Safety and Efficacy of Paclitaxel-Eluting Balloon Angioplasty for Dysfunctional Hemodialysis Access: A randomized trial Comparing with Angioplasty Alone.

PURPOSE: To assess whether angioplasty of hemodialysis access (HA) stenosis with a drug-coated balloon (DCB) would prevent restenosis in comparison with plain-balloon percutaneous transluminal angioplasty (PTA). MATERIALS AND METHODS: This prospective randomized clinical trial enrolled 120 patients with dysfunctional arteriovenous fistulae (n = 109) and grafts (n = 11), due to a ≥50% stenosis between March 2014 and April 2018. All patients underwent high-pressure balloon angioplasty and were then randomized to either DCB (n = 60) or PTA (n = 60). Patients were followed-up for 1 year, and angiography was performed 6 months after angioplasty. The primary endpoint was the late lumen loss (LLL) at 6 months. Secondary endpoints included other angiographic parameters at 6 months and HA failures, adverse event, and mortality at 12 months. Continuous variables were compared with a Student t-test, and Kaplan-Meier curves were used for freedom from HA failure and for mortality. RESULTS: LLL in the DCB and in the PTA group were 0.64 mm ± 1.20 and 1.13 mm ± 1.51, respectively (P = .082, adjusted P = .0498). DCB was associated with lower percentage stenosis (54.2% ± 19.3 vs 61.7% ± 18.2; P = .047) and binary restenosis ≥50% (56.5% vs 81.1%; P = .009) than PTA. The number of HA failures after 12 months was lower for DCB than for PTA (45% vs 66.7%; P = .017). Mortality at 12 months was 10% and 8.3% in the DCB and PTA groups, respectively (P = .75). CONCLUSIONS: Despite LLL improvement that failed to reach statistical significance, this study demonstrated decreased incidence and severity of restenosis with DCB compared with PTA to treat dysfunctional HA.

Plasma Gelsolin and Its Association with Mortality and Hospitalization in Chronic Hemodialysis Patients.

BACKGROUND: Human plasma gelsolin (pGSN) is an actin-binding protein that is secreted into the extracellular fluid, with the skeletal muscle and myocardial tissues being its major source. Depletion of pGSN has been shown to be related to a variety of inflammatory and clinical conditions. METHODS: pGSN levels were prospectively determined in prevalent maintenance hemodialysis (HD) patients from 3 U.S. dialysis centers. Demographics (age, time since dialysis initiation, race, gender, body height and weight, comorbidities), inflammatory markers (C reactive protein, CRP; interleukin 6, IL-6), free triiodothyronine (fT3), and routine laboratory parameters were obtained. We performed Kaplan-Meier and Cox proportional hazard survival analysis for all-cause and cardiovascular mortality, and recurrent event survival analysis for hospitalization. RESULTS: We studied 153 patients; mean age was 60.5 ± 14.7; 52% were males. The mean pGSN level was 6,617 ± 1,789 mU/ml. In univariate analysis, pGSN was positively correlated with body mass index (r = 0.2, p = 0.01), pre-HD serum albumin (r = 0.247, p = 0.002), and pre-HD serum creatinine (r = 0.381, p < 0.001), and inversely with age (r = -0.286, p < 0.001), CRP (r = -0.311, p < 0.001), and IL-6 (r = -0.317, p < 0.001). In the adjusted analysis, the associations with CRP and creatinine were retained. pGSN levels tended to be lower in patients who died (p = 0.08). There was no association with all-cause or cardiovascular mortality, or all-cause hospitalization. Of note, fT3 was lower in patients who died (p = 0.001). CONCLUSIONS: Even though pGSN was inversely correlated with age, CRP and IL-6, suggesting that inflammation may influence pGSN, lower pGSN levels were not associated with hospitalization, all-cause and cardio-vascular mortality in this patient population.

Correlation between Inflammatory Biomarkers and Red Blood Cell Life Span in Chronic Hemodialysis Patients.

BACKGROUND AND OBJECTIVES: The pathogenesis of anemia in hemodialysis (HD) patients is dependent on multiple factors, with decreased red blood cell life span (RBCLS) being a significant contributor. Although the impact of reduced RBCLS on anemia is recognized, it is still a subject that is not well researched. The objective of this study was to investigate the relationship between RBCLS and inflammatory biomarkers in chronic HD patients. DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS: RBCLS was calculated from alveolar carbon monoxide concentrations measured by gas chromatography. Interleukins (IL) IL-6, IL-18, IL-10, and high sensitivity C-reactive protein were measured using bead-based multiplex assay. Measurements were carried out at baseline and during follow-up. The associations between RBCLS and inflammatory biomarkers were evaluated using linear mixed effects models. RESULTS: RBCLS measurements were available for 54 HD patients. Their average age was 58.5 ± 14.4 years, 68.5% were males, 48.1% were diabetics, and the HD vintage was 51 ± 48 months. In 4 patients, RBCLS was measured once, while in 50 patients, up to 5 repeated RBCLS measurements were available. RBCLS was 73.2 ± 17.8 days (range 37.7-115.8 days). No association was found between RBCLS and any of the inflammatory biomarkers. Of note, RBCLS was positively correlated with levels of uric acid (p = 0.02) and blood urea nitrogen (BUN; p = 0.01), respectively. CONCLUSION: Our study suggests that inflammation pathways reported by these biomarkers only have a limited role in causing premature RBC death. The positive correlation with uric acid and BUN warrants further studies.

Neutrophil-lymphocyte ratio as a novel predictor of survival in chronic hemodialysis patients.

BACKGROUND: Increased mortality rate in chronic hemodialysis (HD) patients is partly attributed to a chronic inflammatory state. Neutrophil-lymphocyte ratio (NLR), defined as the neutrophil count divided by lymphocyte count, is increasingly recognized as a marker of systemic inflammation, but its prognostic value in HD patients is unknown. The aim of this study was to assess NLR as a predictor of survival in this patient population. METHODS: In this study incident chronic HD patients were stratified in tertiles of NLR based on measurements obtained 3 months after initiation of dialysis. Multivariable Cox regression was used to calculate the adjusted hazard ratios (HR) for NLR on all-cause survival. Subsequently, similar models were developed at years 2 and 3 to assess predictive value of NLR in prevalent patients. RESULTS: We studied 5,782 incident HD patients (mean ± SD age 62 ± 15 years, 55% male, 43% Black, 52% diabetic). The median (interquartile, (IQR)) NLR at 3 months was 3.0 (2.1 - 4.5). NLR in the highest tertile (NLR ≥ 3.9) was a significant predictor of all-cause mortality after an adjustment for demographic and clinical covariates was performed. These results were confirmed at years 2 and 3. Moreover, NLR is superior to total white blood cell (WBC) count for prediction of all-cause mortality in incident hemodialysis patients (are under the receiver operating characteristic (ROC) curve of 0.66 vs. 0.56). CONCLUSION: This study identifies NLR as a novel and robust predictor of all-cause mortality in incident and prevalent HD patients. NLR is an inexpensive and readily available marker that may help to identify HD patients who are at an increased risk of death.

Available extracorporeal treatments for poisoning: overview and limitations.

Poisoning is a significant public health problem. In severe cases, extracorporeal treatments (ECTRs) may be required to prevent or reverse major toxicity. Available ECTRs include intermittent hemodialysis, sustained low-efficiency dialysis, intermittent hemofiltration and hemodiafiltration, continuous renal replacement therapy, hemoperfusion, therapeutic plasma exchange, exchange transfusion, peritoneal dialysis, albumin dialysis, cerebrospinal fluid exchange, and extracorporeal life support. The aim of this article was to provide an overview of the technical aspects, as well as the potential indications and limitations of the different ECTRs used for poisoned patients.

Hemoperfusion for the treatment of poisoning: technology, determinants of poison clearance, and application in clinical practice.

Hemoperfusion is an extracorporeal treatment based on adsorption, historically reserved for the treatment of acute poisonings. Its use was popularized in the 1970s after several in vitro and animal experiments had demonstrated its efficacy, and was even preferred over hemodialysis in the management of overdosed patients. With the advent of new and more efficient dialytic modalities, hemoperfusion is now less frequently performed in the Western world. However, hemoperfusion still remains popular in developing countries. The present article reviews the technique of hemoperfusion, the factors influencing poison clearance through adsorption and its current applications.

A stepwise approach for the management of poisoning with extracorporeal treatments.

The use of an extracorporeal treatment (ECTR) in a poisoned patient may be life-saving in a limited number of scenarios. The decision-processes surrounding the use of ECTR in poisoning is complex: most nephrologists are not trained to assess a poisoned patient while clinical toxicologists rarely prescribe ECTRs. Deciding on which ECTR is most appropriate for a poison requires a good understanding of the poison's physicochemical and pharmacokinetic properties. Further, a detailed understanding of the capabilities and limitations of the different ECTRs can be useful to select the most appropriate ECTR for a given clinical situation. This manuscript provides a stepwise approach to assess the usefulness of ECTRs in poisoning.

Principles and operational parameters to optimize poison removal with extracorporeal treatments.

A role for nephrologists in the management of a poisoned patient involves evaluating the indications for, and methods of, enhancing the elimination of a poison. Nephrologists are familiar with the various extracorporeal treatments (ECTRs) used in the management of impaired kidney function, and their respective advantages and disadvantages. However, these same skills and knowledge may not always be considered, or applicable, when prescribing ECTR for the treatment of a poisoned patient. Maximizing solute elimination is a key aim of such treatments, perhaps more so than in the treatment of uremia, because ECTR has the potential to reverse clinical toxicity and shorten the duration of poisoning. This manuscript reviews the various principles that govern poison elimination by ECTR (diffusion, convection, adsorption, and centrifugation) and how components of the ECTR can be adjusted to maximize clearance. Data supporting these recommendations will be presented, whenever available.

Guidelines for reporting case studies on extracorporeal treatments in poisonings: methodology.

A literature review performed by the EXtracorporeal TReatments In Poisoning (EXTRIP) workgroup highlighted deficiencies in the existing literature, especially the reporting of case studies. Although general reporting guidelines exist for case studies, there are none in the specific field of extracorporeal treatments in toxicology. Our goal was to construct and propose a checklist that systematically outlines the minimum essential items to be reported in a case study of poisoned patients undergoing extracorporeal treatments. Through a modified two-round Delphi technique, panelists (mostly chosen from the EXTRIP workgroup) were asked to vote on the pertinence of a set of items to identify those considered minimally essential for reporting complete and accurate case reports. Furthermore, independent raters validated the clarity of each selected items between each round of voting. All case reports containing data on extracorporeal treatments in poisoning published in Medline in 2011 were reviewed during the external validation rounds. Twenty-one panelists (20 from the EXTRIP workgroup and an invited expert on pharmacology reporting guidelines) participated in the modified Delphi technique. This group included journal editors and experts in nephrology, clinical toxicology, critical care medicine, emergency medicine, and clinical pharmacology. Three independent raters participated in the validation rounds. Panelists voted on a total of 144 items in the first round and 137 items in the second round, with response rates of 96.3% and 98.3%, respectively. Twenty case reports were evaluated at each validation round and the independent raters' response rate was 99.6% and 98.8% per validation round. The final checklist consists of 114 items considered essential for case study reporting. This methodology of alternate voting and external validation rounds was useful in developing the first reporting guideline for case studies in the field of extracorporeal treatments in poisoning. We believe that this guideline will improve the completeness and transparency of published case reports and that the systematic aggregation of information from case reports may provide early signals of effectiveness and/or harm, thereby improving healthcare decision-making.

Guidelines for Diagnosis and Management of Infective Endocarditis in Adults: A WikiGuidelines Group Consensus Statement.

Importance: Practice guidelines often provide recommendations in which the strength of the recommendation is dissociated from the quality of the evidence. Objective: To create a clinical guideline for the diagnosis and management of adult bacterial infective endocarditis (IE) that addresses the gap between the evidence and recommendation strength. Evidence Review: This consensus statement and systematic review applied an approach previously established by the WikiGuidelines Group to construct collaborative clinical guidelines. In April 2022 a call to new and existing members was released electronically (social media and email) for the next WikiGuidelines topic, and subsequently, topics and questions related to the diagnosis and management of adult bacterial IE were crowdsourced and prioritized by vote. For each topic, PubMed literature searches were conducted including all years and languages. Evidence was reported according to the WikiGuidelines charter: clear recommendations were established only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were crafted discussing the risks and benefits of different approaches. Findings: A total of 51 members from 10 countries reviewed 587 articles and submitted information relevant to 4 sections: establishing the diagnosis of IE (9 questions); multidisciplinary IE teams (1 question); prophylaxis (2 questions); and treatment (5 questions). Of 17 unique questions, a clear recommendation could only be provided for 1 question: 3 randomized clinical trials have established that oral transitional therapy is at least as effective as intravenous (IV)-only therapy for the treatment of IE. Clinical reviews were generated for the remaining questions. Conclusions and Relevance: In this consensus statement that applied the WikiGuideline method for clinical guideline development, oral transitional therapy was at least as effective as IV-only therapy for the treatment of IE. Several randomized clinical trials are underway to inform other areas of practice, and further research is needed.

Dextrose solution for priming and rinsing the extracorporeal circuit in hemodialysis patients: A prospective pilot study.

INTRODUCTION: Excess sodium intake and consequent volume overload are major clinical problems in hemodialysis (HD) contributing to adverse outcomes. Saline used for priming and rinsing of the extracorporeal circuit is a potentially underappreciated source of intradialytic sodium gain. We aimed to examine the feasibility and clinical effects of replacing saline as the priming and rinsing fluid by a 5% dextrose solution. MATERIALS AND METHODS: We enrolled non-diabetic and anuric stable HD patients. First, the extracorporeal circuit was primed and rinsed with approximately 200-250 mL of isotonic saline during 4 weeks (Phase 1), subsequently a similar volume of a 5% dextrose solution replaced the saline for another 4 weeks (Phase 2), followed by another 4 weeks of saline (Phase 3). We collected data on interdialytic weight gain (IDWG), pre- and post-dialysis blood pressure, intradialytic symptoms, and thirst. RESULTS: Seventeen chronic HD patients (11 males, age 54.1 ± 18.7 years) completed the study. The average priming and rinsing volumes were 236.7 ± 77.5 and 245.0 ± 91.8 mL respectively. The mean IDWG did not significantly change (2.52 ± 0.88 kg in Phase 1; 2.28 ± 0.70 kg in Phase 2; and 2.51 ± 1.2 kg in Phase 3). No differences in blood pressures, intradialytic symptoms or thirst were observed. CONCLUSIONS: Replacing saline by 5% dextrose for priming and rinsing is feasible in stable HD patients and may reduce intradialytic sodium loading. A non-significant trend toward a lower IDWG was observed when 5% dextrose was used. Prospective studies with a larger sample size and longer follow-up are needed to gain further insight into the possible effects of using alternate priming and rinsing solutions lowering intradialytic sodium loading. TRIAL REGISTRATION: Identifier NCT01168947 (ClinicalTrials.gov).

Pharmacokinetics of Tobramycin Administered at the Beginning of Intermittent Hemodialysis Session (ESRD Study).

BACKGROUND AND OBJECTIVES: There is a renewed interest in the successful use of aminoglycosides due to increasing resistance in gram-negative infections. Few studies to date have examined the pharmacokinetics (PK) of intradialytic infusions of tobramycin. This study sought to characterize the pharmacokinetic profile of intradialytically administered tobramycin in infected patients receiving chronic intermittent hemodialysis and to determine whether it is possible to achieve favorable PK targets. DESIGN SETTING PARTICIPANTS AND MEASUREMENTS: In this prospective pharmacokinetic study, a single dose (5 mg/kg) of tobramycin was administered intradialytically to 11 noncritically ill patients undergoing chronic intermittent hemodialysis. Blood samples were collected at selected time to determine tobramycin serum concentrations. The PK analysis was performed using Phoenix™ NLME. The efficacy exposure outcome for nonsevere gram-negative infections sensitive to tobramycin with a minimum inhibitory concentration ≤1 were maximum concentration (Cmax ≥ 10 mg/L) and area under the curve (AUC24 h > 30 mg⋅h/L). For toxicity, the goal was to identify plasma trough concentrations <2 mg/L. RESULTS: Tobramycin disposition was best described by a one-compartment model using a total clearance composed of the systemic clearance and a transitory hemodialysis clearance. Tobramycin mean (SD) Cmax, trough levels, and AUC24h were 13.1 (1.3) mg/L, 1.32 (0.47) mg/L, and 61 (23) mg⋅h/L, respectively. Monte Carlo simulation run with 1000 virtual patients showed that a 5 mg/kg dose of tobramycin administered intradialytically can outperformed the usual low-dose postdialysis dosing (80% meeting all targets versus <1%, respectively). CONCLUSIONS: A single high dose of tobramycin can achieve favorable PK outcome when administered using intradialytic infusions in hemodialysis patients. This practical dosing regimen may represent an effective and safer alternative to the usual dosing in the treatment of nonsevere gram-negative infections.

CONTEXTE ET OBJECTIFS: La résistance croissante des infections à Gram négatif suscite un regain d'intérêt pour l'utilisation efficace des aminoglycosides. À ce jour, peu d'études ont examiné la pharmacocinétique (PK) des infusions intradialytiques de tobramycine. La présente étude a tenté de caractériser le profil pharmacocinétique de la tobramycine administrée par infusion intradialytique chez des patients malades recevant des traitements intermittents d'hémodialyse de façon chronique. L'étude visait également à déterminer s'il est possible d'atteindre des objectifs de pharmacocinétique favorables. MÉTHODOLOGIE: Pour cette étude de pharmacocinétique prospective, une dose unique (5 mg/kg) de tobramycine a été administrée par infusion intradialytique à onze patients suivant des traitements d'hémodialyse intermittente de façon chronique ne nécessitant pas une admission aux soins intensifs. Des échantillons de sang ont été prélevés à des moments précis afin de mesurer les concentrations sériques de tobramycine. L'analyse de la PK a été effectuée à l'aide du PhoenixMC NLME. Les issues d'exposition d'efficacité avec une concentration minimale inhibitrice inférieure ou égale à 1 pour les infections à Gram négatifs non graves sensibles à la tobramycine étaient la concentration maximum (Cmax: ≥10 mg/L) et la surface sous la courbe (SSC24h: >30 mg⋅h/L). Quant à la toxicité, l'objectif était l'observation de concentrations plasmatiques inférieures à 2 mg/L. RÉSULTATS: La disponibilité de la tobramycine a été mieux décrite par un modèle à un compartiment utilisant une clairance totale composée de la clairance systémique et de la clairance transitoire de l'hémodialyse. La Cmax moyenne, la concentration minimale et la SSC24h de la tobramycine (écart-type) s'établissaient respectivement à 13,1 (1,3) mg/L, à 1,32 (0,47) mg/L et à 61 (23) mg⋅h/L. Une simulation de Monte Carlo réalisée avec 1 000 patients virtuels a montré qu'une dose unique de 5 mg/kg de tobramycine administrée par infusion intradialytique surpasse la faible dose normalement administrée après la dialyse (80 % des objectifs atteints pour la dose unique contre moins de 1 %, respectivement). CONCLUSIONS: Une dose unique élevée de tobramycine permet d'atteindre des paramètres pharmacocinétiques favorables si elle est administrée par infusion intradialytique chez les patients hémodialysés. Ce schéma posologique peut représenter une solution de remplacement efficace et plus sûre au dosage normalement administré pour le traitement des infections à Gram négatifs non graves.

Fulminant hepatitis induced by lamotrigine.

Anticonvulsant hypersensitivity syndrome (AHS) is a potentially life-threatening adverse drug reaction presenting with fever, skin eruptions, and internal organ involvement. We describe a case of AHS with fulminant hepatitis that occurred two weeks after introduction of lamotrigine in a 40-year-old female patient with a recently diagnosed bipolar disorder, no pre-existent systemic organ involvement, and no other medication. Lamotrigine was introduced at a dosage of 25 mg daily and increased to 50 mg daily 12 days later. The patient had favorable evolution with cessation of lamotrigine and supportive treatment. This report suggests that AHS with fulminant hepatitis may occur idiosyncratically, independent of dosage, titration and comedication with other potentially hepatotoxic drugs.

Association of Neutrophil-to-Lymphocyte Ratio With Inflammation and Erythropoietin Resistance in Chronic Dialysis Patients.

BACKGROUND: Neutrophil-to-lymphocyte ratio (NLR) was widely studied as a prognostic marker in various medical and surgical specialties, but its significance in nephrology is not yet established. OBJECTIVE: We evaluated its accuracy as an inflammation biomarker in a dialysis population. DESIGN SETTING: Single-center retrospective study. PATIENTS: The records of all 550 patients who were treated with hemodialysis (HD) or peritoneal dialysis (PD) from September 2008 to March 2011 were included. MEASUREMENTS: NLR was calculated from the monthly complete blood count. METHODS: Association between NLR and markers of inflammation (C-reactive protein [CRP], serum albumin, and erythropoietin resistance index [ERI]) was measured using Spearman coefficient. RESULTS: In total, 120 patients were eligible for the correlation analyses. We found a positive correlation between NLR and CRP (all patients: r = 0.45, P < .001; HD: r = 0.47, P < .001; PD: r = 0.48, P = .13). NLR and albumin were inversely correlated (r = -0.51, P < .001). Finally, high NLR was associated with a nonsignificant increased ERI, but we have not demonstrated a direct correlation. LIMITATIONS: CRP and albumin are not measured routinely and were ordered for a specific clinical reason leading to an indication bias. Also, no relationship with clinical outcome was established. CONCLUSIONS: NLR seems to be a good inflammatory biomarker in dialysis in addition to being easily available. However, controlled studies should be conducted to properly assess and validate NLR levels that would be clinically significant and relevant, as well as its prognostic significance and utility in a clinical setting.

CONTEXTE: La qualité de marqueur pronostique du ratio neutrophiles/lymphocytes a fait l'objet d'études approfondies dans plusieurs disciplines médicales et spécialités chirurgicales. En revanche, son importance n'est toujours pas établie dans le domaine de la néphrologie. OBJECTIF DE L'ÉTUDE: Nous avons voulu évaluer l'efficacité du ratio neutrophiles/lymphocytes comme biomarqueur de l'inflammation chez une population de patients dialysés. MODÈLE DE L'ÉTUDE: Il s'agit d'une étude rétrospective restreinte à un seul établissement. PARTICIPANTS: Les dossiers médicaux des 550 patients ayant été traités par hémodialyse (HD) ou par dialyse péritonéale (DP) entre septembre 2008 et mars 2011 ont été retenus pour cette étude. MESURES: Le ratio neutrophiles/lymphocytes a été calculé à partir de la formule sanguine complète prélevée mensuellement. MÉTHODOLOGIE: On a utilisé le coefficient de Spearman pour mesurer la corrélation entre le ratio neutrophiles/lymphocytes et certains marqueurs de l'inflammation : la protéine C-réactive, l'albumine sérique et l'index de résistance à l'érythropoïétine (IRE). RÉSULTATS: De tous les dossiers médicaux retenus, seuls 120 patients étaient admissibles à l'analyse de corrélation. Nous avons pu établir une corrélation positive entre le ratio neutrophiles/lymphocytes et la protéine C-réactive (r=0,45; p<0,001 pour l'ensemble des patients, r=0,47; p<0,001 chez les patients en HD, et r=0,48; p=0,13 chez les patients sous DP), alors que la corrélation était inversée dans le cas de l'albumine sérique (r=0,51; p<0,001). Nous avons également observé qu'un ratio neutrophiles/lymphocytes élevé était associé à une élévation non significative de l'IRE, sans toutefois établir une corrélation directe. LIMITES DE L'ÉTUDE: Règle générale, l'albumine sérique et la protéine C-réactive ne sont mesurées que lorsqu'une raison d'ordre clinique le demande, ce qui pourrait signaler un biais. De plus, aucun lien n'a été établi entre le ratio neutrophiles/lymphocytes et les devenirs cliniques des patients. CONCLUSION: Le calcul du ratio neutrophiles/lymphocytes semble être un bon indicateur de l'état inflammatoire chez les patients dialysés. Qui plus est, les données nécessaires pour évaluer ce ratio sont faciles à obtenir. Néanmoins, des études contrôlées devraient être menées pour déterminer les valeurs de ratio neutrophiles/lymphocytes qui seraient significatives du point de vue clinique, de même que pour établir l'importance du ratio neutrophiles/lymphocytes sur le plan du pronostic et sa pertinence dans un cadre clinique.

Conversion of oral alfacalcidol to oral calcitriol in the treatment of secondary hyperparathyroidism in chronic hemodialysis patients.

PURPOSE: The optimal vitamin D3 therapy for the treatment of secondary hyperparathyroidism (SHPT) in chronic hemodialysis patients is still controversial. Recent studies suggest that uremia in end-stage renal disease is associated with enzymatic hepatic dysfunction altering 25-hydroxylation of vitamin D3. The goal of our study was to compare the efficacy of calcitriol, the fully hydroxylated active form of vitamin D3, to alfacalcidol which needs 25-hydroxylation to be effective, for the treatment of SHPT in chronic hemodialysis patients. METHODS: We retrospectively reviewed 45 chronic hemodialysis patients who were switched from oral alfacalcidol to oral calcitriol for the treatment of SHPT. Parathyroid hormone (PTH), serum calcium and serum phosphorus levels were compared pre- and post-conversion using paired Student's t tests. RESULTS: The mean dose of active vitamin D3 decreased from 3.50 mcg/week at baseline to 2.86 mcg (P < 0001) after the switch from alfacalcidol to calcitriol. PTH significantly decreased from 94.4 to 82.6 pmol/L (-11.8 pmol/L, P = 0.02). The mean corrected calcium increased from 2.17 to 2.25 mmol/L (+0.08 mmol/L, P < 0.001) without any clinically significant hypercalcemia, and phosphorus levels were stable. Results were similar in a subgroup of patients (n = 17) for whom the medication was administrated during the hemodialysis session, ensuring a complete compliance. CONCLUSIONS: According to our study, calcitriol in equal dosage is more effective than alfacalcidol in lowering serum PTH level in chronic hemodialysis patients. This suggests that calcitriol may be the optimal active vitamin D3 for the treatment of SHPT in chronic hemodialysis patients.

Pharmacokinetic and Dynamic of Furosemide in Peritoneal Dialysis Patients.

The aim of our study was to evaluate the efficacy and bioavailibility of a commonly used oral furosemide dose (500 mg) compared to a 250 mg intravenous (IV) dose in PD patients with significant residual renal function (urine volume > 100 mL). We also evaluated the immediate blood pressure effect in these patients. The data were obtained from a study we performed for the homologation of a 500-mg dose of furosemide by Health Canada.

Retrospective analysis of the predictive factors of renal function loss after uninephrectomy in patients with chronic kidney disease G3 to G5.

BACKGROUND: The rapid increase in glomerular filtration rate in a normal contralateral kidney after uninephrectomy is well known in living kidney donors but much less well described in chronic kidney disease (CKD). The purpose of this study is to determine the magnitude of this initial compensatory capacity in (CKD) groups 3 to 5 (G3 to G5) patients undergoing uninephrectomy and the clinical factors predicting it. This is a retrospective study of all cases (142) of uninephrectomy in patients with estimated glomerular filtration rate (eGFR; with MDRD equation) <60 ml/min/1.73 m(2), between 2003 and 2010, in two University of Montreal-affiliated teaching hospitals. METHODS: Baseline eGFR, patients' comorbidities, and surgical characteristics and complications were noted. The change of eGFR after nephrectomy was evaluated; moreover, the expected post-op eGFR, i.e. without compensation by the contralateral kidney following surgery, was estimated in a sub-group of patients who had a preoperative renal scintigraphy and compared to the actual eGFR at hospital discharge. RESULTS: The mean change of eGFR from baseline to hospital discharge was -5 ± 12 ml/min/1.73 m(2) (-11 %; 95 % CI -16 to -6 %; P < 0.001). In univariate and multivariate analyses, baseline eGFR did not influence significantly these results. However, in the multivariate model, radical nephrectomy vs. partial nephrectomy and preoperative hypertension predicted a worse renal outcome. In the sub-group of patients with preoperative renal scintigraphy, the actual eGFR at hospital discharge was also higher than expected from the renal split function (13 ml/min/1.73 m(2); 95 % CI 10 to 16; P < 0.001). CONCLUSIONS: After uninephrectomy, the contralateral kidney in patients with CKD G3 to G5 still has a clinically significant initial compensatory capacity. The compensation is statistically smaller if the patient had hypertension or a radical uninephrectomy. This initial compensation is rapid and most probably haemodynamic (hyperfiltration). However, most of the included patients had a CKD G3, limiting the strength of the conclusion for the G4 toG5 patients; the length of observation covers the early postoperative period, i.e. less than 2 weeks, in more than half of the cohort.

MISE EN CONTEXTE: L'accroissement rapide du débit de filtration glomérulaire du rein controlatéral à la suite d'une uninéphrectomie (uniNPX) est bien connu pour les donneurs de rein vivants, mais est beaucoup moins bien documenté dans le cas des patients souffrant d'une insuffisance rénale chronique (IRC). OBJECTIF: L'étude avait pour objectif principal de déterminer à quel point la capacité de compensation initiale du rein controlatéral est maintenue chez les patients souffrant d'IRC de stade 3 à 5 après une NPX et quels facteurs cliniques sont susceptibles d'aider à prévoir la perte d'activité fonctionnelle du rein. CADRE ET TYPE D'ÉTUDE: Il s'agit d'une étude rétrospective de 142 cas de NPX pratiquées entre 2003 et 2010 au sein de deux centres hospitaliers universitaires affiliés à l'Université de Montréal, sur des patients présentant un débit de filtration glomérulaire estimé (DFGe) par l'équation MDRD, inférieur à 60 ml/min/1.73 m2. MÉTHODE: La mesure du débit de filtration glomérulaire préopératoire, les maladies concomitantes inscrites au dossier, les particularités de la chirurgie ainsi que les complications survenues par la suite, ont été notées pour chaque patient. La variation du DFG a été évaluée après la chirurgie. De plus, le DFG post-op attendu, calculé en ne tenant pas en compte la compensation offerte par le rein controlatéral après la chirurgie, a été estimé pour un sous-groupe de patients qui avaient subi une scintigraphie rénale préopératoire et comparé à la mesure du DFG faite au moment de la sortie de l'hôpital. RÉSULTATS: La variation moyenne du DFG entre les mesures prises avant la chirurgie et celles prises lors de la sortie de l'hôpital était de −5 ± 12 ml/min/1.73 m2 (−11 %; 95 % IC −16 % à −6 %; P < 0.001). Le DFG initial n'a en aucun cas influencé significativement les résultats qu'ils aient été analysés par un modèle d'analyse unidimensionnelle ou par un modèle d'analyse à variables multiples. Toutefois, dans le second type d'analyse, la présence d'hypertension préopératoire et le type de néphrectomie pratiquée (partielle ou radicale) ont laissé entrevoir de moins bons résultats. Enfin, le DFG mesuré à la sortie de l'hôpital chez les patients qui avaient subi une scintigraphie rénale préopératoire était plus élevé que le DFG prévu, calculé à partir de la division de la fonction rénale (13 ml/min/1.73 m2; 95 % IC 10 à 16; P < 0.001). CONCLUSIONS ET LIMITES DE L'ÉTUDE: À la suite d'une néphrectomie, le rein controlatéral des patients atteints d'insuffisance rénale chronique de stade 3 à 5 possède toujours une capacité compensatoire significative du point de vue clinique. Par contre, la compensation est moindre si le patient souffre d'hypertension avant la chirurgie ou lorsqu'il subit une uniNPX radicale, elle est également rapide et probablement hémodynamique (hyperfiltration). Il importe également de noter que la majorité des patients ayant participé à l'étude avait une IRC de stade 3 et que ceci ne permet pas de tirer des conclusions sans équivoque pour les patients de stades 4 et 5. De plus, les observations se sont déroulées sur une très courte période, moins de deux semaines pour plus de la moitié de la cohorte, immédiatement après la chirurgie.