On-line continuous venovenous hemodiafiltration: a technique for the control of ultrafiltration and convection during continuous renal replacement therapy.

Continuous renal replacement therapies have been used increasingly in critically ill patients in nephrologic and intensive care units. These techniques are nevertheless time consuming and lack an easy control of ultrafiltration. We conducted continuous venovenous hemodialysis (CVVHD) on a dialysate delivery machine which ensures a volumetric control of ultrafiltration, and which produces both dialysate and infusate with the on-line technique. This new mode of CVVHD was firstly assessed in a feasibility study and was secondly used in a randomized prospective study whose goal was to establish the usefulness of convection. On-line continuous venovenous hemodiafiltration (OL-CVVHDF) appeared safe and time saving, and allowed the fine control of fluid management in critically ill patients. Convective transfers were achieved by a 2 L/h predilutional infusion and increased urea and creatinine clearances twofold. OL-CVVHDF revealed itself to be a valuable method for the control of ultrafiltration and for efficient convective transfers during CVVHD.

[Three-and-a-half years' experience with hemodialysis using 37 Permcaths without infection or definitive thrombosis]. / Trois ans et demi d'expérience en hémodialyse avec 37 Permcath sans infection ou thrombose définitive.

34 patients had 37 Quinton Permcath (PKT), surgically implanted in jugular vein (internal: 29, or external: 8). The first 20 were used for a temporary vascular access (mean: 21 weeks). Then, the next 17 were used for permanent vascular access. 8 could be used for more than 1 year and 2 for more than two years. Anti-aggregant (29 cases) or anticoagulant treatment (8 cases) were systematically prescribed. 6 patients died for unrelated causes (mean delay: 35 weeks). 3 catheters were mispositioned. 2 catheters had to be removed because they were damaged (mean 53 and 69 weeks). Complications were: vein thrombosis (internal jugular vein): 2 cases, vein stenosis (inominate vein): 1 case, heparin overdoses: 3 cases. A partial thrombosis of a single lumen was common but always easily cured by local thrombolysis. Nurses were strongly motivated and followed rigorous educations with help of video-movie. This could be why no infectious (local or generalised) complication was observed. Long-term Permcath dialysis is a precious tool for patient without any peripheral vascular access or in elderly and short-live expectancy.

[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.

[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.

[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.

[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.