Peter J. Garrett

Haemodialysis patients are exposed to high levels of oxidative stress, perhaps contributing to increased rates of cardiovascular and malignant disease. In this context, the body's defence mechanisms against oxidative insult, including activity of the antioxidant enzymes superoxide dismutase (SOD) and glutathione peroxidase (GPx), are known to be deranged. This randomised double-blind study assessed the effects of a novel micronutrient cocktail containing physiological doses of antioxidant vitamins and trace minerals on antioxidant enzyme activity in maintenance haemodialysis. Thirty-seven patients were randomised to receive placebo or micronutrient. SOD and GPx activity was analysed at baseline and after 6 months of treatment. SOD levels did not change in the treatment group but fell significantly (p=0.0443) in controls, while activity of GPx remained unchanged in controls but rose significantly (p=0.0123) in treated patients. These results are consistent with a beneficial effect of the cocktail on antioxidant enzyme activity and may contribute to an indication for large-scale studies to assess clinical outcome measures.

Little published data exists on whether nurse-recorded end-hour values of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) are representative of continuous monitoring during the hour. There is also no standard method of quantifying the observed perturbations in cerebral hemodynamics. This study compared the level of agreement between end-hour values and computer downloaded observations of ICP and CPP at 15-min intervals. We also developed the intracranial hypertension index and the cerebral hypoperfusion index to quantify perturbations in cerebral hemodynamics. Each of these indices relates the number of abnormal observations to the total number of observations taken. Prospective, non-interventional study. The bias and precision between the two methods for ICP and CPP were −0.002±2.6 mmHg and −1.1±6.2 mmHg, respectively. A strong correlation existed between the hourly mean calculated from the 15-min and the end-hour values for both ICP (r ²=0.95, pr ²=0.78, pp= NS). The cerebral hypoperfusion indices were 13.4% and 13.1% with the 15-min and end-hour values, respectively (p= NS). The end-hour values of ICP and CPP are as accurate as more frequent measurements during the hour and are adequate for purposes of epidemiological research and medico-legal audit. The intracranial hypertension and cerebral hypoperfusion indices may be useful in describing cerebral hemodynamics for future interventional studies and for assessing quality in the delivery of neuro-critical care.

The case of a young, heterosexual man who was investigated for proteinuria is reported. A renal biopsy specimen showed a focal and segmental membranous glomerulopathy. He was later found to be HIV positive and died from cerebral infarction associated with HIV vasculitis 16 months after his initial presentation. Unusual forms of immune complex mediated glomerulopathies should alert the pathologist to the possibility of HIV associated disease.

R. C. Duncan, P. S. Bass, P. J. Garrett, J. R. Dathan; Weight at birth and other factors influencing progression of idiopathic membranous nephropathy, Nephrolog

SUMMARY: The coincidence of pulmonary and systemic emboli suggests paradoxical embolism. We present the case of a young man in whom a blood clot travelled from the veins in a retroperitoneal liposarcoma via a patent foramen ovalis to the systemic arterial circulation. Young patients with embolic disease but no obvious source of thrombus may have underlying neoplastic disease.Venous thrombosis is a frequent complication of neoplastic disease. Arterial embolism associated with neoplasm is, however, not widely recognised.

SUMMARY We report our detailed observations on a group of 30 consecutive patients with renal disease, histologically demonstrated glomerulitis or necrotizing vasculitis, and circulating antineutrophil cytoplasm activity (ANCA). The annual incidence of ANCA-related renal disease was seven cases per million population. The sensitivity of serum ANCA for histologically proved glomerular vasculitis was 79 per cent, with a specificity of 87 per cent. Most patients responded to treatment with cyclophosphamide and steroids but complications of therapy occurred in just over half the patients and were serious in 20 per cent. Actuarial survival at 1 year was 60 per cent. Age and dialysis requirement did not influence outcome and the only identified adverse prognostic factor was hypoxic lung disease. We conclude that the association of ANCA with renal disease is not rare and that positive serology accurately identifies a homogeneous group of patients with similar clinical, histological, and prognostic features. Separation of these patients into those with the disease entities of Wegener's granulomatosis and microscopic polyateritis is not straightforward on clinical and histological criteria, and such a distinction does not yield useful therapeutic or prognostic information. Simple urinalysis should always be carried out in patients with undiagnosed systemic illness in order to identify renal disease. ANCA–related renal disease can be treated successfully with cyclophosphamide and steroids and elderly patients should not be excluded from treatment, including dialysis if necessary. The ANCA test is simple and quick to perform and, in the appropriate clinical setting, accurately identifies patients who may benefit from immunosuppressive treatment before a histological diagnosis can be established.

P. J. Garrett, J. Burston, N. J. E. Marley, H. A. Lee; Acute Renal Failure Caused by Infiltration of the Kidneys by Bronchogenic Squamous Cell Carcinoma, Nephro