Why is health literacy an essential component of health of individuals with chronic kidney disease / Pourquoi la littératie en santé est une composante essentielle de la santé des individus ayant une maladie rénale chronique.

Health literacy (HL) is the ability of individuals to access, understand and use health information to improve their health. It is a multidimensional and contextual concept, whose definition has been enriched over time. Considered both as a health risk factor and a skill to be developed by individuals, HL also depends on the healthcare system in which patients have to navigate, and on healthcare professionals' awareness of this concept. In order to promote shared decision-making and thus individual empowerment in the healthcare, HL should be at the core of the concerns of nephrology care teams.

La littératie en santé (LS) est la capacité d'un individu à accéder à des informations en santé, à les comprendre et à les utiliser pour améliorer son état de santé. Il s'agit d'un concept pluridimensionnel et contextuel dont la définition s'est enrichie au fil du temps. Considérée à la fois comme un facteur de risque pour la santé et une aptitude à développer chez les individus, la LS dépend également du système de santé dans lequel les patients doivent naviguer et de la sensibilisation des professionnels de santé à ce concept. Afin de favoriser la décision partagée et ainsi l'émancipation des individus en matière de santé, la LS devrait être au cœur des préoccupations des équipes de néphrologie.

Prophylactic treatment of FSGS recurrence in patients who relapsed in a previous kidney graft.

BACKGROUND AND HYPOTHESIS: Recurrence of focal segmental glomerulosclerosis (FSGS) is common after kidney transplantation and is classically associated with a significant decrease in graft survival. A major risk factor is a prior history of FSGS recurrence on a previous graft. This analysis reports the impact of a prophylactic treatment of FSGS recurrence in very high-risk patients who experienced a recurrence on a previous graft. METHODS: We performed a retrospective multicentre observational study in 25 French transplantation centres. The inclusion criteria were patients aged more than 18 years who had undergone kidney transplant between December 31, 2004, and December 31, 2020, and who had a history of FSGS recurrence on a previous graft. RESULTS: We identified 66 patients: 40 received prophylactic treatment (PT+), including intravenous cyclosporine and/or rituximab and/or plasmapheresis, and 26 did not receive any prophylactic treatment (PT-). The time to progression to end-stage kidney disease was similar between groups. The PT + group was younger at FSGS diagnosis and at the time of kidney retransplantation and lost their previous graft faster. The overall recurrence rate was 72.7% (76.9% in the PT- group and 70.0% in the PT + group, P = 0.54). At least partial remission was achieved in 87.5% of patients. The 5-year graft survival was 67.7% (95% CI: 53.4 to 78.4%): 65.1% (95%CI: 48.7 to 77.4%) in patients with FSGS recurrence vs. 77.3% (95% CI: 43.8 to 92.3%) in patients without recurrence (P = 0.48). CONCLUSION: Our study suggests that prophylactic treatment should not be used routinely in patients receiving a second transplantation after recurrence of FSGS on a previous graft. The recurrence rate is high regardless of the use of prophylactic treatment. However, the 5-year graft survival remains satisfactory.

Is social deprivation associated with the peritoneal dialysis outcomes? A cohort study with REIN registry data.

BACKGROUND: Social deprivation is associated with lower peritoneal dialysis (PD) uptake. This study was carried out to evaluate the role of social deprivation on the outcome of PD. METHODS: This was a retrospective study of data extracted from the Renal Epidemiology and Information Network registry for patients older than 18 years who started PD in metropolitan France between 1 January 2017 and 30 June 2018. The end of the observation period was 31 December 2020. The exposure was the European Deprivation Index calculated using the patient's address. The events of interest were death, transfer to haemodialysis (HD), transplantation and the composite event of death or transfer to HD. A Cox model and Fine and Gray model were used for the analysis. RESULTS: A total of 1581 patients were included, of whom 418 (26.5%) belonged to Quintile 5 of the European Deprivation Index (the most deprived patients). In the Cox model, the most deprived subjects did not have a greater risk of death (cause-specific hazard ratio (cs-HR): 0.76 [95% confidence interval (CI): 0.53-1.10], transfer to HD (cs-HR 1.37 [95% CI: 0.95-1.98]) or the composite event of death or transfer to HD (cs-HR: 1.08 [95% CI: 0.84-1.38]) or a lower risk of kidney transplantation (cs-HR: 0.73 [95% CI: 0.48-1.10]). In the competing risk analysis, the most deprived subjects had a higher risk of transfer to HD (subdistribution hazard ratio (sd-HR): 1.54 [95% CI: 1.08-2.19]) and lower access to kidney transplantation (sd-HR: 0.68 [0.46-0.99]). CONCLUSION: In PD patients, social deprivation was not associated with death or the composite event of death or transfer to HD. Socially deprived individuals had a greater risk of transfer to HD and lower access to kidney transplantation in the competing risk analysis.

Lower access to kidney transplantation for women in France is not explained by comorbidities and social deprivation.

BACKGROUND: Access to kidney transplantation (KT) remains challenging for patients with end-stage kidney disease. This study assessed women's access to KT in France by considering comorbidities and neighborhood social deprivation. METHODS: All incident 18-85-year-old patients starting dialysis in France between January 1, 2017 and December 31, 2019 were included. Three outcomes were assessed: (i) access to the KT waiting list after dialysis start, (ii) KT access after waitlisting, and (iii) KT access after dialysis start. Cox and Fine and Gray models were used. Gender-EDI and gender-age interactions were tested and analyses were performed among strata if required. RESULTS: 29,395 patients were included (35% of women). After adjusting for social deprivation and comorbidities, women were less likely to be waitlisted at 1 (adjHR: 0.91 [0.87-0.96]) and 3 years (adjHR: 0.87 [0.84-0.91]) post-dialysis initiation. This disparity concerned mainly ≥60-year-old women (adjHR: 0.76 [0.71-0.82] at 1 year and 0.75 [0.71-0.81] at 3 years). Access to KT, after 2 years of waitlisting was similar between genders. Access to KT was similar between genders at 3 years after dialysis start, but decreased for women after 4 years (adjHR: 0.93 [0.88-0.99]) and longer follow-up (adjHR: 0.90 [0.85-0.96]). CONCLUSIONS: In France, women are less likely to be waitlisted and undergo kidney transplantation. This is driven by the ≥60-year-old group and is not explained by comorbidities or social deprivation level.

Sex disparities in the utilization of nurse-assisted peritoneal dialysis: a mediation analysis using data from the REIN registry.

Background: This study was carried out to evaluate the association between patient sex and the proportion of nurse-assisted peritoneal dialysis (PD) at dialysis initiation and to explore whether sex disparities in nurse-assisted PD utilization was explained by predialysis care and/or by social deprivation using mediation analysis. Methods: This was a retrospective study using data from the Renal Epidemiology and Information Network (REIN) registry linked to the French National Healthcare Database (SNDS) of incident patients between 1 January 2017 and 30 June 2018. A regression logistic was used for statistical analysis. A mediation analysis explored the direct effect of sex on nurse-assisted PD proportion and the indirect effect through the European Deprivation Index (EDI), and the number of general practitioner (GP) and nephrologist visits before dialysis initiation. Results: Among 1706 patients on PD, there were 637 women (37.3%) and 1069 men (62.7%). Nurse-assisted PD proportion was 332/610 (54.4%) for women vs 464/1036 (44.8%) for men. In the multivariable analysis women were more likely to be treated by nurse-assisted PD {odds ratio (OR) 1.92 [95% confidence interval (CI) 1.46-2.52]}. Nurse-assisted PD was associated with the median number of GP visits [OR 1.44 (95% CI 1.11-1.86)] and with the median number of nephrologist visits [OR 0.59 (95% CI 0.46-0.76)]. The mediation analysis showed a direct effect of sex on nurse-assisted PD [OR 1.90 (95% CI 1.80-2.01)] and an indirect effect through the median number of GP visits [OR 1.05 (95% CI 1.04-1.06], the median number of nephrologist visits [OR 1.02 (95% CI 1.02-1.03)] and quintile 5 of the EDI [OR 1.03 (95% CI 1.02-1.03)]. Conclusion: Women were more frequently treated by nurse-assisted PD than men. Differences between women and men in predialysis care and social deprivation could explain the greater utilization of nurse-assisted PD among women.

Care trajectory differences in women and men with end-stage renal disease after dialysis initiation.

Few studies investigated sex-related differences in care consumption after dialysis initiation. Therefore, the aim of this study was to compare the care trajectory in the first year after dialysis start between men and women by taking into account the context of dialysis initiation. All patients who started dialysis in France in 2015 were included. Clinical data of patients and context of dialysis initiation were extracted from the Renal Epidemiology and Information Network (REIN) registry. Data on care consumption in the first year after dialysis start came from the French national health data system (SNDS): hospital stays <24h, hospital stays to prepare or maintain vascular access, hospital stays >24h for kidney problems and hospital stays >24h for other problems, and consultations with a general practitioner. Variables were compared between men and women with the χ2 test and Student's or Welch t-test and logistic regression models were used to identify the factors associated with care consumption after dialysis start. The analysis concerned 8,856 patients (36% of women). Men were less likely to have a hospital stays >24h for kidney problems than women (OR = 0.8, 95% CI = [0.7-0.9]) and less general practitioner consultations (OR = 0.8, 95% CI = [0.8-0.9]), in the year after dialysis initiation, after adjustment on patient's characteristics. Moreover, hospital stays for vascular access preparation or maintenance were longer in women than men (median duration: 2 days [0-2] vs. 1 day [0-2], p < 0.001). In conclusion, despite greater comorbidities in men, this study found few differences in post-dialysis care trajectory between men and women.

REIN: a tool to highlight inequalities in health / REIN : un outil au service de l'éclairage des inégalités en santé

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of Social Inequalities in Health, the following key messages were retained. Social inequalities in health exist throughout the journey of a patient with chronic kidney disease and manifest as territorial inequalities in access to home-based or independent dialysis treatment and to transplant, whether preemptive or otherwise. SIH are observed in adults as well as in the paediatric population. The female gender appears to be associated with a disparity in access to kidney transplant.

À l'occasion des 20 ans du REIN (Réseau Epidémiologie et Information en Néphrologie), un travail de synthèse sur les apports du registre a été mené. Sur la question des inégalités sociales de santé, les messages clés suivants ont été retenus. Les inégalités sociales de santé existent tout au long du parcours du patient atteint d'une maladie rénale chronique et se traduisent par des inégalités territoriales d'accès au traitement par dialyse au domicile ou autonome, à la greffe qu'elle soit préemptive ou non. Les ISS sont retrouvées chez l'adulte mais aussi dans la population pédiatrique. Le genre féminin semble associé à une disparité d'accès à la greffe rénale.

Social deprivation and kidney failure due to an undiagnosed nephropathy.

BACKGROUND: In France, kidney diseases of undetermined origin account for 5%-20% of all causes of end-stage kidney disease. We investigated the impact of social disadvantage on the lack of aetiological diagnosis of nephropathies. METHODS: Data from patients who started dialysis in France between 1 January 2017 and 30 June 2018 were extracted from the French Renal Epidemiology and Information Network registry. The social deprivation of each individual was estimated by the European Deprivation Index (EDI) defined by the patient's address. Logistic regression was used to perform mediation analysis to study the potential association between social deprivation and unknown nephropathy. RESULTS: Of the 7218 patients included, 1263 (17.5%) had unknown kidney disease. A total of 394 (31.4%) patients in the unknown kidney disease belonged to the most deprived quintile of the EDI [fifth quintile (Q5)], vs 1636 (27.5%) patients in the known kidney disease group. In the multivariate analysis, unknown kidney disease was associated with Q5 (odds ratio 1.40, 95% confidence interval 1.12-1.74, P = .003). Mediation analysis did not identify any variables (e.g. obesity, initiation of dialysis in emergency, number of visits to the general practitioner and nephrologist before initiation of dialysis, date of first nephrology consultation) that mediated the association between social deprivation and nephropathy of unknown origin. CONCLUSIONS: Our results show that, compared with nondeprived subjects, individuals experiencing social deprivation have a higher risk of unknown nephropathy at dialysis initiation. However, mediation analysis did not identify any variables that explained the association between social deprivation and nephropathy of unknown origin.

Pre-dialysis care trajectory and post-dialysis survival and transplantation access in patients with end-stage kidney disease.

BACKGROUND: The pre-dialysis care trajectory impact on post-dialysis outcomes is poorly known. This study assessed survival, access to kidney transplant waiting list and to transplantation after dialysis initiation by taking into account the patients' pre-dialysis care consumption (inpatient and outpatient) and the conditions of dialysis start: initiation context (emergency or planned) and vascular access type (catheter or fistula). METHODS: Adults who started dialysis in France in 2015 were included. Clinical data came from the French REIN registry and data on the care trajectory from the French National Health Data system (SNDS). The Cox model was used to assess survival and access to kidney transplantation. RESULTS: We included 8856 patients with a mean age of 68 years. Survival was shorter in patients with emergency or planned dialysis initiation with a catheter compared to patients with planned dialysis with a fistula. The risk of death was lower in patients who were seen by a nephrologist more than once in the 6 months before dialysis than in those who were seen only once. The rate of kidney transplant at 1 year post-dialysis was lower for patients with emergency or planned dialysis initiation with a catheter (respectively, HR = 0.5 [0.4; 0.8] and HR = 0.7 [0.5; 0.9]) compared to patients with planned dialysis start with a fistula. Patients who were seen by a nephrologist more than three times between 0 and 6 months before dialysis start were more likely to access the waiting list 1 and 3 years after dialysis start (respectively, HR = 1.3 [1.1; 1.5] and HR = 1.2 [1.1; 1.4]). CONCLUSIONS: Nephrological follow-up in the year before dialysis initiation is associated with better survival and higher probability of access to kidney transplantation. These results emphasize the importance of early patient referral to nephrologists by general practitioners.

Predictors of acute ischemic cerebral lesions in immune-mediated thrombotic thrombocytopenic purpura and hemolytic uremic syndrome.

BACKGROUND: The immune form of thrombotic thrombocytopenic purpura (iTTP) and the hemolytic and uremic syndrome (HUS) are two major forms of thrombotic microangiopathy (TMA). Their treatment has been recently greatly improved. In this new era, both the prevalence and predictors of cerebral lesions occurring during the acute phase of these severe conditions remain poorly known. AIM: The prevalence and predictors of cerebral lesions appearing during the acute phase of iTTP and Shiga toxin-producing Escherichia coli-HUS or atypical HUS were evaluated in a prospective multicenter study. METHODS: Univariate analysis was performed to report the main differences between patients with iTTP and those with HUS or between patients with acute cerebral lesions and the others. Multivariable logistic regression analysis was used to identify the potential predictors of these lesions. RESULTS: Among 73 TMA cases (mean age 46.9 ± 16 years (range 21-87 years) with iTTP (n = 57) or HUS (n = 16), one-third presented with acute ischemic cerebral lesions on magnetic resonance imagery (MRI); two individuals also had hemorrhagic lesions. One in ten patients had acute ischemic lesions without any neurological symptom. The neurological manifestations did not differ between iTTP and HUS. In multivariable analysis, three factors predicted the occurrence of acute ischemic lesions on cerebral MRI: (1) the presence of old infarcts on cerebral MRI, (2) the level of blood pulse pressure, (3) the diagnosis of iTTP. CONCLUSION: At the acute phase of iTTP or HUS, both symptomatic and covert ischemic lesions are detected in one third of cases on MRI. Diagnosis of iTTP and the presence of old infarcts on MRI are associated with the occurrence of such acute lesions as well as increased blood pulse pressure, that may represent a potential target to further improve the therapeutic management of these conditions.

The 2022-2026 Transplantation Plan: objectives and priorities for a new development of kidney transplantation / Le Plan greffe 2022-2026 : objectifs et priorités pour un nouvel essor de la transplantation rénale

The 2022-2026 Transplantation Plan has been launched by the French government to stimulate the activities of organ harvesting and transplantation, after the failure of the previous one. It has been designed by the Biomedicine Agency in collaboration with learning societies, including the SFNDT, and patient associations. The plan is original in its objectives, its regional organization with its driving by the Regional Health Agencies, the involvement of advanced practice nurses and its funding. The ambition is to transplant every transplantable patient. The increase in the number of kidney transplantations, more of all from a living donor, requires the active participation of all the nephrologists, who are the first in delivering information to the patients and their family on advanced chronic kidney disease treatment and living donation.

Le Plan greffe 2022-2026 a été lancé par le Gouvernement pour stimuler le prélèvement et la transplantation rénale, après l'échec du plan précédent. Il a été élaboré par l'Agence de biomédecine en concertation avec les sociétés savantes, dont la Société française de néphrologie, dialyse et transplantation (SFNDT), et les associations de patients. Il est original, du fait de ses objectifs concernant l'activité de prélèvement et de transplantation ­ exprimés non pas en données chiffrées mais en couloirs de croissance ­, de son organisation régionale pilotée par les agences régionales de santé, tendant à aligner les niveaux d'activité entre les régions, de l'implication des infirmières de pratique avancée et de son financement. L'ambition est de donner un accès à la greffe à tous les patients transplantables. L'augmentation du nombre de transplantations rénales, en premier lieu à partir d'un donneur vivant, nécessite l'implication de tous les néphrologues, premiers intervenants dans l'information aux patients sur le traitement de l'insuffisance rénale chronique avancée et le don du vivant.

Social deprivation reduced registration for kidney transplantation through markers of nephrological care: a mediation analysis.

OBJECTIVES: We assessed the direct and indirect effect of social deprivation mediated by modifiable markers of nephrological follow-up on registration on the renal transplantation waiting-list. STUDY DESIGN AND SETTINGS: From the Renal Epidemiology and Information Network, we included French incident dialysis patients eligible for a registration evaluation between January 2017 and June 2018. Mediation analyses were conducted to assess effects of social deprivation estimated by quintile 5 (Q5) of the European Deprivation Index on registration defined as wait-listing at dialysis start or within the first 6 months. RESULTS: Among the 11,655 included patients, 2,410 were registered. The Q5 had a direct effect on registration (odds ratio [OR]: 0.82 [0.80-0.84]) and an indirect effect mediated by emergency start dialysis (OR: 0.97 [0.97-0.98]), hemoglobin <11 g/dL and/or lack of erythropoietin (OR 0.96 [0.96-0.96]) and albumin <30 g/L (OR: 0.98 [0.98-0.99]). CONCLUSION: Social deprivation was directly associated with a lower registration on the renal transplantation waiting-list but its effect was also mediated by markers of nephrological care, suggesting that improving the follow-up of the most deprived patients should help to reduce disparities in access to transplantation.

Perception of social inequities in the access to the kidney transplant waiting list by nephrology trainees: a national survey.

BACKGROUND: Social inequalities in health are responsible for disparities in access to the kidney transplant waiting list (KTWL). The perception of disparities by nephrologists has consequences for the registration on the KTWL. The purposes of our study were to assess the perception of the factors implicated in the disparities in access to the KTWL by nephrology trainees and to assess the quality of the questionnaire. METHODS: A questionnaire was developed to assess the perception of the determinants of the inequities in access to waitlisting. Continuous variables were described by median, 1st and 3rd quartiles. Categorical variables were described by frequencies and percentages. A principal component analysis and a hierarchical cluster analysis were performed to approach the correlation between the variables. A scree plot and a factor analysis were performed to determine the dimensions of the questionnaire. The internal consistency was estimated by Cronbach's coefficient. RESULTS: The response rate was 98/110 (89%). The determinants of inequities in the access to KTWL not perceived by the nephrology trainees were "female sex", "income level" and "the centre provision to adapt the information to all of the patients" (18,3%, 36,7, 47% respectively). "Age", "being born abroad", "place of living", "education level", "transplant centre", "the health care provider" were determinants of disparities perceived by most of the trainees (85,7%, 75,5%, 82,6%, 78,6%, 73,5% et 78,5% respectively). Items related to the transplant centre were positively correlated, as well as "being born abroad", "education level" and "income level". The Cronbach's coefficient was 0,60. CONCLUSION: Social inequalities in health are partially perceived by nephrology trainees. A teaching session could raise nephrologists' awareness of this issue and could help reduce the impact of these disparities on the course of ESKD (end-stage kidney disease) patients.

Is there sex disparity in vascular access at dialysis initiation in France? A mediation analysis using data from the Renal Epidemiology and Information Network registry.

Background: This study was conducted to estimate the direct effect of sex on the proportion of hemodialysis (HD) catheters used at dialysis initiation and to investigate whether predialysis care or socioeconomic status acted as a mediator of the sex effect. Methods: Patients who started dialysis between January 1, 2017, and June 30, 2018, in France were included using the data of the Renal Epidemiology and Information Network (REIN) registry. We performed logistic regression to study the association between sex and the proportion of HD catheters used. A mediation analysis with a counterfactual approach was carried out to evaluate whether there was an indirect effect of sex through the proxies of predialysis care {hemoglobin, albumin levels, glomerular filtration rate [GFR] at dialysis initiation} and socioeconomic status. Because an interaction between sex and social deprivation has been identified, we performed a subgroup analysis on deprived and nondeprived patients. Results: The study included 16 032 patients, and the sex ratio (male to female) was 10 405:5627. In the multivariable analysis, women were associated with a greater risk of starting dialysis with a catheter {odds ratio [OR], 1.32 [95% confidence interval (CI): 1.23-1.42]}. There was an indirect effect of sex on the proportion of HD catheters through proxies for predialysis care {albuminemia <30 g/L [OR, 1.08 (95% CI: 1.05-1.10)], hemoglobin <11 g/dL [OR, 1.03 (95% CI: 1.02-1.04)], glomerular filtration rate <7 mL/min [OR, 1.05 (95% CI: 1.04-1.07)]}. Among deprived patients, there was no direct effect of sex on catheter proportion. Conclusions: Women were associated with a higher risk of starting dialysis through an HD catheter. The effect of sex was mediated by predialysis care, particularly for deprived patients.

Women's Access to Kidney Transplantation in France: A Mixed Methods Research Protocol.

Kidney transplantation is the best renal replacement therapy (medically and economically) for eligible patients with end-stage kidney disease. Studies in some French regions and in other countries suggest a lower access to the kidney transplant waiting listing and also to kidney transplantation, once waitlisted, for women. Using a mixed methods approach, this study aims to precisely understand these potential sex disparities and their causes. The quantitative study will explore the geographic disparities, compare the determinants of access to the waiting list and to kidney transplantation, and compare the reasons and duration of inactive status on the waiting list in women and men at different scales (national, regional, departmental, and census-block). The qualitative study will allow describing and comparing women's and men's views about their disease and transplantation, as well as nephrologists' practices relative to the French national guidelines on waiting list registration. This type of study is important in the current societal context in which the reduction of sex/gender-based inequalities is a major social expectation.

Effect of social deprivation on peritoneal dialysis uptake: A mediation analysis with the data of the REIN registry.

BACKGROUND: Social deprivation could act as a barrier to peritoneal dialysis (PD). The objective of this study was to assess the association between social deprivation estimated by the European deprivation index (EDI) and PD uptake and to explore the potential mediators of this association. METHODS: From the Renal Epidemiology and Information Network registry, patients who started dialysis in 2017 were included. The EDI was calculated based on the patient's address. The event of interest was the proportion of PD 3 months after dialysis initiation. A mediation analysis with a counterfactual approach was carried out to evaluate the direct and indirect effect of the EDI on the proportion of PD. RESULTS: Among the 9588 patients included, 1116 patients were on PD; 2894 (30.2%) patients belonged to the most deprived quintile (Q5). PD was associated with age >70 years (odds ratio (OR) 0.79 [95% confidence interval (CI): 0.69-0.91]), male gender (0.85 [95% CI: 0.74-0.97]), cardiovascular disease (OR 0.86 [95% CI: 0.86-1.00]), chronic heart failure (OR 1.34 [95% CI: 1.13-1.58]), active cancer (OR 0.67 [95% CI: 0.53-0.85]) and obesity (OR 0.75 [95% CI: 0.63-0.89]). In the mediation analysis, Q5 had a direct effect on PD proportion OR 0.84 [95% CI: 0.73-0.96]. The effect of Q5 on the proportion of PD was mediated by haemoglobin level at dialysis initiation (OR 0.96 [95% CI: 0.94-0.98]) and emergency start (OR 0.98 [95% CI: 0.96-0.99]). CONCLUSION: Social deprivation, estimated by the EDI, was associated with a lower PD uptake. The effect of social deprivation was mediated by haemoglobin level, a proxy of predialysis care and emergency start.

Are sex differences in the outcome of peritoneal dialysis explained by nurse assistance? A cohort study with data from the Registre de Dialyse Péritonéale de Langue Française.

BACKGROUND: We aimed to evaluate sex differences in peritoneal dialysis (PD) outcomes and to explore direct and indirect effects of nurse-assisted PD on outcomes. METHODS: This was a retrospective study using data from the Registre de Dialyse Péritonéale de Langue Française of incident PD patients between 2005 and 2016. Cox proportional hazards modelling was used to analyse transfer to haemodialysis (HD), death, PD failure, peritonitis and renal transplantation. Mediation analyses with a counterfactual approach were carried out to evaluate natural direct and indirect effects of sex on transfer to HD and peritonitis, with nurse-assisted PD as a mediator a priori. RESULTS: Of the 14 659 patients included, there were 5970 females (41%) and 8689 males (59%). Women were more frequently treated by nurse-assisted PD than men [2926/5970 (49.1%) versus 3357/8689 (38.7%)]. In the multivariable analysis, women had a lower risk of transfer to HD [cause-specific hazard ratio {cs-HR} 0.82 {95% confidence interval (CI) 0.77-0.88}], death [cs-HR 0.90 (95% CI 0.85-0.95)], peritonitis [cs-HR 0.82 (95% CI 0.78-0.87)], PD failure [cs-HR 0.86 (95% CI 0.83-0.90)] and a lower chance of undergoing transplant [cs-HR 0.83 (95% CI 0.77-0.90)] than men. There was a direct effect of sex on the risk of transfer to HD [cs-HR 0.82 (95% CI 0.82-0.83)], with an indirect effect of nurse-assisted PD [cs-HR 0.97 (95% CI 0.96-0.99)]. Nurse-assisted PD had no indirect effect on the risk of peritonitis. CONCLUSIONS: Our results suggest that compared with men, women have a lower risk of both transfer to HD and peritonitis. Mediation analysis showed that nurse assistance was a potential mediator in the causal pathway between sex and transfer to HD.

Characteristics of T- and NK-cell Lymphomas After Renal Transplantation: A French National Multicentric Cohort Study.

BACKGROUND: Posttransplant lymphoproliferative disorders (PTLDs) encompass a spectrum of heterogeneous entities. Because the vast majority of cases PTLD arise from B cells, available data on PTLD of T or NK phenotype (T/NK-cell PTLD) are scarce, which limits the quality of the management of these patients. METHODS: All adult cases of PTLD diagnosed in France were prospectively recorded in the national registry between 1998 and 2007. Crosschecking the registry data with 2 other independent national databases identified 58 cases of T/NK-cell PTLD. This cohort was then compared with (i) the 395 cases of B-cell PTLD from the registry, and of (ii) a cohort of 148 T/NK-cell lymphomas diagnosed in nontransplanted patients. RESULTS: T/NK-cell PTLD occurred significantly later after transplantation and had a worse overall survival than B-cell PTLD. Two subtypes of T/NK-cell PTLD were distinguished: (i) cutaneous (28%) and (ii) systemic (72%), the latter being associated with a worse prognosis. Compared with T/NK-cell lymphomas of nontransplanted patients, overall survival of systemic T/NK-cell PTLD was worse (hazard ratio: 2.64 [1.76-3.94]; P < 0.00001). CONCLUSIONS: This difference, which persisted after adjustment on tumoral mass, histological subtype, and extension of the disease at diagnosis could be explained by the fact that transplanted patients were less intensively treated and responded less to chemotherapy.

Eculizumab discontinuation in children and adults with atypical hemolytic-uremic syndrome: a prospective multicenter study.

The optimal duration of eculizumab treatment in patients with atypical hemolytic uremic syndrome (aHUS) remains poorly defined. We conducted a prospective national multicenter open-label study to assess eculizumab discontinuation in children and adults with aHUS. Fifty-five patients (including 19 children) discontinued eculizumab (mean treatment duration, 16.5 months). Twenty-eight patients (51%) had rare variants in complement genes, mostly in MCP (n = 12; 22%), CFH (n = 6; 11%), and CFI (n = 6; 10%). At eculizumab discontinuation, 17 (30%) and 4 patients (7%) had stage 3 and 4 chronic kidney disease, respectively. During follow-up, 13 patients (23%; 6 children and 7 adults) experienced aHUS relapse. In multivariable analysis, female sex and presence of a rare variant in a complement gene were associated with an increased risk of aHUS relapse, whereas requirement for dialysis during a previous episode of acute aHUS was not. In addition, increased sC5b-9 plasma level at eculizumab discontinuation was associated with a higher risk of aHUS relapse in all patients and in the subset of carriers with a complement gene rare variant, both by log-rank test and in multivariable analysis. Of the 13 relapsing patients, all of whom restarted eculizumab, 11 regained their baseline renal function and 2 had a worsening of their preexisting chronic kidney disease, including 1 patient who progressed to end-stage renal disease. A strategy of eculizumab discontinuation in aHUS patients based on complement genetics is reasonable and safe. It improves the management and quality of life of a sizeable proportion of aHUS patients while reducing the cost of treatment. This trial was registered at www.clinicaltrials.gov as #NCT02574403.