Infections à Cytomégalovirus chez les patients transplantés rénaux: incidence, facteurs de risque, conséquences sur la fonction du greffon à un an de transplantation (Résultats au CHU de Montpellier)

Introduction: Le cytomégalovirus (CMV) est un agent pathogène responsable d'une importante . morbi-mortalité chez les patients transplantés rénaux. Le risque lié au CMV est défini en fonction des sérologies du donneur (D+/D-), du receveur (R+/R-) et de leur appariement. On distingue: le groupe à haut risque (D+/R-), le groupe à faible risque (D-/R-) et le groupe à risque intermédiaire (D+/R+; D-/R+). Les recommandations de 2010 statuent des bonnes pratiques cliniques mais certaines questions persistent: Durée de la prophylaxie du groupe à haut risque (3 mois versus 6 mois)? Prise en charge préemptive ou prophylactique pour le groupe à risque intermédiaire? L'objectif de cette étude rétrospective est d'étudier l'épidémiologie des infections à CMV chez les transplantés rénaux, de mettre en évidence les éventuels facteurs de risque d'infection à CMV dans la première année de greffe chez les patients à risque intermédiaire, d'étudier la fonction du greffon à un an post transplantation et de discuter l'intérêt d'un protocole de surveillance de la virémie CMV standardisé chez ces patients. Patients et méthodes: Etude épidémiologique descriptive et rétrospective, réalisée au centre hospitalier universitaire de Montpellier incluant entre le 01.01.09 et le 30.09.11,342 patients suivis pendant un an post transplantation dont 338 patients analysés. Résultats: L'incidence globale des infections à CMV à un an de greffe dans notre population est de 35.5%. Dans le groupe à haut risque, le taux de primo-infection est de 40.4%. Il n'y a pas de différence significative entre le sous-groupe 3 mois versus 6 mois de prophylaxie en terme d'incidence de primo-infection à CMV, de fonction rénale et de rejet aigu. Dans le groupe à risque intermédiaire le taux de réactivation est de 43%. La dose cumulée de thymoglobulines (ATG) supérieùre à 5 mglkg et la sérologie CMV positive du donneur multiplie par deux le risque de réactivation à CMV. De plus, fa réactivation à CMV est associée à une dégradation de la fonction rénale à un an de greffe. Par ailleurs, il semble qu'un protocole de surveillance standardisé des virémies dans ce groupe permette d'améliorer le diagnostic des réactivations asymptomatiques. Conclusion: Ainsi, concernant le groupe à haut risque, une prophylaxie systématique de 3 mois seulement semble préférable. Concernant le groupe à risque intermédiaire, les patients R+ ayant undonneur positif pour le CMV et/ou une dose cumulée d'ATG supérieure à 5 mglkg pourraientbénéficier d'une prophylaxie systématique de 3 mois et les patients R+ ayant un donneur séronégatif pour le CMV et une dose cumulée d'ATG inférieure à 5mg/Kg pourraient bénéficier d'une prise en charge préemptive avec un protocole de surveillance des virémies standardisé.MONTPELLIER-BU Médecine UPM (341722108) / SudocSudocFranceF

Electrolytes-Enriched Hemodiafiltration Solutions for Continuous Renal Replacement Therapy in Acute Kidney Injury: A Crossover Study

International audienceAIMS:To evaluate the capability of an electrolytes-enriched solution to prevent metabolic disorders during continuous veno-venous hemodiafiltration (CVVHDF).METHODS:Serum biochemistry and clinical tolerance were compared during CVVHDF treatments with an electrolyte-enriched (Phoxilium) or standard solutions in 10 acute renal failure patients.RESULTS:As compared to standard fluids, serum potassium and phosphate levels were maintained in the normal range with Phoxilium without any supplementation but total serum calcium levels were significantly lower. Bicarbonatemia was slightly higher (24-26 vs. 21.5-24.5 mmol/l, p 7.44). Despite the absence of glucose in the Phoxilium solution, blood glucose levels and glucose supplementation were similar between treatments. Clinical tolerance and efficiency of CVVHDF sessions were comparable.CONCLUSION:Phoxilium effectively prevented hypophosphatemia and hypokalemia during CVVHDF. It was, however, associated with a slight metabolic acidosis and hypocalcemia compared with conventional solutions

Short- and Long-Term Outcome of Chronic Dialyzed Patients Admitted to the ICU and Assessment of Prognosis Factors

International audienceObjectives: Data about end-stage kidney disease patients admitted to the ICU are scarce, dated, and mostly limited to short-term survival. The aim of this study was to assess the short- and long-term outcome and to determine the prognostic factors for end-stage kidney disease patients admitted to the ICU.Design: Prospective observational study.Setting: Medical ICUs in two university hospitals.Patients: Consecutive end-stage kidney disease patients admitted in two ICUs between 2012 and 2017.Intervention: None.Measurements and Main Results: Renal replacement therapy variables, demographic, clinical, and biological data were collected. The requirement of mechanical ventilation and vasopressive drugs were also collected. In-ICU and one-year mortality were estimated and all data were analyzed in order to identify predictive factors of short and long-term mortality. A total of 140 patients were included, representing 1.7% of total admissions over the study period. Septic shock was the main reason for admission mostly of pulmonary origin. Median Simplified Acute Physiology Score II and Sequential Organ Failure Assessment score were at 63 and 6.7, respectively. In-ICU, hospital, and 1-year mortality were 41.4%, 46.4%, and 63%, respectively. ICU mortality was significantly higher as compared with ICU control group non-end-stage kidney disease (25% vs 41.4%; p = 0.005). By multivariate analysis, the short-term outcome was significantly associated with nonrenal Sequential Organ Failure Assessment score, and with the requirement of mechanical ventilation or/and vasoconstrictive agents during ICU stay. One-year mortality was associated with increased dialysis duration (> 3 yr) and phosphatemia (> 2.5 mmol/L), with lower albuminemia (< 30 g/L) and nonrenal Sequential Organ Failure Assessment greater than 8.Conclusions: End-stage kidney disease patients presented frequently severe complications requiring critical care that induced significant short- and long-term mortality. ICU and hospital mortality depended mainly on the severity of the critical event reflected by Sequential Organ Failure Assessment score and the need of mechanical ventilation and/or catecholamines. One-year mortality was associated with both albuminemia and phosphatemia and with prior duration of chronic dialysis treatment, and with organ failure at ICU admission

Daily urinary creatinine predicts the weaning of renal replacement therapy in ICU acute kidney injury patients

International audienc

Mortality Associated with Night and Weekend Admissions to ICU with On-Site Intensivist Coverage: Results of a Nine-Year Cohort Study (2006-2014)

International audienc

On-line hemodiafiltration did not induce an overproduction of oxidative stress and inflammatory cytokines in intensive care unit-acute kidney injury

Abstract Background Though on-line intermittent hemodiafiltration (OL-IHDF) is a routine therapy for chronic dialysis patients, it is not yet widespread used in critically ill patients. This study was undergone to evaluate efficiency and tolerance of OL-IHDF and to appreciate inflammatory consequences of its use in intensive care unit (ICU)-acute kidney injury (AKI) patients. Methods In this prospective cohort study conducted in a medical academic ICU in France, 30 AKI patients who underwent OL-IHDF were included. OL-HDF used an ultrapure water production: AQ 1250 line with double reverse osmosis, a generator 5008 with a 1.8m2 dialyzer with Polysulfone membrane (Fresenius Medical Care). Tolerance and efficiency of OL-IHDF were evaluated as well as its inflammatory risk by the measurement of plasma concentrations of proinflammatory (Interleukin 6, IL1β, IL8, Interferon γ) and anti-inflammatory (IL4, IL10) cytokines, Epidermal growth factor (EGF), Vascular Endothelial growth factor (VEGF) and Macrophage Chemoattractive Protein-1 (MCP-1) before and after sessions. Results Intradialytic hypotensive events were observed during 27/203 OL-IHDF sessions accounting for a mal-tolerated session’s rate at 13.3%. Mean delivered urea Kt/V per session was 1.12 ± 0.27 with a percentage of reduction for urea, creatinine, β2-microglobulin and cystatine C at 61.6 ± 8.8%, 55.3 ± 6.7%, 51.5 ± 8.7% and 44.5 ± 9.8% respectively. Production of superoxide anion by leukocytes, mean levels of pro- and anti-inflammatory cytokines and plasmatic concentrations of EGF, VEGF and MCP-1 did not differ before and after OL-IHDF sessions. We observed however a significant decrease of mean TNFα plasmatic concentrations from 8.2 ± 5.8 to 4.8 ± 3.5 pg/ml at the end of OL-IHDF. Conclusions OL-IHDF was not associated with an increase in pro and anti-inflammatory cytokines, oxidative stress or EGF, VEGF and MCP-1 in AKI patients and seems therefore a secure and feasible modality in ICUs

Urinary Biomarkers IGFBP7 and TIMP-2 for the Diagnostic Assessment of Transient and Persistent Acute Kidney Injury in Critically Ill Patients.

The capability of urinary TIMP-2 (tissue inhibitor of metalloproteinase) and IGFBP7 (insulin-like growth factor binding protein)-NephroCheck Test (NC) = ([TIMP-2] x [IGFBP7]) / 1000)-to predict renal recovery from acute kidney injury (AKI) has been poorly studied. The aim of this study was to assess the performance of measurements of ([TIMP-2] x [IGFBP7]) / 1000) over 24 hours to differentiate transient from persistent AKI.Of 460 consecutive adult patients admitted to the ICU, 101 were prospectively studied: 56 men, 62 (52-71) years old. A fresh urine sample was collected at H0, H4, H12 and H24 to determine ([TIMP-2] x [IGFBP7]) / 1000) levels. Areas under the curves of Delta NC H4-Ho and H12-H4 and serum creatinine (sCr) for detection of AKI recovery were compared.Forty-one (40.6%) patient were diagnosed with AKI: 27 transient and 14 persistent AKI. At admission (H0), AKI patients had a significantly higher NC score than patients without AKI (0.43 [0.07-2.06] vs 0.15 [0.07-0.35], p = 0.027). In AKI groups, transient AKI have a higher NC, at H0 and H4, than persistent AKI (0.87 [0.09-2.82] vs 0.13 [0.05-0.66] p = 0.035 and 0.13 [0.07-0.61] vs 0.05 [0.02-0.13] p = 0.013). Thereafter, NC level decreased in both AKI groups with a Delta NC score H4-H0 and H12-H4 significantly more important in transient AKI. Roc curves showed however that delta NC scores did not discriminate between transient and persistent AKI.In our population, absolute urinary levels of NC score were higher at early hours after ICU admission (H0 and H4) in transient AKI as compared to persistent AKI patients. NC variations (Delta NC scores) over the first 12 hours may indicate the AKI's evolving nature with a more significant decrease in case of transient AKI but were not able to differentiate transient from persistent AKI

Reversibility of Acute Kidney Injury in Medical ICU Patients: Predictability Performance of Urinary Tissue Inhibitor of Metalloproteinase-2 x Insulin-Like Growth Factor-Binding Protein 7 and Renal Resistive Index

International audienceObjectives: Urinary biomarkers and renal Doppler sonography remain considered as promising tools to distinguish transient from persistent acute kidney injury. The performance of the urinary biomarker, tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 and of renal resistive index to predict persistent acute kidney injury showed contradictory results. Our aim was to evaluate the performance of tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 and renal resistive index in predicting reversibility of acute kidney injury in critically ill patients.Design: Prospective observational study.Setting: Twenty-bed medical ICU in an university hospital.Patients: Consecutive patients with acute kidney injury.Intervention: None.Measurements and main results: Renal resistive index was measured within 12 hours after admission, and urinary tissue inhibitor of metalloproteinase-2 and insulin-like growth factor-binding protein 7 was measured at H0, H6, H12, and H24. Renal dysfunction reversibility was evaluated at day 3. Receiver operating characteristic curves were plotted to evaluate diagnostic performance of renal resistive index and tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 to predict a persistent acute kidney injury. Overall, 100 patients were included in whom 50 with persistent acute kidney injury. Renal resistive index was higher in persistent acute kidney injury group. Urinary tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 was not significantly different at each time between both groups. The performance of tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 was poor with respectively an area under the receiver operating characteristic curves of 0.57 (95% CI, 0.45-0.68), 0.58 (95% CI, 0.47-0.69), 0.61 (95% CI, 0.50-0.72), and 0.57 (95% CI, 0.46-0.68) at H0, H6, H12, and H24. The area under the receiver operating characteristic curve for renal resistive index was 0.93 (95% CI, 0.89-0.98). A renal resistive index greater than or equal to 0.685 predicting persistent acute kidney injury with 78% (95% CI, 64-88%) sensitivity and 90% (95% CI, 78-97%) specificity.Conclusions: Renal resistive index had a good performance for predicting the reversibility of acute kidney injury in critically ill patients. Urinary tissue inhibitor of metalloproteinase-2 x insulin-like growth factor-binding protein 7 was unable to differentiate transient from persistent acute kidney injury

Feasibility and impact of the implementation of a clinical scale-based sedation-analgesia protocol in severe burn patients undergoing mechanical ventilation. A before-after bi-center study

International audienceBackground: Severe burn patients undergo prolonged administration of sedatives and analgesics for burn care. There are currently no guidelines for the dose adaptation of sedation-analgesia in severe burn patients.Methods:We performed a before-after 2-center study to demonstrate the feasibility and efficacy of a sedation-analgesia scale-based protocol in severely burned patients receiving ≥24 h of invasive mechanical ventilation. Before the intervention, continuous infusion of hypnotic and morphine derivatives was continued. During the Intervention phase, general anesthesia was relayed from day 1 by RASS/BPS-titrated continuous infusion of hypnotic and morphine derivatives and with short half-life drugs adminstered for daily burn dressings. The primary outcome was the duration of invasive mechanical ventilation in the ICU.Results: Eighty-seven (46.2%) patients were included in the Control phase and 101 (53.7%) in the Intervention phase. The median burned cutaneous surface was 20% [11%–38%] and median ABSI was 7 [5–9]. The durations of hypnotic and opioid infusions were not statistically different between the 2 phases (8 days [2–24] vs. 6 days [2–17] (P = 0.3) and 17 days [4–32] vs. 8 days [3–23] (P = 0.06), respectively). The duration of mechanical ventilation was 14 days [3-29] in the Control phase and 7 days [2–24] in the Intervention phase (P = 0.7). When taking into account the competition between mortality and weaning from mechanical ventilation, we found no significant difference between the 2 phases (Gray test, P = 0.4). The time-series analysis showed no difference for the duration of mechanical ventilation in the Intervention phase (P = 0.6). Eighteen (20.7%) patients died in the Control phase, and 18 (18%) in the Intervention phase (P = 0.6).Conclusion: Scale-based lightening of continuous sedation-analgesia with repeated short general anesthesia for dressing is feasible in severe burn patients but failed to demonstrate a decrease in the duration of invasive mechanical ventilatio

Continuous Veno-Venous High Cut-Off Hemodialysis Compared to Continuous Veno-Venous Hemodiafiltration in Intensive Care Unit Acute Kidney Injury Patients

International audienceHigh cut-off (HCO) continuous veno-venous hemodialysis (CVVHD) was compared to high-flux membrane (HFM) continuous veno-venous hemodiafiltration (CVVHDF) in intensive care unit (ICU) acute kidney injury (AKI) in terms of efficiency, hemodynamic tolerance, medium-sized molecules removal, albumin loss, and inflammatory system activation