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BackgroundIn the general population, the CHA2DS2-VASC and the HAS-BLED scores are helpful to predict cerebrovascular events and hemorrhage in patients with atrial fibrillation (AF). However, their predictive value remains controversial in the dialysis population. This study aims to explore the association between these scores and cerebral cardiovascular events in hemodialysis (HD) patients.MethodsThis is a retrospective study including all HD patients treated between January 2010 and December 2019 in two Lebanese dialysis facilities. Exclusion criteria are patients younger than 18 years old and patients with a dialysis vintage less than 6 months.ResultsA total of 256 patients were included (66.8% men; mean age 69.3 ± 13.9 years). The CHA2DS2-VASc score was significantly higher in patients with stroke (P = .043). Interestingly, this difference was significant in patients without AF (P = .017). Using receiver operating curve analysis, CHA2DS2-VASc score had an area under the curve (AUC) of 0.628 [95% confidence interval (CI): 0.539–0.718) and the best cut-off value for this score was 4. The HAS-BLED score was also significantly higher in patients with a hemorrhagic event (P ConclusionsIn HD patients, CHA2DS2-VASc score can be associated with stroke and HAS-BLED score can be associated with hemorrhagic events even in patients without AF. Patients with a CHA2DS2-VASc score ≥4 are at the highest risk for stroke and adverse cardiovascular outcomes, and those with a HAS-BLED score ≥4 are at the highest risk for bleeding.

Objectives Historically, headache was reported in up to 76% of hemodialysis patients. Some authors suggested that headache resulted from caffeine withdrawal. This study aims to compare the incidence of headache and hypotension between patients drinking regular or decaffeinated coffee during dialysis. Methods One-hundred fifty-six patients were enrolled in this randomized, double-blind, placebo-controlled, multicenter study. Patients with atrial fibrillation were excluded. Group A was given 80 mL of regular coffee and group B 80 mL of decaffeinated coffee (placebo) in the middle of the session for 12 consecutive sessions. Ultrafiltration rate was fixed to a maximum of 13 mL/kg/hour. The primary outcome was the incidence of headache during dialysis. Results A total of 139 patients completed the trial (6.4% vs. 15.4% of withdrawal in Groups A and B, respectively). The number of sessions with headache was not significantly different between Group A and B (33.3% vs. 37.1% respectively, P = .522), nor the number of sessions with hypotension (27% vs. 26% respectively, P = .539). In a subgroup analysis, headache tended to be more frequent in Group B (P = .06) in 2 categories of patients: those with the highest potassium dialysate (K = 2) and the non-hypertensive patients. Conclusions Headache occurred in 35% of patients during their chronic hemodialysis sessions. Caffeine intake did not prevent headache occurrence in these patients.

AIM Febuxostat is initiated in chronic kidney disease (CKD) patients to lower uric acid but without any renal dosing scheme. This study aimed to determine a formula that predicts the effective dose of febuxostat in patients with an estimated glomerular filtration rate (eGFR) < 60 mL/min and asymptomatic hyperuricemia. MATERIALS AND METHODS This is a retrospective analysis of 100 CKD patients treated with febuxostat for asymptomatic hyperuricemia in two private Lebanese clinics. Patients with gout were excluded. Collected variables were age, sex, weight, serum creatinine, serum uric acid (sUA) before and after febuxostat, dose of febuxostat used, and diuretic use. Multiple regression analysis was used to derive a formula predicting the dose of febuxostat based on eGFR (2009 Chronic Kidney Disease Epidemiology Collaboration equation), baseline sUA, and sUA reduction ratio. A prospective cohort of 24 patients was then used to validate the derived model. RESULTS 100 patients were included with a median age of 71.5 years (interquartile range (IQR), 64.2 - 79.0); 69% were men. Median baseline sUA was 9.1 mg/dL (IQR, 8.4 - 10.1). Mean eGFR was 31.80 ± 12.96 mL/min/1.73m2. Of the included patients, 18% had CKD stage 3a, 36% had CKD stage 3b, 38% had CKD stage 4, and 8% had non-dialysis CKD stage 5. A formula was computed to predict febuxostat dosing. Variables that were predictive of febuxostat dose and used in the final equation were eGFR, diuretic use, baseline sUA, and sUA reduction ratio. The validation cohort showed no significant difference between the expected sUA and the measured one (p = 0.16). CONCLUSION With this new formula, physicians can initiate febuxostat in CKD patients at an effective dose for any desired sUA reduction ratio.

Background Treatment with erythropoietin is well established for anemia in chronic kidney disease patients but not well studied in acute kidney injury. Methods This is a multicenter, randomized, pragmatic controlled clinical trial. It included 134 hospitalized patients with anemia defined as hemoglobin n = 67) and the second received standard of care (control; n = 67) during the hospitalization until discharge or death. The primary outcome was the need for transfusion; secondary outcomes were death, renal recovery, need for dialysis. Results There was no statistically significant difference in transfusion need (RR = 1.05, 95%CI 0.65,1.68; p = 0.855), in renal recovery full or partial (RR = 0.96, 95%CI 0.81,1.15; p = 0.671), in need for dialysis (RR = 11.00, 95%CI 0.62, 195.08; p = 0.102) or in death (RR = 1.43, 95%CI 0.58,3.53; p = 0.440) between the erythropoietin and the control group. Conclusions Erythropoietin treatment had no impact on transfusions, renal recovery or mortality in acute kidney injury patients with anemia. The trial was registered on ClinicalTrials.gov (NCT03401710, 17/01/2018).

Background Chronic kidney disease (CKD) is the 12th leading cause of death worldwide. Cost-of-illness studies of CKD are scarce in developing countries. This study aims to estimate the cost of illness of all stages of CKD in Lebanon, from early stages until dialysis and kidney transplantation. The secondary objective is to identify factors related to the highest financial burden. Methods This is a cross-sectional study of CKD patients who presented to two nephrology clinics during November 2020. Their medical and administrative records were reviewed for collection of demographics, CKD characteristics, direct medical costs (medications, diagnostic tests, hospitalizations, inpatient care, outpatient care), direct non-medical costs (transportation) and indirect costs (productivity losses) for one year. Kruskal Wallis test was used to compare the costs between different CKD stages and categories. Logistic regression analysis was used to evaluate risk factors associated with costs. Results The sample included 102 non-dialysis CKD patients, 40 hemodialysis, 8 peritoneal dialysis and 10 transplant patients. Their mean age was 66.74 ± 15.36 years, 57.5% were males and 42.5% diabetics. The total median cost per year of CKD across all categories was assessed to be 7,217,500 Lebanese Pounds (3,750,000–35,535,250; 1 $USD = 1515 LBP in 2019) from the societal perspective and 5,685,500 LBP (2,281,750- 32,386,500) from the third-party payer perspective. Statistical analysis showed a higher total cost in hemodialysis (p p p r = -0.391, p = 0.013); the regression analysis found diabetes as a risk factor for higher cost (OR = 2.3; 95%CI: 0.638,8.538; p = 0.201). In the subcategory of CKD-ND patients, age correlated with total societal cost (r = 0.323, p = 0.001); diabetes and coronary artery disease were significantly associated with higher total cost (OR = 2.4; 95%CI: 1.083,5.396; p = 0.031; OR = 3.7; 95%CI: 1.535,8.938; p = 0.004). Conclusions This cost of illness study showed a high burden of hemodialysis and peritoneal dialysis cost compared to transplant and non-dialysis CKD patients. It revealed a significantly higher cost of medications in transplant patients. Health policies should target interventions that prevent end-stage kidney disease and encourage kidney transplantation.

Musculoskeletal disorders remain a major problem in hemodialysis patients. The aim of the study was to estimate the prevalence of musculoskeletal manifestations in hemodialysis patients and identify disease cluster profiles. We performed a cross-sectional study including all adult patients in the hemodialysis unit at Hotel-Dieu de France Hospital. We collected demographic characteristics, musculoskeletal symptoms, biologic parameters, and treatments. Musculoskeletal disorders were classified by a rheumatologist into predefined diagnostic categories. Prevalence was presented, and a cluster analysis was performed. Eighty-nine patients were included, mean age was 67.5 ± 12 years, and 43.8% were female. Dialysis vintage was 5.7 ± 5.37 years. Musculoskeletal symptoms were reported by 76.4% of the patients. Pain was the most frequent symptom (44.9%). The main diagnoses were osteoarthritis (53.9%) and fracture (27%). Musculoskeletal symptoms and disorders were significantly associated with dialysis vintage and age. Cluster analysis identified three patient profiles: younger with low calcium levels, younger but long dialysis vintage with osteoarthritis and carpal tunnel syndrome, and older with long dialysis vintage and fractures. The prevalence of musculoskeletal manifestations is high in the hemodialysis population and increases with dialysis vintage. Musculoskeletal disorders cluster according to age and dialysis vintage. Key Points• Musculoskeletal symptoms are highly prevalent among hemodialysis patients (76.4%).• All musculoskeletal disorders are associated with dialysis vintage and age.• Three clusters are identified among hemodialysis patients: young with low calcium levels, young but long dialysis vintage with osteoarthritis and carpal tunnel syndrome and old with long dialysis vintage with fractures.

Background and Aims Chronic Kidney Disease (CKD) is the 12th leading cause of death worldwide and a high societal burden. Cost-of-illness studies of CKD are scarce in developing countries. Identifying factors associated with the highest cost can help decision makers adapt health policies and sustain kidney health services, especially in limited resources' settings. This study aims to estimate the cost of illness of CKD in Lebanon, from the early stages of CKD until dialysis and kidney transplant and identify cost components related to the highest financial burden. Method This is a cross-sectional study of all CKD patients who presented to two nephrology clinics during the first two weeks of November 2020. The sample size required for the study to be representative was 154 patients. The medical and administrative records were reviewed to collect the demographics and CKD characteristics of patients as well as the direct medical costs (medications, diagnostic tests, hospitalizations, inpatient care, outpatient care), direct non-medical costs (transportation) and indirect costs (productivity losses) for one year between 1st June 2019 and 1st June 2020. Kruskal Wallis test was used to compare the costs between different CKD stages and categories. The study got the approval of the ethics committee of Saint-Joseph University. Results The sample included a total of 160 patients: 102 non-dialysis CKD patients, 40 hemodialysis, 8 peritoneal dialysis and 10 kidney transplant patients. Their mean age was 66.74 ±15.36 years, 57.5% were males and 42.5% diabetics. The mean number of daily medications was 8.75 ±3.38, mean frequency of blood tests per year 6.86 ±6.4 and mean number of hospital admissions per year 0.79 ±1.43. The mean total annual cost of CKD per patient across all categories was assessed at 19,900,164 ±27,893,591 Lebanese Pounds (1 $USD= 1515 LP in 2019). Statistical analysis showed a higher total cost among dialysis patients compared to other categories of CKD (p Conclusion Similar to previous studies from other countries, this cost of illness analysis showed a high burden of dialysis annual costs compared to non-dialysis CKD and transplant patients. It revealed as well a great burden of medications' costs at the level of dialysis and transplantation. It is thus crucial that governments and health policies in low- and middle-income countries target interventions that prevent end-stage kidney disease, reduce medications' costs and most of all create programs that encourage kidney transplantation.

Background and Aims High flux hemodialysis has largely replaced low flux hemodialysis in developed countries. Clinical trials, in particular the Hemo and the MPO studies, conducted many years ago, showed that the survival benefit was mainly for patients on long term hemodialysis for the first one and for high risk patients with low albumin level (less than 40g/dl) for the latter. Moreover, the effect on hematopoiesis or mineral balance is not unequivocally established in the literature. In Lebanon, following the recommendations of the ministry of health, we switched patients undergoing hemodialysis at our center from low to high flux starting April 2019. We aimed in this study to assess the effect of this switch on hemoglobin level, dose of ESA used, mineral metabolism parameters and nutritional parameters. Method This is an observational pre-post study where each patient is his own control. Subjects included are adults on chronic hemodialysis for more than 6 months at Hotel Dieu de France University Hospital. Patients who needed transfusion for bleeding, admission to the hospital or parathyroidectomy during the study period were excluded from the study. Demographic parameters, medical history and laboratory values were extracted from the patients’ files. Paired t- test was used to compare values obtained in the 6 months on low flux compared to the 6 months on high flux hemodialysis. Results Seventy four patients received sequentially both techniques (45 males and 29 females). Mean age was 66 years, mean dialysis vintage 65 months, diabetic and vascular diseases were the most frequent causes of ESRD found in 27 and 15% of the cases. Hemoglobin level significantly increased from 11 +/- 0.82 to 11.26 +/- 0.67 mg/dl (p=0.04) with a non-significant trend towards a lower ESA dose: 11620 UI/week (+/-2275 UI) in the first period versus 10860 UI/week (+/-2609 UI) during the second period (p=0.15). Ferritin levels were higher in the second part of the study (416 v/s 476 ng/ml) which may have contributed to the increase in hemoglobin. Phosphorus level decreased from 1.55 to 1.48 mmol/l (p=0.008) at the same doses of binders and practically stable levels of calcium and PTH. Most interestingly, albumin level increased from 38 to 40.3 g/dl (p Conclusion Assuring quality ultrapure water is still a challenge in many developing countries. Lack of firm evidence on beneficial effect in terms of mortality may delay sanitary authorities from imposing high flux hemodialysis. In our study, switching from low to high flux hemodialysis showed positive impact on phosphorus levels but most interestingly increased albumin levels a major predictor of mortality in hemodialysis patients.

Background: Coronavirus disease 2019 (COVID-19) is a rapidly spreading infective disease caused by the severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2). The management of this disease remains a challenge particularly in certain subgroups of patients such in hemodialysis patients who have higher exposure rates due to the nature of their in-hospital care, and higher mortality due to their burden of comorbidities. Moreover, molecules used in the general population to treat COVID-19 lack data regarding their pharmacodynamics in the hemodialysis population.Case presentation: We report a case of a 52-year-old patient with Von Hippel Lindau syndrome and end stage renal disease on hemodialysis who contracted COVID-19 infection. Due to the patient’s rapidly deteriorating clinical status he was successfully treated with Tocilizumab, despite the lack of data concerning the use of this molecule in this population. The patient was later discharged after a long hospital stay and progressive clinical, biological and radiological improvement.Conclusion: This sub group of patients should be carefully approached due to the unique nature of their comorbidities, and to their immune’s system response to the virus itself and to novel therapies. Although few studies were available regarding the use of Tocilizumab in the dialysis population, its use proved to be effective and well tolerated in our patient.

Targeting the immune system with immune checkpoint inhibitors (ICI) to treat cancer has been lately adopted with a significant improvement of patients’ survival. In parallel, the incidence of malignancy in chronic kidney disease (CKD) patients is increasing, but solid evidence concerning the efficacy and safety of ICI in this population is lacking. Moreover, the use of these agents as immunity boosters in kidney graft recipients treated with immunosuppressors is still controversial. We present in this article a review of the pharmacological properties of these drugs and their behavior with kidney failure and dialysis, as well as evidence of their use in different populations of CKD. Most of the available data are limited to case reports and case series. These drugs appear to be safe without dose adjustment in CKD patients and patients on dialysis. A major concern with this therapy in transplanted patients remains the risk of graft rejection.

Background and Aims Coffee with its major component caffeine can enhance alertness and decrease tiredness and headache. Headache was reported in 40 to 75 % of hemodialysis patients. Caffeine circulates unbound in the blood and passes the dialysis membrane. Some authors suggested that headache can result from caffeine withdrawal. This study aims to compare the incidence of headache and hypotension between patients taking or not coffee during dialysis. Method This is a randomized double-blind multicenter trial. Patients of three hemodialysis units were included. Patients with atrial fibrillation were excluded. 156 patients were randomized to two groups, group A was given 80 cc of coffee and group B 80 cc of decaffeinated coffee in the middle of the session for 12 consecutive sessions. Ultrafiltration rate was fixed to a maximum of 13 ml/kg/h. The primary outcome was the incidence of headache and the secondary incidence of hypotension. This clinical trial received the approval of the ethics committee of Saint-Joseph University (HDF-1463) and was registered on ClinicalTrials.Gov (NCT04057313). Results A total of 139 patients completed the trial (6.4% vs 15.4 % of withdrawal in groups A and B respectively). Baseline characteristics are summarized in Table 1. The number of sessions with headache was not significantly different between group A and B (34% vs 37% respectively, p=0.522), nor the number of sessions with hypotension (27% vs 26% respectively, p= 0.539). In a subgroup analysis, headache was higher in group B (p=0.06) in two categories of patients: those with the highest potassium dialysate (K=2) and the non-hypertensive patients. Conclusion Headache occurred in 34 to 37% of dialysis sessions. There was no difference in headache or hypotensive episodes between patients in the coffee versus decaffeinated group.

Objectives: Hemodialysis is the most used renal replacement modality for end-stage renal disease patients. Dialysis patients are usually assessed for quality of life (QoL) but smiling was never studied. Duchenne smile is a genuine expression of joy, associated with better survival in some groups of the general population. In this study, we aimed to evaluate whether the smile of dialysis patients can predict their QoL and mortality. Methods: All hemodialysis patients in Saint-George Hospital were included in this prospective study. Patients were interviewed using the Health-Related QoL questionnaire and followed for 10 days for smile screening. Those who smiled more than 34% of time were considered as smiling, then followed for death over 2 years. Results: Overall, 71 patients were studied. Duchenne smile was associated with death at 1 and 2 years (HR = 0.194 [95% CI 0.039-0.958], p = .044) but not with sex or diabetes. Smiling showed a statistically significant correlation with older age, fewer hospitalizations, vitality, physical component score, several QoL scores and general health. Conclusions: A simple observation of patients' Duchenne smile by nephrologists in hemodialysis units can give an idea about their QoL and 2-year survival.

Background: Intradialytic hypertension is identified as an independent predictor of adverse clinical outcome in hemodialysis patients. Little is known about its pathophysiological mechanism. Objective: The aim of this study is to provide new insights into the mechanisms underlying this arterial pressure dysregulation. Methods: 62 subjects on chronic hemodialysis were included in this study. Blood pressure was monitored before, during and following each dialysis session for a 3-month period. Pre- and post-dialysis blood samples were drawn from all the subjects to perform immunoassays, monocyte extractions and western blot analyses. Results: Blood pressure values separated the subjects with in two groups: normal blood pressure (n=53) and intradialytic hypertension (n=9) groups. Renin, angiotensin converting enzyme I and aldosterone plasma concentrations significantly diverged between the groups. Vascular endothelial nitric oxide assessment revealed significantly lower plasma L-citrulline and angiotensin-converting enzyme II in post-dialysis intradialytic hypertensive patients, along with high endothelin I and asymmetric dimethylarginine concentrations. Plasma collectrin levels were significantly higher in pre and post-dialysis intradialytic hypertensive group compared to a normal blood pressure group. Post-dialysis interleukin 6 was significantly higher in intradialytic hypertensive group compared to normal blood pressure group. Finally, pre-dialysis intradialytic hypertension was associated with significantly higher circulating vascular endothelial growth factor C with monocytic up-regulation of vascular endothelial growth factor C/tonicity-responsive enhancer binding protein expression. Conclusion: Impairment of vascular endothelial nitric oxide key regulatory elements, as well as monocytic vascular endothelial growth factor C seems to be more prevalent in intradialytic hypertension. These clues could pinpoint novel therapeutic interventions in intradialytic hypertension management.

Background The evaluation of chronic kidney disease (CKD) in cancer patients seems to rely mostly on the Cockcroft-Gault (CG) formula or the creatinine levels to adjust treatment dosages which is a practice refuted by internists. Aims We evaluate the overall agreement of the CG, modification of diet in renal disease (MDRD) and CKD-epidemiology collaboration equations (CKD-EPI) equation with the newly devised Janowitz and Williams' (JW) equation. Methods The renal function was estimated in 235 cancer patients according to the CG, MDRD, body surface area (BSA)-adjusted MDRD, CKD-EPI, BSA-adjusted CKD-EPI and JW formulae. Results JW equation was more in agreement with CG and CKD-EPI estimations than the other equations. Taking JW equation as reference, receiver operating characteristic curve analysis showed that CG eGFR had the higher area under the curve when compared with other equations. Hierarchical cluster analysis showed more proximity between CG and JW equations than the other equations. Conclusion The newly proposed JW eGFR estimation was more in agreement with CG equation than the other equations.

Intradialytic Hypotension is a major complication during hemodialysis session, associated with increased risk of cardiovascular events and mortality. Its pathophysiology is believed to be multifactorial and remains not well elucidated. The aim of this study is to put forward new mechanisms behind the development of intradialytic hypotension. The study included sixty-five subjects on chronic hemodialysis, divided into two groups: intradialytic hypotensive (n=12) and normotensive (n=53), according to the variation of systolic blood pressure between post-dialysis and pre-dialysis measurements. Renin and angiotensin converting enzyme I plasma concentrations increased in both groups but more likely in normotensive group. Aldosterone plasma concentration is increased in the normotensive group while it decreased in the intradialytic hypotension group. Plasma endothelin concentrations showed higher values in intradialytic hypotension group. Post-dialysis asymmetric dimethylarginine and angiotensin converting enzyme 2 plasma concentrations were significantly higher in intradialytic hypotension group as compared to normotensive one. Collectrin plasma concentrations were significantly lower in intradialytic hypotension group. Finally, post-dialysis vascular endothelial growth factor C plasma concentration significantly increased in intradialytic hypotension group. In conclusion, endothelial dysfunction characterized by a lower level of vasoactive molecule seems to play a critical role in intradialytic hypotension development.

Background During their training, Lebanese medical students develop a high medical expertise but are not focusing on other competencies such as communication, collaboration, erudition, professionalism, leadership and health promotion. There is also insufficient data about patients’ preference for these skills. This study describes the different weights patients attribute to these physician’s competencies. Methods This is a cross-sectional study based on a questionnaire distributed to 133 Lebanese patients. It included 15 questions assessing how patients prioritize the physician’s competencies, with open-ended questions asking them to define “the good doctor”. Krippendorff’s alpha coefficient was used to analyze the reliability of the competencies’ classification. Results One hundred twenty five patients completed the questionnaire in this cross-sectional study. Their mean age was 48 ± 16.76 years. When classifying competencies, 73.6% opted for medical expertise as first choice and 48% put communication as second. Based on the Krippendorff’s coefficient, we identified a moderate agreement for the seven choices (alpha = 0.44). In open-ended questions, patients defined the good doctor in 325 answers: 64.3% mentioned medical expertise, 34.1% high ethics and 26.2% communication. Conclusions This patient-centered study concurs well with the worldwide practice that puts medical expertise at the center of medical education. However Lebanese patients don’t perceive equally other competencies and favor professionalism and communication that should be integrated in priority in students’ curricula.

Percutaneous renal biopsy is a well-established diagnostic procedure in patients with underlying medical renal disease. Aim of this study is to compare the adequacy of the biopsy material, the diagnostic yield, and the complication rates of the trans-peritoneal laparoscopic approach and the image-guided percutaneous approach to renal biopsy in the diagnosis of native kidney disease.We performed a matched-pair analysis matching 1:3 40 patients who underwent trans-peritoneal laparoscopic renal biopsy to 120 patients who underwent percutaneous renal biopsy in the same years. Patients were retrospectively analyzed. Differences in adequacy of biopsy material (i.e. number of glomeruli, continuous), diagnostic yield (categorical) and postoperative complications across the two groups were assessed using Wilcoxon Rank sum or χLaparoscopic biopsy was associated with a higher number of harbored glomeruli (median 50, IQR 20-77) compared to the percutaneous approach (median 10, IQR 7-15), P0.001. Adequate biopsies containing at least ten glomeruli were obtained in a significantly higher percentage of patients in the laparoscopic group versus the percutaneous group (92.5% vs. 57.1%, P0.001). The laparoscopic approach was also associated with a significantly higher diagnostic yield than the percutaneous approach (82.5% vs. 63.5%, P=0.027). Patients who underwent laparoscopic biopsy had no perioperative or postoperative complications, resulting in a significantly lower complication rate than percutaneous biopsy (0% vs. 4%, P0.001), particularly in the need for transfusion for post-procedure bleeding (0% vs. 1.8%, P0.001).In this retrospective matched-pair analysis comparing patients undergoing renal biopsy for medical kidney disease, trans-peritoneal laparoscopic renal biopsy was safer and more effective for the diagnosis of medical renal diseases compared to percutaneous renal biopsy. Prospective trials with a good follow-up are needed to define the best candidate for each approach.4.

Salt-sensitive hypertension is a major risk factor for renal impairment leading to chronic kidney disease. High-salt diet leads to hypertonic skin interstitial volume retention enhancing the activation of the tonicity-responsive enhancer-binding protein (TonEBP) within macrophages leading to vascular endothelial growth factor C (VEGF-C) secretion and NOS3 modulation. This promotes skin lymphangiogenesis and blood pressure regulation. Whether VEGF-C administration enhances renal and skin lymphangiogenesis and attenuates renal damage in salt-sensitive hypertension remains to be elucidated. Hypertension was induced in BALB/c mice by a high-salt diet. VEGF-C was administered subcutaneously to high-salt-treated mice as well as control animals. Analyses of kidney injury, inflammation, fibrosis, and biochemical markers were performed in vivo. VEGF-C reduced plasma inflammatory markers in salt-treated mice. In addition, VEGF-C exhibited a renal anti-inflammatory effect with the induction of macrophage M2 phenotype, followed by reductions in interstitial fibrosis. Antioxidant enzymes within the kidney as well as urinary RNA/DNA damage markers were all revelatory of abolished oxidative stress under VEGF-C. Furthermore, VEGF-C decreased the urinary albumin/creatinine ratio and blood pressure as well as glomerular and tubular damages. These improvements were associated with enhanced TonEBP, NOS3, and lymphangiogenesis within the kidney and skin. Our data show that VEGF-C administration plays a major role in preserving renal histology and reducing blood pressure. VEGF-C might constitute an interesting potential therapeutic target for improving renal remodeling in salt-sensitive hypertension.

There is so far no international consensus concerning the prescription of antithrombotic agents in hemodialysis patients. It is not clear yet why they cause more bleeding in some patients and are beneficial in others. We therefore tried to find out what triggers bleeding in this population. This is an observational before-and-after study that included all patients undergoing hemodialysis in our center between 2005 and 2015. We divided the study into two phases: phase one (125 patients) where aspirin was used without restrictions and phase two (110 patients) where aspirin was avoided in severe hypertension and primary prevention. We aimed to assess the differential occurrence of intracerebral hemorrhage between the two phases and the cardiovascular mortality of patients whether on aspirin or not. Bleeding events occurred in 12.8% of patients in phase one and 13.6% in phase two (p = 0.85). Seven out of 125 patients (6%) in phase one experienced intracerebral hemorrhage and none in phase two. Intracerebral hemorrhage was significantly increased in those with the combination of aspirin and severe hypertension (p = 0.003). Aspirin and acenocoumadin were significantly associated with total bleeding (OR = 3.81 and 4.85 with p = 0.005 and 0.001 respectively). Cardiovascular mortality did not differ between phase one and two whether patients were on aspirin or not (p = 0.45 and 0.31 respectively). Minimizing aspirin use in hemodialysis patients with severe hypertension reduced intracerebral bleeding without a significant difference in cardiovascular mortality.

Background Vascular calcifications are highly prevalent in hemodialysis patients. Dephosphorylated-uncarboxylated MGP (dp-ucMGP) was found to increase in vitamin K-deficient patients and may be associated with vascular calcifications. Supplementation of hemodialysis patients with vitamin K2 (menaquinone-7) has been studied in Europe with a maximum 61% drop of dp-ucMGP levels. The aim of this study is to assess first the drop of dp-ucMGP in an Eastern Mediterranean cohort after vitamin K2 treatment and second the correlation between baseline dp-ucMGP and vascular calcification score. Methods This is a prospective, pre-post intervention clinical trial involving 50 hemodialysis patients who received daily 360 μg of menaquinone-7 for 4 weeks. At baseline they were assessed for plasma dp-ucMGP levels and vascular calcification scores (AC-24) as well as for other demographic, clinical and biological variables. Dp-ucMGP levels were measured a second time at 4 weeks. Results At baseline, dp-ucMGP levels were extremely elevated with a median of 3179.15 (1825.25; 4339.50) pM and correlated significantly with AC-24 (Spearman’s rho = 0.43, P = 0.002). Using a bivariate regression analysis, the association between dp-ucMGP levels and AC-24 was most significant when comparing dp-ucMGP levels less than 1000 to those more than 1000 pM (P = 0.02). Dp-ucMGP levels higher than 5000 pM were significantly associated with females, patients with recent fracture and patients with lower serum albumin (respectively P = 0.02, 0.004 and 0.046). The average drop of dp-ucMGP at 4 weeks of treatment was found to be 86% with diabetics having the lowest drop rate (P = 0.01). Conclusion Vitamin K deficiency, as assessed by high dp-ucMGP levels, is profound in hemodialysis patients from the Eastern Mediterranean region and it is significantly correlated with vascular calcifications. Daily 360 μg of menaquinone-7, given for 4 weeks, effectively reduces dp-ucMGP in this population. Future studies are needed to assess the changes in vascular calcifications in hemodialysis patients treated with vitamin K2 over a longer follow-up period. Trial registration The clinical trial was registered on clinicaltrials.gov (Identification number NCT02876354 , on August 11, 2016).

Advances in medical oncology has led cancer patients to live longer. Moreover, the field of molecular oncology is rapidly evolving, new therapies emerge, and drugs are approved quickly. This has led nephrologists to encounter new and partially unrecognized treatments of the targeted therapy agents with kidney adverse effects. These agents fall mainly into 2 categories affecting the vascular endothelial growth factor and endothelial growth factor pathways. This review covers the incidence of kidney disease induced by these agents, pathophysiologic mechanisms, and clinical presentation, and is the first to recommend an adequate management for each pathophysiology.

Third generation parathyroid hormone (PTH) assays are new generation assays that do not recognize the PTH7-84 fragment whereas second generation assays detect both PTH1-84 and PTH7-84 fragments. Despite the excellent correlation between both assays in chronic renal failure (CRF) subjects, the mean PTH levels are typically 50% lower with the third compared to the second generation assays. The assessment of third generation PTH assays has not been extensively studied in hemodialysis subjects. The purpose of our study was to compare a third generation PTH assay to a second generation one in a population of hemodialysis subjects.92 haemodialysis subjects (36 women and 56 men) with a mean age of 67±12.9 years were included in this study. Anthropometric and clinical parameters (Body Mass Index (BMI) and blood pressure) were measured. Second and third generation PTH assays (Cis biomedical and Diasorin respectively) were performed in each subject. In addition, the following biochemical tests were measured: 25-hydroxyvitamin D (25-(OH)D), 1,25-hydroxyvitamin D (1,25-(OH)2D), crosslaps and alkaline phosphatase.The mean second and third generation PTHs are respectively 211±205 pg/ml and 151±164 pg/ml. The mean third generation PTH values are 28.4% lower compared to the second generation ones. Both methods are strongly correlated (r=0.923, p0.001). This correlation persisted without any significant difference after controlling for gender, age, BMI and Blood Pressure. However, the difference between both methods increases when baseline PTH increases. Each of the second and third generation method is significantly correlated with hemodialysis duration (p0.01), crosslaps (p0.001), alkaline phosphatase (p0.05), but not with age, BMI, Blood Pressure, 25-(OH)D or 1,25-(OH) 2D levels.Our results show that both second and third generation PTH methods are strongly correlated in hemodialysis patients mainly when PTH values are low. However, the difference between both methods increases when PTH values are high. More research is needed to establish which method is the gold standard when PTH values are high.

Objective The purpose of the study is to identify factors that may influence the functional limitations of hemodialysis patients and analyze their level of physical activity. Material/patients and methods Cross-sectional descriptive study, for adult patients on chronic hemodialysis in the Hotel-Dieu de France Hospital. A 32-item questionnaire explores the personal data, etiology of renal failure, associated defects, technical data of hemodialysis and seniority, the current seat and pain. Physical activity was assessed by the modified BAECKE score. The information processing is performed with SPSS (Spearman tests, ANOVA and logistic regression). The significance level is 0.05 with information processing is performed with SPSS (Spearman tests, ANOVA and logistic regression). The significance level is 0.05 with descriptive, univariate and multivariate analysis. Results Descriptive analysis. Fifty patients. Mean age 58 years, 56% are female. BMI: 5.71 kg/m 2 . Work 70% before dialysis and 40% after. Etiology of failure: diabetes 28%, hypertension 24% and 20% hereditary connectivitis 12%, chronic urinary tract infections 8% and 2% idiopathic. Joint pain 36%, cardiac failure 26%. Dialysis: three times per week 66%. Average length of dialysis 82 months. Sports: 52% of moderate intensity on the score do BAECKE total (ST) between 1 and 14.78 average 5.36. Univariate analysis. Items related to a total score of BAECKE low: older age ( P = 0.002), lack of employment ( P = 0), chronic urinary tract infections ( P = 0.009), osteoarthritis ( P = 0.003) or pain joints ( P = 0), a high frequency of dialysis per week ( P = 0), the presence of current pain ( P = 0.024). Multivariate analysis. Aggravating factors: chronic infections of the urinary tract ( P = 0.012), the presence of articular pain ( P = 0.024), and a high frequency of dialysis per week ( P = 0.004). Discussion–conclusion The study focuses on factors influencing the decline in physical activity among hemodialysis patients and shows that most patients do not work and have no physical activity and sport. It would be imperative to enable multidisciplinary management and emphasize the role of rehabilitation and exercise in improving the handicap.

Introduction Une etude faite par Sagheb et al. a montre une amelioration des symptomes de SJSR chez les patients hemodialyses supplementes en vitamines C et/ou E. Objectifs Notre objectif est de detecter des facteurs associes au SJSR dans la population des hemodialyses en particulier les taux des vitamines E et C seriques. Patients et methodes Etude transversale sur 77 patients hemodyalises a l’Hopital universitaire HDF, Beyrouth. Patients de plus 18 ans, hemodyalises depuis plus que 6 mois. Le depistage du syndrome des jambes sans repos fait selon les criteres de l’IRLS-SG. Les variables âge, sexe, BMI, duree de l’hemodialyse, uree pre dialyse, hemoglobine, fer, ferritine, PTH et phosphore ont ete analysees avec le dosage serique de la vitamine C et de la vitamine E faits selon les exigences techniques necessaires (traites en Resultats Vingt-sept pour cent des patients presentaient un SJSR (76 % leger, 5 % modere et 19 % severe). Le pourcentage de SJSR diminue de facon significative avec l’augmentation du taux de vitamine C : 0 % des patients ayant une vitamine C elevee (> 14) presentent un SJSR, 36,3 % des patients ayant une vitamine C moyenne (3,3–14) presentent un SJSR et 91,6 % des patients ayant une vitamine C basse (≤ 3,3) presentent un SJSR. Ces differences sont significatives avec p = 0,041. Discussion Le role de la vitamine C dans l’absorption du fer, son role antioxydant ainsi que son role dans la synthese de la dopamine pourraient etre sous-jacents a cette relation entre son taux bas et la presence de SJSR. Conclusion Chez les patients hemodyalises, un taux eleve de vitamine C serait protecteur contre le SJSR et le risque d’avoir un SJSR augmente de facon significative avec la baisse du taux de vitamine C. Informations complementaires Faculte de medecine de l’universite Saint-Joseph, Conseil de recherche.