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Le Touquet – Paris-Plage, France

Bridoux F.,University of Poitiers | Leung N.,Mayo Medical School | Hutchison C.A.,University of Otago | Touchard G.,University of Poitiers | And 11 more authors.
Kidney International

Monoclonal gammopathy of renal significance (MGRS) regroups all renal disorders caused by a monoclonal immunoglobulin (MIg) secreted by a nonmalignant B-cell clone. By definition, patients with MGRS do not meet the criteria for overt multiple myeloma/B-cell proliferation, and the hematologic disorder is generally consistent with monoclonal gammopathy of undetermined significance (MGUS). However, MGRS is associated with high morbidity due to the severity of renal and sometimes systemic lesions induced by the MIg. Early recognition is crucial, as suppression of MIg secretion by chemotherapy often improves outcomes. The spectrum of renal diseases in MGRS is wide, including old entities such as AL amyloidosis and newly described lesions, particularly proliferative glomerulonephritis with monoclonal Ig deposits and C3 glomerulopathy with monoclonal gammopathy. Kidney biopsy is indicated in most cases to determine the exact lesion associated with MGRS and evaluate its severity. Diagnosis requires integration of morphologic alterations by light microscopy, immunofluorescence (IF), electron microscopy, and in some cases by IF staining for Ig isotypes, immunoelectron microscopy, and proteomic analysis. Complete hematologic workup with serum and urine protein electrophoresis, immunofixation, and serum-free light-chain assay is required. This review addresses the pathologic and clinical features of MGRS lesions, indications of renal biopsy, and a proposed algorithm for the hematologic workup. © 2015 International Society of Nephrology. Source

Schwebel C.,Joseph Fourier University | Clec'h C.,Avicenne University Hospital | Magne S.,Joseph Fourier University | Minet C.,Joseph Fourier University | And 12 more authors.
Critical Care Medicine

Objectives: To describe intrahospital transport complications in critically ill patients receiving invasive mechanical ventilation. Design: Prospective multicenter cohort study. Setting: Twelve French ICUs belonging to the OUTCOMEREA study group. Patients: Patients older than or equal to 18 years old admitted in the ICU and requiring invasive mechanical ventilation between April 2000 and November 2010 were included. Interventions: None. Measurements and Main Results: Six thousand two hundred forty-two patients on invasive mechanical ventilation were identified in the OUTCOMEREA database. The statistical analysis included a description of demographic and clinical characteristics of the cohort, identification of risk factors for intrahospital transport and construction of an intrahospital transport propensity score, and an exposed/unexposed study to compare complication of intrahospital transport (excluding transport to the operating room) after adjustment on the propensity score, length of stay, and confounding factors on the day before intrahospital transport. Three thousand and six intrahospital transports occurred in 1,782 patients (28.6%) (1-17 intrahospital transports/patient). Transported patients had higher admission Simplified Acute Physiology Score II values (median [interquartile range], 51 [39-65] vs 46 [33-62], p < 10-4) and longer ICU stay lengths (12 [6-23] vs 5 [3-11] d, p < 10-4). Post-intrahospital transport complications were recorded in 621 patients (37.4%). We matched 1,659 intrahospital transport patients to 3,344 nonintrahospital transport patients according to the intrahospital transport propensity score and previous ICU stay length. After adjustment, intrahospital transport patients were at higher risk for various complications (odds ratio = 1.9; 95% CI, 1.7-2.2; p < 10-4), including pneumothorax, atelectasis, ventilator-associated pneumonia, hypoglycemia, hyperglycemia, and hypernatremia. Intrahospital transport was associated with a longer ICU length of stay but had no significant impact on mortality. Conclusions: Intrahospital transport increases the risk of complications in ventilated critically ill patients. Continuous quality improvement programs should include specific procedures to minimize intrahospital transport-related risks. Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Source

Leung N.,Mayo Medical School | Bridoux F.,University of Poitiers | Hutchison C.A.,University of Birmingham | Nasr S.H.,Mayo Medical School | And 5 more authors.

Multiple myeloma is the most frequent monoclonal gammopathy to involve the kidney; however, a growing number of kidney diseases associated with other monoclonal gammopathies are being recognized. Although many histopathologic patterns exist, they are all distinguished by the monoclonal immunoglobulin (or component) deposits. The hematologic disorder in these patients is more consistent with monoclonal gammopathy of undetermined significance (MGUS) than with multiple myeloma. Unfortunately, due to the limitations of the current diagnostic schema, they are frequently diagnosed as MGUS. Because treatment is not recommended for MGUS, appropriate therapy is commonly withheld. In addition to endstage renal disease, the persistence of the monoclonal gammopathy is associated with high rates of recurrence after kidney transplantation. Preservation and restoration of kidney function are possible with successful treatment targeting the responsible clone. Achievement of hematologic complete response has been shown to prevent recurrence after kidney transplantation. There is a need for a term that properly conveys the pathologic nature of these diseases. We think the term monoclonal gammopathy of renal significance is most helpful to indicate a causal relationship between the monoclonal gammopathy and the renal damage and because the significance of the monoclonal gammopathy is no longer undetermined. © 2012 by The American Society of Hematology. Source

Darmon M.,Jean Monnet University | Pichon M.,Jean Monnet University | Schwebel C.,Joseph Fourier University | Schwebel C.,Grenoble University Hospital Center | And 18 more authors.

Increasing evidence suggests that dysnatremia at intensive care unit (ICU) admission may predict mortality. Little information is available, however, on the potential effect of dysnatremia correction. This is an observational multicenter cohort study in patients admitted between 2005 and 2012 to 18 French ICUs. Hyponatremia and hypernatremia were defined as serum sodium concentration less than 135 and more than 145 mmol/L, respectively. We assessed the influence on day 28 mortality of dysnatremia correction by day 3 and of the dysnatremia correction rate. Of 7,067 included patients, 1,830 (25.9%) had hyponatremia and 634 (9.0%) had hypernatremia at ICU admission (day 1). By day 3, hyponatremia had been corrected in 1,019 (1,019/1,830; 55.7%) and hypernatremia in 393 (393/634; 62.0%) patients. After adjustment for confounders, persistent hyponatremia or hypernatremia on day 3 was independently associated with higher day 28 mortality (odds ratio [OR], 1.31; 95% confidence interval [95% CI], 1.06 Y 1.61; and OR, 1.86; 95% CI, 1.37 Y 2.54; respectively). Hyponatremia corrected by day 3, hypernatremia corrected by day 3, and ICU-acquired hyponatremia were not associated with day 28 mortality. Median correction rate from days 1 to 3 was 2.58 mmol/L per day (interquartile range, 0.67 Y 4.55). Higher natremia correction rate was associated with lower crude and adjusted day 28 mortality rates (OR per mmol/L per day, 0.97; 95% CI, 0.94 Y 1.00; P = 0.04; and OR per mmol/L per day, 0.93; 95% CI, 0.90 Y 0.97; P = 0.0003, respectively). Our results indicate that dysnatremia correction is independently associated with survival, with the effect being greater with faster correction rates of up to 12 mmol/L per day. © 2014 by the Shock Society. Source

Laupland K.B.,Albert Bonniot Institute | Laupland K.B.,University of Calgary | Zahar J.-R.,Albert Bonniot Institute | Zahar J.-R.,Necker University Hospital | And 15 more authors.
Clinical Infectious Diseases

Background. Although hypothermia is widely accepted as a risk factor for subsequent infection in surgical patients, it has not been well defined in medical patients. We sought to assess the risk of acquiring intensive care unit (ICU)-acquired infection after hypothermia among medical ICU patients. Methods. Adults (≥18 years) admitted to French ICUs for at least 2 days between April 2000 and November 2010 were included. Surgical patients were excluded. Patient were classified as having had mild hypothermia (35.0°C-35.9°C), moderate hypothermia (32°C-34.9°C), or severe hypothermia (<32°C), and were followed for the development of pneumonia or bloodstream infection until ICU discharge. Results. A total of 6237 patients were included. Within the first day of admission, 648 (10%) patients had mild hypothermia, 288 (5%) patients had moderate hypothermia, and 45 (1%) patients had severe hypothermia. Among the 5256 patients who did not have any hypothermia at day 1, subsequent hypothermia developed in 868 (17%), of which 673 (13%), 176 (3%), and 19 (<1%) patients had lowest temperatures of 35.0°C-35.9°C, 32.0°C-34.9°C, and <32°C, respectively. During the course of ICU admission, 320 (5%) patients developed ICU-acquired bloodstream infection and 724 (12%) patients developed ICU-acquired pneumonia. After controlling for confounding variables in multivariable analyses, severe hypothermia was found to increase the risk for subsequent ICU-acquired infection, particularly in patients who did not present with severe sepsis or septic shock.Conclusions.The presence of severe hypothermia is a risk factor for development of ICU-acquired infection in medical patients. © 2012 The Author. Source

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