La dénutrition protéino-énergétique est fréquente chez les patients insuffisants rénaux chroniques traités par dialyse péritonéale. La prévention et la correction de ce désordre nécessitent des apports alimentaires protéiques et énergétiques suffisants, associés éventuellement à une supplémentation entérale, ainsi qu'un contrôle régulier de l'efficacité de l'épuration. L'adaptation des techniques de dialyse péritonéale permettant plus aisément d'atteindre des cibles de dialyse adéquate plus élevées, l'utilisation des solutions mises sur le marché récemment ou dans un proche avenir ouvrent des possibilités thérapeutiques nouvelles. Ces difflérentes mesures devraient permettre de diminuer la mortalité et la morbidité, liées aux problèmes nutritionnels.

The particularity of geriatric medicine and the lack of information due to the fact that geriatric nephrology dates back only 10 years explains why the management of chronic uraemia among the elderly presents itself as a succession of difficult dilemmas. (1) Should causes of chronic renal failure be systematically determined and treated? Risk-benefit assessments of the investigations and treatments involved in preventing or slowing down the evolution to end-stage renal disease (ESRD) are required to answer this question. (2) In cases of ESRD, should dialysis always be considered? The fact that life expectancy is limited for the aged does not justify depriving them of treatment. Nevertheless, in some borderline situations, conservative treatment may be preferable. (3) When should dialysis be started? Currently the mortality before the 90th day of dialysis is very high among elderly patients. To improve results it is probably necessary to determine appropriate criteria for starting treatment before complications occur. (4) What is the best method for the first treatment? There is much controversy about the respective advantages of haemodialysis and peritoneal dialysis. The choice depends on the individual's medical and social conditions. (5) Should dialysis treatment be stopped, and, if so, in this case, when? The large acceptance rate of elderly patients for dialysis implies that withdrawal of treatment must sometimes be considered. Fears linked to this dilemma probably explain why some physicians choose to exclude elderly patients from dialysis. It seems to us more ethical to treat this group of patients and assume responsibility for stopping treatment should it be necessary.

There have been improvements in the technique of peritoneal dialysis (PD) over the last ten years. However, peritoneal infections remain the major complication associated with this treatment, and the risk of infection cannot be accurately predicted. Nevertheless, it is widely accepted that simple connections should be replaced by improved systems of connection, and that patient training is important. Peritoneal infection should be suspected when the dialysate is turbid, whether or not associated with peritoneal irritation. None of the various techniques used for the culture of dialysates has been shown to be either more sensitive or more specific than any of the others. Thus, collaboration between the physicians supervising the dialysis and microbiologists is necessary to choose the culture techniques best adapted. The sensitivity should be at least 85 to 90%. If the sensitivity is lower, the techniques used should be reconsidered. There have been several hundred publications assessing treatments of peritoneal infections associated with PD. However, no particular antibiotic treatment has been demonstrated to be systematically superior. The use of associated antibiotics seems to be preferable initially, until the causative agent has been identified. For example, vancomycin with a third generation cephalosporin seems to be the association of choice, because of its efficacy, tolerance and ease of use. The optimal duration of treatment has not been established by randomised study, but 10 days is commonly used for Gram-positive infections, and longer for Gram-negative. Whatever the treatment used, the success rate should be at least 80 to 90%. Randomised trials with sufficiently large numbers of patients are required to determine the indications and delay before withdrawal of the DP catheter in cases of peritonitis which do not respond to antibiotics.

We report a case of autoimmune haemolysis after an ABO- and ABDR-identical kidney transplantation which leads to the discussion of the role of cyclosporin A (CsA). A 46-year-old woman with end-stage renal disease and no history of auto-immune disease received an ABO- and ABDR-identical first renal allograft from a cadaver donor. On day 16, while on a heavy sequential immunosuppressive regimen including anti-thymoglobulins, azathioprine (Aza), prednisolone (Pred) and CsA, she developed an autoimmune haemolysis with positive Coombs test, IgM+C type. Elution of antierythrocyte antibodies did not enable us to identify any specificity. Haemolysis lasted 45 days before haemoglobin slowly increased after CsA had been greatly reduced. Direct antiglobulin tests remained positive 5 months after transplantation and became negative the following month. Eight months after the transplantation the patient had a normal haemoglobin level and normal renal function. Although the typing of autoantibodies was not possible, our data suggest that this patient's haemolysis may be related to the clonal development of donor B lymphocytes in the recipient, favoured by an HLA A-B-DR identity and post-transplant CsA therapy, as exceptionally reported in the literature.

Journal Article Burkitt's lymphoma of the kidney presenting as acute renal failure in AIDS Get access Q. Meulders, Q. Meulders 1Service de Néphrologie, Hôpital TenonParis, France Search for other works by this author on: Oxford Academic PubMed Google Scholar B. Viron, B. Viron 1Service de Néphrologie, Hôpital TenonParis, France Search for other works by this author on: Oxford Academic PubMed Google Scholar C. Michel, C. Michel 1Service de Néphrologie, Hôpital TenonParis, France Search for other works by this author on: Oxford Academic PubMed Google Scholar B. Mougenot, B. Mougenot 1Service de Néphrologie, Hôpital TenonParis, France Search for other works by this author on: Oxford Academic PubMed Google Scholar M. Antoine, M. Antoine 3Service d'Anatomie et de Cytologie Pathologiques (Pr. J. Roland), Hôpital TenonParis, France Search for other works by this author on: Oxford Academic PubMed Google Scholar M.C. Meyohas, M.C. Meyohas 2Service des Maladies Infectieuses (Pr. P. Frottier), Hôpital Saint AntoineParis, France Search for other works by this author on: Oxford Academic PubMed Google Scholar P. Ronco, P. Ronco 1Service de Néphrologie, Hôpital TenonParis, France Search for other works by this author on: Oxford Academic PubMed Google Scholar F. Mignon F. Mignon 1Service de Néphrologie, Hôpital TenonParis, France Correspondence and offprint requests to: Professor F. Mignon, Service de Nephrologie, Hopital Tenon, 4 rue de la chine, 75020 Paris, France Search for other works by this author on: Oxford Academic PubMed Google Scholar Nephrology Dialysis Transplantation, Volume 8, Issue 5, 1993, Pages 458–460, https://doi.org/10.1093/oxfordjournals.ndt.a092503 Published: 01 January 1993 Article history Received: 13 August 1992 Accepted: 22 October 1992 Published: 01 January 1993

In HIV-infected patients with end-stage renal failure maintenance dialysis raises multiple problems, the most important of these being the quality and duration of life in these patients and the risk of contaminating other HIV negative patients under dialysis and/or members of the medical-nursing staff. In this study the results obtained in 14 patients treated in one single centre over a 5-year period are analyzed. Nine patients (group I) had end-stage renal failure consecutive to HIV-associated nephropathy: 5 died after 2 to 30 months (mean 9.2 +/- 5.2) of dialysis, while 4 patients were alive at the end of the study with a mean follow-up of 23.8 +/- 8.8 months (5 to 50). Five patients (group II) had end-stage renal failure consecutive to a nephropathy unrelated to HIV: only 1 female patient died 29 months after she was found to be seropositive; the remaining 4 patients were alive at the end of the study with a mean 47.5 +/- 5.5 months (33 to 58) of follow-up. Ten patients were found to have a less than 8 g/dl Hb anaemia which was corrected in the 4 patients who received recombinant human erythropoietin. Out of the 9 patients treated with zidovudine (300 mg/day) 6 had haematological side-effects. Throughout this study, there was no contamination of HIV negative patients or members of the medical-nursing staff. In these 2 groups, the survival of HIV positive patients dialysed for chronic renal failure seems to have been conditioned by the stage of HIV infection at the time when maintenance dialysis was instituted.

1. The acute effects of a single oral dose of sinorphan (100 mg), an inhibitor of neutral endopeptidase, on the plasma atrial natriuretic factor level and the fractional excretion of sodium were examined in 12 patients with severe chronic renal failure who were not on maintenance haemodialysis and who ingested a normal sodium diet. The drug was administered against placebo by a double-blind cross-over protocol. 2. Basal plasma atrial natriuretic factor level and fractional excretion of sodium were high (23.2 +/- 3.7 pmol/l and 2.64 +/- 0.38%, respectively). Sinorphan inhibited plasma neutral endopeptidase activity by 68-75% 30 min after ingestion. This effect persisted for at least 4 h. There were simultaneously increases in plasma atrial natriuretic factor and cyclic GMP levels to 1.9 and 1.4 times the basal values, respectively. Fractional excretion of sodium increased during the second and third hour periods after ingestion of the drug with a peak of 1.9 times the basal value in the second period. Changes in fractional excretion of sodium were significantly correlated with those in plasma atrial natriuretic factor and cyclic GMP levels. Plasma aldosterone level, creatinine clearance and mean blood pressure were unchanged, whereas plasma renin activity increased slightly. An increase in urinary cyclic GMP excretion was observed in parallel with the increase in plasma cyclic GMP level.(ABSTRACT TRUNCATED AT 250 WORDS)

Eleven uraemic patients were treated with recombinant human erythropoietin (rHuEpo). Seven haemodialysis patients and four peritoneal dialysis patients received a starting dose of 80 IU/kg i.v. and 40 IU/kg s.c. respectively, thrice weekly. The number of burst-forming-unit erythroid (BFU-E), colony-forming-unit erythroid (CFU-E), granulocyte-monocyte (CFU-GM) and megakaryocyte (CFU-Mk) were assayed 2 weeks before (D0), and 1 (M1) and 6 months (M6) after the initiation of rHuEpo treatment by means of a commonly applied in-vitro clonal assay. All the patients showed the same haematopoietic response. A significant increase of CFU-E and CFU-Mk could be observed within 1 month of treatment. At this time, no significant modification was observed in BFU-E and CFU-GM number. At the 6th month the increase of CFU-E was maintained, whereas a significant fall of BFU-E, CFU-GM and CFU-Mk was observed. These results suggest that in-vivo effects of rHuEpo are not restricted to the erythroid lineage but that erythropoietin might also act as a co-factor of megakaryopoiesis. In the long term erythropoietin might induce erythroid differentiation in multipotent progenitor cells at the expense of the non-erythroid progenitors.

Certains patients atteints de myélome compliqué d'une insuffisance rénalc définitive peuvent actuellement accéder à la dialyse chronique. Nous rapportons les résultats obtenus chez huit patients traités par dialyse de suppléance (six par hémodialyse et deux par dialyse péritonéale), dont la moitié recevaient une chimiothérapie. Six patients sont décédées; la survie maximale enregistrée atteint 6 ans. L'infection est la première cause de morbidité, en particulier chez les patients traités par dialyse péritonéale, et l'hémodialyse nous paraît préférable en cas de polychimiothérapie lourde. L'épuration extrarénale nous paraît indiquée dans tous les myélomes même à forte masse. Elle peut permettre en effet d'attendre la réponse à la chimiothérapie et si celle-ci est bonne, d'allonger notablement la survie. Les problèmes recontrés en dialyse sont d'une part la pathologie cardiovasculaire (amylose AL) et d'autre part et surtout, l'anémie, mais celle-ci peut actuellement bénéficier d'un traitement par l'érythropoiétine entraînant une amélioration sensible de la qualité de vie des patients.

NowadaYs, maintenance dialysis can be proposed to patients suffering from myeloma with end-stage chronic renal failure. We report here data from eight patients dialysed either by hemo-(6) or peritoneal dialysis (2), together with chemotherapy in half of them. Six patients died ; the longest survival has been about 6 years. The main cause of morbidity was sepsis, especially in peritoneal dialysis patients ; therefore we now favour hemodialysis in patients exposed to aggressive chemotherapy. We think dialysis justified in all cases, including those with high tumor mass, in order to expect the effect of chemotherapy ; then, provided good response to drugs, further survival can be consistently improved. Once on maintenance dialysis, main drawbacks for these patients are cardiovascular complications (AL amyloidosis) and above all anemia ; the latter however can be markedly improved, thanks to erythropoietin therapy which provides these patients with much better quality of life.

In HIV-infected patients with end-stage renal failure maintenance dialysis raises multiple problems, the most important of these being the quality and duration of life in these patients and the risk of contaminating other HIV negative patients under dialysis and/or members of the medical-nursing staff. In this study the results obtained in 14 patients treated in one single centre over a 5-year period are analyzed. Nine patients (group I) had end-stage renal failure consecutive to HIV-associated nephropathy: 5 died after 2 to 30 months (mean 9.2 +/- 5.2) of dialysis, while 4 patients were alive at the end of the study with a mean follow-up of 23.8 +/- 8.8 months (5 to 50). Five patients (group II) had end-stage renal failure consecutive to a nephropathy unrelated to HIV: only 1 female patient died 29 months after she was found to be seropositive; the remaining 4 patients were alive at the end of the study with a mean 47.5 +/- 5.5 months (33 to 58) of follow-up. Ten patients were found to have a less than 8 g/dl Hb anaemia which was corrected in the 4 patients who received recombinant human erythropoietin. Out of the 9 patients treated with zidovudine (300 mg/day) 6 had haematological side-effects. Throughout this study, there was no contamination of HIV negative patients or members of the medical-nursing staff. In these 2 groups, the survival of HIV positive patients dialysed for chronic renal failure seems to have been conditioned by the stage of HIV infection at the time when maintenance dialysis was instituted.

Dr. Béatrice Viron, Service de Néphrologie, Hôpital Tenon, 4, rue de la Chine, F-75020 Paris (France) Dear Sir, Improved appetit and food intake have been reported from earlier studies of patients treated with recombinant human erythro-poietin (r-Hu EPO) [1]. An increase in BUN, plasma creatinine and plasma phosphorus values as well as, in some cases, severe hyper-kaliemia were observed in certain series [2]. Contrasting with their generally poor nutritional status [3], plasma lipid abnormalities are common in uremic patients [4], especially those maintained on hemodialysis (HD) or peritoneal dialysis (PD). In those patients, particularly prone to diffuse atherosclerosis [5], any deleterious effect of r-Hu EPO on plasma lipids might question the benefit of correcting anemia with this treatment. However, the effect on plasma lipids of the r-Hu-EPO-induced changes concerning the nutritional behavior of uremic patients had not been assessed yet. We have studied 12 patients, 7 HD (4 males, 3 females, mean age 57) and 5 PD (3 males, 2 females, mean age 70). Plasma lipids were measured together with different reliable parameters of the nutritional status [3], first, before initiating r-Hu EPO, then 6 months from the date of correction of anemia (defined as Hb > 10 g/dl). The following data were collected: body mass index, triceps skin-fold thickness (TST), arm muscle circumference (AMC), serum albumin, prealbumin, transferrin, total cholesterol, triglycerides (Tg), apolipoprotein (Apo) Al, Apo B, retinol-binding protein and acid αΓglycopro-tein. These values were compared to those obtained from 7 HD and 12 PD nonanemic patients, matched for age, sex and duration of maintenance dialysis. Before EPO, Hb was 7.2 ± 0.4 g/dl in the HD and 8.6 ± 0.7 g/dl in the PD patients. The PD patients had decreased serum albumin (2.9 ± 0.4 g/dl), increased Tg (2.3 ± 1.4 mmol/ 1) and Apo B (0.16 ± 0.05 g/dl), whereas only Tg were abnormally high (2.0 ± 1.1 mmol/l) in HD patients. However, anthropometric hallmarks of malnutrition were exclusively found in male HD patients, who had low values of body mass index (20.9 ± 1.0 kg/m2), TST (4.2 ± 1.1 mm) and AMC (22.4 ± 2.7 cm). After 6 months with stable Hb (HD: 10.4 ± 0.8 g/dl; PD: 10.1 ± 0.6 g/dl), only the male HD patients exhibited a significant increase in TST (5.1 ± 1.2 mm; p < O.Ol) and AMC (23.1 ±

Ageing does not spare the kidneys but, remarkably, renal impairment is virtually asymptomatic as homaeostasis remains ensured. Nevertheless, in routine practice physicians must take into account the "physiological" renal insufficiency of the elderly. In old people with chronic renal impairment the diagnostic and therapeutic approaches are special, owing to the age-related risks attached to both paraclinical examinations and treatments. Yet in certain subjects treatment can be remarkably effective and prevent the progression to terminal uraemia, and this justifies the detection and exploration of renal insufficiency in elderly patients. In the last few years, iterative dialysis programmes have been made available to third or even fourth age patients who had reached the so-called end-stage renal failure. The results are encouraging, but there are still purely medical questions concerning the measures to be taken in priority and the numerous organization problems to be solved for optimal management of these patients.

The human immunodeficiency virus (HIV) was recently suggested to be involved in generating kidney lesions in HIV-associated nephropathy (HIVN). The possibility that antiretroviral agents can slow down the usually explosive evolution of HIVN to end-stage renal failure (ESRF) has not been studied in many of the series of cases published. The present work is a retrospective analysis of 11 patients with histologically proven HIVN, 6 of whom were treated with zidovudine. Seven patients (group 1) either required dialysis at the outset, when HIVN was diagnosed, or progressed very fast to ESRF within 15-45 days. Two patients of this group were treated with zidovudine, but it had no effect on kidney function. In the remaining 4 patients (group 2), HIVN progressed more slowly than in group 1. All 4 patients were treated with zidovudine at an earlier stage of the disease than ESRF. Only 1 deteriorated to ESRF in 9 months. The 3 others, who did not have ESRF, were followed up for 13, 10 and 32 months, respectively. Although this is a preliminary study, its results do suggest that zidovudine can slow down the evolution of HIVN to ESRF. They highlight the need to screen HIV-positive patients regularly for proteinuria, in order to detect HIVN by renal biopsies at an early stage of renal lesion formation.

We report the case of a female patient with seronegative lupus and predominant bladder and intestinal involvement in the form of interstitial cystitis and protein-losing enteropathy. This association is exceptional in the literature but may be underestimated because of frequent latency of interstitial cystitis. It may define a peculiar subgroup of lupus patients usually responsive to steroid therapy. In this case, only cyclophosphamide markedly improved the protein-losing enteropathy but did not influence the bladder disease.