Predictors of Autogenous Arteriovenous Hemodialysis Access Thrombosis after Renal Transplantation.

BACKGROUND: The fate of autogenous arteriovenous fistula (aAVF) after renal transplantation (RT) remains variable. The aim of this study was to determine the predictors for their thrombosis after RT. METHODS: We conducted a monocentric retrospective review of prospective clinical records of 145 patients with a functional aAVF who had an RT between January 2004 and December 2009 in the University Hospital of Clermont-Ferrand. Our primary end point was the thrombosis of the aAVF. Univariate and multiple logistic regression analyses were used to identify risk factors associated to aAVF thrombosis after RT. RESULTS: There were 105 men (72%) and 40 women (28%), mean age 52 years (range: 18.4-74.7 years). The aAVF was created on average 40 months (range: 2-169) before the RT. The aAVF was distal in 96 cases (66%) and proximal in 49 cases (34%). Nineteen aAVF (13.1%) were complicated and required an endovascular or surgical repair before RT. Forty-nine patients (34%) required multiple aAVF (>2). Mean follow-up from RT was 58 months (range: 1 day-123 months) and from aAVF creation 97 months (range: 5-262 months). At the end of the follow-up, 81 aAVFs (59%) were patent, 42 (29%) were thrombosed, and 22 (15%) were surgically closed. Patients that had multiple fistulas before RT and active smokers were significantly at risk to thrombose their aAVF after the RT in univariate (P = 0.03 and P = 0.02, respectively) and multiple logistic regression analyses (P = 0.03 and P = 0.047, respectively). CONCLUSIONS: Thrombosis is a part of the natural history of the aAVF after RT. A history of multiple aAVF creations before RT and active smoking were associated to significant increased risk for fistula thrombosis. Because hemodialysis may be needed after RT, the aAVF patency should be preserved, excepted when the aAVF resulted in complications. Follow-up of the aAVF after RT is important to detect and treat complications before thrombosis occurs.

INF2 mutations in Charcot-Marie-Tooth disease with glomerulopathy.

BACKGROUND: Charcot-Marie-Tooth neuropathy has been reported to be associated with renal diseases, mostly focal segmental glomerulosclerosis (FSGS). However, the common mechanisms underlying the neuropathy and FSGS remain unknown. Mutations in INF2 were recently identified in patients with autosomal dominant FSGS. INF2 encodes a formin protein that interacts with the Rho-GTPase CDC42 and myelin and lymphocyte protein (MAL) that are implicated in essential steps of myelination and myelin maintenance. We therefore hypothesized that INF2 may be responsible for cases of Charcot-Marie-Tooth neuropathy associated with FSGS. METHODS: We performed direct genotyping of INF2 in 16 index patients with Charcot-Marie-Tooth neuropathy and FSGS who did not have a mutation in PMP22 or MPZ, encoding peripheral myelin protein 22 and myelin protein zero, respectively. Histologic and functional studies were also conducted. RESULTS: We identified nine new heterozygous mutations in 12 of the 16 index patients (75%), all located in exons 2 and 3, encoding the diaphanous-inhibitory domain of INF2. Patients presented with an intermediate form of Charcot-Marie-Tooth neuropathy as well as a glomerulopathy with FSGS on kidney biopsy. Immunohistochemical analysis revealed strong INF2 expression in Schwann-cell cytoplasm and podocytes. Moreover, we demonstrated that INF2 colocalizes and interacts with MAL in Schwann cells. The INF2 mutants perturbed the INF2-MAL-CDC42 pathway, resulting in cytoskeleton disorganization, enhanced INF2 binding to CDC42 and mislocalization of INF2, MAL, and CDC42. CONCLUSIONS: INF2 mutations appear to cause many cases of FSGS-associated Charcot-Marie-Tooth neuropathy, showing that INF2 is involved in a disease affecting both the kidney glomerulus and the peripheral nervous system. These findings provide new insights into the pathophysiological mechanisms linking formin proteins to podocyte and Schwann-cell function. (Funded by the Agence Nationale de la Recherche and others.).

Impact of prior CKD management in a renal care network on early outcomes in incident dialysis patients: a prospective observational study.

BACKGROUND: Effective therapeutic strategies are available to prevent adverse outcomes in patients with chronic kidney disease (CKD) but their clinical results are hindered by unplanned implementation. Coordination of care emerges as a suitable way to improve patient outcomes. In this study, we evaluated the effect of planned and coordinated patient management within a dedicated renal care network comparatively to standard renal care delivered in nephrology departments of teaching hospitals. METHODS: This observational matched cohort study included 40 patients with CKD stage 4-5 in the network group as compared with a control group of 120 patients matched for age, sex and diabetic status. Main outcome was a composite endpoint of death from cardiovascular cause and cardiovascular events during the first year after dialysis initiation. RESULTS: There was no difference between the two groups neither for the primary outcome (40% vs 41%) nor for the occurrence of death from cardiovascular cause or cardiovascular events. Whereas the proportion of patients requiring at least one hospitalization was identical (83.3% vs 75%), network patients experienced less individual hospitalizations than control patients (2.3 ± 2.0 vs 1.6 ± 1.7) during the year before dialysis start. Patients of the network group had a slower renal function decline (7.7 ± 2.5 vs 4.9 ± 1.1 ml/min/1,73 m(2) per year; p=0.04). CONCLUSIONS: In this limited series of patients, we were unable to demonstrate a significant impact of the coordinated renal care provided in the network on early cardiovascular events in incident dialysis patients. However, during the predialysis period, there were less hospitalizations and a slower slope of renal function decrease.

Phenotype and genotype characterization of adenine phosphoribosyltransferase deficiency.

Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive disorder causing 2,8-dihydroxyadenine stones and renal failure secondary to intratubular crystalline precipitation. Little is known regarding the clinical presentation of APRT deficiency, especially in the white population. We retrospectively reviewed all 53 cases of APRT deficiency (from 43 families) identified at a single institution between 1978 and 2009. The median age at diagnosis was 36.3 years (range 0.5 to 78.0 years). In many patients, a several-year delay separated the onset of symptoms and diagnosis. Of the 40 patients from 33 families with full clinical data available, 14 (35%) had decreased renal function at diagnosis. Diagnosis occurred in six (15%) patients after reaching ESRD, with five diagnoses made at the time of disease recurrence in a renal allograft. Eight (20%) patients reached ESRD during a median follow-up of 74 months. Thirty-one families underwent APRT sequencing, which identified 54 (87%) mutant alleles on the 62 chromosomes analyzed. We identified 18 distinct mutations. A single T insertion in a splice donor site in intron 4 (IVS4 + 2insT), which produces a truncated protein, accounted for 40.3% of the mutations. We detected the IVS4 + 2insT mutation in two (0.98%) of 204 chromosomes of healthy newborns. This report, which is the largest published series of APRT deficiency to date, highlights the underdiagnosis and potential severity of this disease. Early diagnosis is crucial for initiation of effective treatment with allopurinol and for prevention of renal complications.

Hemolysis in a patient with alkaptonuria and chronic kidney failure.

In alkaptonuria, the absence of homogentisic acid oxidase results in the accumulation of homogentisic acid (HGA) in the body. Fatal disease cases are infrequent, and death often results from kidney or cardiac complications. We report a 24-year-old alkaptonuric man with severe decreased kidney function who developed fatal metabolic acidosis and intravascular hemolysis. Hemolysis may have been caused by rapid and extensive accumulation of HGA and subsequent accumulation of plasma soluble melanins. Toxic effects of plasma soluble melanins, their intermediates, and reactive oxygen side products are increased when antioxidant mechanisms are overwhelmed. A decrease in serum antioxidative activity has been reported in patients with chronic decreased kidney function. However, despite administration of large doses of an antioxidant agent and ascorbic acid and intensive kidney support, hemolysis and acidosis could not be brought under control and hemolysis led to the death of the patient.

Renal biopsy practice in France: results of a nationwide study.

BACKGROUND: Although several risk factors associated with complications after renal biopsy (RB) have been identified, the gold standard for RB procedures remains to be defined. Practices vary widely among nephrologists, depending on personal experience and the availability of particular techniques. The purpose of our study was to depict the main aspects of the practice of RB in adults in France. METHODS: Members of the Société de Néphrologie in France were asked to participate in a questionnaire survey on RB procedures. RESULTS: Eighty-eight nephrologists from 74 units (27 in teaching hospitals, 35 in public general hospitals and 12 in private centres) participated in our study. Native kidney and graft biopsies were performed in 73 and 35 units, respectively. RB activity was highly variable among units, ranging from several hundred to <10 per year. Transjugular renal biopsy was judged to be smoothly accessible in 28 out of 73 units (38.4%). Significant variations in practices were observed regarding patient information before RB, assessment of haemorrhagic risk factors, management of patients with antiplatelet agents and haemorrhagic risk factors, and radiological guidance. Early discharge (<12 h) was the rule in 3 (4.1%) units for native kidney biopsies and in 10 (28.6%) units for graft biopsies. CONCLUSIONS: Our study is the first to provide a representative picture of 'everyday' RB practices in a country. Important variations in procedures were observed. Our study may represent a preliminary step for the elaboration of guidelines for all aspects of RB practices.

[Epidemiology of acute renal failure]. / Épidémiologie de l'insuffisance rénale aiguë.

The acute renal failure is common in the hospitalized patients with the incidence is increasing. This results from the aging of the population and the widespread use of nephrotoxic therapies or diagnostic techniques. The acute renal failure is associated with an increased length of stay in hospital and the short and long-term mortality. The most common histological injury is the acute tubular necrosis. Although the most of acute renal failure is recovering, recent works have shown that there is a strong association between an acute renal failure and the increased risk of developing a chronic kidney disease.

Do antibiotics administered at the time of central venous catheter removal interfere with the evaluation of colonization?

OBJECTIVE: Catheter colonization is commonly used as an end point in studies on central venous catheter (CVC) infections. This study aimed at comparing the rates of catheter colonization in patients according to the administration of antibiotics at removal. DESIGN: Prospective study over a 5-year period. All patients with a CVC removed without suspicion of CVC infection were included. SETTING: An adult medical/surgical intensive care unit at a university teaching hospital. PATIENTS: A total of 472 patients with CVC inserted for a mean CVC duration of 6.0 +/- 3.7 days were included. METHODS: Antibiotics at removal was defined as antibiotics administered within 48[Symbol: see text]h before CVC removal, and CVC colonization as catheter tip culture yielding > or = 10(3) colony-forming units per milliliter. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Of 472 patients, 302 (64%) were receiving antibiotics at removal. The number of CVC colonizations per number of CVCs inserted was 4.7% (22 of 472) and the number of CVC colonizations per 1000 CVC days was 8.0. Administration of antibiotics at removal was associated with a lower risk of CVC colonization. Irrespective of CVC duration, CVC colonization rate differed between patients with or without antibiotics at removal (Kaplan-Meier test, p=0.04). CONCLUSIONS: The proportion of patients with antibiotics at time of removal should be taken into account when interpreting the results of surveys and trials using the quantitative CVC tip culture to define CVC colonization as an end point.

Catheter colonization in acute renal failure patients: comparison of central venous and dialysis catheters.

BACKGROUND: Little is known about vascular access infections in patients with acute renal failure. METHODS: We prospectively compared infection rates of dialysis catheters (DCs) and central venous catheters (CVCs) in patients in the intensive care unit treated with renal replacement therapy for acute renal failure. The same insertion and maintenance procedures were used for CVCs and DCs. To circumvent the allocation bias caused by severity of patient condition, only patients with both types of catheters were included. RESULTS: A total of 150 CVCs and 130 DCs were analyzed in 99 patients with a mean Simplified Acute Physiology Score II of 67 +/- 21. The major cause of acute renal failure was sepsis (62%). Hospital mortality was 62%. Mean catheter duration was shorter for DCs (6.7 +/- 4.4 days) than CVCs (7.8 +/- 4.9 days; P = 0.03). There was no difference between CVCs and DCs in cumulative incidence of catheter colonization (quantitative catheter cultures > or = 10(3) colony-forming units/mL; 4.7% versus 6.2%; P = 0.58) or incidence density of catheter colonization per 1,000 catheter days (5.9 versus 9.1; P = 0.44, respectively). There also was no difference between CVCs and DCs in cumulative incidence and incidence density regardless of whether catheters were placed at the internal jugular (P = 0.34 and P = 0.23) or femoral site (P = 0.57 and P = 0.80), respectively. Three cases of CVC-related bacteremia (the same microorganism responsible for both catheter colonization and blood culture result) were recorded, but none with DC use. CONCLUSION: When severity of patient condition is controlled for, epidemiological characteristics of colonization in CVCs and DCs are similar if similar infection control measures are used for insertion and maintenance.

Fermentable carbohydrate supplementation alters nitrogen excretion in chronic renal failure.

BACKGROUND: Considerable attention has been given to the impact of nutrition on kidney disease. Most dietary attempts to treat chronic renal failure (CRF) and to decrease uremia use a protein restriction. An alternative dietetic approach based on fermentable carbohydrate (FC) supplementation of the diet could lead to the same urea-lowering effect by increasing urea nitrogen (N) excretion in stool, with a concomitant decrease of the total N quantity excreted in urine. METHODS: In the present prospective study, the impact of FC (40 g/d) on uremia and on N excretion routes was investigated during 5 weeks in nine CRF patients in the presence of a moderated restrictive protein diet (0.8 g/kg/d). Patients were their own controls and were treated by the cross-over method after randomization (5 weeks with FC versus 5 weeks without FC). RESULTS: Feeding FC significantly increased the quantity of N excreted in stool from 2.1 +/- 0.8 to 3.2 +/- 1.1 g/d (+51%) (P < .01) and decreased, in parallel, the urinary N excretion from 9.4 +/- 1.7 to 8.3 +/- 1.4 g/d (-12%) (P < .01). The total N quantities excreted by the two routes were unchanged by the FC, which shows that the FC was efficient to shift N excretion from the urinary route toward the digestive route. As a result of the increase of urea transfer into the colon, the plasma urea concentration was significantly decreased from 26.1 +/- 8.7 to 20.2 +/- 8.2 mmol/L (-23%) (P < .05). CONCLUSIONS: These results show the same beneficial effects in CRF as those obtained with a restrictive protein diet without its nutritional drawbacks. This should be confirmed by other prospective works over a longer duration and a larger number of patients to study the effects of FC on CRF progression and on CRF terminal stage tolerance.

Characteristic pattern of chromosomal imbalances in posttransplantation lymphoproliferative disorders: correlation with histopathological subcategories and EBV status.

BACKGROUND: Posttransplantation lymphoproliferative disorders (PTLDs) are a spectrum of lymphoid proliferations, occurring in immunosuppressed organ transplant recipients. They comprise early lesions, polymorphic (P-PTLD), monomorphic (M-PTLD), and Hodgkin/Hodgkin-like lymphoma PTLD (HL-PTLD) lesions. Most of them are associated with Epstein-Barr virus (EBV). Little is known about their genetic changes. MATERIALS AND METHODS: We have studied 35 PTLDs[7 P-PTLDs (3/7 polyclonal IgH), 26 M-PTLDs (22 B-cell PTLD, 4 T-cell PTLD), 2 HL-PTLDs], using comparative genomic hybridization (CGH), a DNA-based technique allowing a screening of chromosomal imbalances without needing cultured cells. RESULTS.: Overall incidence of chromosomal imbalances: 51.5 %. The most frequent gains involved 8q24, 3q27 [4 cases each]; 2p24p25, 5p, 9q22q34, 11, 12q22q24, 14q32, 17q, 18q21 [2 cases each]. Nonrandom losses were 17p13 [4 cases]; 1p36, 4q [3 cases each]; 17q23q25, Xp [2 cases each]. Three high-level amplifications were detected: 4p16, 9p22p24, 18q21q23. In this latter imbalance, involvement of Bcl2 has been confirmed by FISH. The nonrandom CGH imbalances occurring in M-PTLD are usually described in lymphomas of immunocompetent patients and contain genes known to be involved in lymphomagenesis, while genomic abnormalities detected in half cases of EBV positive P-PTLD are mostly unknown. CONCLUSION: This study reported nonrandom chromosomal imbalances in PTLD and also identified early genomic alterations in EBV positive P-PTLD. These results raise two questions: the role of such lesions in the development and progression of those EBV induced-lymphoproliferations and their clinical significance especially in P-PTLD.

Energy expenditure, spontaneous physical activity and with weight gain in kidney transplant recipients.

BACKGROUND & AIMS: Alterations in energy metabolism could trigger weight gain after renal transplantation. METHODS: Nineteen transplanted non-diabetic men, 53 ± 1.6 years old, receiving calcineurin inhibitors but no corticosteroids were studied. They were compared with nine healthy men matched for height, age and lean body mass. Daily energy expenditure and its components (sleeping, basal and absorptive metabolic rates) were analyzed for 24 h in calorimetric chambers and for 4 days in free living conditions using calibrated accelerometry. Other variables known to influence energy expenditure were assessed: body composition, physical activity, 4-day food intake, drug consumption, serum C-reactive protein, interleukin-6, thyroid and parathyroid hormones, and epinephrine. Transplant recipients who gained more than 5% body weight after transplantation (n = 11, +11.0 ± 1.5 kg) were compared with those who did not (n = 8) and with the controls. RESULTS: Weight gain compared with non-weight gain patients and controls exhibited higher fat mass without change in lean body mass. Daily, sleeping and resting energy expenditure adjusted for lean body mass was significantly higher in non-weight gain (167.1 ± 4.2 kJ/kg/lean body mass/24 h, P < 0.05) compared with weight gain patients (147.4 ± 3.6) and controls (146.1 ± 4.6). Weight gain compared with controls and non-weight gain subjects had lower free living physical activity and a higher consumption of antihypertensive drugs and ß-blockers. CONCLUSIONS: After kidney transplantation, weight gain patients were characterized by lower adjusted energy expenditure, reduced spontaneous physical activity but a more sedentary life style and a trend toward a higher energy intake explaining the reason they gained weight. The nWG KTR had increased resting and sleeping EE which protected them from weight gain. Such hypermetabolism was also observed in 24-h EE measurements. By comparison with the nWG patients, the WG transplant recipients were characterized by higher ß-blocker consumption. These data could be helpful in the prevention of weight gain in kidney transplant recipients.

Flow cytometric evaluation of pregnancy-induced anti-HLA immunization and blood transfusion-induced reactivation.

BACKGROUND: Pregnancy-induced alloimmunization (PIA) may decrease to a level that becomes undetectable by complement-dependent cytotoxicity (CDC). Nevertheless, such alloimmunization may provoke acute rejections after kidney transplantation and lead to broad-spectrum immunizations after transfusion. Flow-cytometry (FC) was used to estimate the frequency of low-level PIA and to evaluate its influence on posttransfusion alloimmunization profiles. METHODS: To evaluate the frequency of low-level PIA, the sera of 36 women, free of CDC-detectable anti-HLA IgG (CDC-IgG- negative), were cross-matched by FC against their husband's or offspring's lymphocytes and further analyzed with human leukocyte antigen (HLA) Ag-coated microbeads (Flow-PRA One-Lambda, Canoga Park, CA). To evaluate the influence of low-level alloimmunization on posttransfusion appearance of CDC-IgG, pretransfusion sera of a second cohort of 43 women, also CDC-IgG-negative and included in a transfusion protocol, were analyzed by Flow-PRA. Posttransfusion sera were analyzed for the development of cytotoxic IgG. RESULTS: Ten of the first cohort of 36 (27.8%) CDC-IgG-negative women showed a positive FC cross-match against the husband or offspring lymphocytes. Flow-PRA analysis confirmed that 9 of 10 positive cross-matched sera contained anti-HLA IgG. Among the 43 transfused patients, 11 of 16 (68.7%) of the women who were CDC-IgG-positive after blood transfusion showed FC-detectable IgG before transfusion; although 2 of 27 (7.4%) of the patients who remained CDC-IgG-negative after transfusion showed FC-detectable IgG before transfusion (P <0.001). CONCLUSION: Most of the de novo anti-HLA immunizations detected by CDC after transfusion in previously pregnant women can be detected by Flow-PRA before transfusion.

[Acute renal failure in the elderly]. / Insuffisance rénale aiguë du sujet âgé

Acute renal failure in elderly patients is common and likely to become more so as life expectancy in France continues to grow. The chances of acute renal failure occurring in the elderly are increased by changes in renal function and the effects of various chronic diseases such as diabetes, hypertension and obstructive urological disorders, all of which increase in incidence with age. The elderly may develop all types of the disease but are most prone to drug-related acute renal failure. The diagnostic and therapeutic strategies adopted are the same as those for adult patients but should take into account the potential risks and benefits in this specific age group. However, age should no longer be considered as the sole determining factor in diagnostic and therapeutic decisions. The elderly are among those who benefit most from preventive measures against acute renal failure.

[Renal biopsy practice: results of a French study and recommendations]. / Pratique de la biopsie rénale: résultat d'une enquête en France, revue de la littérature et recommandations.

BACKGROUND: Although several risk factors associated with complications after renal biopsy (RB) have been identified, recommendations for RB procedures are still lacking. Our working group, appointed by the scientific commission of the Société de néphrologie in France, aimed to depict the main aspects of the practice of RB in adults in France, before establishing some guidelines. METHODS: Members of the Société de néphrologie in France were asked to participate to a questionnaire survey on RB procedures. RESULTS: Eighty-eight nephrologists from 74 units (27 in teaching hospitals, 35 in public general hospitals, and 12 in private centers) participated in our study. Native kidney and graft biopsies were performed in 73 and 35 units, respectively. RB activity was highly variable among units, ranging from several hundred to less than ten per year. Transjugular RB was judged to be smoothly accessible in 28 out of 73 units (38.4%). Significant variations in practices were observed regarding patient information before RB, assessment of hemorrhagic risk factors, care of patients with antiplatelet agents and hemorrhagic risk factors, and radiological guidance. Early discharge (<12 hours) was the rule in three (4.1%) units for native kidney biopsies and in ten (28.6%) units for graft biopsies. CONCLUSIONS: Our study is the first to provide a representative picture of "everyday" RB practices in a country. Consensual recommendations on all points mentioned are provided here.

A rare cause of abdominal compartment syndrome: acute trichlorethylene overdose.

INTRODUCTION: The clinical signs of acute trichlorethylene overdose are commonly coma, cardiac conduction disturbances, diarrhea, and vomiting. We report a case of intentional massive trichlorethylene ingestion inducing a fatal abdominal compartment syndrome (ACS). CASE REPORT: A 47-year-old woman was admitted to the emergency department after intentionally ingesting 500 mL of trichlorethylene and benzodiazepines. She rapidly developed coma and abdominal distension leading to multiple organ failure. Subsequent surgical evaluation revealed abdominal perforation and necrosis, and life-sustaining treatments were therefore withdrawn. DISCUSSION: This is a primary ACS that can be explained from experimental data on the pathophysiology of pneumatosis cystoides coli. For this case, we discuss multiple etiological factors for intra-abdominal hypertension (IAP), such as paralytic ileus and massive fluid resuscitation due to the direct toxicity of ingested trichlorethylene. CONCLUSION: Patients ingesting trichlorethylene need to be closely evaluated for risk of digestive damage and perforation. Early prompt laparotomy must be performed in cases of ACS.

The appropriateness of renal angioplasty. The ANPARIA software: a multidisciplinary expert panel approach.

Percutaneous transluminal renal angioplasty (PTRA) is an invasive technique that is costly and involves the risk of complications and renal failure. The ability of PTRA to reduce the administration of antihypertensive drugs has been demonstrated. A potentially greater benefit, which nevertheless remains to be proven, is the deferral of the need for chronic dialysis. The aim of the study (ANPARIA) was to assess the appropriateness of PTRA to impact on the evolution of renal function. A standardized expert panel method was used to assess the appropriateness of medical treatment alone or medical treatment with revascularization in various clinical situations. The choice of revascularization by either PTRA or surgery was examined for each clinical situation. Analysis was based on a detailed literature review and on systematically elicited expert opinion, which were obtained during a two-round modified Delphi process. The study provides detailed responses on the appropriateness of PTRA for 1848 distinct clinical scenarios. Depending on the major clinical presentation, appropriateness of revascularization varied from 32% to 75% for individual scenarios (overal 48%). Uncertainty as to revascularization was 41% overall. When revascularization was appropriate, PTRA was favored over surgery in 94% of the scenarios, except in certain cases of aortic atheroma where sugery was the preferred choice. Kidney size [7 cm, absence of coexisting disease, acute renal failure, a high degree of stenosis (C70%), and absence of multiple arteries were identified as predictive variables of favorable appropriateness ratings. Situations such as cardiac failure with pulmonary edema or acute thrombosis of the renal artery were defined as indications for PTRA. This study identified clinical situations in which PTRA or surgery are appropriate for renal artery disease. We built a decision tree which can be used via Internet: the ANPARIA software (http://www.chu-clermontferrand.fr/anparia/). In numerous clinical situations uncertainty remains as to whether PTRA prevents deterioration of renal function.