313 taken after failure of the first graft. There was insufficient donor material to perform a B-cell cross-match but in view of the fact that only B-cell antibodies had been detected since failure of the first graft, we felt that this represented a positive B-cell cross-match. Because we were aware of the work from Terasaki’s group, and because the girl was not tolerating dialysis well, we decided to go ahead with the transplant. The kidney did not function immediately, as there had been some 666 min total ischeemia-time, and one dialysis was required on day 3. Function then improved rapidly and her creatinine 31 days post transplant is 110 fJ-m01l1, with a clearance of 65 ml/min. Graft biopsy at transplantation showed some slight polymorph infiltration which might be indicative of some mild antibody-mediated damage. There has been no clinical evidence of rejection to date suggesting that the positive cross-match due to B-cell antibodies has not resulted in any significant graft damage. This could be explained by the lack of B-cell antigens on renal endothelium or parenchyma, or by the enhancing properties of these antibodies in vivo. If further instances of successful transplants in the presence of positive B-cell cross-matches can be documented there are important implications for tissue-typing laboratories. For these laboratories will have to be capable of performing T and B cell cross-matches for their recipients known to have antibodies. It also means that generous portions of donor lymphoid tissues as a source of lymphocytes for B-cell cross-matching must be sent with each kidney.

Nuffield Department of Surgery,

University of Oxford, Radcliffe Infirmary, Oxford

OX2 6HE

PETER J. MORRIS ALAN TING A. S. DAAR DESMOND OLIVER

AUTONOMIC DYSFUNCTION

SIR,-Your editorial

on autonomic dysfunction’ concluded the poor prognosis of patients with this condition. However, in idiopathic orthostatic hypotension, one of the rarer syndromes of autonomic dysfunction, the prognosis is still far from clear 50 years after the original description by Bradbury and Eggleston.2 East and Brigden3 in 1946 concluded that idiopathic orthostatic hypotension was a benign condition, although it was recognised that a few patients might develop generalised neurological involvement.’This was further clarified by Shy and Dragerin 1960, and since then attention has naturally focused on the more severe forms of the disease. Patients with generalised neurological involvement have a poor prognosis.5 However, it is perhaps forgotten that in some patients the disease may remain confined to the autonomic nervous system. This was so in 7 of 23 patients reported by Thomas and

with

a comment on

Schirger.6 We have treated a patient with idiopathic orthostatic hypotension whose disease remained so confined. We found that in about 20% of published cases symptoms had been present many years without progressing to generalised neurological disease.’ We would, therefore, suggest that a more optimistic view of this condition is justified. Active and carefully controlled treatment of the hypotension is worthwhile and can be 8 very successful. Birch Hill Hospital, Rochdale OL12 9QB

Department

of Chemical

University of Leeds

C. DAVIDSON Pathology,

D. B. MORGAN

1. Lancet, 1976,i, 1115. 2. Bradbury, S., Eggleston, C. Am. Heart J. 1925, 1, 73. 3. East, T., Brigden, W. Br. Heart J. 1946, 8, 103. 4. Shy, G. M., Drager, G. A. Archs. Neurol. 1960, 2, 511 5. Thomas, J. E., Schirger, A. ibid. 1970, 22, 289. 6. Thomas, J. E., Schirger, A. ibid. 1963, 8, 204. 7. Davidson, C., Morgan, D. B. J. chron. Dis. (in the press). 8. Davidson, C., Smith, D., Morgan, D. B. Am. J. Med. (in the

press).

HEART-ATTACKS AND THE SAUNA

SIR,-Finland has one of the highest rates of death from ischaemic heart-disease in the world. To what extent can this be attributable to the sudden haemoconcentration and cardiac acceleration in the middle-aged from repeated sauna baths which are so popular there? Military Hospital,

H. FOSTER

Colchester CO2 7UD

PREVENTION OF CORONARY HEART-DISEASE

SIR,-Sir Cyril Clarke and Professor Goodwin (July 24, p. offer an answer to my criticism’ that there was a contradiction between a statement made by the joint workingparty on coronary care of the Royal College of Physicians of London and the British Cardiac Society and one made by the corresponding joint working-party on prevention; but I fear I find the reply unconvincing. In essence what they say is that the contradiction is illusory, and that the reports indicate that we must have plenty of both coronary-care units and prevention ; and, unaccountably, they seek to defend their position, at least in part, by repeating word for word the quotations I gave from the two reports in support of my own position. I shall not now do the same, but will cite one short passage from each. The first report said "More attention must be paid to the said and the second of immediate care ..." provision coronary "the potential benefit from improving emergency services would be disappointingly small". I should have thought that, apart from a direct refutation, this is about as close to a contradiction as one can come; and I repeat my earlier comment that, at a time of the greatest economic stringency, a clear lead on priorities should have been given to Government. Money is scarce. Where in the coronary field is it mainly to be spent? That is the unanswered question. There were two parent bodies to the working-parties. Was it not their duty-is it not still their duty-to resolve the incompatibility mentioned? It is no excuse to say that the first working-party was concerned with treatment, and the second (sharing some members with the first) with prevention: coronary mortality does not wait upon such man-made distinctions which are a product, often a most unfortunate product, of the non-holistic approach to problem solving common among scientists. May I commend to Sir Cyril and Professor Goodwin three items, all published since the working-parties finished their deliberations? First, a Government document on the necessity for choices in the health field2; second, a suggestion3 that in the U.S.A. preventive steps have brought down coronary mortality by 30% in the past 6-8 years; and third, the definitive report from Mather et al.4 showing little difference in mortality among randomly allocated home-treated and hospital-treated coronary patients. The three together, in my view, lend emphasis to what I suggest has been clear for some time-the way in which the coronary financial die should be cast. However, before very long cast it certainly must and will be.

196) kindly

...

Garraway House, How Caple, Hereford

JOHN S. BRADSHAW

SIR,-Many doctors in the U.K. will by now have read their free copy of the booklet Prevention of Coronary Heart Disease, a report of a joint working-party of the Royal College of Physicians and the British Cardiac Society. I note that in the section on physical activity sexual intercourse is not mentioned although the report (p. 36) shows that participation in physical 1. Bradshaw, J. S. Lancet, 1976, i, 1298. 2. Priorities for Health and Personal Social Services ery Office, 1976. 3. Mulcahy, R. Br. med. J. 1976, ii, 157. 4 Mather, H. G., and others ibid. 1976, i, 925.

in

England.

H. M. Station-

Letter: Autonomic dysfunction.

313 taken after failure of the first graft. There was insufficient donor material to perform a B-cell cross-match but in view of the fact that only B-...
163KB Sizes 0 Downloads 0 Views