Nephrologie & therapeutique最新文献

The creation of the National Health Data System aims to collect, structure, and make analyzable the various documents resulting in particular from hospitalization, outpatient care, death certificates, and disability-related measures, in order to provide a population-based, longitudinal, and consistent view of care pathways.

Preeclampsia is a maternal syndrome of placental origin that complicates 2–5% of pregnancies. It remains one of the leading causes of maternal mortality worldwide and is a major contributor to fetal and neonatal morbidity and mortality. It is classically defined, after 20 weeks of gestation, by the combination of arterial hypertension and proteinuria ≥ 0.3 g/24 h. In its severe form, it may induce endothelial injury consistent with thrombotic microangiopathy in the liver and kidneys and can lead to fatal posterior cerebral edema. For many years, preeclampsia was referred to as the “disease of theories,” because the link between this systemic maternal syndrome and the placenta remained elusive until 2003—nearly three centuries after François Mauriceau, surgeon at the Hôtel-Dieu in Paris and obstetrician to the court of Louis XIV, first suggested such a connection.

Background: Real-world practices for managing anemia and iron deficiency in chronic kidney disease appear heterogeneous and sometimes controversial. This study aimed to describe the prescribing preferences and habits of French nephrologists in this area.

Methods: All nephrologists seeing patients at one of the 40 centers participating in the Chronic Kidney Disease - Renal Epidemiology and Information Network (CKD-REIN) cohort were invited to participate in two waves (2015-2016 and 2019-2020) of a practice survey. The self-administered questionnaires collected information on nephrologists' characteristics and their management strategies for anemia and iron deficiency in patients with stage 4-5 CKD.

Results: A total of 137 nephrologists participated in the first wave and 60 in the second wave. Most reported initiating treatment with erythropoiesis-stimulating agents (ESAs) when hemoglobin levels were between 9.5 and 10.5 g/dL (85% in the first wave and 96% in the second). In patients with anemia and iron deficiency, the thresholds for initiating iron therapy varied widely: for oral iron, transferrin saturation (TSAT) ranged from 10% to more than 35% and ferritin from 50 to 500 μg/L; for intravenous iron, TSAT ranged from 10 to 30% and ferritin from 50 to 500 μg/L.

Conclusion: Between 2015-2016 and 2019-2020, French nephrologists' practices for ESA management were relatively homogeneous and in line with current recommendations. In contrast, approaches to iron deficiency varied greatly among practitioners.

We report the case of a 52-year-old man with Von Hippel-Lindau disease who had been receiving nocturnal home hemodialysis for ten months following bilateral nephrectomy for multifocal clear cell renal carcinoma. He presented with a firm, painless subcutaneous nodule on the right anterior thigh, featuring a central crater filled with chalky-white material. Skin biopsy revealed dermal calcium deposits surrounded by a fibrous and histiocytic reaction, consistent with dystrophic calcinosis cutis. Additional nodules were palpable on the left calf and right biceps. Bilateral femur X-rays were normal. Persistent hyperphosphatemia and inadequate dialysis likely contributed to the development of these extraosseous calcifications. Management included intensification of phosphate binder therapy and increased dialysis frequency. This case illustrates the potential interplay between hereditary tumor syndromes and dialysis-related mineral metabolism disorders, highlighting the risk of severe extraosseous calcifications in such patients.

This single-center retrospective cohort study divided 176 adults with biopsy-proven primary glomerulonephritis (GN) between 2014 and 2021 into 4 groups based on cortical interstitial fibrosis (IF) percentage. The primary outcome was disease progression, defined as a ≥ 40 % decline in estimated glomerular filtration rate (eGFR) and/or the need for dialysis. The secondary outcome was complete remission, defined as proteinuria < 300 mg/24 hours.Baseline proteinuria and serum creatinine increased with greater IF severity, while eGFR decreased. Kaplan-Meier analysis showed a higher risk of progression in patients with severe IF. After adjusting for glomerulosclerosis, baseline eGFR, proteinuria, and treatments, IF severity remained an independent predictor of progression (HR 3.15). IF was not independently associated with achieving complete remission. Stratified analyses suggested a stronger association in immunoglobulin-A (IgA) nephropathy, while results for focal segmental glomerulosclerosis (FSGS) and membranous glomerulonephritis (MGN) were inconclusive due to limited statistical power.In summary, the severity of IF on diagnostic biopsy is a strong and independent prognostic factor for disease progression in primary glomerular diseases, supporting its routine standardized assessment to improve risk stratification and personalized patient management.

Introduction: The renal risks of iodinated contrast media (ICM) and the association of gadolinium-based contrast agents (GBCAs) with nephrogenic systemic fibrosis (NSF) have been recently reassessed.

Methods: International guidelines (Société francophone de néphrologie, dialyse et transplantation/Société française de radiologie [SFNDT/SFR], European Society of Urogenital Radiology [ESUR], American College of Radiology/National Kidney Foundation [ACR/NKF], Canadian Association of Radiologists [CAR] 2018-2025) were reviewed, focusing on risk stratification, preventive measures, and the use of ICM and GBCAs in patients with chronic kidney disease (CKD).

Results: Post-contrast acute kidney injury risk is low for eGFR ≥ 30 mL/min/1.73 m². Hydration is recommended only for eGFR < 30 mL/min/1.73 m² or first-pass intra-arterial injections. Group II GBCAs are considered safe even in advanced CKD or dialysis, with a single unconfirmed NSF case reported.

Discussion: Differences between guidelines reflect their timing and limited evidence. Preventive measures should focus on the highest-risk situations.

Conclusion: Clinical indication should guide imaging, which should not be delayed, and recent guidelines support a rational, risk-based approach to contrast media use.

In chronic hemodialysis patients, optimal INR control is critical to reduce bleeding and thromboembolic risks associated with vitamin K antagonist (VKA) therapy. This study evaluates the impact of an optimized protocol combining INR self-testing and supervised VKA administration on anticoagulation quality. A monocentric observational comparative study was conducted in 24 hemodialysis patients treated with VKAs, monitored successively under two modalities: a standard protocol (SP, January–March 2024) followed by an optimized protocol (OP, July–September 2024). Three biological indicators were assessed: mean INR, intra-individual INR variability (coefficient of variation, CV), and time in therapeutic range (TTR, INR 2.0–3.0). No clinical endpoints were collected. The mean INR coefficient of variation (CV) significantly decreased from 35% under the SP to 25% under the OP (p < 0.01), reflecting a marked improvement in treatment stability, particularly among initially unstable patients. The mean TTR, moderately satisfactory under SP (63%), increased to 71% under OP, although this difference did not reach statistical significance (p > 0.05). A reduction in extreme values and a more homogeneous INR distribution were also observed. The implementation of the optimized protocol led to improved INR control by significantly reducing intra-individual variability. This improvement may provide clinical benefits, including a reduced risk of hemorrhagic or thromboembolic events. These findings support the value of enhanced monitoring strategies that combine self-testing and supervised VKA administration to improve patient safety and reinforce treatment adherence.

We report two cases of complete remission of uremic calciphylaxis in hemodialysis patients despite continued use of vitamin K antagonists (VKAs). These cases highlight the potential of a multimodal treatment approach including rheopheresis as a promising therapy when VKA discontinuation is not feasible. Both patients presented with severe calciphylaxis while on VKAs for mechanical mitral valve replacement. They received intensive multimodal treatment, including daily hemodialysis, intravenous sodium thiosulfate, calcimimetics, phosphate binders, opioid analgesics, and plastic surgery evaluation. In addition, rheopheresis was initiated twice weekly for four months, during which VKAs were maintained. Rheopheresis frequency was then gradually reduced. Complete wound healing was achieved within seven months. Both patients subsequently underwent parathyroidectomy for tertiary hyperparathyroidism.To our knowledge, these are the first reported cases of full remission of calciphylaxis without VKA discontinuation. A multimodal, multidisciplinary treatment strategy may represent an effective approach for high-risk anticoagulated patients.

Urinary stone disease is a common and recurrent condition that can lead to complications such as urosepsis or urinary tract obstruction, which may progress to chronic kidney disease. Effective management requires close collaboration between urologists and nephrologists. Urologists manage acute episodes and perform the appropriate surgical procedures, whereas nephrologists conduct second-line metabolic assessments and implement targeted preventive strategies. Stone morpho-constitutional analysis and therapeutic patient education are essential pillars of care. Multidisciplinary meetings enhance coordination and clinician training. At Edouard Herriot Hospital, a structured pathway coordinated by an advanced practice nurse exemplifies the benefits of an integrated, patient-centred approach.

In France, disparities in the supply of and access to care can contribute to differences in population health status. These socio-territorial health inequalities (STHI) are both unfair and avoidable and therefore require better understanding in order to limit their occurrence and consequences. Social deprivation has been shown to be associated with an increased risk of chronic kidney disease, delayed referral to nephrologists, and reduced access to waitlisting and kidney transplantation. We hypothesize that limited access to primary care constitutes a barrier to access to nephrological care. This article proposes an updated overview of the terminology and tools used to define and measure STHI, as well as a review of studies examining the impact of geographical accessibility on the nephrological care pathway.