Pellagra: unusual cause of paranoid delirium in dialysis.

A 60-year-old woman treated by maintenance haemodialysis refused to take part of the usual vitamin supplements for many years. After an intercurrent illness with profound malnutrition, she developed a paranoid delirium and some behavioural disorders; concomitant diarrhoea and a skin rash were noted. Parenteral nicotinamide (500 mg/day) resulted in a complete recovery from the mental disorders after five days. Other causes of mental disturbance as a result of dialysis could be ruled out. However an asymptomatic underlying hypothyroidism may have been one of the conditioning factors as well as the failure to administer nicotinamide supplements during an acute illness. Neurological pellagra could thus be considered as a rare but reversible cause of mental disorders in patients on maintenance haemodialysis.

[Costolumbar pain, aneurysm of the renal artery and hypertension]. / Douleur costo-lombaire, anévrysme de l'artère rénale et hypertension.

Thrombosis of a renal artery aneurysm had provoked renal atrophy and secondary renovascular hypertension in a patient in whom rapid diagnosis was not possible from the abdominal symptomatology and results of biological tests. Investigation of lumbar pain should therefore include an IVU with or without subsequent renal arteriography, the rapid execution of these examinations being of primordial importance. Treatment was by nephrectomy, which allowed hypertension to be controlled and risks related to the aneurysm avoided.

Pulmonary hypertension associated with portal thrombosis.

Pulmonary hypertension accompanying portal hypertension is a rare cause of plexogenic pulmonary arteriopathy, which etiopathogenesis is still unknown. The case report presented is that of a young man who underwent surgery at age 8 for ruptured esophageal varices associated with portal thrombosis, and who later developed pulmonary hypertension which led to death at age 21. Hepatic filtration shunt and similarity of this syndrome to pulmonary hypertension subsequent to ingestion of the appetite depressant Aminorex suggest the hypothesis that pressor substances, not detoxified by the liver, are released into the pulmonary circulation.

Infections associated with subclavian dialysis catheters: the key role of nurse training.

Two hundred subclavian dialysis catheters were placed in 148 patients who kept them in place for a total of 2,798 days. Catheterization time ranged from 1 to 79 days with an average of 14.0 +/- 1.0 days per catheter and 18.9 +/- 1.0 days per patient. Twenty nine catheters were infected, 17 of which were the source of bacteremias due to Staphylococcus epidermidis in 13 cases and to Staphylococcus aureus in 4 cases. The incidence of sepsis was not significantly greater in diabetic patients, in patients with corticotherapy or in patients presenting an underlying systemic disease. On the contrary, the incidence was greater in hospitalized patients (15 bacteremias during 1,948 catheter days) than in ambulatory patients (2 bacteremias during 850 catheters-days) as well as during a period corresponding to a greater number of untrained nurses enrolled in the dialysis team. During this period, 6 sepsies occurred in 19 catheters (other periods: 7 sepsies/116 catheters, p less than 0.01). 6 of 28 nurses had less than 3 months of professional experience (other periods: 1 of 25, p less than 0.01). These data underline the key role of nurse training in the prevention of catheter-related infections.

Complications related to subclavian catheters for hemodialysis. Report and review.

Personal experience with subclavian vein cannulations for hemodialysis are given, and the pertinent literature on the subject is reviewed. Two hundred subclavian dialysis catheters were placed in 148 patients who kept them in place for a total of 2,798 days. Immediate complications were two pneumothoraxes and two hemothoraxes due to subclavian artery puncture. Seventeen cases of bacteremia were related to subclavian catheter infections. In 1 case, a complication of sepsis was a vertebral osteomyelitis. Clinical evidences of subclavian vein thrombosis occurred in 5 cases. Life-threatening complications were met in 2 cases: 1 with pericardial tamponade due to right atrium perforation and 1 with mediastinal hematoma and right hemothorax due to superior vena cava perforation. Review of the literature indicates that pneumothoraxes and/or hemothoraxes occurred in 1.7% of the catheter insertions and that sepsis related to subclavian dialysis catheters occurred in 8.9% of the patients. As systematically investigated subclavian vein thrombosis involved at least 50% of the patients. Our 2 personal cases of life-threatening complications and 14 similar cases of the literature were analyzed: left subclavian catheters were associated with superior vena cava perforation with right hemothorax or mediastinal hematoma, while right subclavian catheters gave atrial perforation with pericardial tamponade. Death occurred in 3 of 16 cases, and emergency surgery was required in 5 of 16 cases. Taking into account all these complications, recommendations are made for the use of subclavian dialysis catheters.