Nephrologie & therapeutique最新文献

The year 2024 of kidney transplantation was rich in communications in five main selected fields: immunomonitoring biomarkers, therapeutic innovation with anti-CD38 antibodies, tele-monitoring opportunities, patients’ quality of life and health equity considerations. Two biomarkers were consecrated in 2024: the TorqueTenoVirus (TTV) viral load and donor-derived cell-free DNA (dd-cfDNA). Antibodies directed against CD38 both in the field of desensitization and treatment of antibody-mediated rejection showed promising results and promise further upcoming clinical trials. Tele-monitoring of transplanted patients, with the use of dedicated smartphone applications, suggests new ways to improve the logistic of care together with the quality of care. This notion of patient-reported quality of life is gathering importance in the field. It is associated with the patient’s microbiome, opening new potential treatment opportunities. Finally, ethical considerations bring us to think of quality of care in female kidney transplant recipients: as of 2024, this quality remains insufficient when compared to male recipients.

The year 2024 marks significant progress in nephrology, particularly in immunoglobulin A (IgA) nephropathy and nephroprotection. In IgA nephropathy, new molecules such as sibeprenlimab and atacicept, targeting the BAFF and APRIL pathways, have shown a reduction in proteinuria and stabilization of glomerular filtration rate (GFR), confirming the importance of these pathways in the disease. Furthermore, the involvement of the microbiota in the pathology opens up promising therapeutic prospects. In nephroprotection, the combination of SGLT2 inhibitors, endothelin receptors and GLP1 agonists enhances the management of chronic kidney disease, including diabetic nephropathy, with positive effects on proteinuria and renal survival. The discovery of anti-nephrin antibodies in idiopathic nephrotic syndrome (INS) marks a major step forward, enabling better prediction of the response to immunosuppressants and a more refined diagnosis between autoimmune and genetic pathologies, and opening up the future prospect of more personalized management of this pathology. Derived from hematology, anti-CD38 therapies are also showing promising results in glomerulopathies, while CAR-T cells are opening the way to new therapeutic options for refractory autoimmune diseases such as lupus. These advances testify to a move towards precision medicine in nephrology, where the personalization of treatments could, in time, significantly improve the management of patients with kidney pathologies.

In 2024, dialysis is experiencing advancements, particularly in environmental sustainability. “Green dialysis” is emerging as a priority, aiming to reduce the carbon footprint of dialysis centers (water and resource consumption, patient transportation). Innovative strategies, such as adjusting dialysate flow rate and temperature, have demonstrated similar effectiveness to standard dialysis in terms of Kt/V while reducing water consumption. A recent Cochrane review confirms the equivalence between peritoneal dialysis (PD) and hemodialysis (HD) in terms of mortality. Additionally, hemodiafiltration (HDF) is regaining attention thanks to the CONVINCE study and its ancillary studies, which show a reduction in mortality risk and an improvement in quality of life. Furthermore, technical adaptations are making HDF more environmentally friendly. Anticoagulation strategies are also evolving: heparin-free dialysis, using calcium-free dialysate and reinjection controlled by ionic dialysance, has proven effective. A large French study based on the Rein registry and the National Health Data System database shows that direct oral anticoagulants, particularly apixaban, although not officially approved for dialysis (off-label use), offer promising prospects for reducing thromboembolic risk. Chronic inflammation, a major cardiovascular risk factor in dialysis patients, is the focus of therapeutic trials targeting IL-6 (clazakizumab), with encouraging phase II results. Meanwhile, dialysate sodium management is being reassessed: individualized reductions can help better control blood pressure but must be used cautiously in certain patients. Finally, in elderly patients contraindicated for transplantation, initiating hemodialysis provides only a modest survival benefit, sometimes at the cost of reduced time spent at home. Decisions between dialysis and conservative management (opting not to dialyze) should therefore be guided by patient preferences and quality of life.

Background: In infants with chronic kidney disease (CKD), the management of nutrition and growth is highly challenging, particularly compared to older children. Management of hyperkalemia and hyperphosphatemia is difficult, and incorporating potassium and phosphate binders directly in formulas could be beneficial, as it avoids direct ingestion of resins by infants.

Materials and methods: We conducted a study using Gallia® standard first-stage infant formula and Pregestimil®. We added either carbonate sevelamer (Renvela®, 200, 400 or 800 mg) or polystyrene sulfonate (Resikali®, 2000, 4000 or 8000 mg) to 90 ml of formula. Additionally, we evaluated the combined use of the resins with Gallia® by adding in 90 mL 200 mg/2000 mg, 400 mg/4000 mg, and 200 mg/4000 mg of Renvela® and Resikali®, respectively. The Milk was decanted for 10 minutes, and the resulting supernatants were weighted and analyzed for osmolality and pH. Sodium, potassium, chlore, bicarbonate, magnesium, glucose, calcium, phosphate, protein, cholesterol, triglycerides, iron, folate, vitamin B12 levels were measured after centrifugation.

Results: With polystyrene sulfonate, potassium levels in milk decreased in a dose-dependent manner, by 36%, 52% and 68%, respectively. Polystyrene sulfonate also reduced magnesium levels and increased both calcium concentration (from 9.7 to 21 mmol/L) and osmolality (from 359 to 423 mOsm/kg). No significant effect on phosphate was observed. Sevelamer decreased both calcium and phosphate concentrations in a dose-dependent manner, by 14%, 26% and 29%, and by 24%, 36% and 40%, respectively. Sevelamer also increased pH from 6.9 to 9.1, and decreased folate levels by 32%, 66% and 81% respectively, from 465 to 88 mmol/L. The combined use of sevelamer and polystyrene sulfonate results in decreased levels of potassium (by 45%, 59% and 59%, respectively), phosphate (by 38%, 39% and 36%, respectively), and folate, albeit with a slighter increase in pH. Osmolality remained unchanged and no other relevant differences were observed.

Conclusion: Pretreating formulas with resins is a reproducible and straightforward method when specific diets for CKD are unavailable. However, it is important to keep in mind that resins may impact the overall composition (osmolality) and the concentration of other nutrients (folates).

The healthcare sector emits 8% of France’s greenhouse gases. Working groups within healthcare establishments and learned societies are proposing actions to reduce emissions in the field of care, but clinical research studies also contribute to the healthcare system’s carbon footprint. Their greenhouse gas emissions are only just beginning to be calculated, and the measures to be put in place imagined. In this article, we present ten proposals for reducing the environmental impact of clinical research. The most significant measures for reducing greenhouse gaz emissions are intensive digitalization of clinical research and almost total elimination of research team and patients’transportation. The contribution of artificial intelligence is certain, but at what price. These measures must be adopted by the pharmaceutical industry and research funders. They also require an adjustment of current regulations.

Purpose: Most kidney stones are made of calcium oxalate. Many kidney stone formers stop drinking tea, resulting in reduced diuresis. The oxalate in tea diffuses rapidly during infusion. We hypothesized that pre-infusion of tea could significantly reduce its oxalate content.

Methods: Tea bags were infused for 0.5, 1, 2 or 3 minutes, with or without a pre-infusion of 10, 30 or 60 seconds (16 conditions, n=4/condition). Oxalate concentration was measured and a blind organoleptic analysis was carried out by 4 operators.

Results: A 10 seconds pre-infusion reduced the oxalate concentration of tea by 10 to 33% (p<0.05). A 30 seconds pre-infusion reduced it by 38 to 51% (p<0.05) and a 1 minute pre-infusion by 59 to 65% (p<0.05). Pre-infusion had no significant impact on satisfaction scores for taste, smell or visual appearance.

Conclusion: Pre-infusion of tea significantly reduces oxalate intake (by up to 2/3 depending on conditions).

Background: The peritoneal dialysis (PD) regimes should be individualized based on clinical tolerance and adequacy. Routine hydrostatic intraperitoneal pressure (IPP) measurements have been suggested to define optimal intraperitoneal dialysate volume (IPV), data on applicability and variability in clinical routine are few.

Methods: We retrospectively analysed 655 IPP measurements monthly performed in 21 children on stable automated PD. IPP was measured with the day-time dwell volume (IPV 606 ± 303 mL/m2) after two-hour dwell time (IPP1; n = 430), and again with the night-time dwell volume (IPV 958 ± 274 mL/m2) after 10 min dwell time (IPP2; n = 225), using bicarbonate (BPDF) and lactate buffered (LPDF) low GDP fluids and icodextrin fluid (IPDF), respectively. Findings were related to PD related complications and Kt/V.

Results: Mean of all IPP measurements was 11.0 ± 2.6 cmH2O or 2.1 ± 0.8 cmH2O/100 mL/m2, with a mean IPV of 7.3 ± 3.4 mL/100 mL/m². Mean IPP1 was 10.3 ± 2.2 cmH2O, corresponding to 6.1 ± 3.1 mL/100 mL/m² IPV, IPP2 was 12.5 ± 2.5 cmH2O, corresponding to 9.6 ± 2.6 mL/100 mL/m² IPV (IPP1 vs IPP2 p < 0.0001).

Conclusion: The values of IPP were acceptable in this pediatric population. IPP is relatively higher with higher fill volumes per BSA. Using single fill volume IPP measurements provides IPP with high intra- and interindividual variability. The relation to patient outcome is uncertain.

The standard immunosuppressive treatment after organ transplantation typically includes a calcineurin inhibitor (tacrolimus or cyclosporine A), an antimetabolite (mycophenolic acid) or an mTOR inhibitor, and corticosteroids. However, these treatments are associated with multiple side effects, including nephrotoxicity. Belatacept, a fusion protein blocking the CD80/86 costimulation pathway, emerges as an effective and well-tolerated alternative. Initial phase III studies showed that de novo belatacept improves renal function and reduces the incidence of donor-specific antibodies, despite a higher rate of acute cellular rejections. Early conversion studies (within the first 6 months post-transplantation) demonstrate significant improvement in renal function, particularly when conversion is performed early. However, the risk of acute rejection and opportunistic infections must be monitored. This article summarizes the available studies on early conversion to belatacept in kidney transplanted patients.