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.

Spice-drug interactions: a case report on the use of turmeric, curry and ginger in a renal transplant patient on tacrolimus.

Tacrolimus is a widely used immunosuppressant for the prevention of rejection after transplantation. In vitro studies suggest that interactions exist between spices and tacrolimus. We present the case of a renal transplant patient aged around 70 years who was treated with prednisone, mycophenolate-mofetil and tacrolimus. The patient had a pre-transplant dietary habit of consuming foods spiced with turmeric, curry and ginger. The following protocol was implemented in parallel with close monitoring of plasma tacrolimus concentrations: administration of 10 g/day of turmeric for 4 days, then 10 g/day of curry for 4 days and then 10 g/day of ginger for 4 days. No change in tacrolimus plasma concentrations during and after the implementation of the protocol was observed. The impact of turmeric, curry and ginger on plasma tacrolimus concentrations seems negligible in vivo although further studies are needed. A shared decision to test the impact of spice consumption in a patient with dietary habits involving these spices seems reasonable.

Fate of discarded kidney transplants: experience of the transplant university hospital center of Rennes / Devenir des greffons rénaux refusés : expérience du centre de transplantation du CHU de Rennes

Introduction: In a context of tension on the number of available kidney transplants compared to the number needed, the practices of refusal of transplants in the Rennes transplantation center were evaluated. Materials and methods: The donors completely refused by our team (no kidney accepted for any Rennes recipient) between January 1st 2012 and December 31st 2015 were identified from the national CRISTAL registry. The outcome of these refused transplants (possible transplantation in another center), the data of the recipients (from Rennes and other centers) and the data of the donors (refused and then finally accepted) were extracted. The outcome of recipients (from Rennes and other centers) was compared: graft survival (censored on death) and patient survival (not censored on cessation of function). The Kidney Donor Profile Index (KDPI) score was calculated and its usefulness studied. Results: Among the 203 rejected donors, 172 (85 %) were accepted for transplantation in another center; 89% of these grafts were functional at one year. In univariate analysis, Rennes recipients transplanted after a refusal had a better graft survival (censored on death) than recipients transplanted in another center with the refused graft (p < 0.001). The main limitation of this analysis is the non-comparability of the groups. The KDPI score was significantly associated with graft survival (censored on death). Of the 151 Rennes patients who had a refusal, 3% were still on the waiting list at the end of the observation period, the others spent a median additional time on dialysis of 220 days (Q1-Q3 81-483). Conclusion: Rennes recipients transplanted after a first refusal seem to have a better graft survival (censored on death) than recipients from other centers transplanted with refused grafts. This is to be weighed against the additional time on dialysis and even the risk of non-transplantation.

Introduction: Dans un contexte de tension sur le nombre de greffons rénaux disponibles comparé au nombre nécessaire, les pratiques de refus des greffons du centre de transplantation rennais ont été évaluées. Matériels et méthodes: À partir du registre national CRISTAL, les donneurs complètement refusés par notre équipe (aucun rein accepté pour aucun receveur rennais) entre le 1er janvier 2012 et le 31 décembre 2015 ont été identifiés. Le devenir de ces greffons refusés (éventuelle greffe dans un autre centre), les données des receveurs (rennais et des autres centres) et les données des donneurs (refusés puis finalement acceptés) ont été extraits. Le devenir des receveurs (rennais et des autres centres) a été comparé : survie du greffon (censurée sur le décès) et du patient (non censurée sur l'arrêt de fonction). Le score KDPI (Kidney Donor Profile Index) a été calculé et son intérêt étudié. Résultats: Parmi les 203 donneurs refusés, 172 (85 %) ont permis une transplantation dans un autre centre, dont 89 % de greffons fonctionnels à un an. En analyse univariée, les receveurs rennais greffés après un refus avaient une meilleure survie greffon (censurée sur le décès) que les receveurs greffés dans un autre centre avec le greffon refusé (p < 0,001). La principale limite de cette analyse est la non-comparabilité des groupes. Le score KDPI était significativement associé à la survie greffon (censurée sur le décès). Parmi les 151 patients rennais qui ont eu un refus, 3 % étaient toujours sur liste d'attente à l'issue de la période d'observation, les autres passaient un temps médian supplémentaire en dialyse de 220 jours (Q1-Q3 81-483). Conclusion: Les receveurs rennais greffés après un premier refus semblent avoir une meilleure survie du greffon (censurée sur le décès) que les receveurs des autres centres greffés avec les greffons refusés. C'est à mettre en balance avec le temps supplémentaire en dialyse, voire le risque de non-greffe.

[Prevalence of iron deficiency in patients with non-dialysis chronic kidney disease: The CARENFER national, multicentre, observational study]. / Prévalence de la carence martiale dans une population de patients insuffisants rénaux chroniques non dialysés : étude nationale multicentrique observationnelle CARENFER.

INTRODUCTION: Iron deficiency is common and associated with worse outcomes in patients with non-dialysis chronic kidney disease. We performed a national, multicentre, observational and transversal study to assess the prevalence of iron deficiency as well as current iron deficiency screening practices in this population. PATIENTS AND METHODS: A total of 25 nephrology centres in France participated in the study. All adult non-dialysis chronic kidney disease patients who met the inclusion (GFR>15mL/min/1.73m2) and exclusion criteria and provided consent were systematically recruited over a 4-week inclusion period. Investigators were asked to perform a blood test (hemoglobin concentration, serum iron, serum ferritin and transferrin saturation) and to complete a questionnaire about their iron status monitoring practices. The primary objective was to assess the prevalence of iron deficiency (serum ferritin<100µg/L and/or transferrin saturation<20%). Secondary objectives were to evaluate the prevalence of absolute iron deficiency (serum ferritin<100µg/L and transferrin saturation<20%) and functional iron deficiency (serum ferritin≥100µg/L and transferrin saturation<20%), the prevalence of iron deficiency according to haemoglobin concentration and chronic kidney disease stage, the proportion of centres that perform routine evaluation of iron status and the number of patients receiving iron supplementation. RESULTS: A total of 1211 patients with non-dialysis chronic kidney disease were included in the analysis. The overall prevalence of iron deficiency was 47.1%. The rates of absolute iron deficiency and functional iron deficiency and anaemia were 13.4% and 17.1%, respectively. Among the 25 participating centres, 12 reported routine assessment of iron status in non-dialysis chronic kidney disease patients. CONCLUSION: In this observational study, a high prevalence of iron deficiency was observed among non-dialysis chronic kidney disease patients. Less than half of participating centres reported routine assessment of iron status.

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.

From tuberous sclerosis complex to end stage renal disease: who are these patients?

In patients with tuberous sclerosis complex (TSC), renal complications are not limited to bleeding angiomyolipoma (AML); although rare, end-stage renal disease (ESRD) may occur. New treatments (e.g., mammalian target of rapamycin (m-Tor) inhibitors) for AML might influence the epidemiology of ESRD in patients with TSC. In France, 99 patients with TSC from the Renal Epidemiology and Information Network (REIN) registry and having undergone renal replacement therapy (RRT) between 2002 and 2016 were included in the present study. Additional data were collected from the patients' medical charts. The mean ± standard deviation age at RRT initiation was 48.4 ± 16.4 and 73.8% had a neurologic impairment. Fifty-four patients underwent kidney transplantation after an average of 23 ± 12.3 months on dialysis. Among the 61 patients with additional data the most common renal lesion was AML: 26.2% of the patients had isolated AML, and 26.2% had AML and renal cysts, 65.6% of patients had undergone nephrectomy, and 16.4% had undergone at least one embolization. None of the patients had been treated with an m-Tor inhibitor before dialysis. The graft survival rate was 92.5% at 5 years and 70.2% at 10 years. The present cohort study is the first to have assessed TSC patients on RRT from a national registry. Nephrectomy or embolization due to AML was the leading cause of ESRD in our cohort. By reducing the size of the AML, m-tor inhibitors might lower the risk of complications and thus reduce the number of patients with TSC requiring RRT.

Cardiac remodelling in secondary tricuspid regurgitation: Should we look beyond the tricuspid annulus diameter?

BACKGROUND: A better understanding of the mechanism of tricuspid regurgitation severity would help to improve the management of this disease. AIM: We sought to characterize the determinants of isolated secondary tricuspid regurgitation severity in patients with preserved left ventricular ejection fraction. METHODS: This was a prospective observational multicentre study. Patients with severe tricuspid regurgitation were asked to participate in a registry that required a control echocardiogram after optimization of medical treatment and a follow-up. Patients had to have at least mild secondary tricuspid regurgitation when clinically stable, and were classified according to five grades of tricuspid regurgitation severity, based on effective regurgitant orifice area. RESULTS: One hundred patients with tricuspid regurgitation (12 mild, 31 moderate, 18 severe, 17 massive and 22 torrential) were enrolled. Right atrial indexed volume and tethering area were statistically associated with the degree of tricuspid regurgitation (P<0.001 and P=0.005, respectively). When the tricuspid annular diameter was≥50mm, the probability of having severe tricuspid regurgitation or a higher grade was>70%. For an increase of 10mL/m2 in right atrial volume, the effective regurgitant orifice area increased by 4.2mm2, and for an increase of 0.1cm2 in the tethering area, the effective regurgitant orifice area increased by 2.35mm2. The degree of right ventricular dilation and changes in tricuspid morphology were significantly related to tricuspid regurgitation severity class (P<0.001). No significant difference in right ventricular function variables was observed between the tricuspid regurgitation classes. CONCLUSIONS: For tricuspid regurgitation to be severe or torrential, both right atrial dilatation and leaflet tethering are needed. Interestingly, right cavities dilated progressively with tricuspid regurgitation severity, without joint degradation of right ventricular systolic function variables.

[Who are these patients on dialysis and not on the kidney transplant waiting list?] / Qui sont ces patients en dialyse non inscrits sur liste d'attente de greffe rénale ?

Access to kidney transplants for patients with end-stage chronic renal disease is a major challenge in France. Registration on the transplant waiting list is a mandatory step to be able to access this technique. The Haute Autorité de santé (HAS) updated, in 2015, the contraindications to access this list. In this context, we wanted to make an inventory of the reasons for non-registration on the renal transplant waiting list in patients on dialysis for at least a year, aged less than 80 years, in France. All patients included in the Epidemiology and Nephrology Information Register (REIN), who were supposed to have their annual monitoring point from August 1 to November 30, 2016 meeting the criteria, were included and a dedicated questionnaire was completed by their dialysis center. Thus, 3172 patients were analyzed: 2302 (73%) had a medical contraindication to transplant, most often (33%) vascular, 458 (14%) refused to be registered, with proportionately more women in this category, and finally in 412 patients (13%), there was no reason given in our questionnaire. However, for 65% of patients in the latter category, an assessment for registration had started. There were therefore, in our cohort, only 144 patients (4.5%) without explanation for the non-registration. This national study is the first to give a view of the reasons for non-registration on the renal transplant list in France. Unsurprisingly, medical contraindication is the primary reason in this population of chronic patients. The high refusal rate should be emphasized and analyzed more precisely, in particular with the patient's point of view. And finally, very few patients have no informed reason or current assessment.