Preliminary evidence for a role of apolipoprotein E alleles in identifying haemodialysis patients at high vascular risk

Conventional risk factors have very low predictive power in identifying haemodialysis patients at high risk of vascular accidents. A role for apolipoprotein E isotypes was looked for in a small, but rigorously defined, cohort of longterm haemodialysis patients. In individuals with high vascular risk, as identified by higher common carotid intima/media thickness, we found an excess of apolipoprotein E4 alleles. This preliminary result requires confirmation in large patient cohorts.      

Leishmaniasis: a rare cause of unexplained fever in a renal graft recipient.

We report a case of visceral leishmaniasis in a 38-year-old renal transplant recipient living in an endemic country. Antimonial derivatives induced a rapid remission. A review of the literature disclosed 8 cases of this association with a fatal fulminant outcome in 5 cases. We suggest that the specific immunosuppression used in renal transplant patients might facilitate the development of a dormant infection and in these patients the misleading presentation may delay the diagnosis. Moreover special caution with treatment of leishmaniasis must be taken in renal transplant because of possible interactions between antimony compounds and ciclosporin metabolites. In renal transplant patients living in endemic countries, visceral leishmaniasis should be kept in mind as a potential cause of unexplained long-standing fever and considered as an opportunistic infection.     

Nosocomial transmission of hepatitis C virus in haemodialysis patients

A systematic virological follow-up of 114 haemodialysis patients treated in the same unit showed that 37, including 17 PCR positive patients, were seropositive for hepatitis C virus (HCV). Type 1b HCV was detected in 10 patients and was much more frequent in this population than in the whole population of patients treated in the hepatogastroenterology departments in southeastern France. The E1/E2 genomic region of seven type 1b HCV strains was sequenced. In four patients, a similar strain was detected in both the E1 variable region and the E2 hypervariable region (HVR1). In addition, two of these four patients were seronegative and PCR negative at the beginning of the study and had not been transfused or transplanted during this period. A phylogenetic tree was drawn which confirmed that these strains were very similar and showed that HCV was transmitted via the nosocomial pathway in this haemodialysis unit. © 1996 Wiley-Liss, Inc.     

Hemodialysis procedure in a patient treated with radioactive iodine

The treatment of a patient with 131I at activity over 740 mega Becquerel (MBq) must be performed in a nuclear medicine department. Isolation is stopped if the patient radiation level is less than 20 muSv/hour at one meter. As regards patients with chronic renal failure treated with hemodialysis (HD), the first HD session will eliminate the major part of the radioactivity. French regulations do not give definite recommendations for this session. However, it imposes to collect liquid and solid wastes contaminated by radioactivity. Thus, it seems necessary to collect dialysate and solid wastes and to stock them in a room dedicated to radiation decay. The risk for dialysis staff is to be contaminated by an accidental ingestion of a biologic fluid from the patient. The usual protection barriers used during the HD session are sufficient: mask, gloves, overgarments, cap. There is no risk linked to external exposure to radiations. The maximal theoretical dose received by the staff during the session is 65 muSv, while annual maximal dose for public exposed to radiations is 1000 muSv. Although the dosimetric follow-up of dialysis staff is not mandatory, the nuclear medicine department of Marseille University Hospital has decided to do it in an information perspective. The session is performed in the presence of a radiation safety technician who gives film badges and active dosimeters to the dialysis staff. He reports the dialysis staff to the nuclear safety agency (Autorité de s?reté nucléaire).     

Experiment of self blood pressure measurement at home in haemodialysis patients in a hospital unit

We analyzed, by home blood pressure (BP) self-measurement and conventional predialytic measurement of BP, a cohort of haemodialysis patients in two hospital units between 2008 and 2010. All patients who already own a BP self-measurement device were included in this study. BP was recorded by the two methods for one week. The number of patients with a validated self-measurement device was 69 of 350 (21%) and 60 patients were included in analyses. These patients were divided into 23 (38%) permanent uncontrolled hypertensive (elevated BP at home and in hospital), 13 (22%) masked hypertensive (normal BP in hospital and elevated at home), eight (13%) white coat hypertensive (elevated BP in hospital and normal at home), and 16 (27%) permanent controlled normotensive (normal BP in hospital and at home). Patient compliance with all the self BP measurements was 95%. We did not find in this cohort the factors associated with masked hypertension in the general population such as being male, smoking and high body mass index. These results obtained in an in-hospital dialysis unit should be extrapolated with caution to all haemodialysis patients. However it is, to our knowledge, the first study on home BP self-measurement published in patients undergoing haemodialysis in France. A significant proportion of patients have masked hypertension. This should alert clinicians because of the poor cardiovascular prognosis associated with masked hypertension.     

TT Virus Infection in French Hemodialysis Patients: Study of Prevalence and Risk Factors

The TT virus (TTV) is a recently discovered DNA virus which was first identified in patients with non-A to -G hepatitis following blood transfusion. In this study, we tested 150 attendees of two hemodialysis (HD) units of the public hospitals of Marseilles, France, for the presence of TTV genome by using a PCR-based methodology. The overall prevalence of TTV viremia was 28% (compared to 5.3% in blood donors from the same region). We demonstrated the existence of chronic infections and superinfections by strains belonging to different genotypes. The prevalence of infection was higher in patients originating from Africa, in patients with previous blood transfusion or organ transplantation, in patients with antibody to hepatitis B core antigen, and in those with diabetes mellitus. A high prevalence of TTV infection (50%) was also observed in a population of patients with diabetes mellitus but without renal disease. No significant relationship was found between TTV viremia and hepatitis C virus or GB virus C, transaminases, age, sex, and duration of HD treatment. The PCR amplification products (located in open reading frame 1 of the TTV genome) were sequenced. These genomic sequences were submitted to phylogenetic analysis by using the Jukes-Cantor algorithm for distance determination and the neighbor-joining method for tree building. In several instances, sequences from viruses isolated in a HD unit were grouped in the same phylogenetic cluster. These results together with the different distribution of cases in the two HD units suggest there is viral transmission within each.     

A New Approach to Evaluate Vascular Access in HemodialysisPatients

Abstract: We evaluated the importance of vascular access in hemodialysis patients using noninvasive methods with the Transonic Systems monitor in 108 patients. Most of these patients (84%) had native vein fistulas. We found that a blood flow rate of below 500 ml/min suggested the occurrence of vascular stenosis and justified confirmation by angiography. Increased recirculation could be evaluated readily and was detected in only 10% of patients. Finally, employing the evaluation of the Kt/V index, we found a good correlation between low flux through the fistula and a low Kt/V value.