[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

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.

[Factors of cardiovascular risk for hypertensive patients followed during primary care]. / Composantes du risque cardiovasculaire chez les patients hypertendus suivis en première ligne (Sousse, Tunisie).

AIM: To describe the elements of cardiovascular risk in order to calculate global cardiovascular risk in primary care hypertensive patients in Sousse Tunisia. METHODS: Cross sectional study including 456 hypertensive patients followed in 7 public health centers. Cardiovascular risk was assessed according the World Health Organization/International health society recommendations. RESULTS: Average age was 65.6 +/- 9.8 years, Sex Ratio was 0.18. Sixth of the patients had at least three risk factors, the most frequent of them were getting advanced in years, mild hypertension and diabetes mellitus. Targer organ damages was showed in 13.8%; 8.3% presented an associated cardiovascular diseases. Cardiovascular risk was very high in about 20% of patients. CONCLUSION: Primary care hypertensive patients show a heterogeneous cardiovascular risk. Patients with very high risk should be referred to specialists in order to benefit by a better care.

[Idiopathic portal hypertension associated with celiac disease: one case]. / Hypertension portale idiopathique associée à une maladie coeliaque: à propos d'un cas.

We describe for the first time a case of idiopathic portal hypertension (IPH) in a 31 year old patient with coeliac disease (CD). She had splenomegaly, pancytopenia and an unexplained portal hypertension in the absence of any histological abnormalities of the liver. The diagnosis of coeliac disease was based on histological and serological data. Treatment included a splenectomy and a splenorenal shunt.

[Epidemiologic and clinical features of patients with type 2 diabetes mellitus in primary care facilities (Sousse, Tunisie)]. / Profil épidémiologique et clinique des diabétiques de type 2 suivis dans les structures de santé de première ligne (Sousse, Tunisie).

As a result of epidemiologic transition, diabetes mellitus became a major public health problem in Tunisia. We tried to determine the epidemiological and clinical features of patients with type 2 diabetes mellitus in primary health care units in Sousse (Tunisia). It was a cross sectional study about a stratified sample of 404 type 2 diabetes mellitus patients followed in primary care offices in Sousse in 2003. Average age was 60 + 10.9 years and sex-ratio was 0.5. Hypertension and obesity were found in respectively 71.3% and 37.6%. Diabetic neuropathy was the most frequent degenerative complication (41.1%) followed by diabetic retinopathy (18.3%). Thus, type 2 diabetes mellitus patients, followed in primary care units show a high cardiovascular risk with serious and frequent complications. That's why, the national care program of type diabetes mellitus, in primary health care should take in consideration, in its guidelines, the clinical and epidemiological characteristics of these patients.

Modifications to bicarbonate conductivity: A way to increase phosphate removal during hemodialysis? Proof of concept.

Introduction Hyperphosphatemia and cardiovascular mortality are associated particularly with end-stage renal disease. Available therapeutic strategies (i.e., diet restriction, calcium [or not]-based phosphate binders, calcimimetics) are associated with extrarenal blood purification. Compartmentalization of phosphate limits its depuration during hemodialysis. Several studies suggest that plasmatic pH is involved in the mobilization of phosphate from intracellular to extracellular compartments. Consequently, the efficiency of modified bicarbonate conductivity to purify blood phosphate was tested. Methods Ten hemodialysis patients with chronic hyperphosphatemia (>2.1 mmol/L) were included in the two three-sessions-per week periods. Bicarbonate concentration was fixed at 40 mmol/L and 30 mmol/L in the first and second periods, respectively. Phosphate depuration was evaluated by phosphate mobilization clearance (KM ). Findings Although bicarbonatemia was lower during the second period (21.0 ± 2.7 vs. 24.4 ± 3.1 mmol/L, P < 0.01), no difference was observed in phosphatemia (2.4 ± 0.5 vs. 2.3 ± 0.4 mmol/L, P = NS). The in-session variation of phosphate was lower (-1.45 ± 0.42 vs. -1.58 ± 0.44 mmol/L, P < 0.05) and KM was higher during the second period (82.94 ± 38.00 vs. 69.74 ± 24.48 mL/min, P < 0.05). Discussion The decrease of in-session phosphate and the increase in KM reflect phosphate refilling during hemodialysis. Thus, modulation of serum bicarbonate may play a role in controlling the phosphate pool. Even though correcting metabolic acidosis during hemodialysis remains important, alkaline excess can impair phosphate mobilization clearance. Clinical trials are needed to test the efficiency and relevance of a strategy where bicarbonatemia is corrected less at the beginning of sessions.

[Quality of medical order writing in general practice facilities (Sousse, Tunisia)]. / Qualité de la rédaction de l'ordonnance médicale dans les structures de médecine générale (Sousse, Tunisie).

BACKGROUND: A medical order is a medical and legal document; careful writing of this document enables the reduction of many therapeutic errors. OBJECTIVE: The objective of this study was to evaluate the quality of order writing in Tunisian primary healthcare centres. METHODS: This was a transversal descriptive survey of 2586 medical orders. The quality of the writing was assessed using two parameters: its legibility and the information delivered in it. RESULTS: Among the main results, 36% of orders contained at least 50% of the items retained, 25% of orders were completely illegible, and the quality of writing was considered good in 14% of cases. DISCUSSION: The study showed that hand-written orders in primary healthcare are far from complying with the medico-legal requirements. The teaching of order-writing technique and its computerisation are needed to improve the quality of medical prescribing.

HNF1B-related diabetes triggered by renal transplantation.

BACKGROUND: A 37-year-old man developed cholestasis-associated pruritus followed by overt hyperglycemia (blood glucose level 23 mmol/l), necessitating insulin treatment, within weeks of undergoing renal transplantation. He had a history of gout, but his fasting blood glucose and glycated hemoglobin concentrations had been normal before transplantation. INVESTIGATIONS: Physical examination; laboratory tests, including assessment of glycated hemoglobin, anti-glutamic-acid-decarboxylase and anti-islet-antigen-2 antibodies, liver enzymes, renal function, tacrolimus blood trough level, exocrine (fecal elastase) and endocrine (C-peptide) pancreatic function; abdominal CT scan; liver biopsy; and screening of the hepatocyte nuclear factor 1 homeobox B (transcription factor 2) gene, HNF1B. DIAGNOSIS: New-onset diabetes after transplantation associated with a newly described deletion in HNF1B. MANAGEMENT: Minimization of tacrolimus exposure and withdrawal of steroids considerably reduced the patient's insulin requirement, and cholestasis-related pruritus was dramatically improved by administration of ursodeoxycholic acid. Renal ultrasonography and screening for the HNF1B molecular abnormality were offered to the patient's relatives.