Cyclosporin A(CyA) is a valuable post graft immunosuppressive agent in allogeneic bone marrow transplantation. The use of CyA is associated with a reduction in severity of graft versus host disease and improved marrow engraftment. A major side effect of CyA is nephrotoxicity. In 33 patients studied during the first 4 weeks of therapy there is a close correlation between trough (12 h) serum cyclosporin A concentrations and plasma creatinine (r = 0.93, P less than 0.001) and urea (r = 0.88, P less than 0.001). Trough CyA serum concentrations of greater than 500 ng/ml are potentially nephrotoxic. Other risk factors for early nephrotoxicity in cyclosporin therapy are the concurrent use of aminoglycoside antibiotics (P = 0.01) and hyperbilirubinaemia (P = 0.01). Early nephrotoxicity can be prevented by maintaining trough CyA levels in the range 100-400 ng/ml. During prolonged CyA therapy, cumulative renal impairment can occur and nephrotoxic episodes associated with microangiopathic peripheral blood changes and hypertension are seen in a minority of patients.

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SUMMARY A study of splenic function in 28 patients with adult coeliac disease showed no significant correlation between the half life of heat-damaged red cells and either the duration of pre-treatment exposure to gluten or the length of time on a gluten free diet. A significant correlation was found between splenic size and duration of treatment; those patients who had been taking a gluten free diet for the longest time had the smallest spleens. Blood films from 11 of these 28 patients taken before treatment with a gluten free diet were compared with those taken between two and 15 years after the start of treatment. There was no tendency for the hyposplenic changes to regress. In the majority, the changes became more prominent despite strict adherence to the gluten free diet. These findings suggest that splenic atrophy in adult coeliac disease is not reversed by treatment with a gluten free diet and is unlikely to be related to the state of the jejunal mucosa or the duration of initial exposure to gluten.Splenic atrophy is now widely recognised as an accompaniment of adult coeliac disease. It has been demonstrated using quantitative techniques such as measuring the half life of heat-damaged red cells and splenic size as defined by area of radioactivity on a rectilinear scan.' The recognition of the changes in red cell morphology characteristic of hyposplenism may first alert the physician to the possibility that the patient has adult coeliac disease.6The mechanism of splenic atrophy is not known. In inflammatory bowel disease, where splenic atrophy may also occur, improvement in splenic function may follow excision of the diseased bowel.7 However, in coeliac disease the small intestinal lesion is presumed to develop in early childhood after weaning onto gluten containing foods. Even if the hyposplenism were related to the mucosal lesion, the factors determining hyposplenism could have been operating long enough to produce irreversible changes by the time a gluten free diet is started in adult life.In this study we have examined the serial changes in red cell morphology which occur when patients with adult coeliac disease are treated with a gluten free diet. In patients already taking a gluten free diet we

The regeneration of peripheral blood cells in six patients receiving ABO incompatible bone marrow transplants for severe aplastic anaemia has been studied. The results are compared with those of 18 similar aplastic patients treated with ABO compatible transplants. Reticulocyte recovery in the ABO incompatible cases was significantly delayed (P less than 0.01) and associated with greatly prolonged red cell transfusion requirements (P less than 0.001). Peripheral blood regeneration of neutrophils, lymphocytes and platelets was also significantly delayed (P less than 0.01). Platelet support was required for longer in the ABO incompatible cases (P less than 0.001) but there was no increase in the incidence or severity of infections in the post transplant period.

The development of acute leukaemia in pregnancy is a rare event, with an estimated incidence of 0.9-1.2 cases per 100,000 per year and with the majority of cases occurring in the second and third trimesters. We report a case of acute promyelocytic leukaemia (APL) developing during the second trimester of pregnancy which was successfully treated with all-trans retinoic acid (ATRA) resulting in a complete morphological remission.