ADHERE: randomized controlled trial comparing renal function in de novo kidney transplant recipients receiving prolonged-release tacrolimus plus mycophenolate mofetil or sirolimus

ADHERE was a randomized, open-label, Phase IV study comparing renal function at Week 52 postkidney transplant, in patients who received prolongedrelease tacrolimus-based immunosuppressive regimens. On Days 0?27, patients received prolonged-release tacrolimus (initially 0.2 mg/kg/day), corticosteroids, and mycophenolate mofetil (MMF). Patients were randomized on Day 28 to receive either prolonged-release tacrolimus plus MMF (Arm 1) or prolongedrelease tacrolimus (?25% dose reduction on Day 42) plus sirolimus (Arm 2). The primary endpoint was glomerular filtration rate by iohexol clearance (mGFR) at Week 52. Secondary endpoints included eGFR, creatinine clearance (CrCl), efficacy failure (patient withdrawal or graft loss), and patient/graft survival. Tolerability was analyzed. The full-analysis set comprised 569 patients (Arm 1: 287; Arm 2: 282). Week 52 mean mGFR was similar in Arm 1 versus Arm 2 (40.73 vs. 41.75 ml/min/1.73 m2; P = 0.405), as were the secondary endpoints, except composite efficacy failure, which was higher in Arm 2 versus 1 (18.2% vs. 11.5%; P = 0.002) owing to a higher postrandomization withdrawal rate due to adverse events (AEs) (14.4% vs. 5.2%). Results from this study show comparable renal function between arms at Week 52, with fewer AEs leading to study discontinuation with prolonged-release tacrolimus plus MMF (Arm 1) versus lower dose prolonged-release tacrolimus plus sirolimus (Arm 2)

Etude prospective des infections urinaires nosocomiales acquises dans un service de néphrologie-transplantation

CLERMONT FD-BCIU-Santé (631132104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Facteurs prédictifs de la survie rénale et des patients dans la maladie athéro-embolique rénale

CLERMONT FD-BCIU-Santé (631132104) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Épidémiologie de l’insuffisance rénale aiguë

International audienc

Prédictions of autogenous arteriovenous hemodialysis access thrombosis after renal transplantation

We conducted a monocentric retrospective review of prospective clinical records of 145 patients with a functional aAVF who had a RT between January 2004 and December 2009 in the University Hospital of Clermont-Ferrand. Our primary endpoint was the thrombosis of the aAVF. Univariate and multiple logistic regression analyses were used to identify risk factors associated to aAVF thrombosis after RT.ResultsThere were 105 men (72 %) and 40 women (28 %), mean age 52 years (range: 18.4-74.7 years). The aAVF was created on average 40 months (range: 2-169) before the RT. The aAVF was distal, in 96 cases (66 %) and proximal in 49 cases (34%). Nineteen aAVF (13.1%) were complicated and required an endovascular or surgical repair before RT. Forty-nine patients (34%) required multiple aAVF (>2). Mean follow-up from RT was 58 months (0.03-123) and from aAVF creation 97 months (5-262). At the end of the follow-up, 81 aAVFs (59%) were patent, 42 (29%) were thrombosed and 22 (15%) were surgically closed. Patients that had multiple fistulas before RT and active smokers were significantly at risk to thrombose their aAVF after the RT in univariate (respectively, P=0.03 and P=0.02) and multiple logistic regression analyses (respectively, P=0.03 and P=0.047).ConclusionsThrombosis is a part of the natural history of the aAVF after RT. A history of multiple aAVF creations before RT and active smoking were associated to significant increased risk for fistula thrombosis. Because hemodialysis may be needed after RT, the aAVF patency should be preserved, excepted when the aAVF resulted in complications. Follow-up of the aAVF after RT is important to detect and treat complications before thrombosis occurs

Fermentable carbohydrate supplementation alters nitrogen excretion in chronic renal failure

International audienceBACKGROUND: Considerable attention has been given to the impact of nutrition on kidney disease. Most dietary attempts to treat chronic renal failure (CRF) and to decrease uremia use a protein restriction. An alternative dietetic approach based on fermentable carbohydrate (FC) supplementation of the diet could lead to the same urea-lowering effect by increasing urea nitrogen (N) excretion in stool, with a concomitant decrease of the total N quantity excreted in urine. METHODS: In the present prospective study, the impact of FC (40 g/d) on uremia and on N excretion routes was investigated during 5 weeks in nine CRF patients in the presence of a moderated restrictive protein diet (0.8 g/kg/d). Patients were their own controls and were treated by the cross-over method after randomization (5 weeks with FC versus 5 weeks without FC). RESULTS: Feeding FC significantly increased the quantity of N excreted in stool from 2.1 +/- 0.8 to 3.2 +/- 1.1 g/d (+51 %) (P < .01) and decreased, in parallel, the urinary N excretion from 9.4 +/- 1.7 to 8.3 +/- 1.4 g/d (-12%) (P < .01). The total N quantities excreted by the two routes were unchanged by the FC, which shows that the FC was efficient to shift N excretion from the urinary route toward the digestive route. As a result of the increase of urea transfer into the colon, the plasma urea concentration was significantly decreased from 26.1 +/- 8.7 to 20.2 +/- 8.2 mmol/L (-23%) (P < .05). CONCLUSIONS: These results show the same beneficial effects in CRF as those obtained with a restrictive protein diet without its nutritional drawbacks. This should be confirmed by other prospective works over a longer duration and a larger number of patients to study the effects of FC on CRF progression and on CRF terminal stage tolerance

Fermentable carbohydrate supplementation alters nitrogen excretion in chronic renal failure

International audienceBACKGROUND: Considerable attention has been given to the impact of nutrition on kidney disease. Most dietary attempts to treat chronic renal failure (CRF) and to decrease uremia use a protein restriction. An alternative dietetic approach based on fermentable carbohydrate (FC) supplementation of the diet could lead to the same urea-lowering effect by increasing urea nitrogen (N) excretion in stool, with a concomitant decrease of the total N quantity excreted in urine. METHODS: In the present prospective study, the impact of FC (40 g/d) on uremia and on N excretion routes was investigated during 5 weeks in nine CRF patients in the presence of a moderated restrictive protein diet (0.8 g/kg/d). Patients were their own controls and were treated by the cross-over method after randomization (5 weeks with FC versus 5 weeks without FC). RESULTS: Feeding FC significantly increased the quantity of N excreted in stool from 2.1 +/- 0.8 to 3.2 +/- 1.1 g/d (+51 %) (P < .01) and decreased, in parallel, the urinary N excretion from 9.4 +/- 1.7 to 8.3 +/- 1.4 g/d (-12%) (P < .01). The total N quantities excreted by the two routes were unchanged by the FC, which shows that the FC was efficient to shift N excretion from the urinary route toward the digestive route. As a result of the increase of urea transfer into the colon, the plasma urea concentration was significantly decreased from 26.1 +/- 8.7 to 20.2 +/- 8.2 mmol/L (-23%) (P < .05). CONCLUSIONS: These results show the same beneficial effects in CRF as those obtained with a restrictive protein diet without its nutritional drawbacks. This should be confirmed by other prospective works over a longer duration and a larger number of patients to study the effects of FC on CRF progression and on CRF terminal stage tolerance

Energy expenditure, spontaneous physical activity and with weight gain in kidney transplant recipients

Background & aims: Alterations in energy metabolism could trigger weight gain after renal transplantation. Methods: Nineteen transplanted non-diabetic men, 53 +/- 1.6 years old, receiving calcineurin inhibitors but no corticosteroids were studied. They were compared with nine healthy men matched for height, age and lean body mass. Daily energy expenditure and its components (sleeping, basal and absorptive metabolic rates) were analyzed for 24 h in calorimetric chambers and for 4 days in free living conditions using calibrated accelerometry. Other variables known to influence energy expenditure were assessed: body composition, physical activity, 4-day food intake, drug consumption, serum C-reactive protein, interleukin-6, thyroid and parathyroid hormones, and epinephrine. Transplant recipients who gained more than 5% body weight after transplantation (n = 11, +11.0 +/- 1.5 kg) were compared with those who did not (n = 8) and with the controls. Results: Weight gain compared with non-weight gain patients and controls exhibited higher fat mass without change in lean body mass. Daily, sleeping and resting energy expenditure adjusted for lean body mass was significantly higher in non-weight gain (167.1 +/- 4.2 kJ/kg/lean body mass/24 h, P < 0.05) compared with weight gain patients (147.4 +/- 3.6) and controls (146.1 +/- 4.6). Weight gain compared with controls and non-weight gain subjects had lower free living physical activity and a higher consumption of antihypertensive drugs and beta-blockers. Conclusions: After kidney transplantation, weight gain patients were characterized by lower adjusted energy expenditure, reduced spontaneous physical activity but a more sedentary life style and a trend toward a higher energy intake explaining the reason they gained weight. The nWG KTR had increased resting and sleeping EE which protected them from weight gain. Such hypermetabolism was also observed in 24-h EE measurements. By comparison with the nWG patients, the WG transplant recipients were characterized by higher beta-blocker consumption. These data could be helpful in the prevention of weight gain in kidney transplant recipients

Impact of Thymoglobulin by Stem Cell Source (Peripheral Blood Stem Cell or Bone Marrow) After Myeloablative Stem Cell Transplantation From HLA 10/10-Matched Unrelated Donors. A Report From the Société Française de Greffe de Moelle et de Thérapie Cellulaire

International audienceBACKGROUND: The impact of antithymocyte globulin (ATG) in the setting of a myeloablative conditioning transplantation remains controversial, especially when using bone marrow (BM) as the stem cell source. METHODS: We therefore conducted a retrospective analysis to investigate the impact of ATG in patients with acute myeloid leukemia or myelodysplastic syndrome receiving myeloablative conditioning followed by a matched 10 of 10 unrelated donor transplant from BM or peripheral blood stem cells (PBSCs). Our study included 356 patients conditioned with cyclophosphamide associated with fractionated total body irradiation or busulfan. RESULTS: Median follow-up was 17.6 months (range, 0-156). The ATG and PBSCs were the only variables that independently decreased the cumulative incidence (CI) of chronic graft-versus-host disease (GvHD) (hazards ratio [HR], 0.4; 95% CI, 0.21-0.73; P \textless 0.01; and HR, 0.53; 95% CI, 0.30-0.90; P = 0.02, respectively). The ATG had no impact on overall survival, disease-free survival, relapse, and nonrelapse mortality. In the PBSC group (n = 139), ATG was associated with a lower CI of both grades III to IV acute GvHD (HR, 0.17; 95% CI, 0.03-0.91; P = 0.04), chronic GvHD (HR, 0.31; 95% CI, 0.11-0.87; P = 0.03), and GvHD-free/relapse-free survival (HR, 0.48; 95% CI, 0.29-0.80; P \textless 0.01), whereas these correlations were not significant in the group of patients (n = 217) receiving BM (HR, 0.36; 95% CI, 0.11-1.93; P = 0.06 for grade III-IV acute GvHD; HR, 0.49; 95% CI, 0.22-1.06; P = 0.08 for chronic GvHD; and HR, 0.69; 95% CI, 0.46-1.01; P = 0.06 for GvHD-free/relapse-free survival). CONCLUSIONS: Although our results confirm the recommendation for ATG to be added after PBSC transplantation, no obvious benefit was identified using this approach in the setting of BM transplantation. Only prospective studies may yield definitive answers to this questio