[Surgical treatment of secondary hyperparathyroidism in chronic renal failure. Report of 57 cases]

AIM

The aim of this study was to report the experience of the department of general surgery (Aile III) Ibn Rochd Hospital in surgical management of hyperparathyroidism in patients with end-stage renal disease (ESRD).

METHODS

Fifty seven patients (24 M, 33F) with hyperparathyroidism underwent surgical parathyroidectomy from 1998 to 2004. Surgical indication was established according to clinical or biological assessment. Fifty nine operations were performed (57 first-hand cervicotomies and resumptions in too cases).

RESULTS

Histological examination of parathyroid gland specimens disclosed adenoma in 33 patients and hyperplasia in 14 patients. The follow-up was normal in 52 patients, marqued by cervical hematoma in 2 cases and death was deplored in 4 patients. The post-operative calcium level was in the normal range in 43 cases, low comparatively to the baseline in 12 cases and high in 2 cases. The PTH levelwas normal in 55 patients and high in two patients. Long-term outcome was evaluated in 36 patients mean follow-up (18 months). A good evolution was noted in all patient referring to clinical, biological and radiological investigations.

CONCLUSION

That, in our context, surgical parathyroidectomy still an appropriate approach for the treatment of hyperparathyroidism in patients with end-stage renal disease.

Diabetic nephropathy in hemodialysis patients in casablanca

Diabetes is the main cause of end-stage renal disease (ESRD) in the developed countries and its prevalence and incidence have been constantly increasing over the years. To determine the prevalence and profile of diabetic nephropathy in our ESRD population, we retrospectively studied 564 hemodialysis patients in ten dialysis units in Casablanca. The mean age was 49 +/-16.2 years. The diabetic nephropathy came at the third rank with a prevalence of 13.5% behind chronic glomerulonephritis (21.8%) and hypertensive nephropathy (14.7%). Almost 74% of our diabetics were type 2. From the time of diagnosis the type 2 diabetics reached the ESRD earlier than the type 1 diabetics with a mean period of 15.1 +/- 7 years and 18.8 +/- 5 years, respectively; however, the difference was not statistically significant. There was at least another microangiopathic complication in 95.4% of the patients and macroangiopathic complication in 82%. The median hemoglobin A1C in all patients was higher than normal value. We conclude that ESRD is a serious complication of diabetes, which is constantly increasing. The appropriate management of diabetes and a multidisciplinary approach are necessary to avoid it or at least delay its occurrence.

[Phototherapy and hemodialysis pruritus]

The renal failure-related pruritus is frequent (10-30%) and this frequency increases in dialysed patients (60-80%). Its physiopathology remains badly known. The prurit is variable in intensity and surface. It predominates on the forehead, the back and the forearms. The skin is normal on it presents non specific lesions. The best treatment would be the renal graft. When it can't be done, phototherapy represents a good therapeutic alternative. We report the experience of our patients from December 1993 to January 2002. The patients could benefit from a steady treatment and be well followed-up. The mean age of our patients was 51 years with a masculine predominance (12 men to 7 women). The mean duration of hemodialysis was 3 years and the one of prurit was 10 months. Between December 1993 and January 2001, UVB phototherapy with a spectrum was used in 14 cases. After this period a phototherapy with a narrow spectrum was used. The mean dose was 2 Joules with a number of sessions. Eventually, the total body irradiation with UVB was the most regularly effective therapy of the hemodialysed prurit. It allows an important reduction, which is a significant result in comparison with UVA irradiation.

[Extramembranous glomerulonephritis and myelodysplastic syndrome]

Membranous glomerulonephritis (MGN) is the main cause of nephrotic syndrome in adults and is usually idiopathic. We report a case of nephrotic MGN associated with a myelodysplastic syndrome (MDS) in a 43 year old man. The initial treatment consisted of oral corticosteroids (1 mg/kg/day). Within 3 months proteinuria decreased from 22.4 g/day to 3.96 g/day and the blood cell count was normalized. Renal biopsy disclosed type I MGN. Ponticelli's protocol was started with a favorable effect: negative proteinuria, normal blood cell count and normal bone marrow cellularity. The association between MGN and MDS is quite rate. The possible links between the two conditions are reviewed.

[Primary focal segmental glomerulosclerosis in adults: response to treatment and outcome]

Response to therapy of primary focal segmental glomerulosclerosis (FSGS) in adults is poor, most studies demonstrated no response at all. We report our experience from a retrospective study about 22 adults patients. All patients presented proteinuria at admission with a nephrotic syndrome in 86 percent of cases. A high blood pressure was noted in 25 percent. A response to corticosteroid was obtained in 8 patients (36%) with complete remission in 5 cases (23%). Three patients were corticosteroid-dependant, two out of them went in remission under cyclophosphamide in one case and under chlorambucil in the other case. Fourteen patients did not respond to corticosteroids. Eight received cyclophosphamide with partial remission in 4 cases and progression to chronic renal failure (CRF) in 4 cases. The six non-responders did not receive immunosuppressive drugs because of severe CRF in 4 cases. The mean duration of follow-up was 39 months (20-55). The response to corticosteroid of primary FSGS in adults remain low (30%). The use of cyclophosphamide has improved the global remission to 50 percent.

[Hemodialysis-related pruritus. A study of 134 Moroccans ]

The prevalence of pruritus varies from 60% to 90% in patients receiving hemodialysis. The aim to this study was to evaluate the frequency of pruritus and its characteristics among moroccan patients receiving hemodialysis. Pruritus related to primary skin disease or other identified cause than chronic renal failure was excluded. Biological parameters were compared between patients with pruritus and those without. Pruritus occurred in 74.4% of hemodialysis patients and concerned 66 men and 68 women, mean age 44.8 + 14 years. Duration of hemodialysis varied between 5 months to 10 years. Main characteristics of pruritus were a general pattern in 70%, moderate intensity in 50%, appearance after dialysis in 81.2% and severe psychologic repercussion in 20.8%. Antihistamines first-line treatment was rarely effective. UVB radiation used in 7 cases leaded to a marked improvement. This study underlined the high frequency of pruritus in moroccan patients with chronic renal failure on maintenance hemodialysis. Hemodialysis can initiate this symptom as well as improve it. Biological parameters were not different between patients with or without pruritus. It also pointed out on therapeutic challenges. However, UVB radiation seems to be an effective therapy in intractable itching as well as increased frequency of weekly courses of hemodialysis. Long term skin hydratation should be also highly recommended.

[Surgical complications of nephrectomy in living donors]

Renal transplantation from a living donor is now considered the best treatment for chronic renal failure. We reviewed the operative complications in 38 living related donor nephrectomies performed at our institution over the past 14 years. The mean age of our donors was 30 years old with age range between 18 and 58 years old and female predominance (55.2%). These swabs were realized by a posterolateral lumbar lombotomy with resection of the 11 third. The left kidney was removed in 34 donors (90%), surgical complications were noted in 39.4% of the cases: one case of wound of inferior vena cava (2.6%), one case of release of the renal artery clamp (2.6%), four cases of pleural grap (10.5%), one case of pneumothorax (2.6%), one case of pleurisy (2.6%), three cases of urinary infection (7.8%), three cases of parietal infection (7.8%) and one case of patient pain at the level of the wound (2.6%). There were no mortalities. We conclude that the morbidity of living donor nephrectomy is negligible compared with the advantages for the recipient.

[Obstetrical acute renal failure. Experience of the nephrology department, Central University Hospital ibn Rochd, Casablanca]

The gravidic acute renal failure (ARF) becomes a rare complications of the pregnancy in the industrialized countries, whereas it is still frequent in the developing countries and responsible of great maternofetal morbidity and mortality. We studied the etiologic and evolutive aspects of the gravidic ARF in 55 patients during 18 years (1981-1998) at the department of nephrology, hospital center Ibn Rochd in Casablanca. The gravidic ARF represents 65% of the gravidic patients. The mean age of the patients is 30.92 +/- 6.44 years old. The mean parity is 3.38 +/- 2.25. The mean term is 31.73 +/- 10.02 weeks of amenorrhea. The main etiology is the preeclampsia and eclampsia, 41 patients (74.5%); the other causes are: the septic conditions: 6 patients (11%); the obstetrical hemorrhages: 4 patients (7.2%); the in uterofetal death: 3 patients (5.5%) and the post-cesarotomy: 1 patient (1.8%). 74.6% of the patients has been hemodialysed. The evolution has been characterized by the normal recuperation of the renal function is 48 patients (87.3%), a chronic renal failure in 2 patients (3.6%) and the death of 5 patients (mortality: 9.1%). The gravidic ARF is still a critical circumstances associated to a severe prognosis as well as in the woman and the fetus. So, the most effective measures are still the prevention and the managing of the obstetrical complications.

Profile of cytokine production in mixed kidney lymphocyte culture

Kidney cells are an important source of immunoregulatory molecules that regulate cell-to-cell interactions, which is the key step in the generation of the immunoresponse to alloantigens. In this study we identified the cytokines that are produced by both lymphoid cells and kidney cells when coincubated in mixed kidney lymphocyte cultures (MKLC). The capacity of kidney cells to stimulate the proliferation of effector allogeneic lymphocytes was assayed by incubating irradiated kidney cells and lymphocyte. The cytokine secretion profile in MKLC was investigated by incubating monolayers of kidney cells with effector peripheral blood mononuclear cells (PBMC). The culture supernatants were harvested on days 1, 2, 3, 4, 5, 6, 7, and 8 and assayed for IL-1beta, IL-2, IL-6, and TNF alpha using an ELISA. Kidney cells, in comparison to PBMC stimulator cells were poor stimulators of the alloproliferation even when HLA expression was increased by IFN gamma treatment. Compared to lymphocyte or kidney cells incubated alone, MKLC induced a considerable stimulation of cytokine production. This increase in cytokine production was observed essentially for IL-2 and IL-6 (at day 3, a 10-fold increase in IL-2 and a 5-fold increase in IL-6). This study provided evidence that target kidney cells and effector lymphocyte interactions generate a number of cytokines such as IL-1beta, IL-2, IL-6, or TNF alpha. These cytokines are known to modulate allo-proliferation and generation of cytotoxic T lymphocytes (CTL).

Effect of immunosuppressive agents FK 506 and cyclosporin and steroids on the expression of IL-6 and its receptor by stimulated lymphocytes and monocytes

The interaction of interleukin-6 (IL-6) with its receptor (IL-6R) is not well understood. In the present study, we investigated the effect of different immunosuppressive agents on the expression of the couple IL-6/IL-6R on cultured lymphocytes and monocytes. IL-6 in culture supernatants from cultured monocytes were analyzed by ELISA. The expression of IL-6R was studied by flow cytometry. Dexamethazone, cyclosporin (CyA), and FK 506 at immunosuppressive concentrations induced a dose-dependent inhibition of IL-6 secretion from adherent monocytes (MO) stimulated with phytohemagglutinin (PHA). Dexamethazone was the most effective agent in inhibiting IL-6 secretion, while the inhibitory effect observed with 1 ng/ml FK 506 was comparable with that obtained with 100 ng/ml CyA. Unstimulated MO strongly expressed IL-6R (80% positive cells). Stimulation of MO with PHA resulted in a significant downregulation of IL-6R expression. Treatment of PHA-stimulated adherent MO with different concentrations of CyA and FK 506 induced a restoration of IL-6R expression. FK 506 was 100 time more effective in restoring IL-6R than CyA. This restoration of IL-6R was incomplete. FK 506, CyA, and steroids may exert their immunosuppressive effect by inhibiting IL-6 secretion and partially restoring MO IL-6R, which may be important in protecting the cell target against IL-6 autocrine stimulation.

[Prevalence of subcutaneous, labial and rectal amyloid lesions in patients wi histologically confirmed renal amyloidosis]

Our work is to evaluate the biopsies rectal (RB), cutaneous and one about the accessory salivary glands (ASGB) in the diagnosis of amyloidosis renal through 20 cases of renal amyloidosis confirmed by renal biopsy in unit of nephrology and hemodialysis in UHC lbn Rochd from February 1996 to January 1998. The mean age of our patients was 39 years old (15-80) with a male predominance of (4/1). The infectious pathology has been the most frequent cause (70%) which consisted essentially in the tuberculosis and the surinfection on dilatation of the bronchi. All the patients had nephrologic symptomatology dominated by the nephrotic syndrome. The 4 biopsies were practised in the 20 patients. Wright's reaction practised in all renal biopsy confirmed the AA nature of the amyloidosis. The amyloïd deposits were noticed in 100% of renal needle biopsy, 80% of accessory gland biopsy, 75% of rectal biopsy and in 35% of cutaneous biopsy. The association of RB and ASGB was positive in 90% of the cases. If the renal biopsy gave more positivity than the other biopsies, it caused complications that were severe sometimes. Also, the biopsy of the ASG, the simple technique is very reliable in the recognition of the amylosis and seems to be the best diagnostic test for this affection.

[Acute obstructive renal failure. Analysis of 28 cases]

This retrospective study is concerned 28 patients hospitalized with acute obstructive renal failure at the department of nephrology in UHC Ibn-Rochd between 1988 and 1995. The objective of this study was to determine the clinical, étiological, therapeutical and evolutive aspects of the acute obstructive renal failure. It concerned 21 men and 7 women, their mean age is 52 years old. The main symptoms were anuria (85%) and lumbar pain (75%), the mean delay of consultation was 42 days. The diagnosis of the acute obstructive renal function and the presence of obstacle on the upper urinary tract. The obstacle was a stone in 19 cases, cancer in 8 cases and one case of retroperitoneal fibrosis was noted. Treatment of the cause was done whenever possible. Treatment was often palliative in the tumoral pathology. We observed 3 deaths (10.5%), 16 recoveries (58%), 6 cases of residual renal failure (21%), 3 cases of terminal chronic renal failure (10.5%) and 4 cases of recurrence. The lithiasic etiology of acute obstructive renal failure led to a high short-term mortality (15.5%), an effective etiologic causative treatment (69.5%) and a high rate or restoration of the renal function (69.5%). On the other hand, in the neoplastic etiology, there were no short-term mortality, but a frequent course to chronic renal failure.

[Acute urine retention. Another presentation of a hydatid cyst of the kidney]

We report on a case of hydatic cyst of the kidney, in a 12 year-old male, revealed by an acute urinary retention. After a brief report of the common signs of this parasitic disease, we emphasize the importance of hydaturia and acute urinary retention as another revealing sign of this disease.

[Tuberculosis in hemodialysis]

The authors report a retrospective study in order to illustrate the particular features of tuberculosis in hemodialysis population. Thirty two patients over 203 (15.8%) in periodic hemodialysis, have presented a tuberculosis between 1983 and 1996. There were 17 men and 15 women aged from 14 to 60 years old. The features of the tuberculosis in these cases were marked by the extrapulmonary localizations (50%) notably nodes tuberculosis, and the difficulties of the diagnosis certainty. The diagnosis was suspected basing on the fever, the weigh loss, the rate sedimentation increase and the radiologic lesions in pulmonary tuberculosis and peripheric or deep lymph nodes involvement. The diagnosis confirmation was established bacteriologically in 6 cases (18.7%) and histologically in 14 cases (43.8%). The treatment consisted on the association of isoniazide, rifampicin and pyrazinamide which leads to recovery in 87.5%. This treatment was a diagnosis proof in the absence of confirmation.

[Heart failure and arterial hypertension disclosing amyloidosis]

Amyloidosis results from protein infiltration of the extracellular space of organs and tissues. Several amyloidosis proteins have been identified. Protein AL, (deriving from immunoglobulin light chain), protein AA and prealbumin are the most involved in this disease. When AL amyloidosis involves the heart, the illness is often terminal. Most clinical symptoms are heart failure and arrhythmia or block conduction. This case was characterised by the unusual combination of hypertension and amyloidosis. The diagnosis suggested by the echocardiographic but was confirmed by the damaged organ's biopsy. The present case concerns a young woman, who has hypertension and a pulmonary oedema. The echocardiographic scan showed a septal hypertrophy with a shining and granite-like aspect which is compatible with heart amyloidosis. Systolic and diastolic disorder with mitral and aortic regurgitation were also revealed. The kidney and rectum biopsies confirmed amyloidosis AL of the Kappa dysglobulinemia type, without extraosseous plasmocytoma. The heart and kidney failure symptoms disappeared after treatment with diuretics and ACE inhibitors.

Rhabdomyolysis and acute renal failure secondary to toxic material abuse in morocco

We have studied 26 patients with rhabdomyolysis complicated with acute renal failure. The causes of rhabdomyolysis were dominated by paraphenylene diamine intoxication (PPD) (13 cases). The other etiologies were: crush syndrome (6 cases), eclampsia (3 cases), intense physical effort (1 case), butane intoxication (1 case), postural rhabdomyolysis induced by a prolonged surgical operation for pheochromocytoma (1 case). None of the patients had any past medical history of muscle or renal disease. Serum level of creatinine phosphokinase varied from 1200 to 5400 IU/L. The mean peak of serum creatinine level was 620 umol/1. Therapy included forced alkaline diuresis in all cases. Hemodialysis was required in 18 cases. All but eight patients survived. We conclude that rahabdomyolysis could be caused by intoxication, which was a prime cause in this study. Prevention may be possible with restriction of use of toxic products.

Human glomerular epithelial cells synthesize and secrete the third component of complement

Complement proteins in serum are mainly synthesized by hepatocytes. Recently, many cell types have been reported to synthesize complement in various tissues. In this study, we report the synthesis and secretion of the third component of complement (C3) by cultured glomerular epithelial cells (GEC). Using reverse transcriptase polymerase reaction, we have found that GEC and whole kidney expressed the C3 mRNA for C3. By ELISA, we have found that C3 was secreted in culture supernatants harvested from cultured GEC. The secretion of C3 is regulated by proinflammatory cytokines (IL-1 beta, TNF-alpha and IL-6). IL-1 beta is shown to be the most potent stimulator of C3 secretion from GEC. The exact significance of C3 produced at glomerular site is not clear, but its upregulation by proinflammatory cytokines may suspect a role in local activation of complement which may lead to glomerular injury. We further studied the expression of C3 step regulatory proteins (membrane cofactor protein (MCP), decay-accelerating factor (DAF), CR-1 and CD59 (a terminal step regulatory protein) by cultured GEC. Treatment of GEC by proinflammatory cytokines IL-1 beta, TGF-beta, TNF-alpha and IL-6 did not modify the expression of MCP, DAF and CR-1 whereas an increase in the expression of CD59 could be observed after treatment with IL-1 beta and TGF-beta. These results indicate that the expression of these regulatory proteins is tissue specific and may be implicated in inflammatory processes.

Interleukin-1-beta activation of cultured glomerular epithelial cells

In crescentic glomerulonephritis, crescent formation involves the active participation of glomerular epithelial cells (GEC) and macrophages recruited to the glomerulus during the evolution of the disease. Cytokines derived from macrophages may affect many functions of GEC. In this study, we found that interleukin-1 beta (IL-1 beta) inhibited GEC growth (DNA synthesis and cell number) in vitro in a dose- and time-dependent manner. This effect was not mediated by tumor growth factor beta (TGF beta) which is a potent inhibitor of GEC growth in vitro. Treatment of GEC with various concentrations of IL-1 beta induced morphologic changes consisting in the loss of their cobblestone shape and acquisition of a fibroblast-like appearance. Moreover, IL-1 beta was shown to stimulate the expression of interleukin-6 (IL-6) by GEC. The increase in IL-6 secretion by GEC treated with IL-1 beta was observed at both the protein and mRNA levels. IL-1 beta also affected the metabolism of laminin in cultured GEC, inducing a dose-dependent increase in laminin production in culture supernatants harvested from GEC. Finally, we investigated the expression of MHC class II antigens and intercellular adhesion molecule-1 (ICAM-1) in GEC, and found that unstimulated GEC are negative for MHC class II antigens, as detected by flow cytometry. In contrast to the induction of effector functions, expression of MHC class II antigens stringently required interferon-gamma. IL-1 beta did not induce MHC class I antigen expression. The regulation of ICAM-1 expression in that unstimulated GEC expressed ICAM-1, and this expression was upregulated by IL-1 beta. We conclude that IL-1 beta alters many functions of GEC, and these changes may be involved in the initiation and amplification of glomerular injury.

Interferon-gamma stimulates neopterin release from cultured kidney epithelial cells

The ability of cultured kidney epithelial cells (KEC) to secrete neopterin, which is a marker of the activation of immune system was studied. In this study interferon gamma (IFN-gamma) was shown to induce neopterin release from KEC in a dose- and time-dependent manner. Many other cytokines and mitogens (IL-1 beta, IL-2, IL-6, LPS and phorbol ester) were tested for their ability to induce neopterin in KEC but all failed to induce a significant release of neopterin from KEC. By itself TNF-alpha induced a release of small amounts of neopterin but strongly potentiated the effect of IFN-gamma in a synergistic manner to induce neopterin secretion. These data indicate that not only monocytes and macrophages which it is well known secrete neopterin, but KEC are responsible also for the high serum or urine level of neopterin observed in patients with kidney allograft rejection or infections episodes. As the amount of neopterin released by KEC is smaller than that secreted by activated macrophages, the contribution of KEC to the overall production of neopterin during certain diseases may be small.

[Acute renal insufficiency in children. Retrospective study of 89 cases]

Between 1982 and 1992, 89 patients aged six months to 15 years were treated for acute renal failure at the Ibn Rochd Teaching Hospital. There were 51 males (57%) and 38 females (43%). All patients received conservative treatment. Fifty-eight patients (65%) required dialysis at the acute phase. The dialysis technique used was peritoneal dialysis in 22 cases (25%) and hemodialysis in 36 (40%). Twenty-nine patients received emergency dialysis for severe sodium and water overload and/or severe hyperkalemia. In the other cases, dialysis was initiated because of high blood urea and creatinine levels; before dialysis, blood urea exceeded 33 mmol/l (2 g/l) in every case and mean urea level was 51 mmol/l. Causes of acute renal failure included glomerulonephritis (n = 46), hemolytic uremic syndrome (n = 12), acute interstitial nephritis (n = 9), urinary tract obstruction (n = 5), and renal hypoperfusion (n = 11); in six cases, no cause was identified. Mortality rate was 17%. Recovery rate was higher in the subgroup of patients without anuria. Outcome was favorable in 65.5% of patients with glomerular disease. Most patients in this study did not require intensive care and none had post-cardiac surgery or neonatal acute renal failure which are known to carry a poor prognosis.

Cytokine-mediated regulation of the surface expression of complement regulatory proteins, CD46(MCP), CD55(DAF), and CD59 on human vascular endothelial cells

Membrane cofactor protein (MCP), decay-accelerating factor (DAF), and CD59 are complement (C) regulatory proteins that protect human hematopoietic cells from damage induced by autologous complement. Using monoclonal antibodies in both western blotting studies and flow cytometry, we found that endothelial cells (EC) expressed on their surface MCP, DAF, and CD59 molecules. We tested whether stimulation of endothelial cells by known EC activators such as LPS, TNF-alpha, IL-1 beta, and IL-4 regulates the expression of these C regulatory proteins. EC activation was assessed in this study by an up-regulation of ICAM-1 expression. Treatment of EC with various concentrations of TNF-alpha, IL-1 beta, or IL-4, at different incubation times did not increase MCP expression on EC surface membrane. In contrast, the level of DAF was altered during EC activation: LPS or IL-1 beta treatment resulted in a slight increase of DAF expression; the most up-regulatory effect was obtained with IL-4. Up-regulation of surface DAF on EC required prolonged treatment of cells with these agents. The level of CD59 was far greater than that of DAF or MCP on EC, and was slightly up-regulated by TNF-alpha and down-regulated by IL-1 beta. These findings indicate that the levels of C regulatory proteins are regulated in an independent fashion on EC, MCP is not regulated by any cytokine tested, while DAF is an EC activation antigen, although it has a different augmentation profile from ICAM-1 since IL-4 up-regulates DAF but not ICAM-1.

[Venous thrombosis after catheterization of the subclavian vein for hemodialysis]

The authors report six cases of subclavian vein thrombosis after transcutaneous catheterization in a group of 70 patients treated by periodical haemodialysis over a 7-year period in a Nephrology department at Casablanca. The subclavian vein has become the favourite access route in most haemodialysis centres because it can be utilized for a longer time, carries a lower risk of infection and is more comfortable for the patient than the other routes. Two main factors facilitate the occurrence of thrombosis: a long duration of catheter insertion and repeated catheterizations.

Contrasting effects of interferon-gamma and interleukin-4 on neopterin generation from human adherent monocytes

The production of neopterin is closely correlated with activation of cell-mediated immunity. Neopterin appears to be produced by human macrophages specifically stimulated with interferon-gamma (IFN-gamma). Interleukin-4 (IL-4), a B and T stimulatory factor, has recently been shown to inhibit monocyte/macrophage functions, including the ability to suppress monocyte-generated cytokines. In this report we confirmed previous studies that identified the monocyte/macrophage as the main producing cell among human blood cells and that secretion is stimulated by IFN-gamma and lipopolysaccharides (LPS). IL-4 inhibits the generation of neopterin from unstimulated monocytes. This inhibitory effect was dose dependent and occurred at concentrations lower than 0.01 ng/ml. However, IL-4 had only a minimal inhibitory effect on LPS-induced generation of neopterin and could not reverse IFN-gamma-induced neopterin secretion from adherent monocytes. Furthermore, we report that LPS induced IFN-gamma production in monocyte culture. This production is strongly inhibited by IL-4 treatment. These findings indicate that IL-4 can regulate the synthesis of neopterin by adherent blood mononuclear cells and provide further evidence that LPS-induced neopterin in macrophages may act by IFN-gamma-independent mechanisms.

[Acute kidney failure in Morocco]

During the February 1983-February 1988 period, 172 patients (113 men and 59 women, mean age 36 years) were admitted to the Ibn-Rochd hospital for acute renal failure (ARF). Oliguria or anuria were present on admission in 131 patients (76.2 per cent). ARF occurred in a medical context in more than two thirds of the cases (73.8 per cent) post-operatively or in a surgical context in 11 per cent in an obstetrical context, notably post-partum, in 15 per cent. The causes of ARF were varied: prerenal in 12 cases, obstructive in 15 cases and renal parenchymal in 141 cases; in the remaining 4 patients no cause could be found. Acute tubular necrosis was the most frequent lesion (104 cases) and it was due to infection in 72 per cent of the cases; acute glomerular lesions were present in 27 patients. In the 108 patients treated by haemodialysis, 4 sessions on average were required for each patient; the main duration of peritoneal dialysis was 6 days. The most frequent complication observed was infection. The mortality rate was 21 per cent (36 deaths).

[Dominant renal polycystic disease]

Autosomal dominant polycystic kidney disease is the third cause of end-stage chronic renal failure (CRF) requiring dialysis and transplantation. Over a 5-year period we collected 21 cases of that disease. The patients' mean age at the time of diagnosis was 48 years and the sex ratio 1.1. Pain was the most frequent signal symptom, being present in 43 p. 100 of the patients. Varying degrees of renal impairment were found in 61 p. 100 of the cases, and arterial hypertension in 38 p. 100. The diagnosis, suspected on clinical grounds, was confirmed by ultrasonography in 95 p. 100 of the patients. Beside CRF and hypertension, the main complications were microscopic haematuria (38 p. 100) and urinary tract infection (24 p. 100). In two patients the disease was associated with hepatic polycystosis. Treatment was symptomatic for CRF (4 patients were put on periodical haemodialysis) and for the other complications. On the basis of this series, we discuss the profile and prognosis of polycystic kidney disease in our environment, and notably its effects on renal function, and we underline the usefulness of familial investigations and the need for genetic counselling.