Evènement hémorragiques chez les patients bénéficiant d'une transplantation rénale sous héparine

Après une transplantation rénale, l'héparinothérapie par voie intraveineuse peut réduire le risque de thrombose de l'artère ou la veine du greffon chez les patients à haut risque thrombotique. Le maniement de ce traitement en post-opératoire est délicat car il existe un risque important d'accident hémorragique. Objectifs : 71 patients transplantés rénaux à Rouen entre 1997 et 2004 traités par héparine en période post-opératoire ont été analysés rétrospectivement afin de comparer les caractéristiques des patients ayant présenté un accident hémorragique à celui des patients n'ayant pas fait d'hémorragie. Résultats : Parmi les 71 patients, 14 (19,7 %) ont présenté un accident hémorragique. Aucun patient du groupe hémorragie n'a présenté de thrombose de la veine ou de l'artère du greffon alors que 3 patients ont présenté 1 thrombose dans l'autre groupe. Les patients du groupe hémorragie comparés aux patients de l'autre groupe étaient plus âgés (56,2 +- 9 vs 49,2 +- 10,8 ans. p=0.03), recevaient un greffon d'un donneur plus âgé (49,7+- 13,3 vs 41 +- 13,9 ans, p=0,03), étaient réopérés plus souvent (42.9 % vs 14,1 %, p=0,02) et étaient hospitalisés plus longtemps (39,2 +-17,6 vs 24 +- 13,9 jours, p=0,001). L'éNénement hémorragique survenait en moyenne 9,7 +- 6,6 jours après la transplantation. Le TCA maximal était en mo~enne plus élevé dans le groupe hémorragie que dans l'autre groupe (2,68 +- 1 vs 2,07 +- 1,04, p=0,01). Les patients du groupe hémorragie tendait à avoir un index de masse corporel plus élevé notamment dans le sous groupe des patients de sexe féminin (26,7 +- 5,6 vs 22,8 +- 3 kg/m2, p=0,09), et à présenter plus souvent un retard de reprise de fonction du greffon (42,8 % vs 24.5 %, p=0.29), mais ces différences n'étaient pas statistiquement significatives. Aucune différence n'était retrouvée entre les 2 groupes concernant le sexe, la durée d'épuration extra-rénale, la néphropathie initiale, la technique de dialyse, les différentes indications d'héparinothérapie, les facteurs de risque cardio-vasculaires, la dose initiale et la durée du traitement anticoagulant, la créatininémie du donneur, le nombre d'incompatibilités et de compatibilités HLA, la durée d'ischémie totale et tiède et l'évolution de la fonction rénale durant la première année de transplantation. Conclusion : Les accidents hémorragiques sont fréquents chez les patients transplantés rénaux traités par héparine. La prévention de ces accidents passe par la surveillance régulière du TCA afin d'éviter les surdosages.ROUEN-BU Médecine-Pharmacie (765402102) / SudocPARIS-BIUM (751062103) / SudocSudocFranceF

Low incidence of SARS-CoV-2, risk factors of mortality and the course of illness in the French national cohort of dialysis patients

International audienceThe aim of this study was to estimate the incidence of COVID-19 disease in the French national population of dialysis patients, their course of illness and to identify the risk factors associated with mortality. Our study included all patients on dialysis recorded in the French REIN Registry in April 2020. Clinical characteristics at last follow-up and the evolution of COVID-19 illness severity over time were recorded for diagnosed cases (either suspicious clinical symptoms, characteristic signs on the chest scan or a positive reverse transcription polymerase chain reaction) for SARS-CoV-2. A total of 1,621 infected patients were reported on the REIN registry from March 16th, 2020 to May 4th, 2020. Of these, 344 died. The prevalence of COVID-19 patients varied from less than 1% to 10% between regions. The probability of being a case was higher in males, patients with diabetes, those in need of assistance for transfer or treated at a self-care unit. Dialysis at home was associated with a lower probability of being infected as was being a smoker, a former smoker, having an active malignancy, or peripheral vascular disease. Mortality in diagnosed cases (21%) was associated with the same causes as in the general population. Higher age, hypoalbuminemia and the presence of an ischemic heart disease were statistically independently associated with a higher risk of death. Being treated at a selfcare unit was associated with a lower risk. Thus, our study showed a relatively low frequency of COVID-19 among dialysis patients contrary to what might have been assumed

Evolution over Time of Ventilatory Management and Outcome of Patients with Neurologic Disease∗

OBJECTIVES: To describe the changes in ventilator management over time in patients with neurologic disease at ICU admission and to estimate factors associated with 28-day hospital mortality. DESIGN: Secondary analysis of three prospective, observational, multicenter studies. SETTING: Cohort studies conducted in 2004, 2010, and 2016. PATIENTS: Adult patients who received mechanical ventilation for more than 12 hours. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Among the 20,929 patients enrolled, we included 4,152 (20%) mechanically ventilated patients due to different neurologic diseases. Hemorrhagic stroke and brain trauma were the most common pathologies associated with the need for mechanical ventilation. Although volume-cycled ventilation remained the preferred ventilation mode, there was a significant (p < 0.001) increment in the use of pressure support ventilation. The proportion of patients receiving a protective lung ventilation strategy was increased over time: 47% in 2004, 63% in 2010, and 65% in 2016 (p < 0.001), as well as the duration of protective ventilation strategies: 406 days per 1,000 mechanical ventilation days in 2004, 523 days per 1,000 mechanical ventilation days in 2010, and 585 days per 1,000 mechanical ventilation days in 2016 (p < 0.001). There were no differences in the length of stay in the ICU, mortality in the ICU, and mortality in hospital from 2004 to 2016. Independent risk factors for 28-day mortality were age greater than 75 years, Simplified Acute Physiology Score II greater than 50, the occurrence of organ dysfunction within first 48 hours after brain injury, and specific neurologic diseases such as hemorrhagic stroke, ischemic stroke, and brain trauma. CONCLUSIONS: More lung-protective ventilatory strategies have been implemented over years in neurologic patients with no effect on pulmonary complications or on survival. We found several prognostic factors on mortality such as advanced age, the severity of the disease, organ dysfunctions, and the etiology of neurologic disease