A methodology for consensus conferences. Société Royale Belge de Gastro-entérologie.

Consensus conference is one of the methods proposed to develop clinical practice guidelines. This method is used when the topic is limited to a small numbers of questions (4 to 6) and when there is a controversy. This process is based on the meeting of a jury which reviews the scientific information provided by the literature and presented by experts. The consensus conference consists of three phases: A preliminary phase during which questions are well defined, experts and jury are chosen by a panel of organizers usually designed by scientific societies. In the jury there are multidisciplinary specialists, generalists practitioners and other people such as nurses, economists, ... Experts conduct the review and analysis of the literature. The jury is informed by organizers about the methodology of a consensus conference and about the quality of scientific information available. The second phase is the plenary session of the consensus conference. It lasts one or two days during which the expert's texts and presentation are discussed by the jury and a public. The third phase is the actual meeting of the jury, behind closed doors, during which conclusions and clinical practice guidelines are formulated. Dissemination of these guidelines is one of the major factors determining the impact of the consensus conference. These guidelines are usually mailed directly to the professionals concerned and published in scientific journals and dissiminated via professional associations, universities, post graduate training bodies, ... The impact of the conference is assessed one or two years after and compared by the same method with the results of a preliminary survey before the conference. This process is long and expensive but is increasingly used because of the necessity for physicians to assimilate and to integrate into their daily clinical practice an increasing mass of scientific information.

Renal disease associated with HIV infection: a multicentric study of 60 patients from Paris hospitals.

Sixty HIV-infected patients presenting renal symptoms who underwent percutaneous renal biopsies were analysed. According to the CDC classification, 44 patients were staged in group IV, five in group III, and 11 in group II. Patients were divided in two groups according to their ethnic origin (29 black patients and 31 white patients). Risk factors such as homosexuality, multiple transfusions or intravenous drug abuse (IVDA) were identified in all white patients except two, but in only nine (31%) of the black patients. Three main patterns of renal disease were observed: focal and segmental glomerulosclerosis (FSGS) was found predominantly in black patients (23 black patients versus 3 Caucasians, P < 0.001) and was associated with the nephrotic syndrome; immune-complex-type glomerulonephritis (ICGN) was frequent in black and white patients (21% and 52% respectively) including four cases of IgA nephritis all seen in white patients; and 10 cases of lupus-like nephritis (4 black and 6 white patients). The frequent hypergammaglobulinaemia in those patients suggests a pathogenic role of polyclonal B cell activation in ICGN. Interstitial nephritis was present in 48 and 52% of the black and white patients respectively and did not seem related to drug toxicity or superimposed infectious disease. In addition to interstitial nephritis, the coexistence of multivisceral lymphocytic infiltration involving accessory salivary glands, liver and/or lung, found in six patients possibly suggests a virus-induced immune disorder.

Nephropathy associated with infection by human immunodeficiency virus: a report on 11 cases including 6 treated with zidovudine.

The human immunodeficiency virus (HIV) was recently suggested to be involved in generating kidney lesions in HIV-associated nephropathy (HIVN). The possibility that antiretroviral agents can slow down the usually explosive evolution of HIVN to end-stage renal failure (ESRF) has not been studied in many of the series of cases published. The present work is a retrospective analysis of 11 patients with histologically proven HIVN, 6 of whom were treated with zidovudine. Seven patients (group 1) either required dialysis at the outset, when HIVN was diagnosed, or progressed very fast to ESRF within 15-45 days. Two patients of this group were treated with zidovudine, but it had no effect on kidney function. In the remaining 4 patients (group 2), HIVN progressed more slowly than in group 1. All 4 patients were treated with zidovudine at an earlier stage of the disease than ESRF. Only 1 deteriorated to ESRF in 9 months. The 3 others, who did not have ESRF, were followed up for 13, 10 and 32 months, respectively. Although this is a preliminary study, its results do suggest that zidovudine can slow down the evolution of HIVN to ESRF. They highlight the need to screen HIV-positive patients regularly for proteinuria, in order to detect HIVN by renal biopsies at an early stage of renal lesion formation.

IgA polyspecific autoantibodies in IgA nephropathy.

The specificity of circulating and kidney-bound IgA during IgA nephropathy is still a matter of discussion. In the present study, high levels of IgA antibodies directed against a panel of self and non-self antigens were found in the serum from patients with IgA nephropathy and were eluted from four out of the seven kidney biopsies studied. After immunoadsorption of pooled selected serum samples on TNP and actin-coated columns, polyspecific IgA antibodies were eluted. This supports the hypothesis that IgA-bearing B cells clones most probably producing polyspecific antibodies are a major feature of human IgA nephropathy. These findings also suggest that it may be hazardous to draw conclusions from the finding of apparently monospecific IgA antibodies in this condition.

Experience with the Hemasite vascular prosthesis.

A 3-year experience with the no-needle vascular prosthesis Hemasite, implanted in 10 patients who underwent hemodialysis and have a long history of multiple vascular access failures, is described. During 182 months of follow-up study, 30 thromboses occurred, while nine of 10 patients did not receive any antiplatelet aggregant treatment. Hemasite was declotted 12 times with a local infusion of urokinase and 12 more times by thrombectomy. A surgical procedure was performed only in the other cases, and the rate of surgical intervention fell from 0.18 interventions per patient per month before Hemasite implantation to 0.027 after implantation.

Plasma exchange and immunosuppression for rapidly progressive glomerulonephritis: prognosis and complications.

Rapidly progressive glomerulonephritis frequently leads to death or dialysis. In 21 cases treated by plasma exchange and immunosuppression we observed seven deaths, with 12 others progressing to chronic renal failure within 3 months. Patients who died were older than those who survived (57.5 +/- 17.7 vs 40.5 +/- 16.5 years, mean +/- SD, P = 0.05), but had similar clinical symptoms (hypertension, haematuria, proteinuria, extrarenal signs) and biochemical presentation (initial creatininaemia). They required the same degree of haemodialysis, of plasma exchanges and of bolus methylprednisolone. The causes of death were infection (three cases), cardiac arrhythmia (two cases) and gastrointestinal bleeding (two cases). Among the 14 remaining patients, only two recovered normal renal function. Twelve had chronic renal failure, six of them requiring chronic dialysis or transplantation. Severe renal failure at entry and anuria were more frequently observed in patients whose renal function did not improve during treatment. Plasma exchange and steroid bolus infusions also seemed to have a beneficial effect on renal function.

[Peritoneal dialysis, the method of treatment for end-stage renal insufficiency: development of indications during the past 10 years in relation to the initial renal disease and extra-renal pathology]. / La dialyse péritonéale, méthode de traitement de l'insuffisance rénale terminale: évolution des indications au cours des dix dernières années en fonction de la maladie rénale initiale et des pathologies extra-rénales.

A decade after its first introduction, the advantages and drawbacks of continuous ambulatory peritoneal dialysis over hemodialysis remain controversial. This present paper is a review of the literature, focused on the indications of this dialysis modality in different circumstances: extra-renal pathology, systemic diseases (lupus erythematosus--diffuse scleroderma--plasma cell disorders--amyloidosis--HIV infected patients) and complications related to hemodialysis.