P.E. Gower

PREVENTION OF URINARY-TRACT INFECTION WITH LOW-DOSE NITROFURANTOIN

Abstract One hundred and two women with normal renal function having recurrent urinary-tract infections took part in trials of low-dose nitrofurantoin at night to prevent recurrence of infection. In the first trial, 50-100 mg. of nitrofurantoin was used and in the double-blind trial the dose was 50 mg. In the first trial the drug was given for periods up to 5 years and the double-blind trial lasted for up to 1 year. Fifteen of the fifty-two women in the first trial had an abnormal intravenous pyelogram. All the other patients had a normal intravenous pyelogram. Both trials demonstrated that such treatment is highly successful in reducing recurrences of infection, is acceptable to the patients, and almost free from side-effects.

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.

FOLLOW-UP OF 164 PATIENTS WITH BACTERIURIA OF PREGNANCY

Abstract 164 of 265 women who had had bacteriuria of pregnancy were investigated six months to four years after delivery. The intravenous pyelograms of 82% showed no renal abnormality. Radiological abnormalities occurred more often in those patients who had had pyelonephritis during pregnancy or in whom there had been some difficulty in eradicating the bacteriuria. There was no evidence to suggest that bacteriuria of pregnancy or acute pyelonephritis of pregnancy caused the renal radiological abnormalities. Six to twelve months after pregnancy approximately a quarter of the women

DIAGNOSIS OF URINARY-TRACT INFECTION IN GENERAL PRACTICE

Abstract The diagnosis of urinary-tract infection in general practice has been assessed with the aid of suprapubic aspiration and the dip-slide technique. Using a laboratory pour-plate method as the criteria of infection it has been found that a combination of suprapubic aspiration and the dip-slide culture confirmed the presence of infection in 92% of cases, direct microscopy of this suprapubic aspirate in 73%, and culture of a single midstream sample of urine in 72%. Suprapubic aspiration was safe and reliable in general practice, and was tolerated well by patients. It is suggested that the diagnosis of a urinary infection in general practice can best be made by the dip-slide inoculation of a suprapubic aspirate of urine.

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.

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.