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International audience; BACKGROUND: Delaying renal replacement therapy (RRT) for some time in critically ill patients with severe acute kidney injury and no severe complication is safe and allows optimisation of the use of medical devices. Major uncertainty remains concerning the duration for which RRT can be postponed without risk. Our aim was to test the hypothesis that a more-delayed initiation strategy would result in more RRT-free days, compared with a delayed strategy. METHODS: This was an unmasked, multicentre, prospective, open-label, randomised, controlled trial done in 39 intensive care units in France. We monitored critically ill patients with severe acute kidney injury (defined as Kidney Disease: Improving Global Outcomes stage 3) until they had oliguria for more than 72 h or a blood urea nitrogen concentration higher than 112 mg/dL. Patients were then randomly assigned (1:1) to either a strategy (delayed strategy) in which RRT was started just after randomisation or to a more-delayed strategy. With the more-delayed strategy, RRT initiation was postponed until mandatory indication (noticeable hyperkalaemia or metabolic acidosis or pulmonary oedema) or until blood urea nitrogen concentration reached 140 mg/dL. The primary outcome was the number of days alive and free of RRT between randomisation and day 28 and was done in the intention-to-treat population. The study is registered with ClinicalTrial.gov, NCT03396757 and is completed. FINDINGS: Between May 7, 2018, and Oct 11, 2019, of 5336 patients assessed, 278 patients underwent randomisation; 137 were assigned to the delayed strategy and 141 to the more-delayed strategy. The number of complications potentially related to acute kidney injury or to RRT were similar between groups. The median number of RRT-free days was 12 days (IQR 0-25) in the delayed strategy and 10 days (IQR 0-24) in the more-delayed strategy (p=0·93). In a multivariable analysis, the hazard ratio for death at 60 days was 1·65 (95% CI 1·09-2·50, p=0·018) with the more-delayed versus the delayed strategy. The number of complications potentially related to acute kidney injury or renal replacement therapy did not differ between groups. INTERPRETATION: In severe acute kidney injury patients with oliguria for more than 72 h or blood urea nitrogen concentration higher than 112 mg/dL and no severe complication that would mandate immediate RRT, longer postponing of RRT initiation did not confer additional benefit and was associated with potential harm. FUNDING: Programme Hospitalier de Recherche Clinique.

Resume Mesurer le developpement d’une culture de securite (CS) des soins en reanimation par le Safety Attitudes Questionnaire (SAQ), un outil de mesure comportant une version specifique a la reanimation (SAQ-ICU). L’objectif de cette etude est de realiser la version francaise de ce questionnaire nord-americain, puis de l’utiliser pour mesurer le niveau de la CS dans 2 unites de reanimation. Realisation avec le consentement des auteurs d’une version francaise du SAQ-ICU testee et validee par retrotraduction. Ce questionnaire comporte 30 items explorant 6 dimensions de la CS (esprit d’equipe ; climat de securite ; satisfaction au travail ; reconnaissance du stress ; perception de l’equipe d’encadrement ; conditions de travail), considerees comme « developpees » (score est > 75 %) et « a ameliorer » (

La Presse Medicale - In Press.Proof corrected by the author Available online since vendredi 5 juin 2015

Antiphospholipid syndrome associate thromboembolic events (arterial or venous), and presence of antiphospholipid antibodies, and require anticoagulation. A catastrophic variant may develop, resulting in multiorgan failure, with high mortality rate. This article presented a patient with antiphospholipid syndrome presenting a catastrophic antiphospholipide syndrome after anticoagulation suspending for gastrointestinal bleeding. Multidisciplinary management in intensive care unit and aggressive therapies (corticosteroids, anticoagulation, plasma exchange) were essential to rescue the patient.

Despite improvement in many aspects of the care of maintenance hemodialysis (HD) patients, protein-calorie malnutrition, which is characterized by an insidious loss of somatic protein, is common and is a major risk factor for increased morbidity and mortality. We present here an overview of the current knowledge on protein metabolism in uremic patients with the expectation of providing insights into the mechanisms involved in HD-associated catabolism and outlining the rationale underlying intradialytic nutrition. We concentrate on the discussion of muscle protein metabolism because muscle is the predominant site of protein storage, and its integrity is mandatory for the maintenance of a good quality of life.

Success in treating severe sepsis will require relevant tools to monitor the patient immunoinflammatory status. This study aimed to investigate the feasibility of measuring a panel of immunological mediator mRNAs in whole blood and to study their prognostic values in septic shock patients. At the onset of shock, compared to healthy volunteers, mRNA levels in septic shock patients were increased for IL-10, IL-1beta, and high mobility group B1 (HMGB1) and decreased for transforming growth factor beta 1, the Th1, and Th2 transcription factors, T-bet and GATA-3, respectively. Single parameter analysis highlighted an increased expression of IL-10 and HMGB1 mRNA in nonsurvivors and a significant rise over time of GATA3 in survivors. Combining the expression levels of four genes, hierarchical cluster analysis showed that up to 95% of the patients with a similar outcome displayed transcriptional similarities. These results illustrate both the potential of whole blood mRNA quantification assays and the interest of a multiparametric strategy to better stratify septic patients.

IGF-I binding proteins, IGF-I binding protein mRNA and IGF-I receptor mRNA in rats with acute renal failure given IGF-I. Background Recombinant human insulin-like growth factor-I (rhIGF-I) accelerates recovery from acute renal failure (ARF) in rats. IGF-I acts through the IGF-I receptor (IGF-IR) and its actions may be modified by IGF-I binding proteins (IGFBPs). It therefore would be of value to determine the effects of both ARF and rhIGF-I treatment on serum IGFBPs and mRNA for IGFBPs and IGF-IR. Methods Rats with ARF and sham-operated control rats were randomized to receive rhIGF-I or vehicle injections thrice daily for 72 to 74hours starting five hours after surgery. Serum IGFPBs 1 to 6 were measured serially, and mRNA for IGFBPs 1 to 6 and for IGF-IR were measured in several tissues obtained 72 to 74hours after surgery. Results At 72 to 74hours, serum IGFBP-1 and IGFBP-2 levels were higher in rhIGF-I treated rats. Serum IGFBP-3 was affected by both ARF and rhIGF-I. IGFBP-4 rose transiently only in ARF groups. At 72 to 74hours, mRNA for several IGFBPs was reduced in renal cortex of ARF rats. Low mRNA for IGFBP-4 and -6 was observed in renal medulla of the ARF rats, particularly in comparison to the sham-operated rats receiving vehicle. Renal medullary IGFBP-2 mRNA was decreased in ARF and sham rats given rhIGF-I as compared to sham animals given vehicle. Hepatic IGFBP-2 mRNA was higher in both rhIGF-I treated groups versus those given vehicle. Otherwise, there were no differences in IGFBP mRNAs among the four groups in lung, heart, and skeletal muscle. IGF-IR mRNA was decreased in renal cortex and medulla of both ARF groups and was not detected in liver in any group. Conclusions Thus, ARF and rhIGF-I treatment each affected certain serum IGFBPs and jointly affected some IGFBPs. ARF suppressed gene transcription for renal cortical and medullary IGF-IR and some IGFBPs. rhIGF-I independently affected some renal cortical or medullary IGFBP mRNAs. rhIGF-I increased hepatic IGFBP-2 mRNA and serum IGFBP-2. These effects of ARF or rhIGF-I may influence rhIGF-I actions in rats with ischemic ARF.

Introduction Le traitement par aminoside en dose unique journaliere, suppose l’obtention de concentrations plasmatiques suffisantes permettant d’avoir un ratio pic/CMI eleve. L’obtention de tels ratios est difficile en reanimation compte tenu des modifications des volumes de distribution des patients septiques [1] . Materiel et methodes Etude observationnelle retro et prospective de juillet 2012 a novembre 2013 dans un service de 29 lits de reanimation medico-chirurgicale chez des patients ayant recu une premiere injection de gentamicine, avec un pic de concentration plasmatique obtenu 30 minutes apres une injection d’une duree de 30 minutes. Ont ete releves : creatininemie, hemoglobinemie, protidemie, hematocrite, uremie, presence d’une alimentation parenterale, de l’administration de catecholamines et d’une ventilation. L’indice de masse corporel a ete calcule. Les resultats sont presentes en moyenne ± ecart-type, des tests de Mann-Whitney et de χ 2 ont ete realises. Resultats Quarante-quatre patients ont ete inclus, dont 66 % d’hommes, avec un âge, un poids et un IMC moyen de 59 ± 18 ans, 77 ± 17 kg et 27 ± 5 respectivement. La dose moyenne administree etait de 6,9 ± 1,9 mg/kg, le Pic moyen etait de 21 ± 8 mg/mL, 23 patients avaient un pic superieur a 20 mg/mL et 6 a 30 mg/mL. Des catecholamines etaient administrees a 45 % des patients, une nutrition parenterale a 20 % et 64 % etaient ventiles. Il existait une correlation significative entre Pic obtenu et dose administree (R = 0,43 p = 0,003). Une courbe de tendance lineaire a ete obtenue ( Fig. 1 ) dont la formule associee a permis de calculer un pic de concentration attendu en fonction de la dose administree par kilo de poids. Deux groupes de 11 patients avec respectivement un pic observe superieur (Pic sup20 % ) et un pic observe inferieur (Pic inf20 % ) de 20 % des pics calcules ont ete formes. Ces deux groupes de patients presentaient des caracteristiques cliniques et biologiques particulieres : les differences statistiquement significatives, etaient pour les 11 patients de Pic sup20 % , une creatininemie et un IMC significativement superieur aux 33 autres patients, respectivement 174 ± 101 μmol/L vs 102 ± 73 μmol/L, p = 0,023 et 31 ± 6 vs 26 ± 5, p = 0,018 ; et pour les 11 patients de Pic inf20 % , une creatininemie significativement inferieure aux 33 autres patients, 73 ± 51 μmol/L vs 136 ± 90 μmol/L, p = 0,023. Discussion La prise en compte de la creatininemie et de l’IMC pourraient aider le clinicien de reanimation dans sa prescription de gentamicine.