Effects of the peroxisome proliferator-activated receptor (PPAR)-gamma agonist pioglitazone on renal and hormonal responses to salt in diabetic and hypertensive individuals.

AIMS/HYPOTHESIS: Glitazones are powerful insulin sensitisers prescribed for the treatment of type 2 diabetes. Their use is, however, associated with fluid retention and an increased risk of congestive heart failure. We previously demonstrated that pioglitazone increases proximal sodium reabsorption in healthy volunteers. This study examines the effects of pioglitazone on renal sodium handling in individuals prone to insulin resistance, i.e. those with diabetes and/or hypertension. METHODS: In this double-blind randomised placebo-controlled four-way crossover study, we examined the effects of pioglitazone (45 mg daily during 6 weeks) or placebo on renal, systemic and hormonal responses to changes in sodium intake in 16 individuals, eight with type 2 diabetes and eight with hypertension. RESULTS: Pioglitazone was associated with a rapid increase in body weight and an increase in diurnal proximal sodium reabsorption, without any change in renal haemodynamics or in the modulation of the renin-angiotensin aldosterone system to changes in salt intake. A compensatory increase in brain natriuretic peptide levels was observed. In spite of sodium retention, pioglitazone dissociated the blood-pressure response to salt and abolished salt sensitivity in salt-sensitive individuals. CONCLUSIONS/INTERPRETATION: Pioglitazone increases diurnal proximal sodium retention in diabetic and hypertensive individuals. These effects cause fluid retention and may contribute to the increased incidence of congestive heart failure with glitazones. TRIAL REGISTRATION: ClinicalTrial.gov NCT01090752 FUNDING: Hypertension Research Foundation Lausanne.

[Role of networks in the screening and management of chronic kidney disease]. / Impact des réseaux sur les pratiques et les résultats de la prise en charge de la maladie rénale chronique.

Whatever the health care system, the prevention of chronic renal failure is at present limited by an insufficient use of available screening and treatment methods for chronic kidney disease. Consequently, most patients with chronic kidney disease remain exposed to an otherwise avoidable progression towards end-stage renal disease, an emergency start of dialysis, and increased cardiovascular risk. The coordination of care within a multiprofessional network including appropriate guidelines, continuous medical education and practice assessment, and patient information and therapeutic education, may radically change the prognosis of chronic kidney disease, and the burden of care.

[Malnutrition on dialysis: the end of a fatality]. / Dénutrition en diatlyse: vers la fin d'une fatalité.

Protein-energy malnutrition in patients treated with haemodialysis (HD) is a complex, multifactorial and prevalent problem, starting well ahead of the dialysis program. It is associated with an increased morbidity and mortality. Uraemic patients are relatively resistant to nutrients because of metabolism abnormalities. Prevention of malnutrition is therefore more efficient than treatment per se. Classical supplementation including oral nutritional supplements, intradialytic parenteral nutrition and enteral nutrition remain efficient, if applied for a sufficient time. A global approach coupling supplementation and strategies designed to optimise metabolism abnormalities should increase treatment efficacy and improve the outcome and quality of life of these patients.

[Hyperuricemia in hypertension: any clinical implication?]. / L'hyperuricemie dans l'hypertension artérielte: quelle implication?

Twenty-five percent of untreated hypertensive patients are hyperuricemic. The causal role of uric acid in the pathogenesis of hypertension has not been clearly demonstrated in humans. An elevated serum uric acid appears to be predictive of the development of hypertension. Serum uric acid has also been considered as a cardiovascular risk factor but this issue is controversial. A high serum uric acid is associated with an increased cardiovascular morbidity and mortality in men. Thus, hyperuricemia in hypertensive patients should be considered as a sign of increased risk leading to a more intensive management of all other risk factors. When managing hypertensive patients with hyperuricemia, physicians should know the impact of antihypertensive drugs on serum uric acid to prevent a further increase in uric acid and the development of gout.

Life-threatening complications of hepatitis B virus-related polyarteritis nodosa developing despite interferon-alpha2b therapy: successful treatment with a combination of interferon, lamivudine, plasma exchanges and steroids.

Polyarteritis nodosa (PAN) is a rare vasculitis associated with hepatitis B virus (HBV) infection in a significant proportion of cases. When used to treat HBV-related PAN, immunosuppressive agents may enhance viral replication and relaspes are frequent. In recent years the use of antiviral drugs has been proposed. We report the case of a patient with HBV-related PAN who, despite 6 weeks of interferon-alpha2b (IFN-alpha2b) monotherapy, developed life-threatening complications with bowel perforation. He was thereafter successfully treated with a combination of IFN-alpha2b, lamivudine, plasma exchanges and short-term steroids. In contrast to IFN-alpha2b, lamivudine is effective in rapidly suppressing viral replication. This may be valuable in the treatment of HBV-related PAN by contributing to a faster diminution of circulating immune complex levels. This case report highlights the importance of aggressive combined therapy in patients with HBV-related PAN.

Thymoma: prognostic factors.

The relative importance of factors influencing prognosis and survival in the treatment of thymoma is still controversial. Fifty-three patients operated on for thymoma from 1966 to 1990 were evaluated, 14 with myasthenia gravis and 39 without. Survival was analyzed as it related to associated disease, gross invasion by the tumor and the predominant cell type. Follow-up information was obtained in all cases (mean observation time: 11.2 years). A high proportion (51%) of our patients had invasive forms (stages III and IV). The overall 5-, 10- and 20-year survival rates were 52%, 46% and 21%, respectively. Factors indicating a poor prognosis included local invasion (P < 0.0001), predominantly, epithelial histologic features (P = 0.002), tumor-related symptoms and the type of surgical procedure. Myasthenia gravis was not an adverse factor for survival. The degree of tumor invasion was the main prognostic factor and treatment should be planned accordingly.