Nephrologie & therapeutique最新文献

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.

The presence of chyle in a hemodialysis catheter is a rare complication, usually observed in case of chylothorax secondary to central vein stenosis, particularly of the superior vena cava and the left brachiocephalic vein.We report the exceptional case of a 55-year-old woman in maintenance hemodialysis presenting with chyle in her left subclavian tunneled cuffed catheter during each interdialytic period, without any recent history of trauma or tumoral disease. The chest CT scan was unremarkable. The milky fluid was systematically observed by the nurses at the beginning of each hemodialysis session, before connection. The diagnosis of chyle was confirmed by a very high triglyceride concentration in the aspirated fluid, and the absence of biological and cytological arguments in favor of an infectious or tumoral pathology.A phlebography combining the opacification of the catheter and the left internal jugular vein revealed an aberrant trajectory of the catheter in an endothelial sheath, probably in communication with the outlet of the thoracic duct, which explains the leak of chyle.The removal of the tunneled catheter was followed by the insertion of a new one in the left internal jugular vein, taking a route outside the faulty endothelial sheath. This procedure resulted in complete resolution of the problem, with no recurrence at 10 months of follow-up.This is the first documented description of the presence of chyle in a tunneled catheter for hemodialysis, with no associated chylothorax nor central vein stenosis. This condition was due to a local mechanical complication, i.e., a communication between an aberrant path of the tunneled catheter within an endothelial sheath and the opening of the thoracic duct. We emphasize the importance of a complete phlebographic assessment in case of unexplained presence of chyle in a hemodialysis catheter.

Primarily a respiratory illness, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has a range of extra-pulmonary involvement, including the kidneys, which are often affected. This infection has been associated with the overproduction of serum amyloid A protein, resulting in systemic AA amyloidosis. We report a case of renal AA amyloidosis presenting as a nephrotic syndrome in a patient without any underlying risk factor except COVID-19 infection. This article offers preliminary insights into a potential connection between this emerging viral disease and this complication, awaiting confirmation through future research.

Rhodococcus equi is an aerobic actinomycete initially identified in foal pneumonia and later recognized as an opportunistic human pathogen, particularly affecting immunocompromised individuals. Its incidence increased during the AIDS pandemic and with the rise of organ transplantation. Both cellular and humoral immunity contribute to host defense against R. equi, which is typically acquired through inhalation or ingestion of contaminated materials. The bacterium causes pneumonia that frequently progresses to lung cavitation, bacteremia, and potential dissemination to other organs.We report three cases of R. equi infection in renal transplant patients and review 35 previously published cases. The median age was 49 years, with a male predominance. Most patients presented with necrotizing pneumonia, often associated with bacteremia and soft tissue involvement. Treatment involved reducing immunosuppressive therapy, using bactericidal and intracellularly active antibiotics, and considering surgery when necessary. Prolonged antibiotic therapy and secondary prophylaxis are recommended. Mortality associated with this infection remains high, highlighting the need for early diagnosis and comprehensive treatment strategies.This report emphasizes the importance of considering infectious causes, such as R. equi, in the differential diagnosis of pulmonary masses in immunocompromised patients. Early diagnosis and combined antibiotic therapy are crucial. Lobectomy, though high-risk, may be required for durable infection control when antibiotic therapy is insufficient.

Chronic kidney disease and dialysis have a major impact on patients’ quality of life, affecting their physical, psychological, and social well-being. The DialiCare project, conducted in partnership with an industry stakeholder and health care professionals involved in dialysis care, aims to address these challenges through a collaborative, patient-centered approach.Structured in two phases, the project first identified the priority needs of patients and health care professionals through surveys and regional working groups. Various project proposals were then submitted to a jury made up of a patient association (France Rein), two professional associations (ANFIPA and AFIDTN), and health care professionals who had participated in the initiative. Three projects were selected. The second phase led to the cocreation of three innovative educational tools: the “Roue du prurit” (Itch Wheel), the “Évadez-vous” (“Escape”) project designed to help patients envision themselves engaging in enjoyable activities, and the “Comment se sentent nos patients” (“How Our Patients Feel”) project, a placemat designed to help patients express their emotions and experiences. These tools aim to improve communication between caregivers and patients, objectify symptoms, and promote patient autonomy.The DialiCare project illustrates the importance of a participatory approach in developing concrete solutions tailored to real-world conditions and capable of sustainably improving the quality of life for dialysis patients.