COVID-19 chez les patients diabétiques avec insuffisance rénale chronique : profile épidémiologique et évolutif

Introduction La pandémie de coronavirus (COVID-19) a été associée à une morbidité et une mortalité accrue chez les patients hémodialysés (HD) Description/méthodes Cette étude descriptive rétrospective a été réalisée entre 2020 et 2021 avec les données de 160 patients diabétiques avec insuffisance rénale chronique atteints d’une infection COVID-19 confirmée afin d’analyser l’aspect épidémiologique et évolutive de ses patients. Résultats La moyenne d’âge des patients était de 60,3 ans, 64,7 % était de sexe masculine. Les comorbidités associées étaient : l’HTA (69,7 %), les maladies cardiovasculaires (5,6 %), les maladies respiratoires chroniques (2,4 %) ;dans notre série, les hémodialysées chronique avaient représenté 77,9 % ;parmi nos patients, 28,8 % étaient hospitalisés au service de réanimation COVID-19. On a enregistré un taux de mortalité de 30,3 % dans notre série. Conclusion Les patients âgés et ceux connus pour des maladies chroniques, telles que diabète, semblent être plus à risque d’atteinte sévère du COVID-19.

Facteurs de risque de mortalité en dialyse péritonéale

Introduction La dialyse péritonéale (DP) est une modalité de suppléance de l’insuffisance rénale chronique terminale, dont le choix dépend de l’indication médicale ainsi que du choix du patient. Elle est associée à un risque de complications surtout infectieuses. Description L’objectif de notre étude est de déterminer le taux de mortalité dans notre unité de dialyse péritonéale ainsi que de déterminer les variables significativement liées à la mortalité. Méthodes Il s’agit d’une étude descriptive rétrospective menée dans notre service, incluant tous les patients traités par DP entre janvier 2006 et janvier 2021. Résultats Durant la période d’étude, la DP était démarrée chez 231 patients, dont 8,6 % étaient âgés de plus de 65 ans. Le taux de mortalité était de 25,5 % (n=60). Parmi eux, 21 décès étaient précoces (dans les 6 mois après démarrage de la DP). La cause du décès était une infection chez 11 patients (18,3 %), dont 3 patients suite à une infection COVID-19, une complication cardiovasculaire chez 9 patients (15 %), un œdème aiguë de poumon chez 6 patients (10 %), une néoplasie chez un seul patient. La cause du décès n’était pas connue dans 55,5 % des cas. Dans ce groupe, la moyenne d’âge à l’initiation de la DP était 55,7±15,8 ans, 58,3 % des patients étaient diabétiques et 13,3 % étaient transférés en DP pour épuisement du capital veineux. Les facteurs associés à l’augmentation de la mortalité en dialyse péritonéale étaient l’âge avancé (p<0,001), l’existence d’un diabète (p<0,001) et l’hypoalbuminémie à l’initiation de la DP (p=0,026). Il n’y avait pas d’impact statistiquement significatif de la survenue de péritonite sur la mortalité. Conclusion L’indication de la DP chez le sujet âgé devrait tenir en compte le risque d’échec de la technique ainsi que le risque de complications et de surmortalité.

COVID-19 in peritoneal dialysis patients in a Tunisian center

Introduction The impact of COVID-19 on patients with chronic kidney disease is poorly understood. Given the co morbidity and immunosuppressed state of these patients, mortality could be higher than that in the general population, especially in patients on dialysis therapy. Description Describe the clinical manifestations and outcomes of SARS-CoV-2 infection in peritoneal dialysis patients. Methods This is a retrospective study including peritoneal dialysis patients in a Tunisian center;data and clinical characteristics of patients on peritoneal dialysis who have been infected with the new corona virus between March 2020 and October 2021 were collected. Results Among 36 patients on peritoneal dialysis, 11 (30%) had COVID-19 infection during this period. The average age was 40 ranging from 18 to 82 years old. Sex ratio was at 1.8. As for initial nephropathy, it was diabetic in 45.45%, vascular in 18.18%, interstitial in 18.18%, lupus in 9.09% and undetermined in 9.09% of cases. Severe forms were noted in 54.54% of cases with a mortality rate among infected patients of 45.45%. Conclusion Mortality due to COVID-19 seems to be increased in peritoneal dialysis patients and special measures must be applied to prevent the transmission of the virus and limit its damage in this vulnerable population.

Automatic evaluation of 3D volume infection rates: Application to the Covid-19 context

Covid-19 is a highly contagious respiratory syndrome, officially declared a global pandemic on 11 March 2020. Due to its rapid spread and the exponential increase in the number of infected and deceased patients, manual diagnosis in the healthcare sector is insufficient to manage each patient individually, even the assessment of lesions by clinicians is approximate. Moreover, to date, no end-to-end tool is proposed for automatic volumetric quantification of Covid lesions. Hence, in this paper we report the implementation of a complete chain for automatic assessment of the degree of Covid-19 lesions. It includes (i) preparation of the private database, (ii) image pre-processing, (iii) automatic segmentation based on U-NET and evaluation of its results by the usual metrics, (iv) 3D reconstruction and finally (v) volumetric quantification of Covid-19 lesions using the digitised images as input. For validation, the process is applied to our own private database that we have created for this purpose. The results obtained are very encouraging. The evaluation of the segmentation for the lung by the metrics DICE, IOU, Precision, Recall and Accuracy yielded respectively: 0.81, 0.90, 0.93, 0.82 and 0.92. Similarly for lesions these values are: 0.89, 0.93, 0.93, 0.81 and 0.93 respectively. © 2022 IEEE.

POS-534 AUTOIMMUNE PANCREATITIS IN SYSTEMIC LUPUS ERYTHEMATOSUS: CASE REPORT

Introduction: Systemic lupus erythematosus (SLE) is a chronic, multifaceted autoimmune inflammatory disease with a wide range of clinical presentations resulting from its effect on multiple organ systems. We report a case of SLE associated with autoimmune pancreatitis. Methods: In this study, we present a patient diagnosed as having SLE who developed acute auto-immune pancreatitis. Results: This is a 36-year-old woman, with lupus diagnosed since 2009. Initially, the manifestations of her disease were dermatological and articular. Then appeared the renal involvement with a lupus nephropathy class IV at the renal biopsy (PBR). She was previously treated with the NIH protocol then oral prednisolone with improvement in her symptoms. She continued these medications but was lost to follow-up since 2016 and presented after 6 years with pigmented skin lesions on her upper and lower limbs, abdominal pain and distension, vomiting, and an altered general condition. In biology, the patient presented a functional acute kidney failure, an elevated amylasemia (30 times normal), an elevated lipasemia (6 times normal), a normocytic normochromic hemolytic anemia with positive direct coombs test, lymphopenia, a positive immunological assessment (AAN, anti DNA AC, anti Sm, anti SSA, anti RNP), a low C3, a low C4. The patient presented a lupus flare with a SLEDAI score of 6 points: moderate lupus activity. Ultrasound confirmed a large abundance of ascites. Ascites fluid puncture showed an exudate with hyperleukocytosis with predominantly PNN and no germ on direct examination nor on culture.The infectious origin of the pancreatitis was eliminated (CMV, tuberculosis, covid19), as well as the tumoral origin (negative tumor markers, abdominal CT scan showed a swollen pancreas in its caudal portion with loss of physiological lobulations and normal spontaneous density.Necrosis flows difficult to individualize. In addition, no deep neoplastic focus). The autoimmune origin of the pancreatitis due to its lupus attack was retained. She was put on corticosteroids (500mg intravenously for 3 days) then relayed by oral route, albumin infusion, evacuation puncture. The subsequent evolution was marked by the progressive normalization of the pancreatic balance and the slower disappearance of the ascites. Conclusions: Acute pancreatitis is an unusual manifestation of SLE and it should be suspected in any SLE patient with these similar symptoms. In many cases, this complication has been attributed to the drugs administered. In our case, a favorable course of pancreatitis with corticosteroids adds further evidence to the idea that lupus-related pancreatitis is not a side effect of corticosteroid therapy. Moreover, treatment with these medications improves the prognosis. No conflict of interest

POS-139 AN ATYPICAL PRESENTATION OF DUAL-POSITIVE ANTI-MYELOPEROXIDASE AND ANTI-GLOMERULAR BASEMENT MEMBRANE ANTIBODIES VASCULITIS WITH PULMONARY-RENAL SYNDROME : A CASE REPORT

Introduction: Double-positive vasculitis with anti-polynuclear cytoplasm (ANCA) and anti-glomerular basement membrane (GBM) antibodies is a rare entity of systemic vasculitis defined by the presence of ANCA and anti-GBM antibodies. Methods: We report a rare case of pulmonary-renal syndrome with atypical clinical presentation. Results: A 52 year-old smoking man with a history of exposure to hydrocarbons and uretheral lithiasis, presented in April 2021 epigastralgia and vomiting. the investigations concluded to H.pylori gastritis and ulcer and he received a quadruple therapy. The kidney function was correct in April 2021. The evolution was marked by the persistence of symptoms and urine output had decreased for a few days. He was found to have renal dysfunction (serum creatinine: 2000 µmol/L). Abdominal CT scan without iodinated contrast injection showed severe hydronephrosis of the right pelvicalyceal system with cortical thinning and dilatation of the right ureter. The two kidneys had regular outlines seat multiple bilateral renal cysts with exophytic development. He had a nephrosomy with secondarily a right double-J stent with slight improvement of renal function. The patient presented then with acute respiratory distress.Testing for COVID-19: PCR and serology were negatives. Chest CT scan showed alveolar syndromeevoking pulmonary overload. No pneumopathy covid was shown. The evolution was marked by the non improvement by depletion and he developed hemoptic sputum and low-abundance epistaxis. The attitude was non-invasive ventilation and broad-spectrum antibiotics therapy. Control chest CT showed emphysematous lung with signs of fibrosis with bilateral subpleural nodules. A rereading of the scanner showed intraalveolar hemorrhage which has regressed on the imaging of the control. Based on these data, pneumo renal syndrome was suspected and a bronchoscopy was performed showing alveolar hemorrhage with 70% siderophageswith Gold score superior to 100. Anti-GBM and p-ANCA and antibodies were positive at a high titer. Electroneuromyogram was without anomaly. Kidney biopsy was not done because of the presence of multiple cysts. The patient received pulse methylprednisone for three days followed by oral prednisone and underwent eleven sessions of plasmapheresis. Intraveinous Cyclophosphamide has been started. He showed remarkable recovery as his lung fields cleared with negativity of GBM antibodies. Kidney function didn't improved and he remained dependent on dialysis. Conclusions: Our observation is exceptional since the clinical and radiological presentation of the patient was not that of a pulmonary-renal syndrome. The elements of this syndrome have in fact been masked by the obstacle on the urinary tract on one hand and the hypothesis of a covid19 pneumonia on the other hand in the face of the epidemiological context. Atypical feature of pulmonary renal syndrome should be kept in mind to avoid diagnostic and treatment delays. No conflict of interest

Le post-COVID : maladie à multiple facettes

Introduction L’infection à SARS-CoV-2 constitue un fléau mondial de la part de sa gravité initiale et aussi à causes des séquelles cliniques fréquemment décrite. Ces complications constituent un fardeau lourd augmentant ainsi sa morbi-mortalité. L’objectif de cette étude est d’étudier la fréquence des signes cliniques persistants à distance de l’épisode aigu et d’en déduire les facteurs favorisants. Méthodes Il s’agit d’une étude prospective intéressant 67 sujets ayant été infectés par le SARS-CoV-2, menée au service de pneumologie COVID. Les patients ont été revus à la consultation externe après trois mois de l’infection. Résultats La population d’étude a été faite de 67 sujets, 59 (88 %) parmi eux ont été hospitalisé. Une prédominance masculine a été notée avec un sex-ratio de 1,5. La moyenne d’âge a été de 62,5±13 ans [33–87]. Les comorbidités associées ont été l’hypertension artérielle, le diabète, la dyslipidémie et l’hypothyroïdie dans 34,4 %, 16,4 %, 14,9 % et 9 % des cas respectivement. Le délai moyen de consultation a été de 93±19 jours [70–138]. Parmi ces patients, 42 sujets (61,8 %) ont gardé plus que 3 symptômes, 22 sujets (33,4 %) ont gardé 1 à 2 symptômes et 4 sujets (5,9 %) n’ont gardé aucun symptôme. Les signes cliniques les plus fréquemment rapportés ont été la dyspnée dans 53,7 % des cas, l’asthénie dans 29,9 % des cas, la céphalée dans 22,4 % des cas et la douleur thoracique dans 20,9 %. Les troubles cognitifs les plus rencontrés ont été les troubles de la mémoire dans 43,3 % des cas et les troubles de la concentration chez 38,8 % des patients. Une symptomatologie certaine d’anxiété et de dépression a été notée dans 9 % et 4,5 % des cas respectivement. L’étude univariée n’a pas montré une association entre la sévérité de la pneumopathie, le rapport neutrophiles sur lymphocytes, le taux de D-dimères et la persistance des signes cliniques initialement décrits. Toutefois, elle a montré une association entre l’âge et la persistance de l’anosmie (p=0,001), l’agueusie (p=0,02), l’anorexie (p=0,001), les palpitations (p=0,02), et les cauchemars (p=0,02). Conclusion Notre étude a permis de mettre en évidence le spectre très large de manifestations cliniques rapportées en post-infection à COVID-19 avec au premier plan l’atteinte respiratoire, les signes généraux et cognitifs. De ce fait, les manifestations du COVID long doit être recherchées et traitées à temps.

Le scanner thoracique lève le voile sur les séquelles pulmonaires du COVID

Introduction La gravité de l’infection à SARS-CoV-2 réside non seulement dans le risque important de mortalité en phase aiguë mais aussi à long terme compte tenu de séquelles essentiellement pulmonaires. Le but de notre étude est de préciser le type d’atteinte parenchymateuse et d’expliquer les facteurs favorisants. Méthodes Il s’agit d’une étude prospective intéressant 45 sujets ayant été infectés par le SARS-CoV-2, menée au service de pneumologie COVID entre octobre et mars 2021. Les patients ont été revus à la consultation externe après trois mois de l’infection avec une TDM thoracique de contrôle. Ils ont été divisés en deux groupes selon la présence ou non d’anomalies scanographiques. Résultats Il s’agit de 45 patients avec un sex-ratio de 2 soit 15 femmes et 30 hommes. La moyenne d’âge a été de 63±11 ans [37–87]. Les comorbidités les plus associées ont été l’hypertension artérielle, la dyslipidémie, le diabète et l’hypothyroïdie dans 40 %, 17,8 %, 15,6 % et 6,7 % des cas respectivement. L’étendue de l’atteinte scanographique initiale a été de moins de 25 % pour 10 sujets, de 25 à 50 % pour 13 patients, de 50 à 75 % pour 10 patients et de plus de 75 % dans 3 cas. Le délai moyen de réalisation du scanner de contrôle a été de 98±31 jours. L’étude scanographique a objectivé la présence d’anomalies parenchymateuses chez 34 (75 %) sujets avec une régression des lésions initiales dans 91 % des cas. Dans le groupe 1, on a noté une fréquence plus importante de sujets âgés, de tabagiques et ceux hospitalisés pour une pneumopathie sévère : 60 % versus 40 %, 65 % versus 35 % et 61 % versus 31 %. Les lésions scanographiques les plus décrites ont été : le verre dépoli dans 53,3 % des cas, les condensations dans 13,3 %, les réticulations dans 28,9 %, l’épaississement des septa dans 15,6 % des cas et le rayon de miel dans 4,4 % des cas. Le degré de l’atteinte scanographique a été de 7±11 % [0–50]. L’étude univariée n’a pas montré d’association entre la persistance d’anomalie scanographique et les comorbidités, l’âge, le rapport neutrophiles sur lymphocytes, la durée de l’oxygénothérapie. Conclusion Les lésions scanographiques les plus trouvées en post-COVID ont été le verre dépoli, les réticulations et l’épaississement des septa. D’où l’intérêt d’une surveillance aussi bien clinique que radiologique des sujets atteints d’une infection à SARS-CoV-2.

Infection par le coronavirus COVID 19 chez les transplantés rénaux : l'expérience de l'hôpital Sahloul Sousse Tunisie

Déclaration de liens d’intérêts: Les auteurs déclarent ne pas avoir de liens d’intérêts.

POS-217 RENAL AMYLOIDOSIS IN AN EXCEPTIONNAL ASSOCIATION OF GLANZMANN'S THROMBASTHENIA AND CROHN'S DISEASE

Introduction: Crohn's disease (CD), a polygenic disorder, is the major subtype of inflammatory bowel disease. There is disease heterogeneity and many patients present extraintestinal manifestations. However, the association of crohn's disease with another genetic disease has not been previously described. Methods: We report the exceptional association of CD with Glanzmann’s thrombasthenia which is a rare inherited bleeding disorder. Indeed, the diagnosis in a patient of kidney amylosis, which we think secondary to CD, has revealed the association of the two diseases in a Tunisian family. Results: A 38 years old man was admitted in August 2020 in our Nephrology department for management of severe nephrotic syndrome with normal renal function. He was born of first-cousin consanguineous parents and diagnosed with Glanzmann's thrombasthenia since childhood. His family history was remarkable: His mother and maternal uncle had CD, his sister have also Glanzmann's thrombasthenia. At examination,blood pressure was 09/60 mmHg and the patient was in anasarque and complained of chronic diarrhea. Given renal biopsy was a high bleeding risk procedure in this patient with Glanzmann thrombasthenia, we decided to perform biopsy of salivary gland and Congo red staining showed the presence of characteristic amyloid deposits. During hospitalization the patient presented persistent diarrhea without fever. Enteroscann showed prominent wall thickening and mucosal hyperemia encompassing a 10 cm segment of ileum. Colonoscopy found discontinuous distribution of longitudinal ulcers with small aphthous ulcerations typical of CD. Biopsy was not performed because the risk of bleeding was high. The diagnosis of renal amyloidosis as a complication of CD was made. Treatment was symptomatic with the introduction of systemic corticosteroid therapy as a treatment for CD. Evolution was marked by the occurrence of acute kidney failure in conjunction with covid 19 infection. Conclusions: We reported the uncommon association of Glanzmann’s thrombasthenia with renal amyloidosis complicating CD in a patient with remarkable family history of consanguineous marriage. It is an association of two hereditary diseases never reported in literature. We believe that a genetic explanation must certainly exist. The family investigation is ongoing. No conflict of interest

POS-112 HEMODIALYSIS EMERGENCIES : A MONOCLONAL EXPERIENCE

Introduction: Hemodialysis emergencies in nephrology are frequent. Prompt diagnosis and management are needed to save life and enhance prognosis. The aim of this work was to determine the hemodialysis’ prevalence in emergency situations, its indications, the clinical, paraclinical and evolutionary profiles and to describe the parameters of the session as well as the per-dialytic incidents and their impacts on patient mortality. Methods: It is a retrospective monocentric descriptive study during 3 months (July, August, and September 2020) carried out in the nephrology department of the University teaching hospital of Sousse. We collect patients who underwent at least one session of HD. Results: We included 61 patients who underwent emergency hemodialysis. The average age of our patients was 58±17 years (17- 95) and the sex ratio was 1,5. Our patients have hypertension and diabetes in respectively 56,1% and 34,4% of cases. 42,6% of patients were admitted from the emergency department, 27,9% of patients from the surgical and urology department, 18% of patients from nephrology departments and 11,5% of patients from other departments. Our population consists in chronic HD patients in 34,5%. Chronic renal failure was noted in 43,6% with diabetic nephropathy as the most primary cause (44,1%). Acute renal failure was found in 18.2% with Obstructive nephropathy (66,1%) as the main etiology.two patients were transplanted (3,3%). HD indications were hyperkalemia in 30%, acute pulmonary edema in 25% and metabolic acidosis in 23,3% of cases. Conventional HD was performed with mean session duration of 3,4 hours. Ultrafiltration was required in 73,8% with an average of 1800ml (range: 500-4000).The most frequently used approach was the femoral route in 54,1% followed by arterioveinous fistula in 24,6%. Transfusion was required in 26,2% of cases. Perdialytic complications were observed in 29,5% of cases. Hypotension was the most common complication present in 13,1% of case;which leads to the interruption of the session in 4.9% of cases;followed by agitation in 4,9% of case. The renal evolution of our population was hemodialysis dependence in 35,6%, back to basic level in13,3%chronic kidney disease in4,4% and recovery in 2,2%. Death occurred in 5 cases including 3 patients outside dialysis and 2 patients on dialysis. Infection by SARS covid 19 was the cause of death in 1 patient. Conclusions: Extra-renal purification (REE) is sometimes essential in an emergency situation in the management of severe ARI or terminal CKD. Early diagnosis and relevant treatment will enhance the prognosis of patients in the short and medium term. No conflict of interest