Epidemiology of end-stage renal failure in Reunion Island (results from the registry of the Indian Ocean Society of Nephrology).

BACKGROUND: End-stage renal disease (ESRD) on long-term dialysis is a substantial problem in Reunion because of the high incidence and prevalence of this disease due to non-insulin-dependent diabetes mellitus (NIDDM) and systemic arterial hypertension. SUBJECTS AND METHODS: In 1996 the renal study group of the Indian Ocean Society of Nephrology established a regional registry of end-stage renal failure (ESRD) on long-term dialysis. The present report summarizes data obtained from this registry. RESULTS: In 1996, there were 125 patients who were initiated on long-term dialysis, 657 patients on dialysis with a mean age 52 +/- 17 years, and 110 patients with a functioning kidney graft. The incidence rate of ESRD was 188 per million population (p.m.p.) and the prevalence rate of this pathology was 1155 p.m.p. The sex ratio (F/M) was 1.4/1. The two most common causes of ESRD were NIDDM in 33.6% and systemic arterial hypertension in 27.5%. The mean Kt/V value was 1.47 +/- 0.23 and the mortality rate was 8.1% per year. CONCLUSION: The results demonstrate high incidence and prevalence rates of ESRD mainly as a result of NIDDM and systemic arterial hypertension.

High dose enalapril impairs the response to erythropoietin treatment in haemodialysis patients.

BACKGROUND: The resistance to recombinant human erythropoietin (rHuEpo) therapy in haemodialysis (HD) patients has multifactorial aetiologies: erythropoietin insufficiency, dialysis insufficiency, iron deficiency, and secondary hyperparathyroidism. Angiotensin-converting enzyme (ACE) inhibitors induce anaemia in patients with essential hypertension, congestive heart failure, chronic renal insufficiency, and renal transplants. Data exist suggesting that ACE inhibitors impair erythropoiesis in HD patients. Therefore the aim of this study was to investigate the impact of enalapril on rHuEpo requirement. METHODS: In the present prospective non-randomized study of 12 months, we compared the effects of enalapril and nifedipine on rHuEpo requirement in 40 hypertensive patients receiving rHuEpo for more than 6 months on maintenance haemodialysis. Twenty normotensive rHuEpo-dependent patients served as a control group. All patients with severe hyperparathyroidism or iron deficiency were excluded. RESULTS: The mean (+/- SD) haemoglobin concentration was > 10 g/dl in all groups. The mean weekly rHuEpo dose increased in the enalapril group (P<0.0001 vs before) and remained constant in the nifedipine and control groups (P=NS vs before). Statistically, there was no differences with regard to iPTH levels, dialysis parameters, iron status, and underlying renal diseases among all groups. CONCLUSION: High-dose enalapril increases rHuEpo requirement and should be reserved for dialysis patients with hypertension uncontrollable with other antihypertensive medications or dialysis patients with cardiac failure.

POEMS syndrome, steroid-dependent diabetes mellitus, erythema elevatum diutinum, and rheumatoid arthritis as extramedullary manifestations of plasma cell dyscrasia.

POEMS syndrome is a rare synopsis of different multisystemic disorders (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammapathy, and skin lesions) associated with plasma cell dyscrasia. We herein report the atypical case of a 44-year-old white man presenting with glomerulopathy, POEMS syndrome, and erythema elevatum diutinum with a few-year history of non-insulin-dependent diabetes mellitus (NIDDM) and seronegative rheumatoid arthritis (RA) as early manifestations of IgAlambda multiple myeloma. The prescription of 1 mg/kg/day prednisone improved the patient's features dramatically. Skin lesions improved by the association of glucocorticoids and plasma exchange, recurred when plasmapheresis ceased, and remitted when plasma exchange was reintroduced. NIDDM requiring insulinotherapy recurred when corticoids were discontinued and remitted when prednisone was reintroduced. However, prednisone and plasmapheresis had no effect on polyneuropathy, M-paraprotein, and plasma cell dyscrasia in our patient, who developed indolent multiple myeloma a few years later. We thus concluded that POEMS syndrome, steroid-dependent diabetes mellitus, rheumatoid arthritis, RA, and skin vasculitis in our patient were triggered by plasma cell dyscrasia.

High-dose alfacalcidol improves anaemia in patients on haemodialysis.

BACKGROUND: Alfacalcidol is efficient for treating secondary hyperparathyroidism in patients on maintenance haemodialysis (HD). Little is known about the direct impact of high-dose alfacalcidol on anaemia in end-stage renal failure. We therefore carried out a prospective study over 18 months to examine the direct effect of high-dose alfacalcidol on erythropoiesis in erythropoietin (rHuEpo)-dependent anaemic patients on HD for more than 6 months with moderate hyperparathyroidism. STUDY DESIGN: Twelve patients received oral alfacalcidol at a dosage of 6-7 micrograms per week and calcium carbonate during the first 12 months, calcium carbonate without alfacalcidol during the next 3 months, and again alfacalcidol and calcium carbonate during the last 3 months. Criteria for selection were haemoglobin < 10 g/dl, iPTH > 250 pg/ml, transferrin saturation (TS) > 25%, S-ferritin > 300 micrograms/l, and S-aluminium < 40 micrograms/l. RESULTS: Haemoglobin (Hb) and reticulocyte counts increased during the first phase, decreased and returned to a baseline prior to starting vitamin D treatment in the second phase, and again increased when alfacalcidol was reintroduced, whereas iPTH decreased during the first 3 months of the first phase and then remained stable, as did S-calcium, which increased during the first 3 months and then remained constant. S-phosphate increased during the first and third phases, and decreased during the second phase. Two patients during the first phase and one patient during the third phase presented hypercalcaemia; requiring a temporary discontinuation of alfacalcidol. CONCLUSION: High-dose alfacalcidol is efficient in anaemic patients with moderate hyperparathyroidism on maintenance HD and has a direct effect on erythropoietic cells regardless of serum calcium and iPTH levels.

[Renal vein thrombosis and constitutional protein S deficiency]. / Thrombose de la veine rénale et déficit constitutionnel en protéine S.

Venous and arterial thrombosis due to a constitutional protein S deficiency is well-known. We report the case of a 36 year-old patient admitted to hospital in 1991 for primary renal vein thrombosis due to a constitutional protein S deficiency of type I. The diagnosis was made by CT scan and angiography. Left nephrectomy, which was made because of doubt with regard to subjacent neoplasm, showed left renal vein thrombosis and multiple renal infarcts. In 1994, after 4 months of discontinuation of oral anticoagulants, the patient presented pulmonary embolism documented by pulmonary scintigraphy and CT scan, partial portal thrombosis and sural thrombophlebitis documented by echography coupled with Doppler. To our knowledge, this is the first reported case of a constitutional protein S deficiency associated with primary renal vein thrombosis.