Nephrologie & therapeutique最新文献

We present an overview of kidney transplantation activity in the Maghreb countries, based on data from the 9th Colloque France-Maghreb (Paris, May 20 and 21, 2022). For Algeria, Morocco and Tunisia, the incidence of end stage renal failure is respectively 120, 130 and 130 per million inhabitants, its prevalence 626, 900 and 833 per million inhabitants and the part of patients with a functional graft of 10.3, 1.8 et 8.5% with an annual number of transplants of 6.5, 0.8 and 8.7 per million inhabitants. Living donor transplants account for 99% of transplants in Algeria, 93% in Morocco and 80% in Tunisia. In conclusion, access to transplantation remains low in the Maghreb countries. All the modalities (living donor with enlargement of the circle of donors, deceased donors) must be further developed. Recommendations were issued to support activity.

Introduction: Patients do not always go to the facility closest to their home.

Description: A study was carried out in Provence-Alpes Côtes d'Azur (PACA) on patients' preferences to mobilize the hemodialysis offer.

Methods: The data were extracted from the REIN Registry. Potential access was compared with actual access. A survey was carried out among a sample of patients travelling an additional distance of more than 25 km.

Results: About a quarter of the patients did not travel to the nearest facility. Of these, 16.3% travelled an additional distance of over 25 km. Patients' choices were determined by the relationship of trust with the team that first set up dialysis, followed by their desire to be followed in a multi-purpose facility.

Discussion: While distance remained the decisive factor, human factors were cited in the majority of cases to explain the bypass.

Conclusion: The links between the first team and the next one should be strengthened.

Introduction: Rheumatoid purpura is the most common vasculitis in children, and its renal involvement determines the prognosis. To date, no national protocol exists for its management. A protocol was drafted for the French Grand Ouest inter-region in 2011 in order to standardize practices.

Objectives: The main objective is to evaluate renal sequelae with a median follow-up of 2 years since the implementation of this protocol. The secondary objectives are to evaluate the different therapeutic and diagnostic management.

Method: Inclusion of all children from 2006 to 2018 with nephropathy due to rheumatoid purpura followed in the university hospitals of Rennes, Nantes, Tours, Angers and Brest.

Results: 169 patients were included, of whom 104 were treated accroding to protocol and 65 differently. Sequels at 2-year follow-up concerned 27.0% of patients with no significant difference according to whether or not the protocol was followed. A significant decrease of 26.1% in the number of renal biopsies was observed in the group that followed the protocol. The latter was performed with a median delay of less than 30 days.

Conclusion: The protocol allowed a standardization of practices without deleterious consequences at 2 years of follow-up and a decrease in renal biopsy punctures. It is in agreement with the recommendations of KDIGO (Kidney Disease Improving Global Outcomes) and European experts. On the other hand, in view of recent studies and the physiopathology, immunosuppressive drugs other than corticosteroids could be introduced earlier in severe forms.

There has been a wealth of new developments in dialysis this year with the publication of several trials relating to dialysis technique, physical activity and the use of new dialysis treatments. Quality of life should be assessed and managed in all dialysis patients. Lowering the temperature of the dialysis bath in the MyTemp trial does not appear to have an effect on mortality and cardiovascular events. High volume convective hemodiafiltration currently represents the reference technique in hemodialysis; the Convince study confirms its superiority in terms of all-cause mortality. The DIATT study shows the benefit of the presence of an adapted physical activity professional to promote physical activity in dialysis patients and shows that it is necessary for this support to be reimbursed. The RENAL-AF and AXADIA-AFNET 8 studies lack power to conclude on the use of new oral anticoagulants in hemodialysis. For angiotensin receptor neprilysin inhibitors, studies are too weak to allow their use. SGLT2 inhibitors could be used in peritoneal dialysis to increase diuresis or delay the appearance of peritoneal fibrosis but to date only studies on models animals exist. Factor XI inhibitors are a new therapeutic class that could be used and would reduce the risk of thrombosis and hemorrhage. Increasingly, the feelings of patients and caregivers are more and more taken into account. Patient/caregiver communication must be at the heart of care. We will also be looking at the conservative treatment, the management of pruritus in hemodialysis and finally the care of patients with calciphylaxis.

Introduction: Pre-emptive access to the kidney transplant (KT) waiting list remains limited in France, with only 3.9% of patients on pre-emptive KT and 5.6% of patients registered at the time of initiation of dialysis. A similar trend was observed in Aquitaine. The aim of this study was to assess the impact of a regional program in terms of access to the waiting list for patients initiating a kidney replacement therapy (KRT).

Methods: We included all patients assessed for registration on the list between 2017 and 2020, 2017 being the reference year and 2018 the beginning of the program. Using the CRISTAL and REIN registries, we assessed changes in the number of patients on the list at the time of initiation of dialysis or transplantation.

Results: The number of new assessed candidates increased gradually each year from 255 in 2017 to 352 in 2020 (+38%). The number of patients on the list sharply increased in 2018 from 229 in 2017 to 319 in 2018 (+39.3%) and then remained stable. At the initiation of KRT, the proportion of patients registered on the waiting list increased gradually from 7.1% in 2017 to 18.2% in 2020. The proportion of pre-emptive KT remained stable between 2017 and 2021 (around 7%) with a decrease in 2020 (4.6%). Approximately 60% of patients had a contraindication to transplantation throughout the study.

Conclusion: This study showed that a regional program aimed at providing better information to healthcare professionals and patients and encouraging rapid assessment of transplant candidates could increase the rate of pre-emptive registration on the KT waiting list for eligible patients over 4 years.

Introduction: Smoking is common in chronic hemodialysis patients who are characterized by a high cardiovascular risk.

Patients & methods: This is a multicenter cross-sectional study over a period of 4 months, from July 2021 to October 2021, in the Agadir province.

Results: Among the 245 patients interviewed, 9,4% were current smokers and 16,7% were former smokers. Compared to non-smoking patients, former and current smokers were predominantly male, had more comorbidities, higher diastolic blood pressure, higher mean ultrafiltration rate and more antihypertensive treatments. In multivariate analysis, active smoking was significantly associated with the presence of cardiovascular disease.

Conclusion: Smoking is an important and modifiable cardiovascular risk factor in chronic hemodialysis patients.

Patients with chronic kidney disease (CKD) have an increased risk of cognitive disorders, presenting as vascular dementia, compared with the general population. These cognitive disorders occur early during the course of the kidney disease and evolve in parallel with the decline in glomerular filtration rate. They affect 30 to 80 % of patients with stage 5 CKD. Kidney transplantation only partially improves cognitive impairment. In this narrative review, we summarize the epidemiology and recent clinical and experimental data on cognitive impairment in CKD and discuss the potential specific mechanisms. Among the factors associated with cognitive impairment, the accumulation of uremic toxins such as indoxyl sulfate appears to be a specific risk factor for cognitive decline. These toxins have an endothelial toxicity that can disrupt the cerebral endothelium. The rupture of the blood-brain barrier (BBB) is a mechanism implicated in several neurodegenerative pathologies and systemic diseases with cerebral tropism. Recent experimental findings in CKD indicate that disruption of the BBB appears to be an important mechanism behind cognitive impairment in CKD. In murine models of CKD, increased BBB permeability is linked to memory impairment and aryl hydrocarbon receptor activation following accumulation of circulating indoxyl sulfate. This disruption of the BBB could also have harmful consequences for stroke susceptibility and drug neurotoxicity in CKD patients.

We report the observations of two patients, having voluntarily ingested lethal doses of paraquat with suicidal intent, with an unfavorable prognostic score. The treatment consisted of gastric lavage, administration of activated charcoal, n-acetylcysteine and cyclophosphamide + methylprednisolone + dexamethasone. The installation of acute renal failure motivated the initiation of daily conventional hemodialysis (HD) over 10 to 14 days, with a favorable evolution. The following complications were recorded: anemia, bacteremia and deep vein thrombosis. These observations raise three questions in the treatment of paraquat intoxication: the effectiveness of HD, the interest of its association with the above therapies in the prevention of pulmonary fibrosis, and the need for infectious prevention and thromboembolism. Furthermore, the absence of a paraquatemia assay cannot constitute a limitation for management, and hemoperfusion on an inaccessible charcoal column can be replaced by an HD usually available.

Introduction: Therapeutic patient education (TPE) is gaining importance in the management of patients with chronic kidney disease (CKD). The objective of this study is to assess the interest of TPE in the acquisition of knowledge concerning CKD and renal replacement therapy, as well as the orientation of the patients towards a personalized choice of treatment.

Materials and methods: Patients with a minimum stage 4 CKD were prospectively included between November 2016 and February 2020. We proposed TPE sessions on CKD and its treatment to all patients. We explained the theoretical part through a slideshow about the definition of end-stage renal disease, its symptoms and the various methods of renal replacement therapy. A “basket” of essential material to illustrate a session of hemodialysis (HD) or peritoneal dialysis (PD) was used to achieve the practical part of the study. Data was collected using two questionnaires: the first one, at the start of the session, included the socio-demographic and clinical characteristics of the patients and evaluated their level of basic knowledge, and the second one, at the end of the session, assessed the evolution of knowledge after TPE, leading to a therapeutic choice.

Results: The mean age of the 211 included patients was 55.59 years old (SD = 15.47). Male to female ratio was 0.73. The level of education was low in 69% of the cases of whom 23.7% were employees. The glomerular filtration rate (GFR) was between 15 and 30 mL/min in 56.8% of the cases. Initial nephropathy was known in 60% of patients while the stage of CKD was unknown in 66.4%. Before TPE, patients with a good level of overall knowledge were around 29%, rising to 73% after TPE. A significant correlation was found between the level of education of the patients and their knowledge score before and after TPE. The choice of renal replacement therapy was taken for PD, TR and HD respectively in 36%, 19% and 11.8% of the cases, while 33.2% asked for time to think. Elderly and/or low educated patients most often remained undecided; moreover those who are young and/or educated prefer TR. During the follow-up period, 46% of patients started renal replacement therapy (36.5% started HD, 8.1% PD and 1.4% KT). The choice made by our patients was respected in 42% of the cases: in all the patients who chose HD; in 36% of those who chose PD, and 19% of those who chose kidney transplantation (KT). The final therapeutic modality was strongly linked to the following parameters: age, GFR and level of education.

Conclusion: This study highlighted the insufficient level of patients’ information about CKD and its treatment and allowed the patients to express their choice of their replacement therapy, which is a complicated process that must ­integrate the opinion of the nephrologist and the patient’s preference to lead to an ­optimal organization of the therapeutic modality.

Late thrombosis of the renal graft vein is a rare complication that results in graft loss in the majority of cases. We describe the case of a 57-year-old female patient who had a kidney transplant 32 years ago and developed a late thrombosis of the graft vein, accompanied by extensive thrombosis in the common femoral and iliac veins. Risk factors included severe malnutrition, chronic inflammation due to an anal fistula, and Cockett syndrome. The treatment consisted of mechanical thrombectomy of the iliac vein, placement of a stent in the common iliac vein, partial thromboaspiration of the renal vein thrombus with local thrombolysis, followed by systemic anticoagulation. With this approach, renal function fully recovered without major complications.