Is renal allograft dysfunction a risk factor for severe infection in kidney transplant recipients?

The ANTICIPE study is a cross-sectional, multicenter, French study. The aim of this study was to describe clinical and biological parameters observed in a cohort of 1446 stable renal transplant recipients, according to the stage of chronic kidney disease. Severe infection was defined as an infection necessitating ≥ 7 days of hospital stay. We observed a negative correlation between declining glomerular filtration rate and occurrence of severe infection (P < .0001). In multivariate analysis, severe infection was associated with age, female gender, chronic kidney disease stage (Kidney Disease Outcomes Quality Initiative classification), and number of acute rejection episodes. Our study suggested that renal allograft function is a predictor not only of cardiac death and cardiovascular complications, but also of severe infections.

[Factors determining the choice of a modality of treatment by dialysis: a study of nine dialysis centers]. / Facteurs déterminant le choix d'une modalité de traitement par dialyse: une enquête dans neuf centres de dialyse.

BACKGROUND: The objective of this cross-sectional study in a population of 1472 dialysis patients was to identify the main factors involved in the choice of a specific option for dialysis therapy, taking into account three different types of criteria such as medical dependence (DM), nurse care requirement (SI) and independence for dialysis therapy (CA). METHODS: Each patient has been analysed, independently of present treatment modality, according to the above three criteria, namely DM, SI and CA. For each type of parameter, patients have been allocated to one of three levels, each level being established to evaluate whether dialytic treatment should be undertaken as hospital centre dialysis (HDC) or in a facility off the hospital. Level 3 of any one category corresponded to the inability of doing haemodialysis at home (HHD) or in self-care unit (AD). Level 2 included patients who could be treated in AD or by peritoneal dialysis (PD) with the assistance of a nurse. CAPD or HHD were considered as potential treatment modalities only in patients qualifying for level 1 of each criterion. RESULTS: In the patient population as a whole, the following treatment options were observed: HHD 3.6%, CAPD 6%, PD 1.8%, AD 16.3% and HDC 72.2%. For medical dependence (DM) there was a relatively even distribution for the three levels in six centres. In contrast, two centres were characterized by a predominance of DM level 3. Differences in DM levels between centres were greatly reduced when considering separately only those patients who were actually treated by CAPD, HDC and AD. SI levels were more uniformly distributed within all centres, and this was true for HCD and AD patients. When considering CA levels in HDC patients, a large predominance of CA level 3 was observed in all centres whereas CA level 1 was nearly in existent. CONCLUSION: The major finding of this study was that the inability or the refusal of dialysis patients to participate at treatment, independently of medical condition and nurse care requirement, was the main factor in the choice of hospital centre dialysis.

[Management of malnutrition in chronic hemodialysis]. / Prise en charge de la dénutrition en hémodialyse chronique.

Malnutrition is an independent factor of morbidity and mortality in hemodialysis patients. Therefore, the nutritional management must be included in the follow-up and treatment of these patients. During hemodialysis, estimated nutritional requirements are 35-40 kcal/kg/day and 1.2-1.4 protein/kg/day. Dietary counseling, performed twice a year, makes it possible to detect the early signs of undernutrition. High risk malnutrition can be identified by the following indicators: normalized catabolic rate < 1 g/kg/j, serum albumin < 35 g/l, serum prealbumin < 300 mg/l. A trimestrial measurement of these variables is recommended. A schematic diagram is proposed for the nutritional management of malnourished hemodialysis patient. The occurrence of malnutrition implies to look for any cause of anorexia or hypercatabolism such as inadequate nutritional intakes, inadequate dialysis, severe anemia and depression. Nutritional supplementation must be adapted according to its ability to satisfy nutritional needs: oral supplements in patients with beginning undernutrition; intradialytic parental nutrition in patients with severe malnutrition and spontaneous intakes more than 20 kcal/kg/day; daily enteral nutrition when spontaneous intakes are less than 20 kcal/kg/day.

Serum lipoprotein changes after prolonged intralipid infusion in malnourished haemodialysis patients.

Fat emulsions have been shown to be on efficient source of energy support in malnourished haemodialysis patients. This work was conducted in order to study the effect of prolonged intralipid infusion, during dialysis, on lipid metabolism. The following fasting serum parameters were measured before and after a 1 month infusion of 20% Intralipid (67 kJ/kg body wt/dialysis) in 10 malnourished patients undergoing dialysis: total cholesterol, triglycerides, phospholipids, HDL-cholesterol, LDL-cholesterol, HDL2-cholesterol, HDL3-cholesterol, apolipoproteins A-I, A-II, A-IV, C-II, C-III, and lipoproteins A-I, A-I A-II, EB and (a). After prolonged lipid infusion, the apoprotein B (p < 0.05) and C-II (p < 0.005) increased suggesting a triglyceride transport activation. Apolipoprotein A-I (p < 0.05) and lipoprotein A-I (p < 0.05) decreased without a change in total cholesterol. Lipoprotein (a) decreased in each case (p < 0.005), suggesting a reduction of its related risk of atherogenesis.

Perdialytic parenteral nutrition with lipids and amino acids in malnourished hemodialysis patients.

A 3-mo perdialytic parenteral nutrition (PDPN) regimen was tested in 26 malnourished adults receiving hemodialysis (HD). Subjects were randomly assigned to receive PDPN (n = 12) or not to receive it (n = 14). PDPN was intravenously infused three times a week during HD; each infusion was made up of 1.6 g fat/kg body wt, 0.08 g N/kg body wt, essential and nonessential amino acids, and glycyl-tyrosine. PDPN, together with a PDPN-induced increase in spontaneous eating, increased intakes from 30 +/- 8.4 kcal.kg body wt-1.d-1 (mean +/- SD) and 1 +/- 0.27 g protein.kg body wt-1.d-1 to 39 +/- 8.5 kcal.kg body wt-1.d-1 and 1.25 +/- 0.30 g protein.kg body wt-1.d-1. Compared with control subjects, PDPN patients were characterized by increases in body weight (P less than 0.01), arm-muscle circumference (P less than 0.02), serum transthyretin and albumin concentrations (P less than 0.05), interdialytic creatinine appearance (P less than 0.01), skin-test reactivity (P less than 0.02), plasma leucine (P less than 0.05) without modifications of other amino acids, and plasma apolipoprotein A-I (P less than 0.01) without significant changes in apolipoprotein B, cholesterol, triglyceride, and phospholipid concentrations. Thus, PDPN appeared to be effective and safe with respect to plasma lipids.

Treatment of progressive systemic sclerosis by plasma exchange: long-term results in 40 patients.

The efficacy of plasma exchanges (PE) during the course of scleroderma has only been investigated for short periods. The aim of this study was to follow patients over a long enough period to observe the course of the clinical and paraclinical symptoms in the short, medium, and long term. Forty patients, 24 women and 16 men, were treated by PE and observed for 1-3, 3-12 and over 12 months. Immunological, biological and clinical course and any undesirable side effects were evaluated using a detailed questionnaire. Concomitant therapies were reported and most frequently consisted of corticosteroids, colchicine, factor XIII or vasodilators (nifedipine, captopril). The therapeutic effectiveness of PE was assessed on the basis of improvements in cutaneous, digestive, joint, muscular, lung, cardiovascular and renal lesions. Our findings confirmed the effectiveness of short-term PE on scleroderma (52% of the patients improved during the first 3 months). However, this improvement was transient (5% improvement between 3 and 12 months and only 2.5% over 12 months) and limited to the cutaneous and muscular lesions. Thus, PE cannot be recommended for the treatment of progressive systemic sclerosis.

Prealbumin-retinol-binding-protein-retinol complex in hemodialysis patients.

In hemodialysis (HD) patients, serum prealbumin (TBPA) is correlated to nutritional status and outcome despite usually elevated serum levels. The purpose of this work was to study the role of TBPA-retinol-binding-protein (RBP)-retinol complex changes in the elevation of serum TBPA in HD patients. Serum TBPA, RBP, and retinol were measured in 30 otherwise healthy HD patients (15 men, 15 women) and in 30 healthy volunteers (15 men, 15 women). The dependence of TBPA on RBP was studied by covariance and regression methods. TBPA (p less than 0.05), RBP (p less than 0.01), and retinol (p less than 0.05) were elevated in HD patients. Elevated TBPA was associated with a decrease of TBPA free from RBP (p less than 0.01). The decrease of free TBPA may explain the reduction of TBPA breakdown and its elevation in HD patients.