Search

Introduction – objectifs L’objectif était d’estimer l’incidence des infections associées aux soins (IAS) chez les patients greffés de rein ou rein-pancréas, peu documentée dans la littérature en France. Matériels et méthodes Une surveillance active prospective a été réalisée entre septembre 2012 et septembre 2013 auprès des nouveaux patients greffés de rein ou rein-pancréas d’un CHU. Les infections urinaires nosocomiales (IUN), bactériémies nosocomiales (BN) et infections sur site opératoire (ISO) survenant durant le séjour post-greffe ont été recensées, elles étaient définies selon les critères du réseau de national de surveillance RAISIN. Résultats Au total, 147 patients ont été greffés dont 28 (19 %) étaient des greffes de rein-pancréas. La durée de séjour moyenne était de 19 jours, un patient est décédé. L’antibioprophylaxie per-opératoire était ceftriaxone pour 91 % (n = 108) des greffés de rein et une association ceftriaxone-metronidazole +/-fluconazole pour 86 % (n = 24) des greffés rein-pancréas. Le taux d’attaque (TA) des IAS était de 20,4 % (n = 30), dont 22 (TA = 15 %) IUN, 5 (TA = 3,4 %) ISO et 10 (TA = 6,8 %) BN. L’incidence des IUN était de 3,8 (IC 95 % 1,9-6,8)/100 patient-jours, l’incidence des BN était de 8,9 (IC 95 % 5,7-13,3)/ 1 000 patient-jours. Les ISO étaient plus fréquentes chez les patients greffés rein-pancréas (10,7 %, n = 3) par rapport au greffés de rein seul (1,7 %, n = 2, p = 0,02), les taux d’IUN et de BN ne différaient pas selon le type de greffe. Les micro-organismes les plus fréquents étaient E. coli (n = 10, 24 %), E. faecalis (n = 10, 24 %) et E. faecium (n = 5, 12 %). Onze des entérobactéries (73 %) étaient résistantes aux céphalosporines de 3e génération. Conclusion Les IAS sont fréquentes chez les patients greffés de rein ou rein-pancréas, les IUN en sont la principale cause. Les patients greffés reinpancréas sont plus à risque d’ISO dans la population de l’étude. [ABSTRACT FROM AUTHOR]

Practices for enrollment on kidney transplantation waiting lists are variable between geographical areas and centers. Early referral of patients with chronic renal failure (CRF) to a nephrologist, particularly one practicing in a transplantation center, is a prerequisite to early enrollment. Despite improved survival in elderly transplant recipients, being aged over 65 years is still a barrier against enrollment. Furthermore certain comorbid conditions such as diabetes mellitus are often wrongly considered as contraindications for transplantation. If nephrological management is initiated early, enrollment could (should?) be considered before the terminal phase of CRF, with the hope of preemptive transplantation with the known advantages not only for the individual recipient but also for the community in general. Glomerular filtration rate below 20 ml/minute could be a reasonable cutoff for enrollment. Patients referred late to a nephrologist will require dialysis. Dialysis center staff should be well trained in delivering appropriate information on kidney transplantation and initiating evaluation. A consultation with a transplantation specialist should be rapidly scheduled.

Purpose: To assess inter-assay variation and accuracy of blood creatinine measurements as well as the effect of the standardization of the calibration procedures on inter-assay variation., Methods: Inter-assay variation and accuracy were assessed using 30 frozen human sera and 3 certified reference materials, which were analysed by 17 creatinine assays (colorimetric: 12, enzymatic: 4, HPLC: 1). Usual calibration procedure was compared with two common calibration procedures using either a reference material (404.1 micromol/L), or secondary sera calibrators (69, 115 et 180 micromol/L)., Results: Most of the commercially available methods display inaccuracy, > 10% for creatininemia < 150 micromol/L in most cases. For this concentration range, the mean creatininemia was statistically significantly different as a function of the assay used (p < 0.001). Enzymatic assays produced lower results than colorimetric ones for low creatinine levels but higher results for high creatinine levels. Assays being calibrated according to the manufacturer's recommendations, the median dispersion factor was 14% for the 20 samples between 45 and 150 micromol/L, and 8% for the 10 samples between 250 and 350 micromol/L. The calibration procedure modified inter-assay variation significantly (p < 0.001) but we gained little advantage from both common calibration procedures. A significant decrease of inter-assay variation occurred within each technical group (colorimetric or enzymatic) when a common calibration was performed using calibrators which concentration(s) was(were) close to the concentrations to be measured., Conclusions: Inter-assay variation is too high to allow prediction of glomerular filtration rate (GFR) or creatinine clearance from serum creatinine level. Our results highlight the interest of a calibration procedure using several concentrations with at least one between 90 and 150 micromol/L. The marketing of such a calibrator should be considered in order to decrease inter-assay variation in the range of creatinine levels which defines a mild chronic renal failure. Such an approach will certainly reduce inter-assay variation only within each technical group but could allow to include technical group as a co-variable in the algorithms developed for predicting GFR or creatinine clearance. A global transferability will certainly need the correlation of all types of creatinine assays versus a definitive method, whom definition remains uncertain., (Copyright John Libbey Eurotext 20003.)

End-stage renal failure (ESRF) is a medical and a public health problem in France and in developed countries due to the increased incidence (100 per million of persons (pmp) in France, in 1998 /year) and prevalence rates (600 pmp in 1998; +8%/year) and due to the high cost of the renal replacement therapy (RRT). This increase is mainly due to the increased incidence and prevalence of type 2 diabetic and vascular nephropathies that represent more than 50% of the ESRF causes. This progression is the consequence of an access to RRT for patients older than 60, of the population ageing, and of a better prevention and management of cardio-vascular complications in elderly ans diabetic patients. More than 30% of the patients are referred too late, leading to an increased morbi-mortality. Clear recommendations are required to make an early diagnosis of renal failure (plasma creatinine > or = 137 mumol/L in man and > or = 104 mumol/L in woman), mainly in the group of at risk patients and in order to improve the management of these patients before the end-stage renal disease.

Type 2 diabetes is becoming a major cause of chronic renal failure leading to health care problem. Literature data do not allow to choose between hemodialysis or peritoneal dialysis as the treatment of choice of end stage renal failure in type II diabetic patients according to their co-morbidities. A retrospective study was performed in 28 type II diabetic patients, either 11% of the total population, who started dialysis in our center between 1994 and 1997. Fourteen patients had chosen peritoneal dialysis and 14 hemodialysis. The 2 groups were not different for their initial neurological, cardiovascular, ophthalmological complications and for their metabolic control. After a mean follow-up of 14 months on dialysis a significant higher number of infections (9 versus 4), of hospitalisation days (34 +/- 19 versus 6.5 +/- 5.5), of technical transfers (6 versus 0) and of deaths (5 versus 0) were recorded in patients on peritoneal dialysis, without any difference in the metabolic control. A prospective, multicenter study is required to identify the best dialysis technique in type 2 diabetic patients, according to their co-morbidities and the dialysis dose.

We report 23 cases of lymphoproliferative diseases which occurred among 2,100 patients with kidney or combined kidney+pancreas transplant. Eleven patients developed a severe diffuse disease within the first 3 months post-transplantation; immunoblastic B cells of recipient origin infiltrated the bone-marrow, transplanted organs, liver, spleen, lymph nodes, lungs, and brain; immunoglobulin abnormalities with fever, leuko-thrombocytopenia and liver dysfunction constituted the symptoms; all patients received anti-lymphocyte globulins; 9 patients were also treated with cyclosporin. Three out of 6 tumors analysed were monoclonal. Epstein-Barr virus was present in 3 lesions analysed. Treatment consisted of cessation of immunosuppressive therapy. Nine patients died with lactic acidosis. Five patients had a less severe form. Seven patients had solid tumors involving the tonsils, lungs (2), lymph nodes (2), and bladder, 8 months after transplantation. All patients received cyclosporin; 4 also received anti-lymphocyte globulins and 3 OKT3. Tumor cells were immunoblasts expressing B cells markers at a late stage of B cell differentiation; 4 tumors were monoclonal. C myc was negative. Treatment consisted of cessation of immunosuppressive therapy, antiviral agents, and monoclonal antibodies (mAb): anti-CD21 and anti-CD24 mAb therapy was followed by cure of the lymphoma in 1 patient, by transient remission in a second one and by failure in the third patient. Two patients had a recurrence of the lymphoma and received chemotherapy; 2 patients died of the lymphoma, 1 died of unrelated cause; 4 are alive, 3 of them having a good graft function.

Using ELISPOT assays, we detected a significant number of cells secreting interferon-gamma and interleukin 6 among 8 irreversibly rejected kidney allografts compared with normal kidneys. Interleukin 2 increases the frequency of interferon-gamma producing cells and interleukin 4 decreases the frequency of both interferon-gamma and interleukin 6 producing cells.

The value of pulsed Doppler velocimetry (PDV) to detect renal graft artery stenosis was evaluated in a prospective study of 42 kidney-transplanted adult patients. The results of PDV were compared with those of arteriography which is regarded as a reference examination. With PDV the diagnostic sensitivity was 85 percent and specificity was 82 percent. The low cost and good sensitivity (provided the interpretation problems are known) of this harmless examination make it a good instrument to detect renal graft artery stenosis. In order to obtain an early diagnosis, 148 kidney-transplanted patients were systematically examined by PDV 1, 3, 6 and 12 months after transplantation. The incidence of renal graft artery stenosis was evaluated at 6.8 percent.

The relative importance of renal biopsy and cytological studies (fine needle aspiration biopsy and urine sediment examination by phase contrast) in the diagnosis of acute rejection episode was evaluated in 30 patients who received a kidney transplant. All patients underwent these 3 examinations simultaneously during an acute degradation of graft function. Sensitivity of renal biopsy, fine needle biopsy and urine sediment was 0.86, 0.68, 0.43 respectively. The association of fine needle biopsy and urine sediment examination increased the sensitivity up to 0.73. Renal biopsy is indicated to assess the vascular and glomerular status or in the presence of inconclusive cytological studies.

The influence of HLA A, B, DR on the incidence and symptoms of cytomegalovirus (CMV) infection was investigated in 143 patients who, between October 1st, 1987 and December 31st, 1989, received kidneys from cadaveric donors. Systematic virological monitoring was carried out weekly during the first hospitalization and thereafter at each new hospitalization or in the presence of clinical signs suggestive of viral infection. The diagnosis of CMV was based on positive isolation in blood or urine, or seroconversion, or 4-dilution rise in the anti-CMV antibodies titre. HLA grouping of all recipients was made in the same histocompatibility laboratory. Immunosuppression was obtained with a quadruple therapy consisting of corticosteroids (15 mg/kg before transplantation, then 1 mg/kg for 10 days, then gradually tapering off dosage), azathioprine (2 to 3 mg/day), cyclosporin A (2 mg/kg i.v. followed by an oral dose adjusted to the residual levels) and a randomized treatment with either monoclonal anti-CD3 antibody or anti-thymocyte globulins administered during the first 10 days. The incidence of CMV infection was 56 percent (80/143), with 25 percent of primary infection (20/80). The number of DR compatibilities was found to have a significant influence on the incidence of CMV infection, which rose from 22 to 50 and 65 percent respectively in the group of patients with 2.1 or 0 DR compatibility (P less than 0.02). The degree of B + DR compatibility was also associated with the occurrence of CMV infection, the incidence of which rose from 0 to 36, 59, 43.5 and 71 percent respectively in the group of patients with 4, 3, 2, 1, 0 B + DR compatibility (P less than 0.03). The incidence of primary CMV infection increased with the number of DR incompatibilities, rising from 0 to 29 and 52 percent respectively in the group of patients with 0, 1 or 2 DR incompatibilities. The symptoms and severity of CMV infection were significantly influenced by the degree of DR and B + DR compatibility. Despite a very strong association between graft rejection and CMV infection (P less than 0.000001), no influence of HLA, and particularly DR or B + DR compatibility on the incidence and number of graft rejections could be demonstrated. It is concluded that, under the above-described quadruple therapy, the HLA DR and B + DR compatibility exerts a predominant influence on the occurrence and severity of CMV infection, and that this effect is independent of any action on graft rejection.(ABSTRACT TRUNCATED AT 400 WORDS)

The frequency and severity of CMV infections in kidney, bone marrow, heart transplant recipients, in polytransfused patients, in immunodeficiencies and in newborns with congenital or peri-natal infection prompted clinical trials of immunoglobulins (Ig) with anti-CMV activity. Among the various methods for titrating Ig of plasmatic or placental origin, polyvalent or hyperimmune, ELISA would be the most sensitive assay and the neutralizing reaction might be the better reflection of a protective effect. In kidney transplantation, two non-randomized clinical trials have suggested a curative effect in association to other treatments, especially when given early. In bone marrow transplantation, three randomized studies have shown a prophylactic effect on incidence of symptomatic infections, interstitial pneumonias due to CMV, but only in seronegative patients not treated with leucocyte transfusions. No effect was observed on the time of infection, the survival of patients, the incidence of surinfections or graft versus host disease. The prophylactic effect of anti-CMV Ig in kidney and heart transplantation as well as in newborns has still to be documented in randomized trials. The possible clinical benefit for the patients and the mode of preparation of effective anti-CMV antibodies need further investigations.