Obesity phenotype and patient-reported outcomes in moderate and severe chronic kidney disease: a cross-sectional study from the CKD-REIN cohort study.

PURPOSE: To evaluate the association between obesity phenotypes and health-related quality of life (HRQoL) in non-dialysis-dependent CKD patients. METHODS: Data from the national CKD-REIN cohort which included 3033 patients with stage 3-4 CKD were used. Patients were divided into three groups: non-obese (NO) patients (BMI < 30 kg/m2), metabolically healthy obese (MHO) (BMI ≥ 30 kg/m2 and ≤ 1 criterion NCEP/ATP III), and metabolically unhealthy obese (MUO) (BMI ≥ 30 kg/m2 and ≥ 2 criteria NCEP/ATP III). HRQoL was measured by the KDQOL-36™ which comprised three disease-specific dimensions: symptoms, effects, and burden and two summaries scores: physical (PCS) and mental (MCS). We used a mixed effect model with adjustment on sociodemographic characteristics and comorbidities. RESULTS: A total of 2693 patients completed the self-administered questionnaires. MHO patients accounted for 3.4% of the cohort and for 12% of obese patients. In the NO group, average HRQoL scores were 77.2 ± 15.9 for symptoms, 83.5 ± 16.5 for effects, 76.8 ± 22.7 for burden, 43.5 ± 9.7 for PCS, and 47.9 ± 7.0 for MCS. In the multivariate analysis, scores were similar in MHO and NO patients, but significantly different with those in MUO patients: symptoms (- 0.7; p = 0.71 vs. - 3.0; p = 0.0025), effects (+ 1.2; p = 0.57 vs. - 4.3; p < 0.0001), burden (+ 2.7; p = 0.31 vs. - 3.6; p = 0.0031), and PCS (- 0.6; p = 0.58 vs. - 4.3; p < 0.0001). MCS was not associated with obesity phenotypes. CONCLUSIONS: This study demonstrated an association between obesity phenotypes and QoL in non-dialysis-dependent CKD patients. MUO patients had worse QoL than NO and MHO patients even after adjustment on comorbidities.

Harnessing Scientific and Technological Advances to Improve Equity in Kidney Allocation Policies.

We reported that current assignment of HLA-DQ is a barrier to organ allocation. Here we simulated the impact of incorporating HLA-DQ antigens and antibodies as A/B and αß allelic variants, respectively, on calculated panel reactive antibody (cPRA) and probability of finding potential compatible donors (PCD). A cohort of 1224 donors and 2075 sensitized candidates was analyzed using HLA-DQαß allelic (study) versus serologic (current practice) nomenclature. A significant (p < 10-4 ) decrease in cPRA was observed with higher impact for male versus female, and first transplant versus retransplant (p < 10-4 ), affecting mostly patients with moderate cPRA (30-80%). Consequently, the number of patients qualifying for 100% cPRA points according to the United Network for Organ Sharing-Kidney Allocation System decreased by 37%. More critically, by using allelic versus serologic nomenclature for HLA-DQ, the number of PCDs for all patients was increased, with male and first-transplant patients showing a higher expansion compared with female and retransplants. Patients of blood group O showed the highest benefit. The goal of reporting unacceptable antigens is to improve accuracy of virtual crossmatching and increase the likelihood of finding immunologically compatible donors. Our simulation provides strong support for the need to re-evaluate the use of allele typing and how HLA-DQ antigens and antibodies are incorporated into allocation policies to ensure equity.

Individual and regional factors of access to the renal transplant waiting list in france in a cohort of dialyzed patients.

Several studies have investigated geographical variations in access to renal transplant waiting lists, but none has assessed the impact on these variations of factors at both the patient and geographic levels. The objective of our study was to identify medical and non-medical factors at both these levels associated with these geographical variations in waiting-list placement in France. We included all incident patients aged 18-80 years in 11 French regions who started dialysis between January 1, 2006, and December 31, 2008. Both a multilevel Cox model with shared frailty and a competing risks model were used for the analyses. At the patient level, old age, comorbidities, diabetic nephropathy, non-autonomous first dialysis, and female gender were the major determinants of a lower probability of being waitlisted. At the regional level, the only factor associated with this probability was an increase in the number of patients on the waiting list from 2005 to 2009. This finding supports a slight but significant impact of a regional organ shortage on waitlisting practices. Our findings demonstrate that patients' age has a major impact on waitlisting practices, even for patients with no comorbidity or disability, whose survival would likely be improved by transplantation compared with dialysis.

[Hepatopulmonary syndrome]. / Le syndrome hépatopulmonaire.

Hepatopulmonary syndrome is characterized by the presence of portal hypertension with or without cirrhosis, an increased alveolar-arterial oxygen partial pressure difference greater than or equal to 15 mm Hg, and dilated pulmonary capillaries. Hepatopulmonary syndrome is found in up to 20% of patients with cirrhosis and should be considered in any patient who develops dyspnea or hypoxemia. Contrast echocardiography is enough to make the diagnosis of hepatopulmonary syndrome. The exact pathophysiology of hepatopulmonary syndrome remains unknown but nitric oxide is an important factor underlying hepatopulmonary syndrome. Hypoxemia progressively deteriorates and worsens the prognosis of cirrhotic patients. Hypoxemic patients must be controlled regularly to optimise the timing of liver transplantation. Indeed, a preoperative PaO(2) of less than or equal to 50 mm Hg alone or in combination with an isotopic shunt fraction greater than or equal to 20% are the strongest predictors of postoperative mortality. There are currently no effective medical therapies for hepatopulmonary syndrome but garlic powder and iloprost inhalation demonstrate clinical improvements in the pre- and in the post-transplant period.

Impact of sex and glucose-lowering treatments on hypoglycaemic symptoms in people with type 2 diabetes and chronic kidney disease. The French Chronic Kidney Disease - Renal Epidemiology and Information Network (CKD-REIN) Study.

AIM: To describe current practices of glucose-lowering treatments in people with diabetes and chronic kidney disease (CKD), the associated glucose control and hypoglycaemic symptoms, with an emphasis on sex differences. METHODS: Among the 3033 patients with CKD stages 3-5 recruited into the French CKD-REIN study, 645 men and 288 women had type 2 diabetes and were treated by glucose-lowering drugs. RESULTS: Overall, 31% were treated only with insulin, 28% with combinations of insulin and another drug, 42% with non-insulin glucose-lowering drugs. In CKD stage 3, 40% of patients used metformin, 12% at stages 4&5, similar for men and women; in CKD stage 3, 53% used insulin, similar for men and women, but at stages 4&5, 59% of men and 77% of women used insulin. Patients were reasonably well controlled, with a median HbA1c of 7.1% (54mmol/mol) in men, 7.4% (57mmol/mol) in women (P=0.0003). Hypoglycaemic symptoms were reported by 40% of men and 59% of women; they were not associated with the estimated glomerular filtration rate, nor with albuminuria or with HbA1c in multivariable analyses, but they were more frequent in people treated with insulin, particularly with fast-acting and pre-mixed insulins. CONCLUSION: Glucose-lowering treatment, HbA1c and hypoglycaemic symptoms were sex dependent. Metformin use was similar in men and women, but unexpectedly low in CKD stage 3; its use could be encouraged rather than resorting to insulin. Hypoglycaemic symptoms were frequent and need to be more closely monitored, with appropriate patient-education, especially in women.

Multi-drug resistance (MDR) activity in acute leukemia determined by rhodamine 123 efflux assay.

We prospectively analyzed MDR functional activity by the Rh123 efflux assay in 84 de novo acute leukemias. Thirty of the 60 AML cases (50%) showed a positive dye efflux (in more than 10% of blast cells). In 19 cases, the dye efflux was superior to 30%. Twenty-four of the 30 efflux positive cases were CD34+ and could be studied in double staining. The mean percentage of effluxing CD34+ blast cells was 54%. There was a high correlation between CD34 expression and MDR activity (P < 10(-4)), MDR activity and PgP expression (P < 10(-6)). All the efflux negative samples were PgP negative. Nine efflux positive cases were PgP negative. Five of the 24 ALL were efflux positive. MDR activity did not correlate with FAB subtype (with the exception of AML3: 1/6 was efflux positive), age, white blood cell count or LDH level. Forty-seven AML patients were treated with conventional chemotherapy including cytarabine and an anthracycline. Thirty-one (66%) entered complete remission (CR). CR rate was statistically lower for efflux positive as compared to efflux negative patients, 46 vs 87% (P = 0.003), for PgP+ as compared to PgP- patients, 40 vs 78% (P = 0.01), for CD34+ as compared to CD34- patients, 45 vs 84% (P = 0.005). There was no correlation between P110 expression (32 AML cases studied) and FAB subtype, MDR status and clinical outcome. Two years survival was 20% for efflux positive patients as compared to 54% for efflux negative patients (P < 0.07), 15% for PgP+ vs 54% for PgP- patients (P < 0.04). The finding of efflux+/PgP- cases suggests the existence of other membrane efflux pumps. Rh123 efflux assay is straightforward in routine and could be included in MDR screening because of its potential interest in clinical outcome in AML.

Prophylactic use of itraconazole for the prevention of invasive pulmonary aspergillosis in high risk neutropenic patients.

Invasive pulmonary aspergillosis (IPA) is an increasing cause of morbidity and mortality in patients with hematologic malignancies. A major program of construction work close to our unit prompted us to evaluate the efficacy of itraconazole prophylaxis in preventing IPA in these patients. During September 1994 to December 1995, 77 patients undergoing 96 neutropenic episodes (mean duration, 19.3 days +/- 9.1) received itraconazole as antifungal prophylaxis. All patients were treated in laminar air flow rooms. Itraconazole was administered at a loading dose of 600mg/d, (day 1 to day 3) and 400mg/d on the following days, in 87 instances. In the remaining episodes, the daily dose was 200 or 400mg. Oral doses were adjusted to reach a plasma itraconazole level (PIL) above 1000ng/l. In cases of inadequate PIL or poor oral intake, IV AmphoB was started at a 20 mg daily dose. Five cases of IPA (proven n = 2, probable n = 3) were observed. This represents an incidence of 5.2% of the total number of episodes. One out of 67 (2%) treatment episodes with adequate PIL were associated with IPA as compared to 4 of 29 (14%) episodes with inadequate PIL, (p < 0.02). AmphoB was added in 28 cases because of low PIL (n = 25), and/or antibiotic-resistant fever persistent pulmonary infiltrate (n = 8). These results need to be interpreted with caution, because of the absence of randomization or a control group. The efficacy of Itraconazole in neutropenic patients with high risk IPA has to be confirmed on larger and prospective studies.

An intelligent Computer-Assisted Instruction system for clinical case teaching.

The use of computers in the field of medical education is common. Our purpose is to present a Computer-Assisted Instruction system which has been developed over ten years at the University of Compiègne and the University of Rennes Medical School. This system can be used to help the student to solve clinical cases by analyzing and critiquing their answers and by using a knowledge base which has been previously structured in a rule network. It is an intelligent Computer-Assisted Instruction system comprising an author module, a pedagogical module and a student module. The CAI system can be used as a simulation model for any type of diagnostic or therapeutic problem. In this paper we present the author and pedagogical module which have been built using our previous work on intelligent computer-assisted instruction systems.

[Sclerotherapy versus ligation in hemorrhage caused by rupture of esophageal varices. Direct meta-analysis of randomized trials]. / Sclérothérapie versus ligature au cours de l'hémorragie par rupture de varices oesophagiennes. Méta-analyse directe des essais randomisés.

OBJECTIVES: To compare the advantages of endoscopic ligation and endoscopic sclerotherapy for bleeding esophageal varices, published randomized clinical trials were critically reviewed by meta-analysis. Only ten clinical trials concerning a history of recent or active bleeding esophageal varices were included. METHODS: The methodology, population, treatment and outcomes of each relevant trial were evaluated by duplicate independent review. RESULTS: Endoscopic sclerotherapy compared to banding ligation significantly increased the rate of rebleeding (OR: 1.6; 95% IC: 1.1-2.3) without increasing early mortality compared to endoscopic banding ligation (OR: 1.3; 95% IC: 0.8-1.9). The rate of varice eradication associated with these two types of treatment was not different (OR: 0.9; 95% IC: 0.6-1.3) but was obtained more quickly with endoscopic banding ligation (3.8 +/- 1.6 versus 5.8 +/- 2.2; P < 0.05). The rate of complications was higher after sclerotherapy (OR: 2.5; 95% IC: 1.7-3.7), in those cases with a positive heterogeneity test. CONCLUSIONS: This meta-analysis shows a lower morbidity with endoscopic banding ligation in patients with variceal hemorrhage. The most important advantage of endoscopic banding ligation was the reduction of the rate of rebleeding.

[Multicenter prospective study of prognostic factors of gastroduodenal ulcer hemorrhages. Reevaluation of clinical and endoscopic factors in the era of endoscopic hemostasis]. / Etude prospective multicentrique des facteurs pronostiques des hémorragies ulcéreuses gastroduodénales. Réévaluation des facteurs cliniques et endoscopiques à l'ère de l'hémostase endoscopique.

AIM: To evaluate in a prospective study the prognostic factors of recurrent bleeding and mortality in patients presenting with high risk peptic ulcer bleeding routinely treated by endoscopic hemostasis. PATIENTS AND METHODS: A multicenter study was carried out in 8 Western French hospitals in 144 patients with gastrointestinal bleeding peptic from ulcer type I or IIa, b as defined by Forrest classification. Thirty four and 38 parameters were studied respectively in order to predict recurrent bleeding and death. Significant predictive factors (P < 0.1) in univariate analysis were entered in a multivariate logistic regression analysis. RESULTS: Endoscopic hemostasis was performed in 108 of 144 cases (75%). Recurrent bleeding and death occurred in 39 (28%) and 22 cases (15%), respectively. By multivariate analysis, the only predictor of rebleeding was hypovolemia at admission. Predictors of death were ASA score, cardiovascular Goldman score and recurrent bleeding. In this study, prevalence of Helicobacter pylori infection was low (41%) but was not a predictive factor. CONCLUSIONS: In a selected population of peptic ulcer bleeding patients with high risk of rebleeding, prevalence of recurrent bleeding and death remains rather high, despite routine endoscopic hemostasis. In the era of endoscopic hemostasis, clinical parameters remain the best prognostic factors of peptic ulcer bleeding outcome.

[Organ graft: indications and principle results in France]. / Greffe d'organe: indications et principaux résultats en France.

Nearly 3,000 solid organ transplantations are performed each year in France. Transplantation constitutes a major and complex treatment procedure which mostly concerns patients with terminal organ failure. The selection of patients to transplant, amongst those with potential indications for transplantation, contributes to improve the whole results of transplantation. The evaluation of transplantation deals with transplants and patients survival as well as quality of life after transplantation which may be assessed by organ function improvement, professional activity restoration or pregnancy eventuality in transplanted women.

[REIN Report 2011--summary]. / Rapport Rein 2011--Synthèse.

INCIDENT PATIENTS: In 2011, in France, we estimate that 9 400 patients started a treatment by dialysis (incidence of dialysis: 144 per million inhabitants) and 335 patients with a pre-emptive graft without previous dialysis (incidence of pre-emptive graft: 5 per million inhabitants). As in 2010, incidence rate seems to stabilize. Elders provide the majority of new patients (median age at RRT start: 71 years old). New patients present a high rate of disabilities especially diabetes (41% of the new patients) and cardiovascular disabilities (>50% of the new patients) that increase with age. Considering treatment and follow-up, the first treatment remains center's hemodialysis and we do not notice any progression of self-dialysis. RRT started in emergency in 33% of the patients. This finding contrasts with the fact that 56% of patients started hemodialysis on a catheter. This, together with the major inter-region variability, suggests that different strategies of management exist. Finally, the hemoglobin level at RRT start seems to be an interesting indicator of good management and follow-up since 13% of patients presenting an underprovided follow-up have a hemoglobin level under 10g/dl, whereas only 2.5% of patients with an appropriate follow-up presented such a condition. PREVALENT PATIENTS: On December 31, 2011, in France, we estimate that 70.700 patients were receiving a renal replacement therapy, 39.600 (56%) on dialysis and 31.100 (44%) living with a functional renal transplant. The overall crude prevalence was 1091 per million inhabitants. It was 1.6 higher in males. Prevalence was subject to regional variations with 5 regions (3 overseas) above the national rate. Renal transplant share varied from 33% in Nord-Pas de Calais to 53% in Pays de Loire, and from 16 to 25% in overseas regions. The study of temporal variations for 18 regions contributing to the registry since 2007 demonstrated a +4% increase in standardized prevalence of ESRD patients with a functional transplant vs. +2% increase for dialysis, resulting in a decreasing gap between dialysis and transplantation prevalence, due to an increase number of renal transplant and a longer survival of transplanted patients. The main dialysis technique was hemodialysis (93.3% of patients). Even if an important inter-region variability remains considering the choices of treatment, more than 50% of the patients are undergoing hemodialysis in a hospital-based incenter unit, and we noticed an increase in hemodialysis in a medical satellite unit with time whereas the rate of self-care hemodialysis decreases. The rate of peritoneal dialysis remains stable. When comparing guidelines to real-life treatments, 77.5% of patients receive adequate dose of treatment (12 H/week, KT/ V>1.2), the rate of patients with a hemoglobin blood-level lower than 10g/dl and without erythropoietin treatment is 1.3%, which confirmed a good management of anemia. On the contrary, 34% of patients have a BMI lower than 23kg/m(2) and only 23% have an albumin blood-level over 40g/l, which underlines that nutritional management of ESRD patients can be improved. MORTALITY: Age strongly influences survival on dialysis. Thus, one year survival of patients under age 65 is over 90%. After 5 years, among patients over 85 years, it is more than 15%. The presence of diabetes or one or more cardiovascular comorbidities also significantly worse patient survival. In terms of trend, we do not find significant improvement in the 2-year survival between patients in the cohort 2006-2007 and the 2008-2009 cohort. Cardiovascular diseases account for 27% of causes of death to infectious diseases (12%) and cancer (10%). Life expectancy of patients is highly dependent on their treatment. Thus, a transplant patient aged 30 has a life expectancy of 41 years versus 23 years for a dialysis patient. ESRD PEDIATRIC PATIENTS: In 2011, the incidence and the prevalence of ESRD among patients under 20 years old remained stable at 8 and 53 per million inhabitants respectively. The first causes of ESDR remain uropathies and hypodysplasia followed by glomerulonephritis and genetic diseases. Considering the initial treatment, we found a high rate of hemodialysis and a low rate of peritoneal dialysis that is mainly used in younger children. In 2011, 31 preemptive transplantations were performed accounting for 27.7% of new patients. Finally, survival analysis confirm that younger children (under 4 years old) have the highest risk of death (88% survival rate at 2 years vs. 98% in patients over 4 years old) and that the treatment of choice remains the renal transplantation since it increases the expected remaining lifetime of 20 to 40 years depending on the considered age. TRANSPLANTATION: Access to the waiting list is evaluated on a cohort of 51,846 new patients who started dialysis between 2002 and 2011 in 25 regions. The probability of first wait-listing was of 3.7% at the start of dialysis (pre-emptive registrations), 15% at 12, 22% at 36 and 24% to 60 months. Patient older than 60 had a very poor access to the waiting list, whatever their diabetes status was. Among 13,653 patients less than 60 years old, the probability of being registered was 11% at the start of dialysis, 43% to 12 months, 62% to 36 months and 66% to 60 months (median dialysis duration: 16 months). Seventeen regions with up to 5 years follow-up show an increase of 8 to 15% in pre-emptive registrations between 2007 and 2001, without change at 1 year. Access to kidney transplant is evaluated on a cohort of 53,301 new patients who started a renal replacement therapy (dialysis or pre-emptive renal transplant) between 2002 and 2011 in 25 regions. The probability of first kidney transplant was of 7% at 12, 17% at 36 and 21% at 60 months. 8,633 patients (16,2%) had received a first renal transplant within 14.7 month median time; 1,455 (2.7%) had received a pre-emptive graft. Among the 14.770 new patients less than 60 years old, the probability of being transplanted was of 21% at 12, 46% at 36 and 58% at 60 months (median dialysis duration: 42 months). When pre-emptive graft were excluded, the probability of being transplanted was of 5% at 12, 15% to 36 and 19% to 60 months FLOW BETWEEN TREATMENT MODALITIES: Among the 36.849 patients on dialysis at 31/10/2010, 79% were already on RRT at 31/12/2009. Respectively 91%, 85% and 93% of the patients on HD in-center, HD self-care unit and peritoneal dialysis were in the same modality of treatment the year before. Among the 29.758 patients with a functioning graft at 31/12/2010, 98% were already on RRT at 31/12/2009, 95% of them with a functioning graft.72%, 72% and 74% of the patients with in-center HD, out-center HD and self-care unit were in the same modality of treatment at 31/12/2011. But 37% of the patients on PD at 31/12/2010 were not on PD at 31/12/2011. In 2011, new patients represented 89% of the entries in peritoneal dialysis. Renal transplantation represented 10% of the outcomes of the HD patients in self-care unit or at home.

[The prevalence of ESRD in 2011]. / Prévalence de l'IRCT en 2011.

This chapter describes temporal and geographical variations of ESRD prevalence in France. This indicator assesses health needs of ESRD patients on dialysis or living with functional transplant. It does not include patients on conservative treatment. On December 31, 2011, 70 300 patients were receiving a renal replacement therapy in one of the 25 regions contributing to the registry, 39 200 (56%) on dialysis and 31 100 (44%) living with a functional renal transplant. The overall crude prevalence was 1091pmh. It was 1.6 higher in males. Prevalence was subject to regional variations with 5 regions (3 overseas) above the national rate. Renal transplant share varied from 33% in Nord-Pas-de-Calais to 53% in Pays de Loire, and from 16 to 25% in overseas regions. The overall sex and age standardised prevalence was 40, 567 and 483 pmh respectively for peritoneal dialysis, haemodialysis and transplantation, with marked regional variations. The study of temporal variations for 18 regions contributing to the registry since 2007 demonstrated a +4% increase in standardised prevalence of ESRD patients with a functional transplant vs +2% increase for dialysis, resulting in a decreasing gap between dialysis and transplantation prevalence, due to an increase number of renal transplant and a longer survival of transplanted patients. Such an evolution should prompt the nephrological community and health authorities to anticipate changes in the ESRD healthcare organisation and to adapt them to the regional context.

[The incidence of ESRD in 2011]. / L'incidence de l'IRCT en 2011

This chapter provides a set of indicators on incident patients with renal replacement therapy. In 2011, in 25 French regions (99% population), 9 248 patients started a treatment by dialysis (incidence of dialysis: 149 per million inhabitants) and 334 patients with a pre-emptive graft without previous dialysis (incidence of pre-emptive graft: 5 per million inhabitants). One patient among two are over 70 years old at renal replacement therapy initiation. As in 2010, incidence rate seems to stabilize.

[Access to the waiting list and renal transplantation]. / Accès à la liste d'attente et à la greffe rénale.

This chapter provides a set of indicators related to Renal Transplantation access in France. It describes patient outcomes and reports on cumulative incidence rates of wait-listing and renal transplantation according to main patient of characteristics and regions. The REIN registry integrates kidney transplant and dialysis data. It provides a comprehensive view on waiting list and renal transplantation access to the patients, nephrologists, and national or regional health authorities. Access to the waiting list is evaluated on a cohort of 51,845 new patients who started dialysis between 2002 and 2011 in 25 regions. The probability of first wait-listing was of 3.7% at the start of dialysis (pre-emptive registrations), 15% at 12, 22% at 36 and 24% to 60 months. The probability of being registered was strongly related to age, diabetes and region. Patient older than 60 had a very poor access to the waiting list, whatever their diabetes status was. Probability of first wait-listing was much lower (36.5% at 60 months) in type 2 diabetic-40 to 59 years old patients. Among 13,653 patients less than 60 years old, the probability of being registered was 11% at the start of dialysis, 43% to 12 months, 62% to 36 months and 66% to 60 months (median dialysis duration: 16 months). Seventeen regions with up to 5 years follow-up show an increase of 8 to 15% in pre-emptive registrations between 2007 and 2001, without change at 1 year. Access to kidney transplant is evaluated on a cohort of 53,301 new patients who started a renal replacement therapy (dialysis or pre-emptive renal transplant) between 2002 and 2011 in 25 regions. The probability of first kidney transplant was of 7% at 12, 17% at 36 and 21% at 60 months. 8,633 patients (16,2%) had received a first renal transplant within 14.7 month median time; 1,455 (2.7%) had received a pre-emptive graft [male: 58%, median age: 48.7y]. Among the 14,770 new patients less than 60 years old, the probability of being transplanted was of 21% at 12, 46% at 36 and 58% at 60 months (median dialysis duration: 42 months). When pre-emptive graft were excluded, the probability of being transplanted was of 5% at 12, 15% to 36 and 19% to 60 months Insofar as kidney transplant is regarded as the most efficient treatment, access to the waiting list and renal transplant are sensitive issues.