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Because of the significant costs related to the treatment of end-stage kidney disease by dialysis, Belgian Health Care Authorities proposed in June 2009 to launch an early multidisciplinary care plan for chronic kidney disease (CKD) patients in the form of a clinical care pathway (CCP) focusing on a combined follow-up by the general practitioner and the nephrologist. The objective was to increase nephro-protection measures, reduce patient morbidity and mortality, and delay admission on dialysis. Our Nephrology Department at Erasme Hospital took the opportunity of CCP to set up workshops on therapy education which promote CKD patients' compliance and autonomy regarding their treatment (" empowerment "). These workshops are conducted by a health professional together with a patient partner recruited by our team according to the model developed by the faculty of medicine at the University of Montreal. This model is based on the patient's valued experience of living with a chronic disease, a knowledge which is complementary to that acquired by any health professional. This patient partnership (PP) may also be implemented in teaching and research. In health care services, patient partners with a resource profile are involved not only in the organization of these services, but also in the development and management of health care political programs. The PP model currently developed in the Nephrology Department is part of the Quality project of our academic hospital and helps to further the co-construction of future health care networks.Suite aux surcoûts liés au traitement de l’insuffisance rénale chronique (IRC) terminale par la dialyse, l’INAMI a proposé depuis juin 2009 une prise en charge multidisciplinaire précoce du patient IRC sous la forme d’un trajet de soins (TDS) privilégiant le suivi par le médecin généraliste en alternance avec le néphrologue. Le but est d’optimiser les mesures de néphroprotection, de réduire la morbi-mortalité des patients et de retarder leur arrivée en dialyse. Notre service a saisi cette opportunité des TDS de l’IRC pour mettre en place des ateliers d’éducation thérapeutique susceptibles de favoriser l’adhésion et l’autonomie des patients IRC vis-à-vis de leur traitement (" empowerment "). Ces ateliers sont co-animés par un professionnel de santé et un patient partenaire recruté par le service selon le modèle développé à la Faculté de Médecine de l’Université de Montréal. Le partenariat patient (PP) s’appuie sur les savoirs expérientiels reconnus des patients, complémentaires aux savoirs professionnels, issus de la vie avec la maladie et acquis par la pratique des soins et des services de santé. Il peut aussi se développer dans l’enseignement et la recherche. En milieux de soins, il s’agit de patients partenaires au profil ressource, partenaires dans les soins directs, mais aussi dans l’organisation des services, la gouvernance et l’élaboration des politiques de santé. Ce modèle, en cours d’implémentation dans le Service de Néphrologie de l’Hôpital Erasme, fait partie du projet qualité institutionnel et tend vers la co-construction des milieux de soins de demain.

despite fluctuations, the prevalence of nephrolithiasis has significantly increased during the last decades in industrialized nations worldwide (1 to 15 %), which has a significant impact on the cost of healthcare. This increased prevalence is mainly explained by diet modifications. Environmental, metabolic and genetic factors may also influence the formation of kidney stones. As a consequence, the medical management of this disease is preferentially multidisciplinary and involves urologists, nephrologists, radiologists, biologists and dietitians. Urological management : may be mandatory during any acute and/or remote phase of an episode of renal colic, in case of residual stones. Several techniques are available: insertion of double J stent, extracorporeal shock wave lithotripsy, ureteroscopy (flexible or rigid), percutaneous nephrolithotomy and more occasionally, open surgery. Nephrological management: is justified in the course of the acute episode and aims to identify the causal factor(s) of kidney stones formation. The diagnostic approach involves a thorough interrogation (personal medical and surgical history, details of the kidney stone disease and family medical history) as well as a metabolic assessment. Moreover, given the high rate of recurrence (about 50 % within 5 to 10 years), individualized secondary prevention measures are necessary. The recommendations should take into account the identified risk factors and any metabolic abnormalities.la néphrolithiase est une affection dont la prévalence (1 à 15 %) a beaucoup augmenté ces dernières décennies dans les pays industrialisés et a, de ce fait, un impact sur les dépenses en soins de santé. Cette augmentation de prévalence s’explique essentiellement par une modification des habitudes alimentaires. La survenue d’une néphrolithiase peut en outre, être influencée par des facteurs environnementaux, métaboliques voire génétiques. La prise en charge de cette affection est le plus souvent pluridisciplinaire, impliquant urologues, néphrologues, radiologues, biologistes et diététiciens. La prise en charge urologique peut être nécessaire en phase aiguë et/ou à distance de l’épisode de colique néphrétique, pour l’élimination éventuelle de calculs résiduels. Plusieurs techniques sont disponibles : la mise en place de sondes double J, la lithotritie extracorporelle, l’urétéroscopie (souple ou rigide) voire la néphrolithotomie percutanée et plus rarement la chirurgie ouverte. La prise en charge néphrologique est justifiée au décours de l’épisode aigu et vise à identifier la ou les cause(s) ayant conduit à la formation de calculs. La démarche diagnostique comporte un interrogatoire approfondi (antécédents personnels médicaux et chirurgicaux, histoire de la maladie lithiasique et antécédents familiaux) et un bilan métabolique. Par ailleurs, compte-tenu du taux élevé de récidive (environ 50 % dans les 5 à 10 ans), la mise en place de mesures individualisées de prévention secondaire est nécessaire. Ces recommandations doivent tenir compte des facteurs de risque identifiés et des éventuelles anomalies du bilan métabolique.

Because of the significant costs related to the treatment of end-stage kidney disease by dialysis, Belgian Health Care Authorities proposed in June 2009 an early multidisciplinary care of the chronic kidney disease (CKD) in a so-called clinical pathway (CP). Working on the hypothesis that inclusion into a CP could result in reduced morbidity and mortality and delayed admission on dialysis, we initiated a retrospective cohort study on dialyzed patients for whom a prior CKD diagnosis was made between June 1, 2009 and August 31, 2013 in the Nephrology Dept of Erasme Hospital. The exposed patient group was defined as enrolled patients into a CP (n = 25), the control patients were free of any CP (n = 25). Survival analyses were performed to search for an association between the inclusion into a CP and the time period needed to reach dialysis, but also to find a possible impact of CP on mortality and risk of hospitalization. The present study showed that CKD-CP significantly delayed the time of dialysis initiation (HR = 0.48 [0.27-0.87]; p = 0.015) but also reduced mortality (HR = 0.10 [0.02-0.53]; p = 0.007) and hospitalization risk (HR = 0.30 [0.11-0.83]; p = 0.020) after starting dialysis. These data suggest the benefit of a multidisciplinary care of CKD patients. However, a larger scale study is necessary to confirm these results.

The accurate estimation of the glomerular filtration rate (GFR) is a goal of multiple interests regarding clinical, research and public health aspects. The strong relationship between progressive loss of renal function and mortality underlines the need for early diagnosis and close follow-up of renal diseases. Creatinine is the commonest biomarker of GFR in use. By reason of non-renal determinants of GFR, it is required to integrate creatinine values within equations that take in account its most important determinants (i.e., age, sex). The CKD-EPI 2009 equation is now recommended as the first line equation to estimate GFR within the general population. In this indication, it should replace MDRD that tends to overestimate the prevalence of stage 3 chronic kidney disease with GFR around 60 ml/min. However, many questions remain about the accuracy of GFR equations in specific situations such as extremes of age or body weight. The identification of new biomarkers, less determined by non-renal determinants, is of importance. Among these biomarkers, cystatin-C is more accurate to estimate GFR when it is combined to creatinine (i.e., equation CKD-EPI 2012). However the indica. tions for using cystatin-C instead of creatinine alone are still unclear and its use remains limited in routine practice. In conclusion, neither biomarker nor equation gives an accurate estimation for the whole range of GFR and for all patient populations. Limits of prediction are relying on both biomarker's properties and the range of GFR that is concerned, but also rely on the measurement methods. Therefore, it is crucial to interpret the estimated GFR according to the strengths and weaknesses of the equation in use.

Introduction Les comorbidites cardiovasculaires des patients dialyses sont a l’avant-plan des facteurs impactant negativement leur pronostic vital. Elles entrainent egalement des complications plus rares mais tout aussi pejoratives, comme illustre dans le cas presente. Observation Mme M…, O. a ete admise en hemodialyse iterative en mars 2004 a l’âge de 72 ans, apres une longue periode d’uremie chronique (nephrectomie G partielle pour neoplasie suivie d’une chimiotherapie a base de cisplatine, HTA de longue date). En 2008, un pontage femoro-jambier D a ete realise au terme d’un bilan vasculaire (angio-RMN a base de gadobutrol). Fin mars 2014, la patiente se plaint a nouveau de douleurs aux membres inferieurs, surtout la nuit et en cours de dialyse. Devant l’apparition d’une plaie malleolaire et l’absence de pouls peripherique, une angio-RMN est realisee (a base de gadobutrol) et les lesions stenotiques femoro-poplitees necessitent un geste de repermeabilisation. Huit semaines apres l’examen, des douleurs intenses apparaissent au niveau de la cicatrice de l’angioplastie (cuisse gauche) qui presente une tumefaction induree, non inflammatoire, non pulsatile, non soufflante. L’echographie de la zone ne montre pas d’hematome collecte mais bien une infiltration diffuse des plans sous-cutanes. Devant l’accentuation des douleurs et l’extension rapide de l’induration aux 2 membres inferieurs jusqu’a la region lombaire basse, une biopsie cutanee est realisee 3 mois plus tard. Elle met en evidence une fibrose severe entreprenant le derme profond et l’hypoderme ; l’immuno-histochimie revele la presence de nombreuses cellules CD34+, signant le diagnostic de fibrose systemique nephrogenique (FSN). La recherche de gadolinium par spectrometrie de masse est en cours dans le departement de dermatologie de l’universite du Colorado [1] , [2] . A ce jour, la patiente a garde le maximum de mobilite grâce a des seances intensives de kinesitherapie et de massages. Discussion Conformement aux cas publies de FSN, les symptomes sont apparus endeans quelques semaines apres l’exposition au gadolinium. De facon surprenante, une dose similaire (15 mL) du meme agent de contraste (gadobutrol) administree 6 ans plus tot n’avait rien provoque. Conclusion En depit de l’utilisation d’agents de contraste a base de gadolinium plus stables que le gadodiamide, une FSN peut survenir chez le patient dialyse. Devant un tableau clinique suggestif, ce diagnostic doit etre evoque et confirme histologiquement.

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Purpose Early breast cancer is commonly treated with anthracyclines and taxanes. However, combining these drugs increases the risk of myelotoxicity and may require granulocyte colony-stimulating factor (G-CSF) support. The highest incidence of febrile neutropenia (FN) and largest benefit of G-CSF during the first cycles of chemotherapy lead to questions about the effectiveness of continued use of G-CSF throughout later cycles of chemotherapy. Patients and Methods In a multicenter study, patients with breast cancer who were considered fit enough to receive 3-weekly polychemotherapy, but also had > 20% risk for FN, were randomly assigned to primary G-CSF prophylaxis during the first two chemotherapy cycles only (experimental arm) or to primary G-CSF prophylaxis throughout all chemotherapy cycles (standard arm). The noninferiority hypothesis was that the incidence of FN would be maximally 7.5% higher in the experimental compared with the standard arm. Results After inclusion of 167 eligible patients, the independent data monitoring committee advised premature study closure. Of 84 patients randomly assigned to G-CSF throughout all chemotherapy cycles, eight (10%) experienced an episode of FN. In contrast, of 83 patients randomly assigned to G-CSF during the first two cycles only, 30 (36%) had an FN episode (95% CI, 0.13 to 0.54), with a peak incidence of 24% in the third cycle (ie, first cycle without G-CSF prophylaxis). Conclusion In patients with early breast cancer at high risk for FN, continued use of primary G-CSF prophylaxis during all chemotherapy cycles is of clinical relevance and thus cannot be abandoned.

Purpose Guidelines advise primary granulocyte colony-stimulating factor (G-CSF) prophylaxis during chemotherapy if risk of febrile neutropenia (FN) is more than 20%, but this comes with considerable costs. We investigated the incremental costs and effects between two treatment strategies of primary pegfilgrastim prophylaxis. Methods Our economic evaluation used a health care perspective and was based on a randomized study in patients with breast cancer with increased risk of FN, comparing primary G-CSF prophylaxis throughout all chemotherapy cycles (G-CSF 1-6 cycles) with prophylaxis during the first two cycles only (G-CSF 1-2 cycles). Primary outcome was cost effectiveness expressed as costs per patient with episodes of FN prevented. Results The incidence of FN increased from 10% in the G-CSF 1 to 6 cycles study arm (eight of 84 patients) to 36% in the G-CSF 1 to 2 cycles study arm (30 of 83 patients), whereas the mean total costs decreased from € 20,658 (95% CI, € 20,049 to € 21,247) to € 17,168 (95% CI € 16,239 to € 18,029) per patient, respectively. Chemotherapy and G-CSF determined 80% of the total costs. As expected, FN-related costs were higher in the G-CSF 1 to 2 cycles arm. The incremental cost effectiveness ratio for the G-CSF 1 to 6 cycles arm compared with the G-CSF 1 to 2 cycles arm was € 13,112 per patient with episodes of FN prevented. Conclusion We conclude that G-CSF prophylaxis throughout all chemotherapy cycles is more effective, but more costly, compared with prophylaxis limited to the first two cycles. Whether G-CSF prophylaxis throughout all chemotherapy cycles is considered cost effective depends on the willingness to pay per patient with episodes of FN prevented.

Introduction Les lesions hemorragiques et (pre)cancereuses du tractus gastro-intestinal sont frequentes chez le patient dialyse. Des agents medicamenteux peuvent aussi etre directement impliques, comme l’illustre le cas clinique presente. Observation Un patient de 73 ans, en hemodialyse chronique depuis 5 ans pour nephroangiosclerose d’origine hypertensive, se presente aux urgences pour des douleurs abdominales en fosse iliaque droite, d’apparition recente, sans trouble du transit associe ni alteration de l’etat general. Il presente un diabete de type 2, une cardiopathie ischemique stentee et un ulcere bulbaire recidivant. Il prend 2 × 800 mg/j de carbonate de sevelamer (Renvela ® ) depuis 7 mois pour controler son hyperphosphoremie. A l’admission, on note un leger syndrome inflammatoire (CRP 100 mg/L, leucocytose 11 800/mm 3 ) et le scanner montre uniquement un epaississement des parois caecales et de la graisse peri-caecale. Apres 1 semaine d’Augmentin ® conduisant a une amelioration des symptomes, la colonoscopie met en evidence une tumeur ulceree, de taille moyenne, non hemorragique au niveau du caecum. Les biopsies montrent de multiples fragments d’une muqueuse largement ulceree, caracterisee par une desepithelisation comblee par un exsudat fibrino-leucocytaire riche en polynucleaires neutrophiles. A cet exsudat et en surface de l’epithelium colique, sont meles des cristaux de couleur eosinophile a jaunâtre ; leur surface est irreguliere, en « ecaille de poisson ». L’image histologique est compatible avec une colopathie liee au sevelamer, decrite pour la 1 re fois en 2013 [1] . L’etat du patient s’ameliore rapidement apres l’arret du Renvela ® . La colonoscopie de controle a 3 mois confirme l’evolution favorable de l’ulcere caecal et les biopsies a ce niveau ne montrent plus la presence de cristaux de sevelamer. Discussion A ce jour, moins de 10 cas ont ete publies chez des patients adultes dialyses, decrivant des complications liees au sevelamer (hemorragie, perforation, colite ischemique). La presence de cristaux de ce chelateur non calcique dans la muqueuse du tractus digestif (œsophage, intestin grele ou colon) confirme le diagnostic. Conclusion Le diagnostic de colopathie liee au sevelamer doit etre evoque chez tout patient dialyse chronique presentant un tableau de douleurs abdominales avec ou sans imagerie probante afin d’eviter des investigations inutiles et couteuses.

All types of acute kidney injury (AKI) (functional /pre-renal, parenchymal/intra-renal, obstructive/post-renal) result in a sharp drop of the glomerular filtration rate, with variable reversibility according to the initial cause. In one case out of five, drug intake can be related to the onset of AKI. Antibiotics, analgesics and nonsteroidal anti-inflammatory drugs, angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists are the agents mostly involved, as well as iodinated radio-contrast agents. Mechanisms are often complex: toxic cellular effect directed on a nephron segment (tubular necrosis) associated or not with intraglomerular hemodynamic changes, or immune process leading to acute tubule-interstitial nephritis. Each underlying risk factor (age60 year, cardiac or hepatic failure, hypertension, diabetes, intra-vascular volume depletion, preexisting or unknown chronic kidney disease) must be taken into consideration by the prescribing physician because it reduces the chance of functional recovery and worsens the renal and the overall prognosis. A pre-renal additional component is often present and avoidable thanks to a strict hemodynamic monitoring. The present article summarizes some recent physiopathological aspects of AKI and makes the link between clinical situations and currently prescribed drugs. Lessons from the radio-contrast induced nephropathy are examined by taking into account prevention aspects and risk factors screening. An effective collaboration between the general practitioner and the nephrologist would benefit in optimizing the treatment of difficult cases.

The World Kidney Day offers a crucial opportunity to the Belgian associations of nephrologists to inform public and medical communities about the global problem of chronic kidney disease (CKD). According to epidemiological data from GNFB/ NBVN registries in our country, cardiovascular diseases and diabetes 2 are responsible for an increasing amount of CKD cases with pejorative evolution to end-stage renal disease requiring cost-effective renal replacement therapies (haemodialysis, peritoneal dialysis or renal transplantation). In these patients, the high level of comorbidities and the late referral to the nephrologists are recognized as enhanced morbidity and mortality factors. These facts underline the need for the nephrologists to stimulate collaboration with general practitioners and specialists from other disciplines in order to set up systematic screening procedures and early follow-up of patients at risk of developing CKD. These procedures should contribute to reduce the progression rate of renal function impairment.

The Department of Nephrology of the Hospital Erasme, opened 25 years ago, is now performing, each year, 22,000 hemodialysis sessions, 800 patient-weeks of peritoneal dialysis treatment and 70 renal grafts. Scientific contributions of the department deal with vascular access for hemodialysis, susceptibility to infections of dialyzed patients, parathyroid surgery, biocompatibility of dialysis membranes, predictive factors of renal graft survival, immunosuppression with monoclonal antibodies, experimental studies of graft tolerance and rejection, toxic nephropathies. The most original contributions are related to anaphylactoïd reactions in hemodialysis by association of acrylonitrile membranes with inhibition of the converting enzyme, to advantages and side effects of OKT3 monoclonal antibody and to discovery and study of the Chinese herbs nephropathy.

This study was designed to evaluate new bone resorption and tumour markers as possible alternatives to serial plain radiographs for the assessment of response to treatment. Thirty-seven patients with newly diagnosed bone metastases from breast cancer, randomized to receive oral pamidronate or placebo tablets in addition to anticancer treatment within the context of a multicentre EORTC trial, who were both assessable for radiographic response in bone and had serum and urine samples collected for more than 1 month were studied. The markers of bone metabolism measured included urinary calcium (uCa), hydroxyproline (hyp), the N-telopeptide cross-links of type I collagen (NTx) and total alkaline phosphatase. The tumour markers measured were CA15-3 and cancer-associated serum antigen (CASA). Before treatment, levels of Ntx, uCa and Hyp were elevated in 41%, 24% and 28% respectively, and CA15-3 and CASA increased in 69% and 50%. For assessment of response and identification of progression, Ntx was the most useful bone marker. All markers behaved similarly in no change (NC) and partial response (PR) patients. There was a significant difference (P ≤ 0.05) in Ntx levels (compared to baseline) at 1 and 4 months and in CA15-3/CASA at 4 months between patients with PR or NC and those with progressive disease (PD), and at 4 months between those with time to progression (TP) > 7 and those with TP ≤ 7 months. The diagnostic efficiency (DE) for prediction of PD following a > 50% increase in Ntx or CA15-3 was 78% and 62% respectively. An algorithm to predict response to therapy has been developed for future prospective evaluation. © 1999 Cancer Research Campaign

Numerous substances from vegetal origin used as herbal remedies can be nephrotoxic. This article summarizes several circumstances of development of acute or chronic renal failure in which the responsible agent has been identified after a thorough toxicologic study. The Chinese herbs nephropathy is extensively described, detailing not only the epidemiological and histological aspects but also the extrarenal and neoplastic complications recently reported.

This article reports an unusual case of acute interstitial nephritis associated with nephrotic syndrome which appeared after oral intake of naproxen and amoxicillin and led to end-stage renal failure. In the light of recent literature on this clinical entity, the authors formulate hypotheses accounting for this outcome.

This article reports the surprising history of a patient presenting a von Recklinghausen neurofibromatosis. Ten years after a full program of radio- and chemotherapy for a so-called invasive uterine leiomyosarcoma, the diagnosis of intestinal neurofibromatosis is finally established and the patient is surgically cured. The authors discuss the difficulties of the histologic diagnosis and the aid of the recent techniques of immunohistochemical markers. The second part of the article provides the actual clinical classification of the different types of neurofibromatosis with their diagnostic approach. It also offers a review of the literature concerning the intestinal location of the disease and the potential risks of cancer formation.