[Hypertension and dementia : A complex link]. / Hypertension artérielle et démence : un lien complexe.

High blood pressure and dementia are both frequent age-related diseases. The purpose of this article is to review the treatment of hypertension and his effects on cognition, and to propose key points to improve hypertension's treatment in dementia suffering patients. The management of hypertension in middle-life patients seems to be very important to avoid or decrease the progression of cognitive impairment or dementia. Nevertheless, there is no guidelines regarding blood pressure in patients concerned by dementia. To personalize the treatment, to take other comorbidities into account, and the frequent reevaluation of the medication are keys of an optimal management of hypertension in general and becomes crucial more specific in this population.

L'HTA et la démence sont deux pathologies fréquentes liées à l'âge. Cet article a pour but de faire le point sur le traitement de l'HTA et son effet sur la survenue de la démence et de proposer quelques réflexions pour une meilleure prise en charge de l'hypertension chez les patients atteints de démence. Le traitement de l'HTA à l'âge mûr de la vie semble indispensable pour éviter ou ralentir la survenue de troubles cognitifs et de démence. Néanmoins, il n'existe pas pour l'instant de recommandation concernant les cibles tensionnelles à viser chez les patients atteints de démence. La personnalisation du traitement, la prise en compte des autres comorbidités et la réévaluation fréquente de la médication antihypertensive sont, d'une façon générale, les clés d'une prise en charge optimale et deviennent cruciales plus spécifiquement dans cette population.

[White coat hypertension and cardiovascular risk: a controversial association?] / Hypertension de la blouse blanche et risque cardiovasculaire†: une association controversée†?

White coat hypertension is a frequent phenomenon. Its diagnosis is based on 24-hours ambulatory blood pressure monitoring or repeated home blood pressure measurement. It has been recognised now as a hypertension phenotype of which innocence is under debate. Some recent studies have suggested an association with an increased risk of cardiovascular disease. The European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) guidelines put strong emphasis on detecting it and taking it in charge with lifestyle changes in addition to drug treatment in specific situations, to lower cardiovascular risk.

L'hypertension (HTA) dite «â€…de la blouse blanche ¼ est un phénomène fréquent dont le diagnostic repose sur la réalisation d'une mesure ambulatoire de la pression artérielle ou d'automesures à domicile. Longtemps ignoré, ce phénotype d'hypertension est maintenant reconnu et son aspect «â€…bénin ¼ est débattu. Plusieurs publications récentes retrouvent un lien entre une HTA de la blouse blanche et une augmentation du risque cardiovasculaire. Dans ce contexte, la Société européenne d'hypertension et la Société européenne de cardiologie insistent sur l'importance de la détecter afin de mettre en place une stratégie appropriée comprenant des mesures hygiéno-diététiques, associées, au cas par cas, à un traitement médicamenteux afin de diminuer le risque cardiovasculaire.

[Calcific uremic arteriolopathy (calciphylaxis) : update in 2018]. / Artériolopathie urémique calcifiante (calciphylaxie) : mise au point en 2018.

Calciphylaxis is a rare disease with a poor prognostic that mostly occurs in patients with renal failure. Diagnosis is difficult and skin biopsy is the gold standard diagnostic procedure, although it may aggravate skin lesions. Identification of the typical cutaneous signs is important to initiate adequate medical care. Several differential diagnoses must be excluded. Treatments should include appropriate pain management, local wound pain, daily dialysis, intravenous sodium thiosulfate treatment, hyperbaric oxygenotherapy, thigh control of calcium-phosphate metabolism and interruption of medications that could contribute to calciphylaxis. Palliative care should be considered in uncontrolled clinical course.

L'artériolopathie urémique calcifiante ou calciphylaxie est une maladie rare mais mortelle associée à l'insuffisance rénale chronique. Son diagnostic n'est pas aisé. La biopsie cutanée est le gold standard pour poser le diagnostic, mais ce geste n'est pas dénué de risque. La reconnaissance des lésions cutanées typiques est importante afin d'initier une prise en charge adéquate. Plusieurs diagnostics différentiels doivent être exclus. La prise en charge de ces patients comprend une intensification de la dialyse, un traitement de thiosulfate de sodium, une antalgie, un soin minutieux des plaies, des séances d'oxygénothérapie hyperbare, une éviction de certains médicaments incriminés et une correction du bilan phosphocalcique. Dans certains cas, la situation clinique ne permet pas une guérison, et des soins palliatifs seront alors proposés.

Risk factors for community-acquired acute kidney injury in patients with and without chronic kidney injury and impact of its initial management on prognosis: a prospective observational study.

BACKGROUND: We aimed to describe clinical characteristics of patients with community-acquired acute kidney injury (CA-AKI), the effectiveness of initial management of CA-AKI, its prognosis and the impact of medication on its occurrence in patients with previous chronic kidney injury (CKI). METHODS: We undertook a prospective observational study within the Emergency Department (ED) of a University Hospital, screening for any patient >16 years admitted with an eGFR <60 ml/mn/1.73 m2 and a rise in serum creatinine as compared to previous values. Patients' medical files were reviewed by a panel of nephrologists in the subsequent days and at one and three-years follow-up. RESULTS: From May 1st to June 21st 2013, there were 8464 admissions in the ED, of which 653 had an eGFR <60 ml/mn/1.73 m2. Of these, 352 had previous CKI, 341 had CA-AKI, and 104 had CA-ACKI (community-acquired acute on chronic kidney injury). Occurrence of superimposed CA-AKI in CKI patients was associated with male gender and with use of diuretics, but not with use of ARBs or ACEIs. Adequate management of CA-AKI defined as identification, diagnostic procedures and therapeutic intervention within 24 h, was recorded in 45% of the cases and was not associated with improved outcomes. Three-year mortality was 21 and 48% in CKI and CA-ACKI patients respectively, and 40% in patients with only CA-AKI (p < 0.001). Mortality was significantly associated with age, hypertension, ischemic heart disease and CA-AKI. Progression of renal insufficiency was associated with male gender and age. CONCLUSIONS: CA-AKI is more frequently encountered in male patients and those treated with diuretics and is an independent risk factor for long-term mortality. Its initial adequate management failed to improve outcomes.

[Chronic kidney diseases do not always pass unnoticed]. / Les maladies rénales chroniques ne sont pas toutes silencieuses!

Kidney diseases are frequent, but most of the time, they develop unnoticed. This paucity of symptoms may lead to delayed diagnosis with important consequences on their outcome. Nevertheless, specific systemic signs such as skin lesions, joint pain or electrolytes disturbances may sometimes alert the clinician and direct the diagnosis to an underlying nephropathy. A high awareness of clinicians is warranted to recognize these red flags and diagnose these diseases early, as illustrated by two clinical cases discussed in this article.

Comparative efficacy of patiromer and sodium polystyrene sulfonate on potassium levels in chronic haemodialysis patients: a randomized crossover trial.

Background: Hyperkalaemia is frequent in haemodialysis (HD) patients and associated with increased cardiovascular mortality. Despite routine clinical use, evidence regarding the efficacy of potassium (K+) binders in HD is scant. We wished to compare the efficacy of patiromer (PAT) and sodium polystyrene sulfonate (SPS) on K+ levels in this setting. Methods: We screened patients in three HD centres with pre-HD K+ value between 5.0 and 6.4 mmol/L, after an initial 2-week washout period for those previously on K+ binders. We included patients in an unblinded two-arm crossover trial comparing SPS 15 g before each meal on non-dialysis days with PAT 16.8 g once daily on non-dialysis days with randomized attribution order and a 2-week intermediate washout period. The primary outcome was the mean weekly K+ value. Results: We included 51 patients and analysed 48 with mean age of 66.4 ± 19.4 years, 72.9% men and 43.4% diabetics. Mean weekly K+ values were 5.00 ± 0.54 mmol/L, 4.55 ± 0.75 mmol/L and 5.17 ± 0.64 mmol/L under PAT (P = .003), SPS (P < .001) and washout, respectively. In direct comparison, K+ values and prevalence of hyperkalaemia were lower under SPS as compared with PAT (P < .001). While the incidence of gastrointestinal side effects was similar between treatments, SPS showed lower subjective tolerability score (6.0 ± 2.4 and 6.9 ± 1.9) and compliance (10.8 ± 20.4% and 2.4 ± 7.3% missed doses) as compared with PAT (P < .001 for both). Conclusion: Both PAT and SPS are effective in decreasing K+ levels in chronic HD patients. However, at the tested doses, SPS was significantly more effective in doing so as compared with PAT, despite lower tolerability and compliance. Larger randomized controlled trials should be conducted in order to confirm our findings and determine whether they would impact clinical outcomes.