The evolution of weight and body composition in renal transplant recipients: Two-year longitudinal study

Previous series have reported weight gain after kidney transplantation. However few studies have investigated the body composition after kidney transplantation, particularly during longitudinal follow-up. In this prospective study, we assessed the changes in body composition after kidney transplantation. We also analyzed the effect of steroid withdrawal from the immunosuppressive regimen on weight gain and body composition.

METHODS

Thirty-eight cadaveric kidney transplant recipients were followed for 2 years posttransplant. Total and segmental body composition were measured by dual energy X-ray absorptiometry (DEXA) at the time of transplantation as well as 3, 6, 12, and 24 months later.

RESULTS

In 28 patients (group A), prednisone was stopped by month 6, whereas, in 10 patients (group B), it was continued throughout the study. In the overall patient group, there were no significant changes in body weight. However, a trend to increased weight was observed in group B. In this group, patients showed an early increase in total body fat with a central accumulation of fat mass that was maintained during the follow-up period. On the other hand, total lean mass increased significantly in group A but did not change significantly in group B.

CONCLUSION

In summary, overall the group showed no major changes in body weight during the 2 years after transplantation. Steroid withdrawal in kidney transplant recipients may have a significant positive effect on body composition.

Pharmacokinetics of mycophenolic acid in kidney transplant patients receiving sirolimus versus cyclosporine

INTRODUCTION

Mycophenolic acid (MPA) pharmacokinetics exhibit large variability in transplant recipients and may be altered due to concurrent immunosuppressants. Little is known about the influence of sirolimus (SRL) on MPA pharmacokinetics in kidney transplant patients.

METHODS

We studied the areas under concentration-time curves (AUC) for MPA in 15 patients receiving immunosuppression combining SRL with mycophenolate mofetil (MMF). The pharmacokinetic measurements were performed in all patients using three MMF dosing regimens (0.5 g twice a day, 0.75 g twice a day, 1 g twice a day). Similar blood AUC profiles were also sampled from 12 patients treated with a fixed dose of MMF 1 g twice a day and cyclosporine (CsA). MPA was measured using HPLC; the AUC0-12 of MPA was determined by the trapezoidal method using four sampling time points: C0, C1, C3, C5.

RESULTS

While patients on SRL were receiving 0.75 g MMF twice a day, mean AUC0-12 and C0 values of MPA were comparable to those of patients receiving CsA and 1 g MMF twice a day (54.1 +/- 17.6 and 3 +/- 1.87 vs 51.7 +/- 16.7 mg.h/L and 2.76 +/- 1.57 mg/L, respectively). On the other hand, 0.5 g MMF twice a day with SRL therapy resulted in AUC0-12 and C0 values of MPA of 32.3 +/- 12.6 mg.h/L and 2.32 +/- 1.72 mg/L, respectively, whereas, 1 g MMF twice a day with SRL resulted in AUC0-12 and C0 values of MPA of 70.9 +/- 19.3 mg.h/L and 4.7 +/- 2.44 mg/L, respectively.

CONCLUSIONS

These findings demonstrate that MPA exposure in the presence of SRL is higher than that with CsA. It appears that the MMF dose should be reduced to 0.75 g twice a day in patients receiving SRL to obtain AUC0-12 of MPA levels comparable to that in patients treated with CsA and MMF 1 g twice a day.

[Factors determining the choice of a modality of treatment by dialysis: a study of nine dialysis centers]

BACKGROUND

The objective of this cross-sectional study in a population of 1472 dialysis patients was to identify the main factors involved in the choice of a specific option for dialysis therapy, taking into account three different types of criteria such as medical dependence (DM), nurse care requirement (SI) and independence for dialysis therapy (CA).

METHODS

Each patient has been analysed, independently of present treatment modality, according to the above three criteria, namely DM, SI and CA. For each type of parameter, patients have been allocated to one of three levels, each level being established to evaluate whether dialytic treatment should be undertaken as hospital centre dialysis (HDC) or in a facility off the hospital. Level 3 of any one category corresponded to the inability of doing haemodialysis at home (HHD) or in self-care unit (AD). Level 2 included patients who could be treated in AD or by peritoneal dialysis (PD) with the assistance of a nurse. CAPD or HHD were considered as potential treatment modalities only in patients qualifying for level 1 of each criterion.

RESULTS

In the patient population as a whole, the following treatment options were observed: HHD 3.6%, CAPD 6%, PD 1.8%, AD 16.3% and HDC 72.2%. For medical dependence (DM) there was a relatively even distribution for the three levels in six centres. In contrast, two centres were characterized by a predominance of DM level 3. Differences in DM levels between centres were greatly reduced when considering separately only those patients who were actually treated by CAPD, HDC and AD. SI levels were more uniformly distributed within all centres, and this was true for HCD and AD patients. When considering CA levels in HDC patients, a large predominance of CA level 3 was observed in all centres whereas CA level 1 was nearly in existent.

CONCLUSION

The major finding of this study was that the inability or the refusal of dialysis patients to participate at treatment, independently of medical condition and nurse care requirement, was the main factor in the choice of hospital centre dialysis.

Factors predicting the long-term success of maintenance cyclosporine monotherapy after kidney transplantation

BACKGROUND

The theoretical aim of maintenance cyclosporine monotherapy (mCsA) after kidney transplantation is to reduce the incidence of the metabolic complications of corticosteroids and to minimize the adverse effects of excessive long-term immunosuppression. This study was performed in low-immunological-risk cadaveric kidney transplant recipients to evaluate the risks and benefits of mCsA and the long-term graft survival, and to determine the factors predicting success of this policy.

METHODS

The multicenter retrospective study was conducted in 329 Caucasian patients receiving mCsA out of 728 first cadaveric kidney transplant recipients. The inclusion criteria were: HLA antibodies < or =25%, serum creatinine <200 micromol/L, and no rejection or only one rejection episode. At the end of the study, we compared the group of patients successfully treated with mCsA (successful group) with those requiring additional immunosuppressive agents (unsuccessful mCsA group).

RESULTS

Overall patient and graft survival rates for the 728 first cadaveric graft were 92% and 64%, respectively, at 8 years. Out of 329 patients enrolled in mCsA, 240 were maintained on this treatment and 89 were withdrawn (3 deaths, 18 graft losses, 68 functional grafts). The 8-year graft survival in the 329 enrolled mCsA patients was 84%, 95% in the successful mCsA group, and 70% in the unsuccessful mCsA group. Multivariate analysis showed that the factors predicting success of mCsA were: donor age <40 years (P = 0.001), serum creatinine at mCsA initiation <125 micromol/L (P = 0.02), no rejection episode before mCsA initiation (P = 0.005), and glomerulopathy as the primary renal disease (P = 0.001).

CONCLUSION

Numerous kidney transplant recipients with a low immunological risk and good and stable renal function may benefit from discontinuation of prednisone and azathioprine in order to reduce the complications related to these drugs. This therapeutic approach had no adverse impact on the overall long-term graft survival for "low risk" and successful patients.

[Requirements for the successful implementation of unity of care: study of a computer-assisted dispensation of pharmaceuticals]

PURPOSE

Even though computerized workstations bring undisputed benefits in nursing units, introducing them is still hard when most of the staff members have to share the workstation. We took advantage of the implementation of the drug prescription software SAUPHIX in a nephrology department to better define the encountered difficulties. The workstation described in this paper is shared by physicians who enter their prescriptions (proprietary names, doses, routes of administration), nurses who use dosage schedules for drug administration, and the chemist who has authority to control prescription orders.

METHODS

Six months after the implementation of the workstation, physicians and nurses had to fill out an anonymous questionnaire aimed at assessing each function of the software.

RESULTS

Prescriptions proved to be more accurate and legible, while management of drugs was more precise. However, interns complained that entering data was time consuming. Furthermore, they raised objections to control of prescription orders. Nurses criticized dosage schedules, the primary reason being that they had to change their practice. The convenience of notebooks was questioned by both physicians and nurses who would have preferred a greater number of desktop computers at their disposition.

CONCLUSION

The implementation of a computerized workstation requires information, diplomacy and negotiations to obtain real implication of the staff. Tasks and schedules must be specified for everybody. The system has to be carefully customized, according to the requirement of the unit. Computers must be properly chosen and allocated in sufficient number. Finally, appropriate preparation, staff training and follow-up of the computerized system are essential.

[AA amyloidosis complicating sarcoidosis]

INTRODUCTION

Amyloidosis combined with sarcoidosis has been very rarely described.

EXEGESIS

We report the case of a 72-year-old man presenting with sarcoidosis and amyloidosis AA. The association of peripheral and retroperitoneal adenopathies accompanied by loss of weight and histopathological results conducted to the diagnosis of sarcoidosis, excluding other causes. Corticosteroid therapy led to a decrease in clinical manifestations and after 2 years, clinical signs of amyloidosis have not progressed.

CONCLUSION

According to results previously described in the literature and the description of the present case, we conclude that sarcoidosis can be complicated by amyloidosis AA, the presence of which may justify corticosteroid therapy.

[Management of malnutrition in peritoneal dialysis]

Peritoneal dialysis is associated with nutritional abnormalities due to peritoneal glucose absorption and protein or amino acid losses into the dialysate. Nutritional assessment, every four months, is essential, based on body composition, anthropometric measurements, clinical characteristics, biochemical parameters and dietary survey. Thus 1.2 g to 1.3 protein/kg/day and 30 to 35 kcal/kg/day energy intake may be required. Oral, parenteral or intraperitoneal amino acids supplementation can improve the nutritional status in peritoneal dialysis patients.

[Anticoagulation of the extracorporeal circuit in chronic hemodialysis]

Continuous or intermittent use of unfractioned heparin is the anticoagulant of choice to prevent the extracorporeal circulation clotting during the hemodialysis session. However, low molecular weight heparin (LMVH) could be an alternative treatment especially in case of high risk bleeding or during some clinical conditions such as diabetes mellitus, cerebrovascular bleeding, malignant hypertension. LMVH may be given as a single initial bolus injection generally adequate. Heparinization must be lowered or stopped when an effective anticoagulation is previously used.

[Distal vascular access for chronic hemodialysis in patients over 65 years of age. Surgical results]

OBJECTIVE

To evaluate the results of vascular accesses for chronic haemodialysis in elderly patients.

MATERIAL AND METHODS

56 consecutive vascular accesses for haemodialysis were performed from November 1993 to December 1995 in patients over the age of 65 years. The policy adopted was to prefer distal accesses: only forearm accesses, primary arteriovenous fistula (AVF) or radio-M venous bioprosthesis shunt (AVS) were performed. Surgical or interventional radiological reoperation rates and abandonment rates were evaluated.

RESULTS

13 AVF (mean age: 74.5 years) and 43 AVS (mean age: 73.8 years) were analysed. The mean number of reoperations was significantly higher in the shunt group. 1 out of 13 AVF was abandoned versus 9 out of 43 AVS (no significant difference).

DISCUSSION

AVS gave poor results in terms of reoperation rate, inducing a high cost and impairment of the quality of life of these patients. Their survival in this population was comparable to that of AVF. Several teams prefer to perform first-line humero-cephalic or humero-basilic arteriovenous fistulas whenever a simple fistula in the forearm cannot be performed. They appear to give better results, but their use in the elderly is poorly evaluated. Peritoneal dialysis may be preferable to haemodialysis in the elderly. As vascular accesses are increasingly performed in elderly subjects with a reduced life expectancy, protection of the proximal venous capital does not appear to be a sufficient argument to justify the use of AVS in this population.

CONCLUSION

This study encouraged us to abandon the use of prostheses in the forearm in favour of direct accesses in the arms.

Peritoneal ultrafiltration and refractory congestive heart failure

This prospective nonrandomized study enrolled 16 patients with congestive heart failure [NYHA (New York Heart Association) III and IV] refractory to a maximal well-tolerated drug therapy. The aims were to evaluate if peritoneal ultrafiltration (PUF) could improve clinical conditions and to determine morbidity secondary to resistant congestive heart failure (RCHF) and PUF. There were 16 patients (12 male, 4 female) with a mean age of 65.4 years (56-81 years) and follow-up of 15.6 months (4-33 months). Thirteen patients had RCHF without end-stage renal disease. Patients were classified as NYHA class IV (n = 11) or class III (n = 5). One anuric patient had been on previous hemodialysis and switched to APD. PUF was obtained with a 2-L hypertonic dialysis solution, once a day (n = 7) or every 2 days (n = 4). Clinical improvement was obtained for all the patients. Weight decreased from 72.2 to 66.7 kg with a weekly ultrafiltration of 3.74 L (2.2-6.5 L). Sodium removal was 79 mmol/day (urinary 43%, peritoneal transport 57%). During the follow-up period, 2 patients received a cardiac transplant since 7 died due to cardiac reasons. Mean hospitalization time was 4.4 and 1.20 per patient per day before and after PUF, respectively. Hospitalization was in keeping with either RCHF (36%), dialysis complications (16%), or miscellaneous causes (48%). Our experience showed that a functional improvement and a better quality of life were achieved for all these patients with a low rate of hospitalization.

[Synchronous bilateral renal cell carcinoma. Renal transplantation after nephrectomy]

INTRODUCTION

Treatment of bilateral and synchronous renal cell cancer may require bilateral nephrectomy and chronic dialysis. After an arbitrarily determined waiting period (2 years) on dialysis, kidney transplantation may be proposed.

CASE REPORTS

Two patients underwent kidney transplantation after bilateral nephrectomy for early-stage low-grade renal cell cancer. Eight years after nephrectomy and 6 years after transplantation, there is no evidence of cancer recurrence and renal function is satisfactory.

DISCUSSION

Certain patients treated for cancer may be candidates for kidney transplantation, even if the risk for cancer is higher in transplant recipients. Moreover, kidney transplantation without a required period on chronic dialysis could be proposed in early-stage lowgrade renal cell cancer.

[Rheumatoid purpura during pregnancy]

We report the case of a 26 year old woman who presented a Henoch Schönlein purpura at 13 weeks' gestation. IgA glomerulonephritis without pejoratif feature was confirmed by renal biopsy. Corticosteroid therapy was unsuccessful on nephrotic syndrome. At 25 weeks' gestation foetal death occurred followed by a rapid development of end stage renal failure.

[Quantitative detection of pp65 intraleukocyte cytomegalic antigen in renal transplantation]

OBJECTIVE

To assess the clinical value of quantitative assay of leukocyte cytomegalovirus antigen (LCA) in the management of immunodepressed patients.

METHODS

Thirty-three kidney transplant recipients followed a weekly follow-up protocol during the first 3 months after transplantation. LCA was compared with cytomegalovirus (CMV) detection in blood using fibroblast cell culture and with serology tests. LCA was expressed in number of positive cells per 2.10(5) leukocytes, detected by immunofluorescence with a specific monoclonal antibody directed against the pp65 antigen. The standard culture method and a rapid centrifuge method were used for blood samples. The serum level of anti CMV antibodies was determined by ELISA.

RESULTS

CMV infection defined as positive viraemia and/or positive serology tests was diagnosed in 22 of the 33 patients. LCA was detected in 20 patients, including all those with clinical signs of infection. Serology was the only method giving a positive diagnosis in 2 patients and was negative in 3 infections positive for LCA. Viraemia was negative in 2 patients positive for LCA. LCA was detected in 60 of the 65 blood samples with a positive viraemia test and in 46 of the 165 negative samples (sensitivity 92% and specificity 72%). Quantitatively, LCA in samples taken from patients with clinical signs was higher than that in samples taken from asymptomatic patients (51 +/- 5 versus 20 +/- 2, p < 0.001). In addition, LCA was detected a mean 7.6 +/- 4 days before significant changes in serology tests, 2.2 +/- 1.6 days before the viraemia and 7.1 +/- 1 days before clinical manifestations.

CONCLUSION

Leukocyte cytomegalovirus antigen gives a sensitive means of early positive diagnosis. The quantified level illustrates the patient's risk of infection. This new method is a very helpful tool in following renal transplantation recipients.

[Nephropathies caused by interferon alpha: apropos of 2 cases]

Two cases reports of interferon alpha-associated nephropathy are reported. The first observation is a membranoproliferative glomerulonephritis and the second a renal microangiopathy. The different cases in the literature are reviewed and the pathophysiology is discussed.

[Quantitative cytomegaloviral leukocytic antigenemia. Clinical aspects]

Cytomegalovirus infection, commonly observed in immunodepressed patients, raises a number of problems both in clinical practice (early rapid diagnosis, therapeutic options) and biological research (resistant strains, mutations). The classical methods of diagnosis do not provide specific information for decision making in each particular clinical situation. We report a case of cytomegalovirus infection in a renal transplant recipient in which quantitative cytomegalovirus antigen level in leukocytes provided rapid early diagnosis of the primary infection and two episodes of recurrent infection. Increase antigen level always preceded clinical manifestations. Three anti-cytomegalovirus regimens were given and the antigen level fell proportionally to clinical improvement. Based on the data in the literature and this clinical observation, it appears that cytomegalovirus antigen level in leukocytes is a precise tool for early diagnosis of cytomegalovirus infection. The technique is rapid, has an excellent sensitivity and the quantitative results are correlated with clinical manifestations. Quantitative anti-cytomegalovirus antigen assay can be a very helpful tool in the management of infected immunodepressed patients.

[Role of peritoneal dialysis in the treatment of terminal chronic renal insufficiency. Survival of patients and method]

Chronic peritoneal dialysis, especially continuous ambulatory peritoneal dialysis, is now a modality of treatment for patients with end stage renal failure. The proportion of patients varies considerably from country to country. Non medical considerations seem to be the main reason for the limited development of the treatment modality. Most of available reports point out no difference in patient or technique survivals on hemodialysis or peritoneal dialysis. Age, diabetes mellitus, cardiovascular diseases, infections complications (peritonitis and exit-site infections) impact on mortality and morbidity (number of hospital days per patient per year). The probability of death or dropout is much higher for patients with diabetes and patients in older age groups. Most patients with end stage renal failure, especially those waiting for a kidney transplant, are suitable for peritoneal dialysis.

Pharmacokinetics of rilmenidine in patients with chronic renal insufficiency and in hemodialysis patients

The pharmacokinetics of rilmenidine (1 mg orally) was studied in 3 groups of patients with stable chronic renal insufficiency. This was an open, single-blind study following a single administration, and after 15 days of treatment. Group 1 included 11 patients with a creatinine clearance between 15 and 80 mL/min. Group 2 included 17 patients with a creatinine clearance < 15 mL/min. Group III included 10 hemodialysis patients. In patients with chronic renal failure, total plasma clearance and renal clearance of rilmenidine decreased; terminal half-life was 30-42 hours, which is clearly longer than previous values achieved in healthy volunteers. After repeated administration (1 mg daily in group 1, 1 mg every other day in group 2, 1 mg at the end of each dialysis session in group 3), the area under the curve was significantly increased, corresponding to drug accumulation. The steady state was reached after 6 days in patients in group 1 and after 8 days in patients in group 2. The pharmacokinetics of rilmenidine was linear since the terminal elimination half-life and renal clearance were not significantly different after single and repeated administration of rilmenidine. A positive correlation was found between rilmenidine total plasma clearance and creatinine clearance, and between rilmenidine renal clearance and creatinine clearance. Mean rilmenidine hemodialysance was 85 mL/min, that is, 26% of the rilmenidine renal clearance value achieved in healthy volunteers (330 mL/min). Thus, the following dosage schedule can be proposed. In patients whose creatinine clearance ranges between 15 and 80 mL/min, a 1 mg dose every day can be recommended.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of nested PCR for detection of DNA in plasma with pp65 leukocytic antigenemia procedure for diagnosis of human cytomegalovirus infection

A nested PCR was used for the detection of human cytomegalovirus (HCMV) DNA in plasma. The presence of HCMV DNA and its correlation to pp65 leukocytic antigenemia were investigated with 299 blood samples from 45 organ transplant recipients and 63 AIDS patients. Of the 53 samples positive by nested PCR, 52 (98%) were also positive for leukocytic antigenemia and 23 had high levels of antigenemia (> 50 positive cells per 2 x 10(5) leukocytes). Of the 246 samples negative in PCR, only 3 (1.2%) had highly positive antigenemia. For 15 patients having a high antigenemia level in the course of their disease, consecutive blood samples were studied and also assessed for viremia in culture. The extent to which HCMV DNA, detected by PCR, was present in plasma correlated with increased levels of HCMV leukocytic antigenemia for six of the eight AIDS patients and for all the organ transplant recipients. Positivity for HCMV DNA in PCR and for viremia in cell culture was usually restricted to the highest antigenemia levels. From a total of 69 blood samples, PCR and culture gave positive results, respectively, for 17 of 32 samples (53%) and 14 of 32 samples (43%) from transplant recipients and for 15 of 37 samples (40%) and 9 of 37 samples (24%) from AIDS patients. Our findings have shown a strong correlation between high levels of leukocytic antigenemia and HCMV DNA in plasma. The detection of HCMV DNA in plasma by this nested PCR can prove HCMV dissemination in blood, but it lacks the rapidity and simplicity of the leukocytic pp65 antigenemia procedure.

Clinical pharmacokinetics of fluconazole

Fluconazole was recently developed for the treatment of superficial and systemic fungal infections. Triazole groups and insertion of 2 fluoride atoms increase the polarity and hydrosolubility of the drug, allowing it to be used in a parenteral form. Bioassay methods using Candida pseudotropicalis as a test organism were the first techniques used for the determination of fluconazole in body fluids. Gas chromatographic and high performance liquid chromatographic methods were later developed with better accuracy and sensitivity. Prediction of efficacious concentrations in patients from the minimum inhibitory concentrations in vitro seems to be uncertain because of low efficacy of the drug on some yeasts in vitro compared with efficacy in vivo in animal models. Oral forms (capsule and solution) are quickly absorbed and bioavailability is nearly complete (about 90%). Plasma protein binding is low (11 to 12%) and fluconazole circulates as active drug. Distribution is extensive throughout the tissues and allows the treatment of a variety of systemic fungal infections. The average elimination half-life (t1/2) of 31.6 +/- 4.9h is long, with a minimum of 6 days needed to reach steady-state; thus, a loading dose (equal to double the maintenance dose) is recommended. The metabolism of fluconazole is not qualitatively or quantitatively significant. The main route of elimination is renal. The mean +/- SD (calculated from published data) total and renal clearance values are 19.5 +/- 4.7 and 14.7 +/- 3.7 ml/min (1.17 +/- 0.28 and 0.88 +/- 0.22 L/h), respectively. Concentrations of fluconazole in blood after administration of single doses correlated well with the administered dose. There was very little interassay variation between the data reported in literature. Concentrations in blood after multiple doses also exhibit little variation and the accumulation factor was between 2.1 and 2.8. Fluconazole was found in many body fluids, especially in cerebrospinal fluid and dialysis fluid, allowing the treatment of systemic fungal infections such as coccidioidal meningitis and fungal peritonitis. Concentrations of 1 to 3 mg/L and 20 mg/L are the extreme values expected in clinical practice. In renal insufficiency the fluconazole t1/2 is longer, requiring dosage adjustment in relation to creatinine clearance. In continuous ambulatory peritoneal dialysis a 150mg dose in a 2L dialysis solution every 2 days has been proposed. In haemodialysis, a dose of 100 or 200mg should be given at the end of each dialysis session. Neither old age nor irradiation affect fluconazole pharmacokinetics, but the t1/2 was shorter in children.(ABSTRACT TRUNCATED AT 400 WORDS)

[Leukocytic cytomegalic antigen. A new diagnostic method of cytomegalovirus infection after transplantation]

The occurrence of cytomegalovirus (CMV) viremia after transplantation is predictive of visceral lesions. Three-hundred and sixty blood samples were collected from 21 transplant recipients and examined. Direct CMV antigen detection was positive in 41 samples (11.4 percent), rapid viral isolation in 24 samples (6.7 percent) and conventional cell culture in 9 cases (2.5 percent). Direct detection of CMV antigen in blood leucocytes is as specific as, and more sensitive and rapid than isolation in culture. In 50 percent of secondary infections the antigenaemia assay and serology were equally sensitive, and antigenemia appeared earlier in 2 primary infections.

Pharmacokinetics of fluconazole in patients undergoing continuous ambulatory peritoneal dialysis

The pharmacokinetics of fluconazole given orally (100 mg) or intraperitoneally (50 and 150 mg) were determined in 15 patients with chronic renal failure who were undergoing continuous ambulatory peritoneal dialysis. The half-life (72 to 85 hours) was intermediate between values obtained in healthy volunteers and in patients with renal insufficiency studied during an interhaemodialysis period. The peritoneal clearance, 0.26 to 0.33 L/h, led to an 18% recovery of administered drug in the dialysates after 48 hours. The peritoneal absorption was slow (time to peak plasma concentration 7 hours) but the peritoneal bioavailability was excellent at 87 +/- 5%. The mean concentrations of fluconazole up to 24 hours were 770 and 1900 micrograms/L after single intraperitoneal doses of 50 and 150 mg, respectively. The volume of distribution (40 to 60 L) did not differ from that determined in patients with normal renal function. In the case of fungal peritonitis essentially attributed to Candida spp., a 6-hour intraperitoneal infusion of fluconazole 150 mg every 2 days appears to be a good regimen to rapidly exceed minimum inhibitory concentrations and treat infection without risk of systemic dissemination of fungi or toxicity.

[Visceral leishmaniasis of favourable course in a patient with renal transplantation]

The authors report a case of non fatal visceral leishmaniasis in a renal transplant recipient and underline the fact that immunosuppressive treatments facilitate the occurrence of this disease. In patients with fever, pancytopenia and spleen enlargement, it is capital to inquire whether they have sojourned in a country where leishmaniasis is endemic. The diagnosis is then confirmed by bone marrow examination. Treatment rests on antimony derivatives, but these must be handled with caution in immunocompromised patients.

Pharmacokinetics of piperacillin in patients on peritoneal dialysis with and without peritonitis

The pharmacokinetics of piperacillin given intravenously (1 or 2 g) to nine patients with chronic renal failure and undergoing continuous ambulatory peritoneal dialysis was intermediate between values obtained in healthy volunteers and in patients with renal insufficiency studied between dialyses: half-life, 2.4 h; total clearance, 100 mL/min; urinary or peritoneal clearance, 3 mL/min. The intraperitoneal administration of piperacillin in dialysis fluid (400 mg or 1 g to five patients) increased the half-life (6 to 7 h) and decreased the volume of distribution of about two thirds. In both instances, the area under the curve was well correlated with dosage. The absorption of piperacillin by an inflamed peritoneum in eight patients suffering from peritonitis and treated with 400 mg, 1 g, or 2 g, was increased and returned to normal concurrently with care. Consequently, the recommended dosage is intravenous administration of 2 g of piperacillin every 8 h or intraperitoneal administration of 1 g every 6 h in the dialysate. With such conditions, serum concentrations greater than minimal inhibitory concentrations and sufficient to avoid dissemination of piperacillin-susceptible organisms without risk of accumulation are obtained.

Massive systemic amyloidosis associated with light-chain deposition disease

A 72-year-old woman presented with rapidly progressive renal failure and multiple myeloma. The patient died 6 months later of severe hepatic insufficiency. The light-microscopic, immunological and ultrastructural findings showed widespread kappa-light-chain deposits including the kidneys, liver, spleen, heart, lungs, tongue, ovary, pancreas and bone marrow associated with massive AL amyloid deposits in the same organs and in the thyroid gland. The concurrent presence of two different deposits is very unusual and the possible mechanisms for such an association are discussed.

Determination of fluconazole in biological fluids by capillary column gas chromatography with a nitrogen detector

Fluconazole concentrations in biological fluids were determined by high-performance gas chromatography. A simple extraction procedure with chloroform, under basic conditions and after the addition of UK-47,265 as the internal standard and with no evaporation stage, was carried out prior to analysis. A solid injector and a 15-m capillary column, coated with a nonpolar phase and connected to a nitrogen-selective detector that afforded an excellent selectivity and sensitivity, constituted the gas chromatographic system. The duration of each analysis was less than 4 min and the minimum detectable serum concentration was 50 ng/mL. In five patients undergoing chronic peritoneal dialysis, the mean serum concentrations +/- SD at 1, 6, and 48 h after the intraperitoneal administration of a single dose of fluconazole were, respectively, 325 +/- 75, 928 +/- 159, and 607 +/- 80 ng/mL.

[Pharmacokinetics of piperacillin during continuous ambulatory peritoneal dialysis]

We studied the kinetics of piperacillin in patients under continuous ambulatory peritoneal dialysis. Piperacillin 2 g was injected intravenously in 6 patients whereas 1 g was given intraperitoneally either a single dose in 3 patients without infection or the same dose every six-hours in 4 patients with peritonitis. Piperacillin was assayed by HPLC. After intravenous administration, the mean plasma piperacillin concentration was 3.1 +/- 5.6 mg/l at 12 h, the mean plasma t1/2 at 2.43 +/- 0.84 h, the volume of distribution at 20.4 +/- 6.3 l and the peritoneal clearance at 0.19 +/- 0.04 ml/min. After iterative intraperitoneal administration, serum and dialysate concentrations of piperacillin were above the minimum inhibitory concentration for susceptible pathogens without antibiotic accumulation. Peritoneal absorption was higher during peritonitis (83.4 +/- 4.8%) than without peritonitis (67.8 +/- 8.5%). Piperacillin 2 g IV every 8 hours or 1 g IP every 6 hours seemed to be the appropriate regimen in patients with chronic renal failure on CAPD.

[Polymorphism of light-chain deposition disease. Apropos of 3 cases]

Three cases of light chain deposition disease are reported. The condition was associated with monoclonal dysglobulinaemia in two cases and with amyloidosis in one case. This, and the different course of the disease in these three patients, illustrates the need for an early histological diagnosis, using immunofluorescence with monospecific anti-light chain sera.

Clinical pharmacokinetics of ketoprofen after single intravenous administration as a bolus or infusion

The pharmacokinetics of ketoprofen were evaluated in 29 patients suffering from acute renal colic following a single intravenous administration as a bolus or short infusion (1.5 and 2 hours), and after a loading dose and a 24-hour infusion. Serum concentrations of ketoprofen were measured by high pressure liquid chromatography. The mean (+/- SD) values of clinical parameters were as follows: distribution half-life = 0.34 +/- 0.19 h; elimination half-life = 2.05 +/- 0.58 h; kel = 0.968 +/- 0.282 h-1; k21 = 0.943 +/- 0.425 h-1; k12 = 1.004 +/- 0.708 h-1; volume of central compartment = 5.58 +/- 1.67L; volume of tissue compartment = 5.14 +/- 2.12L; plasma clearance = 5.10 +/- 1.14L/h. These results concur with previously published data obtained after oral or intramuscular administration. According to clinical observations, administration of a ketoprofen bolus suppressed pain within 5 to 30 minutes; the administration of a loading dose and a 24-hour infusion is almost never followed by a recurrence of pain, and this regimen was proposed as the dosage schedule of ketoprofen to treat renal colic.