Place de l'eculizumab dans le traitement des syndromes hémolytiques et urémiques (histoire familiale d'un syndrome hémolytique et urémique atypique lié à une mutation du gène du C3 récidivant après transplantation rénale et traité par eculizumab)

CAEN-BU Médecine pharmacie (141182102) / SudocSudocFranceF

Why are hospitalisations too long? A simple checklist for identifying the main social barriers to hospital discharge from a nephrology ward

Abstract The present increase in life span has been accompanied by an even higher increase in the burden of comorbidity. The challenges to healthcare systems are enormous and performance measures have been introduced to make the provision of healthcare more cost-efficient. Performance of hospitalisation is basically defined by the relationship between hospital stay, use of hospital resources, and main diagnosis/diagnoses and complication(s), adjusted for case mix. These factors, combined in different indexes, are compared with the performance of similar hospitals in the same and other countries. The reasons why an approach like this is being employed are clear. Cutting costs cannot be the only criteria, in particular in elderly, high-comorbidity patients: in this population, although social issues are important determinants of hospital stay, they are rarely taken into account or quantified in evaluations. Quantifying the impact of the “social barriers” to care can serve as a marker of the overall quality of treatment a network provides, and point to specific out-of-hospital needs, necessary to improve in-hospital performance. We therefore propose a simple, empiric medico-social checklist that can be used in nephrology wards to assess the presence of social barriers to hospital discharge and quantify their weight. Using the checklist should allow: identifying patients with social frailty that could complicate hospitalisation and/or discharge; evaluating the social needs of patient and entourage at the beginning of hospitalisation, adopting timely procedures, within the partnership with out-of-hospital teams; facilitating prioritization of interventions by social workers. The following ten items were empirically identified: reason for hospitalisation; hospitalisation in relation to the caregiver’s problems; recurrent unplanned hospitalisations or early re-hospitalisation; social/family isolation; presence of a dependent relative in the patient’s household; lack of housing or unsuitable housing/accommodation; loss of autonomy; lack of economic resources; lack of a safe environment; evidence of physical or psychological abuse. The simple tool here described needs validation; the present proposal is aimed at raising attention on the importance of non-medical issues in medical organisation in our specialty, and is open to discussion, to allow its refinement

Incidence and Risk Factors for Acute Kidney Injury during the Treatment of Methicillin-Sensitive Staphylococcus aureus Infections with Cloxacillin Based Antibiotic Regimens: A French Retrospective Study

Background: Cloxacillin has been associated with the occurrence of acute kidney injury (AKI). The incidence of this complication in the literature is low (2.5–3.5%) and probably underestimated, since most studies were done by selecting the presence of AKI in discharge codes. Objectives: The primary goal was to define the incidence of AKI in patients with a methicillin-sensitive Staphylococcus aureus infection treated with cloxacillin based antibiotic regimens. The secondary goals were to identify the risk factors associated with this complication and to describe the characteristics of AKI. Patients and methods: We carried out a retrospective study. The inclusion criteria were adult patients hospitalized in a medical department at the Le Mans Hospital between 1 July 2012 and 1 July 2019 with a diagnosis of methicillin-sensitive Staphylococcus aureus infection treated with cloxacillin. Results: One hundred twenty-three patients were included in the study. Forty-two patients (34.2%) developed AKI. In the multivariate analysis, age, the use of diuretics and the presence of endocarditis were independently associated with AKI. Age was associated with an OR of 4.38 (p = 0.002) for patients older than 75, being treated with diuretics was associated with an OR of 2.94 (p = 0.036) for loop diuretics and an OR of 3.05 (p = 0.027) for non-loop diuretics; type of infection was associated with an OR of 3.42 (p = 0.012) for endocarditis. Conclusions: The occurrence of AKI is frequent during cloxacillin based antibiotic regimens for methicillin-sensitive Staphylococcus aureus infections. Being older than 75, being treated with diuretics and the presence of endocarditis were the main risk factors for AKI in our population

Elderly Patients in a Large Nephrology Unit: Who Are Our Old, Old-Old and Oldest-Old Patients?

International audienceThe world population is aging, and the prevalence of chronic kidney disease (CKD) is increasing. Whether this increase is also due to the methods currently being used to assess kidney function in the elderly is still a matter of discussion. We aimed to describe the actual referral pattern of CKD patients in a large nephrology unit and test whether the use of different formulae to estimate kidney function could affect the staging and the need for specialist care in the older subset of our population. In 2019, 1992 patients were referred to our center. Almost 28% of the patients were aged ≥80 and about 6% were ≥90 years old. Among the causes of kidney disease, glomerulonephritis displayed a higher prevalence in younger patients whereas hypertensive or diabetic kidney disease were more prevalent in older patients. The prevalence of referred patients in advanced CKD stages increased with age; estimated glomerular filtration rate (eGFR) decreased with age regardless of which equation was used (chronic kidney disease epidemiology collaboration (CKD-EPI), Lund–Malmö Revised (LMR), modification of diet in renal disease (MDRD), Full Age Spectrum (FAS), or Berlin Initiative Study 1 (BIS)). With CKD-EPI as a reference, MDRD and FAS underestimated the CKD stage while LMR overestimated it. The BIS showed the highest heterogeneity. Considering an eGFR threshold limit of 45 mL/min for defining “significant” CKD in patients over 65 years of age, the variability in CKD staging was 10% no matter which equation was used. Our study quantified the weight of “old” and “old-old” patients on follow-up in a large nephrology outpatient unit and suggested that with the current referral pattern, the type of formula used does not affect the need for CKD care within the context of a relatively late referral, particularly in elderly patien

Characterization of antigen-specific B cells using nominal antigen-coated flow-beads.

In order to characterize the reactivity of B cells against nominal antigens, a method based on the coupling of antigens onto the surface of fluorescent core polystyrene beads was developed. We first demonstrate that murine B cells with a human MOG-specific BCR are able to interact with MOG-coated beads and do not recognize beads coated with human albumin or pp65. B cells purified from human healthy volunteer blood or immunized individuals were tested for their ability to interact with various nominal antigens, including viral, vaccine, self and alloantigens, chosen for their usefulness in studying a variety of pathological processes. A substantial amount of B cells binding self-antigen MOG-coated beads can be detected in normal blood. Furthermore, greater frequencies of B cell against anti-Tetanic Toxin or anti-EBNA1 were observed in primed individuals. This method can reveal increased frequencies of anti-HLA committed B cells in patients with circulating anti-HLA antibodies compared to unsensitized patients and normal individuals. Of interest, those specific CD19 cells were preferentially identified within CD27(-)IgD(+) (i-e naïve) subset. These observations suggest that a broad range of medical situations could benefit from a tool that allows the detection, the quantification and the characterization of antigen-specific blood B cells

Trimethoprim/sulfamethoxazole for nocardiosis in solid organ transplant recipients: Real-life data from a multicentre retrospective study.

BACKGROUND Little is known regarding the optimal management of nocardiosis among solid organ transplant (SOT) recipients. It is often suggested to avoid trimethoprim/sulfamethoxazole (TMP-SMX) monotherapy in heavily immunocompromised patients (such as SOT recipients) and/or in case of severe or disseminated nocardiosis. Our aim was to report our experience with TMP-SMX monotherapy in SOT recipients with nocardiosis. METHODS Using data from a previously published European study, we assessed the incidence of adverse events in SOT recipients receiving TMP-SMX monotherapy and assessed its effectiveness. RESULTS Thirty-one SOT recipients with nocardiosis were included, mostly kidney transplant recipients (20/31, 65%). Eleven (36%) had disseminated infection, and four (13%) had brain nocardiosis. Most patients had lung and/or pleural involvement (26/31, 84%). Daily dose of trimethoprim at initiation was 10 [6.4-14.8] mg/kg. The median estimated glomerular filtration rate at time of diagnosis of nocardiosis was 44 [30-62] ml/min/1.73 m². TMP-SMX was discontinued prematurely in one third of the patients (10/31, 32%, mostly for hematological toxicity [n = 3] or increased serum creatinine [n = 3]). Focusing on the 24 (77%) patients who completed at least 30 days of TMP-SMX monotherapy, 4 had late (>30 days) drug discontinuation, 1 experienced treatment failure, and 19 completed planned TMP-SMX monotherapy. Clinical outcome was favorable in these 19 patients, despite the fact that 8 (42%) had disseminated infection and 2 (11%) brain nocardiosis. Overall, all-cause 1-year mortality was 10% (3/31). CONCLUSIONS TMP-SMX monotherapy appears to be effective for the treatment of most nocardiosis among SOT recipients. Interventional studies are needed to compare its safety and effectiveness with those of other regimens used to treat posttransplant nocardiosis

Separation of B cells interacting with nominal antigen and unbound B cells.

<p>Purified B cells were incubated with single HLA class I coated beads (A) or MOG_1–125 coated beads (B) before being subjected to cell separation using an ARIA FACS-sorter (A) or magnet based purification (B). Frequency of B cells interacting with nominal antigens is shown before purification and in the positive and in the negative fraction. One representative out of three experiments with cells from different donors is shown.</p

Principle of the method of identification of antigen-specific B cells.

<p>After co-incubation, lymphocytes, antigen covered beads and the beads’ B cell rosettes are gated based on their forward scatter and side scatter. After exclusion of the DAPI+ cells, B cells and beads-B cell rosettes are identified based on CD19 expression and the beads’ internal fluorochrome. Specificity of B cell recognition is determined by gating on beads and beads’ B cell rosettes (<b>A</b>) or after the identification of the nominal antigen through the use of the unique ratio of the two internal fluorochromes (<b>B</b>). In the latter, for each nominal antigen, a gate that encompassed beads and B cell rosettes is created followed by the identification of the B cells. Frequency of B cells bound to HLA class I of interest is finally evaluated. Bead-based method allows the detection of antigen-specific B cells. (<b>C</b>). An example of the identification of beads, Bead-cell rosette and lymphocyte is shown. After exclusion of dead cells, the use of the marker CD19 allows the identification of B lymphocyte and a mix of beads and BBR. Thanks to the ratio of two fluorochromes, antigen coated on the beads can be then identified. Beads are excluded using the expression of CD19. A Boolean gate is used to assess the frequency of B cells specific of a given antigen within the whole B cell population.</p