RESUMEN
Transplant recipients receiving a kidney from an extended-criteria donor (ECD) are exposed to calcineurin inhibitor (CNI) nephrotoxicity, as demonstrated by severe delayed graft function and/or a low GFR. Belatacept is a nonnephrotoxic drug that is indicated as an alternative to CNIs. We reported 25 cases of conversion from a CNI to belatacept due to CNI intolerance within the first 6 mo after transplantation. The mean age of the recipients was 59 years, and 24 of 25 patients received ECD kidneys. At the date of the medication switch, 12 of 25 patients displayed a calculated GFR (cGFR) <15 mL/min, six patients remained on dialysis, and the biopsies showed evidence of acute tubular damage associated with severe vascular or tubulointerstitial chronic lesions. Three patients did not recover renal function, and three patients died during the follow-up period. Among the remaining patients, renal function improved: The cGFR was 18.28 ± 12.3 mL/min before the medication switch compared with 34.9 ± 14.5 mL/min at 1 year after conversion to belatacept (p = 0.002). Tolerance of and compliance with belatacept were good, and only one patient experienced acute rejection. Belatacept is an effective therapy that preserves renal function in kidney transplant patients who are intolerant of CNIs.
Asunto(s)
Abatacept/uso terapéutico , Inhibidores de la Calcineurina/efectos adversos , Resistencia a Medicamentos/efectos de los fármacos , Rechazo de Injerto/tratamiento farmacológico , Fallo Renal Crónico/cirugía , Trasplante de Riñón/efectos adversos , Anciano , Funcionamiento Retardado del Injerto/tratamiento farmacológico , Funcionamiento Retardado del Injerto/etiología , Femenino , Estudios de Seguimiento , Tasa de Filtración Glomerular , Rechazo de Injerto/etiología , Supervivencia de Injerto/efectos de los fármacos , Humanos , Inmunosupresores/uso terapéutico , Pruebas de Función Renal , Masculino , Persona de Mediana Edad , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Receptores de TrasplantesRESUMEN
Acute disseminated encephalomyelitis (ADEM) is a rare inflammatory demyelinating disease of the central nervous system, usually occurring after a vaccination or infectious disease. It has been exceptionally described in transplanted patients. The pathophysiology remains incompletely understood. We report the clinical, biological and magnetic resonance imaging (MRI) presentation and evolution of two kidney-transplanted patients with ADEM associated with local Epstein-Barr virus (EBV) reactivation. ADEM may occur in transplanted patients with favorable evolution. Its pathophysiology is uncertain, and the implication of EBV is discussed.
Asunto(s)
Encefalomielitis Aguda Diseminada/inmunología , Encefalomielitis Aguda Diseminada/virología , Infecciones por Virus de Epstein-Barr/inmunología , Herpesvirus Humano 4/fisiología , Huésped Inmunocomprometido/inmunología , Trasplante de Riñón/efectos adversos , Activación Viral , Infecciones por Virus de Epstein-Barr/complicaciones , Femenino , Humanos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Activación Viral/inmunologíaRESUMEN
Efficacy and safety of mycophenolate mofetil (MMF) may be optimized with individualized doses based on therapeutic monitoring of its active metabolite, mycophenolic acid (MPA). In this 12-month study, 137 renal allograft recipients from 11 French centers receiving basiliximab, cyclosporine A, MMF and corticosteroids were randomized to receive either concentration-controlled doses or fixed-dose MMF. A novel Bayesian estimator of MPA AUC based on three-point sampling was used to individualize doses on posttransplant days 7 and 14 and months 1, 3 and 6. The primary endpoint was treatment failure (death, graft loss, acute rejection and MMF discontinuation). Data from 65 patients/group were analyzed. At month 12, the concentration-controlled group had fewer treatment failures (p = 0.03) and acute rejection episodes (p = 0.01) with no differences in adverse event frequency. The MMF dose was higher in the concentration-controlled group at day 14 (p < 0.0001), month 1 (p < 0.0001) and month 3 (p < 0.01), as were median AUCs on day 14 (33.7 vs. 27.1 mg*h/L; p = 0.0001) and at month 1 (45.0 vs. 30.9 mg*h/L; p < 0.0001). Therapeutic MPA monitoring using a limited sampling strategy can reduce the risk of treatment failure and acute rejection in renal allograft recipients 12 months posttransplant with no increase in adverse events.
Asunto(s)
Trasplante de Riñón/inmunología , Ácido Micofenólico/análogos & derivados , Corticoesteroides/uso terapéutico , Anticuerpos Monoclonales/uso terapéutico , Área Bajo la Curva , Basiliximab , Ciclosporina/uso terapéutico , Relación Dosis-Respuesta a Droga , Quimioterapia Combinada , Humanos , Inmunosupresores/administración & dosificación , Inmunosupresores/uso terapéutico , Ácido Micofenólico/administración & dosificación , Ácido Micofenólico/farmacocinética , Ácido Micofenólico/uso terapéutico , Proteínas Recombinantes de Fusión/uso terapéutico , Seguridad , Trasplante HomólogoRESUMEN
Although the association of angiotensin I-converting enzyme inhibitors (ACEis) with a negatively charged membrane is thought to be responsible for hypersensitivity reactions (HSRs) during hemodialysis, we hypothesize that these complications are due to changes in plasma aminopeptidase P (APP) activity and genotype. To test this hypothesis, we measured plasma APP activity in 14 patients who suffered HSR (HSR+) while dialyzed with an AN69 membrane and simultaneously treated with an ACEi. APP activity was also studied in a control group (n=39) dialyzed under the same conditions, but who did not suffer any side effect (HSR-). We found significantly decreased plasma APP activity (P=0.013) in HSR+ subjects as well as altered degradation of endogenous des-Arginine(9)-bradykinin, with a significantly lower beta value (P<0.001). The same analytical approach was taken in 171 relatives of HSR+ patients. Variance component analysis suggested that genetic differences may explain 61% of the phenotypic variability of plasma APP activity (P<0.001) and the kinetic parameters that characterized kinin degradation. We also showed that the C-2399A single-nucleotide polymorphism at the XPNPEP2 locus was a significant predictor of APP activity in the 39 HSR- controls (P=0.029). Furthermore, a recessive genetic model for the A allele disclosed a significant difference in mean APP activity by genotype (P<0.001). Finally, our study defined the nonspecific inhibition of recombinant APP by some ACEis. In conclusion, this paper highlights the complexity of HSR in hemodialysis, suggesting, as with angioedema, that these rare, but life-threatening adverse events are governed by several metabolic and genetic factors.
Asunto(s)
Aminopeptidasas/metabolismo , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Hipersensibilidad a las Drogas/etiología , Hipersensibilidad a las Drogas/metabolismo , Cininas/metabolismo , Diálisis Renal/efectos adversos , Adulto , Anciano , Aminopeptidasas/genética , Bradiquinina/análogos & derivados , Bradiquinina/genética , Bradiquinina/metabolismo , Estudios de Cohortes , Hipersensibilidad a las Drogas/genética , Femenino , Ligamiento Genético/genética , Humanos , Cininas/genética , Masculino , Persona de Mediana Edad , Linaje , Polimorfismo de Nucleótido Simple , Diálisis Renal/métodosRESUMEN
BACKGROUND: Hydrothorax is a rare complication of continuous ambulatory peritoneal dialysis (CAPD). CASE REPORT: A 68-year-old man on CAPD consulted for rapidly progressive dyspnea. An elevated glucose level in the pleural puncture fluid and Tc-99m peritoneoscitigraphy demonstrated pleuroperitoneal communication via Larrey's cleft led to the diagnosis of "sweet" hydrothorax. Resolution was achieved with pleurocentesis and interruption of CAPD. DISCUSSION: Although rare, hydrothorax should be retained as a possible diagnosis in patients who develop dyspnea within the first 2 months after institution of CAPD. Chemistry of the pleural fluid and Tc-99m scintigraphy provide the diagnosis. Conservative treatment by pleural puncture or pleurodesis is indicated. In most cases, CAPD can be resumed without recurrence.
Asunto(s)
Hidrotórax/etiología , Diálisis Peritoneal Ambulatoria Continua/efectos adversos , Anciano , Diagnóstico Diferencial , Disnea/etiología , Humanos , Hidrotórax/diagnóstico , Hidrotórax/diagnóstico por imagen , Masculino , Pleura/química , Cintigrafía , TecnecioRESUMEN
BACKGROUND: It has been postulated that protein glycation and formation of advanced glycation end products (AGE) are among toxic factors in chronic uremia, whether the renal disease is of diabetic or nondiabetic origin. In this setting, AGE-modified beta2-microglobulin (beta2m) may favor dialysis beta2m-related dialysis amyloidosis. Consequently, efficient removal of modified beta2m by highly permeable dialysis membranes is as important as removal of native beta2m to postpone the development of dialysis amyloidosis. METHODS: To define the role of dialysis membrane surface electronegativity on plasma protein transfer, an in vitro model was used to test the interactions of native and glycated beta2m with various highly permeable dialysis membranes. An experimental circuit with minidialyzers was used. The neutral high-flux polysulfone membrane (PS), the electronegative polymethylmetacrylate membrane (PMMA), the electronegative AN69 membrane and a modified AN69 membrane, the surface of which was neutralized with polyethyleneimine (AN69-PEI), were tested using both native beta2m and the more acidic glycated beta2m. Protein mass transfer and binding to the membrane were measured. RESULTS: Mass transfer of glycated beta2m was significantly decreased through all membranes tested when compared with native beta2m. This result was due to the increased molecular weight of beta2m, which became less permeable to porous membranes, whereas adsorption of both native and glycated beta2m to membranes, due to ionic interactions, decreased similarly with AN69 and AN69-PEI, but remained unchanged with PS and PMMA. Moreover, surface neutralization of AN69 membrane did not alter its core binding capacity, since beta2m absorption accounted for 98 and 97% and glycated beta2m for 83.7 and 81.4% of the protein removed with AN69 and AN69-PEI, respectively. CONCLUSION: Clearance of glycated beta2m through highly permeable neutral and negatively charged membranes was lower than that of native beta2m, reflecting a decreased sieving coefficient for the neoformed higher molecular weight and conformationally altered molecule. The binding capacity of the neutral PS was roughly half that of the charged membranes. Neutralizing surface electronegativity of the AN69 membrane with PEI did not alter its binding capacity. These results suggest that it would be useful for dialysis protocols to include comparative studies of both serum native and modified beta2m in order to prevent beta2m-amyloidosis.
Asunto(s)
Acrilonitrilo/análogos & derivados , Eliminación de Componentes Sanguíneos/instrumentación , Eliminación de Componentes Sanguíneos/métodos , Hemofiltración/instrumentación , Hemofiltración/métodos , Membranas Artificiales , Terapia de Reemplazo Renal/instrumentación , Microglobulina beta-2/aislamiento & purificación , Resinas Acrílicas , Amiloidosis/prevención & control , Materiales Biocompatibles , Electricidad , Glicosilación , Humanos , Cinética , Polímeros , Polimetil Metacrilato , Sulfonas , Microglobulina beta-2/metabolismoRESUMEN
BACKGROUND: alpha-Interferon-2a (IFNalpha) alone is a therapy of limited proven benefit for non-uremic patients with chronic hepatitis C virus (HCV) infection. In dialyzed patients, such an effect is suggested on small short-term studies without sufficient clinical and virologic follow-up to document any sustained effect. PROTOCOL: Twelve chronically hemodialyzed patients with chronic hepatitis C and waiting for renal transplantation were included in a prospective open study of treatment with IFNalpha. We used, as did others, doses of 3 million units (MU), three times a week, but for a longer period of treatment of 12 months. Follow-up was continued for 6 months after the end of IFNalpha in order to document any sustained biochemical, virological and histological responses. RESULTS: Aminotransferase levels returned to the normal range within 1-2 months of treatment in all patients in whom they had been elevated at baseline. At 1 month of treatment, serum HCV-RNA was not detected in 5 (41%) patients and in 9 (75%) at 12 months. A sustained virological response was documented in 4 (33%) patients 6 months after the end of treatment. Relapse occurred in 5 patients within 2 months after IFNalpha withdrawal. HCV genotype was not predictive of any sustained response. At inclusion, using the histologic Metavir scoring system, half of the patients had low-grade cytolytic activity and none had cirrhosis. After IFNalpha, liver biopsy specimens were available from 9 patients and showed histologic improvement in 3. IFNalpha tolerance was poor, inducing a 5% mean weight loss and the acute rejection of two nonfunctioning kidney grafts. CONCLUSION: This study documents that administration of IFNalpha at 3 MU three times a week, for 12 months, in hemodialysis patients with chronic hepatitis C was efficient for clearing the serum of HCV-RNA in 75% of the patients. A sustained response was maintained in one third of these patients after cessation of IFNalpha, and was predicted by the early serum clearance of the virus within the first 2 months of treatment. We confirm that a 12-month treatment period carries a higher sustained response rate than shorter treatment periods. These encouraging results call for larger studies in uremic patients, using IFNalpha alone or in association with new antiviral drugs.
Asunto(s)
Antivirales/uso terapéutico , Hepatitis C Crónica/tratamiento farmacológico , Interferón-alfa/uso terapéutico , Diálisis Renal , Adulto , Antivirales/efectos adversos , Recuento de Células Sanguíneas , Femenino , Genotipo , Hepacivirus/genética , Hepatitis C Crónica/patología , Hepatitis C Crónica/virología , Humanos , Interferón alfa-2 , Interferón-alfa/efectos adversos , Hígado/patología , Hígado/virología , Masculino , Persona de Mediana Edad , ARN Viral/sangre , Proteínas RecombinantesRESUMEN
We examined the role of inflammation in the development of renal interstitial fibrosis in Zucker obese rats, which rapidly present kidney lesions in the absence of hypertension and hyperglycemia. Type I and III collagens were quantified using a polarized light and computer-assisted image analyzer. The expression of mRNA encoding matrix components, adhesion molecules, chemokines, and growth factors was followed by RT-PCR. The presence of synthesized proteins as well as lymphocytes and macrophages was determined by immunohistochemistry. Interstitial fibrosis developed in two phases. The first phase occurred as early as 3 mo and resulted from a neosynthesis of type III collagen and fibronectin and a reduction of extracellular matrix catabolism, in parallel with an overexpression of transforming growth factor-beta(1) and in the absence of any lymphocyte or macrophage infiltration. After 6 mo, interstitial fibrosis worsened with a large accumulation of type I collagen, concomitantly with a large macrophage infiltration. Thus inflammation cannot explain the onset of interstitial fibrosis that developed in young, insulinoresistant, normoglycemic, obese Zucker rats but aggravated this process afterward.
Asunto(s)
Glomeruloesclerosis Focal y Segmentaria/inmunología , Glomeruloesclerosis Focal y Segmentaria/patología , Obesidad/inmunología , Obesidad/patología , Factor de Crecimiento Transformador beta/genética , Animales , Glucemia , Colágeno/análisis , Colágeno/genética , Creatinina/sangre , Fibronectinas/genética , Fibrosis , Expresión Génica/fisiología , Hiperinsulinismo/inmunología , Hiperinsulinismo/patología , Hiperlipidemias/inmunología , Hiperlipidemias/patología , Procesamiento de Imagen Asistido por Computador , Inmunohistoquímica , Linfocitos/inmunología , Macrófagos/inmunología , Masculino , ARN Mensajero/análisis , Ratas , Ratas Zucker , Reacción en Cadena de la Polimerasa de Transcriptasa Inversa , Inhibidor Tisular de Metaloproteinasa-1/genética , Factor de Crecimiento Transformador beta1RESUMEN
This study investigated the incidence of subclinical abdominal hernia in patients starting peritoneal dialysis (PD). From April 1995 to August 1999, every new patient without clinical evidence of abdominal leakage underwent peritoneal scintigraphy. A total of 59 patients were enrolled in the study. Imaging of the peritoneal cavity was performed by mixing 74 MBq (2 mCi) of 99 m technetium sulfur colloid with 2 L of 1.36% dextrose peritoneal dialysis solution. Sequential gamma camera static images were obtained at 0 minutes, 60 minutes, and after drainage. Ten abdominal hernias (2 diaphragmatic leaks, 8 inguinal hernias) were observed in ten patients (6 males, 4 females; mean age: 65.1 years). One patient with diaphragmatic leak recovered partial renal function and stopped continuous ambulatory peritoneal dialysis (CAPD); the other was switched to automated peritoneal dialysis (APD). Among the eight patients with inguinal hernia, six had no clinical manifestations within eight months of follow-up. Two patients became symptomatic at 15 months and 25 months respectively. They underwent surgical repair. In CAPD patients without obvious abdominal hernias, peritoneal scintigraphy at onset of dialysis discovered 17% positive cases. The technique of scintigraphy is safe, with a low radiation exposure. Surgical repair for maintenance on CAPD is not always necessary, and a change in the PD strategy may be useful.
Asunto(s)
Hernia Ventral/diagnóstico por imagen , Cavidad Peritoneal/diagnóstico por imagen , Diálisis Peritoneal Ambulatoria Continua , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diálisis Peritoneal Ambulatoria Continua/efectos adversos , Derrame Pleural/diagnóstico por imagen , Derrame Pleural/etiología , Cintigrafía , Radiofármacos , Azufre Coloidal Tecnecio Tc 99mRESUMEN
BACKGROUND: The theoretical aim of maintenance cyclosporine monotherapy (mCsA) after kidney transplantation is to reduce the incidence of the metabolic complications of corticosteroids and to minimize the adverse effects of excessive long-term immunosuppression. This study was performed in low-immunological-risk cadaveric kidney transplant recipients to evaluate the risks and benefits of mCsA and the long-term graft survival, and to determine the factors predicting success of this policy. METHODS: The multicenter retrospective study was conducted in 329 Caucasian patients receiving mCsA out of 728 first cadaveric kidney transplant recipients. The inclusion criteria were: HLA antibodies < or =25%, serum creatinine <200 micromol/L, and no rejection or only one rejection episode. At the end of the study, we compared the group of patients successfully treated with mCsA (successful group) with those requiring additional immunosuppressive agents (unsuccessful mCsA group). RESULTS: Overall patient and graft survival rates for the 728 first cadaveric graft were 92% and 64%, respectively, at 8 years. Out of 329 patients enrolled in mCsA, 240 were maintained on this treatment and 89 were withdrawn (3 deaths, 18 graft losses, 68 functional grafts). The 8-year graft survival in the 329 enrolled mCsA patients was 84%, 95% in the successful mCsA group, and 70% in the unsuccessful mCsA group. Multivariate analysis showed that the factors predicting success of mCsA were: donor age <40 years (P = 0.001), serum creatinine at mCsA initiation <125 micromol/L (P = 0.02), no rejection episode before mCsA initiation (P = 0.005), and glomerulopathy as the primary renal disease (P = 0.001). CONCLUSION: Numerous kidney transplant recipients with a low immunological risk and good and stable renal function may benefit from discontinuation of prednisone and azathioprine in order to reduce the complications related to these drugs. This therapeutic approach had no adverse impact on the overall long-term graft survival for "low risk" and successful patients.
Asunto(s)
Ciclosporina/uso terapéutico , Inmunosupresores/uso terapéutico , Trasplante de Riñón , Cuidados Posoperatorios , Adulto , Estudios de Cohortes , Ciclosporina/administración & dosificación , Ciclosporina/sangre , Relación Dosis-Respuesta a Droga , Femenino , Predicción , Supervivencia de Injerto/efectos de los fármacos , Humanos , Inmunosupresores/administración & dosificación , Inmunosupresores/sangre , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo , Insuficiencia del Tratamiento , Resultado del TratamientoRESUMEN
Since 1992, a registry gathering all the patients with end-stage renal failure is established in Champagne-Ardenne. It is based upon demographic data and allocation of dialysis treatment. It is supported by regional nephrologists. It is exhaustive and has been validated by the regional health administration. It is the only data base considered for the regional scheme of sanitary organization. In 1999 the incidence of terminal renal failure was 119 pmp and, at 1 January 2000, prevalence of uremic patients treated with supportive therapy, except transplantation, was 426 pmp. Our registry may be used as a regional registry awaiting to participate into built the national program project REIN (Renal Epidemiology and Information Network) and to help better health care policy and costs containment.
Asunto(s)
Fallo Renal Crónico/epidemiología , Sistema de Registros , Adolescente , Adulto , Anciano , Francia , Humanos , Fallo Renal Crónico/terapia , Persona de Mediana Edad , Diálisis RenalRESUMEN
The relationship between a cytomegalovirus (CMV) infection and the acute rejection of a renal transplant is not well established. The aim of the study was to document whether the clinical presentation of a CMV infection as a diffuse inflammatory disease or as a clinically asymptomatic illness is a risk factor of acute renal transplant rejection. One hundred and ninety-two consecutive renal transplant recipients were included in a historical cohort study for exposed-non exposed analyses. CMV infection after transplantation was the exposure factor. Before transplantation, 113 patients had antibodies against CMV and 79 were seronegative. The patients were divided into three groups: Group 1 consisted of 64 patients who had neither clinical signs of CMV disease nor CMV serological changes after transplantation, Group 2 consisted of 77 seropositive patients with asymptomatic viremia, and Group 3 consisted of 51 seropositive patients with clinical signs of diffuse inflammation that included fever, neutropenia, and various visceral involvements (CMV disease). Groups 2 and 3, the seropositive patients, were paired with Group 1 patients. Acute rejection was considered as CMV-induced when it occurred within one month following viremia, during the first year after transplantation. Transplant patients with CMV disease, had a significant likelihood of developing acute rejection after CMV infection or reactivation (P < 0.01). The odds ratio for developing rejection was 5.98, 95% confidence interval: 1.21-29.40. Such a link was not documented for recipients with asymptomatic CMV infection. In conclusion, CMV disease, but not asymptomatic viremia, is a risk factor of acute renal transplant rejection. On epidemiological grounds, these results support the hypothesis that factors controlling both the viral replication and the diffuse inflammatory process are implicated in acute graft rejection.
Asunto(s)
Infecciones por Citomegalovirus/epidemiología , Rechazo de Injerto/epidemiología , Trasplante de Riñón/estadística & datos numéricos , Complicaciones Posoperatorias/epidemiología , Viremia/epidemiología , Enfermedad Aguda , Adulto , Anticuerpos Antivirales/sangre , Estudios de Casos y Controles , Estudios de Cohortes , Citomegalovirus/crecimiento & desarrollo , Citomegalovirus/inmunología , Citomegalovirus/fisiología , Infecciones por Citomegalovirus/inmunología , Infecciones por Citomegalovirus/transmisión , Femenino , Rechazo de Injerto/etiología , Rechazo de Injerto/inmunología , Humanos , Terapia de Inmunosupresión/métodos , Trasplante de Riñón/mortalidad , Masculino , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/virología , Riesgo , Factores de Riesgo , Estudios Seroepidemiológicos , Análisis de Supervivencia , Viremia/etiología , Activación Viral , Replicación ViralRESUMEN
Angiotensin converting enzyme (ACE) inhibitors are useful in the treatment of hypertension and heart failure. However, acute renal failure (ARF) may occur in patients who are taking these drugs in situations associated with decreased glomerular filtration pressure, such as dehydration caused by acute diarrhea or diuretic therapy. Sixty-four patients who were admitted to the intensive care unit for ARF associated with ACE inhibitor therapy were followed for more than 5 years. In this historical retrospective study, we documented that 45 patients were treated for hypertension (group I) and 19 were treated for heart failure (group II). Their mean age was 71.2+/-11.6 years. Patients with ARF presented with overt dehydration in 91% and 84% of the cases in groups I and II, respectively. Hypovolemia was caused by diuretics or gastrointestinal fluid loss. Bilateral artery-renal stenosis or stenosis in a solitary kidney was documented in 22% and 10% of patients in groups I and II, respectively. The probability of survival was 91% and 49% at 1 year and 64% and 18% at 5 years, for groups I and II, respectively. Acute renal failure required hemodialysis in seven patients, but none of them became dialysis dependent. In the subgroup of patients with preexisting chronic renal failure, all the patients except for one who belonged to group II died within 2 years. In both groups, after resolution of ARF, plasma creatinine concentration returned to baseline level and the course of renal function was not significantly worsened. In conclusion, ARF associated with ACE inhibitors is likely to occur in many patients without renal artery stenosis after unexpected dehydration, especially in older patients with congestive heart failure. In both groups of patients, in the absence of preexisting chronic uremia, recovery of renal function occurred without sequelae, even after an episode of acute tubular necrosis requiring dialysis.
Asunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Hipertensión/tratamiento farmacológico , Insuficiencia Renal/inducido químicamente , Enfermedad Aguda , Inhibidores de la Enzima Convertidora de Angiotensina/uso terapéutico , Presión Sanguínea/efectos de los fármacos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Insuficiencia Renal/fisiopatología , Estudios Retrospectivos , Factores de TiempoRESUMEN
BACKGROUND: The gold standard for documenting vesicoureteric reflux is direct (retrograde) micturating cystography (MC). In children, radioisotopic MC has been advocated for increased sensitivity and lesser radiation exposure. In renal transplant recipients, where reflux can induce acute pyelonephritis, this technique has not been evaluated. The aim of this study was to assess the radioisotopic technique in these patients. METHODS: Seventeen renal transplant recipients had developed acute pyelonephritis following the surgical grafting procedure. They were investigated using both MC techniques. Radioisotopic MC was performed using 99mTc-pertechnetate. RESULTS: Reflux was documented in nine patients by radioisotopic MC but in only seven with the conventional technique. All negative patients remained symptom free after the pyelonephritis was cured and it was assumed that they had no reflux. Consequently, using the radioisotopic MC as gold standard, the conventional X-ray technique had a sensitivity of 78% and a specificity of 100%. CONCLUSIONS: Direct radioisotopic MC allowing continuous cystogram recording is more accurate than conventional X-ray MC for the diagnosis of vesicoureteric reflux in transplanted patients with acute pyelonephritis.
Asunto(s)
Trasplante de Riñón/efectos adversos , Pielonefritis/diagnóstico por imagen , Pielonefritis/etiología , Vejiga Urinaria/diagnóstico por imagen , Reflujo Vesicoureteral/diagnóstico por imagen , Reflujo Vesicoureteral/etiología , Enfermedad Aguda , Adulto , Niño , Estudios de Evaluación como Asunto , Reacciones Falso Negativas , Reacciones Falso Positivas , Femenino , Humanos , Trasplante de Riñón/diagnóstico por imagen , Masculino , Dosis de Radiación , Radiografía , CintigrafíaRESUMEN
Because hyperlipidemia and macrophage influx appear to play a key role in the genesis of renal glomerulosclerosis, this study examined the temporal relationship between hyperlipidemia (triglycerides and cholesterol), mononuclear cell influx, changes in glomerular structure, and expansion of the extracellular matrices in obese Zucker rats, which rapidly develop hyperlipidemia and spontaneous glomerulosclerosis. Lean and obese Zucker rats were fed a standard diet, and were euthanized at 14 days, 1, 3, 6, 9, and 12 months. Plasma lipid, insulin, and creatinine levels were measured, and the presence of inflammatory cells in the glomerulus was assessed by immunohistochemistry on kidney sections. Plasma lipids and insulin and macrophage density were significantly greater in obese than in lean rats as early as 1 month. Computer-assisted image analysis was used to evaluate the glomerular domain surface areas. The morphometric measurements showed that glomeruli of obese rats rapidly became hypertrophied after 3 months, as a result of a very large increase in the mesangial domain. The expression of genes for extracellular matrix components and inhibitors of extracellular matrix proteinases (TIMP-1 and TIMP-2) was monitored in microdissected glomeruli. Reverse transcription-polymerase chain reaction showed increases in mRNA for Type IV collagen and fibronectin and for the two metalloproteinase inhibitors, each of which might participate in this matrix expansion. Thus, the development of hyperlipidemia plus macrophage influx at a very early age may initiate a sequence of events leading to glomerulosclerosis later on.
Asunto(s)
Glomeruloesclerosis Focal y Segmentaria/etiología , Glomeruloesclerosis Focal y Segmentaria/patología , Glomérulos Renales/patología , Macrófagos/patología , Factores de Edad , Animales , Secuencia de Bases , Creatinina/sangre , Cartilla de ADN/genética , Modelos Animales de Enfermedad , Proteínas de la Matriz Extracelular/genética , Proteínas de la Matriz Extracelular/metabolismo , Glomeruloesclerosis Focal y Segmentaria/genética , Lípidos/sangre , Masculino , Microscopía Electrónica , Obesidad/complicaciones , Reacción en Cadena de la Polimerasa , Proteinuria/etiología , ARN Mensajero/biosíntesis , ARN Mensajero/genética , Ratas , Ratas ZuckerRESUMEN
UNLABELLED: We report our experience in 213 elderly patients over 75 years treated by peritoneal dialysis (PD) as first and exclusive dialysis therapy. The mean age at start of PD was 79.4 +/- 3.6 years, and the cumulative time on PD was 4551 months (mean time: 21.4 +/- 19.8 months). Twenty-six patients lived in institutions and 187 lived at home. Thirty patients had an effective autonomy with the ability to carry on normal activities. One hundred and two patients were cared for by a private nurse at home, and 46 patients were cared for in a family environment. Most cases were treated by three exchanges per day (152 cases) and used a nondisconnect system (175 cases) on account of absence of autonomy. The rate of peritonitis per patient-month was one episode per 16.8 patient-months. Patient survival (Kaplan-Meier curves) was 74%, 59%, 45%, and 19% at one, two, three, and five years, respectively. The causes of death were various with a higher frequency of cardiovascular causes (48.3% of the 116 deaths). Thirty-three patients died in less than six months including 18 patients in less than three months. IN CONCLUSION: elderly uremic patients can be treated with long-term PD with relatively good results. Mortality is high but essentially due to age and poor general status-the dedication of private home nursing is very important in treating elderly PD patients. This fact often is a necessary condition in maintaining these elderly patients at home.
Asunto(s)
Fallo Renal Crónico/terapia , Diálisis Peritoneal Ambulatoria Continua , Anciano , Anciano de 80 o más Años , Causas de Muerte , Comorbilidad , Femenino , Francia , Humanos , Fallo Renal Crónico/mortalidad , Cuidados a Largo Plazo , Masculino , Diálisis Peritoneal Ambulatoria Continua/mortalidad , Estudios Retrospectivos , Tasa de Supervivencia , Resultado del TratamientoRESUMEN
With age, the morphological changes which occur in renal glomeruli in the absence of any added pathology are an expansion of the extracellular matrices (ECM)--glomerular basement membrane (GBM) and mesangial matrix--and lesions of focal and segmental glomerular hyalinosis (FSGH). Although the mechanisms involved in these glomerular changes are still unknown, an inflammatory step seems to precede the expansion of the extracellular matrices, but the nature of the cytokines and adhesion molecules has yet to be explored. In order to understand the cellular and molecular events of the FSGH, we used the genetically obese Zucker rat (fa/fa) which develops several early FSGH lesions. We observed that FSGH is the result of a modification of the podocyte: 1) bulging of the podocyte with endocytotic vesicles rich in albumin; 2) detachment from the GBM, collapsing of the capillary loops with a progressive disappearance of capillary cells and formation of hyalin and lipid deposits, synthesis of new ECM components; 3) focal adherence of the GBM and the basement lamina of Bowman's capsule and synthesis of new matrix. The detachment of the podocytes from the GBM appeared to be linked to the disappearance of the alpha 3 beta 1 integrin, major molecule which anchors the epithelial cells to the GBM. By immuno-gold techniques, we showed that the density of alpha 3 moieties significantly diminished when podocytes are spreaded over the GBM. This integrin is probably bound to the laminin in the GBM.
Asunto(s)
Nefropatías Diabéticas/patología , Nefropatías Diabéticas/fisiopatología , Modelos Animales de Enfermedad , Envejecimiento , Animales , Membrana Basal , Matriz Extracelular/patología , Glomeruloesclerosis Focal y Segmentaria/patología , Integrinas/metabolismo , Riñón/patología , Riñón/fisiología , Glomérulos Renales/patología , Masculino , Ratas , Ratas ZuckerRESUMEN
Anatomical and functional characteristics of the peritoneal cavity have to be evaluated prior to catheter implantation for continuous ambulatory peritoneal dialysis (CAPD). This review summarizes the constraints that may be encountered and the few technical certitudes that have been validated. The American Registry for CAPD is the unique source of validated data, indicating that the early risk for peritonitis following catheter implantation is significantly lessened with a two-cuff catheter used by a surgeon. Catheter shape as well as per-operative antibiotic prophylaxy have no effect on prognosis.