Facteurs de risque cardiovasculaires au cours du lupus systémique

Cette étude a pour objectif d'évaluer la fréquence des facteurs de risque cardiovasculaires au cours du lupus et de préciser leur prévalence. Etude rétrospective portant sur 250 patients ayant un lupus, diagnostiqué selon les critères de l'ACR, hospitalisés entre 1970 et 2013. Les données cliniques et para cliniques ont été recueillies à partir des observations médicales. Il s'agit de 228 femmes et 22 hommes d'âge moyen au diagnostic du lupus de 30, 32 ans (extrêmes: 16-69). La durée moyenne du suivi des patients était de 64 mois (extrêmes: 7 jours- 382mois). Quatre vingt dix patients (36%) étaient hypertendus, 74% avaient une hypercholestérolémie et 22% étaient diabétiques. Pour les autres facteurs de risque cardiovasculaire traditionnels, un âge > 50 ans a été retrouvé dans 40% des cas, le sexe masculin dans 8% des cas, l'obésité dans 76% des cas et le tabagisme dans 11% des cas. Les facteurs de risque surajoutés sont représentés par la présence des anticorps antiphospholipides (47% des cas), la néphropathie lupique (49% des cas), l'insuffisance rénale (42% des cas), la corticothérapie au long cours (74% des cas) et la chronicité de la maladie dans 35% des cas. Les complications cardiovasculaires retrouvées dans notre série étaient: les accidents vasculaires cérébraux (2%) et l'insuffisance coronarienne (5,6%). Devant l'importance du risque cardiovasculaire au cours du lupus, une surveillance rapprochée des facteurs de risque cardio-vasculaires semble primordiale chez les lupiques

[76] Hereditary kidney stones: An experience of a nephrology department

Objective: To determine clinical and metabolic characteristics and progression of hereditary urinary lithiasis. Genetic factors must be considered in the aetiological diagnosis of urinary lithiasis. Methods: A retrospective study was conducted between 2008 and 2018, and 53 patients were included. Patients were referred to our department for aetiological investigation in 36 cases, for chronic renal failure in eight cases, and from paediatric departments to be followed-up in adulthood in nine cases. Results: In all, 32 men and 21 women were enrolled in this study with a male/female sex ratio of 1.52. The mean (range) age at the time of diagnosis of the hereditary character of the urinary lithiasis was 29 years (4 days–63 years).The mean (range) delay between the onset of the lithiasis disease and the aetiological diagnosis was 10.5 (1–42) years. We noted 26 cases of cystinuria, 17 cases of primary hyperoxaluria type 1 with two mutations (I244T in 15 cases and 33–34 Insc in two cases), and 10 cases of renal tubulopathy. In all, 14 patients had chronic renal failure, of which five were in end-stage. Crystalluria was positive in 62% of the cases. The morpho-constitutional analysis of stones was conducted in 31 cases; oxalo-dependent lithiasis was identified in nine cases and cystine lithiasis in 22 cases. After a mean follow-up of 82 months for 43 patients, we noted normal renal function in 21 cases, chronic renal failure in 12 cases, and haemodialysis in nine cases, all with primary hyperoxaluria and transplantation in one case. Conclusion: The aetiological diagnosis of hereditary urinary lithiasis was made with considerable delay. Cystinuria was the most frequent aetiology and primary hyperoxaluria was the most serious affliction

ENDOCARDITIS IN SYSTEMIC LUPUS ERYTHEMATOSUS

Endocarditis is one of the most prevalent forms of cardiac involvement in patients with lupus, as it is considered as one a life-threatening complication. Libman-Sacks endocarditis is common. Infective endocarditis can also cause complications within immunocompromised patients. The aim of this study is to determine particularities of endocarditis in patients with lupus and to look for distinguishing features between infectious or immunological origin. A retrospective study was conducted on patients with lupus presenting endocarditis. Lupus was diagnosed according to the American college of rheumatology criteria. The diagnosis of endocarditis was made based on the modified Duke criteria. The present case report studies seven cases of endocarditis. Six of these patients are women and the other one is a man. They are aged meanly of 29.4 years (extremes: 20-36). Fever was present in all the cases with a new cardiac murmur in six cases and a modification of its intensity in one case. Biologic inflammatory syndrome was present in six cases. Cardiac ultrasound performed in six cases made the diagnosis of endocarditis which involved the left heart valves in five cases and the right heart valves in one case. Valvular insufficiency was identified in six patients. The valve involvement was mitral in two cases, mitro-aortic in two others, aortic in the fifth one and tricuspid in the sixth one. Endocarditis was infectious in 4 cases, thanks to positive blood culture. The germs identified were gram negative bacilli in two cases, anaerobic organism in one case and gram positive cocci in one case. Candida albicans was isolated in one case. Libman-Sacks endocarditis was objectified in three cases. A combination of Libman-Sacks endocarditis with infectious endocarditis was diagnosed in one case. The treatment consisted of antibiotics in four cases with surgery in two cases. The outcome was favorable in five cases and fatal in the two others. Endocarditis in lupus can be infectious or Libman-Sacks endocarditis. These two conditions share several clinical features. The only distinctive argument remains positive blood culture. The treatment should be initiated as early as possible to limit the valve damage and improve the outcome

[78] Idiopathic hypercalciuria complicated by polyuropolydipsic syndrome during pregnancy

Objective: To report on a case of idiopathic hypercalciuria complicated by polyuropolydipsic syndrome during pregnancy. Idiopathic hypercalciuria is most often manifested by urinary lithiasis and/or nephrocalcinosis. The polyuropolydipsic syndrome is a rare complication of this condition and exposes the patient to the risk of hydroelectrolytic disorders. Thiazide diuretics are indicated during this syndrome in the absence of a contraindication. Methods: We report the case of pregnancy during idiopathic hypercalciuria complicated by polyuropolydipsic syndrome. Results: A 33-year-old woman, with no personal or familial pathological history, was referred for polyuropolydipsic syndrome. She had no extra-renal manifestations and her clinical examination was normal. Her diuresis was 6 L/24 h and the biological assessment showed a hypercalciuria at 17.5 mmol/24 h persisting after adjusting the intakes of salts and proteins. Calcium, phosphataemia, 25-OH vitamin D, and parathyroid hormone were normal. The patient was put on thiazide diuretic and the evolution was marked by the normalisation of diuresis and a decrease in calciuria. Before conception the treatment was stopped, and the patient had a pregnancy without complications Conclusion: Pregnancy during idiopathic hypercalciuria with polydipsic polyuria syndrome was completed without complications in this case. The literature is poor regarding this affliction in the pregnant woman

EVALUATION OF NUTRITIONAL STATUS IN HEMODIALYSIS PATIENTS

Malnutrition is a common problem among hemodialysis patients. This factor leads to increased morbidity and mortality. This study evaluates the nutritional status of patients on dialysis and analyses the various parameters used for assessing malnutrition. It is a cross-sectional study of 35 patients aged 18 years and up who have undergone dialysis three days a week for more than a year. The following were analysed: overall subjective assessment technique, Body Mass Index, anthropometric data and biological parameters (serum albumin, serum cholesterol, rate of alkaline reserves and C-reactive protein levels) with a dietary three-day survey. Analysis of food survey data was performed using the software Bilnut. The patients’ average age was 46.7 years with a sex ratio of 1.18. Average waist size was 92.7±16.68 cm. Average arm circumference was 27.2±5.6 cm and average calf circumference was 32.03±5.87 cm. Malnutrition was found in 48% of cases according to SGA. Average BMI was 24.4 kg/m2. It was less than 23 Kg/m2 in 48% of cases. Average serum albumin concentration was 33.6 g/l and average CRP level was 6.16 mg/l. The average energy intake (Kcal/Kg/day) was 30.87±11.92 the day of dialysis, 27.98±9.31 on a resting day and 29.93±9.42 on another day and the average protein intake (g/kg/day) was 1.02±0.44 the day of dialysis, 0.94±0.36 a resting day and 1.04±0.36 on the other day. Malnutrition was frequent among our patients. The assessment of nutritional status in patients on dialysis requires simultaneous combination of several clinical, biologic and dietetic markers. Dietary management is mainly based on food survey regularly established

Recurrent Urolithiasis Revealing Primary Hyperparathyroidism in a Nephrology Department

Background. Urinary lithiasis constitutes a recurrent pathology affecting a relatively young population. The risk of progression to chronic renal failure and the cost of treatment are the most important issues. Primary hyperparathyroidism (PHPT) is responsible for urolithiasis and nephrocalcinosis in 7% of patients, and it represents the 7th cause of urolithiasis in Tunisia. Unfortunately, it remains an underdiagnosed pathology although it is curable. We aim to determine the clinical, biological, therapeutic, and evolutionary particularities of urinary lithiasis associated with PHPT in a nephrology setting. Methods. This is a monocentric, retrospective, descriptive study which took place in our nephrology department during the period from January 2010 to January 2023. Ten patients were included. All of them underwent blood and urine tests and a morphoconstitutional study of the urinary stones if possible. Results. The median age at diagnosis of PHPT was 42 years (34–54). The median time from the onset of kidney stones to the diagnosis of PHPT was 6.2 years (1–17). The male/female gender ratio was 0.66. Five patients had hypertension, two patients had obesity, one patient had diabetes, and three patients had urinary tract infections. Kidney stones were bilateral in eight cases and unilateral in two cases. Nine patients underwent urological intervention: surgery in 5 cases associated with nephrectomy in one case, extracorporeal lithotripsy in 4 cases, and percutaneous nephrolithotomy in two cases. The diagnosis of PHPT was retained with high or uncontrolled PTH associated with hypercalcemia in 8 cases and normocalcemic PHPT was found in 2 patients. Two patients had parathyroid adenoma and one patient had mediastinal adenoma. Radiology exploration was normal for the others patients. Surgery was performed in 7 patients and histology revealed an adenoma in 5 cases and hyperplasia in one case. The predominant urinary risk factors in our study were hypercalciuria in 6 cases and insufficient diuresis in 4 cases. Conclusion. This study underlines the role of the nephrologist in the exploration of urinary lithiasis and the prevention of recurrences, especially as PHPT is a curable aetiology of urolithiasis and affects a relatively young population. The determination of the epidemiological profile of patients with stones associated with primary PHPT and lithogenic risk factors allows the primary and secondary prevention of stone formation

Factors associated with relapse of lupus nephritis: A single center study of 249 cases

This is a retrospective cohort study over 20 years (1990–2013) that included all patients with biopsy-proven lupus nephritis (LN) followed up at our nephrology department. We aimed to determine the clinicobiologic predictors of flare-up of LN. Flare was defined as an increase in systemic lupus erythematosus (SLE) disease activity index (SLEDAI) score of at least four points. Clinical manifestations and laboratory parameters were assessed and the SLEDAI score was determined for each patient. We included patients with SLE who fulfilled at least four of the American College of Rheumatology criteria for the classification of SLE. A total of 249 patients including 227 females and 22 males with a median age at diagnosis of 34.32 years (range 16–69) were studied. The mean follow-up duration was 122.4 ± 27 months. Renal symptoms included hypertension in 40%, nephrotic syndrome in 30%, and renal failure in 69.4% of the cases. Class IV and class III nephritis (ISN/RPS) were observed in 44.9% and 24% of the patients, respectively. On univariate analysis, flare predictors were age <30 years (P = 0.02), lymphocytopenia (P = 0.002), the presence of diffuse proliferative LN (P = 0.009), and discontinuation of immunosuppressive therapy (P = 0.004). Our study suggests that these markers should be monitored routinely as prognostic parameters in SLE to characterize patients who are at risk and who should be followed more closely

Nondiabetic renal disease in patients with type 2 diabetes

Diabetic nephropathy (DN) is one of the major complications of type 2 diabetes mellitus (T2DM). The diagnosis of DN is mostly clinical. Kidney biopsy is indicated only if nondiabetic renal disease (NDRD) is suspected. This study is aimed to assess the prevalence of NDRD and to determine predictor and prognostic factors of DN, NDRD. It was a retrospective analytic study including T2DM patients in whom renal biopsies were performed at our department from 1988 to 2014. Seventy-five patients were included. Mean age was 52.7 years with sex ratio at 1.56. Renal biopsy findings were isolated NDRD in 33 cases, NDRD superimposed on DN in 24 cases, and isolated DN in 18 cases. Most common NDRD found were focal segmental glomerulosclerosis (21%) and membranous nephropathy (19%). Multivariate analysis showed that the absence of ischemic heart disease [odds ratio (OR) = 0.178, 95% confidence interval (CI) = 0.041–0.762], absence of peripheral vascular disease (OR = 0.173, 95% CI = 0.045–0.669), and presence of hematuria (OR = 7.200, 95%CI = 0.886–58.531) were independent predictors of NDRD. 24 patients reached end-stage renal disease 55% in DN group, 16% in DN associated to NDRD group, and 30% in NDRD group. The prevalence of NDRD found in our study confirmed usefulness of renal biopsy in patients with T2DM, especially in those without degenerative complications, hypertension, and insulin therapy

Acute kidney injury with granulomatous interstitial nephritis and vasculitis revealing sarcoidosis

Sarcoidosis is an inflammatory disease that affects mostly the lungs and lymph glands. Renal involvement is rare and especially vasculitis. We report a case who presented an acute kidney failure and had sarcoidosis with vasculitis and nodular splenic involvement. A 35-year-old woman presenting a Lofgren syndrome was hospitalized for acute renal failure with cervical lymphadenopathy without other clinical findings. Laboratory data disclosed elevated angiotensin converting enzyme serum level. Abdominal ultrasound showed a multinodular spleen. Renal histology revealed granulomatous interstitial nephritis with necrotizing vasculitis. Outcome was favorable after the institution of high dose corticosteroids along with cyclophosphamide. Renal involvement is rare in sarcoidosis. However, the diagnostic delay should be avoided to improve the outcome

Primary Hyperoxaluria Type 1: Clinical, Paraclinical, and Evolutionary Aspects in Adults from One Nephrology Center

Introduction. Primary hyperoxaluria type 1 (PH1) is a rare and inherited condition of urolithiasis. The aim of our study was to analyze clinical, paraclinical, and evolutionary aspects of PH1 in adult patients in our Nephrology department. Methods. We conducted a retrospective single-center study between 1990 and 2021. We collected patients followed for PH1 confirmed by genetic study and/or histopathological features of renal biopsy and morphoconstitutional analysis of the calculi. Results. There were 25 patients with a gender ratio of 1.78. The median age at onset of symptoms was 18 years. A delay in diagnosis more than 10 years was noted in 13 cases. The genetic study found the I244T mutation in 17 cases and 33-34 InsC in 4 cases. A kidney biopsy was performed in 5 cases, on a native kidney in 4 cases and on a graft biopsy in one case. The analysis of calculi was done in 10 cases showing type Ic in 2 cases. After a median follow-up of 13 years (1 year–42 years), 14 patients progressed to end-stage chronic renal failure (ESRD). The univariate study demonstrated a remarkable association with progression to ESRD in our population (44% vs. 56%) RR = 13.32 (adjusted ORs (95% CI): 2.82–62.79) (p<0.01). Conclusion. Progression to ESRD was frequent in our series. Early diagnosis and adequate management can delay such an evolution