[Severe Schonlein-Henoch nephritis in adults. A report of twenty cases]. / Les néphropathies sévères du purpura rhumatoïde de l'adulte. A propos de vingt observations.

Twenty patients with severe Schönlein-Henoch nephritis were selected on a histologically basis of diffuse proliferative endo- and/or extracapillary glomerulonephritis during a period of 12 years in Champagne-Ardenne. There were 15 men and 5 women, mean age 44.1 years. An infectious history was found in 40%, an urinary tract cancer in 15%. In all cases there was purpura, in 80% joint pain and in 50% digestive symptoms. Clinical presentation at diagnosis included, in all cases, hematuria (gross in 50%) and proteinuria (of nephrotic range in 80%); there was hypertension in 60% and renal failure in 80%. Histology found, in all cases, mesangial IgA and often C3 deposits, with a diffuse endocapillary proliferation in 10%, extra-capillary proliferation in 30% and both endo-extracapillary in 60%; 45% of the patients had crescents in greater than 50% of glomeruli. The outcome, after steroid and immunosuppressive treatment, was end-stage renal failure in 25%, moderate renal failure in 20%, or normal renal function in 55% with a mean follow-up period of 4.6 years. These severe nephritis were associated with repetitive and often necrotic purpura, frequent joint pain and severe digestive symptoms. The analysis of initial renal presentation confirmed the bad prognosis of nephrotic syndrome, renal failure and especially hypertension, which were well correlated with the severity and diffusion of proliferative lesions. Despite a worse known prognosis, these nephritis responded to an aggressive and early treatment.

Long-term follow-up of acute renal failure caused by angiotensin converting enzyme inhibitors.

Angiotensin converting enzyme (ACE) inhibitors are useful in the treatment of hypertension and heart failure. However, acute renal failure (ARF) may occur in patients who are taking these drugs in situations associated with decreased glomerular filtration pressure, such as dehydration caused by acute diarrhea or diuretic therapy. Sixty-four patients who were admitted to the intensive care unit for ARF associated with ACE inhibitor therapy were followed for more than 5 years. In this historical retrospective study, we documented that 45 patients were treated for hypertension (group I) and 19 were treated for heart failure (group II). Their mean age was 71.2+/-11.6 years. Patients with ARF presented with overt dehydration in 91% and 84% of the cases in groups I and II, respectively. Hypovolemia was caused by diuretics or gastrointestinal fluid loss. Bilateral artery-renal stenosis or stenosis in a solitary kidney was documented in 22% and 10% of patients in groups I and II, respectively. The probability of survival was 91% and 49% at 1 year and 64% and 18% at 5 years, for groups I and II, respectively. Acute renal failure required hemodialysis in seven patients, but none of them became dialysis dependent. In the subgroup of patients with preexisting chronic renal failure, all the patients except for one who belonged to group II died within 2 years. In both groups, after resolution of ARF, plasma creatinine concentration returned to baseline level and the course of renal function was not significantly worsened. In conclusion, ARF associated with ACE inhibitors is likely to occur in many patients without renal artery stenosis after unexpected dehydration, especially in older patients with congestive heart failure. In both groups of patients, in the absence of preexisting chronic uremia, recovery of renal function occurred without sequelae, even after an episode of acute tubular necrosis requiring dialysis.

Failure of acyclovir to prevent cytomegalovirus infection in renal allograft recipients.

Cytomegalovirus (CMV) is the most common opportunistic pathogen following renal transplantation and remains a major concern in transplantation centers owing to its high morbidity and impact on renal allografts. Pending more effective antiviral drugs, efforts have been directed toward prevention strategies. We conducted a retrospective analysis to evaluate the efficacy of various prophylactic options used at our institution during the period April 1986 to August 1990. All CMV-negative patients with CMV-negative kidneys (D-R-) received screened, CMV-negative blood products (n = 19). CMV-specific immunoglobulins (CMV Ig) were used in 6 patients at increased risk for primary CMV infection and acyclovir was administered to 21 patients at an initial intravenous dose of 5 mg/kg body weight; then oral doses of 800-3200 mg per day were given according to the patients' estimated creatinine clearance. Thirty-two patients did not receive any CMV prophylactic treatment and served as controls. CMV monitoring of the patients during the first 6 months after transplantation showed an overall infection and disease rate of 81% and 38.1%, respectively, in the acyclovir-treated group. Compared with controls, the incidences of infection and disease were higher in the acyclovir-treated patients, with a significant difference for CMV infection (P = 0.002, generalized Wilcoxon test). Only 1 of the 19 D-R- patients presented with CMV infection. CMV Ig-treated patients tended to have less severe disease without any apparent reduction in infection incidence. Given the high rate of infection in patients at risk, we infer that high-dose acyclovir does not prevent CMV infection in our setting of renal transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Treatment of legionellosis with ofloxacin in kidney transplanted patients. Lack of interaction with cyclosporin A]. / Traitement des légionelloses par ofloxacine chez le transplanté rénal. Absence d'interférence avec la ciclosporine A.

Seven cases of legionellosis were observed in a series of 81 renal transplant recipients. In the 6 patients with functional graft, pneumonia occurred 17 days on average after the beginning of transplant rejection treatment. The diagnosis was made by bronchoalveolar lavage: the direct immunofluorescence antigen technique was positive in 5 cases and culture in 6 cases. Legionella pneumophila sero-groups 5 and 1 were identified in one and 5 patients respectively. Six of the 7 patients were treated with ofloxacin. This fluoroquinolone was effective in all cases. It was administered as single therapy in 3 patients and did not interfere with ciclosporin A metabolism. Ofloxacin given in mean doses of 400 mg per day adjusted to renal function proved to be a simple, effective and well tolerated treatment of legionellosis in transplant recipients receiving ciclosporin A.

[Continuous hemodialysis with low blood flow and low dialysate flow in the treatment of acute renal insufficiency]. / L'hémodialyse continue à bas débit sanguin et à bas débit de dialysat dans le traitement de l'insuffisance rénale aiguë.

Slow continuous hemodialysis (SCHD) was performed in 9 patients with oliguric acute renal failure and cardiovascular instability. The vascular access was a Scribner's shunt in 7 patients and a double lumen venous catheter with a BSM22 blood system in 2 patients. Three different dialyzers were tested. The mean urea clearance was 10.8 +/- 1.5 ml/min with the 0.2 m2 polysulfone hollow fiber dialyzer, 14.3 +/- 2.7 ml/min with the 0.5 m2 AN 69 S parallel plate dialyzer and 13.8 +/- 1.8 ml/min with the 0.6 m2 AN 69 hollow fiber dialyzer. The mean dialysate flow rate was 15.6 +/- 1.9 ml/min, 15.2 +/- 0.7 ml/min and 15.1 +/- 1.6 ml/min for the three dialyzers, respectively. A linear relationship was documented for blood urea clearance and dialysate flow rate indicating clearly that low blood flow from 60 to 100 ml per min was appropriate for optimal diffusive transfer. The technic required continuous heparin anticoagulation. Three patients died of causes not related to the SCHD technic. When used in critically ill patients, SCHD is a simple method, suitable for intensive care unit staff with no trained dialysis nurses and allows an adequate control of uremia, fluid removal, acid base homeostasis and parenteral nutrition.

[A case of acute myopia with angle-closure glaucoma]. / A propos d'un cas de myopie aiguë avec glaucome par fermeture de l'angle.

The authors report a case of transient myopia with closed angle following the administration of Aspirin and Deturgylone. This treatment was prescribed because of a probably Hantaan virus infection.

[Magnesium hydroxide treatment of hyperphosphatemia in chronic hemodialysis patients with an aluminum overload]. / Traitement par l'hydroxyde de magnésium de l'hyperphosphorémie des hémodialysés chroniques ayant une surcharge en aluminium.

The control of hyperphosphatemia in dialysis patients is frequently achieved using aluminium hydroxide (A1(OH)3) and/or calcium carbonate (Ca CO3). However, this effect is counterbalanced by risk of aluminium intoxication and hypercalcemia. An alternative to the use of these phosphate binders is the prescription of magnesium hydroxide (Mg(OH)2) in association with a magnesium free dialysate. 19 patients with subtoxic plasma aluminium concentration received such a therapy. 9 months after starting the essay 4 patients had been excluded for digestive intolerance (3 cases) and neuro-psychic symptoms related to hypermagnesemia (1 case) after therapy with maximal doses of 6 to 12 g/d. Plasma inorganic phosphorus was decreased from 2.47 +/- 0.32 to 1.86 +/- 0.40 mmol/l (P less than 0.05) and plasma aluminium from 3.03 +/- 0.93 to 1.52 +/- 0.15 mumol/l (P less than 0.05). The results have been obtained without any significant increase in plasma and red cell magnesium levels. Metabolic alkalosis has been observed in association with the increase of ion exchange resin (sodium polystyrene sulfonate: Kayexalate) to treat progressive hyperkalemia. With the exception of possible metabolic effects occurring on a long term basis, Mg(OH)2 in association with magnesium-free dialysate seems of value to treat dialysis hyperphosphatemia.

[Continuous arteriovenous hemofiltration in acute renal failure. Value of regulating the rate of ultrafiltration]. / Hémofiltration artérioveineuse continue dans l'insuffisance rénale aiguë Intérêt de la régulation du débit d'ultrafiltration.

Continuous arteriovenous hemofiltration (CAVH) requires constant supervision and frequent readjustment of the rate of infusion of the substitution fluid because of variable filtration rate. In order to lighten the management of patients treated with CAVH, an ultrafiltration-pump assisted CAVH was used in 16 patients with oliguric renal failure and cardiovascular instability treated in the intensive care unit. A plate hemofilter (Biospal) was used which is equipped with the high hydraulic permeability AN 69 S membrane. The driving pump was set in order to modulate the ultrafiltration rate from 400 to 1000 ml/h. Ultrafiltration-pump assisted CAVH was given for 8.1 +/- 5.3 days and the filtration volume was 16.3 +/- 3.1 l/day. The mean life span of the hemofilter was 36.4 +/- 27.3 hours. No adverse reaction toward the artificial membrane was detected. Adequate control of fluid balance and electrolyte and acid-base homeostasis were obtained allowing parenteral nutrition. However, in two instances additional hemodialysis was required to adequately control urea generation. Ultrafiltration-pump assisted CAVH proved to be a simple and effective method of fluid removal and urea subtraction by convective transport. Maintenance of stable fluid balance and parenteral nutrition without osmotic disequilibrium was allowed. The pump driven hemofiltration allows optimal use of the filter.

[Hemorrhagic fever with renal syndrome due to Hantaan virus or a serologically related virus]. / Fièvre hémorragique avec syndrome rénal due au virus Hantaan ou à un virus sérologiquement apparenté.

Seven cases of acute renal failure consecutive to haemorrhagic fever with renal syndrome (HFRS) due to the Hantaan virus or to a serologically related virus are reported. These cases were observed in north-eastern France between March, 1983 and January, 1984. All patients were of rural origin and had been in contact with field mice. The predominant initial clinical symptoms were signs of infection and diffuse muscle pain, without evidence of haemorrhage. However, massive proteinuria was noted, and acute anuric renal failure unaccompanied by oedema or arterial hypertension developed. Renal biopsy performed in 2 patients showed tubular and interstitial nephritis but no glomerular or vascular lesions. Two patients only required haemodialysis. All patients recovered within 2 to 8 weeks without sequelae. Antibodies directed against the Hantaan virus were detected by indirect immunofluorescence tests, and seroconversion could be demonstrated in 2 patients seen at a sufficiently early stage. The risk of epidemics suggested by this small outbreak of HFRS can only be evaluated after an exhaustive epidemiological study.

Long-term results of dialysis therapy with a highly permeable membrane.

A five-year study of short-term dialysis using highly permeable polyacrylonitrile membrane AN 69 was started in March 1973 to compare the effects of AN 69 and Cuprophan membrane (CM). The time of dialysis was calculated for each patient on the basis of vitamin B12 clearance of the dialyzer and the residual glomerular filtration rate. For the study, 101 patients (38,555 dialysis sessions) who had been dialyzed for more than six months were selected. They were divided into three groups: Group I (n = 31) patients treated with AN 69 only; Group II (n = 31) patients treated with CM; Group III (n = 39) patients treated first with the CM and then with AN 69. Patients treated with AN 69 had higher levels of plasma urea but no particular metabolic disturbances were observed. The dialysis sessions were significantly better tolerated with AN 69 than with CM, however, the main advantage of using AN 69 is the shortening of dialysis time. The duration of dialysis was 9.5 +/- 0.2 hours per week with AN 69 and 16.4 +/- 0.2 hours per week with CM. Shortening of dialysis time permits better social rehabilitation of the patients. The shorter dialysis was not associated with any recognizable side effects that could be demonstrated by routine clinical and biological analysis.

Increased renal excretion of 3 hydroxyproline in patients with active glomerular nephropathies and with polycystic renal disease.

The renal excretion of 3 hydroxyproline (3 HYP) and 4 hydroxyproline (4 HYP) was investigated in control subjects and in patients with various renal diseases. In normal adult subjects urinary 3 HYP was 12.5 +/- 3.5 (SD) mumoles/24 hr, 4 HYP was 226 +/- 62 mumoles/24 hr and the percentage ratio 3 HYP/4 HYP 5.4 +/- 0.5. This ratio was reduced during growth because of a relative excess of 4 HYP. In patients with acute glomerular disease (n = 12) 3 HYP was increased to 17.1 +/- 5.8 mumoles/24 hr (P less than 0.01), and the ratio 3 HYP/4 HYP was 7.3 +/- 0.7% (P less than 0.01). Such an increase in 3 HYP was not observed in patients with chronic glomerulonephritis (n = 24) where 3 HYP was 9.6 +/- 5.0 mumoles/24 hr and 3 HYP/4 HYP 5.7 +/- 1.6% or with diabetic glomerulopathy (n = 6). In patients with chronic interstitial nephritis (n = 8) the 3 HYP/4 HYP ratio was decreased except in patients with polycystic renal disease (PKD) where it was increased (P less than 0.001). The daily urinary content of 3 HYP and 4 HYP was slightly altered by renal insufficiency. Urinary 3 HYP did not change significantly in patients with GN with the nephrotic syndrome whatever the histological lesion. These results indicate that urinary 3 HYP: 1) is increased when glomerulonephritis is clinically acute or subacute; 2) is increased in PKD whatever the level of renal insufficiency.

Polyarteritis nodosa with bilateral ureteric involvement.

Renal insufficiency in necrotizing vasculitis is usually the result of parenchymal damage. A case of polyarteritis nodosa presenting obstructive nephropathy with bilateral ureteric stenosis is reported. The role of the concurrent crescentic glomerulonephritis in the mechanism of renal failure is discussed.