Feasibility, Efficacy, and Safety of Peripheral Venous Access for Chronic Double-Filtration Plasmapheresis with Regional Citrate Anticoagulation.

INTRODUCTION: Peripheral venous access (PVA) is recommended as a first-line vascular approach for therapeutic plasmapheresis with centrifugation methods but not filtration, which usually requires high blood flow. We evaluated the feasibility, efficacy, and safety of double-filtration plasmapheresis (DFPP) with PVA, using ultrasound guidance and regional citrate anticoagulation (RCA), i.e., PVA-RCA-DFPP in patients undergoing chronic DFPP. Secondly, we assessed the number of central venous catheters (CVCs) avoided. METHODS: A single-center retrospective study evaluated 22 adult patients on chronic DFPP to perform PVA-RCA-DFPP. They were classified into 3 groups: successful (i.e., completion of sessions with PVA), primary failure (i.e., no sessions completed), secondary failure (i.e., ≥1 session with PVA completed but secondary return with CVC or arteriovenous fistula). RESULTS: Among the 22 patients included (64% men), 7 patients (32%) were classified as primary failures (2 patient refusals, 5 inadequate PVAs), 1 patient (5%) as a secondary failure (due to uncomfortable venipunctures), and 14 patients (64%) as successful. In the successful group including 12 patients treated for chronic inflammatory demyelinating polyneuropathy (CIDP) and 2 patients for familial hypercholesterolemia (FH) (2 patients), 116 sessions were performed, with a median treated plasma volume of 4.3 L [IQR 3.6-4.6] (45 mL/kg) for a median duration of 134 min [IQR 122-144], and a median blood flow of 94 mL/min [IQR 87-103]. For the CIDP group, 90% of sessions achieved a plasma volume >1 TPV, and for the FH group 91% of sessions achieved an LDLc reduction >60%. Eleven sessions out of 116 (9%) were interrupted, mostly due to PVA dysfunction (5/11) and circuit clotting (4/11). Session interruptions decreased significantly between each patient's first and following sessions (29% to 7%, p = 0.009). CONCLUSION: Chronic PVA-RCA-DFPP can be performed safely and efficiently, avoiding the use of CVCs.

Specificity of severe AKI aetiology and care in the elderly. The IRACIBLE prospective cohort study.

INTRODUCTION: Acute Kidney Injury (AKI) is increasingly common in people over 65 years of age, but its causes and management are poorly described. The purpose of this study was to describe the causes, management and prognosis of patients over 65 hospitalised for severe acute kidney injury (AKI) in all departments of a tertiary centre. METHOD: The prospective IRACIBLE (IRA: AKI in French; CIBLE: target in French) cohort included 480 patients hospitalised at a university hospital over 18 months for severe AKI or subgroup of AKIN3 (Acute Kidney Injury Network classification) defined by an acute creatinine increase > 354 µmol/L or managed with acute renal replacement therapy (RRT). The history, aetiology of AKI, management, and prognosis were compared in three age groups: < 65, 65-75, and > 75 years. RESULTS: The study population included 480 subjects (73% men) with a median body mass index (BMI) of 26.6 kg/m2 [23.3, 30.9], 176 (37%) diabetic patients, 124 (26%) patients < 65 years, 150 (31%) 65-75 years and 206 (43%) > 75 years. Increasing age class was associated with more comorbidities, a significantly lower median estimated glomerular filtration rate (eGFR) 6 months before inclusion (82; 62; 46 ml/min/1.73 m2, p < 0.05) and aetiology of AKI, which was more often obstructive (12%; 15%; 23%, p = 0.03) or part of a cardio-renal syndrome (6%; 9%; /15%, p = 0.04). Older patients were less often managed in the intensive care unit  (54%; 47%; 24%, p < 0.0001), were less frequently treated by RRT (52%; 43%; 31%, p < 0.001) and received fewer invasive treatments  (6%; 9%; 22%, p < 0.0001). Older survivors returned home less often (80%; 73%; 62%, p = 0.05) in favour of transfers to rehabilitation services (10%; 13%; 22%) with higher mortality at 3 months (35%; 32%; 50%, p < 0.0001). CONCLUSION: Older patients hospitalised for severe AKI have a specific profile with more comorbidities, lower baseline renal function, an aetiology of AKI of mainly extra-parenchymal causes and a complex pathway of care with an overall poor prognosis.

Characteristics of outpatients referred for a first consultation with a nephrologist: impact of different guidelines.

INTRODUCTION: Chronic kidney disease (CKD) affects > 10% of the population but not all CKD patients require referral to a nephrologist. Various recommendations for referral to nephrologists are proposed worldwide. We examined the profile of French patients consulting a nephrologist for the first time and compared these characteristics with the recommendations of the International Kidney Disease: Improving Global Outcomes (KDIGO), the French "Haute Autorité de Santé" (HAS), and the Canadian Kidney Failure Risk Equation (KFRE). METHODS: University Hospital electronic medical records were used to study patients referred for consultation with a nephrologist for the first time from 2016 to 2018. Patient characteristics (age, sex, diabetic status, estimated glomerular filtration rate (eGFR) and urine protein-to-creatinine ratio (PCR), etiology reported by the nephrologist) and 1-year patient follow-up were analyzed and compared with the KDIGO, HAS and Canadian-KFRE recommendations for referral to a nephrologist. The stages were defined according to the KDIGO classification, based upon kidney function and proteinuria.  RESULTS: The 1,547 included patients had a median age of 71 [61-79] years with 56% males and 37% with diabetes. The main nephropathies were vascular (40%) and glomerular (20%). The KDIGO classification revealed 30%, 47%, 19%, 4% stages G1-2 to G5, and 50%, 22%, 28% stages A1-A3, respectively. According to KDIGO, HAS and KFRE scores, nephrologist referral was indicated for 42%, 57% and 80% of patients respectively, with poor agreement between recommendations. Furthermore, we observed 890 (57%) patients with an eGFR> 30 ml/min and  a urine protein to creatinine ratio 0.5 g/g, mostly aged over 65 years (67%); 40% were diabetic, and 57% had a eGFR > 45 ml/min/1.73m2, 56% were diagnosed as vascular nephropathy and 11% with unknown nephropathy. CONCLUSION: These results underline the importance of better identifying patients for referral to a nephrologist and informing general practitioners. Other referral criteria (age and etiology of the nephropathy) are debatable.

Heterogeneity of Cause, Care, and Prognosis in Severe Acute Kidney Injury in Hospitalized Patients: A Prospective Observational Study.

BACKGROUND: KDIGO (Kidney Disease: Improving Global Outcomes) defines acute kidney injury (AKI) solely by serum creatinine (SCr) and urine output variation. Severe AKI is a syndrome covering various clinical situations. OBJECTIVE: To describe severe AKI heterogeneity by department of hospitalization. DESIGN: This is a prospective observational single-center study. SETTING: Adult patients hospitalized in a French tertiary hospital from August 2016 to December 2017. PATIENTS: All adults with severe AKI, defined by dialysis for AKI or an increase in SCr above 354 µmol/L. MEASUREMENTS: Patient characteristics, clinical and laboratory presentation, AKI cause, medical indication for renal replacement therapy (RRT), planned palliative care, and vital status 30 days after severe AKI. METHODS: A global description of patient characteristics, care, and prognosis and comparison by department of hospitalization: intensive care unit (ICU), nephrology, and others. RESULTS: The study included 480 patients (73% men, median age: 72 years, range: 64-83), with medical histories including cardiovascular disease, diabetes, cancer, and chronic kidney disease. Principal causes were sepsis (104; 22%), hypovolemia (98; 20%), obstructive AKI (84; 18%), acute tubular necrosis (ATN; 74; 15%), and cardiorenal syndrome (51; 11%). Severe AKI was diagnosed in the ICU for 188 (39%) patients, the nephrology department for 130 (27%), and in other wards for 162 (34%). Patient characteristics differed by department for age, comorbidity, cause, and RRT use and indications. Palliative care was planned for 72 (15%) patients, most frequently in other wards. LIMITATIONS: We studied a subgroup of stage 3 KDIGO AKI patients in a single center without cardiac surgery. CONCLUSION: Patients hospitalized for severe AKI have frequent and various comorbidities, different clinical presentations, care, hospitalization in various departments, and different prognosis. The heterogeneity of this severe AKI implies the need for personalized care, which requires prognostic tools that include information besides SCr and diuresis.

CONTEXTE: Le KDIGO définit l'insuffisance rénale aigüe (IRA) uniquement par une variation de la créatinine sérique (SCr) et de la diurèse. L'IRA grave est un syndrome couvrant diverses situations cliniques. OBJECTIF: Décrire l'hétérogénéité de l'IRA grave selon l'unité d'hospitalisation. TYPE D'ÉTUDE: Étude observationnelle prospective menée dans un seul centre. SUJETS: Des adultes hospitalisés entre août 2016 et décembre 2017 dans un centre de soins tertiaires en France. PARTICIPANTS: Tous les adultes atteints d'IRA grave, définie par un traitement de dialyse ou un taux de SCr au-delà de 354 µmol/l. MESURES: Les caractéristiques du patient, le tableau clinique et de laboratoire, l'étiologie de l'IRA, l'indication médicale pour une thérapie de remplacement rénal (TRR), le plan de soins palliatifs et le statut vital 30 jours après l'épisode d'IRA grave. MÉTHODOLOGIE: Une description globale des caractéristiques des patients, des soins et du pronostic, ainsi qu'une comparaison selon l'unité d'hospitalisation: unité de soins intensifs (USI), néphrologie et autres. RÉSULTATS: L'étude portait sur 480 patients (73 % d'hommes) âgés de 64 à 83 ans (âge médian: 72 ans) avec des antécédents incluant maladies cardiovasculaires, diabète, cancer ou insuffisance rénale chronique. Les principales causes de l'IRA grave étaient une septicémie (104, 22 %), une hypovolémie (98, 20 %), une IRA obstructive (84, 18 %), une nécrose tubulaire aigüe (74, 15 %) ou un syndrome cardio-rénal (51, 11 %). Le diagnostic avait été posé à l'USI pour 188 patients (39 %), en néphrologie pour 130 patients (27 %) et dans d'autres unités pour 162 patients (34 %). Les caractéristiques des patients différaient entre les unités de soins en ce qui concerne l'âge, les comorbidités, l'étiologie et les indications de TRR. Un plan de soins palliatifs existait pour 72 patients (15 %), le plus souvent dans les autres unités. LIMITES: Nous avons étudié un sous-groupe de patients atteints d'IRA de stade 3 (classification KDIGO) dans un seul centre sans chirurgie cardiaque. CONCLUSION: Les patients hospitalisés pour une IRA grave présentent des comorbidités, des tableaux cliniques, des soins et des pronostics variés et sont admis dans différentes unités d'hospitalisation. Cette hétérogénéité de l'IRA grave met en relief le besoin de soins personnalisés qui nécessitent des outils pronostics basés sur des informations autres que la SCr et la diurèse.

Effectiveness of guideline-consistent heart failure drug prescriptions at hospital discharge on 1-year mortality: Results from the EPICAL2 cohort study.

BACKGROUND: We aimed to assess the effectiveness of recommended drug prescriptions at hospital discharge on 1-year mortality in patients with heart failure (HF) and reduced ejection fraction (HFREF). MATERIALS AND METHODS: We used data from the EPICAL2 cohort study. HF patients ≥18years old with left ventricular ejection fraction (LVEF) <40% and alive at discharge were included and followed up for mortality. Socio-demographic, clinical and therapeutic data were collected at admission. Therapeutic data were collected at discharge and at 6month. Prescription of an angiotensin-converting enzyme (ACE) inhibitor (or an angiotensin II receptor blocker [ARB] in case of ACE inhibitor intolerance) and a ß-blocker at discharge were considered "guideline-consistent discharge prescription" (GCDP). A frailty Cox model after propensity score (PS) matching was used to assess the association of GCDP with survival. RESULTS: Among 624 patients included, the mean (SD) age was 73.6 (12.8) years; 65% were male. A total of 412 (65.6%) patients received GCDP, and 82.8% still had guideline consistent prescription at 6months. A total of 166 patients died during the follow-up, 78 in the GCDP group and 88 in the other group. Before PS matching, patients with GCDP were younger (|StDiff|=48.32%) and had higher body mass index (BMI) (|StDiff|=11.71%), lower LVEF (|StDiff|=23.13%) and lower Charlson index (|StDiff|=55.27%) than patients without GCDP. After PS matching, all characteristics were balanced between the two treatment groups, and GCDP was associated with reduced mortality (pooled HR=0.51, 95% CI [0.35-0.73]). CONCLUSION: Prescription of ACE (or ARB) inhibitors and ß-blockers for patients with HFREF may be low despite the evidence for morbidity and mortality improvement with these medications but remains associated with reduced 1-year mortality in unselected HFREF patients.