Since renal biopsy is rarely performed for identifying acute tubular necrosis in ICU patients, there is little information on the real histopathological abnormalities observed in such situations.
The ...clinical data of 27 patients with a confirmed diagnostic of acute tubular necrosis issued from two recent series gathering 125 patients who had renal biopsy during their ICU stay were reviewed. They were divided into sepsis (n = 14) and non-sepsis (n = 13) groups. Histopathologic lesions were reanalyzed and semi-quantitatively graded by a pathologist without knowledge of clinical characteristics of the patients.
SAPS2 and SOFA scores were identical in the two groups. Half of the patients had neither sepsis nor shock. The histopathological score was higher in the septic than in the non-septic group: 9 IC; 9–11 vs 7 IC 5.25–8.75; p = 0.01. There was no striking histopathological difference between septic and non-septic patients. However, the cytotoxic edema score was higher (3 1; 3 vs 1 0; 1; p = 0.006), and interstitial infiltration with polymorphonuclears was more frequent (p = 0.02) in septic than in non-septic patients.
Septic and non-septic ICU patients with ATN had similar histopathologic features but lesions were more severe than in septic than in non-septic patients.
•There is no specific histological feature to discriminate acute tubular necrosis in septic and non septic patients.•Moderate interstitial infiltration is frequently associated with tubular injury both in septic and non septic patients.•Histopathologic alterations in acute tubular necrosis are more severe in septic than in non septic patients.
Background - Extracorporeal photopheresis (ECP) has shown encouraging results in the prevention of allograft rejection in heart transplantation. However, the role of ECP in kidney transplant (KT) ...rejection needs to be determined.
Methods - This multicentre retrospective study included 33 KT recipients who were treated with ECP for allograft rejection (23 acute antibody-mediated rejections (AMRs), 2 chronic AMRs and 8 acute cellular rejections (ACRs)). The ECP indications were KT rejection in patients who were resistant to standard therapies (n = 18) or in patients for whom standard therapies were contraindicated because of concomitant infections or cancers (n = 15).
Results - At 12 months (M12) post-ECP, 11 patients (33%) had a stabilization of kidney function with a graft survival rate of 61%. The Banff AMR score (g + ptc + v) was a risk factor for graft loss at M12 (HR 1.44 1.01–2.05, p < 0.05). The factorial mixed data analysis identified 2 clusters. Patients with a functional graft at M12 tended to have cellular and/or chronic rejections. Patients with graft loss at M12 tended to have acute rejections and/or AMR; higher serum creatinine levels; DSA levels and histologic scores of AMR; and a longer delay between the rejection and ECP start than those of patients with functional grafts.
Conclusions - ECP may be helpful to control ACR or moderate AMR in KT recipients presenting concomitant opportunistic infections or malignancies when it is initiated early.
La hyalinose segmentaire et focale (HSF) représente une cause fréquente de syndrome néphrotique chez l’enfant et l’adulte. Les formes collapsantes sont de mauvais pronostic rénal et le plus souvent ...secondaires à des infections virales avec, en premier lieu, le virus de l’immunodéficience humaine. Parmi les autres étiologies virales, le cytomégalovirus (CMV) est une cause peu fréquente. Nous rapportons le cas d’une patiente âgée de 32ans ayant présenté une HSF collapsante secondaire au cytomégalovirus avec une insuffisance rénale aiguë initiale et une protéinurie à 12,4g/24h. Le traitement a associé du ganciclovir pendant 7jours, puis relais par valganciclovir pendant 14jours, associé à une corticothérapie à 1mg/kg/jour. La fonction rénale s’est améliorée et la protéinurie a diminué sous ce traitement. La protéinurie a augmenté de nouveau 3semaines après l’arrêt du valganciclovir alors que la polymerase chain reaction (PCR) CMV était positive. Le traitement par valganciclovir a alors été repris, permettant la normalisation de la fonction rénale et une baisse de la protéinurie à 4g/24h après un contrôle de la PCR CMV négatif après 15semaines. Un traitement antiviral anti-CMV associé à une corticothérapie semble permettre une réponse rénale en cas d’HSF collapsante secondaire au CMV, même si le pronostic à long terme reste incertain.
Focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome in child and adult. The collapsing forms are of poor renal prognosis and are usually secondary to viral infections with, first and foremost, the human immunodeficiency virus. Among other viral etiologies, cytomegalovirus (CMV) is an uncommon cause. We report a case of a 32years-old patient with collapsing focal segmental glomerulosclerosis induced by cytomegalovirus with initial acute renal failure and proteinuria at 12.4g/24h. The treatment associated ganciclovir during 7days followed by valganciclovir during 14days and steroids at 1mg/kg/day. Renal function improved and proteinuria decreased with this treatment. Proteinuria increase again 3weeks after valganciclovir discontinuation while CMV Polymerase chain reaction (PCR) was positive. Therefore, valganciclovir has been resumed allowing renal function normalization and decrease in proteinuria to 4g/24h after negative CMVPCR assay after 15weeks. Anti-CMV therapy combined with steroids seems to provide a renal response in case of FSGS induced by CMV even if long-term prognosis stays uncertain.
Focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome in child and adult. The collapsing forms are of poor renal prognosis and are usually secondary to viral infections ...with, first and foremost, the human immunodeficiency virus. Among other viral etiologies, cytomegalovirus (CMV) is an uncommon cause. We report a case of a 32years-old patient with collapsing focal segmental glomerulosclerosis induced by cytomegalovirus with initial acute renal failure and proteinuria at 12.4g/24h. The treatment associated ganciclovir during 7days followed by valganciclovir during 14days and steroids at 1mg/kg/day. Renal function improved and proteinuria decreased with this treatment. Proteinuria increase again 3weeks after valganciclovir discontinuation while CMV Polymerase chain reaction (PCR) was positive. Therefore, valganciclovir has been resumed allowing renal function normalization and decrease in proteinuria to 4g/24h after negative CMVPCR assay after 15weeks. Anti-CMV therapy combined with steroids seems to provide a renal response in case of FSGS induced by CMV even if long-term prognosis stays uncertain.
Monoclonal gammopathy of renal significance (MGRS) can manifest in many different ways depending on the nature of the immunoglobulin and its physicochemical properties. MGRS can lead to the discovery ...of a hematological malignancy. We report the case of a 32-year-old female patient who underwent renal biopsy on account of an impure nephrotic syndrome associated with immunoglobulin (Ig)G κ monoclonal gammopathy. Histological analysis revealed membranoproliferative glomerulonephritis with IgG, IgM, κ, λ, and C3 deposits. Due to an unfavorable progression, a second renal biopsy was performed. Electron microscopy analysis revealed an immunotactoid glomerulopathy. At the same time, a POEMS syndrome diagnosis (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin abnormalities) was confirmed in light of the following: 1) IgG κ monoclonal gammopathy, 2) axonal neuropathy, 3) osteosclerosis, 4) melanoderma, 5) hepatosplenomegaly and adenopathies, 6) Castleman disease, and 7) edema. Our observation is the first case of immunotactoid glomerulopathy leading to the discovery of a POEMS syndrome. Renal involvement in POEMS syndrome typically exhibits a thrombotic microangiopathy-like membranoproliferative glomerulonephritis appearance associated with endothelial lesions stigmata. However, monoclonal immunoglobulin deposition disorder should be considered in the event of an atypical case. In this indication, electron microscopy is the examination of choice for assessing immunoglobulin deposition nephropathy. .
Les vascularites associées aux ANCA sont des pathologies auto-immunes sévères qui sont caractérisés par l’inflammation et la nécrose des petits vaisseaux. Les mécanismes physiopathologiques sont ...complexes et ne sont pas totalement élucidés. Plusieurs facteurs environnementaux ont été décrits comme associés : médicaments, agents infectieux… et rarement des néoplasies.
Notre étude multicentrique rétrospective sur une période de 12 ans décrit les patients avec une vascularite à ANCA et une hémopathie maligne, en excluant les hémopathies secondaires au traitement réalisé pour la vascularite.
Seize patients avec une vascularite à ANCA associée à une hémopathie ont été identifiés. Le sex-ratio était de 7 et l’âge moyen de 65 ans. La fréquence de cette association est estimée à 1 %. Les vascularites à ANCA étaient : micropolyangéites (n=7), polyangéites granulomateuses (n=4), vascularites limitées au rein (n=3) et polyangéites granulomateuses éosinophiliques (n=2). Les hémopathies malignes associées étaient principalement des lymphomes non hodgkiniens (n=7) et des myélodysplasies (n=5). Les autres hémopathies étaient : lymphome de Hodgkin, syndrome d’hyperéosinophilie essentielle, myélome et maladie de Waldenstrom. Le traitement de l’hémopathie était associé à celui de la vascularite dans sept cas.
L’association vascularite à ANCA et hémopathie maligne est rare mais ne doit pas être méconnue car : (i) les signes cliniques de ces deux pathologies ne sont pas spécifiques, (ii) les scores de survie utilisés pour les vascularites à ANCA ne semblent pas applicables, (iii) une réflexion thérapeutique commune doit être envisagée pour limiter les risques induits par les thérapeutiques.
PDF
