Serum thyroxine (T4), triiodothyronine (T3), the T3 resin uptake test (T3RU) and TSH were measured in 85 clinically euthyroid patients on regular haemodialysis; sera were collected immediately before dialysis. 32% of patients had goitres. Serum T3 was below the normal range in 34% and T4 in 39%; the T3RU was in the high normal range in most. Serum TSH was slightly elevated in 13 patients. In 20 patients dialysed for 3 months or less the serum T4 was normal in 18 and the free thyroxine index (FTI) was normal in every case; mean T4 and FTI values were significantly lower in patients dialysed for more than 3 months. 16 patients were studied prospectively on two occasions 14 months apart; those initially dialysed for less than 1 year showed a significant fall in mean T4 and FTI values after a further 14 months of dialysis, while levels were unchanged in those dialysed initially for more than a year. Thyroid hormone levels were measured before and immediately after a single dialysis in 57 patients. Dialysis caused significant acute elevations of T3, T4, and FTI, but had no consistent effect on TSH. The TSH and prolactin responses to TRH were investigated in 18 male patients: the mean maximal TSH increment was significantly lower than in controls and peak responses were subnormal in 5 patients. Basal serum prolactin levels were elevated but peak responses were normal. It is concluded that, in patients on regular haemodialysis: (1) goitre may be frequent; (2) in vitro thyroid function tests were often subnormal just before a period of dialysis, but were usually normal immediately after the dialysis; (3) serum T4 levels fall rapidly in the first year of dialysis; (4) the pituitary responsiveness to low serum thyroid hormone levels and to exogenous TRH is often abnormal in dialysed patients, although they appear to be euthyroid.
A white female with chronic glomerular nephritis received a renal transplant in 1971. After 1 year, Livido Reticularis (LR) developed and in 1976 erythematous, painful nodules formed on the LR and ulcerated. The patient also suffered diffuse calcification of the major blood vessels and small arterioles of the extremities with progressive necrosis and gangrene of the fingers.Hyperparathyroidism was evident. The necrotic ulcers yielded Candida albicans and Fusarium oxysporum; both organisms were seen in histological preparations. The ulcers were excised and grafted; no specific antifnngal therapy was given.The mycological study of a patient with chronic glomerular nephritis who received a renal transplant is described. The clinical report is the subject of another publication. CASE REPORTEJ., a 25-year-old white female had a history of chronic glomerular nephritis, possibly an hereditary form, and underwent renal transplantation for the condition in 1971. Approximately 1 year later, she developed Livido Reticularis (LR). In January 1976, she complained of burning sensations over the areas of LR on the skin of the thighs and calves. During 1976, erythematous to violaceous, painful nodules developed at the intersections of the LR (Fig. 1) and subsequently broke down to black, necrotic ulcers (Fig. 2). There was no neuropathy but diffuse calcification of the major blood vessels and of the small arteries and arterioles of the extremities was detected. Thereafter, the tips of the fingers developed progressive ischaemic necrosis and gangrene. Gross evidence of hyperparathyroidism was noted and the patient had 3 glands (total tissue weight 2-5 g) removed.Three leg ulcers were excised and grafted in November, 1976, and the excised material was submitted for histological and cultural investigations. Blood was also sent for fungal serology.The ulcers showed abundant yeasts and pseudohyphae, characteristic of a Candida sp. in the ulcer debris above the stratum corneum; a few of the structures had penetrated the epidermis (Fig. 3). In the epidermal region, large, septate, PAS positive structures were seen resembling a true filamentous fungus (Fig. 4). Portions of the upper median, lower median and posterior ulcers from the leg were cultured on Sabouraud's dextrose agar+chloramphenicol at 26°C and at 37°C and smear preparations were made from the tissue for direct examination. The smears from the 3 ulcers were stained with Gram and Grocott's methenamine silver; in all preparations, yeasts and pseudohyphae, and abundantly distorted, true fungal hyphae were seen {Fig. ;~). 219at Harvard Library on June 27, 2015 http://sabouraudia.oxfordjournals.org/ Downloaded from
A retrospective study of 410 renal transplant recipients showed that 1.96% (8/410) of patients had developed severe non-typhoid salmonella infections. The clinical features seen were fever, leucopenia, pneumonia, diarrhoea, abscesses, pyelonephritis, venous thrombosis and pleural effusion. Neither uraemia nor repeated high doses of steroids seemed to be major precipitating events. All isolates were strains of Salmonella entiritidis. All 8 patients were cured and none became permanent carriers. Salmonella infections cause severe, life-threatening infections in renal transplant patients and require vigorous treatment often with a long-term low-dose regimen. Patients seemed to respond best to chloramphenicol, but ampicillin and co-trimoxazole were useful in some. Bilateral nephrectomy should be performed before the transplantation if the organism is grown from the urine.
Hereditary interstitial nephritides are a heterogeneous group of disorders comprising medullary cystic disease, several varieties of Alport’s syndrome and also one familial disorder with a distinct clinical syndrome and without characteristic ultrastructural glomerular basement membrane changes. Our family consisted of 11 members, 5 of which presented with renal dysfunction of varying degrees. Clinically, the affected siblings presented with long-standing hypertension, minimal proteinuria and no hematuria. All known causes of a secondary diffuse interstitial nephritis, Alport’s syndrome and medullary cystic disease have been excluded. An HLA association is suggested between the affected and unaffected members of the family. Renal biopsy subsequently showed the typical features of a chronic interstitial nephritis without basement membrane changes.
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