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Background: Haemodialysis exposes patients to many potentially sensitizing allergens. Objectives: The primary objective of this study was to evaluate the prevalence of delayed hypersensitivity in a population of haemodialysis patients. Secondary objectives were to identify the possible risk factors for contact sensitization and to propose a series of skin tests adapted to haemodialysis patients. Methods: A prospective monocentric study was carried out in a nonselected population of haemodialysis patients. For each patient, medical history of atopy and allergic contact dermatitis, ongoing treatments (including topical ones), presence of eczema at the site of vascular access for haemodialysis were recorded. Allergological investigation included delayed hypersensitivity tests (European Environmental and Contact Dermatitis Research Group battery, tests GERDA, additional list and a battery of antiseptics and other dialysis-specific allergens) and latex skin prick test. Results: Seventy-five patients (41 men, 34 women, mean age of 65 years old), with a mean 3.8 years under dialysis, were included. Nineteen patients (25%) had at least one positive skin test and 13 (17%) a positive patch test to at least one allergen relative to dialysis process including eight tests to lidocaine–prilocaine cream and three to povidone–iodine. Tests results seemed clinically relevant since nine patients had localized pruritus at the fistula site and six patients active eczema around it. Conclusion: Contact sensitizations are frequent in haemodialysis patients and are linked to vascular access conditioning especially the use of lidocaine–prilocaine cream. Designing a specific test battery could help to diagnose the potential allergens and subsequently to give advice to avoid contact with sensitizing agents.

Immune reconstitution inflammatory syndrome (IRIS) is a rare entity that has been described recently in solid organ transplant (SOT) recipients. IRIS is characterized by an exuberant and dysregulated immune response following treatment of opportunistic infections. We describe here the case of a kidney transplant recipient who developed cryptococcal meningitis that was efficiently treated with antifungal therapy and decreased immunosuppression regimen. Eight months later, a paradoxical worsening of neurological symptoms and neuroradiological findings led to the diagnosis of IRIS. A short course of high-dose steroid therapy allowed complete resolution of neurological symptoms. This report highlights the challenge for physicians to distinguish IRIS from a relapsing cryptococcal infection. Clinical improvement of cryptococcosis-associated IRIS by anti-inflammatory drugs needs to be confirmed among SOT recipients.

Immunosuppressive regimens have lowered the rate of kidney rejection, but with increasing immunodeficiency-related complications. New cytomegalovirus (CMV) prophylaxis also has become available. The impact of these 2 developments on CMV diseases has not been well evaluated. We conducted a randomized trial comparing a drug regimen common in the 1980s, cyclosporin A (CsA) with azathioprine (Aza), with a drug combination used most today, tacrolimus (Tac) with mycophenolate mofetil (MMF), and we analyzed CMV risk factors in kidney transplant patients.The 300 patients included in the trial underwent the same universal prophylaxis and preemptive therapy. CMV events and risk factors were prospectively recorded.With preventive and preemptive strategies combined for 3 months, CMV replication was detected in 32.6% and CMV disease in 18.1% of patients. Multivariate analysis on risk factors for CMV disease were CMV donor (D)/recipient (R) matching and first month renal function (risk ratio [95% confidence interval]: 1.02 [1.01; 1.04]; P=0.011), but not the immunosuppressive regimen (P=0.35). The D+/R- combination increased the risk of CMV disease by a factor of 9 (P0.0001) when compared with D-/R- status, and a factor of 3.5 (P0.0001) when compared with all CMV-positive recipients. Despite the 50% rate of CMV disease in the D+/R- group, no asymptomatic CMV replication was detected with the preemptive strategy.With modern immunosuppression, a sequential quadritherapy with Tac/MMF, and a 3-month CMV prevention strategy, the risk for CMV disease remains close to that with CsA/Aza. A CMV-negative recipient transplanted from a CMV-positive donor (D+/R-) remains a major risk factor, calling for better CMV prophylaxis or matching in negative recipients. Preemptive strategy thus appeared inefficient for this high-risk group. Transplant recipients with altered renal function should also be considered at risk.

Summary: A patient with hyperuricaemia and gouty arthritis due to a new variant of hypoxanthine–guanine phosphoribosyltransferase is described. The mutation (I136T, HPRT Marseille) is in the phosphoribosylpyrophosphate-binding region of the gene and leads to almost total loss of enzyme activity in erythrocytes, with 5% in lymphocytes. Nevertheless, the patient showed no neurological abnormality.

We have prospectively studied in hemodialysis (HD) patients the evolution of hepatitis C virus (HCV) viremia and the putative relationships between the viremia and the biological markers of liver disease. For each of 22 HD patients having detectable antibodies to HCV (anti-HCV+), we looked four times for serum HCV-RNA by nested PCR (N-PCR), in April and November 1992, November 1993 and May 1994. We checked the transaminases (Trans) and the gamma glutamyl transpeptidase (gamma(GT)) levels on the same day as blood tests for the N-PCR. Abnormal Trans or gamma(GT)++ values were considered if they exceeded the upper limit of the normal level for our laboratory. Fifteen patients (68%) were intermittently N-PCR positive (N-PCR+): 3 patients were N-PCR+ at three determinations, 7 were N-PCR+ at two determinations and 5 only one time. Two patients (9%) were always N-PCR+ and five (23%) always negative. No correlation between an abnormal value of either Trans or gamma(GT) and viremia was evidenced at successive determinations. In conclusion, the majority (68%) of the anti-HCV+ patients had intermittent HCV N-PCR+. Among the anti-HCV+ patients, 77% were viremic. Since HCV viremia is often transitory and since there is no correlation between N-PCR positivity and the increase in Trans or gamma(GT) activities, HCV-RNA detection by N-PCR is probably not clinically relevant in anti-HCV+ HD patients.

To evaluate the morbidity of multiple artery renal transplants (1 artery) and to assess the value of this parameter as a risk factor for complications of renal transplantation in adults.140 renal transplants derived from brain dead donors with multiple arteries (2 arteries = 123, 3 arteries = 17) were reviewed with a mean follow-up of 3 years (6-120 months). Pedicle restoration was performed in 57 cases (end-to-side reimplantation of a polar artery = 17, composite aortic patch graft = 14, multiple procedures = 10, ligation of a polar artery = 8, arterial wound = 5, "gun barrel" anastomosis of 2 arteries = 4). Arteriography was performed systematically in 57 cases, in the absence of any signs suggestive of a vascular complication.2 recipients died from a vascular complication. 40% of transplants were functional at 5 years. 10 transplantectomies were performed for a vascular complication. 14 recipients returned to dialysis because of a vascular complication. 7.5% of systematic arteriographies revealed stenosis of the transplant artery. 54 transplants developed a vascular complication: thrombosis = 19, stenosis = 25. Three-artery transplants had a vascular morbidity of 50%. "Gun-barrel" anastomoses and polar reimplantations into the main trunk had a vascular morbidity of 40%. The urological morbidity was 10%.Multiple artery renal transplants, especially 3-artery transplants and certain pedicle restorations, are associated with a high risk of vascular complications. Arterial anatomy is a selection criterion for the donor and recipient which must be taken into account in renal transplantation.

A transmembrane passage of endotoxins may account for the dysfunction of cytokine production which has been often reported in haemodialysis. We developed an assay based on the ability of patient serum to stimulate tumour necrosis factor alpha (TNF alpha) secretion in normal peripheral blood mononuclear cells. Three groups of subjects were investigated: normal controls (n = 14), patients with chronic renal failure, CRF (n = 15), and patients dialysed with polyacrylonitrile (n = 7), polysulphone (n = 8), and cellulose acetate (n = 7). Sera from dialysed patients displayed a significantly higher TNF alpha-inducing activity than those of controls and CRF patients. The ability of serum to elicit TNF alpha secretion was neither modified during the dialysis session nor influenced by the type of haemodialysis membrane. TNF alpha-inducing activity in serum was not inhibited by polymyxin B, known to impair endotoxin-dependent cell responses, thus suggesting that it was not related to circulating endotoxins. We conclude that non-endotoxinic factors are present in serum from dialysed patients and are able to induce cytokine secretion.

Using 31P-nuclear magnetic resonance (NMR) measurements of relaxation rate for 2,3 diphosphoglycerate (DPG) phosphorus atoms, we showed previously that in uraemic red blood cells the DPG-haemoglobin binding is stronger, thus stabilizing the deoxyhaemoglobin form and hence facilitating oxygen release. Here we verified if these modifications of spatial environment of DPG remain in uraemic patients treated by human recombinant erythropoietin (rHuEpo). Simultaneously we measured the intraerythrocytic ATP concentration (ATPi) and pH (pHi) of patients. Our results show a slight decrease on pHi and ATPi values during rHuEpo treatment. For the DPG relaxation rates, we observed a very weak but statistically significant increase 6 months after the beginning of treatment, but we cannot attribute a physiopathological significance to these results because of the lack of accuracy of the NMR determination of relaxation rate in red blood cells. Therefore, the DPG-haemoglobin binding is always stronger than in normal subjects.

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.

The association of membranous glomerulonephritis with carcinoma and minimal change disease with Hogkin's disease are well established. In contrast cancer and crescentic glomerulonephritis is an uncommon association. We report a patient with gastric carcinoma who developed synchronously acute renal failure due to crescentic glomerulonephritis. Corticosteroid therapy, plasma exchanges and tumor resection was associated with a regression of renal failure. Carcinoma must be considered as a possible cause of crescentic glomerulonephritis.

Since 1977, our patients have undergone chronic HD with ultra-pure dialysate (UPD), defined as having endotoxin levels below 0.008 ng/ml and less than 1 bacteria/ml of dialysate. We evaluated the incidence of carpal tunnel syndrome (CTS) in three groups of patients. Group I (GI), 84 patients, dialysed for 6.1 +/- 3.2 years (mean +/- SD) with UPD only; Group II (GII), 39 patients, first dialysed for 3.7 +/- 2.3 years with non-UPD and afterwards for 8.4 +/- 2.1 years with UPD; Group III (G III), 103 patients treated for 6 +/- 5.9 years exclusively with non-UPD. All patients were dialysed with cuprophan or cellulose acetate membranes. Results, expressed by Kaplan-Meier actuarial survival curves as the percent of patients without CTS, show that CTS occurred significantly less in GI than in GIII. This may be due to less stimulation of monocytes resulting from the absence of bacteria, endotoxins and pyrogens in the dialysate, which would reduce the stimulation of cytokines release, interleukin 1 and 6, and tumor necrosis factor, known to stimulate beta 2 microglobulin synthesis.

Hyperkaliema at 6 mmol/l was discovered in a 30-year old man during routine examination. Further investigations showed that the hyperkaliaemia was associated with hyperchloraemic acidosis, stimulable hyporeninaemia and relative hypoaldosteronism in relation to the hyperkaliaemia. Renal and adrenal functions were normal. The finding of 3 identical cases in a French family of 9 persons led to the diagnosis of Gordon's syndrome, a rare hereditary metabolic disorder with a controverted physiopathology.

We examined parathyroid gland function in 47 patients with idiopathic hypercalciuria in an effort to determine whether serum levels of parathyroid hormone (PTH) and/or urinary excretion of cyclic adenosine monophosphate (cyclic AMP) can discriminate between the various forms of hypercalciuria. Although we could separate our 47 patients into two groups, 21 patients with renal hypercalciuria (RH) and 15 patients with absorptive hypercalciuria (AH), there remained a group of 11 patients who did not exactly correspond to either group. Basal serum PTH was normal in the two groups: for RH, 10.32 +/- 0.93; for AH, 11.43 +/- 1.10 microliter Eq/ml. Similarly, urinary cyclic AMP did not differ between the two groups: for RH, 4.88 +/- 0.5; for AH, 4.87 +/- 0.55 nmoles/dl/min GFR. Moreover, the response of the parathyroid glands to acute hypocalcemia produced by intravenous infusion of EDTA was not different among patients with AH, RH, and control subjects. Only one patient showed a marked increase of serum PTH in response to acute hypocalcemia, and the bone biopsy revealed increased osteoclastic resorption. In conclusion, our data show that serum levels of PTH and urinary cyclic AMP do not differentiate between the various forms of idiopathic hypercalciuria. The EDTA test demonstrated that secondary hyperparathyroidism is very uncommon in these patients.

Eighteen hemodialysed patients having a plasma calcium level of 2 mmol/l or less were treated by 1-alpha-OH-D3 at a mean dose of 1.56 microgram per day for six to twelve months. Calcium levels rose significantly. The concomitant rise in phosphorus levels required large doses of aluminum hydroxide. Alkaline phosphatase and parathormone levels were significantly lowered. Seven patients had calcium levels above 2.75 mmol/l and subsequently developed metastatic calcifications. Therefore plasma calcium levels should be carefully monitored during treatment and maintained at normal levels. In twelve cases bone histomorphometric studies were done. When bone demineralization is a prominent feature, satisfactory osteoid tissue mineralization can be obtained, while bone resorption remains unchanged.