Pregnancy in Chronic Kidney Disease: Need for Higher Awareness. A Pragmatic Review Focused on What Could Be Improved in the Different CKD Stages and Phases

Pregnancy is possible in all phases of chronic kidney disease (CKD), but its management may be difficult and the outcomes are not the same as in the overall population. The prevalence of CKD in pregnancy is estimated at about 3%, as high as that of pre-eclampsia (PE), a better-acknowledged risk for adverse pregnancy outcomes. When CKD is known, pregnancy should be considered as high risk and followed accordingly; furthermore, since CKD is often asymptomatic, pregnant women should be screened for the presence of CKD, allowing better management of pregnancy, and timely treatment after pregnancy. The differential diagnosis between CKD and PE is sometimes difficult, but making it may be important for pregnancy management. Pregnancy is possible, even if at high risk for complications, including preterm delivery and intrauterine growth restriction, superimposed PE, and pregnancy-induced hypertension. Results in all phases are strictly dependent upon the socio-sanitary system and the availability of renal and obstetric care and, especially for preterm children, of intensive care units. Women on dialysis should be aware of the possibility of conceiving and having a successful pregnancy, and intensive dialysis (up to daily, long-hours dialysis) is the clinical choice allowing the best results. Such a choice may, however, need adaptation where access to dialysis is limited or distances are prohibitive. After kidney transplantation, pregnancies should be followed up with great attention, to minimize the risks for mother, child, and for the graft. A research agenda supporting international comparisons is highly needed to ameliorate or provide knowledge on specific kidney diseases and to develop context-adapted treatment strategies to improve pregnancy outcomes in CKD women

Quantitative and qualitative evaluation of spirometry for COPD screening in general practice

Introduction: Proper diagnosis of COPD remains a challenge. Spirometry testing in primary care may help to reduce misdiagnosis, but its reliability as a diagnostic instrument needs to be assessed. Objectives: To investigate (1) the validity of spirometry testing performed in primary care and (2) the accuracy of the diagnostic of airflow limitation obtained by these tests. Methods: Subjects attending a COPD screening programme had screening spirometry performed either by general practitioners (GPs) or by trained nurses or technicians, who had all received two 3-hour training sessions. Subjects with airflow limitation and a subset of subjects with normal spirometry at screening were invited to undergo confirmatory spirometry performed by trained nurses in a pulmonary function laboratory. Results: Of the 4610 subjects who attended the screening sessions, 96.5% had a valid screening spirometry test. A total of 392 subjects attended the confirmatory sessions. Values measured by screening spirometry were satisfactory compared with those of confirmatory spirometry (rc = 0.83). Taking confirmatory spirometry as reference, the positive predictive value of screening spirometry for the diagnosis of persistent airflow limitation was 93% with a specificity of 95%. Agreement for the diagnosis of persistent airflow limitation was substantial (k = 0.80). Conclusion: Spirometry performed in primary care by trained personnel reliably identifies persistent airflow limitation. This may encourage pulmonologists to collaborate with primary care providers with the aim of improving appropriate diagnosis of COPD

La résolution de l’inflammation dans la fibrose pulmonaire idiopathique avec un nouvel immunomodulateur

IF0.576National audienceIntroductionLa fibrose pulmonaire idiopathique (FPI) est une fibro-prolifération anormale du tissu pulmonaire dont tous les mécanismes ne sont pas compris. Les cellules effectrices de l’inflammation et du système immunitaire jouent un rôle certain dans la physiopathologie de cette maladie incurable. Il existe des thérapies innovantes qui tentent de résoudre l’inflammation selon le processus naturel et non de simplement l’inhiber. Nous avons évalué in vitro l’effet de SuperMApo, l’une de ces thérapies innovantes, sur les marqueurs d’activation des cellules de l’inflammation (Fig. 1).MéthodesLes patients devaient présenter les critères ATS, ERS de la FPI. Étaient exclus les patients présentant une affection susceptible de modifier la réponse immunitaire autre que la FPI (cancer, diabète déséquilibré, pathologie auto-immune). L’étude a évalué, in vitro et par patient, l’effet de SuperMApo (surnageant de co-culture de macrophages ayant phagocyté des cellules apoptotiques) sur l’expression des marqueurs de maturation CD40, CD86 et HLA de classe II (HLA-DR) à la surface des cellules dendritiques et des monocytes traités ou non avec des agents d’activation. L’expression des marqueurs était évaluée par cytométrie de flux et exprimée en moyenne d’intensité de fluorescence (MFI).RésultatsAu total, 15 patients ont été inclus sur le seul centre de Besançon entre décembre 2015 et mars 2016. Nous avons constaté une majoration, sous l’effet du SuperMapo de l’expression de l’HLA-DR sur les cellules dendritiques plasmacytoïdes (p =0,004) et la diminution de l’expression du facteur de co-stimulation CD86 sur les monocytes (p =0,0034). Nous avons remarqué une tendance à l’association entre activation des cellules inflammatoires et caractère précoce de la fibrose pulmonaire idiopathique.ConclusionDans cette étude préliminaire, SuperMApo a un effet immunomodulateur sur les cellules circulantes dans la FPI. Il semble raisonnable de poursuivre son évaluation dans un modèle animal de fibrose pulmonaire

Anxiety and depression among dairy farmers: the impact of COPD

Alicia Guillien,1 Lucie Laurent,2 Thibaud Soumagne,3 Marc Puyraveau,4 Jean-Jacques Laplante,5 Pascal Andujar,6 Isabella Annesi-Maesano,7 Nicolas Roche,8,9 Bruno Degano,1,* Jean-Charles Dalphin3,* 1Research Unit EA 3920, Franche-Comté University, Besançon, France; 2Department of Clinical Physiology, University Hospital, Besançon, France; 3Department of Respiratory Diseases, University Hospital, Besançon, France; 4Clinical Methodology Center, University Hospital, Besançon, France; 5Department of Occupational Diseases, Mutualité sociale agricole, Besançon, France; 6University of Medical Sciences, Paris-est Créteil University, Créteil, France; 7Epidemiology of Allergic and Respiratory Diseases Department (EPAR), Saint-Antoine Medical School, Paris, France; 8Respiratory and Intensive Care Medicine, Cochin Hospital (AP-HP), University Paris Descartes, Paris, France; 9Research Unit EA 2511, University Paris Descartes, Paris, France *These authors contributed equally to this work Background: Chronic obstructive pulmonary disease (COPD) and farming are two conditions that have been associated with an increased risk of anxiety and depression. Dairy farming is an independent risk factor for COPD.Objective: To test the hypotheses that the prevalence of anxiety and/or depression is higher in dairy farmers with COPD than in farmers without COPD, and higher in dairy farmers with COPD than in non-farmers with COPD.Methods: Anxiety and depression were evaluated using the Hospital Anxiety and Depression Scale in 100 dairy farmers with COPD (DF-COPD), 98 dairy farmers without COPD (DF-controls), 85 non-farming patients with COPD (NF-COPD) and 89 non-farming subjects without COPD (NF-controls), all identified by screening in the Franche-Comté region of France. Anxiety and depression were considered present when the Hospital Anxiety and Depression Scale score was ≥8. COPD was defined by a post-bronchodilator forced expiratory volume in 1 second/forced vital capacity ratio <0.7.Results: The crude prevalence of anxiety did not differ between the four groups, ranging from 36% in NF-controls to 47% in NF-COPD (p=0.15 between groups). Similarly, the prevalence of depression did not differ significantly between the four groups (p=0.16 between groups). In dairy farmers (n=198), the only factors associated with anxiety were quality of life and current smoking. Depression in dairy farmers was associated with airflow limitation (lower forced expiratory volume in 1 second and COPD grade 2 or more) as well as with some COPD-related features (dyspnea severity, current smoking, and poorer quality of life). In non-farmers, both anxiety and depression were associated with airflow limitation and COPD-related features.Conclusion: In our population, the prevalence of anxiety and/or depression was similar in dairy farmers with and without COPD and in non-farmers with COPD. Nevertheless, the degree of airway obstruction and some COPD-related features were associated with depression among dairy farmers, whereas these factors were not associated with anxiety. Keywords: COPD, farmers, forced expiratory volume in 1 second, Hospital Anxiety and Depression Scale, St George’s Respiratory Questionnair