RESUMO
Peritoneal dialysis (PD) has often been considered as a renal replacement method that is not feasible for the elderly population. Numerous recent studies have shown that this method is in fact very well, if not better tolerated by elderly patients. In Switzerland and abroad, its economic advantages have also been underlined during the past ten years. As a consequence, the use of PD is increasing, and primary care physicians are more often confronted to PD patients. Therefore, they have to be aware of some basic treatment principles, which are reviewed in this article.
La dialyse péritonéale (DP) a souvent été considérée à tort comme inadaptée à la population âgée, qui représente la majorité des patients en insuffisance rénale terminale. De nombreuses études ont montré que cette méthode est très bien, voire mieux tolérée que l'hémodialyse par les personnes âgées. Son aspect économique est de plus en plus mis en avant en Suisse et à l'étranger. Alors que la DP représentait longtemps < 10â % de la population dialysée, nous observons ces dernières années une hausse de patients traités par cette méthode. Par conséquent, le médecin traitant et l'interniste hospitalier seront plus fréquemment confrontés à ces patients. Ceci nécessite des bonnes notions de base de cette modalité comme discuté dans cet article.
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Clínicos Gerais/educação , Falência Renal Crônica/terapia , Diálise Peritoneal , Humanos , Falência Renal Crônica/economia , Diálise Peritoneal/economia , SuíçaRESUMO
Recently, comprehension of immune mechanisms involved in anti-tumor responses has permitted the development of new oncologic drugs called immune checkpoint inhibitors. These drugs act by restoring anti-tumor responses. With their increasing use, we note a rise in the incidence rate of immune related adverse events, which can affect many organs. Renal toxicity, more precisely tubulointerstitial nephritis, is still not well understood but an emerging complication.
Récemment, la compréhension des mécanismes immuns impliqués dans la réponse antitumorale a permis de développer de nouveaux traitements oncologiques, les inhibiteurs de points de contrôle immunitaires. L'action de ceux-ci repose sur une rupture des mécanismes de tolérance immune envers la tumeur. Avec leur développement, on observe l'apparition d'effets indésirables d'un nouveau genre, s'apparentant à une autoimmunité et touchant différents systèmes. La toxicité rénale, sous la forme d'une néphrite tubulo-interstitielle, est une complication encore méconnue mais émergeante.
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Fatores Imunológicos/efeitos adversos , Fatores Imunológicos/uso terapêutico , Neoplasias/tratamento farmacológico , Neoplasias/imunologia , Nefrite Intersticial/induzido quimicamente , HumanosRESUMO
BACKGROUND: To describe the optical coherence tomography angiograhy (OCTA) of drusenoid pigment epithelial detachments (PEDs) in a woman affected by Complement 3 (C3) glomerulopathy, which represents a spectrum of glomerular diseases characterized on fluorescent microscopy by C3 accumulation with absent, or scanty, immunoglobulin deposits. It is due to acquired or genetically defective alternative pathway control and is generally associated with drusen-like deposits in Bruch's membrane, as well as choriocapillaris. These retinal lesions can be associated with choroidal neovascularization and central serous chorioretinopathy (CSCR). OCTA is useful to detect neovascularization without injecting a contrast product, particularly in these patients who may have renal insufficiency. CASE PRESENTATION: A 28-year-old woman affected by C3 glomerulpathy was diagnosed with asymptomatic multiple bilateral PEDs during a routine ophthalmologic consultation. To better characterize the lesions, multimodal imaging was performed and included: optic coherence tomography (OCT), en-face OCT, OCTA, fluorescence and indocyanine angiography. The OCTA clearly identified vascular network rarefaction with decreased choriocapillary vascularization. It confirmed that PEDs associated with C3 glomerulonephritis are not vascularized, but rather of serous type. CONCLUSIONS: Patients affected by C3 glomerulopathy can develop neovascular membranes as retinal complications of pigment epithelial detachments. Optical coherence angiography may be indicated to identify this complication, without injecting any contrast product that could produce further kidney damage.
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Glomerulonefrite Membranoproliferativa/complicações , Descolamento Retiniano/patologia , Epitélio Pigmentado da Retina/patologia , Adulto , Complemento C3/metabolismo , Feminino , Angiofluoresceinografia , Humanos , Imagem Multimodal , Descolamento Retiniano/diagnóstico por imagem , Epitélio Pigmentado da Retina/diagnóstico por imagem , Tomografia de Coerência ÓpticaRESUMO
INTRODUCTION: Subclavian steal phenomenon due to proximal subclavian artery stenosis or occlusion is not un-common but often remains asymptomatic. CASE REPORT: We describe the case of a 66-year-old man with end-stage renal disease hemodialysed through a brachio-brachial loop graft of the left forearm. Echo-Doppler precerebral examination showed a high reversed flow of 570 ml/min in the ipsilateral vertebral artery. After successful endovascular recanalization of the subclavian artery, access blood flow increased and vertebral flow decreased to 30 ml/min. Complete neurological examination was normal both before and after endovascular treatment. DISCUSSION: This case demonstrates how high a subclavian steal can be without causing symptoms and how well precerbral and cerebral circulation can adapt to hemodynamic changes.
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Derivação Arteriovenosa Cirúrgica/efeitos adversos , Falência Renal Crônica/terapia , Diálise Renal , Síndrome do Roubo Subclávio/etiologia , Extremidade Superior/irrigação sanguínea , Adaptação Fisiológica , Idoso , Angioplastia com Balão , Circulação Cerebrovascular , Hemodinâmica , Humanos , Falência Renal Crônica/fisiopatologia , Masculino , Fluxo Sanguíneo Regional , Síndrome do Roubo Subclávio/diagnóstico , Síndrome do Roubo Subclávio/fisiopatologia , Síndrome do Roubo Subclávio/terapia , Resultado do Tratamento , Ultrassonografia DopplerRESUMO
The objective of this study is to report three cases of paraneoplastic or ectopic Cushing syndrome, which is a rare phenomenon of the adrenocorticotropic hormone (ACTH)-dependent Cushing syndrome. Three cases are reported in respect of clinical presentation, diagnosis and treatment in addition to relevant literature review. The results showed that ectopic ACTH secretion can be associated with different types of neoplasm most common of which are bronchial carcinoid tumors, which are slow-growing, well-differentiated neoplasms with a favorable prognosis and small-cell lung cancer, which are poorly differentiated tumors with a poor outcome. The latter is present in two out of three cases and in the remaining one, primary tumor could not be localized, representing a small fraction of patients with paraneoplastic Cushing. Diagnosis is established in the setting of high clinical suspicion by documenting an elevated cortisol level, ACTH and doing dexamethasone suppression test. Treatment options include management of the primary tumor by surgery and chemotherapy and treating Cushing syndrome. Prognosis is poor in SCLC. We concluded that in front of a high clinical suspicion, ectopic Cushing syndrome diagnosis should be considered, and identification of the primary tumor is essential. LEARNING POINTS: Learning how to suspect ectopic Cushing syndrome and confirm it among all the causes of excess cortisol.Distinguish between occult and severe ectopic Cushing syndrome and etiology.Providing the adequate treatment of the primary tumor as well as for the cortisol excess.Prognosis depends on the differentiation and type of the primary malignancy.
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BACKGROUND: Worldwide, diabetes has become the most common cause of end-stage renal disease (ESRD), yet Swiss data are largely lacking. METHODS: This observational study examined ESRD patients with diabetes mellitus (ESRD-DM) at end of 2009 and 2014. The prevalence and characteristics of ESRD-DM patients were collected in all dialysis facilities in the Canton of Vaud of Switzerland in 2009 and in 2014, and the 5-year mortality rate was assessed. RESULTS: A total of 107 and 140 ESRD-DM patients underwent dialysis at end of 2009 and 2014, respectively. Within the 5-year period a total of 167 incidental ESRD-DM patients required dialysis, corresponding to an estimated incidental rate of 0.84/1000 person-years in the diabetic population. In 2009, all patients with ESRD-DM underwent haemodialysis, decreasing to 96.2% in 2014, with 3.8% on peritoneal dialysis. Age, sex, body mass index, type of diabetes, duration of diabetes, cause of ESRD, dialysis duration, dialysis frequency, vascular access, and glycosylated haemoglobin levels did not differ between 2009 and 2014. In 2014, macrovascular comorbidity was reported more often than in 2009, but not amputations. Haemoglobin level decreased significantly from 117.9 g/l to 112.3 g/l. Calcium-containing phosphate binder and angiotensin-converting enzyme inhibitor use significantly decreased, whereas iron therapy significantly increased with time. The 5-year mortality rate was 61.7%. Five-year survivors were significantly younger and had a higher body mass index. CONCLUSIONS: The growing prevalence of ESRD-DM emphasises that prevention of chronic kidney disease and its progression should be a public health priority in Switzerland.
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Nefropatias Diabéticas/epidemiologia , Falência Renal Crônica/epidemiologia , Idoso , Nefropatias Diabéticas/complicações , Nefropatias Diabéticas/terapia , Feminino , Humanos , Falência Renal Crônica/etiologia , Falência Renal Crônica/terapia , Masculino , Pessoa de Meia-Idade , Prevalência , Diálise Renal/estatística & dados numéricos , Suíça/epidemiologiaRESUMO
BACKGROUND: To examine whether angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) are associated with a state of recombinant human erythropoietin (rHuEPO) resistance in hemodialyzed patients. METHODS: Cross-sectional study involving all dialysis facilities in French-speaking Switzerland. All patients treated with rHuEPO in March 2001 were included. Demographic, clinical and laboratory data were collected in 515 patients treated with chronic hemodialysis (HD) and rHuEPO. Patients were classified into five groups according to their antihypertensive treatment. The main outcomes of the study were the mean rHuEPO dosage and the prevalence of erythropoietin EPO resistance among the groups. Erythropoietin resistance was defined as a weekly rHuEPO dosage >300 units/kg/wk. RESULTS: The mean rHuEPO dosage and the prevalence of EPO resistance were similar in patients treated with ACEIs (n = 138, mean EPO dosage 109 units/kg/wk, EPO resistance 12%), ARBs (n = 59, mean EPO dosage 120 units/kg/wk, EPO resistance 7%), both (n = 10, mean EPO dosage 109 units/kg/wk, EPO resistance 10%), other drugs (n = 137, mean EPO dosage 110 units/kg/wk, EPO resistance 10%) and no antihypertensive treatment (n = 171, mean EPO dosage 90 units/kg/wk, EPO resistance 9%). Differences were not statistically significant. Patients with rHuEPO resistance were characterized by a higher frequency of hospitalization and a more pronounced inflammatory state. There was no difference in the use of ACEIs and ARBs between patients with and without EPO resistance (37 vs. 41%, ns). CONCLUSIONS: Neither the use of ACEIs nor ARBs is associated with a state of rHuEPO resistance among hemodialyzed patients.
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Anemia/tratamento farmacológico , Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Eritropoetina/uso terapêutico , Hipertensão/tratamento farmacológico , Falência Renal Crônica/terapia , Diálise Renal/efeitos adversos , Idoso , Anemia/etiologia , Estudos Transversais , Relação Dose-Resposta a Droga , Resistência a Medicamentos , Quimioterapia Combinada , Eritropoetina/administração & dosagem , Feminino , Seguimentos , Humanos , Hipertensão/etiologia , Hipertensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Proteínas Recombinantes , Estudos Retrospectivos , Resultado do TratamentoRESUMO
BACKGROUND: In contrast to quality of life, patient satisfaction on chronic haemodialysis (HD) and peritoneal dialysis (PD) has only rarely been studied. PATIENTS AND METHODS: All chronic HD and PD patients of the 19 centres located in western Switzerland were asked to complete a specific questionnaire, assessing dialysis centre characteristics, treatment modalities, and information received before and during dialysis treatment. Comparison between satisfaction with PD and HD was carried out on the patients in the nine centres offering both treatment modalities. RESULTS: Of the 558 questionnaires distributed to chronic HD patients, 455 were returned (response rate 82%). Fifty of 64 PD patients (78%) returned the questionnaire. The two groups were similar in age, gender, and duration of dialysis treatment. Completion rates were >90% for a majority of questions, with the lowest rate for information on sexuality (49% in HD and 54% in PD respectively). The lowest scores were recorded for information received about complications and costs of dialysis, and impact of end-stage kidney disease on sexuality. Satisfaction was lower in anonymous questionnaires. Satisfaction of PD patients was significantly better in 50% of the questions, particularly session tolerance (p<0.001), information about dialysis sessions (p=0.007), and complications (p=0.006). CONCLUSIONS: PD patients were on average more satisfied with their treatment than HD patients. Satisfaction could be improved with more information about potential adverse treatment effects.
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Falência Renal Crônica/terapia , Satisfação do Paciente , Diálise Peritoneal , Diálise Renal , Fatores Etários , Instituições de Assistência Ambulatorial/organização & administração , Estudos Transversais , Feminino , Humanos , Falência Renal Crônica/epidemiologia , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto , Fatores Sexuais , Sexualidade , Inquéritos e Questionários , SuíçaRESUMO
BACKGROUND AND OBJECTIVES: Obstructive sleep apnea is associated with significantly increased cardiovascular morbidity and mortality. Fluid overload may promote obstructive sleep apnea in patients with ESRD through an overnight fluid shift from the legs to the neck soft tissues. Body fluid shift and severity of obstructive sleep apnea before and after hemodialysis were compared in patients with ESRD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Seventeen patients with hemodialysis and moderate to severe obstructive sleep apnea were included. Polysomnographies were performed the night before and after hemodialysis to assess obstructive sleep apnea, and bioimpedance was used to measure fluid overload and leg fluid volume. RESULTS: The mean overnight rostral fluid shift was 1.27±0.41 L prehemodialysis; it correlated positively with fluid overload volume (r=0.39; P=0.02) and was significantly lower posthemodialysis (0.78±0.38 L; P<0.001). There was no significant difference in the mean obstructive apnea-hypopnea index before and after hemodialysis (46.8±22.0 versus 42.1±18.6 per hour; P=0.21), but obstructive apnea-hypopnea index was significantly lower posthemodialysis (-10.1±10.8 per hour) in the group of 12 patients, with a concomitant reduction of fluid overload compared with participants without change in fluid overload (obstructive apnea-hypopnea index +8.2±16.1 per hour; P<0.01). A lower fluid overload after hemodialysis was significantly correlated (r=0.49; P=0.04) with a lower obstructive apnea-hypopnea index. Fluid overload-assessed by bioimpedance-was the best predictor of the change in obstructive apnea-hypopnea index observed after hemodialysis (standardized r=-0.68; P=0.01) in multivariate regression analysis. CONCLUSIONS: Fluid overload influences overnight rostral fluid shift and obstructive sleep apnea severity in patients with ESRD undergoing intermittent hemodialysis. Although no benefit of hemodialysis on obstructive sleep apnea severity was observed in the whole group, the change in obstructive apnea-hypopnea index was significantly correlated with the change in fluid overload after hemodialysis. Moreover, the subgroup with lower fluid overload posthemodialysis showed a significantly lower obstructive sleep apnea severity, which provides a strong incentive to further study whether optimizing fluid status in patients with obstructive sleep apnea and ESRD will improve the obstructive apnea-hypopnea index.
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Deslocamentos de Líquidos Corporais , Falência Renal Crônica/terapia , Diálise Renal , Apneia Obstrutiva do Sono/diagnóstico , Idoso , Composição Corporal , Impedância Elétrica , Feminino , Humanos , Falência Renal Crônica/complicações , Falência Renal Crônica/diagnóstico , Falência Renal Crônica/fisiopatologia , Masculino , Pessoa de Meia-Idade , Polissonografia , Valor Preditivo dos Testes , Fatores de Risco , Índice de Gravidade de Doença , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/fisiopatologia , Suíça , Resultado do TratamentoRESUMO
BACKGROUND: Previous observations found a high prevalence of obstructive sleep apnea (OSA) in the hemodialysis population, but the best diagnostic approach remains undefined. We assessed OSA prevalence and performance of available screening tools to propose a specific diagnostic algorithm. METHODS: 104 patients from 6 Swiss hemodialysis centers underwent polygraphy and completed 3 OSA screening scores: STOP-BANG, Berlin's Questionnaire, and Adjusted Neck Circumference. The OSA predictors were identified on a derivation population and used to develop the diagnostic algorithm, which was validated on an independent population. RESULTS: We found 56% OSA prevalence (AHI ≥ 15/h), which was largely underdiagnosed. Screening scores showed poor performance for OSA screening (ROC areas 0.538 [SE 0.093] to 0.655 [SE 0.083]). Age, neck circumference, and time on renal replacement therapy were the best predictors of OSA and were used to develop a screening algorithm, with higher discriminatory performance than classical screening tools (ROC area 0.831 [0.066]). CONCLUSIONS: Our study confirms the high OSA prevalence and highlights the low diagnosis rate of this treatable cardiovascular risk factor in the hemodialysis population. Considering the poor performance of OSA screening tools, we propose and validate a specific algorithm to identify hemodialysis patients at risk for OSA for whom further sleep investigations should be considered.
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Diálise Renal , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/epidemiologia , Idoso , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prevalência , Curva ROC , Suíça/epidemiologiaRESUMO
BACKGROUND: Fat redistribution, increased inflammation and insulin resistance are prevalent in non-diabetic subjects treated with maintenance dialysis. The aim of this study was to test whether pioglitazone, a powerful insulin sensitizer, alters body fat distribution and adipokine secretion in these subjects and whether it is associated with improved insulin sensitivity. TRIAL DESIGN: This was a double blind cross-over study with 16 weeks of pioglitazone 45 mg vs placebo involving 12 subjects. METHODS: At the end of each phase, body composition (anthropometric measurements, dual energy X-ray absorptometry (DEXA), abdominal CT), hepatic and muscle insulin sensitivity (2-step hyperinsulinemic euglycemic clamp with 2H2-glucose) were measured and fasting blood adipokines and cardiometabolic risk markers were monitored. RESULTS: Four months treatment with pioglitazone had no effect on total body weight or total fat but decreased the visceral/sub-cutaneous adipose tissue ratio by 16% and decreased the leptin/adiponectin (L/A) ratio from 3.63 × 10(-3) to 0.76 × 10(-3). This was associated with a 20% increase in hepatic insulin sensitivity without changes in muscle insulin sensitivity, a 12% increase in HDL cholesterol and a 50% decrease in CRP. CONCLUSIONS/LIMITATIONS: Pioglitazone significantly changes the visceral-subcutaneous fat distribution and plasma L/A ratio in non diabetic subjects on maintenance dialysis. This was associated with improved hepatic insulin sensitivity and a reduction of cardio-metabolic risk markers. Whether these effects may improve the outcome of non diabetic end-stage renal disease subjects on maintenance dialysis still needs further evaluation. TRIAL REGISTRATION: ClinicalTrial.gov NCT01253928.
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Adipocinas/sangue , Tecido Adiposo/efeitos dos fármacos , Resistência à Insulina , Falência Renal Crônica/metabolismo , Fígado/efeitos dos fármacos , Diálise Renal , Tiazolidinedionas/farmacologia , Tecido Adiposo/patologia , Adulto , Composição Corporal/efeitos dos fármacos , Estudos Cross-Over , Método Duplo-Cego , Jejum/sangue , Feminino , Glucose/metabolismo , Homeostase/efeitos dos fármacos , Humanos , Gordura Intra-Abdominal/efeitos dos fármacos , Gordura Intra-Abdominal/patologia , Falência Renal Crônica/sangue , Falência Renal Crônica/patologia , Falência Renal Crônica/terapia , Leptina/sangue , Fígado/metabolismo , Masculino , Pessoa de Meia-Idade , Projetos Piloto , Pioglitazona , Gordura Subcutânea/efeitos dos fármacos , Gordura Subcutânea/patologia , Tiazolidinedionas/efeitos adversosRESUMO
BACKGROUND: Quality indicators for dialysis care vary across countries and regions, but regional variability across centres has received little attention. We analysed variations in quality indicators among dialysis facilities in western Switzerland to identify opportunities for improving care for patients with end-stage kidney disease. METHODS: A cross-sectional study of 617 dialysis patients treated at 19 facilities examined the distribution of indicators of quality of care addressing: adequacy of dialysis (Kt/V > or =1.2 for haemodialysis, Kt/V > or =2 for peritoneal dialysis), anaemia control (haemoglobin > or =110 g/l), calcium and phosphate control (product < or =4.4 mmol2/l2), adequate nutrition (serum albumin >35 g/l), hypertension control (pre-dialysis blood pressure <140/90 mmHg) and type of vascular access. Centre quality targets were the following: achievement of quality criteria for 80% of their patients, except 85% for anaemia control and 60% for arterio-venous fistulae. RESULTS: Most centres fulfilled quality targets for dialysis adequacy, but substantial variations existed among centres (haemodialysis, 76%, range 36-100; peritoneal dialysis, 76%, range 33-100). Results were similar for anaemia (77%, range 35-100), calcium x phosphate product (69%, range 29-92), albumin (63%, range 26-95), hypertension control (33%, range 13-54) and arterio-venous fistula (61%, range 49-92). The between-centre variability was significantly greater than would be expected by chance, for all indicators. Dialysis facilities with >40 patients better fulfilled quality targets than university-based centres. Adjustment for patient characteristics did not modify these results. CONCLUSIONS: Substantial variations in quality indicators existed between dialysis centres in western Switzerland, which could not be attributed to different centre policies, or to differences in available measures of patient case mix. These findings indicate opportunities for improvement in dialysis practice which may translate into improved clinical outcomes.
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Falência Renal Crônica/terapia , Diálise Peritoneal/normas , Diálise Renal/normas , Idoso , Anemia/etiologia , Anemia/terapia , Estudos Transversais , Feminino , Humanos , Falência Renal Crônica/etiologia , Masculino , Pessoa de Meia-Idade , Avaliação Nutricional , Satisfação do Paciente , Garantia da Qualidade dos Cuidados de Saúde , Inquéritos e Questionários , SuíçaRESUMO
We report the case of a 69-year-old woman, with a BMI of 42.9, suffering from bilateral struvite calculi and who raised end stage renal failure. Urease-synthesizing bacteria, leading to the hydrolysis of urea into ammonium and to an alkaline urine (pH > 7.2), are required for struvite stone formation in humans. Struvite component constitutes the majority of staghom calculi. Patients with struvite stones could lose renal function because of obstructive or pyelonephritic episodes and surgical interventions on the kidney. Therapeutic success needs a follow up by a specialized uro-nephrologist team as soon as possible.
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Cálculos Renais/microbiologia , Infecções Urinárias/complicações , Idoso , Feminino , Humanos , Cálculos Renais/diagnóstico , Cálculos Renais/terapia , Infecções Urinárias/diagnóstico , Infecções Urinárias/terapiaRESUMO
BACKGROUND: Quality of life (QOL) assessment in patients on chronic haemodialysis (HD) or peritoneal dialysis (PD) has only rarely been carried out with the generic Euroqol-5D questionnaire. METHODS: All chronic HD and PD patients in the 19 centres of western Switzerland were requested to fill in the validated Euroqol-5D generic QOL questionnaire, assessing health status in five dimensions and on a visual analogue scale, allowing computation of a predicted QOL value, to be compared with the value measured on the visual analogue scale. RESULTS: Of the 558 questionnaires distributed to chronic HD patients, 455 were returned (response rate 82%). Fifty of 64 PD patients (78%) returned the questionnaire. The two groups were similar in age, gender and duration of dialysis treatment. Mean QOL was rated at 60+/-18% for HD and 61+/-19% for PD, for a mean predicted QOL value of 62+/-30 and 58+/-32% respectively. Results of the five dimensions were similar in both groups, except for a greater restriction in usual activities for PD patients (P = 0.007). The highest scores were recorded for self-care, with 71% HD and 74% PD patients reporting no limitation, and the lowest scores for usual activities, with 14% HD and 23% PD patients reporting severe limitation. Experiencing pain/discomfort (for HD and PD) or anxiety/depression (for PD) had the highest impact on QOL. CONCLUSIONS: QOL was equally diminished in HD and PD patients. The questionnaire was well accepted and performed well. Improvement could be achievable in both groups if pain/discomfort and anxiety/depression could be more effectively treated.