[Do initial experience with an enhanced recovery program after surgery (ERAS) improve postoperative outcomes after cystectomy?] / L'application d'un programme de réhabilitation précoce (ERAS) améliore-t-elle les résultats périopératoires après cystectomie ?

OBJECTIVE: To estimate the feasibility and the impact of an ERAS program after radical cystectomy for bladder cancer. MATERIALS AND METHODS: This was a retrospective study comparing a historical pre ERAS group, including all the patients undergoing cystectomy for bladder cancer from January 2013 to December 2015 with a classic procedure, and an interventional ERAS group after introducing an enhanced recovery protocol before, during and after surgery, from February 2016. The principal outcome was the postoperative length of stay. Secondary outcomes mesures were impact on perioperative complication rate (Clavien classification≥3B), readmission rate, reanimation length of stay, ileus rate and adherence to the ERAS protocol. RESULTS: There were no differences between the 2 groups as far as demographics characteristics are concerned. In total, 97 patients were included, 56 in the control group, and 41 in the ERAS group. The adherence to the protocol was about 65.8%. The ERAS group had statistically significantly shorter median length of stay (D19 versus D14; P: 0.021). The major complications rate (Clavien≥3B) were about 23.2% for the control group and 12.1% for the ERAS group (P: NS). The reinsertion of nasogastric tube were higher in the control group (39.3% vs 21.9%; P: NS) and the readmission rate was about 7.1% in the control group versus 14.6% in the ERAS group (P: NS). CONCLUSION: In conclusion, introduction and application of an enhanced recovery protocol (ERAS) after cystectomy for bladder cancer allowed for better management of postoperative outcomes. It is clearly feasible in cystectomy, and improve significantly the median postoperative length of stay. Moreover, it may be effective in terms of faster return of bowel function and reduction of majors complications. LEVEL OF EVIDENCE: 4.

Daclizumab Versus Rabbit Antithymocyte Globulin in High-Risk Renal Transplants: Five-Year Follow-up of a Randomized Study.

We previously reported a randomized controlled trial in which 227 de novo deceased-donor kidney transplant recipients were randomized to rabbit antithymocyte (rATG, Thymoglobulin) or daclizumab if they were considered to be at high immunological risk, defined as high panel reactive antibodies (PRA), loss of a first kidney graft through rejection within 2 years of transplantation, or third or fourth transplantation. Patients treated with rATG had lower incidences of biopsy-proven acute rejection (BPAR) and steroid-resistant rejection at 1 year. Patients were followed to 5 years posttransplant in an observational study; findings are described here. Treatment with rATG was associated with a lower rate of BPAR at 5 years (14.2% vs. 26.0% with daclizumab; p = 0.035). Only one rATG-treated patient (0.9%) and one daclizumab-treated patient (1.0%) developed BPAR after 1 year. Five-year graft and patient survival rates, and renal function, were similar between the two groups. Overall graft survival at 5 years was significantly higher in patients without BPAR (81.0% vs. 54.8%; p < 0.001). In conclusion, rATG is superior to daclizumab for the prevention of BPAR among high-immunological-risk renal transplant recipients. Overall graft survival at 5 years was approximately 70% with either induction therapy, which compares favorably to low-risk cohorts.

Evaluation of intrarenal oxygenation by blood oxygen level-dependent magnetic resonance imaging in living kidney donors and their recipients: preliminary results.

OBJECTIVE: Blood oxygen level-dependent magnetic resonance imaging (BOLD-MRI) is a noninvasive tool to measure modifications in tissue oxygen content. Lower deoxyhemoglobin concentrations due to increased tissue oxygenation induce a longer transverse relaxation time (T2*), thus a stronger MRI signal. We have studied the changes in the kidney oxygenation profiles of living donors and their recipients by BOLD-MRI associated with transplantation and nephrectomy. MATERIALS AND METHODS: Two donor/recipient couples were selected for this preliminary study. BOLD-MRI was performed on the donor on the day prior to surgery, on day 4, and 1 month thereafter, and on the recipient on day 4 and 1 month postsurgery. Mean T2* values were measured in specific target regions in the cortical and medullary regions of each kidney using the T2StarMappingTool (Philips, Eindhoven, Netherlands). Modifications of tissue oxygen profiles were then compared considering the proportionality between T2* values and tissue oxygen content. RESULTS: The clinical courses posttransplantation were uneventful throughout the study; kidney function resumed rapidly. All MRI examinations showed a significantly higher T2* level in the cortex than in the medulla, confirming the notion that the medulla is hypoxic compared to the cortex. Nephrectomy and transplantation induced a significant rise in cortical T2* values in the remnant and transplanted kidney at day 4 and 1 month. Medullary T2* level only increased in the transplanted kidney. CONCLUSIONS: Profound modifications in renal oxygenation intervene following transplantation and nephrectomy. BOLD-MRI may be a useful tool to explore these modifications and possibly identify pathological patterns.

[Psychiatric assessment]. / Evaluation psychiatrique.

Psychiatric disorders and behavioral disturbances may complicate the postsurgical outcome in patients and de novo psychiatric symptoms have been reported. In numerous, but not all epilepsy surgical centers, a psychiatric assessment is included as part of the presurgical evaluation of potential candidates for surgery. Affective disorders and psychosis are the most frequently reported postsurgical psychiatric disorders. There are no absolute psychiatric contraindications to surgery. Specific preexisting psychiatric conditions may need cautious consideration because there may be a risk of postsurgical psychiatric complications. Routine pre- and postsurgical psychiatric evaluations in patients undergoing epilepsy surgery are urgently needed. Clinicians involved in the care of surgical candidates should be aware of the possible psychiatric complications following surgery.

Tolerability of enteric-coated mycophenolate sodium to 1 year in combination with cyclosporine and corticosteroids in renal transplant recipients.

Enteric-coated mycophenolate sodium (EC-MPS) is therapeutically equivalent to mycophenolate mofetil, but delays release of mycophenolic acid until it reaches the small intestine. De novo renal transplant patients taking part in a 12-month, multicenter, randomized study received cyclosporine microemulsion (CsA-ME, early or delayed to day 6), EC-MPS, steroids, and interleukin-2 antagonist induction. Tolerability data relating to EC-MPS are reported. Ninety-seven patients were randomized to early CsA-ME and 100 patients to delayed CsA-ME. Median daily dose of EC-MPS was 1440 mg at all time points throughout the 12-month period. The most frequently reported adverse events were constipation, anemia, urinary tract infection, abdominal pain, leukopenia, and cytomegalovirus infection; there were four malignancies. Fifty patients (24.6%) discontinued EC-MPS prematurely by 12 months, including 42 patients (84%) who discontinued owing to adverse events. No patient discontinued treatment because of gastrointestinal adverse events. Two-thirds of patients (137 [67.5%]) maintained full EC-MPS dose throughout the 12-month study and did not require any dose reduction or dose interruption. EC-MPS is well tolerated in de novo renal transplant recipients when administered in combination with CsA-ME and steroids, with low rates of dose reductions or interruptions. Gastrointestinal adverse events were responsible for dose reduction or interruption in only 5% of patients.

[Management of oncocytoma in transplanted kidney]. / Tumeur à cellules oncocytaires sur transplant rénal: quelle prise en charge?

The authors report a case of oncocytoma arising in a transplanted kidney. The diagnostic and therapeutic management is discussed and compared to the limited data reported in the literature on this subject. Immunosuppression of renal transplant recipients does not appear to increase the incidence of graft tumours, but, in the authors' opinion, modifies the conservative attitude generally proposed for this type of tumour.

Urinary F2-isoprostanes formation in kidney transplantation.

BACKGROUND: Oxygen free-radical mediated lipid peroxidation has been implicated in many diseases such as chronic renal failure, hemodialysis and chronic kidney transplant rejection. However, insight into the role of free radical generation in kidney transplantation has been constrained by the limitations of current indexes of oxidant stress in vivo. Isoprostaglandin F2alpha type-III (iPF2alpha-III, formerly known as 8-iso-prostaglandin F2alpha) is emerging as a reliable marker of oxidant stress in vivo. The purpose of our study was to investigate iPF2alpha-III formation as an index of lipid peroxidation in the 5 d following kidney transplantation. METHODS: Urinary iPF2alpha-III measurements were performed by enzyme immunoassay from day I to 5 in 11 patients undergoing kidney transplantation. Results were compared with 11 healthy volunteers matched in sex, age and cigarette smoking. RESULTS: Urinary excretion of iPF2alpha-III at day 1 did not significantly differ between control and transplant group (111 +/- 17 vs. 92 +/- 10 pM/ mM creatinine, respectively, NS). Urinary iPF2alpha-III levels did not differ between day 1 to 5, and were not correlated to cold ischaemia time. CONCLUSION: Our study shows no evidence of enhanced lipid peroxidation in the first 5 d following kidney transplantation.

Profiles and prognostic values of LDH isoenzymes in patients with non-Hodgkin's lymphoma.

Serum lactic dehydrogenase (LDH) is an important prognostic factor in patients with non-Hodgkin's lymphoma (NHL). We have examined the LDH isoenzyme content in serum and CSF of patients with NHL, at diagnosis and at relapse. In patients with increased serum LDH at diagnosis, the percentage of isoenzyme 2 was increased in 52% of patients and the absolute value of isoenzyme 3 was increased in 64% of patients. In relapsing patients these values were respectively 69% and 65%. Conversely in patients with increased serum LDH due to myeloid regeneration after chemotherapy, isoenzymes 4 and 5, but not isoenzymes 2 or 3, were increased. High absolute values of isoenzyme 3 were correlated with an altered performance status, advanced tumor stage, and aggressive histology whereas high isoenzyme 2 percentages were correlated with altered performance status only. Among patients with high total serum LDH, a high content of isoenzyme 2 and a high absolute value of isoenzyme 3 were correlated with high serum levels of TNFalpha and TNF receptor p75. Analysis of total LDH and LDH isoenzyme profiles in CSF did not reveal any correlation with meningeal involvement by lymphoma. High isoenzyme 2 percentages and high absolute values of isoenzyme 3 in serum were both significantly associated with a shorter freedom-from-progression and overall survival. Isoenzyme 3 remained a prognostic factor for survival even when considering only patients with high total serum LDH at diagnosis. We conclude that there are some characteristic serum LDH isoenzyme profiles in patients with NHL and that some of these specific alterations may help refine the prognostic value of total serum LDH.

[Treatment of heroin addicts by substitution with methadone. Importance, limits and experience in France]. / Les traitements de substitution des héroïnomanes par la méthadone. Intérêt, limites et pratiques en France.

The authors present a review of literature and their personal experience concerning the practice of methadone substitutive therapy for heroin addicts in France. In their experience, the use of methadone, within the frame of a controlled administration and in the perspective of a specific pharmaco-therapeutic profile, is a valuable therapeutical option. Otherwise, methadone could only induce a new and further pharmacological dependence. The use of methadone has often been the subject of controversies overlooking the clinical reality of drug addiction. Therefore, a controlled use of methadone remains a valuable therapeutic tool if its indications are strictly delimited.

[Renal transplantectomy: surgical technics and results. Apropos of 60 patients]. / Transplantectomies rénales: techniques chirurgicales et résultats. A propos de 60 patients.

Nephrectomy of a non-functioning renal transplant after renal transplantation is a delicate operation which the authors evaluate on the basis of a retrospective analysis of 62 patients. A review of the literature helps to more clearly define the indications, optimal time of the operation and the operative technique. A subcapsular approach, by simplifying the operation, constitutes an important factor in reducing the operative morbidity in the late forms. "Early" transplantectomies are often more serious because of the recently operated patient's fragile status and immunosuppression, responsible for frequent infectious complications. Transplantectomy should therefore not be delayed once the permanent loss of transplant function has been confirmed.

[Primary microvascular lesions of the kidney or pre-hypertensive nephroangiosclerosis. 25 cases]. / Lésions microvasculaires primitives du rein ou néphroangiosclérose pré-hypertensive. 25 observations.

Isolated non inflammatory lesions of renal microarteries (eventually with mild thickening of tubular basement membranes, but with negative immunofluorescent glomerular studies) were observed in 25 patients (22 males) in whom renal biopsy have been performed for proteinuria (P). Selection criteria were: pathological lesions by definition; absence of hypertension (HT) in clinical and at the time of biopsy; minimum follow up of 4 years after the first statement of the proteinuria (4 to 29 years; mean 14 years). Three groups have been isolated: 1. 3 patients have had an acute glomerulonephritis followed by disappearance of proteinuria. It reappears 1 to 5 years later. HT was discovered 2, 8 and 11 years after the proteinuria. Renal failure occurred 1 and 3 years after HT. 2. 14 patients had hereditary or acquired vascular risk factors (obesity, smoking, ethylism). In 7, HT occurred 3 to 15 years after P. In 2, renal failure occurred 4 to 8 years later. 3. 8 patients had no vascular risk factor; in 3 of them Ht developed 7, 13 and 20 years after the first statement. A positive immunofluorescence with IgM or C3 on renal arterioles had been found in only 3 of the 10 patients who in group 2 and 3 became hypertensive. A proteinuria may precede the occurrence of HT without being induced by glomerulonephritis. Group 2 and 3 suggest that these renal lesions of arterial sclerosis precede and may be a factor of HT. Indeed, this entity may be considered as a prehypertensive condition.

[Nephrotoxicity of mitomycin C (apropos of 25 case reports). Results of a multicenter survey organized by the Society of Nephrology]. / La néphrotoxicité de la mitomycine C (à propos de 25 observations). Résultats d'une enquête multicentrique organisée par la Société de néphrologie.

We have studied 25 cases of hemolytic and uremic syndrome (H.U.S.) induced by mitomycin C, collected from 1976 to 1982 in 12 Nephrology Centers. Mitomycin C was administered in successive cures at a cumulative dose higher than 50 mg/m2. This H.U.S. is characterized by its slow and late occurrence, by extra-renal, mainly respiratory, manifestations that may reveal the disease, and finally by its pathological aspects. Mesangiolysis and endothelial or mesangial enlarged and atypical nuclei are observed in addition to the usual lesions of thrombotic micro-angiopathy. The prognosis was very poor in the first cases reported. It was better, however, in the patients studied more recently, because the cumulative dose was lower. In severe cases, plasma exchange might improve long-term prognosis. The disease might be due to a direct toxic effect of mitomycin C on the vascular endothelium.

Macrophage function in primary and secondary glomerulonephritis.

The function of the mononuclear phagocyte system was assessed in vivo in 85 patients with primary and secondary glomerulonephritis, by measuring the clearance of IgG - sensitised 51Cr-labelled autologous erythrocytes. Eleven per cent of patients in clinical remission were found to have a delayed clearance, whereas impaired macrophage function was present in 62.5 per cent of the patients with major urinary abnormalities. Blockade of mononuclear phagocyte system, induced at least in part by unidentified factors, might have a role in development and perpetuation of glomerular injury.

[Nephrotoxicity of antitumor chemotherapy]. / Néphrotoxicité des chimiothérapies antitumorales.

The renal toxicity of antitumoral drugs is an increasingly disturbing problem. These drugs are now prescribed in an ever wider variety of cases, and delayed renal reactions, previously unknown, are revealed by the longer survivals obtained. For a number of years, patients whose cancer had been cured have been placed under haemodialysis on account of drug-induced renal failure. The renal toxicity of cisplatinum, nitrosoureas and methotrexate is well-known, but mitomycin C is also capable of inducing permanent renal failure; the delayed toxicity of this drug explains that it has long been underestimated. This example emphasizes the need for close co-operation between oncologists, nephrologists and pharmacologists in order to determine, for each patient, the most effective treatment with the minimum of side effects.

Papillary plasma flow in rats. II. Hormonal control.

Papillary plasma flow (PPF) was measured by the albumin accumulation technique in Wistar rats. PPF was significantly lower in male (293 +/- 5 microliter X min-1 X g-1) than in female (499 +/- 17) rats. Castration in male rats increased PPF; testosterone administration in gonadectomized rats returned PPF to control. Acute indomethacin administration equalized PPF in both sexes to low values close to those found in normal males (320 +/- 5 in males, 326 +/- 17 in females). Conversely, captopril administration equalized PPF in both sexes by raising PPF in males (505 +/- 21) without significant change in females (526 +/- 88). Dehydration decreased PPF slightly in males (255 +/- 28) but more markedly in females (349 +/- 11). This decrease was prevented by captopril administration (520 +/- 34 and 609 +/- 61 in males and females, respectively). In captopril-treated male rats, angiotensin II (AII) was continuously infused by osmotic minipumps at a rate of 5 micrograms/h. This did not restore PPF (405 +/- 12) to basal values. In contrast, AII infusion together with indomethacin administration completely restored PPF (322 +/- 22) in captopril-treated rats whereas indomethacin alone did not normalize PPF (425 +/- 18). We suggest that male sex hormones and AII decrease PPF, and account for the low PPF measured in male rats. Vasodilator PGs are involved in the high PPF found in female rats. The vasodilator action of captopril on papillary circulation is explained by both decreased AII formation and increased PG synthesis.