[Contribution of clinical biology in the etiological exploration and follow-up of urolithiasis]. / Apport de la biologie clinique dans l'exploration étiologique et le suivi de l'urolithiase.

Urolithiasis is a frequent pathology with a constantly increasing prevalence in industrial countries. The relapse frequency is around 50 % with a risk of complications. The laboratory input is essential in the determination of the etiology and in the therapeutic monitoring. The morphoconstitutional analysis of the stone is the most important element. It comprises the examination of the stone with binocular loupes and the simultaneous analysis of its crystalline composition. This can be done by different techniques but infrared spectrophotometry is the most powerful. The chemical analysis should be definitely proscribed. The analysis of crystalluria includes the search, the identification and the counting of crystals in fresh morning urines. It is useful for the diagnosis and for the patient follow-up. Finally, the biochemical analyses in urine and serum, in first line or on the basis of the stone composition, are an important part of the etiological exploration and therapeutic monitoring.

[Twenty years of research in the field of haemodialysis: the contribution of the Nephrology Department of Erasme Hospital]. / Vingt ans de recherche dans le domaine de l'hémodialyse: la contribution du Service de Néphrologie de l'Hôpital Erasme.

This article summarizes the contribution of the Department of Nephrology, Dialysis, and renal Transplantation to the research in the field of haemodialysis during the last twenty years. The most important contributions are devoted, on the one hand, to the infections and immune defenses of the dialysis patient, on the other hand, to the biocompatibility of the materials used for haemodialysis and to the adverse reactions of the patient to these materials.

[Experimental nephrology unit: overview and research projects]. / Unité de néphrologie expérimentale facultaire: etat des lieux et projets d'avenir.

After a short historical background of the Laboratory, the main research topics--renal toxicology, physiopathology of renal interstitial fibrosis and hormonology--are described in the perspective of a partnership between research clinicians and full time scientists. National as well as international scientific collaborations underline the need of combining expertises, stimulating also the training of youngest colleagues to the experimental approach of their future discipline.

Renal hematoma in a patient undergoing hemodialysis. Complication of acquired renal cystic disease.

A spontaneous renal hematoma developed in a patient treated by long-term intermittent maintenance hemodialysis. This scanty complication of hemodialysis was related to the recently described acquired cystic disease of the kidneys. Diagnosis was ascertained before nephrectomy by computed tomography and selective renal angiography.

Long-term results of subcutaneous parathyroid grafts in uremic patients.

HYPOTHESIS: Parathyroid glands are normally surrounded (entirely or partially) by fatty tissue. Subcutaneous parathyroid grafts are thus located in a normal environment. Therefore, we postulated that the late results of subcutaneous implantation of parathyroid tissue in uremic patients should be at least as good as those reported for intramuscular grafting. We also challenged the idea that the recurrence rate of renal hyperparathyroidism after surgery depended solely on the type of hyperplasia (diffuse vs nodular) observed in the implanted tissue. DESIGN: A retrospective study of a series of patients without loss to follow-up. SETTING: A university hospital and 9 affiliated dialysis units. PATIENTS AND INTERVENTIONS: Fifty-nine patients (33 women and 26 men) operated on for renal hyperparathyroidism underwent the resection of at least 4 parathyroid glands followed by presternal subcutaneous implantation of parathyroid tissue. They were followed up for 12 to 130 months (median, 38 months). MAIN OUTCOME MEASURES: Failure of treatment, recurrence of disease, and hypoparathyroidism. RESULTS: During the study period, 9 patients had to undergo another operation: 2 (3%) for persistent hyperparathyroidism due to a fifth ectopic gland and 7 (12%) for recurrence of hyperparathyroidism resulting from hypertrophy of the subcutaneous grafts. Four patients received a kidney transplant. The prevalence of hypoparathyroidism (intact parathyroid hormone serum level <1.6 pmol/L with a normal or low serum calcium concentration) was 14% (8 of 59 patients), and the curve representing the distribution of intact parathyroid hormone serum concentrations among operated on patients was shifted to the left when compared with the curve of patients who underwent hemodialysis and who had no indication for parathyroid surgery. In this latter group, the peak of the curve was situated between 1 and 2 times the upper normal limit, while it was in the normal range 12 to 130 months after total parathyroidectomy and subcutaneous parathyroid autotransplantation. No relation was observed between the recurrence rate of the disease and the histological characteristics of the parathyroid grafts. Also, their function was not influenced by the presence or absence of aluminum deposits in bone biopsy specimens that were obtained at the time of cervical exploration. CONCLUSIONS: The late results of total parathyroidectomy and presternal subcutaneous grafting compare favorably with the published data on other surgical techniques proposed for the treatment of renal hyperparathyroidism. The ease with which the hypertrophied grafts are removed when the disease recurs warrants further use of this procedure.

Campylobacter fetus peritonitis followed by septicaemia in a patient on continuous ambulatory peritoneal dialysis.

A 62-year-old man being treated by continuous ambulatory peritoneal dialysis (CAPD) developed peritonitis due to Campylobacter fetus subspecies fetus (intestinalis), an organism seldom isolated in such circumstances. After appropriate and apparently effective antibiotic therapy, the patient relapsed 6 weeks later with septicaemia. Blood cultures yielded a similar organism, thereby suggesting a clinically silent metastatic infection during the episode of peritonitis, probably at an old arteriovenous fistula. Parenteral tobramycin followed by oral erythromycin achieved a complete cure of this unusual complication.

Efficacy of oral immunotherapy on respiratory infections in hemodialysis patients: a double-blind, placebo-controlled study.

BACKGROUND: Hemodialysis (HD) patients suffer from several immune defects that make them prone to develop bacterial infections, in particular respiratory tract infections (RTIs). PATIENTS AND METHODS: As previous studies have shown that oral immunotherapy with an immunomodulating bacterial extract (IBE) is effective against RTIs, we decided to test its efficacy and safety in HD patients during a double-blind placebo-controlled prospective study. 40 HD patients with a documented history of RTIs in the previous year were treated for 24 weeks of the endemic season with one capsule daily of IBE (n = 21) or placebo (PL, n = 19). Clinical examinations, measurements of Mac-1 and gp150.95 on circulating phagocytes and routine laboratory evaluations were performed at week 0, 4, 12 and 24. Patients were also examined at each dialysis session allowing an accurate recording of any infectious episode, its treatment and of any untoward effect. RESULTS: During the last period of the study (weeks 13-24), IBE significantly reduced the number of patients with RTIs and consequently of antibiotic treatment courses as compared to PL (p = 0.018), whereas no difference was detected between IBE and PL during periods I (weeks 0-4) and II (weeks 5-12). There was no difference between IBE and PL for other, non respiratory infections. IBE was associated at several time points with an increased expression on phagocytes of adhesion molecules involved in phagocytosis (Mac-1 and gp150.95). However, the expression of these molecules was not predictive for the occurrence of RTI. IBE was on the whole as well tolerated as PL, 7 patients presented side effects (5 IBE, 2 PL, NS) which led to drop-out in 4 cases (3 IBE, 1 PL). No serious side effect was recorded, gastrointestinal upset being the most prevalent type. CONCLUSION: The results of this study indicate that immunomodulation with selected bacterial extracts constitutes a promising approach for the prevention of bacterial airway infections in groups at risk, such as HD patients.

Improvement of anemia with deferoxamine in hemodialysis patients with aluminum-induced bone disease.

As microcytic anemia is a feature of aluminium intoxication, we prospectively studied the hematologic effects of deferoxamine in 10 hemodialysis patients with aluminum-induced bone disease. Comparing the mean monthly results of a 4 month period before and during deferoxamine therapy, we observed an important decrease of the transfusion needs (alpha less than 0.025) and an increase of hematocrit (p less than 0.02), hemoglobin (p less than 0.02), MCV (p less than 0.02) and MCH (p less than 0.05); the number of red blood cells remained unchanged. Our results show that deferoxamine treatment of dialysis patients with aluminum bone disease can markedly improve their anemia, even in the absence of recent aggravation, microcytosis and hypochromia. They also suggest that aluminum could participate in the anemia of dialysis patients even if it is normocytic.

Adhesion molecules and leukocyte common antigen on monocytes and granulocytes during hemodialysis.

As contact of blood with artificial membranes may activate cell adhesiveness, we investigated in 5 patients the expression of several adhesion-promoting molecules on monocytes and granulocytes during hemodialysis on cuprophane (CU), cellulose acetate (CA), and polyacrylonitrile (PAN) membranes. After staining with specific fluorescent monoclonal antibodies, flow cytometric analysis was performed to evaluate the expression of CD11b (= Mac 1, CR3, or C3bi receptor), CD11a (= leukocyte function antigen 1 or LFA-1, or gp 180/95), CD54 (= intercellular adhesion molecule 1 or ICAM 1), and CD45 (= leukocyte common antigen) on circulating leukocytes. Granulocytopenia occurred at 15 minutes with CU and CA but not with PAN; significant monocytopenia occurred on the contrary with all 3 membranes. The drop in monocyte counts was maximal at 15 minutes on CU and CA, and at 180 minutes on PAN; it was also more important with CU (88 +/- 2.6%, alpha = 0.005) and CA (66.4 +/- 4.1%, alpha = 0.01) than with PAN (36.2 +/- 6.2%). Hemodialysis on CU, CA, and PAN was associated with a 2- to 3-fold CD11b and CD45 overexpression on peripheral monocytes; these molecules also increased on circulating granulocytes but to a lesser extent on PAN than on CU and CA (alpha < 0.05). There were no hemodialysis-induced changes in CD11a and CD54 expression on circulating monocytes or granulocytes. The upregulation of CD11b may provide a molecular mechanism for the sequestration of monocytes and granulocytes in the circulation during hemodialysis, while upregulation of CD45 might reflect mechanisms regulating the leukocyte activation state.(ABSTRACT TRUNCATED AT 250 WORDS)

Lipid and apoprotein changes during atorvastatin up-titration in hemodialysis patients with hypercholesterolemia: a placebo-controlled study.

BACKGROUND: Patients with end-stage renal disease commonly present with an atherogenic lipid profile characterized by the accumulation of triglyceride-rich, apoprotein B-containing "remnant" lipoproteins, small dense low-density lipoprotein, and low levels of high-density lipoprotein. They are at increased cardiovascular risk and may benefit from drastic lipid-lowering treatment with atorvastatin, a potent, broadacting lipid regulator. This study aims to assess the effects of atorvastatin on the lipid profile in hemodialysis patients, to determine wether atorvastatin is also effective at lowering lipid levels in this particular high-risk subgroup. METHODS: In this randomized, placebo-controlled, double-blind study in hemodialysis patients with hypercholesterolemia (n = 42, mean total cholesterol 243 +/- 33 mg/dl (6.3 +/- 0.8 mmol/l)), the efficacy of 4-weekly increasing doses of atorvastatin (10 - 40 mg daily) was investigated. Lipids and apoproteins were measured in plasma and isolated lipoprotein fractions. RESULTS: Mean total cholesterol and low-density lipoprotein cholesterol progressively decreased with increasing doses of atorvastatin (total cholesterol -33%, low-density lipoprotein cholesterol -43% after 12 weeks), while high-density lipoprotein cholesterol remained unchanged. Plasma levels of apoprotein B and apoprotein E were also significantly reduced by atorvastatin 10 mg, while up-titration to 20 and 40 mg daily provided additional benefits by lowering triglycerides and apoprotein C-III. At week 12, the fraction of small dense low-density lipoprotein was significantly reduced from 23% - 18%, and apoprotein B-containing intermediate-density lipoproteins were no longer detectable. CONCLUSION: In conclusion, atorvastatin not only treated hypercholesterolemia but also favorably affected the uremic lipid profile in patients on hemodialysis. Atorvastatin 4-weekly dose escalation up to 40 mg daily was well-tolerated. Further prospective studies are needed to evaluate the impact of this improved lipid profile on morbidity and mortality.

[Renal complications of diabetes]. / Complications rénales du diabète.

Many diabetic patients will develop a nephropathy that will eventually result in end-stage renal failure. The early stage ("incipient") of diabetic nephropathy generally appears after 5 to 20 years of diabetes and is characterized by microalbuminuria (30 to 300 mg/day), which is only detectable by sensitive radio-immuno-enzymatic methods. When a frank proteinuria develops (> 500 mg/day), the glomerular filtration rate inexorably declines, resulting in terminal renal failure after several years. The onset of microalbuminuria or the elevation of blood pressure (above 120-140/80 mmHg) are predictive of a poor evolution and require appropriate preventive therapeutic interventions. These include an optimal control of hyperglycaemia, dietary proteins and salt restriction, and prescription of anti-hypertensive drugs, with a particular benefit ascribed to angio-tension converting enzyme inhibitors (and maybe to certain calcium channel blockers). These interventions have been proven efficient to prevent or slow down the evolution of diabetic nephropathy.

[Anti-neutrophil cytoplasmic antibodies (ANCA): major progress in the diagnosis of vasculitis]. / Les anticorps anti-cytoplasme des neutrophiles (ANCAs): un progrès majeur dans le diagnostic des vasculites.

ANCA antibodies represent a family of autoantibodies directed against neutrophil enzymes. Immunofluorescence patterns allow to distinguish c-ANCAs from p-ANCAs. The detection of ANCAs is often a key element for the diagnosis of Wegener's granulomatosis, microperiarteritis, Churg-Strauss syndrome and idiopathic rapidly progressive glomerulonephritis. Although the pathogenic role of ANCAs is not firmly established, their detection often allows an early therapeutic decision in necrotizing vasculitides.

[The medico-surgical department of nephrology dialysis and renal transplantation]. / Le département médico-chirurgical de Néphrologie Dialyse et Transplantation Rénale.

The Department of Nephrology of the Hospital Erasme, opened 25 years ago, is now performing, each year, 22,000 hemodialysis sessions, 800 patient-weeks of peritoneal dialysis treatment and 70 renal grafts. Scientific contributions of the department deal with vascular access for hemodialysis, susceptibility to infections of dialyzed patients, parathyroid surgery, biocompatibility of dialysis membranes, predictive factors of renal graft survival, immunosuppression with monoclonal antibodies, experimental studies of graft tolerance and rejection, toxic nephropathies. The most original contributions are related to anaphylactoïd reactions in hemodialysis by association of acrylonitrile membranes with inhibition of the converting enzyme, to advantages and side effects of OKT3 monoclonal antibody and to discovery and study of the Chinese herbs nephropathy.

[Investigation plan for acute kidney failure]. / Plan d'investigation d'une insuffisance rénale aiguë.

Acute renal failure often has a complex origin, especially in critically ill patient. Moreover, the tools for investigation of renal failure are generally unspecific, so that the work-up must be based on several elements. It is particularly important to differentiate failure of the kidney itself from prerenal or postrenal failure, since the therapeutic implications are very different. We propose to base the investigation of acute renal failure on some elements to be evaluated in a rapid succession. The complete evaluation should also take into account the consequences of renal failure, which also have therapeutic implications.

Complement factor H functional assay may help to monitor atypical haemolytic uraemic syndrome: a pilot study.

BACKGROUND: Atypical haemolytic uraemic syndrome (aHUS) results from uncontrolled complement system activation. Complement factor H gene mutations are common causes of aHUS. Plasmatherapy, including plasma infusions and/or plasma exchanges, has been tried in this setting with various successes. At present, we lack a specific marker to monitor functional factor H deficiency-related aHUS. METHODS: We report the use of factor H functional assay in three patients with atypical haemolytic uraemic syndrome. This assay is based on the requirement of soluble complement regulators that bind sheep red cells to prevent haemolysis. As factor H is highly abundant in the plasma, its defect results in haemolysis. Factor H activity was also measured among plasma donors. RESULTS: One patient suffered from a plasma-dependent form of atypical haemolytic uraemic syndrome. Plasma exchanges restored higher factor H activity and were associated with a 15-months disease-free period. In the two other patients, one with a failing renal graft and the other on chronic dialysis, a bout of thrombotic microangiopathy was preceded by a drop of haemolytic activity below normal values. Plasma from healthy donors (N=65) showed only minimal variations of Factor H activity (mean activity: 98.3%, SD=4.0). CONCLUSION: These preliminary data suggest that factor H activity could be of interest in both the diagnosis and the treatment by plasmatherapy of factor H-related aHUS.

Pre-terminal renal insufficiency in a patient with enteric hyperoxaluria: effect of medical management on renal function.

Enteric hyperoxaluria causes tubular deposition calcium oxalate crystals and severe chronic interstitial nephritis. We describe a patient with pre-terminal renal failure due to oxalate nephropathy after ileal resection. Increased oral hydration, low oxalate diet, and oral calcium carbonate and potassium citrate supplements resulted in a significant improvement of renal function. During the three-year follow-up, urinary oxalate concentration was repeatedly reduced below the crystallization threshold and serum creatinine decreased from 4.5 to 1.7 mg/dL. This case illustrates the benefit of combining and optimizing dietary and medical management in enteric hyperoxaluria, even in patients with advanced chronic kidney disease.