Hyperhomocysteinemia, low folate status, homozygous C677T mutation of the methylene tetrahydrofolate reductase and renal arterial thrombosis.

We report a renal artery thrombosis in a 42-year-old man. Fasting homocysteinemia was at 23 micromol/l 3 months later and at 33 pmol/l 5 months after the vascular event. A homozygous C677T MTHFR was found with low folate status. Active smoking may also have contributed to the pathogenesis of renal arterial thrombosis. The other causes of thrombophilia were ruled out. Homocysteine lowering treament was started: homocysteine normalized at 10.6 micromol/l. There was no recurrence of vascular event within 18 months. We propose mild or moderate hyperhomocysteinemia triggered by low folate status in patients with homozygous C677T MTHFR as a cause of renal arterial thrombosis.

[Sclerosing peritonitis]. / Péritonite sclérosante.

The case presented in this study illustrates the peritoneal changes observed in long-term peritoneal dialysis (PD) patients. This male patient was on peritoneal dialysis (CAPD) for seven months before and 86 months after renal transplantation. Two episodes of peritonitis occurred during that time. The patient developed symptoms (ascites, gastro-intestinal disturbances, deteriorating general condition, inflammatory syndrome) four months after starting hemodialysis, one month after ablation of the PD catheter. Other potential causes (infection, malignancy, hepatitis, etc.) of these symptoms were ruled out following an exhaustive etiological work-up. A final diagnosis of sclerosing peritonitis was made, and the patient was started on corticosteroid therapy. Both morphological and functional alterations of the peritoneal membrane associated with long term PD and the detection of such alterations in everyday practice are reviewed here, along with possible etiological factors and therapeutic measures discussed in the literature. A better understanding of the pathophysiological mecHanisms underlying these alterations would make it possible to develop preventive measures, such as more biocompatible dialysates.

Icodextrin cutaneous hypersensitivity: report of 3 psoriasiform cases.

BACKGROUND: Icodextrin is proposed as a new osmotic agent for use in peritoneal dialysis. Because of its recent use, adverse reactions are not well known. Cutaneous adverse effects have been described. We report 3 cases of cutaneous hypersensitivity to icodextrin and discuss the pathogenesis of this reaction. OBSERVATIONS: The cutaneous adverse reaction was psoriasiform in our 3 cases. The eruption was generalized with acute generalized exanthematous pustulosis in 1 case, and limited to the palms and soles in 1 case. It occurred 10 to 15 days after icodextrin therapy was initiated. In patient 1, the results of a rechallenge with icodextrin were positive. Icodextrin therapy was discontinued in all patients. CONCLUSIONS: Some cases of cutaneous reactions to icodextrin have been reported in the literature, but they are rare. As in our cases, most eruptions are psoriasiform, limited to the palms and soles, or extensive. Although the etiology is unclear, a hypersensitivity reaction, with the formation of immunocomplexes, is probable.

Effects of atorvastatin on dyslipidaemia in uraemic patients on peritoneal dialysis.

BACKGROUND: Our purpose was to evaluate the efficacy and safety of atorvastatin, a potent cholesterol- and triglyceride-lowering agent, in peritoneal dialysis patients with dyslipidaemia. METHODS: Peritoneal dialysis patients with hypercholesterolaemia were treated for 4 months with atorvastatin at a starting dose of 10 mg. The dose could be increased to 20 or 40 mg in order to achieve the following targets: plasma LDL-cholesterol of 130 mg/dl for primary prevention of coronary heart disease, plasma LDL cholesterol of 100 mg/dl for secondary prevention, and plasma triglycerides of 200 mg/dl. Plasma lipid profile and liver and muscle enzyme levels were assessed at baseline and then monthly during treatment. RESULTS: Thirty-one patients with hypercholesterolaemia were included (16 males and 15 females; mean age 57+/-16 years; mean duration of peritoneal dialysis 27+/-17 months). Nineteen of the patients also had hypertriglyceridaemia and seven had diabetes. Twenty patients had no coronary history (primary prevention), whereas nine had experienced a coronary event (secondary prevention). In the primary and the secondary prevention patients, mean LDL-cholesterol levels (mg/dl) decreased significantly by 42 and 46% from 204+/-23 to 119+/-27 (P<0. 001) and 198+/-37 to 104+/-21 (P<0.001), and mean triglyceride levels (mg/dl) decreased by 37 and 26% from 289+/-132 to 186+/-92 (P<0.001) and 201+/-62 to 150+/-54 (P<0.001 respectively). Nineteen primary prevention and seven secondary prevention patients achieved the LDL-cholesterol target. The triglyceride target was achieved by 15 of the 19 hypertriglyceridaemic patients. Two patients stopped treatment (one because of gastrointestinal disturbances, the other because of an allergic skin reaction). After 4 months, there were no changes in enzyme levels. CONCLUSION: Atorvastatin is an effective and safe lipid-lowering agent for peritoneal dialysis patients with mixed dyslipidaemia.

The influence of automated peritoneal dialysis on the decrease in residual renal function.

BACKGROUND: Automated peritoneal dialysis (APD) has been increasingly used in recent years. Our purpose was to investigate whether the good preservation of residual renal function (RRF) that has been reported in patients on continuous ambulatory peritoneal dialysis (CAPD) is also observed in APD. METHODS: RRF was determined and compared prospectively over 1 year in two groups of peritoneal dialysis (PD) patients: 18 consecutive new patients starting on APD (12 continuous cyclic peritoneal dialysis (CCPD) patients and six nightly intermittent peritoneal dialysis (NIPD) patients) and 18 selected patients who had started on CAPD at the same time and were matched for baseline characteristics. RRF was assessed on normalized creatinine clearance (ml/min/1.73 m2) measured before the start of PD, at 6 months, and at 1 year. Wilcoxon's rank sum test was used to compare differences between the two groups. RESULTS: Creatinine clearance (ClCr) was 6.1 ml/min in the APD group and 6 ml/min in the CAPD group at the start of PD. The monthly rate of ClCr decrease was significantly higher in the APD group: -0.28 ml/min vs -0.1 ml/min (P = 0.04) at 6 months and -0.26 ml/min vs -0.13 ml/min (P = 0.005) at 1 year. RRF decreased at the same rate in patients treated with NIPD or CCPD. The daily instilled volume of 3.86% glucose dialysis solution (l/day) was higher in APD patients than in CAPD patients: 2.5 vs 0 at 6 months and 1 year but there was no significant difference in ultrafiltration rate (l/day) between APD and CAPD patients at these timepoints: 0.53 vs 0.6 and 0.88 vs 0.7 respectively. There was no difference between the two groups in body weight and blood pressure, which remained stable in both groups throughout the study period. CONCLUSIONS: RRF declined rapidly in APD patients whereas it was well preserved in CAPD patients. This may be explained by the less stable fluid and osmotic load together with the intermittent nature of APD and the larger use of hypertonic dialysate. RRF should be closely monitored in APD patients in order to adjust PD prescriptions and maintain adequacy.

Severe cutaneous hypersensitivity requiring permanent icodextrin withdrawal in a CAPD patient.

We report a case of severe cutaneous hypersensitivity to icodextrin occurring in a CAPD diabetic patient. Icodextrin withdrawal was necessary to achieve cutaneous recovery. Although rare, this adverse event should be kept in mind.