Lupus erythematosus proliferative glomerulonephritis in fetus.

We report the case of a fetus with proliferative glomerulonephritis in the context of maternal systemic lupus erythematosus (SLE). The pattern of the renal lesions correspond to the class III of revisited WHO classification of glomerulonephritis in SLE. Amniotic fluid analysis showed a high level of albumin and the presence of anti-Ro and anti-DNA antibodies that were possibly responsible for the renal injury.

Critical role of the extracorporeal blood temperature in the hemodynamic response during hemofiltration.

Impaired vascular reactivity during combined ultrafiltration-hemodialysis (UF+HD) compared with hemofiltration (HF) remains a rather enigmatic problem, the causes of which are still not well understood. Although a number of factors have been claimed to be responsible, most recent studies point to a major role of the extracorporeal blood temperature, which is usually lower during HF compared with UF + HD. However, previous studies in which hemodynamics were studied during UF + HD and HF in relation to the extracorporeal blood temperature are limited by the use of acetate in UF + HD, and measurements were often confined to BP and heart rate. Therefore, arterial BP, as well as forearm vascular resistance (FVR) and venous tone (strain-gauge plethysmography), was measured in 11 hemodialysis patients during 3 h UF + HD (37.5 degrees C) and predilution HF (39.0 degrees C = warm HF), resulting in equivalent extracorporeal blood temperatures. Patients were also studied during cold HF at an infusate temperature of 36.0 degrees C. UF + HD and HF were matched with respect to the dialysate and infusate composition (bicarbonate), bio-compatibility factors, and small molecule clearance. At equivalent temperatures, UF + HD and HF were associated with a comparable vascular and BP response. Only cold HF was associated with a significant increase in FVR. In addition, FVR and venous tone, as well as arterial BP, were all significantly higher during cold HF compared with both UF + HD and warm HF. These results indicate that the disparity in vascular reactivity between UF + HD and HF is primarily related to differences in the extracorporeal blood temperature.

Pre-/postdilution hemofiltration.

Hemofiltration creates the best conditions for toxin removal and cardiovascular stability in the treatment of chronic renal failure patients. The increase in hematocrit due to erythropoietin, the blood flow rate and the necessary volume of substitution fluid limit the post- or the predilution hemofiltration. The technical progress made now offers the possibility to routinely and safely treat patients with pre-/postdilution hemofiltration. When adjusting the substitution flow rate to the blood flow rate, small-molecule clearances are higher than those in hemodialysis and are close to those in hemodiafiltration.

The effect of renal impairment on the pharmacokinetics of oxcarbazepine and its metabolites.

We have studied the effect of renal impairment on the pharmacokinetics of oxcarbazepine, its active monohydroxy-metabolite (which predominates in plasma), their glucuronides, and the inactive dihydroxy-metabolite after a single oral dose of oxcarbazepine (300 mg). Six subjects with normal renal function and 20 patients with various degrees of renal impairment participated. The mean areas under the plasma concentration-time curves of oxcarbazepine and its monohydroxy-metabolite were 2-2.5-times higher in patients with severe renal impairment (CLCR < 10 ml.min-1) than in healthy subjects. The apparent elimination half-life of the monohydroxy-metabolite [19 (SD 3) h] in these patients was about twice that in healthy subjects. The effect of renal impairment on the plasma concentrations of glucuronides was more marked. The renal clearances of the unconjugated monohydroxy-metabolite and its glucuronides (the main compounds recovered in urine) correlated well with creatinine clearance. The maximum target dose in patients with slight renal impairment (CLCR > 30 ml.min-1) should not be changed. In patients with moderate renal impairment (CLCR 10-30 ml.min-1) it should be reduced by 50%. In patients with severe renal impairment (CLCR < 10 ml.min-1), the glucuronides of oxcarbazepine and its monohydroxy-metabolite are likely to accumulate during repeated administration, and dosage adjustment of oxcarbazepine in these patients could not be proposed from this single administration study.

[Hemofiltration--Hemodiafiltration]. / Hémofiltration--Hémodiafiltration.

Hemofiltration and hemodiafiltration are two modes of extra-renal therapy which characteristics are: high efficiency, biocompatibility, good tolerance, low morbidity. On-line preparation of substitution fluid from sterile and apyrogen dialysate and modelization lead to propose in the futur HF ou HDF for all patients. Adequacy of epuration is not enough defined to conclude that HDF is better than HF.

Phosphate kinetics in dialysis patients.

During extrarenal therapy, plasma phosphate concentrations have specific kinetics: plasma values reach a steady-state nadir 90-120 min after the beginning of the session (from 0.6 to 1.1 mmol/l) with a subsequent high rebound in the 3-4 h following the session. These kinetics are found during haemofiltration (HF) with high ultrafiltration (UF) rates (greater than 270 ml/min) and UF volumes (greater than 30 1). Other HF studies with different UF rates (100 or 200 ml/min) show that delayed mass transfer cannot explain kinetics which result from a phosphate transfer from cellular to extracellular space. Acetate or bicarbonate reinjection fluid does not modify phosphate kinetics. Immediate decrease of ionised calcium after the session argues against a mobilisation from the exchangeable phosphate pool of bone. Only potassium shows a similar pattern to phosphate, so the hypothesis of a relation between cellular phosphate and potassium fluxes is postulated. 31P-NMR study during and after HF does not allow us to specify phosphate transfer from the cell, but various potassium concentrations in the reinjection fluid (0, 2, 3.5, or 4 mmol/l) confirm the influence of potassium removal on phosphate transfer, and a significant linear relationship can be established between cellular potassium and phosphate fluxes. The influence of phosphate removal on phosphataemia has also been investigated using 0, 2, or 3 mmol/l phosphate in the reinjection fluid. Whatever the phosphate modification achieved by the session, the patient's phosphate concentrations are not significantly different 2 days later.(ABSTRACT TRUNCATED AT 250 WORDS)

[Rheumatoid purpura in adults]. / Purpura rhumatoïde de l'adulte.

Generalized vasculitis of unknown pathogeny, involving skin, joints, kidneys and gut in various combinations. Rheumatoid purpura (RP) is rare in adults. Clinical spectrum is more severe than in children, but the outcome is favorable in the majority of patients. RP has an unpredictable nature, but poor prognosis is bound, early, to gastrointestinal complications, specially in old patients, and secondarily to evolution of glomerular lesions. Intensive therapy (plasma exchanges) should be indicated only in severe extra renal complications, and when renal biopsy shows crescents present in more 50 p. 100 of the glomeruli.

Factors predictive of perinatal outcome in pregnancies complicated by hypertension.

Perinatal outcome and various indicators of perinatal risk were analyzed in a prospective study of 268 pregnant women with hypertension. Poor perinatal outcome was defined by stillbirth (n = 13), neonatal death (n = 2), and in surviving babies, by birth before 32 weeks or a birthweight below 1500 g (n = 13). In multivariate analysis, proteinuria and onset of hypertension between the 27th and 36th weeks of amenorrhea were the only two independent indicators of poor outcome (relative risks of 4.0 and 3.7, p less than 0.001 and p less than 0.01 respectively). Both these indicators were more frequent in mothers with no history of pre-pregnancy hypertension.

[Syndrome of alveolar hemorrhage associated with systemic cholesterol embolism]. / Syndrome d'hémorragie alvéolaire associé à des embolies systémiques de cholestérol.

Vascular purpura and haemoptysis developed in a patient suffering from accelerated hypertension and rapidly progressive renal failure due to cholesterol embolism. Alveolar haemorrhage was diagnosed on the association of clinical and endoscopic results, and on the outcome of the disease. This syndrome is usually associated with other immunological disorders and raises the question of immunological phenomena being the cause of some of the clinical manifestations observed after cholesterol embolism.

Technical and clinical data on high-performance hemofiltration: twelve patients during one year.

In 12 chronic hemodialysis patients, postdilutional hemofiltration (HF) was substituted for conventional acetate hemodialysis (HD) (4-5 h/session with high-area capillary dialyzers). In HF, the purposes were to obtain (a) no increase in pre-HF uremia compared with pre-HD uremia (high ultrafiltrate volume), (b) an HF duration shorter than that of HD (mean ultrafiltrate rate greater than 120 ml/min), (c) a disposable cost of an HF session identical to that of an HD session (reuse of hemofilters and extemporaneous preparation of substitution fluid). One-year results were (a) an ultrafiltrate volume of 26.8 L/session and a pre-HF uremia of 35.4 mmol/L (pre-HD uremia 34.0 mmol/L), (b) a mean ultrafiltrate rate of 143 ml/min and a mean HF duration of 190 min (mean HD session duration 250 min), and (c) better clinical tolerance and vascular stability in HF than in HD (weight loss 3.5 kg in HF and 3.0 kg in HD). Reuse of filters and extemporaneous preparation of substitution fluid were not responsible for any pyrogen reaction or bacterial contamination. In conclusion, (a) compared with conventional HD, high-flux HF results included identical removal of small molecules, improvement in vascular stability, decrease in session duration, and identical disposable cost; (b) routine high-flux HF is workable in a dialysis unit; (c) vascular access is the most important limiting factor to high-flux HF. Today 30-40% of patients can be treated with this method.

Oxprenolol placental transfer, plasma concentrations in newborns and passage into breast milk.

Thirty-two pregnant hypertensive patients were treated with oxprenolol administered in combination with dihydralazine as Trasipressol tablets. Before delivery, oxprenolol was demonstrable in the maternal plasma and the amniotic fluid. The free fraction of oxprenolol in the maternal serum (15% +/- 7.8; mean +/- s.d.; n = 25) was similar to that in normal serum. At the end of delivery, oxprenolol was found in both the maternal and umbilical plasma in most cases. Measurable, but low oxprenolol concentrations were present in the newborn plasma. After delivery, oxprenolol was demonstrable in the maternal plasma and breast milk. An infant weighing 3 kg and consuming 500 ml of breast milk per day would receive a maximum dose 60 times less than the normal daily dose for a hypertensive adult (4 mg/kg).

[Systemic periarteritis nodosa associated with monoclonal gammapathy. 4 cases]. / Périartérite noueuse systémique associée à une gammapathie monoclonale. Quatre observations.

Four cases of monoclonal gammopathy associated with polyarteritis nodosa are reported. In view of the chronology of events and course of the disease, the connections between protein peak and polyarteritis nodosa can be considered. Management of polyarteritis nodosa is discussed according to the existence of a peak which may originate in myeloma. The part played by plasma exchanges is debated.

[Nephrotic syndrome with minimal glomerular lesions, sensitive to corticoids, disclosing a chordoid sarcoma]. / Syndrome néphrotique à lésions glomérulaires minimes corticosensible révélateur d'un sarcome chordoïde.

A 65 year old woman had a minimal changes nephrotic syndrome (MCNS) with steroid-induced remission. An underlying malignancy was discovered at the time of relapse of proteinuria: it was a retroperitoneal chordoid sarcoma. Even though the tumor could not be excised, complete remission was again observed with corticosteroids. There was no second relapse when prednisone was discontinued and during the seven months before the patient died. This is a new unusual case of MCNS associated with carcinoma. The response of nephrotic syndrome steroid therapy is further suggestive evidence that deficiency in T-cell function may be involved.