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EFFECT OF STARVATION ON RENAL FUNCTION
613
..
r..
of lymphocyte-rich, and 5 normal controls.
pH activity
granulocyte-rich,
curves
..
leucocyte fractions from 4 subjects with Gaucher’s disease
and mixed
Assays were carried out in the system described in the text, but sodium-citrate buffer, 0-022 activity is that amount of enzyme which will hydrolyse 1 nmole of substrate per minute.
pH 4-0, and 1 to 5 x 106 leucocytes. The results of assays on the peripheral-blood leucocytes from 5 patients with the adult type of Gaucher’s disease, 6 obligate heterozygotes and 13 normal subjects, are shown in the accompanying table. A considerable decrease in enzyme activity of all leucocyte types could be demonstrated in all the patients with Gaucher’s disease. The enzyme activity of the lymyphocytes of one of the heterozygotes was in the lower portion of the normal range; the lymphocytes of the other heterozygotes had clearly lower p-glucosidase activity than the normal subjects. P-GLUCOSIDASE BUFFER,
pH
ACTIVITY OF LEUCOCYTES
4-0
(EXPRESSED
AS
U.U.
PER
MEASURED
107
IN
WHITE BLOOD
ACETATE
CELLS).
M
was
used.
One
(.LV. of
enzyme
activity at pH 5-3 to that at pH 4-0 is much higher in lymphocytes than it is in granulocytes. Selective loss of activity of one of two &bgr;-D-N-acetylhexosaminidases has recently been described in Tay-
of
Sacks disease. The situation in Gaucher’s disease seems be similar, although it appears that in this disorder both isozymes are affected, and to a greatly differing degree. The same type of phenomenon has been observed in the case of red-cell triosephosphate-isomerase deficiency: the activity of all three electrophoretically distinguishable isozymes are affected in this genetic defect, but loss of activity of the more rapidly moving fractions is greatest.8The biochemical bases of these effects requires more study. The techniques we have briefly outlined here will be published in detail elsewhere. They make it possible for the first time to detect in peripheral-blood cells the enzyme deficiency of patients with Gaucher’s disease, and to detect most carriers of Gaucher’s disease using commercially available reagents.
to
We thank Dr. M. Yettra for permission to study two of his patients with Gaucher’s disease. This investigation was supported, in part, by Public Health
Service grant Health. No. of
cases
studied.
t Mean rtr s.E. t Range.
Our studies indicate that normal leucocytes contain at least two acid glucosidases, and that the genetic defect of Gaucher’s disease results in a greater decrease of activity of the (3-glucosidase isozyme with the lower pH optimum. The possibility that a single enzyme is present, and that patients with Gaucher’s disease produce an enzyme with an abnormal pH-optimum curve has been considered. However, the activities of the leucocyte enzymes with pH optima at 5-3 and 4-0 are readily partially separated: the granules which are released from leucocytes by sucrose washing 6 contain a much higher ratio of enzyme activity at pH 5-3—4-0 than do intact cells. Furthermore, the ratio 6.
Cohn, Z. A., Hirsch, J. G. J. exp.
Med. 1960, 112, 983.
no.
HD 01974 from the National Institutes of
Division of Medicine, and Department of Hematology, City of Hope Medical Center, Duarte, California 91010.
ERNEST BEUTLER WANDA KUHL.
EFFECT OF STARVATION ON RENAL FUNCTION been used extensively as a method has SIR,-Starvation of weight reduction since Bloom9 introduced the method in 1959. Numerous published reports have shown that most individuals tolerate even prolonged fasting well. There Okada, S., O’Brien, J. S. Science, N.Y. 1969, 165, 698. Kaplan, J. C., Teeple, L., Shore, N., Beutler, E. Biochem. biophys. Res. Commun. 1968, 31, 768. 9. Bloom, W. L. Metabolism, 1959, 8, 214. 7. 8.
614
have, however, been some cases of unexpected sudden death,’ and there is evidence that liver function is impaired-serum glutamic-oxaloacetic and glutamic-pyruvic transaminases and bilirubin are raised,12 and bromsulphthalein retention is increased.13 Liver function seems to return to normal after refeeding. Renal function has not been studied in detail during starvation; but, in published reports on therapeutic starvation, moderate increments of serum-creatinine have often
HÆMOLYTIC CRISIS PRODUCED BY NALIDIXIC ACID
SIR,-Although a variety of agents can precipitate acute hæmolysis in glucose-6-phosphate-dehydrogenase(G.6P.D.)-deficient individuals, we believe there has so far been no published report of nalidixic acid producing such a response.
haemolytic drug.
We describe below a case in which an acute crisis seems to have been initiated by this
A 21/2-month-old West Indian boy was admitted to Seacroft Hospital on Nov. 27, 1969, with a 3-day history of diarrhoea and vomiting. He was mildly dehydrated on admission, but physical examination revealed no other abnormality apart from mild anxmia (haemoglobin 9-3 g. per 100 ml.). The blood-film showed hypochromia with anisocytosis but no polychromasia. Serum-iron was low (44 g. per 100 ml.), and the child was started on oral iron.
Although
the bowel symptoms
subsided
soon
after
admission, the child continued to have irregular pyrexia, and on the 10th day of admission the urine contained a number of pus-cells. Treatment was immediately started with intramuscular ampicillin. The following day, the report on the urine was that there were 3280 whitecells and more than 100,000 organisms per ml. There was a profuse growth of coliform bacilli, resistant to ampicillin, tetracycline, and sulphafurazole, partially sensitive to cephaloridine, and fully sensitive to nalidixic acid, colistin, nitrofurantoin, and kanamycin. On the 14th day of admission nalidixic acid was substituted for ampicillin. At that stage the child looked clinically well, with no sign of progressive anxmia. Within 48 hours of starting therapy with nalidixic acid, however, his clinical condition deteriorated alarmingly, with rapidly developing pallor and shock. The hxmoglobin had fallen to 2-3 g. per 100 ml.; there were 6 normoblasts per 100 white-cells; and the film showed marked poikilocytosis and fragmentation of redcells. No Heinz bodies were seen. The ditect Coombs test and sickling test were negative, but the red-cells were found to be grossly deficient in G-6-P.D.
large
Renal-function
tests in an
obese
man
treated with low-calorie
diet, fasting, and ketogenic diet.
been recorded in fasting patients. Usually no comment is made on this abnormality. In one paper 14 p-aminohippuricacid (P.A.H.) clearance was described as being largely unaffected by prolonged fasting, and this seemed to indicate satisfactory renal function. We have studied the renal clearance of P.A.H., inulin, and endogenous creatinine in obese patients during" therapeutic starvation and also when they were taking a ketogenic " diet. Fluid intake was adequate during the investigations. Starvation produces a substantial lowering of glomerular filtration-rate (G.F.R.), while P.A.H. clearance is affected little. In some cases, G.F.R. drops to less than 50% of the initial value. Glomerular filtration returns slowly to normal after refeeding. The ketogenic diet does not seem to impair renal function. The accompanying figure shows typical changes in the renal function of a patient during fasting and different types of diet. This patient lost 17 kg. in 9 weeks. The mechanism by which glomerular filtration is reduced during fasting is not clear. We believe that in patients with lowered renal function starvation therapy should be used only with caution. Department of Medicine, Serafimerlasarettet, Stockholm, Sweden.
B. EDGREN P. O. WESTER.
10. Spencer, I. O. B. Lancet, 1968, i, 1288. 11. Garnett, E. S., Barnard, D. L., Ford, J., Goodbody, R. A., Woodehouse, M. A. ibid. 1969, i, 914. 12. Wildenhoff, K. E., Dalsager, H. H., Sørensen, N. S. Nord. Med. 13. 14.
1969, 81, 1201. Rozental, P., Biava, C., Spencer, H., Zimmerman, H. J. Am J. dig. Dis. 1967, 12, 198. Owen, O. E., Felig, P., Morgan, A. P., Wahren, J., Cahill, G. F. J. clin. Invest. 1969, 48, 574.
After prompt blood-transfusion and a change of therapy cephaloridine, the infant’s clinical condition improved dramatically, and since then he has remained quite well. The haemoglobin on Jan. 1, 1970, was 12-0 g. per 100 ml., with 1% reticulocytes and normal film. Detailed familial studies were later carried out. Both the parents were normal, but two of the three children (all males) were found to have G.6-P.D. deficiency.
to
We believe that the rapidly progressive haemolytic anaemia was precipitated by nalidixic acid, and the patient remained quite well so long as he was on ampicillin. Infection itself may produce haemolytic anaemia in people with G.6-P.D. deficiency, but in this case urinary-tract infection was not severe and must have been present for some time. Thus, it is probably not the explanation for the sudden deterioration in the blood-picture.
There has been
no
recorded instance of nalidixic acid
precipitating haemolysis in G.6-P.D.-deficient individuals. The only reported case of haemolytic anaemia due to nalidixic acid was in a newborn baby whose G.6-P.D. test was
within normal limits.1
Nalidixic acid is a valuable and widely used drug, and as G.6-P.D. deficiency states become more and more frequent in our increasingly multiracial population, the possibility of nalidixic acid being responsible for some of the hxmolytic anaemias should be borne in mind. B. K. MANDAL Seacroft Hospital, Leeds 14. J. STEVENSON. 1.
Belton,
E.
M., Vaughan-Jones, R. Lancet, 1965, ii, 691.
..
r..
of lymphocyte-rich, and 5 normal controls.
pH activity
granulocyte-rich,
curves
..
leucocyte fractions from 4 subjects with Gaucher’s disease
and mixed
Assays were carried out in the system described in the text, but sodium-citrate buffer, 0-022 activity is that amount of enzyme which will hydrolyse 1 nmole of substrate per minute.
pH 4-0, and 1 to 5 x 106 leucocytes. The results of assays on the peripheral-blood leucocytes from 5 patients with the adult type of Gaucher’s disease, 6 obligate heterozygotes and 13 normal subjects, are shown in the accompanying table. A considerable decrease in enzyme activity of all leucocyte types could be demonstrated in all the patients with Gaucher’s disease. The enzyme activity of the lymyphocytes of one of the heterozygotes was in the lower portion of the normal range; the lymphocytes of the other heterozygotes had clearly lower p-glucosidase activity than the normal subjects. P-GLUCOSIDASE BUFFER,
pH
ACTIVITY OF LEUCOCYTES
4-0
(EXPRESSED
AS
U.U.
PER
MEASURED
107
IN
WHITE BLOOD
ACETATE
CELLS).
M
was
used.
One
(.LV. of
enzyme
activity at pH 5-3 to that at pH 4-0 is much higher in lymphocytes than it is in granulocytes. Selective loss of activity of one of two &bgr;-D-N-acetylhexosaminidases has recently been described in Tay-
of
Sacks disease. The situation in Gaucher’s disease seems be similar, although it appears that in this disorder both isozymes are affected, and to a greatly differing degree. The same type of phenomenon has been observed in the case of red-cell triosephosphate-isomerase deficiency: the activity of all three electrophoretically distinguishable isozymes are affected in this genetic defect, but loss of activity of the more rapidly moving fractions is greatest.8The biochemical bases of these effects requires more study. The techniques we have briefly outlined here will be published in detail elsewhere. They make it possible for the first time to detect in peripheral-blood cells the enzyme deficiency of patients with Gaucher’s disease, and to detect most carriers of Gaucher’s disease using commercially available reagents.
to
We thank Dr. M. Yettra for permission to study two of his patients with Gaucher’s disease. This investigation was supported, in part, by Public Health
Service grant Health. No. of
cases
studied.
t Mean rtr s.E. t Range.
Our studies indicate that normal leucocytes contain at least two acid glucosidases, and that the genetic defect of Gaucher’s disease results in a greater decrease of activity of the (3-glucosidase isozyme with the lower pH optimum. The possibility that a single enzyme is present, and that patients with Gaucher’s disease produce an enzyme with an abnormal pH-optimum curve has been considered. However, the activities of the leucocyte enzymes with pH optima at 5-3 and 4-0 are readily partially separated: the granules which are released from leucocytes by sucrose washing 6 contain a much higher ratio of enzyme activity at pH 5-3—4-0 than do intact cells. Furthermore, the ratio 6.
Cohn, Z. A., Hirsch, J. G. J. exp.
Med. 1960, 112, 983.
no.
HD 01974 from the National Institutes of
Division of Medicine, and Department of Hematology, City of Hope Medical Center, Duarte, California 91010.
ERNEST BEUTLER WANDA KUHL.
EFFECT OF STARVATION ON RENAL FUNCTION been used extensively as a method has SIR,-Starvation of weight reduction since Bloom9 introduced the method in 1959. Numerous published reports have shown that most individuals tolerate even prolonged fasting well. There Okada, S., O’Brien, J. S. Science, N.Y. 1969, 165, 698. Kaplan, J. C., Teeple, L., Shore, N., Beutler, E. Biochem. biophys. Res. Commun. 1968, 31, 768. 9. Bloom, W. L. Metabolism, 1959, 8, 214. 7. 8.
614
have, however, been some cases of unexpected sudden death,’ and there is evidence that liver function is impaired-serum glutamic-oxaloacetic and glutamic-pyruvic transaminases and bilirubin are raised,12 and bromsulphthalein retention is increased.13 Liver function seems to return to normal after refeeding. Renal function has not been studied in detail during starvation; but, in published reports on therapeutic starvation, moderate increments of serum-creatinine have often
HÆMOLYTIC CRISIS PRODUCED BY NALIDIXIC ACID
SIR,-Although a variety of agents can precipitate acute hæmolysis in glucose-6-phosphate-dehydrogenase(G.6P.D.)-deficient individuals, we believe there has so far been no published report of nalidixic acid producing such a response.
haemolytic drug.
We describe below a case in which an acute crisis seems to have been initiated by this
A 21/2-month-old West Indian boy was admitted to Seacroft Hospital on Nov. 27, 1969, with a 3-day history of diarrhoea and vomiting. He was mildly dehydrated on admission, but physical examination revealed no other abnormality apart from mild anxmia (haemoglobin 9-3 g. per 100 ml.). The blood-film showed hypochromia with anisocytosis but no polychromasia. Serum-iron was low (44 g. per 100 ml.), and the child was started on oral iron.
Although
the bowel symptoms
subsided
soon
after
admission, the child continued to have irregular pyrexia, and on the 10th day of admission the urine contained a number of pus-cells. Treatment was immediately started with intramuscular ampicillin. The following day, the report on the urine was that there were 3280 whitecells and more than 100,000 organisms per ml. There was a profuse growth of coliform bacilli, resistant to ampicillin, tetracycline, and sulphafurazole, partially sensitive to cephaloridine, and fully sensitive to nalidixic acid, colistin, nitrofurantoin, and kanamycin. On the 14th day of admission nalidixic acid was substituted for ampicillin. At that stage the child looked clinically well, with no sign of progressive anxmia. Within 48 hours of starting therapy with nalidixic acid, however, his clinical condition deteriorated alarmingly, with rapidly developing pallor and shock. The hxmoglobin had fallen to 2-3 g. per 100 ml.; there were 6 normoblasts per 100 white-cells; and the film showed marked poikilocytosis and fragmentation of redcells. No Heinz bodies were seen. The ditect Coombs test and sickling test were negative, but the red-cells were found to be grossly deficient in G-6-P.D.
large
Renal-function
tests in an
obese
man
treated with low-calorie
diet, fasting, and ketogenic diet.
been recorded in fasting patients. Usually no comment is made on this abnormality. In one paper 14 p-aminohippuricacid (P.A.H.) clearance was described as being largely unaffected by prolonged fasting, and this seemed to indicate satisfactory renal function. We have studied the renal clearance of P.A.H., inulin, and endogenous creatinine in obese patients during" therapeutic starvation and also when they were taking a ketogenic " diet. Fluid intake was adequate during the investigations. Starvation produces a substantial lowering of glomerular filtration-rate (G.F.R.), while P.A.H. clearance is affected little. In some cases, G.F.R. drops to less than 50% of the initial value. Glomerular filtration returns slowly to normal after refeeding. The ketogenic diet does not seem to impair renal function. The accompanying figure shows typical changes in the renal function of a patient during fasting and different types of diet. This patient lost 17 kg. in 9 weeks. The mechanism by which glomerular filtration is reduced during fasting is not clear. We believe that in patients with lowered renal function starvation therapy should be used only with caution. Department of Medicine, Serafimerlasarettet, Stockholm, Sweden.
B. EDGREN P. O. WESTER.
10. Spencer, I. O. B. Lancet, 1968, i, 1288. 11. Garnett, E. S., Barnard, D. L., Ford, J., Goodbody, R. A., Woodehouse, M. A. ibid. 1969, i, 914. 12. Wildenhoff, K. E., Dalsager, H. H., Sørensen, N. S. Nord. Med. 13. 14.
1969, 81, 1201. Rozental, P., Biava, C., Spencer, H., Zimmerman, H. J. Am J. dig. Dis. 1967, 12, 198. Owen, O. E., Felig, P., Morgan, A. P., Wahren, J., Cahill, G. F. J. clin. Invest. 1969, 48, 574.
After prompt blood-transfusion and a change of therapy cephaloridine, the infant’s clinical condition improved dramatically, and since then he has remained quite well. The haemoglobin on Jan. 1, 1970, was 12-0 g. per 100 ml., with 1% reticulocytes and normal film. Detailed familial studies were later carried out. Both the parents were normal, but two of the three children (all males) were found to have G.6-P.D. deficiency.
to
We believe that the rapidly progressive haemolytic anaemia was precipitated by nalidixic acid, and the patient remained quite well so long as he was on ampicillin. Infection itself may produce haemolytic anaemia in people with G.6-P.D. deficiency, but in this case urinary-tract infection was not severe and must have been present for some time. Thus, it is probably not the explanation for the sudden deterioration in the blood-picture.
There has been
no
recorded instance of nalidixic acid
precipitating haemolysis in G.6-P.D.-deficient individuals. The only reported case of haemolytic anaemia due to nalidixic acid was in a newborn baby whose G.6-P.D. test was
within normal limits.1
Nalidixic acid is a valuable and widely used drug, and as G.6-P.D. deficiency states become more and more frequent in our increasingly multiracial population, the possibility of nalidixic acid being responsible for some of the hxmolytic anaemias should be borne in mind. B. K. MANDAL Seacroft Hospital, Leeds 14. J. STEVENSON. 1.
Belton,
E.
M., Vaughan-Jones, R. Lancet, 1965, ii, 691.