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.

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.

The impact of cat-related peritonitis on peritoneal dialysis outcomes: Results from the RDPLF.

BACKGROUND: Cat ownership is common in peritoneal dialysis (PD) patients, even with recent guidelines recommending avoiding domestic animals during PD exchanges to limit the risk of peritonitis due to pet contamination. We analysed the outcomes of patients who experienced cat-related peritonitis compared with those who experienced peritonitis due to other causes. METHODS: This retrospective study based on the Registre de Dialyse Peritoneale de Langue Française data analysed the outcomes of 52 patients experiencing cat-related peritonitis from the beginning of the database (1986) until 21 June 2022 compared with those of 208 matched patients experiencing peritonitis due to other causes. A Cox regression model examined the association between cat-related peritonitis and the composite end point of death in PD or transfer to haemodialysis (HD), death in PD and transfer to HD. RESULTS: Among patients with an episode of cat-related peritonitis, 11 (21.1%) died, 19 (36.5%) were transferred to HD and 11 (21.1%) were transplanted. In the group with other causes of peritonitis, these numbers were 67 (32%), 81 (39%) and 26 (12.5%), respectively. In multivariate survival analysis, age (hazard ratio (HR): 1.39; 95% confidence interval (CI): 1.13-1.70) and use of assisted PD (HR: 4.07; 95% CI: 2.11-7.86) were associated with the risk of death. Having experienced cat-related peritonitis was not significantly associated with any of the three outcomes (death, transfer to HD or PD cessation). CONCLUSIONS: Patients on PD should be aware that cats may cause a peritoneal infection, which results in similar consequences to those of other causes of peritonitis. However, pets at home should not be considered a contraindication to PD.

How to deal with missing data? Multiple imputation by chained equations: recommendations and explanations for clinical practice / Comment gérer les données manquantes ? Imputation multiple par équations chaînées : recommandations et explications pour la pratique clinique

The presence of missing data, a constant problem in medical research, has several consequences: systematic loss of power, associated or not with a reduction in the representativeness of the sample analyzed. There are three types of missing data: 1) missing completely at random (MCAR); 2) missing at random (MAR); 3) missing not at random (MNAR). Multiple imputation by chained equations allows for the correct handling of missing data under the MCAR and MAR assumptions. It allows to simulate for each missing data j, a number m of simulated values which seem plausible with regard to the other variables. A random effect is included in this simulation to express the uncertainty. Several data sets are thus created and analyzed individually, in an identical way. Then the estimators of each data set are combined to obtain a global estimator. Multiple imputation increases power, corrects for some biases and has the advantage of being applicable to many types of variables. Complete case analysis should no longer be the norm. The objective of this guide is to help the reader in conducting an analysis with multiple imputed data. We cover the following points: the different types of missing data, the different historical approaches to handling them, and then we detail the multiple imputation method using chained equations. We provide a code example for the mice package of R®.

La présence de données manquantes, problème constant en recherche médicale, a plusieurs conséquences : une perte de puissance systématique, associée ou non à une diminution de la représentativité de l'échantillon analysé. Il existe trois types de données manquantes : 1) manquantes complètement au hasard (MCAR - missing completely at random) ; 2) manquantes au hasard (MAR - missing at random) ; 3) manquantes non au hasard (MNAR - missing not at random). L'imputation multiple par équations chaînées permet de prendre en charge correctement les données manquantes sous les hypothèses MCAR et MAR. Elle permet de simuler pour chaque donnée manquante j, un nombre m de valeurs simulées qui semblent plausibles au regard des autres variables. Un effet aléatoire est inclus dans cette simulation pour exprimer l'incertitude. Plusieurs jeux de données sont ainsi créés et analysés individuellement de façon identique. Ensuite, les estimateurs de chaque jeu de données sont regroupés pour obtenir un estimateur global. L'imputation multiple permet d'augmenter la puissance, de corriger certains biais et a l'avantage d'être applicable à de très nombreux types de variables. L'analyse en cas complets ne devrait plus être la norme. L'objectif de ce guide est d'aider le lecteur dans la réalisation d'une analyse avec des données imputées de manière multiple. Nous traitons ici les différents types de données manquantes, les approches historiques pour les gérer, puis nous détaillons la méthode d'imputation multiple par équations chaînées. Nous fournissons un exemple de code pour le package mice de R®.

From transfer to transition: review and proposition of the SFNDT dialysis Commission / Du transfert à la transition : mise au point et proposition de la Commission de dialyse de la SFNDT

Over the course of their disease, patients with chronic kidney disease (CKD) will be treated by several kidney replacement therapy (KRT) modalities. The transitions between KRT modalities can be experienced as traumatic by patients, and are associated with an increased morbidity and mortality, notably when they are not anticipated. Planning these transition phases could reduce the psychological trauma induced by the transfer, as well as reduce the risk of morbidity and mortality. However, the lack of a clear definition of a transfer, and the lack of criteria enabling the identification of patients at risk of transfer, prevents the anticipation of these transition phases at high risk for patients. We here discuss the various possible causes and risk factors of transfer from peritoneal dialysis (PD) to hemodialysis as well as transfer from hemodialysis to PD. The dialysis Commission of the Société francophone de néphrologie, dialyse et transplantation (SFNDT) makes some proposals to improve transition phases, such as the identification of patients at risk, specific PD programs for unplanned PD start, transition unit and hybrid therapy.

Dans le parcours de soins du patient insuffisant rénal chronique, les différentes modalités de suppléance rénale vont se succéder dans le temps créant ainsi des phases de transition. Ces phases de transition peuvent être vécues comme traumatisantes par les patients, et sont associées à une augmentation de la morbi-mortalité, particulièrement lorsqu'elles ne sont pas suffisamment anticipées. La planification de ces phases de transition par l'équipe de dialyse devrait permettre de diminuer l'expérience du traumatisme psychologique induit par le changement et de réduire le risque de sur-morbi-mortalité. Cependant, l'absence de définition standardisée de la phase de transition entre modalités, le manque de critères et d'outils identifiant les patients à risque de transfert et l'absence d'infrastructures dédiées à ces patients transitionnels sont autant de facteurs limitant l'anticipation de ces phases de transition. Nous abordons ici les différentes causes et possibles facteurs de risque du transfert de la dialyse péritonéale (DP) vers l'hémodialyse ainsi que du transfert de l'hémodialyse vers la DP. Dans cette mise au point, la Commission de dialyse de la Société francophone de néphrologie, dialyse et transplantation (SFNDT) émet certaines propositions pour améliorer la définition et la prise en charge de ces phases de transition, et propose des outils d'identification des sujets « transitionnels ¼ ainsi que des exemples structurels de programmes soutenant la transition, tels que le démarrage en urgence de la DP, l'unité transitionnelle et la dialyse hybride.

Transitions between dialysis modalities.

Thanks to the progress of dialysis, survival of patients with end-stage renal disease is increasing. For those patients who cannot benefit from a kidney transplantation, several dialysis alternatives exist, but the transition between dialysis techniques may be difficult. Home dialysis offers many advantages but requires personal commitment from the patients and the caregivers. How can we ensure smooth transitioning to the best dialysis technique at the right time for the right person? One of the main caveats of peritoneal dialysis is its limited technique survival, however, it combines the advantages of preserving residual kidney function, avoiding the need for a vascular access, or preserving it, when present, while providing good cost-effectiveness. On the other hand, home hemodialysis has excellent long-term technique survival. The home integrated model of peritoneal dialysis followed by home hemodialysis has been described as the ideal pathway of care. Eventually, in-center hemodialysis can be provided according to several schedules to adapt to the needs of the patients. The issue of technique survival and the possible need to switch to another technique should be part of the initial discussion, when the patient needs to choose the first dialysis modality. Unplanned transfers are associated with poor outcomes and unwanted shifts to in-center hemodialysis. Therefore, transfers from home-based techniques should be anticipated as much as possible in order to establish a shared decision modality process and to choose the desired new modality. Dialysis units dedicated to "transition care" should answer the needs of patients and smooth the transition process between dialysis modalities.

Switch from Hemodialysis to Peritoneal Dialysis: Does the Time Spent on Hemodialysis Impact Outcomes in Peritoneal Dialysis?

INTRODUCTION: Switch from hemodialysis (HD) to peritoneal dialysis (PD) is unfrequent, but incentive strategies to perform PD can lead to an increase of these transitions. However, data on transitioning from HD to PD are scarce. We hypothesized that time spent on HD before transfer to PD would impact PD outcomes. METHODS: This registry-based, nationwide study analyzed patients transferred from HD to PD. Patients who began HD between January 2008 and December 2016 were included. Cox and Fine and Gray regression models were used to explore the relationship between time spent on HD before PD and outcomes in PD: PD cessation for death or retransfer to HD (composite endpoint); for death; and for retransfer to HD. RESULTS: Over the study period, 1,985 of the 77,587 HD starters (3%) were transferred to PD. The median time spent on HD before transfer to PD was 1.94 months (interquartile range [IQR] 1.02-4.01). The median survival time on PD after this transition was 20 months (IQR 18-21). Time spent on HD before PD was associated with increased risk of death or retransfer to HD (cause-specific hazard ratio [cs-HR] 1.01, 95% confidence interval [CI]: 1-1.02 for a 1-month increase) and death (cs-HR 1.02, 95% CI: 1.01-1.03) but not with retransfer to HD censored on death (cs-HR 1.00, 95% CI: 0.99-1.01). The results were similar when considering competing events. DISCUSSION/CONCLUSION: Switch from HD to PD is rare in France. Time spent on HD before transfer is associated with patient survival but not with retransfer to HD.

Impact of assistance on peritonitis due to breach in aseptic procedure in diabetic patients: A cohort study with the RDPLF data.

BACKGROUND: Diabetic patients often have physical impairment that could lead to manipulation errors in peritoneal dialysis (PD) and touch contamination. Nurse assistance in diabetic PD patients is known to help prevent peritonitis. We made the hypothesis that this lower risk of peritonitis was observed thanks to prevention of breach in aseptic procedure. We evaluated the impact of nurse-assisted PD on specific causes of peritonitis, especially on peritonitis due to a breach in aseptic procedure. METHODS: This was a retrospective observational study of the data from the French Language Peritoneal Dialysis Registry. All diabetic patients older than age 18 years starting PD in France between 1 January 2012 and 31 December 2015 were included in the study. The event of interest was the first peritonitis event due to a breach in aseptic procedure. Death, kidney transplantation and peritonitis due to another mechanism were considered as competing events. We examined the association of the covariates with all the possible outcomes using a subdistribution hazard model developed for survival analysis in the presence of competing risks. RESULTS: Four thousand one hundred one diabetic patients incident in PD were included in the study. At least one peritonitis event occurred in 1611 patients over the study period. A breach in aseptic procedure was reported in 441/1611 cases (27.3%): 209/575 (36.3%) in the self-care PD group, 56/217 (25.8%) in the family-assisted PD group and 176/819 (21.5%) in the nurse-assisted PD group. Both nurse and family assistance were associated with a lower risk of peritonitis due to breach in aseptic procedure in bivariate analysis. After adjustment on age, modified Charlson index, sex and diabetic nephropathy, patients treated by nurse-assisted PD (subdistribution hazard ratio (sd-HR) 0.52, 95% confidence interval (CI) 0.40-0.67) and those treated by family-assisted PD (sd-HR 0.70, 95% CI 0.51-0.95) had a lower likelihood of peritonitis due to a connection error compared to self-care PD in multivariate analysis. The modality of assistance was not associated with other causes of peritonitis in the multivariate analysis. CONCLUSION: While both nurse-assisted PD and family-assisted PD were associated with lower risk of peritonitis due to a breach in aseptic procedure compared to self-care PD in our study, the protective effect was greater with nurse assistance.

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.

Health literacy level in a various nephrology population from Québec: predialysis clinic, in-centre hemodialysis and home dialysis; a transversal monocentric observational study.

BACKGROUND: Health literacy refers to the ability of individuals to gain access to, use, and understand health information and services in order to maintain a good health. It is especially important in nephrology due to the complexity of chronic kidney disease (CKD). The present study sought to define health literacy levels in patients followed in predialysis clinic, in-center dialysis (ICHD), peritoneal dialysis (PD) and home hemodialysis (HHD). METHODS: This transversal monocentric observational study analysed 363 patients between October 2016 and April 2017. The Brief Health Literacy Screen (BHLS) and the Health Literacy Questionnaire (HLQ) were used to measure health literacy. Multivariate linear regressions were used to compare the mean scores on the BHLS and HLQ, across the four groups. RESULTS: Patients on PD had a significantly higher BHLS'score than patients on ICHD (p = 0.04). HLQ's scores differed across the groups: patients on HHD (p = 0.01) and PD (p = 0.002) were more likely to feel understood by their healthcare providers. Compared to ICHD, patients on HHD were more likely to have sufficient information to manage their health (p = 0.02), and patients in the predialysis clinic were more likely to report high abilities for health information appraisal (p < 0.001). CONCLUSION: In a monocentric study, there is a significant proportion of CKD patients, especially in predialysis clinic and in-centre hemodialysis, with limited health literacy. Patients on home dialysis (HHD and PD) had a higher level of health literacy compared to the other groups.

Trends in Peritoneal Dialysis Technique Survival, Death, and Transfer to Hemodialysis: A Decade of Data from the RDPLF.

INTRODUCTION: There is limited information on the trends of peritoneal dialysis (PD) technique survival over time. This study aimed to estimate the effect of calendar time on technique survival, transfer to hemodialysis (HD) (and the individual causes of transfer), and patient survival. METHODS: This retrospective, multicenter study, based on data from the French Language Peritoneal Dialysis Registry, analyzed 14,673 patients who initiated PD in France between January 1, 2005, and December 31, 2016. Adjusted Cox regressions with robust variance were used to examine the probability of a composite end point of either death or transfer to HD, death, and transfer to HD, accounting for the nonlinear impact of PD start time. RESULTS: There were 10,201 (69.5%) cases of PD cessation over the study period: 5,495 (37.4%) deaths and 4,706 (32.1%) transfers to HD. The rate of PD cessation due to death or transfer to HD decreased over time (PR 0.96, 95% CI: 0.95-0.97). Compared to 2009-2010, starting PD between 2005 and 2008 or 2011 and 2016 was strongly associated with a lower rate of transfer to HD (PR 0.88, 95% CI: 0.81-0.96, and PR 0.91, 95% CI: 0.84-0.99, respectively), mostly due to a decline in the rate of infection-related transfers to HD (PR 0.96, 95% CI: 0.94-0.98). CONCLUSIONS: Rates of the composite end point of either death or transfer to HD, death, and transfer to HD have decreased in recent decades. The decline in transfers to HD rates, observed since 2011, is mainly the result of a significant decline in infection-related transfers.

Assisted peritoneal dialysis and transfer to haemodialysis: a cause-specific analysis with data from the RDPLF.

BACKGROUND: Technique failure, defined as death or transfer to haemodialysis (HD), is a major concern in peritoneal dialysis (PD). Nurse-assisted PD is globally associated with a lower risk of transfer to HD. We aimed to evaluate the association between assisted PD and the risk of the different causes of transfer to HD. METHODS: This was a retrospective study using data from the French Language PD Registry of patients on incident PD from 2006 to 2015. The association between the use of assisted PD and the causes of transfer to HD was evaluated using survival analysis with competing events in unmatched and propensity score-matched cohorts. RESULTS: The study included 11 093 incident PD patients treated in 123 French PD units. There were 4273 deaths, 3330 transfers to HD and 2210 renal transplantations. The causes of transfer to HD were inadequate dialysis (1283), infection (524), catheter-related problems (334), social issues (250), other causes linked to PD (422), other causes not linked to PD (481) and encapsulating peritoneal sclerosis (6). Nurse-assisted PD patients were older and more comorbid. Assistance by nurse was associated with a higher risk of death [cause-specific hazard ratio (cs-HR) 2.49, 95% confidence interval (CI) 2.26-2.74], but with a lower risk of transfer to HD [subdistributionHR (sd-HR) 0.68, 95% CI 0.62-0.76], especially due to inadequate dialysis (cs-HR 0.83, 95% CI 0.75-0). CONCLUSIONS: The lower risk of transfer to HD associated with nurse assistance should encourage decision makers to launch reimbursement programmes in countries where it is not available.

Hand function assessment in peritoneal dialysis patient: a pilot study.

BACKGROUND: There is variability among centres regarding the utilization of assisted peritoneal dialysis (PD). Functional impairment is one of the leading causes of assisted PD. Tools to assess the patient's ability to manipulate PD devices are required. The objective of this study was to evaluate the feasibility of hand function evaluation in PD patients and to test the association between hand function estimation and assisted PD. METHODS: This was a pilot study of adults treated with PD in a dialysis unit in January 2019. Hand function was evaluated by Purdue Pegboard, Jebsen, Jamar and pinch tests. Relative risks were calculated with a Cox model to evaluate the association between each test and assisted PD. RESULTS: Among the 43 PD patients included, 16 were autonomous and 27 were assisted in performing dialysis. The Jebsen and Purdue Pegboard tests were completed by 41 patients (95.3%). All patients succeeded in performing the Jamar and pinch tests. The median time to complete all tests was 22 min. After adjustment based on the Charlson comorbidity index, the assembly test of the Purdue Pegboard (RR 0.92 [95% confidence interval (CI) 0.86-0.98]), total Jebsen (RR 1.01 [95% CI 1.00-1.01]) and Jamar test (RR 0.94 [95% CI 0.90-0.99] with the dominant hand; OR 0.94 [95% CI 0.88-0.98] with the non-dominant hand) scores were associated with assisted PD. CONCLUSION: The evaluation of hand function of PD patients is feasible in daily practice using the Jebsen, Purdue Pegboard, pinch and Jamar tests and may support choosing the appropriate utilization of assisted PD.

Effects of Social Deprivation on the Proportion of Preemptive Kidney Transplantation: A Mediation Analysis.

Social inequalities in health lead to an increased risk of chronic kidney disease and less access to renal transplantation. The objective of this study was to assess the association between social deprivation estimated by the fifth quintile of the European Deprivation Index (EDI) and preemptive kidney transplantation (PKT) and to explore the potential mediators of this association. Methods: This retrospective observational multicenter study included 8701 patients who received their first renal transplant in France between 2010 and 2014. Mediation analyses were performed to assess the direct and indirect effects of the EDI on PKT. Results: Among the 8701 transplant recipients, 32.4% belonged to the most deprived quintile of the EDI (quintile 5) and 16% received a PKT (performed either with a deceased- or living-donor). There was a significant association between quintile 5 of the EDI and PKT (total effect: odds ratio [OR]: 0.64 [95% confidence interval (CI): 0.55-0.73]). Living-donor kidney transplantation was the main mediator of this association (natural indirect effect: OR: 0.92 [0.89-0.95]). To a lesser extent, positive cytomegalovirus and hepatitis C serologies and blood group B were also mediators (respective natural indirect effects: OR: 0.98 [95% CI: 0.95-1.00], OR: 0.99 [95% CI: 0.99-1.00], and OR: 0.99 [95% CI: 0.98-1.00], P < 0.05). Conclusions: Our study suggests that social deprivation is associated with a decreased proportion of PKT. This association might be mitigated by promoting living-donor transplantation.

Paternity in male kidney transplant recipients: a French national survey, the PATeRNAL study.

BACKGROUND: There is concern about the impact of immunosuppressive agents taken by male kidney transplant (KT) recipients on the risk of foetal malformations. The aim of our survey was to estimate the paternity rate and the outcomes of pregnancies fathered by kidney transplanted males. METHODS: This survey analysed 1332 male KT recipients older than 18 years, followed in 13 centres in France. A self-reported questionnaire was used to collect data on the patients, treatments at the time of conception and the pregnancy outcomes. RESULTS: The study included data on 349 children from 404 pregnancies fathered by 232 male KT recipients. The paternity rate was 17% (95% CI [15-20]). There were 37 (9%, 95% CI [7-12]) spontaneous abortions, 12 (3%, 95% CI [2-5]) therapeutic abortions, 2 (0.5%, 95% CI [0.1-1]) still births, and 13 (4%, 95% CI [2-6]) malformations reported. Compared to the general population, there was no difference in the proportion of congenital malformations nor unwanted outcomes whether the father was exposed or not to immunosuppressive agents. CONCLUSIONS: This survey does not provide any warning signal that pregnancies fathered by male patients exposed to immunosuppressive agents, notably the debated MMF/MPA, have more complications than pregnancies in the general population.

Effects of educational practices on the peritonitis risk in peritoneal dialysis: a retrospective cohort study with data from the French peritoneal Dialysis registry (RDPLF).

BACKGROUND: Peritoneal dialysis (PD) is a home-based therapy performed by patients or their relatives in numerous cases, and the role of patients' educational practices in the risk of peritonitis is not well assessed. Our aim was to evaluate the effect of PD learning methods on the risk of peritonitis. METHODS: This was a retrospective multicentric study based on data from a French registry. All incident adults assisted by family or autonomous for PD exchanges in France between 2012 and 2015 were included. The event of interest was the occurrence of peritonitis. Cox and hurdle regression models were used for statistical analysis to asses for the survival free of peritonitis, and the risk of first and subsequent peritonitis. RESULTS: 1035 patients were included. 967 (93%) received education from a specialized nurse. Written support was used for the PD learning in 907 (87%) patients, audio support in 221 (21%) patients, and an evaluation grid was used to assess the comprehension in 625 (60%) patients. In the "zero" part of the hurdle model, the use of a written support and starting PD learning with hands-on training alone were associated with a lower survival free of peritonitis (respectively HR 1.59, 95%CI 1.01-2.5 and HR 1.94, 95%CI 1.08-3.49), whereas in the "count" part, the use of an audio support and starting of PD learning with hands-on training in combination with theory were associated with a lower risk of presenting further episodes of peritonitis after a first episode (respectively HR 0.55, 95%CI 0.31-0.98 and HR 0.57, 95%CI 0.33-0.96). CONCLUSIONS: The various PD education modalities were associated with differences in the risk of peritonitis. Prospective randomized trials are necessary to confirm causal effect. Caregivers should assess the patient's preferred learning style and their literacy level and adjust the PD learning method to each individual.

Impact of the implementation of an assisted peritoneal dialysis service on peritoneal dialysis initiation.

BACKGROUND: There is limited information available on the impact that provision of an assisted peritoneal dialysis (PD) service has on the initiation of PD. The aim of this study was to assess this impact in a centre following initiation of assisted PD in 2011. METHODS: This retrospective, single-centre study analysed 1576 patients incident to renal replacement therapies (RRTs) between January 2002 and 2017. Adjusted Cox regression with a time-varying explanatory variable and a Fine and Gray model were used to examine the effect of assisted PD use on the rates and cumulative incidence of PD initiation, accounting for the non-linear impact of RRT starting time and the competing risks (transplant and death). RESULTS: Patients starting PD with assistance were older than those starting unassisted: median (interquartile range): 70.0 (61.5-78.3) versus 58.7 (43.8-69.2) years old, respectively. In the adjusted analysis assisted PD service availability was associated with an increased rate of PD initiation [cause-specific hazard ratio (cs-HR) 1.78, 95% confidence interval 1.21-2.61]. During the study period, the rate of starting PD fell before flattening out. Transplantation and death rates increased over time but this did not affect the fall in PD initiation [for each year in the study cs-HR of starting PD 0.95 (0.93-0.98), sub-distribution HR 0.95 (0.94-0.97)]. CONCLUSIONS: In a single-centre study, introducing an assisted PD service significantly increased the rate of PD initiation, benefitting older patients most. This offsets a fall in PD usage over time, which was not explained by changes in transplantation or death.

[How to manage abdominal hernia on peritoneal dialysis?] / Comment prendre en charge une hernie abdominale en dialyse péritonéale ?

Abdominal hernias are a frequent complication in peritoneal dialysis, representing up to 60.4% of anatomical complications. Their prevalence varies between 7 and 27.5%. Established risk factors are male gender, an older age, multiparity, a low body mass index and a paramedian approach for the catheter insertion. Polykystic renal disease and the intra-peritoneal volume are controversial risk factors. The diagnosis is mainly clinical, though peritoneography imaging can be useful in difficult cases. Hernia's complications, of strangulation, incarceration, bowel occlusion and peritonitis; can be very serious, leading to technique failure and may result in death. The complication risk varies from 4 to 20% in the literature review. There are no guidelines regarding hernia's prevention or treatment. A surgical repair is recommended, by implementing a synthetic prothesis with an inguinal approach for inguinal and femoral hernias, with a simple stitch or a bioprothesis for ombilical hernias. The management of peritoneal dialysis after hernia repair is not codified. After an initial 48h interruption, an intermittent peritoneal dialysis program using low volume seems efficient at low risk, preventing a temporary transfer to haemodialysis.

[Nephropathy associated with hypocomplementemic urticarial vasculitis: A case report and literature review]. / Néphropathie associée à une vascularite urticarienne hypocomplémentémique : présentation d'un cas clinique et revue de la littérature.

Hypocomplementemic urticarial vasculitis is a rare systemic vasculitis, affecting small vessels, characterised by chronicle urticaria, hypocomplementemia, and systemic manifestations. Renal involvement, whose prevalence varies between 9% and 60%, is mainly glomerular. We here report the case of a 59 years old woman presenting kidney failure, associated with chronicle urticaria and arthralgias. Laboratory investigation showed haematuria, proteinuria, hypocomplementemia and anti-SSa antibody positivity. A percutaneous kidney biopsy revealed focal and segmental glomerulonephritis associated with an acute interstitial nephritis. Hypocomplementemic urticarial vasculitis diagnosis was established after identifying anti-C1q antibodies. The lack of a dry syndrome, the negativity of a Schirmer test and the lack of sialadenitis on a salivary gland biopsy excluded an associated Gougerot-Sjögren Syndrome. The patient was treated with hydroxychloroquine and low-dose steroids, enabling a clinical and biological recovery. Of the 82 cases in the literature describing hypocomplementemic urticarial vasculitis associated nephropathies, 72 (88%) were a glomerular impairment, most frequently secondary to membranoproliferative glomerulonephritis. Only 6 (7%) tubulo-interstitial nephritis have been reported, 4 of them being associated with a glomerulonephritis. Patients were more likely to be women, aged in their third decade. The most frequent renal manifestations were haematuria (60%), and proteinuria (52%). Kidney failure was rarely observed (22%), with a fairly good renal prognosis. Hypocomplementemic urticarial vasculitis was associated with a systemic disease in 11 (13%) patients. In the absence of recommendations, the treatment strategy remains to be defined.