Nephrologie & therapeutique最新文献

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.

Introduction: Iron deficiency (ID) is common in patients with chronic kidney disease (CKD) but remains under-diagnosed and its prognosis poorly documented in the absence of anemia. The aim of the study was to assess the relationship between ID and the risk of major adverse outcomes in patients with CKD.

Methods: Using data from the French Chronic Kidney Disease - Renal Epidemiology and Information Network (CKD-REIN) cohort which included and followed over five years, 3,033 patients with CKD stages 2 to 5 CKD, we estimated the prevalence of ID, defined by a ferritin level < 100 μg/L and/or a transferrin saturation < 20%, and associated hazard ratios (HR) of kidney failure with replacement therapy, kidney failure defined by an eGFR < 15 mL/min per 1.73 m2 or initiation of kidney replacement therapy, all-cause mortality, and death or hospitalization for heart failure.

Results: Baseline prevalence of ID in the cohort (66% men; mean age 67 ± 13 years) was 50% (48-52). Mean hemoglobin was 13 ± 1.7 g/dL, and only 31% of patients with ID also had a hemoglobin < 12 g/dL. In 2,803 patients with CKD stages 2-4 at baseline, ID was associated with significant increased risk of kidney failure, and of kidney failure with replacement therapy, with HRs adjusted for confounders and hemoglobin level of 1.22 (1.03-1.45) and 1.57 (1.27-1.94), respectively. Adjusted HRs for all-cause mortality and hospitalization or death for heart failure, were 1.31 (1.04-1.66) and 1.38 (1.07-1.80), respectively.

Conclusion: This study shows that ID is significantly associated with the risk for kidney failure, all-cause mortality, and heart failure, independent of the presence of anemia.

Acute kidney injury is a common drug adverse reaction and may concerned antibiotics. We report a case of an acute renal failure due to amoxicillin occurring twice in the same patient. Two mechanisms have been described for amoxicillin, with an immuno-allergic origin observed in our case. The diagnosis, supported by kidney biopsy, was confirmed by rechallenge with this patient.

Introduction: Primary hyperoxalurias (PH) are rare and serious genetic diseases. Their prognosis is improved with early medical management. However, diagnosis often occurs at the end-stage of renal failure. To understand this delay, collecting real-world data on the clinical practices of nephrologists may be helpful.

Materials and methods: Between October 2021 and October 2022, a retrospective survey was conducted in France among 76 nephrologists to assess management practices for patients with chronic kidney disease (CKD) of unknown aetiology, associated with urinary lithiasis and/or nephrocalcinosis. Data on patient profiles, tests conducted, diagnoses considered, and management of suspected PH cases were collected.

Results: 97% of patients (n = 386/400) underwent a renal examination, 92% (n = 370/400) a thorough urinary check-up, and 65% (n = 260/400) had an interpretable oxaluria value from a 24-hour urine sample (Uox24h). Of these 260 patients, 50% (n = 130/260) had Uox24h > 500 µmol/24 h: 23% (n = 30/130) were suspected of PH by the nephrologists, and 15% (n = 19/130) were referred for genotyping. Considering all criteria, 52 patients were suspected of PH (42% of whom did not have Uox24h > 500 µmol/24 h), and 33% (n = 17/52) were not referred for genotyping.

Discussion: The survey highlights nephrologists' adherence to recommendations for prescribing biological tests. However, in cases of hyperoxaluria or suspected PH, genotyping was not always prescribed. The barriers to this prescription need further exploration.

Introduction: Sleep and mood disorders are common in hemodialysis, but the effect of light therapy remains unknown in this population.

Methods: We conducted a randomized, controlled, open-label pilot trial comparing two group of either 30 minutes of light therapy three times a week, or no exposure. The primary endpoint was change in sleep quality (PSQI) after five weeks of light therapy, with change in mood (DASS-21) as a secondary endpoint. We added the description of the same criteria in a prospective, non-randomized, real-life post-trial cohort.

Study results: We included 28 analyzable patients in the pilot study. Light therapy had no significant effect on PSQI reduction (p = 0.496). There was a trend towards a reduction in depression (-6.2 [95% CI, -12.5 to -0.05], p = 0.058). In the real-life cohort, out of 27 patients, 12 had a significant reduction in depression score (≥ 6 points).

Discussion: Light therapy performed in hemodialysis three times a week appears to have no effect on sleep quality, but could reduce depressive states. The technique is easy to implement, well tolerated and inexpensive. A multicenter randomized trial against the sham device will be needed to validate its effect on depression.

Acute kidney injury is a common drug adverse reaction and may concerned antibiotics. We report a case of an acute renal failure due to amoxicillin occurring twice in the same patient. Two mechanisms have been described for amoxicillin, with an immuno-allergic origin observed in our case. The diagnosis, supported by kidney biopsy, was confirmed by rechallenge with this patient.