[Are preoperative examinations useful in the management of patients with renal hyperparathyroidism?]. / L'imagerie préopératoire des hyperparathyroïdies des insuffisants rénaux a-t-elle un intérêt en pratique clinique?

AIM OF THE STUDY: To evaluate the efficiency of preoperative parathyroid ultrasonography and scintigraphy in the management of renal hyperparathyroidism. PATIENTS AND METHODS: The charts of the last consecutive 200 patients who underwent surgery for renal hyperparathyroidism from 1998 to 2003 were retrospectively reviewed to collect data concerning parathyroid gland function, results of preoperative ultrasonography and scintigraphy, as well as modalities and results of surgical exploration. RESULTS: Ultrasonography and scintigraphy sensibilities were 36.4% and 49.3%, respectively. Efficiency of both examinations was improved when they were combined (sensibility of 64.7%) and in those patients managed for recurrent hyperparathyroidism. Were more often detected by preoperative examinations glands with high weight and/or greatest diameter, orthotopic and inferior glands as well as glands exhibiting nodular hyperplasia content upon pathological examination. CONCLUSION: Parathyroid ultrasonography and scintigraphy are of poor interest in the management of renal hyperparathyroidism. In a preoperative setting, they should be performed only in patients with recurrent disease.

[Imaging in urinary tract infections in adults]. / Place de l'imagerie dans les infections du tractus urinaire de l'adulte.

Uncomplicated infection of the urinary tract is frequent and usually resolves rapidly with treatment and imaging is unnecessary. Progression to complex infection often occurs in patients with predisposing factors. Imaging assists in evaluating the extent of disease, plays a role in directing therapy and guides interventional procedures if necessary. This pictorial essay reviews the role of imaging and intervention in infections of the urinary tract.

Apo(a) phenotypes and lp(a) concentrations in renal transplant patients.

Plasma lipoprotein (a) (LP(a)) concentrations are increased in patients with end-stage renal disease. Considering the influence of the apolipoprotein (a) (Apo(a)) polymorphism and the mode of dialysis in this prospective longitudinal study, we compared Lp(a) concentrations before and after the first 6 months of a successful kidney transplantation in 125 recipient patients. Apo(a) phenotyping was performed by using SDS-PAGE and SDS-agarose, isoforms were classified into high molecular weight (HMW) and low molecular weight (LMW). Before the graft, the Lp(a) concentrations were significantly higher in CAPD than in hemodialysis patients (p = 0.021). Six months after transplantation, Lp(a) fell in both treatment groups. This decrease occurred within both LMW and HMW but to a different extent: median relative variations were -35 and -50%, respectively (p = 0. 048). Among patients with Lp(a) concentration >30 mg/dl 6 months after transplantation, 74% had LMW Apo(a) isoform while the remaining 26% had HMW isoform. Successful renal transplantation leads rapidly to a correction of Lp(a) concentrations, especially in patients treated with CAPD who have higher Lp(a) levels. The most important factor seems to be the LMW status corresponding to high Lp(a) levels.

Renal thrombotic microangiopathy in systemic lupus erythematosus: clinical correlations and long-term renal survival.

BACKGROUND: Renal thrombotic microangiopathy (TMA) is an uncommon vascular complication of systemic lupus erythematosus (SLE). Its clinical symptoms and impact on renal survival remain unclear. METHODS: Eight patients aged 25 +/- 6 years with biopsy-proven renal TMA and at least four ARA criteria for the diagnosis of SLE were retrospectively studied over a 7-year period. RESULTS: All patients presented with renal failure (creatinine 3.3 +/- 2.1 mg/dl), six had proteinuria (2.5 +/- 1.3 g/day) with microscopic haematuria in four cases. Six patients had hypertension, which was severe in five cases. Renal histology disclosed arterial and/or arteriolar thrombosis with parietal thickening without angeitis (8 patients), glomerular microthrombi (3 patients), and vascular fibrin deposits (5/6 patients). In two cases, vascular lesions were associated with a mesangial or a proliferative glomerulonephritis. Thrombocytopenia was present in four patients with haemolytic microangiopathic anaemia in one case. Lupus anticoagulant (LA) was detected in five of eight patients, who also had anticardiolipin antibodies (3/7 patients) and/or were positive for VDRL (3/6 patients). Four patients with LA experienced arterial thrombosis and/or repeated spontaneous abortions. Treatment consisted of corticosteroids (8 patients), cytotoxic drugs (4 patients), plasma exchanges and/or intravenous immunoglobulins (4 patients) and antiplatelet and/or anticoagulant therapy (3 patients). Two patients recovered normal renal function and five had persistent renal insufficiency. One patient started haemodialysis on admission and died of sepsis 2 months later. CONCLUSIONS: TMA may be the sole renal complication in SLE and is not usually associated with haemolytic microangiopathic anaemia. In our series renal survival was influenced by the extent and severity of vascular lesions. Despite a frequent association with antiphospholipid antibodies, pathophysiological mechanisms of renal TMA in SLE remain unknown. Renal histology is mandatory for the diagnosis and the prognostic evaluation of renal vasculopathy in SLE.

Erythrocyte sedimentation rate, an underestimated tool in chronic renal failure.

BACKGROUND: Erythrocyte sedimentation rate is widely used in the general population. It has seldom been studied in patients with chronic renal failure. The purpose of this study was to assess its usefulness in haemodialysis patients. METHODS: Forty-five haemodialysis patients with no evidence of acute or chronic inflammatory illness were studied. Nine were diabetic, and 12 used a non-biocompatible membrane. Erythrocyte sedimentation rate was determined, using a modified Westergren method. Plasma fibrinogen concentration, complete blood count, and serum chemistries were also studied. RESULTS: Erythrocyte sedimentation rate was normal or mildly elevated in most of our patients, with a median of 30 mm/h. Linear analysis found positive correlation between erythrocyte sedimentation rate and fibrinogen concentration, globulin level, platelet, and white cell counts, and negative correlation with haematocrit. Fibrinogen concentration was normal in 22 patients, and moderately elevated in 14. It was significantly higher in diabetic patients, or those using a non-biocompatible membrane. The same positive correlations were found for fibrinogen concentration as for erythrocyte sedimentation rate. CONCLUSIONS: We conclude that erythrocyte sedimentation rate can be used in haemodialysis patients much in the same way as in the general population, as it is influenced by the same factors, and its baseline value is lower than previously reported. The lower concentration of fibrinogen, an independent predictor of cardiovascular risk, in patients treated with biocompatible membranes may be of clinical relevance.

Alteration of the lipid and apolipoprotein contents of lipoprotein (a) in haemodialysis patients.

BACKGROUND: To examine the possible alteration in Lp(a) composition, protein and lipid contents of Lp(a) were determined in 10 haemodialysis patients (HD) matched with 10 controls (C) for apo(a) phenotypes. METHODS: All subjects (HD and C) had Lp(a) concentrations greater than 30 mg/dl (mean+/-SD : 82.3+/-41.4 vs 49. 3+22.5 mg/dl), a concentration which has been determined to be associated with an elevated cardiovascular risk. Apo(a)-containing particles were isolated by immunoaffinity chromatography using a monoclonal anti-apo(a) antibody. RESULTS: The molar concentrations of lipid and protein constituents of immunoaffinity isolated Lp(a) were expressed as number of moles per mole of apo(a). Lp(a) from HD patients were significantly richer in apo Cl11 (P<0.05) and triglycerides (TG) (P<0.05), compared to those of controls. Molar ratios of apo B, apo E, cholesterol and phospholipid s per apo(a)-containing particles were in the same range in both groups. CONCLUSION: Lp(a) from HD patients is characterized by an elevated content in TH and apo Cl11 in comparison with those of controls. Further studies are needed to evaluate in HD patients the contribution of changes in Lp(a) composition towards the metabolism of these particles.

Neutral-lipid transfers and cholesteryl ester transfer protein in hemodialyzed patients.

Abnormalities in cholesteryl ester transfers may play a role in the development of atherosclerosis observed in patients with end-stage renal failure treated by chronic hemodialysis. Net neutral-lipid transfers and cholesteryl ester transfer protein activity and mass were investigated in 20 hemodialyzed patients, arbitrarily divided into two groups based on fasting triglyceride levels, and compared to triglyceride-matched control groups. In the hypertriglyceridemic subjects (plasma triglyceride values > 150 mg/dl), high-density lipoprotein cholesterol was decreased, and the net cholesteryl ester transfer rates were significantly higher than the rates in normolipidemic subjects. The comparison of subjects matched for plasma triglyceride and cholesterol levels showed no significant difference in cholesteryl ester or triglyceride transfer rates between patients and controls. Our results suggest that normal or elevated net neutral-lipid transfers are not related to the renal status of the subjects, but rather to their plasma triglyceride levels.

Apolipoprotein AI and apolipoprotein B containing particle analysis in normolipidemic hemodialyzed patients: evidence of free apolipoprotein E.

Whole plasma from 6 normolipidemic chronic renal failure (CRF) patients undergoing hemodialysis treatment was passed through the anti-apolipoprotein (Apo) AI immunosorbent column connected to the anti-Apo B immunoaffinity column. Apo AI and B containing particles were analyzed for lipid and Apo contents. The results were compared with findings obtained in age-matched normolipidemic healthy controls. Although plasma Apo AI and AII levels decreased in CRF patients, the concentrations of Apo CII, CIII, and E coeluted with Apo AI were similar to those of the controls. The slightly elevated plasma concentrations of Apo CII and CIII in the CRF patients studied were shown to be associated with Apo B containing particles. The nonretained fraction from both groups contains no Apo AI and no Apo B, but still contains lipids and other Apo such as Apo AII and Apo CII. The occurrence of approximately 29% of plasma Apo E in this fraction constitutes the main abnormality found in these patients (< 5% in controls). A two-phase electroimmunoassay shows that this Apo E did not correspond to the plasma E-AII complex. These findings show that the compositional alterations of Apo AI and Apo B containing particles in CRF patients were observed even in normolipidemic patients and suggest that the kidney may play a metabolic role in the removal of free forms of lipoprotein particles such as free Apo E.

[Axillo-axillary access in hemodialysis]. / L'abord axillo-axillaire en hémodialyse.

Axillo-axillary angio-access can be an alternative device (bovine graft or synthetic graft) for dialysis patients among whom upper arm peripheral veins are impracticable or previous fistulas are thrombose. This procedure was used in seven dialysis patient (length of dialysis: 52.2 +/- 40.6 months) among whom forty one angio access were done. Except one immediate failure, these access were patent until, either the death of patients or the achievement of a cadaveric renal graft. The clinical and hemodynamic tolerance were perfect.

Plasma level of lipoprotein Lp(a) is high in predialysis or hemodialysis, but not in CAPD.

Plasma Lp(a) lipoprotein level was determined in chronic renal failure (CRF) patients, 24 before initiation of dialysis, 18 undergoing hemodialysis, and 24 on continuous ambulatory peritoneal dialysis (CAPD). Eighteen healthy subjects were studied as controls. Median of Lp(a) level in both predialysis and dialysis patients was significantly increased: 23.5 mg/dl (range: 0 to 109) and 24.0 mg/dl (range: 1.4 to 90), respectively, as compared to healthy controls: 4.7 mg/dl (range: 1.8 to 27; P less than 0.001). By contrast, the median Lp(a) level in CAPD patients, 2.4 mg/dl (range: 0 to 39.5), was similar to the control group. Whether the CAPD procedure reduces the Lp(a) level in CRF patients has to be established in a prospective study.

Incidence and clinical profile of microvascular complications in renal allografted patients treated with cyclosporine.

The incidence of cyclosporine (CsA) vascular toxicity is open to debate. We attempted to evaluate the incidence of hemolytic accidents in our series of patients taking all clinical forms into consideration. From January, 1989, to December, 1990, 117 patients received kidneys from cadaver donors and were treated with CsA. Five patients presented hemolytic uremic syndrome (HUS) accompanied by a rejection crisis; 6 patients presented hemolytic anemia associated in 2 cases with marked thrombocytopenia without any evidence of rejection. Cytomegalovirus (CMV) infection was diagnosed in 2 patients and bacterial infection preceded hemolysis in 2 other cases, suggesting a triggering factor. In addition, when we systematically determined haptoglobin levels after introduction of CsA treatment, we found asymptomatic hemolytic episodes more frequently. Our incidence of hemolytic accidents was approximately 10%. Hemolysis could indicate ischemic vascular damage leading to arteriolar medial hyalinosis preceding fibrosis in CsA nephrotoxicity. Thus, it would be interesting to detect asymptomatic forms of hemolysis by monitoring haptoglobin levels. This approach could lead to a reduction of the CsA dose in patients presenting low haptoglobin levels, even in the absence of evidence of nephrotoxicity.

[Auricular chondritis, malignant glomerulonephritis and pulmonary hemorrhage]. / Chondrite auriculaire, glomérulonéphrite maligne et hémorragies pulmonaires.

Relapsing polychondritis is a rare connective tissue disorder characterized by inflammation of cartilagenous structures such as ears, nose, joints, trachea and larynx. Renal disease is unusual. A 41 years old man presented with auricular chondritis, subacute renal failure and lung hemorrhage. A renal biopsy disclosed a diffuse proliferative glomerulonephritis with extensive crescents. Immunofluorescent studies suggested a GNRP type III so called "non immunologic disease". He was treated by prednisone and plasmapheresis with rapid disappearance of pulmonary hemorrhages and good renal functional improvement.

Plasmapheresis in a patient with severe asthma associated with auto-antibodies to platelets.

Although the pathogenesis of aspirin-sensitive asthma remains to be specified, it is known that in the presence of acetylsalicylic acid or non-steroidal anti-inflammatory drugs, platelets from aspirin-sensitive asthmatics have been described as generating cytocidal mediators that killed parasite targets such as Schistosoma mansoni larvae. Here we report, in a patient with corticosteroid-dependent asthma associated with aspirin sensitivity, the presence of circulating IgE antibodies against 55 kD and 68 kD platelet antigens. In addition, the serum from this patient was shown to contain a factor able to trigger the release of cytocidal mediators from his platelets as well as from normal individual platelets. This platelet stimulatory activity was presumably supported by IgE antibodies or immune complexes. After informed consent the patient was submitted to plasma exchanges. Plasma removal induced clinical improvement, anti-platelet antibody decrease, and the reduction of the platelet stimulatory activity. All clinical symptoms disappeared within 2 weeks. The disease remained quiescent for 2 months, and daily requirements for prednisone (20-5 mg), and beta-agonist (10-16 to 0-1 inhalations) could be kept at a low level follow-up. The plasma exchanges were delayed by 3 mg kg-1 azathioprine with the maintenance of clinical improvement. A relapse occurred after the arrest of immunosuppressive therapy with the reappearance of both asthma attacks and anti-platelet antibodies, as well as the increase of the platelet stimulatory activity.(ABSTRACT TRUNCATED AT 250 WORDS)

[Rapidly progressive glomerulonephritis in pneumoconiotic coal miners]. / Glomérulonéphrites rapidement progressives chez les mineurs de charbon pneumoconiotiques.

We review a series of 11 silicotic coal miners demonstrating a progressive renal failure with a syndrome of rapidly progressive glomerulonephritis. Renal biopsies reveal crescentic glomerulonephritides associated three times with angeitis. These cases confirm that silica induced glomerulonephritides can be an occupational hazard and warrant further clinical and epidemiological research.