Epidemiology and prevention of Staphylococcus aureus nasal carriage in hemodialyzed patients

Nasal carriage of Staphylococcus aureus may be responsible for some serious infections among hemodialyzed patients. Its pathogenic potential and commensal nature allows for an easy transmission both in and out of hospital environment.

PURPOSE

This study was to assess the prevalence of S. aureus nasal carriage, to determine its frequency and nature in hemodialyzed patients of the Rabat Ibn Sina University hospital, in Morocco.

PATIENT AND METHOD

The study began in March 2008 according to the following protocol: screening of nasal carriage with five samplings, performed once a month three times, then once a month two times again after an interruption period of three months. Screening was performed weekly during the first month in hemodialyzed patients treated with mupirocin (Bactroban(®) 2%), and then monthly, to monitor the kinetics of S. aureus eradication.

RESULTS

The study included 54 hemodialyzed patients with a mean 44.16±14 years of age, sex ratio of 0.54, and mean hemodialysis duration of 118.7±67 months. Permanent and intermittent S. aureus carriage was found in respectively 18.52% and 25.92% of patients. Eighty-one strains of S. aureus were identified, 14.81% of which were methicillin resistant. Eradication was sustained beyond 20 months in patients treated with mupirocin.

CONCLUSION

This investigation allowed us to identify hemodialyzed patients at risk, so as to implement the rules of individual and collective hygiene, and to extend mupirocin antibiotic prophylaxis in our hemodialysis unit.

[The evaluation and analysis of chronic pain in chronic hemodialysis patients]

INTRODUCTION

Pain is a sensorial experience and emotional discomfort associated with a potential tissue damage or described in terms evoking such injuries. Its management is a task for every physician. However, the epidemiology and characteristics of pain among chronic hemodialysis patients are incompletely defined. PURPOSE OF OUR STUDY: To evaluate the prevalence, characteristics, impact and treatment of chronic pain in chronic hemodialysis and its potential risk factors.

METHODS

A cross-sectional study included 67 chronic hemodialysis patients in the Ibn Sina Hospital hemodialysis center in Rabat. We evaluated the sociodemographic characteristics of patients and pain features, as well as the response to analgesics. Pain is described as chronic when it persists for more than 3 months. The pain intensity was specified by a verbal scale.

RESULTS

The mean age of our patients was 43.5+/-12.9 years with a feminine predominance (58.2%). The prevalence of pain was 50.7%. The pain was noticed for a mean period of 21 months (six to 60). This pain was continuous, frequent, intermittent and rare in respectively 20.6, 17.6, 47.1 and 14.7% of cases. The intensity of the pain was low in 3%, moderate in 41%, severe in 44% and very severe in 12% of cases. An osteoarticular origin was found in 76.5% of cases. A physical activity disorder was found in 67.6% of cases. Half of our patients were taking analgesics in 23.5% of cases, as daily use in 29.7% of cases frequently, and in 47.1% of cases rarely. These analgesics were level 1 in 47.1% and level 2 in 52.9% of cases. The therapeutic response is characterized by the disappearance of pain in 35.5% of cases. During dialysis sessions, pain intensity was the same in 79.4% of the patients. The risk factors associated with pain were an advanced age and a long length of time on dialysis.

CONCLUSION

A systematic evaluation of pain is required to improve the quality of life of hemodialysis patients.

[The factors for progression of the diabetic nephropathy: management and evolution]

The diabetic nephropathy is among the first causes of end stage renal disease worldwide. However, the diabetics are often lately refered to the nephrologists. The goal of our study is to determine the stage of the diabetic nephropathy, its risk factors and to appreciate its evolution after a nephrology management in Morocco.

METHODS

Prospective study including 728 patients diabetic type 2 addressed for a nephrologic follow up between January 2000 and December 2007. We evaluated the stage of diabetic nephropathy by the dosage of the urinary albumin excretion of 24 hours and the estimation of the renal function by the creatinine clearance. Four stages have been distinguished: negative microalbuminuria, positive microalbuminuria, macroalbuminuria and renal failure. After the instauration of the measures of nephroprotection, we appreciated the evolution of this diabetic nephropathy after a minimum follow-up of six months.

RESULTS

The mean age of our patients was of 61,8 years. At the first consultation, 68,9% of patients had a renal failure. The diabetes duration was of 13,8 years. The unbalanced diabetes was noted at 68,7% of the patients. The risk factors of the renal failure were age, systolic arterial tension, retinopathy diabetic and anemia. After a mean follow-up of 22,4 months, the urinary albumin excretion became negative in 42,6% of the patients. The deterioration of the renal function was slow (creatinine clearance: 52,2ml versus 45,5ml/min/1,73m(2)).

CONCLUSION

The majority of our patients had renal failure at the first consultation, showing the late referal of the diabetics to the nephrologists, complicating their management. The early screening would permit to assure the nephroprotection.

[Microscopic polyangiitis induced by a serotonin reuptake inhibitor. Case report]

Microscopic polyangiitis is an ANCA-associated vasculitis and affects small sized vessels. We report a case of microscopic polyangiitis, in a 31 year old patient with renal, skin and neurologic manifestations, which was probably triggered by a selective serotonin reuptake inhibitor. Under induction therapy with corticosteroids and cyclophosphamide, the kidney recovery is complete, neurological is slow but satisfactory.

[Evaluation of the prescription of long-term systemic steroid-therapy associated measures]

INTRODUCTION

To prevent the occurrence of corticosteroid's side effects, adjuvant measures are prescribed in a very different way depending on the practitioner's experience. The aim of this study was to assess the physicians' practices regarding the prescription of long-term corticosteroid therapy.

METHODS

In May 2010, we realized a cross-sectional study among physicians in Ibn Sina University Hospital in Rabat. With a data collection form, we assessed the principal indications for prescribing steroids and the frequency of prescription of measures sometimes associated with systemic corticosteroid.

RESULTS

Fifty-nine out of eighty physicians completed the data collection form (response rate: 69.4%). Calcium-vitamin D supplementation was recommended by most of the physicians. Half of them were prescribing biphosphonate therapy. Most of them propose a low-sodium, a low-fat and a low-carbohydrate dietary regimen. Regular physical exercise was recommended by 35% of physicians. Gastric protection was indicating by 54.4% of practicians and potassium supplementation by 42.1% of them. Finally, the recommendation for influenza vaccination, hydrocortisone prescription and Synacthen(®) test, varied between physicians.

CONCLUSION

The prescription of adjuvant measures with a long-term corticosteroid therapy was very heterogeneous. There is no consensus regarding most of the measures.

Siamese twin pregnancy in peritoneal dialysis : first case in the world

 Introduction: The probability of conception is low in peritoneal dialysis (PD), and the probability of successful pregnancy is even lower. Nearly 60 years after the first reported case of successful pregnancy in a dialysis patient, many questions about pregnancy during dialysis remain unresolved, namely the required dialysis dose, the follow-up rhythm, the choice of the the most appropriate dialysis technique. Case report: We report the first case worldwide of twin Siamese pregnancy in a patient on continuous ambulatory peritoneal dialysis (CAPD). The pregnancy was diagnosed at 7 weeks of amenorrhea (WA). The patient was initially under 2 exchanges per day, with 2-liter bags of Dianealof 1.36% glucose. As soon as the pregnancy was discovered, the prescription was modified, putting the patient under 3 exchanges a day with the same concentrates. The infusion volume was maintained at 2 liters up to 18 WA , and then reduced to 1.5 liters due to patient discomfort and abdominal hyperpressure. Daily ultrafiltration ranged from 180 to 800 ml with 1 liter diuresis. The blood pressure was well controlled, with an average of 125/80 mmHg, without need of  antihypertensive drugs. On a biological level, the Kt / V was 2.2, nPCR was 0.8, and the weekly clearance was 80 L / 1.73 m². The average hemoglobin was 11.5 g / dl under erythropoietin 9000 units per week. At 20 WA, obstetrical ultrasound revealed a mono-chorionic, mono-amniotic twin pregnancy. Due to high maternal and fetal risks, closer obstetrical control was indicated. At 24 WA, morphological obstetrical ultrasound coupled with Doppler examination of the uterine and umbilical arteries favored the diagnosis of mono-amniotic mono-chorionic twin pregnancy with strong suspicion of Siamese contiguous to the pelvis, with a cerebral malformation in one of the fetuses. The patient experienced intense contractions and pelvic pain leading to an emergency cesarean section with two surviving Siamese twins, contiguous to the pelvis, weighing 900g, but who died one day after delivery. Conclusion: Pregnancy during dialysis is at high maternal and fetal risks. It is necessary to prepare and follow this pregnancy to optimize the chances of success. This implies an adaptation of the medical treatment and dialysis prescription, including the volume and modality of exchanges. The same holds true for gynecological and obstetrical follow-up, which must be regular and strict, in order to prevent any maternal-fetal complications.

Peritoneal Dialysis at Ibn Sina Hospital in Rabat: 10 years’ experience

Introduction:  The choice of dialysis modality has become an important decision that affects not only the country's health policy in the management of chronic end stage renal failure, but also the quality of life of patients and their survival. Peritoneal dialysis is an alternative for the treatment of these patients. The objective of our work is to report the epidemiological, clinical and biological results in the unit of PD, UHC of Rabat and to clarify the obstacles to the development of PD in Morocco.  Material and Methods:  We conducted a descriptive retrospective study in our PD unit from July 2006 to July 2017, including all patients who were in PD by choice or necessity and enrolled in the French Peritoneal Dialysis Registry (RDPLF).  Results: In 10 years, 159 patients were placed in PD, with an average age of 50.44 +/- 17.42 years and a sex ratio of 1.36. The indication for placement of setting in PD was by choice in 34% of the cases, social in 52% and medical in 14% of cases. Mechanical complications were dominated by catheter migrations. Infectious complications were represented by peritonitis, caused by poor of hygiene in 42% of cases. Conclusion: The obstacles to the development of PD are the lack of knowledge of the technique by the patients, as well as the prejudices or myths about the technique.

Le taux d’anticorps anti-COVID19 à distance de la troisième dose de vaccin en hémodialyse

Introduction

Les hémodialysés chroniques sont parmi les patients les plus vulnérables à l’infection COVID-19. La vaccination dans ce groupe à risque est absolument une priorité vitale. Cependant, la persistance d’anticorps à distance de la 3^e dose de vaccin n’est pas complètement établie en HD.

Description

Nous avons examiné le taux d’anticorps 10 mois après la vaccination complète. L’objectif secondaire est de comparer les taux d’IgG anti-SPIKE selon les différents types de filtres de dialyses.

Méthodes

Nous avons évalué la réponse à long terme d’un Vaccin anti-covid-19 (BNT162b2 mRNA COVID-19, Pfizer-BioNTech), chez 110 patients hémodialysés chroniques 10 mois après la vaccination complète. Le titre des anticorps neutralisant IgG contre la protéine S (Spike) est quantifié par ELISA, 10 mois après avoir reçu le schéma. Les facteurs associés avec le niveau de la réponse : (taux < 218 BAU/ml- Taux entre 506 et 218 BAU/ml et > 506 BAU/ml) sont identifiés.

Résultats

La réponse vaccinale a été observée chez 70 sur 110 patients après avoir appliqué les critères de l’exclusion. 84,3 % ont un taux d’IgG anti-SPIKE satisfaisant. 15,7 % ont un taux moins ou non satisfaisant. Les patients ayant eu un antécédent de SARS COV2 ont mieux répondu au vaccin. Nous avons constaté une association significative entre le filtre de dialyse et la réponse vaccinale, (p = 0,01). Un filtre PMMA était associé avec un taux d’AC IgG anti-spike >506 BAU/ml (Fig. 1).

Conclusion

En HD, la réponse globale au vaccin à base d’ARNm est de 84,3 %, 10 mois après le rappel. L’utilisation du filtre PMMA semble améliorer cette réponse.

Myopericarditis in a Patient With Cryoglobulinemic Kidney Disease: A Case Report

Cryoglobulinemic vasculitis is a rare small-vessel vasculitis leading to multi-organ dysfunction, often associated with chronic infections like hepatitis C virus (HCV), and autoimmune disorders. Most cases involve mixed monoclonal or polyclonal immunoglobulins, presenting symptoms such as purpura, arthralgias, and weakness. Severe organ involvement, particularly cardiac, is rare but potentially life-threatening. We report the case of a 48-year-old woman without prior medical history who presented with acute dyspnea, generalized petechial purpura, and signs of global heart failure. Imaging and laboratory findings indicated cardiomegaly, pericardial effusion, and significant nephrotic syndrome with renal failure. The diagnosis of cryoglobulinaemia was confirmed through histology and serology, showing monoclonal IgM with kappa hypergammaglobulinaemia and complement consumption. Treatment included various immunosuppressants, corticosteroids, and rituximab combined with renal replacement therapy. Following the initiation of treatment and proper management of heart failure, the patient's condition significantly improved. Cardiac involvement in cryoglobulinemic vasculitis, though rare, can lead to severe heart failure. This often involves necrotizing vasculitis of the coronary arteries or systemic inflammation damaging the cardiac muscle, as observed here. Cardiac manifestations with immunosuppressive therapy are reversible despite a poor long-term prognosis for patients with cardiac lesions. In conclusion, cryoglobulinemic vasculitis has a grim prognosis due to its multi-organ impact and the severity of the lesions. Early and aggressive treatment is essential to manage life-threatening acute presentations, even before confirming the diagnosis biologically or histologically.

Kaposi's sarcoma following immunosuppressive therapy for vasculitis

Kaposi's sarcoma (KS) is widely reported to develop after renal transplantation and is induced by activation of a latent human herpes virus 8. We report the clinical features and outcome of a 50-year-old woman who presented with KS 18 weeks after starting immunosuppressive therapy for vasculitis. She had positive-titer IgG antibody to human herpes virus 8. Cyclophosphamide pulses were interrupted, and prednisone was decreased gradually to 10 mg/day. Skin lesions showed important regression with stabilization of the general state and renal function. Eight months later, the patient presented with a diffuse cutaneous KS that required the discontinuation of steroids. Within 1 month, her general status and renal function deteriorated, and she died with a disseminated intravascular coagulation syndrome.

[Thymoglobulin as induction treatment in kidney transplantants with low immunological risk: a Moroccan experience]

Introduction

Thymoglobulin® is a polyclonal antibody indicated for induction treatment in kidney transplantation. The purpose of this study is to estimate the effectiveness of Thymoglobulin® as induction treatment in kidney transplant patients with low immune risk.

Methods

we conducted a retrospective study between January 2012 and September 2017. Patients with low immunological risk, defined as the absence of previous transplantation and donor-specific antibodies (DSA), were included and received Thymoglobulin® induction therapy. Demographic and clinical characteristics, biological parameters and post-renal transplant complications were studied.

Results

we enrolled 55 kidney transplant patients with an average follow-up period of 38 ± 16 months. The average age of patients was 39,1 ± 12,1 years with a male predominance (58.2%). No patient had DSA prior to transplant. Cumulative dose of Thymoglobulin® was 4,26 ± 0,87 mg/kg, with an average duration of 5 ± 0,82 days. Lymphocyte depletion was maximal on the first day of infusion. Three patients had delayed graft function, at least one episode of bacterial infection in 56,4% of patients, 7 cases of CMV infections (12,7%) and 2 cases of CMV disease (3,6%). Graft survival rate was calculated for all patients with an average serum creatinine of 11,7 ± 3,6 mg/l during the last visit.

Conclusion

although it is not indicated for first line treatment in patients with low immunological risk, Thymoglobulin® can nevertheless be prescribed at a lower dose, with similar efficacy and without exposure to a higher risk of rejection.

Management of fungal peritonitis : a Moroccan single peritoneal dialysis unit experience

Introduction: Fungal peritonitis (PF) in peritoneal dialysis (PD) is a serious infection that involves the functional prognosis of the peritoneum and the patient's vital prognosis. It must benefit from a fast handling but nevertheless not very codified. Each center therefore ensures an individual care of its patients. Materiel and method: The purpose of our study is to describe our 10-year experience through our patients who presented FP. We performed a descriptive retrospective study of FP cases documented in the PD unit. Results: the prevalence of FP was 5,1%, which represent 9 cases. Predominant clinical signs were dialysat turbidity and abdominal pain. FP was primitive for 3 patients. The antifungal therapy used was Fluconazole, which was combined with an increased number of peritoneal exchanges. DP catheter ablation was done for 8 patients with an average delay of 5.5 days. The overall outcome was favorable and 3 patients continued PD. No death or encapsulating peritonitis was a consequence of FP. Discussion and conclusion: FP is an infectious complication in PD. Its’ death rate is elevated; dropping-out of PD rate too is elevated. The favorable evolution of our patients that stayed in PD let us think that it may be possible to maintain more patients in PD after FP.