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Large cohort studies suggest that high convective volumes associated with online hemodiafiltration may reduce the risk of mortality/morbidity compared to optimal high-flux hemodialysis. By contrast, intradialytic tolerance is not well studied. The aim of the FRENCHIE (French Convective versus Hemodialysis in Elderly) study was to compare high-flux hemodialysis and online hemodiafiltration in terms of intradialytic tolerance. In this prospective, open-label randomized controlled trial, 381 elderly chronic hemodialysis patients (over age 65) were randomly assigned in a one-to-one ratio to either high-flux hemodialysis or online hemodiafiltration. The primary outcome was intradialytic tolerance (day 30-day 120). Secondary outcomes included health-related quality of life, cardiovascular risk biomarkers, morbidity, and mortality. During the observational period for intradialytic tolerance, 85% and 84% of patients in high-flux hemodialysis and online hemodiafiltration arms, respectively, experienced at least one adverse event without significant difference between groups. As exploratory analysis, intradialytic tolerance was also studied, considering the sessions as a statistical unit according to treatment actually received. Over a total of 11,981 sessions, 2,935 were complicated by the occurrence of at least one adverse event, with a significantly lower occurrence in online hemodiafiltration with fewer episodes of intradialytic symptomatic hypotension and muscle cramps. By contrast, health-related quality of life, morbidity, and mortality were not different in both groups. An improvement in the control of metabolic bone disease biomarkers and β2-microglobulin level without change in serum albumin concentration was observed with online hemodiafiltration. Thus, overall outcomes favor online hemodiafiltration over high-flux hemodialysis in the elderly.

Background Hemodialysis requires effective anticoagulation to avoid blood circuit clotting. In patients at high risk for bleeding, several alternative methods have been developed. Study Design Multicenter, prospective, randomized, crossover study evaluating the noninferiority of vitamin E–coated compared with heparin-coated dialyzers in a 4-hour heparin-free hemodialysis strategy. Settings & Participants 32 adult long-term hemodialysis patients from 2 French hemodialysis units with well-functioning fistulas or double-lumen catheters. Intervention Patients were randomly allocated to a first period using either vitamin E– or heparin-coated dialyzers. After a washout period of 2 hemodialysis sessions, each patient was switched to the alternative dialyzer for a second period. Each study period started with 2 hemodialysis sessions with reduced heparin dose (50% and 25% of usual heparin dose, respectively, for sessions 1 and 2) followed by 2 heparin-free sessions. Outcomes The primary end point was the percentage of successful study periods, defined as no circuit-clotting event leading to premature interruption of any of the 4 dialysis sessions. Secondary end points included total number and cumulative duration of hemodialysis sessions without clotting, number of saline solution flushes, dialysis circuit bubble trap status and dialyzer membrane status by visual inspection, and dialysis adequacy. Results The percentage of success with vitamin E–coated dialyzers (25/32 study periods [78%]) was not inferior to that with heparin-coated dialyzers (26/32 study periods [81%]). Visual inspection showed equal numbers of clean dialysis circuit bubble traps (vitamin E–coated, 34/121; heparin-coated, 32/120), whereas clean fiber bundles were more frequently noted with the vitamin E–coated compared with heparin-coated dialyzers (25/121 vs 2/120; P = 0.002). Limitations Results may not extrapolate to critically ill patients. Differences in dialyzer transparency may account for visual inspection scores. Conclusions The success rate of 4-hour heparin-free hemodialysis sessions is lower than that previously claimed in uncontrolled studies. Vitamin E–coated and heparin-coated dialyzers exposed patients to similar and unacceptable high failure rates. Further studies are required to improve heparin-free hemodialysis.

Resume Introduction L’augmentation croissante de l’incidence des cancers chez des patients en dialyse a ete etudiee depuis les annees 1970. Parallelement, l’emergence des therapies ciblees oblige les oncologues, nephrologues et les pharmaciens a s’interroger sur le maniement en dialyse de ces nouvelles classes de medicaments pour lesquels on dispose peu de donnees. Methode Cette revue de la litterature fait le point sur la pharmacocinetique, la tolerance et l’efficacite des principales therapies ciblees en France, les anticorps monoclonaux et les inhibiteurs de tyrosine kinase. Cette revue a ete realisee en utilisant sur Pubmed les mots cles : rein, dialyse, hemodialyse, insuffisance renale terminale ainsi que le nom de chaque medicament. Resultats De la meme facon que pour les medicaments cytotoxiques, il n’existe dans la litterature que des rapports de cas isoles ou des series de cas isoles. Il est cependant possible d’emettre quelques recommandations : il n’est pas necessaire de modifier la posologie des anticorps monoclonaux de par leur nature meme. En revanche, la pharmacocinetique des inhibiteurs de tyrosine kinase differe d’un medicament a l’autre et il n’est pas possible de faire de recommandations globales. Conclusion Le recours aux therapies ciblees est possible chez les patients dialyses. Cependant, plusieurs medicaments necessitent une attention particuliere en situation de dialyse. De plus, dans la mesure oU ces medicaments sont recents, il est important que les oncologues, nephrologues et les pharmaciens soient particulierement vigilants dans l’evolution de leurs pratiques d’utilisation. La publication de toute information d’utilisation dans cette situation doit etre encouragee.

Objective Although the end cephalic vein-to-side radial artery arteriovenous fistula is the "gold standard" procedure for primary hemodialysis access, it is associated with high rates of primary failure because of the development of neointimal hyperplasia and juxta-anastomotic stenosis. We report initial results of a new approach to perform radial-cephalic fistulas, radial artery deviation and reimplantation (RADAR), designed to avoid juxta-anastomotic stenosis. Methods RADAR patients' data were prospectively maintained and retrospectively reviewed and compared with a historical control group of traditional radial-cephalic fistulas created in the same center. Duplex ultrasound was used to monitor maturation (flow ≥500 mL/min and venous diameter ≥5 mm) and to diagnose juxta-anastomotic stenosis. Study end points were rates of maturation, juxta-anastomotic stenosis, reintervention, and primary and secondary patency. Results There were 53 RADAR fistulas performed (follow-up, 10.5 ± 2.6 months) and compared with 73 control fistulas (follow-up, 12.0 ± 6.6 months). RADAR fistulas had increased rates of maturation compared with control fistulas (75% vs 45% at 6 weeks, P = .001; 92% vs 71% at 3 months, P = .003) and decreased incidence of juxta-anastomotic venous stenoses (2% vs 41%; P = .001). At 6 months, RADAR fistulas had increased primary patency (93% vs 53%; P P = .0003) and decreased incidence of reinterventions (10% vs 74%; P = .001) compared with control fistulas. No RADAR fistulas caused ischemic symptoms. Conclusions The RADAR technique is associated with less juxta-anastomotic stenosis, increased maturation and patency, and fewer secondary interventions. These improved outcomes suggest that RADAR may be the preferred surgical technique to perform radial-cephalic arteriovenous fistula.

The increased incidence of cancer in dialysis patients has been discussed since the mid 1970s. Furthermore, the emergence of targeted therapies (TT) requires oncologists, nephrologists and pharmacists to question themselves about the handling of these new classes of drugs in dialysis patients. While the cytotoxic drugs have been used in oncology for a long time, these new molecules are recent and clinical studies on their management in dialysis patients are missing.We reviewed the international literature on the pharmacokinetics, efficacy, tolerance and dosage adjustment of TT used in hemodialysis cancer patients, using the following keywords: kidney; renal; dialysis; hemodialysis; end-stage renal disease and the name of each drug.As described for cytotoxic drugs, there are only case reports or series published in the international literature. However, it is possible to propose some recommendations on TT handling in dialysis patients. It is not necessary to adapt the dose of monoclonal antibodies in dialysis patients. But it is important to considerer that this "class effect" is not true for all the other classes of drugs. In fact, the pharmacokinetic of tyrosine kinase inhibitors varies from drug to drug.The use of TT is possible in dialysis patients. However, many drugs require special attention in dialysis. In addition, because these drugs are new, it is important that oncologists, nephrologists, and pharmacists remain up to date about the management of TT in dialysis patients.

ObjectiveThe timing and urgency of salvage attempts for acutely thrombosed hemodialysis vascular accesses remain poorly defined. We examined the outcome of early surgical thrombectomy after acute access thrombosis to assess the influence of expedited timing on access salvage.MethodsBetween January 2007 and October 2012, 114 surgical thrombectomy attempts were performed on 82 patients to salvage 89 accesses. The time between the diagnosis of thrombosis and admission to the operative suite (T1), the time between diagnosis and the following dialysis session (T2), and clinical and biologic parameters were collected prospectively. Data were retrospectively compared between the early (T1 6 hours) treatment groups. The main outcome measure was technical success. Kaplan-Meier survival analysis was used to estimate functional patency rates.ResultsMean patient follow-up was 22 ± 18 months. The mean time from referral to procedure (T1) was 5.7 ± 4.5 hours. The mean time T1 was 3.6 ± 1.2 hours in the early group and 10.3 ± 5.4 hours in the later group. The mean time to dialysis (T2) was 14.3 ± 6.5 hours in the early group and 23.9 ± 9.4 hours in the later group. Thrombectomy performed ≤6 hours after diagnosis (T1 6 hours; P = .04). The two groups did not differ significantly in patient comorbidities, type of access, or adjunctive procedures performed (P ≥ .1). At 12 months, the primary patency rate for all index cases, including technical failures, was 55% ± 7.1% in the early group and 33% ± 9.7% in the later group (P = .13). The secondary patency rate was 67% ± 6.8% in the early group and 50% ± 9.9% in the later group (P = .05).ConclusionsAfter acute access thrombosis, early surgical thrombectomy was associated with higher technical success and potentially improved midterm patency.

ContexteEn France et dans le monde, la prévalence de la maladie rénale chronique (MRC) augmente, notamment chez les personnes âgées qui ne bénéficient d’aucune recommandation spécifique de prise en charge.Populations et méthodesNotre étude épidémiologique, descriptive a été réalisée en 2 parties : l’une quantitative à partir de laquelle 197 dossiers médicaux de patients âgés de 75 ans ou plus présentant une MRC modérée à sévère ont été inclus. L’autre partie, qualitative par auto-questionnaires administrés à 18 médecins généralistes des Alpes-Maritimes. Les objectifs de notre étude étaient : de caractériser sur le plan médical la personne âgée atteinte d’une MRC en soins primaires ; de décrire et d’évaluer sa prise en charge et enfin d’identifier les difficultés rencontrées par les médecins dans cette pratique.RésultatsNous avons identifié certaines lacunes dans la prise en charge : une sous-utilisation de l’échographie (38%) ou de la recherche de protéinurie (21%), ainsi qu’un contrôle insuffisant de la pression artérielle (43%). La majorité des médecins (83%) estiment que la prise en charge de la maladie rénale chronique de la personne âgée est difficile principalement en lien avec la polypathologie (66.7%). Alors que la majorité des médecins (78%) ont un correspondant néphrologue avec lesquels plus de la moitié (57%) estiment avoir de bonnes relations ; peu ont eu recours à son avis (11%) et 38% des patients ont débuté un suivi néphrologique en «référence tardive » aux stades 4 et 5 de la MRC dont 5% ont été pris en dialyse en urgence. Les difficultés sont rencontrées principalement lors du contrôle des prescriptions et l’ajustement thérapeutique (67%) ; dans le choix et la mise en place du traitement néphroprotecteur (55%) et dans le suivi (50%). D’autres part, 56% des médecins interrogés ne connaissent pas les recommandations sur la prise en charge de la MRC (HAS 2012) et seulement un tiers (27.8%) ont assisté à une FMC sur ce thème. 43% estiment que les relations peuvent être améliorées notamment sur le plan de la communication ainsi que sur le retour d’information.ConclusionsPour améliorer cette prise en charge il semble donc nécessaire de développer des formations auprès des médecins généralistes, de diffuser des recommandations adaptées à la pratique quotidienne concernant la personne âgée polypathologique, d’améliorer la communication et le partage d’information médecin généraliste – néphrologue. Le dispositif des réseaux de santé peut constituer une piste de réponse particulièrement adaptées aux besoins des patients atteints de MRC ainsi que des médecins.