Sirolimus-associated acute respiratory distress syndrome in a renal transplant recipient.

Sirolimus is a new potent immunosuppressive drug used in organ transplantation; its major advantage is the absence of deterioration in renal function. Documented adverse effects include myelosuppression and hyperlipidemia. Recently several cases of sirolimus-associated interstitial pneumonitis have been reported, usually of mild severity. We report a new case that was complicated by a severe acute respiratory distress syndrome, which required several days of mechanical ventilation. No infectious or cardiogenic etiology was documented. Low sirolimus blood levels and acute CD4 lymphocytic alveolitis suggested an immune-related mechanism rather than a direct toxic effect of the drug. The patient recovered after discontinuation of sirolimus and the administration of corticosteroids.

[Severe imported malaria in adults: a retrospective study of 32 cases admitted to intensive care units]. / Paludisme grave d'importation chez l'adulte: étude rétrospective de 32 cas admis en réanimation.

INTRODUCTION: Few studies have focused on severe imported malaria in patients admitted to intensive care units. We, therefore, undertook a retrospective study in the University Hospital of Montpellier. MATERIAL AND METHODS: All patients, more than 15 years-old with falciparum malaria who were admitted to intensive care units between October 1997 and April 2004 were included. Main epidemiological features, criteria of admission, treatment and outcome were investigated. RESULTS: Thirty-two patients were included, representing 9% of falciparum malaria cases diagnosed in the same period. The mean age was 44 years. All patients acquired falciparum malaria in sub-Sahara Africa and 25 patients were nonimmune. Chemoprophylaxis was absent or inadequate in 94%. The mean time from symptom onset and treatment initiation was 6 days. Mean parasitemia on admission was 15%. Criteria of admission were impaired consciousness in 69%, acute renal failure in 19% and isolated high parasitemia in 19% of the cases. All, but one received quinine therapy and a loading dose was performed in 34%. Seven patients (22%) had community-acquired coinfections and six (19%) had nosocomial infections. Mortality was 16%. Causes of death were refractory shock, cerebral edema, and acute respiratory distress syndrome. CONCLUSION: Severe imported malaria remains associated with a bad outcome. Improving chemoprophylaxis and an earlier diagnosis may reduce significantly this mortality.

Mechanism of in vitro heme-induced LDL oxidation: effects of antioxidants.

BACKGROUND: Heme protein toxicity, owing to generation of reactive oxygen species most likely by direct interaction between heme iron and hydrogen peroxide (H2O2), may be involved in various pathologies, including atherogenesis and pigmentary acute renal failure. The aim of this study was to investigate the mechanism of heme cytotoxicity and the effects of antioxidant therapies in an in vitro model of heme-induced low-density lipoprotein (LDL) oxidation. MATERIALS AND METHODS: Human LDLs were exposed to heme, iron (Fe), protoporphyrin (PPIX) and PPIX-Zinc (Zn) with or without H2O2. Lipid peroxidation was monitored by measurement of conjugated diene formation (at the 234-nm absorbance). The effect of various antioxidants, such as vitamin E and vitamin C, reduced glutathione (GSH), and oxidized glutathione (GSSG), mannitol and desferoxamine (DFO) was further investigated in the established in vitro model of LDL oxidation. RESULTS: Incubation of LDLs in the presence of heme/H2O2 induced lipid peroxidation with the optimal oxidation rate being at 5 microm heme/100 microm H2O2 doses. By contrast, incubation of LDL with H2O2, Fe, Fe/H2O2, PPIX, PPIX/H2O2, heme or PPIX-Zn did not initiate any LDL oxidation. In vitro, the vitamin E load protected native LDLs against heme/H2O2 oxidative modifications. Incubation of LDLs with increasing doses of vitamin C, GSH and DFO conferred a dose-dependent protection, while mannitol and GSSG had no effect. CONCLUSIONS: Initiation and propagation of heme-induced lipid peroxidation is not mediated by a Fenton reaction but depends on specific interactions between heme and H2O2. It may result from the generation of ferryl and perferryl radicals derived from hemic Fe and H2O2 interactions. A protective effect of vitamins E, C, GSH and DFO was demonstrated in this model.

[Epidemiology and prognosis of hyperosmolar state in the elderly]. / Epidémiologie et facteurs pronostiques des états hyperosmolaires chez le sujet âgé.

OBJECTIVE: We studied elderly patients admitted for hyperosmolar state (HS) to evaluate current outcome of HS and identify prognosis factors associated with mortality. STUDY DESIGN: A clinical retrospective study in an eight bed ICU. PATIENTS AND METHODS: Eighteen over 65-year-old patients admitted with a serum osmolality greater than 325 mOsm/kg were reviewed. Age, sex, diabetes mellitus, underlying medical condition, presence of an acute precipitating factor, Apache II and Glasgow scores, systolic arterial pressure, state of hydration, core temperature, heart rate, serum osmolality, creatininemia, lactatemia, plasma urea and bicarbonate, and protidemia were collected at the admission. Amount of fluid, time course of osmolality correction, length of hospitalization and mortality were recorded. All data were analyzed to identify possible correlations with patient outcome. RESULTS: Mean age: 75 +/- 11 years; sex ratio 1/2; hyperosmolar hyperglycemic states: 13 patients; hyperosmolar hypernatremic states: five patients; mean Apache II score: 18 +/- 7; Glasgow coma score: 11 +/- 3; mean osmolality: 370 +/- 25 mOsm/kg. In nine patients, infection was the precipitating factor. Five patients died (28%). At the admission, low blood pressure and high heart rate were related to mortality. During hospitalization, the occurrence of an acute cardiocirculatory failure and/or the need of mechanical ventilation significantly worsens the outcome. CONCLUSION: Our results showed that ICU mortality of HS in the elderly was at 28%. Haemodynamic state was the only factor of prognosis at the admission. Deaths were mostly related to acute respiratory and circulatory failure.

[Thyreotoxic periodic paralysis. A cause of pseudo-paralysing hypokalemia that should not be ignored in Caucasians]. / Paralysie périodique thyréotoxique. Une cause d'hypokaliémie pseudoparalysante à ne pas méconnaître chez le Caucasien.

INTRODUCTION: Despite its rare occurrence in Caucasians, thyreotoxic periodic paralysis should be evoked in young male Caucasians presenting with episodes of pseudo-paralytic hypokalemia. OBSERVATION: A 37 year-old Caucasian was admitted in intensive care for an acute episode of hypotonic tetraplegia and hypokalemia during which laboratory tests revealed hyperthyroidism due to Basedow's disease. The clinical course was rapidly favourable after a small dose of intravenous potassium. Antithyroid treatment avoided any new occurrence of similar episodes. DISCUSSION: In Caucasians, sporadic acute paralysis with hypokalemia requires testing for hyperthyroidism. Though it is well know that hypokalemia results from potassium intracellular shift, the underlying mechanism remains poorly elucidated. Treatment includes potassium administration with caution and/or beta blockers but the specific treatment is that of hyperthyroidism.

[Acute motor axonal neuropathy and aseptic meningitis due to Staphylococcus aureus endocarditis]. / Neuropathie axonale motrice aiguë et méningite aseptique révélant une endocardite à Staphylococcus aureus.

INTRODUCTION: Central nervous system complications are commonly described in Staphylococcus aureus endocarditis but peripheral nervous system involvement is rare. EXEGESIS: We report the case of a 65-year-old woman who had tetraparesia and aseptic meningitis revealing S. aureus endocarditis. The presence of purpura on the lower limbs led to an initial diagnosis of meningococcal meningitis. Tetraparesia was due to an acute motor axonal neuropathy. Anti-GM1 antibodies were negative. Meningitis and tetraparesia improved with antibiotic therapy. CONCLUSION: Acute motor axonal neuropathy may be a presenting symptom of S. aureus endocarditis.

Fatal systemic reaction after multiple doses of intravesical bacillus Calmette-Guérin for polyposis.

OBJECTIVE: To report a case of fatal systemic reaction after intravesical administrations of bacillus Calmette-Guérin (BCG) for polyposis. CASE SUMMARY: A 72-year-old white man was treated by monthly injections of intravesical BCG immunotherapy for polyposis of the urinary bladder. He received a total of eight injections; four hours after the seventh injection, he presented with pyrexia associated with chills, sweating, headache, and vomiting, which quickly resolved. Four hours after the eighth injection, the patient presented with the same symptoms plus a left-hemisphere deficiency. Results of a cerebral scan performed at this time were normal. The clinical status of the patient quickly worsened, with the appearance of disseminated intravascular coagulation, acute anuric renal insufficiency, rhabdomyolysis, hemolysis, and cytolytic and cholestatic hepatitis. The patient required hemodialysis and symptomatic treatment. Lactic acidosis with hemolytic-uremic syndrome appeared, and he died as the result of a multivisceral (respiratory, renal, hepatic) deficiency. DISCUSSION: The patient presented with symptoms compatible with a severe systemic reaction to BCG therapy, a rare but possible adverse effect. CONCLUSIONS: BCG instillation is a valuable tool in the therapy of bladder carcinoma, but increasing reports of severe adverse reactions should continue to remind practicing urologists to be alert to the possibility of common and uncommon reactions after its use.

Temporary vascular access for extracorporeal renal replacement therapies in acute renal failure patients.

Temporary vascular access is an essential component to perform any extracorporeal renal replacement therapy (RRT) in the acute renal failure patient. RRT used in the acute setting may be categorized in two groups: intermittent (IRRT) and continuous (CRRT). Therapeutic indications are based on clinical and technical considerations. Continuous modalities are mainly utilized in intensive care units for hemodynamically compromised patient. Initially performed spontaneously via an arteriovenous circuit, CRRT modalities have progressively become venovenous with the circulatory assistance of a blood pump. Since both intermittent and continuous RRT modalities are now performed almost exclusively by venovenous modalities, this article deals exclusively with temporary venous catheters. At present, double-lumen catheters represent the most common vascular access for RRT modalities. Semi-rigid polyurethane catheters currently used in case of emergency are limited to short term use. Hemocompatible, flexible silicone catheters, less aggressive for the vessels, seem better suited for the medium and long term run. The tunneled silicone catheters (DualCath type) meet the short and long term needs, and allow for blood flow rates up to 400 ml/min. The internal jugular vein, particularly the right one, seems to warrant the proper functioning of catheters while reducing the risk of stenotic complications. Subclavian access should be limited in time and reserved for silicone catheters in order to limit the risk of stenosis and/or thrombosis. Femoral access, very useful in cases of emergency and respiratory problems, greatly impairs the patient's mobility and should be limited by time to prevent thrombosis and/or infection. Late and/or delayed dysfunctioning of catheters are indicative of a thrombosis. Performance standards of catheters are less of a limiting factor in continuous low flow RRT modalities than in the intermittent ones. Finally, careful handling of the catheter essential to prevent infectious complications.

[Acute renal insufficiency: nutrition disorders and therapeutic consequences]. / Insuffisance rénale aiguë: désordres nutritionnels et conséquences thérapeutiques.

Catabolism is usually enhanced in acute renal failure (ARF). Its magnitude varies from one patient to another and can change significantly in the same patient from day to day, reflecting its clinical course. It depends on the severity of the ARF, the underlying process, the associated co-morbidity, and therapeutic approach. The detection of patients at high risk for malnutrition is extremely important; nutritional markers and indexes of caloric and protein requirements are useful to adapt renal replacement and nutritional support to ARF patients. Various biochemical parameters (namely, serum albumin and prealbumin), anthropometic measures, indirect calorimetry, urea and creatinine kinetics are all useful tools to evaluate metabolic status and requirements nutritional. Commonly, the caloric requirements are nearly 35 kcal/kg/24 h with correction factors applied for certain clinical situations: carbohydrates account for 50 to 60% of those needs whereas lipids account for the rest. The total amount of fluid administered has to be adapted to the possible ultrafiltration achieved by dialysis. Daily dialysis sessions and continuous renal replacement therapy allow larger volumes and thus facilitate nutritional support. Protein needs frequently exceed 1.2 g/kg/24 h to maintain the nitrogen balance, with a calorie to protein ration close to 150 kcal per g of nitrogen. Sufficient amounts of vitamins and oligo-elements are necessary. Stimulating anabolism by exogenous mediators, such as androgenic hormones or growth factors (rh-IGF1, rh-GH) is an avenue that deserves better definition in critically ill ARF patients.

Nephrotic syndrome associated with chronic lymphocytic leukemia resistant to immunosuppressive drugs: remission obtained by splenectomy.

Chronic lymphocytic leukemia is a common disease in the elderly but is rarely associated with a nephrotic syndrome. The rarity of this association suggests that leukemic cells may have certain properties or features that may lead to the development of glomerulonephritis. Effective medical treatment of the leukemia may not necessarily allow regression of the nephrotic syndrome; however, the effects of splenectomy on nephrotic proteinuria when associated to chronic lymphocytic leukemia have never been evaluated. We report the case of a 50-year-old male with stage C CD5+ chronic lymphocytic leukemia associated with a nephrotic syndrome due to Type I membranoproliferative glomerulonephritis. Chlorambucil and prednisone were unable to control the leukemia and the nephrotic range proteinuria, and were discontinued because of poor hematologic tolerance. A splenectomy immediately resulted in a spectacular remission of both chronic lymphocytic leukemia and the nephrotic syndrome. Spleen lymphocytes were collected and tested in quantitative flow cytometry for the expression of the main B cell associated markers. They did not exhibit any particular immunophenotypic pattern. This report of a remission of a glomerulonephritis associated with chronic leukemia following splenectomy is evidence of a possible relationship between the two diseases.

Prognosis of acute renal failure in the elderly.

UNLABELLED: Life expectancy is uncertain in the elderly with ARF. In order to determine whether a costly supportive management is worthwhile, we have studied a group of 68 elderly patients (over 65 years of age) admitted to the ICU with ARF. PATIENTS: 47 male; 21 female; 72 +/- 6 years old. Types of ARF include prerenal 24; obstructive 9; intrinsic 35 (acute tubular necrosis 30; glomerulonephritis 4; vascular 1). The mean simplified acute physiology score (SAPS) was 14 +/- 4; 39 patients (57.3%) had more than two underlying diseases; 42 patients (61.7%) were on mechanical ventilation; 40 patients (60%) underwent haemodialysis. The overall survival rate was 36.7%. Among the parameters studied, organic systemic failure index (OSF), diuresis, blood lactate, systolic blood pressure, urea appearance rate (UAR), differed significantly in survivors and deceased. From these results we conclude that the elderly with non-oliguric ARF, normal blood lactate, low catabolic state, and no more than two organ failures have a fair chance of recovering and should therefore be treated aggressively. In other cases, decisions to proceed with intensive supportive measures should be made according to individual characteristics.

[Amanita proxima poisoning: a new cause of acute renal insufficiency]. / Intoxication par Amanita proxima: une nouvelle cause d'insuffisance rénale aiguë.

To our knowledge Amanita proxima poisoning has never been reported. Amanita proxima is a mushroom seldomy encountered, similar to a common and edible species: Amanita ovoïdae. During October 1992, we had the opportunity to care for five cases of intoxications with Amanita proxima. In all cases early digestive disorders, cytolytic hepatitis and acute renal failure were noted. Outcome was favourable for all patients within three weeks with total recovery of both renal and hepatic functions with symptomatic treatment. Temporary dialysis was required in four patients.

[Temporary vascular access: from peripheral to central, from temporary to permanent]. / Accès vasculaire temporaire: du périphérique au central, du temporaire au permanent.

Temporary vascular access (TVA) is a basic requirement in clinical nephrology. TVA permits immediate and repeated hemodialysis for all type of ESRD patient. Going from peripheral to central and from temporary to permanent angioaccess are the two main trends observed in TVA in contemporary dialysis. Our experience over the last decade illustrates this TVA changes. On the one hand peripheral arterio-venous shunt has been forsaken in favour of percutaneous implanted central venous catheters. On the other hand, two types of central venous catheters have been used covering up our preferences: catheters for short term use (< 7 days) usually via femoral vein and catheters for long term use (7 days to months) mainly via the internal jugular vein. Due to traumatic and/or long term mechanical risks (venous stenosis and/or thrombosis), the subclavian way has been abandoned in our unit. Performances (blood flow rate 250-350 ml/min, recirculation rate 9-12%) obtained in about 1500 patients warranted dialysis efficiency. Traumatic and/or mechanic lesions were the most frequent complications observed with the femoral catheter, while infection remained the most important one associated with the long term use of jugular vein catheters. Therefore, it is clear that over the last decade temporary vascular access was becoming synonymous with percutaneous central venous catheter. Such an approach has greatly simplified the task of physicians while facilitating the management of large uremia treatment program.