Hemodialysis has considerably prolonged the life of patients suffering from terminal renal failure. However, long-term hemodialysis leads to new bone complications and spinal disorders such as destructive spondyloarthropathy (DSA). At the present time DSA is reported in 8% to 18% of the dialysed patients. Diagnosis is based on severe narrowing of the intervertebral disk, erosions and geodes of the adjacent vertebral plates simulating infectious spondylitis. Lesions progressively involve posterior joints and may lead to severe destruction of the spine. The pathogenesis of this syndrome is still unknown. Several factors have been implicated, including microcrystal deposition, amyloidosis, inflammatory and foreign body reactions and suggest that the pathogenesis of erosive spondyloarthropathies of hemodialysed patients is multifactorial. Spinal instability inducing myelopathy and radiculopathy were observed in 8% of the cases. Treatment must be accorded to the natural disease course and to the quality of the bone. We report the case of a chronic dialysed patient with destructive spondyloarthropathy involving the cervical and thoracic spine. Pathogenesis, radiological datas and therapeutic approach are discussed.

Le développement et la généralisation des techniques d'hémodialyse, tout en améliorant la qualité de vie et la survie des patients insuffisants rénaux, a sensiblement modifié les pathologies osseuses et, plus particulièrement, la pathologie rachidienne habituellement rencontrée dans cette population de patient. Après plusieurs années d'hémodialyse, on note l'apparition de spondylarthropathie érosive (SE) ou destructive. On estime la prévalence de 8 % à 18 % des patients hémodialysés. Elle présente un aspect destructeur qui s'étend progressivement du disque inter-vertébral au cartilage articulaire, au tissu osseux et au système disco-ligamentaire. Les lésions discales peuvent faire évoquer à tort une spondylodiscite infectieuse. L'étiopathogénie de ce processus n'est pas encore élucidée. Toutefois, l'examen microscopique en révélant des lésions inconstantes et diverses telles que des dépôts amyloïdes, des microcristaux ou une simple réaction inflammatoire non spécifique permet de considérer ces lésions comme le résultat d'une réaction inflammatoire influencée par de multiples facteurs. Ces lésions destructrices entraînent une instabilité rachidienne pouvant se compliquer d'une compression médullaire ou radiculaire nécessitant un traitement chirurgical dans 8 % des cas. La qualité mécanique du tissu osseux chez ces patients insuffisants rénaux et l'évolution naturelle de ces lésions sont des facteurs importants dans le choix thérapeutique. Nous rapportons l'observation d'un patient hémodialysé de longue date et présentant une spondylarthropathie érosive sévère intéressant à la fois le rachis cervical et le rachis thoracique. La revue de la littérature permet de recenser les données étiologiques, radiologiques, diagnostiques et thérapeutiques actuellement proposées. Hemodialysis has considerably prolonged the life of patients suffering from terminal renal failure. However, long-term hemodialysis leads to new bone complications and spinal disorders such as destructive spondyloarthropathy (DSA). At the present time DSA is reported in 8% to 18% of the dialysed patients. Diagnosis is based on severe narrowing of the intervertebral disk, erosions and geodes of the adjacent vertebral plates simulating infectious spondylitis. Lesions progressively involve posterior joints and may lead to severe destruction of the spine. The pathogenesis of this syndrome is still unknown. Several factors have been implicated, including microcrystal deposition, amyloidosis, inflammatory and foreign body reactions and suggest that the pathogenesis of erosive spondyloarthropathies of hemodialysed patients is multifactorial. Spinal instability inducing myelopathy and radiculopathy were observed in 8% of the cases. Treatment must be accorded to the natural disease course and to the quality of the bone. We report the case of a chronic dialysed patient with destructive spondyloarthropathy involving the cervical and thoracic spine. Pathogenesis, radiological datas and therapeutic approach are discussed.

A total of 1,305 blood samples from 85 solid organ transplant (SOT) recipients and 25 stem cell transplant (SCT) recipients at risk for cytomegalovirus (CMV) infection were prospectively collected and tested using the shell vial assay (SVA) and a leukocytic qualitative PCR (q-PCR). Of these, 462 specimens were further tested by direct quantification of CMV antigenemia by flow cytometry (FC-Ag), 125 were tested with a quantitative competitive PCR, and 200 were tested for pp65 antigenemia using the slide method (S-Ag). Laboratory data were statistically analyzed according to the presence of CMV-related symptoms. In SOT and SCT recipients, active CMV infection occurred in 63.5 and 36%, respectively, and CMV disease occurred in 53 and 24%, respectively. FC-Ag results correlated better with q-PCR and S-Ag than with SVA. The first test found to be positive during follow-up was FC-Ag in 73% of cases. In SOT recipients, FC-Ag showed the highest sensitivity and negative predictive value for the diagnosis of any grade of CMV disease. For FC-Ag, the threshold beyond which CMV disease was highly probable seemed to lie at 0.20% positive polymorphonuclear leukocytes. FC-Ag appears to be a useful test for the early detection of CMV infection and the prediction of CMV disease.

Human cytomegalovirus replication was evaluated in polymorphonuclear leukocytes from ten renal transplant recipients. Three new reverse transcription polymerase chain reactions with plate hybridization suitable for automation were developed for the detection of immediate-early spliced UL123 mRNA, early-late pp65 mRNA, and late spliced UL22 mRNA. The presence of UL22mRNA was found to be significantly associated with the occurrence of cytomegalovirus (CMV) disease.

Cytomegalovirus (CMV) antigenemia was directly detected in polymorphonuclear leukocytes (PMNLs) from transplant recipients by using flow cytometry (FC). Two fixation and permeabilization methods and seven anti-CMV monoclonal antibodies (MAbs) were evaluated. 1C3, SL20, and NEA-9221 MAbs were more efficacious. The antigenemia detection threshold of FC was 0.05% positive PMNLs, and percentages correlated well with DNA viral load and the appearance of clinical symptoms.

Human cytomegalovirus (HCMV) is responsible for severe infections in immunocompromised patients. Viral load has recently been identified as one of the major risk factors for subsequent development of HCMV disease. In this context, we developed a protocol allowing rapid, sensitive and precise quantification of HCMV DNA using competitive PCR run to saturation. Long primers were used for amplification, and internal DNA standard was constructed by PCR, with a primer inducing formation of a loop on the target sequence. The obtained fragment differed from the wild one (142 bp) by 6 bp. Quantitative analysis of PCR-amplified HCMV DNA was carried out using an original system combining capillary gel electrophoresis and u.v. detection. This procedure was evaluated on renal transplant recipients, and the results of quantitative PCR were compared with those of viraemia, qualitative DNAemia and HCMV-related symptoms. High levels of HCMV DNA were associated with HCMV-related symptoms, and in all cases a significant decrease of viral load was observed following DHPG treatment. Competitive PCR with capillary electrophoresis detection appears to provide a sensitive quantification method for HCMV DNA in leukocytes and is easily adaptable to routine laboratory use.

Background. The purpose of this prospective study was to evaluate the usefulness of quantifying DNA-cytomegalovirus (CMV) load for the diagnosis and monitoring of CMV disease among renal and pancreas transplant patients under immunosuppressive drugs. Methods. A longitudinal study was conducted among 34 consecutive, unselected renal and pancreas/renal transplanted patients in our unit. During the first 3 posttransplant months, weekly monitoring of CMV infection and CMV disease was done, involving the determination of viremia by the shell vial assay, qualitative DNAemia by semi-nested polymerase chain reaction (PCR) and quantitative DNAemia by the hybrid capture system (HCS), a new and original hybridization method (337 samples were collected for each test). Qualitative and quantitative DNAemia results were blinded to physicians and three grades of disease were defined according to CMV related symptom occurrence. Results. PCR was the most sensitive (100%) but the least specific (78%) method for the diagnosis of CMV disease. HCS was specific for CMV genome detection, sensitive and reproducible. Blood DNA levels above 60 pg/ml were predictive of severe or moderate CMV disease (sensitivity, 92%; specificity, 100%). A significant decrease in viral load was observed after ganciclovir administration, and a positive PCR or HCS result at the end of the antiviral treatment was associated with relapse of CMV infection or disease. Conclusions. It is concluded that quantitative DNAemia detection, with this new commercially available method, can predict disease and may be useful for a rational evaluation of ganciclovir preemptive therapy in such patients.

Twenty-five type-1 diabetic uremic patients (14 men, 11 women, mean age forty ± eleven years, range, nineteen to sixty) were prospectively analyzed for coronary artery disease (CAD) by thallium scan (TLS) before syn chronus pancreas and kidney trans plantation. Duration of diabetes ranged from ten to thirty-two years (mean twenty-two ± five). Fifteen pa tients (60%) were in dialysis from two to sixty months (mean twenty ± eigh teen). Advanced diabetic degenerative complications were present in all pa tients. Twenty exercise and five phar macologic thallium scans were performed. Forty-four percent of patients (6 men, 5 women, mean age forty-two ± eleven years, range, twenty-six to sixty) had a positive (reversible or per manent defects) TLS. In 2/11 cases, se vere CAD required further cardiac investigations for therapeutic manage ment decision. A statistical correlation with resting ECG nonspecific ST-seg ment and T-wave abnormalities was observed (p<0.05) despite the absence of angor in 8 of the 11 patients. On the contrary, no statistical correlations were found regarding high blood pres sure, smoking, hypercholesterolemia, duration of diabetes, and duration of dialysis. In this particular diabetic popula tion (young age, male/female ratio = 1.2) with high incidence of silent isch emia, resting ECG repolarization ab normalities, though predictive, were not specific or prognostic of CAD severity; in these cases, exercise and pharmacologic TLS, a noninvasive and sensitive cardiovascular test, may be of great interest in diagnosis of CAD, allowing adequate cardiac man agement before, during, and after pancreas transplantation.