Service de Nephrologie Dialyse

Saint-Ouen, France

Service de Nephrologie Dialyse

Saint-Ouen, France

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PubMed | Service de reanimation medicale, Service de Reanimation, Service de Reanimation medicale, Assistance Publique Hopitaux de Paris and 11 more.
Type: Journal Article | Journal: Annals of intensive care | Year: 2016

Acute kidney injury (AKI) is a syndrome that has progressed a great deal over the last 20years. The decrease in urine output and the increase in classical renal biomarkers, such as blood urea nitrogen and serum creatinine, have largely been used as surrogate markers for decreased glomerular filtration rate (GFR), which defines AKI. However, using such markers of GFR as criteria for diagnosing AKI has several limits including the difficult diagnosis of non-organic AKI, also called functional renal insufficiency or pre-renal insufficiency. This situation is characterized by an oliguria and an increase in creatininemia as a consequence of a reduction in renal blood flow related to systemic haemodynamic abnormalities. In this situation, renal insufficiency seems rather inappropriate as kidney function is not impaired. On the contrary, the kidney delivers an appropriate response aiming to recover optimal systemic physiological haemodynamic conditions. Considering the kidney as insufficient is erroneous because this suggests that it does not work correctly, whereas the opposite is occurring, because the kidney is healthy even in a threatening situation. With current definitions of AKI, normalization of volaemia is needed before defining AKI in order to avoid this pitfall.


Krzesinski J.-M.,University of Liège | Saint-Remy A.,Service de Nephrologie Dialyse
Revue Medicale de Liege | Year: 2012

Essential hypertension, defined as a blood pressure equal to or above 140/90 mmHg, is a common (25% of the population), but complex disease the phenotype of which results from interactions between numerous genes and environmental factors. The role attributable to genetic factors amounts to some 25% among hypertensive families, but can reach 65% when monozygotic twins are compared. In the present state of our knowledge, there is no hope to obtain a genetic test of value for the diagnosis and prognosis of hypertension. An individualized environmental approach, applied early in life, is the only worhtwhile attitude. Nonetheless, in the presence of a subject with still normal blood pressure values, but with a family history of hypertension, the physician should firmly recommend an appropriate hygieno-dietetic lifestyle with a view to lower blood pressure, or retard the development of arterial hypertension.


Raggi P.,Emory University | Chertow G.M.,Stanford University | Torres P.U.,Service de Nephrologie Dialyse | Csiky B.,University of Pécs | And 8 more authors.
Nephrology Dialysis Transplantation | Year: 2011

Background. This prospective, randomized, controlled trial compared the progression of vascular and cardiac valve calcification in 360 prevalent adult hemodialysis patients with secondary hyperparathyroidism treated with either cinacalcet plus low-dose vitamin D sterols or flexible doses of vitamin D sterols alone.Methods. Eligible subjects were on hemodialysis for < 3 months with parathyroid hormone (PTH) > 300 pg/mL or PTH 150300 pg/mL with calciumphosphorus product > 50 mg2/dL2 while receiving vitamin D. All subjects received calcium-based phosphate binders. Coronary artery calcification (CAC) and aorta and cardiac valve calcium scores were determined both by Agatston and volume scoring using multi-detector computed tomography. Subjects with Agatston CAC scores < 30 were randomized to cinacalcet (30180 mg/day) plus low-dose calcitriol or vitamin D analog (≤ 2 μg paricalcitol equivalent/dialysis), or flexible vitamin D therapy. The primary end point was percentage change in Agatston CAC score from baseline to Week 52.Results. Median (P10, P90) Agatston CAC scores increased 24% (- 22%, 119%) in the cinacalcet group and 31% (- 9%, 179%) in the flexible vitamin D group (P = 0.073). Corresponding changes in volume CAC scores were 22% (- 12%, 105%) and 30% (- 6%, 133%; P = 0.009). Increases in calcification scores were consistently less in the aorta, aortic valve and mitral valve among subjects treated with cinacalcet plus low-dose vitamin D sterols, and the differences between groups were significant at the aortic valve.Conclusions. In hemodialysis patients with moderate to severe secondary hyperparathyroidism, cinacalcet plus low-dose vitamin D sterols may attenuate vascular and cardiac valve calcification. © 2010 The Author.


Krzesinski J.-M.,University of Liège | Saint-Remy A.,Service de Nephrologie Dialyse
Revue Medicale de Liege | Year: 2012

Routinely measuring blood pressure is still performed according to the auscultatory method using recognition of Korotkoff sounds. This usual technique is, however, often mishandled and is thus a source of error in the estimation of the true blood pressure level. Accuracy of such measure is, however, of paramount importance to be useful in daily medical practice. This methodology paper more specifically written for medical students recalls the essential principles of blood pressure measurement at the medical office, but also at home.


Therapeutic inertia, i.e. the absence of introduction of an antihypertensive treatment or on adjustment of its intensity by the medical doctor if the blood pressure is elevated or the goal not reached, is frequent and does play a role in the insufficient control of blood presure in the hypertensive population. The responsibility of the medical doctor is high in this respect. A strict medical approach is required, step by step, to correct this lack of reaction.


Floege J.,RWTH Aachen | Raggi P.,Emory University | Block G.A.,Denver Nephrology | Torres P.U.,Service de Nephrologie Dialyse | And 9 more authors.
Nephrology Dialysis Transplantation | Year: 2010

Background. The ADVANCE (A Randomized Study to Evaluate the Effects of Cinacalcet plus Low-Dose Vitamin D on Vascular Calcification in Subjects with Chronic Kidney Disease Receiving Haemodialysis) Study objective is to assess the effect of cinacalcet plus low-dose active vitamin D versus flexible dosing of active vitamin D on progression of coronary artery calcification (CAC) in haemodialysis patients. We report the ADVANCE Study design and baseline subject characteristics.Methods. ADVANCE is a multinational, multicentre, randomized, open-label study. Adult haemodialysis patients with moderate to severe secondary hyperparathyroidism (intact parathyroid hormone [iPTH] >300 pg/mL or bio-intact PTH >160 pg/mL) and baseline CAC score ≥30 were stratified by CAC score (≥30-399, ≥400-999, ≥1000) and randomized in a 1:1 ratio to cinacalcet (30-180 mg/day) plus low-dose active vitamin D (cinacalcet group) or flexible dosing of active vitamin D alone (control). The study had three phases: screening, 20-week dose titration and 32-week follow-up. CAC scores obtained by cardiac computed tomography were determined at screening and weeks 28 and 52. The primary end point was percentage change in CAC score from baseline to Week 52.Results. Subjects (n = 360) were randomized to cinacalcet or control. Mean age was 61.5 years, 43% were women, and median dialysis vintage was 36.7 months (range, 2.7-351.5 months). The baseline geometric mean CAC score by the Agatston method was 548.7 (95% confidence interval, 480.5-626.6). Baseline CAC score was independently associated with age, sex, dialysis vintage, diabetes and iPTH. Subjects also had extensive aortic and valvular calcification at baseline.Conclusions. Subjects enrolled in ADVANCE have extensive CAC at baseline. The ADVANCE Study should help determine whether cinacalcet attenuates progression of vascular calcification. © 2010 The Author.


Hindie E.,University Paris Diderot | Hindie E.,Paris West University Nanterre La Défense | Zanotti-Fregonara P.,University Paris - Sud | Just P.-A.,University Paris Diderot | And 7 more authors.
European Journal of Nuclear Medicine and Molecular Imaging | Year: 2010

Background: Parathyroidectomy (PTX), either subtotal or total with forearm autografting, is a well-established treatment for refractory renal hyperparathyroidism (RHPT). However, 20-30% of patients develop persistent or recurrent disease. Obtaining accurate localization before reoperation is difficult. Patients and methods: The study group comprised 21 consecutive adult patients (18 undergoing haemodialysis and 3 with a renal graft) imaged using 99mTc-sestamibi/123I subtraction scintigraphy. Of the 21 patients, 12 had undergone one previous PTX and the other 9 between two and four parathyroid operations. All patients had symptoms and signs of severe RHPT. The mean serum PTH level was 1,142 pg/ml. 99mTc-Sestamibi and 123I images were recorded simultaneously. Imaging views comprised a planar view of the neck and mediastinum, followed by a magnified pinhole view over the thyroid bed area. If parathyroid ectopy was detected, SPECT or SPECT-CT was performed. The forearm was imaged in case of autograft. Results: Parathyroid scintigraphy was negative in one patient and positive in the other 20 (sensitivity 95.2%). One patient had uptake corresponding to two unresected parathyroid glands. Recurrence at the site of the partially resected gland or autograft was seen in 11 patients. However, six of them had a second 99mTc-sestamibi focus corresponding to a supernumerary parathyroid gland. Seven other patients had a supernumerary parathyroid gland as the sole cause of relapse. Three of the supernumerary glands showed major ectopy (intrathyroidal, low mediastinal, undescended within the vagus nerve). One patient had parathyromatosis with multiple parathyroid nodules scattered over the left side of the neck. Reoperation was possible in 13 patients, with no false-positive findings. Conclusion: Many patients referred with the hypothesis of hyperplasia of a subtotally resected parathyroid gland or autograft were found to harbour a supernumerary parathyroid gland missed at the initial surgery. © 2009 Springer-Verlag.


Urena-Torres P.,Service de Nephrologie Dialyse | Prie D.,Service de Physiologie Explorations Fonctionnelles | Keddad K.,Shire Inc | Preston P.,Shire Inc | And 3 more authors.
BMC Nephrology | Year: 2014

Background: High levels of circulating fibroblast growth factor 23 (FGF23) are associated with chronic kidney disease (CKD) progression and high mortality. In the Phosphate Reduction Evaluation of FGF23 in Early CKD Treatment (PREFECT) study, we assessed the effect of reducing intestinal phosphate absorption using lanthanum carbonate on FGF23 levels in normophosphatemic patients with CKD stage 3. Methods. Thirty-five individuals were randomized to lanthanum carbonate 3000 mg/day (n = 23) or placebo (n = 12) for 12 weeks. Levels of intact FGF23 (iFGF23), C-terminal FGF23, serum and urinary phosphate and calcium, intact parathyroid hormone and 1,25-dihydroxyvitamin D were assessed. Results: The median age was 65 years in the lanthanum group and 73 years in the placebo group; 58.8% and 41.7% were men, respectively. No significant difference was seen in mean iFGF23 between groups at week 12. There was, however, a transient reduction from baseline in iFGF23 in the lanthanum group at week 1, from 70.5 pg/ml to 51.9 pg/ml, which was not seen in the placebo group; this between-group difference in percentage change from baseline was significant in post hoc analyses (p = 0.0102). Urinary phosphate decreased after 1 week of lanthanum treatment and remained low at week 12. Conclusions: Reducing intestinal phosphate absorption with lanthanum carbonate did not lead to sustained reductions in iFGF23 in patients with CKD stage 3, although phosphaturia decreased. This suggests that factors other than phosphate burden may be responsible for driving increases in circulating FGF23 in patients with CKD. Trial registration. ClinicalTrials.gov NCT01128179, 20 May 2010. © 2014 Ureña-Torres et al.; licensee BioMed Central Ltd.


High levels of circulating fibroblast growth factor 23 (FGF23) are associated with chronic kidney disease (CKD) progression and high mortality. In the Phosphate Reduction Evaluation of FGF23 in Early CKD Treatment (PREFECT) study, we assessed the effect of reducing intestinal phosphate absorption using lanthanum carbonate on FGF23 levels in normophosphatemic patients with CKD stage 3.Thirty-five individuals were randomized to lanthanum carbonate 3000 mg/day (n=23) or placebo (n=12) for 12 weeks. Levels of intact FGF23 (iFGF23), C-terminal FGF23, serum and urinary phosphate and calcium, intact parathyroid hormone and 1,25-dihydroxyvitamin D were assessed.The median age was 65 years in the lanthanum group and 73 years in the placebo group; 58.8% and 41.7% were men, respectively. No significant difference was seen in mean iFGF23 between groups at week 12. There was, however, a transient reduction from baseline in iFGF23 in the lanthanum group at week 1, from 70.5 pg/ml to 51.9 pg/ml, which was not seen in the placebo group; this between-group difference in percentage change from baseline was significant in post hoc analyses (p=0.0102). Urinary phosphate decreased after 1 week of lanthanum treatment and remained low at week 12.Reducing intestinal phosphate absorption with lanthanum carbonate did not lead to sustained reductions in iFGF23 in patients with CKD stage 3, although phosphaturia decreased. This suggests that factors other than phosphate burden may be responsible for driving increases in circulating FGF23 in patients with CKD.ClinicalTrials.gov NCT01128179, 20 May 2010.


PubMed | Service durologie, Service de nephrologie dialyse, Service de nephrologie, University Paris Est Creteil and 3 more.
Type: Journal Article | Journal: La Revue de medecine interne | Year: 2016

Retroperitoneal fibrosis (RPF) is a rare disorder characterized by the sheathing of retroperitoneal structures by fibro-inflammatory process. It can be either isolated or associated with an underlying disease or condition. In the absence of consistent and consensual approach, the objective of this study was to assess the relevance of diagnostic tests performed during the diagnostic work-up of RPF.Seventy-seven patients were included in this retrospective multicenter study. The diagnosis of RPF was defined by the presence of a thickened circumferential homogeneous tissue unsheathing the infrarenal aorta, excluding peri-aneurysmal fibrosis and a clear evidence of a cancer.In 62cases (80.5%), the RPF was considered as being primary or idiopathic. Surgical (n=31) or CT-guided (n=9) biopsies of the RPF were performed in half of the patients showing some fibrotic or non-specific inflammatory lesions in 98% of cases. A bone marrow biopsy was performed in 23patients leading to diagnosis of low gradeB cell non-Hodgkin lymphoma in a single patient who also had a monoclonal gammopathy IgM. The systematic search for autoantibodies or serum tumor markers was of no diagnostic value.Although the diagnostic procedure was heterogeneous, no cause or associated disease was found in the majority of cases of FRP in this series. In the absence of any clinical or paraclinical evidence suggesting an underlying disease or any atypical features at presentation, a number of non-invasive tests (autoantibodies, tumor markers, bone scintigraphy) and also more invasive diagnostic tests (bone marrow and RPF biopsies) seem of little relevance.

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