Jean-Pierre Wauters

Herpes simplex esophagitis after renal transplantation.

This paper describes five renal transplant recipients, out of a series of 221 consecutive patients, who developed herpes simplex esophatitis. This opportunistic infection presented as odyno-and/or dysphagia. It occurred during or shortly after treatment of acute cellular rejection episodes with high doses of steroids and, in four cases, of antilymphocyte globulins. The infection responded to acyclovir in all patients. We conclude from these observations that herpes esophagitis occurs during periods of intensive immunosuppression. Because its endoscopic manifestations are variable, biopsies and cultures are essential to reach the diagnosis. Prevention may be possible by avoiding transplantation from a seropositive donor to a negative recipient and by prophylactic oral acyclovir.

Drug interaction between sevelamer and cyclosporin

Sir, Sevelamer hydrochloride is a calcium-free polymer licensed recently as a phosphate binder in haemodialysis (HD) patients. Its use is associated with a slower progression of coronary and aortic calcifications than the use of calciumbased binders in such patients [1]. Sevelamer not only binds phosphate but also bile acids, thereby reducing LDL cholesterol levels [2]. Whether this effect on the enterohepatic cycle may lead to clinically relevant drug interactions is unknown. We report a definite interaction between sevelamer and cyclosporin A (CsA) in a liver transplant (TP) recipient on maintenance HD. A 70-year-old female on thrice weekly HD for 3 years for a chronic glomerulopathy (not biopsied) was started on sevelamer for persistent hyperphosphataemia (7.1mg/dl). Her past medical history included type 2 diabetes mellitus in 1974 and orthotopic liver transplantation for cirrhotic hepatitis C in 1991, with recurrent cirrhosis on the graft in 2003. Her daily drug treatment included: cyclosporin (Neoral ) 60mg, propranolol 40mg, doxepin 25mg, clonazepam 0.25mg, zolpidem 10mg, omeprazole 10mg, insulin and calcium carbonate. Physical examination showed a body mass index of 17 and a non-tender liver palpable 3 cm below the right costal margin. Upon start of sevelamer (3 806mg/day), CsA trough level, previously stable, decreased markedly, prompting an increase of CsA dosage to 85mg (arrow in Figure 1). Complaints of digestive intolerance prompted subsequent sevelamer withdrawal. The CsA level then increased soon, to decrease again consistently upon resumption of sevelamer (Figure 1). Our case provides evidence for an impact of sevelamer intake on CsA level, confirmed by rechallenge. The mechanism of this interaction likely involves the reduction of CsA absorption through an effect on the enterohepatic cycle of bile acids. The absorption by the gut of CsA (including the Neoral formulation) is indeed bile dependent [3]. Alternative explanations appear unlikely as sevelamer is not absorbed by the gastrointestinal tract and thus is devoid of any ‘systemic’ effect [1]. The observed interaction is relevant for the growing cohort of renal TP recipients entering ESRD under CsA, but also for the 5–10% of liver and heart TP recipients with ESRD [4,5]. This interaction may have been favoured by the cirrhotic state of our patient. Whether sevelamer may interact with other lipophilic drugs such as tacrolimus, that shares many drug interactions with CsA, will require further investigation.

Laparoscopic procurement of kidney grafts from living donors does not impair initial renal function.

THE PERSISTENT SHORTAGE of kidneys available for transplantation has stimulated live donation. The excellent results obtained with both genetically related and unrelated donors have increased this trend. The recent description of laparoscopic allograft harvesting has promoted this option even further. The benefits of the laparoscopic procedure for the donor have been extensively described, but whether the functional results of the laparoscopically procured grafts are equivalent to those obtained by the classical open method remains to be proved. In this single-center study we compared the early function of the grafts harvested by laparoscopy and by the open technique.

Preoperative assessment of laparoscopic live kidney donors by gadolinium-enhanced magnetic resonance angiography

KIDNEY transplantation from living related and unrelated donors has become increasingly common due to the shortage of cadaveric organs. In this context, laparoscopic nephrectomy is now often proposed to encourage donation because it offers the well-known advantages of minimally invasive surgery. Before operation, a careful radiologic assessment is essential, however, because arterial and venous anatomy may be more difficult to appreciate during laparoscopy than at open surgery. The number, length, size, and location of the renal arteries and veins need to be determined, as well as anomalies of the urinary tract. Finally, rare contraindications to donation, such as a tumor or a malformation, must be excluded. Potential living donors have traditionally undergone intraarterial angiography. This “gold standard” technique is very accurate but requires arterial catheterization and injection of an iodinated contrast medium, and therefore the procedure is not free of complications. It is also relatively expensive and time-consuming, and requires ionizing radiation. These disadvantages have prompted the use of a new noninvasive technique: three-dimensional (3D) gadolinium (Gd)-enhanced magnetic resonance angiography (MRA). Other MRA techniques without contrast have also been investigated but were found unreliable for detection of all renal arteries. MRA with Gd is a far superior method with regard to image quality and identification of accessory renal arteries. The purpose of this study is to prospectively assess the accuracy of Gd-enhanced MRA to define renal vascular anatomy prior to laparoscopic nephrectomy in living kidney donors.

Facteurs de risque cardiovasculaire chez l’insuffisant rénal dialysé : diamant alpin, une étude prospective multicentrique

La mortalite cardiovasculaire reste tres importante chez l’insuffisant renal dialyse. Diamant alpin est une etude de cohorte, prospective et multicentrique (CHU, CHG et centres prives, n = 8) menee en France, Italie et Suisse incluant 279 patients au moment de la prise en charge en dialyse. Les objectifs de l’etudesont la recherche de FDR cliniques ou biologiques (phenotype et genotype), en particulier l’hyperho-mocystinemie. Critere de jugement La mortalite et la morbidite cardiovasculaires (coronaire, AOMI, AVC) survenant lors du suivi systematique dans les deux ans. Population Cent soixante dix-sept hommes et 102 femmes âges en mediane de 66 ans (de 22 a 92 ans). Quatre-vingt-dix pour cent de ces patients etaient hypertendus, 29 % presentaient une dyslipidemie traitee, 29 % un diabete et 18 % fumaient au moment de la prise en charge en dialyse. En consequence, 26 % des patients avaient une localisation de maladie atheromateuse a expression clinique (essentiellement coronaire) et 16 % avaient 2 localisations de maladie atheromateuse. Une nephropathie vasculaire etait en cause pour 30 % des patients. Methode statistique Kaplan meyer, test du Log rank et modele de Cox ; p Resultats La probabilite de survenue d’un evenement cardiovasculaire est de 24 % a un an et de 35 % a deux ans. En analyse multivariee, les facteurs de risque cliniques de survenue d’un evenement cardiovasculaire sont les antecedents connus d’atteinte atheromateuse (OR = 5 si deux localisations connues et OR = 2 si une seule localisation connue) et l’âge superieur a 75 ans (OR = 1,7). Sur le plan biologique, une CRP > 10 mg/1 et un taux de Lp(a) > 300 mg/1 sont associes a un OR de 1,7. Un taux d’homocystinemie > a 30 μmoles/1 est associe a un OR de 2,5. Les patients homozygotes pour la MTHFR ont un OR de 1,7. Cette caracteristique genetique est particulierement informative si le taux d’homocystinemie est a 30 μg/1 (OR = 0,9 NS). Les autres genotypes etudies (enzyme de conversion de l’angiotensine, PAI, ApoE) ne sont pas significatifs. Conclusion Cette etude confirme le haut niveau de risque cardiovasculaire des patients pris en charge en dialyse. Parmi les FDR identifies, un taux d’homocystinemie superieur a 30 mg/1 est un FDR independant. Compte tenu du contexte d’insuffisance renale, le seuil usuel de 14 μ/1 doit donc etre modifie pour l’homocystine.