[Preservation of residual kidney function in chronic haemodialysis]. / Préservation de la fonction rénale résiduelle et hémodialyse incrémentale.

Residual kidney function (RKF) is defined as the production of a clinically significant amount of urine in dialysis patients. Observational studies suggest that those with preserved RKF have a better prognosis than anuric patients. Preserved RKF allows the prescription of a lower dialysis dose compared to the traditional thrice weekly schedule. Such an "incremental" approach has also been associated with a better global prognosis. In view of the overall growth of incremental HD in the western world, we review the main studies supporting this approach, as well as the benefits and limitations related to RKF preservation.

Chez les patients hémodialysés, la fonction rénale résiduelle (FRR) est définie comme la production d'une quantité d'urine significative du point de vue clinique. Les données observationnelles suggèrent que les patients en hémodialyse (HD) ayant une FRR conservée ont un meilleur pronostic que les patients anuriques. Une FRR préservée permet également la prescription d'une dose d'HD inférieure au schéma traditionnel de 3 séances par semaine. Ce type d'approche «â€…incrémentale ¼ a elle aussi été associée à une amélioration du pronostic global. Au vu de l'essor de l'HD incrémentale dans les pays développés, nous revenons dans cet article sur les principales études qui soutiennent cette approche ainsi que sur les bénéfices et limitations liées à la préservation de la FRR.

[Nephrology: what's new in 2023]. / Néphrologie: ce qui a changé en 2023.

Molecules such as sparsentan and budesonide look promising to treat proteinuric IGA nephropathy. SLGT2 inhibitors have a prominent place in nephroprotection and could be used in the treatment of acute kidney injury due to heart failure as well. High volume hemodiafiltration compared to hemodialysis improves survival in dialysis patients. Lessening dialysate temperature does not improve hemodynamic stability during the dialysis session. Sodium bicarbonate does not seem to protect renal function in renal transplant patients. SGLT2 inhibitors may have a beneficial effect in these patients in terms of nephroprotection.

Dans les formes protéinuriques de néphropathie à IgA, le sparsentan et le budésonide semblent être des molécules prometteuses. Les inhibiteurs du SGLT2 (iSGLT2) confirment leur place primordiale dans la néphroprotection et pourraient être utilisés dans le traitement de l'insuffisance rénale aiguë (IRA) liée à l'insuffisance cardiaque. En hémodialyse, l'hémodiafiltration à haut-débit comparée à l'hémodialyse diminue la mortalité d'environ 22 %. Abaisser la température du dialysat n'améliore pas la stabilité cardiovasculaire durant la séance d'hémodialyse. Le bicarbonate de sodium ne semble pas avoir d'effet néphroprotecteur sur la fonction rénale des greffés rénaux alors que les iSGLT2 pourraient avoir un effet bénéfique.

[Nephrology: what's new in 2022]. / Néphrologie : ce qui a changé en 2022.

Severe cases of IGA nephropathy might benefit from corticosteroid therapy. Inflimidase may be a promising treatment of Goodpasture disease. SGLT2 inhibitors and acetazolamide act synergistically with loop diuretics in the treatment of acute cardiac failure. In hemodialysis, use of lung ultrasound to determine the ultrafiltration seems to decrease hospitalizations due to acute heart failure but does not reduce patient-centered outcomes. Icodextrin may mitigate the loss of ultrafiltration in PD patients who are carriers of the Aquaporin I promotor TT genotype. MICA-antibodies have an impact on the risk of graft rejection. Xenotransplantation may become a reality.

Une corticothérapie peut être proposée dans les formes sévères de néphropathie à IgA. L'inflimidase est une molécule prometteuse dans le traitement de la maladie de Goodpasture. Les inhibiteurs du SGLT2 et l'acétazolamide sont des diurétiques d'appoint aux diurétiques de l'anse dans le traitement de l'insuffisance cardiaque aiguë. En hémodialyse, l'ultrason pulmonaire pour déterminer le volume d'ultrafiltration diminue les hospitalisations pour insuffisance cardiaque mais pas la morbimortalité globale. L'hémodialyse incrémentale gagne en popularité. L'icodextrine permet de pallier la baisse de l'ultrafiltration chez les patients en dialyse péritonéale porteurs du génotype TT du promoteur de l'aquaporine-1. Les anticorps anti-MICA dirigés spécifiquement contre le greffon rénal ont un impact sur le risque de rejet du greffon. La xénotransplantation devient une réalité.

[Collaboration in nephrology between Geneva and Yaoundé: a convincing example]. / Néphrologie solidaire : la coopération Genève-Yaoundé.

Chronic kidney disease (CKD) has a high prevalence in Cameroon and will become an important public health problem. Its management must be comprehensive, starting with CKD prevention to the implementation of renal replacement therapies best suited to the needs of patients and resources available in Cameroon. Practical interventions involving nephrology departments in both Africa and Europe can contribute to an improved management of CKD in Africa. The current collaboration between the Geneva University Hospitals and the Yaoundé teaching hospitals is a convincing example. It includes a clinical trial on the treatment of metabolic acidosis linked to CKD, assistance with the placement of hemodialysis catheters by sonography and the initiation of a kidney transplantation program with living donors.

La maladie rénale chronique (MRC) a une haute prévalence au Cameroun et va devenir un important problème de santé publique. Sa prise en charge doit être globale, partant de la prévention de la MRC jusqu'à la mise en place des techniques de suppléance extrarénale les plus adaptées aux besoins des patients et aux ressources disponibles localement. Des actions concrètes, dans le cadre d'une néphrologie solidaire, impliquant des services de néphrologie d'Afrique et d'Europe, peuvent y contribuer. La collaboration entre les Hôpitaux universitaires de Genève et ceux de Yaoundé en est un exemple probant, avec la mise en place d'un essai clinique sur le traitement de l'acidose métabolique liée à la MRC, une aide à la pose des cathéters de dialyse par sonographie et l'initiation d'un programme de transplantation rénale avec des donneurs vivants.

Outcomes of incident patients treated with incremental haemodialysis as compared with standard haemodialysis and peritoneal dialysis.

BACKGROUND: Residual kidney function is considered better preserved with incremental haemodialysis (I-HD) or peritoneal dialysis (PD) as compared with conventional thrice-weekly HD (TW-HD) and is associated with improved survival. We aimed to describe outcomes of patients initiating dialysis with I-HD, TW-HD or PD. METHODS: We conducted a retrospective analysis of a prospectively assembled cohort in a single university centre including all adults initiating dialysis from January 2013 to December 2020. Primary and secondary endpoints were overall survival and hospitalization days at 1 year, respectively. RESULTS: We included 313 patients with 234 starting on HD (166 TW-HD and 68 I-HD) and 79 on PD. At the end of the study, 10 were still on I-HD while 45 transitioned to TW-HD after a mean duration of 9.8 ± 9.1 months. Patients who stayed on I-HD were less frequently diabetics (P = .007). Mean follow-up was 33.1 ± 30.8 months during which 124 (39.6%) patients died. Compared with patients on TW-HD, those on I-HD had improved survival (hazard ratio 0.49, 95% confidence interval 0.26-0.93, P = .029), while those on PD had similar survival. Initial kidney replacement therapy modality was not significantly associated with hospitalization days at 1 year. CONCLUSIONS: I-HD is suitable for selected patients starting dialysis and can be maintained for a significant amount of time before transition to TW-HD, with diabetes being a risk factor. Although hospitalization days at 1 year are similar, initiation with I-HD is associated with improved survival as compared with TW-HD or PD. Results of randomized controlled trials are awaited prior to large-scale implementation of I-HD programmes.

[Hemodynamic and cardiovascular implications of arteriovenous fistulas in hemodialysis]. / Répercussions hémodynamiques et cardiovasculaires des fistules artérioveineuses en hémodialyse.

Arteriovenous fistula (AVF) remains the vascular access of choice in hemodialysis but generates cardiovascular constraints. Its creation immediately induces an increase in cardiac output. Increased venous return and subsequent volume overload lead to biventricular remodeling, and eventually to dysfunction. High-output heart failure (HOHF) caused by high-flow AVF is a recognized but not strictly defined clinical entity, based on the combination of hypervolemia with an elevated cardiac output. A Qa greater than 2 L/min is a risk factor for HOHF, particularly in susceptible patients. The most used flow reduction procedure is post-anastomotic vein caliber reduction by a banding technique, relieving symptoms and partially reversing previously induced structural abnormalities, but the benefit often remains limited in time.

La fistule artérioveineuse (FAV) demeure l'accès vasculaire de choix en hémodialyse mais engendre des contraintes cardiovasculaires. Sa création génère une élévation du débit cardiaque. L'augmentation du retour veineux puis la surcharge en volume induisent un remodelage biventriculaire pouvant mener à une dysfonction. L'insuffisance cardiaque à haut débit (ICHD) causée par un hyperdébit de la FAV est une entité clinique connue mais pas strictement définie, reposant sur une hypervolémie et une élévation du débit cardiaque. Un débit d'accès supérieur à 2 l/min est un facteur de risque d'ICHD, en particulier chez des patients susceptibles. Une intervention possible de réduction de débit est la réduction du calibre de la veine post-anastomotique par cerclage, soulageant les symptômes et inversant partiellement les anomalies structurelles induites mais a souvent un effet transitoire.

[Nephrology: what's new in 2021?] / Néphrologie.

Major advances in the treatment of nondiabetic chronic nephropathy and ANCA associated-renal vasculitis were published within the past two years. A new formula for assessing GFR was developed that does not take ethnicity into account. For hemodialysis patients, hemodiafiltration does not diminish uremic neuropathy. In hemodialysis patients, DOACs induce less bleeding than K vitamin antagonists. Weaning of steroids should be more rapid in some transplant patients. COVID-19 vaccination is less effective in dialysis and transplant patients and will necessitate a third dose.

De grandes avancées thérapeutiques ont été publiées récemment dans le chapitre de la néphropathie chronique non diabétique et des vascularites rénales. Une nouvelle formule d'estimation du débit de filtration glomérulaire estimé a été développée sans facteur de correction ethnique. En hémodialyse, l'hémodiafiltration ne diminue pas la neuropathie urémique et les anticoagulants oraux directs occasionnent moins de complications hémorragiques que les antivitamines K. Un sevrage plus rapide des corticostéroïdes chez certains greffés rénaux est possible. La vaccination contre le Covid a une efficacité moindre chez les dialysés et les transplantés rénaux, et nécessite une troisième dose.

Relationship between renal function and blood pressure dipping status in renal transplant recipients: a longitudinal study.

BACKGROUND: Hypertension (HT) is associated with adverse outcomes in kidney transplant (KTX) recipients. Blunting of physiological decrease in nighttime compared to daytime blood pressure (non-dipping status) is frequent in this setting. However, weather non-dipping is independently associated with renal function decline in KTX patients is unknown. METHODS: We retrospectively screened KTX outpatients attending for a routine ambulatory blood pressure monitoring (ABPM) (T1) at a single tertiary hospital. Patients had two successive follow-up visits, 1 (T2) and 2 (T3) years later respectively. Routine clinical and laboratory data were collected at each visit. Mixed linear regression models were used with estimated glomerular filtration rate (eGFR) as the dependent variable. RESULTS: A total of 123 patients were included with a mean follow-up of 2.12 ± 0.45 years after ABPM. Mean age and eGFR at T1 were 56.0 ± 15.1 and 54.9 ± 20.0 mL/min/1.73m2 respectively. 61 patients (50.4%) had sustained HT and 81 (65.8%) were non-dippers. In multivariate analysis, systolic dipping status was positively associated with eGFR (p = 0.009) and compared to non-dippers, dippers had a 10.4 mL/min/1.73m2 higher eGFR. HT was negatively associated with eGFR (p = 0.003). CONCLUSIONS: We confirm a high prevalence of non-dippers in KTX recipients. We suggest that preserved systolic dipping is associated with improved renal function in this setting independently of potential confounders, including HT and proteinuria. Whether modification of dipping status by chronotherapy would preserve renal function remains to be tested in clinical trials.

[Nephrology†: what's new in 2020†?] / Néphrologie.

Impact of gliflozines in the treatment of non-diabetic nephropathies and cardiac failure has lately been demonstrated. Tolvaptan has now been recognized in Switzerland as a treatment of hyponatremia. In hemodialysis, some progress has been made in the management of dysfunctional arterio-venous fistulas. A glimmer of hope in the treatment of uremic pruritus? Conservative management of a stable coronary heart disease is also advocated in patients with end-stage kidney disease. Therapy with immune cells may either minimize or remove the need for immunosuppression in renal transplant patients. A new predictive score combining several markers can predict long-term graft failure.

L'efficacité des gliflozines est également reconnue dans le traitement de l'insuffisance cardiaque et des néphropathies non diabétiques. Le tolvaptan est maintenant reconnu en Suisse pour le traitement de l'hyponatrémie. Une stratégie de mise en dialyse plus attentiste dans l'insuffisance rénale aiguë est définitivement confirmée. En hémodialyse, quelques progrès sont obtenus dans la prise en charge des dysfonctions d'accès vasculaires et du prurit urémique. Un traitement conservateur d'emblée est préconisé pour une coronaropathie stable également chez les patients en insuffisance rénale terminale. En transplantation rénale, l'emploi d'une immunothérapie cellulaire permettrait de diminuer ou même d'arrêter l'immunosuppression. La perte du greffon peut être évaluée avec un nouveau score prédictif combinant plusieurs marqueurs.

[Covid-19 pandemic in patients with chronic kidney disease]. / Impact de la pandémie de Covid-19 sur les patients avec insuffisance rénale chronique.

Patients with chronic nephropathies were particularly affected during the COVID-19 pandemic. These patients suffer from multiple comorbidities and some specific treatments may put them at risk towards severe complications. Hemodialysis patients necessitating an in-center hemodialysis maintenance regimen were unable to be confined and despite strict prevention protocols suffered high infection and subsequently fatality rates. Renal transplant patients, because of their immunosuppressive drugs, also represent an at-risk population of acquiring the SARS-CoV-2.

Au vu de leurs particularités, les patients avec insuffisance rénale chronique ont été particulièrement affectés par la pandémie de Covid-19. Ces patients fragiles ont souvent de multiples comorbidités associées et, dans certains cas, reçoivent des traitements qui les mettent à risque de contracter ce virus et de développer des formes sévères. Les hémodialysés en centre ne pouvant être confinés et, malgré des protocoles rigoureux de prévention, ont eu dans la région genevoise une prévalence élevée d'infection. Les transplantés rénaux, du fait de leur immunosuppression, constituent également une population à risque.

Case report: a 58 -year -old man with small kidneys and elevated liver enzymes.

BACKGROUND: The conjunction of hepatitis and renal disease can be seen in several clinical context, including karyomegalic nephritis (KIN). Karyomegalic nephritis (KIN) is a rare genetic disease, with less than 50 cases reported, which incidence is probably underestimated. We report here an unusual case presentation of KIN with obtention of several organ biopsies and a novel mutation leading to the disease. CASE PRESENTATION: A 58 year old Caucasian without relevant family history presents with advanced chronic kidney disease, elevated liver enzymes and recurrent pulmonary infection. Familial history was negative. Renal biopsy revealed a chronic tubulo-intertsitial nephritis with enlarged and irregular hyperchromatic nuclei. Karyomegalic nephritis (KIN) was confirmed by genetic testing with a non-sense mutation and a deletion in the Fanconi anemia associated nuclease 1 (FAN1) gene. CONCLUSIONS: KIN is rare disease to be suspected in the presence of renal disease, biological hepatitis and recurrent pulmonary infections, even without a familial history. Diagnosis of this condition is crucial to perform family screening, avoid progression factors, and adapt post transplantation immunosuppression. Finally, avoiding familial heterozygote donors appears of major importance in this condition.

Impact of superimposed nephrological care to guidelines-directed management by primary care physicians of patients with stable chronic kidney disease: a randomized controlled trial.

BACKGROUND: Optimal clinical care of patients with chronic kidney disease (CKD) requires collaboration between primary care physicians (PCPs) and nephrologists. We undertook a randomised trial to determine the impact of superimposed nephrologist care compared to guidelines-directed management by PCPs in CKD patients after hospital discharge. METHODS: Stage 3b-4 CKD patients were enrolled during a hospitalization and randomised in two arms: Co-management by PCPs and nephrologists (interventional arm) versus management by PCPs with written instructions and consultations by nephrologists on demand (standard care). Our primary outcome was death or rehospitalisation within the 2 years post-randomisation. Secondary outcomes were: urgent renal replacement therapy (RRT), decline of renal function and decrease of quality of life at 2 years. RESULTS: From November 2009 to the end of June 2013, we randomised 242 patients. Mean follow-up was 51 + 20 months. Survival without rehospitalisation, GFR decline and elective dialysis initiation did not differ between the two arms. Quality of life was also similar in both groups. Compared to randomised patients, those who either declined to participate in the study or were previously known by nephrologists had a worse survival. CONCLUSION: These results do not demonstrate a benefit of a regular renal care compared to guided PCPs care in terms of survival or dialysis initiation in CKD patients. Increased awareness of renal disease management among PCPs may be as effective as a co-management by PCPs and nephrologists in order to improve the prognosis of moderate-to-severe CKD. TRIAL REGISTRATION: This study was registered on June 29, 2009 in clinicaltrials.gov (NCT00929760) and adheres to CONSORT 2010 guidelines.

[Incremental hemodialysis «â€ less is more†¼ also when starting hemodialysis†?] / Hémodialyse incrémentale ­ «â€ less is more†¼ lors de l'initiation de la dialyse†?

When initiating hemodialysis, incremental hemodialysis takes into account the residual kidney function (RKF) and adds a dialysis regimen to achieve a satisfactory clearance and ultrafiltration. This approach allows less frequent or shorter dialysis sessions than the standard of 3 sessions per week regimen. It is associated with multiple benefits for the patient. However, RKF has to be monitored regularly to enable the dialysis regimen to be adapted accordingly in order to avoid under-dialysis.

Lors de l'initiation d'un traitement d'hémodialyse chronique, l'hémodialyse incrémentale prend en compte la fonction rénale résiduelle (FRR) du patient et complète celle-ci par une dose de dialyse pour atteindre un niveau d'épuration et d'ultrafiltration satisfaisant. Cela permet d'effectuer des séances d'hémodialyse qui sont plus courtes et moins intenses ou moins fréquentes que la prescription standard de 3 dialyses par semaine. Cette méthode est associée à de multiples bénéfices pour le patient. Néanmoins, la FRR doit être monitorée régulièrement afin d'adapter la dose de dialyse et d'éviter une sous-dialyse.

[Nephrology†: what's new in 2019†?] / Néphrologie.

Impact of gliflozines and rituximab in the treatments of diabetic and membranous nephropathies respectively has been confirmed. Roxadustat may be the new promising treatment of renal anemia. Long-acting erythropoietins may be associated with a higher death rate than short-acting ones in hemodialysis patients. Kidneys of HCV-seropositive donors can be proposed to any wait-listed patient for renal transplantation. Immunosupression minimizing the use of calcineurin inhibitors may be achieved with an everolimus-based protocol.

L'intérêt des gliflozines dans le traitement de la néphropathie diabétique et du rituximab dans celui de la néphropathie membraneuse est confirmé. Le roxadustat pourrait devenir un nouveau traitement prometteur de l'anémie rénale. En hémodialyse, les érythropoïétines à longue durée d'action seraient associées à une plus forte mortalité que celles à courte durée d'action. En transplantation rénale, les reins de donneurs VHC-séropositifs (virus de l'hépatite C-séropositifs) peuvent être proposés à tous les receveurs potentiels. L'emploi de l'évérolimus permettrait une immunosupression avec épargne des inhibiteurs de la calcineurine.

[Ethylene glycol intoxication requires a multidisciplinary approach]. / L'intoxication à l'éthylène glycol nécessite une approche multidisciplinaire.

Cheap and easy to access, ethylene glycol is used in the synthesis of antifreezes. Intoxication has potentially irreversible morbid consequences. Ingestion of a small amount can lead to death. Due to its ubiquitous distribution and potential complications, it is of paramount importance for the practitioner to recognize its manifestations and metabolic complications in order to implement its therapy in partnership with the nephrologist and the intensivist. A successful treatment depends on rapid and multidisciplinary management, as reviewed in this article.

L'éthylène glycol (EG), bon marché et facile d'accès, est notamment utilisé dans la synthèse des antigels. Une intoxication à l'EG a des conséquences morbides potentiellement irréversibles et est associée à une mortalité non négligeable. Du fait des complications et de sa distribution en libre-service, il convient pour le praticien des urgences d'en reconnaître les manifestations, notamment métaboliques, afin d'en assumer le traitement en partenariat avec l'intensiviste et le néphrologue. Le succès dépend d'une reconnaissance rapide et d'une prise en charge multidisciplinaire dont une approche est suggérée dans cet article.

[Hepatorenal syndrome : something new?] / Syndrome hépatorénal : quoi de neuf ?

Hepatorenal syndrome is a serious and frequent complication in patients suffering from liver cirrhosis. Its most severe type is characterized by the rapid occurrence of a functional acute kidney injury. However it is mainly an exclusion diagnosis. Although the pathophysiology is not yet fully understood, the principal hypothesis is a splanchnic vasodilatation leading to a systemic and renal vasoconstriction associated with sodium and water retention and progressive cardiac failure. Intravenous albumin associated with systemic vasoconstrictors, terlipressin or noradrenaline, is recommended. Because this pathology is associated with high mortality rate, liver transplantation should be discussed. A multidisciplinary approach is mandatory due to the renal disease but also to multiorganic failure.

Le syndrome hépatorénal est une complication grave et fréquente, décrite chez les patients atteints de cirrhose hépatique. Dans sa forme sévère, il est caractérisé par une insuffisance rénale aiguë d'origine fonctionnelle. Cependant, il s'agit le plus souvent d'un diagnostic d'exclusion. La physiopathologie, qui n'est pas encore totalement claire, repose sur une vasodilatation splanchnique associée à une vasoconstriction systémique et rénale avec une rétention hydrosodée secondaire et une dysfonction cardiaque progressive. Parmi les alternatives thérapeutiques, l'administration d'albumine associée à des vasoconstricteurs intraveineux, terlipressine ou noradrénaline, est recommandée. Toutefois la question d'une transplantation hépatique doit se poser en raison de l'impact de cette pathologie sur la survie. Au vu de l'atteinte rénale et de la défaillance souvent multiorganique, une prise en charge multidisciplinaire est nécessaire.

[Nephrology : what's new in 2018 ?] / Néphrologie.

Major advances in the treatment of ANCA associated-renal vasculitides, IGA nephropathy and renal autosomal dominant polycystic disease were published within the past year. There is neither clear benefit of early initiation of renal replacement therapy in the intensive care unit nor with the use of chloride-poor solutions to prevent kidney failure. Maintenance parenteral iron supplementation in hemodialysis patients is neither associated with infectious nor cardiovascular risks. Cognitive decline may be more associated with hemodialysis than peritoneal dialysis. In transplantation, the persistence of complement-binding donor-specific antibodies after treatment is predictor of graft loss. Tocilizumab is a promising treatment for chronic antibody-mediated rejection.

Des progrès importants ont été effectués cette année dans le traitement des vascularites rénales à ANCA (anticorps anti-cytoplasme des polynucléaires neutrophiles), de la néphropathie à IgA et de la polykystose rénale. Il n'y a pas d'avantage clair à l'initiation précoce de la dialyse en cas d'insuffisance rénale sévère et à l'utilisation des solutions pauvres en chlore dans le remplissage volémique. En hémodialyse chronique, une supplémentation en fer parentéral jusqu'à 400 mg par mois n'est pas associée à un risque infectieux ou cardiovasculaire augmenté. L'hémodialyse pourrait être associée à un déclin cognitif plus important que la dialyse péritonéale. En transplantation, la persistance d'anticorps dirigés contre le greffon et liant le complément après traitement du rejet, est prédicteur de perte du greffon. Le tocilizumab serait un traitement prometteur du rejet chronique médié par les anticorps.

Renal replacement therapy intensity for acute kidney injury and recovery to dialysis independence: a systematic review and individual patient data meta-analysis.

Background: There is no consensus whether higher intensity dose renal replacement therapy (RRT) compared with standard intensity RRT has survival benefit and achieves better renal recovery in acute kidney injury (AKI). Methods: In an individual patient data meta-analysis, we merged individual patient data from randomized controlled trials (RCTs) comparing high with standard intensity RRT in intensive care unit patients with severe AKI. The primary outcome was all-cause mortality. The secondary outcome was renal recovery assessed as the proportion of patients who were RRT dependent at key trial endpoints and by time to the end of RRT dependence. Results: Of the eight prospective RCTs assessing different RRT intensities, seven contributed individual patient data (n = 3682) to the analysis. Mortality was similar between the two groups at 28 days [769/1884 (40.8%) and 744/1798 (41.4%), respectively; P = 0.40] after randomization. However, more participants assigned to higher intensity therapy remained RRT dependent at the most common key study point of 28 days [e.g. 292/983 (29.7%) versus 235/943 (24.9%); relative risk 1.15 (95% confidence interval 1.00-1.33); P = 0.05]. Time to cessation of RRT through 28 days was longer in patients receiving higher intensity RRT (log-rank test P = 0.02) and when continuous renal replacement therapy was used as the initial modality of RRT (log-rank test P = 0.03). Conclusions: In severe AKI patients, higher intensity RRT does not affect mortality but appears to delay renal recovery. Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR) identifier ACTRN12615000394549 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12615000394549).

[Nephrology]. / Néphrologie.

New antidiabetic drugs which slow effectively the course of diabetic nephropathy are now available. There is no benefit of prophylactic hydratation to prevent contrast nephropathy in patients with moderate chronic kidney disease. In elderly hemodialysis patients, hemodiafiltration seems better tolerated than conventional hemodialysis, although there is a similar dialysis-induced myocardial stress with both methods. Role of de novo donor-specific antibodies is better characterized, which may subsequently lead to new treatments of graft rejection.

La prise en charge de la néphropathie diabétique a connu une avancée majeure avec de nouvelles classes thérapeutiques aux propriétés néphro- et cardioprotectrices importantes. L'hydratation prophylactique n'apporte pas de bénéfice avéré lors d'administration de produit de contraste chez des patients avec insuffisance rénale chronique modérée. En hémodialyse chonique, l'hémodiafiltration semble mieux tolérée chez les personnes âgées que l'hémodialyse traditionnelle, bien qu'elle engendre durant la séance de dialyse le même stress myocardique. En transplantation, le rôle des anticorps dirigés contre le donneur est mieux précisé et laisse espérer à l'avenir des traitements mieux ciblés pour éviter le rejet.

Risk factors for community-acquired acute kidney injury in patients with and without chronic kidney injury and impact of its initial management on prognosis: a prospective observational study.

BACKGROUND: We aimed to describe clinical characteristics of patients with community-acquired acute kidney injury (CA-AKI), the effectiveness of initial management of CA-AKI, its prognosis and the impact of medication on its occurrence in patients with previous chronic kidney injury (CKI). METHODS: We undertook a prospective observational study within the Emergency Department (ED) of a University Hospital, screening for any patient >16 years admitted with an eGFR <60 ml/mn/1.73 m2 and a rise in serum creatinine as compared to previous values. Patients' medical files were reviewed by a panel of nephrologists in the subsequent days and at one and three-years follow-up. RESULTS: From May 1st to June 21st 2013, there were 8464 admissions in the ED, of which 653 had an eGFR <60 ml/mn/1.73 m2. Of these, 352 had previous CKI, 341 had CA-AKI, and 104 had CA-ACKI (community-acquired acute on chronic kidney injury). Occurrence of superimposed CA-AKI in CKI patients was associated with male gender and with use of diuretics, but not with use of ARBs or ACEIs. Adequate management of CA-AKI defined as identification, diagnostic procedures and therapeutic intervention within 24 h, was recorded in 45% of the cases and was not associated with improved outcomes. Three-year mortality was 21 and 48% in CKI and CA-ACKI patients respectively, and 40% in patients with only CA-AKI (p < 0.001). Mortality was significantly associated with age, hypertension, ischemic heart disease and CA-AKI. Progression of renal insufficiency was associated with male gender and age. CONCLUSIONS: CA-AKI is more frequently encountered in male patients and those treated with diuretics and is an independent risk factor for long-term mortality. Its initial adequate management failed to improve outcomes.