[Parathyroidectomy in end-stage renal disease: perioperative management of calcium-phosphorus balance]. / Parathyroïdectomie en insuffisance rénale terminale: prise en charge péri-opératoire de l'équilibre phosphocalcique.

The management of metabolic problems following parathyroidectomy in end stage renal disease remains poorly defined. Hypocalcemia is a common and serious complication in the post-operative period. The objective of the present study was to develop a protocol for the management of patients during the immediate perioperative period based on the best available data from the literature, and to verify its effectiveness and safety in three patients on chronic hemodialysis. A patient management protocol was developed based on data reported in the literature and was subsequently tested on three chronic dialysis patients suffering from tertiary hyperparathyroidism with an indication of parathyroidectomy. According to the literature, the risk of hypocalcemia following parathyroidectomy can be decreased by tight surveillance of calcium levels and preventive administration of calcium and vitamin D analogue to patients at high risk of hypocalcemia. By applying this protocol, profound hypocalcemia was avoided and the immediate post-operative period was uneventful in the three patients under study. In summary, the proposed protocol is safe and effective for the peri-parathyroidectomy management of patients on chronic hemodialysis.

Veno-venous continuous renal replacement therapy for burned patients with acute renal failure.

From 1995 to 1998, 12 burned patients with acute renal failure (ARF) were treated by veno-venous continuous renal replacement therapy (CRRT) at the Burn Unit of Hôtel-Dieu de Montréal. Their mean (+/-SD) age was 51+/-12 years, and the mean burned surface covered 48.6+/-15.8% of total body surface area. All patients were mechanically ventilated and presented evidence of sepsis. The mean delay before occurrence of ARF was 15+/-6 days and ARF was mainly related to sepsis and hypotension. Main reasons for CRRT initiation were azotemia and fluid overload. A total of 15 CRRT modalities were applied (12 continuous veno-venous hemodiafiltration, CVVHDF; two continuous veno-venous hemofiltration, CVVH; and one continuous veno-venous hemodialysis, CVVHD) over 14+/-13 days. For CRRT, nine patients received heparin and three were not anticoagulated. Mean values for dialysate and reinjection flow rates were 1134+/-250 ml/h and 635+/-327 ml/h, respectively. Admission weight was 78.8+/-12.7 kg with a mean weight gain before CRRT initiation of 10.0+/-5.8 kg and a mean weight loss during CRRT of 8.9+/-5.5 kg. Nine patients received enteral plus parenteral nutrition, and three, parenteral nutrition only; the total caloric intake was 31.5+/-7.0 kcal/kg/day and protein intake, 1.8+/-0.4 g/kg/day. The normalized protein catabolic rate (nPCR) was evaluated at 2.28+/-0.78 g/kg/day during CRRT. The mortality rate was 50%. The six survivors all recovered normal renal function with four of them requiring intermittent hemodialysis for short periods. In conclusion, veno-venous CRRT is particularly well suited for this selected population allowing smooth fluid removal and aggressive nutritional support.

Continuous haemofiltration and haemodiafiltration for acute renal failure in severely burned patients.

Among 970 burned patients admitted between April 1987 and September 1994, 16 (1.6 per cent) presented acute renal failure requiring dialytic support and were treated by continuous renal replacement therapy as first-line modality. Their mean burned surface area was 58.0 +/- 5.7 per cent. Acute renal failure mainly occurred in the second week following admission in relation to sepsis and nephrotoxic drugs. Four types of continuous renal replacement therapy were performed: continuous arteriovenous haemofiltration and haemodiafiltration (CAVH and CAVHDF) and continuous venovenous haemofiltration and haemodiafiltration (CVVH and CVVHDF). Compared to 33 critically ill patients without burns also treated for acute renal failure by continuous haemofiltration or haemodiafiltration during the same period, the mean duration of therapy was longer for the burned patients (24.2 +/- 9.4 vs. 5.3 +/- 0.8 days). Although mean urine outputs and ultrafiltration rates were similar for both groups, fluid administration was higher for burned patients (8.2 +/- 0.7 vs. 3.3 +/- 0.2 l/day). Total weight loss during therapy was significantly greater in burned patients (12.6 +/- 3.6 vs. 6.8 +/- 1.0 kg), in relation to longer treatment period. Bleeding complications were more frequent in burned patients (56 vs. 15 per cent). Mortality rates were similar in both groups (82 vs. 82 per cent). In conclusion, when aggressive initial fluid resuscitation is applied following burn injury, the occurrence of acute renal failure is low, delayed and multifactorial. Since they are haemodynamically well tolerated and provide a good metabolic and volaemic control, continuous renal replacement therapies appear to be useful modalities for burned patients with acute renal failure. However, as bleeding complications are more frequent, careful monitoring is necessary.

Treatment of renal angioplasty failure by percutaneous renal artery stenting with Palmaz stents: midterm technical and clinical results.

OBJECTIVE: Renal artery stenting has recently been used to treat failures or complications of renal angioplasty. Although technical results and complication rates have been reported, clinical follow-up and long-term data are limited. The purpose of this study was to evaluate the midterm clinical efficacy and safety of Palmaz stents in rescuing renal artery angioplasty failures. MATERIALS AND METHODS: Palmaz stents were placed in 35 renal arteries of 33 patients (14 men and 19 women; 37-77 years old; mean age, 62.6 years old) for immediate angioplasty failure (29 arteries) or for recurrent stenosis after previous angioplasty (six arteries). Indications for treatment were hypertension alone (16 patients) or hypertension associated with renal failure (17 patients). Blood pressure, medication, and serum creatinine level were followed after stenting. RESULTS: No residual stenosis was found immediately after stenting. Mean clinical follow-up was 13.4 months (range, 1-34 months). Of the 33 patients, two (6%) were cured of their hypertension, 20 (61%) were improved, and 11 (33%) did not respond to renal artery stenting. Of the 17 patients whose serum creatinine level was greater than 132 mumol/dl (1.5 mg/dl), seven (41%) were improved by renal artery stenting, six (35%) were stabilized, and renal function deteriorated in four (24%). Of the 33 patients, seven developed complications including one renal artery thrombosis, four renal artery emboli, one cholesterol embolization to the lower limbs, and one femoral hematoma that required surgery. CONCLUSION: Midterm results of renal artery stenting with the Palmaz stent to treat immediate or late angioplasty failures reveal improvements in blood pressure and renal function similar to those of successful primary balloon angioplasty.

Radionuclide captopril renography in postpartum renal artery aneurysms.

We report the case of a young woman with three left renal artery aneurysms, diagnosed immediately postpartum, associated with a de novo high blood pressure. To assess anatomical and functional characteristics of renal artery aneurysms, renal angiogram, MRI, intravenous pyelography, ultrasonography and radionuclide renography were performed. Two patent saccular renal artery aneurysms were demonstrated in the left kidney by renal angiogram. A larger, thrombosed aneurysm was also depicted on the left side on ultrasonography, MRI and renal angiogram. The larger aneurysm was responsible for renovascular disease of the middle third of the kidney, as demonstrated by captopril and baseline radionuclide renographic studies. It also impeded drainage of the lower pyelocalyceal group, without obstructing it, as shown by concomitant furosemide (Lasix) evaluations.

Familial hemolytic-uremic syndrome and homozygous factor H deficiency.

Inherited hemolytic-uremic syndrome (HUS) is unusual. We report the occurrence of HUS in two siblings; one died at an early age while the other (the proband) has presented with three episodes of HUS since the age of 19 years. The finding of a persistently low serum C3 level in this patient led to a thorough evaluation of her complement cascade and a family investigation. The proband and her asymptomatic younger sister were found to have very low serum levels (5% of normal) of factor H, a regulatory protein of the alternative complement pathway. Both patients had low levels of serum C3, factor B, CH50 and VAH50, reflecting persistent alternative pathway activation. The father and mother both had half-normal serum factor H levels but an otherwise normal complement profile. Other members of the extended pedigree were also found to have half-normal serum factor H levels. In conclusion, in this family, factor H deficiency appears to be associated with HUS and is transmitted as an autosomal recessive trait. Persistent C3 hypocomplementemia in the setting of familial and/or recurrent HUS should be a clue to a possible inherited complement deficiency.

Pharmacokinetics and pharmacodynamics of trandolapril after repeated administration of 2 mg to patients with chronic renal failure and healthy control subjects.

A new, long-acting angiotensin-converting enzyme (ACE) inhibitor, trandolapril, was administered daily for 10 days to 13 patients with chronic renal failure [CRF; creatinine clearance (CLCR) 7-55 ml/min/1.73 m2) and 8 healthy volunteers (CLCR > 80 ml/min/1.73 m2)]. Plasma ACE inhibition parameters were the same, irrespective of the degree of renal insufficiency, although renal failure tended to prolong ACE inhibition. The pharmacokinetics of trandolapril were not affected by CRF; hence, no accumulation of trandolapril was detected. After single or repeated administration the active metabolite, trandolaprilat, showed an inverse correlation between maximal plasma concentrations (Cmax) and CLCR (r = -0.676 day 1 and r = -0.864 day 10) and area under the concentration-time curve (AUC) and CLCR (r = -0.635 day 1 and r = -0.794 day 10). The renal clearance of trandolaprilat showed significant linear correlation (r = > 0.885, p < 0.0001) with CLCR after single (r = 0.879) and repeated administration (r = 0.957). Significantly reduced excretion of trandolaprilat was seen only when the CLCR was < 30 ml/min/1.73 m2. A steady state had been achieved by 7 days in all patients, and extrapolation suggested that this was achieved in most cases after 4 days. The drug was well tolerated. The effect of CRF on the pharmacokinetics and pharmacodynamics of trandolaprilat is of significance only when CLCR is < 30 ml/min/1.73 m2. Hence, in these patients the standard dose should be reduced.

Early experience with laparoscopic approach for adrenalectomy.

BACKGROUND: Adrenalectomy performed by a posterior or transabdominal approach causes substantial postoperative pain. The purpose of this study was to evaluate laparoscopy as a potential approach for adrenalectomy. METHODS: We performed 25 consecutive laparoscopic adrenalectomies on 22 patients from April 1, 1992, to March 30, 1993. Laparoscopic surgery was performed by using a lateral decubitus flank approach with four 11 mm trocars. RESULTS: Twelve right and 13 left adrenal glands were removed in a mean time of 2.3 hours. Three patients underwent bilateral adrenalectomies in a mean time of 5.3 hours. The 15 women and 7 men range in age from 31 to 60 years (mean, 42 years). The adrenal gland diseases were nonfunctional adenoma (seven), pheochromocytoma (five), Cushing's disease (four), Cushing's adenoma (four), primary aldosteronism (two), dehydroepiandrostenedione sulfate hypersecretion (one), angiomyolipoma (one), and medullary cyst (one). Average tumor size was 4.1 cm (range, 1 to 15 cm). Laparoscopic adrenalectomy was successful in 96% of patients, with one patient requiring a laparotomy because of inadequate exposure. The median postoperative stay was 4 days (range, 2 to 19), with a mean of five narcotic injections. There were no deaths, and morbidity was minor. CONCLUSIONS: Laparoscopy can be used successfully for adrenalectomy. It produces less postoperative pain and rapid return to normal activity. It may be the preferred method for removing most adrenal gland lesions that require operation.

Renal function recovery in end-stage renal disease.

Renal function recovery (RFR) is a rare event in patients with end-stage renal disease (ESRD). Although some predictive factors have been described, there are still unresolved questions. We have analyzed the Canadian Organ Replacement Register data for the 1981 to 1989 period to assess the incidence and factors predictive of RFR in a large ESRD population as well as the outcome after recovery. Renal function recovery was defined as the interruption of renal replacement therapy (RRT) for more than 3 months. Patients on RRT for < or = 45 days were excluded. Of 14,318 registered ESRD patients, 342 (2.4%) experienced RFR after 8.9 +/- 0.5 months of RRT (mean +/- SEM); 52.3% of the recoveries occurred within 6 months of initiating RRT, while 23.7% were only observed after 12 months or more. By Cox regression, patients within the following diagnostic groups had a significantly higher rate of RFR than those with primary glomerulonephritis, who are considered to comprise the reference group: myeloma (relative rate [RR] = 6.00; P < 0.001), drug-induced disease (RR = 4.21; P < 0.001), vascular/hypertensive disease (RR = 2.60; P < 0.001), and systemic disease (RR = 2.58; P < 0.001). Inversely, patients with polycystic kidneys (RR = 0.06; P = 0.004) and diabetic patients (RR = 0.56; P = 0.024) had a lower rate of RFR than those with glomerulonephritis. Men younger than 45 years had a lower rate of RFR than older men and women of all ages (P < or = 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Ciclosporin in Goodpasture's syndrome.

We report the case of a 39-year-old male patient with Goodpasture's syndrome. Despite therapy with prednisone, cyclophosphamide and plasma exchanges, serum creatinine (Scr) progressively increased up to 10.3 mg/dl (936 mumol/l) and hemoptysis recurred 3 months after initiation of treatment. Ciclosporin (CS) starting at 6 mg/kg/day was given. Scr began to decrease 2 weeks later and eventually stabilized at approximately 2.0 mg% (182 mumol/l). This case illustrates one of the potential uses of CS in human glomerular disease.

Single-dose pharmacokinetics of 14C-lovastatin in chronic renal failure.

An open study on the pharmacokinetics of lovastatin was conducted in six patients with chronic renal failure (mean creatinine clearance, 0.40 ml/sec; range, 0.20 to 0.65 ml/sec) and seven healthy subjects. Plasma levels of 3-hydroxy-3-methylglutaryl-coenzyme reductase inhibitory activity (total and active) and total radioactivity were determined over 168 hours after a single dose of 80 mg 14C-lovastatin. The mean area under the plasma concentration-time curve for active inhibitors were 606 +/- 346 and 282 +/- 138 ngEq.hr/ml (p = 0.04) in patients and control subjects, respectively. Total inhibitors in plasma and total radioactivity were similarly elevated in patients with chronic renal failure. Results indicate that patients with severe renal dysfunction have altered elimination kinetics of lovastatin. Current ongoing clinical studies in patients with renal dysfunction will allow better assessment of the pharmacodynamic meaning of our observations.

Effects of cyclosporine in severe systemic lupus erythematosus.

Thirteen patients with severe steroid-resistant or steroid-dependent forms of systemic lupus erythematosus were treated with cyclosporine (average dose 5 mg/kg/d) for an average period of 12 months. In eight patients the disease activity decreased, as substantiated by the reduction in the amount of steroid required to control the clinical manifestations. Interruption of cyclosporine treatment was associated with relapse or worsening of disease in five subjects. These favorable clinical results occurred in the absence of changes in the levels of antinuclear, anti-double-stranded deoxyribonucleic acid autoantibodies or plasma complement components; plasma IgG concentration increased significantly. Six patients had signs of moderate cyclosporine nephrotoxicity that disappeared when the administration of the drug was discontinued. Hypertension was the most serious side effect observed in eight subjects; in every case it was controlled by antihypertensive medicine. These data indicate that cyclosporine may be beneficial in the treatment of some patients with severe forms of systemic lupus erythematosus.

Linear glomerular IgG fixation in renal allografts: incidence and significance in Alport's syndrome.

Twelve of 767 renal allograft recipients developed linear fixation of IgG along the glomerular basement membrane (GBM) by direct immunofluorescence technique. This was associated with linear fixation along the tubular basement membrane in 7 of them. Circulating anti-GBM antibodies were not detected by indirect immunofluorescence or radioimmunoassay in any patient whereas anti-TBM antibodies were found in 2 of 4 with linear TBM fixation. Among the 12 patients with linear GBM fixation, 5 had Alport's syndrome; the 7 others had various renal diseases, excluding anti-GBM nephritis. Among the 767 patients, 34 had Alport's syndrome or variants (i.e., 4.5%). The incidence of linear GBM fixation is much higher in Alport's syndrome than in other renal diseases. Linear GBM fixation was not clearly related to anti-GBM antibodies and was not accompanied by significant deterioration of graft function. These findings may be relevant, however, to the missing GBM antigen in Alport's syndrome.

Specificity of acebutolol-induced antinuclear antibodies.

Treatment with the beta blocker acebutolol may trigger antinuclear antibody (ANA) production. We retrospectively studied 97 sera from 47 patients who developed ANA during acebutolol treatment. Anti-histone and anti-denatured (ss) DNA antibodies were found in 53% and 66% respectively of the sera tested. The activities of these two antibodies correlated well with the total ANA titer. Anti-native (ds) DNA were absent or present at low titer. This immunochemical pattern of acebutolol-induced ANA is similar to that reported for other drug-induced ANA. To date, the presence such isolated ANA is not known to expose patients to any particular risk other than exceptional and minor clinical manifestations of lupus which are rapidly reversible following therapy cessation.