[Use of stress echocardiography in detecting silent myocardial ischemia in hemodialysis patients]. / Dépistage de l'ischémie myocardique silencieuse par échographie cardiaque de stress chez l'hémodialysé.

UNLABELLED: The chronic renal failure treated by hemodialysis is associated with a high incidence of prematured cardiovascular diseases, which represents the major causes of morbidity and mortality in hemodialysis patients. OBJECTIVE OF THE STUDY: To evaluate the interest of stress echocardiography for the detection of silent myocardial ischaemia in the chronic renal failure treated by hemodialysis. METHODS: 24 dobutamine stress echocardiography have been achieved in to patients having an average old of 61 +/- 11 years, 15 men and 3 women, with an average dialysis duration of 55 +/- 27 months. Only asymptomatic patients and those presenting an anomaly during the systematic annual echocardiography supervision have been included in this retrospective work. All echocardiography enregistrements have been achieved in the same center and by the same and experimented cardiologist. RESULTS: 75% of patients had an arterial hypertension antecedents, 65% were smokers, 50% had a dyslipidemia, 38% presented an arteriopathy of the inferior members, 30% had diabetes and 22% were obese; 8 (33.5%) stress echocardiographies were negatives. 6 patients have had 2 stress echocardiographies. A coronarography was realized in 16 patients and one of those was strictly normal (6.25% were false positive). 8 patients have had an angioplasty with stent making (1 simple stent, 7 double stent); 2 coronaries by-pass have been done in 2 patients. One patients refused surgery. Insignificant atheroumatous coronary lesions have been detected in 4 patients. In this study, the stress echocardiography enabled to detect a silent myocardial ischaemia in 15/16 patients (93.7%) and to treat 10/15 patients (66.5% including 20% by surgery). CONCLUSION: The sensibility of this test must be compared to the thallium scintigraphy coupled with dipyridamole as part of a larger prospective study.

[Proposal of a clinical prediction score for atheromatous renal artery stenosis]. / Proposition d'un score clinique de prédiction d'une sténose rénale athéromateuse.

UNLABELLED: Renal vascular pathologies are important causes of the chronic renal failure progression. This work aims to define retrospectively a score based on simple clinical and paraclinical helping to select atheromatous renal stenosis affected patients; 67 patients more than 50 years old have been explored by arteriography because of degradation of the renal function or hypertension: 45 of them had one, or many, significant stenosis of the renal arteries. Were analyzed: clinical data: age, weight, sex, blood pressure, previous ateromatous lesions (cardiac, peripheral, aortic), smoking, associated diabetes; biological data: serum cholesterol and creatinine, creatinine variation under angiotensin-coverting enzyme inhibitor or sodium depletion, kaliemia; radiologic data: kidney size through scanning, renal arterial and aortic calcifications on abdominal plain films and profile. The group with and without stenosis differed considerably for age (68.9 vs 64 years old, p < 0.05), smoking (26.3 vs 11.5 packet-year, p < 0.001), variation of creatinine after sensibilisation (140 mumol/l vs 17 mumol/l, p < 0.001), presence of arterial calcification (p < 0.001). A score taking in to account these four criteria was established with performances in terms of specificity and sensibility amounted to 83%. CONCLUSION: The reliable aspect of this score enabling to define a group seriously risking a renal stenosis must be checked through a prospective study.

[Smoking and atheromatous stenosis of the renal arteries]. / Tabac et sténoses athéromateuses des artères rénales.

UNLABELLED: Renal vascular pathologies are important causes of the chronic renal failure progression. In these pathologies, the role of smoking in so far as factor of risk was discussed. This work aims to evaluate the effect of smoking exposure on renal arteries of patients with both renal failure and hypertension. 67 patients more than 50 years old, having both renal failure and hypertension, have been explored by arteriography. The active smoking was required among all patients. Patients were classified in 2 groups: group (I) of 45 patients with one or more atheromatous stenoses of renal arteries considered to be significant and group (II) of 22 patients without significant atheromatous stenoses of renal arteries. [table: see text] 80.5% of patients of group (I) have smoked against only 44.4% in group (II). The fact that the presence of atheromatous stenoses of renal arteries was connected to the number of cigarettes and the exposure time, and not to the current comportment of patients towards smoking, this suggested a cumulative effect of smoking. CONCLUSION: This work shown a relation between the consumption of smoking and the existence of atheromatous stenoses of renal arteries, a reason moreover to fight against smoking. The prevention of smoking intoxication appears important to decrease the incidence of the renal vascular pathologies.

Fermentable carbohydrate and digestive nitrogen excretion.

BACKGROUND: Interventions that restrict protein intake lower plasma urea concentration and may slow the progression of renal failure. The question arises whether the effect of a dietary protein restriction could be reinforced by enrichment of the diet with fermentable carbohydrate because these carbohydrates may stimulate the extra-renal route of nitrogen (N) excretion through the digestive route. METHODS: The influence of fermentable carbohydrate and moderate protein restriction on N metabolism was investigated in a rat model of renal failure with ablation of 70% of renal mass compared with control rats with intact kidneys. Animals were adapted to diets varying with respect to nondigestible fermentable carbohydrate (0% or 10% fructooligosaccharide [FOS]) and with respect to protein content (10% or 18% casein). RESULTS: Feeding FOS led to a considerable enlargement of the cecum (increase in contents, wall thickness, and blood flow). These changes resulted in a concomitant enhancement of urea N uptake into the cecum and a decrease in plasma urea concentration (-30%). The extent of urea uptake by the cecum was influenced by plasma urea level that was determined by the dietary protein level and by the renal function. Thus, compared with control rats, the rate of urea uptake by the cecum and the total N excreted by the uremic rats was greater under all nutritional conditions. It is noteworthy that, when expressed as a percentage of total N excretion, fecal N excretion nearly doubled in rats adapted to the low-protein diets containing FOS. These effects occurred in both control rats and in uremic rats, in which a 22% decrease in urinary N was recorded as a result of FOS in addition to the low-protein diet. Globally, decreasing the amount of protein in the diet and adding a fermentable carbohydrate led to a decrease in urinary N excretion of more than 65% in uremic rats. CONCLUSION: These results suggest a possible usefulness for combining fermentable carbohydrate, such as FOS, with a low-protein diet to increase N excretion through the digestive route in detriment of the renal route. This may represent an efficient preventive measure to relieve the renal function in case of renal failure.

Deregulated platelet-activating factor levels and acetylhydrolase activity in patients with idiopathic IgA nephropathy.

BACKGROUND: Platelet-activating factor (PAF) is a phospholipid mediator with potent inflammatory activities. PAF stimulates IgA synthesis by B cells while IgA aggregates enhance PAF production by neutrophils and mesangial cells. These results led us to investigate blood PAF levels and plasma acetylhydrolase (AHA, the PAF catabolic enzyme) activity in patients with idiopathic IgA nephropathy (IgAN). METHODS: PAF and AHA levels were investigated using the platelet aggregation assay and degradation of (3)H-labelled PAF, respectively. The genotype of AHA with regard to the G994-->T mutation in exon 9 was assessed by an allele-specific polymerase chain reaction. RESULTS: Blood PAF levels were significantly (P:=0.003, Mann-Whitney U:-test) elevated in IgAN patients (50.6+/-6.8 pg/ml, n=33) compared with healthy controls (18+/-5 pg/ml, n=18). In contrast, plasma AHA levels were significantly (P:=0.0001, Mann-Whitney U:-test) reduced in patients with IgAN (61+/-2 nmol/ml/min, n=51) compared with healthy controls (78+/-4 nmol/ml/min, n=53). G994-->T transversion in exon 9 of AHA was not found in any of the IgAN patients. CONCLUSION: Elevated circulating levels of PAF in IgAN patients might result from an insufficient AHA probably related to environmental factors rather than genetic ones. The mechanism and the precise role of the PAF/AHA deregulation in IgAN patients remain to be clarified.

Role of fermentable carbohydrate supplements with a low-protein diet in the course of chronic renal failure: experimental bases.

During the past few years, considerable attention has been given to the impact of nutrition on kidney disease. The question arises of whether the effect of a moderate dietary protein restriction could be reinforced by enrichment of the diet with fermentable carbohydrates. Feeding fermentable carbohydrates may stimulate the extrarenal route of nitrogen (N) excretion through the fecal route. Such an effect has been reported in several species, including healthy humans and patients with chronic renal failure (CRF). Furthermore, studies of these subjects show that the greater fecal N excretion during the fermentable carbohydrate supplementation period was accompanied by a significant decrease in plasma urea concentration. In animal models of experimental renal failure, the consumption of diets containing fermentable carbohydrates results in a greater rate of urea N transfer from blood to the cecal lumen, where it is hydrolyzed by bacterial urease before subsequent microflora metabolism and proliferation. Therefore, this results in a greater fecal N excretion, coupled with a reduction in urinary N excretion and plasma urea concentration. Because elevated concentrations of serum urea N have been associated with adverse clinical symptoms of CRF, these results suggest a possible usefulness of combining fermentable carbohydrates with a low-protein diet to increase N excretion through the fecal route. Further investigations in this population of patients of whether fermentable carbohydrates in the diet may be beneficial in delaying or treating the symptoms and chronic complications of CRF will certainly emerge in the future. This should be realized without adversely affecting nutritional status and, as far as possible, by optimizing protein intake for the patients without being detrimental to renal function.

[General physiopathology of chronic left ventricular insufficiency]. / Physiopathologie générale de l'insuffisance ventriculaire gauche chronique.

The failing heart is unable to provide some organs, notably the brain and the myocardium, with the amount of blood flow they require. To this myocardial inadequacy and resulting "circulatory insufficient" the body reacts by setting in action compensatory mechanisms which are "intracardiac" first (Starling's heterometric regulation, ventricular hypertrophy), then neurohormonal, with the activation of vasoconstrictor systems (noradrenergic system, renin-angiotensin-aldosterone system, arginine-vasopressin system) counterbalanced by the activation of vasodilator systems (vasodilator prostaglandins, atrial natriuretic factor and kinins). However, the vasoconstrictor systems outweigh the vasodilator systems. They create an excessive arterial and venous vasoconstriction, together with water-and-salt retention, which leads to an increase of left ventricular work during both systole and diastole and to a gradual worsening of the heart failure. The present-day treatment of heart failure aims at reducing the water-and-salt retention and at restoring the balance between the vasoconstrictor and vasodilator systems.

[Natural history of arterial hypertension due to primary hyperreninism]. / Histoire naturelle d'une hypertension artérielle par hyperréninisme primaire.

This case report deals with an eight-year duration severe high renin hypertension and its consequences. In 1975, a 13 years old girl was found to have blood pressure (BP) levels of 240/150 mmHg with bilateral papilloedema. Hypokalemic alkalosis, a 45 mm Sokolow index (SI) and very high peripheral renin activity (PRA) were also noticed. Renal vein renin sampling (RVRS) suggested secretion from the left kidney but intravenous pyelography and renal arteriography were normal. BP levels were first controlled by triple treatment but rose one year later, despite adjunction of beta-blockers. High PRA was again found, but without hormonal gradient on a second RVRS. From 1977 to 1982, BP never fell to normal levels despite quadruple treatment. In 1982, a stage II optic fundus, a 58 mm SI and 2 g/day proteinuria are noticed, so that a new complete etiologic work up is undertaken in 1983: PRA is still high, with a dramatic acute BP fall after captopril and no gradient on a third RVRS, but intravenous pyelography, tomodensitometry and selective arteriography disclose a 4 cm diameter poorly vascularized tumour on the surface of the lower pole of the right kidney. BP levels are controlled for three months by captopril + chlorothiazide. The tumour is removed in january 1984. RVRS by direct peroperative punction indicates (a posteriori) hormonal secretion from the right kidney lower pole. Histologic examination and immunofluorescence with antirenin serum corroborate the juxtaglomerular origin of the tumour. Eighteen months later, BP is permanently normal, SI is 30 mm, and there is no proteinuria.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioimmunoblastic lymphadenopathy with dysproteinaemia (AILD) and sicca syndrome.

We report a case of AILD and sicca syndrome. The patient had presented with renal insufficiency, lymphadenopathy, hepatosplenomegaly, polyclonal hypergammaglobulinaemia, dryness of the eyes and mouth. Lip biopsy specimens showed an unusual cellular infiltrate similar to his kidney lesions. Data from the eight previously reported cases support the hypothesis that the association is a distinct pathological entity differing from pseudolymphoma and malignant lymphoma, which occur in the course of Sjögren's syndrome. The recognition of AILD is important because lymphoproliferation may lead to death after a few months.

[Report of eight aglomerular segmental renal hypoplasia in adult (author's transl)]. / A proposede huit cas d'hypoplasie rénale segmentaire aglomérulaire chez l'adulte.

A radiological aspect of segmental hypoplasia of the kidney was found on intravenous urography of eight patients. Urography was performed five times for arterial hypertension, two times for proteinuria and one time for pathological pregnancy. Aglomerular segmental hypoplasia was constantly observed on histological examination, and in three cases an important follicular ureteritis was found. Medical treatment and unilateral nephrectomy greatly improved clinical symptoms of six cases.

Focal glomerulosclerosis: natural history and treatment. A report of 70 cases.

70 cases of focal glomerulosclerosis (FGS) followed for periods ranging from 1 to 24 years are reported. 39 patients had a nephrotic syndrome. 31 patients had asymptomatic proteinuria. 97 renal biopsies were performed. At least one biopsy specimen from every patient showed focal and segmental involvement of glomeruli, but no lesions were observed on the first biopsy in 6 patients. 26 of the 35 patients with a nephrotic syndrome were treated with steroids alone and/or chemotherapy and/or indomethacin. Resistance to treatment was encountered in 21 patients. Complete remission was observed in 6 cases, despite persistence or accentuation of histological lesions on serial biopsies in 3 cases. Actuarial renal survival rate at 10 years was 45% in the group with a nephrotic syndrome versus 91% in patients with proteinuria. FGS with a persistent nephrotic syndrome represents the 'malignant' form of the disease. Recurrence of the disease was observed after transplantation in 2 cases and was absent in 1.

[Anuric tubular nephritis caused by rifampicin allergy]. / Tubulonéphrite anurique par allergie à la rifampicine.

Starting again a Rifampicin treatment gave rise to an acute renal insufficiency, reversible by hemodialysis. This incident resulted from an immunopathological conflict revealed by the presence of anti-Rifampicin antibodies. Renal needle biopsy did not show any immune deposits. The mechanism of these incidents is discussed. Authors draw attention to the necessity of avoiding discontinuous Rifampicin treatment.