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Background Kidney failure with replacement therapy and hemodialysis are associated with a decrease in quality of life (QOL). Self-reported QOL symptoms are not always prioritized by the medical team, potentially leading to conflicting priorities with patients. Electronic patient-reported outcome measures (ePROMs) allow physicians to better identify these symptoms. The objective was to describe the prevalence of symptoms self-reported by hemodialysis (HD) patients. Methods A multicenter cross-sectional study was conducted in three HD centers. Patients were included if they were 18 years old or over treated with HD for at least 3 months in a center. Data were collected by the patient via a self-administered ePROMs questionnaire. Data included patient characteristics, post-dialysis fatigue and intensity, recovery time after a session, perceived stress, impaired sleep the day before the dialysis session, current state of health and the change from the past year. A multivariate analysis was conducted to identify relations between symptoms. Results In total, we included 173 patients with a mean age of 66.2 years, a mean ± SD hemodialysis duration of 48.9 ± 58.02 months. The prevalence of fatigue was 72%. 66% had a high level of stress (level B or C). Recovery time was more than 6 h after a HD session for 25% of patients and 78% declared they had a better or unchanged health status than the previous year. Sleep disturbance was associated with cardiovascular comorbidities (OR 5.08 [95% CI, 1.56 to 16.59], p = 0.007). Conclusions Fatigue and stress were the main symptoms reported by HD patients. The patient’s care teams should better consider these symptoms.

Advanced glycation products are proteins whose structural and functional properties have been modified by a process of oxidative glycation. The accumulation of advanced glycation products in most tissues and the oxidative stress and inflammatory reactions that accompany it, account for the multi-systemic impairment observed particularly in the elderly, diabetics and in chronic renal failure. The advanced glycation products endogenous production is continuous, related to oxidative stress, but the most important source of advanced glycation products is exogenous, mainly of food origin. Exogenous advanced glycation products are developed during the preparation of food and beverages. The advanced glycation products content is higher for animal foods, but it is mainly the preparation and cooking methods that play a decisive role. Dietary advice is based on the selection of foods and the choice of methods of preparation. Several randomized controlled studies have confirmed the favorable effect of these recommendations on serum advanced glycation products concentrations. In humans, as in animals, regular physical activity also results in a reduction of serum and tissue concentrations of advanced glycation products. There is a need for prospective clinical study to confirm the effects of hygienic and dietary recommendations that have only been appreciated, so far, on biological markers.

Background and Aims End Stage renal disease (ESRD) and hemodialysis are associated with a decrease in quality of life (QOL). Self-reported QOL symptoms are not always prioritized by the medical team, potentially leading to conflicting priorities with patients. Electronic patient-reported outcome measures (ePROMs) allow physicians to better describe these symptoms. The objective was to describe the prevalence of symptoms self-reported by HD patients. Method A multicenter cross-sectional study was conducted in three HD centers. Patients were included if they were 18 years old or over and treated with HD for at least three months in a center. Data were collected by the patient via a self-administered ePROMs questionnaire. Data included patient characteristics, post-dialysis fatigue and intensity, recovery time after a session, perceived stress, impaired sleep the day before the dialysis session, current state of health, and the one-year change. Results In total, we included 173 patients with a mean age of 66.2 years, a mean ± SD hemodialysis duration of 48.9 ± 58.02 months, mainly treated in self-dialysis unit (67%) and having at least one comorbidity (72.5%). The prevalence of fatigue was 72.1% [IC 95% 64.7% to 78.7%] with a mean severity score of 5.84± 2.12. 66.4% had a high level of stress (level B or C). Recovery time was more than 6 hours for 24.9% of patients and 78 % declared they had a better or unchanged health status than the previous year. The self-perceived health status of patients was 6.2± 2.12 and 77.5% [IC 95% 70.5% to 83.5%] of patients stated that they had not a worsened health status than the year before. No statistical differences were observed between centers for the PROMS. Despite significant differences in patient characteristics from the three centers including age, comorbidities or type of dialysis, no differences were found on the prevalence of the various PROMs, in favor of internally Conclusion Fatigue and stress were the main symptoms reported by HD patients. There was no association between symptoms reported and comorbidities clinical results of patients. The patient’s care teams should better consider these symptoms.

Background and Aims The health crisis linked to the COVID-19 epidemic has required lockdown measures in France and changes in practices in dialysis centers. The objective was to assess the depressive and anxiety symptoms during lockdown in hemodialysis patients and their caregivers, to assess their coping strategies during this period and to assess the symptoms of depression, anxiety and post traumatic stress beyond confinement. Method We sent, during lockdown period, between April and May 2020, self-questionnaires to voluntary subjects (patients and caregivers), treated by hemodialysis or who worked in hemodialysis in one of the 14 participating centers in France. We analyzed their perception of dialysis sessions (beneficial or worrying), their stress level (VAS rated from 0 to 10), their anxiety and depressive symptoms (HADS). Factors associated with stress, anxiety and depression were analyzed with multiple logistic regression models. We will look for associations between coping strategies, participant characteristics and symptoms of stress, anxiety and depression using chi-square tests. A second questionnaire was sent out in October to collect symptoms of depression, anxiety and post-traumatic stress beyond confinement. Symptoms will be described and factors associated with stress, anxiety and depression will be analyzed with multiple logistic regression models. Results 669 patients and 325 caregivers agreed to participate. 70% of participants found it beneficial to come to dialysis during confinement. The proportions of subjects with a stress level ≥ 6 linked to the epidemic, confinement, fear of contracting COVID-19 and fear of infecting a loved one were respectively 23.9%, 26.2%, 33.4% and 42%. 39.2% presented with certain (13.7%) or doubtful (19.2%) anxious symptoms. 21.2% presented a certain (7.9%) or doubtful (13.3%) depressive symptomatology. Age, gender, history of psychological disorders and perception of dialysis sessions were associated with levels of stress, anxiety and depression. 685 subjects participated in the second part of the study (68.9% of the participants of the first part). Analyzes of this data are in progress. Conclusion During the lockdown period, in France, the majority of hemodialysis patients and caregivers found it beneficial to come to dialysis. One in 3 subjects had anxiety symptoms and one in 5 subjects had depressive symptoms. It will be interesting to investigate if there was an association between the coping strategies implemented by the participants and their level of stress, anxiety and depression during confinement and to analyze the evolution of the anxiety-depressive symptoms over time.

Background: End Stage renal disease (ESRD) and hemodialysis are associated with a decrease in quality of life (QOL). Self-reported QOL symptoms are not always prioritized by the medical team, potentially leading to conflicting priorities with patients. Electronic patient-reported outcome measures (ePROMs) allow physicians to better identify these symptoms. The objective was to describe the prevalence of symptoms self-reported by hemodialysis (HD) patients.Methods: A multicenter cross-sectional study was conducted in three HD centers. Patients were included if they were 18 years old or over and treated with HD for at least three months in a center. Data were collected by the patient via a self-administered ePROMs questionnaire. Data included patient characteristics, post-dialysis fatigue and intensity, recovery time after a session, perceived stress, impaired sleep the day before the dialysis session, current state of health, and the one-year change. Results: In total, we included 173 patients with a mean age of 66.2 years, a mean ± SD hemodialysis duration of 48.9 ± 58.02 months. They were mainly treated in self-dialysis unit (67%) with at least one comorbidity (72.5%). The prevalence of fatigue was 72.1%. 66.4% had a high level of stress (level B or C). Recovery time was more than 6 hours after a HD session for 24.9% of patients and 78 % declared they had a better or unchanged health status than the previous year. Sleep disturbance was associated with cardiovascular comorbidities. Conclusions: Fatigue and stress were the main symptoms reported by HD patients. The patient’s care teams should better consider these symptoms.Trial registration: Commission Nationale de l'Informatique et des Libertés (CNIL): N° 2214737V0, Date First Registered: 2019-08-20. The CPP (Patient Protection Committee) Ile-de-France VII (2019-12-26) in accordance with French regulations N° ID-RCB: 2019-AO1373-54. Date First Registered: 2019-08-19.All methods were carried out in accordance with the relevant guidelines and regulations. Informed consent was obtained from all subjects, no subjects were under 18 years of age

INTRODUCTION: The health crisis linked to the COVID-19 epidemic has required lockdown measures in France and changes in practices in dialysis centers. The objective was to assess the depressive and anxiety symptoms during lockdown in hemodialysis patients and their caregivers. METHODS: We sent, during lockdown period, between April and May 2020, self-questionnaires to voluntary subjects (patients and caregivers), treated by hemodialysis or who worked in hemodialysis in one of the 14 participating centers in France. We analyzed their perception of dialysis sessions (beneficial or worrying), their stress level (VAS rated from 0 to 10), their anxiety and depressive symptoms (Hospital anxiety and depression scale). Factors associated with stress, anxiety and depression were analyzed with multiple linear regression models. RESULTS: 669 patients and 325 caregivers agreed to participate. 70 % of participants found it beneficial to come to dialysis during confinement. The proportions of subjects with a stress level ≥ 6 linked to the epidemic, confinement, fear of contracting COVID-19 and fear of infecting a loved one were respectively 23.9%, 26.2%, 33.4% and 42%. 39.2% presented with certain (13.7%) or doubtful (19.2%) anxious symptoms. 21.2% presented a certain (7.9%) or doubtful (13.3%) depressive symptomatology. Age, gender, history of psychological disorders and perception of dialysis sessions were associated with levels of stress, anxiety and depression. CONCLUSION: During the lockdown period, in France, the majority of hemodialysis patients and caregivers found it beneficial to come to dialysis. One in three subjects had anxiety symptoms and one in five subjects had depressive symptoms.; INTRODUCTION: La crise sanitaire liée à l’épidémie de COVID-19 a nécessité des mesures de confinement en France et des changements de pratiques dans les centres de dialyse. L’objectif était d’évaluer les symptômes d’anxiété, de dépression et de stress pendant le confinement chez les patients hémodialysés et leurs soignants. MÉTHODES: Nous avons adressé, pendant le confinement, entre avril et mai 2020, des autoquestionnaires à des sujets volontaires qui étaient traités par hémodialyse (patients) ou qui travaillaient en hémodialyse (soignants) dans l’un des 14 centres de France participants. Nous avons analysé leur perception des séances de dialyse (bénéfique ou inquiétante), leur niveau de stress (échelle visuelle analogique cotée de 0 à 10), et leur symptomatologie anxieuse et dépressive (échelle Hospital anxiety and depression scale). Les facteurs associés au stress, à l’anxiété et à la dépression ont été analysés avec des modèles de régression linéaire multiple. RÉSULTATS: Parmi les 669 patients et 325 soignants ayant répondu, 70 % trouvaient bénéfique de venir en dialyse pendant le confinement. Les proportions de sujets présentant un niveau de stress ≥ 6 lié à l’épidémie, au confinement, à la peur de contracter la COVID-19 et à la peur de contaminer un proche étaient respectivement de 23,9, 26,2, 33,4 et 42 %. De plus, 39,2 % présentaient une symptomatologie anxieuse certaine (13,7 %) ou douteuse (19,2 %), et 21,2 % présentaient une symptomatologie dépressive certaine (7,9 %) ou douteuse (13,3 %). L’âge, le sexe, les antécédents de troubles psychologiques et la perception des séances de dialyse étaient les facteurs principaux associés aux niveaux de stress, d’anxiété et de dépression. CONCLUSION: Pendant le confinement, en France, la majorité des patients et des soignants en hémodialyse ont trouvé bénéfique de venir en séance de dialyse. Un sujet sur trois présentait une symptomatologie anxieuse et un sujet sur cinq présentait une symptomatologie dépressive.

The aim of this study was to estimate the incidence of COVID-19 disease in the French national population of dialysis patients, their course of illness and to identify the risk factors associated with mortality. Our study included all patients on dialysis recorded in the French REIN Registry in April 2020. Clinical characteristics at last follow-up and the evolution of COVID-19 illness severity over time were recorded for diagnosed cases (either suspicious clinical symptoms, characteristic signs on the chest scan or a positive reverse transcription polymerase chain reaction) for SARS-CoV-2. A total of 1,621 infected patients were reported on the REIN registry from March 16th, 2020 to May 4th, 2020. Of these, 344 died. The prevalence of COVID-19 patients varied from less than 1% to 10% between regions. The probability of being a case was higher in males, patients with diabetes, those in need of assistance for transfer or treated at a self-care unit. Dialysis at home was associated with a lower probability of being infected as was being a smoker, a former smoker, having an active malignancy, or peripheral vascular disease. Mortality in diagnosed cases (21%) was associated with the same causes as in the general population. Higher age, hypoalbuminemia and the presence of an ischemic heart disease were statistically independently associated with a higher risk of death. Being treated at a selfcare unit was associated with a lower risk. Thus, our study showed a relatively low frequency of COVID-19 among dialysis patients contrary to what might have been assumed., Graphical abstract

Introduction La crise sanitaire liée à l’épidémie de COVID-19 a nécessité des mesures de confinement en France et des changements de pratiques dans les centres de dialyse. L’objectif était d’évaluer les symptômes d’anxiété, de dépression et de stress pendant le confinement chez les patients hémodialysés et leurs soignants. Méthodes Nous avons adressé, pendant le confinement, entre avril et mai 2020, des autoquestionnaires à des sujets volontaires qui étaient traités par hémodialyse (patients) ou qui travaillaient en hémodialyse (soignants) dans l’un des 14 centres de France participants. Nous avons analysé leur perception des séances de dialyse (bénéfique ou inquiétante), leur niveau de stress (échelle visuelle analogique cotée de 0 à 10), et leur symptomatologie anxieuse et dépressive (échelle Hospital anxiety and depression scale). Les facteurs associés au stress, à l’anxiété et à la dépression ont été analysés avec des modèles de régression linéaire multiple. Résultats Parmi les 669 patients et 325 soignants ayant répondu, 70 % trouvaient bénéfique de venir en dialyse pendant le confinement. Les proportions de sujets présentant un niveau de stress ≥ 6 lié à l’épidémie, au confinement, à la peur de contracter la COVID-19 et à la peur de contaminer un proche étaient respectivement de 23,9, 26,2, 33,4 et 42 %. De plus, 39,2 % présentaient une symptomatologie anxieuse certaine (13,7 %) ou douteuse (19,2 %), et 21,2 % présentaient une symptomatologie dépressive certaine (7,9 %) ou douteuse (13,3 %). L’âge, le sexe, les antécédents de troubles psychologiques et la perception des séances de dialyse étaient les facteurs principaux associés aux niveaux de stress, d’anxiété et de dépression. Conclusion Pendant le confinement, en France, la majorité des patients et des soignants en hémodialyse ont trouvé bénéfique de venir en séance de dialyse. Un sujet sur trois présentait une symptomatologie anxieuse et un sujet sur cinq présentait une symptomatologie dépressive.

International audience

The acid production of endogenous origin depends mainly on the metabolism of the food and varies with the nature of these. Of the order of 1mEq/kg/day for contemporary food in industrialized countries, it is reduced by more than one third among vegetarians and close to neutrality among vegans. The dietary acid load is eliminated by the normal kidneys, thus maintaining the acid-base equilibrium. In the setting of CKD, it will overflow the capacities of the nephrons, generating a retention of H+ ions, promoting subclinical acidosis. This tissue retention of H+ ions was confirmed by direct techniques in animal models and indirect techniques in humans. The systemic retention of H+ ions and the accompanying compensatory mechanisms have negative consequences on bone tissue, skeletal muscle, cardiovascular risk and renal function. In the animal, the substitution of casein (acid) by soy (alkaline) prevents metabolic acidosis and slows the progression of renal insufficiency. In man, various prospective studies have confirmed that the risk of renal insufficiency was positively correlated with the dietary acid load. Conversely, bicarbonate supplementation and/or a diet enriched with fruits and vegetables, have a favorable effect on renal insufficiency, including in subjects with normal bicarbonate. These results lead to reconsider the K/DOQI recommendations to correct acidosis when the bicarbonate level falls below 22mEq/L, since tissue retention of H+ ions and its negative consequences appear at higher or even normal levels of bicarbonates.

Restricted protein diets in patients with chronic kidney disease have been debated for several decades. In chronic kidney disease as in other chronic diseases, the modulation of the nutritional intake is the object of a certain renewal. It is supported by recent studies that highlight the importance of modulating nutrient intake by diets that are healthier, less rich in animal proteins and richer in plants. The recent reintroduction in France of amino acid supplements and ketoanalogs of amino acids allows the prescription of a very restricted diet. Historical studies have only focused on the relationship between protein intake and renal function degradation. Recent studies on acid loading, bone metabolism or potassium intake allow revisiting the interest of restricted diets. As with any change in eating habits, the selection of patients, information, education and monitoring during the diet are very important and help prevent undernutrition: this is the purpose of this short review.

The gradual loss of weight and function of muscle in patients with chronic kidney disease as in the elderly impacts the quality of life. Early management should help slow the functional limitation. Physical activity is the first therapy to propose that ensures stability of muscle mass and improved function. Resistance training programs have proven effective but are not yet widely available in nephrology units. The nutritional management should not be forgotten because there is a resistance to anabolism and protein intake should be involved in physical activity program. Associated treatments should not be neglected: vitamin D, anti-inflammatory, androgens. Some are still under evaluation. Therapeutic option, tomorrow, could be anti-myostatin antibodies and glitazones.

ContextThe role of comprehensive geriatric assessment for older patients with advanced chronic kidney disease still needs to be defined. In this population, data is lacking on the care proposals made by geriatricians during comprehensive geriatric assessment and on the follow-up of these proposals.ObjectivesTo describe a population of older outpatients with advanced renal disease seen at a geriatric consultation, and geriatric syndromes identified. To study care suggestions made by the geriatrician, and the follow-up of these suggestions.MethodsRetrospective monocentric study, including all outpatients treated with hemodialysis and seen at the geriatric consultation implemented in a dialysis facilities network in Aquitaine region, France, from 2014 to 2017. Six domains were analysed: functional independence, cognition, gait/balance, mood, nutrition and drug prescription.ResultsAmong 49 patients, mean age 79 years, 50% had a loss of independence, 32% cognitive impairment, 24% mood disturbance, 55% gait or balance disturbance, and 65% potentially inappropriate medications. The most frequent care suggestions of the geriatrician were drugs optimisation, intervention of a psychologist, a dietetician or a speech and language therapist, home support service implementation, and the exploration of cognitive impairment. Suggestions of intervention of other healthcare professionals, drug optimisation and biological/imaging tests were followed in respectively 46, 33 and 18% of cases.ConclusionA geriatric outpatient consultation in a nephrology facility allows identification of frequent and multiples geriatric syndromes, requiring coordinated interventions. Collaboration between healthcare professionals, including a geriatrician, should be reinforced to improve design and follow-up of the individualised care plan for older patients with advanced chronic kidney disease.; ContexteLa place de l’évaluation gériatrique dans la prise en charge des patients âgés avec insuffisance rénale chronique avancée reste à définir. Dans cette population, les connaissances manquent sur les propositions de soins faites par les gériatres lors de cette évaluation, et sur le suivi de ces propositions.ObjectifsDécrire une population de patients dialysés âgés vus en consultation gériatrique ainsi que les syndromes gériatriques identifiés, et étudier les propositions de soins du gériatre et le suivi de ces propositions.MéthodesIl s’agit d’une étude rétrospective, monocentrique, incluant les patients hémodialysés vus à la consultation gériatrique d’une association d’antenne d’auto-dialyse en Aquitaine, de mars 2014 à octobre 2017. Une analyse séparée a été réalisée par domaines : dépendance, cognition, thymie, locomotion, nutrition, médicaments.RésultatsSur 49 patients, d’âge médian 79 ans, 50 % avaient une perte d’indépendance dans les actes de la vie quotidienne, 32 % présentaient des troubles cognitifs, 24 % des troubles thymiques, 55 % des troubles locomoteurs, et 65 % avaient des médicaments potentiellement inappropriés. Les propositions les plus fréquentes du gériatre étaient la révision d’ordonnance, l’intervention du psychologue, du diététicien ou de l’orthophoniste, l’ajout d’aides à domicile, l’exploration des troubles cognitifs. Respectivement, 46, 33 et 18 % des propositions d’intervention d’autres professionnels, d’optimisation médicamenteuse et d’examens complémentaires étaient suivies.ConclusionEn antenne d’auto-dialyse, une consultation gériatrique permet de mettre en évidence des syndromes gériatriques fréquents, souvent multiples, nécessitant des interventions coordonnées. La collaboration entre soignants, incluant le gériatre, devrait être renforcée afin d’améliorer le plan de soins personnalisé des patients âgés avec insuffisance rénale chronique avancée, et son suivi.

The role of comprehensive geriatric assessment for older patients with advanced chronic kidney disease still needs to be defined. In this population, data is lacking on the care proposals made by geriatricians during comprehensive geriatric assessment and on the follow-up of these proposals.To describe a population of older outpatients with advanced renal disease seen at a geriatric consultation, and geriatric syndromes identified. To study care suggestions made by the geriatrician, and the follow-up of these suggestions.Retrospective monocentric study, including all outpatients treated with hemodialysis and seen at the geriatric consultation implemented in a dialysis facilities network in Aquitaine region, France, from 2014 to 2017. Six domains were analysed: functional independence, cognition, gait/balance, mood, nutrition and drug prescription.Among 49 patients, mean age 79 years, 50% had a loss of independence, 32% cognitive impairment, 24% mood disturbance, 55% gait or balance disturbance, and 65% potentially inappropriate medications. The most frequent care suggestions of the geriatrician were drugs optimisation, intervention of a psychologist, a dietetician or a speech and language therapist, home support service implementation, and the exploration of cognitive impairment. Suggestions of intervention of other healthcare professionals, drug optimisation and biological/imaging tests were followed in respectively 46, 33 and 18% of cases.A geriatric outpatient consultation in a nephrology facility allows identification of frequent and multiples geriatric syndromes, requiring coordinated interventions. Collaboration between healthcare professionals, including a geriatrician, should be reinforced to improve design and follow-up of the individualised care plan for older patients with advanced chronic kidney disease.

Advanced glycation products are proteins whose structural and functional properties have been modified by a process of oxidative glycation. The accumulation of advanced glycation products in most tissues and the oxidative stress and inflammatory reactions that accompany it, account for the multi-systemic impairment observed particularly in the elderly, diabetics and in chronic renal failure. The advanced glycation products endogenous production is continuous, related to oxidative stress, but the most important source of advanced glycation products is exogenous, mainly of food origin. Exogenous advanced glycation products are developed during the preparation of food and beverages. The advanced glycation products content is higher for animal foods, but it is mainly the preparation and cooking methods that play a decisive role. Dietary advice is based on the selection of foods and the choice of methods of preparation. Several randomized controlled studies have confirmed the favorable effect of these recommendations on serum advanced glycation products concentrations. In humans, as in animals, regular physical activity also results in a reduction of serum and tissue concentrations of advanced glycation products. There is a need for prospective clinical study to confirm the effects of hygienic and dietary recommendations that have only been appreciated, so far, on biological markers.

Often underestimated or misunderstood in chronic renal failure (CRF), muscle wasting is nevertheless common and concerns about 50% of dialysis patients. The consequences of this myopathy on quality of life and outcomes of patients are unfavorable, identical to those observed in sarcopenia in elderly subjects with sarcopenia. The similarities between the two situations also concern the symptoms, the underlying muscle damages and the pathogenic mechanisms and may be partly explained by the frequently high age of ESRD patients. Skeletal muscle involvement should be systematically investigated in the IRC patient as in the elderly with sarcopenia to propose as early as possible a treatment of which physical activity and nutritional interventions are the mainstay.

While dietary restriction of protein intake has long been proposed as a possible kidney-protective treatment, the effects of changes in the quality of ingested proteins on the prevalence and risk of progression of chronic kidney disease (CKD) have been scarcely studied; these two aspects are reviewed in the present article. The prevalence of hypertension, type 2 diabetes and metabolic syndrome, which are the main causes of CKD in Western countries, is lower in vegetarian populations. Moreover, there is a negative relationship between several components of plant-based diets and numerous factors related to CKD progression such as uraemic toxins, inflammation, oxidative stress, metabolic acidosis, phosphate load and insulin resistance. In fact, results from different studies seem to confirm a kidney-protective effect of plant-based diets in the primary prevention of CKD and the secondary prevention of CKD progression. Various studies have determined the nutritional safety of plant-based diets in CKD patients, despite the combination of a more or less severe dietary protein restriction. As observed in the healthy population, this dietary pattern is associated with a reduced risk of all-cause mortality in CKD patients. We propose that plant-based diets should be included as part of the clinical recommendations for both the prevention and management of CKD.

Introduction Les bienfaits de l’Activite Physique (AP) chez les patients dialyses sont reconnus notamment sur la qualite de vie. L’effet sur l’estime de soi dans le domaine corporel a ete peu etudie. C’est l’objectif de notre etude. Methodes (1) Population : patients hemodialyses repertories selon leur pratique en AP : AP reguliere, AP irreguliere, Pas AP. (2) Outils : Estime de soi dans le domaine corporel et physique evalue par un auto-questionnaire de 25 items, l’ISP25 compose de 6 dimensions : estime globale de soi, valeur physique percue, condition physique, competence sportive, apparence physique et force physique. (3) Procedure : Le protocole a ete propose aux patients a deux temps : environ 1 mois apres leur arrivee en auto-dialyse (T1) et 6 mois apres (T2). (4) Analyses des donnees : des comparaisons de moyennes ont ete realisees (ANOVA). Resultats obtenus ou attendus A T1, les patients pratiquant une AP irreguliere ont significativement un moins bon score total d’estime de soi (F = 4,09, p = 0,025), ont une moins bonne estime de leur force (F = 5,47, p = 0,008) et de leur endurance (F = 5,9, p = 0,006) que les patients ne pratiquant pas d’AP. A T2, seules des tendances sont observees pour deux dimensions (estime de soi globale et endurance). Conclusion Les resultats sur l’estime de soi physique suggerent un effet « deletere » d’une pratique physique irreguliere (par rapport a pas d’AP du tout). Ce resultat peut s’expliquer par l’instabilite de leur pratique, leur difficulte a s’engager pleinement et donc efficacement dans une AP. Ils necessitent confirmation sur une population plus importante.

The acid production of endogenous origin depends mainly on the metabolism of the food and varies with the nature of these. Of the order of 1mEq/kg/day for contemporary food in industrialized countries, it is reduced by more than one third among vegetarians and close to neutrality among vegans. The dietary acid load is eliminated by the normal kidneys, thus maintaining the acid-base equilibrium. In the setting of CKD, it will overflow the capacities of the nephrons, generating a retention of H+ ions, promoting subclinical acidosis. This tissue retention of H+ ions was confirmed by direct techniques in animal models and indirect techniques in humans. The systemic retention of H+ ions and the accompanying compensatory mechanisms have negative consequences on bone tissue, skeletal muscle, cardiovascular risk and renal function. In the animal, the substitution of casein (acid) by soy (alkaline) prevents metabolic acidosis and slows the progression of renal insufficiency. In man, various prospective studies have confirmed that the risk of renal insufficiency was positively correlated with the dietary acid load. Conversely, bicarbonate supplementation and/or a diet enriched with fruits and vegetables, have a favorable effect on renal insufficiency, including in subjects with normal bicarbonate. These results lead to reconsider the K/DOQI recommendations to correct acidosis when the bicarbonate level falls below 22mEq/L, since tissue retention of H+ ions and its negative consequences appear at higher or even normal levels of bicarbonates.

The studies that evaluated physical activity in dialysis patients show a significant inactivity. This inactivity is associated with increased mortality. In contrast, the benefits in terms of morbidity and mortality of physical activity in this population are numerous. Recommendations exist for these patients: those set out for the general elderly adult population. However, few centers are implementing training programs in dialysis patients. There are many reasons, among which the lack of knowledge of the medical staff. The purpose of this article is to clarify the assessment of physical activity in dialysis patients and implementation program for the fight against inactivity. The initial assessment by simple means is essential. It ideally requires the intervention of a specialist in physical activity. The main types of exercise are presented as well as the different types of program and their results. It is important to note that no serious adverse events were reported in the different programs and their feasibility has been demonstrated. The fight against the sedentary patients undergoing dialysis should be a goal of health care teams, as well as the fight against the other cardiovascular risk factors.

The gradual loss of weight and function of muscle in patients with chronic kidney disease as in the elderly impacts the quality of life. Early management should help slow the functional limitation. Physical activity is the first therapy to propose that ensures stability of muscle mass and improved function. Resistance training programs have proven effective but are not yet widely available in nephrology units. The nutritional management should not be forgotten because there is a resistance to anabolism and protein intake should be involved in physical activity program. Associated treatments should not be neglected: vitamin D, anti-inflammatory, androgens. Some are still under evaluation. Therapeutic option, tomorrow, could be anti-myostatin antibodies and glitazones.

The risk of non-traumatic fractures is greatly increased in kidney disease patients and well demonstrated in dialysis patients. If osteoporosis plays a major role in the general population, in chronic kidney disease renal osteodystrophy is associated with neurological and muscular disorders, which probably worsen the risk. The decrease in physical activity is a factor contributing to the loss of bone mass and the initiation of a rehabilitation program improves the prognosis. Despite the association between chronic renal disease and sedentary lifestyle, the relationship between physical inactivity and bones in dialysis patients and the effect of increased activity programs, are not well documented in the literature.

Introduction Les patients âges constituent le groupe d’insuffisants renaux chroniques stade 5 qui augmente le plus massivement. La place et les apports de l’evaluation geriatrique (EG) dans leur prise en charge ne sont pas bien definis. Aucun outil de depistage valide predisant une EG pathologique n’est disponible pour le nephrologue. Objectif principal Mettre en evidence les caracteristiques demographiques et nephrologiques predictives d’une EG pathologique. Objectifs secondaires Decrire les syndromes geriatriques identifies, les interventions proposees suite a l’EG, le suivi des propositions. Rechercher les facteurs geriatriques ayant une valeur pronostique (associes a la mortalite et aux hospitalisations dans l’annee suivant l’evaluation). Patients et methodes Schema : etude retrospective, monocentrique. Criteres d’inclusion : patients de 70 ans et plus, hemodialyses, vus a la consultation geriatrique mise en place dans leur centre de dialyse. Periode : mars 2013–octobre 2017. Criteres de jugement : resultats de l’EG (autonomie, cognition, thymie, locomotion, contexte social, medicaments), interventions proposees par le geriatre, mortalite a 6, 12 et 18 mois apres l’EG, nombre de jours d’hospitalisation dans l’annee suivant l’EG. Resultats Cinquante-six patients inclus. Analyse des donnees en cours. Conclusion Resultats et retombees attendus : mettre en evidence les facteurs predisant une EG pathologique permettra de rationaliser le recours a cette evaluation (adresser au geriatre les patients les plus susceptibles de necessiter son intervention). Cela ouvrira des pistes vers un outil de depistage geriatrique utilisable par le nephrologue ; confirmer la valeur pronostique de l’EG dans ce contexte sera un argument en faveur du recours a l’EG dans la population IRC stade 5 âgee ; ameliorer la collaboration entre nephrologues et geriatres, dans l’interet des patients.

High blood pressure and proteinuria are the major factors that drive progression of chronic kidney disease. Target levels for preserving renal function are blood pressure less than 130/80 mmHg and proteinuria less than 0.5 g/day. Angiotensin II converting enzyme inhibitors and sartans should be used as first-line therapy to reach these targets. Their use requires close monitoring of renal function and serum potassium levels. Moderate sodium restriction, possibly combined with diuretic therapy, helps to maximize the effect of renin-angiotensin inhibitors. Patients with chronic kidney disease have a high risk of acute kidney failure, especially due to drugs. All prescriptions must take into account the existence and extent of kidney disease. Patient adhesion and collaboration between health professionals are required if these measures are to be effective in the long term.

OBJECTIVE—About 20% of diabetic patients with chronic kidney disease (CKD) detected from the new American Diabetes Association recommendations (albumin excretion rate >30 mg/24 h or estimated glomerular filtration rate [GFR] RESEARCH DESIGN AND METHODS—A total of 89 patients with diabetes and a modification of diet in renal disease (MDRD) estimated GFR (e-GFR) RESULTS—The mean MDRD e-GFR (41.3 ± 13.1 ml/min per 1.73 m2) did not significantly differ from the i-GFR (45.6 ± 29.7). Of the subjects, 15 (17%) were normoalbuminuric. Their i-GFR did not differ from the albuminuric rate and from their MDRD e-GFR, although their serum creatinine was lower (122 ± 27 vs. 160 ± 71 μmol/l, P < 0.05): 71% would not have been detected by measuring serum creatinine (sCr) alone. They were less affected by diabetic retinopathy, and their HDL cholesterol and hemoglobin were higher (P < 0.05 vs. albuminuric). None of the CKD normoalbuminuric subjects started dialysis (microalbuminuric: 2/36, macroalbuminuric: 10/38) or died (microalbuminuric: 3/36, macroalbuminuric: 7/38) during the follow-up period (log-rank test: P < 0.005 for death or dialysis), and their albumin excretion rate and sCr values were stable after 38 months, whereas the AER increased in the microalbuminuric patients (P < 0.05), and the sCr increased in the macroalbuminuric patients (P < 0.01). CONCLUSIONS—Although their sCr is usually normal, most of the normoalbuminuric diabetic subjects with CKD according to an MDRD e-GFR below 60 ml/min per 1.73 m2 do really have a GFR below 60 ml/min per 1.73 m2. However, as expected, because of normoalbuminuria and other favorable characteristics, their risk for CKD progression or death is lower.

The purpose of this study was to evaluate the detection and characterization of macrophage infiltration in native and transplanted kidneys using ultrasmall superparamagnetic iron oxide particles (USPIO). Among 21 patients initially enrolled, 12 scheduled for renal biopsy for acute or rapidly progressive renal failure (n = 7) or renal graft rejection (n = 5) completed the study. Three magnetic resonance (MR) sessions were performed with a 1.5-T system, before, immediately after and 72 h after i.v. injection of USPIO at doses of 1.7-2.6 mg of iron/kg. Signal intensity change was evaluated visually and calculated based on a region of interest (ROI) positioned on the kidney compartments. Histological examination showed cortical macrophage infiltration in four patients (5 macrophages/mm(2)), two in native kidneys (proliferative extracapillary glomerulonephritis) and two in transplants (acute rejection). These patients showed a 33 +/- 18% mean cortical signal loss on T2*-weighted images. In the remaining eight patients, with5 macrophages/mm(2), there was no cortical signal loss. However, in three of these, presenting with ischemic acute tubular necrosis, a strong (42 +/- 18%) signal drop was found in the medulla exclusively. USPIO-enhanced MR imaging can demonstrate infiltration of the kidneys by macrophages both in native and transplanted kidneys and may help to differentiate between kidney diseases.

Often underestimated or misunderstood in chronic renal failure (CRF), muscle wasting is nevertheless common and concerns about 50% of dialysis patients. The consequences of this myopathy on quality of life and outcomes of patients are unfavorable, identical to those observed in sarcopenia in elderly subjects with sarcopenia. The similarities between the two situations also concern the symptoms, the underlying muscle damages and the pathogenic mechanisms and may be partly explained by the frequently high age of ESRD patients. Skeletal muscle involvement should be systematically investigated in the IRC patient as in the elderly with sarcopenia to propose as early as possible a treatment of which physical activity and nutritional interventions are the mainstay.

Objectives To measure the mass transfer and clearance of procalcitonin (PCT) in patients with septic shock during continuous venovenous hemofiltration (CVVH), and to assess the mechanisms of elimination of PCT. Setting The medical department of intensive care. Design A prospective, observational study. Patients Thirteen critically ill patients with septic shock and oliguric acute renal failure requiring continuous venovenous postdilution hemofiltration with a high-flux membrane (AN69 or polyamide) and a 'conventional' substitution volume (< 2.5 l/hour). Measurements and main results PCT was measured with the Lumitest PCT Brahms® in the prefilter and postfilter plasma, in the ultrafiltrate at the beginning of CVVH (T0) and 15 min (T15'), 60 min (T60') and 6 hours (T6h) after setup of CVVH, and in the prefilter every 24 hours during 4 days. Mass transfer was determined and the clearance and the sieving coefficient were calculated according to the mass conservation principle. Plasma and ultrafiltrate clearances, respectively, at T15', T60' and T6h were 37 ± 8.6 ml/min (not significant) and 1.8 ± 1.7 ml/min (P < 0.01), 34.7 ± 4.1 ml/min (not significant) and 2.3 ± 1.8 ml/min (P < 0.01), and 31.5 ± 7 ml/min (not significant) and 5 ± 2.3 ml/min (P < 0.01). The sieving coefficient significantly increased from 0.07 at T15' to 0.19 at T6h, with no difference according to the nature of the membrane. PCT plasma levels were not significantly modified during the course of CCVH. Conclusions We conclude that PCT is removed from the plasma of patients with septic shock during CCVH. Most of the mass is eliminated by convective flow, but adsorption also contributes to elimination during the first hours of CVVH. The effect of PCT removal with a conventional CVVH substitution fluid rate (

We have previously shown in a transversal study that PCT combined to CRP is associated to an altered nutritional status in hemodialysis patients. In a 2-year prospective study, we have assessed the relationship between markers of inflammation or nutrition and mortality.Two-year prospective study, in 61 patients dialyzed in our unit (29 M/32 F, age 63 +/- 15 years, on dialysis for 76 +/- 94 months, 12 hrs/wk, on high-flux (HF) membrane for 25 patients and low-flux (LF) for 36 patients, without reuse). Kt/V was 1.53 +/- 0.30.Hospital-based dialysis unit.CRP, PCT, ferritin, albumin, and prealbumin, were measured in 04/99 (T0) and every 6 months thereafter. Interleukin-6 (IL6) and fibrinogen were measured at the start of study. The outcome and the causes of death of patients were noted in 58 patients, 3 patients were lost of follow-up.The mortality (24 deaths) was 42% at 2 years in this hospital based unit. The main causes of mortality were cardiovascular diseases (71%) and infection (17%). Patients were classified according to their CRP (CRP+ if CRPor = 5 mg/L; n = 40), and PCT values (PCT + if PCTor = 0.5 ng/mL; n = 25). IL6 level wasor = 10 pg/mL for 95% of the patients. Mortality was higher in the CRP+ group (Kaplan-Meier test P.01) but not in the PCT or IL6 positive patients. All patients of the CRP+ group at T0 remained CRP+. Only 56% of patients of PCT+ remained positive at 6 months. When patients were grouped according to CRP quartile the difference on survival remained significant (P = .03), patients who were classified in the third and fourth quartile (upper than 9.9 mg/L), exhibited a higher rate of mortality than the lower quartile. The concomitant presence of a high level of PCT and CRP was associated with a worsened nutritional status at T0 but PCT level had no influence on 2-year mortality.In this 2-year prospective study in a hospital-based cohort of high-risk hemodialysis patients, elevated CRP, but not raised PCT, was associated with increased mortality. Inflammation remained present throughout a 2-year follow-up in patients with an initial CRP higher than 5 mg/L. An upper value of CRP above 9.9 mg/L is independly predictive of mortality, mainly from cardiovascular causes. The association of high PCT and CRP was no more predictive of mortality than high CRP.

International audience; OBJECTIVE: The "Pas a Pas" initiative aimed at evaluating the weekly physical activity (PA) and its determinants in a large cohort of dialysis patients. SETTING: Physical inactivity is a risk factor for mortality in maintenance dialysis patients and is still poorly documented in this population. DESIGN: A prospective national epidemiological study was performed. SUBJECTS: A total of 1,163 patients on maintenance dialysis (hemodialysis and peritoneal dialysis) were included. INTERVENTION AND MAIN OUTCOME MEASURE: PA was recorded during seven consecutive days using a pedometer to measure daily step numbers. RESULTS: Median age was 63 years (Q1 51-Q3 75). Sixty-three percent were sedentary (\textless5000 steps/day) with a median of 3,688 steps/day (1,866-6,271)]. PA level was similar between hemodialysis patients and those on peritoneal dialysis (3,693 steps [1,896-6,307] vs. 3,320 [1,478-5,926], P = .33). In hemodialysis patients, PA was lower on dialysis days compared with nondialysis days (2,912 [1,439-5,232] vs. 4,054 [2,136-7,108], respectively, P \textless .01). PA gradually decreased with age, 57% being sedentary between 50 and 65 years and 83% of patients after 80 years. Beyond this age effect, we identified, for the first time, specific phenotypes of patients with lower PA, such as inflammation, cardiovascular disease, protein energy wasting, obesity, and diabetes. By contrast, previous kidney transplantation and a higher muscle mass were associated with higher PA. CONCLUSIONS: Dialysis patients present a very low level of PA with high sedentary. Acting on patient's modifiable phenotypes may help to increase PA to improve morbidity, mortality, and quality of life.

The studies that evaluated physical activity in dialysis patients show a significant inactivity. This inactivity is associated with increased mortality. In contrast, the benefits in terms of morbidity and mortality of physical activity in this population are numerous. Recommendations exist for these patients: those set out for the general elderly adult population. However, few centers are implementing training programs in dialysis patients. There are many reasons, among which the lack of knowledge of the medical staff. The purpose of this article is to clarify the assessment of physical activity in dialysis patients and implementation program for the fight against inactivity. The initial assessment by simple means is essential. It ideally requires the intervention of a specialist in physical activity. The main types of exercise are presented as well as the different types of program and their results. It is important to note that no serious adverse events were reported in the different programs and their feasibility has been demonstrated. The fight against the sedentary patients undergoing dialysis should be a goal of health care teams, as well as the fight against the other cardiovascular risk factors.

The risk of non-traumatic fractures is greatly increased in kidney disease patients and well demonstrated in dialysis patients. If osteoporosis plays a major role in the general population, in chronic kidney disease renal osteodystrophy is associated with neurological and muscular disorders, which probably worsen the risk. The decrease in physical activity is a factor contributing to the loss of bone mass and the initiation of a rehabilitation program improves the prognosis. Despite the association between chronic renal disease and sedentary lifestyle, the relationship between physical inactivity and bones in dialysis patients and the effect of increased activity programs, are not well documented in the literature.

Intradialytic morbid events (IMEs) during haemodialysis (HD), including symptomatic hypotension, are related to ultrafiltration (UF)-induced hypovolaemia. Blood volume monitoring and automatic feedback control of the UF rate were developed to limit the extent of hypovolaemia during dialysis. The present study investigated the effect of blood volume (BV)-controlled UF on the incidence of HD treatments with IMEs.This prospective randomised crossover study included hypotension-prone patients, characterised by occurrence of IMEs in at least 33% of HD treatments during a 6-week screening phase. These patients underwent 2 treatment phases, each lasting 6 weeks, in randomised order. Each patient served as their own control, treated with standard HD in one phase and with BV-controlled UF in the other phase.Thirty-four patients from 9 HD centres were enrolled; 26 could be included in the analysis population. In comparison with standard HD, BV-controlled UF reduced the percentage of HD sessions complicated by IME significantly from 40%+/-27% to 32%+/-25% (p=0.02). A lower frequency of HD sessions with IME could be observed in 46% of the patients. The frequency of treatments with symptomatic hypotension was reduced from 32%+/-23% in standard HD to 24%+/-21% with BV-controlled UF (p=0.04). Changes in blood pressure and heart rate from start to end of the HD session were not different between the 2 treatment modes.This crossover study showed improved intradialytic stability with BV-controlled UF, compared with standard HD.

Background Treatment of patients with membranous glomerulonephritis (MGN) is controversial because of the lack of clear benefit of the immunosuppressive regimens on patient or renal survival. The objective of this study is to evaluate the efficacy and safety of mycophenolate mofetil (MMF) for patients with MGN. Study Design 1-year prospective, randomized, and controlled clinical trial. Setting & Participants 36 patients with biopsy-proven idiopathic MGN and nephrotic syndrome. Intervention 19 patients received MMF (2 g/d) for 12 months and 17 patients were in the control group. All patients had the same conservative treatment based on renin-angiotensin blockers, statins, low-salt and low-protein diet, and diuretics in case of edema. Outcomes & Measurements End points were the mean proteinuria over creatinuria ratio in mg/g throughout the study and numbers of complete and partial remissions at 1 year (month 12). Data were analyzed on an intention-to-treat analysis. Results Mean proteinuria over creatinuria ratio was stable in both groups throughout the study (P = 0.1). Mean proteinuria over creatinuria ratio was 4,690 ± 2,212 mg/g in the MMF group and 6,548 ± 4,601 mg/g in the control group (95% confidence interval of the difference, −619 to +4,247; P = 0.1). Remission was complete in 3 patients (1 in the MMF group, 2 in the control group; P = 0.5) and partial in 11 patients (6 in the MMF group, 5 in the control group; P = 0.9). The probability of complete or partial remission did not differ between the 2 groups after 12 months (relative risk, 0.92; 95% confidence interval, 0.48 to 1.75; P = 0.7). Kidney function was stable in the 2 groups according to estimated glomerular filtration rate and serum creatinine level. Limitations The small number of patients and short follow-up prevent generalizations. Conclusions A 12-month regimen of MMF did not decrease mean proteinuria over creatinuria ratio or increase partial and complete remissions. Serious adverse effects were observed in 4 patients (20%) receiving MMF.

OBJECTIVE—The Cockcroft-Gault and Modification of Diet in Renal Disease (MDRD) equations poorly predict glomerular filtration rate (GFR) decline in diabetic patients. We sought to discover whether new equations based on serum creatinine (the Mayo Clinic Quadratic [MCQ] or reexpressed MDRD equations) or four cystatin C–based equations (glomerular filtration rate estimated via cystatin formula [Cys-eGFR]) were less biased and better predicted GFR changes. RESEARCH DESIGN AND METHODS—In 124 diabetic patients with a large range of isotopic GFR (iGFR) (56.1 ± 35.3 ml/min per 1.73 m2 [range 5–164]), we compared the performances of the equations before and after categorization in GFR tertiles. A total of 20 patients had a second determination 2 years later. RESULTS—The Cockcroft-Gault equation was the least precise. The MDRD equation was the most precise but the most biased according to the Bland-Altman procedure. By contrast with the MDRD and, to a lesser extent, the MCQ, three of the four Cys-eGFRs were not biased. All equations overestimated the low GFRs, whereas only the MDRD and Rule's Cys-eGFR equations underestimated the high GFRs. For the subjects studied twice, iGFR changed by −8.5 ± 17.9 ml/min per 1.73 m2. GFR changes estimated by the Cockcroft-Gault (−4.5 ± 6.8) and MDRD (−5.7 ± 6.2) equations did not correlate with the isotopic changes, whereas new equation-predicted changes did: MCQ: −8.7 ± 9.4 (r = 0.44, P < 0.05) and all four Cys-eGFRs: −6.2 ± 7.4 to −7.3 ± 8.4 (r = 0.60 to 0.62, all P < 0.005), such as 100/cystatin-C (r = 0.61, P < 0.005). CONCLUSIONS—The new predictive equations better estimate GFR than the Cockcroft-Gault equation. Although the MDRD equation remains the most accurate, it poorly predicts GFR decline, as it overestimates low and underestimates high GFRs. This bias is lesser with the MCQ and Cys-eGFR equations, so they better predict GFR changes.

About 20% of diabetic patients with chronic kidney disease (CKD) detected from the new American Diabetes Association recommendations (albumin excretion rate30 mg/24 h or estimated glomerular filtration rate [GFR]60 ml/min per 1.73 m2) may be normoalbuminuric. Do the characteristics and outcome differ for subjects with and without albuminuria?A total of 89 patients with diabetes and a modification of diet in renal disease (MDRD) estimated GFR (e-GFR)60 ml/min per 1.73 m2 underwent a 51Cr-EDTA B-isotopic GFR determination and were followed up for 38 +/- 11 months.The mean MDRD e-GFR (41.3 +/- 13.1 ml/min per 1.73 m2) did not significantly differ from the i-GFR (45.6 +/- 29.7). Of the subjects, 15 (17%) were normoalbuminuric. Their i-GFR did not differ from the albuminuric rate and from their MDRD e-GFR, although their serum creatinine was lower (122 +/- 27 vs. 160 +/- 71 micromol/l, P0.05): 71% would not have been detected by measuring serum creatinine (sCr) alone. They were less affected by diabetic retinopathy, and their HDL cholesterol and hemoglobin were higher (P0.05 vs. albuminuric). None of the CKD normoalbuminuric subjects started dialysis (microalbuminuric: 2/36, macroalbuminuric: 10/38) or died (microalbuminuric: 3/36, macroalbuminuric: 7/38) during the follow-up period (log-rank test: P0.005 for death or dialysis), and their albumin excretion rate and sCr values were stable after 38 months, whereas the AER increased in the microalbuminuric patients (P0.05), and the sCr increased in the macroalbuminuric patients (P0.01).Although their sCr is usually normal, most of the normoalbuminuric diabetic subjects with CKD according to an MDRD e-GFR below 60 ml/min per 1.73 m2 do really have a GFR below 60 ml/min per 1.73 m2. However, as expected, because of normoalbuminuria and other favorable characteristics, their risk for CKD progression or death is lower.

High blood pressure and proteinuria are the major factors that drive progression of chronic kidney disease. Target levels for preserving renal function are blood pressure less than 130/80 mmHg and proteinuria less than 0.5 g/day. Angiotensin II converting enzyme inhibitors and sartans should be used as first-line therapy to reach these targets. Their use requires close monitoring of renal function and serum potassium levels. Moderate sodium restriction, possibly combined with diuretic therapy, helps to maximize the effect of renin-angiotensin inhibitors. Patients with chronic kidney disease have a high risk of acute kidney failure, especially due to drugs. All prescriptions must take into account the existence and extent of kidney disease. Patient adhesion and collaboration between health professionals are required if these measures are to be effective in the long term.

Diabetologists and nephrologists must cooperate to improve uraemic diabetic patient's outcome, with a special attention to their nutritional status. We describe the management of these patients at the CHU of Bordeaux since 2001, and its first results. Renal function is assessed by the glomerular filtration rate, predicted by the Cockcroft-Gault formula according to clinical guidelines. We compared its results to reference isotopic measurements (51Cr-EDTA) in one hundred and twenty two patients. This comparaison showed clearly a bias because the GFR calculated by the formula is proportionnal to body weight: the prediction is overestimated by 55% in obese (BMI30) and 15% in overweighted (25BMI30) patients, who represent the majority of type 2 diabetic patients; the MDRD equation is not affected by this bias. Nutritional follow-up is based on body composition assessment by DEXA, but more simple methods (Skinfold thickness, bio-impedancemetry) have given similar results in our first forty nine patients. After 2 years of follow-up, no patient have lost fat or fat-free mass, except seven patients who have lost 6 kg fat-free mass during the 6 months after starting hemodialysis. The kind of this fat-free mass loss (muscular loss, or correction of hyperhydratation) remains a matter of discussion.

Background : A poor nutritional status reduces the life expectancy of diabetes patients undergoing hemodialysis. Objective : The study objective was to specify the nutritional outcome in patients with chronic kidney disease (CKD) and well-controlled diabetes. Design : Forty-five diabetes patients with CKD were enrolled in a cooperative-care program designed to control glucose, blood pressure, LDL cholesterol, and the albumin excretion rate (AER). Their glomerular filtration rate (GFR), body composition, serum albumin (SA), and resting energy expenditure were assessed and compared at baseline and 2 y later. Results : Thirty-five patients did not start dialysis. Their glycated hemoglobin, blood pressure, LDL cholesterol, and AER improved; their GFR declined slowly (-3.3 mL·min -1 .1.73 m -2 .y -1 ) .Their body mass index (BMI), lean body mass, and SA increased. The GFR decline was correlated negatively with the initial BMI (r = -0.37, P < 0.05) and positively with the initial GFR (r = 0.34, P < 0.05). Ten patients started hemodialysis : except for higher total body water (P < 0.05) and extracellular volume (P < 0.01), their initial nutritional status did not differ significantly from that of 10 patients with comparable baseline severe CKD but without dialysis. At the second evaluation, patients on hemodialysis lost lean body mass, and their SA was lower than that of the patients with severe CKD (P = 0.05); lean body mass was unchanged and SA was higher (P = 0.01) in the patients with severe CKD. No significant difference was detected for resting energy expenditure. Conclusions : Nutritional status improved in CKD patients with well-controlled diabetes without dialysis, and it deteriorated in patients who started dialysis. A high initial BMI was associated with a slower decline in GFR.

OBJECTIVE—Hyperglycemia increases glomerular filtration rate (GFR), but the influence of HbA1c (A1C) on GFR and GFR’s prediction by recommended equations remains to be determined. RESEARCH DESIGN AND METHODS—In 193 diabetic patients, we searched for an association between A1C and isotopically measured GFR (51Cr-EDTA) and their predictions by the Cockcroft and Gault formula (CG) and the modification of diet in renal disease (MDRD) equation. Their accuracy for the diagnosis of moderate (GFR RESULTS—The mean GFR was 57.0 ± 34.8 ml/min per 1.73 m2 and was well correlated with both estimations (CG r = 0.75, MDRD r = 0.83; P < 0.05). The areas under the ROC curves were higher with the MDRD (P < 0.05). A1C was correlated (P < 0.001) with the GFR (r = 0.29), MDRD (r = 0.38), CG (r = 0.26), and the absolute differences between the GFR and their CG but not MDRD estimations (r = 0.17, P < 0.05). Each +1% A1C was associated with +6.0 ml/min per 1.73 m2 GFR (CG +5.6, MDRD +5.3). After separating well-controlled (n = 88, A1C 7.0 ± 0.7%) and poorly controlled (n = 105, 9.6 ± 1.3%) patients, the diagnostic accuracies were better (P < 0.05) for the MDRD, except for the diagnosis of moderate renal failure in well-controlled patients (NS). CONCLUSIONS—GFR and its estimations correlate with A1C. Although the relations between GFR and its estimations were not affected by the degree of glucose control, the precision and diagnostic accuracy of the CG formula were diminished for A1C >8%. The MDRD equation was more accurate and robust in diabetic patients with impaired renal function.

The Cockcroft-Gault formula is recommended for the evaluation of renal function in diabetic patients. The more recent Modification of Diet in Renal Disease (MDRD) study equation seems more accurate, but it has not been validated in diabetic patients. This study compares the two methods.In 160 diabetic patients, we compared the Cockcroft-Gault formula and MDRD equation estimations to glomerular filtration rates (GFRs) measured by an isotopic method ((51)Cr-EDTA) by correlation studies and a Bland-Altman procedure. Their accuracy for the diagnosis of moderately (GFR60 ml . min(-1) . 1.73 m(-2)) or severely (GFR30 ml . min(-1) . 1.73 m(-2)) impaired renal function were compared with receiver operating characteristic (ROC) curves.Both the Cockcroft-Gault formula (r = 0.74; P0.0001) and MDRD equation (r = 0.81; P0.0001) were well correlated with isotopic GFR. The Bland-Altman procedure revealed a bias for the MDRD equation, which was not the case for the Cockcroft-Gault formula. Analysis of ROC curves showed that the MDRD equation had a better maximal accuracy for the diagnosis of moderate (areas under the curve [AUCs] 0.868 for the Cockcroft-Gault formula and 0.927 for the MDRD equation; P = 0.012) and severe renal failure (AUC 0.883 for the Cockcroft-Gault formula and 0.962 for the MDRD equation; P = 0.0001). In the 87 patients with renal insufficiency, the MDRD equation estimation was better correlated with isotopic GFR (Cockcroft-Gault formula r = 0.57; the MDRD equation r = 0.78; P0.01), and it was not biased as evaluated by the Bland-Altman procedure.Although both equations have imperfections, the MDRD equation is more accurate for the diagnosis and stratification of renal failure in diabetic patients.

International audience; Objective: Determine the mechanism of glucose intolerance in chronically uremic subjects. Design: Comparison of doubly labeled oral glucose tolerance tests. Subjects: Seven nondialyzed chronically uremic subjects (creatinine, 420 ± 104 μmol/L) and 7 healthy subjects, matched for age and body mass index. Intervention: Plasma glucose was labeled by an infusion of dideuterated glucose started 120 minutes before ingestion of 1 g/kg of naturally 13C-enriched corn starch glucose. Glucose levels and oxidation were monitored for 330 minutes after glucose ingestion. Results: Uremic subjects had normal fasting plasma glucose levels and impaired glucose tolerance with high plasma insulin (P < .001 versus controls). Glucose tolerance was impaired because of an increased total rate of appearance of glucose (cumulated on 330 minutes: uremic, 1,231 ± 42 mg/kg/330 min, controls, 1,031 ± 64; P < .05). Peripheral glucose uptake was increased (P < .05) because of an increased nonoxidative disposal (P = .051). Conclusions: Although peripheral glucose uptake resisted the stimulatory effect of the high insulin levels, glucose tolerance was impaired through splanchnic metabolic disturbances: reduced splanchnic glucose uptake and increased endogenous glucose production. The respective contribution of these abnormalities remains to be determined.

Background: The use of a central venous catheter as a permanent vascular access is constantly growing. The recirculation rate in this type of vascular access varies depending on the site of insertion, the length of the catheter, the blood flow and the time elapsed since catheter insertion. When the in/out flow of the lumens of the catheter is reduced, it is sometimes necessary to inverse the arterial and venous lines of the catheter at the beginning or in the course of the dialysis session. The impact of such a practice on the recirculation rate has only been assessed by the low flow urea dilution method. Methods: The blood recirculation rate was measured using the ultrasound dilution velocity method (Transonic® system, Ithaca, N.Y.) in 14 patients (aged 64 ± 15 years), with a right internal jugular (n = 9) or right subclavian (n = 5) central catheter (Twincath, Medcomp®), used over a mean period of 16.3 (range 1–42) months. No clinical dysfunction of the catheter was apparently noted. The distance between the vein and the artery end of the catheter was 3.9 ± 2.8 cm, measured on chest radiography. The recirculation rate was measured over a single dialysis session at increasing blood flows in the normal and inversed position of the catheter. Results: The difference between the prescribed and effective blood flow was significant with an effective blood flow of 180± 16 ml/min for 200 ml/min, 264 ± 27 ml/min for 300 ml/min and 329 ± 16 ml/min for 400 ml/min prescribed blood flow. There was no relationship between the recirculation rate and blood flow whatever the position of the lines on the catheter. There was also no relationship between the recirculation rate and the distance between the catheter ends. However, reversing the catheter ends significantly increased the recirculation rates from 2.9 ± 5 to 12 ± 9% whatever the blood flow. Conclusion: The use of central catheters in an inversed position can result in a higher recirculation rate. Reversing the lines of the central catheters may lead to less effective hemodialysis and it seems particularly important for the nursing staff to be aware of this phenomenon. Thus, measurement of the effective blood flow and recirculation by ultrasound velocity should be included in quality monitoring and maintenance.