Nurse-assisted arterio-venous fistula cannulation during home hemodialysis: first results of the DIADIDEAL study / La ponction de fistule assistée par infirmier libéral en hémodialyse à domicile : premiers résultats de l'étude DIADIDEAL.

Introduction: We have launched a pilot study, called DIADIDEAL, to propose nurse-assistance at home for arterio-venous fistula (AVF) cannulation in home hemodialysis (HHD) patients. The aim of the present study was to describe enrollment of the patients and their nurses. Materials: All prevalent HD patients on 30th November 2018 with no medical contraindication to HDD treatment and all incident patients on dialysis from the 30th November 2018 to the 21st April 2023 were eligible. Results: Among 155 prevalent HD patients, 4 patients were included. Among the 276 incident patients on dialysis during the study period, 6 were included. We have phoned 23 nurse centers during the recruitment period. Eight of them agreed to learn in our unit how to cannulate AVF; 27 private nurses were enrolled. Discussion: The results of the DIADIDEAL study will be available in 2024; we hope it will lead to a reimbursement of nurse-AVF cannulation at home in HDD.

Introduction: L'étude DIADIDEAL est une étude pilote sur la ponction de fistule artério-veineuse (FAV) assistée par infirmier libéral en hémodialyse à domicile (HDD). L'objectif de l'étude actuelle est de rapporter le recrutement des patients et de leurs infirmiers diplômés d'État libéraux (IDEL). Matériels et méthodes: Tous les patients prévalents en HD au 30 novembre 2018 n'ayant pas de contre-indication médicale à un traitement par HDD ainsi que tous les patients incidents en dialyse du 30 novembre 2018 au 21 avril 2023 étaient éligibles. Résultats: Parmi les 155 patients prévalents en hémodialyse, 4 ont été inclus. Parmi les 276 patients incidents en dialyse sur la période, 6 ont été inclus dans l'étude. Parmi les 23 cabinets IDEL contactés pour l'étude, 8 ont accepté et 27 IDEL ont été formés à la ponction de FAV. Discussion: Les résultats de l'étude DIADIDEAL seront disponibles en 2024 et viseront à obtenir une nomenclature pour l'acte de ponction de FAV par les IDEL.

Nurse-assisted arterio-venous fistula cannulation during home hemodialysis: first results of the DIADIDEAL study / La ponction de fistule assistée par infirmier libéral en hémodialyse à domicile : premiers résultats de l'étude DIADIDEAL.

Introduction: We have launched a pilot study, called DIADIDEAL, to propose nurse-assistance at home for arterio-venous fistula (AVF) cannulation in home hemodialysis (HHD) patients. The aim of the present study was to describe enrollment of the patients and their nurses. Materials: All prevalent HD patients on 30th November 2018 with no medical contraindication to HDD treatment and all incident patients on dialysis from the 30th November 2018 to the 21st April 2023 were eligible. Results: Among 155 prevalent HD patients, 4 patients were included. Among the 276 incident patients on dialysis during the study period, 6 were included. We have phoned 23 nurse centers during the recruitment period. Eight of them agreed to learn in our unit how to cannulate AVF; 27 private nurses were enrolled. Discussion: The results of the DIADIDEAL study will be available in 2024; we hope it will lead to a reimbursement of nurse-AVF cannulation at home in HDD.

Introduction: L'étude DIADIDEAL est une étude pilote sur la ponction de fistule artério-veineuse (FAV) assistée par infirmier libéral en hémodialyse à domicile (HDD). L'objectif de l'étude actuelle est de rapporter le recrutement des patients et de leurs infirmiers diplômés d'État libéraux (IDEL). Matériels et méthodes: Tous les patients prévalents en HD au 30 novembre 2018 n'ayant pas de contre-indication médicale à un traitement par HDD ainsi que tous les patients incidents en dialyse du 30 novembre 2018 au 21 avril 2023 étaient éligibles. Résultats: Parmi les 155 patients prévalents en hémodialyse, 4 ont été inclus. Parmi les 276 patients incidents en dialyse sur la période, 6 ont été inclus dans l'étude. Parmi les 23 cabinets IDEL contactés pour l'étude, 8 ont accepté et 27 IDEL ont été formés à la ponction de FAV. Discussion: Les résultats de l'étude DIADIDEAL seront disponibles en 2024 et viseront à obtenir une nomenclature pour l'acte de ponction de FAV par les IDEL.

Impact of simulation-based training in addition to theoretical training versus theoretical training of nurses alone in the occurrence of adverse events related to arteriovenous fistula puncture in chronic hemodialysis patients: study for a cluster randomized controlled trial (SIMFAV2).

BACKGROUND: The technique of arteriovenous fistula (AVF) puncture is currently taught by colleagues within hemodialysis units. Even if the main principles of the technique are well known and common to all hemodialysis units, strong rationales are still missing to standardize fine practices such as the relative position of the needles, the angle of the needle at puncture, and the position of the bevel at the time of puncture and after the needle is in the vascular lumen. METHODS: We are conducting a prospective, comparative, center-randomized, multicenter study involving 8 hemodialysis centers. The primary objective is to compare the number of adverse events related to AVF puncture between a group receiving theoretical training plus simulation-based training (4 centers) and a group receiving only theoretical training (4 centers). The study will include all adult patients who are scheduled to have an AVF puncture performed by a hemodialysis-trained nurse during a scheduled chronic dialysis session. DISCUSSION: We hypothesize that a training program for nurses on the AVF approach in procedural simulation versus theoretical input alone would decrease the adverse events related to AVF punctures and would be beneficial for the patient. This study is innovative for several reasons. First, simulation-based training in continuing education among professionals is not widely used. Furthermore, training allows for the standardization of practices within the team, both technically and relationally. TRIAL REGISTRATION: ClinicalTrials.gov NCT05302505 . Registered on March 17, 2022.

A New Procedure for Guidewire Exchange of Tunneled Hemodialysis Catheters in Chronic Hemodialysis Patients: A Pilot Study.

INTRODUCTION: Different techniques of guidewire exchange of tunneled catheters for hemodialysis (HD) have been reported. This study was carried out to assess the feasibility of a new procedure in chronic HD patients who needed catheter exchange because of mechanical dysfunction. METHODS: The guidewire exchange method was based on the creation of a new exit site and a new subcutaneous tunnel while using the same venous insertion site. This was a retrospective study of exchanged tunneled catheters because of mechanical complications in patients on chronic HD between June 1, 2015, and December 31, 2019. The feasibility of the procedure was defined by successful exchange and catheter patency at 6 months. Catheter survival and immediate complications were reported. RESULTS: A total of 49 procedures were performed in 34 HD patients. There was no catheter insertion failure. At 6 months, 6 catheters have lost their patency because of a mechanical complication. Thus, the success rate of the procedure was 43/49 (87.8%). Catheter survival censored on death, transplantation, or vascular access creation was 97.8% at 90 days, 86.2% at 180 days, and 74.5% at 1 year. The median catheter survival was 10.2 months. Among the 49 procedures, there were 9 hematomas at the insertion site that did not require surgical intervention. Discussion/Conlusion: Our study shows that guidewire exchange of a tunneled HD catheter by creating a new exit site and a new subcutaneous tunnel by using the same venous access is a newer method in chronic HD patients. This procedure should not be used in patients with coagulation issues. Additional studies are needed to compare the different methods of HD catheter exchange.

Prevalência de Sintomas Depressivos em Usuários de Unidades Básicas de Saúde em uma Cidade do Sul de Santa Catarina / Prevalence of depressive symptoms in users of basic health units in a city in southern Santa Catarina

Introdução: A depressão é um grande problema de saúde pública, sendo das causas mais frequentes de busca de atendimento nas Unidades Básicas de Saúde. O objetivo deste estudo foi investigar a prevalência de sintomas depressivos em usuários de Unidades Básicas de Saúde em uma cidade do sul de Santa Catarina, além de verificar a associação dos sintomas depressivos com o perfil sociodemográfico desses usuários. Métodos: Estudo observacional do tipo transversal realizado com 375 usuários de Unidades Básicas de Saúde do município de Tubarão/SC, no período de setembro a dezembro de 2019. Foram utilizados o Inventário de Depressão de Beck para investigação de sintomas depressivos e um questionário para avaliação de dados sociodemográficos. Resultados: A maior parte do estudo foi composta por mulheres, de faixa etária de 18 a 39 anos, caucasianos e com escolaridade até ensino fundamental. Houve significância estatística na associação de sintomas depressivos com o gênero, escolaridade, nível de renda, situação de trabalho, prática de atividade física, tabagismo, uso de psicofármacos, diagnóstico prévio de depressão e presença de comorbidades. Conclusão: A prevalência de sintomas depressivos encontrada neste estudo foi de 49,1%. Os fatores relacionados à maior prevalência de sintomas depressivos foram sexo feminino, baixa escolaridade, menores níveis de renda, ausência de trabalho, ausência de prática de atividade física, tabagismo, uso de psicofármacos, diagnóstico prévio de depressão e presença de comorbidades.

Introduction: Depression is a significant public health problem and is one of the most frequent causes of seeking care in basic health units. This study aimed to investigate the prevalence of depressive symptoms in users of basic health units in a city in southern Santa Catarina and to verify the association of depressive symptoms with the sociodemographic profile of these users. Methods: A cross-sectional observational study was conducted with 375 users of basic health units in Tubarão/ SC from September to December 2019. The Beck Depression Inventory was used to investigate depressive symptoms, and a questionnaire to assess sociodemographic data. Results: The majority of the study was composed of women aged 18-39 years, Caucasian, and with education up to elementary school. There was statistical significance in the association of depressive symptoms with gender, education, income level, work situation, the practice of physical activity, smoking, use of psychoactive drugs, previous diagnosis of depression, and presence of comorbidities. Conclusions: The prevalence of depressive symptoms found in this study was 49.1%. The factors related to the highest prevalence of depressive symptoms were female gender, low education, lower income levels, absence of work, absence of physical activity, smoking, use of psychiatric drugs, previous diagnosis of depression, and presence of comorbidities.

Nível de Atividade Física, Força de Preensão Palmar e Variabilidade da Frequência Cardíaca em Idosos / Physical activity level, grip strength and heart rate variability in elderly

Introdução: O processo de envelhecimento ocasiona alterações no sistema cardiovascular e afeta a capacidade funcional. Objetivo: Analisar as associações entre indicadores sociodemográficos, índice de massa corporal (IMC), comorbidades, nível de atividade física (NAF) e força de preensão palmar (FPP) na variabilidade da frequência cardíaca (VFC) em idosos. Métodos: Estudo transversal com idosos participantes de grupos de convivência no município de Tubarão, Santa Catarina. As variáveis sexo, idade, altura, peso, tabagismo e comorbidades foram autorreferidas. O NAF foi calculado pelo Questionário Internacional de Atividade Física (IPAQ) versão curta. Os dados da VFC foram obtidos com um cardiofrequencímetro, sendo extraídos os componentes FC média (frequência cardíaca média), SDNN (desvio-padrão de todos os intervalos RR), RMSSD (raiz quadrada da média do quadrado das diferenças entre intervalos RR normais adjacentes), RRTri (índice triangular), LF (componente de baixa frequência), HF (componente de alta frequência) e LF/HF (razão entre os componentes de baixa e alta frequência). A FPP foi mensurada com um dinamômetro. Resultados: Participaram 73 idosos com mediana (p25-p75) de idade de 77,0 (68,5 - 77,0) anos, sendo 65 (89%) mulheres. Verificou-se aumento de HF nos homens e RMSSD superior na faixa etária de 70 a 80 anos. Ocorreu diminuição da FC média e aumento de RRTri e LF quando NAF moderado/alto. Um acréscimo de SDNN, RMSSD e HF foi observado em valores diminuídos de FPP das mulheres. Conclusão: Sexo, faixa etária, NAF e FPP das mulheres estiveram associados na modulação autonômica cardíaca, enquanto que IMC, comorbidades, tabagismo e FPP dos homens não interferiram significativamente.

Introduction: The aging process causes changes in the cardiovascular system and affects functional capacity. Objective: To analyze the associations between sociodemographic indicators, body mass index (BMI), comorbidities, level of physical activity (LPA), and grip strength (GS) in heart rate variability (HRV) in the elderly. Methods: A cross-sectional study was carried out with elderly participants of socialization groups in Tubarão, Santa Catarina. The variables sex, age, height, weight, smoking, and comorbidities were self-reported. The LPA was calculated by the short version of the International Physical Activity Questionnaire (IPAQ). The HRV data were obtained with a cardiofrequency meter, and the following components were extracted: mean HR (mean heart rate), SDNN (standard deviation of all RR intervals), RMSSD (square root of the mean square of the differences between adjacent normal RR intervals), RRTri (triangular index), LF (low frequency component), HF (high frequency component) and LF/HF (ratio between low and high frequency components). The measuring of GS was with a dynamometer. Results: 73 elders participated, with a median (p25p75) age of 77.0 (68.5 77.0) years, 65 (89%) of whom were women. An increased HF in men and higher RMSSD in the 70 to 80 years old age group were verified. A decrease in mean HR and an increase in RRTri and LF occurred when moderate/high LPA. The study showed an increase in SDNN, RMSSD, and HF in decreased GS values of women. Conclusion: Sex, age group, LPA, and GS of women were associated with cardiac autonomic modulation, while BMI, comorbidities, smoking, and GS of men did not interfere significantly.

Innovations en hémodialyse à domicile: Innovations in home hemodialysis.

Dialysis is a restrictive treatment with a significant impact on the quality of life of patients. Home hemodialysis (HHD) allows to maintain quality of life while improving the conditions of purification, in particular with the daily or even nocturnal practice of hemodialysis. The arrival of systems with a cycler in the 2010s for home hemodialysis brings a new dynamism for this type of technique. The practice with dialysate low flow with the optimization of storage space, the simplification of the use of generators and the emmergence of telemonitoring tools increases the accessibility of this dialysis technique, so that we can hope in the coming years to be able to offer this dialysis modality to any patient with chronic renal failure requiring extra-renal purification. ©2022 Société francophone de néphrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.

[Descriptive study of practices with patients in conservative care practices in a French district, the Normandy]. / Étude descriptive des pratiques normandes dans la prise en charge des patients en traitement conservateur.

INTRODUCTION: Renal replacement therapy and renal transplantation can't be considered as the only way to treat old end-stage renal disease patients. Nowadays conservative management has to be considered and proposed as a treatment option to patients with a chronic kidney disease. The aim of this study was to describe nephrologists' practices concerning conservative management care in a French department. MATERIAL AND METHOD: A cross-sectional practices survey has been conducted in 2015. A survey was sent to 66 nephrologists in 14 treatment centers in the Normandy region. RESULTS: 49 of the 66 nephrologists responded to the questionnaire. Among the 48 nephrologists who responded to the questionnaire, 38 out of 48 (79.2%) did not use decision support tools to implement conservative treatment. In all, 42/48 (87.5%) nephrologists did not discuss with their colleagues before providing conservative treatment. Meeting dedicated to the decision of conservative treatment did not exist in any center surveyed in this study. When conservative management was chosen, 34/48 nephrologists (70.8%) discussed end-of-life. And 31/48 nephrologists (64.6%) used the term "death". CONCLUSION: The results of this study show that the course of the patients in conservative treatment is heterogeneous and is not formalized. Improvements are needed to integrate conservative treatment for patients with chronic kidney disease.

[Clinical management of patients with hemophilia A in nephrology: Diagnostic and therapeutic challenges illustrated by the cases of 2 patients]. / Prise en charge néphrologique des patients hémophiles A : difficultés diagnostiques et thérapeutiques illustrées par le cas de 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.

Impact of pharmacist interventions on clinical outcome and cost avoidance in a university teaching hospital.

Background A significant number of clinical pharmacy services have shown to improve in-hospital medication safety and patient outcome. Prescription review and pharmacist interventions are a fundamental part of hospital clinical pharmacy activities. In a context of restricted financial resources, proving the economic and clinical impact of this activity seems necessary. Objective The aim of this study was to assess the clinical impact on patient outcomes and economic benefit of prescription review by pharmacists. Setting 1624-bed tertiary French university teaching hospital. Method Prospective single center study evaluating prescriptions for which a pharmacist intervention was issued over a 6-month period. The clinical impact of every pharmacist intervention was evaluated by a multidisciplinary experts committee. Economic benefit was evaluated from the public health care system spending standpoint. Main outcome measures Number of avoided hospitalization days and associated public health care system cost-avoidance. Results Prescription review and interventions by pharmacists prevented 73 intensive care unit hospitalization days, 74 continuous monitoring unit hospitalization days and 66 days of conventional hospitalization. €252,294.00 in public health expenditure were thus prevented. For every Euro invested in the prescription review activity, €5.09 of public health spending were potentially saved. Conclusion Our study shows that prescription review and clinical pharmacists' interventions had an impact on clinical outcomes which translated into prevented hospitalization days. Prescription optimization through pharmacist interventions allows significant health care cost savings which makes this service highly efficient.

Does the Blood Pump Flow Rate have an Impact on the Dialysis Dose During Low Dialysate Flow Rate Hemodialysis?

We conducted a prospective study to assess the impact of the blood pump flow rate (BFR) on the dialysis dose with a low dialysate flow rate. Seventeen patients were observed for 3 short hemodialysis sessions in which only the BFR was altered (300,350 and 450 mL/min). Kt/V urea increased from 0.54 ± 0.10 to 0.58 ± 0.08 and 0.61 ± 0.09 for BFR of 300, 400 and 450 mL/min. For the same BFR variations, the reduction ratio (RR) of ß2microglobulin increased from 0.40 ± 0.07 to 0.45 ± 0.06 and 0.48 ± 0.06 and the RR phosphorus increased from 0.46 ± 0.1 to 0.48 ± 0.08 and 0.49 ± 0.07. In bivariate analysis accounting for repeated observations, an increasing BFR resulted in an increase in spKt/V (0.048 per 100 mL/min increment in BPR [p < 0.05, 95% CI (0.03-0.06)]) and an increase in the RR ß2m (5% per 100 mL/min increment in BPR [p < 0.05, 95% CI (0.03-0.07)]). An increasing BFR with low dialysate improves the removal of urea and ß2m but with a potentially limited clinical impact.

Pregnancy on short-daily home hemodialysis using low dialysate flow rate: A new hope for the end-stage renal disease patients.

INTRODUCTION: In France in 2014, there were approximately 1500 patients of reproductive age treated by dialysis. Pregnancy in these patients remains rare, however, the incidence has increased since the 2000s, with a parallel increase in the fetal survival rate. We report 2 cases of pregnancy in short-daily home hemodialysis using low dialysate flow rate. METHODS: Short-daily hemodialysis was continued at the request of the patients. The treatment consisted in an increase of frequency and duration of hemodialysis sessions, an independent blood pressure and dry weight control supervised by nephrological monitoring twice a month and a regular obstetrics follow-up. FINDINGS: Both patients continued hemodialysis at home until delivery and gave birth to 2 moderately premature babies, without other complication and resumed short-daily home hemodialysis fastly after delivery. CONCLUSION: Short-daily hemodialysis using low dialysate flow rate during pregnancy seems to allow a good control of uremia and blood pressure without requiring a major increase of weekly dialysis duration. Therefore, it could become an alternative to other hemodialysis programs while allowing the patients to continue their treatment at home. However, other studies are necessary in order to define the position of this procedure during pregnancy.

[Low flux dialysate daily home hemodialysis: A result for the 62 first French and Belgian patients]. / Hémodialyse quotidienne à bas débit de dialysat à domicile : résultats cliniques et biologiques des 62 premiers patients traités en France et en Belgique.

Since 2011, a new device is available for low flux dialysate quotidian home hemodialysis in France and Belgium. This study aims to evaluate the characteristics and dialysis prescriptions for Nx Stage System One™ users. We retrospectively included patients trained between 2011 and 2013 in France and Belgium. We collected data concerning their clinical features, their dialysis prescriptions, their laboratory parameters until 6 months of dialysis and, reason for dropping in case of cessation. Sixty-two patients from 31 centers, aged 48±18 years old, with a sex ratio 46/16 (M/F) are included with a median Charlson comorbidity index of 1 [0-3]. Of these patients, 71% are anuric and have been on dialysis for a mean time of 136.6±125 months. Previously, most of them had been taken care of in satellite units of dialysis (45%) and 14% are incident patients. In total, A total of 60% have an arterio-veinous fistula (AVF), with 18 patients using the Buttonhole system and 2 patients have a tunneled catheter. Median time for training was 26.5 days (17-45). Among the patients, 69% are dialyzed 6 days a week, during a mean time of 142.5±20 minutes with a volume of 20.9±3 liters of dialysate and without anticoagulant (63%). Predialytic levels of hemoglobin, creatinin, urea, phosphorus and ß2microglobulin remain stable. On the contrary, there is a significant improvement of albumin and bicarbonate levels. Technique survival was 75% at 1 year, and major reason for cessation was kidney transplant. It seems that this device fits for young patients, with few comorbidities and a long past in renal chronic failure. These results suggest that dialysis adequacy is acceptable despite low dialysate volumes but need confirmation with a longer follow up and a larger cohort.

[BK virus infections in kidney transplantation]. / Infections à BK virus en transplantation rénale.

BK virus is near ubiquitous, with a seroprevalence of around 80% in the general population. Subsequent to an asymptomatic primary infection, BK virus then remains dormant in healthy subjects. Reactivation occurs in immunocompromised people. BKv is pathogenic mainly among patients who have received a kidney transplant, in whom the virus can cause specific tubulo-interstitial nephritis and even result in graft failure among approximately 20 to 30% of nephritic cases. Since the mid 90 s, incidence has increased with the use of new powerful immunosuppressor treatments. The cornerstone of BK virus infection or BK virus-associated nephropathy treatment is a decrease of the immunosuppressive regimen, which must then be offset with the risk of rejection. The use of several adjuvant therapies has been submitted (fluoroquinolones, leflunomide, intravenous immunoglobulins, cidofovir), with no sufficient proof enabling the recommendation of first-line prescription. The high frequency of this infection and its potential harmfulness argue for the use of prevention strategies, at least among patients presenting risk factors. Retransplantation is safe after a first kidney allograft loss caused by BK-virus nephropathy, on condition that a screening for viremia is frequently conducted.

Effectiveness of continuous glucose monitoring in dialysis patients with diabetes: the DIALYDIAB pilot study.

AIMS: The DIALYDIAB trial addresses the contribution of iterative sequences of continuous glucose monitoring (CGM) on glucose control in dialysis patients with diabetes. MATERIALS AND METHODS: In this before-after monocentric 12-week pilot study, dialysis patients with diabetes were monitored with self-monitoring blood glucose (SMBG) 3 times per day during a 6-week period followed by a 5-day CGM recording at 2-week interval during another 6-week period. SMBG and CGM profiles were remotely analyzed by a single diabetes expert who gave therapeutic counseling to dialysis physicians. RESULTS: Fifteen patients who entered the study had a male/female ratio 8/7, age 60.9±14.8 years, BMI 29.9±7.8, diabetes duration 19.2±8.5 years and dialysis duration 6.5±6.9 years. Treatments were diet alone (20%) or diet plus insulin (80%). Mean CGM glucose level was 8.3±2.5 mmol/l at baseline (T0), 8.2±1.6 mmol/l at the end of the SMBG period (T1) (ns) and 7.7±1.6 mmol/l at the end of the CGM period (T2) (p<0.05 vs. T0). Glucose AUC>10 mmol/l was 0.9±1.4 mmol/l/day at T0 and decreased to 0.4±0.5 at T2 (p<0.05)) without change in glucose AUC<3.3 mmol/l. Treatment adaptation was higher during the CGM period (1.4±1.0 and 2.1±0.9 treatment change at T1 and T2, respectively; p<0.05). CONCLUSIONS: In patients with diabetes on chronic dialysis, iterative CGM monitoring was associated with more frequent treatment changes and finally, better glucose control, without increased risk of hypoglycemia.

Hemodialysis in satellite dialysis units: incidence of patient fallback to the in-center dialysis unit.

BACKGROUND: Patient fallbacks occur when a patient treated in a satellite dialysis unit (SDU) must be transferred to an in-center dialysis unit. Fallbacks have an impact on the in-center dialysis unit organization. This study was carried out to estimate the incidence and risk factors of patient fallback. METHODS: Between 01/01/2006 and 31/12/2010 there were 193 patients starting dialysis in SDUs in one French region. The primary outcome was the incidence of temporary and permanent fallbacks with or without hospitalization. A survival analysis and binomial negative regression were used for the statistical analysis. RESULTS: Among the 193 patients, 117 (60.6%; 95% confidence interval [CI]: 53.3-67.6) had at least one fallback, which occurred within a median of 249 days (interquartile range [IQR]: 71-469) after the first session in the SDU. The median number of fallbacks by subject was 1 (IQR: 0-4). The median duration of the fallback period was 4 days (IQR: 1-8) and median number of dialysis sessions during the fallback time was 1 (IQR: 1-3). Of the 494 temporary fallbacks, 210 were due to patient hospitalization, the main cause of which was cardiovascular disease. At univariate analysis, patients permanently transferred to in-center hemodialysis units were older, had more peripheral arteriopathy, cancer and arrhythmia. At multivariate analysis, peripheral arteriopathy (relative risk [RR] 2.06, 95% CI 1.05-4.09) and the center (center 2: RR 0.42, 95% CI 0.21-0.84; center 3: RR 2.88, 95% CI 1.20-6.91) were significantly associated with the number of fallbacks. CONCLUSION: Fallback is a common event in hemodialysis patients treated in SDUs. Yet, the SDU system operates well since a third of patients treated in these units are still in SDUs at 2 years of follow-up. Factors associated with patient fallback are the center and cardiovascular disease.

Comparison between on-line high-efficiency hemodiafiltration and conventional high-flux hemodialysis for polyclonal free light chain removal.

BACKGROUND: Polyclonal free light chains (FLC) are considered as middle molecular weight uremic toxins in chronic kidney disease. In this study, we investigate polyclonal FLC removal by comparing conventional high-flux hemodialysis (HD) and online high-efficiency hemodiafiltration (ol-HDF) in end-stage renal disease patients. METHODS: We analyzed 31 chronic dialysis patients who were treated by HD then by postdilution ol-HDF during a prospective study. All patients were anuric and without monoclonal gammopathy. Serum pre- and postdialysis FLC were collected during 4 sessions: 1 HD session and 3 ol-HDF sessions. We calculated the reduction ratio using kinetic modeling. RESULTS: The κ reduction ratio was higher with ol-HDF than with HD (66 ± 14 vs. 52 ± 13%, p < 0.001). However, the λ reduction ratio was not significantly higher with ol-HDF (37 ± 20 vs. 37 ± 15%, p = 0.67). Furthermore, predialysis κ- and λ-FLC increased with ol-HDF compared with HD (κ 155 ± 82 vs. 87 ± 47 mg/l, p < 0.05; λ 101 ± 46 vs. 72 ± 41 mg/l, p < 0.05). Postdialysis FLC levels were raised only for λ-FLC with ol-HDF (74 ± 39 vs. 53 ± 31 mg/l, p < 0.05) and were not significantly different for κ. CONCLUSIONS: This study shows that κ-FLC removal is better in ol-HDF compared with HD, whereas there is no difference in λ-FLC removal. Surprisingly, predialysis κ and λ levels are both increased in ol-HDF, which is disturbing since polyclonal excess of λ-FLC is associated with mortality in chronic kidney disease.

[Extracellular hydration status and residual urinary sodium excretion in chronic hemodialysis patients: a cross-sectional multicenter study]. / Statut d'hydratation extracellulaire et natriurèse résiduelle en hémodialyse chronique : une étude transversale multicentrique.

BACKGROUND: In dialysis patients, a misevaluation of dry weight may lead to an increased morbidity and mortality. The aim of this cross-sectional multicenter study was to evaluate the association between residual urinary sodium excretion and extracellular volume status in chronically treated hemodialysis patients. PATIENTS AND METHODS: Dry weight was determined clinically and by whole-body bioimpedance spectroscopy (Body Composition Monitor, Fresenius Medical Care) prior to a mid-week session in 40 chronic hemodialysis patients with significant residual diuresis (more than 250 mL per day) and receiving treatment in four dialysis centers. Regarding their hydration status assessed by the Body Composition Monitor and in comparison to a healthy reference population, patients were assigned to 1 of the 3 categories: overhydrated, normohydrated and dehydrated. Urine output, urinary sodium excretion and residual renal function were measured for all patients within 30 days before dry weight assessment. RESULTS: The median post-HD session FO was of-0.40 L (IQR: from-1.95 to+0.90) and the median residual urinary sodium excretion was of 64 mmol/L (IQR: 46-79). Among these patients, 16 were normohydated, 16 were dehydrated and 8 were overhydrated. There was a linear relationship between the hydration status after HD session and the urinary sodium excretion (estimate: 5.6±1.5; p<0.001). Compared with normohydrated patients, overhydrated patients had a higher residual urinary sodium excretion (estimate: 26±10; p<0.01). CONCLUSION: In this study, urinary sodium excretion is associated with the hydration status evaluated by whole-body bioimpedance spectroscopy.

[Who is the physician in charge with the primary care of the dialysis patients?]. / Qui est le médecin de soins primaires du patient traité par hémodialyse ?

INTRODUCTION: The role played by nephrologists in hemodialysis patients' primary care is not well known. We hypothesized that primary care are provided by nephrologists and not by general practitioners for most of these patients. The aim of this study was to estimate the rate of hemodialysis patients having a nephrologist as primary care provider, and to determine which factors were associated with non-resort to a general practitioner for primary care. METHODS: Patients older than 18 years treated by hemodialysis for more than 3 months in the Calvados district were included and were interviewed with a standardized questionnaire. A log-binomial regression was used to study factors associated with non-resort to a general practitioner for primary care. RESULTS: Only 26% of patients had a general practitioner involved in the primary care; whereas 47% considered that nephrologists were the physician in charge of the primary care. Time spent in hemodialysis was associated with non-resort to a general practitioner, while patients living in nursing home were more likely to have regularly a regular follow up by a general practitioner. Dialysis center was a factor associated with the general practitioner as a primary care provider. CONCLUSION: Primary care of the hemodialysis patient is provided by nephrologists.

Mesangial immunoglobulin (Ig)A glomerulonephritis in a patient with rheumatoid arthritis treated with abatacept.

We report observations of a 47-year-old seropositive woman with rheumatoid arthritis (RA) suffering from mesangial immunoglobulin (Ig)A glomerulonephritis (GN) after initiation of abatacept, a selective T-cell co-stimulation modulator cytotoxic T-lymphocyte antigen 4 (CTLA4)-Ig. She was initially treated by corticosteroids, followed by methotrexate associated with a TNF inhibitor (adalimumab then switched to etanercept), finally switched to abatacept monotherapy, after secondary failure of these two forms of TNF inhibitors. Due to a progressively increased hematuria and proteinuria after abatacept therapy initiation, a renal biopsy was performed highlighting GN with mesangial IgA deposits, with necrosis and extracapillary crescent formations. IgA GN as a possible adverse event to abatacept was considered. Abatacept was stopped and a treatment by corticosteroids was initiated. Proteinuria decreased a couple of months after abatacept interruption. The short term between abatacept induction and IgA GN onset, as well as GN improvement since abatacept discontinuation, lend weight to the argument that CTLA4-Ig may play a crucial role in IgA GN pathogenesis. The possibility of a drug postponed adverse event justifies a long-term renal surveillance in RA patients treated by abatacept.