Dear Sir,5-Aminosalicylic acid has recently been introduced for the treatment of inflammatory bowel disease (IBD). Few cases of nephrotoxicity have been reported [1]. We describe a patient who developed nephrotic syndrome within 9 months after starting treatment with mesalazine (5-aminosalicylic acid coated with anacrylic-based resin).A 59-year-old white woman with a known history of ulcerative colitis was admitted because of the sudden onset of swelling of her face and a moderate exacerbation of colitis. Her medical history revealed unilateral nephrectomy for pyonephrosis 6 years ago. Nine months before admission, colitis had been treated by mesalazine (500 mg thrice daily for 6 months and thereafter 1,000 mg thrice weekly in enema). Examination showed periorbital, ankle and sacral edema. Blood pressure was 130/80 mm Hg. Laboratory investigations showed full-blown nephrotic syndrome: serum albumin concentration 20 g/l and proteinuria was 12.9 g/day, creatinine clearance calculated by the Cockroft formula was 35 ml/min. Urinary sediment was unremarkable. A transjugular renal biopsy showed normal glomeruli and interstitial tissue. Results of immunofluorescence were negative leading to the diagnosis of minimal change nephropathy (MCN). Oliguria (urine output of 500 ml/24 h) developed and creatinine clearance decreased to 20 ml/min 2 days after admission. Mesalazine was stopped and prednisone (1 mg/kg/day) started together with furosemide. The nephrotic syndrome resolved after 4 weeks of treatment. Prednisone was tapered off to a stop at 5 months. Six months later she was still in complete remission.5-Aminosalicylic acid is released in the large bowel on dissolution of the resin coating of mesalazine tablets [2]. The nephrotoxicity of 5-aminosalicylic acid therapy is commonly acute or chronic tubulointerstitial nephritis, renal papillary necrosis [3] (but the possibility of other allergic effects should be considered, especially hepatic injury). Idiopathic interstitial nephritis complicating ulcerative colitis was reported, but the association between MCN and ulcerative colitis has never been pointed out. However MCN has been reported in 2 patients with IBD treated by mesalazine [4] or sulfasalazine [5]. We suggest that the nephrotic syndrome in patients with ulcerative colitis treated with sulfasalazine or mesalazine may be caused by 5-aminosalicylic acid, which is common to both these drugs. Short-term corticosteroid treatment should be successful (similar cases, with histological changes mainly confined to the interstitium, have previously been reported in association with nonsteroidal anti-inflammatory drugs; it has been suggested that the nephrotic syndrome in these cases may be mediated by T-lymphocyte activation).
There is currently no validated strategy for the timing of renal replacement therapy (RRT) for acute kidney injury (AKI) in the ICU when short-term life-threatening metabolic abnormalities are absent. No adequately powered prospective randomized study has to date addressed this issue. As a result, significant practice heterogeneity exists and may expose patients either to unnecessary hazardous procedures or to undue delay in RRT.
Acute cor pulmonale (ACP) and patent foramen ovale (PFO) remain common in patients under protective ventilation for acute respiratory distress syndrome (ARDS). We sought to describe the hemodynamic profile associated with either ACP or PFO, or both, during the early course of moderate-to-severe ARDS using echocardiography.In this 32-month prospective multicenter study, 195 patients with moderate-to-severe ARDS were assessed using echocardiography during the first 48 h of admission (age: 56 (SD: 15) years; Simplified Acute Physiology Score: 46 (17); PaO2/FiO2: 115 (39); VT: 6.5 (1.7) mL/kg; PEEP: 11 (3) cmH2O; driving pressure: 15 (5) cmH2O). ACP was defined by the association of right ventricular (RV) dilatation and systolic paradoxical ventricular septal motion. PFO was detected during a contrast study using agitated saline in the transesophageal bicaval view.ACP was present in 36 patients, PFO in 21 patients, both PFO and ACP in 8 patients and the 130 remaining patients had neither PFO nor ACP. Patients with ACP exhibited a restricted left ventricle (LV) secondary to RV dilatation and had concomitant RV dysfunction, irrespective of associated PFO, but preserved LV systolic function. Despite elevated systolic pulmonary artery pressure (sPAP), patients with isolated PFO had a normal RV systolic function. sPAP and PaCO2 levels were significantly correlated.In patients under protective mechanical ventilation with moderate-to-severe ARDS, ACP was associated with LV restriction and RV failure, whether PFO was present or not. Despite elevated sPAP, PFO shunting was associated with preserved RV systolic function.
Objective Pneumonia in the intensive care unit is associated with a high mortality rate. Diagnostic accuracy is mandatory to improve prognosis. However, in many hospitals, samples from the respiratory tract cannot be immediately processed bacteriologically around the clock. This may complicate therapeutic choice based on invasive diagnostic procedures. We evaluated the effect of storing bronchoalveolar lavage fluid at 4°C for 24 hrs on direct examination and culturing for diagnosing pneumonia. Design Prospective, paired comparison study. Setting Intensive care unit in a university hospital. Patients A total of 93 bronchoalveolar lavages were performed on 66 intensive care unit patients who were suspected to have bacterial pneumonia. Intervention Each sample was divided into two; one half was processed immediately (H0), and the other was processed after refrigeration at 4°C for 24 hrs (H24). Measurements and Main Results All negative H0 culture samples (n = 31) were also negative for pathogens in H24 samples. Sixty two bronchoalveolar lavage cultures yielded one or more microorganisms, giving a total of 113 microorganisms in one or both samples. The results of positive cultures at H0 and H24 for the culturing diagnostic threshold of 104 colony forming units/mL agreed well (Kappa coefficient, 0.84); agreement was even better (Kappa coefficient, 0.85) when possible contaminants were excluded. The bias calculated as the mean difference between paired culture results was 0.195 ± 1.31 (Δlog). When considering the accepted threshold of 104 colony forming units/mL, specificity at H24 compared to H0 was excellent (100%), but sensitivity was slightly lower (80%). Conclusion Delayed processing of bronchoalveolar lavage sampling is an acceptable alternative when immediate culturing cannot be performed because it enables antibiotic administration.
Sevoflurane sample data in a standard single patient ICU room, VieCuri Medical Centre. Physical data of the ICU room: 52 m3, air refreshing rate minimum 6/hr
La loi du 22 avril 2005 relative aux droits des malades et à la fin de la vie dite loi Leonetti a donné un cadre légal aux décisions de limitation et d’arrêt de traitement en interdisant l’obstination déraisonnable. Elle a imposé une délibération collégiale lorsque le patient était hors d’état de s’exprimer. Un décret d’application en 2006 a précisé que le médecin en charge du patient devait prendre l’avis d’un autre médecin dit « consultant » et consulter l’équipe soignante en raison de sa proximité avec le patient. Le terme pluri-ou interdisciplinarité semble plus approprié que collégialité pour décrire le processus rassemblant des intervenants de statuts et de compétences différentes. En réanimation, l’interdisciplinarité désigne essentiellement les médecins et les soignants. L’intérêt de la discussion interdisciplinaire est de confronter des arguments de registres différents. Cela permet une approche holistique du patient plutôt qu’une approche médicale seule. Le registre des arguments de chacun doit être reconnu comme valide. L’implication des soignants dans le processus décisionnel reste insuffisante même si elle progresse. Ce défaut de concertation entre médecins et soignants dans les situations de fin de vie est à l’origine de conflits, de détresse morale et d’épuisement professionnel. L’amélioration de la collaboration médicosoignante est un enjeu important de la qualité des soins. C’est un requis nécessaire à une pluridisciplinarité aboutie dans le processus décisionnel de fin de vie.
Abstract Background Intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) are the two main RRT modalities in patients with severe acute kidney injury (AKI). Meta-analyses conducted more than 10 years ago did not show survival difference between these two modalities. As the quality of RRT delivery has improved since then, we aimed to reassess whether the choice of IHD or CRRT as first modality affects survival of patients with severe AKI. Methods This is a secondary analysis of two multicenter randomized controlled trials (AKIKI and IDEAL-ICU) that compared an early RRT initiation strategy with a delayed one. We included patients allocated to the early strategy in order to emulate a trial where patients would have been randomized to receive either IHD or CRRT within twelve hours after the documentation of severe AKI. We determined each patient’s modality group as the first RRT modality they received. The primary outcome was 60-day overall survival. We used two propensity score methods to balance the differences in baseline characteristics between groups and the primary analysis relied on inverse probability of treatment weighting. Results A total of 543 patients were included. Continuous RRT was the first modality in 269 patients and IHD in 274. Patients receiving CRRT had higher cardiovascular and total-SOFA scores. Inverse probability weighting allowed to adequately balance groups on all predefined confounders. The weighted Kaplan–Meier death rate at day 60 was 54·4% in the CRRT group and 46·5% in the IHD group (weighted HR 1·26, 95% CI 1·01–1·60). In a complementary analysis of less severely ill patients (SOFA score: 3–10), receiving IHD was associated with better day 60 survival compared to CRRT (weighted HR 1.82, 95% CI 1·01–3·28; p < 0.01). We found no evidence of a survival difference between the two RRT modalities in more severe patients. Conclusion Compared to IHD, CRRT as first modality seemed to convey no benefit in terms of survival or of kidney recovery and might even have been associated with less favorable outcome in patients with lesser severity of disease. A prospective randomized non-inferiority trial should be implemented to solve the persistent conundrum of the optimal RRT technique.
