[Is the management of anemia in hemodialysis patients improving in France? Results of the DiaNE study]. / La prise en charge de l'anémie du patient hémodialysé en France s'améliore-t-elle? Résultats de l'étude DiaNE.

French and international clinical practice guidelines recommend a minimum hemoglobin level of 11 g/dl in patients with chronic kidney disease. Previous studies implemented between 1996 and 2003 showed that only 35 to 55% the patients reach this target. Dialysis NeoRecormon Epidemiology (DiaNE) is a one-year French multicentric observational study designed to follow a cohort of 1200 patients with ESRD treated with epoetin beta to assess the management of anemia in routine nephrologic practice. From December 2003 to September 2004, 1241 hemodialysis patients were recruited by 229 centers. At baseline, 64.4% of patients had hemoglobin levels greater than 11 g/dl. The proportion of patients with hemoglobin levels greater than 11 g/dl at the end of the study was 71.6%. These results could be partly explained by iron deficiency: 46% of patients had a serum ferritin between 200 and 500 microg/l and about one third of patients had a transferrin-iron saturation percentage greater or equal to 30% at baseline and at the end of the study. Epoetin beta was administrated by subcutaneous route in 65.5% of patients with similar efficacy and with less mean doses than intravenous route (114.6+/-81.5 IU/kg versus 146.5+/-124.3 IU/kg at the end of the study). In conclusion, the management of anemia in hemodialysis patients is not optimal but is slightly better than the management observed between 1996 and 2003. Iron and inflammatory status should be taken into account to improve the efficacy of anemia therapy using erythropoietin-stimulating agents.

[When to place a patient on the kidney transplantation waiting list?]. / Quand faut-il inscrire un patient sur la liste d'attente de transplantation rénale?

Practices for enrollment on kidney transplantation waiting lists are variable between geographical areas and centers. Early referral of patients with chronic renal failure (CRF) to a nephrologist, particularly one practicing in a transplantation center, is a prerequisite to early enrollment. Despite improved survival in elderly transplant recipients, being aged over 65 years is still a barrier against enrollment. Furthermore certain comorbid conditions such as diabetes mellitus are often wrongly considered as contraindications for transplantation. If nephrological management is initiated early, enrollment could (should?) be considered before the terminal phase of CRF, with the hope of preemptive transplantation with the known advantages not only for the individual recipient but also for the community in general. Glomerular filtration rate below 20 ml/minute could be a reasonable cutoff for enrollment. Patients referred late to a nephrologist will require dialysis. Dialysis center staff should be well trained in delivering appropriate information on kidney transplantation and initiating evaluation. A consultation with a transplantation specialist should be rapidly scheduled.

[Anemia management in French hemodialysis patients: DiaNE study results at 3 years (DiaNE2)]. / Prise en charge de l'anémie des patients hémodialysés en France : résultats de l'étude DiaNE à trois ans (DiaNE 2).

The observational study DiaNE provides a current state of anemia management with Epoetine bêta in hemodialysis patients regarding European recommendations over a 3-year period in France. Patients still treated with Epoetine bêta twelve months after their inclusion in DiaNE were eligible for a 24-month extension phase entitled DiaNE 2. Data regarding 439 patients followed during three years, from M0 to M36, were analyzed. Hemoglobin (Hb) level of the cohort remained over the target value of 11g/dL during the study (M0: 11.3±1.2g/dL; M36: 11.8±1.3g/dL). The anemia management had evolved with European recommendations updates and was in accordance with the last recommended target range (11-12g/dL) in a third of patients. During the follow-up, the majority of patients (97%) had at least one modification of treatment with Epoetine bêta (change in frequency of injections, adjustment of doses) mainly justified by excursion of Hb level out of the target range. However, the median dose of Epoetine bêta was relatively stable. The number of patients with iron treatment remained stable (60%). In spite of undertaken efforts, anemia management of hemodialysed patients in France still needs optimization for maintaining Hb level in the recommended target range.