Outcomes, risk factors and health burden of contrast-induced acute kidney injury: an observational study of one million hospitalizations with image-guided cardiovascular procedures.

BACKGROUND: Despite the use of low-osmolar contrast media that have significantly reduced the occurrence of severe adverse reactions, contrast-induced (CI) acute kidney injury (AKI) remains the third cause of AKI in hospitals. We sought to estimate the frequency of CI-AKI among hospitalized patients undergoing image-guided cardiovascular procedures, to quantify the effect of risk factors on the development of this complication and to assess relative organizational and economic burden in healthcare. METHODS: A retrospective cross-sectional population-based study using the extensive French hospital discharge database (PMSI) was carried out. Hospitalizations with image-guided cardiovascular procedures using a contrast media were identified in adults over a 2-year period (2012-2013). Suspected CI-AKI was defined as the presence, during hospitalization, of a diagnostic code of AKI (International Classification of Diseases, 10th revision [ICD-10] codes: N141, 142, N144, N990, N17, N19 or R392) or a code of renal replacement therapy procedure (Classification Commune des Actes Médicaux [CCAM] codes: JVJB001, JVJF002-005 and JVJF008) as creatinine criteria were not available. RESULTS: During 1,047,329 hospitalizations studied, 32,308 suspected CI-AKI were observed, yielding a frequency of 3.1 %. By multivariate analysis, factors that significantly increased the risk of suspected CI-AKI included cardiogenic shock (odds ratio [OR] = 20.5, 95 % confidence interval [95 % CI] [18.7; 22.5]), acute heart failure (OR = 2.5, 95 % CI [2.4; 2.6]) and chronic kidney disease (OR = 2.3, 95 % CI [2.2; 2.3]. Renal replacement therapy was initiated during 6,335 (0.6 %) hospitalizations. The mean length of stay and cost of hospitalizations associated with suspected CI-AKI was higher than in hospitalizations without suspected CI-AKI (20.5 vs 4.7 days, p < 0.00001 and €15,765 vs €3,352, p < 0.0001, respectively). CONCLUSIONS: This is the first large-scale population-based study to estimate frequency and health burden of suspected CI-AKI occurring after image-guided cardiovascular procedures, and the first available data in a French population. We showed that this iatrogenic complication remains of high concern despite prevention efforts and contrast media product improvement. From our results, suspected CI-AKI is associated with particularly high mortality, significantly extends hospitalizations, and leads to additional costs reaching a total of €200M per year.

Endovascular treatment of immature, dysfunctional and thrombosed forearm autogenous ulnar-basilic and radial-basilic fistulas for haemodialysis.

BACKGROUND: Forearm basilic fistulas are rarely used as vascular accesses for haemodialysis but they represent a valuable option when autogenous radial-cephalic fistulas cannot be performed. There is no information in the literature to date about the outcome of direct ulnar-basilic or transposed radial-basilic forearm autogenous fistulas after endovascular treatment of stenosis or thrombosis. METHODS: This retrospective study included 78 consecutive patients from eight dialysis units who were referred to a single interventional radiology centre for endovascular treatment of delayed maturation (n = 30), dysfunction (n = 35) or thrombosis (n = 13) of their autogenous forearm ulnar-basilic (n = 62) or radial-basilic fistulas (n = 16). The male/female ratio was 54/24, mean age was 64.7 years, 26% had diabetes, 83% were treated for hypertension and the mean body mass index was 24 kg/m(2). Immature and dysfunctional fistulas were treated by dilation and thrombosed fistulas by aspiration thrombectomy. Clinical success was defined as the perception of a continuous palpable thrill and the ability to perform dialysis. Fistula patency rates were calculated with the Kaplan-Meier method. RESULTS: Overall primary patency rates were 51% and 44% at 1 and 2 years, respectively. These rates were lower for immature and thrombosed fistulas compared to dysfunctional mature fistulas. Secondary patency rates were 96% and 91% at 1 and 4 years, respectively. Immediate overall clinical success was 97%. The two failures occurred with an immature and a thrombosed fistula. Immediate complications included two transient dilation-induced ruptures treated by prolonged balloon inflation. One case of subsequent hand ischaemia was successfully treated by distal artery ligation. CONCLUSIONS: Endovascular treatment plays a major role in the maturation process, maintenance and salvage of radial and ulnar-basilic fistulas. The preservation of upper arm veins for the future, with low risk of hand ischaemia or hyperflow, might encourage nephrologists and surgeons to consider forearm basilic fistulas systematically in their strategy of vascular access creation.

Percutaneous dilation of the radial artery in nonmaturing autogenous radial-cephalic fistulas for haemodialysis.

BACKGROUND: Delayed maturation of radial-cephalic fistulas can be due to lesions of the radial artery that are amenable to percutaneous dilation. METHODS: Over a period of 7 years, 74 consecutive patients underwent angiography of an immature fistula that showed either stenosis or an insufficient enlargement of the radial artery that was treated by percutaneous dilation. Success, complications and secondary interventions were recorded according to consensus definitions. Patency following angioplasty was estimated with the Kaplan-Meier technique. RESULTS: The mean patient age was 70 years, 44% were women, 69% had diabetes, 23% were smokers, 76% had hypertension, 64% had coronary disease and 46% had peripheral artery occlusive disease. Concomitant venous stenosis was diagnosed in 53% of patients. Arterial stenosis was >5 cm long in 53 cases. Technical success was achieved in 73/74 cases following angioplasty. All but two fistulas were then successfully used for dialysis. Dilation-induced rupture occurred in 13 cases (17%) but required only two stent placements. Five cases (7%) of hand ischaemia within 1 month of dilation were treated successfully by ligation of the distal artery. Primary patency rates at 12 and 24 months were significantly better for pure arterial lesions, with 65% and 61% compared to 42% and 35% in cases of concomitant venous stenosis (P < 0.04). The secondary patency rates were 96% and 94% at 1 and 2 years, respectively. CONCLUSION: Dilation of the radial artery yields higher patency rates than for veins. Surgeons might therefore be less demanding about the initial quality of the radial artery prior to creation of radial-cephalic fistulas.

[Is the management of anemia in hemodialysis patients improving in France? Results of the DiaNE study]. / La prise en charge de l'anémie du patient hémodialysé en France s'améliore-t-elle? Résultats de l'étude DiaNE.

French and international clinical practice guidelines recommend a minimum hemoglobin level of 11 g/dl in patients with chronic kidney disease. Previous studies implemented between 1996 and 2003 showed that only 35 to 55% the patients reach this target. Dialysis NeoRecormon Epidemiology (DiaNE) is a one-year French multicentric observational study designed to follow a cohort of 1200 patients with ESRD treated with epoetin beta to assess the management of anemia in routine nephrologic practice. From December 2003 to September 2004, 1241 hemodialysis patients were recruited by 229 centers. At baseline, 64.4% of patients had hemoglobin levels greater than 11 g/dl. The proportion of patients with hemoglobin levels greater than 11 g/dl at the end of the study was 71.6%. These results could be partly explained by iron deficiency: 46% of patients had a serum ferritin between 200 and 500 microg/l and about one third of patients had a transferrin-iron saturation percentage greater or equal to 30% at baseline and at the end of the study. Epoetin beta was administrated by subcutaneous route in 65.5% of patients with similar efficacy and with less mean doses than intravenous route (114.6+/-81.5 IU/kg versus 146.5+/-124.3 IU/kg at the end of the study). In conclusion, the management of anemia in hemodialysis patients is not optimal but is slightly better than the management observed between 1996 and 2003. Iron and inflammatory status should be taken into account to improve the efficacy of anemia therapy using erythropoietin-stimulating agents.

[Anemia management in French hemodialysis patients: DiaNE study results at 3 years (DiaNE2)]. / Prise en charge de l'anémie des patients hémodialysés en France : résultats de l'étude DiaNE à trois ans (DiaNE 2).

The observational study DiaNE provides a current state of anemia management with Epoetine bêta in hemodialysis patients regarding European recommendations over a 3-year period in France. Patients still treated with Epoetine bêta twelve months after their inclusion in DiaNE were eligible for a 24-month extension phase entitled DiaNE 2. Data regarding 439 patients followed during three years, from M0 to M36, were analyzed. Hemoglobin (Hb) level of the cohort remained over the target value of 11g/dL during the study (M0: 11.3±1.2g/dL; M36: 11.8±1.3g/dL). The anemia management had evolved with European recommendations updates and was in accordance with the last recommended target range (11-12g/dL) in a third of patients. During the follow-up, the majority of patients (97%) had at least one modification of treatment with Epoetine bêta (change in frequency of injections, adjustment of doses) mainly justified by excursion of Hb level out of the target range. However, the median dose of Epoetine bêta was relatively stable. The number of patients with iron treatment remained stable (60%). In spite of undertaken efforts, anemia management of hemodialysed patients in France still needs optimization for maintaining Hb level in the recommended target range.

Death after withdrawal from dialysis: the most common cause of death in a French dialysis population.

BACKGROUND: Discontinuation of dialysis is a common cause of death in end-stage renal disease (ESRD) patients in North America and the UK, but appears to be unusual in the rest of Europe. The aim of this retrospective study was to characterize withdrawal from dialysis in a French population cohort. METHODS: We assessed the cause of death, and the medical and social characteristics of chronic dialysis patients in a French population who died in 2001. We compared patients who died after withdrawal from dialysis and patients continuing dialysis until death. We determined the decision-making process when dialysis was withdrawn. RESULTS: In a population cohort of 1436 dialysis patients, 196 died (13.9%). Of them, 40 patients (20.4%) died following withdrawal from dialysis. This was the most common cause of death, followed by cardio-vascular disease (18.4%). Patients withdrawing from dialysis had a significantly higher rate of dementia (17.5 vs 6.4%, P = 0.02), a poor general condition (55 vs 15.4%, P < 0.001), and were dependent in their life for everyday activities in comparison with patients who died from other causes. They were not different in age, sex, duration of dialysis treatment, dialysis technique, cardio-vascular disease, diabetes, stroke or cancer, but the sample size was small. Treatment was more often removed in patients with severe medical complications and/or cachexia (90%). The decision to stop dialysis was made most often by a physician (77.5%). CONCLUSION: Death after withdrawing from dialysis was the most common cause of death in ESRD patients in our French population cohort. The patients who died after discontinuation of treatment were more often in a poor general condition, near the end of life, and most often the physician decided to stop dialysis treatment.