[Prevention of bacteremia from central venous catheters in hemodialysis: value of application of a mixture of rifampicin and protamine at the insertion site]

During the last 8.5 years, authors observed only 3 bacteremias out of 249 catheters in place in different sites corresponding to a total of 10,063 days with central venous catheterization in hemodialysis (0.30/1000 catheter days). This good result seems to be correlated mainly with the preventive application, on catheter insertion-site, of a rifampin and protamine sulphate mixture. This protocol appears worthy to be known because, at the present time, whatever the new preventive strategies, infection rates reported in the literature are generally more consequent and it is necessary to consider all the possibilities of decreasing them.

[Value of isotretinoin in the treatment of acne in hemodialysis patients: apropos of 1 case]

Rare are reports about isoretinoin treatment for acne in dialysis or kidney transplant patients whereas its efficacy and safety make it very interesting. Authors report here an additional observation of a 32 year-old young woman, hemodialyzed after one period of 12 years renal transplantation, and presenting a diffuse and severe acne. Treatment by isotretinoin with a moderate amount of 20 mg (0.38 mg/kg) per day cures this dermatosis in 2 months and half, without severe clinical side effect or significant metabolic disturbance, apart from a transient increase in parathormone rate.

[Drug induced linear IgA bullous dermatosis]

Linear IgA disease is an autoimmune subepidermal bullous disease in which linear IgA deposits are found at the basement membrane zone. It is classically idiopathic but a drug-induced variant seems to be individualized in which cutaneous lesions resolve spontaneously after cessation of responsible treatment. Among the commonly implicated drugs, vancomycin is the most frequently reported. One should not however ignore other precipitating events sometimes associated, particularly infectious diseases and non-lymphoid or lymphoproliferative malignancies. Authors present here clinical and histological features of this disease as well as drugs that have been implicated.

[Colonic necrosis caused by sodium polystyrene (kayexalate) in hemodialysis: myth or reality? Two case reports]

Among gastro-intestinal complications reported in uremic or transplanted patients, colonic necrosis due to Kayexalate and sorbitol is not so unusual for english authors. This iatrogenic event is probably underestimated by physicians and pathologists. In France, neither literature nor pharmacovigilance refer this complication but Vidal dictionary advises against such association. We thought of interest to report 2 representative observations and, after reviewing literature, to discuss diagnostics circumstances and etiopathogenic hypothesis and then to give some advices.

Use of midodrine (Gutron) to treat permanent hypotension in a chronic hemodialysis patient

Chronic hypotension, infrequent though possible in chronic renal failure patients on hemodialysis, has harmful consequences on their physical state and hence general well-being. These patients often experience acute intradialytic manifestations while non-pharmacologic interventions as pharmacologic agents are sometimes insufficient to improve symptoms. Well tolerated, midodrine appears to be a suitable and effective agent as it raises blood pressure significantly via its effect on peripheral alpha-adrenergic receptors. The authors describe their use of midodrine in a dialysis patient for the longest period of time reported up to now, documented by a pharmacokinetic study, confirming long-term both clinical efficacy and safety of the drug.

[Pulmonary migration of an axillary stent in a chronic hemodialysis patient]

The short-lived results of angioplasty for venous stenosis of a dialysis access led to stent placement. Its migration is a rare but dangerous complication, because of its final destination, that is right heart or pulmonary artery. We report on such a case and compare it with three cases found in literature.

[Value of an end-stage renal failure registry. Experience of the Champagne-Ardenne region]

Since 1992, a registry gathering all the patients with end-stage renal failure is established in Champagne-Ardenne. It is based upon demographic data and allocation of dialysis treatment. It is supported by regional nephrologists. It is exhaustive and has been validated by the regional health administration. It is the only data base considered for the regional scheme of sanitary organization. In 1999 the incidence of terminal renal failure was 119 pmp and, at 1 January 2000, prevalence of uremic patients treated with supportive therapy, except transplantation, was 426 pmp. Our registry may be used as a regional registry awaiting to participate into built the national program project REIN (Renal Epidemiology and Information Network) and to help better health care policy and costs containment.

[Severe Schonlein-Henoch nephritis in adults. A report of twenty cases]

Twenty patients with severe Schönlein-Henoch nephritis were selected on a histologically basis of diffuse proliferative endo- and/or extracapillary glomerulonephritis during a period of 12 years in Champagne-Ardenne. There were 15 men and 5 women, mean age 44.1 years. An infectious history was found in 40%, an urinary tract cancer in 15%. In all cases there was purpura, in 80% joint pain and in 50% digestive symptoms. Clinical presentation at diagnosis included, in all cases, hematuria (gross in 50%) and proteinuria (of nephrotic range in 80%); there was hypertension in 60% and renal failure in 80%. Histology found, in all cases, mesangial IgA and often C3 deposits, with a diffuse endocapillary proliferation in 10%, extra-capillary proliferation in 30% and both endo-extracapillary in 60%; 45% of the patients had crescents in greater than 50% of glomeruli. The outcome, after steroid and immunosuppressive treatment, was end-stage renal failure in 25%, moderate renal failure in 20%, or normal renal function in 55% with a mean follow-up period of 4.6 years. These severe nephritis were associated with repetitive and often necrotic purpura, frequent joint pain and severe digestive symptoms. The analysis of initial renal presentation confirmed the bad prognosis of nephrotic syndrome, renal failure and especially hypertension, which were well correlated with the severity and diffusion of proliferative lesions. Despite a worse known prognosis, these nephritis responded to an aggressive and early treatment.

[Midodrine (Gutron) treatment of permanent arterial hypotension in a chronic hemodialysis patient]

Chronic hypotension, although unfrequent in uremic patients on hemodialysis, accentuates the deterioration of patients physical state and thus, their general well-being. These patients often experience acute intradialytic symptoms and respond very poorly to conventional therapies. Well tolerated, midodrine is a suitable and effective choice as it raises blood pressure significantly through its effect on peripheral alpha-adrenergic receptors. The authors report observing the use of midodrine by a dialysis patient during the longest time period published to date, documented by a pharmacokinetic study, and that confirms the excellent results and proves long term tolerance for that drug.

[Severe renal forms of leptospirosis. Apropos of 6 cases seen in 15 years at one center]

We report on six cases of leptospirosis observed in fifteen years in our department of nephrology. The contamination is two times from professional origin and four times linked to water leisures, during hot season, from june to september for the majority. Two serotypes are found: L. icterohaemorragiae characterized by marked jaundice, and L. patoc with anicteric form. Acute renal failure, five times oliguro-anuric, necessitates in the six cases hemodialysis (two to six sessions). Meningitis is found in four patients, associated in one case to an encephalitis and a polyradiculoneuritis. In one case, there were interstitial pulmonary lesions, in one another, a myocarditis with conduction disorders, responsible of the only death of this series, and finally, in three cases, a gastrointestinal hemorrhage. Bacteriological diagnosis seems little profitable and microagglutination remains the reference technique, helped by the IgM detecting through ELISA, looking forward to the evaluation of PCR (Polymerase Chain Reaction).

[Renal sarcoidosis with a pseudotumoral pyelic localization]

BACKGROUND

Renal sarcoidosis exceptionally presents as a unilateral pyelic pseudotumor as in this case where it was associated with granulomatous nephropathy.

CASE REPORT

A 33-year-old man had a two-year history of systemic sarcoidosis with no renal involvement. He developed renal failure related to interstitial granulomatous nephropathy associated with a pyelic localization leading to unilateral hydronephrosis. Urine drainage associated with corticosteroid therapy provided a favorable course.

DISCUSSION

Renal involvement in sarcoidosis is usually the consequence of hypercalcemia and hypercalciuria related to ectopic secretion of calcitriol by the sarcoidosic granulomas, with urinary lithiasis and nephrocalcinosis leading to renal failure and also granluomatous interstitial nephropathy. Glomerulopathy or obstructive nephropathy are rarely reported. Intraluminal localizations such as the pyelic lesion in our case are exceptional but must be detected early since they respond to corticosteroid therapy.

[Nephrotic syndrome revealing malignant thymoma]

BACKGROUND

A well-established manifestation of neoplastic disease, nephrotic syndrome is infrequently associated with thymoma. Only 18 cases have been reported in the literature.

CASE REPORTS

A 65-year-old man and a 60-year-old woman were seen for nephrotic syndrome. Minimal change renal disease was observed in the first patient whose nephrotic syndrome was steroid resistant. The second patient had membranous glomerulopathy and pure red cell aplasia. In both cases, nephrotic syndrome revealed thymoma.

DISCUSSION

The histological lesions in 17 of the 18 biopsied cases reported in the literature were minimal change in 10, focal segmental glomerulonephritis in 4, proliferative glomerulonephritis in 2, and membranous glomerulopathy in only one. The outcome of the nephrotic syndrome was dependent on the success of the thymoma treatment. Some patients responded to steroid and immunosuppressive agents. Pure red cell aplasia is uncommon and prognosis is poor. It can be successfully treated with cyclosporin A as in our second case.

[Bilateral nephrectomy before renal transplantation in autosomal dominant polycystic renal disease]

Patients with autosomal dominant polycystic kidney disease are good candidates for renal transplantation, despite the fact that they are older at initiation of dialysis treatment. After grafting, the native polycystic kidneys are, however, at risk of infectious and hemorrhagic complications, in addition to patient's discomfort and technical difficulties with graft placement. We report on 10 successful cases of pretransplant binephrectomy performed in one time and analyse the risk factors of such a surgery. Nowadays, it appears that the disadvantages of an anephric state can be balanced by substitutive therapy. In conclusion, after this short series, we think that bilateral nephrectomy has to be considered in patients with autosomal polycystic kidney disease, especially when they have a prior history of renal infections and/or repeated hematurias.

[Urinary calculi and crystalluria in HIV+ patients treated with indinavir sulfate]

OBJECTIVES

Anti-proteases, a new class of anti-HIV drugs used in combination with reverse transcriptase inhibitors have led to spectacular improvement in the patients' clinical status. Since April 1996, indinavir is the most widely prescribed anti-protease in France.

PATIENTS AND METHODS

From July 1996 to July 1997, we analyzed 46 spontaneously expulsed stones in 45 HIV+ patients (35 men and 10 women; age range 25 to 64 years) given indinavir in combination with other drugs since one week to ten months. Only six patients were known to have a past history of renal lithiasis.

RESULTS

Forty-one calculi contained indinavir monohydrate (INDM) identified by mass spectrometry and infrared spectrophotometry. INDM was the only component excepting proteins in 39/45 calculi. In the 12 others, other compounds were also identified. Among the 114 urine samples collected 2 to 3 hours after an 800 mg dose of indinavir, 38 (33%) monohydrate indinavir crystals, identified by infrared microscopy. Mean urinary pH was significantly higher than in samples without INDM crystals (6.53 +/- 0.68 versus 5.96 +/- 0.71, p < 0.001).

CONCLUSION

Two measures could possibly reduce the risk of crystalization: administration of urine acidifiers and increased fluid intake to raise diuresis. Alkalinisation is not indicated. Long-term increased fluid intake should be preferred over acidification which could be reserved solely for the treatment of drug-induced lithiasis.

Indwelling silicone femoral catheters: experience of three haemodialysis centres

The aim of this study is to describe the experience of three haemodialysis centres using indwelling femoral silicone catheter (model SSL 1220M, Medcomp, USA) in 55 patients, three with acute renal failure, one requiring plasmapheresis, and 51 with chronic renal failure but no other available vascular access. Sixty-four catheters were in place for a mean duration of 41.5 +/- 30 days. The rate of catheter-related complications, including mechanical problems, thromboses, and infections was low and they were never life-threatening. The results of the study suggest that femoral cannulation with modern flexible devices can be considered as a reliable temporary access, even for extended periods, with advantages exceeding those for subclavian and jugular routes.

[Recombinant human erythropoietin (epoetin) and autologous blood transfusion in chronic hemodialysis. Apropos of 2 cases]

Recombinant human erythropoietin (epoetin) is sometimes used in order to enhance autologous blood predonation before scheduled hemorrhagic surgery. This procedure reduces and some times better avoids homologous blood transfusions with their disadvantages. In certain circumstances, it will be of particular importance and, despite of its cost, has to be discussed for several surgical operations in some patients. Among them, pre-dialysis and dialysis patients can benefit of autologous blood transfusion if their anemic state and the response to epoetin and iron supplementation allow a sufficient and well-tolerated preoperative collection. As such observations are rare, we report two successful cases of autologous transfusion strategy with epoetin therapy in chronic hemodialyzed patients undergoing orthopedic surgery.

[Auto-dialysis: an 11-year experience of a hemodialysis center in France]

OBJECTIVES

Report 11 years of experience with self-managed hemodialysis in patients medically apt for extra-hospital dialysis and living close enough to small outpatient hemodialysis units to become totally self-sufficient.

RESULTS

Among the 276 patients with chronic renal failure managed at the hemodialysis center at the Troyes hospital during the 11-year study period from 1984 through 1994, self-managed hemodialysis at small outpatient units was initiated in 127 (46%). None of these 127 patients required medical assistance or specific care during dialysis sessions. At initial hospital admission, only 60/127 (47%) were totally self-sufficient: 52 (41%) were later graft recipients; and 21 (16.5%) had to return to the hospital for a medical or surgical condition incompatible with extra-hospital care but all of these 21 patients remained self-sufficient.

CONCLUSION

Extra-hospital hemodialysis in units close to the patients residence offers patients a better quality of life, even when medical assistance is required. All patients who require hemodialysis can thus be treated at lower cost without compromising quality of treatment. Perfect self-sufficiency may not be a goal in itself, but self-managed hemodialysis can be a very useful technique for patients without major medical problems. Continuing contact with the organizing hemodialysis center guarantees the safety of the system.

Chronic renal failure and its treatment in tuberous sclerosis

BACKGROUND

Chronic renal failure is rare in tuberous sclerosis, but its precise frequency is not known and treatment modalities have not been evaluated.

METHODS

A questionnaire was addressed to the 260 French dialysis centres and the characteristics of 65 patients with tuberous sclerosis and chronic renal failure were analysed.

RESULTS

In France the approximate prevalence of tuberous sclerosis with end-stage renal failure is 0.7 cases per million and that of end-stage renal failure in tuberous sclerosis 1 per 100. Tuberous sclerosis with chronic renal failure was more frequent in females (63.1%) and was diagnosed at a mean age of 29 years. Renal impairment was the first manifestation of tuberous sclerosis in about half the cases. Renal tumours were frequent, with angiomyolipomas in 15 cases (23.1%), cysts in 12 cases (18.5%), and both in 35 cases (53.8%). Malignancies were associated in nine cases (13.8%). Nephrectomy was done before dialysis in 21 cases (32.3%), and after the start of dialysis in six cases (9.2%). All but one of the 48 patients with end-stage renal failure were treated by dialysis; 20 were transplanted, with good results.

CONCLUSIONS

Tuberous sclerosis with end-stage renal failure is rare. These patients require dialysis and renal transplantation, but we recommend binephrectomy after starting dialysis and before transplantation, given the risk of cancer and bleeding related to angiomyolipomas.

[Femoral indwelling silicone catheter: experience of three hemodialysis centers]

The use of femoral vein for temporary access in hemodialysis patients is still considered as a slightly desirable route. However recent technical improvements have made this approach more reliable because the new femoral catheters can be left in place for a long time and used for ambulatory treatment. We describe the experience of three hemodialysis centres with temporary indwelling femoral catheter made of silicone (SSL 1220 M, Medcomp) in 55 patients: 3 patients with acute renal failure, 1 requiring plasmapheresis and 51 with chronic renal failure but no other available vascular access. Sixty four catheters were implanted and left in place for a mean of 41.5 +/- 30 days. Complications (mechanical, thrombotic and infectious) were infrequent and never life-threatening. These results suggest that the femoral route can be used reliably for temporary access, and provides advantages over subclavian and jugular routes in certain circumstances.

[Repeated studies of the prevalence of Staphylococcus aureus in the nasal cavity in hemodialysed patients]

OBJECTIVES

In order to better establish a prevention strategy based on mupirocin, we evaluated nasal carriage of Staphylococcus aureus in haemodialysis patients over a 15 month period.

METHODS

Search for Staphylococcus aureus in the nasal cavities was made every 2 months in 92 chronic dialysis patients. These patients were divided into 3 groups according to the nature of the carriage: non-permanent, intermittent or permanent.

RESULTS

Among the 80 patients retained for analysis, there were 27.5% with intermittent carriage and 11.25% with permanent carriage. Factors which appeared to protect against carriage were rural residence and home self-dialysis.

CONCLUSION

Repeated long-term search for nasal carriage of Staphylococcus aureus has provided reliable data for each patient and gave information on the effects of epidemiological conditions and health care structures.

[IgG kappa myeloma with Fanconi's syndrome and crystalline inclusions. Immunohistochemical and ultrastructural study]

An IgG kappa light-chain myeloma, remarkable for the presence of inclusions in plasmocytes and proximal renal tubular cells, was discovered during investigations for renal failure associated with partial Fanconi's syndrome. An immunohistochemical study showed that the crystalline inclusions were positive for IgG and kappa light-chain in plasmocytes and exclusively for kappa light-chain in the renal tubular cells. An ultrastructural study showed that the inclusions were localized in lysosomes and had a 55 A periodicity. This case is similar to the forty odd myelomas or light-chain diseases reported in the literature and revealed by Fanconi's syndrome. Their prognosis is good, with a slow progression towards late renal failure. In our patient the preference of lesions for proximal tubular cells, the site of protein catabolism, was particular since in myelomas they are usually located in the distal tubular cells.

[Human papillomavirus, cervical intraepithelial cancer and immunosuppression. Two cases in renal transplant recipients]

Immunosuppression is therapeutically induced in an increasing number of patients, exceeding largely the only transplant recipients. Its carcinological complications are a major preoccupation, among which the uterine cervix intraepithelial neoplasia. The strong relationship between these genital neoplasia and the lesions caused by human Papillomavirus is now evident and has to be taken in consideration for an early and regular follow-up of these women. Cervical smear tests, colposcopic assessment and histological examinations allow to undertake the adequate treatment and to give some preventive advice.

Post catheterisation vein stenosis in haemodialysis: comparative angiographic study of 50 subclavian and 50 internal jugular accesses

From January 1986 to December 1990 we studied angiographically the subclavian-brachiocephalic vein of 100 patients dialysed by subclavian catheter for 50 (first group) and by internal jugular catheter for the 50 others (second group). These two groups were not statistically different as regards age (61.6 +/- 11.3 years in the first and 61 +/- 11.1 in the second), sex (48% and 56% were women), duration of catheter insertion (31 +/- 21.8 and 31.7 +/- 16 days), and the number of dialysis sessions (13.5 +/- 9.1 and 13.6 +/- 7.1). The type of catheters, the frequency of removal for poor flow (16% in both groups) or infections (6% in both groups), and the local nursing were similar in the two groups. The only difference was the side of cannulation: the right side in 58% of cases in group 1 and 78% in group 2. The angiographic study revealed a stenosis of the vein in 42% of the subclavian group and in 10% of the internal jugular group: a dramatic difference in favour of the internal jugular route, whose superiority over the subclavian route is asserted in respect of venous access of dialysed patients.

[Myopathy in uremic patients]

Uremic myopathy seems unfrequently studied although it can be really inconvenient in daily activities for some patients. Its is a proximal and non specific myopathy that should be discriminated from uremic neuropathy. Several disturbances from renal insufficiency have been incriminated but they only play an adjuvant role in regard with renal osteodystrophy. Indeed the presence of myopathy in cases of severe osteodystrophy and its close similarity with myopathies accompanying the different forms of osteomalacia and/or hyperparathyroidism without renal failure suggest that the most important pathogenic factors come from calcium metabolic disorders: excessive parathyroid hormone, vitamin D deficiency, and/or impaired calcium transport. The treatment is subject to the predominant bone lesions: secondary hyperparathyroidism or osteomalacia; but the best attitude remains their prevention.