Education thérapeutique et VIH, bases, expérience du service des maladies infectieuses et tropicales du CHU de Toulouse (place du pharmacien)

L'éducation thérapeutique du patient est une étape incontournable dans la gestion des maladies chroniques. Elle a fait ses preuves avec de nombreuses pathologies comme le diabète, l'asthme, et depuis quelques années, le VIH. Avec l'arrivée sans cesse de nouvelles molécules, et de schémas thérapeutiques lourds, un soutien thérapeutique s'impose. L'objectif des consultations d'éducation thérapeutique est de soutenir le patient dans le vécu de la maladie et dans sa démarche thérapeutique. Après avoir établi avec lui une relation de confiance, il est nécessaire d'élargir ses compétences sur la connaissance de la maladie, de son traitement, définir des objectifs et un projet de vie, tout ceci dans le but de permettre au patient d'aller vers une autonomie complète. Le pharmacien pourra renforcer de par ses connaissances sur le médicament, les messages médicaux, apporter des informations pratiques et théoriques afin de faciliter l'adhésion au traitement.TOULOUSE3-BU Santé-Centrale (315552105) / SudocSudocFranceF

Education thérapeutique et VIH, bases, expérience du service des maladies infectieuses et tropicales du CHU de Toulouse (place du pharmacien)

L'éducation thérapeutique du patient est une étape incontournable dans la gestion des maladies chroniques. Elle a fait ses preuves avec de nombreuses pathologies comme le diabète, l'asthme, et depuis quelques années, le VIH. Avec l'arrivée sans cesse de nouvelles molécules, et de schémas thérapeutiques lourds, un soutien thérapeutique s'impose. L'objectif des consultations d'éducation thérapeutique est de soutenir le patient dans le vécu de la maladie et dans sa démarche thérapeutique. Après avoir établi avec lui une relation de confiance, il est nécessaire d'élargir ses compétences sur la connaissance de la maladie, de son traitement, définir des objectifs et un projet de vie, tout ceci dans le but de permettre au patient d'aller vers une autonomie complète. Le pharmacien pourra renforcer de par ses connaissances sur le médicament, les messages médicaux, apporter des informations pratiques et théoriques afin de faciliter l'adhésion au traitement.TOULOUSE3-BU Santé-Centrale (315552105) / SudocSudocFranceF

Management of severe renal disease in anti-neutrophil-cytoplasmic-antibody-associated vasculitis: the place of rituximab and plasma exchange?

Abstract Objective The optimal induction therapy for severe glomerulonephritis of ANCA-associated vasculitis (AAV) is debated. We compared the efficacy of glucocorticoid and rituximab (RTX) or CYC induction therapy for severe AAV-related glomerulonephritis and evaluated the potential benefit of plasma exchange (PE) as adjunct therapy to CYC. Methods This retrospective, multicentre study included AAV patients with severe renal active disease (serum creatinine level ≥350 µmol/l and/or estimated glomerular filtration ratio ≤15 ml/min/1.73 m2). Propensity-score analysis was used to adjust for potential confounders. Results Between 2005 and 2017, 153 patients with AAV-related glomerulonephritis were studied (96 [60%] men; mean [s.d.] age 63 [13.1] years): 19 (12%) were treated with RTX and 134 (88%) with CYC. Remission rates did not differ between RTX- and CYC-treated groups. Although more patients with RTX than CYC were dialysis-free at month (M) 12 (79% vs 68%), the difference was not significant after adjustment. Among 134 patients with CYC-treated glomerulonephritis, 76 (57%) also had PE. M3 and M6 remission rates were comparable for weighted CYC groups with or without PE. For weighted groups, the dialysis-free survival rate with CYC was higher with than without PE at M6 (72% vs 64%; odds ratio 2.58) and M12 (74% vs 60%; odds ratio 2.78) reaching statistical significance at M12. Conclusion We could not find any difference between RTX and CYC as induction therapy for patients with severe AAV-related glomerulonephritis. In patients receiving CYC induction regimen, the addition of PE conferred short-term benefits with higher dialysis-free rate at M12

Kidney Transplantation in Patients With AA Amyloidosis: Outcomes in a French Multicenter Cohort

International audienceRationale & ObjectiveOutcomes of kidney transplantation for patients with renal AA amyloidosis are uncertain, with reports of poor survival and high rates of disease recurrence. However, data are inconclusive and mostly based on studies from the early 2000s and earlier.Study DesignRetrospective multicenter cohort study.Setting & ParticipantsWe searched the French national transplant database to identify all patients with renal AA amyloidosis who underwent kidney transplantation between 2008 and 2018.ExposuresAge, cause of amyloidosis, use of biotherapies, CRP levels.OutcomesOutcomes were all-cause mortality and allograft loss. We also reported amyloidosis allograft recurrence, occurrence of acute rejection episodes, as well as infectious, cardiovascular, and neoplastic disease events.Analytical ApproachThe Kaplan-Meier estimator for mortality and the cumulative incidence function method for allograft loss. Factors associated with patient and allograft survival were investigated using a Cox proportional hazards model and a cause-specific hazards model, respectively.ResultsEighty-six patients who received kidney transplants for AA amyloidosis at 26 French centers were included. The median age was 49.4 years (interquartile range 39.7-61.1). The main cause of amyloidosis was Familial Mediterranean Fever (37 cases, 43%). Sixteen (18.6%) patients received a biotherapy after transplantation. Patient survival was 94.0% (95% confidence interval 89.1-99.2) at 1 year and 85.5% (77.8-94.0) at 5 years post-transplantation. The cumulative incidence of allograft loss was 10.5% (4.0-17.0) at 1 year, and 13.0% (5.8-20.1) at 5 years post-transplantation. Histologically proven AA amyloidosis recurrence occurred in 5 transplants (5.8%). 55.8% of cases developed an infection requiring hospitalization and 27.9% acute allograft rejection. Multivariable analysis showed that CRP concentration at the time of transplantation was associated with patient survival (HR 1.01, 95% CI 1.00-1.02, p=0.01) and with allograft survival (HR 1.68, 95% CI 1.10-2.57, p 0.02).LimitationsThe study lacked a control group and the effect of biotherapies on transplantation outcomes could not be explored.ConclusionsThis relatively contemporary cohort of patients who received a kidney transplant for AA amyloidosis experienced favorable rates of survival and lower recurrence rates than previously reported. These data support the practice of treating these patients with kidney transplantation for end-stage kidney disease

French recommendations for the management of systemic necrotizing vasculitides (polyarteritis nodosa and ANCA-associated vasculitides)

International audienceSystemic necrotizing vasculitis comprises a group of diseases resembling polyarteritis nodosa and anti-neutrophil cytoplasmic antibody-associated vasculitis (ANCA): granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, and microscopic polyangiitis. The definitive diagnosis is made in cooperation with a reference center for autoimmune diseases and rare systemic diseases or a competency center. The management goals are: to obtain remission and, in the long term, healing; to reduce the risk of relapses; to limit and reduce the sequelae linked to the disease; to limit the side effects and the sequelae linked to the treatments; to improve or at least maintain the best possible quality of life; and to maintain socio-professional integration and/or allow a rapid return to school and/or professional activity. Information and therapeutic education of the patients and those around them are an integral part of the care. All health professionals and patients should be informed of the existence of patient associations. The treatment of vasculitis is based on variable combinations of glucocorticoids and immunosuppressants, chosen and adapted according to the disease concerned, the severity and/or extent of the disease, and the underlying factors (age, kidney function, etc.). Follow-up clinical and paraclinical examinations must be carried out regularly to clarify the progression of the disease, detect and manage treatment failures and possible relapses early on, and limit sequelae and complications (early then late) related to the disease or treatment. A distinction is made between the induction therapy, lasting approximately 3-6 months and aimed at putting the disease into remission, and the maintenance treatment, lasting 12-48 months, or even longer. The role of the increase or testing positive again for ANCA as a predictor of a relapse, which has long been controversial, now seems to have greater consensus: Anti-myeloperoxidase ANCAs are less often associated with a relapse of vasculitis than anti-PR3 ANCA

Kidney Histopathology Can Predict Kidney Function in ANCA-Associated Vasculitides with Acute Kidney Injury Treated with Plasma Exchanges

International audienceBackground Data from the PEXIVAS trial challenged the role of plasma exchange (PLEX) in ANCA-associated vasculitides (AAV). We aimed to describe kidney biopsy from patients with AAV treated with PLEX, evaluate whether histopathologic findings could predict kidney function, and identify which patients would most benefit from PLEX. Methods We performed a multicenter, retrospective study on 188 patients with AAV and AKI treated with PLEX and 237 not treated with PLEX. The primary outcome was mortality or KRT at 12 months (M12). Results No significant benefit of PLEX for the primary outcome was found. To identify patients benefitting from PLEX, we developed a model predicting the average treatment effect of PLEX for an individual depending on covariables. Using the prediction model, 223 patients had a better predicted outcome with PLEX than without PLEX, and 177 of them had >5% increased predicted probability with PLEX compared with without PLEX of being alive and free from KRT at M12, which defined the PLEX-recommended group. Risk difference for death or KRT at M12 was significantly lower with PLEX in the PLEX-recommended group (−15.9%; 95% CI, −29.4 to −2.5) compared with the PLEX not recommended group (−4.8%; 95% CI, 14.9 to 5.3). Microscopic polyangiitis, MPO-ANCA, higher serum creatinine, crescentic and sclerotic classes, and higher Brix score were more frequent in the PLEX-recommended group. An easy to use score identified patients who would benefit from PLEX. The average treatment effect of PLEX for those with recommended treatment corresponded to an absolute risk reduction for death or KRT at M12 of 24.6%. Conclusions PLEX was not associated with a better primary outcome in the whole study population, but we identified a subset of patients who could benefit from PLEX. However, these findings must be validated before utilized in clinical decision making