Nephrologie & therapeutique最新文献

The year 2025 confirms the transition of kidney transplantation toward a precision-­medicine paradigm, marked by major advances in pathophysiology, diagnostics, and therapeutics. The study by Sablik et al. redefined the spectrum of antibody-mediated rejection (ABMR) by highlighting the prognostic importance of microvascular inflammation, even in the absence of DSA or C4d deposition. Circulating biomarkers (donor-derived cell-free DNA [dd-cfDNA] and transcriptomic signatures) are now established as key tools for detecting and monitoring rejection, while anti-CD38 antibodies and intravenous immunoglobulins open new therapeutic perspectives in chronic active ABMR. Antiviral immunomonitoring and virus-specific cellular therapies represent a decisive step toward targeted restoration of antiviral immunity, and SGLT2 inhibitors are emerging as cornerstone agents for cardio-renal protection. Advances in quantitative imaging enable non-invasive assessment of graft fibrosis. Finally, xenotransplantation has entered a phase of experimental validation, with the first detailed immunologic characterizations in humans. Together, these developments confirm the convergence of molecular, immunologic, and technological approaches toward truly individualized management of kidney-transplant recipients.

Cardiovascular mortality among hemodialysis patients remains strikingly high—around 10% per year—despite substantial advances in dialysis technology and medical care. Historically, several strategies extrapolated from the general population have failed to improve outcomes: The landmark 4D and AURORA trials showed no cardiovascular or survival benefit from statin therapy in dialysis patients, whereas high-volume online hemodiafiltration (ESHOL, CONVINCE) significantly reduced all-cause mortality, though without a specific reduction in cardiovascular deaths. More recently, large randomized controlled trials have again underscored the difficulty of improving cardiovascular outcomes in dialysis through pharmacological means: The ACHIEVE and ALCHEMIST trials found no clinical benefit from low-dose spironolactone on cardiovascular mortality or heart-failure hospitalization, and the DIALIZE-Outcomes trial showed that improved potassium control with sodium zirconium cyclosilicate did not reduce sudden cardiac death or arrhythmic events. Taken together, these neutral findings emphasize the complex, multifactorial nature of cardiovascular risk in dialysis, driven by “non-traditional” mechanisms such as inflammation, vascular calcification, oxidative stress, and intradialytic myocardial ischemia. In this context, recent studies from the Avignon group in France have identified intradialytic and pre-­dialysis exercise as a promising non-pharmacological intervention capable of mitigating myocardial stunning and improving cardiac function. In summary, while classical cardioprotective strategies continue to fall short, emerging evidence highlights the potential of innovative, physiology-based approaches—optimizing dialysis modalities and leveraging exercise-induced cardioprotection—to address the persistent cardiovascular burden of uremia.

In 2025, nephrology saw major advances in diagnosing and managing chronic kidney diseases. A new diagnostic framework, CKDx (chronic kidney disease of unexplained cause), was proposed to standardize patient evaluation by integrating genetic and histological tests. Therapeutic progress includes the demonstrated efficacy of atrasentan, an endothelin type A receptor antagonist, in IgA nephropathy, as well as that of iptacopan, an oral inhibitor of factor B, in IgA nephropathy and C3-deposit glomerulopathy. Obinutuzumab, a humanized anti-CD20 antibody, has also shown efficacy in lupus nephritis. Nephroprotective strategies, such as the finerenone-empagliflozin combination, have revealed significant benefits. Finally, emerging molecules such as baxdrostat, an aldosterone synthase inhibitor, and oral semaglutide, a GLP-1 analog, have demonstrated efficacy in resistant hypertension and in cardiovascular-risk reduction, respectively. These two molecules are currently being evaluated for preventing the progression of chronic kidney disease. However, challenges persist, including unequal access to innovative treatments, gaps in early screening, and the impact of climate change on kidney function. These results highlight the need for an integrated approach, combining innovation, equity, and adaptation to environmental changes to improve the care of patients with kidney diseases.

Until 2009, atypical hemolytic uremic syndrome (aHUS), a disease mediated by complement-induced endothelial activation, had a poor renal prognosis, with common progression to kidney failure and frequent recurrence after kidney transplantation, condemning often young patients to lifelong dialysis. Initially developed for paroxysmal nocturnal hemoglobinuria, anti-C5 monoclonal antibodies – eculizumab and later ravulizumab – were rapidly evaluated for the management of atypical HUS. Clinical development was based on uncontrolled studies, but with effects on microangiopathy and renal function recovery that were clearly more favorable than the spontaneous course of the disease.Nowadays, the use of anti-C5 monoclonal antibodies is recommended as first-line therapy for thrombotic microangiopathy associated with atypical HUS and for relapse prevention, particularly in the context of kidney transplantation, in both adults and children. Ravulizumab appears to have the same efficacy as eculizumab while allowing injections to be spaced every 8 weeks instead of every 2. Finally, the most feared adverse effect of these treatments is meningococcal infection, whose frequency is fortunately low thanks to prophylactic vaccination strategies and antibiotic prevention.

Background: Young carers are aged between 6 and 25 and regularly provide support to a sick relative. No study has yet focused on these young people in the context of parental dialysis. The aim of this study was to explore how parents on dialysis experience the support provided by their children, and to compare the experiences of parents undergoing dialysis at home and those treated in medical facilities.

Method: Thirty parents on dialysis (19 at home, 11 in facilities) completed a questionnaire (sociodemographic and medical information, autonomy in activities, quality of life, and support provided by their children). Fifteen parents also took part in semi-structured interviews.

Results: Overall, parents on dialysis reported low levels of support from their children, whether in terms of emotional support, household tasks, instrumental assistance, or personal care. Parents receiving dialysis outside the home perceived higher levels of support than those receiving dialysis at home. The interviews helped to clarify the observed differences and highlighted the specific forms of support provided by children of parents undergoing home dialysis. Parents also reported negative emotions among their children (anxiety, sadness) as well as the development of psychosocial skills.

Conclusion: These results underline the importance of paying attention to the children of dialysis patients and the support they may provide. Further studies are needed to better understand the underlying family dynamics and to explore the children’s perspective.

Malnutrition remains a major concern among hemodialysis patients in France and worldwide. An online survey was disseminated by the Association de Diététique et Nutrition en Néphrologie (ADNN) between March and June 2023, targeting its dietitian members via email and professional social networks. A total of 88 responses were collected (35% of those solicited), of which 73% were from the public or non-profit sector, and 47% of professionals reported following more than 150 hemodialysis patients annually. The aim of this study was to assess the practices of dietitian-nutritionists regarding the screening, diagnosis, and treatment of malnutrition, with a particular focus on the use of intradialytic parenteral nutrition (IDPN) in France. The reported prevalence of malnutrition ranged from 20 to 75% of patients, with 60% of dietitians estimating it between 20 and 50%. Screening was performed every 1 to 3 months by 70% of respondents, mainly based on weight loss (98%), body mass index (BMI) (89%), and biological markers such as albumin and CRP (monitored monthly by 50 to 60%). Normalized protein nitrogen appearance (nPNA) was used monthly by 42% of dietitians and at least annually by 80%. Regarding IDPN, only 35% reported having a protocol, 69% initiated it in cases of severe malnutrition or significant weight loss, and 45% reported infusion volumes of between 500 and 1,000 mL per session. The mean duration of use was 3 months for 28% of respondents but could extend beyond a year depending on nutritional recovery. Overall, 81% reported insufficient knowledge, and 75% expressed a need for additional training. This survey highlights a marked heterogeneity in the choice, duration, and monitoring of IDPN, the frequent absence of standardized protocols, and substantial training needs. It also underscores the lack of dedicated time for dietitians to follow up with hemodialysis patients: More than half of the respondents reported spending less than 30% of their working time on this population, thereby compromising the effectiveness of nutritional screening and management. Better standardization of practices, increased time allocation for patient care, and enhanced competencies in artificial nutrition appear essential to optimize the nutritional management of hemodialysis patients.

Non-adherence to treatment affects 30% to 50% of patients with chronic diseases. It is associated with an increase in the frequency of acute complications and hospitalizations. In chronic kidney disease (CKD), non-adherence concerns drug treatment, diet, and lifestyle. It may affect up to 62% of hemodialysis patients and 28% of kidney transplant recipients. The long asymptomatic phase of CKD contrasts with a heavy medication burden—two factors that can hinder treatment adherence. In addition, the high prevalence of cognitive and depressive disorders, often underdiagnosed, is associated with the risk of non-adherence in CKD patients. Young age and social isolation have also been identified as risk factors. However, adherence is often difficult to assess. It may vary from one patient to the other, and in the same patient over the course of the disease. Non-adherence can sometimes reflect underlying psychological, personal, or social difficulties. Every health care professional involved in the care of CKD patients has a role to play in detecting poor adherence. In this general review, we discuss the psychological and medical aspects underlying non-adherence, as well as potential therapeutic levers.

Introduction: Type II mixed cryoglobulinemia is most commonly associated with chronic hepatitis C virus infection. The occurrence of marginal zone lymphoma as the underlying cause is rare, especially in the absence of gastric involvement.

Case report: A 63-year-old woman with hypertension and hypothyroidism initially presented with transient purpura following a urinary tract infection. Two months later, she developed acute kidney injury, proteinuria (2.3 g/24 h), and microscopic hematuria. Laboratory tests showed type II mixed cryoglobulinemia (IgM κ + IgG) with hypocomplementemia. Viral serologies, including HCV, were negative. Renal biopsy revealed membranoproliferative glomerulonephritis with IgM and IgG deposits. Blood and bone marrow immunophenotyping confirmed an extragastric marginal zone lymphoma. The patient was treated with six cycles of rituximab-bendamustine.

Results: Complete remission was achieved: recovery of renal function (creatinine 84 μmol/L at 12 months), resolution of proteinuria, improvement of anemia, and regression of splenomegaly. No relapse was observed after 18 months of follow-up.

Discussion/conclusion: This case represents a particularly rare presentation of type II mixed cryoglobulinemia revealing an extragastric marginal zone lymphoma in the absence of viral infection or gastric involvement. It contributes to the sparse literature on this uncommon association. Treatment with rituximab-bendamustine appears to be effective.