Nephrologie & therapeutique最新文献

Due to increased use of kidneys from extended criteria donors, there is an increase early use of belatacept to avoid the nephrotoxicity of calcineurin inhibitors. A belatacept calcineurin inhibitors-free regimen is associated with an increased risk of T-cell mediated rejection and opportunistic infections, particularly cytomegalovirus infection. To prevent cytomegalovirus infection, a novel anti-viral drug, letermovir, is now available. In patients who present refractory/resistant cytomegalovirus infections, it is nowadays recommended to use maribavir. However, the management of CMV infection still requires further studies. For instance, the role of anti-cytomegalovirus immunoglobulins to prevent or to treat cytomegalovirus infection in association to classical anti-viral drugs requires to be studied. The effect of belatacept on BK virus replication is controversial. There is no specific anti-viral treatment directed against BK virus. It is recommended to monitor closely BKV DNAemia and to reduce immunosuppression in case of positivity, especially in patients with high viral load or polyomavirus BKV-associated nephropathy

Background: Interfering RNA therapies (RNAi) have changed the management of patients with hyperoxaluria type 1 (PH1); data in dialysis remain scarce.

Results: A PH1 teenager undergoing intensive hemodiafiltration received lumasiran. POx levels almost halved during the loading phase (98 to 52 µmol/L), but rebound occurred when doses were quarterly-spaced, with POx at 94 µmol/L at 5 months. Lumasiran injections were therefore performed monthly, allowing adequate POx control (52 µmol/L) and isolated kidney transplantation. We also evaluated POx in 26 non-PH1 children with current dialysis techniques at a median(range) age of 10.9 (2.6-17.0) years, time on dialysis 14 (0-52) months, and POx 35 (8-125) µmol/L; residual diuresis was associated with lower POx. Circulating glycolate levels were normal in non-PH1 patients.

Conclusion: Intensification of lumasiran therapy is possible in dialysis and improves POx levels before kidney transplantation; POx levels in non-PH1 pediatrics patients in dialysis are provided to improve decision making in transplantation.

Sleep disorders are common in all stages of chronic kidney disease and significantly affect the quality of life of these patients. The main causes of sleep disorders are pruritus, depression, restless legs syndrome and obstructive sleep apnea. To date, there is no defined strategy or expert consensus for the screening of sleep disorders in this population, nor any recommendation on a specific management strategy according to etiology. We propose to use the PROMIS-29 questionnaire, to which two questions have been added: “Do you scratch yourself? Do you snore?” The answers to these questions, together with the scores for the “Sleep disorders” (score ≥ 12), “Depression” (score ≥ 11), “Pain” (score ≥ 11) and “Fatigue” (score ≥ 14) domains make it possible to screen for sleep disorders, specify their etiology and refer patients for appropriate management. We suggest a standardized management strategy for each major orientation. This pathway, to be adapted according to the resources of each center, should lead to the diagnosis of more patients suffering from sleep disorders and improve their quality of life.

Background: Acute Kidney Injury (AKI) in pregnant women admitted for severe pre-eclampsia (PE) is common in developing countries. The aim of this study was to determine the frequency and associated factors of AKI in severe pre-eclampsia in Lomé.

Methods: A case series study was conducted from July 18, 2019, to August 17, 2022, at the Sylvanus Olympio University Hospital (CHU-SO) in Lomé, Togo. All pregnant women who were admitted with severe pre-eclampsia and had at least two measures of creatinine were included. AKI was defined according to the Kidney Disease Improving Global Outcomes (KDIGO) 2012 criteria.

Results: A total of 220 cases of severe preeclampsia were analysed during the study period. 44 cases of severe pre-eclampsia (20%) were complicated in AKI. The mean age of patients with AKI was 30 ± 5.40 years (versus 30.2 ± 6.94 years for patients without AKI). Factors associated with the occurrence of AKI in multivariate analysis were multigravidity (adjusted Odd Ratio [aOR] = 3.15, 95% CI, [1.16-8.57]); the presence of infectious syndrome (aOR = 2.69; 95% CI, [1.05-6.91]) and haemoglobin levels ≤ 10 g/dL (aOR: 2.76; 95% CI [1.34-5.69]). There were no maternal deaths.

Conclusions: The occurrence of AKI during severe preeclampsia is high at the CHU-SO in Lomé, Togo. The factors associated to AKI occurrence were multigravidity, infectious syndrome and haemoglobin level. Pregnant women with these factors should be closely monitored to avoid the occurrence of AKI.

HUS induced by shigatoxin-producing Escherichia coli (STEC HUS) is a serious disease requiring dialysis in 50% of cases, but renal recovery is frequent. Renal sequelae such as proteinuria, arterial hypertension (AH) and chronic renal failure (CRF) are possible in 30% of cases. Several prognostic factors have been identified, the main one being the duration of anuria. The aim of our paper is to describe the outcome of typical HUS in a cohort of patients followed over three years, and to detect reliable early predictors of poor prognosis in a specialized department in Algeria. Our study is observational and longitudinal. Inclusion criteria were the triad anemia-thrombocytopenia-acute renal failure (ARF) in children under sixteen years of age. Clinical and laboratory data were collected prospectively at baseline, at three months and every six months.A cohort of 23 children was recruited. The rate of recovery of renal function and death was 83% and 13%, respectively. There is a significant correlation between the presence of neurological damage, young age < 2 years and the occurrence of kidney damage. Late dialysis > 48 hours multiplies the relative risk of kidney damage by four. Event-free survival (death or occurrence of proteinuria, hypertension and/or CKD) is significantly related to young age and the time to dialysis > 48 hours. Delayed dialysis has a significant impact on overall survival. The latter factor increases the risk of death. Early diagnosis and management are important prognostic factors. Nephrological follow-up of all children with HUS is necessary in order to detect progression to CKD.

Renal involvement in ANCA vasculitides (AAV) is frequent and often severe, leading to end-stage kidney disease either immediately, in the follow-up or after episodes of relapses. Renal involvement is associated with other organ involvement in granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (PAM), but may also be isolated in vasculitis limited to the kidney. It is less common in eosinophilic granulomatosis with polyangiitis (GEPA). The classical clinical presentation is one of rapidly progressive glomerulonephritis, associated with the presence of PR3-ANCA or MPO-ANCA. Kidney biopsy (showing pauci-immune extra-capillary glomerulonephritis) is not essential for the diagnosis of VAA, but it does have a prognostic value, can rule out other causes of glomerulonephritis (especially in renal-limited forms of AAV) and can help for the decision of plasma exchange use.Treatment of AAV with renal involvement is based on a combination of corticosteroids and immunosuppressants (rituximab or cyclophosphamide). Avacopan may also be proposed as a cortisone-sparing treatment. This review sets out the various recommended therapeutic protocols and their scope of application. The role of plasma exchange is also discussed.

Medullary sponge kidney is a disease characterized by precaliceal dilatation of the renal tubules. Clinical manifestations include recurrent kidney stones, urinary tract infections, hematuria and back pain. Biological abnormalities such as hypocitraturia, hypercalciuria or hyperoxaluria are most often associated with active and recurrent lithiasis. Diagnosis is challenging, based on imaging, formerly intravenous urography and now Multidetector computed tomography urogram, or ureteroscopy. The pathophysiology is not well understood, hypotheses involve disturbances in renal organogenesis. Genetic origin and congenital nature of the disease are suspected. Treatment is mainly symptomatic and includes prophylactic dietary rules common to all nephrolithiasis patients. The natural course of the disease is unknown. Further data are needed to better characterize these patients.

Objectives: To assess the impact of teaching methods on skill acquisition in medical students, using an objective structured clinical examination (OSCE).

Methods: Observational study on medical students in France after training on hyponatremia using lecture course, individualized teaching without presentation, or reverse OSCE.

Results: We included 77 students. Their mean score ± standard deviation was 55 ± 15 points [2.5-90]. Students using the reverse OSCE scored significantly lower in both the test and the overall evaluation, although this teaching modality was preferred, even after adjustment for the year of study. A significant correlation between self-evaluation and test results was observed. Most students felt that the OSCE evaluation allows them to measure their level of learning.

Conclusion: The OSCE is an assessment method appreciated by medical students, but reverse OSCE were not associated with improved results at evaluation, although a possible bias due to center effect needs to be acknowledged.

Proper management of lithiasis-related diseases is essential, as they often cause pain that can be difficult to alleviate, leading to significant morbidity and substantial healthcare costs. In rare cases, lithiasis may indicate a more serious underlying condition that could progress to chronic kidney disease.The French Association of Urology (AFU) provides recommendations for the initial assessment of any patient experiencing a first episode of lithiasis, emphasizing the importance of stone analysis, dietary assessment, and crystalluria analysis when available. Simple measures, such as ensuring adequate hydration and a balanced intake of sodium, protein, and calcium, can help reduce the risk of stone formation in most cases. The use of a crystallization inhibitor, such as citrate, may also be indicated. Additional treatments may be considered depending on the stone type and any underlying biochemical abnormalities.These guidelines also describe criteria leading to a more comprehensive secondary evaluation, which may reveal conditions such as hyperoxaluria. This condition can be dietary, secondary to malabsorption, or due to genetic causes, such as primary hyperoxaluria (PH). Diagnosing PH is particularly crucial in the case of type 1 PH, as it can lead to renal failure and systemic oxalate accumulation, with a high risk of immediate recurrence in transplanted kidneys.Before the advent of RNA interference (siRNA) therapies, conservative treatment options—such as pyridoxine, hyperhydration, and crystallization inhibitors—were the primary strategies to slow the progression toward renal failure, with combined liver-kidney transplantation considered for end-stage renal disease. Current approaches now favor isolated kidney transplantation with adjunctive siRNA therapy, although this strategy requires careful, case-by-case consideration.

Context: Poor medication management can lead to adverse outcomes for transplant patients, including acute rejection and graft loss. In recent years, mobile applications have been proposed as innovative tools to improve patient treatment management.

Objective: This review aimed to systematically evaluate the available research evidence on the relationship between mobile applications and treatment management in transplant patients.

Methods: The following databases were systematically searched for relevant publications on April 8, 2022, using the PRISMA method: PubMed, Embase, and Google Scholar. The Cochrane risk of bias tool was used to assess the included studies. Observational or interventional studies focusing on the use of mobile applications in adult solid organ transplant patients were included for analysis.

Results: A total of 28 articles met the inclusion criteria. The overall methodological quality of the evidence was assessed as low. Most studies were monocentric (n = 23, 82%). The majority of follow-ups focused on kidney transplants (n = 12, 42.9%) with small sample sizes (54%, n < 99), including participants < 60 years old (n = 26, 93%) with follow-up ≤ 6 months (61%). Medication adherence rates showed significant improvements in seven out of 13 trials compared to standard care or placebo. Several features were reported to be most effective in improving patient treatment management, such as self-registration and monitoring, medication reminders based on alerts, and caregiver monitoring to check patients' health indicators or medication adherence.

Conclusion: Mobile applications tended to improve medication management in transplant patients compared to standard care. However, due to the heterogeneity of the objectives of the analyzed studies, which do not allow for meta-analysis, further high-level evidence studies evaluating the effects of mobile applications in this area are needed to support effective interventions.