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Resume Objectif A travers une revue retrospective de quatre cas, nous rapportons notre experience sur l’approche cœlioscopique de l’autotransplantation renale a partir d’une seule incision iliaque dans la prise en charge du syndrome des hematuries recidivantes douloureuses ( loin pain hematuria syndrome , ou syndrome LPH). Materiel et methodes Quatre patientes âgees de 23 a 36 ans (âge moyen 29,5 ans) ont subi une nephrectomie cœlioscopique et une autotransplantation renale en utilisant une seule incision iliaque afin de prelever le rein et le transplanter. Pour deux interventions, nous avons utilise une assistance manuelle avant le clampage du pedicule renal. Les quatre patientes necessitaient avant l’operation un traitement antalgique a base de morphine. Resultats La duree operatoire moyenne etait de 4,1 heures. Le temps operatoire moyen concernant la nephrectomie cœlioscopique etait de 1,9 heures. La duree d’ischemie chaude etait en moyenne de cinq minutes, le temps d’ischemie froide moyen de 58 minutes. La duree moyenne d’hospitalisation etait de six jours. La fonction renale n’a pas ete modifiee. Apres l’operation, trois patientes ont eu des douleurs de la fosse iliaque au niveau de la cicatrice. Deux patientes sur quatre ont pu etre sevrees en morphine. Pour les deux autres, les doses de morphine ont pu etre reduites de maniere significative. Aucune des patientes operees n’a necessite de nephrectomie par la suite. (Suivi moyen : neuf mois). Conclusion L’approche cœlioscopique de l’autotransplantation renale est un traitement moins invasif comparee a la technique classique par voie ouverte. Cette technique peut etre etendue a d’autres pathologies urologiques pour lesquelles l’autotransplantation est indiquee.

Resume La prise en charge nutritionnelle du malade renal chronique (mRC) demeure une question centrale qui fait l’objet de travaux permanents. Les benefices de la restriction proteique sont de nouveau mis en lumiere, que ce soit par reduction de l’uree hyperglycemiante ameliorant l’insulino-sensibilite peripherique, ou par diminution de la charge en phosphore et de l’hormone FGF23, respectivement associes a une nephroprotection et a une baisse des evenements cardiovasculaires. Les nombreuses recherches menees sur le microbiote intestinal ouvrent egalement des pistes prometteuses d’une meilleure comprehension du role de cet ecosysteme dans la maladie renale chronique (MRC). Enfin, l’interet de la dialyse incrementale est relance, des resultats montrent qu’elle serait associee a une moindre perte proteique et a une preservation de la fonction renale residuelle. L’elaboration recente d’un score nutritionnel, tres informatif en termes de prediction de survie, offre par ailleurs la possibilite d’assurer un meilleur suivi des patients.

The link between vascular calcification (VC) and increased mortality is now well established. Over time, as clinical importance of this phenomenon has begun to be fully considered, scientists have highlighted more and more physiopathological mechanisms and signaling pathways that underlie VC. Several conditions such as diabetes, dyslipidemia and renal diseases are undoubtedly identified as predisposing factors. But even if the process is better understood, many questions still remain unanswered. This review briefly develops the various theories that attempt to explain mineralization genesis. Nonetheless, the main purpose of the article is to provide a profile of the various existing biomarkers of VC. Indeed, in the past years, a lot of inhibitors and promoters, which form a dense and interconnected network, were identified. Given importance to assess and control mineralization process, a focusing on accumulated knowledge of each marker seemed to be necessary. Therefore, we tried to define their respective role in the physiopathology and how they can contribute to calcification risk assessment. Among these, Klotho/fibroblast growth factor-23, fetuin-A, Matrix Gla protein, Bone morphogenetic protein-2, osteoprotegerin, osteopontin, osteonectin, osteocalcin, pyrophosphate and sclerostin are specifically discussed.

International audience

Recently, the Kidney Disease: Improving Global Outcomes (KDIGO) group has produced comprehensive clinical practice guidelines for the management of anaemia in CKD patients. These guidelines addressed all of the important points related to anaemia management in CKD patients, including therapy with erythropoieis stimulating agents (ESA), iron therapy, ESA resistance and blood transfusion use. Because most guidelines were ‘soft’ rather than ‘strong’, and because global guidelines need to be adapted and implemented into the regional context where they are used, on behalf of the European Renal Best Practice Advisory Board some of its members, and other external experts in this field, who were not participants in the KDIGO guidelines group, were invited to participate in this anaemia working group to examine and comment on the KDIGO documents in this position paper. In this article, the group concentrated only on those guidelines which we considered worth amending or adapting. All guidelines not specifically mentioned are fully endorsed.

How to obtain definite information from incomplete information A systematic review of treatment proposed for a specific disease should be based on an exhaustive literature search, which should identify all randomized clinical trials (RCTs) relevant to the selected topic. Controlled non randomized studies may also be included in situations where random allocation of treatment is deemed to be difficult or impossible, or when no such trials exist. If enough trials are found and these report conflicting results, a meta-analysis is one way of assessing the efficacy of the treatment. Meta-analysis is a clinical research tool allowing the pooling of results from different clinical trials evaluating comparable treatments for a given condition. This is particularly useful when the number of patients is low, or the observed event rate is low. Meta-analyses can reduce the size of the confidence interval from the point estimate for the treatment effect. Thus if the treatment effect in each of three small trials shows a non-significant trend to efficacy, the pooling of the trials may result in a significant trend to efficacy. The selection of trials to be pooled, however, is an important step in a process that includes a rigorous statistical analysis (i.e. Mantel and Haenszel method). The choice of the outcome to be analysed should be based on strong epidemiological data or related to a clinically relevant question. Outcomes should be 'hard' objective events that are easily observed by non-specialists, such

Various diethyl β-functional γ-oxo alkylphosphonates (3) were conveniently prepared using two complementary inexpensive strategies, and were reacted with hydrazine, methylhydrazine or phenylhydrazine giving regioselectively new diethyl 1-(pyrazol-4-yl)-alkylphosphonates (4), isolated in high yields.

To review retrospectively our experience with laparoscopic approach to renal autotransplantation in four patients using a single iliac incision in the management of loin pain hematuria (LPH) syndrome.Four patients with LPH (all women, mean age 29.5 years, range 23-36 years) underwent four technically successful laparoscopic nephrectomies with renal autotransplantation, using a single iliac incision to both harvest and transplant the kidney. Hand assistance was used in two patients immediately before clamping the renal pedicle. All patients required narcotic analgesics preoperatively.Mean total surgical time was 4.1 hours. For laparoscopic donor nephrectomy phase, mean operative time was 1.9 hours. The warm ischemia time was 5 minutes. The cold ischemia time was 58 minutes. The hospital stay was 6 days. None of the patients had abnormal renal function postoperatively. Three of four patients had episodes of iliac fossa pain with effort at the level of the transplantation incision. Two of four patients became Morphine-free. The other two required a significantly reduced dose of oral narcotics. None of these patients required nephrectomy. (Median follow-up 9 months).Laparoscopic approach to renal autotransplantaion using a single extended iliac incision in the management of LPH syndrome can be considered as a less invasive treatment compared to open renal autotransplantation in selected patients. This technique may be extended to patients having other conditions requiring autotransplantation.

In chronic kidney disease patients with secondary hyperparathyroidism (SHPT), the recommended K/DOQI™ target serum levels of parathyroid hormone (PTH), calcium (Ca) and phosphorus (P) are difficult to reach and maintain stable. We present the results of the French cohort from the European study ECHO which investigated the use and effectiveness of cinacalcet in real-world clinical practice.An observational study of the SHPT management in dialysis patients, partially retrospective (from 6 months prior to cinacalcet initiation) and partially prospective (up to 12 months of cinacalcet treatment).Four hundred and eighty-five French patients were enrolled from 44 centres. Cinacalcet was given in combination with active vitamin D treatment (39%) and phosphate binders (87%). After 12 months, the proportion of patients reaching recommended K/DOQI™ target levels had increased from 2.5% to 28.8% for PTH, from 46.8% to 50.1% for Ca, from 40.0% to 49.9% for P and 54.8% to 77.7% for the CaxP product. The proportions of patients using active vitamin D and sevelamer decreased by 6% and 20% respectively. Adverse events were reported in 37 (7.6%) patients, mainly nausea (2.1%), vomiting (2.1%) and dyspepsia (1.2%).The results of this study are consistent with data from controlled and randomized studies showing that cinacalcet increases the proportion of patients achieving the K/DOQI™ targets for PTH, Ca, P and CaxP in real-world clinical practice.

Diethyl 2,4-dioxoalkylphosphonates are prepared in excellent yields by Claisen condensation of the dianion of diethyl 2-oxoalkylphosphonates with ethyl esters or acyl chlorides in the presence of one equivalent of lithium diisopropylamide (LDA).

Diethyl 2,4-dioxoalkylphosphonates are prepared in excellent yields by Claisen condensation of the dianion of diethyl 2-oxoalkylphosphonates with ethyl esters or acyl chlorides in the presence of one equivalent of lithium diisopropylamide (LDA).

For more than fifty years, low protein diets have been proposed to patients with kidney failure. However, the effects of these diets in preventing severe renal failure and the need for maintenance dialysis have not been resolved.To determine the efficacy of low protein diets in delaying the need to start maintenance dialysis.Cochrane Renal Group trials register, the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE. Congress abstracts (American Society of Nephrology since 1990, European Dialysis Transplant Association since 1985, International Society of Nephrology since 1987). Direct contacts with investigators. Date of most recent search: December 2004.Randomised trials comparing two different levels of protein intake in adult patients suffering from moderate to severe renal failure, followed for at least one year.Two reviewers independently selected studies and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes with 95% confidence intervals (CI). Collection of the number of "renal deaths" defined as the need for starting dialysis, the death of a patient or a kidney transplant during the trial.Eight trials were identified from over 40 studies. A total of 1524 patients were analysed, 763 had received reduced protein intake and 761 a higher protein intake. Two hundred and fifty one renal deaths were recorded, 103 in the low protein diet and 148 in the higher protein diet group (RR 0.69, 95% CI 0.56 to 0.86, P = 0.0007). To avoid one renal death, 2 to 56 patients need to be treated with a low protein diet during one year.Reducing protein intake in patients with chronic kidney disease reduces the occurrence of renal death by 31% as compared with higher or unrestricted protein intake. The optimal level of protein intake cannot be confirmed from these studies.

We describe 2 patients with AA renal amyloidosis secondary to bronchiectasis (one patient had tracheobronchomegaly or Mounier-Kuhn syndrome).The time period between the diagnosis of bronchiectasis and the development of renal amyloidosis was 40 years and 30 years respectively. Both patients evolved to end-stage renal failure requiring dialysis.Although the incidence of renal amyloidosis secondary to bronchectasis has declined, it remains a dreadful complication.

Renal involvement is an unusual complication of human visceral leishmaniasis (VL). The kidney lesions are characterized more by interstitial damage than glomerular or vascular damage. This case represents a 20 years-old man admitted with pancytopenia, purpura, acute renal failure, and nephrotic syndrome associated with heavy proteinuria. The diagnosis of VL was made on bone marrow smear cytology where Leishmania amastigotes were found. The renal biopsy revealed a segmental necrotising glomerulonephritis with 70% crescents. Treatment with liposomal amphotericine B alone has been ineffective on the course of renal failure, however, partial recovery was obtained after the administration of high dose corticosteroids. We present the various clinical, biological, and histological aspects of this case, from the south of France. It gave us the opportunity to discuss these unusual manifestations of immunomediated necrotising skin and renal lesions.

Chronic inflammation is very common in patients on maintenance dialysis. It is associated with an increase of many cytokines (especially: IL-1, IL-6 and TNF alpha). This inflammation leads to hormonal dysregulation (leptin, adiponectin, insulin). Increase in cytokines is associated with a high cardio-vascular morbi-mortality for general population as well as for uremic patients. Many metabolic abnormalities are due to chronic inflammation: protein catabolism, anorexia and many others. Among them, the "metabolic" syndrome includes adiposis, dyslipemia, insulinoresistance and high blood pressure very often present in chronic uremic patients. It is still unknown whether anti-inflammatory treatments would improve inflammation consequences in dialysis.

For more than fifty years, low protein diets have been proposed to patients with kidney failure. However, the effects of these diets in preventing severe renal failure and the need for maintenance dialysis have not been resolved.To determine the efficacy of low protein diets in delaying the need to start maintenance dialysis.Medline and Embase search from January 1966 through to June 1999. Congress abstracts (American Society of Nephrology since 1990, European Dialysis Transplant Association since 1985, International Society of Nephrology since 1987). Direct contacts with investigators.Randomised trials comparing two different levels of protein intake in adult patients suffering from moderate to severe renal failure, followed for at least one year. Diabetic nephropathy patients were excluded.Seven trials were selected from over 40 studies since 1975. A total of 1494 patients were analysed, 753 had received reduced protein intake and 741 a higher protein intake. Collection of the number of "renal deaths" defined as the need for starting dialysis, the death of a patient or a kidney transplant during the trial.Two hundred and forty two renal deaths were recorded, 101 in the low protein diet and 141 in the higher protein diet group, giving an odds ratio of 0.62 with a 95% confidence interval of 0.46 to 0.83 (p=0.006). To avoid one renal death, four to 56 patients need to be treated with a low protein diet during one year.Reducing protein intake in patients with chronic renal failure reduces the occurrence of renal death by about 40% as compared with higher or unrestricted protein intake. The optimal level of protein intake cannot be confirmed from these studies.

Since recent years, a number of systematic reviews have been published in the renal field. These publications will be used to develop the concept of evidence based nephrology. The design and quality of renal systematic reviews relies on technical skills and efficient trials search. The reasons for discrepancies that are sometimes reported between systematic reviews and controlled clinical trials are now better understood and may be partly explained by inadequate trial recovery and publication biases. The applicability of evidence findings is not always an easy task on patients level. The example of the low protein diet in chronic renal failure highlights such caveats. However, producing high level systematic reviews in the renal field may be of great help to clarify the use of controversial treatments and to design new studies in the renal field.

protein intake to retard or even halt the development Background. The objective of this study was to deter- of non-specific glomerular or interstitial lesions, and mine the efficacy of low protein diets in delaying the hence, the progression of patients towards end-stage need to start maintenance dialysis based on an analysis renal disease. Despite the large number of studies on of published literature. dietary interventions that were performed a few decMethods. The search strategy involved a Medline and ades ago, it is still unclear if patients should limit their Embase search from January 1966 through to June protein intake and if so, to what extent nutritional 1999, congress abstracts (American Society of behaviour should be changed during chronic renal Nephrology since 1990, European Dialysis Transplant failure. Most of the clinical studies were designed to Association since 1985, International Society of test the efficacy of reducing protein intake on surrogate Nephrology since 1987) and direct contacts with invest- renal function outcomes, such as serum creatinine igators. The selection criteria included randomized increase or creatinine clearance decrease over time. trials comparing two different levels of protein intake Unfortunately, changing protein intake will modify all in adult patients suffering from moderate to severe creatinine markers and, therefore, no valid conclusions renal failure, followed for at least 1 year. Patients with can be drawn from these studies. Although a few trials diabetic nephropathy were excluded. Seven trials were used what are considered as gold standard renal funcselected from 40 studies since 1975. A total of 1494 tion assessments such as glomerular filtration rate patients were analysed: 753 had received reduced pro- (GFR), the results from these studies have been contein intake and 741 a higher protein intake. The flicting. Moreover, GFR is not a clinical outcome. numbers of ‘renal deaths’ (defined as the need for starting dialysis, the death of a patient or kidney transplant during the trial ) were collected. Results. 242 renal deaths were recorded, 101 in the Methods low protein diet and 141 in the higher protein diet group, giving an odds ratio of 0.61 with a 95% confid- The objective of this review was to determine the efficacy of ence interval of 0.46 to 0.83 (P=0.006). low protein diets in preventing the natural progression of Conclusion. Reducing protein intake in patients with chronic renal failure towards end-stage renal disease and chronic renal failure reduces the occurrence of renal therefore delaying the need for starting maintenance dialysis. death by about 40% as compared with larger or For this purpose, we defined the ‘renal death’ outcome, i.e. unrestricted protein intake. The optimal level of protein the number of deaths or number of patients who will start intake cannot be confirmed from these studies. dialysis or will receive a kidney transplant during the observa

In recent years a number of meta-analyses have been published in the renal field. These publications will be used to develop the concept of evidence-based nephrology. The design and quality of renal systematic reviews relies on technical skills and an efficient trial search. The reasons for discrepancies between systematic reviews and controlled clinical trials are now understood better and may be partly explained by inadequate trial recovery, and publication bias. Application of evidence findings is not always an easy task on the patient's level. The example of the low-protein diet in chronic renal failure highlights these obstacles. However, producing high-level systematic reviews in the renal field may greatly help in clarifying the use of controversial treatments and designing new studies.

Membranous nephropathy in adults causes 20% of nephrotic syndromes. Spontaneous outcome of this glomerulopathy is difficult to evaluate from clinical and histological data. Some patients can achieve complete remission, while others develop progressive renal failure. In this study we assessed alpha-smooth muscle actin (alpha-SMA) expression in renal interstitial myofibroblasts as a marker to predict the outcome of membranous nephropathy.Renal function tests in tandem with alpha-SMA immunolabelling were performed on 25 patients with a mean follow-up of 7.2+/-5.6 years. The intensity of interstitial alpha-SMA (ialpha-SMA) immunostaining was compared to changes in glomerular filtration rate (GFR) evaluated by inulin clearance, between the time of diagnosis (GFR1) and the end of follow-up (GFR2).A significant correlation (r = 0.62, p0.001) was found, between the intensity of interstitial myofibroblasts, immunolabeling and GFR at the end of follow-up. Moreover, the annual GFR variation and the annual percentage of GFR variation were correlated to interstitial myofibroblast labeling (respectively r = 0.62, p0.001; r = 0.67, p0.001). In addition, the importance of proteinuria, initial GFR impairment and fibrosis were confirmed as prognostic criteria.This study strongly shows that ialpha-SMA expression is a useful and early prognostic marker in the evolution of membranous nephropathy.

Systematic reviews and meta-analyses are the best approaches available for summarizing the available evidence concerning the efficacy of therapies. Although the renal field has been slow to use these techniques, they are being used increasingly. In March 1997, the Cochrane Renal Group was formed, and this group aims to produce and maintain up to date systematic reviews of the evidence on the effectiveness of therapies used to treat patients with renal diseases. This group is part of the Cochrane Collaboration which is an international structure grouping collaborators together, with the aim of preparing, maintaining and disseminating systematic reviews of the effects of health care in all areas of medicine.

Despite numerous progresses, including extracorporeal epuration, acute renal failure (ARF) remains associated with a high level of mortality and morbidity, particularly in intensive care unit. Experimental research on different acute renal failure models has clearly shown that growth factors and particularly Insulin-like Growth Factor I (IGF-I) can reduce renal injury, improve renal recovery and even reduce mortality. IGF-I, that is locally produced in injured renal tubules, promotes the proliferation and differentiation of new tubular cells. Moreover, IGF-I carriers (IGFBPs) and IGF-I receptor are altered in ARF and modify the growth factor bioactivity. To date, only two clinical trials studied IGF-I treatment in the ARF condition. Other studies are required to demonstrate a role for IGF-I in treating or preventing acute renal failure.

We designed a short-term randomized controlled study in 12 adult patients with chronic renal failure to assess the metabolic effects of a low-protein diet (LPD) supplemented or not with ketoacids (Cetolog, Clintec Corp., France). Dietary survey included a monthly 3-day food record and a 24-hour urinary urea measurement. After a baseline period (1.11 g protein, 31.7 kcal/kg BW/day), patients reduced their protein intake (PI) to 0.71 g/kg BW/day. Energy intake (EI) was kept constant (31.4 kcal/kg BW/day) during the 3-month period. Baseline plasma lipids did not show overt hyperlipemia. After reducing PI, a significant increase in apolipoprotein AI and the Apo-AI/Apo-B ratio was observed. Plasma Lp(a) levels were elevated at baseline and did not change during the 3-month LPD period. There was no difference between groups receiving ketoacids or not. Thus, in adult chronic renal failure, under a sufficient EI, reducing PI by 40% had a beneficial effect on plasma lipid profile. This improvement in lipid profile might reduce the high cardiovascular risk in these patients.

The adult protein turn-over daily affects 250 grammes, which is equivalent to four times the average daily protein intake. Regulation of synthesis and catabolism appears to occur by independent ways. These systems are altered during the nephrotic syndrome and ultimately lead to a loss of total body nitrogen and a risk for malnutrition. Indeed, during the nephrotic syndrome, muscle protein synthesis is further impaired as the urinary protein losses increase. This may suggest that anabolic compounds are lost in the urine of such patients. A moderate protein restriction (0.8 g/kg BW/day) allows a reduction in proteinuria, as well as pharmacological agents (ACE inhibitors) and should therefore slow the progressive renal insult.