Patrice Deteix

Dialysis and central venous catheter infections in critically ill patients: results of a prospective study.

OBJECTIVE To determine the incidence of dialysis catheter (DC)-related infections in intensive care unit (ICU) patients, and to compare the frequency of DC and central venous catheter (CVC) infections in an ICU setting. DESIGN Prospective, descriptive survey. SETTING An adult, 10-bed medical/surgical ICU at a university hospital. PATIENTS A total of 151 DCs and 230 CVCs placed in 170 patients were evaluated. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Catheter colonization was defined by a quantitative catheter tip culture yielding > or =10(3) colony-forming units/mL, catheter-related bacteremia was defined as catheter colonization and blood culture positive for the same organism, and site infection was defined as the presence of pus at the insertion site. The mean duration of catheterization was 6.8+/-6 days for DCs and 5.9+/-4.6 for CVCs (p = .52). There was no difference between DCs and CVCs in catheter colonization and catheter-related bacteremia incidence rates per 1000 days of catheter use (24.2 vs. 19.8 [p = .46] and 0.96 vs. 1.5 [p = .60], respectively). Site infection was observed in one patient (CVC placement). For DCs and CVCs the duration of catheterization was associated with catheter infection (p = .0007 and p = .04, respectively), but when the catheters were examined over 5-day intervals, the incidence of catheter infections did not increase with duration of catheter use (p = .23 and p = .10, respectively). CONCLUSIONS DC-related infections are associated with DC longevity. As shown by the 5-day-interval analysis, the incidence of DC-related infections did not increase with DC duration, suggesting that the risk for DC-related infections remained unchanged with time. The characteristics of DC-related infections in ICU patients were comparable to those previously reported for CVC-related infections.

Growth factors and proinflammatory cytokines in the renal involvement of POEMS syndrome.

The POEMS syndrome is a multisystemic syndrome associated with plasma cell dyscrasia, characterized by the combination of polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes. Renal involvement in POEMS syndrome is rare (26 reported cases). It has been described as membranoproliferative glomerulonephritis-like lesions (MPGN-like), mesangiolytic glomerulonephritis, or thrombotic microangiopathy. Proinflammatory cytokines (TNF-alpha, IL-1, IL-6) have been implicated in the physiopathogenesis of POEMS syndrome, particularly when there is renal involvement. Growth factors (FGF-beta, TGF-beta, PDGF) have been implicated in renal lesions of the same histological type but of different origins. An increase in serum vascular endothelial growth factor (VEGF) has been reported in POEMS syndrome (20 of 22 cases). Circulating levels of these factors were determined in 4 patients with POEMS and renal involvement (3 MPGN-like, 1 MPGN-like, and mesangiolysis) and compared with those obtained in 4 patients with POEMS without clinical renal involvement and in 4 patients with primitive membranoproliferative glomerulonephritis (MPGN). TNF-alpha, IL-1beta, and IL-6 were determined with an immunoradiometric assay, and VEGF, PDGF, FGF-beta, and TGF-beta with an enzyme-linked immunosorbent assay. Among the patients with POEMS syndrome, there was no difference in proinflammatory cytokines and growth factors between those with or without renal involvement. VEGF is the only growth factor that differentiates MPGN in POEMS syndrome from primitive MPGN.

Phenotype and Genotype Characterization of Adenine Phosphoribosyltransferase Deficiency

Adenine phosphoribosyltransferase (APRT) deficiency is a rare autosomal recessive disorder causing 2,8-dihydroxyadenine stones and renal failure secondary to intratubular crystalline precipitation. Little is known regarding the clinical presentation of APRT deficiency, especially in the white population. We retrospectively reviewed all 53 cases of APRT deficiency (from 43 families) identified at a single institution between 1978 and 2009. The median age at diagnosis was 36.3 years (range 0.5 to 78.0 years). In many patients, a several-year delay separated the onset of symptoms and diagnosis. Of the 40 patients from 33 families with full clinical data available, 14 (35%) had decreased renal function at diagnosis. Diagnosis occurred in six (15%) patients after reaching ESRD, with five diagnoses made at the time of disease recurrence in a renal allograft. Eight (20%) patients reached ESRD during a median follow-up of 74 months. Thirty-one families underwent APRT sequencing, which identified 54 (87%) mutant alleles on the 62 chromosomes analyzed. We identified 18 distinct mutations. A single T insertion in a splice donor site in intron 4 (IVS4 + 2insT), which produces a truncated protein, accounted for 40.3% of the mutations. We detected the IVS4 + 2insT mutation in two (0.98%) of 204 chromosomes of healthy newborns. This report, which is the largest published series of APRT deficiency to date, highlights the underdiagnosis and potential severity of this disease. Early diagnosis is crucial for initiation of effective treatment with allopurinol and for prevention of renal complications.

Ventilator-associated sinusitis: microbiological results of sinus aspirates in patients on antibiotics.

BackgroundThe efficacy of systemic antibiotics on the treatment of ventilator-associated infectious maxillary sinusitis (VAIMS) is debated. The objective of this study was to determine the etiologic diagnosis of VAIMS in patients receiving antibiotics. MethodsPatients mechanically ventilated for more than or equal to 72 h, who had persistent fever while on antibiotics for more than or equal to 48 h, underwent computed tomography scan followed by transnasal puncture of involved maxillary sinuses. VAIMS was defined as follows: fever greater than or equal to 38°C, radiographic signs (air fluid level or opacification of maxillary sinuses on computed tomography scan), and a quantitative culture of sinus aspirate yielding more than or equal to 103 colony-forming units/ml. ResultsTwenty-four patients had radiographic signs of sinusitis. The mean ± SD prior durations of mechanical ventilation and antibiotic exposure were 9.5 ± 4.7 days and 6 ± 4 days, respectively. Six unilateral and nine bilateral VAIMS were diagnosed in 15 patients. The median number of etiologic organisms per patient was two (range, one to four). The bacteriologic cultures yielded gram-positive bacteria (n = 21), gram-negative bacteria (n = 22), and yeasts (n = 5). Forty percent of causative agents were susceptible to the antibiotics prescribed. Seven patients with VAIMS developed 10 concomitant infections: ventilator-associated pneumonia (n = 5), urinary tract infection (n = 3), catheter infections (n = 2). In all cases of ventilator-associated pneumonia, the implicated agents were the causative agents of VAIMS. ConclusionIn VAIMS patients on antibiotics, quantitative cultures of sinus aspirates may contribute to establish the diagnosis. The frequent recovery of microorganisms susceptible to the antimicrobial treatment administered suggests that therapy of VAIMS with systemic antibiotics may not be sufficient.

Rapid decrease in plasma D-lactate as an early potential predictor of diminished 28-day mortality in critically ill septic shock patients

Abstract Background: Splanchnic ischemia plays a major role in the development of organ failure during septic shock. Plasma D-lactate has been proposed as a better marker of splanchnic hypoperfusion than L-lactate. We studied the prognostic ability of plasma D- and L-lactate levels. Methods: A prospective study was performed in an intensive care unit and included patients with septic shock. Two samples for plasma D- and L-lactate determination were collected: the first within 6h after the patient met the criteria for septic shock (day 1) and the second 24h later (day 2). Results: In univariate analysis, day 1 plasma D- and L-lactate values were associated with 28-day mortality. For plasma D- and L- lactate, the area under the receiver operating characteristic curve was 0.68±0.09 and 0.84±0.07 on day 1 (p=0.09), and 0.74±0.10 and 0.90±0.07 on day 2 (p=0.06), respectively. In survivors, D-lactate levels decreased between day 1 and day 2 (p=0.03), but L-lactate did not (p=0.29). In septic shock patients, plasma D- and L-lactate levels reliably discriminate between survivors and non-survivors. The prognostic ability of plasma L-lactate was better than that of plasma D-lactate. Conclusion: A rapid decrease in plasma D-lactate during the course of septic shock could indicate reduced 28-day mortality.

Hemolysis in a Patient With Alkaptonuria and Chronic Kidney Failure

In alkaptonuria, the absence of homogentisic acid oxidase results in the accumulation of homogentisic acid (HGA) in the body. Fatal disease cases are infrequent, and death often results from kidney or cardiac complications. We report a 24-year-old alkaptonuric man with severe decreased kidney function who developed fatal metabolic acidosis and intravascular hemolysis. Hemolysis may have been caused by rapid and extensive accumulation of HGA and subsequent accumulation of plasma soluble melanins. Toxic effects of plasma soluble melanins, their intermediates, and reactive oxygen side products are increased when antioxidant mechanisms are overwhelmed. A decrease in serum antioxidative activity has been reported in patients with chronic decreased kidney function. However, despite administration of large doses of an antioxidant agent and ascorbic acid and intensive kidney support, hemolysis and acidosis could not be brought under control and hemolysis led to the death of the patient.

Energy expenditure, spontaneous physical activity and with weight gain in kidney transplant recipients

BACKGROUND & AIMS Alterations in energy metabolism could trigger weight gain after renal transplantation. METHODS Nineteen transplanted non-diabetic men, 53 ± 1.6 years old, receiving calcineurin inhibitors but no corticosteroids were studied. They were compared with nine healthy men matched for height, age and lean body mass. Daily energy expenditure and its components (sleeping, basal and absorptive metabolic rates) were analyzed for 24 h in calorimetric chambers and for 4 days in free living conditions using calibrated accelerometry. Other variables known to influence energy expenditure were assessed: body composition, physical activity, 4-day food intake, drug consumption, serum C-reactive protein, interleukin-6, thyroid and parathyroid hormones, and epinephrine. Transplant recipients who gained more than 5% body weight after transplantation (n = 11, +11.0 ± 1.5 kg) were compared with those who did not (n = 8) and with the controls. RESULTS Weight gain compared with non-weight gain patients and controls exhibited higher fat mass without change in lean body mass. Daily, sleeping and resting energy expenditure adjusted for lean body mass was significantly higher in non-weight gain (167.1 ± 4.2 kJ/kg/lean body mass/24 h, P < 0.05) compared with weight gain patients (147.4 ± 3.6) and controls (146.1 ± 4.6). Weight gain compared with controls and non-weight gain subjects had lower free living physical activity and a higher consumption of antihypertensive drugs and β-blockers. CONCLUSIONS After kidney transplantation, weight gain patients were characterized by lower adjusted energy expenditure, reduced spontaneous physical activity but a more sedentary life style and a trend toward a higher energy intake explaining the reason they gained weight. The nWG KTR had increased resting and sleeping EE which protected them from weight gain. Such hypermetabolism was also observed in 24-h EE measurements. By comparison with the nWG patients, the WG transplant recipients were characterized by higher β-blocker consumption. These data could be helpful in the prevention of weight gain in kidney transplant recipients.

A rare cause of abdominal compartment syndrome: acute trichlorethylene overdose

Introduction. The clinical signs of acute trichlorethylene overdose are commonly coma, cardiac conduction disturbances, diarrhea, and vomiting. We report a case of intentional massive trichlorethylene ingestion inducing a fatal abdominal compartment syndrome (ACS). Case report. A 47-year-old woman was admitted to the emergency department after intentionally ingesting 500 mL of trichlorethylene and benzodiazepines. She rapidly developed coma and abdominal distension leading to multiple organ failure. Subsequent surgical evaluation revealed abdominal perforation and necrosis, and life-sustaining treatments were therefore withdrawn. Discussion. This is a primary ACS that can be explained from experimental data on the pathophysiology of pneumatosis cystoides coli. For this case, we discuss multiple etiological factors for intra-abdominal hypertension (IAP), such as paralytic ileus and massive fluid resuscitation due to the direct toxicity of ingested trichlorethylene. Conclusion. Patients ingesting trichlorethylene need to be closely evaluated for risk of digestive damage and perforation. Early prompt laparotomy must be performed in cases of ACS.

The Appropriateness of Renal Angioplasty. The ANPARIA Software: A Multidisciplinary Expert Panel Approach

Percutaneous transluminal renal angioplasty (PTRA) is an invasive technique that is costly and involves the risk of complications and renal failure. The ability of PTRA to reduce the administration of antihypertensive drugs has been demonstrated. A potentially greater benefit, which nevertheless remains to be proven, is the deferral of the need for chronic dialysis. The aim of the study (ANPARIA) was to assess the appropriateness of PTRA to impact on the evolution of renal function. A standardized expert panel method was used to assess the appropriateness of medical treatment alone or medical treatment with revascularization in various clinical situations. The choice of revascularization by either PTRA or surgery was examined for each clinical situation. Analysis was based on a detailed literature review and on systematically elicited expert opinion, which were obtained during a two-round modified Delphi process. The study provides detailed responses on the appropriateness of PTRA for 1848 distinct clinical scenarios. Depending on the major clinical presentation, appropriateness of revascularization varied from 32% to 75% for individual scenarios (overal 48%). Uncertainty as to revascularization was 41% overall. When revascularization was appropriate, PTRA was favored over surgery in 94% of the scenarios, except in certain cases of aortic atheroma where sugery was the preferred choice. Kidney size >7 cm, absence of coexisting disease, acute renal failure, a high degree of stenosis (≥70%), and absence of multiple arteries were identified as predictive variables of favorable appropriateness ratings. Situations such as cardiac failure with pulmonary edema or acute thrombosis of the renal artery were defined as indications for PTRA. This study identified clinical situations in which PTRA or surgery are appropriate for renal artery disease. We built a decision tree which can be used via Internet: the ANPARIA software (http://www.chu-clermontferrand.fr/anparia/). In numerous clinical situations uncertainty remains as to whether PTRA prevents deterioration of renal function.

Quinine clearance during continuous veno-venous high-volume hemofiltration

Quinine is eliminated primarily via hepatic biotransformation and only 15–30% is urinary excreted. There is no standard recommended quinine dose in patients with severe malaria requiring renal replacement therapy. Data on quinine levels during renal replacement therapy in patients with acute renal failure are scarce [1–4]. Previous reports describing the pharmacokinetics of quinine during hemofiltration showed no impact of the technique on quinine levels [1, 2]. However, it is unknown whether increasing the ultrafiltrate flow rate has an impact on quinine clearance and therefore requires quinine dosage to be modified. To our knowledge this is the first report of quinine level monitoring in an anuric patient treated with continuous venovenous high volume hemofiltration (CVVHVHF). A 44-year-old man weighing 83 kg was admitted to the intensive care unit (ICU) for coma and shock due to severe imported falciparum malaria with an initial parasitemia of 25%. Quinine was continuously administered in intravenous mode (24 mg/kg/ day) after a 1300 mg-loading dose. The patient rapidly developed multiorgan failure with anuria, and CVVHVHF was initiated 30 h after ICU admission (Fig. 1). Venous access was achieved with two polyurethane single lumen dialysis catheters (Gamcath catheters, Gambro, Hechingen, Germany) placed side by side. A Diapact continuous renal replacement therapy machine (Braun, Melsungen, Germany) was used with a high-flux synthetic membrane, polyamide Polyflux 14S (Gambro SA), 1.4 m Kuf, 50 mL/h per mmHg. Blood and ultrafiltrate flows were 200 ml/min and 6 L/h, respectively. The replacement fluid (Hemosol B0, Biosol, Sondalo, Italy) was delivered before filtering. No change was made to the quinine regimen. Ultrafiltrate and plasma quinine levels were determined during CVVHVHF (Fig. 1) with a gas chromatography/ mass spectrometric method. Samples were obtained before the addition of the replacement fluid and after filtering. Extraction of both protein-bound and -unbound quinine was made with Oasis MCX cartridges. The mass spectrometry was run in Selected Ion Monitoring mode. Quantification and confirmation ions were m/z 136, 261 and 381. Quantification range was 40– 10,000 lg/L. Standard formulae were used for mass transfer and clearance calculations [5]. During CVVHVHF, no great variation in prefilter and postfilter plasma quinine levels, and in quinine mass transfer were observed over time, probably because of the relatively high volume of distribution (1.8 ± 0.4 L/kg), and high protein binding rate (85–90%) of quinine. Since the sieving coefficient was 0.04 ± 0.01 (range 0.02–0.05), despite a high ultrafiltrate flow rate, the value of quinine clearance remained low 3.7 ± 0.8 ml/min range (1.9–5.1). The results observed were similar during the three CVVHD sessions suggesting that the quinine pharmacokinetic observed in our patient may be extrapolated to other patients treated with CVVHVHF. One limitation of the study is the absence of concomitant determination of 3-hydroxyquinine, the main metabolite of the quinine, that accumulates in acute renal failure but that probably contributes relatively little to antimalarial activity or toxicity in the acute phase of the disease [4]. Our findings suggest the need to use a standard quinine dosage (and not a high one) to achieve therapeutic levels during CVVHVHF in severe anuric malaria. 0,1 1,0 10,0 100,0