Chronic kidney disease in America, Africa, and Asia: Overview of treatment cost and options

Chronic kidney disease (CKD) is one of the non-infectious diseases that threaten patients' lives on a daily basis. Its prevalence is high, but under-reported by patients and those living with the disease, as it is silent and asymptomatic in the early stages. Kidney disease increases the risk of heart and vascular disease. These problems can manifest themselves slowly, over a long period of time. Early detection and treatment can often prevent chronic kidney disease from worsening. As kidney disease progresses, it can lead to kidney failure, requiring dialysis or a kidney transplant to stay alive. In this narrative review, we will mainly discuss different treatment option costs in different countries and how much they cost healthcare systems in countries in three different continents.

[Evolution of the incidence and results at 12 months of parathyroidectomy: 40 years of experience in a dialysis center with two successive surgical departments]

INTRODUCTION

Secondary hyperparathyroidism remains the main complication of mineral and bone metabolism in patients with chronic kidney disease. In case of resistance to medical treatment (native and active vitamin D, calcium and calcimimetics), surgical parathyroidectomy is indicated. The aim of this retrospective study is to show the evolution of the incidence and results of surgical parathyroidectomy in our center between 1980 and 2020 as patient characteristics, diagnostic and therapeutic strategies have changed.

PATIENTS AND METHODS

We collected data from dialysis patients who had a first surgical parathyroidectomy between 2000 and 2020 (period 2) in the same surgical department and compared them with historical data between 1980 and 1999 (period 1) operated in one other center.

RESULTS

In period 1, 53 surgical parathyroidectomy were performed (2.78/year, 0 to 5, 8.5/1000 patients-year) vs.56 surgical parathyroidectomy in period 2 (2.8/year, 0 to 9, 8/1000 patients-year). The patients of the 2 periods were comparable except for the higher dialysis vintage in period 1 (149±170 vs.89±94 months; P=0.02). In comparison with dialysis patients not requiring surgical parathyroidectomy during the same period, patients who had surgical parathyroidectomy were younger, had higher dialysis vintage and lower diabetes prevalence, but more frequently carriers of glomerulopathy or polycystosis. Systematically performed in period 2, cervical ultrasound identified at least one visible gland in 78.6% of cases while the scintigraphy, performed only in 66% of cases, found at least one gland in 81% of cases. Twelve months after surgery, PTH > 300 pg/mL (marker of secondary hyperparathyroidism recurrence or surgery failure) was present in 30% of patients in period 1 vs. 5.3% in period 2. Hypoparathyroidism was also more frequently observed in period 2 (35.7 vs. 18.8%). Surgical complications were also higher in period 1.

CONCLUSION

Despite therapeutic and strategic advances, severe secondary hyperparathyroidism is still as common as ever. It is favored by excessively high PTH targets, by suboptimal prevention before dialysis and poor tolerance of calcimimetics. The surgical parathyroidectomy is effective and safe in the hands of a specialized team with an ultrasound and scintigraphic preoperative assessment.

[Evaluation of serum iron as a predictor of a hemoglobin response to injectable iron treatment in chronic hemodialysis patients]

BACKGROUND

The detection and correction of iron deficiency are essential for the treatment of anemia in chronic hemodialysis patients. The aim of our study was to assess the ability of serum iron to predict hemoglobin response to intravenous iron supplementation in hemodialysis patients.

METHODS

It is a retrospective study in 91 hemodialysis patients during 2016 at Clermont-Ferrand University Hospital for whom intravenous iron supplementation had been started. A responder patient was defined as an increase in hemoglobin greater than or equal to 1 g/dL/month and/or a decrease in the dose of erythropoiesis stimulating agent after two months of iron supplementation.

RESULTS

In responding patients, serum iron was significantly lower (6.7 ± 2.7 μmol/L) compared to non-responding patients (8.9±2.9 μmol/L; P<0.001). The positive response to iron supplementation was significantly associated with low serum iron (odds ratio = 0.58 [0.42-0.81]; P=0.002) in a logistic regression model taking into account ferritin, transferrin saturation coefficient, dose variation monthly iron and erythropoiesis stimulating agent and the duration of dialysis. The area under the receiver operating characteristic curve of serum iron, ferritin and transferrin saturation coefficient to predict the response to iron supplementation were 0.72, 0.51 and 0.64, respectively (serum iron versus ferritin [P=0.006] and serum iron versus transferrin saturation coefficient [P=0.04]). The sensitivity for serum iron below 7.5 μmol/L was better than that for ferritin below 86 ng/mL (P<0.001) and the specificity for serum iron below 7.5 μmol/L was better than that for TSC less than 19% (P=0.02).

CONCLUSION

Serum iron below 7.5 μmol/L can predict the success of the response to iron supplementation in chronic hemodialysis patients.

[Contribution of hemostatic dressings in the hemostasis of arteriovenous fistula? A quality improvement program in our center]

INTRODUCTION

In haemodialysis patients the length of bleeding times after fistula cannulation is an easy and fairly used method of monitoring vascular access. In the most cases, compression is performed manually by nurses and the use of haemostatic dressing is common. As data in the literature are scares, we have decided to develop a quality improvement program in our hemodialysis center to manage this issue.

MATERIAL AND METHODS

After informed consent, 35 hemodialysis outpatients were selected in order to study the bleeding time using haemostatic dressing or not during two weeks in a cross over schema. The dialysis schedule was unchanged and comparative analysis of parameters such as blood flow rate or anticoagulant treatment were done between the groups.

RESULTS

Compression times with and without hemostatic dressing were not different (12.6 min and 12.9 min, respectively). Patients with an anticoagulation during the dialysis session greater than 0.35 IU/kg/session had a longer bleeding time (12.75 min vs 11.75 min; P=0.008).

CONCLUSION

In our evaluation, the use of haemostatic dressings is not associated with a real shorter bleeding time. Their use generate an additional cost estimated on average at 164 euros/year/patient. Patients and team realized that compression time is important for fistula monitoring and using compresses does not really increase this time.

[Not Available]

Home hemodialysis (HHD) is closely associated with the development of in-center hemodialysis (HD), being introduced gradually as the survival of dialysis patients increased with the progress of technology and scientific research. It peaked fifty years ago and then gradually declined. Nowadays there is a revival of HHD highlighting the clinical and quality of life benefits attributed to it. The practice is already solid in several countries internationally and in France the trend is growing up. However, in-center HD remains largely majority and several obstacles to the development of HHD are reported. In this article we address in particular the complex clinical context (heart failure, central venous catheter) of situations that may arise in daily practice that may call into question a HHD project. © 2022 Société francophone de néphrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.

[Acute pancreatitis as a complication of massive hemolysis in patients on hemodialysis: About three observations]

Haemolysis is an uncommon complication of haemodialysis which can be serious. We herein report on three patients with kidney failure who developed acute pancreatitis due to mechanical haemolysis during a haemodialysis session. We also review the current literature and discuss putative etiopathogenic mechanisms.

[Prevalence of malnutrition and absolute and functional iron deficiency anemia in nondialysis-dependent chronic kidney disease and hemodialysis Algerian patients]

In chronic kidney disease, anemia and malnutrition coupled with inflammation as malnutrition-inflammation complex syndrom are common and considered as morbidity-mortality factors. The link between these two factors has been described at length in the literature highlighting an association of malnutrition with iron deficiency considered itself as one of the causes of anemia in chronic kidney disease (non-dialysis and hemodialysis). Our study aims to know the prevalence of these two factors in a population of chronic kidney disease (non-dialysis and hemodialysis) of Algiers and to highlight the possible associations between them.

PATIENTS AND METHODS

This is a multicentre, cross-sectional and descriptive study carried out over a period of 6months (August 2018 to January 2019). Anemia and malnutrition were assessed by various biological and clinical tools such as the malnutrition inflammation score and the International Society of Renal Nutrition and Metabolism criteria. Statistical tests were performed on the R studio software, considering P<0.05 as a statistically significant value.

RESULTS

Two hundred and nine patients on chronic kidney disease were included (90 non dialysis and 119 hemodialysis). The median age was 70 (IQR=16) for non dialysis and 56 (IQR=16.5) for hemodialysis. The prevalence of anemia was 66.66% (n=60) in non dialysis and 70.58% (n=84) in hemodialysis. Absolute iron deficiency anemia was higher in non dialysis (48.33%; n=29) while functional iron deficiency anemia was higher in hemodialysis (34.52%; n=29). The prevalence of malnutrition by malnutrition inflammation score was relatively low. Only functional iron deficiency anemia was associated with malnutrition.

CONCLUSION

The prevalence of anemia was higher in Algerian chronic kidney disease (non-dialysis and hemodialysis) unlike malnutrition which remains associated with functional iron deficiency anemia.

[Out-of-center blood pressure measurements in dialysis patients: Feasibility and comparison of methods]

The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA)/European Society of Hypertension (ESH) recommends out-of-center blood pressure measurements, self-blood pressure measurement or ambulatory blood pressure measurement in dialysis patients. However, the feasibility of out-of-center blood pressure measurements in routine care is not known. The objective of our study was to quantify it as "a priori" i.e. the percentage of hemodialysis to whom out-of-center blood pressure measurements can be proposed and who accept it, as "a posteriori", i.e. the percentage of out-of-center blood pressure measurements made and valid. A systematic out-of-center blood pressure measurements program was implemented from April to October 2019 in our chronic hemodialysis structures. It was proposed to each dialysis patient to carry out after education, an self-blood pressure measurement (Omron M3®), from 2 measurements, to 1 to 2minutes interval, mornings and evenings of 6days without dialysis (validity: 15 measures). Apart from arrhythmic patients, to all patients "not eligible" for self-blood pressure measurement (visually impaired, hemiplegic, neuropsychological disorders, language barrier), a 44-hour ambulatory blood pressure measurement (Microlife WatchBP 03®) was proposed separating 2 hemodialysis sessions; measures every 15minutes from 7 a.m. to 10 p.m. and 30minutes from 10 p.m. to 7 a.m. (validity: 40 measurements/day and 14/night). This is a study evaluating practices recommended for routine care in 18-year-old hemodialysis, having given their consent to the collection and analysis of the data. One hundred twenty nine patients were treated with chronic hemodialysis in our structures during the out-of-center blood pressure measurements campaign. Out-of-center blood pressure measurements could not be done in 21 patients (4 deceased, 2 transplanted and 4 absent before evaluation; 7 arrhythmics; 3 refusals and 1 multiple-disabled). Of these 108 patients (sex ratio 1.25; 69.3±13.5 years), 23 were ineligible for self-blood pressure measurement (visually impaired, neuro- and/or psychological disorders, language barrier). Due to 4 self-blood pressure measurement failures, the feasibility of the self-blood pressure measurement (n=81/129) is 62.8 % (CI95% 54.2-70.7). Of the 24 ambulatory blood pressure measurements performed (23 among those not eligible for self-blood pressure measurement and 1 failure of self-blood pressure measurement), 19 were valid. The "a posteriori" feasibility of out-of-center blood pressure measurements (n=100/129) is 77.5 % (CI95% 69.6-83.4). The feasibility of out-of-center blood pressure measurements in hemodialysis patients is good, making the application of the recommendations possible.

[Diagnosis and treatment of catheter-related bloodstream infection in hemodialysis: 10 years later]

Patients in hemodialysis on central venous catheter as vascular access are at risk of infections. Catheter-related bloodstream infection is one of the most serious catheter-complications in hemodialysis patients. Its clinical and microbiological diagnosis is challenging. The implementation of empiric antibiotic therapy is based on old recommendations proposing the combination of a molecule targeting methicillin-resistant Staphylococcus aureus and a betalactamin active on P. aeruginosa, and also adapting this probabilistic treatment by carrying out a microbiological register on a local scale, which is rarely done. In our hemodialysis center at Bordeaux University Hospital, an analysis of the microorganisms causing all catheter-related bloodstream infection over the period 2018-2020 enabled us to propose, in agreement with the infectious disease specialists, an adapted probabilistic antibiotic therapy protocol. This approach allowed us to observe a low incidence of meticillinoresistance of Staphylococcus. For catheters inserted more than 6 months ago, we observed no Staphylococcus, no multi-resistant Pseudomonas, and only 2% of Enterobacteria resistant to cephalosporins. A frequent updating of the microbiological epidemiology of catheter-related bloodstream infection, in partnership with the infectious diseases team in each hemodialysis center, allowing an adaptation of the probabilistic antibiotic therapy, and seems to have a good feasibility. This strategy might favor the preservation of microbial ecology on an individual and collective scale in maintenance hemodialysis patients.

[Left ventricular hypertrophy in hemodialysis patient: Prevalence, electrocardiographic, echocardiographic study and associated risk factors]

BACKGROUND

Left ventricular hypertrophy is the most prevalent cardiac abnormality in hemodialysis patients. The diagnosis of this abnormality is possible by electrocardiogram and/or echocardiography. Our study aimed to assess the prevalence of left ventricular hypertrophy in hemodialysis patients and the accuracy of different electrocardiographic criteria.

METHODS

This was a cross-sectional retrospective study including 60 hemodialysis patients between 2017 and 2018. A left ventricular mass index higher than 115g/m² and 95g/m² respectively in men and women defines echocardiographic left ventricular hypertrophy. We assessed left ventricular hypertrophy prevalence, sensitivity, specificity, and area under the receiver-operating characteristics (ROC) curve of fourteen different electrocardiographic criteria for identification of left ventricular hypertrophy.

RESULTS

This was a cohort of 60 patients composed of 27 men and 33 women with a mean age 52.6±15,8years. Hypertension was the most common cardiovascular risk factor (82 %). The prevalence of left ventricular hypertrophy at echography was 65 %. Prevalence of left ventricular hypertrophy at electrocardiographic varied across the different criteria ranging from 5 % (R wave in DI) to 32 % (Perugia score). The highest left ventricular hypertrophy prevalence at electrocardiographic was found with the five following criteria: Perugia score (32 %), Peguero-Lo Presti index (28 %), Sokolow-Lyon index, Cornell index, Framingham-adjusted Cornell voltage (17 %). Sensitivity was ranged from 5 % (R in DI, Gubner-Ungerleider index, and product) to 41 % (Perugia score). The specificity of most criteria was ≥90 % except for the Perugia score (85 %). The sensitivity, specificity, postitive and negative productive values and left ventricular hypertrophy prevalence using the five most accurate criteria combined were respectively 48, 90, 70.28, 77.85 and 33 %. Hypertension, duration of HD, arteriovenous fistula, interdialytic weight gain, systolic blood pressure, hemoglobin <9g/dL and hyperparathyroidism were significantly associated with left ventricular hypertrophy.

CONCLUSION

The prevalence of left ventricular hypertrophy detected by echocardiography was high. All electrocardiographic criteria had a low sensibility and a high specificity in the diagnostic of echocardiographic left ventricular hypertrophy. To improve the accuracy of electrocardiographic criteria, it is necessary to combine several electrocardiographic criteria and not often focused on a single classic electrocardiographic index.

[Evaluation of ambulance transport relevance of dialysis patients in the PACA region (France), and estimation of savings by the Health Insurance]

INTRODUCTION

Patient transport represents the second largest item of cost of dialysis after hospitalization. A significant proportion of patients transported by ambulance are self-sufficient for walking.

DESCRIPTION

A study was carried out in the PACA region (France) to analyse the profile of patients transported by ambulance and self-sufficient for walking and then to evaluate the savings for the Health Insurance.

METHODS

A triangulation of data was carried out using data from haemodialysis patients recorded in the French REIN Registry in 2017 and data from two surveys: one of a sample of patients transported by ambulance and autonomous in walking, and the other of 62 nephrologists.

RESULTS

The data from the REIN register allowed us to estimate that 44 % of patients transported by ambulance are self-sufficient for walking. Our study allowed us to estimate that 2/3 of patients transported by ambulance, self-sufficient for walking, have a reason for being transported by ambulance; for the third without a reason, the health insurance savings would amount to €2 million per year with a reclassification of their transport as seated transport. The survey of prescribers showed that there are exemptions justified by a temporary deterioration in health and/or housing conditions, but also by the lack of seated transport.

CONCLUSION

One third of the patients, transported by ambulance and self-sufficient for walking, would have an inappropriate transport. This would be explained by the fluctuating state of health of the patients and would also linked to the lack of seated transportation. Savings are possible and depend in part on improved management of the supply.

[COVID-19 crisis management during the first three waves in a large dialysis organisation: Feedback from NephroCare France]

At the start of the COVID crisis, NephroCare operated 40 dialysis units in 7 regions, with 2,740 hemodialysis patients. The national COVID-19 crisis team implemented early the necessary measures to ensure the safety of dialysis patients and caregivers in the context of the pandemic. These measures were mostly traditional, but some were specific to our organization. They were modified during the 3 successive waves. The first wave mainly impacted NephroCare Ile-de-France which recorded 75% of the contaminations with an impact on the dialysis parameters of non-COVID patients which was not found during the second wave due to reduced stress (34% of contaminations) and a better management of COVID+ patients. The effectiveness of the measures put in place is suggested by the absence of PCR+ in asymptomatic patients and the perfect adequacy of the anti-SARS-CoV2 antibodies with the diagnosis of COVID in one severely impacted Ile-de-France unit, opposite to literature reporting significant rates of positive PCR or serology in asymptomatic patients. In addition, the contamination rate was calculated below the national rate reported by the Biomedicine Agency. The third wave was marked by the implementation of the anti-SARS-CoV2 vaccination with a proportion of vaccinated patients not different from national data and a decrease in COVID cases at the end of the third wave while the national incidence remained stable on the period. In conclusion, this experience of facing an unprecedented serious situation showed the responsiveness of the organization, significant innovations and the efficacy of the implemented measures.

[COVID-19 vaccination in dialysis and kidney transplant patients]

Au cours de la COVID-19, la dialyse et la transplantation rénale ont été identifiées comme d’importants facteurs de risque de développer une forme sévère de la maladie. La réponse immunitaire humorale post-infection est durable. Cependant, après vaccination, celle-ci apparaît plus limitée, tant en termes de taux de réponse (séropositivité post-vaccination) qu’en termes de taux quantitatif d’anticorps. Alors que les patients dialysés ont un taux de réponse de 80–95 % en fonction des études, la réponse est particulièrement faible chez les patients transplantés rénaux, avec des taux de séropositivité de 30–50 %, et notamment s’ils sont traités par bélatacept (environ 5 % de réponse). Ces éléments ont poussé à proposer des schémas vaccinaux alternatifs en France, avec notamment l’utilisation d’une 3^e injection de vaccin ARNm. Malgré ces résultats, de nombreuses questions sur la vaccination des insuffisants rénaux restent en suspens, concernant notamment la qualité des réponses cellulaires (encore peu étudiées), la durabilité des réponses post-vaccinales, et surtout l’efficacité clinique des vaccins.

[Repigmentation in vitiligo universalis triggered by hemodialysis]

Vitiligo is an acquired depigmenting disorder. Vitiligo universalis is a rare form responsible for significant aesthetic damage. To date, the exact pathogenesis remains unknown. Its treatment, a real challenge, consists rather in removing the still pigmented areas. We report a case of a patient followed for stable vitiligo universalis from an early age who presented with repigmentation shortly after initiation of hemodialysis.

[Nutritional status of elderly hemodialysis people in Tunisia]

INTRODUCTION

The nutritional status of old hemodialysis patients determines their prognosis. The aim of this study was to evaluate the spontaneous dietary intake of hemodialysis of elderly patients.

METHODS

This cross-sectional descriptive study included 40 elderly hemodialysis patients recruited at the M8 nephrology department of Charles Nicolle hospital in Tunis. All patients went through a clinical examination to specify anthropometric measurements and a dietary survey based on food registration for 3 consecutive days to obtain a nutritional assessment.

RESULTS

The evaluation of patients' energy intake showed an average daily intake of 25.3±12.3kcal/kg of ideal weight/day. The average total energy intake of patients on dialysis and non-dialysis days was 29.7±17.7kcal/kg and 20.9±6.9kcal/kg, respectively, with a statistically significant difference (P=0.001). The average daily protein intake was 0.99±0.57g/kg on the day of no dialysis. It decreased statistically significantly (P=0.005) on the day of no dialysis at 0.73±0.28g/kg. Phosphorus consumption was excessive on dialysis and non-dialysis days respectively in 20% and 3% of cases. Deficiency of calcium intake affected the entire population studied on the day of non-dialysis. Only 6% of patients had a calcium intake satisfactory on the day of dialysis.

CONCLUSION

A lot of dietary errors were noticed in our study. The assessment of nutritional intake in elderly people with hemodialysis should be part of their management systematically.

[Prevalence and risk factors associated with intradialytic hypotension in Sub-Saharan Africa: The case of Burkina Faso]

AIM

The aim of our study was to determine the prevalence and factors associated with intradialytic hypotension in our cohort of chronic hemodialysis patients.

METHODS

This was a prospective monocentric study over a six-month period. Intradialytic hypotension was defined as a decrease in systolic blood pressure ≥ 20mmHg or a decrease in mean arterial pressure of 10mmHg associated with clinical events and the need for nursing interventions. The groups were compared using univariate analysis of variance.

RESULTS

We included 48 patients and counted 3014 hemodialysis sessions. The mean age was 44.7±15 years. The prevalence of intradialytic hypotension was 12.4%, with cramps 20 (41.7%) as the main symptom. Factors associated with frequent intradialytic hypotension compared to the groups without intradialytic hypotension and with infrequent intradialytic hypotension were age (61±13 years, p=0.018), diabetes (33.3%, p=0.019), high body mass index (27, 3±7.8kg/m2, p=0.002), interdialytic weight gain ≥ 5% of baseline weight (66.7%, p=0.033), hourly ultrafiltration (800±275ml/h, p=0.037) and perdialytic feeding (33.3%, p=0.016). Low pre-dialysis diastolic blood pressure (72±13mmHg, p=0.012) and high baseline weight (73.9±17.5kg, p=0.028) were associated with frequent versus infrequent intradialytic hypotension.

CONCLUSION

Intradialytic hypotension is common in our context. Its prevention in at-risk patients is critical to reducing morbidity and mortality and improving quality of life.

[Burnout syndrome in hemodialysis health workers in Cameroon: Prevalence and associated factors]

BACKGROUND

Hemodialysis medical staffs usually work in a stressful environment. In low resource countries, professional conditions are worse and can lead to burnout syndrome. The aim of this study was to determine the prevalence of burnout syndrome and its associated factors in hemodialysis health care workers in Cameroon.

PATIENTS AND METHODS

We conducted a cross sectional study in all hemodialysis centers from Cameroon between January to August 2017. The Maslach Burnout Inventory was used for assessment of burnout level. Burnout syndrome was defined as the presence of emotional exhaustion, depersonalization or decreased professional achievement.

RESULTS

A total of 92 health workers (women 60%; n=55) among 105 identified were recorded. The median age was 42 years. Most of the workers were nurses (78.5%) and 8.5% were nephrologists. Burnout syndrome was found in 76 (82.6%) workers, 35 (38%) had emotional exhaustion, 44 (48%) depersonalization and 57 (62%) decreased professional achievements. Burnout was significantly more prevalent in overcrowded centers (100% vs. 47%; P<0.001). Hemodialysis position<5 years was less prevalent in participants with emotional exhaustion and depersonalization. Desire to change position (OR 19.61 [2.074-185.4]; P=0,009) was associated with burnout syndrome.

CONCLUSION

Burnout syndrome is very common among Cameroonian hemodialysis medical staff. Improvement of work conditions, limiting posting in hemodialysis to less than 5 years and change of position when requested may be potential preventive measures.

[Natriuretic peptides in dialysis: From theory to clinical practice]

Cardiologists and emergency-wards physicians are used to check natriuretic peptides serum level, mainly B-type natriuretic peptide and N-terminal pro-Brain natriuretic peptide for acute cardiac failure diagnosis. Due to their accumulation in chronic kidney disease and their elimination by dialysis, natriuretic peptides sampling remains debatable in chronic kidney disease patients. In dialysis patients, high natriuretic peptides values are associated with mortality, left ventricular hypertrophy and cardiac failure. However, a single value cannot provide a reliable diagnosis. Our clinical practice is as follows: First, we prefer B-type natriuretic peptide to N-terminal pro-Brain natriuretic peptide because of its shorter half-life, with less impact of renal function and dialysis, making its interpretation easier in case of advanced chronic kidney disease or in dialysis patients; second, we define a reference value of B-type natriuretic peptide at dry weight from serial measurements; third, the B-type natriuretic peptide changes are interpreted according to extracellular fluid and cardiac status, but also from the arteriovenous fistula blood flow. In stable dialysis patients, B-type natriuretic peptide is sampled monthly and weekly in unstable patients. We illustrate our experience using clinical cases of overhydration, new cardiac disease onset, hypovolemia and arteriovenous fistula with high blood flow. Longitudinal follow-up of B-type natriuretic peptide is an important advance in dialysis patients in order to detect and treat extracellular fluid variations and cardiac disease status early, both important factors associated with hard outcomes.

[Analysis of the infectious risk around the patient in the hemodialysis unit of Ibn Sina Rabat hospital using the failure modes, effects and criticality analysis method]

INTRODUCTION

Hemodialysis is a technique of extra-renal purification associated with high level of risk. The objective is to assess infectious risk during a hemodialysis session on hygiene around the patient in hospital.

METHODS

An a priori risk assessment by Failure Modes, Effects and Criticality Analysis method (FMECA) was carried out from May to August 2018, in order to overview infectious risk during the process of hemodialysis in the Ibn Sina Hospital (Rabat, Morocco).

RESULTS

Twenty eight failure modes were identified during the hemodialysis process around the patient: fourteen criticality level 1, ten level 2, and four level 3. A prevention plan has been drafted. Three of the four level 3 failure modes were reduced to level 1 and one to level 2.

DISCUSSION

FMECA have enabled us to identify the potential risks, to reconsider certain procedures and to suggest measure matrix for the coverage of the most critical risks.

CONCLUSION

This analysis makes it possible, through periodic evaluations, to enter a real quality approach, which reinforces the satisfaction of the patients as well as all the actors of the hemodialysis center.

[Risk factors for progression of coronary artery calcification over 5 years in hemodialysis patients]

BACKGROUND

Although progression of coronary artery calcification (CAC) has been established as an important marker for cardiovascular morbidity, very few studies have studied it in end-stage renal disease patients. Thus we examined and evaluate risk factors of calcification changes in dialysis patients.

METHOD

Among 28 hemodialysis (HD) patients, CAC was measured in Agatston units at baseline and after five years using the 64 multi-slice ultra-fast CT. The HD patients were classified as progressors or no progressors according to the change in the CAC score across these 2 measurements.

RESULTS

Over an average 63 months follow-up, participants without CAC at baseline had no incident CAC. The progression of CAC was slow and was found only in 6 patients (21.4%). It was significantly associated with several cardiovascular risk factors, namely, older age (P=0.03), diabetes (P=0.05), male sex (P=0.02), hypercholesterolemia (P=0.05), anemia (P=0.017), inflammation (P=0.05), and hyperphosphataemia (P=0.012). However, calcemia, parathormone levels, dialysis duration, tobacco, high blood pressure and dialysis dose did not seem to influence the progression of CAC in our series. A strong association was found between basal calcification scores and Delta increment at 5 years.

CONCLUSIONS

Our study suggests that CAC progression in dialysis is a complex phenomenon, associated with several risk factors with special regard to elevated basal scores. This progression can be avoided or slowed with appropriate management, which must begin in the early stages of chronic kidney disease.

[Chronic renal failure's profile in hemodialysis at the Edith Lucie Bongo Ondimba General Hospital]

INTRODUCTION

Our objective was to evaluate the management of chronic renal failure in hemodialysis at the Edith Lucie Bongo Ondimba General Hospital (HGELBO).

MATERIALS AND METHODS

This was a cross-sectional and analytical study over a 10-month period from March 1, 2018 to December 31, 2018. This included all patients aged 16 and over whohad at least one treatment session hemodialysis during the study period. The sociodemographic, clinical, biological, therapeutic and evolutionaryparameters of the patients werenoted. And data entry wasdoneusing Excel 2013 and EPI Infos version 3 software with a p <0.05 consideredstatisticallysignificant.

RESULTS

The number of patients hospitalized for chronic and acute renal failurein 10 months was 101 patients, of whom 97 received hemodialysis treatment. The sex ratio was 1.4 with 59% males. The meanagewas 49.19 ± 28.4 years. The most affected intervalisbetween 50 and 59 years old with 19 patients or 29.68%. The patients came from Brazzaville in 60.93%. The first indication of hemodialysis wasuremiapoorlytoleratedin 81, 25% of cases. Diabeticnephropathywas the leading cause of CKD in hemodialysis. Meanserumcreatinine at initiation of hemodialysis was128.5 ± 75.12 mg / l. The incidence of HIV in hemodialysis is 6.4%, those of hepatitis B and C are 1.25% respectively. There were 54 patients (84.37%) whobenefited from femoralcatheter placement at baseline. We have so far 7 deaths out of 64 patients.

CONCLUSION

This center of hemodialysis contributes to the improvement of the management of the renal insufficiency in the stage of hemodialysis. The assessment of this work reveals strong and weak points and we are consideringother work, more hemodialysis stations and itwould be interesting to do some work on the prevalence of renal disease in the Republic of Congo.

[Epidemioclinical Profile Of Chronic Hemodialysis Patients At Tengandogo University Hospital, Ouagadougou]

Nephrology in Burkina Faso faces many challenges, including insufficient epidemiological data.

AIMS

Our study aims to describe the epidemiological and clinical characteristics of patients on chronic hemodialysis in a new hemodialysis center.

METHOD

This was a cross-sectional, descriptive, monocentric study conducted in the hemodialysis unit of Tengandogo University Hospital from February 1, 2018 to January 31, 2019.

RESULT

We recorded 94 patients undergoing hemodialysis for end-stage kidney disease, including 63 patients with hemodialysis incidents versus 31 patients transferred to us from other centers. The average age was 43.7 years[4-85 years]. The average age of hemodialysis was 42.5 years[4-85 years]. The average duration of hemodialysis was 1.2 years[0-12 years].The sex ratio was 2.48. The main comorbidity was high blood pressure with 63.8%. In 43.6% of cases, the cause of chronic kidney disease could not be determined. Vascular nephropathy of hypertensive origin and chronic glomerulonephritis are found respectively with 27.6% and 12.7%. The mortality rate is 23.4 per 100 people years. In 82% of cases, death occurred within the first month following hemodialysis.Young age, diagnostic difficulties and high mortality rates reveal the inadequacies of our health system and negatively affect socio-economic development.

CONCLUSION

These data show the need for a kidney disease prevention program.

[Conservative aneurysmorrhaphy for hemodialysis arteriovenous fistula]

The aim of this study was to evaluate the results of conservative surgical treatment of the aneurysmal complications of arteriovenous hemodialysis fistulae and to determine the factors predictive of long- and mid-term patency of treated fistulae. The surgical treatment was mainly based on caliber reduction and reconstruction.

METHODS

This was a descriptive retrospective study with a five-year duration, going from January 2013 to December 2018. This study included 40 patients presenting aneurysmal complications of their hemodialysis vascular access who were treated with aneurysmorrhaphy.

RESULTS

The mean age of the aneurysmal-complicated hemodialysis vascular access was 42 months. The indications for treatment were puncture-related difficulties in 42.5% of cases, rapid increase of the aneurysmal diameter in 27.5%, skin thinning in 25% and aneurysmal rupture in 5%. The mean aneurysmal course was 6.6 months with an average diameter of 3.25cm at the moment of management. The initial technical success rate was 100%. Twenty patients had complications in the postoperative period. Patency rates at 3, 6, 12 and 24 months were 89.5%, 81.6%, 71% and 63.1%, respectively. Factors predictive of thrombosis were diabetes (P=0.001), peripheral arterial disease (P=0.003), number of punctures per week (P=0.003) and context of emergency presentation (P=0.001).

CONCLUSION

Aneurysmorrhaphy seems to be the best conservative surgical treatment for aneurysmal complications of hemodialysis vascular access fistulae. This surgical approach allows us to conserve the native autologous vascular access and spare the patient's venous network.

[Impact of comorbidities on hemoglobin stability in patients with chronic kidney insufficiency on hemodialysis, treated with CERA in current practice: The MIRIADE study]

This national, prospective and multicenter study aimed to describe the real-life impact of comorbidities on hemoglobin stability in patients with chronic kidney disease on hemodialysis, treated with CERA in relay of an erythropoietin stimulating agent. Comorbidities were defined by the Charlson Index (adjusted on age) and hemoglobin stability as a variation of ±1g/dL after the 6-month treatment period. The 585 analyzed patients were distributed as follows according to the adjusted Charlson index: score≤3 (12% of patients), 4≤score≤5 (17%), 6≤score≤7 (31%) and score≥8 (40%). At CERA start, its median monthly dose was of 100μg for the overall population, with no changes during the treatment period and with little variation according to the comorbidity score. Patients with stable hemoglobin (56%, 67% if score≤3) were more numerous to reach the therapeutic target range between 10 and 12g/dL after 6 months (85% versus 43% if not stable hemoglobin). Patients with low C-reactive protein value (≤5mg/L ; P=0.04), no red blood cell transfusion (P=0.03), or no/low dose of intravenous iron (≤200mg ; P=0.03) were more likely to reach stable hemoglobin under CERA after 6 months. Among the 644 CERA-treated patients, 4 patients (<1%) had one serious adverse event related to treatment. A stable hemoglobin within the therapeutic target was reached in the majority of the patients after 6 months in current practice with a lower CERA dose, regardless of the comorbidities scores of patients on hemodialysis.

[Isolated diastolic hypotension in hemodialysis: Risk factor for novel cardiovascular complications and all-cause mortality]

Intra dialytic hypotension is the most common complication in hemodialysis. However, isolated diastolic hypotension (IDH) in hemodialysis is asymptomatic and its detection requires repeated monitoring of blood pressure during dialysis sessions. To study this phenomenon, we conducted a prospective study over a period of 5 years in 45 chronic hemodialysis patients. The IDH, was noted in 42% at inclusion, and in 59,5% of the cases at the end of the study. IDH was associated with advanced age, female gender, high relative critical blood volume, cardiac arrhythmias and diastolic dysfunction of the left ventricle. IDH was also significantly associated with novel cardiovascular complications (P=0.004) and all-cause mortality (P=0.038). Isolated diastolic hypotension is a particularly common phenomenon in hemodialysis. Our data encourage in-depth reflection on this subject in hemodialysis. In addition, our study highlights the value of screening for IDH by close monitoring of hemodynamic parameters, and calls for personalized dialysis management based on the analysis of the demonstrated risk factors and on the study of the associated comorbidities.

[Clinical management of patients with hemophilia A in nephrology: Diagnostic and therapeutic challenges illustrated by the cases of 2 patients]

Hemophilia A is an X-linked genetic hemorrhagic disorder characterized by a factor VIII deficiency. The availability of secured substitution products has led to a dramatic improvement of life expectancy in hemophiliac patients. Nowadays, adult hemophiliac patients may develop Chronic Kidney Disease (CKD) resulting from age-related comorbidities (hypertension, obesity, diabetes). In addition, the high prevalence of viral infections in this population exposes patients to an increased risk of CKD. The risk of hemorrhage in hemophiliac patients is a challenge for their clinical management, both for diagnostic procedures (kidney biopsy in particular) and for renal replacement therapy (dialysis or renal transplantation) when it is needed. This work provides an update of the literature data concerning the management of hemophiliac patients in nephrology, illustrated by the cases of two patients.

[Pregnancy In Chronic Hemodialysis, Case Study]

For a long time, pregnancy in chronic hemodialysis was considered medically contraindicated, because of the many maternal complications that it could cause. Its management is as heavy for the medical teams (nephrologist, obstetrician and neonatologist) as for the patient herself. We report here a case of pregnancy in a dialysis patient observed at the Madeleine clinic in Dakar, Senegal. This pregnancy is the first described with a birth of a living child having a normal birth weight without abnormal malformative thanks to the multidisciplinary follow-up nephrologist, obstetrician and neonatologist), the intensification of dialysis care, the correction of anemia, control of blood pressure and improvement of the mother status nutritional.

[Kaposi sarcoma in a patient with ANCA vasculitis requiring hemodialysis]

INTRODUCTION

Iatrogenic Kaposi's sarcoma is widely reported after transplantation. Less commonly, it occurs in patients receiving immunosuppressive therapy for ANCA associated vasculitis. We report here the rare association of Kaposi's sarcoma, prurigo nodularis and ANCA associated vasculitis in a hemodialysis patient.

CASE REPORT

We describe a 58-year-old woman who presented granulomatosis with polyangeiitis with alveolar hemorrhage and renal failure requiring hemodialysis. She developed cutaneous Kaposi's sarcoma seven weeks after the beginning of immunosuppressive therapy. Biological tests showed negative HHV8 virus infection. Lesions of Kaposi's sarcoma responded to a discontinuation of immunosuppressive drugs and a decreasing dosage of corticosteroids.

CONCLUSION

Our case showed that the immunosuppressed state related to multiple factors such as underlying disease, immunosuppressive therapy and hemodialysis may all have contributed to the development of this neoplastic disorder in our patient.

[Incremental haemodialysis]

The majority of incidental haemodialysis patients are systematically treated at the rate of three sessions per week, regardless of their level of residual kidney function. Incremental haemodialysis is a therapeutic strategy adapted to the residual kidney function level of each patient, to offer patients only the "dialysis dose" needed to supplement their residual kidney function, while ensuring that they achieve the objective of total clearance (renal+per-HD) recommended (weekly Standard Kt/V urea>2.3 volumes. Incremental haemodialysis therefore allows a lower dose and lower dialysis frequency in patients with residual kidney function. Incremental haemodialysis through better residual kidney function preservation could improve patient survival and also have other benefits in terms of quality of life, preservation of vascular access and in terms of decreased expenditure health. Some logistical hurdles make its safely prescription still difficult but software should soon be made available to practitioners for a simpler and more accurate daily management of this prescription.

[Prevalent Of Echocardiography Anomaly In Chronic Hemodialysis Patients At The Point G Hospital]

INTRODUCTION

Cardiovascular abnormalities are frequent and often early, severe and masked in patients with renal impairment. These cardiovascular complications are the main causes of death in hemodialysis patients. The diagnosis of these cardiovascular anomalies by cardiac ultrasound allows the individualization of patients at high cardiovascular risk. We conducted this study to evaluate the echo-cardiographic aspects of chronic hemodialysis in the nephrology and hemodialysis department of the G-Point CHU.

METHODS

This is a retrospective study of chronic renal failure patients who have undergone extra-renal treatment for 6 months or more from January 1, 2011 to December 31, 2012. Results: During this study, 83 files were retained The sex ratio was 1.51 in favor of men. The average age of patients was 48 years old. HTA (59%) and tobacco (43.3%) remain the dominant risk factors. Vascular nephropathy was the leading cause of CKD, 44.6%. Echo-cardiac abnormalities are dominated by cavitary dilatation (78.3%), LVH (41%), cardiac dysfunction (83.2%), valvular lesion (30.1%), and pericarditis (22,9%). The cardiovascular complications were LVH (41%), hypertension (25.3%) and dilated cardiomyopathy (9.7%). The evolution was favorable for 73.5% of the patients, the mortality represented 8.4% with various complication (18.1%).

[Is cancer incidence different between type 2 diabetes patients compared to non-diabetics in hemodialysis? A study from the REIN registry]

BACKGROUND AND OBJECTIVES

In France, diabetes mellitus is now the second cause of end stage renal disease. In a large previous French national study, we observed that dialyzed diabetics have a significant lower risk of death by cancer. This first study was focused on cancer death but did not investigate cancer incidence. In this context, the aim of this second study was to compare the incidence of cancer in diabetic dialyzed patients compared to non-diabetic dialyzed patients in a French region.

METHODS

This epidemiologic multicentric study included 588 diabetic and non-diabetic patients starting hemodialysis between 2002 and 2007 in Bretagne. Data were issued from REIN registry and cancer incidence were individually collected from medical records. Diabetics and non-diabetics were matched one by one on age, sex and year of dialysis initiation.

RESULTS

During the follow-up, we observed 28 cancers (9.4%) in diabetic patients and 26 cancers (8.9%) in non-diabetics patients. The cumulative incidence to develop a cancer 2 years after the dialysis start was approximately 6% in both diabetics and non-diabetics patients. In univariate Fine and Gray analysis, BMI, hemoglobin, statin use had P-value<0.2. However, in the adjusted model, these variables were not significantly associated with cancer incidence.

CONCLUSION

This study lead on a little number of dialyzed patients did not show any significant difference on cancer incidence between diabetic and non-diabetic patients after hemodialysis start.

[Comparison of citrate 4% and heparin as tunneled-catheters-locking solution in chronic hemodialysis]

INTRODUCTION

Citrate 4% is an alternative to heparin as catheter-locking solution in chronic hemodialysis patients. We compared catheter dysfunction episodes, dialysis adequacy, plasminogen-tissular activators use and costs according to catheter-locking solution in our centre.

METHODS

Prospective, monocentric, cohort study (NephroCare Tassin-Charcot) on 49 prevalent patients in chronic hemodialysis. Two main groups were formed according to the prescription of catheter-locking solution at the beginning of the study (03/02/2016) and followed until 05/10/2016: heparin (n=26) and citrate (n=22).

RESULTS

The number of diabetic patients was higher in the citrate group (12/22) than in the heparin one (5/26; P=0.025). The 2 groups were comparable for the other studied variables. We didn't observe any difference in terms of catheter-dysfunction (4.23 versus 4.14% in heparin and citrate groups, respectively; P=1.0) and dialysis adequacy. The prescription of citrate was associated with lower TPA uses (1/604 versus 14/946; P=0.022) and lower costs (1.42 € for one session versus 2.94 €).

CONCLUSION

Administration of citrate 4% as a catheter-locking solution is not inferior to heparin in terms of catheter-dysfunction episodes, is associated with similar dialysis adequacy results, lower plasminogen-tissular activators uses and reduced costs in chronic prevalent hemodialysed patients.

[Initiating hemodialysis in Morocco: Impact of late referral]

INTRODUCTION

End-stage renal disease (ESRD) is a major public health concern in Morocco with an incidence in constant progression according to MAGREDIAL "Morocco Dialysis Registry". Patients are often sent late to nephrologists, which is a source of complications recognized in several countries. For these reasons, we tried to evaluate, in our context, the prevalence and factors of this late referral (LR).

METHODS

This is a retrospective study which included all patients initiating hemodialysis between January 2007 and December 2015. We found the history of following these patients and sought their clinical characteristics at the time of setting hemodialysis.

RESULTS

During the study, 318 patients were admitted for management of ESRD. Their average age was 54.31 years and diabetic nephropathy was the most common cause of 41% of cases. Only 105 patients (33%) had a nephrological follw up in almost two thirds of cases, hemodialysis was started by using a temporary central venous catheter especially femoral. we have identified five factors associated with LR: nemia, hypoalbuminemia, inflammatory syndrome, a longer initial hospitalization, a greater use of temporary catheterization as first access.

CONCLUSION

LR patients with ESRD remains very common in our context. It is about 67% and complicates implementation hemodialysis patients with anemia and more use of central catheters that are predictors of mortality previously described in the literature. Economically, LR significantly increases the cost of care by significantly increasing the duration of hospitalization.

[Infections on catheters in hemodialysis: Temporal fluctuations of the infectious risk]

BACKGROUND

International guidelines recommend to limit the long-term use of central-veinous catheters in patients undergoing hemodialysis, because they expose the patient to a higher infectious risk than the fistulas. However, for some patients with comorbidity, switching to a permanent vascular access is not possible. In such case, the catheter is used for a longer period. It seems therefore important to study the influence of a prolonged duration of catheterization on infectious complications. The temporal fluctuation profile of the infectious risk is poorly studied in the literature and the results published may be contradictory.

METHODS

This multicentric prospective study included 1053 incident tunneled catheters. Multivariate logistic regression was used to identify significant risk factors of infection. An infection-free survival analysis was performed afterwards to estimate the variation of the instantaneous infectious risk during catheterization.

RESULTS

The major risks factors of infections on tunneled catheters were: previous Staphylococcus aureus infection (aOR=1.95 [1.16-3.27]; P=0.012), diabetes (aOR=1.67 [1.16-2.41]; P=0.006), and long duration of catheterization (0-3months vs.≥24months: aOR=2.42 [1.34-4.36]; P=0.003). The survival analysis showed a higher risk of infections of tunneled catheters during the first months after placement. Risk declines over time.

CONCLUSIONS

The fluctuation profile of the infectious risk show that preventive precautions should target the first months of catheterization.

[Modelling of phosphorus transfers during haemodialysis]

Chronic kidney disease causes hyperphosphatemia, which is associated with increased cardiovascular risk and mortality. In patients with end-stage renal disease, haemodialysis allows the control of hyperphosphatemia. During a 4-h haemodialysis session, between 600 and 700mg of phosphate are extracted from the plasma, whereas the latter contains only 90mg of inorganic phosphate. The precise origin of phosphates remains unknown. The modelling of phosphorus transfers allows to predict the outcome after changes in dialysis prescription (duration, frequency) with simple two-compartment models and to describe the transfers between the different body compartments with more complex models. Work using ³¹P nuclear magnetic resonance spectroscopy performed in animals showed an increase in intracellular phosphate concentration and a decrease in intracellular ATP during a haemodialysis session suggesting an intracellular origin of phosphates.

[Tuberculosis among chronic hemodialysis patients in Togo: Report of 10 cases]

GOALS

To determine the frequency of tuberculosis among hemodialysis patients in Togo, specify its different localizations and identify its diagnostic and therapeutic difficulties.

PATIENTS AND METHODS

This was a retrospective study over a period of 5 years (2010-2015). It includes the records of periodic hemodialysis patients in the Nephrology Department of the Sylvanus-Olympio University Teaching Hospital in Lomé. The diagnosis of tuberculosis was selected on the basis of clinical and laboratory data. The specific treatment has involved the association of 4 antituberculosis, which was adapted to the renal function.

RESULTS

Of 91 chronic hemodialysis patients treated in Hospital Sylvanus-Olympio hemodialysis center, 10 cases (10.9%) of tuberculosis were diagnosed. The mean age was 37.3±12.8 years, and the sex ratio was 1.5. The median time to onset of tuberculosis after initiation of hemodialysis was 16.8±9 months. Extrapulmonary sites are found in 100% of cases (5 had both peritoneal and pleural localization, only 5 had pleural localization). The tuberculin skin test was positive in 4 patients (40%). The search for Mycobacterium tuberculosis was unsuccessful in all types of samples. Tuberculosis treatment was generally tolerated. Two patients (20%) had died during treatment.

CONCLUSION

Tuberculosis is relatively common in hemodialysis patients. Diagnosis is difficult and may be based on the therapeutic trial.

[Sofosbuvir and daclatasvir combination therapy in hemodialysis patient with liver transplantation]

We report a case of sustained remission of a liver transplant patient infected with hepatitis C virus (HCV) genotype 1 undergoing hemodialysis treatment. Oral treatment regimen of the HCV infection consists of a combination of sofosbuvir 400 mg after each hemodialysis session and daclatasvir 60 mg daily, for a period of 3 months. Laboratory testing indicate that the combination regimen was well-tolerated with no sign of drug-drug interaction. Confirmation of these clinical observations in large clinical studies may help improve morbidity and decrease mortality outcome in patients infected with HCV and undergoing hemodialysis treatment.

[Predictors of physical incapacity degree to chronic hemodialysis patients in Kinshasa : Key role of the residual diuresis]

OBJECTIVE

Identifying predictors of physical incapacity degree in patients on chronic hemodialysis in Kinshasa.

METHODS

Bicentric analytical study, between January 2007 and July 2013. Degree of physical handicap was evaluated at 6months of hemodialysis based on the scale of Rosser. Logistic regression sought the predictors of no or light physical incapacity (Rosser<3) vs. moderate to maximum (Rosser≥3). P was set at 0.05.

RESULTS

One hundred twenty-seven patients (127) patients received at least 6months of hemodialysis (53.3±11years; 73.2 % male), 79 (62.2 %) had no or light incapacity and 48 (37.8 %) moderate to maximum. Predictors of lower physical incapacity in univaried analysis were: secured funding, high socioeconomic level, lack of diabetes mellitus, high body weight, normal systolic and diastolic blood pressure, residual diuresis 3months later, hemoglobin and hematocrit, low comorbidity, arteriovenous fistula, erythropoietin, at least 12hours of hemodialysis per week and lack of intradialytic complications. After logistic regression, a high residual diuresis 3months of hemodialysis has proved an independent predictor of lower physical Incapacity (aOR 0.998; P=0.024) next to the lack of diabetes mellitus (aOR 0.239; P=0.024), good control of systolic (aOR 0.958; P=0.013) and diastolic (aOR 1.089; P=0.003) blood pressure and the use of erythropoietin (aOR 5.687; P=0.004).

CONCLUSION

Preserving residual diuresis is associated with lower physical incapacity and must be integrated in the management in hemodialysis.

[Evaluation of educational interventions with dialysis patient]

The treatment of end-stage renal disease requires a significant number of drug treatments. At patient level, daily management is somewhat difficult: Number of prescribed pills, medication side effects, treatment of asymptomatic diseases… The objective of the study was to investigate the effect of guidance tailored to each patient receiving hemodialysis, performed by the pharmacist (educational interventions). Adult haemodialysis patients with hyperphosphatemia despite phosphate binders were eligible for study entry. The study was controlled with a retrospective group. The primary end point was a change in serum phosphate levels. The secondary end points were therapy adherence, knowledge regarding phosphate management and patient satisfaction with the programme. Sixteen patients in each group participated in the study. The mean serum phosphate level at endpoint was decreased by 0.25 mmol/L in the intervention group (0.41 mmol/L for patients with expectancy for this reduction) and by 0.11 mmol/L in the control group. Five patients normalized their serum phosphate level in the intervention group against three patients in the control group. The mean score of adherence decreased from 1.75 to 1.50. The main factors affecting adherence were forgetfulness or carelessness in taking medications and number of daily doses. This study showed the feasibility of an improvement in serum phosphate level and adherence driven by therapeutic education, though effect was highly amplified by the motivation induced by pharmaceutical guidance. Patients emphasize the importance of the involvement of pharmacist in their care.

[Access to kidney transplantation's waiting list: Setting up a clinical pathway]

Early information about the kidney transplant is recommended to begin quickly the process of registration on the kidney transplantation waiting list, even for the patients not dialyzed at stage V of the renal insufficiency. It is a strategic choice for the patient care. From the arrival of all the patients in our center of dialysis, a systematic evaluation of the access to the kidney transplant waiting list is organized thanks to a clinical pathway. The impact of this new organization was estimated at 18 months with regard to the information about the kidney transplant transmitted to the patient, of the time required for the assessment of pre-kidney transplant evaluation, and of putting in contraindication. On 78 incident patients, 64 received the information concerning the kidney transplant. After 18 months, 50 clinical pathways are finalized at the time of the analysis among which 25 with a period lower than 6 days and 25 with a median of 169 days. A significant difference of age exists between both groups. The main causes of definitive medical contraindications were estimated. Twenty-two percent of the clinical pathway finalized is awaiting lifting of temporary contraindication. The management of the patient is improved, due to motivation of all the medical teams and a considerable work of coordination between the secretarial department and the department of transplantation in teaching hospital.

[Comparison of peritoneal dialysis and hemodialysis survival in Provence-Alpes-Côte d'Azur]

PURPOSE

To analyze and compare survival of patients initially treated with peritoneal dialysis (PD) or hemodialysis (HD).

METHODS

We used data from the French REIN registry. We included all patients aged 18 years or more who started dialysis between 1st January 2004 and 12 December 2012 in Provence-Alpes-Côte d'Azur Region (PACA). These patients were followed up until 30 June 2014. Survival curves were generated using the Kaplan-Meier technique and tested using the log-rank test. Variables predictive of all-cause mortality were determined using Cox regression models. The propensity score was used.

MAIN RESULTS

Survival was similar between initial dialysis modalities: PD and HD, even after adjusting for the propensity score. But, when we exclude the patients who had switched from one technique of dialysis to another, survival was better in HD patients. According to the multivariate analysis, advanced age and the lack of walking autonomy appear to be associated with an increase in mortality in dialysis patients. But, the presence of hypertension improve the survival in this cohort.

CONCLUSION

The survival is similar between hemodialysis and peritoneal dialysis.

[Medical simulation in hemodialysis]

INTRODUCTION

Simulation is an innovative educational tool based on learning experience in a secure environment without fear of repercussions especially in critical situations such as in emergencies. It offers great prospects in the development of dialysis training.

METHODS

We report the results of an observational study comparing medical simulation to conventional training methods in the management of hemodialysis in emergency situations. We discuss afterwards the possibilities currently allowed by medical simulation in dialysis training.

RESULTS

The training was beneficial (significant difference between initial and final level of knowledge) for all participants. There was no significant difference between the conventional approach, simulation training and the two combined tools. However, satisfaction rate was higher in simulation training. We observed a tendency to have better results in "active players" of the simulation compared to observers.

CONCLUSION

We emphasize the importance of integrating medical simulation training in our dialysis training strategies as a complementary tool to classical teaching/learning methods.

[Factors associated with depressive symptoms in chronic hemodialysis patients of centre hospitalier universitaire Yalgado Ouédraogo (Burkina Faso)]

OBJECTIVE

To determine the factors associated with depressive symptoms in chronic hemodialysis patients at centre hospitalier universitaire Yalgado Ouédraogo de Ouagadougou (CHU-YO).

PATIENTS AND METHODS

The study was cross sectional and descriptive, from June 2nd to July 30th, 2014. We included chronic hemodialysis patients of CHU-YO. The frequency of hemodialysis sessions was of every four to five days. The French version of Hamilton depression psychometric scale was used to assess depressive symptoms. The factors associated with depression were identified after descriptive and explanatory analysis.

RESULTS

Depressive symptoms were identified in 140 of the 162 patients included in the study, or a prevalence of 86.4%. The average age of the 140 patients was 38.9±12.9years. In bivariate analysis, the risk of having depressive symptoms was 1.5 times for women, 1.7 times for patients with severe anemia, 1.5 times for hemodialysis catheter holders, 1.8 both in case of duration in hemodialysis less than six months. In multivariate analysis, gender and duration in hemodialysis were factors associated with the occurrence of depressive symptomatology.

CONCLUSION

Our study confirms the high frequency of depressive symptoms in patients on hemodialysis. To improve the overall care of hemodialysis patients, we suggest routine screening for depressive symptoms and specific support.

[Brown tumors in chronic hemodialysis patients]

PURPOSE

Brown tumors are rare and severe manifestations of secondary hyperparathyroidism. We propose in this study: to define and illustrate brown tumors observed in our hemodialysis center; to show the frequency for 20 years in our center; to identify risk factors compared to the rest of dialysis patients; and finally to offer improved support for reducing the incidence.

PATIENTS AND METHODS

We conducted a retrospective and descriptive study, over a period of 20 years (1993-2013), including 311 cumulative patients which are chronic hemodialysis in our unit.

RESULTS

Twenty-one patients had brown tumors (6.75%). The average age was 36.1 years and the sex ratio M/F is of 0.6. The average time between the start of hemodialysis and the diagnosis of brown tumor was 87.6 months. Clinical symptoms were dominated by bone pain, found in 76.1% of cases. The most frequent locations were costal (28.5% of cases), while spinal involvement was less frequent (4.76% of cases). The location was multifocal in 57.1% of cases. The mean serum calcium was of 2.08 mmol/L, the serum phosphate of 2.25 mmol/L, alkaline phosphatase of 1709 IU/L and the average value of parathyroid hormone of 1934 pg/mL. Radiography was the key of diagnostic. Resonance magnetic imaging and computed tomography had an interest in the exploration of spinal locations and maxillo-mandibular locations. All patients underwent parathyroidectomy and it was total in one patient. Tumorectomy was necessary in three patients (14.2% of cases). The outcome was favorable in 85.7% of cases.

CONCLUSION

Our work relates one of the most important series published of brown tumors and is characterized by the multifocal character of these tumors.

[Changes in mineral and bone disorder management in a French cohort of hemodialysis patients between 2008 and 2012: The National Bone and Mineral Metabolism observatory (Photo-Graphe 2 and 3)]

INTRODUCTION

Chronic kidney disease progressively induces a disorder of mineral and bone metabolism (CKD-MBD) which also leads to cardiovascular abnormalities. Previous studies showed that only few hemodialysis patients had serum calcium, phosphate and parathyroid hormone levels within the K/DOQI (Kidney-Disease Outcomes Quality Initiative) targets of 2003. Our aim was to identify the impact of different therapeutic strategies and that of the KDIGO (Kidney-Disease: Improving Global Outcomes) targets of 2009 on the control of CKD-MBD.

PATIENTS AND METHODS

The French calcium and phosphate observatory monitors the mineral metabolism of patients with CKD at the local, regional and national level every six months. We compared the data recorded in June 2008 (n=1914 patients) with those collected in October 2012 (n=2481) for patients aged 18 years or more, who started hemodialysis therapy within the last 12 months.

RESULTS

As compared with 2008, in 2012 fewer patients had hyperphosphatemia (55.1 % versus 64.7 %), hypocalcemia (35.5 % versus 40.3 %) and hyperparathyroidism (9.8 % versus 10.1 %) according to the KDIGO guideline, and more had hypophosphatemia (9.6 % versus 6.5 %), hypercalcemia (3.9 % versus 2.2 %) and hypoparathyroidism (31.5 % versus 25.8 %) (P<0.001, P<0.001 and P=0.002 respectively for differences in serum phosphate, calcium and PTH levels). Mean (± standard deviation [SD]) serum 25 OH vitamin D levels increased by 1.6-fold, from 48.3±42.6 nmol/L in 2008 to 76.6±45.8 nmol/L in 2012. Between 2008 and 2012, the prescription of native vitamin D derivatives and sevelamer (HCl or carbonate) increased whereas that of cinacalcet, lanthanum carbonate, calcium-chelating agents and active vitamin D derivatives decreased.

CONCLUSION

Despite a slight improvement of biochemical CKD-MBD parameters in the observation period only few patients reached the three KDIGO targets (11.5 % in 2012 versus 11.1 % in 2008).

[Conservative treatment, hemodialysis or peritoneal dialysis for elderly patients: The choice of treatment does not influence the survival]

Hemodialysis is the predominant replacement therapy in the 70 year-old French population (18% in peritoneal dialysis, 72% in hemodialysis from the REIN registry). Managing older patients reaching the end stage renal disease poses many ethical questions, since outcomes balanced regarding survival and quality of life. The aim of this study was to compare the survival of patients aged over 70 years according to the ESRD treatment choice: conservative treatment without dialysis (CT), hemodialysis (HD) and peritoneal dialysis (PD). We included all patients over 70 years reaching stade IV CKD integrated in a predialysis information program between 01/01/2005 and 31/12/2010. We compared their survival from the start of their program, in function of their treatment choice: HD, PD or CT. On this period, 148 patients were included, we excluded from analysis 17 patients who had a contraindication to PD, 26 patients who did not make a choice because their kidney function was stabilized, 4 patients lost to follow-up and 12 patients who died before the treatment choice. The average age was 79±6 years, 40% of patients were women, and the mean eGFR was 16±9 mL/min/1.73 m(2) at the entry in the program. Among the 89 patients, 21 choose CT (24%), 68 accepted dialysis (76%), including 48 HD (71%) and 20 PD (29%). No significant eGFR difference at the inclusion time between the groups. The time initiation of dialysis was significantly shorter in the PD group (146 days vs 442 in the HD group; P=0.004). Survival between the groups of patients who accepted or refused dialysis was not statistically different (749 days or 2 years in the HD + PD group vs 562 days, or 1 year and 6 months in the CT group; P=0.95) and between the HD group (760 days or 2 years and 2 months) and the PD group (343 days or 11 months; P=0.32). As measured from the time they entered in the predialysis program, the survival of older patients over 70 years does not seem to depend on their choice of treatment modality. Whether they accepted or refused dialysis, whatever their choice concerning hemodialysis or peritoneal dialysis, their survival was close to one year.

[Cardiac arrest in dialysis patients: Risk factors, preventive measures and management in 2015]

Patients undergoing hemodialysis have a 10 to 20 times higher risk of sudden cardiac arrest (SCA) than the general population. Sudden cardiac death is a rare event (approximately 1 event per 10,000 sessions) but has a very high mortality rate. Epidemiological data comes almost exclusively from North American studies; there is a great lack of European data on the subject. Ventricular arrhythmia is the main mechanism of sudden cardiac deaths in dialysis patients. These patients develop increased sensitivity mainly due to a high prevalence of severe ischemic heart disease and left ventricular hypertrophy and to a frequent trigger event: electrolytic and plasma volume shifts during dialysis sessions. Unfortunately, accurate predictive markers of SCA do not exist, however some primary prevention trials using beta-blockers or angiotensin II receptor blockers are encouraging, while the use of implantable cardioverter defibrillators in the population of chronic dialysis patients remains controversial. Identification of patients at risk, minimizing trigger events such as electrolytic shifts and improving team skills in the diagnosis and initial resuscitation with the latest recommendations from 2010 seem necessary to reduce incidence and improve survival in this high risk population. Organization of European studies would also allow a more accurate view of this reality in our dialysis units.

[Falls among hemodialysis patients: Incidence and risk factors]

Falls and mineral and bones disorders are both implicated in the occurrence of pathological fractures in patients undergoing chronic dialysis. However, data on falls among this population are rare. We carried out a prospective study during four weeks and included 70 patients on chronic hemodialysis with the main objectives being to evaluate the incidence of falls and factors related to it. At the end of the four weeks, 16 patients (22.86%) fell at least once, with a total of 17 falls during 4 weeks, giving an incidence of 3.2 falls per patient/year. The mean age was 40 ± 16 years. Five patients (31.2%) had a past history of pathological fractures. Ten patients (62.5%) presented intra- and post-dialysis hypotension, six (37.5%) was diagnosed of gait disorders and two (12.5%) had sensory deficit of the lower limbs. Six patients (37.5%) presented frailty. Hypotension (P=0.004), frailty (P=0.047) and sensory deficit (P=0.049) were significantly associated with the occurrence of falls. The incidence of falls is relatively high in our hemodialysis patients and real risk factors exist. Hence, it is important to implement programs for falls prevention to reduce their incidence and impact.