[Chronic kidney disease in geriatrics]. / La maladie rénale chronique en gériatrie.

Chronic kidney disease (CKD) affects almost 10% of the world's population, and over 30% of people aged over 70 [1,2]. The overall incidence of treated CKD is stable in France, but continues to rise sharply in people aged over 85 [3]. In its advanced stages, CKD is associated with numerous complications linked to disturbances in water, acid-base and phosphocalcium balance, as well as anemia and increased cardiovascular risk. A better understanding of risk factors, improved practices to promote nephroprotection, and progress in therapeutic education and preparation for suppletive techniques would help reduce this risk.

[Substitution treatments for chronic kidney disease in geriatrics: dialysis, transplantation and medical treatment without dialysis]. / Traitements de suppléance de la maladie rénale chronique en gériatrie : dialyse, transplantation et traitement médical sans dialyse.

Kidney disease, whether acute or chronic, is a particularly common condition in the elderly, due to its main risk factors, the prevalence of which increases with age, and the fact that recovery from acute tubular damage is slower. Wherever possible, treatment of renal failure should be anticipated and discussed with the patient as part of a shared medical decision. Numerous treatment options are available to ensure maximum integration into the patient's life and care plan: renal transplantation for the most robust patients, hemodialysis in a care facility or at home, peritoneal dialysis at home, or medical treatment without dialysis. The choice of one of these treatments must leave the patient free to change his or her treatment modality at any time.

Humoral Immune Response to SARS-CoV-2 Vaccination after a Booster Vaccine Dose in Two Kidney Transplant Recipients with Fabry Disease and Variable Secondary Immunosuppressive Regimens.

The urgent need to fight the COVID-19 pandemic has accelerated the development of vaccines against SARS-CoV-2 and approval processes. Initial analysis of two-dose regimens with mRNA vaccines reported up to 95% efficacy against the original strain of the SARS-CoV-2 virus. Challenges arose with the appearance of new strains of the virus, and reports that solid organ transplant recipients may have reduced vaccination success rates after a two-dose mRNA vaccination regimen encouraged health authorities to recommend a booster in immunocompromised patients. Fabry disease is an X-linked inherited lysosomal disorder, which may lead to chronic end-stage renal disease. We report on two patients with advanced Fabry disease, renal graft and adjunctive immunosuppressive therapies who exhibited variable humoral vaccination-related immune responses against SARS-CoV-2 after three vaccine doses. The first patient developed mild COVID-19 infection, while the second patient did not seroconvert after three shots of an mRNA vaccine. Both cases emphasize that patients with Fabry disease and renal graft are susceptible to develop a weak response to COVID-19 vaccination and highlight the importance of maintaining barrier protection measures. Vaccination of family members should be encouraged to lower the risk of viral transmission to immunocompromised, transplanted patients, including vaccinated ones.

Severe Strongyloidiasis in Solid Organ Transplant Recipients: Should We Preventively Treat the Recipient, the Donor, or Both?

Strongyloidiasis is caused by a soil-transmitted helminth that is endemic in tropical and subtropical countries. The parasite can complete its life cycle without leaving the host, allowing autoinfection and persistence. The risk of infection in travelers is low, but the disease may become lethal following immunosuppression. In case of solid organ transplantation, the risk of donor transmission has been suspected for several years. However, the management of live donors in this context has only recently been considered, and no guidelines exist for the management of deceased donors. To highlight the complexity of diagnosing, treating, and preventing strongyloidiasis donor transmission, we describe a case of possible transmission of severe strongyloidiasis to a kidney transplant recipient with limited travel history. Taking into account the difficulty of diagnosing chronic strongyloidiasis infection and the increase in travel and immunosuppressive treatments, we recommend pragmatic management guidelines to limit the risks of infection.

How Feasible Is Renal Transplantation in HIV-Infected Patients?

HIV infection has been considered for a long time an absolute contraindication to transplantation. The introduction of highly active antiretroviral therapy has led to improved immunovirological control and increased survival in HIV-infected patients. Renal transplantation can now be performed if these patients are on stable highly active antiretroviral therapy and achieve undetectable viral load and a sufficient CD4 level, in the absence of untreatable infections and cancers. Highly active antiretroviral therapy and immunosuppressive medication should be maintained for life in these patients, raising the problem of multiple drugdrug interactions. Thus, an increased rate of rejection was attributed to the difficulty of achieving sufficient immunosuppressive levels but also to the intrinsic immune system activation despite suppressed HIV RNA levels. HIV infection of the kidney allograft could constitute a renal viral reservoir that impacts long term graft survival. Future options are developing, such as transplanting organs from HIV-infected donors. With highly active antiretroviral therapy, patient and graft survival in HIV-infected kidney transplant recipients are improving and approaching that of non-infected controls.

Catheter-related infections in chronic hemodialysis: a clinical and economic perspective.

PURPOSE: Central venous catheters emerged as a major risk factor for infectious complications in hemodialysis (HD) patients. We aimed to assess the incidence of bacteremia in catheter-dependent HD patients and to characterize its clinical and economic impact. METHODS: We retrospectively collected clinical data and healthcare costs from 15 months for 75 admitted catheter-dependent HD patients, to document the type of bacteremia (complicated or not), pathogen and inflammation. RESULTS: Bacteremia (97 % with Staphylococcus aureus, 33 % methicillin-resistant) was present in 51 % patients, with an overall infections incidence of 5.79 per 1,000 catheter-days. Metastatic complications occurred in 21 % of bacteremic patients and were associated with higher mortality (38 vs. 4 %; p = 0.001). Although, in patients starting dialysis on catheter (41 %) as compared to those using catheter as bridge angioaccess, inflammation (higher C-reactive protein; p = 0.006) and anemia (lower Hb; p = 0.008) were more pronounced, bacteremia occurred in a lower proportion (32 vs. 64 %, p = 0.007). The total medical costs were 47 % higher in patients with complicated bacteremia than in those without bacteremia (p = 0.008) and 45 % higher in patients starting HD on catheter than in those using catheter as bridge angioaccess (p = 0.002). CONCLUSIONS: Despite the limitations resulting from retrospective cross-sectional single-center design, our study suggests that patients already on HD who required catheters as bridge angioaccess were more prone to bacteremia. This highlights the importance of close angioaccess monitoring to avoid unnecessary catheter usage. A similar increase in costs when initiating dialysis on catheter as in case of complicated bacteremia strongly supports the initial placement of a native arteriovenous fistula.