[A patient with visceral leishmaniasis and acute renal failure in necrotizing glomerulonephritis]. / Leishmaniose viscérale autochtone avec insuffisance rénale aiguë par glomérulonéphrite infectieuse.

Renal involvement is an unusual complication of human visceral leishmaniasis (VL). The kidney lesions are characterized more by interstitial damage than glomerular or vascular damage. This case represents a 20 years-old man admitted with pancytopenia, purpura, acute renal failure, and nephrotic syndrome associated with heavy proteinuria. The diagnosis of VL was made on bone marrow smear cytology where Leishmania amastigotes were found. The renal biopsy revealed a segmental necrotising glomerulonephritis with 70% crescents. Treatment with liposomal amphotericine B alone has been ineffective on the course of renal failure, however, partial recovery was obtained after the administration of high dose corticosteroids. We present the various clinical, biological, and histological aspects of this case, from the south of France. It gave us the opportunity to discuss these unusual manifestations of immunomediated necrotising skin and renal lesions.

Prognostic factors in mesangial IgA glomerulonephritis: an extensive study with univariate and multivariate analyses.

To clarify the risk factors for chronic renal failure in idiopathic IgA glomerulonephritis (IgA-GN), we performed a dual study on 282 patients using both standard univariate statistical methods and the multivariate regression model of Cox. During a follow-up ranging from 1 to 36 years, with a mean of 8 years, 18% of the patients (50/282) had gone into chronic renal failure (CRF), with 18 of them in end-stage renal disease (ESRD) (6%). The univariate comparison of patients with CRF versus patients without CRF showed multiple risk factors: mainly arterial hypertension, an amount of proteinuria, nephrotic syndrome, a high level of serum IgA, presence of HLA-B35 antigen, and the intensity of most pathological lesions on light microscopy. The actuarial survival rate for a normal renal function (serum creatinine less than 135 mumol/L [1.5 mg/dL]) was 84% at 10 years and 64% at 20 years. The multivariate study allowed the isolation of only four risk factors with a significant effect on survival rate. These were the amount of proteinuria, the global optical score on first renal biopsy, the presence of an initial hypertension, and the presence of the HLA-B35 antigen. From these results, the probability of renal survival for individual patients may be calculated and a high-risk subgroup defined. Our data confirm the greater usefulness of multivariate over univariate statistical analyses in finding risk factors for CRF in IgA-GN.

[Influence of dialysis and kidney transplantation on the survival of patients with end-stage chronic kidney failure. A multifactorial analysis]. / Influence de la dialyse et de la transplantation sur la survie des malades en insuffisance rénale chronique terminale. Analyse multifactorielle.

In a series of 296 patients treated in our centre by dialysis and/or renal transplantation over the last 15 years, the actuarial survival rates at 5, 10 and 15 years were 79, 68 and 57 percent respectively. Comparing the influence on survival of each of these two treatments separately should avoid two methodological biases represented by the sequential risk due to the succession of treatments and by different pretherapeutic situations. We therefore analysed these patients' survivals by the unbiased Mantel-Byar method, using a comparison of multiple survival factors (Cox's technique). We showed that treatment was an independent factor of survival and that transplantation had a more beneficial effect than dialysis. However, these replacement techniques seem to have less influence on survival than the pretherapeutic situations.

Comparison of pathological lesions on repeated renal biopsies in 73 patients with primary IgA glomerulonephritis: value of quantitative scoring and approach to final prognosis.

In order to improve our possibility of establishing a long-term prognosis in IgA nephritis, 73 patients out of a cohort of 282, followed over a mean period of 12 years at the same institution for an IgA nephritis, had a prospective second renal biopsy 5 years later. For all biopsies (RB1 and RB2), we developed a quantitative scoring for all elementary lesions with a glomerular, an interstitial, a tubular and a vascular index. The sum of these 4 indexes gave a global optical score (GOS). Pathological improvement on light microscopy (delta GOS less than or equal to -2) was noticed only in 3 patients (4%), stability (-2 less than delta GOS less than +2) in 30 patients (41%), mild deterioration (+2 less than or equal to GOS less than 5) in 23 patients (32%) and major progression (delta GOS greater than or equal to 5) in 17 patients (23%). We observed no pathological remission, even in the 14 patients with complete clinical remission. The pathological progression was characterized by an increase in all elementary lesions, mainly the tubulo-interstitial and vascular ones. By immunofluorescence mesangial IgA deposits remained stable with no disappearance; however, the number and intensity of vascular C3 deposits were significantly greater on RB2. Chronic renal failure (serum creatinine greater than 1.5 mg/dl) correlated best with major pathological progression and mainly with the progression of extraglomerular lesions. IgA nephritis is a slowly progressive disease with no pathological remission, and its evolution is characterized by progression of extraglomerular lesions, mainly vascular, which might play a major role in the ultimate development of chronic renal failure.

Exit-site care and exit-site infection in continuous ambulatory peritoneal dialysis (CAPD): results of a randomized multicenter trial.

A total of 127 patients from 8 hospitals were randomized into 1 of 2 exit-site care regimes to evaluate their effect on rate of exit-site infection (ESI). Group 1 used povidone iodine and nonocclusive dressings changed 2 to 3 times weekly; Group 2 simply cleansed the exit site with nondisinfectant soap and water. Incidence, cause, duration, and treatment of ESI and peritonitis (P) were noted. Groups were analysed for age, sex, end-stage renal disease (ESRD), catheter, and systems. Total cumulative follow up time was 95.6 years. There was a significantly higher rate (p = 0.0183) of ESI in Group 2 (soap and water). The mean rate of ESI was 0.27 episodes/patient year for Group 1 versus 0.71 episodes/patient year for Group 2. Rates of P for the two groups were not significantly different (p greater than 0.50): 0.446 episodes/year for Group 1 versus 0.574 episodes/year for Group 2. S. aureus was responsible for 83% of ESI in Group 1 and 67% of ESI in Group 2. Protective dressing with a disinfectant is associated with significantly less ESI than minimum care. However, further research in exit-site care aimed specifically at reducing S. aureus infection is still required.

[Renal insufficiency and severe genital prolapse. 2 cases]. / Insuffisance rénale et prolapsus génital majeur. Deux cas.

The authors report two patients with renal failure due to total procidentia. Surgical repair led to an improvement in renal function. Mild chronic renal failure persisted. Thus the renal status must be assessed in cases of uterine prolapse.

[Development of renal function in the transplanted patient with renal hypertension treated with enalapril]. / Evolution de la fonction rénale chez le transplanté rénal hypertendu traité par enalapril.

We report our experience with a converting-enzyme inhibitor, enalapril, as antihypertensive agent in eighteen patients with hypertension after renal transplantation. Renal function was prospectively followed up. Six patients demonstrated an acute renal failure episode (defined by a 25% increase of serum creatinine during enalapril therapy). Renal failure was always reversible with interruption or dosage reduction of the drug. We recommend to start therapy with low dose and to closely monitor renal function.

IgA mesangial deposits in C3H/HeJ mice after oral immunization with ferritin or bovine serum albumin.

In order to study an experimental model of IgA nephropathy, C3H/HeJ mice which are high IgA responders were strongly immunized orally with ferritin and compared to syngeneic C3H/eB. C3H/HeJ exhibited a significant increase of total IgA level in the serum and of IgA deposits in the mesangium. However the low level of IgA antibody to ferritin detected in the serum and the unsuccessful search for ferritin and antibody to ferritin in the glomeruli suggest that strong oral immunization of C3H/HeJ mice leads to high level of non specific IgA in the serum and deposition of IgA in the kidney.

[Allopurinol toxicity. Apropos of 1 case]. / Toxicité sévère de l'allopurinol. A propos d'un cas.

Allopurinol is widely used in the treatment of hyperuricemia. Unusual (78 cases published up to 1984) but severe toxicity includes renal, skin and hepatic involvement. We report a new case of serious toxic manifestations with acute interstitial nephritis. We stress the need to adapt the daily dosage of the drug to the glomerular filtration rate and to interrupt drug administration rapidly if allergic manifestations develop.

[Pheochromocytoma with multiple localizations manifested by a hemorrhagic bladder tumor]. / Phéochromocytome à localisations multiples révélé par une tumeur vésicale hémorragique.

Pheochromocytoma is an endocrine tumor derived from neuroectodermal tissue. Pheochromocytomas usually arises in the adrenal glands but may develop in other organs. We report a case of pheochromocytoma of the bladder with hematuria as the presenting symptom. This tumor was removed by partial cystectomy. Following this procedure, biologic disorders persisted (catecholamines, vandylmandelic acid and metanephrines) leading to the diagnosis of an adrenal pheochromocytoma. The patient recovered after removal of the adrenal tumor. Discussion, review of the literature and bibliography.

IgA mesangial deposits in C3H/HeJ mice after oral immunisation.

In order to develop an experimental IgA nephropathy, C3H/HeJ mice, high producers of IgA, were strongly immunised orally by ferritin and compared to C3H/eB mice. After immunisation, serum IgA and IgG titres increased significantly only in C3H/HeJ mice. Specific antiferritin antibody could be detected in the serum. Mesangial IgA deposits were present in most of C3H/HeJ mice after immunisation and were significantly higher than in C3H/eB mice. No ferritin deposits could be detected in the kidney. No clinical manifestation appeared in these animals.

[Circulating immune complexes, detection in human glomerulonephritis by the PEG-EDTA technique (author's transl)]. / Détection des complexes immuns-circulants par la méthode au PEG-EDTA dans les glomérulonéphritis humaines.

In a prospective study, we screened sera samples of 128 patients with glomerulonephritis (GN) for the presence of circulating immune-complexes (CIC) fixing C1q by precipitation of native C1q with 2% polyethylene glycol (PEG) in the presence of 10 mM EDTA. The amount of precipitated C1q, as measured by Mancini, is less than 27% (m +/- 2 SD) of the original value in control sera. We found 35/128 (27%) positives samples, distributed as follows: 4/17 (24%) in acute GN, 10/15 (67%) in SLE, 2/16 (13%) in membraneous GN, 13/24 (54%) in membranoproliferative GN, 3/16 (19%) in segmental focal hyalinosis, 2/10 (20%) in minimal lesions nephrotic syndrome, and 1/30 (3%) in mesangial IgA GN. We then correlated these results with clinical, serological and pathological data. Whatever the type of GN, the presence of CIC fixing C1q correlated significantly, well with : the presence of chronic renal failure (serum creatinine greater than or equal to 2 mg/dl) (X2 = 5.48, p less than 0.02), the presence of hypocomplementemia (X2 = 12.30, p less than 0.001), the presence of low serum C3 (X2 = 8.25, p less than 0.01), the activation of C3 through normal pathway (low serum C4 and/or C1q) (X2 - 18.12, p less than 0.001) and the presence of glomerular deposits of C3 (X2 = 8.52, p less than 0.01), of C4 (X2 = 7.10, p less than 0.01), and of C1q (X2 = 4.11, p less than 0.05). The technique is simple, does not require labeled C1q, and allows the further study of antigen or antibody determinants of the complexes. Its sensitivity is near that of the 125 I-C1q binding assay technique. Such routine screening is a major immunopathologic step in the investigation of human GN.

[Progression and severity of arterial hypertension in aged subjects (12 cases]. / Evolutivité et gravité de l'hypertension artérielle du sujet âgé (12 observations).

We analyzed retrospectively 12 patients, aged from 63 to 73 years, with renovascular hypertension due to unilateral or bilateral atheromatous lesions (4 out of 12). Malignant or accelerated hypertension with multiple visceral involvement was frequent (8 out of 12). The proximal lesions (stenosis) of the renal arteries were rapidly progressive, leading to complete thrombosis in 8 cases. Five patients received medical treatment only, but 2 worsened their GFR and 2 had a poor blood pressure control. Of the 5 patients who underwent renal surgery 2 had nephrectomy, 2 had an aorto-renal bypass and 1 a bypass plus nephrectomy; 2 of them recovered a normal GFR, but 2 died in the post-operative period. Three patients had selective embolization of a renal artery, but only one was definitely improved. So far, the treatment of such cases still is very difficult.