Le cas rapporté concerne un patient caucasien de 63 ans greffé en septembre 2003 ayant pour principaux antécédents une HTA et une dyslipidémie traitée. Une biopsie rénale, réalisée un an auparavant, avait mis en évidence une néphropathie chronique évoluée avec néphroangiosclérose et précisant la présence de microcristaux intra tubulaires. En raison d’une dysfonction persistante du greffon à J26, une biopsie a été réalisé mettant en évidence des lésions de tubulopathie aiguë en rapport avec de très nombreux microcristaux intra tubulaires brunâtres fortement polarisants. L’analyse en spectrométrie infrarouge de ces cristaux intra parenchymateux et celle des cristaux recueillis par cristallurie ont permis de déterminer un spectre identique de cristaux de 2-8 dihydroxyadénine caractéristique d’un déficit en Adénine phosphoribosyltransférase (APRT). Le déficit a été confirmé par l’absence d’activité enzymatique de l’APRT sur les lymphocytes, traduisant une anomalie génétique homozygote vraisemblable. Le patient est traité par Allopurinol. Une biopsie à 5 mois a montré une diminution significative du nombre et de la taille des cristaux dans le parenchyme rénal témoignant de l’efficacité du traitement au long cours. La cristallurie s’était rapidement normalisée. Seuls 6 autres cas de récidive sur le transplant d’un déficit d’une néphropathie par déficit en APRT ont été publié dans la littérature. Il s’agit du premier cas rapporté pour un patient greffé en France. Ce cas illustre l’importance primordiale de l’identification de tout cristal dans une biopsie de rein afin d’éviter les récidives au cours de la transplantation. Cette maladie rénale est rare mais potentiellement sévère. Son diagnostic repose sur la cristallurie confirmée par spectrométrie infrarouge du culot ou par analyse spectrométrique des cristaux intra parenchymateux prélevés à partir des coupes histologiques. Elle peut être prévenue et traitée sous réserve d’un diagnostic précoce.

To assess the influence of the timing of nephrology referral on the short- and long-term outcome of hemodialysis patients, we retrospectively studied 309 patients who had end-stage renal failure and entered the chronic hemodialysis program in Sainte-Marguerite University Hospital between January 1, 1989, and December 31, 1996. We excluded from the analysis five patients without available data on referral pattern and 34 patients with irreversible acute renal failure. Of the remaining 270 patients, 177 patients (58%) had an early referral (ER) 16 or more weeks before the start of dialysis, and 93 patients (31%) had a late referral (LR) of less than 16 weeks before dialysis. Short-time morbidity (initial emergent dialysis, pulmonary edema, severe hypertension, temporary vascular access placement for first dialysis, prolonged initial hospitalization) was significantly more frequent in LR patients. Long-term evolution (mean follow-up, 26.5 ± 26 months) did not differ between the two groups. The number of days of hospitalization per patient-year at risk beyond the third month was 21.5 ± 33.7 days for ER and 21.1 ± 36 days for LR patients. Survival analysis showed no difference between the two groups: 3-month survival rates were 96% in both groups, 1-year survival rates were 90% in the ER and 89% in the LR group, and 5-year survival rates were 52% in the ER and 56% in the LR group. In a Cox hazards regression model, referral pattern was not associated with a greater risk for death. In conclusion, delayed nephrology referral generated strikingly greater initial morbidity, but long-term outcome of hemodialysis patients was not modified by delayed nephrological care.

BACKGROUND:The high social-economic cost of nephrolithiasis wholly justifies the attempts to understand its mechanism and avoid recurrences. The influence of dietary habits and urinary risk factors has been evaluated, but the results were discrepant, probably because of differences in the methodologies used to compare patients and controls.METHODS:The aim was to assess dietary and urinary risk factors for urinary stones by comparison between 108 calcium stone formers (SF) and 210 healthy subjects (HS). All subjects were recruited during the same 1 year period. Personal characteristics, dietary habits (evaluated through a food frequency questionnaire) and urinary biochemical parameters were collected. The high predominance of men in the SF group led us to focus on the 79 SF and the 96 HS men.RESULTS:A familial history of stones was reported more frequently in SF than in HS, 42.9% vs 17.6%, P<0.005. Body weight was higher in SF, 76.8+/-12.2 kg vs 72.8+/-9.6 kg, P=0.02; and calcium intake was lower in SF, 794.8+/-294.1 mg vs 943.6+/-345.4 mg, P<0.01. For urinary parameters, calcium and oxalate output were significantly higher in SF. Urinary urea, as a reflection of daily protein intake, and uric acid were also higher in SF. Urinary citrate excretion related to body weight was lower in SF. Calciuria was significantly correlated with urinary urea in both SF and HS, but the correlation was stronger for SF. Calciuria correlated significantly with natriuria only in HS.CONCLUSIONS:The main differences between SF and HS were that SF had a family history of stones, a higher body weight, a lower daily intake of calcium, and a higher urinary output of calcium and oxalate. These results underline the combined role of genetic and nutritional factors in the pathogenesis of urinary stone formation.

Previous studies aimed at identifying the causes, risk factors, and outcome of kidney transplant recipients with delayed graft function (DGF) have yielded controversial results. We retrospectively analyzed the causes and risk factors for DGF in 263 cadaveric kidney transplantations from November 1988 to March 1997 in one center. Causes of DGF were assessed by postoperative graft evolution and graft biopsy. Univariate and multivariate analysis were used to investigate the risk factors for DGF induced by acute tubular necrosis (ATN). Seventy-six patients (29%) had DGF, which was caused by ATN in 70 patients (92.1%) and acute rejection (AR) in 6 patients (7.9%). Therefore, we focused on risk factors and consequences for ATN-induced DGF. In monofactorial analysis, ATN was significantly associated with greater weight and presence of an atheromatous disease in both donor and recipient. Other risk factors for ATN were older age of donor, recipient American Society of Anesthesiology (ASA) physical status category IV, cold ischemia time (CIT), and transplantation using the right kidney. The multivariate analysis showed that donor and recipient weight, donor age, transplantation using the right kidney, preservation in Eurocollins solution, ASA score, and CIT were associated with ATN. The incidence of rejection and renal function were not different at 3 months or 1 and 5 years. ATN is the main cause of DGF in kidney transplant recipients. ATN is caused by donor and recipient vascular background, grafting the right kidney, and CIT. ATN does not appear to have an adverse effect on long-term kidney function.

BACKGROUNDMany factors can impair haemodialysis (HD) tolerance. Some such as age and diabetes mellitus are linked to the patient. Others, such as dialysate, machine, and membrane are linked to the treatment characteristics. The duration of the HD sessions may represent another factor in tolerance since it influences the rate of ultrafiltration. However, its influence has not been studied independently of the type of membrane or dialysate buffer.METHODSIn a randomized crossover study, the incidence of intradialytic symptoms was compared during 4-h and 5-h HD sessions in 38 patients. The study period was 2 weeks for each dialysis time. The influence of age and diabetes was also analysed. Sessions requiring more than 4 litres of ultrafiltration were excluded.RESULTSDuring the 5-h period, the incidence of headache, nausea, chills, back pain and pruritus was significantly greater. On the contrary, the incidence of hypotension and postdialytic orthostatic hypotension was significantly less. We also demonstrated that ultrafiltration rate and orthostatic hypotension were correlated, and that age over 65 years and diabetes influenced HD tolerance. The incidence of hypotension was significantly less in patients over 65 receiving 5-h HD treatment.CONCLUSIONSAlthough some symptoms were more frequent during the 5-h HD sessions, the incidence of hypotension and postdialytic orthostatic hypotension was significantly less. This resulted in an improvement in acute haemodynamic HD tolerance, which could also influence long-term morbidity and mortality, especially in patients over 65 years.

Our aims were to analyze the protein composition of the organic matrix of urinary stones and to investigate the role of albumin in its constitution. Five different morphological types of stones were studied. Proteins extracted from the stone were submitted to sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and analyzed by immunoblotting with antibodies to 13 urinary proteins. Nine of the 13 proteins were found in all types of stone: human serum albumin (HSA), α1-acid glycoprotein (α1-GP), α1-microglobulin (α1-M), immunoglobulins (Igs), apolipoprotein A1 (apo-A1), transferrin (Tr), α1-antitrypsin (α1-T), retinol-binding protein (RBP) and renal lithostathine (RL). The β2-microglobulin (β2-M) was present only in calcium oxalate and uric acid stones. In contrast, ceruloplasmin, haptoglobin and Tamm-Horsfall protein (THP) were detected in none of them. Because HSA appeared as the major protein component in all stones, we wondered whether it might play a specific role in the constitution of the stone matrix. Association of HSA with urinary proteins that were present in stones was demonstrated by showing that proteins present in the matrix comigrated with HSA on gel filtration, whereas proteins that were absent did not. Moreover, HSA induced the binding of stone matrix proteins to an albumin-specific affinity column. Finally, we evidenced HSA binding to calcium oxalate monohydrate (COM) crystals in a solution similar to urine. It was concluded that (1) only a subset of urinary proteins is present in stone matrix, (2) the same proteins are found in all types of stones, (3) HSA shows significant affinity for several proteins of the matrix, but not for proteins absent from stones and, (4) HSA also displays significant affinity for COM crystals.

Our aims were to analyze the protein composition of the organic matrix of urinary stones and to investigate the role of albumin in its constitution. Five different morphological types of stones were studied. Proteins extracted from the stone were submitted to sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE) and analyzed by immunoblotting with antibodies to 13 urinary proteins. Nine of the 13 proteins were found in all types of stone: human serum albumin (HSA), alpha 1-acid glycoprotein (alpha 1-GP), alpha 1-microglobulin (alpha 1-M), immunoglobulins (Igs), apolipoprotein A1 (apo-A1), transferrin (Tr), alpha 1-antitrypsin (alpha 1-T), retinol-binding protein (RBP) and renal lithostathine (RL). The beta 2-microglobulin (beta 2-M) was present only in calcium oxalate and uric acid stones. In contrast, ceruloplasmin, haptoglobin and Tamm-Horsfall protein (THP) were detected in none of them. Because HSA appeared as the major protein component in all stones, we wondered whether it might play a specific role in the constitution of the stone matrix. Association of HSA with urinary proteins that were present in stones was demonstrated by showing that proteins present in the matrix comigrated with HSA on gel filtration, whereas proteins that were absent did not. Moreover, HSA induced the binding of stone matrix proteins to an albumin-specific affinity column. Finally, we evidenced HSA binding to calcium oxalate monohydrate (COM) crystals in a solution similar to urine.(ABSTRACT TRUNCATED AT 250 WORDS)

We describe two cases of chronic Q fever in hemodialysis patients (HD). In the first case, we discovered chronic Q fever when looking for the cause of an unexplained fever. In the second case, Q fever was diagnosed in a patient who complained of an unexplained shoulder arthritis. To our knowledge these are the first reported cases of chronic Q fever in HD.

Predialysis plasma endothelin (ET) values were followed during the first 8 weeks of rHuEpo treatment in 12 patients on routine haemodialysis. Mean plasma ET was significantly increased in uraemic patients before rHuEpo (27.9 +/- 11.4 pmol/l), as compared to 40 healthy controls (16.5 +/- 5.7 pmol/l) (P < 0.0001). Under rHuEpo treatment, predialysis values remained unchanged although diastolic blood pressure increased after 2 and 6 weeks. We found no correlation between ET and haemoglobin or blood pressure before or under rHuEpo treatment. These results confirmed the high levels of plasma ET in haemodialysis patients, but no increase was observed during rHuEpo treatment.

Acute renal failure due to angiotensin-converting enzyme inhibitors (ACEI) usually results from a marked fall in renal perfusion pressure in patients with renovascular disease. We report herein one case of acute kidney transplant artery thrombosis in a patient with renovascular hypertension. The thrombosis occurred immediately after a single dose of ACEI for evaluation of a renal transplant artery stenosis by renal scintigraphy. The dramatic fall of arterial pressure observed in our patient probably played an important role in the thrombosis. The risk of the administration of a single dose of ACEI coupled with renal scintigraphy in diagnosing renovascular hypertension is stressed.

Muscular disorders are usual in hypothyroidism, but hypothyroid myopathy is most often limited to myalgias, muscle stiffness and cramps with sometimes elevated levels of muscle enzymes. We report a case of acute renal failure related to rhabdomyolysis, which complicated hypothyroïd myopathy. Thyroid hormone replacement therapy improved thyroid and renal function, and reversal rhabdomyolysis. Hypothyroidism appears to be an authentic cause of rhabdomyolysis and should be eliminated in all patients with serum muscle enzyme increase.