Dominique Hestin

Bacteremia in patients on chronic hemodialysis : a multicenter prospective survey

A prospective epidemiologic survey of bacterial infections in chronic hemodialysis patients was conducted from September 1, 1989 to February 28, 1990 in 27 dialysis units. Of the 1,455 patients enrolled in the study, 55 presented 63 episodes of bacteremia (incidence of 0.7 bacteremia per 100 patient-months). The portal of entry of sepsis was the vascular access in 50.8% of the episodes. The causative microorganisms were most often gram-positive cocci (69.8%). 23% of the teremic patients had a serum ferritin > 1,000 micrograms/l versus 7% of the nonbacteremic infected patients (p = 0.005). 39.7% of the patients had undergone a surgical operation during the month preceding the bacteremia. Eight patients had a recurrence during the study period and 8 had a metastatic localization: spondylodiscitis 2, septic pulmonary embolus 2, endocarditis 1, arthritis 1, liver abscess 1 and endophthalmia 1. 66% of the episodes required a hospitalization that lasted an average of 20 days. Mortality rate was 6.3%. This prospective study showed a trend towards a reduction in incidence and mortality of bacteremia in patients on chronic hemodialysis.

Recurrence of immunoglobulin a nephropathy after renal transplantation in the cyclosporine era

Immunoglobulin A nephropathy (IgAN) frequently recurs in patients after renal transplantation (RT) on a conventional regimen of immunosuppressive therapy, but little is known about the influence of cyclosporine (Cs) on such a recurrence. We studied 84 patients retrospectively who underwent RT for renal failure attributable to IgAN (n = 71) or Henoch-Schönlein purpura nephropathy (HSPN) (n = 13) in two transplantation units, between January 1985 and June 1991 and were treated with Cs. Four patients died 3 months to 8 years after RT. Graft survival was 88% at 1 year, 75.2% at 5 years, and 63% at 8 years. Fifty patients underwent at least one graft biopsy, but studies with immunofluorescence were performed on only 28 (23 IgAN and 5 HSPN). After a mean follow-up of 68.1 +/- 37.2 months, mesangial IgA deposits recurred in 13 of the 28 patients (12 IgAN and 1 HSP) (prevalence, 46.4%). Among the 13 patients with recurrence of IgA deposits, all but 4 had urinary abnormalities. Light microscopy showed mesangial deposits and focal and segmental glomerular changes in 9 cases. Four patients lost their graft function 69 to 119 months after RT, and 2 had severe graft dysfunction. The rates of graft failure and mean serum creatinine at 1, 5, and 8 years were similar in the 13 patients with recurrence and the 15 patients without proven recurrence. In conclusion, Cs did not reduce the incidence or severity of IgAN recurrence. The latter was the cause of graft loss or dysfunction in 46.1 % of the patients with recurrent IgA deposits. Recurrent glomerulonephritis did not influence the 8-year graft survival in patients with IgAN or HSPN, but it may be an important cause of graft loss as evidenced by more extended follow-up.

Epstein-Barr virus lymphoproliferative disease of donor origin after kidney transplantation: A case report

A case of an Epstein-Barr virus (EBV)-associated B lymphoproliferative disorder presented as a renal transplant obstruction is reported. The diagnosis was made from histology, immunohistochemistry, and EBV expression studies. Cytogenetic analysis showed the tumor to be of donor origin and revealed chromosomal translocation 46, XY, inv (1)(p35; q41), involving the EBV insertion site 1(1p35) and transforming growth factor beta 2(1q41) loci.

A renal allograft recipient with late recurrence of focal and segmental glomerulosclerosis after switching from cyclosporine to tacrolimus.

BACKGROUND Focal and segmental glomerulosclerosis (FSGS) is one of the most frequent and severe primary glomerulonephritis that recurs in transplanted kidneys. Although cyclosporine seems to have no effect on the frequency of FSGS recurrence, there is evidence that cyclosporine reduces proteinuria and prolongs graft survival in patients with recurrent glomerulonephritis after renal transplantation. The effect of tacrolimus on nephrotic syndrome after renal transplantation is controversial. METHODS We describe the case of a 30-year-old man with steroid-resistant nephrotic syndrome due to FSGS who developed nephrotic syndrome 5 years after renal transplantation due to recurrent disease when he was switched from cyclosporine to tacrolimus. RESULTS He was given pulses of methylprednisolone and returned to cyclosporine. His proteinuria decreased, but he rapidly developed chronic renal failure. CONCLUSIONS This observation strongly suggests that tacrolimus should be given with considerable care in renal transplant recipients with FSGS.

Metronidazole-Associated Hepatotoxicity in a Hemodialyzed Patient

Dr. D. Hestin, Service de Néphrologie, Hôpital de Nancy-Brabois, Rue du Morvan, F-54500 Vandœuvre (France) Dear Sir, Metronidazole is a synthetic nitroimida-zole derivative used in the treatment of infection caused by anaerobic bacteria and protozoa. Although animal toxicity tests have revealed histological liver changes in monkeys treated with high doses of metronidazole [1], only 2 cases of hepatitis associated with metronidazole have been published [2, 3]. A 68-year-old woman treated with regular hemodialysis since 1982 was admitted to hospital for a septicemia caused by Stcψhylococ-cus aureus related to infection of the vascular access. Treatment consisted of the administration of intravenous vancomycin and netilmicin at the end of each dialysis session (vancomycin 500 mg and netilmicin 100 mg). The fever dropped within 24 h, but on the 5th day, a puncture site abscess appeared, which had to be lanced surgically. Bacieroides fragilis was isolated from culture of abscess material and metronidazole 250 mg b.i.d. per os was added to antibiotic therapy, while netilmicin was stopped. The patient then became asymptomatic and was discharged from hospital. Four days after the initiation of metronidazole, she was readmitted for drowsiness, vomiting, nausea and pain in the right upper abdominal quadrant. On physical examination, the liver was moderately enlarged, and laboratory tests detected elevated liver enzymes: aspartate aminotransferase (AST) 1,450 IU/1 (normal < 27 IU/1), alanine aminotransferase (ALT) 650 IU/1 (normal < 20 IU/1), but there was no evidence of cholestasis. Laboratory tests performed before starting metronidazole were unremarkable (AST 17, ALT 14). There was no history of alcohol abuse, no blood transfusion and the patient had been taking antidepressants for many years. Antibodies against hepatitis C virus were detected 3 years previously, without episodes of cytolysis. Se-rological tests for viral hepatitis A, B and delta, and HIV were negative. Metronidazole was withdrawn and vancomycin maintained for 1 month. Within 4 days, serum levels of AST and ALT decreased and returned to normal values in 15 days. This case strongly suggests a drug-induced hepatic disease because of the rapid onset of abnormalities after starting metronidazole and their complete regression when this agent (alone) was withdrawn. Although the half life of the parent drug is not altered in patients with impaired

Antibiotic-Induced or Aspergillus Infection Related Acute Interstitial Nephritis?

Antibiotic-Induced or Aspergillus Infection Related Acute Interstitial Nephritis? E. Edith Renoult B. Bernadette Aymard F. François Chabot D. Dominique Hestin N. Nicolas Delorme L. Lyliane Kures J.-M. Jean-Marie Polu M. Michèle Kessler Service de Néphrologie, Laboratoire d’Anatomie et de Cytologie, Pathologiques, Service des Maladies Respiratoires et de Réanimation Respiratoire, et Laboratoire Central de Parasitologie et Mycologie, Centre Hospitalo-Universitaire de Nancy, France