Atteintes cardiovasculaires associées à la polykystose rénale autosomique dominante

Autosomal dominant polycystic kidney disease is the most frequent genetic kidney disease. Cardiovascular disorders associated with autosomal dominant polycystic kidney disease are multiple and may occur early in life. In autosomal dominant polycystic kidney disease cardiovascular morbidity and mortality are related both to the nonspecific consequences of chronic kidney disease and to the particular phenotype of autosomal dominant polycystic kidney disease. Compared to the general population, patients with autosomal dominant polycystic kidney disease present an increased prevalence of hypertension, left ventricular hypertrophy, atrial fibrillation, valvular diseases, aneurisms and arterial dissections. This review article provides an update on cardiovascular disorders associated with autosomal dominant polycystic kidney disease and recent pathophysiological developments.     

Étude prospective du squelette de la main par densitométrie à rayons X et par ultrasons,chez les sujets atteints de polyarthrite rhumatoïde récente

Objective. Bone demineralization observed in early rheumatoid arthritis is not easily measured. To measure bone loss and to discriminate between rheumatoid arthritis and other rheumatic diseases, we used 2 methods: dual-energy X-ray absorptiometry and ultrasonography. Methods. From a population-based recruitment, 32 patients with early peripheral polyarthritis (median disease duration: 4 months) were studied. Clinical, laboratory, functional, hand-bone assessments were made at the entry, at month 6 and 12. Bone X rays densitometry measurements were made on 16 areas of the hand. Speed of sound  was measured across the proximal phalanges of the 4 fingers. X- rays of both hands was scored according to the modified Sharp’s score. At 12 months, patients were classified as rheumatoid arthritis (n=15; 9 F) or as other rheumatic diseases. Results. We found: 1) significantly decreased bone mineral density (BMD) of the whole hand, in the rheumatoid arthritis group versus the other rheumatic diseases group, at 6 and 12 months (p < 0.05); 2) no significant decrease of BMD in other areas in the rheumatoid arthritis group; 3) no significant change of ultrasounds in either group; 4) no significant correlation between the decrease of BMD in the rheumatoid arthritis group and clinical, biological or radiological parameters, except for IFNγ whose production in whole blood cell culture was lower at entry in rheumatoid arthritis group. Conclusion. DEXA bone assessment in rheumatoid arthritis was able to detect bone loss in the whole hand at 6 months.     

Intoxication sévère à la caféine traitée par hémodialyse et hémodiafiltration

A 21-year-old man ingested 75 g of pure caffeine, in an attempt to commit suicide. This represents 7.5 times the minimal lethal dose. Caffeine, 1,3,7-trimethylxanthine, is the most widely consumed psychoactive compound worldwide. It is mostly found in coffee, tea, energizing drinks and in some drugs. However, it has become really easy to obtain pure caffeine (powder or tablets) on the Internet. Mechanisms of action are dose-dependent. When caffeine overdosing occurs, neurologic, cardiovascular and renal systems are mainly affected. Severe intoxication can be fatal. No antidote is available and treatment is purely symptomatic. Hemoperfusion has previously been carried out in the 1990's to treat patients with caffeine intoxication. Since 2009, hemodialysis and hemofiltration have proposed as well. Our patient was successfully treated with a combination of hemodiafiltration, intermittent and then continuous.     

Évolution de la densité minérale osseuse chez des hommes ostéoporotiques et hypercalciuriques traités par diurétiques thiazidiques

A few studies suggest that thiazide diuretic agents may have modest beneficial effects on bone. Few data are available on the effects of these medications in patients with osteoporosis and hypercalciuria.Objective. – To evaluate the effects of thiazide diuretic therapy on bone mass and urinary calcium excretion in hypercalciuretic osteoporotic male patients.Patients and methods. – Osteoporosis was defined as a greater than 2.5 standard-deviation decrease in bone mineral density (BMD) at the lumbar spine or hip (T score) We used an open-label prospective design to compare 14 patients with hypercalciuretic osteoporosis treated with a thiazide diuretic for 18 months and 13 patients with primary osteoporosis treated with calcium and vitamin D supplementation. Mean age was 53.5 ± 9.6 years in the thiazide group and 48.7 ± 8.4 years in the calcium–vitamin D supplementation group. The following serum parameters were assayed at baseline: 25 OH-D3, 1,25 OH-D3, parathyroid hormone (PTH), and bone turnover markers. Urinary calcium excretion and BMD by dual-energy X-ray absorptiometry at the spine and hip were determined at baseline and after 18 months of treatment.Results. – Annual BMD increases were similar in the two groups during the 18-month treatment period: lumbar spine, 0.6% ± 2.5% (P = 0.47) in the thiazide group and 0.004% ± 3% (P = 0.78) in the supplementation group; femoral neck, 0.47% ± 2.6% (P = 0.89) and 1.1% ± 3.2% (P = 0.22); total hip, 0.65% ± 2.5% (P = 0.37) and 0.12% ± 2.1% (P = 0.51). Urinary calcium excretion fell by 45.9% in the thiazide group from baseline to study completion (P = 0.0015).Conclusion. – We found no evidence that thiazide therapy increased bone mass in patients with hypercalciuria and osteoporosis as compared to calcium–vitamin D supplementation in patients with osteoporosis but no hypercalciuria. In contrast, our results establish the efficacy of thiazide diuretics in reducing urinary calcium excretion, an effect that may decrease the risk of urinary lithiasis. Studies in larger patient cohorts treated for longer periods are needed to confirm or refute our findings.     

Vers une extension du registre REIN aux patients avec une maladie rénale chronique au stade 5 non traités par dialyse ou greffe ? Étude pilote

To date, it is important to know more about the population of CKD stage 5 patients in order to better understand the practices of access to renal replacement therapy (RRT) or conservative treatment and to anticipate future needs. In April 2015, at the instigation of the Scientific Committee of REIN, a working group was formed to reflect on the opportunity and feasibility of a data collection on these patients. Between September 2017 and March 2018, 21 participating centers included 390 patients over a period of at least one month. The data collected included the patient's living conditions, level of study, mode of referral, clinical data and the therapeutic project. The median age at baseline was 71.4 years (IQR: 58.4–80.4), 39.9% were diabetic. The median eGFR was 12 mL/min/1.73 m² (IQR: 9–14). At inclusion, 77% of the patients were already followed in nephrology, 11% had been referred by a general practitioner. For the majority of patients included (81%), there was a RRT project. In 10% of cases, there was a project of conservative care, in 5% of cases the project was not yet decided and in 7% the project had not been yet discussed. At the latest news (median time 4.0 months), 35% of patients were dialyzed, 9 (2%) have been pre-emptively transplanted, 25 (6%) died, 210 (54%) were still with a CKD stage 5. Our pilot study has shown the feasibility and interest of setting up such a data collection. Such a registry will provide important public health information regarding the demographic of nephrologists and advanced practices nurses. At the local level, this information will help the department to organize themselves to set-up pre-RRT information, implementation of care pathway nurses and multidisciplinary meetings for difficult cases. However, our pilot study shows that to ensure the completeness of the collection, the tracking upstream or downstream of nephrology consultations for eligible patients is essential and therefore requires dedicated human time on site.     

Impact des comorbidités sur la stabilité de l’hémoglobine chez des patients insuffisants rénaux chroniques en hémodialyse,traités par CERA en pratique courante : l’étude MIRIADE

This national, prospective and multicenter study aimed to describe the real-life impact of comorbidities on hemoglobin stability in patients with chronic kidney disease on hemodialysis, treated with CERA in relay of an erythropoietin stimulating agent. Comorbidities were defined by the Charlson Index (adjusted on age) and hemoglobin stability as a variation of ±1 g/dL after the 6-month treatment period. The 585 analyzed patients were distributed as follows according to the adjusted Charlson index: score ≤ 3 (12% of patients), 4 ≤ score ≤ 5 (17%), 6 ≤ score ≤ 7 (31%) and score ≥ 8 (40%). At CERA start, its median monthly dose was of 100 μg for the overall population, with no changes during the treatment period and with little variation according to the comorbidity score. Patients with stable hemoglobin (56%, 67% if score ≤ 3) were more numerous to reach the therapeutic target range between 10 and 12 g/dL after 6 months (85% versus 43% if not stable hemoglobin). Patients with low C-reactive protein value (≤ 5 mg/L ; P = 0.04), no red blood cell transfusion (P = 0.03), or no/low dose of intravenous iron (≤ 200 mg ; P = 0.03) were more likely to reach stable hemoglobin under CERA after 6 months. Among the 644 CERA-treated patients, 4 patients (< 1%) had one serious adverse event related to treatment. A stable hemoglobin within the therapeutic target was reached in the majority of the patients after 6 months in current practice with a lower CERA dose, regardless of the comorbidities scores of patients on hemodialysis.     

Faible indice de masse corporelle et impact des antirétroviraux sur la néphrotoxicité, la maladie rénale chronique chez les patients infectés par le VIH à Brazzaville,Congo

ObjectiveTo describe the incidence and risks factors of ART induced nephrotoxicity and chronic kidney disease in HIV-1-infected adults with low body mass index (<18.5 kg/m²).MethodsA retrospective cohort study at the Ambulatory Treatment Center in Brazzaville, Congo. Patients with estimated glomerular filtration rate decrease by 25% compared to baseline or a 0.5 mg/dL increase in serum creatinine above baseline were classified as having nephrotoxicity, and chronic kidney disease was defined as a value less than 60 mL/min/1.73 m². We used Cox proportional hazards regression models to determine factors associated with nephrotoxicity and chronic kidney disease.ResultsOf 325 patients, 73.23% were women. Median values were an age 37.55 years (IQR: 33.51–44.96), weight 45 kg (IQR: 41–49), CD4 count 137.5 cells/μL (42–245). In the first 24–months, follow-up on ART incidence rate of nephrotoxicity and chronic kidney disease was 27.95 and 7.44 per 100 persons-year respectively. Multivariate analysis identified as a risk factor of nephrotoxicity, baseline haemoglobin below or equal 8 g/dL (aHR = 2.25; 95%CI 1.28–3.98; P = 0.005) and the use of tenofovir (aHR = 1.51; 95%CI 1.01–2.27; P = 0.04). DFG between 60-80 mL/min/1.73 m2 (aHR = 0.35; 95%CI 0.21–0.59; P < 0.001) and 45-59 mL/min/1.73 m² (aHR = 0.10; 95%CI 0.01–0.72; P = 0.02) was not a contraindication for initiating antiretroviral therapy. Each 10-year older age was associated with an increased risk of developing chronic kidney disease (aHR = 1.95; 95%CI 1.2–3.17; P = 0.007).ConclusionIncidence of nephrotoxicity and chronic kidney disease were high. African HIV-positive patient with low body mass index at baseline need close monitoring of their renal function when treated with tenofovir.