[Physician-patient communication in nephrology]. / La communication médecin-malade en néphrologie.

Training the nephrologist-to-be to physician-patient communication (PPC) has several objectives: to guide his/her history taking in order to make a diagnosis, of course, but also to help him/her establish a long-lasting relationship, inform and motivate the patient, and prepare him/her to break bad news and to deal with end-of-life issues. PPC rests on specific strategies and on the ethical grounds of a human encounter, the success of which expresses itself in care. An effective PPC offers many benefits to the patient, but also to the clinician. Talking about renal failure and dialysis, about kidney transplantation, and about withdrawing or not starting therapy: these are a few of the communicational challenges awaiting the nephrologist in training, mostly with patients requiring long-term follow-up. PPC also requires specific skills in the field of pediatric nephrology, where one deals alternately with children, adolescents and parents. Whatever the personal abilities of the nephrologist-to-be, PPC is a competency that can be learned and improved, for the benefit of the patient, and also of the physician.

Measurement of the international normalized ratio (INR) in hemodialysis patients with heparin-locked central venous catheters: evaluation of a novel blood sampling method.

BACKGROUND: Accurate measurement of the international normalized ratio (INR) may be difficult in hemodialysis (HD) patients with heparin-locked central catheters. Blood contamination with locking solutions may interfere with INR measurement when samples are collected directly from the catheter. METHODS: The aim of our study was to evaluate a novel sampling method for the measurement of INR in HD patients with heparin-locked central catheters. This novel method consists of measuring the INR directly from the dialysis circuit (arterial bloodline sample port) after 1 hr of treatment regardless of heparin administration during dialysis. We compared this method to the gold standard (peripheral venipuncture prior to dialysis) using the paired t-test. We included 30 patients (23 with warfarin therapy and 7 without). RESULTS: INRs obtained using the novel sampling method were only minimally overestimated compared to venipuncture values (mean INR overestimation: 0.2 +/- 0.2). This overestimation was not clinically significant and did not lead to changes in warfarin prescription for any of the patients. Correlation tests confirmed the influence of heparin administration on INR overestimation (R=0.4; p=0.05). This influence was present mostly among patients receiving more than 100 Units/kg of heparin during their treatment. CONCLUSION: This novel sampling technique provides a convenient and simple method of monitoring INR among HD patients.

FSGS permeability factor-associated nephrotic syndrome: remission after oral galactose therapy.

Some cases of nephrotic syndrome in focal and segmental glomerulosclerosis (FSGS) are associated with a circulating factor, the FSGS permeability factor (FSPF). Galactose has a high affinity for FSPF, and experimental data suggest that it could reduce its activity. We describe the case of a 48-year-old male with a nephrotic syndrome found to be resistant to corticosteroids, immunosuppression and plasmaphaeresis. The patient was given oral galactose as a last resort treatment, which was followed by a remission of his nephrotic syndrome that correlated with a reduction of FSPF activity. This case is the first report of a long-standing remission of an FSPF-associated nephrotic syndrome on oral galactose therapy.

[Nephrogenic systemic fibrosis: more hard times for renal failure patients]. / La fibrose systémique néphrogénique: nouveau coup dur pour les insuffisants rénaux.

To date, more than 200 cases of nephrogenic systemic fibrosis have been documented worldwide. All patients have had renal failure, most of them requiring dialysis. We herein describe the course of a hemodialyzed patient who developed nephrogenic systemic fibrosis in the months following magnetic resonance angiography of the lower extremities. The disease is characterized by skin thickening and tendon fibrosis leading to joint contractures that can quickly confine the patient to a wheelchair. Systemic involvement may occur, leading to cardiomyopathy, pulmonary fibrosis, pulmonary hypertension or even death. No consistently effective therapy has been reported. An association between gadolinium exposure and the development of the disease has been found, although no causal link has yet been proven. In a patient with renal failure, magnetic resonance imaging with gadolinium enhancement should be done only after having seriously considered the risk/benefit ratio. Implications concerning the choice of imaging methods when searching for ischemic nephropathy or aorto-iliac disease before renal transplantation are discussed.

Systemic anticoagulation and prevention of hemodialysis catheter malfunction.

Although chronic anticoagulation is commonly prescribed to prevent thrombosis and malfunction of hemodialysis tunneled cuffed catheters (TCC), there are only limited data regarding its efficacy. The aim of this prospective study was to evaluate whether anticoagulation with adjusted-dose warfarin targeting an international normalized ratio (INR) of 1.5-2.0 is associated with improved catheter outcome in long-term patients at high risk of TCC malfunction. Among the 65 patients included in the study, 35 were considered at high risk (i.e., patients with a history of previous TCC thrombosis requiring catheter replacement and/or with TCC malfunction occurring within 2 weeks after catheter insertion in the absence of mechanical problems) and were prescribed warfarin, whereas 30 low-risk patients did not receive anticoagulation. During follow-up, TCC malfunction, defined as the need for inversion of catheter lines and/or recombinant tissue-type plasminogen activator infusion, was observed in 61.5% of patients. Among patients receiving warfarin, 19 (54.3%) achieved adequate anticoagulation (i.e., > 80% of follow-up INR values and INR value at the time of malfunction within target range). Anticoagulation was considered inadequate in 16 patients (45.7%). Malfunction-free catheter survival at 9 months was 47.1% in patients with adequate anticoagulation compared with 8.1% in patients with inadequate anticoagulation (p = 0.01). This difference remained statistically significant after adjustment for aspirin intake. These results suggest that achieving adequate anticoagulation with target INR 1.5-2.0 may prevent TCC malfunction and improve catheter outcome.

Measurement of blood volume during hemodialysis is a useful tool to achieve safely adequate dry weight by enhanced ultrafiltration.

Chronic fluid overload and hypertension are highly prevalent in the dialysis population. Measurement of blood volume (BV) during hemodialysis (HD) may prove useful to achieve dry weight (DW). Twelve (12) chronic hemodynamically stable dialysis patients were randomly selected to participate in a pilot study. BV changes were measured using an online blood volume monitor (Hemoscan, Gambro AB, Stockholm, Sweden). As part of an initial observation phase, the magnitude of BV variation (deltaBV) in percentage and total UF volume (UF) in liters were recorded for each dialysis session, and the deltaBV/UF ratio was calculated. DW was subsequently reduced by 0.5 kg in all patients and the tolerance of the procedure was assessed. Attempted DW reduction was successful in seven patients, whereas it resulted in hypotension or symptoms in the other five cases. The deltaBV/UF ratio was found to be significantly lower in patients in whom attempted DW reduction was successful (2.47%/L vs. 3.45%/L, P < 0.05). Using receiver operating characteristic (ROC) curve analysis, a deltaBV/UF ratio of less than 2.6%/L offered the best overall prediction of successful DW reduction. These results suggest that measurement of BV changes during HD and calculation of the deltaBV/UF ratio are valuable tools for management of DW in clinically stable patients.