Validation of the international IgA nephropathy prediction tool in a French cohort beyond 10 years after diagnosis.

INTRODUCTION: The International IgA Nephropathy Network developed a tool (IINN-PT) for predicting the risk of end-stage renal disease (ESRD) or a 50% decline in the estimated glomerular filtration rate (eGFR). We aimed to validate this tool in a French cohort with longer follow-up than previously published validation studies. METHODS: The predicted survival of patients with biopsy-proven immunoglobulin A nephropathy (IgAN) from the Saint Etienne University Hospital cohort was computed with IINN-PT models with or without ethnicity. The primary outcome was the occurrence of either ESRD or a 50% decline in eGFR. The models' performances were evaluated through c-statistics, discrimination and calibration analysis. RESULTS: There were 473 patients with biopsy-proven IgAN, with a median follow-up of 12.4 years. Models with and without ethnicity showed areas under the curve (95% confidence interval) of 0.817 (0.765; 0.869) and 0.833 (0.791; 0.875) and R2D of 0.28 and 0.29, respectively, and an excellent discrimination of groups of increasing predicted risk (P < .001). The calibration analysis was good for both models up to 15 years after diagnosis. The model without ethnicity exhibited a mathematical issue of survival function after 15 years. DISCUSSION: The IINN-PT provided good performances even after 10 years post-biopsy as showed by our study based on a cohort with a longer follow-up than previous cohorts (12.4 versus <6 years). The model without ethnicity exhibited better performances up to 15 years but became aberrant beyond this point due to a mathematical issue affecting the survival function. Our study sheds light on the usefulness of integrating ethnicity as a covariable for prediction of IgAN course.

Mycophenolate sodium dosing in combination with tacrolimus: pharmacokinetic evaluation of a novel regimen in de novo tacrolimus-treated kidney transplant patients.

BACKGROUND: There are no clear guidelines concerning the appropriate dose of mycophenolate acid (MPA) to be used in association with tacrolimus. When MPA is given at an approved fixed dose in cyclosporine-treated patients, initial systemic under exposure is frequent and associated with the occurrence of acute rejection. We pharmacologically evaluated in tacrolimus-treated recipients a novel dosing regimen of MPA with an initial high dose followed by a gradual decrease over time. METHODS: 15 de novo tacrolimus-treated kidney transplant patients were administered mycophenolate sodium at the dose of 720 mg b.i.d. for the first week post-transplant, 540 mg b.i.d. until Day 30, and then 360 mg b.i.d. until Day 90. MPA exposure was evaluated by the 12 h area under MPA concentration versus time curve (AUC) determined at Days 2, 7, 15, 30 and 90 post-transplant. RESULTS: Median MPA AUC was constantly within the therapeutic window of 30 - 60 mg/l × h throughout the three months of evaluation. More than 75% of patients had a MPA AUC above 30 mg/l × h at Day 2 and Day 7 post-transplant. CONCLUSION: This exploratory study suggests that such a dosing regimen of mycophenolate sodium might quickly offer and sustain an optimal exposure to MPA in tacrolimus-treated kidney transplant patients.

The use of the Oxford classification of IgA nephropathy to predict renal survival.

BACKGROUND AND OBJECTIVES: A new classification for IgA nephropathy was recently proposed, namely the Oxford classification. It established specific pathologic features that predict the risk of progression of renal disease. This classification needs validation in different patient populations. We propose a retrospective study to evaluate the predictive value of the Oxford classification on renal survival defined by doubling creatinine or end-stage renal disease in patients with IgA nephropathy. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We included 183 patients with primary IgA nephropathy diagnosed between 1994 and 2005. Mean follow-up time was 77 months. Doubling creatinine occurred in 20% of the patients, and end-stage renal disease occurred in 16%. The biopsies were revisited to apply the Oxford classification. The influence of pathologic features on renal survival was analyzed in univariate and multivariate models. RESULTS: In univariate time-dependent analyses, tubular atrophy/interstitial fibrosis, segmental glomerulosclerosis, and endocapillary hypercellularity strongly impacted doubling creatinine or end-stage renal disease. On the contrary, mesangial hypercellularity was not associated with renal outcome. In the multivariate model, only estimated GFR at baseline was a risk factor, pathologic lesions having no independent influence. CONCLUSIONS: We confirm the usefulness of the Oxford classification to establish the renal prognosis of patients with IgA nephropathy, although renal function at baseline seems to be of a greater importance than pathologic lesions.

[Telemedicine: an unfruitful experience of tele-expertise in nephrology]. / Télémédecine : une expérience infructueuse de télé-expertise en néphrologie.

INTRODUCTION: We developed a new system of medical tele-expertise to improve detection and care of chronic renal failure by way of a better communication between general practitioners and specialists. It has been known for long that the incidence of chronic renal failure is increasing while cost of its treatment is very high. Unfortunately, late referral of patients with kidney diseases remains around 30%. Our goal was to help physicians to get access to nephrologists, hence to improve the cure of renal diseases. An early treatment of nephropathies may avoid the evolution to the stage of dialysis. METHODS: We created a website with the technical support of the firm Unimedecine. It allowed a secure and fast exchange of medical data, all about the case of a one patient. RESULTS: General practitioners seemed enthusiastic, but at the end, only a few of them did use the website. The number of connexion remained low throughout a 3-year experience. Questions were about advices but no progressive nephropathy was discovered. The cost of the website was a prohibitive 75 000 euros for 3 years. Therefore, we had no choice that to close the experience. DISCUSSION: Telemedicine needs juridical rules and specific finances to work on a long run.