1177

Effect of vegetarian diet

systemic lupus erythematosus on

SIR,-Kjeldsen-Kragh and colleagues’ have reported that subtotal fasting for 7-10 days plus a subsequent one-year vegetarian diet seems to be a useful supplement to conventional treatment of rheumatoid arthritis. In rheumatoid arthritis, similar benefits of fasting2 or "diet therapy"3 have been reported by others but we know of no reports of diet therapy in systemic lupus erythematosus (SLE). We describe here a patient with SLE whose urinary excretion of protein and antinuclear and anti-DNA antibody decreased after steroids were tapered off and a vegetarian diet was adopted. A 16-year-old girl presented with fever, arthralgia, facial erythema, and stomatitis, and was admitted to hospital in June, 1980. She had proteinuria (0-6-2-5 g in 24 h), a raised erythrocyte sedimentation rate (47 mm/h), anaemia, thrombocytopenia; a fluorescent antinuclear antibody test was positive (titre 320, shaggy and homogeneous pattern), as was her DNA antibody titre (150 U/rnl); and she was LE cell positive and had hypocomplementaemia. Needle biopsy revealed membranous proliferative glomerulonephritis and deposition of IgG, IgA, IgM, and C3 in glomeruli. These findings suggested SLE, and prednisolone 60 mg daily was initiated. However, the proteinuria worsened and complement values did not improve. Plasmapheresis and pulsed steroid therapy were tried later in 1980 but urinary protein excretion continued. Azathioprine was tried from January to June, 1981, with daily prednisolone. Her 24 h urinary protein fell below 1gand she was discharged in August, 1981. From the end of 1983 (20 mg prednisolone daily), urinary protein increased with frequent episodes of hypoalbuminaemia and oedema. still 1985-when she had In late proteinuria, hypocomplementaemia, and positive antinuclear and anti-DNA titres-she tapered off the steroids and started a vegetarian diet. This

was

done

on

the instructions of her parents and without

our

permission. The diet was: Nutruitional analysis* Before After

Nutritional analysis*

/nfae Daily intake Da/7/

*Before and after vegetarian diet.

After she started this vegetarian diet antibody titres fell to normal, urinary excretion of protein decreased, and serum albumin rose:

Daily predESR

Antibody titres Date

FANA Anti-DNA

*DNA test (U/ml), other figures tlnitiation of vegetanan diet.

Protein and calorie intake

Serum Urinary albumin protein

nisolone

(mm/h) (g/dl) (mg/dl) (mg)

are tltres

was

(RIA)

much reduced

by the diet, with

little reduction in fat. It has been suggested that food allergy or intolerance is involved in the pathogenesis of rheumatoid arthritis4 and beneficial effects of diet therapy have been reported. 1-3 However, food allergy was not evident in this patient’s history. Interest has also focused on dietary fatty acids and the inflammatory

process.sA change to a vegetarian diet might alter the fatty acid profile of phospholipids.6 On the other hand, malnutrition can suppress

immunity,7 and energy intake in patients with

SLE who

need steroid therapy has been reported to be higher than that in patients who are not steroid dependent. Furthermore, Nishimura et al8 have reported that foods containing reduced amounts of phenylalanine and tyrosine improve clinical and laboratory findings in discoid lupus erythematosus, rheumatoid arthritis, and progressive systemic sclerosis. A diet low in energy (especially animal fat and protein) may exert beneficial effects on disease activity in patients with SLE. First Department of Internal Medicine, Tottori University, School of Medicine,

Yonago 683, Japan

CHIAKI SHIGEMASA TAKASHI TANAKA HIROTO MASHIBA

Kjkeldsen-Kragh J, Haugen M, Brochgrevink CF, et al. Controlled trial of fasting and one-year vegetarian diet in rheumatoid arthritis. Lancet 1991; 338: 899-904. 2. Uden A, Trang L, Venizelos N, Palmblod J, Harms-Ringdahl M. Neutrophil function and clinical performance after total fasting in patients with rheumatoid arthritis. 1.

Ann Rheum Dis 1983; 42: 45-51. 3. Panush RS, Carter RL, Katz P, Kowsan B, Longley S, Finnie S. Diet therapy for rheumatoid arthritis. Arthritis Rheum 1983; 26: 462-71. 4. Panush RS. Food induced ("allergic") arthritis: clinical and serologic studies. J Rheumatol 1990; 17: 291-94. 5. Kremer JM, Lawrence DA, Jubiz N, et al. Dietary fish oil and olive oil supplementation in patients with rheumatoid arthritis. clinical and immunological effects. Arthritis Rheum 1990; 33: 810-20. 6. Phinney SO, Odin RS, Johnson SB, Holman RT. Reduced arachidonate in serum phospholipids and cholesterol esters associated with vegetarian diets in humans. Am J Clin Nutr 1990; 51: 585-95. 7. Good RA. Nutrition and immunity. J Clin Immunol 1981; 1: 3-11. 8. Nishimura N, Okamoto H, Yasui M, Maeda K, Ogura K. Intermediary metabolism of phenylalanine and tyrosine in diffuse collagen disease. AMA Archs Dermatol 1959; 80: 466-77.

Dermatan

sulphate in acute leukaemia

SIR,-Consumption coagulopathy in acute leukaemia is due mainly to the release of procoagulant activity from blast cells and intravascular production of thrombin.1 Heparin, which rapidly inhibits thrombin formation, has been widely used to control this coagulopathy, but not universally because of the risk of excessive bleeding.2,3 Dermatan sulphate enhances thrombin inhibition by heparin cofactor II with far less activated partial thromboplastin time (aPTT) prolongation than heparin, and without appreciable interference with platelet function.4 It has been shown to be an effective antithrombotic agent in experimental thrombosis, with a better haemorrhagic to antithrombotic ratio than heparin.S Professor Lane and colleagues (Feb 8, p 334) report it to be effective as an anticoagulant in patients on maintenance haemodialysis, and it has also proved useful in the prevention of deep-vein thrombosis in hip fracture 6 We have evaluated the efficacy and safety of dermatan sulphate compared with heparin in quenching the intravascular thrombin generation triggered by blast cells in acute leukaemia. Dermatan sulphate (MF 701, Mediolanum Farmaceutica, Milan: 0-3 mg/kg per h) or heparin (8-5 U/kg per h) was randomly administered by continuous intravenous infusion to ten patients under 70 years of age with acute leukaemia (treated with intensive antiblastic chemotherapy) and consumption coagulopathy was diagnosed by two or all three of the following: prothrombin activity < 70%, fibrinogen < 150 mg/dl, cross-linked fibrin degradation products (XDP) > 500 ng/ml. It was calculated that these anticoagulant doses would be safe and result in a moderate prolongation of standard coagulation indices. Supportive treatment with packed red cells, platelet concentrates, fresh frozen plasma, and fibrinogen cryoprecipitate was given if needed. The two treatment groups were similar with respect to major baseline characteristics. All had presented with minor haemorrhagic diatheses (petechiae, ecchymoses, gingival bleeding). The mean duration of treatment was 11 days (range 4-15) in the heparin group and 13 days (7-18 days) in the dermatan group. Laboratory tests were daily (aPTT, thrombin time [TT], fibrinogen [Clauss]) or thrice weekly (thrombin-antithrombin complexes [ATM] by Boehringer Mannheim Asserachrom; D-dimer by kit Ortho Diagnostic Systems Immertest) for about 20 days from the start of antiblastic chemotherapy.

Effect of vegetarian diet on systemic lupus erythematosus.

1177 Effect of vegetarian diet systemic lupus erythematosus on SIR,-Kjeldsen-Kragh and colleagues’ have reported that subtotal fasting for 7-10 day...
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