Thrombotic microangiopathy (TMA) is a poorly recognized cause of collapsing glomerulopathy. The frequency and significance of collapsing glomerulopathy associated with renal TMA have not been ...specifically studied in native kidney biopsy specimens. Here we retrospectively documented clinicopathologic features of 53 patients with histologically proven TMA in the native kidney, with special emphasis on changes due to focal segmental glomerulosclerosis (FSGS). Histological TMA was related to hypertensive nephropathy in 21 patients, genetic complement abnormalities in 9, drugs in 7, and to other causes in 16 patients. Almost half (26 patients) presented with arteriolar, 6 with glomerular, and 21 with mixed TMA. Using the Columbia classification system for the 53 patients with histological TMA, 33 had concurrent FSGS lesions with collapsing glomerulopathy the dominant variant in 19 patients (58% of the FSGS cases), not otherwise specified in 9 patients, cellular in 3, and perihilar or tip lesions in 1 patient each. The presence of FSGS was associated with a poor renal prognosis, with no prognostic difference between collapsing glomerulopathy and other FSGS variants. Thus, collapsing glomerulopathy is frequently found in native kidney biopsies with TMA, suggesting that endothelial injury may play an important role in the pathophysiology of FSGS.
Previous small studies have reported favorable results of peritoneal dialysis (PD) in the setting of chronic refractory heart failure (CRHF). We evaluated the impact of PD in a larger cohort of ...patients with CHRF where end-stage renal disease was excluded. ♢
All patients who received PD therapy for CRHF between January 1995 and December 2010 in two medical centers in France were included in this retrospective study. Baseline characteristics were compared with clinical parameters during the first year after initiation of PD. Mortality, safety, and sustainability of PD were also analyzed. ♢
The 126 patients included had a mean age of 72 ± 11 years and an estimated glomerular filtration rate of 33.5 ± 15.1 mL/min/1.73 m2. Mean time on PD was 16 ± 16.6 months. During the first year, patients with a left ventricular ejection fraction (LVEF) of 30% or less experienced improvement in cardiac function (30% ± 10% vs 20% ± 6%, p < 0.0001). We observed a significant reduction in the number of days of hospitalization for acute decompensated heart failure after PD initiation (3.3 ± 2.6 days/patient-month vs 0.3 ± 0.5 days/patient-month, p < 0.0001). One-year mortality was 42%. ♢
In CRHF, PD significantly reduces the number of days of hospitalization for acute heart failure. Improved LVEF may have led to the comparatively good 1-year survival in this cohort.
Light chain cast nephropathy is the most common form of kidney disease in patients with multiple myeloma. Light chain casts may occasionally show amyloid staining properties, that is, green ...birefringence after Congo red staining. The frequency and clinical significance of this intratubular amyloid are poorly understood. Here, we retrospectively assessed the clinicopathological features of 60 patients with histologically proven light chain cast nephropathy with a specific emphasis on intratubular amyloid, especially, its association with extrarenal systemic light chain amyloidosis. We found intratubular amyloid in 17 cases (17/60, 28%) and it was more frequent in patients with λ light chain gammopathy (13/17 in the 'intratubular amyloid' group vs 19/43 in the 'no intratubular amyloid' group, P=0.02). Pathological examination of extrarenal specimens showed that intratubular amyloid was significantly associated with the occurrence of systemic light chain amyloidosis (5/13 in the 'intratubular amyloid' group vs 0/30 in the 'no intratubular amyloid' group, P=0.001). Our results indicate that first, intratubular amyloid is not a rare finding in kidney biopsies of patients with light chain cast nephropathy, and, second, it reflects an amyloidogenic capacity of light chains that can manifest as systemic light chain amyloidosis. Thus, intratubular amyloid should be systematically screened for in kidney biopsies from patients with light chain cast nephropathy and, if detected, should prompt a work-up for associated systemic light chain amyloidosis.
Chronic heart failure is a growing problem. Despite progress in its management, many patients become refractory to therapies including diuretic resistance, major congestion, and worsening renal ...function. The only alternative to get rid of excess water and sodium is ultrafiltration, which can be achieved via hemodialysis or peritoneal dialysis (PD). The majority of studies have shown multiple benefits of PD as an improvement in functional class, a reduction in hospitalization leading to increased quality of life, and even a reduction in mortality. Being a home dialysis technique, it is more favorably accepted by patients. It remains necessary to confirm these potential positive outcomes and to identify patients who would benefit the most from this treatment in the era of new therapies available to date.
Acid-base status of patients on peritoneal dialysis is influenced by multiple factors. Metabolic acidosis is a common feature of chronic renal failure and dialysis treatment provides alkali in the ...dialysate in order to maintain a normal acid-base balance. This paper reports the prevalence of acid-base disorders in peritoneal dialysis patients and their associations with clinical and laboratory parameters. This is a cross-sectional retrospective study that included all PD patients registered in the RDPLF database. Metabolic acidosis was found in 20.4% of patients while 27.8% of patients had metabolic alkalosis. There is a significant relationship between age, protein intake estimated by nPNA and the level of alkaline reserve pleading in favor of the influence of dietary intakes in the maintenance of metabolic acidosis. Low residual renal function is associated with a lower probability of being in metabolic alkalosis. These results could allow an individual choice of the dialysate buffer in order to permanently obtain stable acid-base status in patients on peritoneal dialysis.
Home telemonitoring has developed considerably over recent years in chronic diseases in order to improve communication between healthcare professionals and patients and to promote early detection of ...deteriorating health status. In the nephrology setting, home telemonitoring has been evaluated in home dialysis patients but data are scarce concerning chronic kidney disease (CKD) patients before and after renal replacement therapy. The eNephro study is designed to assess the cost effectiveness, clinical/biological impact, and patient perception of a home telemonitoring for CKD patients. Our purpose is to present the rationale, design and organisational aspects of this study.
eNephro is a pragmatic randomised controlled trial, comparing home telemonitoring versus usual care in three populations of CKD patients: stage 3B/4 (n = 320); stage 5D CKD on dialysis (n = 260); stage 5 T CKD treated with transplantation (n= 260). Five hospitals and three not-for-profit providers managing self-care dialysis situated in three administrative regions in France are participating. The trial began in December 2015, with a scheduled 12-month inclusion period and 12 months follow-up. Outcomes include clinical and biological data (e.g. blood pressure, haemoglobin) collected from patient records, perceived health status (e.g. health related quality of life) collected from self-administered questionnaires, and health expenditure data retrieved from the French health insurance database (SNIIRAM) using a probabilistic matching procedure.
The hypothesis is that home telemonitoring enables better control of clinical and biological parameters as well as improved perceived health status. This better control should limit emergency consultations and hospitalisations leading to decreased healthcare expenditure, compensating for the financial investment due to the telemedicine system.
This study has been registered at ClinicalTrials.gov under NCT02082093 (date of registration: February 14, 2014).
The nutritional status of patients on peritoneal dialysis (PD) is influenced by patient- and disease-related factors and lifestyle. This analysis evaluated the association of PD prescription with ...body composition and patient outcomes in the prospective incident Initiative for Patient Outcomes in Dialysis-Peritoneal Dialysis (IPOD-PD) patient cohort.
In this observational, international cohort study with longitudinal follow-up of 1,054 incident PD patients, the association of PD prescription with body composition was analyzed by using the linear mixed models, and the association of body composition with death and change to hemodialysis (HD) by means of a competing risk analysis combined with a spline analysis. Body composition was regularly assessed with the body composition monitor, a device applying bioimpedance spectroscopy.
Age, time on PD, and the use of hypertonic and polyglucose solutions were significantly associated with a decrease in lean tissue index (LTI) and an increase in fat tissue index (FTI) over time. Competing risk analysis revealed a
-shaped association of body mass index (BMI) with the subdistributional hazard ratio (
) for risk of death. High LTI was associated with a lower subdistributional
, whereas low LTI was associated with an increased subdistributional
when compared with the median LTI as a reference. High FTI was associated with a higher subdistributional
when compared with the median as a reference. Subdistributional
for risk of change to HD was not associated with any of the body composition parameters. The use of polyglucose or hypertonic PD solutions was predictive of an increased probability of change to HD, and the use of biocompatible solutions was predictive of a decreased probability of change to HD.
Body composition is associated with non-modifiable patient-specific and modifiable treatment-related factors. The association between lean tissue and fat tissue mass and death and change to HD in patients on PD suggests developing interventions and patient counseling to improve nutritional markers and, ultimately, patient outcomes.
The study has been registered at Clinicaltrials.gov (NCT01285726).
Nutritional factors and dialysis adequacy are associated with outcome in hemodialyzed patients, but their relative contribution remains controversial, particularly when dialysis adequacy complies ...with current recommendations (Kt/V >1.2). Survival, clinical, and nutritional data from a cohort of prevalent 1,610 patients treated by hemodialysis in 20 centers in France have been collected over a 2.5-year period, from January 1996 to July 1998. Data including age, sex, cause of end-stage renal disease (ESRD), clinical outcome, time on dialysis, body mass index (BMI), blood levels of midweek predialysis albumin, prealbumin, and bicarbonate were analyzed. Normalized protein catabolic rate (nPCR), dialysis adequacy parameters, and estimation of lean body mass (LBM) from creatinine generation were computed from pre- and postdialysis urea and creatinine levels. The characteristics of the patients were as follows: age 59.6 ± 16.5 years, 58.8% males, 11% of diabetics, time on dialysis 63.2 ± 64.5 m. Weekly dialysis time was 12.18 ± 1.78 hrs, Kt/V 1.34 ± 0.34, nPCR 1.10 ± 0.35 g/kg body weight/day. Albumin concentration was 39.4 ± 5.3 g/L, prealbumin was 0.33 ± 0.09 g/L, BMI was 23.0 ± 4.5 kg/m2. Overall survival was 89.7% ± 0.8% and 78.4% ± 1.1% after 1 and 2 years. In the Cox proportional hazard model, survival was significantly influenced by age, the presence of diabetes, and by concentrations of albumin and prealbumin, but not by other variables, including Kt/V and urea reduction ratio. These results indicate that nutritional protein concentrations were predictive of dialysis outcome, whereas variables reflecting actual body composition and dialysis dose were not. Furthermore, in this well-dialyzed population, dialysis adequacy had no influence on survival. In conclusion, when adequacy targets are met in hemodialyzed patients, survival is mainly dependent on age and nutritional status. Efforts should be focused on the most efficient ways to maintain nutritional status in these patients.
L’acidose métabolique est une complication fréquente de l’insuffisance rénale chronique. Bien qu’elle apparaisse classiquement à des stades avancés, de nombreuses études suggèrent un état de ...« rétention protonique global » dès les stades précoces de la maladie, responsables de lésions tissulaires, notamment musculo-squelettiques, d’altération du métabolisme protidique et endocrinien, favorisant la dénutrition et l’inflammation chronique, et enfin augmentant la mortalité globale. La plupart des recommandations internationales préconisent une supplémentation par substrats alcalins, notamment par bicarbonate de sodium, pour lutter contre cette complication. Une alternative intéressante pour corriger l’acidose métabolique consisterait à moduler la production endogène d’acides ou d’alcalins en jouant sur les apports alimentaires. Il a en effet été démontré que le métabolisme de certains aliments consomme ou produit des protons. Ainsi, les régimes hypoprotidiques et riches en fruits et légumes frais permettraient de corriger au moins aussi bien que la supplémentation par bicarbonate l’acidose métabolique, et de lutter contre ses complications, notamment en permettant de ralentir le déclin de la fonction rénale en diminuant les mécanismes adaptatifs délétères pro-fibrosants, comme en témoigne la diminution des marqueurs urinaires de souffrance tubulo-interstitielle. À condition d’être bien conduits, ces régimes ne semblent pas être pourvoyeurs de dénutrition protéino-énergétique ou d’hyperkaliémie. Ceux-ci apparaissent donc comme des alternatives séduisantes, efficaces et sûres, pour lutter contre l’acidose métabolique de l’insuffisance rénale chronique et ses complications.
Metabolic acidosis is a frequent complication of chronic kidney disease. Although it is known to appear at advanced stages, many studies suggest a state of “global protonic retention” starting at early stages of the disease, responsible of tissue damage, particularly musculoskeletal, alteration of protidic metabolism and endocrine disorders, promoting malnutrition and chronic inflammation, and finally increasing mortality. The majority of international recommandations suggest of supplementation by alkali, most of the time by sodium bicarbonate, to struggle against this complication. An interesting alternative to correct acidosis would consist on the modulation of the endogenous production of acid by playing with the alimentary incomes. In fact, it has been demonstrated that some different types of food produce or consume protons during their metabolism. Low protein diet and rich fresh fruits and vegetables diet would manage to correct at least as well as the supplementation by sodium bicarbonate the metabolic acidosis, and to struggle against its complications, noteworthy by slowing the decline of glomerular filtration rate by limiting the toxic adaptative fibrotic mechanisms, demonstrated by the decrease of urinary tubulo-interstitial suffering markers. Of the condition of being well led, those diets do not seem to expose patients to an over-risk of malnutrition or hyperkaliemia. They therefore appear to be an attractive alternative, efficiency and safe, to fight against chronic kidney disease metabolic acidosis and its complications.
Malnutrition in hemodialysis diabetic patients: Evaluation and prognostic influence.
This work aimed to evaluate the role of malnutrition in the increased mortality rate of hemodialysis diabetic ...patients from a French cooperative series.
Body mass index (BMI), serum albumin, prealbumin, cholesterol, and pre-dialysis creatinine, normalized protein catabolic rate and lean body mass (LBM) were measured in 734 diabetic and 6389 non-diabetic patients (aged 63.4 ± 12.2 and 62.0 ± 15.9 years; 1.01 male to 1.40 female ratio). The outcome of 1610 of these patients, including 170 diabetics, was assessed during a 30-month follow-up.
Diabetic as compared to non-diabetic patients showed a significant (P < 10-4) increased BMI (25.9 ± 5.2 vs. 23.1 ± 4.3) and cholesterol (5.5 ± 1.6 vs. 5.3 ± 1.5 mmol/L), and decreased albumin (37.8 ± 5.4 vs. 38.9 ± 5.3 g/L), prealbumin (317 ± 91 vs. 340 ± 94 mg/L), creatinine (711 ± 184 vs. 816 ± 217 μmol/L) and LBM (76 ± 18 vs. 87 ± 21%). Normalized protein catabolic rate was similar in the two groups (1.11 ± 0.31 vs. 1.13 ± 0.32 g/kg/L). One and two-year survival was 83.7 ± 2.9% and 65.5 ± 3.8% in diabetic patients versus 90.3 ± 0.8% and 79.9 ± 1.1% in non-diabetics (relative risk 1.26, P < 0.01). Independent predictors of survival were age, albumin and prealbumin in non-diabetics and only age in diabetics.
Diabetic patients compared to non-diabetics were characterized by an increased incidence of protein malnutrition and decreased survival. However, the higher death risk associated with diabetes was not related to malnutrition.
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