Search

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., Graphical abstract

Renal cell carcinoma can metastasize to several locations but rarely in muscles. However, this possibility must never be overlooked because muscle metastases may occur a very long time after the initial nephrectomy. So the post-operative follow-up, according to the recommendations, with thoraco-abdomino-pelvic imaging (computed tomography or nuclear magnetic resonance) allowing to detect metastases, including muscle metastases in the trunk, does not have to neglect the metastases located in the members. This search is based upon a thorough clinical examination, completed by targeted imaging in case of symptoms and/or palpable mass.

Watermelon stomach or gastric antral vascular ectasia (GAVE) syndrome is an uncommon cause of sometimes severe upper gastro-intestinal bleeding. Essentially based on a pathognomonic endoscopic appearance, its diagnosis may be unrecognised because mistaken with portal hypertensive gastropathy, while treatment of these two entities is different. Its etiopathogeny remains still unclear, even if it is frequently associated with different systemic illnesses as hepatic cirrhosis, autoimmune disorders and chronic renal failure. The mechanism inducing these vascular ectasia may be linked with mechanical stress on submucosal vessels due to antropyloric peristaltic motility dysfunction modulated by neurohormonal vasoactive alterations. Because medical therapies are not very satisfactory, among the endoscopic modalities, argon plasma coagulation seems to be actually the first-line treatment because the most effective and safe. However, surgical antrectomy may be sometimes necessary. Recently GAVE syndrome appeared as a new adverse reaction of imatinib mesylate, one of the tyrosine kinase inhibitors used in chronic myeloid leukemia, and we report here the observation of such a pathology in one patient treated at the same time by haemodialysis and by imatinib mesylate for chronic myeloid leukemia.

Nephrologie & Therapeutique - In Press.Proof corrected by the author Available online since mardi 1 janvier 2013

Bariatric surgery is now recognized as a sure and effective way for weight reduction in morbid obesity. However some procedures induce intestinal malabsorption leading to enteric hyperoxaluria. So bariatric surgery could place these patients not only at risk for nephrolithiasis but also for oxalate induced nephropathy and chronic renal failure. Because of the growing incidence of obesity worldwide, physicians and patients should be aware of such potential complications. There is no mean to discuss this treatment because of its spectacular efficiency on obesity and its comorbidities. But it is necessary to choose the surgical technique according to the risk factors of the patients. Following surgery, preventive treatment strategies are indicated, such as modified dietary lifestyle and specific drugs as we suggested to limit or even avoid these complications. However observance could fail in the long term. In case of oxalate nephropathy, surgery may be proposed to restore the intestinal tract but with the risk of overweight relapse. To illustrate this matter, we report here significant observations of three patients, which, having successfully benefited from the same bariatric surgery, have presented lithiasic complications for two of them and oxalate nephropathy leading to chronic renal failure and hemodialysis for the third.

When seen, some habits of calcium oxalate monohydrate crystals (whewellite) are so typical of ethylene glycol intoxication that they may be helpful for its diagnosis when circumstances are not clearly established.

Several alternative anticoagulation drugs are now available for patients with heparin induced thrombocytopenia type II (HIT II). However, their indication is not yet reaching a consensus. Moreover, some of them have not yet their marketing approval. The importantly use in hemodialyzed patients should be taken with caution since most of them are excreted by the kidneys. The use of fondaparinux, which exerts high anti-Xa activity, is not well documented. We report here our experience on the use of fondaparinux in an hemodialyzed patient with HIT II, not only as anticoagulation during hemodialysis sessions but also as interdialytic anticoagulation locking solution of her central venous catheter. The use of fondaparinux seems to us simple enough (even if its ready-for-use syringe requires adjustments to deliver the required doses) and its efficacy, safety and economic cost lead us to think that it is an indication of choice for an alternative anticoagulation in hemodialyzed patients with HIT II. Control prospective trials should be performed in order to confirm the preliminary favourable data and to support the proposal of marketing approval in this indication.

Resume Si la maladie de Wegener touche preferentiellement les voies aeriennes superieures et inferieures et les reins, de nombreux autres organes et tissus peuvent etre egalement atteints, dont toutes les structures orbitaires et oculaires. Ces complications ophtalmologiques relativement frequentes, parfois inaugurales, sont observees seules ou associees a d’autres manifestations systemiques de la maladie. Elles conduisent parfois a la perte de la fonction visuelle. Les lesions le plus souvent rencontrees sont les atteintes orbitaires inflammatoires pseudotumorales, les sclerites parfois necrosantes, avec ou sans keratopathie, les episclerites, les conjonctivites avec meme ulceration, les obstructions des voies lacrymales, les uveites, les vascularites retiniennes et les thromboses de l’artere centrale de la retine, les nevrites optiques. Ces lesions oculaires sont liees soit a l’extension d’un processus granulomateux ORL de voisinage, soit a un processus focal de vascularite. Elles doivent etre reconnues au plus tot pour qu’un diagnostic precoce de la maladie permette d’instituer le traitement adapte destine a preserver le pronostic non seulement visuel mais egalement vital.

Patients with cystic fibrosis (CF) show a continuing improvement in their life expectancy thanks to advances in knowledge of this disorder, allowing better multidisciplinary routine monitoring and earlier therapeutic interventions. Likewise, more than of 40% of these patients are adults and CF is no more only a pediatric disease. Due to their higher life expectancy, CF patients present new and unusual complications that were not recorded before. Among them, some renal disorders have to be added to the CF-related renal diseases. They are due to frequent and prolonged exposure to various potentially nephrotoxic factors that need to be taken into account early enough in order to avoid renal failure : essentially risk factors for kidney stones formation, bacterial infections with their associated immune complexes diseases, nephrotoxic effects of antibiotics, diabetes mellitus. Because we observed a case of IgA glomerulonephritis in a 35-year-old patient with cystic fibrosis, we have searched about all these renal consequences due to this affection and here report them.

Resume Depuis deux decennies, l’âge des patients dialyses et le nombre de patients âges ne cesse de croitre. La plus forte morbi-mortalite observee par rapport aux adultes plus jeunes ne doit cependant pas, sauf cas particuliers, contre indiquer leur prise en charge en hemodialyse car les resultats en matiere de survie et de qualite de vie sont satisfaisants. Ils tendent meme a s’ameliorer grâce a une bonne gestion des differentes particularites de ces tranches d’âge eleve que nous analysons dans cette revue en essayant de faire parallelement des propositions therapeutiques. La situation est d’autant plus aisee que le recours aux nephrologues est assez precoce pour instituer au plus tot une preparation adequate. Le recours a la suppleance renale peut etre ainsi aborde dans de meilleures conditions medicales et psychologiques que lors de prises en dialyse en urgence, si deleteres et pourtant encore trop nombreuses. Outre l’aspect pronostique medical et humain plus favorable, une prise en charge precoce ne peut avoir qu’un impact economique non negligeable sur le cout global du traitement qui ne fait qu’augmenter parallelement a l’accroissement du nombre de dialyses.

Resume Lors d'une prise en charge d'œdemes, la decouverte d'une hypoprotidemie sans cause nutritionnelle, renale, hepatique ou cardiaque, doit faire rechercher une cause digestive exsudative, dont la gastrite lymphocytaire, comme les auteurs en rapportent une nouvelle observation chez une femme de 73 ans. A l'endoscopie, l'aspect est celui d'une gastrite varioliforme, mais la constatation d'une infiltration massive, dense et diffuse, de l'epithelium gastrique par des lymphocytes en fait une entite histopathologique bien a part au sein des gastropathies. Son etiopathogenie reste encore indeterminee mais les inhibiteurs de la pompe a protons constituent un traitement efficace.

HemoCue Hb 201+ is a portable photometric analyser providing easy, rapid and accurate determination of hemoglobin from arterial, venous or capillary blood. It is worth that dialysis units have knowledge of its use for a close hematologic monitoring of their patients and a judicious management of erythropoietin (EPO). For the autodialysis > centers, it allows a flexibility that private laboratories cannot have in daily practice. Therefore authors present this device and the evaluation they obtained from 148 hemoglobin measures. Then they expose the advantages and the indications of its use.

Renal cell carcinoma can metastasize to several locations but rarely in muscles. However, this possibility must never be overlooked because muscle metastases may occur a very long time after the initial nephrectomy. So the post-operative follow-up, according to the recommendations, with thoraco-abdomino-pelvic imaging (computed tomography or nuclear magnetic resonance) allowing to detect metastases, including muscle metastases in the trunk, does not have to neglect the metastases located in the members. This search is based upon a thorough clinical examination, completed by targeted imaging in case of symptoms and/or palpable mass.

Watermelon stomach or gastric antral vascular ectasia (GAVE) syndrome is an uncommon cause of sometimes severe upper gastro-intestinal bleeding. Essentially based on a pathognomonic endoscopic appearance, its diagnosis may be unrecognised because mistaken with portal hypertensive gastropathy, while treatment of these two entities is different. Its etiopathogeny remains still unclear, even if it is frequently associated with different systemic illnesses as hepatic cirrhosis, autoimmune disorders and chronic renal failure. The mechanism inducing these vascular ectasia may be linked with mechanical stress on submucosal vessels due to antropyloric peristaltic motility dysfunction modulated by neurohormonal vasoactive alterations. Because medical therapies are not very satisfactory, among the endoscopic modalities, argon plasma coagulation seems to be actually the first-line treatment because the most effective and safe. However, surgical antrectomy may be sometimes necessary. Recently GAVE syndrome appeared as a new adverse reaction of imatinib mesylate, one of the tyrosine kinase inhibitors used in chronic myeloid leukemia, and we report here the observation of such a pathology in one patient treated at the same time by haemodialysis and by imatinib mesylate for chronic myeloid leukemia.

Resume Les troubles du rythme frequemment observes chez les insuffisants renaux chroniques peuvent amener a prescrire des antiarythmiques, parmi lesquels l'acetate de flecainide. Or les grandes variabilites interindividuelles du metabolisme de celui-ci ne permettent pas d'en adapter la posologie selon la seule clairance renale. Cela devient encore plus complexe au stade d'hemodialyse, surtout si une hepatopathie et/ou certains traitements s'y associent. Cet antiarythmique doit donc etre instaure a posologie prudente qui pourra etre ensuite modifiee sous surveillance des taux seriques pour ne pas exposer les patients a des effets secondaires parfois handicapants comme dans notre observation, voire a des complications cardiaques plus graves.

Bad dental status is very often observed in hemodialyzed patients due to the fact of a frequent poor oral hygiene and, in addition of the traditional risk factors, the consequences of uraemic state and its treatment. However , among such immunodepressed patients, oral and dental lesions represent a risk of septic complications. Moreover some works point out the prevalence of inflammation and denutrition due to dental lesions in the uraemic population, with potential atherosclerosis. Therefore, in order to anticipate all these adverse effects and to restore their mouth to health, patients have to be encouraged to have regularly a full dental evaluation and correction if not elimination of all potential sources of infection and other complications. To ensure the best treatment, a close collaboration has to be established with dental practitioners who must be aware and convinced of the complexity of such patients: immunodepression due to uraemic state and sometimes to drug therapy; importance of prophylactic antibiotic therapy surrounding dental cares; cautions to hemostasis circumstances; adjusted use of some medications. To illustrate this matter, we report here a study involving 96 hemodialyzed patients who were investigated by panoramic radiography and clinical cross- examination about their dental complaints and habits. We then expose our practices and detail our collaboration with their dentists in establishing a plan of dental treatment.

About an observation of aspergillus sinusitis in an hemodialyzed patient, correlation between chronic maxillary sinusitis, its aspergillus origin and previous dental treatments is emphasized. Eventual severe complications then evolved in immunocompromised patients justify having the knowledge of this possible pathology in hemodialyzed and transplanted patients.

At the end of assessment of an hypercalcemia with acute renal failure in a seventy year-old man, is discovered a tumorlike muscular sarcoidosis of both thighs whose steroid treatment quickly proves effective. Rarity of such forms urges us to report this observation which allows to remind that, in case of a suggestive picture of sarcoidosis, it is necessary to look minutely for any muscular abnormality.

A 58 year-old woman developed an acute renal failure very quickly after ingestion of two 500 mg tablets of ciprofloxacin, without any other identifiable risk factor. Renal biopsy was performed. No sign of acute interstitial nephritis was observed but tubular lesions were found, accompanied by deposits of a brown-yellowish substance identified by infrared microscopy as a ciprofloxacin salt. The outcome was favourable. This observation gives the opportunity to remind the different forms of quinolone-induced renal injury and to discuss the possible ways for preventing renal side-effects related to the quinolone use.

When seen, some habits of calcium oxalate monohydrate crystals (whewellite) are so typical of ethylene glycol intoxication that they may be helpful for its diagnosis when circumstances are not clearly established.

Resume La prise de polystyrene sulfonate de sodium (Kayexalate®) pour chelater une hyperkaliemie en cas d’insuffisance renale peut, dans certaines circonstances, induire des complications digestives dont les plus severes seront des necroses ou des perforations intestinales. Nous en evoquons ici les mecanismes favorisants et illustrons cette pathologie par quelques images.

Bariatric surgery is now recognized as a sure and effective way for weight reduction in morbid obesity. However some procedures induce intestinal malabsorption leading to enteric hyperoxaluria. So bariatric surgery could place these patients not only at risk for nephrolithiasis but also for oxalate induced nephropathy and chronic renal failure. Because of the growing incidence of obesity worldwide, physicians and patients should be aware of such potential complications. There is no mean to discuss this treatment because of its spectacular efficiency on obesity and its comorbidities. But it is necessary to choose the surgical technique according to the risk factors of the patients. Following surgery, preventive treatment strategies are indicated, such as modified dietary lifestyle and specific drugs as we suggested to limit or even avoid these complications. However observance could fail in the long term. In case of oxalate nephropathy, surgery may be proposed to restore the intestinal tract but with the risk of overweight relapse. To illustrate this matter, we report here significant observations of three patients, which, having successfully benefited from the same bariatric surgery, have presented lithiasic complications for two of them and oxalate nephropathy leading to chronic renal failure and hemodialysis for the third.

Several alternative anticoagulation drugs are now available for patients with heparin induced thrombocytopenia type II (HIT II). However, their indication is not yet reaching a consensus. Moreover, some of them have not yet their marketing approval. The importantly use in hemodialyzed patients should be taken with caution since most of them are excreted by the kidneys. The use of fondaparinux, which exerts high anti-Xa activity, is not well documented. We report here our experience on the use of fondaparinux in an hemodialyzed patient with HIT II, not only as anticoagulation during hemodialysis sessions but also as interdialytic anticoagulation locking solution of her central venous catheter. The use of fondaparinux seems to us simple enough (even if its ready-for-use syringe requires adjustments to deliver the required doses) and its efficacy, safety and economic cost lead us to think that it is an indication of choice for an alternative anticoagulation in hemodialyzed patients with HIT II. Control prospective trials should be performed in order to confirm the preliminary favourable data and to support the proposal of marketing approval in this indication.

Wegener's granulomatosis mainly affects the upper respiratory tract, the lungs and the kidneys but many other organs and tissues may be affected, as well including any eye structures. Ocular and orbital structures involvement is frequently encountered, sometimes inaugural, with or without obvious systemic manifestations, sometimes leading to visual loss. The most frequent ophthalmic lesions are inflammatory orbital disease, (necrotising) scleritis with or without keratopathy, episcleritis, conjunctivitis and even conjunctival ulcer, nasolacrimal ducts obstruction, uveitis, retinal vasculitis and even central retinal vascular occlusion, optic neuritis. These ocular lesions result either from extensive granulomatous inflammation or from focal vasculitis. These complications need to be recognized as soon as possible so that an early diagnosis may allow the appropriate treatment meant to keep both visual and even general prognosis.

Patients with cystic fibrosis (CF) show a continuing improvement in their life expectancy thanks to advances in knowledge of this disorder, allowing better multidisciplinary routine monitoring and earlier therapeutic interventions. Likewise, more than of 40% of these patients are adults and CF is no more only a pediatric disease. Due to their higher life expectancy, CF patients present new and unusual complications that were not recorded before. Among them, some renal disorders have to be added to the CF-related renal diseases. They are due to frequent and prolonged exposure to various potentially nephrotoxic factors that need to be taken into account early enough in order to avoid renal failure : essentially risk factors for kidney stones formation, bacterial infections with their associated immune complexes diseases, nephrotoxic effects of antibiotics, diabetes mellitus. Because we observed a case of IgA glomerulonephritis in a 35-year-old patient with cystic fibrosis, we have searched about all these renal consequences due to this affection and here report them.

Administered to reduce hyperkaliema in patients with chronic renal failure, sodium polystyrene sulfonate (Kayexalate) can cause digestive complications. The most severe complication could be the intestinal necrosis or perforation. In the present report, we evoke these complications and illustrate them with some pictures from personal observations.

Renal tumours, in tuberous sclerosis, are mainly benign and correspond to angiomyolipomas, multiple and bilateral, sometimes enormous with an hemorrhagic risk, frequently associated with cysts of variable size and number and seldom with high metastatic carcinomas. Chronic renal failure is rare and related to focal glomerulosclerosis secondary to hyperfiltration due to nephronic reduction owing to surgery or to tumour invasion, in particular cysts. Data about 65 patients with tuberous sclerosis and chronic renal failure were collected thanks to a national survey. They were females in 63.1% of cases, with a mean age of 29, 2 years at the time of the diagnosis of tuberous sclerosis, revealed in near half of cases by renal involvement. There were angiomyolipomas in 23.1% of cases, cysts in 18.5%, both in 53.8% and malignancies in 12.3%. All but one of the 48 patients with end stage renal failure were treated by dialysis; 20 were transplanted, with good results.

A 58 year-old woman developed an acute renal failure very quickly after ingestion of two 500 mg tablets of ciprofloxacin, without any other identifiable risk factor. Renal biopsy was performed. No sign of acute interstitial nephritis was observed but tubular lesions were found, accompanied by deposits of a brown-yellowish substance identified by infrared microscopy as a ciprofloxacin salt. The outcome was favourable. This observation gives the opportunity to remind the different forms of quinolone-induced renal injury and to discuss the possible ways for preventing renal side-effects related to the quinolone use.

At the end of assessment of an hypercalcemia with acute renal failure in a seventy year-old man, is discovered a tumorlike muscular sarcoidosis of both thighs whose steroid treatment quickly proves effective. Rarity of such forms urges us to report this observation which allows to remind that, in case of a suggestive picture of sarcoidosis, it is necessary to look minutely for any muscular abnormality.

HemoCue Hb 201+ is a portable photometric analyser providing easy, rapid and accurate determination of hemoglobin from arterial, venous or capillary blood. It is worth that dialysis units have knowledge of its use for a close hematologic monitoring of their patients and a judicious management of erythropoietin (EPO). For the autodialysisout hospitalcenters, it allows a flexibility that private laboratories cannot have in daily practice. Therefore authors present this device and the evaluation they obtained from 148 hemoglobin measures. Then they expose the advantages and the indications of its use.

Diagnosis of edema secondary to hypoprotidemia but without nutritional, renal, hepatic or cardiac cause, must consider exudative digestive disease, of which the lymphocytic gastritis, as the authors report here a new observation diagnosed in a 73 year-old woman. Gastroscopy reveals varioliform gastritis and biopsy demonstrates diffuse infiltration of the gastric epithelium by lymphocytes, making of it a real histopathologic entity among the gastropathies. Etiology and pathogeny remain still unknown but proton pump gastric inhibitors are an effective treatment.

Bad dental status is very often observed in hemodialyzed patients due to the fact of a frequent poor oral hygiene and, in addition of the traditional risk factors, the consequences of uraemic state and its treatment. However , among such immunodepressed patients, oral and dental lesions represent a risk of septic complications. Moreover some works point out the prevalence of inflammation and denutrition due to dental lesions in the uraemic population, with potential atherosclerosis. Therefore, in order to anticipate all these adverse effects and to restore their mouth to health, patients have to be encouraged to have regularly a full dental evaluation and correction if not elimination of all potential sources of infection and other complications. To ensure the best treatment, a close collaboration has to be established with dental practitioners who must be aware and convinced of the complexity of such patients: immunodepression due to uraemic state and sometimes to drug therapy; importance of prophylactic antibiotic therapy surrounding dental cares; cautions to hemostasis circumstances; adjusted use of some medications. To illustrate this matter, we report here a study involving 96 hemodialyzed patients who were investigated by panoramic radiography and clinical cross- examination about their dental complaints and habits. We then expose our practices and detail our collaboration with their dentists in establishing a plan of dental treatment.

Cardiac arrhythmias are frequent by hemodialyzed patients and may lead to the prescription of antiarrhythmic drugs among which flecainide. However there is for this latter a wide interindividual variability in the dose-plasma concentration relationship because of a genetically controlled polymorphic metabolism. That explains why it is not possible to adjust dose only to renal clearance. It becomes even more difficult at hemodialysis stage, especially if hepatic insufficiency and/or certain medications join to it. So this antiarrhythmic drug has to be cautiously initiated and plasma concentrations have to be carefully monitored to avoid side effects, sometimes crippling as in our observation, sometimes as cardiac complications.

About an observation of aspergillus sinusitis in an hemodialyzed patient, correlation between chronic maxillary sinusitis, its aspergillus origin and previous dental treatments is emphasized. Eventual severe complications then evolved in immunocompromised patients justify having the knowledge of this possible pathology in hemodialyzed and transplanted patients.

From January 1986 to December 1990 we studied angiographically the subclavian-brachiocephalic vein of 100 patients dialysed by subclavian catheter for 50 (first group) and by internal jugular catheter for the 50 others (second group). These two groups were not statistically different as regards age (61.6 +/- 11.3 years in the first and 61 +/- 11.1 in the second), sex (48% and 56% were women), duration of catheter insertion (31 +/- 21.8 and 31.7 +/- 16 days), and the number of dialysis sessions (13.5 +/- 9.1 and 13.6 +/- 7.1). The type of catheters, the frequency of removal for poor flow (16% in both groups) or infections (6% in both groups), and the local nursing were similar in the two groups. The only difference was the side of cannulation: the right side in 58% of cases in group 1 and 78% in group 2. The angiographic study revealed a stenosis of the vein in 42% of the subclavian group and in 10% of the internal jugular group: a dramatic difference in favour of the internal jugular route, whose superiority over the subclavian route is asserted in respect of venous access of dialysed patients.