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Néphrologie & Thérapeutique

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Assessment of iron deficiency anemia management in the general hospital of Grenoble: A 12-month follow-up of an intravenous ferric carboxymaltose treatment program in a cohort of patients with non-dialysis-dependent chronic kidney disease Volume 15, issue 2, Avril 2019

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Authors

Beta-blockers have numerous indications in the general population and are strongly recommended in heart failure, post-myocardial infarction and arrhythmias. In hemodialysis patients, their use is based on weak evidence because of the lack of a sufficient number of randomized clinical trials. The strongest evidence is based on two trials. The first showed better survival with carvedilol in hemodialysis patients with four sessions per week and systolic heart failure. The second found reduced cardiovascular morbidity with atenolol compared to lisinopril in mostly black hypertensive hemodialysis patients. No clinical trials exist regarding myocardial infarction. Large retrospective studies have assessed the benefits of beta-blockers in hemodialysis. A large cohort of hemodialysis patients with new-onset heart failure showed better survival when treated with carvedilol, bisoprolol or metoprolol. Another recent one of 20,064 patients found out that metoprolol compared to carvedilol was associated with less all-cause mortality. There is still uncertainty also regarding the impact of dialysability of beta-blockers on patient's survival. On top of that, many observations suggested that beta-blockers were associated with a reduced rate of sudden cardiac death in hemodialysis patients but recent data show a link between bradycardia and sudden cardiac death questioning the benefit of beta-blockade in this population. Finally, what we know for sure so far is that beta-blockers should be avoided in patients with intradialytic hypotension associated with bradycardia.

Background

Acquired hyponatremia is a life threatening event. Intravenous infusion of a mixture of 5% glucose and sodium solute is mainly used, but its contribution in the occurrence of acquired hyponatremia in adult, is under-investigated outside intensive care unit.

Objective

To evaluate the place of intravenous infusion of a mixture of 5% glucose and sodium in predicting acquired hyponatremia in adult polyvalent medicine service.

Patients and methods

A case-control study have been conducted. The main exposure was intravenous infusion of a mixture of 5% glucose and sodium solute (4 grams NaCl/liter of 5% glucose).

Outcome

Acquired hyponatremia during hospitalization. By logistic regression, the global multifactorial model predicting acquired hyponatremia, and its sub-models were established; as well as following parameters: area under the Receiving Operator Characteristic curve (AUC), maximal Youden's index with its couple of coordinates (sensibility-specificity), Nagelkerke's R-squared adjusted.

Results

Adjusted odds ratio (cases/controls; main exposure; outcome) ORa=2.73 (95% CI 1.40–5.32; P=0.003). Prediction of acquired hyponatremia: global multifactorial model: AUC=0.78 (95% CI 0.72–0.85; P<0.0001), Youden's index=0.34 (95% CI 0.24–0.41); sub-model (global multifactorial model without main exposure): AUC=0.72 (95% CI 0.66–0.78; P<0.0001), Youden's index=0.18 (95% CI 0.07–0.22).

Conclusion

Intravenous infusion of a mixture of 5% glucose and sodium mainly used, highly contribute to predict acquired hyponatremia in adult polyvalent medicine service, and should be the first cause to consider for managing this acquired hyponatremia.

Rationnel

L’étude FIND-CKD a validé l’intérêt de l’injection de carboxymaltose ferrique (CMF) avec une cible de ferritinémie entre 400 et 600ng/mL dans la prise en charge de l’anémie ferriprive du patient insuffisant rénal chronique non dialysé (IRC-ND). Afin d’estimer cette stratégie en pratique clinique, nous avons évalué en soins courants la cohorte de patients de l’hôpital de jour de néphrologie du CHU de Grenoble-Alpes.

Patients et méthodes

Les patients présentaient une IRC-ND de stades 3 à 5, une hémoglobinémie (Hb)<13g/dL (hommes) ou<12g/dL (femmes), avec une ferritinémie (F)<100ng/mL ou un coefficient de saturation de la transferrine (CST)<20 %. Ils ne recevaient pas d’agent stimulant l’érythropoïèse (ASE) depuis au moins un mois et un traitement par fer per os avait été mal toléré ou inefficace. La première dose de CMF était ajustée en fonction du poids. Une nouvelle perfusion était possible, au moins un mois après, avec une dose diminuée de moitié si le coefficient de saturation de la transferrine (CST) était<20 % mais que la ferritinémie (F) était≥200ng/mL ; aucune perfusion n’était réalisée si la F était≥400ng/mL.

Résultats

Cinquante-trois patients ont été inclus avec une Hb moyenne de 11,4g/dL et un coefficient TSAT moyen de 16 %. Sur 1 an de suivi, seuls 12 patients (22,6 %) ont nécessité un autre traitement de l’anémie (transfusion ou ASE). Aucun patient n’a présenté une baisse significative de l’Hb. Soixante-deux pour cent des patients n’ont reçu qu’une seule perfusion de CMF.

Conclusion

L’administration de CMF IV s’est révélée efficace avec une ferritinémie dans les cibles recommandées pour corriger l’anémie de patients IRC-ND, en limitant le recours à une autre stratégie thérapeutique.

Introduction

The FIND-CKD study has validated the use of ferric carboxymaltose (FCM) injection with a target of ferritin level between 400 and 600ng/mL to treat iron deficiency anemia in non-dialysis-dependent chronic kidney disease (ND-CKD) patients. In order to assess this strategy in clinical practice, we constituted a cohort of patients within our nephrology department.

Patients and methods

Patients had CKD stages 3 to 5, hemoglobin level (Hb)<13g/dL (men) or<12g/dL (women), and ferritin level (F)<100ng/mL or transferrin saturation (TSAT)<20%. They were not treated by erythropoiesis-stimulating agent (ESA) for at least one month, and oral iron had been poorly tolerated or ineffective. FCM first dose was adjusted according to patient weight. A new infusion was possible, at least one month after the first, with a half-dose if TSAT<20% but F≥200ng/mL; no perfusion was performed if F≥400ng/mL.

Results

In all, 53 patients were included with a mean Hb of 11.4g/dL and a mean TSAT of 16%. Over one year of follow-up, only 12 patients (22.6%) needed another treatment for anemia (blood transfusion or ESA). No patient showed a significant decrease in Hb. In all, 62% of patients received only one infusion of FCM.

Conclusion

The administration of FCM IV with ferritin levels in the recommended target has proven effective in correcting anemia of ND-CKD patients while limiting the use of another therapeutic strategy.