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Cardiovascular disease (CVD) remains the major cause of death in patients with end-stage renal disease (ESRD). Traditional risk factors do not explain the high prevalence of CVD in this population, and other non-traditional cardiovascular (CV) risk markers have now been described. Therefore, the potential relationship between CVD and phenotypic and genotypic risk markers was investigated prospectively in incident dialysis patients cohort. The 279 patients (244 on hemodialysis, 35 on peritoneal dialysis) within the Diamant Alpin Dialysis Cohort Study were investigated. Phenotypic and genotypic parameters were determined at dialysis initiation, patients monitored over a 2-year period, and CV events (morbidity and mortality) recorded. Globally, 82 CV events occurred and 26 patients (9.3%) died from CVD, whereas 28 (10%) died from non-CV causes. Previous CV events were strongly predictive of CV events occurrence, whatever patients had had one (hazard ratio (HR) 2, 95% confidence intervals (CI) 1.1-3.5) or more (HR 3.9, 95% CI 2.1-7.1) CV accidents before starting dialysis. Both lipoprotein(a) (HR 1.67, 95% CI 1-2.5) and total plasma homocysteine at cutoff 30 micromol/l (HR 1.7, 95% CI 1.1-2.8) were independent predictors of CV events outcome. In the subgroup of patients with homocysteine < 30 micromol/l, methylenetetrahydrofolate reductase (MTHFR) TT was the sole biological parameter predictive of CV event outcome (HR 2.5, 95% CI 1.1-10, P = 0.03). ESRD patients who enter chronic dialysis with a previous CV event, high total homocysteinemia levels, or MTHFR 677TT genotype must be considered at high risk of incident CV events.

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.

Background. In the Irbesartan in Diabetic Nephropathy Trial (IDNT), treatment with irbesartan demonstrated 23 and 20% reductions in the combined endpoint of doubling of serum creatinine (DSC), endstage renal disease (ESRD) or death in patients with hypertension, type 2 diabetes and overt nephropathy compared with amlodipine and control, respectively. A simulation model was developed to project long-term cost consequences of the IDNT in Belgium and France. Methods. A Markov model simulated progression from nephropathy to DSC, ESRD and death in patients with hypertension, type 2 diabetes and overt nephropathy. Treatment-specific probabilities were derived from IDNT. Country-specific ESRD-related data were retrieved from published sources. Delay in onset of ESRD, life expectancy and mean lifetime costs were calculated for patients with a baseline age of 59 years. Future costs were discounted at 3% per annum (p.a.), and clinical benefits were discounted at 0 and 3% p.a.. Extensive sensitivity analyses were performed. Results. Onset of ESRD was delayed with irbesartan by 1.41 and 1.35 years vs amlodipine and control, respectively. When a 10-year time horizon was considered, delay in ESRD onset led to anticipated improvements in life expectancy of 0.13 years vs amlodipine and 0.26 years vs control. Irbesartan was associated with cost savings of “14 949 and “9205/patient in Belgium, and “20 128 and “13 337 in France, vs amlodipine and control, respectively. The results were robust under a wide range of plausible assumptions. Conclusions. Treating patients with hypertension, type 2 diabetes and overt nephropathy using irbesartan was both cost- and life-saving compared with amlodipine and control.

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.

OBJECTIVE: We evaluated the prognostic value of an exercise stress test and thallium-201 scintigraphy for the prediction of cardiac events in selected high-risk NIDDM patients. RESEARCH DESIGN AND METHODS: NIDDM patients (n = 158, 105 men, aged 63 +/- 9 years) with two or more of the following criteria were prospectively included: age > or = 65 years, active smoking, hypertension > 160/95 mmHg, hypercholesterolemia (cholesterol > 5.70 mmol/l or LDL > 3.10 mmol/l), peripheral artery disease, abnormal rest electrocardiogram, or microalbuminuria (20-200 micrograms/min). An exercise-stress scintigraphy was performed in 77 patients able to exercise, while a dipyridamole scintigraphy was performed in 80 patients unable to exercise. Follow-up was 23 +/- 17 months. Major end points were cardiac deaths or nonfatal myocardial infarction. RESULTS: The annual event rate was 7.31% (deaths: 8, myocardial infarction: 14). Independent predictors of events were as follows: an age > 60 (P = 0.02), an abnormal rest electrocardiogram (P = 0.02), microalbuminuria (P = 0.001), the inability to exercise (P = 0.009), and the presence of more than two defects on scintigraphy (P = 0.001). A cardiac death occurred in 1.3% of patients able to exercise versus 8.8% of patients unable to exercise (odds ratio = 6.8, P = 0.001). Among patients unable to exercise, large perfusion defects corresponded to an annual mortality rate of 22.3%. Conversely, the negative predictive value of a normal scintigraphy for the occurrence of death was 97%. CONCLUSIONS: Inability to exercise and large perfusion defects on thallium-201 scan are major predictors of future death and myocardial infarction in high-risk NIDDM patients.

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.

Acute allograft rejection is the major risk factor of renal function decline and graft loss. Beside histocompatibility matches and pharmacological immunosuppression, blood transfusion is empirically used to detect responder subjects and to induce immune tolerance. Alloimmunization associated with blood transfusions readily detected by anti-HLA antibodies could induce acute vascular rejection episodes during the early period after grafting. Our open prospective study was aimed at analyzing the 1 year follow-up of 105 successive first cadaver renal transplant recipients according to the transfusion protocol as assessed by anti-HLA antibody production, acute rejection episodes, and graft survival. Our conventional transfusion protocol involved 3 nonphenotyped blood transfusions set up at least 20 days before grafting in a control cohort (group A) and was compared with a single pretransplant HLA haplo- or semi-identical blood transfusion in a successive group of patients (group B). Our results suggest that both protocols were associated with similar 1-year graft survivals (> 96% in both groups) and number of patients experiencing rejection episodes (20.7% in group A; 9.6% in group B; P NS). HLA haplo- or semi-identical transfusion was significantly beneficial in naive patients without previous alloantigen contact by pregnancy or blood transfusions during dialysis. Naive patients in group B did not develop post-transfusion anti-HLA antibodies compared to naive patients in group A (16.6%; P < 0.001), and they experienced significantly less acute rejection episodes (2.7%) compared to group A naive patients (20.8%; P = 0.02).

Detection of hepatitis C virus RNA by polymerase chain reaction was performed in 26 patients with type II mixed cryoglobulinemia, and compared with anti-HCV antibody detection. The patients were divided into two groups according to etiology: 15 had essential type II mixed cryoglobulinemia and 11 had secondary type II mixed cryoglobulinemia. In the essential type II mixed cryoglobulinemia group, the prevalence of hepatitis C virus RNA detected by polymerase chain reaction was 60% in the supernatant and 93% in the cryoprecipitate. In the secondary type II mixed cryoglobulinemia group the prevalence of hepatitis C virus RNA was 45% in the supernatant and 55% in the cryoprecipitate. The differences between the two groups were not statistically significant. In both patient groups, detection of hepatitis C virus RNA in the cryoprecipitate was the most sensitive test for hepatitis C virus infection. These results suggest that hepatitis C virus might be involved in the origin of mixed cryoglobulinemia.

Since it has been suggested that omega-3 polyunsaturated fatty acids (PUFA) may be an efficient treatment for dyslipoproteinaemia and renal function in uraemic patients, this study was carried out to evaluate the potential adverse effects of polyunsaturated acids on lipid peroxidation in patients with chronic renal failure.Five uraemic predialysis patients with various renal diseases presenting progressive renal failure and moderate hypertriglyceridaemia (1.93 +/- 0.60 g/L) in comparison with the reference values of our laboratory (0.88 +/- 0.20 g/L) were given 6 g of fish oil per day for 6 months in the form of Maxepa capsules containing a low dose of tocopherol acetate (10.5 mg/day). During the treatment we investigated the effect (expected to be beneficial) of n-3 PUFA on triglyceride plasma levels and renal function. We also investigated the potential side effect of such a treatment on lipid peroxidation.A moderate decrease of triglycerides early after the introduction of the treatment (1.93 +/- 0.6 g/L vs 1.33 +/- 0.58 g/L; 0 vs 0.5 months) was observed. In all patients, lipid peroxides measured as thiobarbituric acid reactants increased early after the introduction of the n-3 PUFA therapy (2.8 + 0.8 vs 3.76 +/- 0.15 mumol/L; 0 vs 0.5 months). Organic hyperoxides were significantly different in these patients compared with laboratory values, but they did not increase significantly during the treatment.It must be noted that polyunsaturated fatty acids should be used with caution in predialysis patients.

As part of a large epidemiological study concerning 494 diabetic patients undergoing dialysis throughout France--the so-called Uremidiab section study--we collected data with the aim of describing objective as well as subjective aspects of quality of survival. Questionnaires were completed from medical records and from direct interviews by trained collectors. The data included: (a) medical status and impairments; (b) functional status with the Barthel index for basic activities of daily living; (c) subjective aspects through self-estimation of fatigue, pain, care burden, quality of life and working capacity. Only 21% of the patients had type 1 diabetes and more than 71% were currently insulin-treated. Among the various long-term complications registered, visual impairment was a prominent feature: 25% of the patients were blind and the best eye vision scored 0.8 or more for only 20%. The differences found between the two types of diabetes are discussed. As a result of these impairments, functional status was poor even when considering basic activities, with a mean Barthel index (BI) of 80 +/- 19. Type 2 patients and those patients undergoing continuous ambulatory peritoneal dialysis had significantly lower BI. The results are discussed in the light of the literature. Compared with a group of 121 non-dialyzed diabetics, patients scored higher for fatigue and pain, but not for care burden and quality of life.

An epidemiologic study of end-stage diabetic nephropathy in France (Uremidiab) was performed, aiming to establish the prevalence of both types of diabetes in dialysis patients. Because discrimination between type I and type II diabetes remains mostly clinical, our aim was to evaluate what the most fitted clinical criteria were. We studied 494 hemodialyzed diabetic patients. A first classification (Cn) was offered by the nephrologist. Clinical data of 472 patients (22 patients of the 494 have been excluded) were then collected with a standardized questionnaire, allowing one diabetologist of us to establish the diagnosis of type of diabetes (classification Cd). Plasma C-peptide at this stage of the disease was expected to be very discriminative, measured in 88 patients and defined classification Ccp (or = 0.6 ng/ml = "negative C-peptide" = type I,0.6 ng/ml = "positive C-peptide" = type II). Classification Cd observed 98 type I and 374 type II diabetes. Cn overestimated type I diabetes, 37% of type II diabetes being misclassified because insulin-treated. Classification Ccp observed 74 positive C-peptide patients, classified as type II, among whom 45 were insulin-treated. Only 3 patients were discordant for classification Cd and Ccp. Predictive value of "negative C-peptide" and "positive C-peptide" were 100% and 96% respectively. Multiple regression analysis of the Ccp classification was performed with the clinical criteria and showed very significant correlation with: age at the time of diagnosis of diabetes (AGE), maximal body mass index ever reached (BMI MAX) and delay between diagnosis and consistent insulin use (DI).(ABSTRACT TRUNCATED AT 250 WORDS)

The prevalence of diabetes mellitus among patients treated for end-stage renal failure was studied using a questionnaire mailed to all dialysis units of mainland France in 1989. With a response rate of 80.8%, the study population amounted to 12,903 dialysed patients of whom 884 were declared diabetic (6.9%). In a second phase, the study focused on the diabetic patients treated in the 63 largest units (those with at least four diabetic patients). Seven specially trained physicians completed questionnaires after having interviewed the patients and checked their medical records. All this material was reviewed by the same diabetologist. The conflict of diabetes type declared by both sources of information (the nephrologists and the diabetologist) showed a misclassification rate of 31.2%. Using these new data, the prevalence of type 1 diabetes mellitus was estimated at 1.4% of patients on dialysis therapy in mainland France, and 5.5% for type 2 diabetes mellitus. A north-south declining trend was suggested for type 2 diabetes mellitus. Diabetic nephropathy was the only primary renal diagnosis among 93.9% of type 1 diabetic patients, but only for 36.8% of type 2 diabetic patients. Of the latter, 51.6% had a non-diabetic cause of renal failure. These data show that the proportion of diabetics among patients receiving dialysis, while steadily increasing in France, remains lower than in other countries in Europe and in North America. However, the validity of international comparisons depends on diabetes ascertainment. Heterogeneity in selection of patients and in diabetes type classification by dialysis units may account to a considerable degree for the differences between diabetes mellitus prevalence across countries.

We present a case of monoclonal cryoglobulinemia with double monoclonal component IgA lambda-IgG lambda, without complement activation, membranoproliferative glomerulonephritis (MPGN) with deposits of IgA, IgG and lambda chains and lymphocytic IgA-lambda-chain-secreting lymphoma. This case emphasizes the possibility that double monoclonal cryoglobulins could behave differently compared to type I cryoglobulins, determining a MPGN-like type II cryoglobulins do, but without activating the complement cascade.

The concentrations of cadralazine in plasma were studied in 101 hypertensive patients treated with oral doses of 10, 15, or 20 mg of cadralazine once daily. Most of the patients received additionally a beta-blocking drug (n = 87) and a diuretic (n = 52). Few blood samples were collected in each patient on several occasions during the treatment, which usually lasted for more than 6 months. No accumulation of cadralazine in plasma occurred in any of the patients and the maximum concentrations were similar to those recorded in a small sample of healthy volunteers. The terminal half-life of elimination (3.6 h) was longer than that observed in healthy subjects (approximately 2.5 h). Conversely, the total clearance (197 ml/min) was lower (285 ml/min in healthy). The half-life and the total clearance in plasma were not dose dependent. In the patients treated for more than 6 months, no change in the pharmacokinetics of cadralazine was detected. The description of the distribution of concentrations showed that one-half of the patients behaved similarly to healthy subjects concerning half-life and total clearance. The other half presented a slower elimination of the drug (t 1/2 = 4.4 h and ClT = 130 ml/min) and these patients were significantly older (p = 0.01) than the former. This suggests that special attention should be paid to old hypertensive patients when a dose higher than 15 mg once daily is prescribed. Though concentrations were proportional to the dose, the body weight was not found to be a determining factor for dose adjustment.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

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.

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.

A prospective randomised trial was carried out in 14 patients with severe 'idiopathic' acute crescentic glomerulonephritis. The mean percentage of crescents was 78 per cent and 11 patients were anuric at presentation. Eight patients received pulses of methylprednisolone, immunosuppressive drugs and anticoagulants and six the same therapeutic regimen plus plasma exchanges for one to two months. Mean follow-up was 22 months. Recovery was statistically better in the PE+ group (p less than 0.02), but for discontinuation of dialysis, the difference is significant only at two months (p less than 0.02), perhaps because of the small number of patients. For this reason and because all pathological subgroups cannot be analysed separately, this study is continuing.

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.