The Green Nephrology Group of the SFNDT: initial reflections / Groupe Néphrologie verte de la SFNDT : premières réflexions

Preserving the environment is becoming a universal priority. Human activities must be redesigned to best adapt them to available resources and to reduce their deleterious impact on the planet. The Green Nephrology Group of the "Société française de néphrologie, dialyse et transplantation" (SFNDT) has started a reflection on these issues, in particular on dialysis, a vital treatment but with high carbon production, associated with high water consumption. The data available on these points are presented such as, among others, the collection of indicators and action plans, the recycling of waste from water treatment, the reduction of dialysate flow, the reuse and regeneration of spent dialysate as well as calculations of carbon emission by dialysis activity. Architectural experiences are reported as well as the regulatory constraints applying to manufacturers and organizations in the sector. Potential solutions require the mobilization of all stakeholders, ranging from patients to health authorities, including caregivers, pharmacists, technicians, nephrologists and facility managers. They will be formalized very soon in a guide being prepared by the SFNDT Green Nephrology Group.

La préservation de l'environnement devient une priorité universelle. Les activités humaines doivent être repensées pour les adapter au mieux aux ressources disponibles et réduire leur impact délétère sur la planète. Le groupe Néphrologie verte de la Société francophone de néphrologie, dialyse et transplantation (SFNDT) a entamé une réflexion sur ces problématiques, en particulier sur la dialyse, traitement à caractère vital mais à production de carbone élevée, associée à une consommation d'eau importante. Les données disponibles sur ces points sont présentées comme, entre autres, le recueil d'indicateurs et les plans d'action, le recyclage du rejet du traitement d'eau, la réduction de débit du dialysat, la réutilisation et régénération du dialysat usé ainsi que les calculs d'émission de carbone par l'activité de dialyse. Les expériences architecturales sont rapportées de même que les contraintes réglementaires s'appliquant aux industriels et établissements du secteur. Les solutions potentielles nécessitent la mobilisation de tous les acteurs, allant des patients aux autorités de santé, en passant par les soignants, pharmaciens, techniciens, néphrologues et les directions d'établissement. Elles seront formalisées très prochainement dans un guide en cours de préparation par le groupe Néphrologie verte de la SFNDT.

Patient-reported outcome measures in hemodialysis patients: results of the first multicenter cross-sectional ePROMs study in France.

BACKGROUND: Kidney failure with replacement therapy and hemodialysis are associated with a decrease in quality of life (QOL). Self-reported QOL symptoms are not always prioritized by the medical team, potentially leading to conflicting priorities with patients. Electronic patient-reported outcome measures (ePROMs) allow physicians to better identify these symptoms. The objective was to describe the prevalence of symptoms self-reported by hemodialysis (HD) patients. METHODS: A multicenter cross-sectional study was conducted in three HD centers. Patients were included if they were 18 years old or over treated with HD for at least 3 months in a center. Data were collected by the patient via a self-administered ePROMs questionnaire. Data included patient characteristics, post-dialysis fatigue and intensity, recovery time after a session, perceived stress, impaired sleep the day before the dialysis session, current state of health and the change from the past year. A multivariate analysis was conducted to identify relations between symptoms. RESULTS: In total, we included 173 patients with a mean age of 66.2 years, a mean ± SD hemodialysis duration of 48.9 ± 58.02 months. The prevalence of fatigue was 72%. 66% had a high level of stress (level B or C). Recovery time was more than 6 h after a HD session for 25% of patients and 78% declared they had a better or unchanged health status than the previous year. Sleep disturbance was associated with cardiovascular comorbidities (OR 5.08 [95% CI, 1.56 to 16.59], p = 0.007). CONCLUSIONS: Fatigue and stress were the main symptoms reported by HD patients. The patient's care teams should better consider these symptoms.

[Psychological impact of lockdown and the COVID-19 epidemic on haemodialysis patients and carers in France]. / Répercussions psychologiques du confinement et de l'épidémie à COVID-19 chez les patients et soignants en hémodialyse en France.

INTRODUCTION: The health crisis linked to the COVID-19 epidemic has required lockdown measures in France and changes in practices in dialysis centers. The objective was to assess the depressive and anxiety symptoms during lockdown in hemodialysis patients and their caregivers. METHODS: We sent, during lockdown period, between April and May 2020, self-questionnaires to voluntary subjects (patients and caregivers), treated by hemodialysis or who worked in hemodialysis in one of the 14 participating centers in France. We analyzed their perception of dialysis sessions (beneficial or worrying), their stress level (VAS rated from 0 to 10), their anxiety and depressive symptoms (Hospital anxiety and depression scale). Factors associated with stress, anxiety and depression were analyzed with multiple linear regression models. RESULTS: 669 patients and 325 caregivers agreed to participate. 70 % of participants found it beneficial to come to dialysis during confinement. The proportions of subjects with a stress level ≥ 6 linked to the epidemic, confinement, fear of contracting COVID-19 and fear of infecting a loved one were respectively 23.9%, 26.2%, 33.4% and 42%. 39.2% presented with certain (13.7%) or doubtful (19.2%) anxious symptoms. 21.2% presented a certain (7.9%) or doubtful (13.3%) depressive symptomatology. Age, gender, history of psychological disorders and perception of dialysis sessions were associated with levels of stress, anxiety and depression. CONCLUSION: During the lockdown period, in France, the majority of hemodialysis patients and caregivers found it beneficial to come to dialysis. One in three subjects had anxiety symptoms and one in five subjects had depressive symptoms.

[Contributions of a geriatric outpatient consultation in a dialysis facility]. / Apports d'une consultation gériatrique dans une association d'antennes d'auto-dialyse.

CONTEXT: The role of comprehensive geriatric assessment for older patients with advanced chronic kidney disease still needs to be defined. In this population, data is lacking on the care proposals made by geriatricians during comprehensive geriatric assessment and on the follow-up of these proposals. OBJECTIVES: To describe a population of older outpatients with advanced renal disease seen at a geriatric consultation, and geriatric syndromes identified. To study care suggestions made by the geriatrician, and the follow-up of these suggestions. METHODS: Retrospective monocentric study, including all outpatients treated with hemodialysis and seen at the geriatric consultation implemented in a dialysis facilities network in Aquitaine region, France, from 2014 to 2017. Six domains were analysed: functional independence, cognition, gait/balance, mood, nutrition and drug prescription. RESULTS: Among 49 patients, mean age 79 years, 50% had a loss of independence, 32% cognitive impairment, 24% mood disturbance, 55% gait or balance disturbance, and 65% potentially inappropriate medications. The most frequent care suggestions of the geriatrician were drugs optimisation, intervention of a psychologist, a dietetician or a speech and language therapist, home support service implementation, and the exploration of cognitive impairment. Suggestions of intervention of other healthcare professionals, drug optimisation and biological/imaging tests were followed in respectively 46, 33 and 18% of cases. CONCLUSION: A geriatric outpatient consultation in a nephrology facility allows identification of frequent and multiples geriatric syndromes, requiring coordinated interventions. Collaboration between healthcare professionals, including a geriatrician, should be reinforced to improve design and follow-up of the individualised care plan for older patients with advanced chronic kidney disease.

[Hygieno-dietetic recommendations in the prevention of accumulation of advanced glycation products]. / Place des recommandations hygiéno-diététiques dans la prévention de l'accumulation des produits de glycation avancée.

Advanced glycation products are proteins whose structural and functional properties have been modified by a process of oxidative glycation. The accumulation of advanced glycation products in most tissues and the oxidative stress and inflammatory reactions that accompany it, account for the multi-systemic impairment observed particularly in the elderly, diabetics and in chronic renal failure. The advanced glycation products endogenous production is continuous, related to oxidative stress, but the most important source of advanced glycation products is exogenous, mainly of food origin. Exogenous advanced glycation products are developed during the preparation of food and beverages. The advanced glycation products content is higher for animal foods, but it is mainly the preparation and cooking methods that play a decisive role. Dietary advice is based on the selection of foods and the choice of methods of preparation. Several randomized controlled studies have confirmed the favorable effect of these recommendations on serum advanced glycation products concentrations. In humans, as in animals, regular physical activity also results in a reduction of serum and tissue concentrations of advanced glycation products. There is a need for prospective clinical study to confirm the effects of hygienic and dietary recommendations that have only been appreciated, so far, on biological markers.

Vegetarian diets and chronic kidney disease.

While dietary restriction of protein intake has long been proposed as a possible kidney-protective treatment, the effects of changes in the quality of ingested proteins on the prevalence and risk of progression of chronic kidney disease (CKD) have been scarcely studied; these two aspects are reviewed in the present article. The prevalence of hypertension, type 2 diabetes and metabolic syndrome, which are the main causes of CKD in Western countries, is lower in vegetarian populations. Moreover, there is a negative relationship between several components of plant-based diets and numerous factors related to CKD progression such as uraemic toxins, inflammation, oxidative stress, metabolic acidosis, phosphate load and insulin resistance. In fact, results from different studies seem to confirm a kidney-protective effect of plant-based diets in the primary prevention of CKD and the secondary prevention of CKD progression. Various studies have determined the nutritional safety of plant-based diets in CKD patients, despite the combination of a more or less severe dietary protein restriction. As observed in the healthy population, this dietary pattern is associated with a reduced risk of all-cause mortality in CKD patients. We propose that plant-based diets should be included as part of the clinical recommendations for both the prevention and management of CKD.

[Dietary acid load: A novel target for the nephrologist?] / La charge acide d'origine alimentaire : une nouvelle cible pour le néphrologue ?

The acid production of endogenous origin depends mainly on the metabolism of the food and varies with the nature of these. Of the order of 1mEq/kg/day for contemporary food in industrialized countries, it is reduced by more than one third among vegetarians and close to neutrality among vegans. The dietary acid load is eliminated by the normal kidneys, thus maintaining the acid-base equilibrium. In the setting of CKD, it will overflow the capacities of the nephrons, generating a retention of H+ ions, promoting subclinical acidosis. This tissue retention of H+ ions was confirmed by direct techniques in animal models and indirect techniques in humans. The systemic retention of H+ ions and the accompanying compensatory mechanisms have negative consequences on bone tissue, skeletal muscle, cardiovascular risk and renal function. In the animal, the substitution of casein (acid) by soy (alkaline) prevents metabolic acidosis and slows the progression of renal insufficiency. In man, various prospective studies have confirmed that the risk of renal insufficiency was positively correlated with the dietary acid load. Conversely, bicarbonate supplementation and/or a diet enriched with fruits and vegetables, have a favorable effect on renal insufficiency, including in subjects with normal bicarbonate. These results lead to reconsider the K/DOQI recommendations to correct acidosis when the bicarbonate level falls below 22mEq/L, since tissue retention of H+ ions and its negative consequences appear at higher or even normal levels of bicarbonates.

[Common therapeutic approaches of sarcopenia in the elderly and uremic myopathy]. / Approches thérapeutiques communes de la sarcopénie du sujet âgé et de la myopathie urémique.

The gradual loss of weight and function of muscle in patients with chronic kidney disease as in the elderly impacts the quality of life. Early management should help slow the functional limitation. Physical activity is the first therapy to propose that ensures stability of muscle mass and improved function. Resistance training programs have proven effective but are not yet widely available in nephrology units. The nutritional management should not be forgotten because there is a resistance to anabolism and protein intake should be involved in physical activity program. Associated treatments should not be neglected: vitamin D, anti-inflammatory, androgens. Some are still under evaluation. Therapeutic option, tomorrow, could be anti-myostatin antibodies and glitazones.

[Sarcopenia or uremic myopathy in CKD patients]. / Sarcopénie et myopathie urémique: similitudes et différences.

Often underestimated or misunderstood in chronic renal failure (CRF), muscle wasting is nevertheless common and concerns about 50% of dialysis patients. The consequences of this myopathy on quality of life and outcomes of patients are unfavorable, identical to those observed in sarcopenia in elderly subjects with sarcopenia. The similarities between the two situations also concern the symptoms, the underlying muscle damages and the pathogenic mechanisms and may be partly explained by the frequently high age of ESRD patients. Skeletal muscle involvement should be systematically investigated in the IRC patient as in the elderly with sarcopenia to propose as early as possible a treatment of which physical activity and nutritional interventions are the mainstay.

Phenotypes influencing low physical activity in maintenance dialysis.

OBJECTIVE: The "Pas à Pas" initiative aimed at evaluating the weekly physical activity (PA) and its determinants in a large cohort of dialysis patients. SETTING: Physical inactivity is a risk factor for mortality in maintenance dialysis patients and is still poorly documented in this population. DESIGN: A prospective national epidemiological study was performed. SUBJECTS: A total of 1,163 patients on maintenance dialysis (hemodialysis and peritoneal dialysis) were included. INTERVENTION AND MAIN OUTCOME MEASURE: PA was recorded during seven consecutive days using a pedometer to measure daily step numbers. RESULTS: Median age was 63 years (Q1 51-Q3 75). Sixty-three percent were sedentary (<5000 steps/day) with a median of 3,688 steps/day (1,866-6,271)]. PA level was similar between hemodialysis patients and those on peritoneal dialysis (3,693 steps [1,896-6,307] vs. 3,320 [1,478-5,926], P = .33). In hemodialysis patients, PA was lower on dialysis days compared with nondialysis days (2,912 [1,439-5,232] vs. 4,054 [2,136-7,108], respectively, P < .01). PA gradually decreased with age, 57% being sedentary between 50 and 65 years and 83% of patients after 80 years. Beyond this age effect, we identified, for the first time, specific phenotypes of patients with lower PA, such as inflammation, cardiovascular disease, protein energy wasting, obesity, and diabetes. By contrast, previous kidney transplantation and a higher muscle mass were associated with higher PA. CONCLUSIONS: Dialysis patients present a very low level of PA with high sedentary. Acting on patient's modifiable phenotypes may help to increase PA to improve morbidity, mortality, and quality of life.

[Physical activity in dialysis population: how and why to assess and establish a program?]. / Activité physique chez les patients dialysés: comment et pourquoi l'évaluer et mettre en place un programme?

The studies that evaluated physical activity in dialysis patients show a significant inactivity. This inactivity is associated with increased mortality. In contrast, the benefits in terms of morbidity and mortality of physical activity in this population are numerous. Recommendations exist for these patients: those set out for the general elderly adult population. However, few centers are implementing training programs in dialysis patients. There are many reasons, among which the lack of knowledge of the medical staff. The purpose of this article is to clarify the assessment of physical activity in dialysis patients and implementation program for the fight against inactivity. The initial assessment by simple means is essential. It ideally requires the intervention of a specialist in physical activity. The main types of exercise are presented as well as the different types of program and their results. It is important to note that no serious adverse events were reported in the different programs and their feasibility has been demonstrated. The fight against the sedentary patients undergoing dialysis should be a goal of health care teams, as well as the fight against the other cardiovascular risk factors.

[Is there a place for the physical activity in the prevention of the fractures of chronic kidney disease patients?]. / Y a-t-il une place pour l'exercice physique dans la prévention des fractures non traumatiques de l'insuffisant rénal chronique ?

The risk of non-traumatic fractures is greatly increased in kidney disease patients and well demonstrated in dialysis patients. If osteoporosis plays a major role in the general population, in chronic kidney disease renal osteodystrophy is associated with neurological and muscular disorders, which probably worsen the risk. The decrease in physical activity is a factor contributing to the loss of bone mass and the initiation of a rehabilitation program improves the prognosis. Despite the association between chronic renal disease and sedentary lifestyle, the relationship between physical inactivity and bones in dialysis patients and the effect of increased activity programs, are not well documented in the literature.

Family relations, mental health and adherence to nutritional guidelines in patients facing dialysis initiation.

This study investigated the effect of family relations on patients' adjustment to dialysis. The two main aims were to develop a family typology, and to explore the influence of family profile on the patient's anxiety, depression and adherence to nutritional guidelines. The sample consisted of 120 patients (mean age 63 years; 67.5% of men). They completed several measures 1, 6 and 12 months after dialysis initiation. The scales used were the Family Relationship Index and the Hospital Anxiety and Depression Scale. Perceived adherence to nutritional guidelines was assessed using two visual analogical scales. Results showed that family relations remained stable over time. Cluster analysis yielded three family profiles, which were named conflict, communicative and supportive families. Patients belonging to conflict families perceived themselves as less adhering to nutritional guidelines. For these patients, anxiety and depressive moods increased significantly over time, whereas mental health remained stable over time for communicative and supportive families. This research underlines that family relations are essential in global consideration of the care of patients treated by dialysis. Conflict families seem especially at risk. They should be identified early to help them adapt to this stressful treatment.

Large kidneys predict poor renal outcome in subjects with diabetes and chronic kidney disease.

BACKGROUND: Renal hypertrophy occurs early in diabetic nephropathy, its later value is unknown. Do large kidneys still predict poor outcome in patients with diabetes and Chronic Kidney Disease (CKD)? METHODS: Seventy-five patients with diabetes and CKD according to a Glomerular Filtration Rate (GFR, by 51Cr-EDTA clearance) below 60 mL/min/1.73 m2 or an Albumin Excretion Rate above 30 mg/24 H, had an ultrasound imaging of the kidneys and were cooperatively followed during five years by the Diabetology and Nephrology departments of the Centre Hospitalier Universitaire de Bordeaux. RESULTS: The patients were mainly men (44/75), aged 62 +/- 13 yrs, with long-standing diabetes (duration:17 +/- 9 yrs, 55/75 type 2), and CKD: initial GFR: 56.5 (8.5-209) mL/min/1.73 m2, AER: 196 (20-2358) mg/24 H. Their mean kidney lenght (108 +/- 13 mm, 67-147) was correlated to the GFR (r = 0.23, p < 0.05). During the follow-up, 9/11 of the patients who had to start dialysis came from the half with the largest kidneys (LogRank: p < 0.05), despite a 40% higher initial isotopic GFR. Serum creatinine were initially lower (Small kidneys: 125 (79-320) micromol/L, Large: 103 (50-371), p < 0.05), but significantly increased in the "large kidneys" group at the end of the follow-up (Small kidneys: 129 (69-283) micromol/L, Large: 140 (50-952), p < 0.005 vs initial). The difference persisted in the patients with severe renal failure (KDOQI stages 4,5). CONCLUSIONS: Large kidneys still predict progression in advanced CKD complicating diabetes. In these patients, ultrasound imaging not only excludes obstructive renal disease, but also provides information on the progression of the renal disease.

Improved intradialytic stability during haemodialysis with blood volume-controlled ultrafiltration.

BACKGROUND: Intradialytic morbid events (IMEs) during haemodialysis (HD), including symptomatic hypotension, are related to ultrafiltration (UF)-induced hypovolaemia. Blood volume monitoring and automatic feedback control of the UF rate were developed to limit the extent of hypovolaemia during dialysis. The present study investigated the effect of blood volume (BV)-controlled UF on the incidence of HD treatments with IMEs. METHODS: This prospective randomised crossover study included hypotension-prone patients, characterised by occurrence of IMEs in at least 33% of HD treatments during a 6-week screening phase. These patients underwent 2 treatment phases, each lasting 6 weeks, in randomised order. Each patient served as their own control, treated with standard HD in one phase and with BV-controlled UF in the other phase. RESULTS: Thirty-four patients from 9 HD centres were enrolled; 26 could be included in the analysis population. In comparison with standard HD, BV-controlled UF reduced the percentage of HD sessions complicated by IME significantly from 40%+/-27% to 32%+/-25% (p=0.02). A lower frequency of HD sessions with IME could be observed in 46% of the patients. The frequency of treatments with symptomatic hypotension was reduced from 32%+/-23% in standard HD to 24%+/-21% with BV-controlled UF (p=0.04). Changes in blood pressure and heart rate from start to end of the HD session were not different between the 2 treatment modes. CONCLUSIONS: This crossover study showed improved intradialytic stability with BV-controlled UF, compared with standard HD.

Progression-related bias in the monitoring of kidney function in patients with diabetes and chronic kidney disease.

The Cockcroft and Gault (CG) and Modification of Diet in Renal Disease (MDRD) equations underestimate the glomerular filtration rate (GFR) decline in diabetes. Do this decline and the albumin excretion rate (AER) influence their validity? In 161 diabetic patients, isotopically determined GFR (i-GFR) (51Cr-EDTA) was compared with estimated GFR (e-GFR) by the CG, MDRD, and the new Mayo Clinic Quadratic (MCQ) equations. We searched for a relation between the error in e-GFR and the AER. An influence of the AER outcome on the e-GFR decline was evaluated in 63 subjects followed up over 3 years. The MDRD and the MCQ were more precise and accurate than the CG, but they were biased. The error increased with AER for the CG (r = 0.25, P = .001) and the MDRD (r = 0.20, P = .009), but not for the MCQ. For the 63 patients followed up, the e-GFR declines by the 3 estimations were related to the initial AER, whereas no relation with arterial blood pressure, hemoglobin A(1C), hemoglobin, and blood lipids emerged. The MCQ declines were more pronounced: -10.5% +/- 8.9% in the macroalbuminuric group (P < .05 vs both microalbuminuric [-2.6% +/- 10.1%] and normoalbuminuric [-0.1% +/- 6.6%] groups), and were related to the outcome of the AER (r = 0.33, P < .05). As chronic kidney disease progresses in diabetes, the declining GFR and rising AER influence the estimation of GFR by the CG and MDRD equations, underestimating the GFR decline and the benefit of reducing the AER. The less affected MCQ evidences a slower e-GFR decline with AER control.