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.

Long-term ambulatory peritoneal insulin infusion of brittle diabetes with portable pumps: comparison with intravenous and subcutaneous routes.

This work compares different routes of insulin infusion via portable pumps with chronically implanted catheters and evaluates the long-term feasibility of the technique. Six severely unstable (i.e., uncontrolled by optimized intensive insulin therapy) diabetic individuals (age range: 35 +/- 4 yr; duration: 11 +/- 2 yr) were selected. Promedos pumps (Siemens A. G., Erlangen, West Germany) were exclusively used because of their portability and long-life insulin reservoir (1-mo duration with U40 acidic Hoechst insulin). Each patient underwent three randomized 1-mo periods of insulin infusion: subcutaneous (s.c.), intravenous (i.v.), and intraperitoneal (i.p.) before the catheter was left indefinitely in one of these sites. Diabetic control was improved and insulin doses reduced whatever the route of infusion, although the s.c. route gave slightly higher values. These results did not deteriorate with time: mean blood glucose was 126 +/- 3 mg/dl and HbA1 was 8.3 +/- 0.6% after 10-18 mo of constant infusion versus 237 +/- 35 mg/dl and 10.0 +/- 0.8%, respectively, under conventional therapy. From a practical point of view, the i.p. route seems preferable since all s.c. catheters provoked local reactions after less than 1 mo and the two chronic i.v. catheters obstructed after 8 and 9 mo. All other incidents were minor and curable without removal of the catheters. All patients argued improvement of both diabetes and quality of life and no one has resigned so far. Thus, the i.p. infusion technique seems beneficial to unstable diabetic individuals and adaptable to long-term therapy, although intensive education and careful follow-up are necessary.

Reversal of acute renal failure following percutaneous transluminal recanalization of an atherosclerotic renal artery occlusion.

Thrombosis of the renal artery to a single functioning kidney is a known cause of anuric acute renal failure in atherosclerotic hypertensive patients. In the present report, recovery of renal function rapidly occurred following transluminal recanalization of the occluded artery with a 7F catheter after a 5-week period of anuria. The most interesting feature was that improvement of renal artery permeability was observed following a minimal interventional procedure.

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.

Failure to achieve tight control of plasma cholesterol and apolipoprotein B with intraperitoneal insulin infusion in type 1 diabetes.

The best route of insulin administration by infusion pumps remains a subject of controversy. For that reason plasma lipids and apolipoproteins were compared in three groups of nine patients who had been treated for several months or years with conventional treatment (group I), continuous subcutaneous insulin infusion (CSII, group II) or continuous intraperitoneal insulin infusion (CPII, group III). Plasma cholesterol and apolipoprotein B remained increased on CPII compared with CSII even when similar satisfactory or even tight diabetic control was achieved with both techniques. This study suggests that cholesterol and perhaps apolipoprotein B biosynthesis by the liver is increased in patients treated with CPII compared to those treated with CSII.

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.

[Acute renal failure and hepatitis induced by clometacin]. / Insuffisance rénale aiguë et hépatite à la clométacine.

Various types of allergic accidents have been reported with clometacin (Duperan), a synthetic analgesic introduced in France in 1971. The most prominent is hepatitis in elderly women, with hyperglobulinemia, eosinophilia, autoantibodies and giant multinucleated hepatocytes. The case presented herein concerns a 73-year-old woman who, on two separate occasions after the ingestion of clometacin at recommended dosages, developed at the same time typical acute hepatitis and non-oliguric acute renal failure. The second episode came soon after the medication was inadvertently reintroduced. Both hepatic and renal involvements were fully reversible. A renal biopsy showed predominant lesions of acute interstitial nephritis and tubulonecrosis. Three possible mechanisms are discussed: 1) sensitivity of the kidney to drugs because of preceding angiosclerosis, 2) impaired regulation of renal blood flow because of clometacin provoked decrease of prostaglandin synthesis, and 3) as in the case of nephrotoxicity due to other medications, allergic mechanisms.

[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.

[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.