Bladder perforation in a peritoneal dialysis patient.

The dysfunction of the catheter in peritoneal dialysis (PD) is a frequent complication. However, perforation of organs are rare, particularly that of the urinary bladder. This requires an early diagnosis and prompt treatment of patients. We report here the case of a 38-year-old woman having end-stage renal disease due to autosomal-dominant polycystic kidney disease treated by PD since November 2000. Three years later, she was treated for Staphylococcal peritonitis. Four months later, she presented with a severe urge to urinate at the time of the fluid exchanges. The biochemical analysis of the fluid from the bladder showed that it was dialysis fluid. Injection of contrast through the catheter demonstrated the presence of a fistula between the bladder and the peritoneal cavity. She underwent cystoscopic closure of the fistulous tract and the PD catheter was removed. Subsequently, the patient was treated by hemodialysis. One month later, a second catheter was implanted surgically after confirming the closure of the fistula. Ten days later, she presented with pain at the catheter site and along the tunnel, which was found to be swollen along its track. The injection of contrast produced swelling of the subcutaneous tunnel but without extravasation of the dye. PD was withdrawn and the patient was put back on hemodialysis. Bladder fistula is a rare complication in PD and diagnosis should be suspected when patient complains of an urge to pass urine during the exchanges, which can be confirmed by contrast study showing presence of dye in the bladder. PD may be possible after the closure of the fistula, but recurrence may occur.

Incidence and risk factors for post-renal transplant diabetes mellitus.

INTRODUCTION: Posttransplant diabetes mellitus (PTDM) is a common, serious complication of renal transplantation. The aim of this retrospective study was to estimate the incidence and to identify potential factors predisposing to PTDM. PATIENTS AND METHODS: We evaluated 296 adult nondiabetic patients who underwent kidney transplantation at our center. PTDM was defined according to 2003 international consensus guidelines. Potential factors predisposing to PTDM were analyzed individually and simultaneously using a logistic regression model. RESULTS: Over 2054.5 years of cumulative follow-up, 51 patients (17.2%) developed diabetes corresponding to an annual incidence of 2.5%. PTDM was diagnosed after a median of 2.9 months (range: 0.2-168). The mean age of affect individuals was 33.3±7.4 years. Patients with PTDM were significantly older (P<.0005) and showed an higher body mass index (BMI; P<.004). Univariate analysis revealed that age, BMI, family history of diabetes, vascular nephropathy, and hepatitis C infection were associated with PTDM. Multivariate analysis rescaled the roles of age (relative risk [RR]=1.046/y; P<.04), BMI (RR=1.107/kg/m2, P<.05), vascular nephropathy (RR=7.06, P<.03), and hepatitis C infection (RR=2.72, P<.03) as independent factors predisposing to PTDM. CONCLUSION: Among our relatively young kidney transplant recipients, in whom only 8% received tacrolimus, PTDM was a frequent complication. We suggest that the use of oral glucose tolerance tests to screen patients identifies those predisposed to develop this complication.

[A rare cause of pruritus in an hemodialysed patient]. / Une Cause Rare de Prurit chez une Hémodialysée Chronique.

BACKGROUND: Uremic pruritus is frequent in patients undergoing hemodialysis. It's multifactorial secondary in most cases to metabolic complications related to uremia. AIM: We report a rare cause of pruritus in an haemodialysed patient. OBSERVATION: It's a 48-year-old woman in periodic haemodialysis during 17 years. She suffered from generalized pruritus associated with psychiatric disturbance without neurologic deficits. CT scan and magnetic resonance imaging revealed extensive, diffuse and bilateral involvement of the white matter. The diagnosis of large low grade B cell lymphoma was confirmed by the histologic examination of stereotactic biopsy which leads to early intracranial hemorrhage and death. CONCLUSION: Before attributing pruritus to renal failure, one should exclude other causes such as the NHL even rarely reported especially when it associated with psychiatric disturbances. CT scan and magnetic resonance imaging contribute to diagnosis.

Nephrolithiasis-induced end stage renal disease.

INTRODUCTION: Nephrolithiasis still remains a too frequent and underappreciated cause of end stage renal disease (ESRD). METHODS AND PATIENTS: Of the entire cohort of 7128 consecutive patients who started maintenance dialysis in our nephrology department between January 1992 and December 2006, a total of 45 patients (26 women, 19 men) had renal stone disease as the cause of ESRD. The type of nephrolithiasis was determined in 45 cases and etiology in 42. The treatment and evolution of stone disease and patient's survival were studied. RESULTS: The overall proportion of nephrolithiasis related ESRD was 0.63%. The mean age was 48.4 years. Infection stones (struvite) accounted for 40%, calcium stones, 26.67% (primary hyperparathyroidism:15.56%; familial hypercalciuria: 4.44%, unknown etiology: 6.66%), primary hyperoxaluria type 1, 17.78% and uric acid lithiasis in 15.56% of cases. The mean delay of the evolution of the stone renal disease to chronic renal failure was 85.8 months. The feminine gender, obesity and elevated alkaline phosphatases >128 IU/L were significantly correlated with fast evolution of ESRD. The median evolution to ESRD was 12 months. The normal body mass index (BMI), medical treatment of stone and primary hyperoxaluria type 1 were correlated with fast evolution to ESRD. All patients were treated by hemodialysis during a mean evolution of 60 months. Sixteen patients died. The patient's survival rate at 1, 3 and 5 years was 97.6, 92.8 and 69% respectively. Hypocalcemia, cardiopathy and normal calcium-phosphate product were significantly correlated with lower survival rate. CONCLUSION: Severe forms of nephrolithiasis remain an underestimated cause of ESRD. These findings highlight the crucial importance of accurate stone analysis and metabolic evaluation to provide early diagnosis and efficient treatment for conditions leading to ESRD.

Kidney transplantation during autoimmune diseases.

Herein, we report the results of kidney transplantation in 9 of 376 patients who underwent kidney transplantation at our center between 1986 and 2007 because of chronic renal failure associated with autoimmune disease. Four of the 9 patients had systemic lupus erythematosus, 3 had Wegener granulomatosis, and 2 had Goodpasture syndrome. Six patients received organs from living donors, and 3 received cadaver organs. Infections were frequent and included cytomegalovirus and urinary tract infection in most cases. There was no difference in occurrence of metabolic and cardiovascular complications in our study patients compared with other transplant recipients. Incidence of allograft loss (n = 1) was similar to that in our entire transplantation population, with an overall rate of 2.9%. We conclude that kidney transplantation is a reasonable therapeutic option in patients with autoimmune disease with end-stage renal disease because of good graft and patient survival compared with kidney recipients without autoimmune diseases.

Hyalohyphomycosis caused by Paecilomyces lilacinus after kidney transplantation.

Hyalohyphomycosis caused by Paecilomyces has rarely been described among solid organ recipients. Its management is elusive without an established consensus concerning antifungal therapy. Herein we have reported a case of extensive cellulitis caused by Paecilomyces lilacinus observed in a 48-year-old kidney transplanted woman with hepatitis C. Kidney transplantation from a cadaveric donor was performed in October 2006 with an uneventful early course except for posttransplant diabetes mellitus and a reversible acute rejection episode. Cutaneous nodular and verrucous lesions of the left leg appeared in August 2007. In a few weeks, these lesions become ulcerated, hemorrhagic, and painful. The diagnosis was made on the basis of microbiologic culture and histological examination. There was no improvement in the skin lesions after 6 weeks treatment with itraconazole, but voriconazole yielded a good response within the first 2 weeks. There was a good tolerance to antifungal therapy; graft function and liver tests remained normal. We concluded that an increasing emerging of fungal infections is observed with the introduction of more powerful immunosuppressive drugs. Diagnosis and management of such infections is elusive. Preventive measures should be considered including the adaptation of immunosuppressive therapy among at-risk patients especially those with hepatitis C virus infection and diabetics.

The first year renal function as a predictor of long-term graft survival after kidney transplantation.

This study examined the impact of graft function at the end of the first year after kidney transplantation on long-term graft survival. We analyzed the roles of serum creatinine (Scr) and other variables as predictors of graft survival among 235 adult kidney transplant patients. The subjects were divided into 3 groups according to their Scr at the end of the first year: group 1, Scr < 100 micromol/L; group 2, 100 micromol/L < or = Scr < or = 150 micromol/L; and group 3, Scr >150 micromol/L. The annual rate of graft loss of 0.7% (95% confidence interval [CI], 0.63-0.77) in group 1, was lower than those in group 2 (2.1%; 95% CI, 2.02-2.18; P < .0001) and group 3 (6%; 5.74-6.26; P < .0001). Regression analysis showed the role of recipient age at the time of operation, and Scr level at the end of the first year to be independent predictors of graft loss. Graft survival was not influenced by any other studied parameter, including donor age, year of procedure, warm ischemia time, history of acute tubular necrosis, and occurrence of an acute rejection episode. We conclude that the 1-year Scr value predicts long-term renal graft survival, representing a simple, practical tool to identify recipients with an high risk for late graft failure.

Kidney transplantation: Charles Nicolle Hospital experience.

The aim of our retrospective study was to analyze the short- and long-term follow-up of 298 renal transplantations performed between June 1986 and May 2005. All were first transplantations except 4 cases, with 54 from cadaveric and 244 from living donors. The recipients included 196 males and 102 females of overall mean age of 31.21 +/- 8.9 years (range, 16-61 years). A combination of prednisolone and azathioprine was presented for 212 patients or mycophenolate mofetil for 86 patients. Polyclonal or monoclonal antibodies were used as induction therapy in 183 cases. Cyclosporine was administered to 188 cases and tacrolimus only to 16. HLA matching was 0 mismatches (MM) in 65 cases; 1 or 2 MM in 113; 3 MM in 99; and > or =4 MM in 21. Acute tubular necrosis occurred in 45 cases. One hundred eighteen patients experienced at least 1 acute rejection episode: 102 cases (41.8%) among living and 16 (29.6%) among cadaveric kidneys donor (P = .0007). The actuarial patient and graft survival rates at 1, 5, 10, 15, and 20 years were 95.9%, 87.4%, 77.5%, 65.6%, and 60.8%, and 94.9%, 84.5%, 75.4%, 65.4%, and 53%, respectively. Sixty-three patients died and 72 patients returned to dialysis. Our results were comparable to experienced centers. However, the member of kidney transplantations does not match the increased number of patients on renal replacement therapy. It is advisable to promote obtaining organs from brain-dead donors.

[Association of disseminated nocardiosis and Kaposi's sarcoma after kidney transplantation]. / Nocardiose disséminée associée à un sarcome de Kaposi après transplantation rénale.

We report a 40-year-old kidney recipient who developed disseminated nocardiosis associated with cutaneous Kaposi's sarcoma. The withdrawal of immunosuppressive therapy and prolonged antibiotic therapy, including imipenem and trimethoprim-sulfamethoxazole, resulted in a favourable outcome of both disorders. Three years later, graft function remains stable with a complete regression of skin and pulmonary abnormalities. This case report illustrates the predisposing role of immunosuppressive treatment in the occurrence of infectious and neoplastic complications observed after solid-organ transplantation.

[Lymphoproliferative disorders in kidney transplant recipients: incidence, clinical characteristics and outcome]. / Syndromes lymphoprolifératifs après transplantation rénale: incidence et particularités cliniques et évolutives.

PURPOSE: The aim of this study was to determine the epidemiological and the clinical characteristics of post-transplant lymphoproliferative disease (PTLD) and to evaluate its impact on patients' and grafts' survival. PATIENTS AND METHODS: Three hundred and sixteen adult kidney recipients, transplanted between June 1986 and May 2006, were included. The incidence rates were calculated by dividing the number of different events (PTLD, death and graft-loss) by the total duration of follow-up. The survival rates and the cumulated frequency of PTLD were calculated according to the actuarial method. RESULTS: Seven recipients developed PTLD during a cumulated follow-up of 2202 years. The annual incidence was of 0.32% (95% CI : 0.30-0.34). It was of 0.81% (0.70-0.92) in recipients of kidneys from deceased donors, and of 0.25% (0.23-0.27) in patients transplanted from living donors (NS). The delay after transplantation for the diagnosis of PTLD ranged from 7.4 months to 7.7 years. PTLD was a B cell lymphoma in six cases and affected extra nodal sites in most of the cases. The treatment, comprising the cessation of immunosuppressive therapy in all cases, resulted in complete remission in four patients. Three patients died, representing an annual death rate of 6.1%, versus 2.8% in patients without PTLD (NS). The annual incidence of graft loss was 6.1% versus 3.2% among patients without PTLD (NS). CONCLUSION: PTLD was observed in 2.2% of our patients, with an annual incidence of 0.32%. It resulted in a decrease of both patients' and grafts' survivals. Preventive measures, including the improvement of the monitoring of immunosuppressive drugs and the prevention of viral infections, should be considered to reduce the risk of PTLD.

Impact of dialysis modality on posttransplantation results in kidney transplantation.

Studies looking at the type of pretransplantation renal replacement therapy on graft and patient survivals after kidney transplantation have produced conflicting results. Therefore, we studied the effect of pretransplantation dialysis modality (peritoneal dialysis [PD] or hemodialysis [HD]) on transplant outcomes. We performed a retrospective study of 78 patients (39 PD and 39 HD) who had their first renal transplantation between January 1986 and December 2004. Comparisons between groups were made using chi-square tests for qualitative parameters and nonpaired Student t tests for continuous variables. Comparisons between actuarial curves of patient and technique survivals used log-rank tests. The percentages of recipient males, cadaveric donors, transplant-induced diabetes, mean period of dialysis, mean transplantation follow-up, mean duration of first hospital stay, first infection, acute tubular necrosis, and acute rejection episodes were not significantly different among PD versus HD patients, whereas recipient and donor mean ages were significantly higher in HD and PD patients, respectively. There were no differences in graft and recipient survivals among PD versus HD patients. After kidney transplantation, there was no difference between PD and HD patients concerning percentages of infection, acute tubular necrosis, acute rejection episodes or graft and recipient survivals.

[A case of preserved fertility in an hemodialyzed patient with systemic lupus erythematosus]. / Cas original d'une fertilité particulièrement conservée chez une patiente lupique en hémodialyse chronique.

BACKGROUND: Pregnancy and child birth in haemodialysis remains a rare event, even more, when pregnancy occurs in patient with systemic lupus erythematosus (SLE). AIM: We report a case of a patient with end stage renal failure secondary to SLE and who carried out 3 pregnancies. CASE REPORT: She was a woman with proliferative and diffuse lupus glomerulonephritis since 1985 treated by corticosteroids and cyclophosphamide. In 1995, she developed chronic renal failure. In 1996, she underwent a 1st full term spontaneous pregnancy with normal birth weight. In 2001, she underwent a second spontaneous pregnancy while she was on periodic haemodialysis. She had a full term baby birth with a birth weight at 1 Kg 700 and who died 4 days later. In 2002, she had a third pregnancy with voluntary abortion at 8 weeks. CONCLUSION: Our patient had conserved fertility despite treatment by cyclophosphamide, chronic renal failure and haemodialysis. The two successful deliveries may be attributed to the control of SLE activity and to the adequacy of haemodialysis.

Avascular osteonecrosis after renal transplantation.

Avascular osteonecrosis (AVN) is a serious osseous complication after renal transplantation. Its prevalence clearly decreased from 20% to 4% after introduction of cyclosporine and reduction of steroid doses. The aim of our study was to evaluate the frequency of AVN among kidney transplant recipients and to determine the risk factors by comparing them with a population without AVN. Among 326 kidney transplant recipients between June 1986 and December 2004, 15 patients developed AVN with mean age of 40.86 years, including 11 men and 4 women. Fifteen kidney transplant recipients without AVN were selected to be matched for age, gender, and date of transplantation (control group). Cases of symptomatic AVN were diagnosed by hip X-ray, radioisotope bone scan, or magnetic resonance imaging. AVN was diagnosed at a mean of 3.5 years after transplantation (range, 0.5-13 years). The main localization of AVN was the femoral head in 12 cases and the femoral condyle in 3 cases. We studied the following risk factors: the type of donor (cadaver or living donor), the duration on dialysis before transplantation, the cumulative steroid dose, the acute rejection rate, and the posttransplantation weight gain. Statistical analysis showed that the cumulative steroid dose and the acute rejection rate were higher among the AVN group than the control group (P=.04 and P=.058, respectively). The prevalence of AVN in our population is 4.6%, which is probably an underestimate since these were symptomatic cases. The reduction or early withdrawal of steroids remains the only efficient preventive treatment for AVN.

[Renal manifestations in tuberous sclerosis]. / Atteinte rénale au cours de la sclérose tubéreuse de Bourneville.

BACKGROUND: Tuberous sclerosis is a rare inherited disease which can involve several organs. Renal involvement is one of the most severe manifestations of the disease. We analysed in this study renal involvement of tuberous sclerosis. METHODS: We studied retrospectively nine cases of tuberous sclerosis with renal involvement diagnosed between 1994 and 2005. The diagnosis was based on the presence of typical extra-renal manifestations and familial history of tuberous sclerosis. RESULTS: There were eight females and one male. Their mean age was 40.8+/-16.4 years (range: 15-62). At first presentation, we noted hypertension in three cases, proteinuria in seven cases, hematuria in eight cases and renal failure in five cases (end stage renal failure in four cases). By ultrasonography, we found angiomyolipoma in one case, cysts in four cases and angiomyolipoma associated to cysts in four cases. Nephrectomy was performed in two patients, in one case for hydronephrosis secondary to urolithiasis and in the other for hemorrhagic complication. In the later, pathological examination revealed renal carcinoma. At last evaluation, two patients were lost to follow-up, one had normal serum creatinine, five were on renal replacement therapy and the latter died from sepsis following kidney removal. CONCLUSIONS: In our patients, renal disease was diagnosed late at chronic renal failure stage. Patients with end-stage renal failure require dialysis and renal transplantation, but we recommend binephrectomy after starting dialysis and before transplantation due to the risk of cancer and bleeding related to angiomyolipomas.

[Indications, complications and cost of internal jugular catheters in hemodialysed patients: study of 533 cases]. / Indications, complications et cout des catheters jugulaires internes chez les hemodialyses: etude de 533 cas.

INTRODUCTION: Central venous catheters for hemodialysis are very useful as blood accesses when arteriovenous fistulas (AVF) are not available. The aim of this study is to analyse the clinical impact of internal jugular catheters (IJC) in hemodialysed patients and to assess their economic consequences. PATIENTS AND METHODS: It is a prospective study realised from July 1998 to March 2002 including 533 hemodialysed patients without functional AVF: 280 males and 253 females aged between 17 and 87 years (mean age: 54.1 +/- 15 years). Single lumen polyurethane Vygon were used. All catheters were placed using Seldinger procedure and the posterior route of Jernigan which is more comfortable for patient. RESULTS: Indications of IJC placement were new hemodialysed patients without AVF in 73.5% cases and no functional AVF in 26.5% cases. During the period of the study. IJC was placed in 533 patients. We failed to place the IJC at the first attempt in 42 patients but we succeed in placing it on the controlateral side. During IJC placement, we observed 50 (9.4%) cases of accidental puncture of carotid artery. The median duration use of IJC was 41 days (extreme: 1 to 413 days). IJC were removed mainly because of the use of AVF in 469 (88%) cases and the catheter infection in 41 (77%) cases. Bacteriological analysis were made only for 25 patients: staphylococci were identified in 16 cases and catheter cultures were negative in the 9 other cases. All patients were treated with antibiotics. Outcome was favourable for 39 of them and we had 2 deaths by septicemia. The IJC cost was 44,287 Tunisian Dinars (DT) coresponding to 31.633 Euro including 10125 DT (7,232 Euro) for infectious treatment. CONCLUSION: The use of IJC is frequent in our center with a high rate of infectious complications which increased the hemodialysis cost. The realisation of AVF, in patients with chronic renal failure before the beginning of hemodialysis, is the best way to limit the use of catheters.

[Renal involvement in ankylosing spondylitis: concerning 210 cases]. / Les manifestations rénales de la spondylarthrite ankylosante: à propos de 210 cas.

PURPOSE: To define the epidemiology, clinical, biological and histological features of renal diseases in ankylosing spondylitis, ginving special attention to unusual forms. METHODS: We retrospectively reviewed the medical record of 28 cases with renal involvement among 210 cases of ankylosing spondylitis seen over a 27 year period who met the Amor criteria. RESULTS: Twenty-eight of 210 patients (13,3%) presented one or more signs of renal involvement: macroscopic hematuria (4 patients), microscopic hematuria (8 patients), proteinuria (15 patients), nephrotic syndrome (6 patients), decreased renal function (13 patients). Secondary renal amyloidosis and nephrolithiasis (8 patients) were the most common cause of renal involvement in ankylosing spondylitis followed by IgA nephropathy (3 patients). CONCLUSION: The funding of renal abnormalities in 13,3% of our patients suggests that in this illness evidence of renal involvement should be actively investigated in ankylosing spondylitis.

[Retroperitoneal fibrosis]. / La fibrose rétropéritonéale.

OBJECTIVE: We studied the clinical, therapeutic and progressive characteristics of retroperitoneal fibrosis. METHODS: We analysed the observations of retroperitoneal fibrosis diagnosed between 1980 and 2002 in our hospital, from the summaries of 15 patients exhibiting retroperitoneal fibrosis (RPF). Therapeutical supervision was based on biology and radiology. RESULTS: There were 11 men and 4 women with a mean age of 44.5 years ranging from 28-64 years. Pain was predominantly lumbar or abdominal in all patients. An inflammatory syndrome was observed in all patients and renal failure in 11. Radiological examinations revealed single or bilateral in 14 cases and the fibrosis plaque in 13 cases. Treatment consisted in corticosteroids alone in 9 patients, surgery alone in 3 cases and surgery with corticosteroids in 3 patients. Ten relapses (range: 1-5) occurred in 4 patients when corticosteroids were stopped. After a mean follow-up of 36 months (range:18 days-11 years), one death was observed, 12 patients had normal renal function and 2 patients had persistent moderate renal failure. CONCLUSION: This study confirms the rarity of retroperitoneal fibrosis, the difficulty in its diagnosis, the frequency of pain, inflammatory syndrome and renal failure. Corticosteroids are efficient and regular follow-up is required.

[Lupus nephritis: 211 cases]. / Néphropathie lupique : à propos de 211 cas.

PURPOSE: Renal involvement is one of the most severe and frequent manifestations of systemic lupus erythematosus. Prognosis factors are variable in the different studies. We analyze in 211 patients clinical, biological and histologic characteristics of lupus nephritis and the different prognosis factors. METHODS: It's a retrospective study in 211 with lupus nephritis followed-up between 1975 and 2003. RESULTS: There were 195 women and 16 men aged meanly of 28,8 years. At first presentation, we noted hypertension in 32,3% of cases, nephrotic syndrome in 47,7% of cases and renal failure in 51,6% of cases. histologic examination of kidney revealed class III in 59 cases, class IV in 97 cases and class V in 33 cases. Two hundred and five patients were treated by corticosteriods associated with immunosupressive agents in 95 cases. After a mean follow-up of 103 months (2-289 months), we obtained remission in 55,3% deterioration of renal function in 34,8% with end stage renal failure in 14,7% and relapses occurred in 51% of cases. Thirty-three patients died. Age <24 years, hypertension, nephrotic syndrome and initial renal failure were statistically associated with deterioration of renal function. CONCLUSION: Lupus nephritis is severe in our patients with predominance of proliferative forms. Age <24 years, hypertension, nephrotic syndrome and initial renal failure were statistically associated with deterioration of renal function.

[Particularities of visceral leishmaniasis in adults not infected by HIV in Tunisia]. / Particularités de la leishmaniose viscérale de l'adulte non infecté par le VIH en Tunisie.

The incidence of adult visceral leishmaniasis in Tunisia has increased in recent years. As a result the epidemiological profile of the disease in our country is now closer to those observed in other Mediterranean countries. Most of the increase involves adults not infected by human immunodeficiency virus (HIV) although 56% of patients presented concurrent disease. In comparison with pediatric visceral leishmaniasis, adult disease is characterized by inconsistence occurrence of some major symptoms such as fever and spleen enlargement. For this reason the clinical disease syndrome may be incomplete and diagnosis may be difficult. Laboratory tests are essential for definitive diagnosis. Although no test is specific, some findings are highly useful, e.g, elevated g-globulins which was observed in 94% of patients in our series. Standard serology is less sensitive in adults with 18% of false negatives in our series probably as a result of immunodeficiency in some patients.