Renal complications of intravesical bacillus Calmette-Guérin therapy.

We report 3 patients who developed signs of systemic infection and renal insufficiency after intravesical bacillus Calmette-Guérin (BCG) instillations for a bladder cancer. Renal biopsy showed tubulo-interstitial nephritis with or without epithelioid granulomas in 2 cases, and mesangial glomerulonephritis in the last case. All patients had granulomatous hepatitis in association. It seems that hematogenous dissemination via a traumatic instillation of BCG and/or an immune-complex mechanism may have contributed to the renal damage, which was only partially reversible in 2 patients.

Comparative evaluation of bone aluminum content and bone histology in patients on chronic hemodialysis and hemofiltration.

In order to compare hemofiltration (HF) and hemodialysis (HD) in connection with the risk of aluminum overload and renal osteodystrophy, double bone biopsies after double tetracycline labeling and a desferrioxamine test were performed in 12 patients on HF and 15 patients on HD. The aluminum concentration was low (less than 0.6 mumol/l) both in the dialysate and the substitution fluid. The duration of treatment (about 2 years) and the cumulative doses of Al(OH)3 and CaCO3 were comparable in the two groups. None of the patients was taking 1 alpha-OH-D. The aluminum balance during an HF run ranged from -22 to +1.8 mumol/l, the balance being positive only when the plasma aluminum was less than 0.5 mumol/l. Basal plasma aluminum and its increase induced by desferrioxamine were comparable in the two groups. Bone aluminum content was also comparable, but was about 10 times higher than in 7 nonuremic controls. Bone aluminum content and plasma aluminum increase after desferrioxamine were correlated to the Al(OH)3 cumulative dose. None of the patients had florid osteomalacia with increased osteoid thickness, and only 1 in each group had traces of stainable aluminum. The mineralization front was decreased in 8 of 12 HF and in 9 of 14 HD patients, so that no difference was observed between the means of the two groups. The predominant histological bone picture of the patients was osteitis fibrosa which was present in 10 of 12 HF and in 13 of 15 HD patients. Mean osteoclast count and active resorption surface were comparable in the two groups, but was increased (5-10 times the mean of the controls).(ABSTRACT TRUNCATED AT 250 WORDS)

Renin angiotensin aldosterone system, urinary prostaglandins and kallikrein in pregnancy induced hypertension. Evidence for a disregulation of the renin-angiotensin-prostacyclin loop.

Plasma renin activity and aldosterone concentrations were measured simultaneously with urinary excretion of kallikrein and four prostaglandins (PGE2, PGF2 alpha, 6 keto PFG1 alpha and TXB2) in 23 patients with pregnancy induced hypertension (17 with permanent PIH and six with labile PIH, since in these latter their hypertension was controlled only by home bed rest) and in 16 normotensive pregnant women at the same stage of gestation (31 +/- 3 weeks). PRA was lower in permanent PIH than in controls and in labile PIH. No difference between the three groups was observed for plasma aldosterone and the urinary excretion of kallikrein and of the prostaglandins except that TXB2 was higher in labile PIH than in permanent PIH. Correlation studies of kallikrein disclosed correlations with most prostaglandin excretions, explained by the physiological stimulation of phospholipase A2 by kallidin. Correlation studies of PRA disclosed unexpected negative correlation with PGE2 and 6 keto PGF1 alpha in the permanent PIH group. In conclusion, labile PIH has a different biological profile than permanent PIH since they have higher PRA and higher TXB2 excretion, an association which suggests a more pronounced ureteral compression by the gravid uterus in this group. Permanent PIH has a disregulation of the renin angiotensin-prostacyclin loop since PRA and 6 keto PGF1 are negatively correlated. This suggests the role of an independent vasopressive substance which would stimulate PGI2 and suppress renin secretion.

Plasma renin activity, blood uric acid and plasma volume in pregnancy-induced hypertension.

UNLABELLED: Plasma renin activity (PRA), plasma aldosterone (PA), blood uric acid (BUA), plasma concentrations of catecholamines (Pcat) and plasma volume (PV) were measured simultaneously in 24 patients with pregnancy-induced hypertension. This hypertensive group was divided into labile (LH) and permanent hypertension (PH) groups according to the response of their blood pressure to home bed rest. As compared to normal theoretical values, PV was decreased in both hypertensive groups (LH = -70%; PH = -14%). As compared to a control group of 16 normotensive pregnant women, PRA was higher in LH and lower in PH whereas PA was lower in both hypertensive groups. In both hypertensive groups, BUA was higher than in the control group. No difference in Pcat was found between the three groups. In the PH group negative correlations were found between BUA and PRA, as well as between BUA and PV, but no correlation between PRA and PV nor between Pcat and BUA were found. CONCLUSIONS: LH and PH are two pathophysiologically different entities in pregnancy-induced hypertension. In PH, renin secretion is not appropriate to hypovolemia and therefore not primarily involved in the pathogenesis of hypertension. The role of hypovolemia in the increase of BUA may be discussed.

Critical role of oxalate restriction in association with calcium restriction to decrease the probability of being a stone former: insufficient effect in idiopathic hypercalciuria.

The probability of being a stone former (PSF) was calculated in 3 groups of idiopathic calcium stone formers [with normocalciuria (NC), dietary hypercalciuria (DH) and idiopathic hypercalciuria (IH)] in 4 conditions: while on a free diet; on a calcium- and oxalate-restricted diet during 4 days; after an oxalate load, while on a 1.5-gram calcium diet, and after an oxalate load while on a calcium-restricted diet. Combined calcium and oxalate restriction significantly decreased PSF only in NC and DH whereas the decrease was not significant in IH because of a concomitant significant increase in oxalate excretion. Increase of PSF with the oxalate load was significantly greater during a calcium-restricted diet than during the 1.5-gram calcium diet in all groups of patients (4, 6 and 12 times greater in NC, DH and IH, respectively). These data show the critical role of oxalate restriction when calcium is restricted in order to decrease the PSF. This combined restriction is however not sufficient in idiopathic hypercalciuric patients to decrease their PSF.

[Renin-angiotensin-aldosterone system, blood volume, serum uric acid and urinary excretion of prostaglandins and kallikrein in the arterial hypertension induced by pregnancy]. / Système rénine-angiotensine-aldostérone, volémie, uricémie et excrétion urinaire de prostaglandines et kallicréine au cours de l'hypertension artérielle induite par la grossesse.

The plasma renin activity (PRA), plasma volume (PV), urinary excretion of Kallikrein (UK) and PGE2, PGF2 alpha, 6-keto PGF1 alpha and TXB2 were measured in 24 ambulant patients without treatment on normal sodium diets with pregnancy-induced hypertension (HT) (diastolic BP greater than or equal to 90 mmHg, appearing after 20 weeks' pregnancy and absent 2 months after delivery). The UK was measured by an esterase technique, prostaglandins by radioimmunological assay and PV by dye dilution (Evans blue). Two subgroups of patients were identified according to the evolution of their blood pressure at rest at home; the first (7 patients) with labile HT, and the second (14 patients) with permanent HT. The PRA was significantly lower (p less than 0,001) in patients with permanent compared to labile hypertension (4,7 +/- 0,3 compared to 12,2 +/- 0,8 ng/ml/h) and compared to a control group of normotensive pregnant women (6,5 +/- 0,5). The PV, expressed as a percentage of the theoretical volume with respect to the stage of pregnancy and body surface area was low in both groups. In permanent HT: 1) there was no correlation between PV and PRA, 2) a positive correlation between UK and urinary 6-keto PGF1 alpha (r = 0,62; p less than 0,001) and PGE2 (r = -0,51, p less than 0,05). Discriminative linear analysis showed that urinary 6-keto PGF1 alpha was mainly related to PRA and to a lesser degree to UK.(ABSTRACT TRUNCATED AT 250 WORDS)

[Real-time ultrasonographic study of the parathyroid glands. Apropos of 100 explorations]. / Etude ultrasonographique temps réel des parathyroïdes. A propos de 100 explorations.

The authors using high resolution (8 MHz) real-time echotomography have explored 100 patients. They certify that the presence of little hypoechogenic spicules at the periphery of a mass is strongly in relation with a parathyroid. They found in 17 patients signs of hypertrophic parathyroid; 8 of these had surgery with very good results for echotomography in 7 cases. Localizing parathyroid masses before surgery did not shorter time of exploration in these 8 cases. Ultrasonography, if positive, may relate biological troubles to a parathyroid etiology. It appears, that echotomography is a method of choice to survey chronic hemodialysis.

[Treatment of peritonitis in peritoneal dialysis. Comparison between continuous lavage with a machine and intermittent lavage with 4 CAPD bags/day]. / Traitement des péritonites en dialyse péritonéale. Comparaison entre lavage continu avec machine et lavage intermittent par quatre sacs/jour de DPCA.

Since 1978, 54 episodes of PT occurred in patients treated by PD, first 26 PT (group A) were treated by CLM (40 l/day) and in situ antibiotics (AB): in the absence of Candida, the association of sulfamethoxazol (SMZ: 80 mg/l) and trimethoprime (TMP: 16 mg/l) was used. Only when a Candida was present amphotericine B (AMB: 5 mg/l) was used. CLM was continued until PT was cured. The last 29 PT (group B) were treated by 4 bags/day of CAPD with in situ AB: SMZ: 200 mg/l and TMP 40 mg/l and a systematic oral prophylaxis of Candida was performed by AMB 1,5 g/day. In group A, 5 patients died and 2 others in group B. Complications were more frequent in group A (14) than in group B (6): p less than 0.02. In group A, the AB was changed in 7 cases because of initial resistance (1) or bacterial superinfection (2) or Candida superinfection (4). In group B, AB was changed in 9 cases because of initial resistance (7) or Candida superinfection (2). In conclusion the treatment of PT by 4 bags per day with in situ AB cure PT as rapidly as CLM in spite of lower doses of SMZ - TMP. However, this method is easier to perform and give less complication than CLM. It must be the treatment of choice of PT from peritoneal dialysis.

[Exploration by high-resolution real-time ultrasonography of the parathyroid glands in 60 chronic hemodialysis. Preliminary results and comparison with other indices of secondary hyperparathyroidism]. / Exploration par ultrasonographie à haute résolution en temps réel des parathyroïdes de 60 hémodialysés chroniques. Résultats préliminaires et comparaison avec les autres indices d'hyperparathyroïdie secondaire.

Systematic study by high resolution real time ultrasonography of the parathyroïd glands unequivocally showed parathyroid hyperplasia in 13% of 60 patients on chronic hemodialysis. Hyperplasia was associated with greater severity of hyperparathyroidism, as demonstrated by subperiostal bone resorption and increased serum levels of alkaline phosphatase, parathormone and calcium. Correlation between ultrasonographic and surgical findings in 5 patients was excellent, and actual weights of removed hyperplastic glands were correlated to calculated volumes. The demonstration of hyperplastic parathyroid glands by ultrasonography was of great help for surgical indication in cases where the classical biochemical and radiological parameters were unavailable or of uncertain significance. In absence of hypercalcemia and/or of hyperphosphoremia which may hinder "medical parathyroidectomy" by vitamin D metabolites, ultrasonographic demonstration of hyperplastic glands represents an unresolved problem as to the choice of surgical or medical parathyroidectomy.

Plasma renin activity, blood uric acid and plasma volume in pregnancy-induced hypertension.

UNLABELLED: Plasma renin activity (PRA), plasma aldosterone (PA), blood uric acid (BUA), plasma concentrations of catecholamines (Pcat) and plasma volume (PV) were measured simultaneously in 24 patients with pregnancy-induced hypertension (PIH). This hypertensive group was divided into labile (LH) and persistent hypertension (PH) groups according to the response of their blood pressure to home bed rest. Compared to normal theoretical values, PV was decreased in both hypertensive groups (LH = -7%; PH = -14%). Compared to a control group (C) of 16 normotensive pregnant women, PRA was higher in LH and lower in PH whereas PA was lower in both hypertensive groups. BUA was higher than in C in both hypertensive groups. No difference in PCat was found between the three groups. In the PH group negative correlations were found between BUA and PRA, as well as between BUA and PV but no correlation between PRA and PV nor between Pcat and BUA were found. IN CONCLUSION: LH and PH are two pathophysiologically different entities in PIH. In PH renin secretion is not appropriate to hypovolaemia and therefore not primarily involved in the pathogenesis of hypertension. Hypovolaemia may play a role in the increase of BUA in PIH.

Substitution of aluminium hydroxide by high doses of calcium carbonate in patients on chronic haemodialysis: disappearance of hyperaluminaemia and equal control of hyperparathyroidism.

Al(OH)3 was discontinued in 26 patients on chronic haemodialysis as well as vitamin D metabolites in eight. Oral CaCO3 was progressively increased from 4 +/- 3 to 10 +/- 5g/d to keep plasma PO4 less than 6.0mg/dl and P Ca less than 10.5mg/dl. This treatment had to be discontinued in three cases because of diarrhoea and/or uncontrolled hyperphosphataemia. In the remaining patients the control of hyperphosphataemia and of PTH values was as good or even better. Hyperaluminaemia disappeared in most patients demonstrating the role of oral Al(OH)3 in the induction of hyperaluminaemia. Because of frequent transient hypercalcaemia and of the occurrence of vascular calcification in two patients, high doses of CaCO3 after discontinuation of Al(OH)3 are advised only in cases of hyperaluminaemia.

Critical role of oxalate restriction in association with calcium restriction to decrease the probability of being a stone former: insufficient effect in idiopathic hypercalciuria.

The probability of being a stone former (PSF) was calculated according to the method of Robertson in three groups of idiopathic calcium stone formers (normocalciuria (NCa), dietary hypercalciuria (DH) and idiopathic hypercalciuria (IH] during four conditions: on a free diet; on a calcium and oxalate restricted diet for four days and after an oxalate load (200 g of spinach) while on a calcium unrestricted or calcium restricted diet. Combined calciuria (Ca) and oxaluria (Ox) restriction significantly decreased PSF only in NCa and DH whereas the decrease was not significant in IH because of a concomitant significant increase in oxalate excretion. Increase of PSF with the oxalate load was significantly greater on calcium restricted than on calcium unrestricted diets in all groups of patients (4-6-12 times greater in NCa, DH and IH respectively). This shows the critical role of oxalate restriction when calcium is restricted in order to decrease the PSF. Combined restriction is not sufficient in idiopathic hypercalciuric patients to decrease their probability of stone formation.

[Treatment of peritonitis in continuous ambulatory peritoneal dialysis ]. / Traitement des péritonites en dialyse péritonéale continue ambulatoire.

UNLABELLED: Thirty patients were treated with continuous ambulatory peritoneal dialysis during 313 patients months. 26 episodes of peritonitis defined by a cloudy dialysate with more than 100 cells/mm1 and more than 50 p. cent of polynuclear were observed. The organisms initially responsible were Gram-positive in 11 cases (6 Staphylococcus aureus, 1 Staphylococcus albus, 4 Streptococcus viridans), a gram negative in 3 cases (1 Klebsiella, 1 serratio, one unidentified), a Candida in 2 cases. In 10 cases, the culture was negative, Initial treatment was peritoneal lavage (40 l/day) with in situ antibiotics: in the absence of Candida, the association sulfamethoxazole (SMZ) (80 mg/l) and trimethoprim (TMP) (16 mg/l) was used; when Candida was present amphotericin B (5 mg/l) was used. The association SMZ + TMP led to cure of PT in 17 cases, in 7 +/- 4 days. In 5 cases, this initial treatment was changed at the 48th hour because of initial resistance in one case or secondary resistance of Candida surinfection (2 cases). Candida surinfection occurred later in 2 other cases. For these 6 primary or secondary Candida peritonitis, the catheter was changed within 48 hours. Nevertheless, death occurred in 3 cases and cure was obtained after 51 +/- 11 days in the 3 other cases. CONCLUSIONS: 1) The initial treatment by SMZ + TMP appears quite effective in most cases (73%). 2) The severity and the high incidence of Candida surinfection suggest that its systematic prophylaxis may be appropriate.

Possible link between changes in plasma 24,25-dihydroxyvitamin D and healing of bone resorption in dialysis osteodystrophy.

Histomorphometric studies of bone biopsies were performed on 12 hemodialyzed patients before and after six months of treatment with 25-(OH) and 1 alpha-(OH) vitamin D3. Patients could be classified into three groups according to bone resorption: Group I with normal bone resorption; Group II with elevated initial bone resorption unresponsive to vitamin D treatment; group III with elevated initial bone resorption sensitive to vitamin D treatment. None of the patients had histological signs of osteomalacia. In Group I, plasma concentrations of 24,25-(OH)2D and the ratio of 24,25-(OH)2D to 25-(OH) D remained in the normal range throughout the study; in Group II these parameters were subnormal initially and did not increase above normal except in one case; in Group III, plasma concentrations of 24,25-(OH)2D were high before or at the beginning of vitamin D administration and normal at the time of the second biopsy and wide variations were observed in the ratio of 24,25-(OH)2D to 25-(OH)D. No difference was found between these last two groups with regard to the cumulative dose of vitamin D derivatives administered or the changes in plasma PTH, CT, calcium and phosphate. These observations suggest a specific regulation of plasma 24,25-(OH)2D concentrations in hemodialyzed patients and a possible link (independent of circulating PTH, CT, or phosphate) between this regulation and healing of bone resorption. However, no correlation was found between plasma 24,25-(OH)2D and either one of the simultaneously measured biochemical or histological parameters.