Risk of heparin lock-related bleeding when using indwelling venous catheter in haemodialysis.

BACKGROUND: The indwelling venous catheter such as Dual-Cath or Twin-Cath is widely used in haemodialysis. Although the manufacturer recommends filling the catheter lumen with heparin after the dialysis session to prevent clotting, little is known about the systemic effects of such a procedure. METHODS: Twenty haemodialysis patients with Dual-Cath were studied. Dialysis anticoagulation was achieved by injecting a bolus of dalteparin. The patient/control ratio of activated partial thromboplastin time (aPTT) was determined at the end of the session immediately before and 10 min after locking with 2 ml of undiluted heparin (10,000 U/catheter). We also determined the catheter volume for each patient and measured aPTT immediately before and 10 min after heparin locking with this patient-specific volume. Catheter patency was followed over a 2-week period. RESULTS: The aPTT values determined at the end of two consecutive dialysis sessions were nearly normal, respectively 1.29 (+/-0.17) and 1.33 (+/-0.22), whereas all patients had uncoagulable blood (aPTT >3.75) 10 min after locking with 2 ml of heparin. When catheter volumes were individually calculated, they were found to be substantially lower than 2.0 ml (1.21+/-0.12 for the arterial branch and 1.27+/-0.13 for the venous branch). aPTT was only 2.42+/-0.73 10 min after locking with the estimated volumes except in one patient (aPTT >3.75). No catheter clotting was observed despite these smaller locking volumes. CONCLUSIONS: A risk of inducing serious bleeding does indeed exist with Dual-Cath heparin locking, especially in postoperative patients. This risk can be reduced by measuring catheter length at the time of placement in order to ensure an appropriate lock volume. Sodium citrate, polygeline, or urokinase are possible alternatives to heparin.

Factors predicting the long-term success of maintenance cyclosporine monotherapy after kidney transplantation.

BACKGROUND: The theoretical aim of maintenance cyclosporine monotherapy (mCsA) after kidney transplantation is to reduce the incidence of the metabolic complications of corticosteroids and to minimize the adverse effects of excessive long-term immunosuppression. This study was performed in low-immunological-risk cadaveric kidney transplant recipients to evaluate the risks and benefits of mCsA and the long-term graft survival, and to determine the factors predicting success of this policy. METHODS: The multicenter retrospective study was conducted in 329 Caucasian patients receiving mCsA out of 728 first cadaveric kidney transplant recipients. The inclusion criteria were: HLA antibodies < or =25%, serum creatinine <200 micromol/L, and no rejection or only one rejection episode. At the end of the study, we compared the group of patients successfully treated with mCsA (successful group) with those requiring additional immunosuppressive agents (unsuccessful mCsA group). RESULTS: Overall patient and graft survival rates for the 728 first cadaveric graft were 92% and 64%, respectively, at 8 years. Out of 329 patients enrolled in mCsA, 240 were maintained on this treatment and 89 were withdrawn (3 deaths, 18 graft losses, 68 functional grafts). The 8-year graft survival in the 329 enrolled mCsA patients was 84%, 95% in the successful mCsA group, and 70% in the unsuccessful mCsA group. Multivariate analysis showed that the factors predicting success of mCsA were: donor age <40 years (P = 0.001), serum creatinine at mCsA initiation <125 micromol/L (P = 0.02), no rejection episode before mCsA initiation (P = 0.005), and glomerulopathy as the primary renal disease (P = 0.001). CONCLUSION: Numerous kidney transplant recipients with a low immunological risk and good and stable renal function may benefit from discontinuation of prednisone and azathioprine in order to reduce the complications related to these drugs. This therapeutic approach had no adverse impact on the overall long-term graft survival for "low risk" and successful patients.

[Lymphoproliferative syndromes after renal transplantation]. / Syndromes lymphoprolifératifs après transplantation rénale.

UNLABELLED: Following kidney transplantation, lymphoproliferative disorders (LD) are encountered at a frequency of 1%. The onset of these LD is correlated with the degree of immunosuppression. The mortality is elevated (> 50%) especially in late forms. Since 1984 we have performed two hundred and seventeen kidney transplantations. The patients received sequential quadruple-drug immunosuppressive therapy: antilymphocyte globulin (ALG), azathioprine, corticosteroids and cyclosporine. A diagnosis of LD was established in ten patients, four were of early onset (within twelve months of transplantation) and six late (after five to nine years). Rejection occurred in two patients, one of which was steroid resistant requiring ALG. Three LD arose from the graft hilum, four had a voluminous tumor mass with extranodal sites: the graft (1), stomach (2), gingiva (1), meninges (1), and bone marrow (1). Histologically there were eight cases of large-cell B lymphoma, 1 mononucleosis-like LD, and a MALT lymphoma. A search for EBV was positive seven times. Treatment consisted of decreasing immunosuppressive therapy only (1), combined with antiviral treatment (1), or with surgical removal of the graft (3), and/or chemotherapy (5). Nine patients are still alive, in complete remission, graft loss occurred in four cases. CONCLUSION: In our series, we found a high frequency of LD. Despite 4 LD with a voluminous tumor mass and unfavorable histological prognosis requiring chemotherapy, all the LD in our series had a favorable outcome.

Successful surgical management of a ruptured abdominal aortic aneurysm in a renal transplant patient. A case report.

With extended indications for renal transplantation and increasing survival, it can be expected that atherosclerotic vascular disease in the post-transplant patient will become more frequent. The authors report a case of a ruptured abdominal aortic aneurysm in a renal transplant recipient. A temporary axillo-femoral shunt was used to maintain perfusion of the renal graft during aortic cross-clamping. They review the literature and discuss the available methods for preserving renal function.

Maintenance cyclosporin monotherapy after renal transplantation--clinical predictors of long-term outcome.

BACKGROUND: There is considerable debate about whether maintenance cyclosporin (CsA) monotherapy is advisable or not in renal transplantation. METHODS: Between August 1984 and December 1989, 463 adult patients received a first cadaver graft. Initial immunosuppression was sequential: antilymphocyte or antithymocyte globulins (10-14 days), prednisone and azathioprine were combined and CsA was introduced (6-8 mg/kg/day) when the antilymphocyte or antithymocyte globulins were discontinued. When the graft function was stable and the peak of preformed lymphocytotoxic antibodies was < or = 25% and/or the number of rejection episodes was < or = 1, the steroid therapy was stopped within 1.5-3 months after transplantation, and azathioprine within 3-12 months. Patients with both anti HLA antibodies > 25% and more than one rejection episode were excluded. Cyclosporin doses were adapted for whole-blood trough levels between 100 and 200 ng/ml (monoclonal antibody radioimmunoassay or high-performance liquid chromatography). Cyclosporin monotherapy was attempted in 234 of the 463 patients. RESULTS: At the end of the investigation in January 1993 (follow-up time > 36 months, mean 60.5 +/- 4.5 months), 135 patients were receiving CsA without steroids or azathioprine. The 99 CsA monotherapy failures were due to rejection episodes in 48 cases, CsA A nephrotoxicity in 26 cases, and other causes in 25 cases, including five deaths and four with poor compliance. Renal function was stable in patients with successful CsA monotherapy: mean creatininaemia was 124 +/- 10 mumol/l at the time of CsA monotherapy inclusion and 129 +/- 10 mumol/l at the end of follow-up (mean time of CsA monotherapy 52 +/- 6 months). The parameters for predicting monotherapy success were age (43.2 versus 37.8. P = 0.0014), timing of trial inclusion > or = 6 months post-transplant (7.9 +/- 3 versus 5.3 +/- 3.1 months, P = 0.04), and excellent and stable renal function at the time of inclusion (124 +/- 10 versus 145 +/- 32 mumol/l, P < 0.001). CONCLUSIONS: Maintenance CsA monotherapy was effective in 58% of low-immunological-risk first-graft patients and probably did not jeopardize overall results of our first grafts: patient and graft survival were respectively 90 and 73% at 6 years. We propose this policy to avoid long-term complications of glucocorticoid and azathioprine in selected compliant recipients with low immunological risk, follow-up time post-transplantation > 6 months, and stable creatininaemia levels.

[Treatment with cyclosporin A, with low doses, in high-risk penetrating keratoplasties. A bi-centric study of 90 cases]. / Traitement par ciclosporine A, à doses faibles, dans les kératoplasties transfixiantes à haut risque. Etude bicentrique de 90 cas.

PURPOSE: Evaluation of cyclosporin-A in prevention of immune reaction in high-risk penetrating keratoplasties. MATERIAL AND METHODS: Cyclosporin A was given to 45 corneal allograft recipients, 5 mg/kg/j (cyclosporinemy between 100 and 150 ng/l), for three months following surgery. 45 controls have undergone penetrating keratoplasty during the same period. Mean follow-up was respectively 431 days and 402 days. Survival was analysed according to Kaplan-Meier's method, and then using Cox model. RESULTS: The significant predictive factors were the number of neovascularized quadrants, and the graft diameter. No significant effect of cyclosporin is evidenced. Side effects are marginal. CONCLUSION: Three hypothesis may explain the absence of prognosis improvement in the Cyclosporin A treated group: insufficient dose or duration of treatment, individual risk factors that prevents correct pairing, or corneal-specific immunological mechanisms.

Acquired ichthyosis and pyoderma gangrenosum in a patient with systemic lupus erythematosus.

A 25-year-old woman who was 20 weeks pregnant developed systemic lupus erythematosus with acquired ichthyosis and pyoderma gangrenosum. The course of these dermatoses suggests that an immunopathological mechanism was implicated in their pathogenesis.

[Type IV Ehlers-Danlos syndrome disclosed by acute obstructive renal insufficiency]. / Un syndrome d'Ehlers-Danlos de type IV révélé par une insuffisance rénale aiguë obstructive.

A 64 year-old man was admitted for congestive heart failure induced by an acute renal failure due to obstruction. Retroperitoneal periaortic-aneurysmal fibrosis was the etiology of the obstruction. Type IV Ehlers-Danlos syndrome was diagnosed based upon clinical and histological cutaneous signs.

Hypokalemic quadriplegia and respiratory arrest revealing primary Sjögren's syndrome.

We report a case of hypokalemic flaccid quadriplegia with sudden respiratory arrest in a 38-year-old woman discovered to have distal renal tubular acidosis which lead to the diagnosis of primary Sjögren's syndrome. This case is compared to 8 similar cases previously described in the literature.

Prophylactic use of a monoclonal antibody (33B3.1) directed against interleukin 2 receptor following human renal transplantation.

33B3.1, a rat IgG2a monoclonal antibody (MAb) directed against interleukin 2 receptor, has been given in association with prednisone and azathioprine to prevent rejection in 30 recipients of a primary cadaveric kidney transplant. The MAb 33B3.1 had been administered intravenously (IV) at 10 mg per day for 2 weeks. Clinical and biological tolerance were excellent. Only one patient had a rejection episode (reversible) during the MAb treatment period. These results were significantly better than those recorded from a historical group of patients that received only prednisone and azathioprine, and were similar to those from patients who received antithymocyte globulin instead of 33B3.1. There was no life threatening infectious episode and all patients are alive. Ninety-seven percent of the patients have a functional graft (follow-up, 30 to 210 days). Enzyme-linked immunosorbent assay (ELISA) of 33B3.1 indicate that circulating trough blood level peaked at day 6 (30 nm). The majority of patients (85%) developed either IgG or IgM antibodies with a maximal response at day 24 for both isotypes. We conclude that this new treatment that targets a functional receptor present on activated lymphocytes only, is well tolerated and highly efficient in preventing early rejection after human renal transplantation.

Prevention of rejection of kidney transplants by monoclonal antibody directed against interleukin 2.

The effect of 33B3.1, a rat IgG2a monoclonal antibody (MAb) directed against interleukin 2 receptors on activated T lymphocytes, was studied during the first two weeks after transplantation in an attempt to prevent rejection in primary, cadaveric, kidney transplant recipients. 9 patients received 5 mg 33B3.1 daily by intravenous infusion for 14 days (group A) and 18 received 10 mg daily (group B). Both groups also received prednisone and azathioprine. In threatened rejection, rescue treatment consisted of anti-thymocyte globulin (ATG). 33B3.1 was well tolerated, with mild fever during the first 2 days being the most common side-effect. 3 patients in group A had a reversible acute rejection episode before day 14, whereas only 1 patient in group B had reversible rejection. 20 of 30 historical control patients (prednisone/azathioprine) and 2 of 55 patients previously treated with ATG had a rejection episode in a similar period after transplantation. Trough levels of 33B3.1 in the blood ranged from undetectable to 1.6 micrograms/ml in group A and from 0.3 to 9 micrograms/ml in group B. Most patients had antibodies against 33B3.1 by the end of treatment.

Fungal peritonitis in patients on continuous ambulatory peritoneal dialysis. Three recoveries in 5 cases without catheter removal.

We attempted to treat 5 patients on CAPD with fungal peritonitis without removing the catheter. In 1 case, amphotericin B caused a severe chemical peritonitis. The other 4 patients received amphotericin B intravenously and miconazole or flucytosine intraperitoneally. Recovery was obtained in 3 cases without removing the catheter and in 1 case the patient died.