[Chronic kidney failure. Etiology, physiopathology, diagnosis, treatment].
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Adult↗
Biomedical subjects
F Mignon
Publications and source records attributed to F Mignon.
The management of uraemia in the elderly: treatment choices.
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.
Aged↗
[A consensus conference in nephrology].
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Consensus Statements as Topic↗
[How to diagnose and treat peritoneal infections in patients with terminal chronic renal insufficiency treated by peritoneal dialysis].
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.
Anti-Bacterial Agents↗
[Diagnostic value of myocardial thallium stress scintigraphy in the detection of coronary artery disease in patients undergoing chronic hemodialysis].
Atherosclerotic heart disease is the leading cause of death in patients with end stage renal disease, but its non invasive detection remains difficult because of a low efficacy of exercise testing. The aim of the study was to evaluate diagnostic accuracy of thallium myocardial imaging after dipyridamole combined with exercise. Forty two chronic dialysis patients (34 men, 8 women) aged 55 +/- 11 years (range: 36 to 75) without symptom of angina nor myocardial infarction were studied. In each patient, an echocardiography, a myocardial scintigraphy with dipyridamole combined with symptom-limited exercise, and coronarography were performed. A coronary heart disease was diagnosed by coronarography in 10 patients (4.5 and 1 respectively with 1, 2 and 3 vessels diseased). Echocardiography detected a left ventricular hypertrophy (LVH) in 26 patients and a regional asynergia in 14 patients. A positive scintigraphy was present in 11 patients. Three false-positive and 2 false-negative on scintigraphy were noted. Sensibility, specificity, positive predictive value and negative predictive value were respectively evaluated at 80, 73, 73 and 93%. All the five patients with either false-positive or false-negative scintigraphy exhibited a LVH. CONCLUSION. In chronic dialysis patients, coronary heart disease may be detected by thallium myocardial imaging after dipyridamole combined with exercise.
Adult↗
[Sclerosing peritonitis. A series of 10 cases and review of the literature].
OBJECTIVE AND METHODS: The aim of this study was to describe the main features of sclerosing peritonitis, using a retrospective study in 10 patients. RESULTS: The main causes of sclerosing peritonitis were continual ambulatory peritoneal dialysis (n = 3), peritoneal chemotherapy (n = 2) and liver cirrhosis (n = 2). Sclerosing peritonitis was revealed by acute or chronic bowel obstruction (n = 8). Small bowel X-rays and abdominal tomodensitometry showed a small bowel dilatation with a normal mucosa (n = 7), ascites (n = 5) as well as agglutination and fixation of small bowel loops within a cocoon (n = 3). Surgical viscerolysis was performed in 9 patients and allowed prolonged clinical remission in 4; 3 patients died postoperatively (1 had a cirrhosis and 2 were treated with continuous ambulatory peritoneal dialysis), 1 patient had a complicated postoperative course with recurrent enterocutaneous fistulae. CONCLUSION: Sclerosing peritonitis may be suspected in a patient who presents a combination of bowel obstruction, small bowel dilatation without mucosal disease and ascites. Surgical viscerolysis is a dangerous operation associated with high mortality in patients with renal failure or cirrhosis.
Adult↗
Pharmacokinetics of rilmenidine in patients with chronic renal insufficiency and in hemodialysis patients.
The pharmacokinetics of rilmenidine (1 mg orally) was studied in 3 groups of patients with stable chronic renal insufficiency. This was an open, single-blind study following a single administration, and after 15 days of treatment. Group 1 included 11 patients with a creatinine clearance between 15 and 80 mL/min. Group 2 included 17 patients with a creatinine clearance < 15 mL/min. Group III included 10 hemodialysis patients. In patients with chronic renal failure, total plasma clearance and renal clearance of rilmenidine decreased; terminal half-life was 30-42 hours, which is clearly longer than previous values achieved in healthy volunteers. After repeated administration (1 mg daily in group 1, 1 mg every other day in group 2, 1 mg at the end of each dialysis session in group 3), the area under the curve was significantly increased, corresponding to drug accumulation. The steady state was reached after 6 days in patients in group 1 and after 8 days in patients in group 2. The pharmacokinetics of rilmenidine was linear since the terminal elimination half-life and renal clearance were not significantly different after single and repeated administration of rilmenidine. A positive correlation was found between rilmenidine total plasma clearance and creatinine clearance, and between rilmenidine renal clearance and creatinine clearance. Mean rilmenidine hemodialysance was 85 mL/min, that is, 26% of the rilmenidine renal clearance value achieved in healthy volunteers (330 mL/min). Thus, the following dosage schedule can be proposed. In patients whose creatinine clearance ranges between 15 and 80 mL/min, a 1 mg dose every day can be recommended.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Randomised controlled trial of enalapril and beta blockers in non-diabetic chronic renal failure.
OBJECTIVE: To compare the ability of angiotensin converting enzyme inhibitors and beta blockers to slow the development of end stage renal failure in non-diabetic patients with chronic renal failure. DESIGN: Open randomised multicentre trial with three year follow up. SETTING: Outpatient departments of six French hospitals. PATIENTS: 100 hypertensive patients with chronic renal failure (initial serum creatinine 200-400 mumol/l. 52 randomised to enalapril and 48 to beta blockers (conventional treatment). INTERVENTIONS: Enalapril or beta blocker was combined with frusemide and, if necessary, a calcium blocker or centrally acting drug in patients whose diastolic pressure remained above 90 mm Hg. RESULTS: 17 patients receiving conventional treatment and 10 receiving enalapril developed end stage renal failure. The cumulative renal survival rate was significantly better in the enalapril group than in the conventional group (P < 0.05). The slope of the reciprocal serum creatinine concentration was steeper in the conventionally treated patients (-6.89 x 10(-5)l/mumol/month) than in the enalapril group (-4.17 x 10(-5)l/mumol/month; P < 0.05). No difference in blood pressure was found between groups. CONCLUSION: In hypertensive patients with chronic renal failure enalapril slows progression towards end stage renal failure compared with beta blockers. This effect was probably not mediated through controlling blood pressure.
Acebutolol↗
Autoimmune haemolytic anaemia after ABO-match, ABDR full match kidney transplantation.
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.
ABO Blood-Group System↗
Fungal peritonitis in patients on peritoneal dialysis.
Fungal peritonitis (FP) is a serious complication of peritoneal dialysis, both in terms of morbidity and mortality. Available data on the effectiveness of fluconazole in eradicating FP without catheter removal are still controversial. We reviewed 20 FP cases that occurred among 325 patients who underwent peritoneal dialysis in our center between January 1984 and January 1992, in order to establish whether a profile of patients at risk of developing FP could be identified and to evaluate the effectiveness of fluconazole in treating FP (7 cases). Age, sex, a particular cause of end-stage renal disease, and the presence of diabetes did not correlate significantly with the development of FP. The risk of FP increased in patients on immunosuppressive treatment. Sixteen of our 20 patients had bacterial peritonitis during the month before they developed FP. Nineteen were treated with antibiotics. Neither the type of bacterial organism isolated during the bacterial peritonitis preceding FP nor modality and duration of antibiotic treatment correlated significantly with the development of FP. Patients who subsequently developed FP were more frequently treated with antibiotics while in hospital (p < 0.001). Candida species accounted for 15 of our 20 FP cases (75%), with Candida albicans being by far the most common isolate. Treatment strategies varied among the 20 patients. The combination of intravenous or intraperitoneal administration of 5-fluorocytosine and oral administration of fluconazole was used in 7 cases: only 1 patient was cured without catheter removal, 1 patient died within the first 4 days of treatment, removal of peritoneal catheter was necessary in the other 5 patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Plasma atrial natriuretic factor and blood pressure drops during hemodialysis.
The potential role of atrial natriuretic factor (ANF) in blood pressure (BP) drops during hemodialysis (HD) has been examined in 30 patients with end-stage chronic renal failure. Echocardiographic measurements and evaluation of cardiac parasympathetic function were performed prior to HD sessions, simultaneously with hormonal determinations. The plasma ANF level was correlated with the peak value of the E wave and the Doppler index of the left ventricular preload and was more elevated in 'denervated' than in intact patients. During the HD sessions, the BP fell in 18 patients (group 1) and remained stable in 12 others (group 2), despite similar weight losses. Both groups differed by the basal values of plasma ANF, greater in group 1 than in group 2 (100.0 +/- 13.3 vs. 65.7 +/- 3.4 fmol/ml; p < 0.05). The magnitude of plasma ANF decrease was identical in both groups despite the BP decrease in group 1 at the end of the session. These results suggest that the ANF release depends not only on hemodynamics but also on cardiac innervation in dialyzed patients and that high plasma ANF levels are implied in the BP drops during HD session.
Adult↗
[Reflections apropos the stopping of dialysis treatments].
In North America, the withdrawal from dialysis is one of the major causes of death among patients treated for end-stage renal disease, especially when it comes to the elderly. The reasons for the decision to terminate treatment are either medical or can be seen in what we commonly call the "quality of life", even though the latter is difficult to define. Situations such as these are hardly ever referred to in European medical literature. They create difficult psychological, ethical and event legal problems that need to be anticipated and resolved for each individual case. According to the authors, the basis for this thinking and the debate surrounding the termination of treatment as well as the final decision to do so ultimately rest with the physician. The quality of the relationship established between patient, family and medical staff during the course of treatment is essential in situations like these.
Ethics, Medical↗
[Management of chronic renal insufficiency in the elderly].
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Age Factors↗
[Tubulo-interstitial renal complications of myeloma].
Tubulo-interstitial lesions are the main causes of renal failure in patients with myeloma, and they sometimes reveal this tumour. They are mainly found in large tumoral mass myelomas and are characterized by tubular lesions and specific casts of unexplained physiopathology. Symptomatic and aetiological treatments must be instituted at an early stage to obtain the recovery, at least partial, of renal function, as observed in more than 50% of the cases. The persistence of renal failure carries a sombre prognosis, which emphasizes the importance of a preventive treatment that is too often omitted. Functional tubular disorders are frequent but seldom result in Fanconi's syndrome. A better understanding of the mechanisms underlying the nephrotoxicity of monoclonal immunoglobulins should permit to reduce the incidence of tubular lesions in myelomas.
Fanconi Syndrome↗
[End-stage chronic renal failure in myeloma: results of dialysis].
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.
Aged↗
Inhibition of neutral endopeptidase stimulates renal sodium excretion in patients with chronic renal failure.
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)
Adult↗
Effects of clonidine on plasma catecholamines and neuropeptide Y in hypertensive patients at rest and during stress.
Neuropeptide Y (NPY), a potent vasoconstrictor agent reported to be released, in addition to norepinephrine (NE), by sympathetic nerve endings during stress, may contribute to the pressor response to various stimuli. The objectives of this study were to determine (a) whether plasma NPY concentrations are altered during different types of stress (cold pressor test, mental stress, and active orthostatism) and (b) whether clonidine, via its central sympatholytic effect, affects the stress-induced blood pressure, NPY, and/or catecholamine changes. Eighteen untreated patients with mild essential or borderline hypertension participated in an acute randomized, double-blind, parallel study. The blood pressure and heart rate were recorded during three control periods, each followed by either a cold pressor test (CPT), a mental stress test (MS: mental arithmetic), or active orthostatism (AO), performed in a random order. Venous blood samples for catecholamines and NPY determination were taken at the end of each control and test period. This entire procedure was repeated after oral clonidine (150 micrograms) or placebo. Before treatment, a CPT, MS, or AO increased the blood pressure to the same extent. The stress-induced increase in plasma NE was greater during AO (+99 +/- 23%) than during CPT (+35 +/- 8%) and MS (+55 +/- 12%). The stress-induced increase in plasma epinephrine was only significant during MS (+142 +/- 69%). A small but significant increase in NPY (p < 0.05) was observed during AO only (+10 +/- 7%). Compared to placebo, clonidine significantly decreased the basal blood pressure and the pressor response to CPT, but did not change the pressor response to MS and AO.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Doppler echocardiographic evaluation of physical properties of the aorta and left ventricular geometry in normotensive hemodialyzed patients].
Twenty-five patients undergoing hemodialysis therapy with a normal blood pressure (16 men, 9 women, age = 54 +/- 14 years) and 25 sex and age-matched healthy normotensive subjects were examined by doppler-echocardiography. Pulse wave velocity (PWV) in the thoracic descending aorta, diameter of the ascending aorta (AD), left ventricular mass (m), thickness-radius ratio (th/r), shortening fraction (SF), end systolic pressure-diameter ratio (P/D) and the ratio of late and early mitral velocity (A/E) were obtained. Pulse wave velocity, SF, P/D, were not significantly different in the 2 groups whereas AD, m, th/r, and A/E were significantly larger in dialysis patients than in controls (both, p < 0.001). These results indicate that in patients treated by hemodialysis with a normal blood pressure, a concentric left ventricular hypertrophy is associated with a normal aortic stiffness, suggesting a depressed myocardial contractility.
Adult↗