Limberg skin flap for treatment of necrosis and bleeding at haemodialysis arteriovenous angioaccess puncture sites.

OBJECTIVE: To assess the efficacy of a Limberg skin flap to treat non-infected necrosis and bleeding at angioaccess puncture sites. METHODS: Retrospective analysis of 40 selected (no infection, necrosis <20 mm diameter) patients (25 arteriovenous fistulae [AVF], 15 grafts) treated between 1998 and 2012 by rhomboid excision, vessel repair, and a locally rotated full-thickness Limberg skin flap together with early postoperative percutaneous transluminal angioplasty (PTA; n = 23/40). Success was defined as wound healing and angioaccess patency without complications. RESULTS: Success rates at 1 and 6 months were 96% (24/25) and 76% (19/25), respectively, for AVF, and 80% (12/15) and 40% (6/15) for arteriovenous grafts. Complications included flap necrosis (n = 2), graft thrombosis (n = 4), minor sepsis (n = 1), death (n = 2), and new puncture site necrosis (n = 3). Four patients were lost to follow-up. CONCLUSIONS: Vessel or graft repair, PTA for distal stenoses and local debridement followed by a Limberg skin flap for tissue defects prevented further bleeding and maintained vascular access patency in 25/40 (62%) patients.

Proximal radial artery ligation (PRAL) for reduction of flow in autogenous radial cephalic accesses for haemodialysis.

OBJECTIVE: Juxta-anastomosis proximal radial artery ligation (PRAL) is a new surgical technique for reduction of excessive blood flow of radial cephalic fistulas (RCFs). PATIENTS AND METHODS: This prospective study included 37 consecutive patients (eight children and 29 adults) who underwent PRAL of high-flow RCFs causing ischaemia (n = 2), aneurysmal degeneration of the vein (n = 14), and cardiac insufficiency (n = 7) or for prevention of cardiac overload (n = 14). Mean fistula age was 2.6 years for children and 7.4 years for adults. None had diabetes. Anatomical prerequisites (side-to-end anastomosis fistula and retrograde flow in the distal radial artery) were checked by ultrasound or angiography. Division and ligation of the juxta-anastomosis proximal radial artery were performed under regional anaesthesia. Patency following ligation was estimated according to the life table method. RESULTS: The success rate was 92% (34/37). The three failures included one excessive and two insufficient reductions of flow (<33%). Mean flow reduction rates were 50% in children and 53% in adults. Primary patency rates at 1 and 2 years were 88% +/- 6% and 74% +/- 9%, respectively. Secondary patency rates were 88% +/- 6% and 78% +/- 8%, respectively. CONCLUSION: PRAL is a simple, safe, and effective technique for reduction of flow in RCFs.

Durable remission after aggressive chemotherapy for very late post-kidney transplant lymphoproliferation: A report of 16 cases observed in a single center.

PURPOSE: Posttransplant lymphoproliferative diseases (PTLDs) represent a group of potentially lethal lymphoid proliferations that may complicate the course of solid organ transplantation. Although early-onset PTLDs frequently have a favorable outcome, late-onset PTLDs behave more alike aggressive lymphoma. We report a monocentric retrospective study that focused on PTLDs occurring later than 1 year after kidney transplantation (very late-onset PTLDs) to define their incidence, clinical presentation, pathologic features, and outcome. We particularly emphasized the follow-up of patients treated with conventional chemotherapy. PATIENTS AND METHODS: The medical histories of all patients who developed very late-onset PTLD in our institution were reviewed, and diagnostic biopsy materials were retrospectively studied. RESULTS: Very late-onset PTLDs were diagnosed in 16 (1.1%) of 1,421 patients. Mean (+/- SD) time to tumor onset was 103.93 +/- 70.88 months. Most tumors were Epstein-Barr virus-related monomorphic large-cell PTLDs of B phenotype. Ten patients received conventional chemotherapy (cyclophosphamide, doxorubicin, vincristine, and prednisone regimen). Two of them died within 2 months, two achieved partial remission, and six achieved definitive complete remission. Overall median survival time was 13 months and rose to 27 months in the treated group. The main cause of mortality was sepsis. None of the treated patients experienced rejection despite withdrawal of immunosuppressive treatment. CONCLUSION: Despite characteristics of aggressive lymphoma, very late-onset PTLDs after renal transplantation may respond to conventional chemotherapy. However, because a high rate of infectious complications occurred, new therapeutic strategies, such as combinations of anti-CD20 monoclonal antibodies and lower doses of chemotherapy, are warranted.

Allogeneic bone marrow transplantation vs filgrastim-mobilised peripheral blood progenitor cell transplantation in patients with early leukaemia: first results of a randomised multicentre trial of the European Group for Blood and Marrow Transplantation.

In a multicentre trial involving 20 transplant centres from 10 countries haematopoietic stem cells were obtained either from the bone marrow of 33 sibling donors or from the peripheral blood of 33 such donors after administration of filgrastim (10 microg/kg/day). The haematopoietic stem cells were infused into their HLA-identical recipients suffering from acute leukaemias in remission or chronic myeloid leukaemia in chronic phase. PBPC donors tolerated filgrastim administration and leukapheresis well with the most frequent side-effects being musculoskeletal pain, headache, and mild increases of LDH, AP, Gamma-GT or SGPT. Pain and haematoma at the harvest site and mild anaemia were the most frequent complaints of BM donors. Severe or life-threatening complications were not seen with any type of harvest procedure. Time to platelet recovery greater than 20 x 10(9)/l was 15 days (95% confidence interval (CI) 13-16 days) in the PBPCT group and 19 days (CI 16-25) in the BMT group. Time to neutrophil recovery greater than 0.5 x 10(9)/l was 14 days (CI 12-15 days) in the PBPCT group as compared to 15 days (CI 15-16 days) in the BMT group. The numbers of platelet transfusions administered to PBPCT and BMT patients were 12 (range: 1-28) and 10 (range: 3-39), respectively. Sixteen patients (48%) transplanted with bone marrow and 18 patients (54%) transplanted with PBPC developed acute GVHD of grades II-IV; acute GVHD of grades III or IV developed in six (18%) and seven (21%) patients, respectively. Kaplan-Meier plots for transplant-related mortality until day 100 and leukaemia-free survival at a median of 400 days after BMT or PBPCT showed no significant differences. Administration of filgrastim and leukapheresis in normal donors were feasible and well tolerated. The number of days with restricted activity and of nights spent in hospital was lower in donors of PBPC. Transplantation of PBPC to HLA-identical siblings with early leukaemia resulted in earlier platelet engraftment. The incidence of moderate to severe acute GVHD, transplant-related mortality, and leukaemia-free survival did not show striking differences. Further investigation of allogeneic PBPCT as a substitute for allogeneic BMT is warranted.

Hemophagocytic syndrome associated with Bacteroides fragilis infection in a patient with acute monoblastic leukemia.

The HS has been associated with malignant hemopathies. We report here a case of HS related to Bacteroides fragilis during the course of acute monoblastic leukemia. Evolution was fatal despite remission of the leukemia process and response of the infection to appropriate antibiotic therapy.

Clinical and biological analysis of peripheral T-cell lymphomas: a single institution study.

Peripheral T-cell lymphoma (PTCL) accounts for 15-20% of non-Hodgkin's lymphoma in the Western World. Clinical, histopathologic, phenotypic and genotypic data were received from 33 cases of PTCL referred to our institution. The median age order was 50 years, 78% were males, and 18% had a history of a preceding disorder of the lymphoid system. 60% had stage 4 at diagnosis and B symptoms were also present in 60%. The most frequent sites of extranodal involvement were bone marrow (54%), liver (45%) and skin (33%). Twenty-eight of 33 cases were histologically classified according to the Working Formulation (most in the diffuse mixed and large-cell subgroups) and the Kiel updated system. Phenotypic and genotypic studies of malignant cells showed a considerable heterogeneity with respect to the expression of either T-cell receptor (TCR) alpha beta and gamma delta and pan-T differentiation molecules. Of the studied cases 63% expressed TCR-alpha beta. All five patients with PTCL of the TCR-gamma delta subtype had a peculiar extra-nodal presentation. The vast majority of cases expressed an abnormal T-cell phenotype with respect to the expression of pan-T antigens, including the lack of expression of the TCR-associated CD3 molecule in 2 cases. Rearrangements of the TCR beta and/or delta-chain genes showed clonality in 21 of the 23 studied cases. Twenty-five patients were treated with a multiagent chemotherapy regimen with curative intent and the remainder received a less intensive palliative regimen. Only 9 patients achieved CR (8 of whom had received an anthracycline-containing regimen) and the 4-year survival rate was 25%.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous transluminal angioplasty of stenotic lesions in dialysis vascular accesses.

Forty-five stenoses behind arteriovenous fistulas in 35' haemodialysed patients were treated with percutaneous transluminal angioplasty (PTA). Immediate stenoses dilatation results in relation to the AVF type were haemodynamically significant in 40 cases (88%), with poorer results on bovine heterograft stenoses. Dilatation results in relation to the site of the lesion showed haemodynamically efficient angioplasty on stenoses next to the anastomosis (67.5%) but a poor result on distal lesions (4 cases). We observed 4 cases of thrombosis but 2 recovered after treatment, one after local fibrinolytic perfusion one after surgical thrombectomy. Follow-up over a period of one to 18 months (mean 8 months) including angiography and appreciation of the dialysis quality were performed in 30 patients who had a successful dilatation. PTA appears to be a technically feasible and clinically effective method of treating stenoses lying on the venous limb fistula in patients on chronic haemodialysis.

Treatment and prognosis of post-transplant lymphoproliferative disease.

Post-transplant lymphoproliferative diseases (PTLDs) are a clinically and morphologically heterogeneous group of lymphoid proliferations. They represent a life-threatening complication of solid organ transplantation. The mechanisms of their pathogenesis are not yet fully understood. A combination of impaired immunity, oncogenic consequences of immunosuppressive therapy and EBV infection may play a role. Studies on incidence, treatment and prognosis are difficult because of the small number of cases occurring at each transplant center and the lack of reliable classification. Overall mortality remains high even though 25% of patients require no other measure than reduction in immunosuppression which must be the first step of treatment. Several treatments are currently used but more adequate classification as well as multicenter studies are urgently needed because many questions remain with regard to therapeutic strategy. Late-onset monoclonal tumors may be treated by conventional chemotherapy, while EBV-positive PTLDs may benefit from other approaches such as antiviral therapies or immunologic modulation of tumor functions.

[Value of the Hickman catheter in pediatric nephrology]. / Intérêt du cathéter de Hickman en néphrologie pédiatrique.

The Hickman catheter is a single or double lumen catheter made of a silicone polymer; it is introduced surgically into the superior vena cava or the right atrium. The authors have used this catheter in 11 children, aged from 3 to 15 years and weighing from 10 to 40 kg, either for haemodialysis in children without arteriovenous fistula (n = 10), or for plasma exchanges (n = 1). In 5 of the 10 children, an arteriovenous fistula was created while the catheter was being installed. The catheter was left in place for a mean period of 48 days and a maximum period of 5 months. Data from the literature suggests that this instrument can be used for even longer periods. Dialysis was satisfactory in 8 out of 10 cases. No infection or thrombosis of the catheter was observed. The catheter was not perfused between haemodialysis sessions or blood exchanges.

[Persistent or recurrent hyperparathyroidism in periodically hemodialyzed patients. Value of preoperative cervical ultrasonography. 6 cases]. / Hyperparathyroïdies persistantes ou récurrentes des hémodialysés périodiques. Intérêt de l'échographie cervicale préopératoire. Six observations.

In 2 cases of recurrent secondary hyperparathyroidism and 4 cases of persisting secondary hyperparathyroidism observed in patients treated by chronic haemodialysis, 8 hyperplastic parathyroid masses and 1 parathyroid adenoma, all located in the lower part of the neck, were removed after percutaneous ultrasonographic detection. There were 7 true positive and 1 unexplained false positive results. In 1 out of the 2 false negative results, the mass located behind the esophagus could not be detected because of the laryngotracheal gas. Two masses located inside the thyroid gland and a 5th hyperplastic gland were correctly identified by ultrasound. Two reluctant patients accepted a new cervicotomy because of the ultrasound reports. The reports played a prominent role in the operative technique in 3 cases.

[Hemophagocytic syndrome in HIV infection]. / Syndrome d'hémophagocytose au cours de l'infection par le VIH.

This report describes the clinical spectrum and outcome of the hemophagocytic syndrome (HS) in 5 HIV infected patients. All 5 patients presented with fever, hepatomegaly and/or splenomegaly, confusion or coma and respiratory symptoms. Severe anemia was associated with thrombocytopenia and with neutropenia in 4 cases. Diffuse intravascular coagulopathy was present in 2 cases. Liver function tests were abnormal in three patients. The diagnosis of HS was made 2 to 12 weeks after the onset of symptoms and required in most patients repeated examinations of the bone-marrow, showing infiltration by histiocytes with prominent phagocytosis of blood cells. In one case this infiltration was not seen in the bone-marrow but only in the liver and the spleen. Varicella, mycobacterium infection, oesophageal candidiasis, Kaposi sarcoma were observed in the evolution of 3 patients. Anaplastic large cell Ki-1 lymphoma was present in one case. Four patients died as a result of complications of HS. The one patient with lymphoma survived.

[Central venous stenoses after using a Hickman catheter in hemodialysis in children. Apropos of 4 cases]. / Sténoses veineuses centrales après utilisation du cathéter de Hickman pour hémodialyse chez l'enfant. A propos de quatre cas.

Four cases of central vein stenosis occurred after the use of Hickman's catheter in 32 children at the beginning of chronic hemodialysis. The seriousness for future angioaccesses is emphasized.

[Magnetic resonance imaging of pelvic tumors in men. Preliminary results in a series of 28 patients]. / L'imagerie par résonance magnétique des tumeurs pelviennes de l'homme. Résultats préliminaires dans une série de vingt-huit patients.

The authors conducted a retrospective evaluation of the diagnostic value of nuclear magnetic resonance in comparison with other imaging techniques in a series of 28 pelvic tumours, with the exclusion of gastrointestinal tumours. The positive diagnosis of the lesion was obtained in every case. The variation of the signal provided information concerning the tissues, while the sections in three planes, the spontaneous visibility of the vessels and the very good natural contrast related to the presence of fat which gives a high signal, facilitated staging of the tumour.

[Arteriovenous fistula and related techniques: creation and follow-up]. / Les fistules artérioveineuses et techniques apparentées: réalisation, surveillance.

In chronic haemodialysis the arteriovenous fistula is the angioaccess that has the longest survival. Its surgical creation has been considerably improved by microsurgery, notably in children. A sufficient time lag between the creation and use of the fistula is of paramount importance. The arteviovenous bridge-graft is used when the superficial venous system has been destroyed. Its survival is jeopardized by the risk of stenosis of the venous anastomosis and by the risk of infection. Venous catheterization through the internal jugular vein (never through the subclavian vein) is a temporary solution pending the arteriovenous approach; it is sometimes a permanent, but then highly risky, solution.

[Immunoglobulin amyloidosis]. / Amylose immunoglobulinique.

AL amyloidosis is a rare disease. Its diagnosis is based on histopathology. It is always secondary to light chain, only rarely heavy chain, synthesis of monoclonal immunoglobulin, associated or not with tumoural proliferation (myeloma, Waldenström's macroglobulinaemia). Its pathophysiology has not been elucidated, but recent progress provided by biochemical and molecular biology studies has provided some data on the structural anomalies responsible for the formation of amyloid fibrils. As in AA amyloidosis, the clinical picture is heterogeneous and mainly depends on the degree and extent of the lesions. Prognosis remains poor and is influenced by the degree of cardiac, gastrointestinal, neurologic and renal involvement, but also by the presence of absence of underlying hemopathy, and particularly of myeloma. Treatment is still essentially symptomatic, but recent progress points to hope of effective treatment modalities aiming at reducing or eliminating the clone producing the immunoglobulin, or inhibiting the formation or amyloid fibrils.