[Antihypertensive action of indapamide in hypertension of chronic renal failure]. / Action antihypertensive de l'indapamide dans l'hypertension de l'insuffisance rénale chronique.

Indapamide, a molecule with moderate diuretic effect, is an efficient antihypertensive drug. Blood pressure control is mostly explained by a direct action on peripheral vascular resistance. This action on peripheral resistances, as opposed to that on sodium balance, has rarely been indisputably substantiated. In order to dissociate its diuretic effect from its activity on peripheral resistances, we undertook a study on the efficacy of adding indapamide to the antihypertensive regimen of 12 patients suffering from chronic renal failure complicated by hypertension, and in whom control of high blood pressure had not been achieved with one to four antihypertensive drugs, plus furesemide in case of overhydration. Renal insufficiency was defined by serum creatinine levels of (m +/- SD) 271 +/- 171 mumol/l and a glomerular filtration rate of 36.7 +/- 18.6 ml/min. Before indapamide was introduced, blood pressure was 172.4 +/- 23.1 mmHg/109.6 +/- 9.55 mmHg. After 1 to 6 months of treatment, blood pressure was normalised. Systolic BP was 141.6 +/- 19 mmHg (p < 0.001) and diastolic BP was 89.7 +/- 8.6 mmHg (p < 0.001). Absence of diuretic effect and/or of modification of water and electrolytes was verified by the stability of body weight and serum electrolytes. At end point, body weight, electrolytes and renal function were unchanged. This study confirms that indapamide exerts an antihypertensive effect by lowering peripheral vascular resistances and not by diminishing the volume of extracellular fluid. Indapamide can be listed among antihypertensive agents that are advisable in the treatment of high blood pressure in patients with chronic renal insufficiency. Its antihypertensive effect in such patients is independent of any natriuretic action.

[Clinical description of acute pyelonephritis]. / Description clinique de la pyélonéphrite aiguë.

Acute pyelonephritis is frequent. Its usual signs and symptoms comprise renal pain, fever, inflammation, and presence of germs and leukocytes in the urine. Primary acute E. coli pyelonephritis is frequent in the young female and in most cases is a benign condition. Atypical pyelonephritis may be painless, or without high fever, or lacking bacterial growth in the urine owing to previous inappropriate treatment. Severe pyelonephritis is mainly observed in diabetic, alcoholic or immunocompromised patients. In occasional cases, a common form of pyelonephritis may develop to formation of a renal abscess requiring drainage. When secondary to urinary tract abnormalities, pyelonephritis may be complicated with septicaemia and can induce early and severe renal tissue damage. This form warrants early urological treatment. The common pyelonephritis of the young female without previous history of febrile urinary tract infection requires little imaging. Conversely, extensive uroradiological workup is mandatory in the very young and the elderly, in the male, when treatment is not rapidly effective or in case or early relapse. In some cases, pyelonephritis leads to the development of cortical scars, the long-term prognosis of which remains to be determined.

Treatment of adult idiopathic nephrotic syndrome with cyclosporin A: minimal-change disease and focal-segmental glomerulosclerosis. Collaborative Group of the French Society of Nephrology.

Two open studies were conducted to determine the efficacy and tolerance of cyclosporin A (CyA, Sandimmun) 5 mg/kg/day. Sixty-four patients received CyA as monotherapy, and efficacy was assessed at three months; in 48 other patients, CyA was given with prednisone 12-15 mg/kg/day, and efficacy was assessed at six months. Of these 112 patients, 14 withdrew prematurely because of adverse events or other reasons, and a further nine patients were excluded for protocol violation. The remaining 98 patients were considered valid for the evaluation of efficacy (52 with minimal-change disease [MCD] and 46 with focal-segmental glomerulosclerosis [FSGS]; 37/98 were steroid-dependent [SD], and 61/98 were steroid-resistant [SR]). The remission:failure rate depended on histology (36:16 in MCD, 11:35 in FSGS) and steroid response (25:12 in SD, 22:39 in SR). The rate of remission was highest in SD MCD (71%) and lowest in SR FSGS (20%; chi square = 18.6, p less than 0.001). Tolerance was assessed by serum creatinine and, in 36 cases, by repeat renal biopsy at six to 42 months. Serum creatinine was remarkably stable in MCD. Rising creatinines were observed mostly in cases of SR FSGS, particularly those who had pretreatment interstitial lesions; this was considered due to both an increase of interstitial lesions and progression of the glomerular lesions of FSGS.(ABSTRACT TRUNCATED AT 250 WORDS)

[Atypical forms of primary acute pyelonephritis]. / Les formes atypiques des pyélonéphrites aiguës primitives.

In acute "primary" pyelonephritis (APP), kidney infection occurs despite normal urinary tract morphology. Typical features of APP are spiking fever and chills, loin pain, pyuria, bacteriuria, isolation of uropathogenic strains of E. coli, and specific renal CT scan images. APP may be atypical when lacking pain, or fever, or when urine cultures are negative, or when urinary bacteria do not exhibit characters of uropathogenicity, or when CT scan examination is negative. Such atypical features entail loss of time in diagnosis, and thereby delayed treatment and increased risk of cortical scar formation. However, they are virtually never observed simultaneously in a given patient.

Frequency of development of early cortical scarring in acute primary pyelonephritis.

Fifty-five cases of primary (that is, without urinary tract abnormalities), acute pyelonephritis (PN) were studied by computed tomodensitometry (CT). There were 48 women and 7 men. All were febrile and 16 had positive blood cultures. In 7 cases, (4 diabetics and 3 malnourished alcoholics) PN was painless, diagnosis was delayed and lesions were severe. Two diabetics underwent emergency nephrectomy for sepsis. Conventional radiological techniques (IVP and ultrasonography) were poorly informative. In contrast, initial CT abnormalities were visible in 44 patients. They consisted of triangular or round hypodense images, diffuse hypodensity in a grossly swollen kidney, and/or abscesses. Hypodense images were presumably due to acute focal ischemia. Renal histology was available in five patients. It showed acute interstitial nephritis with leukocyte infiltrates, edema and hemorrhagic streaks. Pyelonephritis was due to E. coli in 48 cases (87.5%). In 27 cases E. coli isolates were studied by genotypic assays which detect the three most frequent (pap, afa and sfa) of the four operons known to encode adhesin. In all cases, at least one of these genotypic markers of uropathogenicity was found. In 27 cases, repeat CT was done shortly after treatment. It showed healing in only 12. Early cortical scar formation was visible in 2. Final evaluation in 27 cases with adequate follow-up showed that (in addition to the 2 patients who had been nephrectomized), in only 17 of 27 (63%) had the kidneys recovered a normal appearance. In two cases one kidney had undergone atrophy; renal biopsy showed subacute-chronic interstitial nephritis.(ABSTRACT TRUNCATED AT 250 WORDS)