Impact of age and renal function on usefulness of NT-proBNP to diagnose heart failure
.

AIMS: NT-proBNP is a useful biomarker for heart failure (HF) diagnosis. We aimed to determine NT-proBNP's ability to diagnose HF by age and renal function. MATERIALS AND METHODS: We analyzed 3,699 consecutive and unique adults admitted for dyspnea at the Emergency Unit of St. Joseph St. Luc Hospital, Lyon, France, from December 1, 2012 to June 30, 2016, who had concomitant measurement of NT-proBNP and serum creatinine. We excluded patients with acute coronary syndrome and dialysis patients. Receiving operating characteristic (ROC) analysis assessed ability and cut-off points of NT-proBNP to diagnose HF. RESULTS: Mean age was 79.1 ± 13.0 years. Mean estimated glomerular filtration rate (eGFR, CKD EPI formula) was 64 ± 26 mL/min/1.73m2. The ROC area under the curve (AUC) was 0.813 on average, optimal NT-proBNP cut-off point was 1,896 ng/L. AUC decreased (0.882, 0.813, 0.767) by age class (18 - 69, 70 - 84, 85+ years, respectively), and optimal cut-off points increased (1,041, 1,902, 2,321 ng/L). AUC decreased (0.881, 0.830, 0.783, 0.781, 0.705) by eGFR class (≥ 90, 60 - 89, 45 - 59, 30 - 44, < 30 mL/min/1.73m2), and cut-off points increased (757, 1,362, 2,283, 4,108, 7,288 ng/L). The lowest value of cut-off points associated with highest sensitivity and specificity was detected in young patients with eGFR ≥ 90 (597 ng/L) while the worst value was found in age 85+ patients with eGFR < 30 (7,288 ng/L). AUC decreased below 0.8 in age 70+ patients with eGFR < 45 mL/min/1.73m2;. CONCLUSION: The ability of NT-proBNP to diagnose HF decreased strongly with age and renal function. NT-proBNP's usefulness in diagnosing HF in age 70+ patients with eGFR < 45 mL/min/1.73m2 remains uncertain.

Restricted mean survival time over 15 years for patients starting renal replacement therapy.

Background: The restricted mean survival time (RMST) estimates life expectancy up to a given time horizon and can thus express the impact of a disease. The aim of this study was to estimate the 15-year RMST of a hypothetical cohort of incident patients starting renal replacement therapy (RRT), according to their age, gender and diabetes status, and to compare it with the expected RMST of the general population. Methods: Using data from 67 258 adult patients in the French Renal Epidemiology and Information Network (REIN) registry, we estimated the RMST of a hypothetical patient cohort (and its subgroups) for the first 15 years after starting RRT (cRMST) and used the general population mortality tables to estimate the expected RMST (pRMST). Results were expressed in three different ways: the cRMST, which calculates the years of life gained under the hypothesis of 100% death without RRT treatment, the difference between the pRMST and the cRMST (the years lost), and a ratio expressing the percentage reduction of the expected RMST: (pRMST - cRMST)/pRMST. Results: Over their first 15 years of RRT, the RMST of end-stage renal disease (ESRD) patients decreased with age, ranging from 14.3 years in patients without diabetes aged 18 years at ESRD to 1.8 years for those aged 90 years, and from 12.7 to 1.6 years, respectively, for those with diabetes; expected RMST varied from 15.0 to 4.1 years between 18 and 90 years. The number of years lost in all subgroups followed a bell curve that was highest for patients aged 70 years. After the age of 55 years in patients with and 70 years in patients without diabetes, the reduction of the expected RMST was >50%. Conclusion: While neither a clinician nor a survival curve can predict with absolute certainty how long a patient will live, providing estimates on years gained or lost, or percentage reduction of expected RMST, may improve the accuracy of the prognostic estimates that influence clinical decisions and information given to patients.

Economic impact of a modification of the treatment trajectories of patients with end-stage renal disease.

BACKGROUND: This study assumed that some patients currently treated at hospital-based haemodialysis centres can be treated with another renal replacement therapy (RRT) modality without any increase in mortality risk and sought to evaluate the monthly cost impact of replacing hospital-based haemodialysis, for which fees are highest, by different proportions of other modalities. METHODS: We used a deterministic model tool to predict the outcomes and trajectories of hypothetical cohorts of incident adult end-stage renal disease (ESRD) patients for 15 years of RRT (10 different modalities). Our estimates were based on data from 67 258 patients in the REIN registry and 65 662 patients in the French national health insurance information system. Patients were categorized into six subcohorts, stratified for age and diabetes at ESRD onset, and analyses run for each subcohort. We simulated new strategies of care by changing any or all of the following: initial distributions in treatment modalities, transition rates and some costs. Strategies were classified according to their monthly per-patient cost compared to current practices (cost-minimization analysis). RESULTS: Simulations of the status quo for the next 15 years predicted a per-patient monthly cost of €2684 for a patient aged 18-45 years without diabetes and €7361 for one older than 70 years with diabetes. All of the strategies we analysed had monthly per-patient costs lower than the status quo, except for daily home HD. None impaired expected survival. Savings varied by strategy. CONCLUSIONS: Alternative strategies may well be less expensive than current practices. The decision to implement new strategies must nonetheless consider the number of patients concerned, feasibility of renal care reorganization, and investment costs. It must also take into account the role of patients' choice and the availability of professionals.

Trends in the epidemiology and care of diabetes mellitus-related end-stage renal disease in France, 2007-2011.

AIMS/HYPOTHESIS: The aim was to study geographic variations and recent trends in the incidence of end-stage renal disease (ESRD) by diabetes status and type, and in patient condition and modalities of care at initiation of renal replacement therapy. METHODS: Data from the French population-based dialysis and transplantation registry of all ESRD patients were used to study geographic variations in 5,857 patients without diabetes mellitus, 227 with type 1 diabetes mellitus, and 3,410 with type 2. Trends in incidence and patient care from 2007 to 2011 were estimated. RESULTS: Age- and sex-adjusted incidence rates were higher in the overseas territories than in continental France for ESRD unrelated to diabetes and related to type 2 diabetes, but quite similar for type 1 diabetes-related ESRD. ESRD incidence decreased significantly over time for patients with type 1 diabetes (-10% annually) and not significantly for non-diabetic patients (0.2%), but increased significantly for patients with type 2 diabetes (+7% annually until 2009 and seemingly stabilised thereafter). In type 2 diabetes, the net change in the absolute number was +21%, of which +3% can be attributed to population ageing, +2% to population growth and +16% to the residual effect of the disease. Patients with type 2 diabetes more often started dialysis as an emergency (32%) than those with type 1 (20%) or no diabetes. CONCLUSIONS/INTERPRETATION: The major impact of diabetes on ESRD incidence is due to type 2 diabetes mellitus. Our data demonstrate the need to reinforce strategies for optimal management of patients with diabetes to improve prevention, or delay the onset, of diabetic nephropathy, ESRD and cardiovascular comorbidities, and to reduce the rate of emergency dialysis.

[Evaluation of an algorithm based on quantitative assays of glomerular parameters (albuminuria and urinary IgG) for proteinuria typing]. / Évaluation d'un algorithme basé sur des dosages quantitatifs de paramètres glomérulaires (albuminurie et IgG urinaires) afin de typer une protéinurie.

The first orientation test for proteinuria typing is electrophoresis. However, this technique has several drawbacks, such as delayed turnaround time and subjective readings. Some laboratories therefore use quantitative assays of glomerular markers combined with tubular markers. However, the cost of reagents and the instability of certain markers are significant drawbacks for some peripheral laboratories. The aim of this study is to evaluate the implementation of an algorithm based on parameters that can be used by all laboratories for proteinuria typing within a timeframe compatible with the urgency of the situation. Albuminuria and urinary IgG were determined on 161 urines. ROC curves were produced, using urine electrophoresis read by an expert center as the reference method. The decision thresholds used are: glomerular proteinuria is defined by a Albumin+IgGproteinsratio greater than 75.4% (100% specificity), and tubular or overload proteinuria is defined by by a Albuminproteinsratio less than 37.3% (100% sensitivity). Agreement between the results of the algorithm selected and the reference method used in our study was 88 %, with a kappa value of 0.807 (95% CI [0.729 to 0.885]). The algorithm's performance suggests that it can find its place in the diagnostic strategy for clinically significant proteinuria, despite its limited indications. It is up to each biologist to assess the value of this algorithm in relation to the recruitment, habits and needs of clinicians.

Continuous glucose monitoring with FreeStyle Libre PRO sensor in patients with type 2 diabetes and end-stage renal failure on haemoDIALysis (FSLPRO-DIAL pilot study).

AIMS: For end-stage renal disease (ESRD) patients with diabetes on haemodialysis, diabetes control is difficult to achieve. Hypoglycaemia is a major problem in these frailty subjects. Continuous glucose monitoring (CGM) devices appear therefore to be a good tool to help patients monitor their glycaemic control and to help practitioners optimize treatment. We aimed to compare the laboratory value of Hba1c with the sensor-estimated value of Hba1c (= glucose management indicator, GMI) in ESRD patients with type 2 diabetes (T2D) (with or without insulin treatment) on haemodialysis. Secondly, we aimed to identify CGM-derived monitoring parameters [time in range, time in hypo/hyperglycaemia, glycaemic variability (coefficient of variation, CV)] to identify patients at risk of frequent hypo- or hyperglycaemia. METHODS: The FSLPRO-DIAL pilot study (NCT04641650) was a prospective monocentric cohort study including 29 subjects with T2D who achieve the protocol. Inclusion criteria were: age ≥ 18 years, haemodialysis duration for at least 3 months, type 2 diabetes with no change in treatment for at least 3 months. Demographic data and blood sample were collected at the day of inclusion. Freestyle Libre pro IQ sensor (blinded CGM) was inserted for 14 days. After this period, all CGMs data were collected and analysed. RESULTS: Data were available for 27 patients. Mean age was 73 ± 10, mean BMI 27.2 kg/m2, mean duration of diabetes 16.9 years and mean dialysis duration 2.9 years. Twenty-four subjects were treated with insulin. Mean HbA1c was 6.6% (SD 1.2), and mean GMI was 6.7% (SD 0.9) (no significant difference, p = 0.3). Twelve subjects (44.4%) had a discordance between HbA1c and GMI of < 0.5%, 11 (40.8%) had a discordance between 0.5 and 1%, and only 4 (14.8%) had a discordance of > 1%. Mean time in range (70-180 mg/dl) was 71.9%, mean time below range (< 70 mg/dl) was 5.6%, and mean time above range (> 180 mg/dl) was 22.1%. Mean CV was 31.8%. For 13 out of 27 patients, we reduced antidiabetic treatment by stopping treatments or reducing insulin doses. CONCLUSION: In this pilot study, there was no global significant difference between HbA1c and GMI in this particular cohort with very well-controlled diabetes. However, the use of the sensor enabled us to identify an excessive time in hypoglycemia in this fragile population and to adapt their treatment.

Modelling treatment trajectories to optimize the organization of renal replacement therapy and public health decision-making.

BACKGROUND: Nephrologists need to better understand the impact of their decisions about long-term treatment strategies. Healthcare planning requires the anticipation of demand. Indicators from ESRD registries are especially difficult to interpret when the underlying dynamic process is not well understood. Therefore, we have developed a statistical tool to study the course of incident ESRD patient cohorts over time and to quantify, by simulations, the impact of various expected changes or new strategies. METHODS: Based on the data from 67 258 ESRD adult patients, we first estimated transition rates between 10 different modalities of treatment ('compartments') with a multistate model. In a second step, we predicted the number of patients in each compartment at each time point for a cohort of 1000 patients for 180 months after the onset of renal replacement therapy (RRT). We tested two scenarios to illustrate the possibility of simulating policy changes. RESULTS: Increased use of non-assisted automated peritoneal dialysis (PD) (from 7.7 to 19.2% at RRT onset) will not substantially influence the proportion of total RRT time in PD for patients aged 18-44 without diabetes. Improving access to kidney transplants from cadaveric donors for patients aged 45-69 with diabetes will increase the 15-year restricted mean lifetime by 5 months and the time spent with a functioning graft (34 versus 23%). CONCLUSIONS: A model based on patients' treatment trajectories can improve the description and understanding of RRT as a dynamic phenomenon. Its use for simulation may help professionals and decision-makers to optimize renal organization and care.

Excess risk of death increases with time from first dialysis for patients on the waiting list: implications for renal allograft allocation policy.

BACKGROUND: Subgroups of patients registered on a kidney transplant waiting list have higher than usual mortality levels. This study used data from the French Renal Epidemiology and Information Network (REIN) Registry to quantify the impact over time of various comorbidities on the excess risk of death among patients on the waiting list. METHODS: Lexis diagrams were used to analyze time since onset of end-stage renal disease and time since registration on the waiting list. The number of excess deaths was calculated by comparison with the number of expected deaths in the general population of the same age and sex. RESULTS: During 45,013 person-years of follow-up, 7,224 patients died, 5,956 (82%) more than expected relative to the general population. There were 101 deaths among wait-listed dialysis patients, 76 more than expected. The excess risk of death increased by 45% per additional year on the waiting list (18-79%, p = 0.0005). Time from end-stage renal disease onset until list registration (p = 0.004), time since registration (p < 0.001), age >65 years (p = 0.008), the presence of a primary renal disease (p = 0.028), and the number of comorbidities (p = 0.035) were independent predictors of death while on the waiting list. CONCLUSIONS: The excess risk of death while on the waiting list increased faster in patients with comorbidities. These results require consideration of ways to accelerate access to transplantation in high-risk patients.

Impact of post-transplant anemia on patient and graft survival rates after kidney transplantation: a meta-analysis.

The impact of post-kidney transplant anemia (PTA) on patient and graft survival rates remains controversial. We performed a meta-analysis to evaluate its impact in causing death of a patient with a functioning graft (DPWFG) and death-censored graft loss (DCGL). A systematic review of 11 observational studies (11,632 kidney transplant patients) that reported the impact of PTA or hemoglobin (Hb) level on these endpoints was performed. Using the World Health Organization (WHO) definition (Hb <12 g/dL in women and Hb <13 g/dL in men), PTA was not associated with DPWFG when results were expressed as an adjusted hazard ratio (aHR: 1.23 [0.97-1.57]), but was associated with higher DPWFG when results were expressed as unadjusted rates (aHR: 2.48 [1.36-4.52]) and when cut-off level for anemia was lower than the WHO definition (aHR: 3.12 [1.92-5.07]). A -1 g/dL decrease in Hb level was associated with higher DPWFG rates (aHR: 1.19 [1.12-1.26]). Using WHO criteria, PTA was associated with higher DCGL rates when results were expressed as aHR (aHR: 1.53 [1.26-1.85]) or as unadjusted rates (aHR: 3.55 [2.36-5.33]); a -1 g/dL decrease in Hb level was associated with higher DCGL rates (aHR: 1.14 [1.11-1.16]). This meta-analysis reveals that the association between PTA and DPWFG varies with PTA definition and adjustment for confounders. In all sub-meta-analyses, PTA was significantly associated with DCGL.

Survival advantage of hemodialysis relative to peritoneal dialysis in patients with end-stage renal disease and congestive heart failure.

Peritoneal dialysis (PD) has been proposed as a therapeutic option for patients with end-stage renal disease and associated congestive heart failure (CHF). Here, we compare mortality risks in these patients by dialysis modality by including all patients who started planned chronic dialysis with associated congestive heart failure and were prospectively enrolled in the French REIN Registry. Survival was compared between 933 PD and 3468 hemodialysis (HD) patients using a Kaplan-Meier model, Cox regression, and propensity score analysis. The patients were followed from their first dialysis session and stratified by modality at day 90 or last modality if death occurred prior. There was a significant difference in the median survival time of 20.4 months in the PD group and 36.7 months in the HD group (hazard ratio, 1.55). After correction for confounders, the adjusted hazard ratio for death in PD compared to the HD patients remained significant at 1.48. Subgroup analyses showed that the results were not changed with regard to the New York Heart Association stage, age strata, or estimated glomerular filtration rate strata at first renal replacement therapy. The use of propensity score did not change results (adjusted hazard ratio, 1.55). Thus, mortality risk was higher with PD than with HD among incident patients with end-stage renal disease and congestive heart failure. These results may help guide clinical decisions and also highlight the need for randomized clinical trials.

Reversible ileitis secondary to high dose intravenous immunoglobulin in adult kidney transplant patient treated for acute humoral rejection.

Use of high dose intravenous immunoglobulin (IVIg) has been associated with necrotizing enterocolitis in late-preterm and term infants treated for severe isoimmune hemolytic jaundice. We present the first adult case of reversible ileitis related to high dose IVIg that occurred during the treatment of acute humoral rejection in a kidney transplant recipient (original nephropathy: lupus). At the third of the 5 days of a 0.4 g/kg/day IVIg infusion, he had periumbilical pain and nausea. Non-iodine injected abdominal computed tomography (CT) demonstrated a major proximal ileitis that was absent 1 month earlier on a previous CT. After the fourth injection, IVIg therapy was discontinued. Clinical and radiological signs disappeared, respectively, 5 and 7 days after IVIg discontinuation. No other causes of ileitis were diagnosed (especially infectious, vascular, or lupus-related bowel disease causes). Usual abdominal pain and nausea during IVIg therapy may be related to sub-clinical ileitis and/or enteritis. As in newborn, such complication has to be diagnosed and IVIg infusion discontinued because of potential evolution to intestinal necrosis.

Age and comorbidity may explain the paradoxical association of an early dialysis start with poor survival.

Starting patients on dialysis early has been increasing in incidence in several countries. However, some studies have questioned its utility, finding a counter-intuitive effect of increased mortality when dialysis was started at a higher estimated glomerular filtration rate (eGFR). To examine this issue in more detail we measured mortality hazard ratios associated with Modification of Diet in Renal Disease eGFR at dialysis initiation for 11,685 patients from the French REIN Registry, with sequential adjustment for a number of covariates. The eGFR was analyzed both quantitatively by 5-ml/min per 1.73 m(2) increments and by demi-decile (i.e., 5 percentiles of the distribution); the 15th demi-decile, including values around 10 ml/min per 1.73 m(2), was our reference point. The patients more likely to begin dialysis at a higher eGFR were older male patients; had diabetes, cardiovascular diseases, or low body mass index and level of albuminemia; or were started with peritoneal dialysis. During a median follow-up of 21.9 months, 3945 patients died. The 2-year crude survival decreased from 79 to 46%, with increasing eGFR from less than 5 to over 20 ml/min per 1.73 m(2). Each 5-ml/min/1.73 m(2) increase in eGFR was associated with a 40% increase in crude mortality risk, which weakened to 9%, but remained statistically significant after adjusting for the above covariates. Analysis by demi-decile showed only the highest to be at significantly higher risk. Hence we found that age and patient condition strongly determine the decision to start dialysis and may explain most of the inverse association between eGFR and survival.

Antioxidant Properties of Embelin in Cell Culture. Electrochemistry and Theoretical Mechanism of Scavenging. Potential Scavenging of Superoxide Radical through the Cell Membrane.

Embelin, a plant natural product found in Lysimachia punctata (Primulaceae), and Embelia ribes Burm (Myrsinaceae) fruit, possesses interesting biological and pharmacological properties. It is a unique chemical species as it includes both quinone and hydroquinone functional groups plus a long hydrophobic tail. By using hydrodynamic voltammetry, which generates the superoxide radical in situ, we show an unusual scavenging capability by embelin. Embelin as a scavenger of superoxide is stronger than the common food additive antioxidant 2,6-bis(1,1-dimethylethyl)-4-20 methylphenol, (butylated hydroxytoluene, BHT). In fact, embelin is even able to completely abolish the superoxide radical in the voltaic cell. Computational results indicate that two different types of embelin scavenging actions may be involved, initially through π-π interaction and followed by proton capture in the cell. A related mechanism describes embelin's ability to circumvent superoxide leaking by transforming the anion radical into molecular oxygen. In order to confirm its antioxidant properties, its biological activity was tested in a study carried out in THP-1 human leukemic monocytes and BV-2 mice microglia. A 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay, proliferation curves and antioxidant activity by the use of a fluorescent probe showed good antioxidant properties at 24 h. This suggests that embelin's long alkyl C10 tail may be useful for cell membrane insertion which stimulates the antioxidant defense system, and cytoprotection in microglia. In conclusion, embelin could be an interesting pharmacological tool able to decrease the damage associated with metabolic and neurodegenerative diseases.

[Towards an extension of the REIN registry to patients with chronic kidney disease at stage 5 not treated with dialysis or transplantation? A pilot study]. / Vers une extension du registre REIN aux patients avec une maladie rénale chronique au stade 5 non traités par dialyse ou greffe ? Étude pilote.

To date, it is important to know more about the population of CKD stage 5 patients in order to better understand the practices of access to renal replacement therapy (RRT) or conservative treatment and to anticipate future needs. In April 2015, at the instigation of the Scientific Committee of REIN, a working group was formed to reflect on the opportunity and feasibility of a data collection on these patients. Between September 2017 and March 2018, 21 participating centers included 390 patients over a period of at least one month. The data collected included the patient's living conditions, level of study, mode of referral, clinical data and the therapeutic project. The median age at baseline was 71.4years (IQR: 58.4-80.4), 39.9% were diabetic. The median eGFR was 12mL/min/1.73m2 (IQR: 9-14). At inclusion, 77% of the patients were already followed in nephrology, 11% had been referred by a general practitioner. For the majority of patients included (81%), there was a RRT project. In 10% of cases, there was a project of conservative care, in 5% of cases the project was not yet decided and in 7% the project had not been yet discussed. At the latest news (median time 4.0months), 35% of patients were dialyzed, 9 (2%) have been pre-emptively transplanted, 25 (6%) died, 210 (54%) were still with a CKD stage 5. Our pilot study has shown the feasibility and interest of setting up such a data collection. Such a registry will provide important public health information regarding the demographic of nephrologists and advanced practices nurses. At the local level, this information will help the department to organize themselves to set-up pre-RRT information, implementation of care pathway nurses and multidisciplinary meetings for difficult cases. However, our pilot study shows that to ensure the completeness of the collection, the tracking upstream or downstream of nephrology consultations for eligible patients is essential and therefore requires dedicated human time on site.

Mycophenolate mofetil monotherapy in membranous nephropathy: a 1-year randomized controlled trial.

BACKGROUND: Treatment of patients with membranous glomerulonephritis (MGN) is controversial because of the lack of clear benefit of the immunosuppressive regimens on patient or renal survival. The objective of this study is to evaluate the efficacy and safety of mycophenolate mofetil (MMF) for patients with MGN. STUDY DESIGN: 1-year prospective, randomized, and controlled clinical trial. SETTING & PARTICIPANTS: 36 patients with biopsy-proven idiopathic MGN and nephrotic syndrome. INTERVENTION: 19 patients received MMF (2 g/d) for 12 months and 17 patients were in the control group. All patients had the same conservative treatment based on renin-angiotensin blockers, statins, low-salt and low-protein diet, and diuretics in case of edema. OUTCOMES & MEASUREMENTS: End points were the mean proteinuria over creatinuria ratio in mg/g throughout the study and numbers of complete and partial remissions at 1 year (month 12). Data were analyzed on an intention-to-treat analysis. RESULTS: Mean proteinuria over creatinuria ratio was stable in both groups throughout the study (P = 0.1). Mean proteinuria over creatinuria ratio was 4,690 +/- 2,212 mg/g in the MMF group and 6,548 +/- 4,601 mg/g in the control group (95% confidence interval of the difference, -619 to +4,247; P = 0.1). Remission was complete in 3 patients (1 in the MMF group, 2 in the control group; P = 0.5) and partial in 11 patients (6 in the MMF group, 5 in the control group; P = 0.9). The probability of complete or partial remission did not differ between the 2 groups after 12 months (relative risk, 0.92; 95% confidence interval, 0.48 to 1.75; P = 0.7). Kidney function was stable in the 2 groups according to estimated glomerular filtration rate and serum creatinine level. LIMITATIONS: The small number of patients and short follow-up prevent generalizations. CONCLUSIONS: A 12-month regimen of MMF did not decrease mean proteinuria over creatinuria ratio or increase partial and complete remissions. Serious adverse effects were observed in 4 patients (20%) receiving MMF.

Evaluation and determinants of underprescription of erythropoiesis stimulating agents in pre-dialysis patients with anaemia.

BACKGROUND: Inadequate anaemia correction (haemoglobin (Hb) <11 g/dl without receiving an erythropoiesis-stimulating agent (ESA) is common in pre-dialysis patients, but little is known about its determinants. We used data from the French end-stage renal disease (ESRD) registry to investigate these determinants and the patients' anaemia status 1 year after starting dialysis. METHODS: Pre-dialysis anaemia care was studied in 6,271 incident ESRD patients from 13 regions, who were first treated between 2003 and 2005. Data included pre-dialysis Hb measure and ESA use, patient's condition and modalities of dialysis initiation. Anaemia status at 1 year was studied in 925 patients from four regions who started dialysis in 2003 and 2004, were still on dialysis one year later, and had completed the annual registry data form. RESULTS: Overall, 34.7% of the patients had inadequate pre-dialysis anaemia correction, with variations across regions from 21.1 to 43.2%. Inadequate anaemia correction decreased from 38.0% in 2003 to 33.2% in 2005. It was less likely in patients with diabetic or polycystic kidney disease and more likely in those with malignancy, unplanned haemodialysis, and low glomerular filtration rate or low serum albumin at dialysis initiation. One year after starting dialysis, inadequate correction concerned only 2.6% of the patients. Hb level had risen from 10.3 g/dl in pre-dialysis to 11.7 g/dl, but remained lower in those with inadequate pre-dialysis correction. CONCLUSION: Despite improvement over time, inadequate correction with ESAs remains high in pre-dialysis patients in contrast with those on dialysis. As the timing of dialysis initiation is uncertain, continuous management of anaemia is requested.

[Specificities of the methodology of survival analysis in dialysis patients]. / Spécificités méthodologiques de l'analyse de survie des patients dialysés.

Epidemiological and observational studies are needed in nephrology for evidence-based medical decision and global knowledge of renal patients. Using strong methodology, such studies are useful to formulate hypotheses for further explanatory studies or clinical trials. Survival analysis of dialysis patients are based on the usual and robust Kaplan-Meier and Cox regression methods. Nevertheless, their use should take into account the specificities of the dialysis population, especially when non-constant risks for death with time and sub-groups analyses are considered. In addition, survival curves from birth or standardised mortality ratio are able to provide a new view of survival by changing of analytical perspective. Our aim is to summarize the specificities of survival study methodology in dialysis patients using concrete examples in French cohorts.

[A giant cell arteritis revealing a Goodpasture's syndrome]. / Une artérite à cellules géantes révélatrice d'un syndrome de Goodpasture.

Goodpasture's syndrome is a triad of anti-glomerular basement membrane (anti-GBM) circulating antibodies, glomerulonephritis and pulmonary hemorrhage. We reported a 65-year-old woman with headaches, asthenia and weight loss. Giant cell arteritis was confirmed by temporal artery biopsy. The patient had associated renal condition with moderate acute renal failure, proteinuria and haematuria. Renal biopsy showed extracapillary glomerulonephritis and linear staining of immunoglobulins G along glomerular basement membrane. There was no clinical pulmonary involvement. Anti-MBG antibody was positive and allowed Goodpasture's syndrome diagnosis. The patient was treated with corticoids and cyclophosphamide. Patient's condition and renal function improved quickly and anti-MBG antibodies became negative. Goodpasture's syndrome may be characterized by isolated renal expression without pulmonary involvement. We described for the first time association of Goodpasture's syndrome with giant cell arteritis.