[Epidemiological, clinical, biological and developmental aspects of leptospirosis: apropos of 30 cases in Aquitaine]. / Aspects épidémiologiques, cliniques, biologiques et évolutifs de la leptospirose: à propos de 30 observations recueillies en Aquitaine.

We have studied retrospectively 30 cases of leptospirosis observed in Aquitaine (South West France) from 1980 till 1992. This review was made in three internal and a nephrology department in Bordeaux hospital. Most cases occurred by indirect contact with infected animals or by occupational exposures. Onset was brutal with fever often associated with painful syndrome and sometimes conjunctival suffusion. Jaundice (70%), acute renal failure (67%), meningitis (50%) and hemorrhagic signs (50%) were among the major visceral manifestations. Diagnosis was always confirmed by micro-agglutination test. Leptospira ictero-hemorrhage was the predominant serogroup found. The outcome was favorable in 22 patients; reversible complications were seen in six cases (five acute renal failure with hemodialysis myocarditis and pulmonary edema in two hemodialysed patients, polyradiculoneuritis). Two patients died (acute respiratory failure and meningo-encephalitis with diffuse hemorrhagic syndrome). The characteristic of our series is the high frequency of hepatorenal syndrome due to the importance of our nephrologist recruitment. Furthermore our study confirm the vital prognostic characters of the pulmonary, renal, hemorrhagic and neurologic complications. No absolute relationship was found between the clinical and laboratory findings and the serotype of leptospira. Penicillin remains the treatment of choice and should be started as soon as possible the avoid the life threatening visceral complications.

Use of red blood cell indices (MCV, MCH, RDW) in monitoring chronic hemodialysis patients treated with recombinant erythropoietin.

Human recombinant erythropoietin (rHu-Epo) is now extensively used in chronic renal failures; this treatment, resulting in a correction of the severe anemias seen in hemodialysed patients, may in turn lead to a resistance to rHu-Epo therapy by reason of the shortage of erythropoiesis factors, such as iron, vitamin B12 and folates. The utility of the red cell indices (MCV, MCH, RDW) for detection of early iron, folate and B12 deficiencies was studied in eighteen hemodialysed patients with end-stage renal failure treated with rHu-Epo; Microcytosis (MCV < 80 fl) was found ineffective in detecting iron deficiencies as well as macrocytosis (MCV > 100 fl) in folate and B12 deficiencies, partly due to the high incidence of associated iron and folate deficiencies. Lowered MCH (< 27 pg) was not more efficient than microcytosis in detecting early iron deficiencies. Increased RDW was the most sensitive feature for folate, iron and B12 deficiencies with respective sensitivities of 62.5%, 72% and 75%. The global specificity for detecting all deficiencies was 74%. However, high RDW values were not indicative of any type of deficiency; it may thus be concluded that RDW is a non expensive, non invasive and sensitive test, which allows a selection of hemodialysed patients treated with rHu-Epo for a complete investigation program, in order to detect early iron, B12 and folate deficiencies.

[Peritoneal dialysis catheters. Immediate outcome after 30 days]. / Les cathéters de dialyse péritonéale. Leur devenir immédiat à 30 jours.

Results of a retrospective study of 124 peritoneal dialysis catheters introduced in 74 patients from October 1982 to November 1991 showed that 91% of catheters were functional at 30 day follow up, allowing continuous ambulatory peritoneal dialysis to proceed under satisfactory conditions. However, surgical replacement was necessary in 21.81% (26 catheters) during the first month, due essentially to mechanical complications: exteriorized or non exteriorized leaks (7 cases), dysfunction with faulty perfusion or emptying (11 cases) and catheter displacement (3 cases). Five catheters (4.25%) had to be withdrawn because of infection, suggestive of the need for prophylactic antibiotic therapy. No determining factor could be found in the present series or in the literature to explain the genesis of these mechanical complications, the cause of which is without doubt multifactorial. Rapid surgical replacement allows functional survival of the majority of catheters without increasing the risk of infection.

Staphylococcus aureus nasal carriage and infection in patients on continuous ambulatory peritoneal dialysis.

We studied 140 consecutive patients beginning continuous ambulatory peritoneal dialysis (CAPD) at one of seven hospitals to assess the relation of the nasal carriage of Staphylococcus aureus to subsequent catheter-exit-site infection or peritonitis. Shortly before the implantation of the catheters, the patients' anterior nares were cultured for the presence of S. aureus. Antibiotics were not prescribed for the S. aureus carriers, but all the patients were monitored for signs of catheter infection (median follow-up, 10.4 months). At the initiation of CAPD, 63 patients (45 percent) carried S. aureus in the nares. Nasal carriage was more frequent among the 30 patients with diabetes (77 percent) than among the 110 without the disease (36 percent). The carriers of S. aureus had a significantly higher rate of exit-site infection than the noncarriers (0.40 vs. 0.10 episode per year; P = 0.012). Of these episodes, 24 of 34 were caused by S. aureus. The rates of peritonitis of all bacterial types did not differ significantly between the groups, but all 11 episodes of peritonitis caused by S. aureus occurred among the carriers. In 85 percent of the patients with clinical S. aureus infections, the strain from the nares and the strain causing the infection were similar in phage type and antibiotic profile. We conclude that in patients beginning ambulatory peritoneal dialysis, the nasal carriage of S. aureus is associated with an increased risk of catheter-exit-site infection and that the performance of nasal cultures before the implantation of the catheter can identify patients at high risk of subsequent morbidity.

[Treatment of peritonitis under continuous ambulatory peritoneal dialysis using intraperitoneal ceftazidime]. / Traitement des péritonites en dialyse péritonéale ambulatoire continue par la ceftazidime intrapéritonéale.

Management of peritonitis related to chronic ambulatory peritoneal ceftazidime. In 15 patients under CAPD, 22 cases of bacterial peritonitis were observed with clinical manifestation in 14. The mean cell count in peritoneal dialysis fluid was 3 580/mm3 with 3 040/mm3 polymorphonuclear leukocytes. Causative pathogens were: Staphylococcus in 11 cases, Streptococcus in 3, Sarcines in 2, Corynebacterium in 2, Micrococcus varians in 1, Gram negative in 3. First choice treatment was a intraperitoneal injection of 1 g of ceftazidime every 48 hours, 54.5% of patients recovered within 5 days. Failures were due to 4 Staphylococcus aureus, 3 Staphylococcus epidermidis, 1 Sarcine, 1 Streptococcus liquefaciens, 1 Corynebacterium hofmanii. Mean ceftazidime concentrations 48 hours after the intraperitoneal injection were 35 mg/l (range = 14-54 mg/l) in serum and 5.5 mg/l (E: 2.8,8 mg/l) in dialysate. These concentrations in dialysate, are not greater than most of ceftazidime'S CMI for susceptible bacteria. A single daily intraperitoneal injection of ceftazidime is desirable.

[Use of a thin wall Impra prosthesis for a vascular approach in chronic hemodialysis. Short- and middle-term evaluation. Apropos of 66 cases]. / L'utilisation des prothèses Impra à paroi fine dans l'abord vasculaire en hémodialyse chronique. Evaluation à court et à moyen terme. A propos de 66 observations.

The authors report their experience of thin wall PTFE IMPRA prostheses in providing vascular access for chronic haemodialysis. Sixty-six prostheses were inserted between 14/10/1983 and 31/10/1986, with review of all patients at 31/6/1987. Twenty-three per cent of patients died during the study period. Patency analysed by the actuarial method was 49.07 +/- 15.7% at 2 years. There was no evidence of any significant difference between use of the forearm and of the arm. The main cause of failure was early (responsible for the loss of 9.2% of prostheses) or secondary (after the first month) thrombosis. A total of 30.3% of prostheses were lost by thrombosis by the end of 2 years, the principal cause being anastomotic or post-anastomotic venous stenosis. The use of thin walls in no way modified the incidence of this complication. The authors suggest its preventive protection by routine ansography. False aneurysms occurred beyond 18 months of dialysis requiring removal of the prosthesis in 3 cases. Thinning of the wall is one of the probable factors involved in this complications, justifying the abandonment of this type of prosthesis in this indication despite technical advantages at implantation and during use.

Increase of erythrocyte resistance to hemolysis and modification of membrane lipids induced by hemodialysis.

Mechanical fragility, deformability and lipid composition of erythrocyte membranes were studied in 22 uremic dialysed patients before and after dialysis in comparison to controls. While deformability was not affected by a dialysis session, osmotic and saponin resistances to hemolysis were significantly increased after dialysis (p less than 0.001). The lipid composition of erythrocyte membranes was also altered during dialysis, with a notable increase in cholesterol and a different phospholipid distribution, i.e. phosphatidylcholine and sphingomyelin significantly decreased (p less than 0.001). Likewise, the fatty acid distribution showed large variations with an increase in polyunsaturated fatty acid. The acute effect of dialysis on the membrane lipid composition seems to be linked to erythrocyte alterations. Its significance is discussed in relation to the asymmetric transverse distribution of phospholipids previously described in human erythrocyte.

[Treatment of peritonitis in continuous ambulatory peritoneal dialysis with intraperitoneal ceftriaxone]. / Traitement des péritonites en dialyse péritonéale continue ambulatoire par la ceftriaxone intrapéritonéale.

In 16 patients under CAPD, 29 cases of bacterial peritonitis were observed, with clinical manifestations in 23. The mean cell count in peritoneal dialysis fluid was 5608/mm3 with 4991/mm3 polymorphonuclear, Leukocytes Causative pathogens were Staphylococcus in 14 cases, Streptococcus in 6, Bacillus in one, Enterobacteria in 5, Pseudomonas aeruginosa in 1 and Moraxella in 1. Three cultures were negative. First choice treatment was a daily intraperitoneal injection of 1 g of ceftriaxone. 79.3% of patients recovered within 5 days. Failure were due to a Methicillin-resistant Staphylococcus epidermidis in one case, a Streptococcus faecalis in two cases, and a Staphylococcus aureus in three observations, which two were responsible of abscess round catheter peritoneal. Mean ceftriaxone concentrations 24 hours after the intraperitoneal injection were 50.6 mg/l (range: 3.3-141 mg/l) in serum and 58.1 mg/l (range: 4.3-180 mg/l) in dialysate. These concentrations are greater than most of ceftriaxone's MICs for susceptible bacteria, a finding that confirm the value of treatment with a single daily intraperitoneal injection of ceftriaxone.

[Pulmonary manifestations in severe ictero-hemorrhagic leptospirosis]. / Manifestations pulmonaires au cours de leptospiroses ictéro-hémorragiques sévères.

Eight cases of pulmonary involvement were observed in 17 severe cases of ictero-haemorrhagic leptospirosis. Haemoptysis (7 cases) occurred on the 4th day of the infectious syndrome and was associated with other haemorrhagic manifestations in 4 cases. Cough, pain and polypnoea were not constant. Chest X-ray showed diffuse, non-specific changes, such as nodular opacities or infiltrates. Septicaemia was confirmed in all cases with acute renal failure in 7 cases and meningitis in 6 cases. Severe thrombocytopenia was demonstrated in 2 cases. Six patients recovered quickly with regression of the lung changes within 12 days. Two patients died, one of a fulminant haemoptysis related to a disseminated intravascular coagulation syndrome, and the other of acute respiratory failure. All cases were confirmed serologically. Although lung changes in leptospirosis are usually benign and mild, haemoptysis and polypnoea with diffuse radiological changes are poor prognostic factors. The pathological changes were similar to those of haemorrhagic alveolitis. These changes may be either due to the liberation of toxins or to an immunological phenomenon.

[Value of exchange transfusion in the treatment of severe malaria (apropos of 5 cases)]. / Intérêt de l'exsanguinotransfusion dans le traitement du paludisme grave (à propos de 5 observations).

Five imported falciparum malaria cases with severe evolution are reported. Treatment associated a blood exchange transfusion and an antimalaria chemotherapy (mefloquine in three patients and quinine in two patients). All patients were successfully cured despite of serious visceral complications occurring in two patients (pulmonary and cerebral oedema). Technical management of treatment is detailed. Exchange transfusion should be considered in falciparum malaria when parasitaemia overcomes 20% and when serious visceral impairment, hemolysis or consumption coagulopathy are occurring.

[Treatment of peritonitis due to continuous ambulatory peritoneal dialysis using a single daily intraperitoneal dose of 1g cefotiam]. / Traitement des péritonites en dialyse péritonéale continue ambulatoire par une dose unique quotidienne de 1g de céfotiam par voie intrapéritonéale.

Peritonitis remains the main complication of CAPD. This study demonstrates that most cases can be successfully treated with cefotiam. In 17 patients under CAPD, 33 cases of bacterial peritonitis were observed, with clinical manifestations in 28. The mean cell count in peritoneal dialysis fluid was 2 820/mm3, with 2 200/mm3 polymorphonuclear leukocytes. Causative pathogens were Staphylococcus in 18 cases, Streptococcus in 4, Stomatococcus mucilaginous in 1, Corynebacterium J.K. in 1, Enterobacter in 3, Acinetobacter in 3 and Pseudomonas in 2. Two cultures were negative. First choice treatment was a daily intraperitoneal injection of 1 g cefotiam. 68.80% of patients recovered within 6 days. Failures were due to a methicillin-resistant Staphylococcus epidermidis in 3 cases, a relapsing Stomatococcus mucilaginous infection in 1, a Streptococcus faecalis in 1, an Acinetobacter in 3 and a Pseudomonas in 2. Mean cefotiam concentrations 24 hours after the intraperitoneal injection were 9.4 +/- 7.0 micrograms/ml (range 1.3-26.4 micrograms/ml) in serum and 3.4 +/- 3.3 micrograms/ml (range 0.4-12.2 micrograms/ml) in dialysate. These concentrations are greater than most of cefotiam's MICs for susceptible bacteria, a finding that confirms the value of treatment with a single daily intraperitoneal injection of cefotiam.

Pharmacokinetics of intravenous and intraperitoneal moxalactam in chronic ambulatory peritoneal dialysis.

The kinetics of moxalactam has been investigated in 10 subjects undergoing continuous ambulatory peritoneal dialysis (CAPD). A single 1 g dose was injected i.v. and a 1 g dose was given intraperitoneally in the CAPD fluid during a 4 h dwell-time. Moxalactam was assayed by HPLC. After i.v. injection, the serum kinetics of moxalactam were: plasma t 1/2 = 17.9 h; volume of distribution at steady-state, 0.27 l/kg; total plasma clearance, 12.8 ml/min; peritoneal clearance, 2.1 ml/min. Dialysate moxalactam concentrations rose rapidly but only 20% of the dose was eliminated by the peritoneal route. After intraperitoneal instillation, moxalactam appeared in the serum rapidly and the peak serum concentration ranged from 21 to 49 micrograms/ml after between 4 and 5 h. The absorption of moxalactam from the peritoneal space was 57 +/- 16%. The data suggest that moxalactam has bidirectional exchange characteristics through the peritoneal membrane. Instillation of moxalactam in CAPD fluid may permit rapid absorption and the appearance of a therapeutic serum concentration.

Pharmacokinetics of intravenous and intraperitoneal ceftriaxone in chronic ambulatory peritoneal dialysis.

The kinetics of ceftriaxone was investigated in 8 patients without infection, who were receiving continuous ambulatory peritoneal dialysis (CAPD). Ceftriaxone 1 g was injected i.v. and 1 g was given intraperitoneally in the CAPD fluid during a 4-h dwell time. Ceftriaxone was assayed by HPLC. After intravenous administration, the kinetic parameters of ceftriaxone were: plasma t1/2, 12.3 h, total plasma clearance, 14.0 ml/min, volume of distribution at steady state 0.18 l/kg, and peritoneal clearance 0.59 ml/min. Over 72 hours only 5.5% of the dose was eliminated by the peritoneal route. After intraperitoneal administration, ceftriaxone rapidly appeared in serum; the absorption t1/2 was 1.1 h and the mean peak concentration was 38.8 micrograms/ml. The absorption of ceftriaxone from the peritoneal space was 39%. A single 1.0 g IP dose led to serum and dialysate concentrations of ceftriaxone above the minimum inhibitory concentration for susceptible pathogens for 24 hours.

[Peritoneal complications during continuous ambulatory peritoneal dialysis: surgical aspects]. / Les complications péritonéales au cours de la dialyse péritonéale continue ambulatoire: aspects chirurgicaux.

The principal complication of continuous ambulatory peritoneal dialysis (CAPD) is peritonitis in most cases benign and treated effectively by local, specific antibiotic therapy. In some cases, however, the infection fails to respond to medical treatment and surgical exploration occasionally reveals serious lesions such as sclerosing peritonitis or an intestinal perforation. Prognosis is dependent not only on the extent and severity of the lesion but also on the rapidity of operative intervention. The development of an appendicitis, often masked by early antibiotic therapy, represents a particular course of peritoneal infection during CAPD.

[5 years of continuous ambulatory peritoneal dialysis (CAPD) (multicenter study of 345 patients)]. / Bilan de cinq années de dialyse péritonéale continue ambulatoire (DPCA) (étude multicentrique de 345 patients).

A retrospective survey has been undertaken in 7 different centers: 345 patients trained to CAPD between 1978 and 1983 were studied: technic success and survival rate were analysed using actuarial methods. Drop-out has dramatically decreased after May 1981 due to a lower mortality whatever the age. For all patients the actuarial survival at two years after 1981 is 87.1%. Related to a lower mortality, better results are obtained in patients younger than 55. However peritonitis is the main complication since they are involved in 1/3 of drop-out causes. It is concluded that CAPD might be used in almost 30% of chronic renal failure patients and that patients waiting for a kidney transplantation represent the best indication. In aged patients, nutritional status and psychosocial background must be carefully analysed before starting CAPD.