Nephrologie & therapeutique最新文献

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.

Self-medication among kidney transplant patients may pose a risk to the graft. This study examined the prevalence of self-medication in patients who had undergone kidney transplantation. These patients, receiving immunosuppressive therapy, are informed during post-transplant therapeutic education about the risks associated with drug interactions. This prospective single-center study, including 66 patients, shows that 80.3% of participants reported self-medicating one month after hospital discharge, with 18.2% engaging in practices deemed “risky”. Self-medication mainly involved analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs), sleeping pills, and treatments for heartburn, such as proton pump inhibitors (PPIs) and antacids. The results show that neither age, sex, education level, nor employment status were significantly associated with risky self-medication. However, the high prevalence of this practice highlights the need for increased patient awareness of potential dangers, particularly those related to NSAIDs and drug interactions. PPIs, often used for heartburn, carry interaction risks, especially with tacrolimus, and prolonged use may lead to kidney complications. Herbal medicine, also used by some patients, may present interaction risks with immunosuppressants.The study suggests strengthening patient therapeutic education (PTE) by emphasizing the risks of inappropriate self-medication and proposes safe alternatives, such as antacids, or seeking medical consultation. These results, based on self-reported data, may underestimate the true prevalence of self-medication. The study recommends continuous vigilance and further research to assess these practices over the long term.

Introduction: End-stage kidney disease radically alters the patients' lives. The aim of this pilot study was to describe this impact in patients treated with autonomous dialysis modality in France: Long Nocturnal Hemodialysis (LNHD), Daily Home Hemodialysis (DHHD), Automated Peritoneal Dialysis (APD), and hemodialysis in a self-care unit (SCHD).

Methods: French voluntary patients (n = 182) treated with an autonomous dialysis modality completed an anonymous e-questionnaire that included items on type of paid employment, voluntary work and leisure activities, and three self-report questionnaires (SONG-Fatigue, RPAQ, and EQ-5D-5L).

Results: Overall, 33% of patients had a remunerated activity, 10% of patients were considered as sedentary and 39.6% reported an important physical activity. The SONG-Fatigue median score was 3 (IQR 2-5). 54%, 89% and 56% of patients did not report any problem with mobility, self-care, and usual activities, respectively. 35% of patients did not complain about pain or discomfort and 59% had no anxiety or depression symptoms. Patients estimated their global health status at 60 (IQ 50-80). Compared to SCHD, the LNHD group had more often a remunerated activity and the DHHD group reported fewer problems with usual activities. The APD and LNHD groups experienced pain more often.

Conclusion: This pilot survey of middle-aged patients with autonomous dialysis showed that dialysis affected their professional status, social activities, fatigue, quality of life and energy expenditure with few differences according to dialysis modality.

Replacement of disposable by reusable care materiel is a mandatory question in sustainability management in nephrology. Recommandations have already been edited for individual protection in the operating room and the DGOS (Direction générale de l’offre de soins) will soon launch an experimentation in the reuse of some catheters and endoscopes. The literature is unanimous on the advantage, in the fields studied, of reuse over disposable material regarding green house gaz emissions. However, this advantage can be lost when considering water consumption that partly results from washing and sterilization activities. Our article aims to encourage nephrologists to start applying some measures in their clinical practice and be aware of the coming innovations.

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.