Journal de néphrologie et thérapeutique

A 21-year-old male patient whose primary kidney disease was focal segmental glomerulosclerosis (FSGS) received a living kidney transplant 7 years after starting hemodialysis (haploidentic from his mother). His kidney disease was primary recurrent FSGS treated since the age of four with corticosteroids and switching different options of Immunosuppressive treatment Calcineurin inhibitors and mycophenolate Mofetil). The transplantation induction protocol was Corticosteroid (CS) boli and Basiliximab without added preventive Therapeutic Plasma Exchange (TPE/ Plasmapheresis) sessions. Then for maintain, he took CS, Mycophenolate Mofetil and Cyclosporine A. After 9 liters of urine output at day zero after transplantation, he developed severe recurrence of proteinuria (up to 23 g/24 hat day 2) and anuria with creatinin level ascension to reach 500 micromol/l. The immunosuppressive treatment consisted of ten daily Plasmapheresis sessions, five intravenous doses of Rituximab (RTX-375/m2) 700 mg at days 1, 5, 9, 13 and three boli of CS (500 mg) in addition to Cyclosporine (oral). At hospital discharge (1 month), proteinuria increased below nephrotic range at day 14 and serum creatinine returned progressively to normal values. He underwent two other Plasmapheresis sessions (TPE) but the third was delayed because of technical problems. At the sixth month, urine output decreased and proteinuria rose again. It was a relapse. Histology examination showed recurrence signs and he underwent additional Plasmapheresis sessions, another RTX intravenous dose, 500 mg of CS and switched to Tacrolimus. This strategy allowed obtaining sustained full remission of the proteinuria and excellent graft function, which persists over 9 months after transplantation. No notable adverse events related to RTX or TPE were observed. This case confirms that RTX associated with Plasmapheresis may be an effective treatment of recurrent Nephrotic Syndrom (NS) due to FSGS.

Background: With the improvement of life expectancy in developing countries, there is a growing population of elderly admitted on maintenance hemodialysis. This study assessed the survival among incident elderly patients on maintenance hemodialysis in Cameroon.

Patients and method: We carried out a retrospective cohort study of 6.3 years in the main hemodialysis units of Cameroon. All incident chronic hemodialysis patients of at least 65 years of age at dialysis initiation were included. Participants were followed for a minimum of 4 months up until death or abandon of dialysis. Their baseline characteristics and survival outcome were assessed.

Results: A total of 107 patients were included in this study, representing a cumulative incidence of hemodialysis among elderly patients of 10.9% during the study period. The median age at dialysis initiation was 68 years [IQR 66-72]. The median modified Charlson Comorbidity Index (mCCI) was 2 [IQR 2-5], and 35 (33%) patients had a comorbidity index greater than 3. Emergency dialysis at initiation was noted in 71 (69%) participants. Twenty four (22.5%) patients were hospitalized, mainly because of sepsis. The median survival time was 19.5 months [IQR 42-6]. Survival rates at 1 year and 2 year were 65.4% and 41.5%, respectively. The lowest survival time (4 months) was observed in the very elderly (> 80 years) with high comorbidity index. Patients with a history of hospitalization and those with emergency dialysis initiation also had low survival rates.

Conclusion: In our setting, one out of ten incident hemodialysis patients is an elderly. Nearly two-thirds of elderly are still alive one year after hemodialysis initiation. Comorbidity, emergency dialysis initiation and hospitalization are the main factors associated with mortality.

Metformin a biguanide derivative is the preferred initial pharmacologic agent for the treatment of type 2 diabetes mellitus per current guidelines of the American Diabetes Association. It is prescribed to an estimated 120 million people worldwide. Type B lactic acidosis is a reported but rare side effect of Metformin use. Serum Metformin level is not routinely monitored or available in most hospitals, but it can be a useful test to confirm the diagnosis and guide future use of Metformin in at risk patients. We present a case of a 78-year old African American diabetic female on prescribed dose of Metformin with no history of kidney disease who presented with acute encephalopathy and hemodynamic instability. Her laboratory data showed acute kidney injury (AKI) with severe lactic acidosis (LA). She required large amount of intravenous bicarbonate infusions and urgent initiation of Continuous Veno-Venous Hemodialysis (CVVHD) due to severe refractory metabolic acidosis. Her serum Metformin level sent 12 hours after initiation of CVVHD was still critically elevated at 19 mcg/ml. Her acidosis and AKI started to resolve after 48 hours of CVVHD with resolution of encephalopathy as well. Her renal function returned to baseline and she was eventually discharged home, but Metformin was not resumed back.