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Néphrologie & Thérapeutique

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CKD care in French nephrology practices Volume 17, issue 7, Décembre 2021

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Authors

Background

Amphotericin B is a broad-spectrum antifungal agent and is the backbone of the treatment for medically important opportunistic fungal pathogens in children. This study aimed to compare the nephrotoxicity associated with L-AmB in children with acute lymphoblastic leukemia and acute myeloid leukemia.

Materials and methods

A total of 112 pediatric acute lymphoblastic leukemia or acute myeloid leukemia patients who received treatment with L-AmB (Ambisome®) at the University of Health Sciences Dr Behcet Uz Children's Hospital over 7 years were included. The incidence of hypokalemia, decreased estimated glomerular filtration rate and presence of acute kidney injury was recorded.

Results

The average L-AmB treatment duration was 17.1±15.0 days. Five patients (4.4%) of the patients had grade I acute renal injury according to KDIGO criteria and 16 patients (14.2%) had increased risk for kidney injury according to RIFLE criteria. There were no patients with eGFR decrease above 50% and no renal injury and failure were observed during L-AmB treatment. The rate of patients with hypokalemia in the pre-treatment was 17.9% and the post-L-AmB group was 50.0%. The rate of hypokalemia was higher in the post-treatment group (P=0.0015). Among the 112 patients, only two patients (1.7%) required cessation of L-AmB treatment due to resistant hypokalemia despite supplementation.

Conclusions

Hypokalemia was more common compared to glomerulotoxicity and acute renal injury (according to KDIGO and RIFLE criteria) in pediatric leukemia patients treated with L-AmB. Hypokalemia developed in nearly half of the patients and the study shows the need for randomized controlled trials and strategies for hypokalemia associated with L-AmB treatment.

Introduction

L’état des lieux de la prise en charge de la maladie rénale chronique avant le déploiement du forfait-parcours des patients est important à connaître pour permettre d’en mesurer l’impact à terme.

Patients et méthodes

Nous avons décrit la prise en charge en néphrologie sur 3 ans de 2835 patients ayant une maladie rénale chronique modérée à sévère, suivis dans la cohorte CKD-REIN entre 2013 et 2019, et son adéquation au référentiel de la Haute Autorité de Santé en vigueur sur la période.

Résultats

Le nombre moyen de consultations néphrologiques des patients (âge moyen 67 ans ; 65 % d’hommes ; 43 % de MRC stade 4 ou 5) augmentait de 1,1 à 2,7 par an, du stade 3A au stade 5 de la maladie rénale chronique. Aux stades 3B, 4 et 5, respectivement 84, 63 et 33 % des patients avaient le nombre minimum de consultations de néphrologie recommandé par la Haute Autorité de Santé. Au stade 4 ou 5 de la maladie rénale chronique, seuls 34 et 40 % des patients, respectivement, avaient bénéficié de consultation diététique, et 33 et 54 % avaient reçu des informations sur les options de traitement. Le délai moyen d’attente pour une première consultation de néphrologie était plus long (60 vs 45 jours), et leur durée moyenne plus courte (30 vs 38 à 40 minutes) en CHU comparé aux centres hospitaliers et aux établissements privés.

Conclusion

L’écart important constaté entre les pratiques réelles et les recommandations témoigne des limites des ressources humaines et des organisations dans la prise en charge de la maladie rénale chronique en néphrologie, pour lesquelles des avancées sont attendues avec le financement au forfait.

Background

To be able to assess the impact of the bundled payment system on real-life management of patients with chronic kidney disease, an overview of patient-care management before its implementation is needed.

Patients and methods

We describe patterns of nephrology care over 3 years in 2835 patients with moderate to severe chronic kidney disease, who were followed-up from 2013 to 2019 in the CKD-REIN cohort study. Compliance with health authority guidelines during this period is also studied.

Results

At baseline, patients’ mean age was 67 years, 65% were men, and 43% had chronic kidney disease stage 4 or 5. The mean number of nephrology visits increased from 1.1 to 2.7 per year, from chronic kidney disease stage 3A to stage 5. The minimum number of nephrology visits as recommended by health authorities was achieved in 84%, 63%, and 33% of patients with chronic kidney disease stages 3B, 4, and 5, respectively. In chronic kidney disease stages 4 and 5, only 34% and 40% of patients had seen a dietitian, and 33% and 54% had received information about treatment options, respectively. The average waiting time for a first appointment with a nephrologist was longer, 60 days and its duration shorter, 30 vs 38 to 40 minutes, in university hospitals compared with non-university hospitals and private clinics.

Conclusion

The significant gap between received and recommended care reflects human resources and organizational limits in chronic kidney disease management in the nephrology setting. Improvements with bundled payment are expected.