A recently developed, simple and sensitive radioimmunoassay has been used to examine 24 h excretion and plasma levels of Tamm-Horsfall glycoprotein (THG) in normal subjects, stone formers and patients with stable chronic renal disease. In normal subjects THG excretion ranged from 22 to 66 mg/24 h, with no sex difference and no correlation with creatinine clearance or body surface area. There was no correlation between 24 h THG excretion and urine volume, pH or osmolality, excretion of Na+, K+ or Ca2+ or free-water clearance. There was a small significant correlation between plasma THG concentration and urinary THG excretion. A good correlation was obtained between the THG/creatinine ratio in 24 h and random samples. This made possible the use of random samples to establish a reference range for THG excretion of 0.15-0.50 micrograms/ml of creatinine clearance which did not depend on sex or age. The excretion rate of THG in stone formers was generally within the reference range. It was not significantly different in those who were hypercalciuric or in those taking thiazides. In patients with chronic renal disease there was a good correlation between 24 h THG excretion, plasma THG concentration and creatinine clearance. The range of excretion of THG per ml of creatinine clearance was greater than in normal subjects, independent of the type of renal disease and unrelated to proteinuria. In patients with glomerulonephritis the excretion of THG per ml of creatinine clearance was significantly higher in those with well-preserved tubules compared with those with tubular atrophy.

Sixty patients with idiopathic retroperitoneal fibrosis presenting between 1965 and 1984 are reviewed. Their mean age at presentation was 56 years and the male:female ratio was 3:1. The commonest presenting symptoms were flank and abdominal pain, weight loss, nausea and polyuria. Physical examination was usually normal, expect for the presence of hypertension. Anaemia and elevation of erythrocyte sedimentation rate were usually present. Proteinuria was found in less than a third of patients at presentation and significant bacteriuria was uncommon. The correct diagnosis was made or suspected in very few patients before referral. The cumulative actuarial survival rate was 86% at 1 year and 78% at 2 years. Seventeen patients died; they were significantly older and more uraemic at the time of referral than those who survived. A few patients did well with either corticosteroid therapy or ureterolysis alone. In the majority, both operation and steroid treatment were necessary. In bilateral obstruction with residual function in both kidneys, bilateral ureterolysis proved superior to unilateral operation (each followed by steroid therapy) in conserving renal function. Operation alone or steroid therapy alone should be considered in cases where steroids or surgery respectively present particular hazards. The less traumatic unilateral operation should be considered in poor risk patients and in those whose renal function is absent on one side. In many survivors, disease activity has persisted for many years. Life-long follow-up is recommended.

ESCHERZCHZA C O L Z is the pathogen most commonly isolated in urinarytract infections (UTI). It is thought that E. coli from the gut colonise the periurethral area, extend into the anterior urethra and are introduced into the bladder during micturition. Imperfections in the host defence mechanisms allow bacteria to multiply in the bladder urine and, in some cases, to cause an ascending infection of the kidney (O'Grady et al., 1970).Unless urinary-tract infection differs from infection elsewhere in the body it is likely that some strains of E. coli possess properties that enable them to overcome host defences more easily. Numerous reports have examined whether certain serotypes of E. coli are more common in UTI simply because they are more common in the faeces or because they possess specific uropathogenic properties. The properties that might be implicated in the pathogenesis of UTI include: (1) the ability to colonise the urinary tract by the production of mucinase that enables the organisms to reach the uroepithelium, or the possession of fimbriae that allow adhesion to the mucosal surface; (2) preferential nutritional requirements for substances present in urine or relative resistance to urinary inhibitors such as urea or lowpH; (3) resistance to phagocytosis and the serum bactericidal system; (4) the elaboration of toxins.We studied several properties that may influence the pathogenicity of E. coli strains and compared their occurrence in strains isolated from (i) the urine of patients with UTI, (ii) the urethral meatus of nephrourological patients without current UTI and (iii) the urethral meatus of normal subjects. MATERIALS AND METHODS SubjectsOne hundred and sixty seven patients and 28 controls were studied. The patients were referred to the Nephrourological Clinic at St Bartholomew's Hospital because of known or suspected UTI; all had been followed for at least 3 months. Intravenous pyelograms were routinely performed and, where necessary, residual urine volumes were measured by the ~ ~~ Present addresses:

Glycation of proteins in the peritoneum might occur due to the extremely high glucose concentrations (75 to 214 mmol/liter) in the dialysate of patients on continuous ambulatory peritoneal dialysis (CAPD) and may be involved in the etiology of ultrafiltration failure. Formation of both early (glycated albumin) and late (advanced glycation end products; AGE, measured as protein-derived fluorescence intensity, FI) Maillard reaction products was studied in vitro in dialysis fluids obtained from seven patients on CAPD and in phosphate buffered saline (PBS) controls paired for glucose and albumin concentrations. Percentage glycated albumin (median, range) increased (P < 0.02) from baseline after 10 and 21 days in both dialysate and PBS but did not differ (P > 0.05) between the two media at any time point (day 0, 3.6, 3.1-4.5 vs. 4.1, 3.0-4.6; day 10, 19.4, 7.9-54.8 vs. 19.1, 8.7-50.1; day 21, 29.0, 12.0-75.6 vs. 30.0, 11.7-69.8). Glycated albumin formation was linearly related to the glucose concentration (r > 0.98, P < 0.001) in both dialysate and PBS at 10 and 21 days. FI (U/g/liter albumin, median, range) increased (P < 0.02) from baseline after 10 and 21 days in dialysate but only after 21 days in PBS; this increase was significantly greater (P < 0.02) in dialysate than in PBS after 10 and 21 days (day 0, 41, 36-46 vs. 42, 37-46; day 10, 99, 88-161 vs. 51, 34-68; day 21, 113, 102-239 vs. 68, 54-91). After 21 days, FI was significantly related to glucose concentration (r = 0.90, P < 0.01) and to % glycated albumin (r = 0.92, P < 0.01) in PBS but not in dialysate (P > 0.05). AGE formation, but not glycation, decreased as a function of the dialysate dwell time and was inhibited by aminoguanidine. Our results demonstrate that formation of AGE products occurs in dialysis fluid and that factors in dialysate can modulate this process.

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SUMMARY Carcinoma of the larynx was treated by irradiation followed by laryngectomy in a man who had been receiving regular haemodialysis for two years. At least one, and probably two, parathyroid glands were removed at this time, and the remaining two were removed three years later for tertiary hyperparathyroidism. A portion of one gland was implanted into the forearm. The forearm implant was resected the following year for recurrent hypercalcaemia. Six years later, again with recurrent hypercalcaemia, he died of bronchopneumonia. Metastatic parathyroid carcinoma was found in the apex of the left lung. The source of this parathyroid tissue and the possible role of irradiation in the pathogenesis of parathyroid cancer in this patient were investigated.Parathyroid carcinoma may present diagnostic difficulty to both clinicians and histopathologists. We describe a man with tertiary hyperparathyroidism and systemic sarcoidosis who had previously received radiotherapy to the neck for laryngeal carcinoma and was receiving regular haemodialysis, in whom the diagnosis of parathyroid carcinoma was made only at necropsy. This case illustrates the diagnostic difficulties sometimes presented by the condition and raises the question of the possible role of radiation in inducing malignant change in parathyroid tissue already stimulated as a result of longstanding renal failure. CASE REPORTA 34 year old man began regular haemodialysis for chronic renal failure resulting from congenital hypoplasia of a solitary right kidney in 1972. Two years later a squamous carcinoma of the larynx was treated with radiotherapy (total dose 3250 cGy divided into six doses over 18 days: source, Co II, field 7 x 7 cm). His chest was screened during radiation. The carcinoma was not cured, and total laryngectomy, which included removal of the left lobe of the thyroid and at least one, but probably both, left parathyroids, was carried out four months later. Serum calcium concentration was 2-76 mmolI (11 mg/ 100 ml) (corrected to a serum albumin concentration of 41 g/l, as described by Tomlinson and Accepted for publication 17 June 1985 O'Riordan'; normal range 2-20-2-70 mmoVI (8.8-10-8 mg/100 ml)) and alkaline phosphatase 58 IU/I (normal range 25-100). Fig. 1 shows the serial calcium measurements recorded. Hilar lymphadenopathy and miliary mottling were noted on a chest radiograph.By 1977 he had developed symptomatic hypercalcaemia (serum calcium concentration 3 07 mmol/l (1 2 3 mg/ 100 ml) and alkaline phosphatase 169 IU/ 1). Serum parathyroid hormone concentration (N terminal assay2) was raised at 1-43 ,ug/l (normal <0-73,ug/l). Digital subperiosteal erosions were visible on radiography. Hydrocortisone 40 mg was given thrice daily for 30 days: no change in serum calcium concentration occurred, suggesting that hyperparathyroidism was the cause of the hypercalcaemia. At an exploration of the neck in July 1977 both right parathyroid glands were enlarged (see below) and were excised intact. About one third of the superior parathyroid (0.3 x 1 0 ...

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Peritoneal equilibration tests (PET) were performed on 47 patients (15 diabetics) who had been on CAPD for 1 to 112 months. Among new patients on CAPD (1 to 3 months) with no history of peritonitis, diabetics had higher D/PCr than non-diabetics (P < 0.02). However, after > or = 7 months of CAPD, in patients with < or = 2 episodes of peritonitis, glucose and creatinine transport rates were lower (P < 0.05) in diabetic than non-diabetic patients. Among patients on CAPD for > or = 7 months, creatinine (P < 0.05) and glucose transport (P < 0.01) were higher in patients with a history of > or = 3 episodes of peritonitis than in those with < or = 2 episodes. Drain volumes did not differ between any of the subgroups (all P > 0.05). The observations in patients newly established on CAPD were substantiated in a larger study of 55 non-diabetic and 35 non-insulin dependent diabetic patients. D/D0 glucose correlated with plasma glucose (r = 0.40, P < 0.02) in the diabetic group. Net ultrafiltration was reduced in hyperglycemic (P = 0.022) but not normoglycemic diabetics (non-diabetics 231 +/- 167 ml, hyperglycemic diabetics 127 +/- 177 ml, normoglycemic diabetics 238 +/- 159 ml). Creatinine clearance was higher in normoglycemic (P = 0.02) but not hyperglycemic diabetics (non-diabetics 6.8 +/- 0.9 ml/min, hyperglycemic diabetics 6.9 +/- 0.8 ml/min, normoglycemic diabetics 7.4 +/- 0.7 ml/min). These data show that diabetes and peritonitis incidence should be borne in mind when interpreting results of the PET.(ABSTRACT TRUNCATED AT 250 WORDS)