN-DEGRADATION PRODUCTS AND THE SITE OF URINARY INFECTION

Abstract Estimation of spot urinary fibrin-degradation products (F.D.P.) may be of value as an indirect method of determining the site of urinary infection. Urinary F.D.P. were high in 19 of 48 patients with upper-tract infections (40%), whereas only 1 out of 26 patients with proven bladder infections had a high urinary F.D.P. level. The test may be of value in ruling out the bladder as the site of a urinary-tract infection.

Membranous Glomerulonephritis and Pregnancy

The clinical courses of 33 pregnancies in 24 patients with biopsy proven membranous glomerulonephritis have been analyzed. Twenty-four percent (8) of pregnancies resulted in fetal loss, 43% (14) in premature delivery and 33% (11) in a live birth after 36 weeks gestation. Maternal renal function declined during pregnancy in 9% (3) of the pregnancies and in 46% (15) hypertension developed. In 55% (18) proteinuria increased significantly during pregnancy. In 30% (10) nephrotic range proteinuria was recorded in the first trimester. Presence of nephrotic range proteinuria during the first trimester correlated with both poor fetal and poor maternal outcome (p less than 0.0004 and p less than 0.0002, respectively). It is concluded that pregnancy in patients with membranous glomerulonephritis is associated with increased fetal loss and, in some instances, a worsening in maternal renal function. The literature on this topic is reviewed in relation to these findings.