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Measurement of urinary albumin excretion (UAE) may be done on a morning urinary sample or on a 24 hour-urine sample. Values defining microalbuminuria are: - 24-hour urine sample: 30-300 mg/24 hours - Morning urine sample: 20-200 mg/mL or 30-300 mg/g creatinine or 2.5-25 mg/mmol creatinine (men) or 3.5-35 mg/mol (women). - Timed urine sample: 20-200 mug/min. The optimal use of semi-quantitative urine test-strip is not clearly defined. It is generally believed that microalbuminuria reflects a generalized impairment of the endothelium; however, no definite proof has been shown in humans. In diabetic subjects, microalbuminuria is a marker of increased risk of cardiovascular (CV) and renal morbidity and mortality in type 1 and type 2 diabetic subjects. The increase in UAE during follow-up is also a marker of CV and renal risk in type 1 and type 2 diabetic subjects; its decrease during follow-up is associated with lower risks. In non-diabetic subjects, microalbuminuria is a marker of increased risk for diabetes mellitus, deterioration of the renal function, CV morbidity and all-cause mortality. It is a marker of increased risk for the development of hypertension in normotensive subjects, and is associated with unfavorable outcome in patients with cancer and lymphoma. Persistence or elevation of UAE overtime is associated with deleterious outcome in some hypertensive subjects. Measurement of UAE may be recommended in hypertensive subjects with 1 or 2 CV risk factors in whom CV risk remains difficult to assess, and in those with refractory hypertension: microalbuminuria indicates a high CV risk and must lead to strict control of arterial pressure. Studies focused on microalbuminuria in non-diabetic, non-hypertensive subjects are limited; most of them suggest that microalbuminuria predicts CV complications and deleterious outcome as it is in diabetic or hypertensive subjects. Subjects with a history of CV or cerebrovascular disease have an even greater CV risk if microalbuminuria is present than if it is not; however, in all cases, therapeutic intervention must be aggressive regardless of whether microalbuminuria is present or not. It is not recommended to measure UAE in non-diabetic non-hypertensive subjects in the absence of history of renal disease. Monitoring of renal function (UAE, serum creatinine and estimation of GFR) is annually recommended in all subjects with microalbuminuria.in patients with microalbuminuria, weight reduction, sodium restriction (6 g/day), smoking cessation, strict glucose control in diabetic subjects, strict arterial pressure control are necessary; in diabetic subjects: use of maximal doses of ACEI or ARB are recommended; ACEI/ARB and thiazides have synergistic actions on arterial pressure and reduction of UAE; in non-diabetic subjects, any of the five classes of anti-hypertensive medications (ACEI, ARB, thiazides, calcium channel blockers or beta-blockers) can be used.

Total plasma homocysteine emerged in the past few years as an independent risk factor for cardiovascular diseases. This test is now currently prescribed for the diagnosis of unexplained thrombosis in young adults or recurrent thrombosis in patients with arteriopathy. This sulphured amino-acid is an important intermediate in transsulfuration and remethylation pathways of methionine metabolism. Within the context of a collaboration between Monastir and Grenoble Universities and because a gas chromatograph mass spectrometer (GC-MS) instrument was available in Monastir, we proposed to transpose a GC-MS method previously developed in Grenoble's hospital for this parameter and to validate it by comparison with the liquid chromatography tandem mass spectrometry (LC-MS-MS) method, used at present. Analytical performances were good: detection limit 0.4 micromol/L and linear range up to 4 mg/L (29.6 micromol/L), and between-run and within-run precision with coefficients of variation5% and8 %, respectively. The comparison with LC-MS-MS method showed a good correlation (y = 0.9874 x -0.208; r(2) = 0.84). Mean difference from LC-MS-MS was -0.4 micromol/L. Plasma concentrations of homocysteine (mean + SD) determined among Tunisian adults, 29 men, 27 women, of the same age were respectively: 11.6 +/- 2.4 micromol/L and 10.1 +/- 2.7 micromol/L, p = 0.025. This method is now currently used to evaluate tHcy concentration in patients with risk factors for cardiovascular disease.

We have used a minimally invasive technique for fixation of trochanteric fractures since 2003. We use the percuntaneous compression plate described by Gotfried. We describe here the osteosynthsis technique and our special approach which limits operative time. This technique avoids wide opening of the aponeurosis of the tensor fascia lata, major detachment, and section of the vastus lateralis. The plate is inserted via a 2-cm incision over the greater trochanter. Head and shaft screws are inserted via a second incision measuring 3 to 4 cm. Perfect reduction before plate insertion is the key to success. The results of our first twenty cases have demonstrated an uneventful postoperative period and a short operative time of 25 minutes on average. Peri-operative bleeding has been very limited. Radiographic healing was obtained in three months. Weight bearing was possible immediately after fixation in five cases and was delayed in fifteen. There were two early displacements which were analyzed.

We report the case of a 10-year-old child who presented a severely deformed upper limb due to post-traumatic partial proximal epiphysiodesis of the humerus. The goal of treatment was to correct the severe angular deformity, prevent recurrence, and lengthen the humerus 6 cm. We used the De Bastiani callotasis method with osteotomy of the humeral shaft and unilateral external fixation (Orthofix LRS). The bony deformations were corrected progressively. Angular correction induced a geometric lengthening sufficient to match the length of the healthy limb. Lengthening index was 22.7 days/cm. The functional and esthetic results were remarkable. Complementary epiphysiodesis of the proximal physis successfully prevented recurrent deformation.

We led a retrospective study to determine the causes of the tendon ruptures post-operating in the surgery of the wrist rheumatoid dorsal and to estimate the clinical result. At follow-up, we measured the extension lag and the rolling-up of fingers by the distance palm-pulps. Nine patients were so revised in the average of 40 months, average age was of 50.7 years. The tendon ruptures arose in 3 months in 67% of the cases. Seven times, a procedure on the distal radio-ulnar joint had been necessary (5 Sauvé-Kapandji and 2 Darrach). Thirty tendons had been concerned in this study, that is 3.3 tendons on average (1-5). Two main causes were found: attrition on the stub ulnaire and great intra-tendinous synovitis (per operating observation). At the revision, the lag extension means was 23 degrees (0-40). Rolling-up of the long fingers was complete 4 times on 7. The best results were observed after tendinous grafting or index proprius transfer with a lateral suture. Tendinous adhesions had arisen 6 times and persisted still at 3 patients. Our study underlines the interest to stabilize the stub ulnaire to prevent the post-operating ruptures and proposes a transfer or a graft in front of tendons very weakened by the synovitis.

The "late referral to nephrologist" (LRN) phenomenon has been described recently, first in Europe and subsequently in every country where dialysis and transplantation are offered without restriction. Definition of LRN is based on an arbitrary date of referral which is three months before the first dialysis session. LRN patients suffer much more morbidities and consequently more hospitalizations, particularly in intensive care units. They have less access to home and self dialysis, to peritoneal dialysis and to renal transplantation than their "on time" referred counterparts. Even if mortality is more important in late referred patients, the additional cost of LRN phenomenon is substantial; it has been evaluated from 16 800 to 30 500 euros for the first year of treatment. Every kind of patients are concerned, including diabetics. Explanation of the LRN phenomenon is complex and needs a multidisciplinary approach.

To assess renal replacement therapy in elderly subjects aged 80 years or more in order to depict factors predicting mortality.We retrospectively studied 30 consecutive patients at the time of starting dialysis from January 1995 to August 1995 and followed this population though March 1996.Only past ischemic heart disease and emergency situations were emphasized as predictor factors of mortality risk. No difference according to mortality between hemodialysis and peritoneal dialysis subgroups was found.Excepting usual contraindications for uremic populations, no objective medical criteria are at present time sufficient for excluding chronic renal replacement therapy in very old patients. However, its effect on quality of life must be estimated in order to determine the cost/benefit ratio.

We report our first eleven uses of a new cement mantle extraction system. The basis of this technique relies on a cement bone interface with a lower strength compared to the old cement-new cement interface.The first stage of the procedure consists in a specific preparation of the inner surface of the old cement, mantle. It should be clean and dry after being abraded with a stainless steel wire brush. Then a thin cement syringe filled with low Viscosity PMMA cement, is injected in the old mantle in a retrograde fashion. A threaded rod with nuts is centered within the cement sheath to the bottom and held until the injected cement has fully polymerised. Then the threaded rod is unscrewed from the femur; nuts are established along the entire length of the cement column. To prevent trochanteric fracture occurring upon cement extraction, its is important to clear away sufficient bone from the lateral aspect of the canal. A series of extraction rods are then used to sequentially remove the cement mantle. The removal rod is screwed back into the threaded channel at a distance of every one to three nuts, and then attached to the slap hammer via a quick release connection. Cement extraction is performed using deliberate slaps of the slap hammer. The last segment is drilled with the use of a distal plug drill centering sleeve. After having inserted the plug removal rod, the last segment is extracted. We used this technique eleven times in 8 hips for 5 loosening of femoral component and 3 revisions hip arthroplasties without loosening and 2 revisions knee arthroplasties without loosening (an extraction system for the femur and the tibia).For the 5 loosening cases extraction was easy. In 2 cases, cement mantle was removed as a single "en bloc" piece. In the 3 other cases, the extraction was segmental only in the distal third of the cement mantle. Without loosening, the extraction was completely segmental. In all cases, cement mantles were successfully removed. There was no fracture and no loss of bone stock. There was only one "fissuration" alpha the great trochanter and we only made one distal window. All hip arthroplasties were replaced and arthrodesis were performed after removal of the knee arthroplasties.The cement-assisted mantle removal technique appears to be a simple, quick and effective methods for cement mantle removal. Perforation and diaphyseal window can be avoided by the technique even when loosening does not exist. However, it is necessary to establish a thorough preoperating plan in order to eliminate contraindications such as too narrow or too curved sheath.It appears that this new procedure will facilitate future reoperations which are reputed to be difficult and dangerous.

Detecting a microalbuminuria in a diabetic patient is enough to diagnose a diabetic glomerulopathy (which is more properly termed diabetic nephropathy). To appreciate exactly means to know what are the lesions of mesangium matrix and interstitial tissue; therefore, a renal biopsy is useful, (but needs to be examined by quantitative histo-morphometry). Numerous factors facilitate the progression of renal insufficiency in these patients: high blood pressure, poor glycemie control, high protein diet. Avoiding each of these factors allows to delay the time of dialysis and renal transplantation. Now diabetics represent the large group of patients in renal replacement therapy world-wide. These therapies are twice to thrice as expensive as they are for non diabetic patients.

Arthropathy affecting the small joints of the hand are one of the osteo-articular complications of chronic renal failure treated by hemodialysis. Amongst the 44 patients studied, there were 9 cases of arthropathy of the fingers. The clinical characteristics (age, duration of hemodialysis) and paraclinical characteristics (oxygenated free radical activity indicators, serum levels of aluminium and beta-2-microglobulins) appear to be specific to this population and may help us to understand the pathogenesis of the joint lesions.

A 14 year old boy presented with swelling of the middle finger. X-rays showed calcifications of the palmar surface of the head of the third metacarpal and over the first and second phalanges. The natural course was followed over a period of two years with a diagnosis of calcifying peritendonitis. Due to the increased volume of the calcification deforming the proximal phalanx, the masses were resected revealing a diagnosis of chondroma. The discovery of free foreign bodies in the synovial sheath of the flexors and histological examination established the diagnosis of tenosynovial osteochondromatosis, which is rarely located in the hand. No recurrence has been observed after 8 years of follow-up.

The incidence of late discovery of congenital dislocation of the hip is getting lower, thanks to systematic screening. We have treated 14 children during the past 5 years. Clinical diagnosis was confirmed by radiography. Thirteen children were treated by slow reduction, and immobilization according to Somerville-Petit's method. Four surgical treatments were performed (1 Klisic operation by first intention, 3 Salter operations by second intention). Good clinical results have not always correlated with radiologic normalization. These results were evaluated by Séverin's classification: 9 excellent or good (I or II), 4 poor results (III). Although improvement is expected in the future, repeated clinical and radiological supervision permits evaluation of the indications for a subsequent operation at the most favorable time.

The authors have studied 35 fractures of the calcaneal thalamus and compared the information provided by plain radiology and CT scans of the calcaneal tuberosity, especially those connected with the condition of the posterior subtalar joint. In 8 cases out of 35, the study of the CT sections yielded information that allowed changing the indications for treatment. The authors emphasize the quality of the data obtained, which makes it possible to justify a functional treatment or to establish a preoperative schedule.

A technique is described which combines ultracentrifugation in a density gradient stabilized by gelification, with agar gel immunodiffusion. The use of this procedure to determine sedimentation parameters and antigenic determinations is presented and illustrated with the diagramms obtained in the identification of various cryoglobulins.

This method has been used with good results in three patients, two of whom had single kidneys.

Schistosomiasis due to Schistosoma mansoni affects more than 40 millions people all over the world. Renal involvement is observed mainly in endemic areas. We report a case of hypocomplementemic membrano-proliferative glomerulonephritis in a malagasy man who suffered also from hepatosplenic bilharziosis. The relation between Schistosoma mansoni and the nephropathy was proved by indirect immunofluorescence test using a monoclonal antibody directed against the caecum of adult Schistosoma mansoni.

The renal toxicity of antitumoral drugs is an increasingly disturbing problem. These drugs are now prescribed in an ever wider variety of cases, and delayed renal reactions, previously unknown, are revealed by the longer survivals obtained. For a number of years, patients whose cancer had been cured have been placed under haemodialysis on account of drug-induced renal failure. The renal toxicity of cisplatinum, nitrosoureas and methotrexate is well-known, but mitomycin C is also capable of inducing permanent renal failure; the delayed toxicity of this drug explains that it has long been underestimated. This example emphasizes the need for close co-operation between oncologists, nephrologists and pharmacologists in order to determine, for each patient, the most effective treatment with the minimum of side effects.

Isolated non inflammatory lesions of renal microarteries (eventually with mild thickening of tubular basement membranes, but with negative immunofluorescent glomerular studies) were observed in 25 patients (22 males) in whom renal biopsy have been performed for proteinuria (P). Selection criteria were: pathological lesions by definition; absence of hypertension (HT) in clinical and at the time of biopsy; minimum follow up of 4 years after the first statement of the proteinuria (4 to 29 years; mean 14 years). Three groups have been isolated: 1. 3 patients have had an acute glomerulonephritis followed by disappearance of proteinuria. It reappears 1 to 5 years later. HT was discovered 2, 8 and 11 years after the proteinuria. Renal failure occurred 1 and 3 years after HT. 2. 14 patients had hereditary or acquired vascular risk factors (obesity, smoking, ethylism). In 7, HT occurred 3 to 15 years after P. In 2, renal failure occurred 4 to 8 years later. 3. 8 patients had no vascular risk factor; in 3 of them Ht developed 7, 13 and 20 years after the first statement. A positive immunofluorescence with IgM or C3 on renal arterioles had been found in only 3 of the 10 patients who in group 2 and 3 became hypertensive. A proteinuria may precede the occurrence of HT without being induced by glomerulonephritis. Group 2 and 3 suggest that these renal lesions of arterial sclerosis precede and may be a factor of HT. Indeed, this entity may be considered as a prehypertensive condition.

We have studied 25 cases of hemolytic and uremic syndrome (H.U.S.) induced by mitomycin C, collected from 1976 to 1982 in 12 Nephrology Centers. Mitomycin C was administered in successive cures at a cumulative dose higher than 50 mg/m2. This H.U.S. is characterized by its slow and late occurrence, by extra-renal, mainly respiratory, manifestations that may reveal the disease, and finally by its pathological aspects. Mesangiolysis and endothelial or mesangial enlarged and atypical nuclei are observed in addition to the usual lesions of thrombotic micro-angiopathy. The prognosis was very poor in the first cases reported. It was better, however, in the patients studied more recently, because the cumulative dose was lower. In severe cases, plasma exchange might improve long-term prognosis. The disease might be due to a direct toxic effect of mitomycin C on the vascular endothelium.

Mixed cryoglobulinemia associated with liver disease is well known, but its mechanism and signification still have to be elucidated. The purpose of this study was to identify and to characterize hepatic disease by their immunochemical features among 60 patients presenting with mixed cryoglobulinemia. Thirteen cases of alcoholic liver disease and 8 of virus B hepatitis out of 40 cases in all of hepatic disease in this group were studied. A higher frequency of type III immunochemical features of cryoglobulinemia in alcoholic disease (83 p. 100), no matter how severe, as well as a higher frequency of type II in virus B hepatitis (62 p. 100) was demonstrated. There was no relationship between virus B hepatitis and cryoglobulinemia in our population. Therefore, the responsibility of virus B hepatitis in essential mixed cryoglobulinemia genesis has to be clarified. The localization of cryoglobulin in the Kupffer cell in two patients with chronic hepatitis confirms the essential role of the reticuloendothelial system in blood clearance of circulating immune complexes.