Belatacept Rescue Therapy in Kidney Transplant Recipients With Vascular Lesions: A Case Control Study.

Immunosuppression in kidney transplant recipients with decreased graft function and severe histological vascular changes can be particularly challenging. Belatacept could be a valuable option, as a rescue therapy in this context. We report a retrospective case control study comparing a CNI to belatacept switch in 17 patients with vascular damage and low eGFR to a control group of 18 matched patients with CNI continuation. Belatacept switch was performed on average 51.5 months after kidney transplantation (6.2-198 months). There was no difference between the two groups regarding eGFR at inclusion, and 3 months before inclusion. In the "CNI to belatacept switch group," mean eGFR increased significantly from 23.5 ± 6.7 mL/min/1.73m2 on day 0, to 30.4 ± 9.1 mL/min/1.73 m2 on month 6 (p < 0.001) compared to the control group, in which no improvement was observed. These results were still significant on month 12. Two patients experienced biopsy-proven acute rejection. One was effectively treated without belatacept discontinuation. Two patients needed belatacept discontinuation for infection. In conclusion, the remplacement of CNI with belatacept in patients with decreased allograft function and vascular lesions is associated with an improvement in eGFR.

A 5-year prospective follow-up study in essential cryofibrinogenemia patients.

INTRODUCTION: Cryofibrinogenemia may be essential, or secondary to diseases such as neoplasia, infection, thrombosis, and collagen vascular diseases. In a previous study, we reported the occurrence of neoplasia in some essential cryofibrinogenemia patients after a short period of follow-up. PURPOSE: We performed a prospective multi-center 5-year follow-up study in essential cryofibrinogenemia patients (2005-2009). RESULTS: 23 patients with essential cryofibrinogenemia were included, mean age 59 years (range: 33-79), 14 males. After a mean follow-up period of 24 months, 11/23 (47%) of cases that were initially diagnosed as essential cryofibrinogenemia were found to have an underlying lymphoma (6 T lymphoma and 5 B lymphoma). CONCLUSION: This prospective study suggests that some cases of cryofibrinogenemia that are initially considered as essential, may have underlying lymphoma. Thus, we further suggest that regular follow-up should be performed in patients with essential cryofibrinogenemia.

[Percutaneous treatment of aortic stenosis]. / Traitement percutané du rétrécissement aortique.

Degenerative aortic stenosis is the most frequent valvular disease in developed countries. The reference treatment is surgical valve replacement but one third of the patients are not eligible for surgery. Alternative options have been recently proposed using transcatheter valve implantation (transfemoral or trans-apical approaches) in this subset of patients. Two models of valve (balloon expandable or self-expandable) have demonstrated their efficacy and have been implanted to date in over 4000 patients worldwide. These techniques are promising but several issues remain such as the selection of patients, and the safety and durability of the devices currently used.

Chronic lymphocytic leukemia: a hazardous condition before kidney transplantation.

Long-term survival of patients with chronic lymphocytic leukemia (CLL) is over 10 years, and such patients are thus potential kidney recipients in the case of superimposed end-stage renal disease. However, the renal and patient outcome in this condition is unknown. We report the charts of four patients with CLL who were engrafted in France with a deceased-donor kidney and underwent routine triple immunosuppressive therapy. The results show that these patients developed severe infectious episodes (fatal in one case) and tumoral complications including rapid progression of CLL in two cases. Moreover, the graft may be infiltrated and damaged by monoclonal B cells: one patient lost his graft 14 months after transplantation. Various therapeutic options (modifications of the immunosuppressive regimen, anti-CD20 antibodies, irradiation of the graft) showed little (if any) efficacy. Therefore, we believe that CLL is a too hazardous condition to envisage solid organ transplantation with a routine immunosuppressive regimen, and we propose a more appropriate approach.

Outcome of essential cryofibrinogenaemia in a series of 61 patients.

OBJECTIVES: The present study assessed the outcome of several cases of cryofibrinogenaemia detected in our hospitals during a 10-yr period (December 1996-April 2007), and also attempted to evaluate the clinical manifestations and associated diseases. METHODS: We performed a retrospective study in a series of 61 consecutive cryofibrinogenemia patients detected in our hospitals. RESULTS: In the 61 cryofibrinogenaemia patients, 18 had essential cryofibrinogenaemia and 43 secondary cryofibrinogaemia. Five out of the 18 patients with primary cryofibrinogaemia (27%) developed lymphoma after a 5-yr follow-up period. The main manifestations were cutaneous, and there were no differences in clinical presentation and disease severity in both types of cryofibrinogenaemia. A small number of patients (six) had cryofibrinogenaemia associated with cryoglobulinaemia, and in two cases, hepatitis C virus infection was detected; but no differences were observed between these two groups of patients. CONCLUSION: Cryofibrinogenaemia was found in our study with a high prevalence, suggesting that this pathology is rather underestimated. Our data further suggests that these patients should have a regular follow-up because of the high risk of symptom recurrence. We also hypothesize that in some cases essential cryofibrinogenaemia might be a prerequisite for a secondary disease.

Adenocarcinoma on renal allograft as a complication at 5 years.

We report a new case of renal carcinoma in allograft kidney, 5 years after transplantation, which presented as a suspect allograft abscess in a complex history of recurrent urinary infection. Only surgical management with peroperative histological evaluation permitted us to confirm the diagnosis of malignancy.

Nasal augmentation using Gore-Tex. A 10-year experience.

OBJECTIVE: To determine on an ongoing basis the safety and efficacy of expanded polytetrafluoroethylene (Gore-Tex soft tissue patch and preformed nasal implants) as an implant in rhinoplasty. DESIGN: A retrospective study of 309 consecutive patients who underwent rhinoplasty, including augmentation with Gore-Tex, during a 10-year period. SETTING: Two major academic medical centers and 2 private office surgical centers. INTERVENTION: One hundred sixty-two patients (52%) presented for primary rhinoplasty; the remaining 147 (48%) presented for revision surgery. All received Gore-Tex implants to augment the nasal dorsum and/or base. The grafts ranged from 1 to 10 mm in thickness. Follow-up ranged from 5 months to 10 years, 5 months, with an average of 40.4 months. MAIN OUTCOME MEASURES: Clinically noted complications and patient satisfaction. RESULTS: Ten (3.2%) of 309 grafts became infected and were removed. One graft was removed and 1 graft was modified and replaced postoperatively because of excessive augmentation. Infection requiring removal occurred in 8 patients (5.4%) undergoing revision rhinoplasty and in 2 patients (1.2%) undergoing primary rhinoplasty. Nasal septal perforation was present preoperatively in 3 of the patients who developed infection requiring removal, and we consider it a contraindication for nasal Gore-Tex implantation. CONCLUSIONS: Gore-Tex remains an effective implant material for nasal augmentation in rhinoplasty. The complication rate in primary cases is low. The risk of infection necessitating removal rises significantly in revision cases, where its use may still be desirable but must be weighed more carefully.

Effect of the serotonin 5-HT4 receptor agonist cisapride on aldosterone secretion in corticotropic insufficiency and primary hyperaldosteronism.

Serotonin (5-HT) stimulates aldosterone secretion in man through activation of 5-HT4 receptors coupled to adenylyl cyclase via a Gs regulatory protein. In adrenocortical cells, the levels of expression of the Gs protein and ACTH receptor are decreased when the cells are deprived of ACTH and angiotensin II (ANG II). In order to examine the possible influence of ACTH and ANG II on the responsiveness of human glomerulosa cells to 5-HT, we have investigated the effect of cisapride, a 5-HT4 receptor agonist, on plasma aldosterone in patients with suppressed plasma ACTH, i.e. patients with corticotropic insufficiency (CI), and in patients with suppressed renin-ANG II activity, i.e. patients with primary hyperaldosteronism (PH) including both aldosterone-producing adenoma and idiopathic hyperaldosteronism. After 2 h of recumbency, all patients received a single oral dose of 10 mg cisapride. In the CI group, cisapride induced a 5-fold increase in plasma aldosterone levels without any modification of plasma renin, potassium or cortisol levels. Combined administration of cisapride and ACTH caused an increase in plasma aldosterone similar to that produced by ACTH alone. In the PH group, cisapride was still able to cause a 3.6-fold increase in plasma aldosterone levels while renin remained suppressed throughout the study. Taken together, these data show that cisapride stimulates aldosterone secretion in CI and PH patients, indicating that prolonged suppression of plasma ACTH or renin-ANG II activity does not affect the sensitivity of glomerulosa cells to 5-HT. The present study also demonstrates that the stimulatory effects of 5-HT and ACTH on aldosterone secretion are not additive.

[Coronary involvement in systemic lupus erythematosus]. / Atteinte coronarienne au cours du lupus Erythémateux systeémique.

BACKGROUND: Coronary artery disease is an uncommon event in lupus erythematosus. The mechanisms responsible for coronary occlusion are probably complex and intermixed. We report three patients with lupus erythematosus and antiphospholipid antibodies who had coronary artery disease diagnosed with coronary angiogram. OBSERVATION: Coronary artery disease occurred in three young patients aged from 21 to 35 years 3 to 11 years after the onset of lupus. They all had antiphospholipid antibodies. They had been treated with corticosteroids for 6 to 36 months. Two of them were smokers. Angiograms showed coronary occlusion two patients while the third one had probable myocardial microvasculopathy. The lupus was quiescent in all cases when coronary artery disease occurred. DISCUSSION: Antiphospholipid antibodies associated with smoking may be involved in the pathogenesis of coronary artery disease in these 3 patients.

Crescentic glomerulonephritis in juvenile chronic arthritis.

Juvenile chronic arthritis (JCA) was diagnosed in 2 young girls. In one of them, antinuclear antibodies (ANA) were strongly positive during the course of erosive polyarthritis. After 5 years followup, severe renal insufficiency occurred. Antineutrophil cytoplasmic antibodies (ANCA) were positive with a perinuclear pattern on indirect immunofluorescence (IIF) and antimyeloperoxidase (MPO) specificity. Renal biopsy showed severe crescentic glomerulonephritis without significant deposits on IIF. Treatment consisted of prednisone and monthly intravenous cyclophosphamide pulse. Renal failure worsened and hemodialysis was necessary. A 2nd patient was referred for polyarthritis with positive rheumatoid factors without positive ANA. The presence of microscopic hematuria led to the discovery of crescentic glomerulonephritis with positive ANCA of anti-MPO specificity. At latest examination, after prednisone for 10 months and azathioprine for 6 months, the patient had moderate proteinuria with normal renal function. These observations emphasize that in juvenile onset chronic polyarthritis, renal microscopic angiitis with ANCA of anti-MPO specificity may occur.

The use of expanded polytetrafluoroethylene (Gore-Tex) in rhinoplasty. A 6-year experience.

OBJECTIVE: To determine the safety and efficacy of expanded polytetrafluoroethylene (Gore-Tex soft-tissue patch, W. L. Gore & Assoc Inc, Flagstaff, Ariz) as an implant in rhinoplasty. DESIGN: A retrospective study of 137 patients who underwent rhinoplasty including augmentation with Gore-Tex over a 6-year period. A review of the medical literature concerning the use of Gore-Tex as an implant in the head and neck was also conducted. SETTING: Two major academic medical centers and two private office surgical centers. PARTICIPANTS: One hundred thirty-seven consecutive patients who received Gore-Tex implants in the course of rhinoplasty. INTERVENTION: Sixty-nine patients presented for primary rhinoplasty; the remaining 68 presented for revision surgery. All received Gore-Tex nasal implants to augment the nasal dorsum and/or base. The grafts ranged from 1 to 6 mm in thickness. Follow-up ranged from 6 to 80 months, with an average of 25 months. OUTCOME MEASURES: Clinically noted complications and patient satisfaction. RESULTS: Three (2.2%) of 137 grafts became infected and were removed. One graft was removed 5 months post-operatively because of excessive augmentation. None of the patients who underwent implant removal required subsequent augmentation. All 137 patients are pleased with their results. CONCLUSION: Gore-Tex is a safe and effective implant material to use in primary and revision rhinoplasty when augmentation is needed and autogenous material is not available or desirable.

The anterior extension face-lift.

OBJECTIVE: To describe a face-lift technique with emphasis on extension of the temporal incision into the lateral orbital area. This modification serves several beneficial ends but must be used only in carefully selected patients. Gathering of excess skin in the lateral orbital area is prevented, eliminating the typical disparity between relatively tight lower and middle facial skin and flaccid upper facial skin, which is commonly seen after rhytidectomy. The anterior extension also helps to support the lower eyelid, which is helpful when lid laxity exists or when concomitant blepharoplasty is performed. SETTING: A private cosmetic surgery center. PARTICIPANTS: Thirty-five patients undergoing rhytidectomy (15 primary and 20 revision procedures). OUTCOME MEASURE: Patient satisfaction at 3 months after surgery. RESULTS: Thirty-four (97%) of 35 patients were pleased with their results. CONCLUSIONS: The anterior extension face-lift can provide excellent results in carefully selected patients. We have found this procedure to be especially helpful in patients undergoing revision surgery and in older patients with facial skin laxity.

The tension nose: open structure rhinoplasty approach.

The term tension nose is known to many rhinoplastic surgeons, yet confusion exists as to its precise meaning. We define the tension deformity as excessive growth of the quadrilateral cartilage, resulting in a high nasal dorsum and anterior and sometimes inferior displacement of the nasal tip cartilages. A review of the surgical literature shows that little attention has been given to the evaluation and management of this problem. We reviewed 50 consecutive primary rhinoplasty candidates and found that 46 percent had some manifestation of tension deformity that required correction at the time of surgery. The techniques of open structure rhinoplasty are ideally suited to manage the tension nose. The essence of correction is a deprojection-reprojection process. First, excessive elements of the septal cartilage and anterior nasal spine, which comprise what we have termed the nasal pedestal, are reduced, resulting in tip deprojection. Open structure methods are then employed to achieve reprojection of the domes by using cartilage grafts and suturing techniques to build strength, support, and elegance into the nasal tip.