[Interventions implemented to control an outbreak of vancomycin-resistant enterococci in a university hospital]. / Conduite adoptée face à une épidémie à ERG (ERV) dans un établissement de santé

At the end of 2004, a Vancomycin-resistant enterococci (VRE) outbreak occurred in the university hospital of Nancy. Interventions were simultaneous implemented in this hospital (promotion of hand washing, gathering of VRE carriers in the same part of units) and the outbreak seemed to be controlled before the end of 2005. But one year later, the number of discovered new colonisations increased again. Then, promotion of exclusive hand disinfection with alcohol-based hand-rub solutions and cohorting of VRE carriers in a dedicate ward were the only two effective interventions to control the outbreak. At the beginning of the year 2007, before being controlled, this outbreak expanded to several other healthcare centres in Lorraine. A specific regional team was set up in July 2007. A programme to eradicate VRE was elaborated based on national guidelines modified and adapted regarding particularities of each situation. These new guidelines were published on an internet site. A list of all healthcare centres accommodating patients colonized with VRE is established weekly and diffused to all hospitals in Lorraine which then could optimise readmission conditions of potential VRE carriers or contact patients. Between 2004 and 2008, more than 900 patients were found colonized with VRE in Lorraine. Finally, the application of all the measures previously described, seemed to be efficient to control the ERV outbreak in Lorraine.

[Control measures for a VRE outbreak in a haemodialysis unit]. / Mise en oeuvre de mesures visant à contrôler une épidémie de portage d'Entérocoques Résistants aux Glycopeptides dans un centre d'hémodialyse.

We report an outbreak of colonization with Vancomycin Resistant Enterococci (VRE) in the Haemodialysis unit of our hospital. From October 2004 to September 2008, 19 patients were found positive. The risk of acquiring this multi-resistant bacterium is extremely important in patients undergoing haemodialysis, heightened measures have gradually been set to control cross transmissions: first isolation, then geographic clustering of carriers and finally creating cohorting sectors with different staff for carriers, contacts and VRE free patients. This re-organization was supplemented by strengthening procedures for hand hygiene, active screening of patients and enhanced cleaning. Monitoring of the epidemic curve has allowed us to demonstrate the effectiveness of measures introduced. However, deleterious effects were observed in patients whose habits were changed; we could also highlight significant impact on the activity of the unit.

Successful surgical thrombectomy of renal allograft vein thrombosis in the early postoperative period.

We report the successful surgical treatment of two cases of renal vein thrombosis, each occurring early after kidney transplantation. Prompt intervention was a result of accurate diagnosis by color Doppler ultrasonography. Invasive radiological procedures were not useful. Although recent advances in thrombolytic therapy have created several alternatives to open surgery, the rationale for surgical exploration in these cases was to remove the thrombus quickly, to avoid the postoperative bleeding complications of thrombolytic therapy, and to correct any technical or anatomic problems.

Treatment of end-stage renal failure after heart transplantation.

BACKGROUND: Five to 10% of heart-transplant recipients develop end-stage renal failure (ESRF). Little is known about the outcome of these patients under renal replacement therapy. METHODS: We conducted a retrospective study in 16 men (mean age 52.8+/-7.4 years at heart transplantation) who developed ESRF 5.3+/-2.1 years later. Results. Haemodialysis (HD) was the first-line treatment (mean Kt/V 1.35+/-0.4). Vascular access was unsuccessful in six patients (37.5%) due to peripheral arteriopathy and they were treated with tunnelled catheters for an average 15 months without bacterial infection. Mean weight was 68.4+/-10 kg at onset of HD and 61.7+/-9 kg one month later. Despite this reduction in extracellular overload, one antihypertensive drug was required in 75% of patients and two drugs in 12.5%. One patient tolerated automated peritoneal dialysis (PD) for 16 months (weekly Kt/V 2.1) despite persistent anuria. Renal transplantation (RT) was contraindicated in eight patients because of aortoiliac arteriopathy (n=5), poor general status (n=2), or ischaemic heart disease (n=1). RT was performed in eight patients with no acute episode of heart or renal graft rejection. There were no serious infectious complications. Three months after RT, mean serum creatinine was 115 micromol/l. One patient developed post-transplant lymphoproliferative disorder 3.5 months after RT and was successfully treated with transplant nephrectomy. Sudden death occurred in two patients 18 and 33 months after RT. Overall patient survival was 100, 78, and 59%, 1, 2 and 3 years after HD onset respectively. Using a time-dependent variable, the Cox model analysis demonstrated that heart-transplant recipients with ESRF have a relative risk of death 3.2 times higher than those without ESRF (95% CI = 1.3-7.8). CONCLUSIONS: HD, PD, and RT can be useful for the treatment of ESRF after heart transplantation. After initiating HD, patient survival is nearly the same as that reported in patients in Europe undergoing HD for other causes. But ESRF seems to reduce life expectancy in heart-transplant recipients.

Elevated body lead burden from drinking water in end-stage chronic renal failure.

Delta aminolaevulinic acid dehydratase (ALA-D) who assayed in 66 patients with end-stage renal failure who live in a region where there is a high risk of lead poisoning from drinking water (Vosges mountains). Sixty patients received dialysis and six underwent renal transplantation. Results were compared to those obtained in 366 control subjects with normal renal function hospitalized in a department of Internal Medicine and living in the same geographical area. The ALA-D level was significantly lower in dialysed patients (0.40 +/- 20) than in controls (0.57 +/- 0.31) (P = 0.0014). Transplant recipients had ALA-D levels comparable to subjects with normal renal function (0.59 +/- 0.37). In this high-risk population an EDTA test was performed in 74 subjects (with normal renal function and 17 dialysis patients in combination with haemofiltration for the latter patients. In the two study groups a negative correlation was found between ALA-D and the amount of lead chelated during the 24 h following administration of EDTA (r = -0.77 and -0.88 respectively). In subjects who live in an area of endemic lead poisoning, the incidence of elevated body lead burden from drinking water was similar in the group with normal renal function and in the group of dialysed patients (18.6 and 8.3% respectively). This study shows (i) that in dialysis patients, measurement of ALA-D represents an accurate screening test for lead overload, provided that the lower threshold of normal is lowered from 0.40 to 0.20, and (ii) that diagnosis and treatment are possible by administering EDTA in conjunction with haemofiltration or CAPD.

[Incidence of hepatitis C virus in kidney transplantation recipients]. / Incidence du virus de l'hépatite C chez les transplantés rénaux.

The investigation was carried on 122 waiting renal transplantation hospitalized patients. Detection of HCV antibodies was done before transplantation and after renal transplantation. HCV antibodies were detected by immunosorbent assay (ELISA) for C 100-3 protein of HC virus (Lab. ORTHO). Positive results were checked by a second test (immunoblot RIBA II) to detect antibodies against C100-3, 5-1-1, C33, C22 proteins of HCV genome. Before transplantation, 112 patients were negative and 10 positive. After transplantation, 104 were checked: 103 had identical serology (93- and 10+); only one patient has shown a seroconversion six months after the transplantation, demonstrating the late apparition of HCV antibodies, but immunological status of donor was unknown. Renal transplantation does not seem a risk factor of HCV contamination: only 1 seroconversion on 122 patients or 0.8%: near percentage of French blood donors (0.68%). The percentage of positivity HCV before transplantation (9%) answered with that of European hemophils (5 to 20%). Second generation tests demonstrate a better sensibility and specificity than the first.

[Error of dialysis concentrate: a cause of severe metabolic acidosis not detected by certain generators]. / Erreur de concentré de dialyse: une cause d'acidose métabolique sévère non détectée par certains générateurs.

The authors report three cases of severe metabolic acidosis caused by errors of concentrate during hemodialysis "acide concentrate" instead of "acetate" bath. Symptoms began towards the second hour of the session with sickness and important vomits. Blood chemistries showed in all severe acidosis with hyperchloremia and hyperkaliemia while proper conductivity was obtained without alarm. Reconnection on dialysis with a correct bath was able to improve the above mentioned abnormalities. In vitro errors with different types of concentrates and machines have been simulated and the safeguards are discussed. The pH meter with alarm is proposed for all proportioning equipments, not only on "bicarbonate" generator but also on "acetate" delivery systems and especially in centers where these two types of concentrates are prescribed. Being vigilant remains nevertheless the best safeguard against human errors.

[Osteo-articular manifestations in dialysis of patients over 70 years]. / Manifestations ostéo-articulaires du dialysé de plus de 70 ans.

A clinical, biological and radiological prospective study was carried out in 21 patients over 70 years of age and treated by hemodialysis or chronic ambulatory peritoneal dialysis (CAPD) to evaluate the frequency and specificity of rheumatic diseases observed in aged chronic renal failure patients. Some are caused or favored by old age and are not in any way related to renal failure and its replacement therapy. Such was the case with arthrosis which was present in 85% of patients, ankylosing vertebral hyperostosis (14%), Paget's disease (5%) and gouty arthritis (10%). Elsewhere there is an implication between abnormalities due to aging and those linked to renal failure and/or dialysis, some of which can worsen or accelerate others. Secondary hyperparathyroidism seems less frequent in the elderly than in the young patients. Common vitamin dependent osteomalacia should not be neglected because it can be either prevented or efficiently treated. Osteoporosis is another important factor in osteopenia. Extra-skeletal calcifications are frequent: periarticular calcifications (38%), chondrocalcinosis (14%) and disc calcifications (24%). Dialysis arthropathy comprising: carpal tunnel syndrome, erosive lesions of large and intermediate limb joint articulations and destructive spondylarthropathy is observed in 43% of patients after an average dialysis period of 44 months. The advent of this complication seems to be quite early in the elderly, as compared to the young population, which confirms the role played by age as a favoring factor.

[Joint complications in patients with chronic renal failure hemodialyzed for over 10 years. 40 cases]. / Complications articulaires chez les insuffisants rénaux chroniques hémodialysés depuis plus de 10 ans. Quarante cas.

A retrospective study of 40 patients with chronic renal failure who underwent haemodialysis for more than 10 years (mean: 153 months) showed that 18 patients (45 p. 100) had arthralgia in the shoulders, hands, wrists and knees, 13 (32 p. 100) had carpal tunnel syndrome requiring surgery, and 20 (50 p. 100) were found to have bone cavities in the humeral head, external supra-acetabular region, carpus and patella. Aluminium overload was present in 47 p. 100 of the patients, and amyloid deposits were found in 10 of the 12 patient operated upon for carpal tunnel syndrome. This study confirms the frequency in patients under long-term haemodialysis of an articular pathological entity consisting of arthralgia, carpal tunnel syndrome, juxta-articular bone cavities and amyloid deposits which are now known to be made of beta 2-microglobulin. The initial lesion seems to affect the synovial membrane; it appears to be facilitated by age and is often associated with aluminium overload. The mechanism(s) responsible for amyloid deposits remain (s) to be elucidated.

[Treatment of lead poisoning by drinking water using hemofiltration and chelationin a hemodialysed anuric patient]. / Traitement par hémofiltration et chélation d'un saturnisme hydrique domestique chez une malade hémodialysée anurique.

Lead intoxication was diagnosed in April 1984 in an anuric woman of 65 years of age, whose hemodialysis had begun 9 years previously. Lead poisoning was completely cured by repeated hemofiltration with calcium EDTA. 28.2 mg of lead were extracted during 26 hemofiltration sessions. After the twentieth session, the rate of extracted lead was 500 micrograms per session and the rate of delta-aminolevulinic acid dehydrase was normalized. This exceptional observation allowed a nearly experimental study of the kinetics and metabolism of Ca EDTA chelated lead.