[Central venous stenosis: review of the literature from 1980 to 2000]. / Les sténoses des veines centrales: revue de littérature de 1980 à 2000.

Publications of central veins stenoses were still frequently related though improvements of the catheter quality and the catheterism procedures since the 1980's. The review of the literature during the period of 1980-2000 helped us in observations as following: Global incidence was 15.6% in subclavian vein stenoses (SVSC), 2.7% in jugular stenoses (SVJ) and 0-3.8% in femoral stenoses (SVF). The "non-symptomatic" SVSC, detected by Venograms, represented only 23-33% of all SVSC publications but they showed higher incidence in the patients than "symptomatic" SVSC: 41% versus 3.3% just as for non-symptomatic SVJ: 9% versus 1.6% in symptomatic SVJ. Venograms with "in-arm-injections" mostly used by authors should underevaluated the incidence of SVJ. Mecanisms were betterly detailed with SVSC than SVJ and SVF (Catheter quality, venous lesions by portions and artérialisation by fistulas, anatomic constraints of the subclavian vein in the triangle space behind the clavicular, fibrin sleeve, thrombus and microtraumatism of the Veins walls...). Global results of the treatment, though improvement with angioplasty-Stent, remained disappointing by early recurrences. Worsened dialysis adequacy and life quality of the patients should be the issues. The number of the catheters currently used in temporary accesses, including the subclavian veins, and in permanent accesses was still higher than DOQI/NKF recommendations. Anticipated creations of Fistulas should be one efficient prevention.

Mobilization of lead from bone in end-stage renal failure patients with secondary hyperparathyroidism.

BACKGROUND: It is now recognized that long-term exposure to even low levels of lead may increase bone lead content. Lead can then be released in toxicologically significant amounts during critical states of increased bone turnover. METHODS: Two patients with end-stage renal failure, one on haemodialysis and the other on continuous ambulatory peritoneal dialysis (CAPD), had been exposed to lead and developed secondary hyperparathyroidism. An edetate calcium disodium (EDTA) test was performed in combination with haemofiltration or CAPD before and after parathyroidectomy. RESULTS: Before parathyroidectomy, both patients had low delta aminolaevulinic acid dehydrase (ALA-D) and high concentrations of chelated lead. After parathyroidectomy, there was a dramatic decrease in chelated lead and the ALA-D returned to normal. CONCLUSION: Secondary hyperparathyroidism increases mobilization of bone lead in dialysis patients with an elevated lead burden. This may cause toxic effects.

IgA nephropathy: prognostic classification of end-stage renal failure. L'Association des Néphrologues de l'Est.

BACKGROUND: As yet, no clinical or morphological prognostic classification of IgA nephropathy (IgAN) has been generally accepted. The objective of our study was to quantify the risk of developing end-stage renal failure (ESRF) in IgAN. METHODS: We report a prospective longitudinal study of 210 patients with IgAN confirmed by biopsy between 1987 and 1991. Thirty-two (15.2%) patients were lost to follow-up. Mean follow-up after renal biopsy was 5.6 (SD = 2.6) years. The variables included age, gender, illnesses prior to discovery of IgAN, clinical features at IgAN discovery, 24-h proteinuria, serum creatinine, IgA level, and antihypertensive drugs taken at the time of renal biopsy. Sixty-six renal biopsies were classified by light-microscopy according to Lee's morphological classification. The end-point was ESRF. Survival was analysed by a backward and forward stepwise procedure using the Cox model. The most accurate determination of relative risk was obtained by assessing collinearity of the variables. RESULTS: Thirty-three patients (15.7%) (31 men) developed ESRF. The five univariately significant variables: gender, gross haematuria, 24-h proteinuria (24-P), serum creatinine (SC), and antihypertensive treatment, were candidates for multivariate analysis. The final model used SC (< or = 100, 100-150, > 150 mumol/l), 24-P (< 1, > or = 1 g/day) and gender (female vs male) as independent variables (relative risk and 95% confidence interval were 3.5 (2.1, 5.9) for SC; 5.1 (1.9, 13.6) for 24-P; and 3.5 (0.9, 15) for gender). These estimates were used to construct a prognostic classification of ERSF for men with IgAN: stage 1 (SC < or = 150 mumol/l and 24-P < 1 g/day), stage 2 ((SC > 150 mumol/l and 24-P < 1 g/day) or (SC < or = 150 mumol/l and 24-P > or = 1 g/day)); stage 3 (SC > 150 mumol/l and 24-P > or = 1 g/day). The ESRF-free survival was estimated with Kaplan-Meier analysis. It was 98.5% for stage 1, 86.6% for stage 2, 21.3% for stage 3 (P < 0.001), 7 years after histological diagnosis. The validity of Lee's prognostic classification was confirmed using an independent sample. CONCLUSIONS: These classifications identify groups at high risk of ESRF. Therapeutic studies should focus on these groups.

Renal transplantation in patients over sixty years of age.

The aim of this study was to analyze whether old age affects the outcome of renal transplantation. Data were presented on all 337 renal allografts performed from January 1, 1987 to November 30, 1992 in the department of Nephrology and Urology, University Hospital of Nancy. Of these, 32 (9.5%) were performed in patients over 60 years old at the time of transplantation (mean duration of follow-up 22.3 +/- 17.1 months). No significant difference was noted in patient and graft survivals between the two groups at 36 months (respectively 83.8% and 76.1% in elderly patients; 96% and 82.8% in younger recipients). In the older group, all grafts were lost due to death (2/5) or nephrectomy (3/5) with a functional transplant (3/5) whereas chronic rejection accounted for the majority of graft loss in the younger group (23/43, p < 0.05). Episodes of acute rejection occurred with a very low incidence in elderly patients (15.6%). Infections were infrequent in this group and did not represent serious complications. Functional rehabilitation and quality of life were as good in elderly as in younger recipients. These results suggest that renal transplantation is an acceptable form of treatment for patients older than 60 years with end-stage renal disease in the absence of obvious contraindication.

[Endothelin and kidney]. / Endothéline et rein.

Endothelial and epithelial cells release a potent 21-residue peptide, endothelin (ET) which is an endothelium-derived-contracting-factor (EDCF). The peptide causes contraction of vessels and induces sustained blood pressure elevation. Beside its role in the vasoconstriction ET has strong inotropic effect on the myocardium and induces smooth muscle cells contractions. Renal actions, similar to angiotensin and norepinephrine, focus on its potential importance in nephrology. Acute and chronic renal failure showed increased plasma and urinary ET levels. An understanding of the regulation of the release of ET may provide knowledge about the pathogenesis of acute renal failure, the progression of chronic renal failure and cyclosporin A induced toxicity. Further research is needed to substantiate the new and promising perspective of ET in human diseases and therapy.

Acquired renal cystic disease mimicking adult polycystic kidney disease in a patient undergoing long-term hemodialysis.

Acquired renal cystic disease (ARCD) is defined as the development of multiple cysts in the renal cortex and medulla in patients with chronic renal failure who are free from congenital polycystic kidney disease. ARCD develops generally in contracted kidneys. We report a case of grotesque enlargement of a single kidney in a patient who had been receiving hemodialysis for 18 years. Although the exact causes of ARCD are not known, 3 factors may contribute to the development of nephromegaly; the sex, the duration of hemodialysis and previous unilateral nephrectomy. As in polycystic disease, when the involved kidney reaches considerable size, ARCD may have a favorable effect on anemia caused by chronic renal failure.

[Is enoxaparine (PK 10169) a good anticoagulant in chronic hemodialysis?]. / L'énoxaparine (PK 10,169) est-elle un bon anticoagulant dans l'hémodialyse itérative?

Tolerance and efficacy of single i. v. injections of PK 10169 (1 mg/kg) during installation were evaluated in 10 patients with stable chronic renal insufficiency treated with 3 sessions of hemodialysis weekly (sessions of 4 and 5 hours). Tolerance was good in all cases. Efficacy was globally satisfactory (no complete coagulation) but by the 4th hour in 7 out of 30 sessions coagulation was apparent in the bubble trap with elevation of residual blood volume, recurring in the same patient but not affecting result of dialysis. In these cases anti-Xa activity was reduced from the 2nd hour and at end of dialysis, with a markedly elevated FPA level. For most patients it is possible to envisage 5-hour sessions, but in those few susceptible to develop coagulation repeated clinical surveillance of all circuit elements is necessary.