Kidney Transplantation in Patients With AA Amyloidosis: Outcomes in a French Multicenter Cohort.

RATIONALE & OBJECTIVE: Outcomes of kidney transplantation for patients with renal AA amyloidosis are uncertain, with reports of poor survival and high rates of disease recurrence. However, the data are inconclusive and mostly based on studies from the early 2000s and earlier. STUDY DESIGN: Retrospective multicenter cohort study. SETTING & PARTICIPANTS: We searched the French national transplant database to identify all patients with renal AA amyloidosis who underwent kidney transplantation between 2008 and 2018. EXPOSURES: Age, cause of amyloidosis, use of biotherapies, and C-reactive protein levels. OUTCOMES: Outcomes were all-cause mortality and allograft loss. We also reported amyloidosis allograft recurrence, occurrence of acute rejection episodes, as well as infectious, cardiovascular, and neoplastic disease events. ANALYTICAL APPROACH: Kaplan-Meier estimator for mortality and cumulative incidence function method for allograft loss. Factors associated with patient and allograft survival were investigated using a Cox proportional hazards model and a cause-specific hazards model, respectively. RESULTS: 86 patients who received kidney transplants for AA amyloidosis at 26 French centers were included. The median age was 49.4 years (IQR, 39.7-61.1). The main cause of amyloidosis was familial Mediterranean fever (37 cases; 43%). 16 (18.6%) patients received biotherapy after transplantation. Patient survival rates were 94.0% (95% CI, 89.1-99.2) at 1 year and 85.5% (77.8-94.0) at 5 years after transplantation. Cumulative incidences of allograft loss were 10.5% (4.0-17.0) at 1 year and 13.0% (5.8-20.1) at 5 years after transplantation. Histologically proven AA amyloidosis recurrence occurred in 5 transplants (5.8%). An infection requiring hospitalization developed in 55.8% of cases, and there was a 27.9% incidence of acute allograft rejection. Multivariable analysis showed that C-reactive protein concentration at the time of transplantation was associated with patient survival (HR, 1.01; 95% CI, 1.00-1.02; P=0.01) and allograft survival (HR, 1.68; 95% CI, 1.10-2.57; P=0.02). LIMITATIONS: The study lacked a control group, and the effect of biotherapies on transplantation outcomes could not be explored. CONCLUSIONS: This relatively contemporary cohort of patients who received a kidney transplant for AA amyloidosis experienced favorable rates of survival and lower recurrence rates than previously reported. These data support the practice of treating these patients with kidney transplantation for end-stage kidney disease. PLAIN-LANGUAGE SUMMARY: AA amyloidosis is a severe and rare disease. Kidney involvement is frequent and leads to end-stage kidney disease. Because of the involvement of other organs, these patients are often frail, which has raised concerns about their suitability for kidney transplantation. We reviewed all patients with AA amyloidosis nephropathy who underwent kidney transplantation in France in the recent era (2008-2018) and found that the outcomes after kidney transplantation were favorable, with 85.5% of patients still alive 5 years after transplantation, a survival rate that is comparable to the outcomes of patients receiving a transplant for other forms of kidney diseases. Recurrence of amyloidosis in the transplanted kidney was infrequent (5.8%). These data support the practice of kidney transplantation for patients with AA amyloidosis who experience kidney failure.

A New Procedure for Guidewire Exchange of Tunneled Hemodialysis Catheters in Chronic Hemodialysis Patients: A Pilot Study.

INTRODUCTION: Different techniques of guidewire exchange of tunneled catheters for hemodialysis (HD) have been reported. This study was carried out to assess the feasibility of a new procedure in chronic HD patients who needed catheter exchange because of mechanical dysfunction. METHODS: The guidewire exchange method was based on the creation of a new exit site and a new subcutaneous tunnel while using the same venous insertion site. This was a retrospective study of exchanged tunneled catheters because of mechanical complications in patients on chronic HD between June 1, 2015, and December 31, 2019. The feasibility of the procedure was defined by successful exchange and catheter patency at 6 months. Catheter survival and immediate complications were reported. RESULTS: A total of 49 procedures were performed in 34 HD patients. There was no catheter insertion failure. At 6 months, 6 catheters have lost their patency because of a mechanical complication. Thus, the success rate of the procedure was 43/49 (87.8%). Catheter survival censored on death, transplantation, or vascular access creation was 97.8% at 90 days, 86.2% at 180 days, and 74.5% at 1 year. The median catheter survival was 10.2 months. Among the 49 procedures, there were 9 hematomas at the insertion site that did not require surgical intervention. Discussion/Conlusion: Our study shows that guidewire exchange of a tunneled HD catheter by creating a new exit site and a new subcutaneous tunnel by using the same venous access is a newer method in chronic HD patients. This procedure should not be used in patients with coagulation issues. Additional studies are needed to compare the different methods of HD catheter exchange.

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.

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.

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.

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.

Assessment for Assisted Peritoneal Dialysis by Peritoneal Dialysis Nurses: Results of a Cohort Study.

BACKGROUND: Selection of patients for assisted peritoneal dialysis (PD) is based on the nurse's assessment of the patient. There is no data available about the nurse's assessment of the PD patient at the initiation of PD to estimate the need for assisted PD at the national level. This study was carried out to evaluate the association between the nurse's subjective assessment of the patient's inability to be treated by self-care PD, the nurse evaluation of the patient disabilities and the utilization of nurse or family assisted PD. METHODS: This was a retrospective study of patients starting PD between July 1, 2010 and 2015 and registered in the nurse section of the French Language PD Registry (RDPLF). Poisson regression and a linear regression model with a robust variance estimator were used for the statistical analysis to determine relative risks (RRs) and risk differences (RDs). RESULTS: Of 4,101 PD patients, 403 were treated by family assisted PD, and 1,695 were treated by nurse-assisted PD. In the multivariate analysis, the nurse's subjective assessment of the patient's inability to be treated by self-care PD was associated with nurse-assisted PD (5.40 [4.58-6.35], 67% [64-70%]) and family assisted PD (11.11 [8.49-14.56], RD 62% [57-67%]). Nurse-assisted PD and family assisted PD were associated with functional impairment (RR 1.25 [95% CI 1.16-1.36], RD 14% [95% CI 10-19%] and RR 2.02 [95% CI 1.69-2.41], RD 27% [95% CI 20-34%] respectively), cognitive dysfunction (RR 1.23 [95% CI 1.15-1.32], RD 15% [95% CI 11-18%] and RR 1.73 [95% CI 1.39-2.16], RD 12% [95% CI 7-18%] respectively) and deafness (RR 1.10 [95% CI 1.04-1.16], RD 8% [95% CI 5-11%] and RR 1.46 [95% CI 1.22-1.74], RD 10% [95% CI 6-14%] respectively). CONCLUSION: Our results showed that the nurse's subjective assessment of the patient's inability to be treated by self-care PD and the patient's disabilities were strongly associated with the utilization of nurse- and family assisted PD.

Impact of Assisted Peritoneal Dialysis Modality on Outcomes: A Cohort Study of the French Language Peritoneal Dialysis Registry.

BACKGROUND: Patients on peritoneal dialysis (PD) can be assisted by a nurse or a family member and treated either by automated PD (APD) or continuous ambulatory PD (CAPD). The aim of this study was to evaluate the effect of PD modality and type of assistance on the risk of transfer to haemodialysis (HD) and on the peritonitis risk in assisted PD patients. METHOD: This was a retrospective study based on data from the French Language PD Registry. All adults starting assisted PD in France between 2006 and 2015 were included. Events of interest were transfer to HD, peritonitis and death. Cox regression models were used for statistical analysis. RESULTS: Among the 12,144 incident patients who started PD in France during the study period, 6,167 were assisted. There were 5,060 nurse-assisted and 1,095 family-assisted PD patients. Overall, 5,171 were treated by CAPD and 996 by APD. In multivariate analysis, CAPD, compared to APD, was not associated with the risk of transfer to HD (cause specific hazard ratios [cs-HR] 0.96 [95% CI 0.84-1.09]). Patients on nurse-assisted PD had a lower risk of transfer to HD than family assisted PD patients (cs-HR 0.85 [95% CI 0.75-0.97]). Neither PD modality nor type of assistance were associated with peritonitis risk. CONCLUSIONS: In assisted PD, technique survival was not associated with PD modality. Nurse-assisted patients had a lower risk of transfer to HD than family assisted patients. Peritonitis risk was not influenced either by PD modality, or by type of assistance. Both APD and CAPD should be offered to assisted-PD patients.

Factors associated with nurse assistance among peritoneal dialysis patients: a cohort study from the French Language Peritoneal Dialysis Registry.

Background: No information is available regarding nurse-assisted peritoneal dialysis (PD) in non-elderly subjects. This study was carried out to estimate the rate of nurse-assisted PD among non-elderly patients and to assess which individual and centre factors were associated with nurse-assisted PD. The other objective was to estimate the magnitude of the centre effect on the utilization of nurse-assisted PD using hierarchical modelling. Methods: This was a retrospective study based on data from the French Language Peritoneal Dialysis Registry. Patients incident on PD > 18 and < 65 years of age were included. Results: There were 2269 incidents of PD initiation between January 2008 and December 2012 in 127 PD centres with 114 (5%) on family-assisted PD and 272 (12%) on nurse-assisted PD. At the individual level, compared with autonomous patients, nurse assistance was associated with age {odds ratio [OR] 1.79 [95% confidence interval (CI) 1.51-2.13]}, gender [OR 0.47 (95% CI 0.35-0.64)], comorbidities and underlying nephropathy. There was significant heterogeneity between centres in the nurse assistance utilization (variance of random effect 0.12). At the centre level, the type of centre, centre experience, centre organization and private nurse density were not associated with nurse-assisted PD. Conclusions: The rate of nurse-assisted PD among non-elderly patients was 12%. There was a significant centre effect in the utilization of nurse assistance that was not explained by the centres' characteristics. Nurse-assisted PD utilization in non-elderly patients is associated with patient characteristics and also with centre practices.

Centre characteristics associated with the risk of peritonitis in peritoneal dialysis: a hierarchical modelling approach based on the data of the French Language Peritoneal Dialysis Registry.

BACKGROUND.: This study investigated the centre effect on the risk of peritonitis in peritoneal dialysis (PD) patients. METHODS.: This was a retrospective cohort study based on data from the French Language Peritoneal Dialysis Registry. We analysed 5017 incident patients starting PD between January 2008 and December 2012 in 127 PD centres. The end of the observation period was 1 January 2014. The event of interest was the first peritonitis episode. The analysis was performed with a multilevel Cox model and a Fine and Gray model. RESULTS.: Among the 5017 patients, 3190 peritonitis episodes occurred in 1796 patients. There was significant heterogeneity between centres (variance of the random effect: 0.11). The variance of the centre effect was reduced by 9% after adjusting for patient characteristics and by 35% after adjusting on centre covariate. In the multivariate analysis with a multilevel Cox model, centre with a nurse specialized in PD or centre providing home visits before dialysis initiation decreased the centre effect on peritonitis. Patients treated in centres with a nurse specialized in PD or in centres providing home visits before dialysis initiation had a lower risk of peritonitis [cause-specific hazard ratio (cs-HR): 0.75 (95% confidence interval, CI, 0.67-0.83) and cs-HR: 0.87 (95% CI 0.76-0.97), respectively]. The data show that neither centre type nor centre volume influenced peritonitis risk. In the competing risk analysis, centre with a nurse specialized in PD and centre with home visits had a protective effect on peritonitis [sub-distribution HR (sd-HR): 0.77 (95% CI 0.70-0.85) and sd-HR: 0.85 (95% CI 0.77-0.94), respectively]. CONCLUSION.: There is a significant centre effect on the risk of peritonitis that can be decreased by home visits before dialysis initiation and by the presence of a nurse specialized in PD.

Efficacy of Prophylactic Antibiotics at Peritoneal Catheter Insertion on Early Peritonitis: Data from the Catheter Section of the French Language Peritoneal Dialysis Registry.

BACKGROUND: International guidelines recommend the use of a prophylactic antibiotic before the peritoneal dialysis (PD) catheter can be inserted. The main objective of this study was to assess whether this practice is associated with a lower risk of early peritonitis and to estimate the magnitude of the centre effect. METHODS: A retrospective, multi-centric study was conducted, in which data from the French Language Peritoneal Dialysis Registry was analysed. Patients were separated into 2 groups based on whether or not prophylactic antibiotics were used prior to catheter placement. RESULTS: Out of the 2,014 patients who had a PD catheter placed between February 1, 2012 and December 31, 2014, 1,105 were given a prophylactic antibiotic. In a classical logit model, the use of prophylactic antibiotics was found to protect the individual against the risk of early peritonitis (OR 0.67, 95% CI 0.49-0.92). However, this association lost significance in a mixed logistic regression model with centre as a random effect: OR 0.73 (95% CI 0.48-1.09). Covariates associated with the risk of developing early peritonitis were age over 65: OR 0.73 (95% CI 0.39-0.85), body mass index over 35 kg/m2: OR 1.99 (95% CI 1.13-3.47), transfer to PD due to graft failure: OR 2.24 (95% CI 1.22-4.11), assisted PD: OR 1.96 (95% CI 1.31-2.93), and the use of the Moncrief technique: OR 3.07 (95% CI 1.85-5.11). CONCLUSION: There is a beneficial effect of prophylactic antibiotic used prior to peritoneal catheter placement, on the occurence of early peritonitis. However, the beneficial effect could be masked by a centre effect.

Diagnosis and management of pruritus associated with chronic kidney disease in hemodialyzed patients / Diagnostic et prise en charge du prurit associé à la maladie rénale chronique chez les patients hémodialysés

Chronic kidney disease-associated pruritus (CKD-aP) is a disabling symptom which is frequent and often underestimated. Pa-MRC has a negative impact on quality of life, and is frequently accompanied by sleep disorders and depression. The approval of difelikefalin ­ a kappa opioid receptor agonist ­ in this indication requires updated recommendations. As a first step, secondary causes of pruritus without skin lesions must be ruled out, and general measures taken (emollients, psychological support, optimization of dialysis, normalization of serum calcium, phosphate and PTH in the range proposed by the KGIDO guidelines, treatment of iron deficiency). A therapeutic test with a non-sedating oral antihistamine may be proposed. If this test is negative, Pa-MRC must be strongly suspected, and its intensity (WI-NRS scale) and impact on quality of life assessed. In the case of mild Pa-MRC (WI-NRS ≤ 3), only general measures are implemented. If Pa-MRC is moderate to severe (WI-NRS ≥ 4), specific treatment with difelikefaline can be initiated for 6 months in addition to general measures. At 3 months, if the response is complete (WI-NRS score ≤ 1) or partial (decline ≥ 3 points), treatment is continued. At 6 months, if the response is complete, treatment may be discontinued with the patient's agreement; treatment is maintained if the response is partial. At 3 or 6 months, if response is insufficient (decline < 3 points) and/or in the event of intolerance, treatment is discontinued and an alternative treatment (e.g., gabapentinoids, UVB) may be considered after dermatological consultation.

Le prurit associé à la maladie rénale chronique (Pa-MRC) est un symptôme invalidant qui est fréquent et souvent sous-estimé. Le Pa-MRC a des conséquences négatives sur la qualité de vie et s'accompagne fréquemment de troubles du sommeil et de dépression. L'approbation de la difélikéfaline ­ agoniste des récepteurs opioïdes kappa ­ dans cette indication nécessite l'actualisation des recommandations. Les causes secondaires de prurit sans lésions cutanées doivent être exclues et des mesures générales doivent être prises (émollients, aide psychologique, optimisation de la dialyse, équilibre phosphocalcique avec parathormone [PTH] dans la cible KDIGO [Kidney Disease: Improving Global Outcomes], traitement de la carence martiale). Une épreuve thérapeutique avec un antihistaminique oral non sédatif peut être proposée. En cas de test négatif, il faut fortement suspecter un Pa-MRC et évaluer son intensité (échelle WI-NRS [Worst Itch Numeric Rating Scale]) et son impact sur la qualité de vie. En cas de Pa-MRC léger (WI-NRS ≤ 3), seules les mesures générales sont mises en œuvre. Si le Pa-MRC est modéré à sévère (WI-NRS ≥ 4), un traitement spécifique par difélikéfaline peut être instauré pour 6 mois en plus des mesures générales. À 3 mois, si la réponse est complète (score WI-NRS ≤ 1) ou partielle (baisse ≥ 3 points), le traitement est poursuivi. À 6 mois, si la réponse est complète, l'arrêt du traitement peut être envisagé avec l'accord du patient ; il est maintenu en cas de réponse partielle. À 3 ou 6 mois, en cas de réponse insuffisante (baisse < 3 points) et/ou d'intolérance, le traitement est interrompu et un autre traitement (par exemple, gabapentinoïdes, ultraviolet de type B [UVB]) peut être envisagé après avis dermatologique.

Simulation-based learning in nephrology.

Simulation is a technique to replace and amplify real experiences with guided ones that evoke or replicate substantial aspects of the real world in a fully interactive fashion. In nephrology (a particularly complex specialty), simulation can be used by patients, nurses, residents, and attending physicians alike. It allows one to learn techniques outside the stressful environment of care such as central venous catheter placement, arteriovenous fistula management, learning about peritoneal dialysis, or performing a kidney biopsy. Serious games and virtual reality are emerging methods that show promise. Simulation could also be important in relational aspects of working in a team or with the patient. The development of simulation as a teaching tool in nephrology allows for maintaining high-quality training for residents, tailored to their future practice, and minimizing risks for patients. Additionally, this education helps nephrologists maintain mastery of technical procedures, making the specialty attractive to younger generations. Unfortunately, the inclusion of simulation training programmes faces occasional logistical or funding limitations that universities must overcome with the assistance and innovation of teaching nephrologists. The impact of simulation-based teaching on clinical outcomes needs to be investigated in clinical studies.

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.

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.

Hemodialysis complications: focus on pruritus and vascular calcifications / Complications en hémodialyse : focus sur le prurit et les calcifications vasculaires

Chronic kidney disease-associated pruritus (CKD-aP) is a frequent complication, with an estimated prevalence of 24-37% in patients treated with hemodialysis. Its pathophysiology is complex and includes four interrelated axes: accumulation of uremic toxins, peripheral neuropathy, an imbalance in the opioid receptors balance, and abnormal activation of immune cells. This symptom which is associated with impaired quality of life is underestimated by caregivers and underreported by patients. Management is not uniformly codified. It includes the use of skin emollients, optimization of dialysis parameters and management of chronic kidney disease complications, and specifically the use of difelikefalin. Patients treated with hemodialysis have an increased risk of calcifications that can affect the arteries and heart valves. These calcifications are associated with decreased survival and several scores based on radiological examinations have been proposed for screening. Although recommended, this screening is rarely performed in dialysis centers. Prevention and treatment against the development of cardiovascular calcifications are the control of risk factors associated with atherosclerosis, control of phosphatemia, and new therapeutic strategies such as sodium thiosulfate, rheopheresis, vitamin K, magnesium supplementation or SNF-472, a calcium chelator currently in clinical development.

Le prurit associé à la maladie rénale chronique (MRC) est une complication fréquente, dont la prévalence est estimée entre 24 et 37 % chez les patients traités par hémodialyse. Sa physiopathologie est complexe et comprend quatre axes intriqués : l'accumulation des toxines urémiques, la neuropathie périphérique, un déséquilibre de la balance des récepteurs opioïdes et une activation anormale des cellules immunitaires. Ce symptôme est associé à une altération de la qualité de vie, mais il est pourtant sous-estimé par les soignants et sous-déclaré par les patients. La prise en charge n'est pas uniformément codifiée. Elle comprend l'usage d'émollients cutanés, l'optimisation des paramètres de dialyse et de la prise en charge des complications de la MRC, et de manière spécifique la difélikéfaline. Les patients traités par hémodialyse présentent un risque augmenté de calcifications qui peuvent toucher les artères et les valves cardiaques. Ces calcifications sont associées à une diminution de la survie et plusieurs scores s'appuyant sur les examens radiologiques ont été proposés pour le dépistage. Bien que recommandé, ce dépistage est peu réalisé dans les centres de dialyse. La prévention et le traitement contre le développement des calcifications cardiovasculaires reposent sur la correction des facteurs de risque associés à l'athérosclérose, le contrôle de la phosphatémie, et des nouvelles stratégies thérapeutiques comme le thiosulfate de sodium, la rhéophérèse, la vitamine K, la supplémentation en magnésium ou le SNF-472, qui est un chélateur du calcium en cours de développement clinique.

Pruritus associated with chronic kidney disease in hemodialysis patients: a survey in French nephrologists / Prurit associé à la maladie rénale chronique chez les patients hémodialysés : une enquête auprès des néphrologues français

Background: Chronic kidney disease-associated pruritus (CKD-aP) is common in hemodialysis patients and severely impairs their quality of life, but the practices of nephrologists remain poorly known. Methods: The objective of this on-line survey was to describe the management of CKD-aP in French nephrologists affiliated with the French-speaking Society of Nephrology, Dialysis and Transplantation (SFNDT) and involved in hemodialysis. Results: In total, 122 questionnaires were completed and 100 were usable. Nephrologists reported they personally managed a median of 52 patients; they estimated that the CKD-aP prevalence in their hemodialysis patients was a median of 10% (IQR, 6.3-17.2); 6% of nephrologists reported not following any patient with CKD-aP. In case of CKD-aP, the first-intention intervention was the evaluation of phosphocalcic metabolism (53.5%) and verification of dialysis adequacy (52%). For moderate-to-severe CKD-aP, the first-line prescription was topical therapy (71.3%), antihistamine (23.2%) and membrane change (15.9%). Patients were referred to a dermatologist mainly in case of treatment failure (86.9%) or scratching lesions (40.4%). Available treatments were considered ineffective for 50.5% of nephrologists, partially effective for 45.5% and effective for only 4%. Conclusion: These results show that according to the opinion of nephrologists, the pruritus prevalence is low in dialysis patients. This is inconsistent with studies based on systematic patient interviews, thus suggesting that pruritus is a symptom overlooked by nephrologists. In the context of the arrival of a new drug for pruritus, patients should be more questioned about this symptom in order to propose this treatment.

Introduction: Le prurit associé à l'insuffisance rénale chronique (Pa-IRC) est fréquent chez les patients hémodialysés et altère gravement leur qualité de vie, mais les pratiques des néphrologues restent mal connues. Méthodes: L'objectif de cette enquête en ligne était de décrire la prise en charge du Pa-IRC par les néphrologues français hémodialyseurs affiliés à la Société francophone de néphrologie, dialyse et transplantation (SFNDT). Résultats: Au total, 122 questionnaires ont été remplis et 100 étaient utilisables. Les néphrologues suivaient personnellement 52 patients (médiane). Ils estimaient que la prévalence du Pa-IRC chez ces patients était de 10 % (médiane ; écart interquartile : 6,3-17,2) ; 6 % des néphrologues ont déclaré ne suivre aucun patient atteint de Pa-IRC. En cas de Pa-IRC, l'intervention de première intention était l'évaluation du métabolisme phosphocalcique (53,5 %) et la vérification de la qualité de dialyse (52 %). Pour le Pa-IRC modéré à sévère, la prescription de première intention était un traitement topique (71,3 %), un antihistaminique (23,2 %) et un changement de membrane (15,9 %). Les traitements disponibles étaient considérés comme inefficaces pour 50,5 % des néphrologues, partiellement efficaces pour 45,5 % et efficaces pour seulement 4 %. Conclusion: Ces résultats montrent que selon l'opinion des néphrologues, la prévalence du prurit est faible chez les patients dialysés. Ceci est en contradiction avec les études basées sur des entretiens systématiques avec les patients, suggérant ainsi que le prurit est un symptôme sous-estimé par les néphrologues. Dans le contexte de l'arrivée d'un nouveau médicament pour le prurit, les patients devraient être davantage interrogés sur ce symptôme afin de proposer ce traitement.

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.