Clinical and microcirculatory effects of transcutaneous CO2 therapy in intermittent claudication. Randomized double-blind clinical trial with a parallel design.

BACKGROUND: This randomized, double blind trial determined the short and long-term clinical and hemodynamic vasodilator effects induced by percutaneous applications of natural CO2 gas in patients with moderate Fontaine stage II. PATIENTS AND METHODS: 62 patients with intermittent claudication (100-500 meters) were randomized to 18 consecutive days of CO2 treatment or placebo (air). The gas fluids were applied at a constant temperature of 30 degrees C on pre-humidified skin. The effects of the treatment were evaluated by total distance walked (primary criterion) and hemodynamic and microcirculatory findings. Patients also answered a quality of life questionnaire. RESULTS: The Strandness test showed a significant increase in total distance walked (+ 131 meters, 66%; p = 0.001) and pain-free distance (+ 81 meters, 73%; p = 0.02) after 18 days of CO2 treatment. The improvement was maintained 3 and 12 months later. The systolic pressure index (ABI) increased by 37% (p = 0.001) 1 minute after treadmill walking and ABI recovery time decreased significantly by 38% (p = 0.002). Microcirculatory findings showed an increase in systolic pressure of the great toe (13%; p < 0.0001), in baseline pO2 (20%; p = 0.01) and in vasomotion (78%; p = 0.001) in the treatment group. The improvement in total walking distance was correlated with the increase in ABI and peripheral cutaneous oxygenation. Patients' subjective assessments corroborated the benefits. No significant change was observed in the placebo group. CONCLUSIONS: This study demonstrates that 18 consecutive days of percutaneous CO2 treatment significantly increases walking distance in patients with moderate intermittent claudication. This effect, which was associated with an increase in peripheral systolic pressure and pO2, is evidence of a better ability to withstand effort.

Pharmacokinetics of quinupristin/ dalfopristin in patients with severe chronic renal insufficiency.

OBJECTIVE: To compare the pharmacokinetic profile of a single intravenous injection of quinupristin/dalfopristin, a new injectable streptogramin, in healthy young individuals and patients with severe chronic renal insufficiency. A secondary objective was to assess the relative tolerability of this dose in these patients compared with healthy individuals. PATIENTS AND PARTICIPANTS: 13 patients with severe chronic renal insufficiency (creatinine clearance 6 to 28 ml/min/1.73m2) were individually matched for gender, bodyweight and age to a healthy volunteer. METHODS: Participants received a single dose of quinupristin/dalfopristin 7.5 mg/kg bodyweight as a continuous 1-hour intravenous infusion, followed by serial blood sampling. RESULTS: The disposition profile of unchanged quinupristin was similar in the 2 groups. However, the elimination of quinupristin derivatives in patients with renal impairment tended to be decreased: mean peak plasma drug concentration (Cmax) and area under the concentration-time curve from zero to infinity (AUCinfinity) of quinupristin plus its active derivatives were about 1.4 times higher in the patients with renal impairment compared with healthy volunteers. The mean Cmax and AUCinfinity of both unchanged dalfopristin and dalfopristin plus its active derivatives were about 1.3 times higher in renally impaired patients than in healthy volunteers. Adverse events were generally mild and transient. No severe or serious adverse events were reported and no participants prematurely discontinued the study. Venous tolerability tended to be better in healthy volunteers than in the patients with renal impairment. CONCLUSION: These results suggest that no formal reduction in the dosage of quinupristin/dalfopristin is necessary in patients with severe chronic renal impairment.

Hemoperitoneum in patients receiving hemodialysis.

Acute abdominal pain in chronic hemodialysis patients has well-known causes, including acute pancreatitis, mesenteric arterial insufficiency, or complicated duodenal ulcer. Others, such as hemoperitoneum, are far less common. Although hemoperitoneum occurs in patients receiving peritoneal dialysis, dialysis is seldom if ever the direct cause of the bleeding. Hemoperitoneum is often related to menses or ovulation, particularly to ovarian cyst rupture; therefore, it is more common in young women. In most cases, no specific treatment is required. Hemoperitoneum is rarely considered as the cause of acute abdominal pain in chronic hemodialysis patients. In this report of hemoperitoneum confirmed by emergency laparotomy in 3 women, bleeding was not related to gynecologic origin. All of the women were younger than age 50 and undergoing long-term hemodialysis. All patients had a history of acute abdominal pain associated with shock. The cause of bleeding was always an organ lesion: hepatic amyloidosis with suspected portal hypertension or sclerosing peritonitis and acute hemorrhagic pancreatitis. Coagulation abnormalities and the use of anticoagulants during hemodialysis sessions may have been aggravating factors in all three patients. Hemoperitoneum is difficult to diagnose, particularly in the minor forms, and consequently its incidence may be underestimated. Therefore, it should be considered whenever a chronic hemodialysis patient presents with persistent acute abdominal pain.

[Intestinal complications of thrombotic microangiopathy in the adult. 4 cases and review of the literature]. / Complications intestinales de la microangiopathie thrombotique de l'adulte. Quatre observations et revue de la littérature.

We report four cases of adult thrombotic microangiopathy associating diarrhea with severe ischemic colitis. In one case, the intestinal complications was severe and diffuse ischemic colitis, in two cases an inaugural colonic perforation requiring colectomy and in the last case a massive mesenteric infarct. In three cases, histologic examination showed vessel occlusion with microthrombi. Despite treatment with plasma exchange and plasma infusion, death ensued in two cases. Principally described in childhood thrombotic microangiopathy, intestinal complications occur exceptionally in adult thrombotic microangiopathy and are associated with a poor prognosis. Inaugural ischemic colitis revealing an adult thrombotic microangiopathy is also uncommon and thrombotic microangiopathy could be evoked in all patients presenting acute ischemic colitis.

[Association of acute pericarditis and acute renal insufficiency: causes and prognosis]. / Association d'une péricardite aiguë à une insuffisance rénale aiguë: causes et pronostic. 11 observations.

OBJECTIVE: To assess the etiologic diagnoses and outcome of acute pericardial effusion associated to acute renal renal failure. PATIENTS AND METHODS: A retrospective study from 1978 to 1996 in a 10 bed medical/surgical intensive care unit included 11 patients who have an acute pericardial effusion associated with an acute renal failure. RESULTS: Etiological diagnoses were systemic lupus with extracapillary glomerulonephritis (n = 2), systemic fibrosis with obstructive renal failure (n = 2), anticoagulation accident with hemodynamic renal failure (n = 2), lung adenocarcinoma (n = 2), adenocarcinoma of undetermined origin (n = 1), systemic polyarteritis nodosa (n = 1), and Wegener granulomatosis (n = 1). Intensive care unit deaths was 4, including 2 cases of neoplasic origin. DISCUSSION: Despite infection or malignancy being claimed as the leading causes of acute pericardial effusion, when associated to acute renal failure other etiologic diagnoses, such connectivite tissue disease or vasculitis, must be evoked that prompt specific treatment and could prevent unfavorable evolution. Neoplasic causes were characterised by receiving pericardial effusion and a high mortality rate.

[Bilateral adrenal cysts and hepatorenal polycystic disease]. / Kystes surrénaliens bilatéraux et polykystose hépato-rénale.

BACKGROUND: Cyst formation may occur in many localization in patients with polycystic renal disease. Adrenal gland cysts have not previously been reported. CASE REPORT: Hepatorenal polycystic disease was diagnosed in a 38-year-old man who underwent abdominal ultrasound examination for acute back pain. Subsequent computed tomography evidenced several cysts in both adrenal glands. DISCUSSION: Incidental discovery of cysts in the adrenal glands accounts for 4 to 22% of all cyst formations in this organ. Four types of cysts are observed: parasite cysts, epithelial cysts and adenomas, pseudocysts, and endothelial cysts. Appropriate treatment depends on the size of the cyst, the etiology context, and clinical manifestations. Treatment is indicated in case of symptomatic disease or when the ultrasound or CT-scan aspect is atypical.

Cellulitis due to Streptococcus pneumoniae with diminished susceptibility to penicillin in an immunocompromised patient.

A 74-year-old man with multiple myeloma developed facial and cervical cellulitis and severe sepsis as a complication of surgery (alar region basal cell carcinoma). The etiological agent was, surprisingly, penicillin-resistant Streptococcus pneumoniae (PRSP). The patient successfully received 16 days of antibiotics. Amoxicillin was given as monotherapy during the last 14 days of treatment. PRSP can be responsible not only for otitis media, pneumonia or meningitis, but also for various other types of infection in patients with predisposing factors.

Kinetics, safety, and efficacy of ramipril after long-term administration in hemodialyzed patients.

We studied the efficacy and safety of ramipril and the kinetics of its active moiety ramiprilat in 12 hypertensive patients receiving regular hemodialysis, after a single dose and after long-term (28 days) administration. Patients received 2.5 mg ramipril after each hemodialysis. On days 1 and 29, ramipril was administered 4 h before the hemodialysis and serial blood samples were obtained for 9 h for determination of pharmacokinetic parameters. Tolerability was good, and all patients completed the study. There was a high degree of angiotensin-converting enzyme (ACE) inhibition throughout the study. Ramipril had a clear-cut antihypertensive effect. Long-term administration of ramipril did not modify the time to peak ramiprilat concentration, but increased the mean maximal concentration significantly: 20.2 +/- 12.7 vs. 10.4 +/- 7.1 ng center dot ml-1. The mean accumulation ratio was 2.2. Ramiprilat hemodialysis clearance was 31.7 ml/min (range 4.2-64.9 ml/min) on day 1 and 21.0 ml/min (range 7.9-56.5 ml/min) on day 29. Ramipril 2.5 mg, administered after hemodialysis, appears to be safe and effective in hypertensive patients receiving periodic hemodialysis. Despite an increase in ramiprilat concentration from day 1 to day 29, the steady state was reached. We describe the role of nonrenal clearance of ramiprilat.

[Thermal treatment in arterial diseases: an expensive placebo or an effective therapy?]. / Le traitement thermal des maladies artérielles: un placebo coûteux ou une thérapeutique à part entière?

Each year, Royat (Auvergne) receives about 20,000 patients (80 per cent with intermittent claudication), treated by thermal gas (99.5 per cent of CO2). CO2 therapy is dispensed with thermal water or with dry gas (general or local immersion and local subcutaneous injections of gas) during 3 weeks. Local vasodilator effects of CO2 have been demonstrated with several methods in Royat. Physiological and therapeutic effects of thermal CO2 therapy, also used in Germany and Central Europe, were precisely reported during the Consensus Congress of Fribourg in Brisgau (1989); more particularly, this treatment seems provide a reduced ability of haemoglobin to fix oxygen, and therefore a release of oxygen within the cells. Patients with peripheral arterial disease (stage 2) have a walking distance increased and post-exercise ankles' pressures improved after a thermal course of treatment in Royat, while a control group has no significant changes. The discussion will concern also the socio-economic aspects of thermal treatment of arterial diseases.

[Evolution of serum creatinine level 48 hours after angioplasty for renal artery stenosis in 91 patients]. / Evolution de la créatininémie 48 heures après angioplastie de sténose artérielle rénale chez 91 patients.

To determine variations of serum creatinine level immediately after percutaneous angioplasty for renal artery stenosis. After technical success of unilateral or bilateral percutaneous angioplasty for renal artery stenosis in 91 patients (mean age 62.7 years) in whom ioxaglate was always used (90 to 300 ml, mean 195), serum creatinine levels immediately before and 48 hours after dilatation were compared. In the whole population, no significant variation was observed in the overall population. No significant difference was observed between unilateral and bilateral renal angioplasty. The volume of contrast media did not influence creatinine level, nor did iodine injection performed during (n = 4) or more than 3 days before angioplasty. A significant difference was observed with or without diabetes mellitus (n = 15, p = 0.05). In patients without diabetes mellitus technically successful percutaneous angioplasty for renal artery stenosis when using ioxaglate do not significant alter serum creatinine level 48 hours later.

Percutaneous recanalization of recent renal artery occlusions: report of 10 cases.

PURPOSE: Percutaneous recanalization of renal artery occlusion was attempted in 10 patients. METHODS: All patients were hypertensive; before the procedure, the serum creatinine level was 80 mumol/L in one patient, ranged from 130-250 mumol/L in four patients, and was greater than 350 mumol/L in five, three of whom had anuria. Nine occlusions were thrombotic, one due to bilateral renal artery embolism. In four patients, percutaneous transluminal angioplasty of a contralateral renal artery occlusion was bilateral. In three patients, complementary local fibrinolysis was necessary. RESULTS: Three technical failures and one rethrombosis occurred after 24 h; in three of these cases the date of previous occlusion was unknown, whereas a relatively precise data was known for the seven other patients. One false aneurysm of the femoral artery was found 1 month after the procedure. One patient, after six technical successes, died 5 weeks after the procedure; follow-up for the other five was 6-36 months. Blood pressure was unchanged in four patients and improved in two. A significant and durable improvement of creatinine serum level (at least a 20% decrease) was observed in all six patients, usually after 1 month, thus enabling discontinuance of dialysis in three patients. CONCLUSION: Percutaneous recanalization should be proposed in cases of renal artery occlusion, especially to avoid terminal vascular azotemia and dialysis.

Reticulocyte response to endogenous erythropoietin after renal transplantation.

We determined in a prospective study reticulocyte counts and serum erythropoietin concentrations after renal transplantation in 37 recipients of renal allografts. Erythropoietin decreased in 35 patients out of 37 during surgery. Results concerning reticulocyte counts allowed us to define two groups of patients. Group 1: 33 patients had a reticulocyte peak before d29. Among them the reticulocyte peak followed the first Epo peak in 22 patients (1a) and occurred after several Epo peaks in 11 patients (1b). Patients of groups 1b had a serum creatinine level above 300 mumol/l at the time of the first Epo peak. Group 2: 4 patients with acute tubular necrosis had no reticulocytes peak before d29 despite one or several erythropoietin peaks. Post-operative erythropoietin reduction was not entirely explained by hemodilution or by per-operative blood transfusions. The erythropoietin peak appeared to be efficient only when creatinine at the time of the peak was under 200 mumol/l according to the inhibition of erythropoiesis during renal failure.

Effects of alpha-1 acid glycoprotein on human polymorphonuclear neutrophils: influence of glycan microheterogeneity.

The biological functions of alpha-1 acid glycoprotein (AGP) are poorly understood but appear to depend on glycan microheterogeneity. Variations of AGP glycan structure (in terms of concanavalin A (ConA) reactivity) have been observed during the inflammatory process. We studied these modifications in AGP from patients with chronic renal impairment and investigated the effects of AGP microheterogeneity on healthy polymorphonuclear leukocyte (PMN) chemotaxis and oxidative metabolism. AGP was extracted by a two-step procedure from sera from ten patients with various degrees of renal impairment, selected according to AGP glycan heterogeneity determined by crossed immunoaffinity electrophoresis with ConA. AGP (0.5 g/l) significantly inhibited the chemotactic response of PMN to formyl-methionyl-leucyl-phenylalanine (10(-7) mol/l) and complement fraction C5a, regardless of ConA reactivity. AGP also inhibited superoxide anion generation in response to phorbol myristate acetate (10(-7) mol/l). After stimulation by opsonized zymosan (1 g/l), the effect of AGP appeared to depend on its glycan structure (r = 0.70, P < 0.05), decreasing with ConA non-reactivity. These data suggest that AGP can down-regulate neutrophil responsiveness, an effect that depends in part on its glycan microheterogeneity. Alterations of AGP microheterogeneity in various pathological states, particularly renal failure, may be related to the inflammatory process.

[Pattern of blood creatinine levels in 140 hypertensive patients after successful percutaneous transluminal angioplasty for renal artery stenosis]. / Evolution de la créatininémie chez 140 patients hypertendus après succès technique de l'angioplastie transluminale percutanée de sténoses de l'artère rénale.

Long term effects on creatinine serum level of successful percutaneous transluminal renal angioplasty were retrospectively studied in 140 patients. 3 groups were distinguished: the first one (80 patients) included unilateral renal angioplasties, with normal contralateral kidney and renal artery; the second group (35 patients) included bilateral renal angioplasties; the third group (25 patients) included solitary kidney renal artery angioplasties. In each group, subgroups were defined whether creatinine serum level was upper or lower than 130 mumol/l. Renal function was considered to be improved if serum creatinine was reduced by 20% or more, maintained if serum creatinine variations were below 20%, worsened if its increase was upper than 20%. Global complication rate was 4.9% (9 between 185 patients) of whom 1 (0.54%) needed a surgical revascularization. At the end of follow-up (mean between 4 and 10 months), subgroups improvement and stabilization rates varied between 67 and 100%, with the best scores in the second group (96.2 and 100%) and solitary kidney with renal insufficiency subgroup (77.25%).

Serum and urinary alpha-1 acid glycoprotein in chronic renal failure.

The concentration and concanavalin A (ConA)-dependent microheterogeneity of serum and urinary alpha 1-acid glycoprotein (AGP) were studied in patients with various degrees of renal impairment and compared with healthy control values. Serum concentrations of AGP were significantly higher in hemodialyzed and uremic patients than in the control subjects (1.54 +/- 0.42 g/l, p < 0.05, and 1.20 +/- 0.40 g/l, p < 0.05, respectively, versus 0.83 +/- 0.17 g/l). There was a similar increase in serum alpha 1-protease inhibitor and haptoglobin concentrations in the uremic patients (r = 0.87 and r = 0.70; p < 0.001). Urinary concentrations of AGP were also significantly higher in the hemodialyzed and uremic patients than in the control subjects, despite wide variability in the patients (20 +/- 14 mg/24 h, p < 0.05, and 126 +/- 160 mg/24 h, p < 0.05, respectively, versus 3 +/- 1 mg/24 h). AGP clearance was significantly higher in the uremic patients than in the hemodialyzed patients (p < 0.01) and the control subjects (p < 0.01). The proportions of strongly ConA-reactive AGP fractions were higher in the serum of the hemodialyzed (18.6 +/- 5.2%; p < 0.05) and uremic patients (18.1 +/- 5.3%; p < 0.05) than in the control subjects (14.5 +/- 2.5%). There was a similar difference in the urine samples (26.7 +/- 8.2%, p < 0.01; 20.1 +/- 6.2%, p < 0.01, respectively, versus 10.3 +/- 4.8%), with also a significant difference between the hemodialyzed and uremic patients (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

[Kinetics of erythropoietin blood levels from D-1 to D-29 in kidney transplantation]. / Cinétique de l'érythropoïétinémie de J-1 à J29 en transplantation rénale.

This study of serum erythropoietin levels and reticulocytes counts in the first month after kidney transplantation shows that the erythropoietin peak is efficient only when serum creatinine level at the time of the peak is under 200 mumol/l.