Acute kidney injury in non-critical care setting: elaboration and validation of an in-hospital death prognosis score.

BACKGROUND: Acute kidney injury (AKI) is still characterized by a high mortality rate. While most patients with AKI are admitted in conventional medical units, current available data are still obtained from studies designed for patients admitted in intensive care units (ICU). Our study aimed to elaborate and validate an in-hospital death prognosis score for AKI admitted in conventional medical care units. METHODS: We included two prospective cohorts of consecutive patients with AKI admitted between 2001 and 2004 (elaboration cohort (EC)) and between 2010 and 2014 (validation cohort (VC)). We developed a scoring system from clinical and biological parameters recorded at admission from the EC to predict in-hospital mortality. This score was then tested for validation in the VC. RESULTS: Three-hundred and twenty-three and 534 patients were included in the EC and VC cohorts, respectively. The proportion of in-hospital death were 15.5% (EC) and 8.9% (VC), mainly due to sepsis. The parameters independently associated with the in-hospital death in the EC were Glasgow score, oxygen requirement, fluid overload, blood diastolic pressure, multiple myeloma and prothrombin time. The in-hospital death prognosis score AUC was 0.845 +/- 0.297 (p < 0.001) after validation in the VC. CONCLUSIONS: Our in-hospital death prognosis score is the first to be prospectively developed and validated for AKI admitted in a conventional medical care unit. Based on current parameters, easily collected at time of admission, this score could be a useful tool for physicians and nephrologists to determine the in-hospital death prognosis of this AKI population.

Serum immunoglobulin G levels and peritonitis in peritoneal dialysis patients.

BACKGROUND: Peritonitis is a frequent and serious complication of peritoneal dialysis (PD). Whether low immunoglobulin level is associated with PD-related peritonitis is unknown. METHODS: We conducted a prospective study to assess whether immunoglobulin levels at PD onset could predict the occurrence of peritonitis. All patients starting peritoneal dialysis between 01/2005 and 12/2010 at the University hospital of Besançon, France, were included in the study. RESULTS: Of 240 consecutive PD patients enrolled (mean follow-up 25 ± 12 months), 76 (32%) had at least one episode of peritonitis. Mean immunoglobulin (Ig)G level at PD start was lower in patients who subsequently experienced peritonitis (7.9 + 3.4 vs. 9.7 + 3.4 g/l, p = 0.005). An increased IgG level at PD onset was associated with a reduced risk of peritonitis [hazard ratio (HR) 0.88, 95% confidence interval (CI) 0.80-0.97 for each increase of 1 g/l in IgG, p = 0.008]. IgG level ≤6.4 g/l ("low IgG") was the best predictive value for the occurrence of subsequent peritonitis: 52 patients (24%) had low IgG levels. At multivariate analysis, both low IgG level (HR 2.49, 95% CI 1.32-4.69, p = 0.005) and diabetes (HR 2.78, 95% CI 1.49-5.20, p = 0.001) were predictive of the occurrence of peritonitis. CONCLUSION: Low IgG levels predict the occurrence of PD-related peritonitis. Randomized studies should determine whether such patients could benefit from intravenous immunoglobulin administration.

Long-term toxicity of antithymocyte globulin induction may vary with choice of agent: a single-center retrospective study.

BACKGROUND: Antithymocyte globulin (ATG) preparations are frequently used as induction treatment in renal transplantation, but little is known about the clinical equivalence of these different agents. We performed a retrospective, single-center study to compare the long-term clinical effects of ATG Fresenius (ATGF) and Thymoglobulin (SangStat, Fremont, CA) in renal transplant recipients. PATIENTS AND METHODS: A total of 194 consecutive renal transplant recipients were included who had undergone transplantation in our center between June 1993 and April 2001 and had received ATGF or Thymoglobulin as induction treatment. RESULTS: A total of 129 patients received ATGF and 65 patients received Thymoglobulin. Thirty patients (23%) in the ATGF group demonstrated cytomegalovirus (CMV) disease, whereas 24 patients (37%) in the Thymoglobulin group demonstrated CMV (P =0.02). Five patients (3.9%) in the ATGF group and eight patients (12.3%) in the Thymoglobulin group developed posttransplant malignancy (P =0.01). Five patients (3.9%) in the ATGF group and nine patients (13.8%) in the Thymoglobulin group died during follow-up (P =0.005). Cox regression analysis revealed that Thymoglobulin was an independent predictor of CMV disease (relative risk [RR] 2.16, confidence interval [CI] 95% [1.04-4.48]), malignancy (RR 2.16, CI 95% [1.04-4.48]), and death (RR 4.14, CI 95% [1.36-12.6]). CONCLUSION: In renal transplant recipients, induction therapy with Thymoglobulin seems to be associated with a significantly greater incidence of CMV disease, malignancy, and death compared with ATGF.

Peritoneal dialysis reduces the number of hospitalization days in heart failure patients refractory to diuretics.

BACKGROUND: Previous small studies have reported favorable results of peritoneal dialysis (PD) in the setting of chronic refractory heart failure (CRHF). We evaluated the impact of PD in a larger cohort of patients with CHRF where end-stage renal disease was excluded. ♢ METHODS: All patients who received PD therapy for CRHF between January 1995 and December 2010 in two medical centers in France were included in this retrospective study. Baseline characteristics were compared with clinical parameters during the first year after initiation of PD. Mortality, safety, and sustainability of PD were also analyzed. ♢ RESULTS: The 126 patients included had a mean age of 72 ± 11 years and an estimated glomerular filtration rate of 33.5 ± 15.1 mL/min/1.73 m2. Mean time on PD was 16 ± 16.6 months. During the first year, patients with a left ventricular ejection fraction (LVEF) of 30% or less experienced improvement in cardiac function (30% ± 10% vs 20% ± 6%, p < 0.0001). We observed a significant reduction in the number of days of hospitalization for acute decompensated heart failure after PD initiation (3.3 ± 2.6 days/patient-month vs 0.3 ± 0.5 days/patient-month, p < 0.0001). One-year mortality was 42%. ♢ CONCLUSIONS: In CRHF, PD significantly reduces the number of days of hospitalization for acute heart failure. Improved LVEF may have led to the comparatively good 1-year survival in this cohort.

C-reactive protein and cardiovascular disease in peritoneal dialysis patients.

BACKGROUND: Elevated plasma concentrations of C-reactive protein (CRP) is a risk factor for cardiovascular disease (CVD) in the general population and in hemodialysis patients. The prognostic value of CRP is less well known in peritoneal dialysis (PD) patients. We examined the association between CRP and cardiovascular event (CVE) in a large population of PD patients. METHODS: Two hundred and forty patients starting PD were enrolled in this prospective study. The role of CRP was analyzed with respect to other known cardiovascular risk factors. RESULTS: The patients were followed for a mean duration of 41 +/- 21 months; the median value of CRP was 7 mg/L. Eighty-nine cardiovascular events (CVE; 37.1%) occurred in 84 patients and the CRP levels were higher in patients who experienced CVE (27 +/- 14 vs. 6 +/- 8 mg/L; P < 0.0001). In the Cox model, patients in the three lower quartiles of the CRP levels had a decreased risk of CVE compared with those in the highest quartile. Cox regression analysis also revealed that age, a previous history of cardiovascular disease, hyperhomocysteinemia and hypoalbuminemia were risk factors for CVE. CRP levels were higher in patients who died during the study period (25 +/- 12 vs. 5 +/- 8 mg/L; P = 0.003). In the Cox model, patients with CRP levels above the median had an increased risk of death compared with those in the lowest quartile. CONCLUSIONS: Chronic inflammation, as reflected by elevated CRP levels, is frequent in patients starting PD and independently contributes to an increased incidence of CVE in this population.

Cyclosporin withdrawal with concomitant conversion from azathioprine to mycophenolate mofetil in renal transplant recipients with chronic allograft nephropathy: a 2-year follow-up.

Because recent large studies have demonstrated that mycophenolate mofetil (MMF) is superior to azathioprine (AZA) as a post-transplant immunosuppressant, it has been speculated that MMF could have a cyclosporin (CsA)-sparing effect in renal transplant recipients with chronic allograft dysfunction. Between April 1996 and October 1998, 31 patients with chronic allograft dysfunction were assigned to have conversion from AZA to MMF with concomitant CsA withdrawal. Patient and graft outcomes were analysed. Mean follow-up time after MMF conversion was 27+/-11 months. Serum creatinine concentration (sCt) significantly decreased after conversion and remained stable at the end of follow-up (227+/-31 micro mol/l vs. 185+/-50 micro mol/l; P<0.0005). Mean variation in sCt was -24% after conversion, whereas it was +20% in the year before conversion ( P<0.001). There was a significant inverse relationship between proteinuria at baseline and improvement in renal function (r=-0.35; P=0.01). Proteinuria increased during follow-up (0.79+/-0.6 vs. 1.79+/-1.08 g/day; P=0.04). Isolated CsA nephropathy was associated with the best outcome. Renal function significantly improved in patients with grade 1 chronic rejection and remained stable in patients with grade 2 chronic rejection. Two patients (6.5%) experienced late acute rejection, respectively 13 and 24 months after CsA withdrawal. Eight patients (29%) experienced systemic infections requiring hospitalization. Blood pressure control and lipid profile improved after conversion. CsA withdrawal with a concomitant switch from AZA to MMF allows a substantial and durable improvement in renal function. Both allograft histology and proteinuria at baseline are predictive of the evolution of renal function after conversion. Physicians should consider the risk of over-immunosuppression possibly associated with this therapeutic strategy.

Lymphocyte subsets and assessment of cancer risk in renal transplant recipients.

Renal transplant recipients have a well-recognized increased risk of de novo neoplasia. In this study, we investigated whether lymphocyte subset count could predict the risk of developing noncutaneous neoplasia (NCSC) in renal transplant recipients (RTR). Between January 1995 and December 1995, lymphocyte subsets (CD4, CD8, CD19) were measured in 281 RTR. This population was studied until November 1999 for the development of NCSC. The mean follow-up was 42+/-9 months. Neoplasm was diagnosed in 22 patients (7.9%). Patients who developed a cancer were significantly older (53.8+/-6 years vs 38+/-16 years, P<0.0001), had lower CD4 (234+/-126/mm(3) vs 543+/-214/mm(3), P<0.005) and CD19 (19+/-9/mm(3) vs 51+/-22/mm(3), P<0.0001) levels, and more frequently had past histories of skin cancer (24% vs 4%, P<0.01). Cox regression revealed that high CD4 levels (RR 0.73, 95% CI 0.62-0.89 for each 100/mm(3) increase in CD4 cell count) were associated with decreased risk of NCSC, whereas age (RR 2.49, 95% CI 1.12-5.92 for each 10-year increase in age) was predictive of the subsequent development of NCSC. To conclude, CD4 cell depletion is associated with the development of solid cancers and lymphoma in RTR.