1416
solely with AN69 membranes, which are more permeable and more biocompatible. Kessler et al’s data, based on only 15 AN69 patients, do not add to
If epidemiological studies are to unravel the factors onset and development of dialysis-related arthropathy, specific and reliable criteria should be first delineated. Patients with dialysis-associated arthropathy were heterogeneous: they included patients with dialysis-related amyloidosis, conclusions. that influence
our
microcrystalline disease, aluminium or iron-related bone disease, and hyperparathyroidism. Spondyloarthropathy, another entity .2 assessed by Kessler et al, is equally heterogeneous Kessler et al’s criteria of arthropathy include "subchondrial juxta-articular erosions or cysts" without specification of size, localisation, growth rate, or adjoining joint-space status. In the absence of a strict definition, these lesions are non-specific, as shown by Gielen et aP who identified them in up to 30% of non-uraemic patients. Dialysis-related amyloidosis (as well as the heterogeneous dialysis-associated arthropathy) is time-dependent, a characteristic to be taken into account in any meaningful analysis. Although the patients in Kessler et al’s two membrane groups had a similar duration of haemodialysis, each patient was evaluated at different time intervals. A crude cross-sectional analysis may fail to detect the earlier onset of a complication in one group. For instance, carpal tunnel syndrome may have occurred later in the two cases (13%) of the AN69 group than in the 34 cases (36%) of the cuprophane group. Only an analysis based on life tables or the Cox proportional model can lead to correct conclusions. With such a method Chanard et all found a significant effect of membranes on the incidence of carpal tunnel syndrome. Department of Nephrology, Cliniques Universitaires St-Luc, University of Louvain Medical School,
C. VAN YPERSELE DE STRIHOU M. JADOUL
1200 Brussels,
J. JAMART
Belgium
Ypersele de Strihou C, Jadoul M, Malghem J, Maldague B, Jamart J, and the Working Party on Dialysis Amyloidosis. Effect of dialysis membrane and patient’s age on signs of dialysis related amyloidosis. Kidney Int 1991; 39: 1012-19. 2. Bindi P, Chanard J. Destructive spondylarthropathy in dialysis patients’ an overview. Nephron 1990; 55: 104-09. 3. Gielen JL, van Holsbeek MT, Hauglustaine ED, et al. Growing bone cysts in long-term hemodialysis. Skeletal Radiol 1990; 19: 43-49. 4. Chanard J, Bindi P, Lavaud S, Toupace O, Maheut H, Lacour F. Carpal tunnel syndrome and type of dialysis membrane. Br Med J 1989; 298: 867-68. 1.
van
Percutaneous transhepatic venogram before (right) rt-PA.
(left) and
after
local or systemic bleeding occurred and detailed coagulation studies (including assays for fibrinogen) remained unaltered. After a 5-month follow-up, pulsed-doppler ultrasonography confirmed patency of the portal vein. Systemic and local administration of thrombolytic agents such as rt-PA in deep venous thrombosis have been reported previously.’ A local approach achieves the highest concentration of fibrinolytic agent in the thrombus while decreasing the risk of side-effects.z Moreover, lower concentrations of rt-PA are required and some of the relative contraindications (thrombocytopenia and varices in this case) of systemic administration may be avoided. Only a few cases of venous clearance by direct injection of fibrinolytic agents have been reported before.3-5 We believe that local rt-PA infusion may be a valuable alternative in the treatment of recently diagnosed portal vein thrombosis, especially in those patients who are candidates for liver
transplantation. THIERRY BIZOLLON
Fibrinolytic therapy for portal vein thrombosis SIR,-Portal vein thrombosis is
a serious complication in Portal patients. hypertension is aggravated and liver transplantation becomes technically more difficult. We now report the efficacy of local thrombolytic therapy in the treatment of portal vein thrombosis. A 65-year-old woman with advanced post-hepatic cirrhosis (hepatitis-C-antibody positive) and severe portal hypertension was admitted to hospital in November, 1990, with a 2-day history of severe epigastric pain and fever (38°C). Physical examination revealed hepatosplenomegaly. Her platelet count was 61 x 109/1. Upper gastrointestinal endoscopy found prominent oesophageal varices, and abdominal ultrasonography showed a posterior mural thrombus in the portal vein, which was absent 6 months earlier. 48 h later the thrombus had extended to the splenoportal junction. After informed consent had been obtained, a percutaneous transhepatic puncture of the portal vein was completed directly into the thrombus with ultrasonographic guidance. Injection of contrast medium showed fresh-looking thrombus at the splenomesenteric confluence (figure, left-hand radiograph). 20 mg recombinant tissue plasminogen activator (rt-PA) was injected into the thrombus over 4 min. After this procedure, which was well tolerated, the patient was given subcutaneous low molecular weight heparin (3075 anti-factor Xa IU twice daily). Abdominal pain and hyperthermia abated over 24 h. On day 4 angiographic and computed tomographic imaging showed nearly total dissolution of clot and the patency of both portal vein and its splenic and superior mesenteric branches was largely restored (figure, right hand radiograph). No
cirrhotic
Hepatology and Radiology Units, Hotel Dieu Hospital, 69288 Lyon Cedex 02, France
FRANÇOIS BISSUEL LAURENT DETRY CHRISTIAN TREPO
1 Collen D. Tissue-type plasminogen activator. Therapeutic potential in thrombotic disease states. Drugs 1986; 31: 1-5. 2. Berridge DC, Eamshaw JJ, Westby JC, Maskin GS, Hopkinson BR. Fibrinolytic profiles in local low-dose thrombolysis with streptokinase and recombinant tissue plasminogen activator Thromb Haemost 1989; 61: 275-78. 3. Yankes JR, Uglietta JP, Grant J, Braun SD. Percutaneous transhepatic recanalization and thrombolysis of the supenor mesentenc vein. AJR 1988; 151: 289-90 4. Fine DG, Shepherd RFJ, Welch TJ. Thrombolytic therapy for supenor vena cava syndrome. Lancet 1989; i: 1200-01. 5. Rauweda JA, Bakker FC, van den Broek TAA, Dwars DJ. Spontaneous subclavian vein thrombosis: a successful combined approach of local thrombolytic therapy followed by first-rib resection. Surgery 1988; 103: 477-80
ANCA and infection basis of extensive studies about the value of autoantibodies directed against immunodiagnostic cytoplasmic components of neutrophils and monocytes (ANCA),1-3 we do not agree with the conclusions of Dr Efthimiou and colleagues (April 27, p 1037). They found ANCA in sera from 7 of 13 patients with severe infections, and concluded that respiratory tract infection is associated with ANCA independently of any vasculitic process. In our experience, ANCA is associated with vasculitis and not infectious disorders. We screened 14 982 sera from 8890 patients. A classic ANCA (cANCA) was associated with Wegener’s granulomatosis (WG) and closely related vasculitic disorders. A perinuclear pattern (pANCA) is a common finding in (renal) microscopic polyarteritis,
SIR,--0n
the
solely with AN69 membranes, which are more permeable and more biocompatible. Kessler et al’s data, based on only 15 AN69 patients, do not add to
If epidemiological studies are to unravel the factors onset and development of dialysis-related arthropathy, specific and reliable criteria should be first delineated. Patients with dialysis-associated arthropathy were heterogeneous: they included patients with dialysis-related amyloidosis, conclusions. that influence
our
microcrystalline disease, aluminium or iron-related bone disease, and hyperparathyroidism. Spondyloarthropathy, another entity .2 assessed by Kessler et al, is equally heterogeneous Kessler et al’s criteria of arthropathy include "subchondrial juxta-articular erosions or cysts" without specification of size, localisation, growth rate, or adjoining joint-space status. In the absence of a strict definition, these lesions are non-specific, as shown by Gielen et aP who identified them in up to 30% of non-uraemic patients. Dialysis-related amyloidosis (as well as the heterogeneous dialysis-associated arthropathy) is time-dependent, a characteristic to be taken into account in any meaningful analysis. Although the patients in Kessler et al’s two membrane groups had a similar duration of haemodialysis, each patient was evaluated at different time intervals. A crude cross-sectional analysis may fail to detect the earlier onset of a complication in one group. For instance, carpal tunnel syndrome may have occurred later in the two cases (13%) of the AN69 group than in the 34 cases (36%) of the cuprophane group. Only an analysis based on life tables or the Cox proportional model can lead to correct conclusions. With such a method Chanard et all found a significant effect of membranes on the incidence of carpal tunnel syndrome. Department of Nephrology, Cliniques Universitaires St-Luc, University of Louvain Medical School,
C. VAN YPERSELE DE STRIHOU M. JADOUL
1200 Brussels,
J. JAMART
Belgium
Ypersele de Strihou C, Jadoul M, Malghem J, Maldague B, Jamart J, and the Working Party on Dialysis Amyloidosis. Effect of dialysis membrane and patient’s age on signs of dialysis related amyloidosis. Kidney Int 1991; 39: 1012-19. 2. Bindi P, Chanard J. Destructive spondylarthropathy in dialysis patients’ an overview. Nephron 1990; 55: 104-09. 3. Gielen JL, van Holsbeek MT, Hauglustaine ED, et al. Growing bone cysts in long-term hemodialysis. Skeletal Radiol 1990; 19: 43-49. 4. Chanard J, Bindi P, Lavaud S, Toupace O, Maheut H, Lacour F. Carpal tunnel syndrome and type of dialysis membrane. Br Med J 1989; 298: 867-68. 1.
van
Percutaneous transhepatic venogram before (right) rt-PA.
(left) and
after
local or systemic bleeding occurred and detailed coagulation studies (including assays for fibrinogen) remained unaltered. After a 5-month follow-up, pulsed-doppler ultrasonography confirmed patency of the portal vein. Systemic and local administration of thrombolytic agents such as rt-PA in deep venous thrombosis have been reported previously.’ A local approach achieves the highest concentration of fibrinolytic agent in the thrombus while decreasing the risk of side-effects.z Moreover, lower concentrations of rt-PA are required and some of the relative contraindications (thrombocytopenia and varices in this case) of systemic administration may be avoided. Only a few cases of venous clearance by direct injection of fibrinolytic agents have been reported before.3-5 We believe that local rt-PA infusion may be a valuable alternative in the treatment of recently diagnosed portal vein thrombosis, especially in those patients who are candidates for liver
transplantation. THIERRY BIZOLLON
Fibrinolytic therapy for portal vein thrombosis SIR,-Portal vein thrombosis is
a serious complication in Portal patients. hypertension is aggravated and liver transplantation becomes technically more difficult. We now report the efficacy of local thrombolytic therapy in the treatment of portal vein thrombosis. A 65-year-old woman with advanced post-hepatic cirrhosis (hepatitis-C-antibody positive) and severe portal hypertension was admitted to hospital in November, 1990, with a 2-day history of severe epigastric pain and fever (38°C). Physical examination revealed hepatosplenomegaly. Her platelet count was 61 x 109/1. Upper gastrointestinal endoscopy found prominent oesophageal varices, and abdominal ultrasonography showed a posterior mural thrombus in the portal vein, which was absent 6 months earlier. 48 h later the thrombus had extended to the splenoportal junction. After informed consent had been obtained, a percutaneous transhepatic puncture of the portal vein was completed directly into the thrombus with ultrasonographic guidance. Injection of contrast medium showed fresh-looking thrombus at the splenomesenteric confluence (figure, left-hand radiograph). 20 mg recombinant tissue plasminogen activator (rt-PA) was injected into the thrombus over 4 min. After this procedure, which was well tolerated, the patient was given subcutaneous low molecular weight heparin (3075 anti-factor Xa IU twice daily). Abdominal pain and hyperthermia abated over 24 h. On day 4 angiographic and computed tomographic imaging showed nearly total dissolution of clot and the patency of both portal vein and its splenic and superior mesenteric branches was largely restored (figure, right hand radiograph). No
cirrhotic
Hepatology and Radiology Units, Hotel Dieu Hospital, 69288 Lyon Cedex 02, France
FRANÇOIS BISSUEL LAURENT DETRY CHRISTIAN TREPO
1 Collen D. Tissue-type plasminogen activator. Therapeutic potential in thrombotic disease states. Drugs 1986; 31: 1-5. 2. Berridge DC, Eamshaw JJ, Westby JC, Maskin GS, Hopkinson BR. Fibrinolytic profiles in local low-dose thrombolysis with streptokinase and recombinant tissue plasminogen activator Thromb Haemost 1989; 61: 275-78. 3. Yankes JR, Uglietta JP, Grant J, Braun SD. Percutaneous transhepatic recanalization and thrombolysis of the supenor mesentenc vein. AJR 1988; 151: 289-90 4. Fine DG, Shepherd RFJ, Welch TJ. Thrombolytic therapy for supenor vena cava syndrome. Lancet 1989; i: 1200-01. 5. Rauweda JA, Bakker FC, van den Broek TAA, Dwars DJ. Spontaneous subclavian vein thrombosis: a successful combined approach of local thrombolytic therapy followed by first-rib resection. Surgery 1988; 103: 477-80
ANCA and infection basis of extensive studies about the value of autoantibodies directed against immunodiagnostic cytoplasmic components of neutrophils and monocytes (ANCA),1-3 we do not agree with the conclusions of Dr Efthimiou and colleagues (April 27, p 1037). They found ANCA in sera from 7 of 13 patients with severe infections, and concluded that respiratory tract infection is associated with ANCA independently of any vasculitic process. In our experience, ANCA is associated with vasculitis and not infectious disorders. We screened 14 982 sera from 8890 patients. A classic ANCA (cANCA) was associated with Wegener’s granulomatosis (WG) and closely related vasculitic disorders. A perinuclear pattern (pANCA) is a common finding in (renal) microscopic polyarteritis,
SIR,--0n
the
