[Renal transplantation using a Maastricht category III non-heartbeating donor: First French experience and review of the literature]. / Transplantation rénale à partir d'un donneur décédé par arrêt circulatoire Maastricht III : première expérience française et revue de la littérature.

In 2015, Annecy Hospital was the first French hospital to perform non-heartbeating organ donation from a Maastricht category III donor (patient awaiting cardiac arrest after withdrawal of treatment). Non-heartbeating organ donation (NHBD), performed in France since 2006, had initially excluded this category, due to ethical questions concerning end of life and treatment withdrawal, as well as technical specificities linked to this procedure. Grenoble University Hospital and Edouard-Herriot Hospital in Lyon then performed the first kidney transplants, with satisfactory outcomes in both recipients. This article presents the details and results of this new experience, challenging both on a deontological and organizational level. Functional outcomes of kidney grafts from NHBD are now well known in the literature and confirm their benefit for patients, with similar results to those from heartbeating donors (HBD). International experiences concerning specifically Maastricht category III NHBD are encouraging and promising.

[Non-heart-beating renal donors: organization in a non-university hospital]. / Prélèvement rénal sur donneur décédé par arrêt cardiaque (DDAC): organisation dans un centre hospitalier non universitaire.

INTRODUCTION: In 2011 in France, all kidneys from patients with brain death and from living donors cannot meet the demand for renal transplants. Since 2006, sampling protocols kidneys from non-heart-beating donors (NHBD) are developed to increase the number of renal transplants. The objective was to describe the organization of a protocol NHBD in a non-university hospital. MATERIALS AND METHODS: Patients with inclusion criteria of protocol NHBD of the Agency of Biomedicine were prospectively included between 1st July 2011 and 31 December 2012. The protocol data were comparable to national data. Vascular canulation was performed by urologists. The epidemiological, clinical and biological characteristics of patients included, the different times and deadlines of the protocol, and data of renal transplantation were collected and analyzed. RESULTS: Over the period of 18 months, 16 patients were included in the protocol NHBD, with a median age of 42 years, and 87.5% of males; 93.8% of patients made a cardiac arrest outside the hospital. The median duration of no-flow was 4.3 minutes (0; 23), the median time between the cardiac arrest and admission to hospital was 90 minutes (0; 116), the median time between the cardiac arrest and the start of the normothermic recirculation was 139 minutes (40; 150), and the median duration of normothermic recirculation was 212 minutes (186; 240). For urologists, the median duration of mobilization was 178 minutes and 97 minutes after 20 h. Twenty-four kidneys were collected (75%) and 22 kidneys were transplanted (91.7%). The median duration of cold ischemia was 9 h 12 (5 h 25; 18 h 02). No primary non-function of graft was observed. Delayed graft function was observed in 50% of cases and the median duration of dialysis was 2 days (0; 19). After 12 months of inclusion, our center accounted for 8% of the national census and 16% of transplanted kidneys NHBD. CONCLUSION: The involvement of rescue, coordination, anesthesiologists and urologists, and the concentration of jobs in our center have helped to minimize response times NHBD in the protocol for maximum quality of kidneys taken with transplant rates and results are very encouraging.

Itraconazole lung concentrations in haematological patients.

Itraconazole distribution is largely dependent on its high liposolubility. Intrapulmonary lung concentrations remain unknown in haematological patients. We report itraconazole lung concentrations in such patients treated with itraconazole. Itraconazole and hydroxyitraconazole were measured by high-performance liquid chromatography in concomitant blood samples and lung post-mortem biopsies (three cases) or lung lobectomy (one case). These itraconazole and metabolite lung concentrations were sufficient to be active on Aspergillus.

Acetate-free biofiltration for acute renal failure.

The characteristics of acetate-free biofiltration (AFB) are now well documented in patients with chronic renal failure: hemodynamic tolerance, correction of acid-base imbalance, buffer-free dialysate (without acetate) and absence of backfiltration. This hemodialysis technique can be beneficial to patients with acute renal failure (ARF). In our intensive care unit, we prospectively studied 29 patients with isolated ARF or ARF associated with failure of other organs. All eligible patients were randomly assigned to undergo dialysis with bicarbonate hemodialysis (BH) or with (AFB). All used the same high flux biocompatible dialysis membranes. Effectiveness and hemodynamic tolerance of hemodialysis sessions and evolution of patients were analyzed. Correction of metabolic disorders, although better in the AFB group was not statistically different from that in the BH group. Re-equilibration of acid-base balance was also similar, with or without mechanical ventilation. Heparin consumption was significantly higher in the AFB group, with no effect on haemorrhagic complications. Analysis of hypo- and hypertensive episodes, defined as arterial pressure (AP) variations 20% greater than initial pressure, showed no difference in terms of number or degree of AP variation. However, weight loss and the rate of ultrafiltration led to a higher hypotensive risk in the BH group (p < 0.05). Finally, the clinical course and prognosis was similar in both groups. In summary, AFB may be considered as effective a hemodialysis technique as BH in patients with ARF. Weight loss was better tolerated in the AFB group and can be a favorable factor considering the deleterious effect of overhydration in patients admitted to an intensive care unit. This study invites a comparison of longer dialysis session of AFB therapy and continuous hemodiafiltration.

Intensive regimen of cytokines with interleukin-2 and interferon alfa-2b in selected patients with metastatic renal carcinoma.

We conducted a Phase II trial using an intensive regimen combining interleukin-2 (IL2), interferon-alfa-2b (IFN), and lymphokine-activated killer (LAK) cells. The aim of this study was to evaluate the toxicity and the efficacy of this combination in selected patients with metastatic renal cell carcinoma. Thirty-one assessable patients were treated with at least one cycle of a regimen consisting of 20 x 10(6) IU/day s.c. IFN for 5 days, followed 2 days later by i.v. injections of 24 x 10(6) IU/m2/day IL2 every 8 h together with i.v. bolus of 5 x 10(6) IU/m2/day IFN every 8 h during 5 days. After a 6-day break, during which four leukophereses were performed, this i.v. combination was administered along with the LAK cell reinjections for a maximum of 5 days. Twenty-seven patients underwent the two parts of the first course of treatment; respectively, 42% and 46% of the planned dose of IL2 and IFN were administered. Several severe toxicities were observed including two treatment-related deaths. Significant tumor responses were observed in seven patients, including two complete remissions. Two of these patients remain alive without evidence of disease 36 and 40 months after treatment, respectively. This intensive regimen of IL2 together with IFN and LAK cells cannot be recommended even in selected patients with metastatic renal cell carcinoma. In addition, our results argue against the concept of a dose-response relationship in this setting.

[Acute respiratory insufficiency in sickle cell disease]. / Insuffisance respiratoire aigu au cours de la crise drépanocytaire.

Two cases are reported of acute respiratory failure occurring during sickling crises. In the first one, the crisis was characterised by priapism, and in the other one, by abdominal pain. The different causes of these respiratory effects are discussed: infection, fat embolism, pulmonary infarct, haemodynamic pulmonary oedema, as was probably the case in the first patient, or non haemodynamic pulmonary oedema due to sickling, as during conventional treatment of a sickling crisis (oxygen, antibiotics, blood transfusion, cytapheresis). Invasive investigations may contribute to keeping up the clinical picture, because of hypoxic sickling. The water equilibrium of these patients must be monitored with great care. Worsening of the patient's condition despite 48 h of correct treatment must lead to the search for a specific cause.