[Coronary artery disease and coronary angioplasty in chronic hemodialysis patients]. / Coronaropathie et angioplastie coronaire dans l'insuffisance rénale dialysée.

Chronic renal insufficiency leads to many cardiovascular complications and provide worst prognosis, especially when patients need hemodialysis. The atherosclerosis of chronic hemodialysis patients is qualified as "accelerated" by some authors, because of a very fast and large progression. To improve prognosis, it seems to be very important to detect and treat the frequent and serious underlying cardiovascular disease. Because of the high rate of diabetes mellitus, silent ischemia is a very frequent clinical situation. In the other hand, coronary artery disease in chronic hemodialysis patients is frequently complex, with a large coronary extension and high rate of coronary calcifications. Consequently, this disease needs a specific therapeutic approach. Even though, percutaneous coronary interventions (PCI) are more complex in this population, it provides good results, and improves patient's prognosis. However, the rate of complications of the vascular approach and the rate of restenosis is high. New devices, such as Drug Eluting Stents (DES) can critically decrease restenosis rate, and closure devices for trans-femoral approach, provides very encouraging results in this high risk population. Despite, good results of PCI with DES use, the mortality is still high in this population. To improve our efficiency, we have to progress in our therapeutic strategies and optimize medical approach to treat the important biological perturbations.

Reversal effects of topical retinoic acid on the skin of kidney transplant recipients under systemic corticotherapy.

The systemic long-term corticosteroid treatment administered to kidney graft recipients (KGR) within the framework of the required immunosuppressive therapy induces an atrophy of the skin, from the sixth month onwards. We studied the effect of topical all-trans retinoic acid (0.05%; Galderma Labs.) applied to the forearms of 27 KGR (14 men, 13 women) over a 6-month period. Twenty-four subjects completed the trial. The following results were obtained in the treated forearm versus the untreated forearm (excipient alone): clinically, an increase in skin thickness; by noninvasive techniques, an increase in skin thickness, skin elasticity, skin conductance, and TEWL, and a reduction in the size of the corneocytes. No change in stratum corneum lipid content was observed. A sex-related difference was noted in the response to treatment under our experimental conditions, the female patients responding better. A punch biopsy (4 mm) was performed on both forearms of four patients after the 6-month period. Histologic and ultrastructural examination revealed epidermal and dermal changes evoking increased cellular metabolism in the retinoic acid-treated forearms.

Lymphadenopathy in renal transplant patients treated with immunosuppressive antibodies (OKT3 and anti-thymocyte globulin). A report of nine cases.

A clinicopathological study of nine patients who developed systemic lymphadenopathy following renal transplantation and immunosuppressive therapy (OKT3 and anti-thymocyte globulin) showed a rapidity of onset and disappearance of lymphadenopathy (nine of nine cases), a frequent association of systemic signs (nine of nine cases), and a heterogeneity of histological patterns ranging from diffuse lymphoid hyperplasia to one incorrectly considered to be immunoblastic lymphoma. The coexpression of both light chains was useful in the exclusion of the diagnosis of B lymphoma. These posttransplant lymphoproliferative syndromes seem to represent an allergic reaction to the introduction of foreign protein resembling serum sickness rather than a viral infection favored by immunosuppression, although in one case (with pseudolymphomatous features) a virus was the likely mechanism.

Toxoplasma antibody titers in renal transplant recipients. Pretransplant evaluation and posttransplant follow-up of 73 patients.

In 73 consecutive kidney transplant recipients, anti-Toxoplasma antibodies were determined before transplantation and during a 3-year follow-up after transplantation. In 9 patients, antibody titers increased significantly after transplantation. Antibody titers to various viral antigens determined in parallel remained unchanged, suggesting that the anti-Toxoplasma antibody increase was not due to polyclonal nonspecific stimulation. In 2 of the 24 pretransplant seronegative patients, acquired toxoplasmosis was diagnosed serologically after transplantation, with the observation of a strong IgM and IgG antibody response. The incidence of toxoplasmosis in this group of patients was not found to be significantly different from that in a normal population, suggesting that transmission of Toxoplasma from the transplanted kidney may not be a significant mode of contamination. Among the 49 patients who were seropositive before transplantation, reactivation of toxoplasmosis was suspected in 7 cases on the basis of a significant increase in IgG antibodies. Reactivation occurred more frequently in patients treated with azathioprine and antithymocyte globulin, and a direct relationship between administration of steroids and antibody increase was demonstrated in three patients. Although toxoplasmosis has occasionally been reported as a major infectious problem in kidney transplant recipients, our clinical and serological data show that the potential risk of developing Toxoplasma infection is low since none of the patients with either acquired or reactivated toxoplasmosis developed clinical disease.

One-month prophylactic use of OKT3 in cadaver kidney transplant recipients.

Fifty-five recipients of first cadaveric renal allografts were randomly assigned to three treatment groups in order to compare the safety and efficacy of a mouse antihuman T cell monoclonal antibody (OKT3) given prophylactically for a one-month period. This long period of administration was made possible by concomitant administration of azathioprine. The immune response against the foreign immunoglobulin was thus delayed and decreased in both intensity and severity, and OKT3 treatment could be given during almost the entire month in the majority of patients. The 18 patients who were enrolled in this treatment group had significantly (P less than 0.01) fewer rejection episodes during the first month posttransplantation than the 19 patients allocated to the high-dose (HD) steroid control group or the 18 patients allocated to the low-dose (LD) control group. Actual 2-year as well as actuarial 4-year graft survival rates were 89% in the OKT3 group, whereas they were 70% and 67% respectively in the steroid control groups. Four-year serum creatinine levels were normal and doses of steroids and other immunosuppressive agents were lower in the OKT3 group as compared with the control groups. Tolerance to OKT3 was good, and while viral infections were more frequently observed in OKT3 treated patients, the total number and the severity of infectious episodes were similar in all groups. The combination of one-month OKT3 plus azathioprine prophylaxis followed by conventional azathioprine plus low-dose steroid maintenance produced very satisfactory long-term results comparable to the best results now being obtained with cyclosporine regimens.

Antibiotic-lock technique: a new approach to optimal therapy for catheter-related sepsis in home-parenteral nutrition patients.

During a cumulated survey of 286 months, covering 11 gastroenterological patients under nocturnal-cyclic home parenteral nutrition, 24 cases of catheter-related sepsis were observed (one/11.9 months). None of these were associated with focus of infection at the cutaneous entry point or at the subcutaneous tunnel of the catheters. In this study attempt was made to control sepsis without removal of the surgically implanted siliconed lines (Vygon code 180-20 with an internal filling volume of 1 ml). The first two catheter-sepsis were conventionally treated with systemic antibiotics for 3 weeks which meant a 1-month hospital admission each time. Consequently, we used a new antibiotic therapy consisting of locking 12 hr/day 2 ml of highly concentrated antibiotic solution within the catheter. After identification of bacterial strains by blood cultures, the antibiotic lock-technique was daily applied either alone for 16 days (group I, n = 11) or for 12 days following a 3-day course of systemic antibiotics (group II, n = 11). After starting antibiotics via the infected line, the time taken for fever abatement and for obtaining negative in-line blood cultures were 2 and 4 days, respectively, and identical in group I and II. Failure of antibiotic treatment leading to catheter withdrawal was observed once in each group (9%) and was due to secondary candida catheter-sepsis. The time for hospital stay was shorter p less than 0.02 in group I (4 days) than in group II (7 days). Antibiotic-lock technique was then applied by trained patients at home.(ABSTRACT TRUNCATED AT 250 WORDS)

[Comparison of the implantation and metabolic activity of human and rat fecal flora administered to axenic rats]. / Comparaison de l'implantation et de l'activité métabolique d'une flore fécale de rat et d'une flore fécale humaine inoculées chez le rat axénique.

Gnotobiotic rodents are increasingly used as a model for studying in vivo the characteristics of human colonic flora. However, the value of this model has been poorly assessed. In this study fecal bacterial flora provided either by a conventional rat (group RFR) or by man (group RFH) was administered orally to two groups of 6 germ-free rats. One month later, quantitative bacteriological analyses of feces revealed that bacterial populations were close to those of donors in both groups. The metabolic activity of the genuine flora was further compared in groups RFR and RFH with that of the implanted flora: a) concentrations of each fecal volatile fatty acid and of fecal bile acids were similar in conventional and RFR rats as well as the percentage of transformation of cholesterol into coprostanol (48 p. 100 and 54 +/- 5 p. 100 respectively; m +/- SD); b) similar concentrations of fecal volatile fatty acids were obtained from the human donor and RFH rats. Alpha, beta and omega muricholic acids absent in human donor's feces were found in RFH feces. Cholesterol transformation was lower in RFH rats (48 +/- 9 p. 100) than in man (85 p. 100); c) a single dose of lactulose (3 g/kg) increased breath hydrogen excretion in man but not in conventional or in RFR rats and RFH. Chronic lactulose ingestion (3 g/kg d.i.b. for 8 days) had no effect in conventional or RFR rats. Hydrogen excretion was decreased in man, whereas it was significantly increased in RFH rats.(ABSTRACT TRUNCATED AT 250 WORDS)

[Role of the digestive tract immune system in the control of bacterial translocation in gnotoxenic mice]. / Rôle du système immunitaire digestif dans le contrôle de la translocation bactérienne chez la souris gnotoxénique.

The aim of this work was to study the role of gut associated lymphoid tissue in the control of bacterial translocation. Two strains of Escherichia coli were orally inoculated to 71 axenic mice. Ten days after, the 2 initial strains and 2 others, resulting from plasmidic exchanges, were present in the digestive tract of the mice which were divided in two groups: the first group (n = 41) received one intraperitoneal injection of cyclophosphamide 100 mg/kg; the second control group (n = 30) received isotonic saline. The following parameters were studied 3, 5 and 9 days after the injection: the population level of the 4 strains in the caecum, their translocation to mesenteric lymph nodes, liver, spleen and circulating blood, the density per unit surface of lamina propria plasma cells and intraepithelial lymphocytes in duodenal and caecal mucosae. The population in each strain found in the caecum was different from the 3 others but similar within the two groups of animals and remained unchanged with time. In the control group, bacterial translocation to the mesenteric lymph nodes decreased (p less than 0.01), while the density of plasma cells increased (p less than 0.01) from the 3rd to the 9th days. In the cyclophosphamide treated group, translocation to the mesenteric lymph nodes increased (p less than 0.01), while the density of intestinal plasma cells decreased (p less than 0.05) from the 3rd to the 9th days. Density of intraepithelial lymphocytes did not vary with time in each group and from one group to another. Bacterial translocation to liver, spleen and systemic blood was weak and did not increase in the treated group.(ABSTRACT TRUNCATED AT 250 WORDS)

Translocation of strictly anaerobic bacteria from the intestinal tract to the mesenteric lymph nodes in gnotobiotic rodents.

Viable cells of some strictly anaerobic strains belonging to Bacteroides, Clostridium and Fusobacterium genera were present in mesenteric lymph nodes of gnotobiotic rodents harbouring these strains. Various parameters were found to affect the incidence of translocation, including the caecal population level, the length of association with the host and the nature of the strains and host.

[Complications of infections attributed to cytomegalovirus in a group of 52 kidney transplant patients]. / Incidence des infections attribuables au cytomégalovirus dans un groupe de 52 transplantés rénaux.

Cytomegalovirus (CMV) infection after renal transplantation was studied over a one year period in 52 patients receiving immunosuppressive drugs. During the infectious episodes, viral shedding was systematically detected in the blood and urines by culture on MRC5 cells and CMV antibodies were titrated in the serum by ELISA (IgG: M. A. Bioproducts, IgM: immunocapture Wellcome) and compared to the initial antibody titer determined the day of transplantation. Primary CMV infection was observed in 6 of 22 seronegative patients, attested by CMV shedding from urine and/or blood and by the emergence of CMV IgM antibodies. This primary infection was severe, including at least 4 of the following features: fever greater than 38 degrees C, neutropenia, thrombocytopenia, cytolytic hepatitis, pneumonia, impaired renal function, neurological syndrome, usually occurring about 6 weeks after transplantation. Reactivation was found in 12 of 30 seropositive patients, as shown by excretion of CMV in the urine and significant rise of specific antibodies. This reactivation occurring about 9 weeks after surgery was symptomatic in 5 patients with severe illness and associated with the presence of IgM antibodies in 2 cases. Rise of CMV antibodies was observed in 10 seropositive patients without excretion of virus. It coincided with symptomatic infection in only three patients who displayed severe symptoms, with presence of CMV IgM antibodies in one case. As previously reported, we confirm that CMV infection is a frequent complication of organ transplantation. It may be clinically silent in renal transplant patients or cause problems ranging from fever to pneumonia or retinitis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Optic neuritis and sarcoidosis (author's transl)]. / Névrite optique et sarcoïdose.

Case report of a sarcoidosis in a young west-indies feurale: ganglio-mediastinal and lung lesions, liver and salivary glands right optic nerve with retrobulbar optic neuritis. This lesions were quickly and totally reversible with tetracosactide and prednisone therapy.

Chronic hepatitis in kidney allograft recipients.

98 HBsAg-positive and 31 HBsAg-negative kidney recipients were compared to assess the effect of renal transplantation on chronic liver disease and vice versa. Diagnosis was based on analysis of liver biopsy specimens including semiquantitative evaluation of histological features of chronic hepatitis. Serial specimens were examined: chronic liver disease occurred in 88% of HBsAg-positive patients and 4% of HBsAg-negative patients with normal liver at the time of transplantation. Liver abnormalities in the former were chronic persistent hepatitis (32%), chronic active hepatitis (51%), and cirrhosis (17%). Actuarial patient survival was similar in HBsAg-positive (78%) and HBsAg-negative (87%) patients, as was allograft survival (64% and 71%, respectively). In both HBsAg-positive and HBsAg-negative patients chronic alcohol consumption was more frequent in those with chronic liver disease than those without. These data suggest that renal transplantation may be appropriate for haemodialysis patients with chronic hepatitis whatever their HBV status.

Hepatitis B virus and hepatitis B-related viral infection in renal transplant recipients. A prospective study of 90 patients.

Hepatitis B virus (HBV) infection may induce severe hepatitis and affect long-term survival of kidney transplant recipients. Persistent viral infection has been shown to occur despite the absence of usual serologic markers. The liver and serum HBV deoxyribonucleic acid (DNA) status of 90 patients were studied prospectively; recently transplanted patients, both hepatitis B virus surface antigen (HBsAg)-positive and negative, with and without liver disease, were investigated with HBV serology, serum HBV DNA, and liver histology. Thirty-four patients had detectable HBsAg, and 21 had viral multiplication at the time of transplantation. Serial HBV DNA determinations performed in 57 of 90 patients disclosed (a) reactivation of HBV replication in 11 of 12 HBsAg-positive patients, (b) increase of viral replication when positive on the initial sample in 6 of 11 patients, and (c) development of HBV replication in 7 of 35 of the HBsAg-negative patients. Moreover, liver HBV DNA studies showed a statistical correlation between the presence of integrated liver HBV DNA and chronic hepatitis in HBsAg-negative patients. This study demonstrates prospectively the significant association of HBsAg-positive as well as HBsAg-negative HBV infection with chronic hepatitis and suggests that immunosuppressive therapy may enhance the viral replication in both HBsAg-positive and negative subjects.