[How is the management of diabetic hypertensive patients different?] / En quoi la prise en charge de l'hypertendu diabétique est-elle différente?

High blood pressure (HBP) is common in diabetic patients and significantly increases complications of diabetes and cardiovascular risk. It is therefore particularly important to routinely screen and treat HBP in these patients. Blood pressure targets in this population (<130/80mmHg) should be adapted to age and comorbidities. The therapeutic strategy has expanded beyond renin-angiotensin-aldosterone system inhibitors in the diabetic population, with treatments which decrease cardiovascular and renal risk, such as SGLT2 inhibitors, GLP-1 receptor agonists, and soon finerenone.

L'hypertension artérielle (HTA) est fréquente chez les patients diabétiques et augmente de manière considérable les complications du diabète et le risque cardiovasculaire. Il est donc particulièrement important de dépister de manière systématique et de traiter l'HTA chez ces patients. Les cibles tensionnelles dans cette population (< 130/80 mmHg) doivent être adaptées à l'âge et aux comorbidités. Dans la population diabétique, l'arsenal thérapeutique s'est élargi au-delà des inhibiteurs du système rénine-angiotensine-aldostérone, avec des traitements qui influencent le pronostic cardiovasculaire et rénal, comme c'est le cas pour les inhibiteurs du SGLT2, les agonistes des récepteurs du GLP-1 et, bientôt, la finérénone.

Dialysis initiation improves calcification propensity.

BACKGROUND: Cardiovascular morbidity and mortality is high in patients starting dialysis and could be related to modifications of calcification inducers and inhibitors by dialysis, promoting cardiovascular events. The impact of dialysis initiation on serum calcification propensity evolution and arterial stiffness is unknown. We therefore prospectively determined the evolution of the one-half maximal transition time (T50) value and its main determinants as well as pulse wave velocity over the first 3 months of dialysis initiation. METHODS: We analysed the evolution of T50, fetuin-A and mineral metabolism parameters before dialysis initiation (M0) and monthly until Month 3 (M3) in incident patients starting haemodialysis (HD) or peritoneal dialysis (PD) in two tertiary Swiss university hospitals. Arterial stiffness was assessed by pulse tonometry at M0 and M3 and biological parameters were compared between M0 and M3 and before/after HD. Linear mixed models were used to assess parameter evolution over time, taking into account repeated measures and other influencing variables. RESULTS: Forty-six patients on HD and 12 on PD were followed. Among them, 45 were male (78%) with a median age of 67 years (25th-75th quartile range 54-77). T50 significantly increased between M0 and M3 from 183 (120-266) to 246 min (175-330) (P < 0.001). Fetuin-A, calcium and magnesium also increased while phosphate decreased. Factors associated with T50 changes over time were fetuin-A, phosphate and magnesium (P < 0.001). Fetuin-A changes were associated with inflammation-related factors (albumin, C-reactive protein) but not calcium and phosphate levels. Arterial stiffness was not significantly modified over 3 months. PD and HD initiation showed similar trends. CONCLUSIONS: Dialysis initiation significantly improves calcification propensity and fetuin-A levels. These modifications do not explain the high mortality related to dialysis initiation. The clinical relevance of using T50 values to initiate dialysis awaits further studies.

[Anti-hypertensive treatment and chronotherapy†: when should the pill be taken†?] / Traitement antihypertenseur et chronothérapie†: quand faut-il avaler la pilule†?

When should antihypertensive treatments be administered ? The concept of chronotherapy has been attractive for several years, in connection with the importance of circadian variations in blood pressure. The "too" promising results of the Hygia study argue in its favour. Yet experts caution us about the methodology and results of this study. Vesperal administration of routine anti-hypertensive treatments in all patients is not recommended to date, with a non-negligible risk of excessively lowering the nocturnal blood pressure in some patients (increase of ischemic risk in target organ damage) and on the other hand reducing therapeutic adherence by increasing the number of drug doses. Chronotherapy will therefore only be fully effective if patients are willing to adhere to it.

Quand administrer les traitements antihypertenseurs ? Le concept de chronothérapie séduit depuis plusieurs années, en lien avec l'importance des variations circadiennes de la pression artérielle. Les résultats, «â€…trop ¼ prometteurs de l'étude HYGIA, plaident en sa faveur. Pourtant les experts nous mettent en garde sur la méthodologie et les résultats de cette étude. L'administration vespérale de routine des traitements antihypertenseurs chez tous les patients n'est à ce jour pas recommandée, avec un risque non négligeable, d'une part, de trop baisser la pression artérielle nocturne chez certains patients (augmentation du risque ischémique au niveau des organes cibles) et, d'autre part, de diminuer l'adhérence thérapeutique, en multipliant les prises médicamenteuses. La chronothérapie ne déploiera donc tous ses effets qu'avec l'adhésion thérapeutique des patients.

[What place for therapeutic education in nephrology ?] / Quelle place pour l'éducation thérapeutique en néphrologie ?

Chronic kidney disease (CKD) usually goes unrecognized for patients until late symptomatic stages. In preterminal CKD, extrarenal substitution methods are usually presented to patients. This is felt like a breakdown, implying major modifications of everyday life. Acquisition of health literacy is necessary for patients with CKD to become autonomous and increase their empowerment toward the disease. Therapeutic education in nephrology plays a major role in improving the care of CKD patients.

L'insuffisance rénale chronique (IRC) est une maladie silencieuse, évolutive, souvent asymptomatique dans ses stades précoces. Elle devient réelle lorsque les symptômes apparaissent, lors des stades avancés. Lorsque l'insuffisance rénale est préterminale, les différentes méthodes de substitutions extrarénales sont présentées au patient. Ceci raisonne souvent comme un choc, car elles impliquent des modifications majeures de la vie quotidienne. L'acquisition des compétences en santé devient une nécessité dans la maladie chronique afin de permettre au patient son empowerment (autonomisation et autodétermination, englobant la capacité de prendre des décisions et d'exercer un contrôle sur sa vie). L'éducation thérapeutique en néphrologie tient donc une place prépondérante dans la prise en charge des patients atteints d'IRC, afin d'améliorer leur autonomisation dans leur prise en charge et leur qualité de vie.

Association of serum copeptin and urinary uromodulin with kidney function, blood pressure and albuminuria at 6 weeks post-partum in pre-eclampsia.

Background: Preeclampsia (PE) is associated with subsequent higher risk of cardiovascular and kidney disease. Serum copeptin, as a proxy for vasopressin, and urinary uromodulin, were associated with PE physiopathology and kidney functional mass respectively. We describe concentrations of these proteins in the post-partum period and characterize their association with persistent hypertension (HTN) or albuminuria. Methods: Patients with PE and healthy controls with uncomplicated pregnancy were prospectively included at two teaching hospitals in Switzerland. Clinical parameters along with serum copeptin and urinary uromodulin were measured at 6 weeks post-partum. PE patients were further characterized based on presence of HTN (defined as either systolic BP (SBP) ≥140 mmHg or diastolic (BP) ≥90 mmHg) or albuminuria [defined as urinary albumin to creatinine ratio (ACR) ≥3 mg/mmol]. Results: We included 226 patients with 35 controls, 120 (62.8%) PE with persistent HTN/albuminuria and 71 (37.1%) PE without persistent HTN/albuminuria. Median serum copeptin concentration was 4.27 (2.9-6.2) pmol/L without differences between study groups (p > 0.05). Higher copeptin levels were associated with higher SBP in controls (p = 0.039), but not in PE (p > 0.05). Median urinary uromodulin concentration was 17.5 (7.8-28.7) mg/g with lower levels in PE patients as compared to healthy controls (p < 0.001), but comparable levels between PE patients with or without HTN/albuminuria (p > 0.05). Higher uromodulin levels were associated with lower albuminuria in PE as well as control patients (p = 0.040). Conclusion: Serum copeptin levels at 6 weeks post-partum are similar between PE patients and healthy controls and cannot distinguish between PE with or without residual kidney damage. This would argue against a significant pathophysiological role of the vasopressin pathway in mediating organ damage in the post-partum period. On the opposite, post-partum urinary uromodulin levels are markedly lower in PE patients as compared to healthy controls, potentially reflecting an increased susceptibility to vascular and kidney damage that could associate with adverse long-term cardiovascular and kidney outcomes.

[Serious game, a new approach for advance care planning with dialysis patients]. / « Jeux sérieux ¼, une nouvelle approche pour aborder le projet de soins anticipé avec les patients dialysés.

Due to the high morbidity and mortality with limited life expectancy of dialysis patients, it is essential to implement advance care planning in order to know patients' values and care preferences and respect their autonomy. However, advance care planning is rarely carried out, due to the difficulties in initiating end-of-life discussions, both by patients and healthcare professionals. The use of "serious games" in the form of card games has shown promise in supporting the implementation of advance care planning. In this article, we present the development process of an advance care planning intervention for dialysis patients using a card game (the Go Wish), in the Division of Nephrology of the University Hospitals of Geneva.

[Therapeutic education program should be adapted to the specificity of chronic kidney disease]. / Comment adapter une offre éducative aux spécificités des patients atteints d'insuffisance rénale chronique ?

INTRODUCTION: Chronic kidney disease (CKD) is an evolutive disease. In its early stages the disease often goes asymptomatic and unrecognized. For CKD patients, disease awareness is usually late, with the occurrence of the first symptoms. In more advanced stages, CKD implies massive consequences on patient's life. Extrarenal substitution methods (such as hemodialysis, peritoneal dialysis or transplantation) are presented to the patient, who is facing a very difficult choice, inducing major changes in his lifestyle. DESCRIPTION: In this article, we share the adaptation process of a therapeutic education program in nephrology, presenting its specificity and the encountered difficulties. We propose to develop an educative program adapted to patient's needs, which differs according to CKD stage. CONCLUSION: Therapeutic patient education (TPE) has become a need in the care of CKD patients, even at early stages of the disease. TPE allows to prepare the patients, favoring autonomy and shared decision making about his disease, in collaboration with healthcare workers and patient's relatives.