[Focusing on peritoneal dialysis adequacy]. / Adéquation en dialyse péritonéale : mise au point.

The optimal method to assess the adequacy of peritoneal dialysis therapies is controversial. Today, the adequacy must not be considered as a number or a concept assessed only by two parameters (total KT/V urea and total solute clearance) but defined by many more items. In the absence of data, based on theoretical considerations, the reanalysis of the CANUSA study showed that renal kidney function, rather than peritoneal clearance, was associated with improved survival. Residual renal function is considered as a major predictor factor of cardiovascular mortality. Results of this reanalysis were supported by the adequacy data in ADEMEX, EAPOS and ANZDATA studies. Therefore, clinical assessment plays a major role in PD adequacy. The management of fluid balance, the regular monitoring of malnutrition, the control of mineral metabolism and particularly the glucose load, considered as the "corner-stone" of the system, are the main points to be considered in the adequacy of PD patients. The essential goal is to minimize glucose load by glucose-sparing strategies in order to reduce the neoangiogenesis of the peritoneal membrane.

How to avoid technique failure in peritoneal dialysis patients?

It is well established that technique failure is one of the main reasons for peritoneal dialysis cessation. Early PD failures occur during the first 6 months of PD and are mainly related to catheter dysfunction and psychosocial problems. Catheter malfunction should be treated by a video-laparoscopic procedure as this prolongs the catheter survival. Assisted peritoneal dialysis could help patients to cope with peritoneal dialysis. Preservation of residual renal function is of importance in peritoneal dialysis patients as it affects both patients and technique survival. Failure to obtain a sufficient ultrafiltration volume to maintain a euvolemic state without using large amount of hypertonic glucose solution can cause peritoneal dialysis failure. New approaches in the use of icodextrin to increase ultrafiltration and sodium removal are under investigation. A novel modality of prescribing automated peritoneal dialysis would improve ultrafiltration in peritoneal dialysis patients.

Complicated lymphoceles after kidney transplantation.

Lymphocele is a common surgical complication after renal transplantation. The incidence of lymphocele ranges from 0.6% to 18%. The aim of this study was to determine incidence, risk factors and prognosis of complicated lymphocele in the era of modern immunosuppression. We retrospectively reviewed 311 renal transplants from January 2003 to September 2008, we excluding patients who received sirolimus or underwent multiorgan transplantations. A complicated lymphocele was defined by the requirement for a surgical procedure for cure. Of the 311 transplant recipients, we included 269 in the study with 49 (18.9%) presenting a complicated lymphocele after transplantation. Cold ischemia time, waiting time on dialysis, gender, donor source, induction therapy (thymoglobulin vs basiliximab), and dialysis modality were similar between the 2 groups. Mycophenolate mofetil (MMF) doses were higher among the lymphocele than the nonlymphocele group (2.7 ± 0.54 g/d vs 2.36 ± 0.68 g/d; P < .05). However, the areas under the concentration-time curves of mycophenolic acid were not significantly different between the 2 groups (43.7 ± 15.3 h·mg/L vs 48 ± 21 h·mg/L; P = .33). However, a multivariate analysis showed complicated lymphocele to be associated with greater MMF doses (odds ratio [OR] 2.75; P < .01), warm ischemia time (OR 1.035; P < .05), and recipient age (OR 1.04; P < .05). In conclusion, we identified high MMF doses as an independent risk factor for lymphocele formation after renal transplantation.

[Medical and economic evaluation of new peritoneal dialysis solutions]. / Evaluation médico-économique des nouvelles solutions en dialyse péritonéale.

Conventional peritoneal dialysis solutions are mostly bioincompatible in relationship with a low pH, a high glucose and glucose degradation products (GDP) concentrations inducing anatomical and functional peritoneal membrane alterations. Use of icodextrin solution instead of glucose hypertonic solution preserves peritoneal membrane minimizing glucose exposure and its peritoneal absorption. Physiological fluids with a neutral pH and less GDP seem to have a positive effect on residual renal function which declines more slowly when they are early prescribed, before highly damaged and sclerotic kidneys. Preliminary data show that patients and technique survivals are better when physiological solutions are used either for diabetic and non diabetic patients. However, these new solutions do not improve peritonitis rates except for bicarbonate solutions but this fact must still be confirmed by other studies. In spite of a higher cost, physiological solutions must be proposed mainly for patients with a low comorbidity index and a high life expectancy.

A trial comparing local pain after subcutaneous injection of epoetin-beta versus darbepoetin-alpha in healthy volunteers.

BACKGROUND: The aim of this study was to compare local pain experienced with subcutaneous (s.c.) injection of epoetin-beta vs. darbepoetin-alpha. METHODS: 40 healthy volunteers were enrolled into this single-blind, crossover study. After receiving an injection of placebo, individuals were randomized to receive s.c. injections of epoetin-beta 6,000 IU (0.3 ml) or darbepoetin-alpha 30 mg (0.3 ml), with a 1-week washout period between injections. Local pain was evaluated using a Visual Analog Scale (VAS) and a 6-item Verbal Rating Scale (VRS) immediately after (T0) and 1 h after injection (T1). RESULTS: The respective mean (standard deviation) and median (range) VAS values at T0 were 1.2 (1.7) and 0.5 (0.0 - 6.9) for epoetin-beta vs. 2.8 (2.4) and 1.9 (0.0 - 9.0) for darbepoetin-alpha (p < 0.0001). At T0, VRS scores demonstrated that 51% of individuals experienced no pain after epoetin- injection compared with 16% of those receiving darbepoetin-alpha. The percentage of individuals perceiving moderate or important pain was significantly greater with darbepoetin-alpha (38%) compared with epoetin-beta (5%, p = 0.0005) and placebo (14%). Pain evaluation at T1 showed no difference between treatment groups. Local tolerance was excellent except for a small hematoma with epoetin- at T1 and with darbepoetin-alpha at T0 which persisted at T1. CONCLUSION: In healthy volunteers, s.c. injection of epoetin-beta was significantly less painful than with darbepoetin-alpha and comparable with placebo. No significant pain was apparent at T1 in any group.

The evolution of weight and body composition in renal transplant recipients: Two-year longitudinal study.

UNLABELLED: Previous series have reported weight gain after kidney transplantation. However few studies have investigated the body composition after kidney transplantation, particularly during longitudinal follow-up. In this prospective study, we assessed the changes in body composition after kidney transplantation. We also analyzed the effect of steroid withdrawal from the immunosuppressive regimen on weight gain and body composition. METHODS: Thirty-eight cadaveric kidney transplant recipients were followed for 2 years posttransplant. Total and segmental body composition were measured by dual energy X-ray absorptiometry (DEXA) at the time of transplantation as well as 3, 6, 12, and 24 months later. RESULTS: In 28 patients (group A), prednisone was stopped by month 6, whereas, in 10 patients (group B), it was continued throughout the study. In the overall patient group, there were no significant changes in body weight. However, a trend to increased weight was observed in group B. In this group, patients showed an early increase in total body fat with a central accumulation of fat mass that was maintained during the follow-up period. On the other hand, total lean mass increased significantly in group A but did not change significantly in group B. CONCLUSION: In summary, overall the group showed no major changes in body weight during the 2 years after transplantation. Steroid withdrawal in kidney transplant recipients may have a significant positive effect on body composition.

French peritoneal dialysis registry (RDPLF): outline and main results.

The Registre de Dialyse Péritonéale de Langue Française (RDPLF Registry) is a non-profit association that has been set up to assist physicians and nurses in evaluating their practical experience and results regarding peritoneal dialysis (PD). Five French-speaking and two Spanish-speaking countries have participated in this initiative (which includes 21 000 patients). In France, 82% of all PD patients are included in the registry and the main results for the period from 1995 to January 2006 form the basis of this report: of 11 744 incident patients with a median age of 71 years, 21.5% were over 80 years of age and 56% were not able to perform PD treatment at home without assistance. Eighty-six percent of the latter group received external assistance from a private nurse and 14% were aided by their family. The overall average rate of peritonitis was one episode every 29 months. The probability of being peritonitis-free appeared to be better for patients on automated PD (59.4% at 2 year) than for those on continuous ambulatory PD (55.3%), but this finding requires further validation. The average waiting time before transplantation was about 2 years. In patients who had undergone transplantation, the peritonitis rate was one episode per 42 months before transplantation compared to one episode per 29 months for patients who had not received a transplant. Eighty-three percent of patients had a hemoglobin level greater than 11 g%. Catheter survival was 92% at 2 years post-insertion and 85% at 5 years, with 94% being implanted by experienced surgeons. In conclusion, the RDPLF results demonstrate that PD may be successfully prescribed for older patients who receive assistance either from their family or from a nurse. Further, a larger number of younger patients should also be prescribed this technique in France. Patients eligible for transplantation and on short-term PD have the lowest risk of developing peritonitis; PD before transplantation may help prolong residual renal function, and initial treatment by PD may also help to preserve vascular access for the future.

Pharmacokinetics of mycophenolic acid in kidney transplant patients receiving sirolimus versus cyclosporine.

INTRODUCTION: Mycophenolic acid (MPA) pharmacokinetics exhibit large variability in transplant recipients and may be altered due to concurrent immunosuppressants. Little is known about the influence of sirolimus (SRL) on MPA pharmacokinetics in kidney transplant patients. METHODS: We studied the areas under concentration-time curves (AUC) for MPA in 15 patients receiving immunosuppression combining SRL with mycophenolate mofetil (MMF). The pharmacokinetic measurements were performed in all patients using three MMF dosing regimens (0.5 g twice a day, 0.75 g twice a day, 1 g twice a day). Similar blood AUC profiles were also sampled from 12 patients treated with a fixed dose of MMF 1 g twice a day and cyclosporine (CsA). MPA was measured using HPLC; the AUC0-12 of MPA was determined by the trapezoidal method using four sampling time points: C0, C1, C3, C5. RESULTS: While patients on SRL were receiving 0.75 g MMF twice a day, mean AUC0-12 and C0 values of MPA were comparable to those of patients receiving CsA and 1 g MMF twice a day (54.1 +/- 17.6 and 3 +/- 1.87 vs 51.7 +/- 16.7 mg.h/L and 2.76 +/- 1.57 mg/L, respectively). On the other hand, 0.5 g MMF twice a day with SRL therapy resulted in AUC0-12 and C0 values of MPA of 32.3 +/- 12.6 mg.h/L and 2.32 +/- 1.72 mg/L, respectively, whereas, 1 g MMF twice a day with SRL resulted in AUC0-12 and C0 values of MPA of 70.9 +/- 19.3 mg.h/L and 4.7 +/- 2.44 mg/L, respectively. CONCLUSIONS: These findings demonstrate that MPA exposure in the presence of SRL is higher than that with CsA. It appears that the MMF dose should be reduced to 0.75 g twice a day in patients receiving SRL to obtain AUC0-12 of MPA levels comparable to that in patients treated with CsA and MMF 1 g twice a day.

[Factors determining the choice of a modality of treatment by dialysis: a study of nine dialysis centers]. / Facteurs déterminant le choix d'une modalité de traitement par dialyse: une enquête dans neuf centres de dialyse.

BACKGROUND: The objective of this cross-sectional study in a population of 1472 dialysis patients was to identify the main factors involved in the choice of a specific option for dialysis therapy, taking into account three different types of criteria such as medical dependence (DM), nurse care requirement (SI) and independence for dialysis therapy (CA). METHODS: Each patient has been analysed, independently of present treatment modality, according to the above three criteria, namely DM, SI and CA. For each type of parameter, patients have been allocated to one of three levels, each level being established to evaluate whether dialytic treatment should be undertaken as hospital centre dialysis (HDC) or in a facility off the hospital. Level 3 of any one category corresponded to the inability of doing haemodialysis at home (HHD) or in self-care unit (AD). Level 2 included patients who could be treated in AD or by peritoneal dialysis (PD) with the assistance of a nurse. CAPD or HHD were considered as potential treatment modalities only in patients qualifying for level 1 of each criterion. RESULTS: In the patient population as a whole, the following treatment options were observed: HHD 3.6%, CAPD 6%, PD 1.8%, AD 16.3% and HDC 72.2%. For medical dependence (DM) there was a relatively even distribution for the three levels in six centres. In contrast, two centres were characterized by a predominance of DM level 3. Differences in DM levels between centres were greatly reduced when considering separately only those patients who were actually treated by CAPD, HDC and AD. SI levels were more uniformly distributed within all centres, and this was true for HCD and AD patients. When considering CA levels in HDC patients, a large predominance of CA level 3 was observed in all centres whereas CA level 1 was nearly in existent. CONCLUSION: The major finding of this study was that the inability or the refusal of dialysis patients to participate at treatment, independently of medical condition and nurse care requirement, was the main factor in the choice of hospital centre dialysis.

Factors predicting the long-term success of maintenance cyclosporine monotherapy after kidney transplantation.

BACKGROUND: The theoretical aim of maintenance cyclosporine monotherapy (mCsA) after kidney transplantation is to reduce the incidence of the metabolic complications of corticosteroids and to minimize the adverse effects of excessive long-term immunosuppression. This study was performed in low-immunological-risk cadaveric kidney transplant recipients to evaluate the risks and benefits of mCsA and the long-term graft survival, and to determine the factors predicting success of this policy. METHODS: The multicenter retrospective study was conducted in 329 Caucasian patients receiving mCsA out of 728 first cadaveric kidney transplant recipients. The inclusion criteria were: HLA antibodies < or =25%, serum creatinine <200 micromol/L, and no rejection or only one rejection episode. At the end of the study, we compared the group of patients successfully treated with mCsA (successful group) with those requiring additional immunosuppressive agents (unsuccessful mCsA group). RESULTS: Overall patient and graft survival rates for the 728 first cadaveric graft were 92% and 64%, respectively, at 8 years. Out of 329 patients enrolled in mCsA, 240 were maintained on this treatment and 89 were withdrawn (3 deaths, 18 graft losses, 68 functional grafts). The 8-year graft survival in the 329 enrolled mCsA patients was 84%, 95% in the successful mCsA group, and 70% in the unsuccessful mCsA group. Multivariate analysis showed that the factors predicting success of mCsA were: donor age <40 years (P = 0.001), serum creatinine at mCsA initiation <125 micromol/L (P = 0.02), no rejection episode before mCsA initiation (P = 0.005), and glomerulopathy as the primary renal disease (P = 0.001). CONCLUSION: Numerous kidney transplant recipients with a low immunological risk and good and stable renal function may benefit from discontinuation of prednisone and azathioprine in order to reduce the complications related to these drugs. This therapeutic approach had no adverse impact on the overall long-term graft survival for "low risk" and successful patients.

[Requirements for the successful implementation of unity of care: study of a computer-assisted dispensation of pharmaceuticals]. / Les conditions du succès de l'informatisation de l'unité de soins: à propos d'un logiciel de dispensation pharmaceutique.

PURPOSE: Even though computerized workstations bring undisputed benefits in nursing units, introducing them is still hard when most of the staff members have to share the workstation. We took advantage of the implementation of the drug prescription software SAUPHIX in a nephrology department to better define the encountered difficulties. The workstation described in this paper is shared by physicians who enter their prescriptions (proprietary names, doses, routes of administration), nurses who use dosage schedules for drug administration, and the chemist who has authority to control prescription orders. METHODS: Six months after the implementation of the workstation, physicians and nurses had to fill out an anonymous questionnaire aimed at assessing each function of the software. RESULTS: Prescriptions proved to be more accurate and legible, while management of drugs was more precise. However, interns complained that entering data was time consuming. Furthermore, they raised objections to control of prescription orders. Nurses criticized dosage schedules, the primary reason being that they had to change their practice. The convenience of notebooks was questioned by both physicians and nurses who would have preferred a greater number of desktop computers at their disposition. CONCLUSION: The implementation of a computerized workstation requires information, diplomacy and negotiations to obtain real implication of the staff. Tasks and schedules must be specified for everybody. The system has to be carefully customized, according to the requirement of the unit. Computers must be properly chosen and allocated in sufficient number. Finally, appropriate preparation, staff training and follow-up of the computerized system are essential.

[AA amyloidosis complicating sarcoidosis]. / Amylose AA compliquant une sarcoïdose.

INTRODUCTION: Amyloidosis combined with sarcoidosis has been very rarely described. EXEGESIS: We report the case of a 72-year-old man presenting with sarcoidosis and amyloidosis AA. The association of peripheral and retroperitoneal adenopathies accompanied by loss of weight and histopathological results conducted to the diagnosis of sarcoidosis, excluding other causes. Corticosteroid therapy led to a decrease in clinical manifestations and after 2 years, clinical signs of amyloidosis have not progressed. CONCLUSION: According to results previously described in the literature and the description of the present case, we conclude that sarcoidosis can be complicated by amyloidosis AA, the presence of which may justify corticosteroid therapy.

[Anticoagulation of the extracorporeal circuit in chronic hemodialysis]. / Anticoagulation du circuit extracorporel en hémodialyse chronique.

Continuous or intermittent use of unfractioned heparin is the anticoagulant of choice to prevent the extracorporeal circulation clotting during the hemodialysis session. However, low molecular weight heparin (LMVH) could be an alternative treatment especially in case of high risk bleeding or during some clinical conditions such as diabetes mellitus, cerebrovascular bleeding, malignant hypertension. LMVH may be given as a single initial bolus injection generally adequate. Heparinization must be lowered or stopped when an effective anticoagulation is previously used.