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SCREENING FOR ASYMPTOMATIC URINARY-TRACT INFECTION IN SCHOOLGIRLS
Saturday 7 July
SCREENING FOR ASYMPTOMATIC URINARY-TRACT INFECTION IN SCHOOLGIRLS A Two-centre
A. W. ASSCHER R. VERRIER JONES M. SUSSMAN
Feasibility Study
JOHNSTON
S. MELLER SYLVIE HARRISON
Procedures In Cardiff, screening was carried out in a mobile cliniclaboratory which visited each of the primary and infant schools in turn. Fig. 1 shows the ground-floor plan of the laboratory, which was built by Glover, Webb, and Liversedge Ltd. (London) on the basis of a design provided by Dr J. B. Selkon, of Newcastle upon Tyne. The 27-foot caravan is divided into three parts-a waiting and registration area, a urine-collection area, and a laboratory. The laboratory was staffed by two nurses who had been trained Before each school to inoculate and interpret dip-slides. was visited, the school health authorities notified the head teacher, parents, and general practitioners. In some of the schools a mobile demonstration explaining the aims of the study was shown at parent-teacher association meetings, before the children were screened. Urine specimens were collected from all girls aged 5-11 years; the total population available for screening was identified from class lists. The specimens were collected in sterile disposable paper cups which were suspended in the lavatory bowl with a metal wire holder as shown in fig. 2. This arrangement ensured that the first and final parts of the urinary stream missed the cup, whereas the middle of the stream was collected. It also enabled the children to micturate in privacy, thus reducing the number of children unable to produce a specimen on command. ’Uricult’ dip-slides were inoculated immediately and incubated overnight at 37 °C. All girls whose first specimen showed more than 105 organisms per ml. of urine in pure or almost pure culture were recalled and a further specimen was collected after perineal cleansing with sterile swabs dipped in dilute green soap solution and after drying the perineum with a sterile swab. All girls in whom the second specimen contained more than 105 organisms per ml. were referred to the hospital clinic. In Oxford, screening was undertaken in collaboration with the city health department. Head teachers and parents were informed of the purpose of the study. The
GILLIAN SLEIGHT
E. W. FLETCHER
Oxford
An economic method of screening for asymptomatic bacteriuria (A.S.B.) in 5-11-year-old schoolgirls has been compared with an " ideal " method. The economical method, which employs unsupervised urine collection in the home, has been shown to give results superior to those given by the ideal method, in which urine specimens are collected under supervision and are cultured on the spot in a specially built mobile clinic-laboratory. The results establish that repeated screening of schoolgirls for A.S.B. is feasible on a national scale at low cost. The value of instituting such a programme remains to be demonstrated.
Sum ary
et
Introduction al.1 showed that the prevalence of
asymptomatic bacteriuria (A.S.B.) in 5-year-old schoolgirls in Charlottesville, Virginia, U.S.A., was 1-2%. Two studies in Britain 2.3 have confirmed this finding. Between the ages of 5 and 12 the prevalence of A.s.B. rises with an annual acquisition-rate of 0-32%. The late effects of
A.s.B. are undecided. It is not known how frequently these infections lead to kidney damage or whether their eradication can prevent such damage. Should it prove possible to prevent kidney damage by controlling infection, it would be necessary, in view of the annual acquisition-rate of bacteriuria, to screen schoolgirls for urinary-tract infection repeatedly rather than to confine the screening to a particular age-group. This would be an arduous task unless a simple and cheap screening procedure could be used which would be acceptable to the children, parents, school health authorities, and bacteriologists. The present study compares the results of screening for A.S.B. in schoolgirls using a supervised urine-
7819
represents the first part of a controlled trial of treatment and its effect on the natural history of A.S.B. Materials and Methods
Public Health Laboratory Service, Health Department and Radcliffe Infirmary,
Kunin
technique with those of a technique involving unsupervised collection of urine. The study collection
M. S. F. MCLACHLAN
Welsh National School of Medicine and Department of Public Health, Cardiff
H. H.
1973
Screening
Fig. 1-Floor plan
of
laboratory.
2
specimen was plated out on blood-agar and McConkey agar using a bacteriological loop calibrated to deliver 0’02 ml. The urine was centrifuged and a gram-stained deposit was examined. Specimens were scored positive if a dipslide count of greater than 105 organisms per ml. was corroborated by the plate-count and if the centrifuged deposit did not show epithelial cells or bacteria suggestive of perineal contamination. In cases where the first specimen was positive by these criteria, a health visitor delivered two collection kits, identical with those originally used at the school, to the home. Parents were asked to collect two further specimens and to deliver these to the laboratory. All girls in whom two urine samples contained more than 105 organisms per ml. without contamination, as judged by culture and microscopy, were referred to the hospital clinic. Hospital Procedures Identical procedures
were used in Oxford and Cardiff. Since these are not relevant to the present communication, it suffices to say that, following clinical assessment, arrangements were made for excretion urography and micturating cystography. At the time of cystography a catheter specimen of urine was collected and cultured immediately. The results of these cultures were used to check the accuracy of the screening procedures. In the present analysis the radiological findings were used to determine whether the screening procedures in the two cities identified similar populations.
Results Fig. 2-Lavatory in mobile laboratory. of 5-11-year-old girls in each school was defined from the class lists, and labelled urine containers and uricult dip-slides were prepared at the laboratory and sent to the school, where they were given to the children to take home. In a simple set of written instructions the children were asked to pass urine directly into the container-a 100 ml. wide-mouthed disposable plastic jar to which 0’5 g. of boric acid had been added.-5 They were then asked to dip the slide into the urine and to return both the urine specimen and the dip-slide to school. No instructions were given regarding perineal cleansing nor were the children asked to produce a mid-stream specimen. In general, specimens were passed at home but some were produced at school. No record was made of the time of collection during the 24-hour period between issue of the container and its recovery from the school. On receipt the dip-slides were incubated overnight at 37 °C. In urines where the dip-slide growth indicated a count in excess of 105 organisms per ml., the borate-preserved
population
6394 girls at 27 of the 62 junior and infant schools in Cardiff and 3247 girl pupils of 21 of the 40 junior and infant schools in Oxford were screened. Tables 5772 (90.3%) of I and 11 summarise the findings. the Cardiff girls provided specimens, compared with 2950 (90.5%) of the girls in Oxford. The tables show that in Cardiff the prevalence of A.S.B rises with age, from 0-7% at 5 years to 2-8% at 11 years. In Oxford, where detailed figures according to age were not available, the prevalence of bacteriuria in infant schools (2’4%) was higher than that in junior schools (1-8%). In both cities the decrease in the percentage of positive urine cultures between first and second testing was greatest in the younger age-groups. This suggests that contamination is a more serious problem in the younger than the older girls. The similarity of the data obtained in the two cities establishes that the unsupervised urine-collection technique employed in Oxford is the equal of the supervised method used
TABLE I-PREVALENCE OF BACTERIURIA IN CARDIFF SCHOOLGIRLS
*
Percentage of number eligible in parentheses.
t Percentage of number tested in parentheses.
t Catheter specimen of urine.
3 TABLE II-PREVALENCE OF BACTERIURIA IN OXFORD SCHOOLGIRLS
*
Percentage of number eligible. t Percentage of number tested.
t Catheter specimen of urine.
in Cardiff.
In Cardiff it was possible to record the and reasons for failure to cooperate. frequency Failure of cooperation was commonest in the youngest girls and the most usual reason was inability to micturate on demand. In Oxford the degree of cooperation in the infant and junior schools was similar, probably because the urine-collection technique did not involve micturition on demand. The results of culture of the catheter specimens of urine confirmed infection in 78% of the Cardiff girls and 94% of the girls in Oxford. The sensitivity of the Oxford screening method therefore exceeds that of the Cardiff method. The radiological findings, which are summarised in table ill, show that the two screening methods identify populations with very similar abnormalities of the urinary tract. The tended to show renal fewer acquired younger girls abnormalities than the older girls. Thus 5 of the 41 (12%) girls born in 1965-67 showed acquired renal abnormalities, compared with 19 of the 78 (24%) girls born in 1960-64.
Cost
ofScreening
Mr D. M. P. Jones and Mr S. Rama, of the organisation and method department of the Oxford Regional Hospital Board, assessed the cost of screening for A.S.B. Assuming a 25 % annual depreciation of the mobile laboratory, the cost of screening
in Cardiff was 75p per child, compared with 15p per child in Oxford. This marked difference is attributable to costs directly related to the requirement for supervised urine collection. Thus, even if it was assumed that the mobile laboratory showed no depreciation, the cost of screening in Cardiff would still be 54p per child.
Discussion It has become a matter of some urgency to establish whether there is a need to screen schoolgirls for asymptomatic infections of the urinary tract. The solution of this problem requires a controlled study of the effect of treatment on the long-term natural history of these infections. To achieve success, it is necessary to follow a sizeable population of treated and untreated bacteriuric girls. Since the prevalence of urinary-tract infection in 5-year-old girls is only of the order of 1 %,’ it was decided to combine studies in the cities of Oxford and Cardiff in order to increase the number of children entering the trial. It was deliberate policy to use different screening techniques in the two cities, in order to establish whether a practical method such as the one employed in Oxford could yield results comparable with those of the more demanding method used in Cardiff. Since 0-32 % of the schoolgirl population acquires bacteriuria each
TABLE III-RADIOLOGICAL FINDINGS
’ Percentage of total in parentheses. t Excretion urogram only. t Congenital anomalies of the urinary tract have not been included. Duplex ureters and congenital bladder diverticula (of Hutch) 15 children, being equally common in those with acquired lesions and those without.
were
present in
4 there is
need
devise
economically realistic method of screening; for, if screening were to be shown to have preventive value, it would have to be carried out repeatedly rather than on a single year,’
a
to
an
occasion such as school entry. The present study establishes that examination by the dip-slide technique of urine specimens collected without supervision may be used to screen for urinarytract infection in schoolgirls provided that positive cultures are validated by microscopic and bacteriological examination of a borate-preserved urine specimen. In this survey, this simple technique gave results which were superior to those obtained by immediate culture of mid-stream urine specimens collected under supervision in a mobile laboratory. The Oxford method requires the cooperation of a diagnostic laboratory where skilled observers can interpret the urine deposit. Facilities of this kind are widely available in the United Kingdom. It must be emphasised that only a small number of the urines received needed detailed microscopic examination, as the majority could be declared negative on the basis of the dip-slide findings. The Oxford method has three advantages over the method used in Cardiffnamely, greater speed, lower cost, and a higher degree of cooperation by the younger girls, who were frequently unable to micturate on demand in the mobile laboratory. The last of these advantages could well be the most important, since it seems likely that the preventive value of screening for urinary-tract infection is greatest in the youngest girls. The radiological data lend some support to this view since pyelonephritic scarring appeared to be commoner in the older than the younger girls. The valuable advice of Prof. Paul Beeson, Prof. A. L. Cochrane, Dr J. G. G. Ledingham, Mr J. C. Smith, and Mr D. Hole is acknowledged. We thank Dr J. F. Warin, Dr Marie Richards, and the head teachers of the schools; our nurses, Mrs E. Barnett, Mrs E. Brown, Mrs J. Kidd, and Mrs J. Critchley; and Mrs S. Chick, Miss V. Moss, and Mr E. Roberts for technical assistance. Administrative help was given by Miss P. Mannings. The study is supported by a grant from the Kidney Research Foundation for Wales (K.R.U.F.). Bristol Myers Laboratory Ltd. supplied the dip-slides. Requests for reprints should be addressed to A. W. A., K.R.U.F. Institute of Renal Disease, Royal Infirmary, Cardiff. REFERENCES 1. 2.
3. 4. 5.
Kunin, C. M., Southall, I., Paquin, A. J. New Engl. J. Med. 1960, 263, 817. Savage, D. C. L., Wilson, M. I., Ross, E. M., Fee, W. M. Br. med. J. 1969, iii, 75. Meadow, R. S., White, R. H. R., Johnston, N. M. ibid. p. 81. Kunin, C. M. Pediatrics, Springfield, 1968, 41, 968. Porter, I. A., Brodie, J. Br. med. J. 1969, i, 353.
RENAL TRANSPLANTATION IN PATIENTS WITH INSULIN-DEPENDENT DIABETES CARL M. KJELLSTRAND RICHARD L. SIMMONS FREDERICK C. GOETZ THEODORE J. BUSELMEIER JEFFREY R. SHIDEMAN BARRY VON HARTITZSCH JOHN S. NAJARIAN
Department of Surgery and Medicine, University of Minnesota, Minneapolis, U.S.A.
Forty patients (age 23-48 years) with insulin-dependent diabetes mellitus and end-stage renal failure were accepted for renal transplantation at the University of Minnesota between June, 1969, and September, 1972. Fifteen patients died: six before transplantation, three within 6 months of transplantation, and six after this period. Infections and myocardial infarctions were the principle causes of death. Age, age at onset of diabetes, duration of diabetes, electrocardiogram changes, a history of angina, or severity of retinopathy were unreliable as prognostic indicators. Women had much Summary
better results than men. Rehabilitation and management of the diabetes mellitus in the patients with viable grafts was good. Diabetic nephropathy did not recur and hypertension was easily controlled. Visual acuity, which had rapidly deteriorated in uræmic diabetics, remained stable after transplantation.
Introduction
URaeMIA is a common cause of death in patients with juvenile-onset insulin-dependent diabetesi These patients are usually excluded from dialysis and transplantation.2-9 Except for the reports by Blagg et a1,5 and Ghavamian et al.,s the rather dismal results of haemodialysis for diabetic renal diseases 3,7 have only been reported in abstracts and short caselo reports, and apart from a preliminary report by us" the same is true of transplantation in such
pa tients. 2,4,9 We report
experiences with forty patients with insulin-dependent diabetes who were accepted for renal transplantation from June, 1969, to September, 1972. Ten patients who received both pancreas and kidney transplants 11 and patients with diabetes our
mellitus not in need of insulin the present report.
are not
included in
Patients and Methods " ... the NHS may have had little impact in the past 10 years terms of increasing the expectation of life-which only went up by 0-7 years between 1961 and 1971, from 67-9 to 68-6 years for men (in contrast, it went up by more than 5 years in the decade before Lloyd George introduced his health insurance scheme: thereafter, the rate of improvement dropped sharply). But the NHS may have had a great deal of impact in terms of making life easier for the chronic bronchitic or the depressive housewife. It would be just as unwise to deduce the failure of the NHS from the inadequacy of the statistics as it is to assume its success in improving the nation’s health as an article of religious faith and as such beyond rational proof or disproof."RUDOLF KLEIN, Political Quarterly, 1973, 44, 320.
in
The
age of our forty patients with diabetes (fourtwenty-six men) at the time of acceptance was 33-5 years (range 23-48). Each patient had severe hypertension requiring antihypertensive drugs. The mean duration of diabetes was 20 years (range 14-34), and kidney disease had been present for a mean of 4 years (range 0.5-6). The mean serum-creatinine level at the time of the first dialysis was 14’3 mg. per 100 ml. (range 5’8-23’6). The mean predialysis blood-urea-nitrogen was 116 mg. per 100 ml. (range 40-303). Six patients died before transplantation. The remaining thirty-four patients received 37 kidney transplants, 27 from related donor and mean
teen women,
SCREENING FOR ASYMPTOMATIC URINARY-TRACT INFECTION IN SCHOOLGIRLS A Two-centre
A. W. ASSCHER R. VERRIER JONES M. SUSSMAN
Feasibility Study
JOHNSTON
S. MELLER SYLVIE HARRISON
Procedures In Cardiff, screening was carried out in a mobile cliniclaboratory which visited each of the primary and infant schools in turn. Fig. 1 shows the ground-floor plan of the laboratory, which was built by Glover, Webb, and Liversedge Ltd. (London) on the basis of a design provided by Dr J. B. Selkon, of Newcastle upon Tyne. The 27-foot caravan is divided into three parts-a waiting and registration area, a urine-collection area, and a laboratory. The laboratory was staffed by two nurses who had been trained Before each school to inoculate and interpret dip-slides. was visited, the school health authorities notified the head teacher, parents, and general practitioners. In some of the schools a mobile demonstration explaining the aims of the study was shown at parent-teacher association meetings, before the children were screened. Urine specimens were collected from all girls aged 5-11 years; the total population available for screening was identified from class lists. The specimens were collected in sterile disposable paper cups which were suspended in the lavatory bowl with a metal wire holder as shown in fig. 2. This arrangement ensured that the first and final parts of the urinary stream missed the cup, whereas the middle of the stream was collected. It also enabled the children to micturate in privacy, thus reducing the number of children unable to produce a specimen on command. ’Uricult’ dip-slides were inoculated immediately and incubated overnight at 37 °C. All girls whose first specimen showed more than 105 organisms per ml. of urine in pure or almost pure culture were recalled and a further specimen was collected after perineal cleansing with sterile swabs dipped in dilute green soap solution and after drying the perineum with a sterile swab. All girls in whom the second specimen contained more than 105 organisms per ml. were referred to the hospital clinic. In Oxford, screening was undertaken in collaboration with the city health department. Head teachers and parents were informed of the purpose of the study. The
GILLIAN SLEIGHT
E. W. FLETCHER
Oxford
An economic method of screening for asymptomatic bacteriuria (A.S.B.) in 5-11-year-old schoolgirls has been compared with an " ideal " method. The economical method, which employs unsupervised urine collection in the home, has been shown to give results superior to those given by the ideal method, in which urine specimens are collected under supervision and are cultured on the spot in a specially built mobile clinic-laboratory. The results establish that repeated screening of schoolgirls for A.S.B. is feasible on a national scale at low cost. The value of instituting such a programme remains to be demonstrated.
Sum ary
et
Introduction al.1 showed that the prevalence of
asymptomatic bacteriuria (A.S.B.) in 5-year-old schoolgirls in Charlottesville, Virginia, U.S.A., was 1-2%. Two studies in Britain 2.3 have confirmed this finding. Between the ages of 5 and 12 the prevalence of A.s.B. rises with an annual acquisition-rate of 0-32%. The late effects of
A.s.B. are undecided. It is not known how frequently these infections lead to kidney damage or whether their eradication can prevent such damage. Should it prove possible to prevent kidney damage by controlling infection, it would be necessary, in view of the annual acquisition-rate of bacteriuria, to screen schoolgirls for urinary-tract infection repeatedly rather than to confine the screening to a particular age-group. This would be an arduous task unless a simple and cheap screening procedure could be used which would be acceptable to the children, parents, school health authorities, and bacteriologists. The present study compares the results of screening for A.S.B. in schoolgirls using a supervised urine-
7819
represents the first part of a controlled trial of treatment and its effect on the natural history of A.S.B. Materials and Methods
Public Health Laboratory Service, Health Department and Radcliffe Infirmary,
Kunin
technique with those of a technique involving unsupervised collection of urine. The study collection
M. S. F. MCLACHLAN
Welsh National School of Medicine and Department of Public Health, Cardiff
H. H.
1973
Screening
Fig. 1-Floor plan
of
laboratory.
2
specimen was plated out on blood-agar and McConkey agar using a bacteriological loop calibrated to deliver 0’02 ml. The urine was centrifuged and a gram-stained deposit was examined. Specimens were scored positive if a dipslide count of greater than 105 organisms per ml. was corroborated by the plate-count and if the centrifuged deposit did not show epithelial cells or bacteria suggestive of perineal contamination. In cases where the first specimen was positive by these criteria, a health visitor delivered two collection kits, identical with those originally used at the school, to the home. Parents were asked to collect two further specimens and to deliver these to the laboratory. All girls in whom two urine samples contained more than 105 organisms per ml. without contamination, as judged by culture and microscopy, were referred to the hospital clinic. Hospital Procedures Identical procedures
were used in Oxford and Cardiff. Since these are not relevant to the present communication, it suffices to say that, following clinical assessment, arrangements were made for excretion urography and micturating cystography. At the time of cystography a catheter specimen of urine was collected and cultured immediately. The results of these cultures were used to check the accuracy of the screening procedures. In the present analysis the radiological findings were used to determine whether the screening procedures in the two cities identified similar populations.
Results Fig. 2-Lavatory in mobile laboratory. of 5-11-year-old girls in each school was defined from the class lists, and labelled urine containers and uricult dip-slides were prepared at the laboratory and sent to the school, where they were given to the children to take home. In a simple set of written instructions the children were asked to pass urine directly into the container-a 100 ml. wide-mouthed disposable plastic jar to which 0’5 g. of boric acid had been added.-5 They were then asked to dip the slide into the urine and to return both the urine specimen and the dip-slide to school. No instructions were given regarding perineal cleansing nor were the children asked to produce a mid-stream specimen. In general, specimens were passed at home but some were produced at school. No record was made of the time of collection during the 24-hour period between issue of the container and its recovery from the school. On receipt the dip-slides were incubated overnight at 37 °C. In urines where the dip-slide growth indicated a count in excess of 105 organisms per ml., the borate-preserved
population
6394 girls at 27 of the 62 junior and infant schools in Cardiff and 3247 girl pupils of 21 of the 40 junior and infant schools in Oxford were screened. Tables 5772 (90.3%) of I and 11 summarise the findings. the Cardiff girls provided specimens, compared with 2950 (90.5%) of the girls in Oxford. The tables show that in Cardiff the prevalence of A.S.B rises with age, from 0-7% at 5 years to 2-8% at 11 years. In Oxford, where detailed figures according to age were not available, the prevalence of bacteriuria in infant schools (2’4%) was higher than that in junior schools (1-8%). In both cities the decrease in the percentage of positive urine cultures between first and second testing was greatest in the younger age-groups. This suggests that contamination is a more serious problem in the younger than the older girls. The similarity of the data obtained in the two cities establishes that the unsupervised urine-collection technique employed in Oxford is the equal of the supervised method used
TABLE I-PREVALENCE OF BACTERIURIA IN CARDIFF SCHOOLGIRLS
*
Percentage of number eligible in parentheses.
t Percentage of number tested in parentheses.
t Catheter specimen of urine.
3 TABLE II-PREVALENCE OF BACTERIURIA IN OXFORD SCHOOLGIRLS
*
Percentage of number eligible. t Percentage of number tested.
t Catheter specimen of urine.
in Cardiff.
In Cardiff it was possible to record the and reasons for failure to cooperate. frequency Failure of cooperation was commonest in the youngest girls and the most usual reason was inability to micturate on demand. In Oxford the degree of cooperation in the infant and junior schools was similar, probably because the urine-collection technique did not involve micturition on demand. The results of culture of the catheter specimens of urine confirmed infection in 78% of the Cardiff girls and 94% of the girls in Oxford. The sensitivity of the Oxford screening method therefore exceeds that of the Cardiff method. The radiological findings, which are summarised in table ill, show that the two screening methods identify populations with very similar abnormalities of the urinary tract. The tended to show renal fewer acquired younger girls abnormalities than the older girls. Thus 5 of the 41 (12%) girls born in 1965-67 showed acquired renal abnormalities, compared with 19 of the 78 (24%) girls born in 1960-64.
Cost
ofScreening
Mr D. M. P. Jones and Mr S. Rama, of the organisation and method department of the Oxford Regional Hospital Board, assessed the cost of screening for A.S.B. Assuming a 25 % annual depreciation of the mobile laboratory, the cost of screening
in Cardiff was 75p per child, compared with 15p per child in Oxford. This marked difference is attributable to costs directly related to the requirement for supervised urine collection. Thus, even if it was assumed that the mobile laboratory showed no depreciation, the cost of screening in Cardiff would still be 54p per child.
Discussion It has become a matter of some urgency to establish whether there is a need to screen schoolgirls for asymptomatic infections of the urinary tract. The solution of this problem requires a controlled study of the effect of treatment on the long-term natural history of these infections. To achieve success, it is necessary to follow a sizeable population of treated and untreated bacteriuric girls. Since the prevalence of urinary-tract infection in 5-year-old girls is only of the order of 1 %,’ it was decided to combine studies in the cities of Oxford and Cardiff in order to increase the number of children entering the trial. It was deliberate policy to use different screening techniques in the two cities, in order to establish whether a practical method such as the one employed in Oxford could yield results comparable with those of the more demanding method used in Cardiff. Since 0-32 % of the schoolgirl population acquires bacteriuria each
TABLE III-RADIOLOGICAL FINDINGS
’ Percentage of total in parentheses. t Excretion urogram only. t Congenital anomalies of the urinary tract have not been included. Duplex ureters and congenital bladder diverticula (of Hutch) 15 children, being equally common in those with acquired lesions and those without.
were
present in
4 there is
need
devise
economically realistic method of screening; for, if screening were to be shown to have preventive value, it would have to be carried out repeatedly rather than on a single year,’
a
to
an
occasion such as school entry. The present study establishes that examination by the dip-slide technique of urine specimens collected without supervision may be used to screen for urinarytract infection in schoolgirls provided that positive cultures are validated by microscopic and bacteriological examination of a borate-preserved urine specimen. In this survey, this simple technique gave results which were superior to those obtained by immediate culture of mid-stream urine specimens collected under supervision in a mobile laboratory. The Oxford method requires the cooperation of a diagnostic laboratory where skilled observers can interpret the urine deposit. Facilities of this kind are widely available in the United Kingdom. It must be emphasised that only a small number of the urines received needed detailed microscopic examination, as the majority could be declared negative on the basis of the dip-slide findings. The Oxford method has three advantages over the method used in Cardiffnamely, greater speed, lower cost, and a higher degree of cooperation by the younger girls, who were frequently unable to micturate on demand in the mobile laboratory. The last of these advantages could well be the most important, since it seems likely that the preventive value of screening for urinary-tract infection is greatest in the youngest girls. The radiological data lend some support to this view since pyelonephritic scarring appeared to be commoner in the older than the younger girls. The valuable advice of Prof. Paul Beeson, Prof. A. L. Cochrane, Dr J. G. G. Ledingham, Mr J. C. Smith, and Mr D. Hole is acknowledged. We thank Dr J. F. Warin, Dr Marie Richards, and the head teachers of the schools; our nurses, Mrs E. Barnett, Mrs E. Brown, Mrs J. Kidd, and Mrs J. Critchley; and Mrs S. Chick, Miss V. Moss, and Mr E. Roberts for technical assistance. Administrative help was given by Miss P. Mannings. The study is supported by a grant from the Kidney Research Foundation for Wales (K.R.U.F.). Bristol Myers Laboratory Ltd. supplied the dip-slides. Requests for reprints should be addressed to A. W. A., K.R.U.F. Institute of Renal Disease, Royal Infirmary, Cardiff. REFERENCES 1. 2.
3. 4. 5.
Kunin, C. M., Southall, I., Paquin, A. J. New Engl. J. Med. 1960, 263, 817. Savage, D. C. L., Wilson, M. I., Ross, E. M., Fee, W. M. Br. med. J. 1969, iii, 75. Meadow, R. S., White, R. H. R., Johnston, N. M. ibid. p. 81. Kunin, C. M. Pediatrics, Springfield, 1968, 41, 968. Porter, I. A., Brodie, J. Br. med. J. 1969, i, 353.
RENAL TRANSPLANTATION IN PATIENTS WITH INSULIN-DEPENDENT DIABETES CARL M. KJELLSTRAND RICHARD L. SIMMONS FREDERICK C. GOETZ THEODORE J. BUSELMEIER JEFFREY R. SHIDEMAN BARRY VON HARTITZSCH JOHN S. NAJARIAN
Department of Surgery and Medicine, University of Minnesota, Minneapolis, U.S.A.
Forty patients (age 23-48 years) with insulin-dependent diabetes mellitus and end-stage renal failure were accepted for renal transplantation at the University of Minnesota between June, 1969, and September, 1972. Fifteen patients died: six before transplantation, three within 6 months of transplantation, and six after this period. Infections and myocardial infarctions were the principle causes of death. Age, age at onset of diabetes, duration of diabetes, electrocardiogram changes, a history of angina, or severity of retinopathy were unreliable as prognostic indicators. Women had much Summary
better results than men. Rehabilitation and management of the diabetes mellitus in the patients with viable grafts was good. Diabetic nephropathy did not recur and hypertension was easily controlled. Visual acuity, which had rapidly deteriorated in uræmic diabetics, remained stable after transplantation.
Introduction
URaeMIA is a common cause of death in patients with juvenile-onset insulin-dependent diabetesi These patients are usually excluded from dialysis and transplantation.2-9 Except for the reports by Blagg et a1,5 and Ghavamian et al.,s the rather dismal results of haemodialysis for diabetic renal diseases 3,7 have only been reported in abstracts and short caselo reports, and apart from a preliminary report by us" the same is true of transplantation in such
pa tients. 2,4,9 We report
experiences with forty patients with insulin-dependent diabetes who were accepted for renal transplantation from June, 1969, to September, 1972. Ten patients who received both pancreas and kidney transplants 11 and patients with diabetes our
mellitus not in need of insulin the present report.
are not
included in
Patients and Methods " ... the NHS may have had little impact in the past 10 years terms of increasing the expectation of life-which only went up by 0-7 years between 1961 and 1971, from 67-9 to 68-6 years for men (in contrast, it went up by more than 5 years in the decade before Lloyd George introduced his health insurance scheme: thereafter, the rate of improvement dropped sharply). But the NHS may have had a great deal of impact in terms of making life easier for the chronic bronchitic or the depressive housewife. It would be just as unwise to deduce the failure of the NHS from the inadequacy of the statistics as it is to assume its success in improving the nation’s health as an article of religious faith and as such beyond rational proof or disproof."RUDOLF KLEIN, Political Quarterly, 1973, 44, 320.
in
The
age of our forty patients with diabetes (fourtwenty-six men) at the time of acceptance was 33-5 years (range 23-48). Each patient had severe hypertension requiring antihypertensive drugs. The mean duration of diabetes was 20 years (range 14-34), and kidney disease had been present for a mean of 4 years (range 0.5-6). The mean serum-creatinine level at the time of the first dialysis was 14’3 mg. per 100 ml. (range 5’8-23’6). The mean predialysis blood-urea-nitrogen was 116 mg. per 100 ml. (range 40-303). Six patients died before transplantation. The remaining thirty-four patients received 37 kidney transplants, 27 from related donor and mean
teen women,