Ambulatory monitoring of blood pressure in normal pregnancy.

The definition of hypertensive disorders in pregnancy is plagued by many difficulties, in part related to the limits of intermittent clinic readings of blood pressure. In order to better define the evolution of arterial blood pressure in normal subjects during normal pregnancy, casual and ambulatory (Spacelabs 90207, n = 22 or Diasys 200, n = 26) measurements of blood pressure were performed at gestational months 3, 6, and 9, in 48 normal women aged 18 to 39, both nulliparas (n = 19) and multiparas (n = 29). Ambulatory blood pressure levels were lowest in the first gestational trimester (24-hour mean: 104 +/- 8/63 +/- 6 mm Hg) and rose by a small increment during the last trimester (109 +/- 8/67 +/- 7 mm Hg at 8 months). Mean daytime ambulatory pressure was almost superimposable to clinic measurements at the three time points. A day-night variation in blood pressure level was detectable in all subjects at each recording. It is concluded that during normal pregnancy, ambulatory blood pressure levels were highest in the day and lowest at night at all gestational ages and increased only minimally before the ninth month. Reference values, as defined by the percentile distribution of daytime and nighttime systolic and diastolic blood pressure, may help define more precisely an alteration in the level and/or the circadian variation of arterial blood pressure during abnormal pregnancies.

Continuous ambulatory peritoneal dialysis (CAPD) or center hemodialysis? Retrospective evaluation of the success of both methods.

In a retrospective study, the authors analysed the dialysis-technique success rate in 276 chronic renal patients. Of these, 137 patients have been treated with in center hemodialysis (CHD) from 1972 to 1989 and 139 with continuous ambulatory peritoneal dialysis (CAPD) from 1978 to 1989. The six-year technique success rate was 28% in CAPD and 31% in CHD (statistically not significantly different). Various risk factors influence the technique-success rate of both methods in the same way. The results suggest that in our center CAPD is as effective as CHD in the treatment of patients with end-stage renal failure.

Treatment of chronic renal failure: situation of CAPD.

The authors are using Continuous Ambulatory Peritroneal Dialysis (CAPD) in the treatment of chronic renal failure. Started in May 1978, their experience encompasses 19 patients (9 men, 10 women). The method, developed by Oreopoulos, consists of exchanging 2 liters of dialysate 4 times a day, 7 days a week. They report their clinical and biological results and the complications. The most frequent is peritonitis (1 episode per 9.3 patients months). The simplicity and the efficacy of CAPD permits them to treat 30% of the renal patients who need chronic dialysis.

Computerized patient management in a nephrology department.

An integrated approach is described for the computerized management of a nephrology department. On a medical point of view, the system comprises a minimum medical record for every patient, different specialized records and knowledge bases presently covering hypertension, diabetes and chronic renal failure. From a technical point of view, the methodology used integrates data and knowledge management techniques. Various individual reports facilitate patient management. For hypertensive patients, an expert system is combined with the record system. The results of a preliminary evaluation are reported and future developments considered.

[Decentralization of the ARTEMIS system in a nephrology service in a general hospital]. / Expérience de dècentralisation du système "ARTEMIS" dans un service de néphrologie en hôpital général.

"ARTEMIS" is a standardized and computerized medical file which is intended for improving the follow-up of hypertensive patients, the efficacy of treatment and for realising national-wide surveys. The software "LIED" of data base for "ARTEMIS" is nowadays transposable on mini-computer. In Nephrology Unit of General Hospital from Colmar, the system has been working since September 1985 with MICRO-MEGA E 32 (Thomson). The administrative and medical data are directly acquired by the doctors and secretaries of the Unit on a conversational mode from six terminals. There is no writing collecting of data. An evaluation of the system was realized with the 113 first hypertensive patients. The results were compared to those obtained from patients of Paris area.

Pharmacokinetics of cadralazine and its hydrazino-metabolite in patients with renal impairment after repeated administration of 5 mg once daily.

Since the hydrazino-pyridazine metabolite of cadralazine, CGP 22 639 is believed to contribute to the activity of the drug, its pharmacokinetics and that of cadralazine were investigated in 8 hypertensive patients with renal impairment. The creatinine clearance (CLcr) of patients ranged from 10 to 60 ml/min. The concentrations of cadralazine in plasma and urine, and of CGP 22 639 (plus its possible hydrazones) in plasma were measured after single and repeated administration of 5 mg of cadralazine once daily. A hypotension possibly linked to cadralazine treatment was recorded on day 3 for the patient with CLcr = 10 ml/min. Metabolite concentrations were found to be at least twice as high as in other patients indicating that in this patient, the daily dose of 5 mg was probably too high. The pharmacokinetics of cadralazine were not modified by repeated administration. The drug and its metabolite were eliminated more slowly in patients with low creatinine clearance. The t1/2 of CGP 22 639 was about twice the t1/2 of the unchanged drug. In patients whose CLcr ranged from 19-37 ml/min the mean accumulation factor of apparent CGP 22 639 was 1.7 times that of the unchanged drug. It shows that the apparent CGP 22 639 accumulated more than the unchanged drug. A starting daily dose of 2.5 mg of cadralazine in patients with CLcr < 40 ml/min appears to be suited to take into account the pharmacokinetics of CGP 22 639. This dose can be increased by 2.5 mg steps if the antihypertensive effect is not sufficient (maximum dose with CLcr < 40 ml/min: 10 mg).(ABSTRACT TRUNCATED AT 250 WORDS)

[Continuous ambulatory peritoneal dialysis in schizophrenia. Experimentation in 3 cases]. / La dialyse péritonéale continue ambulatoire chez les schizophrènes. Expérimentation dans trois cas.

The authors report their experience in using Continuous Ambulatory Peritoneal Dialysis (C.A.P.D.), in the treatment of chronic schizophrenia. This attempt refers to studies which confirm any role of endorphins in the origin of schizophrenia. Consecutively to american authors who found endorphins (molecular weight 3 300) in the dialysat of hemodialysed schizophrenics, they choose C.A.P.D. This continue technic of dialysis is more efficient than hemodialysis in removal of substances which molecular weight is between 1 500 and 5 000. This technic was used in 3 chronic schizophrenics: the disease has developed since 6 to 17 years and all the previous treatments failed. The duration of C.A.P.D. was 3 to 6 months. The only complication was one episode of inflammation of the peritoneum during 14 months of dialysis. Followed by the same staff with the AMDP 3 scale, the psychiatric evolution includes: --improvement and relapse in 2 patients (but we have to consider the difficulties of socioprofessional rehabilitation of these long term patients); --"clinical recovery" (17 months) in the third patient. The incidence of mothering and institutionalism is not negligible. Dosage of Met-enkephalin and beta-endorphin by radioimmunoassay in the drained dialysat did not show any difference between schizophrenics and the reference chronic renal patient. The results obtained with C.A.P.D. are not very satisfactory so far. But further research especially on the role of endorphins in schizophrenia and on their analysis technics in the body fluids perhaps will allow to treat schizophrenia again by dialysis.

[Evaluation of the control quality of arterial hypertension over a 10-year period at a hemodialysis center]. / Evaluation de la qualité du contrôle de l'hypertension artérielle pendant dix ans dans un centre d'hémodialyse.

Using the "Diaphane" computed medical record system enables multicentric statistical studies to be conducted. With this system, the quality of arterial hypertension control (supine systolic and diastolic arterial pressure before and after dialysis) was evaluated over a 10-year period in chronic haemodialysis patients in comparison with a multicentric population. A continuous statistical study of the results showed a regular voluntary decrease in arterial pressure. The evaluation of the quality of medical care represented by this comparison contributes to a therapeutic improvement.

[Continuous ambulatory peritoneal dialysis: the perfect dialysis?]. / La dialyse péritonéale continue ambulatoire: dialyse idéale?

Among the dialysis method, Continuous Ambulatory Peritoneal Dialysis (CAPD) is considered as simple, efficient, economical and giving autonomy to the patient. After more than ten year using Continuous Ambulatory Peritoneal Dialysis, results are evaluated. The method remains simple, but the obvious simplicity demands a strict medical control. It is efficient, but the hope in anemia and osteodystrophy correction is not confirmed. It offers more freedom but with a lot of restraints: the dietary restriction must be followed and there is only relative moving autonomia. It is economical, but the costs with the use of disconnectable systems which reduce morbidity, bring it near to the home hemodialysis.

["The Dialybre card". The minimum portable dialysis medical record. Results of the development phase]. / "La carte à mémoire Dialybre". Le dossier médical minimum portable du dialysé. Résultats de la phase de développement.

Dialybre is the research study on portable minimum medical records related to patients treated by hemodialysis. It uses the chip card, a new technology which makes relationships between health practitioners and patients easier. Since 1992, it is broadcasted in 15 hemodialysis centers. Evaluation of the development phase shows that despite its advantages, the chip card is not much used for the following reasons: usage not yet fully understood, lack of coherence in the computerized hospital information system, not enough card readers which are very costly, and a cultural lack of trust in any new technology. There is, more over, extra work involved for entering data in "Logidial" (computerized medical records) from where "Dialybre" is automatically updated.

[Acetate dialysate: responsible for decrease in ultrafiltration in continuous ambulatory peritoneal dialysis]. / Le dialysat à l'acétate: responsable de la perte de l'ultrafiltration en dialyse péritonéale continue ambulatoire.

The authors report the follow up of ultrafiltration in 45 chronic renal patients treated by continuous ambulatory peritoneal dialysis from May 1978 to August 1983. 31 patients have been using acetate buffered dialysate, 14 patients lactate buffered dialysate. Ultrafiltration obtained with acetate fluid has always been less important compared with lactate fluid (p less than 0,001). This decrease has been observed in all the acetate patients and has worsened as a function of duration of treatment, whereas it has only been observed in 14,3% of the lactate-dialysed patients.

[Continuous ambulatory peritoneal dialysis: results after more than 3 years]. / La dialyse péritonéale continue ambulatoire: bilan à plus de trois ans.

The authors report the result obtained with CAPD in 20 chronic renal patients treated during 4.6 years in average. The dialysis possibilities have maintained at middle term. Nevertheless, the awaited advantages concerning anemia, calcium and phosphorus disorders, neuropathy, are transient and incomplete. The water and sodium intakes need strongly to be controlled in order to achieve normal blood pressure. Finally the use of "Y" disconnect systems dramatically reduces the peritonitis rate.

[Local immunologic reactions induced by CAPD]. / Les réactions immunologiques locales induites par la DPCA.

During CAPD, the peritoneal cavity is submitted to situations such as the accidental bacterial contaminations and the continuous presence of dialysate, which stimulate immunological factors. The antibacterial defenses include opsonins and cells. Only IgG and fibronectin are present in the peritoneal effluent but they are diluted by the dialysate. Macrophages represent 70 to 80% of the peritoneal cells. Beside good phagocytic capacity, some may have a defective bactericidal activity. The continuous presence of dialysate leads to a chronic local inflammation. Macrophages and lymphocytes will synthesize IL-1, PGE2 and IFN-Y. These substances generate movement, attachment and proliferation of fibroblasts in the peritoneal submesothelial tissue, resulting in progressive fibrosis. This fibrosis, generally asymptomatic, may be responsible for loss of Ultrafiltration (UF) and Sclerosing Encapsulating Peritonitis (SEP).

[Daily hemodialysis of ultra-short duration with non-traumatic vascular access. Two cases]. / Expérience d'hémodialyse quotidienne ultra-courte avec abord vasculaire atraumatique. A propos de deux cas.

The authors report their experience on treating two patients, suffering end-stage renal disease, by daily hemodialysis of ultra-short duration with a non-traumatic vascular access. 90 minutes dialysis are realized 6 days a week. Clinical tolerance is excellent and patients' adhesion is satisfactory. However, despite reutilization of the dialyzer, the method remains costly.