A 33-year-old white man first presented to the Royal Infirmary Stirling, Scotland, 24 years ago with a history of recent-onset hematuria. Intravenous urography at that time showed a filling defect in the right kidney; a subsequent aortogram demonstrated a single simple cyst in the right kidney. Over the next nine years he suffered from occasional episodes of back pain, particularly on the right side. His renal tract was further investigated at the Borders General Hospital 14 years ago because of recurrent urinary tract infections. His blood pressure at that time ranged from 130/100 mm Hg to 170/1 10 mm Hg. His hemoglobin was 15.7 mg/dl, with a hematocrit of 45.6%. Plasma urea and creatinine were normal at 5.1 mmol/liter (normal, 2.5—6.5 mmol/liter), and 75 jtmol/liter (normal, 55—150 jmol/ liter) respectively. Cystoscopy showed only moderate bladder inflammation, but a further aortogram at the Royal Infirmary Edinburgh demonstrated enlarged cystic kidneys bilaterally. The right kidney was significantly larger and more cystic than the left; a diagnosis of polycystic kidney disease was made. Until 11 years ago, the patient's condition was characterized by recurrent episodes of back and abdominal pain, but he was able to continue in his job as a supervisor in a knitwear factory. Cyst aspirations on two occasions conferred some relief of pain. Eleven years ago, he was admitted to the Borders General Hospital with acute-onset chest pain. Acute myocardial infarction was diagnosed on the basis of an increase in cardiac enzymes and anterior T-wave inversion on the electrocardiogram. His hemoglobin was 15.6 g/dl. with a hematocrit of 44.7%; his renal function remained normal. At discharge, therapy with metoprolol, 50 mg twice daily, and isosorbide mononitrate, 40 mg twice daily, had lowered his blood pressure to 110/60mm Hg. Because of subsequent episodes of chest pain, coronary angiography was performed in Edinburgh. The test showed a dilated left-ventricular cavity with apical hypokinesia and moderate