[Are preoperative examinations useful in the management of patients with renal hyperparathyroidism?]. / L'imagerie préopératoire des hyperparathyroïdies des insuffisants rénaux a-t-elle un intérêt en pratique clinique?

AIM OF THE STUDY: To evaluate the efficiency of preoperative parathyroid ultrasonography and scintigraphy in the management of renal hyperparathyroidism. PATIENTS AND METHODS: The charts of the last consecutive 200 patients who underwent surgery for renal hyperparathyroidism from 1998 to 2003 were retrospectively reviewed to collect data concerning parathyroid gland function, results of preoperative ultrasonography and scintigraphy, as well as modalities and results of surgical exploration. RESULTS: Ultrasonography and scintigraphy sensibilities were 36.4% and 49.3%, respectively. Efficiency of both examinations was improved when they were combined (sensibility of 64.7%) and in those patients managed for recurrent hyperparathyroidism. Were more often detected by preoperative examinations glands with high weight and/or greatest diameter, orthotopic and inferior glands as well as glands exhibiting nodular hyperplasia content upon pathological examination. CONCLUSION: Parathyroid ultrasonography and scintigraphy are of poor interest in the management of renal hyperparathyroidism. In a preoperative setting, they should be performed only in patients with recurrent disease.

[Imaging in urinary tract infections in adults]. / Place de l'imagerie dans les infections du tractus urinaire de l'adulte.

Uncomplicated infection of the urinary tract is frequent and usually resolves rapidly with treatment and imaging is unnecessary. Progression to complex infection often occurs in patients with predisposing factors. Imaging assists in evaluating the extent of disease, plays a role in directing therapy and guides interventional procedures if necessary. This pictorial essay reviews the role of imaging and intervention in infections of the urinary tract.

Renal thrombotic microangiopathy in systemic lupus erythematosus: clinical correlations and long-term renal survival.

BACKGROUND: Renal thrombotic microangiopathy (TMA) is an uncommon vascular complication of systemic lupus erythematosus (SLE). Its clinical symptoms and impact on renal survival remain unclear. METHODS: Eight patients aged 25 +/- 6 years with biopsy-proven renal TMA and at least four ARA criteria for the diagnosis of SLE were retrospectively studied over a 7-year period. RESULTS: All patients presented with renal failure (creatinine 3.3 +/- 2.1 mg/dl), six had proteinuria (2.5 +/- 1.3 g/day) with microscopic haematuria in four cases. Six patients had hypertension, which was severe in five cases. Renal histology disclosed arterial and/or arteriolar thrombosis with parietal thickening without angeitis (8 patients), glomerular microthrombi (3 patients), and vascular fibrin deposits (5/6 patients). In two cases, vascular lesions were associated with a mesangial or a proliferative glomerulonephritis. Thrombocytopenia was present in four patients with haemolytic microangiopathic anaemia in one case. Lupus anticoagulant (LA) was detected in five of eight patients, who also had anticardiolipin antibodies (3/7 patients) and/or were positive for VDRL (3/6 patients). Four patients with LA experienced arterial thrombosis and/or repeated spontaneous abortions. Treatment consisted of corticosteroids (8 patients), cytotoxic drugs (4 patients), plasma exchanges and/or intravenous immunoglobulins (4 patients) and antiplatelet and/or anticoagulant therapy (3 patients). Two patients recovered normal renal function and five had persistent renal insufficiency. One patient started haemodialysis on admission and died of sepsis 2 months later. CONCLUSIONS: TMA may be the sole renal complication in SLE and is not usually associated with haemolytic microangiopathic anaemia. In our series renal survival was influenced by the extent and severity of vascular lesions. Despite a frequent association with antiphospholipid antibodies, pathophysiological mechanisms of renal TMA in SLE remain unknown. Renal histology is mandatory for the diagnosis and the prognostic evaluation of renal vasculopathy in SLE.

[Auricular chondritis, malignant glomerulonephritis and pulmonary hemorrhage]. / Chondrite auriculaire, glomérulonéphrite maligne et hémorragies pulmonaires.

Relapsing polychondritis is a rare connective tissue disorder characterized by inflammation of cartilagenous structures such as ears, nose, joints, trachea and larynx. Renal disease is unusual. A 41 years old man presented with auricular chondritis, subacute renal failure and lung hemorrhage. A renal biopsy disclosed a diffuse proliferative glomerulonephritis with extensive crescents. Immunofluorescent studies suggested a GNRP type III so called "non immunologic disease". He was treated by prednisone and plasmapheresis with rapid disappearance of pulmonary hemorrhages and good renal functional improvement.

Apolipoprotein B immunochemical heterogeneity in dialysed patients with chronic renal failure and patients with coronary artery stenosis.

Serum cholesterol, triglyceride, apolipoprotein B (apo B) and the cholesterol and phospholipid content of apo-B-containing particles was determined in 41 male patients on dialysis for chronic renal failure, in 41 male patients with coronary artery disease selected on the basis of a total cholesterol level below 6.72 mmol/l and in 41 male control subjects of similar age. Apo B was assessed as total B protein determined using polyclonal antibodies and also by measuring the expression of epitopes recognized by three different monoclonal antibodies (BL3, BL5 and BL7). Triglyceride was increased (p less than 0.01) and cholesterol was decreased (p less than 0.01) in the dialysed patients with chronic renal failure. Total apo B was similar in the three tested groups while the expression of the BL7 epitope was increased in the group of dialysed patients with chronic renal failure (p less than 0.001). The expression of BL3 and BL5 epitopes was increased in patients with coronary artery disease (BL3: p less than 0.05; BL5: p less than 0.02) but not in dialysed patients with chronic renal failure. These results suggest an abnormal composition and an immunological heterogeneity of apo-B-containing lipoprotein particles in patients with coronary artery stenosis and in dialysed patients with chronic renal failure.

Alveolar macrophage dysfunction in systemic lupus erythematosus.

A high frequency of pulmonary infections has been a well-described feature of systemic lupus erythematosus (SLE). Alveolar macrophages (AM) play a crucial role in pulmonary bacterial defense. We therefore examined the antibacterial activity of AM and generation of superoxide anion in 17 patients with SLE without clinical or radiologic pulmonary changes and in 8 control subjects. Total cell count and cellular viability of AM (trypan blue exclusion) did not differ significantly between patients and control subjects. Antibacterial activity v/s Staphylococcus aureus was significantly decreased in both untreated and corticosteroid-treated patients (respectively, -16.2 +/- 7.4 and -42 +/- 12% compared with the normal value of 51 +/- 12%, p less than 0.001). The defect of antibacterial activity was observed as well v/s S. aureus as v/s Escherichia coli. In contrast, chemiluminescence response of AM before and after stimulation by either phorbol myristate acetate or opsonized zymosan did not differ among control subjects and treated and untreated patients with SLE. We did not find any correlation between disease activity and AM function. Antibacterial activity of normal AM was shown to be significantly reduced by previous incubation with SLE serum compared with normal human serum. Thus, our findings suggest that alteration of antibacterial activity of AM may contribute to the increased susceptibility to lung infections observed in SLE.

[Acute interstitial nephritis and uveitis in the adult: apropos of 3 cases]. / Néphrite interstitielle aiguë avec uvéite chez l'adulte: à propos de trois observations.

Acute renal failure due to tubulo-interstitial nephritis accompanied by uveitis has been observed in 3 young women (TINU syndrome). In these 3 cases, the nephropathy was preceded (1-3 months) by asthenia, anorexia, weight loss and a major inflammatory syndrome. Nonsteroidal anti-inflammatory drugs (NSAID) administration was noted. In 2 cases, uveitis appeared after the nephropathy had subsided. Renal biopsies performed in the 3 patients revealed mainly interstitial changes with mononuclear cell infiltration; immunofluorescence studies were negative. Although the severity of renal failure varied among patients, renal function recovered completely, returning to normal within 2, 3 and 24 months respectively, on corticosteroid therapy. The TINU syndrome is a rare situation compared to drug-induced acute interstitial nephritis, including NSAID related-nephritis. However, the real incidence of this syndrome might be underestimated since the uveitis can appear a few weeks later and its origin may not be related to the renal episode.

[Risk of bone disease as a result of fluoride intake in chronic renal insufficiency]. / Risque osseux de l'apport fluoré chez l'insuffisant rénal chronique.

Four cases of osteosclerosis were observed in patients with renal failure. All subjects presented with moderate reduction in renal function which had been stabilized for several years. Osteosclerosis appeared progressively but was clinically symptomatic in only one patient. Fluoride intoxication was ascertained on the basis of X-ray examination and bone biopsy. In addition, the source of fluoride intoxication was easily recognized as the drinking water (2 to 3 1/day), "Vichy Saint Yorre" commercial mineral water (fluoride concentration 9 mg/l) in 3 cases, and tap water in the fourth case. These observations emphasize the risk of high chronic fluoride intake in patients with renal failure, even with mild reduction of glomerular filtration rate.

Drug-induced granulomatous interstitial nephritis.

Among 22 cases of drug-induced acute interstitial nephritis (AIN), noncaseating interstitial granulomas were found in eight cases (36%). Acute renal failure (ARF), oliguric in three patients, appeared within 1-20 days after the beginning of therapy. Clinical symptoms suggesting a hypersensitivity reaction were unusual, marked blood eosinophilia was absent, and immunologic tests were inconstantly positive. The discovery of interstitial granulomas may be a clue to the diagnosis of drug-induced AIN, especially when the inflammatory infiltrates do not contain eosinophils. Since significant residual renal impairment may be observed the benefit of early steroid therapy must be debated.

[Current aspects of acute renal failure]. / Aspects actuels de l'insuffisance rénale aiguë.

The retrospective review of 115 case-histories of patients with acute renal failure (ARF) seen over the last two years showed that etiologies were distributed as follows: acute tubular necrosis in 65% of cases, urinary tract obstruction in 16%, acute glomerulonephritis in 3,5%, acute interstitial nephritis (AIN) in 8% and acute microvascular nephropathy in 3,5%. The diagnostic value of renal biopsy in ARF is discussed. In spite of recent advances in the treatment of ARF, the mortality rate remains as high as 48%. This is mainly due to current etiologic circumstances, to the age of the patients and to the complications of ARF, with infectious complications being the most serious. Urea nitrogen accumulation is not a poor prognosis factor. Furosemide in high doses does not alter the prognosis but reduces the total number of dialysis indications (81% in 1970, 60% in 1980), the number of dialysis sessions per patient (1 only in 62% of patients), and the duration of the ARF episode (mean duration: 10,7 days).