[Retrospective study of the one-year patency of a cuffed polytetrafluoroethylene Venaflo-type graft placed for venous hemodialysis access]. / Etude de la perméabilité à un an des anses de dialyse en polytétrafluoroéthylène avec chambre d'anastomose veineuse de type venaflo.

PURPOSE: The objective of this study was to determine retrospectively the one year patency of a new polytetrafluoroethylene (ePTFE) graft with a cuff at the graft-vein anastomosis (Venaflo, Bard industries) placed for hemodialysis access. METHODS: From April first 1999 to December thirty first 2001, 37 consecutive patients (56.8 medium age) underwent 39 Venaflo graft for hemodialysis in Vascular Surgery Section from Bordeaux University Hospital. All medical files have been reviewed at the end of the first year following the operation, by consultation or phone call from the referent nephrologist. Six patients deceased with a functional graft before the end of the study. The patency outcomes were calculated with Kaplan Meier life table method. RESULTS: The one year primary patency is 60.03% with a 95% confident interval [43%; 77%] and secondary patency is 83.73% [70%; 96%]. CONCLUSION: The patency of cuffed ePTFE grafts for hemodialysis was satisfactory in comparison with the result of classic ePTFE grafts in the medical literacy. A large prospective multicentric medium term study would be necessary in order to confirm or not these results.

[Does nutrition affect the prognosis of aged hemodialysis patients?]. / L'état nutritionnel influence-t-il le pronostic des sujets âgés traités par hémodialyse?

Most authors agree that the prevalence of malnutrition is increased in patients treated by dialysis, particularly in the elderly. Malnutrition is a powerful risk factor for mortality; however, the strong association between nutritional status and mortality does not mean a causal relationship. It has been proposed that nutritional disorders that may occur in dialysis patients are mainly related to two different mechanisms. The first type of malnutrition is associated with a low protein and energy intake due to uremic toxicity, to physical changes and to psychosocial and psycho economic factors frequently found in the elderly. The second type of malnutrition is associated with increased protein catabolism from inflammatory origin. In the later case there are strong interactions between atherosclerotic cardiovascular disease, inflammation and nutritional parameters. Up to now the treatments have aimed at improving nutritional intake by increasing dialysis doses in association with dietary counselling and protein/calories supplementation. Complementary anti-inflammatory therapies acting on the inflammatory component of malnutrition may have a beneficial effect on the outcome of these patients.

[Hemolytic-uremic syndrome complicating a long-term treatment with gemcitabine. Report of a case and review of the literature]. / Syndrome hémolytique et urémique compliquant un traitement au long cours par gemcitabine. A propos d'un cas, revue de la littérature.

INTRODUCTION: Gemcitabine is a nucleoside analog used in solid tumors since 1987. The main side effect is myelosuppression. Acute renal failure with thrombotic microangiopathy has also been reported. We report a new case and suggest to screen for this complication. EXEGESIS: A 71-year-old man with metastatic adenocarcinoma of the pancreas was treated with gemcitabine. He developed episodes of recurred haemolysis followed by haemolytic uremic syndrome. One single haemodialysis session was performed. No other known causes for haemolytic and uremic syndrome were found. Gemcitabine appears to be a new cause of thrombotic microangiopathy. It results from cumulative effects, arises preferentially when there is a renal dysfunction and diagnosis is often delayed. Treatment must be stopped. CONCLUSION: We suggest that reticulocyte count, haptoglobin level and urinalysis could help the clinician to maintain high vigilance and to have a rapid diagnosis for this rare disorder.

No change of hyperleptinemia despite a decrease in insulin concentration in patients with chronic renal failure on a supplemented very low protein diet.

Chronic renal failure (CRF) is often accompanied by hyperleptinemia caused by deficient renal metabolism of leptin and possibly increased leptin production, which in turn may result from the hyperinsulinemia and increased proinflammatory cytokine levels in patients with CRF. The hyperinsulinemia and insulin resistance observed in patients with CRF improve on supplemented very low protein diets (SVLPDs). The goal of our study is to determine whether the correction of hyperinsulinemia and insulin resistance in patients with CRF by SVLPDs is accompanied by improvement in hyperleptinemia. Thirteen patients were studied before and 1 year after following SVLPDs providing 0.3 g/kg/d of protein, supplemented with amino acids and ketoanalogues. After 1 year, patients showed markedly less hyperinsulinemia (7.4 +/- 1.6 versus 13.8 +/- 2 microU/mL at the start of diet; P: = 0.05) and insulin resistance, whereas serum leptin levels remained unchanged (16.1 +/- 4.7 versus 19.1 +/- 7.4 ng/mL at start of the study; P: = not significant). The initial correlation between serum leptin level and percentage of body fat persisted during follow-up. No correlation was found between insulin and leptin levels or between the variation of these two parameters during the study. Our study shows that the correction of hyperinsulinemia and insulin resistance in patients with CRF by SVLPDs is not accompanied by improvement in hyperleptinemia, which consequently does not appear to result from changes in carbohydrate metabolism.

[Acute renal failure after polyvalent immunoglobulin therapy]. / Inuffisance rénale aiguë après cure d'immunoglobulines polyvalentes.

BACKGROUND: Acute renal failure can be induced by intravenous administration of immunoglobulins, especially in patients with a predisposition for nephrotoxicity. The onset and resolution of acute renal failure is typically rapid, but in some cases hemodialysis may be needed. CASE REPORT: We present 2 cases of acute renal failure associated with intravenous immunoglobulin therapy: a 76-year-old man with a history of non-insulin-dependent diabetes mellitus and hypertension and a 77-year-old woman using nonsteroidal antiinflammatory drugs. DISCUSSION: Intravenous immunoglobulins must be used with precaution in patients with risk factors for acute renal failure. In such patients, renal failure may be avoided by using preparations without sucrose.

Outcome of nutritional status and body composition of uremic patients on a very low protein diet.

Concern has been raised about the nutritional adequacy of a very low protein diet (VLPD). Monthly clinical evaluation by a physician and dietitian and quarterly dietary records, anthropometric measurements, blood testing, and dual energy X-ray absorptiometry (DEXA) were used to assess the course of nutritional status for 1 year in 10 clinically stable patients (six men, four women; age, 57.1 +/- 9.3 years) with advanced chronic renal failure (mean glomerular filtration rate, 13.2 +/- 4.8 mL/min/1.73 m(2)). These patients received a VLPD providing 0.3 g/kg/d of protein and were supplemented with amino acids and ketoanalogues. Conventional nutritional markers remained unchanged after 1 year of the VLPD. However, during the same period, whole-body DEXA showed a significant decrease in lean tissue from 46.2 +/- 10.2 to 45.0 +/- 9. 8 kg (P < 0.02); limb-trunk lean tissue ratio was reduced from 0.86 +/- 0.12 to 0.82 +/- 0.12 (P < 0.02), total-body fat increased from 20.0 +/- 6.9 to 21.4 +/- 7.0 kg (P < 0.05), and the percentage of total-body fat increased from 29.2% +/- 8.7% to 31.7% +/- 8.8% (P < 0.03). These different modifications occurred abruptly during the first 3 months, then stabilized or slightly improved thereafter. These mild changes do not appear to be deleterious given the favorable long-term outcome of these patients, even after they began treatment by dialysis or after renal transplantation.

Volume flow measurement in hemodialysis shunts using time-domain correlation.

Volume flow was measured in 58 hemodialysis shunts (32 grafts and 26 radial fistulas) using the color velocity imaging-quantification method. This method is based on time-domain correlation for velocity calculation and integration of time-varying velocity profiles generated by M-mode sampling. Measurements were made in the brachial artery to estimate radial fistula flow or directly in the grafts. Intraoperator reproducibility was 14.9% for fistulas and 11.6% for grafts. Flow rate was significantly lower in abnormal shunts associated with a functional disorder or a morphologic complication (808 ml/min +/- 484) than in shunts associated with no abnormalities (1401 ml/min +/- 562). Receiver operating characteristic curves showed that a flow rate of 900 ml/min for fistulas and 1300 ml/min for grafts provided 81% and 79% sensitivity and 79% and 67% specificity, respectively. A functional disorder or a morphologic complication was associated with all fistulas and grafts in which flow rates were lower than 500 ml/min and 800 ml/min, respectively.

[Spontaneous rupture of the esophagus (Boerhaave syndrome) in a patient with scleroderma treated by continuous ambulatory peritoneal dialysis]. / Rupture spontanée de l'oesophage (syndrome de Boerhaave) chez une patiente sclérodermique traitée par dialyse péritonéale continue ambulatoire.

Esophageal involvement is a common situation found in 50 to 80% of patients with scleroderma, but Boerhaave's syndrome is rare in this context. The authors report the first case of spontaneous esophageal rupture occurring in a chronic renal failure patient treated by continuous ambulatory peritoneal dialysis. In this observation, sclerodermal esophageal dyskinesia, chronic renal failure which is a classical cause of vomiting and the peritoneal dialysis which play an increasing role in the intraabdominal pressure are potential contributing factors to Boerhave's syndrome. In such patients presenting risk factors, even if they are asymptomatic, it seems reasonable to propose esophageal explorations with manometry or/and endoscopy looking for dyskinesia or other complications of gastro-esophageal reflux.

[Rheumatoid purpura in adults. Apropos of 40 cases]. / Purpura rhumatoïde de l'adulte. A propos de 40 observations.

Fourty cases of Henoch-Schönlein purpura in adults (21 females, 19 males--age 39 years) are reviewed [departments of nephrology (28 cases) and internal medicine (12 cases)]. Dermatological manifestations occur in 39 cases and are similar to those seen in children. Gastrointestinal involvement (23 cases) usually takes the form of abdominal pains or diarrhea; gastrointestinal haemorrhages are rare. These symptoms are less severe than in children in this review as in the literature. Joint manifestations (22 cases) disappear without sequelae. The outcome of the disease depends on the nephropathy, present in 33 patients (82.5%) (all of those of the department of nephrology (100%) and 42% of those of the department of internal medicine). In one third of cases, renal manifestation appears after the onset of the disease (until 24 months). As in the children, haematuria and proteinuria are quasi constant. The renal histopathology is a focal and segmental proliferative glomerulonephritis in 58%, with IgA deposition in the mesangium (16/21 cases). Treatment regimen includes steroïds (10 cases), combination of steroïds with immunosuppressive agents (8 cases), steroïds-immunosuppressive drugs-plasma exchange (2 cases), dapsone (1 case). Of the 26 patients followed for 27 months, 11 are in clinical remission, 7 have persistent proteinuria or hematuria, and 8 have chronic renal failure after 3 months to 13 years. In this review, renal insufficiency, hypertension and young age predict a poor outcome. This severe outcome is probably explained by the fact that most of our patients referred to renal units. Unlike in the children, in which the affection is usually an acute illness, Henoch-Schönlein purpura in the adults seems to be a chronic disease, with prognosis depending on the nephropathy.

Improvement in lipid profiles and triglyceride removal in patients on polyamide membrane hemodialysis.

Cardiovascular morbidity and mortality in hemodialyzed patients are increased due to the frequently abnormal lipid metabolism. It has been reported that this abnormal lipid metabolism could be partially corrected by some highly permeable membranes, such as polysulfone or cellulose triacetate. We investigated the influence of 4 months of dialysis with a polyamide membrane upon the course of lipid parameters in 6 patients presenting a hypertriglyceridemia > 2 mmol/l while on bicarbonate dialysis with a cellulose membrane. Lipid parameters improved after 4 months of hemodialysis with a polyamide membrane. Serum triglyceride and cholesterol levels decreased, while HDL cholesterol and HDL levels rose significantly (p < 0.05). Apolipoprotein B decreased significantly (p < 0.05). Following heparin administration, lipoprotein lipase activity improved (p < 0.02), associated with a decrease apolipoprotein C3 (p < 0.05). The fractional clearance rate of triglycerides rose significantly (p < 0.01). The use of highly permeable polyamide membranes results in a significant improvement in lipid disturbances of dialysis patients due to an increased lipoprotein lipase activity, induced perhaps by the removal of circulating inhibitors such as apolipoprotein C3.

[Role of phosphorus in hyperparathyroidism secondary to non-dialysed adult chronic renal insufficiency]. / Le rôle du phosphore dans l'hyperparathyroïdie secondaire de l'insuffisant rénal chronique adulte non dialysé.

Secondary hyperparathyroidism (HPT II) occurs early in the course of chronic renal failure (CRF), mainly because of decreased calcitriol levels, low levels of serum calcium, retention of phosphorus, abnormal parathyroid gland function and hyperplasia, and peripheral resistance to the action of parathormone (PTH). Amongst these factors, phosphorus retention plays a crucial role in moderate and advanced CRF, by inhibiting renal calcitriol synthesis, lowering serum calcium levels and stimulating PTH secretion. In patients with mild CRF, phosphorus restriction prevents the development of HPT II by increasing renal calcitriol secretion. In patients with advanced CRF, the suppressive effect of phosphorus restriction may be obtained independent of any changes in plasma calcitriol levels, suggesting a direct effect of phosphorus on parathyroid function. Phosphorus restriction should be used in the early stages of CRF, together with a sufficient intake of calcium in the form of phosphorus chelating salts. When phosphorus and calcium serum concentrations are normalised but PTH levels are not in the target range, 1 alpha hydroxy vitamin D3 derivatives may be used, with a careful monitoring to avoid high serum levels of phosphorus or calcium.

Clinical evaluation of an optimized 1.1% amino-acid solution for peritoneal dialysis.

A significant percentage of dialysed patients have inadequate protein intake. One strategy for treating the protein malnutrition in peritoneal dialysis patients is to replace glucose in the dialysis solution by amino acids. A new peritoneal dialysis solution containing 1.1% amino acids in a formulation optimized for renal patients and with a lactate concentration of 40 mmol/l has been evaluated. Fifteen CAPD patients completed a non-randomized prospective 3-month study. Each patient received 2 litres of the optimised 1.1% amino acid solution for the second exchange of the day with a dwell time of 5-6 h. Indicators of efficacy were serum albumin and transferrin. After 3 months of intraperitoneal amino acids, serum albumin levels significantly increased from 32.7 +/- 2.3 to 35.1 +/- 2.2 g/l (mean +/- SD; P < 0.01). This occurred in parallel with a significant increase in transferrin levels from 2.21 +/- 0.26 to 2.39 +/- 0.27 g/l (P < 0.05). As expected, urea rose from 23.7 +/- 6.8 to 29.9 +/- 9.4 mmol/l. Interestingly bicarbonate did not change (25.5 +/- 4.2 versus 25.2 +/- 3.3 mmol/l). These results suggest that the optimized formulation is effective in improving nutritional parameters in CAPD patients while avoiding unwanted side-effects such as acidosis.

[Nutrition and continuous ambulatory dialysis]. / Nutrition et dialyse péritonéale continue ambulatoire.

Nearly 50% of patients treated by CAPD develop a more or less severe state of denutrition with which morbidity and mortality are closely linked. Though many biological and biophysical examinations have been proposed to evaluate the nutritional status of patients, it appears that, from a practical standpoint, the information furnished by the medical history, anthropometric parameters, nitrogen balance and serum protein levels are sufficient. The prevention and/or treatment of this malnutrition can only be achieved by correcting the two principal contributing factors which are the reduced energetico protidic supply (especially protidic) and the inadequate dialysis in connection particularly with the progressive loss of the residual renal function.

Correction of chronic metabolic acidosis in haemodialysed patients by acetate-free biofiltration does not influence parathyroid function.

In eight patients remaining acidotic after more than 1 year of bicarbonate haemodialysis, we studied the effect of correcting the chronic metabolic acidosis using acetate-free biofiltration for 4 months on the course of secondary hyperparathyroidism. An AN69 capillary membrane was employed with a bicarbonate infusion rate initially set at 1.8 l/h in all patients and then adjusted in each one to obtain a predialysis bicarbonate of > or = 23 mmol/l. Standard blood chemistry parameters were determined every 2 weeks. Measurements of PTH, calcifediol and calcitriol, as well as calcium-PTH curves were determined at the beginning and end of the study. While acetate-free biofiltration appears to be an adequate technique for the correction of chronic metabolic acidosis when bicarbonate dialysis fails, this study indicates that it does not influence secondary hyperparathyroidism in haemodialysed patients. The level of intact PTH did not vary significantly and the calcium-PTH curves at 0 and 4 months were superimposable with no significant differences in the set point and the slope of the curves.

Evaluation of red blood cell lipoperoxidation in hemodialysed patients during erythropoietin therapy supplemented or not with iron.

To investigate the effects of erythropoietin (rHuEPO) therapy supplemented or not with iron on hemolysis in hemodialysed patients (HD) we evaluated lipoperoxidation (LPO) by assaying (i) the red blood cell (RBC) antioxidant enzymatic system including superoxide dismutase (SOD), glutathione peroxidase, and catalase (Cat), (ii) RBC polyunsaturated fatty acids (PUFA) and (iii) malondialdehyde (MDA). Group 1 included 12 HD patients, group 2 had 7 HD patients with iron supplementation, group 3 comprised 12 HD patients with rHuEPO therapy and group 4 included 9 HD patients with both iron and rHuEPO therapies. No LPO was found in group 1 as regards MDA and PUFA levels. However, SOD and Cat activities were significantly elevated as compared to controls (p < 0.001). In the second group, a significant decrease in PUFA percentage was observed, particularly in 20:4(n-6) and 22:4(n-6) (the main ones involved in LPO) as compared to the other groups, whereas total MDA level was higher than that of the other groups. Similarly a decreased SOD activity was observed as compared to group 1 (p < 0.001), indicating its inactivation subsequent to an hyperproduction of reactive oxygen species through iron injection. In groups 3 and 4 no change was observed in MDA levels or PUFA percentages indicating no LPO. However, marked differences were observed in the enzymatic defense system. Particularly in group 3, SOD and Cat activities decreased when compared to group 1 (p < 0.001) whereas the association of erythropoietin and iron (group 4) increased the three enzymatic activities (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)