[Chronic kidney disease: therapy and care]. / Prise en charge de la maladie rénale chronique.

Chronic kidney disease (CKD) is a major public health problem. It is therefore important to slow its progression and to treat its complications. Regardless of the causal nephropathy, arterial hypertension and proteinuria are the major progression factors of CKD. Thus, optimal control of blood pressure, reduction of proteinuria by using rennin angiotension system inhibitors can slow the progression of CKD. This effect can be enhanced by reducing sodium intake. The recent recommendations suggest that blood pressure should not be higher than 130/80 mmHg and proteinuria should not exceed 0,5 g/day. The consequences of advanced stages of the CKD have to be diagnosed and treated early: anemia, abnormal bone metabolism, hyperkalemia, fluid overload, metabolic acidosis... A particular emphasis has to be given to cardiovascular complications and risk factors. Monitoring data are well defined by the actual recommandations. Nephrologist can provide a set of recommended intervention to the primary care physician. The most accepted criterion of initiation of dialysis, in absence of clinic uremic manifestation is a glomerular filtration rate lower than 7 ml/min/1,73m2. Psychological and medical preparation of the patient to dialysis is essential. The possibility of renal transplantation should be evaluated during the following of patient with CKD

The Role of Community Pharmacists in the Detection of Clinically Relevant Drug-Related Problems in Chronic Kidney Disease Patients.

Community pharmacists (CPs) have traditionally had limited access to patients' estimated glomerular filtration rate (eGFR) during the medication-dispensing process. The increasing access to shared electronic health records is making eGFR available, but the skills needed to detect and manage clinically relevant drug-related problems (DRPs) are poorly documented. The primary objective of this study was to investigate the role of CPs in the medication-dispensation process for elderly patients with renal impairment. A total of 70 CPs participated in this 6 month study. Community pharmacists asked all patients ≥65 years to bring their laboratory test values for the next medication-dispensing process. Drug-related problem detection rates were compared between CPs (prospective period) and expert pharmacists (retrospectively). The clinical relevance of each DRP was assessed by nephrologists and general practitioners using an appropriate tool. Community pharmacists recruited n = 442 patients with eGFR < 60 mL/min/1.73 m2 and detected n = 99 DRPs, whereas expert pharmacists detected n = 184 DRPs. The most frequently detected DRPs were dosage problems and contraindications. According to assessment by clinicians, CPs and expert pharmacists identified 54.0% and 84.7% of clinically relevant DRPs, respectively. This study suggests a positive impact of the systematic availability of eGFR to CPs on the detection of several DRPs with clinical relevance.

Risk factors for severity of COVID-19 in chronic dialysis patients from a multicentre French cohort.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an emerging infectious disease, related to severe acute respiratory syndrome coronavirus 2 infection. Few data are available in patients with end-stage renal disease (ESRD). METHODS: We conducted an observational cohort study of COVID-19 patients at 11 dialysis centres in two distinct districts of France to examine the epidemiological and clinical characteristics of COVID-19 in this population, and to determine risk factors of disease severity (defined as a composite outcome including intensive care unit admission or death) and mortality. RESULTS: Among the 2336 patients enrolled, 5.5% had confirmed COVID-19 diagnosis. Of the 122 patients with a follow-up superior to 28 days, 37% reached the composite outcome and 28% died. Multivariate analysis showed that oxygen therapy on diagnosis and a decrease in lymphocyte count were independent risk factors associated with disease severity and with mortality. Chronic use of angiotensin II receptor blockers (ARBs) (18% of patients) was associated with a protective effect on mortality. Treatment with azithromycin and hydroxychloroquine (AZT/HCQ) (46% of patients) were not associated with the composite outcome and with death in univariate and multivariate analyses. CONCLUSIONS: COVID-19 is a severe disease with poor prognosis in patients with ESRD. Usual treatment with ARBs seems to be protective of critical evolution and mortality. There is no evidence of clinical benefit with the combination of AZT/HCQ.

[Towards an extension of the REIN registry to patients with chronic kidney disease at stage 5 not treated with dialysis or transplantation? A pilot study]. / 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 71.4years (IQR: 58.4-80.4), 39.9% were diabetic. The median eGFR was 12mL/min/1.73m2 (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 4.0months), 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.

[Pathophysiology, epidemiology, clinical presentation, diagnosis and treatment options for autosomal dominant polycystic kidney disease]. / Pathophysiologie, épidémiologie, présentation clinique, diagnostic et options thérapeutiques dans la polykystose rénale autosomique dominante.

Autosomal dominant polycystic kidney disease (ADPKD) is the leading genetic cause of end-stage renal disease (ESRD) worldwide. Its prevalence is evaluated according to studies and population between 1/1000 and 1/4000 live births and it accounts for 6 to 8% of incident ESRD patients in developed countries. ADPKD is characterized by numerous cysts in both kidneys and various extrarenal manifestations that are detailed in this review. Clinico-radiological and genetic diagnosis are also discussed. Mutations in the PKD1 and PKD2 codifying for polycystin-1 (PC-1) and polycystin-2 (PC-2) are responsible for the 85 and 15% of ADPKD cases, respectively. In primary cilia of normal kidney epithelial cells, PC-1 and PC-2 interact forming a complex involved in flow- and cilia-dependant signalling pathways where intracellular calcium and cAMP play a central role. Alteration of these multiple signal transduction pathways leads to cystogenesis accompanied by dysregulated planar cell polarity, excessive cell proliferation and fluid secretion, and pathogenic interactions of epithelial cells with an abnormal extracellular matrix. The mass effect of expanding cyst is responsible for the decline in glomerular filtration rate that occurs late in the course of the disease. For many decades, the treatment for ADPKD aims to lessen the condition's symptoms, limit kidney damage, and prevent complications. Recently, the development of promising specific treatment raises the hope to slow the growth of cysts and delay the disease. Treatment strategies targeting cAMP signalling such as vasopressin receptor antagonists or somatostatin analogs have been tested successfully in clinical trials with relative safety. Newer treatments supported by preclinical trials will become available in the next future. Recognizing early markers of renal progression (clinical, imaging, and genetic markers) to identify high-risk patients and multidrug approaches with synergistic effects may provide new opportunities for the treatment of ADPKD.

Postherpetic neuralgia in older adults: culture, quality of life, and the use of alternative/complementary therapies.

The purpose of this article is to describe current knowledge and standards of care for postherpetic neuralgia (PHN) among older persons. Three influencing factors are considered: cultural implications, quality of life (QOL), and current practice of alternative/complementary therapy. A review of literature published between 2001 and 2006 was conducted. The findings indicate that PHN has debilitating effects on older adults regardless of culture. The impact of PHN on culture and ethnicity, particularly on the relationship between culture and patient's self-report of herpes zoster and/or PHN, has not been well investigated as evidenced in the literature. PHN is found to be associated with decreased health-related QOL among the elderly, with the most affected domains being sleep, mood, and general activity. Alternative and complementary therapy offers many advantages such as ease of use, availability, and low cost. However, due to lack of controlled trials and insufficient evidence, alternative therapy is not currently used widely and recommended. As the US population ages, the incidence of herpes zoster and PHN is expected to rise. Clinical trials that explore the response of the culturally diverse older adults to current treatment guidelines, strategies for prevention of PHN and its corresponding decrease in QOL, as well as controlled trials of alternative/complementary remedies should be considered.