RESUMO
The mean age of patients returning to dialysis after a first kidney transplantation (KT) has increased in the past decades. We aimed to assess the association between second KT (2KT) and survival according to age at the time of return to dialysis. Data of 5334 patients registered in the French Renal Epidemiology and Information Network (REIN) (mean age 56.6 ± 13.6 years) who returned to dialysis after a first KT were collected. The association of 2KT with death was assessed using a propensity score-based analysis taking into account baseline and follow-up variables. In relisted patients (3272 patients, 61.3%), retransplantation was associated with better overall survival in comparison with patients who remained in dialysis (adjusted HR 0.75 [0.63-0.89], p = .0009). The survival advantage conferred by retransplantation gradually declined with increasing age (adjusted HR 0.41 [0.24-0.70] in patients <50, HR 0.94 (0.69-1.27) in patients aged 70 or older, p for interaction 0.034 for age considered as a continuous variable). 2KT is associated with better survival as opposed to remaining on dialysis after a first kidney graft failure. Nevertheless, this survival benefit is age dependent and diminishes with increasing age. The risk/benefit ratio should be comprehensively assessed in the oldest patients when relisting is considered.
Assuntos
Falência Renal Crônica , Transplante de Rim , Adulto , Idoso , Sobrevivência de Enxerto , Humanos , Rim , Pessoa de Meia-Idade , Sistema de Registros , Diálise Renal , ReoperaçãoRESUMO
The aim of this study was to estimate the incidence of COVID-19 disease in the French national population of dialysis patients, their course of illness and to identify the risk factors associated with mortality. Our study included all patients on dialysis recorded in the French REIN Registry in April 2020. Clinical characteristics at last follow-up and the evolution of COVID-19 illness severity over time were recorded for diagnosed cases (either suspicious clinical symptoms, characteristic signs on the chest scan or a positive reverse transcription polymerase chain reaction) for SARS-CoV-2. A total of 1,621 infected patients were reported on the REIN registry from March 16th, 2020 to May 4th, 2020. Of these, 344 died. The prevalence of COVID-19 patients varied from less than 1% to 10% between regions. The probability of being a case was higher in males, patients with diabetes, those in need of assistance for transfer or treated at a self-care unit. Dialysis at home was associated with a lower probability of being infected as was being a smoker, a former smoker, having an active malignancy, or peripheral vascular disease. Mortality in diagnosed cases (21%) was associated with the same causes as in the general population. Higher age, hypoalbuminemia and the presence of an ischemic heart disease were statistically independently associated with a higher risk of death. Being treated at a selfcare unit was associated with a lower risk. Thus, our study showed a relatively low frequency of COVID-19 among dialysis patients contrary to what might have been assumed.
Assuntos
COVID-19/epidemiologia , Diálise Renal/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Instituições de Assistência Ambulatorial/estatística & dados numéricos , COVID-19/mortalidade , COVID-19/terapia , Estudos de Casos e Controles , Cuidados Críticos/estatística & dados numéricos , Feminino , França/epidemiologia , Hemodiálise no Domicílio/estatística & dados numéricos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Gravidade do Paciente , Prevalência , Fatores de Proteção , Sistema de Registros , Fatores de Risco , SARS-CoV-2 , Fatores SexuaisRESUMO
Extraintestinal manifestations in inflammatory bowel disease involve most frequently the joints, the skin, the eyes, the liver and the biliary tract. Renal involvement is rare, and manifested as nephrolithiasis, tubulointerstitial nephritis, glomerulonephritis and amyloidosis. In patients with inflammatory bowel disease, renal disease is most frequently due to treatment nephrotoxicity and rarely as a guenine extraintestinal manifestation of inflammatory bowel disease. We are reporting a case of tubulointerstitial nephritis as an extraintestinal manifestation of Crohn's disease and we are explaining the diagnostic difficulty to distinguish this from drug-induced nephrotoxicity.
Assuntos
Adalimumab/efeitos adversos , Anti-Inflamatórios/efeitos adversos , Doença de Crohn/tratamento farmacológico , Nefrite Intersticial/etiologia , Adalimumab/administração & dosagem , Adulto , Anti-Inflamatórios/administração & dosagem , Doença de Crohn/complicações , Humanos , MasculinoRESUMO
This study investigated geographical variations of access to renal transplantation using three outcomes (access to the transplant waiting list, access to renal transplantation after waitlisting and access to renal transplantation after dialysis start). Associations of patient-related and regional variables with the studied outcomes were assessed using a Cox shared frailty model and a Fine and Gray model. At the study endpoint (December 31, 2015), 26.3% of all 18-90-year-old patients who started dialysis in the 22 mainland and four overseas French regions in 2012 (n = 9312) were waitlisted and 15.1% received a kidney transplant. The geographical disparities of access to renal transplantation varied according to the studied outcome. Patients from the Ile-de-France region had the highest probability of being waitlisted, but were less likely to receive a kidney transplant. Two regional factors were associated with the access to the waiting list and to renal transplantation from dialysis start: the incidence of preemptive kidney transplantation and of ESRD. The use of different outcomes to evaluate access to kidney transplantation could help healthcare policy-makers to select the most appropriate interventions for each region in order to reduce treatment disparities.
Assuntos
Acessibilidade aos Serviços de Saúde , Transplante de Rim , Diálise Renal , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Listas de Espera , Adulto JovemRESUMO
OBJECTIVES: To define groups of patients according to the changes of biochemical parameters, that is, serum calcium, phosphate and parathyroid hormone (PTH), over a 2-year follow-up period using group-based multi-trajectory modeling (GBMM) among a cohort of dialysis patients with newly diagnosed secondary hyperparathyroidism (SHPT) (ie, PTH≥500â ng/L for the first time) and to compare their patient characteristics and treatments. DESIGN: Pharmacoepidemiological study. SETTING: In the 12 dialysis units located in the French region of Lorraine. PARTICIPANTS: A total of 269 dialysis patients with newly diagnosed SHPT were prospectively included from December 2009 to May 2012 and followed-up for 2â years. RESULTS: We identified four distinct trajectory groups: 'rapid PTH drop' experiencing a rapid and sharp decrease (over weeks) in PTH level associated with decreasing phosphate level within normal range (n=34; 12.7%), 'gradual PTH decrease' experiencing a gradual and continuous decrease (over months) in PTH level and maintaining phosphate at a middle level throughout the study (n=98; 36.4%), 'slow PTH decrease with high phosphate' experiencing a slow decrease in PTH level associated with a relatively high phosphate level (n=105; 39.0%) and 'uncontrolled SHPT' with high levels of PTH and phosphate throughout the study (n=32; 11.9%). Patients in the 'uncontrolled SHPT' group were significantly (p<0.00001) younger than patients in other groups. Kidney Disease Improving Global Outcomes (KDIGO) targets for PTH, phosphate and calcium were reached simultaneously for 14.9% of patients at baseline and 16.7% at the end of the study. Patients were given cinacalcet more frequently at months 3 and 6 in the 'rapid PTH drop' and at month 24 in the 'uncontrolled SHPT' groups. CONCLUSIONS: Over 2â years following a new SHPT diagnosis, a younger age and a higher rate of alkaline phosphatase were associated to a continuous uncontrolled SHPT. Patients with the lowest PTH at the end of the follow-up tended to receive more often cinacalcet. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov number, NCT02888639, post results.
Assuntos
Fosfatase Alcalina/metabolismo , Calcimiméticos/uso terapêutico , Cálcio/metabolismo , Distúrbio Mineral e Ósseo na Doença Renal Crônica/metabolismo , Cinacalcete/uso terapêutico , Hiperparatireoidismo Secundário/metabolismo , Hormônio Paratireóideo/metabolismo , Farmacoepidemiologia , Adulto , Distúrbio Mineral e Ósseo na Doença Renal Crônica/tratamento farmacológico , Distúrbio Mineral e Ósseo na Doença Renal Crônica/epidemiologia , Distúrbio Mineral e Ósseo na Doença Renal Crônica/fisiopatologia , Feminino , Seguimentos , França/epidemiologia , Humanos , Hiperparatireoidismo Secundário/epidemiologia , Hiperparatireoidismo Secundário/fisiopatologia , Masculino , Modelos Biológicos , Estudos Prospectivos , Padrões de Referência , Diálise Renal , Resultado do TratamentoRESUMO
BACKGROUND: Recommendations for secondary hyperparathyroidism (SHPT) consider that a "one-size-fits-all" target enables efficacy of care. In routine clinical practice, SHPT continues to pose diagnosis and treatment challenges. One hypothesis that could explain these difficulties is that dialysis population with SHPT is not homogeneous. METHODS: EPHEYL is a prospective, multicenter, pharmacoepidemiological study including chronic dialysis patients (≥ 3 months) with newly SHPT diagnosis, i.e. parathyroid hormone (PTH) ≥ 500 ng/L for the first time, or initiation of cinacalcet, or parathyroidectomy. Multiple correspondence analysis and ascendant hierarchical clustering on clinico-biological (symptoms, PTH, plasma phosphorus and alkaline phosphatase) and treatment of SHPT (cinacalcet, vitamin D, calcium, or calcium-free calcic phosphate binder) were performed to identify distinct phenotypes. RESULTS: 305 patients (261 with incident PTH ≥ 500 ng/L; 44 with cinacalcet initiation) were included. Their mean age was 67 ± 15 years, and 60% were men, 92% on hemodialysis and 8% on peritoneal dialysis. Four subgroups of SHPT patients were identified: 1/ "intermediate" phenotype with hyperphosphatemia without hypocalcemia (n = 113); 2/ younger patients with severe comorbidities, hyperphosphatemia and hypocalcemia, despite SHPT multiple medical treatments, suggesting poor adherence (n = 73); 3/ elderly patients with few cardiovascular comorbidities, controlled phospho-calcium balance, higher PTH, and few treatments (n = 75); 4/ patients who initiated cinacalcet (n = 43). The quality criterion of the model had a cut-off of 14 (>2), suggesting a relevant classification. CONCLUSION: In real life, dialysis patients with newly diagnosed SHPT constitute a very heterogeneous population. A "one-size-fits-all" target approach is probably not appropriate. Therapeutic management needs to be adjusted to the 4 different phenotypes.
Assuntos
Sistemas de Liberação de Medicamentos/métodos , Hiperparatireoidismo Secundário/sangue , Hiperparatireoidismo Secundário/tratamento farmacológico , Naftalenos/administração & dosagem , Hormônio Paratireóideo/sangue , Idoso , Idoso de 80 Anos ou mais , Cinacalcete , Estudos de Coortes , Feminino , Seguimentos , Humanos , Hiperparatireoidismo Secundário/epidemiologia , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/antagonistas & inibidores , Estudos ProspectivosRESUMO
The AVENIR study is a pharmaco-epidemiological study, lead in Lorraine region (France) between 1st January, 2005 and 31st December, 2006, which aim at: evaluating the quality of therapeutic practices, delivered by nephrologists, for chronic kidney disease patients during the year preceding dialysis onset, assessing the association between quality of predialysis therapeutic practices and survival and hospitalization during the first year of dialysis, and health-related quality of life at dialysis onset. Several data were collected for the AVENIR study: demographic, clinical, biological and therapeutic data before dialysis, morbidity and mortality during dialysis treatment. These data were used for secondary analyses investigating the decline in glomerular filtration rate over the year preceding dialysis, the management of hypertension and proteinuria before dialysis, and characteristics and outcomes of patients with delayed dialysis initiation. Results from the AVENIR study have been published in various international journals. The aim of this manuscript is to present a summary of these results and the lessons we can learn for the nephrological practice.
Assuntos
Farmacoepidemiologia , Padrões de Prática Médica/estatística & dados numéricos , Diálise Renal , Insuficiência Renal Crônica/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , França , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Morbidade , Nefrologia , Prognóstico , Estudos Prospectivos , Qualidade da Assistência à Saúde , Qualidade de Vida , Insuficiência Renal Crônica/mortalidade , Taxa de SobrevidaRESUMO
New very high permeability dialysis membranes have been developed to enable the clearance of free light chains in myeloma cast nephropathy. These new dialysis techniques, in combination with chemotherapy, should allow improved prognosis in patients with myeloma cast nephropathy. We report a prospective observational study comparing patients who underwent hemodialysis in our center in 2009 for cast nephropathy revealing multiple myeloma vs. patients treated for the same condition during the same period in other centers in our region. The main difference in the management protocols was the use of high cutoff (HCO) membranes in our center. We described the clinical features, the management protocols, and the outcomes as of June 1, 2010. In 2009, five patients were treated for myeloma cast nephropathy with HCO hemodialysis in our center. At 386 ± 100 days follow-up, one patient died, while three of the five patients recovered their renal function, allowing cessation of hemodialysis. During the same period, five patients were treated for myeloma cast nephropathy in other centers in our region. At 398 ± 131 days follow-up, four patients died, and none of the patients recovered renal function, allowing cessation of hemodialysis. In our study, light chain clearance allowed recovery of renal function and cessation of hemodialysis in three of five patients with acute kidney injury secondary to myeloma cast nephropathy. A randomized trial comparing this technique with conventional hemodialysis techniques should be conducted to raise the level of proof for this therapeutic option. The overall prognosis, including quality of life and cost-effectiveness, of HCO hemodialysis should also be examined.