Mechanisms of oedema formation: The minor role of hypoalbuminaemia

Objectives: Seriously ill patients often suffer from disorders of salt and water balance and present with clinical signs of either dehydration or oedema. The relationship of hypoalbuminaemia to oedema is complex and controversial and formed the central issue of this study. Design: Prospective study Setting: Medical wards of New Somerset Secondary Hospital, November 2004. Subjects: 50 patients admitted consecutively to the medical wards at New Somerset Hospital were evaluated. 26 males and 24 females participated. Outcome measures:. An attempt was made to correlate causes of salt and water imbalance with the clinical assessment of volume status, oedema formation, nutritional state and serum albumin levels. Results: Hypoalbuminaemia was not related to oedema in this study. From the 24 patients with serum albumin below 30 g/L, only 6 had oedema. These patients all had other abnormalities which could have resulted in the oedema: notably primary salt retention by failing kidneys, cor pulmonale and malignancy. None of the patients with serum albumin levels below 15 g/L had any signs of oedema. The combined insult of a chronic inflammatory disease and malnutrition had a marked effect on serum albumin levels. Conclusion: Significant hypoalbuminaemia was present in a substantial portion of the patients included in this study, yet oedema was detected infrequently and generally had an easily identifiable cause not related to low albumin levels. Most patients with hypoalbuminaemia presented with normal or positive water balance. This study supports the notion that hypoalbuminaemia is infrequently associated with oedema and plays a minor role in its formation

The use of vincristine in refractory auto-immune thrombocytopenic purpura

Two patients with auto-immune thrombocytopenic purpura are reported who continued to bleed despite high doses of corticosteroids, immunosuppressive therapy and splenectomy. The addition of vincristine to their therapeutic regimen produced a response in each case and both patients are now off all therapy without significant bleeding. It is suggested that this agent may be of value in selected cases where conventional regimens have failed or where splenectomy and corticosteroids are contra-indicated.S. Afr. Med. J., 48, 2039 (1974)

Chronic obstructive pulmonary disease in South Africa: Under-recognised and undertreated

Chronic obstructive pulmonary disease (COPD) is acommon, preventable but incurable condition currentlyranked third in global mortality estimates. Worldwide,65 million people are estimated to have moderate to severeCOPD, and the disease accounts for 3 million deathsannually, of which 90% are said to occur in low- and middle-incomecountries. Yet, despite these staggering numbers, COPD remains bothunder-recognised and undertreated in most populations, also in SouthAfrica (SA). There are many reasons for this, not least of which isthe attitude of clinicians, which can often be fatalistic with regard toCOPD. This edition of CME highlights key aspects of the diagnosisand treatment – pharmacological and non-pharmacological –and new developments in the management of severe disease.Furthermore, we have included articles focusing on non-smokingrelatedCOPD and tips for good spirometry

Cost-effectiveness of Hepatitis B vaccination in haemodialysis patients

Background. Vaccination against hepatitis B virus is an important means of controlling the infection, but its role in haemodialysis patients has been questioned due to the latter's impaired immune response.Methods. Forty-eight of 79 haemodialysis patients who were negative for antibodies to both hepatitis Bsurface and core antigens were entered into a vaccination programme. Standard doses of a plasma-derived vaccine were administered into the deltoid muscle at 0, 1,2 and 4 months, and the antibody response was measured at 1 and 2 months after the third and fourth doses.Results. The peak mean antibody titre of 372 ill/I was recorded at 1 month after the fourth dose, and the maximum response rate was achieved at 2 months after the final dose. Seroconversion occurred in 26 of 36 patients (72%) who completed the programme, and protective levels of antibody above 10 IU/I were found in 25 of 36 patients (69%). Cost analysis of the project revealed a net saving of ± R90/patient entered at the end of the first year, due to the reduced number of patients requiring monthly surveillance tests for hepatitis B surface antigen. After that, an annual saving of ± R380/patient is projected.Conclusion. In view of the high prevalence of chronic hepatitis B carriers in the South African population, the reduction in the number of patients at risk of infection, combined with a net cost saving, makes it reasonable to recommend vaccination in all non-immune haemodialysis patients despite a reduced response rate

Renal outcome of type 2 diabetes in South Africa - a 12-year follow-up study

Aims. Previous studies of type 2 diabetes mellitus have indicated a benign renal outcome after long-term  follow-up. The aim of this study was to determine how often renal failure due to diabetic nephropathy was  a cause of death in patients with type 2 diabetes.Methods. Prospective observational study of 59 South African patients with type 2 diabetes over a 12-year period. During the study repeated clinical evaluations were accompanied by measurements of serum creatinine, serum cholesterol, random blood sugar, and urine protein/ creatinine ratios.Results. The mean duration of diabetes at the end of the study was 17.8 years. There was a wide variation in the time from clinical diagnosis of diabetes to macroprQteinuria (mean 9.7 years, SD 5.9, range 0- 21) and the rate of deterioration of renal function. This rate correlated with poor control of blood pressure, a glucose level of> 14 mmol/1, heavy proteinuria, a high retinopathy score, a body mass index of < 28 and the number of pack years of smoking. At the end of the study 47 patients (79.7%) had died. Of these deaths 17 (28.8%) were due to chronic renal failure.Conclusions. In contrast to other studies we have shown that in a developing country renal failure in  type 2 diabetic patients is a major cause of death. Determining the prognosis for an individual patient is difficult as there are wide ranges in the time of onset of proteinuria, the rise in serum creatinine and the time to ultimate progression to end-stage renal failure

Unrecognised acute renal failure following the Comrades Marathon

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Transplantation for diabetic nephropathy at Groote Schuur Hospital

Over a period of 6 years, 9 patients with diabetic nephropathy received renal allografts at Groote Schuur Hospital. This low figure represents 2,8% of the total number of renal transplants done at our institution, and is evidence of concern about the apparent poor results of transplantation in these patients. After 2 years, patients and graft survival rates in diabetics were 87% and 62% respectively. Vascular disease was a major problem. Six patients developed limb gangrene, and symptomatic coronary and cerebrovascular disease developed in 2 patients. Infections were common and included wound sepsis, cellulitis, candidiasis and urinary tract infections. Diabetes was poorly controlled after transplantation in 5 patients. Proliferative retinopathy was present in 6 patients but remained stable after transplantation.Despite very strict selection criteria, the results of renal transplantation in diabetic patients remain poor. Better treatment strategies are needed to justify acceptance of these patients for transplantation