Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

Background: The EMPA KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. Methods: EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. Findings: Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5–2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62–0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16–1·59), representing a 50% (42–58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). Interpretation: In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. Funding: Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council

Cum au devenit invisibili : copiii strazii din Bucuresti pe perioada postcomunista

Le phénomène des enfants des rues de Bucarest, qui devient visible après la chute du régime de Niculae Ceausescu, ne disparait pas malgré les bouleversements des années de transition. En dépit de l’abolition de la politique nataliste, l’effondrement de la natalité, la reprise économique, la réforme des dispositifs de protection de l’enfance et l’intégration européenne, des centaines de mineurs grandissent sur le pavé. L’analyse historique et longitudinale du phénomène met en évidence la persistance, dans la partie la plus vulnérable de la population, des facteurs à l’origine de son apparition : le cercle vicieux de la paupérisation et de la marginalisation continue à fragiliser les familles les plus nombreuses. Les enfants des rues de Bucarest sont un héritage du régime communiste, dont ils manifestent l’empreinte durable sur la société. Corrélé aux réalités sociales de l’abandon et du placement des enfants, qui l’ont éclipsé, ce phénomène ne s’est pas constitué comme un enjeu politique dans la Roumanie postcommuniste. Notre recherche met en évidence les modalités selon lesquelles ils sont devenus invisibles, en mettant en perspective la construction de la (non-) représentation politique des enfants des rues avec les parcours d’un certain nombre d’entre eux, de 1990 à 2015. L’incapacité à limiter l’installation des mineurs dans la rue n’est ni une spécificité roumaine, ni une caractéristique de pays pauvres ou en transition. L’exemple de l’enlisement des mineurs roumains à Paris, comme le sort d’un certain nombre de mineurs migrants isolés en Europe, soulignent le défi politique que posent, dans une région riche rompue au droit de l’enfant, les mineurs sans toits ni droits.Despite major changes during transition years since 1989 in Bucharest, the street children phenomenon which became visible after the fall of Niculae Ceausescu’s communist regime has not disappeared. In spite of the abolition of the communist regime natalist policy, the demographic fertility collapse, economic growth, child welfare reforms and EU integration process, hundreds of minors keep sleeping roughless.The historical and longitudinal analysis of the phenomenon highlights lasting causal factors in the most vulnerable part of the population: the vicious circle of pauperization and marginalization undermines the most numerous families. The Bucharest street children phenomena is an inheritance of the communist regime, a sign of its enduring imprint on Romanian society. It is correlated to – and overshadowed by – social realities such as children abandonment and institutionalization, which have prevented it from gaining political ground. Our work brings out how they have become invisible: on the one hand, we analyze the construction of the political (non)-representation of street children in postcommunist years, and, on the other hand, the street experience and trajectories of some of them, from 1990 to 2015. Being unable to prevent minors from settling in the streets is neither a Romanian feature nor a characteristic specific to poor or transition countries. The case of Romanian migrants in Paris, as well as the living conditions of a number of isolated migrant minors in Europe, illustrate how, when faced with homeless and right deprived children, a wealthy region acquainted with child rights’ issues such as the EU experiences the same political challenge and dilemma as that of postcommunist Romania.Fenomenul copiilor străzii din București apare după Revoluția din decembrie 1989 și, în pofida numeroaselor bulversări din perioada de tranziție, nu pare să-și piardă nicidecum din amplitudine. În ciuda abolirii legislației pro-nataliste, a scăderii brutale a natalității, a creșterii economice și a reformelor din sistemul de protecție a copilului în contextul integrării europene, sute de minori continuă să considere strada drept acasă. Analiza istorică a fenomenului pune in evidență continuitatea cauzelor care stau la baza apariției fenomenului, în cazul categoriei celei mai vulnerabile a populației. Cercul vicios al pauperizării și al marginalizării continuă să fragilizeze familiile numeroase. Copiii străzii din București sunt o moștenire a regimului comunist, o amprentă durabilă asupra societății romanești. Acest fenomen, corelat cu realitățile abandonului și instituționalizării copiilor, care le-a eclipsat, nu a luat o dimensiune politică în România postcomunistă. Cercetarea noastră pune în evidență felul în care copiii străzii au devenit invizibili și urmărește în paralel construirea (ne)reprezentării politice a acestor copii, precum și parcursurile lor de viață în stradă, din 1990 până în 2015. Incapacitatea autorităților de a frâna instalarea copiilor în stradă nu este o specificitate românească, și nici o singularitate a statelor sărace sau aflate in situație de tranziție. Exemplul minorilor români aflați în situație de stradă la Paris, precum și soarta unui număr important de minori emigranți izolați în Europa, pun în evidență provocările politice pe care, într-o regiune bogată si cu experienta in domeniul drepturilor copilului, o ridică fenomenul copiilor nimănui

Le pédiatre et la santé bucco-dentaire de l'enfant

Le pédiatre doit s'impliquer dans tous les aspects de la santé et du développement des enfants. Si le pédiatre manque de formation dans le domaine spécifique de la santé bucco-dentaire (il doit donc s'informer des possibilités de soins et de prévention), sa compétence est reconnue dans la prévention de la carie dentaire

Contribution à l'étude de l'âge critique. L'âge critique chez l'homme (Troubles nerveux et psychiques)

Thèse : Médecine : Université de Bordeaux : 1907N° d'ordre : 7

Un atlas du paléo-environnement de la plaine alluviale du Rhône, de la frontière suisse à la mer

This paper presents the atlas of palaeo-environment recently established for the alluvial plain of the Rhone River from the Swiss border to the Mediterranean Sea, under the leadership of the French DIREN -Rhône-Alpes and the assistance of the French CETE-Méditerranée. This atlas takes into account the Holocene fluvial dynamics and mainly aims at contributing to a better knowledge of Rhône River floods. As examples, two areas (upstream and downstream) are presented.Cet article présente I 'atlas du paléo-environnement récemment établi pour la plaine alluviale du Rhône , de la frontière suisse à la mer ; sous la maîtrise d'ouvrage de la DIREN-Rhône-Alpes, et avec l'assistance du CETE-Méditerranée. Cet atlas prend en compte la dynamique fluviale qui s 'est exercée tout au long de l 'Holocène, et il a été conçu dans le but premier de contribuer à la connaissance des inondations du Rhône. A titre d'exemples, sont présentées les cartes de deux secteurs, le premier à l 'amont, et le second à l 'aval.Bravard Jean-Paul, Lippmann-Provansal Mireille, Arnaud-Fassetta Gilles, Chabbert Simon, Gaydou Pauline, Dufour Simon, Richard France, Valleteau Sophie, Melun Gabriel, Passy Paul. Un atlas du paléo-environnement de la plaine alluviale du Rhône, de la frontière suisse à la mer. In: Collection EDYTEM. Cahiers de géographie, numéro 6, 2008. Du climat à l’homme, dynamique holocène de l’environnement dans le Jura et les Alpes. pp. 101-116

Allergie aux protéines du lait de vache : guide pratique de la réintroduction des protéines du lait de vache : quand, comment réintroduire

International audienceOnce cow’s milk protein allergy (CMA) has been diagnosed, the question is when and how it should be reintroduced. Current knowledge makes it possible to offer treatments suited to the diversity of clinical presentations. After a summary analysis of recent advances in different forms of CMA, based on current knowledge about cow’s milk immunotherapy, we propose practical approaches for indications and reintroduction methods in both non-IgE-mediated and IgE-mediated CMA. This article reflects a recent literature analysis as well as the experiences of various contributors.Une fois le diagnostic d’allergie aux protéines du lait de vache (APLV) effectué se posent les questions du moment et des modalités de la réintroduction. Les connaissances actuelles permettent de proposer des prises en charge adaptées à la diversité des tableaux cliniques de l’APLV. Après avoir rappelé les acquis récents dans les différentes formes d’APLV, envisagé les connaissances actuelles sur l’immunothérapie au lait de vache, nous proposerons des attitudes pratiques sur les indications et les modalités de réintroduction dans les APLV de forme non IgE médiée et IgE médiée. Cet article reflète l’analyse récente de la littérature et les expériences des différents contributeurs