Asunto(s)
Adenocarcinoma/secundario , Interleucina-2/administración & dosificación , Neoplasias Renales/patología , Adenocarcinoma/cirugía , Humanos , Inyecciones Subcutáneas , Neoplasias Renales/cirugía , Neoplasias Pulmonares/secundario , Masculino , Persona de Mediana Edad , Recurrencia Local de Neoplasia , Nefrectomía , Neoplasias Pleurales/secundario , Diálisis RenalRESUMEN
Systemic cholesterol crystal emboli (SCCE) are no longer a rare complication of severe atheroma. Sixty-year old men, with many vascular problems are typically involved. SCCE, released from atheromatous ulcerated "plaques", invade one or more arteriolar beds. Clinical presentation is polymorphic: skin, muscle, kidney, digestive tract and other abdominal organs, retina, bone narrow ... may be embolized. SCCE are associated with triggering conditions: vascular surgery, anticlotting agents and fibrinolysis, femoral retrograd catheterization by radiologists or cardiologists. This last factor is presently predominant. Clinical signs depend on atheroma localization, intensity and repetition of embols and topography of arteriolar beds susceptible to be embolized: livedo reticularis, acute renal failure with high blood pressure, limbs or abdominal pain, periarteritis nodosa-like syndrome. Diagnosis is based on the discovery of ocular fundi (cholesterol crystals in arterioles) and evidence of cholesterol crystals in various biopsies: skin, muscle, kidneys. Prognosis and curative treatment are poor. Mortality is greater than 80% in systemic forms. Surgical palliative treatment was recently proposed (bypass). Prevention is essential: triggering manipulations i.e. retrograd femoral catheterism have to be avoided by radiologists or cardiologists in exposed patients. In high risk atheromatous patients symptomatic treatment including repetitive dialysis is able to induce significative survival.
Asunto(s)
Embolia por Colesterol , Embolia por Colesterol/etiología , Embolia por Colesterol/fisiopatología , Embolia por Colesterol/terapia , Humanos , Masculino , Pronóstico , Factores de RiesgoRESUMEN
The authors report a case of renal hemosiderosis in a 33 year old patient with mitral valve replacement with a Saint Jude Medical prosthesis. Chronic, well-tolerated hemolysis developed after surgery and a peri-prosthetic leak was demonstrated. Alteration of renal function and abnormalities on urinalysis led to renal biopsy which showed massive localised hemosiderosis, mainly in the interstitial tissues. Repeat mitral valve replacement led to a regression of the hemolysis. Significant hemolysis in patients with mechanical cardiac valves prostheses should lead to investigation of prosthetic valve function and, if dysfunction is demonstrated, the patient should be considered for reoperation because of the potential severity of renal complications.
Asunto(s)
Anemia Hemolítica/etiología , Prótesis Valvulares Cardíacas/efectos adversos , Hemólisis , Hemosiderosis/etiología , Enfermedades Renales/etiología , Humanos , Enfermedades Renales/patología , Masculino , Persona de Mediana Edad , Válvula Mitral , Falla de Prótesis , ReoperaciónRESUMEN
Medial calcification of the arteries, because of non-distensibility of the blood vessel walls, may overestimate the real intra-arterial pressure when blood pressure (BP) is measured by indirect sphygmomanometry cuff. In order to assess the best method for measuring BP, we compared direct intra-arterial measurements with indirect cuff sphygmomanometry as well as automatic oscillometric measurements in 15 hypertensive patients. Mean age +/- standard deviation (SD) was 62 +/- 9 years; all patients had medial calcifications of forearm and/or brachial arteries, and Osler's maneuver was negative in all. Ten sets of direct and indirect BP measurements were obtained for each patient. Results are expressed as mean +/- SD: (table; see text) There was no significant difference between cuff pressure and systolic intra-arterial pressure. The automatic oscillometric method underestimated systolic intra-arterial BP. Great individual variability was observed and could not be predicted clinically. Indirect diastolic BP values were greater than intra-arterial BP in all patients with the sphygmomanometer cuff and in 10 patients with the oscillometric recorder. There existed a direct relation between intra-arterial BP and differences between indirect BP measurements and intra-arterial BP as follows: intra-arterial BP was overestimated by indirect methods for values under 150 mmHg, and underestimated above 150 mmHg. In conclusion, invasive intra-arterial BP measurement seem to be necessary to distinguish between hypertensive and pseudo-hypertensive patients, in case of radiologic evidence of arterial calcification.
Asunto(s)
Arterias , Determinación de la Presión Sanguínea/métodos , Calcinosis/fisiopatología , Hipertensión/fisiopatología , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Enfermedades Vasculares/fisiopatologíaRESUMEN
Non occlusive mesenteric ischaemia is a serious complication of maintenance haemodialysis. Its physiopathological mechanisms are controversial and its frequency is underestimated. Eight cases (in 5 patients) are reported: the clinical syndrome consisted of acute abdominal pain without evidence of shock or abdominal wall rigidity at palpation, associated with hyperleucocytosis and hyperkaliemic acidosis. The normality of the mesenteric vessels was confirmed at autopsy in one patient and during surgery in all others. Two patients were found to have caecal necrosis, 2 had diffuse necrotizing enterocolitis and 1 had necrosis of the left colon. The prognosis of this complication is sombre: 4 of our 5 patients died, including 3 who had relapsed 1, 4 and 18 months respectively after surgery (diffuse ileocolic necrosis). The usually accepted physiopathological mechanism is volaemic contraction consecutive to haemodialysis in often atheromatous subjects; however, the fact that the mesenteric infarction is not occlusive, that it occurs sometime after the end of the haemodialysis session and above all, the lack of haemodynamic changes during or immediately after the session suggest that other factors (bioincompatibility) are involved.
Asunto(s)
Isquemia/etiología , Diálisis Renal/efectos adversos , Abdomen Agudo/etiología , Adulto , Anciano , Volumen Sanguíneo , Enfermedades del Colon/etiología , Enterocolitis Seudomembranosa/etiología , Femenino , Humanos , Isquemia/fisiopatología , Masculino , Arterias Mesentéricas , Oclusión Vascular Mesentérica/fisiopatología , Persona de Mediana Edad , Necrosis/etiología , PronósticoAsunto(s)
Lesión Renal Aguda/enzimología , Amilasas/sangre , Lipasa/sangre , Pancreatitis/enzimología , Enfermedad Aguda , Anciano , Femenino , Humanos , MasculinoRESUMEN
Often unrecognized, renal cholesterol embolization generally results in renal failure and a high rate of death. In the recent years, it was discovered only during autopsy, but now antemortem observations are not exceptional. In the most cases, the existence of a triggering factor may suggest a iatrogenic cause. We report six patients who developed cholesterol atheroembolic renal disease after aortic surgery and/or retrograde catheterization. Cholesterol embolism was demonstrated by the finding of cholesterol crystals in the arteriolar lumens: either on renal biopsies, or on skin biopsy. The five surviving patients required dialysis with recovery of renal function in only one case. Three of four patients on regular dialysis treatment died of unrelated complications. The responsibility of angiography in the origin of acute renal failure appeared major in this report. It is the rupture of an eroded atherosclerotic plaque caused by the catheter which causes the release of large quantity of cholesterol crystals in the circulation. Therefore, in the atheromatous patients, it appears safer to realize a computerized i.v. angiography.