Prevalence of End Stage Kidney Disease and distribution of treatment modalities / Prévalence de l'IRCT et part des différentes modalités de traitement

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of ESKD prevalence, the following key messages were retained. While chronic kidney disease affects all age groups, there always are more patients to treat in the older age groups, with a median age of 71.1 years (IIQ 60.3-80.0) under dialysis and 58.7 years (IIQ 47.4-68.3) under renal transplant. Despite an increase in transplant activity and improved survival of grafts, the gap between the number of dialysis patients and transplant patients at the end of each year is only moderately reduced. There has been a moderate decrease in the proportion of in-centre haemodialysis that is explained by a significant increase in medicalised dialysis units (out-centre haemodialysis) and a decrease in self-care haemodialysis. Finally, a stable home-based care has been observed despite the ministerial incentives and the recommendations of the French-speaking scientific society (SFNDT-white paper).

À l'occasion des 20 ans du REIN (Réseau Epidémiologie et Information en Néphrologie), un travail de synthèse sur les apports du registre a été mené. Sur la question de la prévalence de la maladie rénale stade 5, les messages clés suivants ont été retenus. Si la maladie rénale chronique touche toutes les tranches d'âge, il y a toujours plus de patients à prendre en charge dans les tranches d'âge les plus élevées, avec un âge médian de 71,1 ans (Intervalle Inter Quartile (IIQ) 60,3-80,0) en dialyse et 58,7 ans (IIQ 47,4-68,3) en transplantation rénale. Malgré une augmentation de l'activité de greffe et une meilleure survie des greffons, l'écart entre le nombre de patients dialysés et greffés à la fin de chaque année ne diminue que de façon modérée. On observe une baisse modérée de la part de l'hémodialyse en centre expliquée par une hausse importante des unités de dialyse médicalisée (UDM) et une baisse de l'autodialyse. Enfin, on note une prise en charge à domicile stable malgré les incitations ministérielles et les recommandations de la société savante (SFNDT-livre blanc).

Why and how should we promote home dialysis for patients with end-stage kidney disease during and after the coronavirus 2019 disease pandemic? A French perspective.

The health crisis induced by the pandemic of coronavirus 2019 disease (COVID-19) has had a major impact on dialysis patients in France. The incidence of infection with acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the first wave of the COVID-19 epidemic was 3.3% among dialysis patients-13 times higher than in the general population. The corresponding mortality rate was high, reaching 21%. As of 19th April, 2021, the cumulative prevalence of SARS-CoV-2 infection in French dialysis patients was 14%. Convergent scientific data from France, Italy, the United Kingdom and Canada show that home dialysis reduces the risk of SARS-CoV-2 infection by a factor of at least two. Unfortunately, home dialysis in France is not sufficiently developed: the proportion of dialysis patients being treated at home is only 7%. The obstacles to the provision of home care for patients with end-stage kidney disease in France include (i) an unfavourable pricing policy for home haemodialysis and nurse visits for assisted peritoneal dialysis (PD), (ii) insufficient training in home dialysis for nephrologists, (iii) the small number of administrative authorizations for home dialysis programs, and (iv) a lack of structured, objective information on renal replacement therapies for patients with advanced chronic kidney disease (CKD). We propose a number of pragmatic initiatives that could be simultaneously enacted to improve the situation in three areas: (i) the provision of objective information on renal replacement therapies for patients with advanced CKD, (ii) wider authorization of home dialysis networks and (iii) price increases in favour of home dialysis procedures.

Unilateral nephrectomy versus renal arterial embolization and technique survival in peritoneal dialysis patients with autosomal dominant polycystic kidney disease.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is a common genetic disorder associated with progressive enlargement of the kidneys and liver. ADPKD patients may require renal volume reduction, especially before renal transplantation. The standard treatment is unilateral nephrectomy. However, surgery incurs a risk of blood transfusion and alloimmunization. Furthermore, when patients are treated with peritoneal dialysis (PD), surgery is associated with an increased risk of temporary or definitive switch to haemodialysis (HD). Unilateral renal arterial embolization can be used as an alternative approach to nephrectomy. METHODS: We performed a multicentre retrospective study to compare the technique of survival of PD after transcatheter renal artery embolization with that of nephrectomy in an ADPKD population. We included ADPKD patients treated with PD submitted to renal volume reduction by either surgery or arterial embolization. Secondary objectives were to compare the frequency and duration of a temporary switch to HD in both groups and the impact of the procedure on PD adequacy parameters. RESULTS: More than 700 patient files from 12 centres were screened. Only 37 patients met the inclusion criteria (i.e. treated with PD at the time of renal volume reduction) and were included in the study (21 embolized and 16 nephrectomized). Permanent switch to HD was observed in 6 embolized patients (28.6%) versus 11 nephrectomized patients (68.8%) (P = 0.0001). Renal artery embolization was associated with better technique survival: subdistribution hazard ratio (SHR) 0.29 [95% confidence interval (CI) 0.12-0.75; P = 0.01]. By multivariate analysis, renal volume reduction by embolization and male gender were associated with a decreased risk of switching to HD. After embolization, a decrease in PD adequacy parameters was observed but no embolized patients required temporary HD; the duration of hospitalization was significantly lower [5 days [interquartile range (IQR) 4.0-6.0] in the embolization group versus 8.5 days (IQR 6.0-11.0) in the surgery group. CONCLUSIONS: Transcatheter renal artery embolization yields better technique survival of PD in ADPKD patients requiring renal volume reduction.

Liver Iron Load Influences Hepatic Fat Fraction in End-Stage Renal Disease Patients on Dialysis: A Proof of Concept Study.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a spectrum of diseases including steatosis, nonalcoholic steatohepatitis (NASH), cirrhosis, and end-stage liver failure. Hepatic iron accumulation has been linked to hepatic fibrosis severity in NASH and NAFLD. Iron overload induced by parenteral (IV) iron therapy is a potential clinical problem in dialysis patients. We analyzed the hypothetical triggering and aggravating role of iron on NAFLD in patients on dialysis. METHODS: Liver iron concentration (LIC) and hepatic proton density fat fraction (PDFF) were analyzed prospectively in 68 dialysis patients by magnetic resonance imaging (MRI). Follow up of LIC and PDFF was performed in 17 dialysis patients during iron therapy. FINDINGS: PDFF differed significantly among dialysis patients classified according to LIC: patients with moderate or severe iron overload had increased fat fraction (PDFF: 7.9% (0.5-14.8%)) when compared to those with normal LIC (PDFF: 5% (0.27-11%)) or mild iron overload (PDFF: 5% (0.30-11.6%); P = 0.0049). PDFF correlated with LIC, and ferritin and body mass index. In seven patients monitored during IV iron therapy, LIC and PDFF increased concomitantly (PDFF: initial 2.5%, final 8%, P = 0.0156; LIC: initial 20 µmol/g, final 160 µmol/g: P = 0.0156), whereas in ten patients with iron overload, PDFF decreased after IV iron withdrawal or major dose reduction (initial: 8%, final: 4%; P = 0.0098) in parallel with LIC (initial: 195 µmol/g, final: 45 µmol/g; P = 0.002). INTERPRETATION: Liver iron load influences hepatic fat fraction in dialysis patients. Iron overload induced by iron therapy may aggravate or trigger NAFLD in dialysis patients. TRIAL REGISTRATION NUMBER (ISRCTN): 80100088.

[Peritoneal dialysis for acute renal failure: Rediscovery of an old modality of renal replacement therapy]. / Intérêt de la dialyse péritonéale dans le traitement de l'insuffisance rénale aiguë de l'adulte : redécouverte d'une modalité complémentaire d'épuration extracorporelle continue.

Acute renal failure (ARF) in adults in the intensive care unit (ICU) often evolves in a context of multiple organ failure, which explains the high mortality rate and increase treatment needs. Among, two modalities of renal replacement therapy, peritoneal dialysis (PD) was the first modality used for the treatment of ARF in the 1950s. Today, while PD is generalized for chronic renal failure treatment, its use in the ICU is limited, particularly, due to the advent of new hemodialysis techniques and the development of continuous replacement therapy. Recently, a renewed interest in the use of PD in patients with ARF has manifested in several emerging countries (Brazil, Vietnam). A systematic review in 2013 showed a similar mortality in ARF patients having PD (58%) and those treated by hemodialysis or hemodiafiltration/hemofiltration (56.1%). In the International society of peritoneal dialysis (ISPD)'s guideline (2013), PD may be used in adult ARF as the other blood extracorporeal epuration technics (recommendation with grade 1B). PD is the preferred method in cardiorenal syndromes, in frailty patients with hemodynamic instability and those lacking vascular access; finally PD is also an option in elderly and patients with bleeding tendency. In industrial countries, high volume automated PD with a flexible catheter (usually Tenckhoff) is advocated.

[Focusing on peritoneal dialysis adequacy]. / Adéquation en dialyse péritonéale : mise au point.

The optimal method to assess the adequacy of peritoneal dialysis therapies is controversial. Today, the adequacy must not be considered as a number or a concept assessed only by two parameters (total KT/V urea and total solute clearance) but defined by many more items. In the absence of data, based on theoretical considerations, the reanalysis of the CANUSA study showed that renal kidney function, rather than peritoneal clearance, was associated with improved survival. Residual renal function is considered as a major predictor factor of cardiovascular mortality. Results of this reanalysis were supported by the adequacy data in ADEMEX, EAPOS and ANZDATA studies. Therefore, clinical assessment plays a major role in PD adequacy. The management of fluid balance, the regular monitoring of malnutrition, the control of mineral metabolism and particularly the glucose load, considered as the "corner-stone" of the system, are the main points to be considered in the adequacy of PD patients. The essential goal is to minimize glucose load by glucose-sparing strategies in order to reduce the neoangiogenesis of the peritoneal membrane.

The beneficial influence on the effectiveness of automated peritoneal dialysis of varying the dwell time (short/long) and fill volume (small/large): a randomized controlled trial.

BACKGROUND: It is well known that the efficiency of peritoneal dialysis (PD) varies with the duration of the dwell and with the prescribed fill volume. Automated PD (APD) is classically given as a series of recurrent exchanges, each having the same dwell time and fill volume-that is, conventional APD (APD-C). We propose a new way of giving PD, using a modified version of APD-C. This method first uses a short dwell time with a small fill volume to promote ultrafiltration (UF) and subsequently uses a longer dwell time and a larger fill volume to promote removal of uremic toxins from the blood. We use the term "adapted APD" (APD-A) to describe this modified form of PD. METHODS: We designed a multicenter prospective randomized crossover trial to assess the impact of APD-A in comparison with APD-C on the efficacy of dialysis. The parameters investigated were overnight UF; weekly peritoneal Kt/V(urea); weekly peritoneal creatinine clearance corrected to 1.73 m(2) body surface area (K(creat)); and phosphate (PDR) and sodium dialytic removal (SDR) in millimoles per session, corrected for glucose absorption, which provides an estimate of metabolic cost. Blood pressure was also regularly monitored. Initially, 25 patients were identified for inclusion in the study. There were 6 withdrawals in total: 2 at enrolment, 1 at day 75 (transplantation), 2 at day 30 (catheter dysfunction), and 1 for drainage alarms. All patients received the same duration of overnight APD, using the same total volume of dialysate, with the same 1.5% glucose, lactate-buffered dialysate (Balance: Fresenius Medical Care, Bad Homburg, Germany). RESULTS: Tolerance was good. Compared with APD-C, APD-A resulted in a significant enhancement of Kt/V(urea), K(creat), and PDR. The metabolic cost, in terms of glucose absorption, required to achieve dialytic capacity for urea, creatinine, and phosphate blood purification was significantly lower for APD-A than for APD-C, and UF increased during APD-A. With APD-A, each gram of glucose absorbed contributed to 18.25 ± 15.82 mL UF; in APD-C, each gram of glucose absorbed contributed to 15.79 ± 11.24 mL UF. However, that difference was not found to be significant (p=0.1218). The SDR was significantly higher with APD-A than with APD-C: 35.23 ± 52.00 mmol and 18.35 ± 48.68 mmol per session respectively (p<0.01). The mean blood pressure recorded at the end of each PD period (on day 45) was significantly lower when patients received APD-A than when they received APD-C. CONCLUSIONS: Our study provides evidence that, compared with the uniform dwell times and fill volumes used throughout an APD-C dialysis session, the varying dwell times and fill volumes as described for an APD-A dialysis session result in improved dialysis efficiency in terms of UF, Kt/V(urea), K(creat), PDR, and SDR. Those results were achieved without incurring any extra financial costs and with a reduction in the metabolic cost (assessed using glucose absorption).

Rapid curbing of a vancomycin-resistant Enterococcus faecium outbreak in a nephrology department.

BACKGROUND AND OBJECTIVES: Vancomycin-resistant enterococci (VRE) are recovered with increasing frequency among patients with chronic renal failure, making VRE a major concern in nephrology departments, especially for patients who are treated by hemodialysis. We report herein the successful aggressive management of a VRE outbreak in a nephrology department. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: An Enterococcus faecium vanB strain was isolated from a peritoneal dialysis solution from an inpatient. Immediately, infection control measures were enforced and active screening was performed for all contact patients. Carriers were isolated, and patients were divided into three cohorts: Positive, contact, and noncontact patients. We then performed a case-control study to understand risk factors for VRE carriage comparing VRE carriers with contact patients who were negative for VRE. RESULTS: A total of 14 VRE-positive and 125 VRE-negative contact patients were identified. VRE-positive patients were more likely to receive hemodialysis and have longer hospital stays in nephrology. VRE-positive patients more often had a central venous catheter for a longer period of time and received more antibiotics than VRE-negative patients. Treatment with large-spectrum beta-lactams and number of days in the nephrology ward were significantly associated with a higher risk for VRE carriage by using multivariate analysis. CONCLUSIONS: These findings suggest that case mix, longer hospital stays, and antibiotic use are major risk factors for VRE acquisition. In addition, it demonstrates that strict enforcement of isolation precautions and cohorting associated with active screening are successful to curb the transmission of VRE in renal units despite continuous colonization pressure.

A combined crystalloid and colloid pd solution as a glucose-sparing strategy for volume control in high-transport apd patients: a prospective multicenter study.

BACKGROUND: Evidence is accumulating that the continuous exposure to high glucose concentrations during peritoneal dialysis (PD) is an important cause of ultrafiltration (UF) failure. The cornerstone of prevention and treatment of UF failure is reduction of glucose exposure, which will also alleviate the systemic impact of significant free glucose absorption. The challenge for the future is to discover new therapeutic strategies to enhance fluid and sodium removal while diminishing glucose load and exposure using combinations of available osmotic agents. OBJECTIVES: To investigate in patients on automated PD (APD) with a fast transport pattern whether there is a glucose-sparing advantage to replacing 7.5% icodextrin (ICO) during the long dwell with a mixed crystalloid and colloid PD fluid (bimodal UF) in an attempt to promote daytime UF and sodium removal while diminishing the glucose strength of the dialysate at night. DESIGN: A 2 parallel arm, 4 month, prospective nonrandomized study. SETTING: PD units or university hospitals in 4 French and Belgian districts. RESULTS: During the 4-month intervention period, net UF and peritoneal sodium removal during the long dwell when treated by bimodal UF was about 2-fold higher than baseline (with ICO). The estimated percent change (95% confidence interval) from baseline in net daytime UF for the bimodal solution was 150% (106% - 193%), versus 18% (-7% - 43%) for ICO (p < 0.001). The estimated percent change from baseline in peritoneal sodium removal for the bimodal solution was 147% (112% - 183%), versus 23% (-2% - 48%) for ICO (p < 0.001). The estimated percent change from baseline in UF efficiency (24-hour net UF divided by the amount of glucose absorbed) was significantly higher (p < 0.001) when using the bimodal solution was 71%, versus -5% for ICO. CONCLUSION: Prescription of bimodal UF during the day in APD patients offers the opportunity to optimize the long dwell exchange in a complete 24-hour APD cycle. The current study demonstrated that a bimodal solution based on the mixing of glucose (2.6%) and icodextrin (6.8%) achieved the double target of significantly improving UF and peritoneal sodium removal by exploring a new concept of glucose-sparing PD therapy.

[Peritoneal access: the nephrologist's viewpoint]. / L'accès péritonéal : le point de vue du néphrologue.

The frequency of transfers from peritoneal dialysis to haemodialysis secondary to the catheter-related complications has been estimated between eight to 20% depending the countries. Therefore, it is recommended that the insertion of peritoneal dialysis catheters be made by competent and experienced operators. Indeed, despite the development of new insertion techniques and the availability of new sophisticated catheters, the major prognostic factor remains the quality of the surgical procedure and the postoperative care. As regards the choice between various catheters, there is no consensus for the superiority of one in comparison with others. However it should be noted that a catheter survival rate from 80 to 90% at one year is a recognized index of quality.

[Peritoneal dialysis as prime treatment for diabetic patient with ESRD]. / La dialyse péritonéale comme traitement de choix du diabétique insuffisant rénal chronique.

In all countries, the number of diabetic patients with end stage renal disease is growing. The question is whether this mode of therapy is the most appropriate for uremic diabetics. The superiority of any type replacement renal therapy (RRT) over another cannot be unequivocally proven in the absence of a truly random long-term prospective study, which for obvious reasons, has not and probably will not be carried out. Today, the decision on the final choice is indeed dependant on patient preferences, medical factors, physician's biais, local facilities and financial aspects. If in most centers, survival analysis results performed in Europe and in North America regarding diabetic patients RRT are conflicting, the interpretation of comparisons of survival rates published in different studies must be treated with great caution. Nevertheless, if diabetic patients survival is significantly lower than that of non diabetic patients independently of the technique chosen there is no argument to assess that survival at 2 years of diabetic patients aged less 55 years is better on PD than on HD. There is no argument to assess that survival at 2 years of diabetic patients aged more 55 years is better or less appropriate on PD than on HD, excepted in the North America where survival seems to be less appropriate on PD. The present report summarizes the major advantages and drawbacks of the PD method in insulin treated diabetic patients.

Do health causal attributions and coping strategies act as moderators of quality of life in peritoneal dialysis patients?

OBJECTIVE: The present study aimed at testing the relationships between health causal attribution and coping mechanisms with quality of life (QOL) in patients who have end-stage renal disease (ESRD) undergoing a peritoneal dialysis (PD) treatment. It was hypothesized that QOL should be negatively associated with the severity of the disease. Problem-focused coping, internal health-related locus of control (HRLOC) and medical power HRLOC were hypothesized as positive moderators preserving a better QOL, after controlling for the severity of the disease. METHODS: A total of 47 PD patients completed the Kidney Disease Quality of Life (KD-QOL) scale encompassing the Medical Outcomes Study Short-Form (MOS SF-36) self-administered questionnaire, the Multidimensional Health Locus of Control scale and the Ways of Coping Check-List (WCCL) scale. RESULTS: Low scores for all QOL scores were found except for pain dimension, as compared with scores available from a general French population. Globally, QOL was not related to the severity of the disease. Univariate analysis showed that the physical component score (PCS) of QOL was positively associated with internal HRLOC (r=.35; P<.05), and negatively with medical power HRLOC (r=-.36; P<.05). Multivariate analysis adjusting for age confirmed these results. Mental component score (MCS) was negatively associated with the use of emotion-focused coping and seeking social support (r=-.45; P=.001 and r=-.30; P<.05, respectively), the first association persisting in multivariate analysis. Neither PCS nor MCS was linked to the use of problem-focused coping. CONCLUSION: These results suggest that physical QOL is all the more preserved when patients are more convinced that their behaviour can influence their health condition and that psychological QOL is all the more impaired when health condition is perceived as less controllable, requiring emotion-focused coping (avoidance strategies). Health causal attributions and coping act respectively as moderators of physical and psychological components of QOL.

Continuous flow peritoneal dialysis: assessment of fluid and solute removal in a high-flow model of "fresh dialysate single pass".

BACKGROUND: Growing concern over the limited capacity of the peritoneal dialysis (PD) system has revived interest in continuous flow peritoneal dialysis (CFPD), a modality in which continuous circulation of PD fluid is maintained at a high flow rate using two separate catheters or one dual-lumen catheter. The CFPD regimen contrasts the "inflow/outflow" regimen, which requires specific times devoted to filling and draining the peritoneum via a single-lumen catheter. Historical data established CFPD capabilities in providing higher solute clearance and ultrafiltration rate (UFR) using either an open loop system with a single pass of fresh PD fluid, or various external purifications of the spent dialysate. OBJECTIVE: To compare, in patients with various peritoneal transport patterns, fluid and solute removal achieved during a standardized program of CFPD versus two control schedules: nightly intermittent peritoneal dialysis (NIPD) and nightly tidal peritoneal dialysis (NTPD). This study focused on small solute clearances and UFR using only isotonic PD solution (Dianeal PD1 1.36%; Baxter Healthcare, Castlebar, Ireland). The model of fresh dialysate, single pass, was used to optimize solute gradients and to characterize the impact of a continuous flow regimen on peritoneal transport characteristics. METHODS: In a crossover trial, 4-hour CFPD sessions were performed at a fixed dialysate flow rate (100 mL/ minute) in 5 patients being treated with automated PD. A hemofiltration monitor (BM25; Baxter Healthcare, Brussels, Belgium) was adapted to the CFPD technique. The peritoneal cavity was filled through a temporary second catheter and simultaneously drained using the permanent peritoneal access. Fluid and solute removal were compared to data obtained from a control period based on 8-hour sessions of NIPD or NTPD using 13 L of isotonic dialysate. RESULTS: High-flow CFPD enhanced the diffusive transport coefficient compared with the alternative flow regimen in patients ranging from low to high transporters. Weekly creatinine clearance increased from 36.9 L (22.3 - 49.6 L) and 37.3 L (27.5 - 45.0 L) with NIPD and NTPD respectively, to 74.9 L (42.3 - 107.5 L) with CFPD. Mean UFR was 2.44 mL/min with CFPD versus 0.92 and 0.89 mL/min with NIPD and NTPD respectively. The mass transfer area coefficient (MTAC) of creatinine with CFPD was 2.5-fold that obtained from the peritoneal equilibration test data. CONCLUSION: Our results confirm that CFPD is highly effective in increasing fluid and solute removal. Furthermore, consistent with historical data, our findings indicate that the enhanced solute transfer is not due only to steeper solute gradients, but also depends on increased MTAC in a wide range of peritoneum transport characteristics.

[The EPO beta injection pen in patients in maintenance dialysis or predialysis: acceptability, satisfaction and cost assessment]. / Le stylo injecteur d'EPO beta chez les patients dialysés: acceptabilité, satisfaction et bilan économique.

OBJECTIVE: This study was aimed at evaluating the acceptability and economic impact of the utilisation of Reco-Pen, an injection pen equipped with cartridges in patients requiring treatment with recombinant human erythropoietin (rHu-EPO). METHOD: A random sample of 124 patients in maintenance dialysis or in pre-dialysis were enrolled in 42 French centres in 2001. 87% of patients were in maintenance therapy and the rest in correction phase. A nurse was dedicated in each centre to educate and assist the patients during the whole study period (2 months). The economic analysis compared the treatment costs in the subgroup of 108 patients already treated at inclusion. RESULTS: The satisfaction scores were positive in 80% of patients in terms of improved autonomy and comfort and 93% declared themselves ready to continue using the pen. After a mean 2-month period of follow up, the self-injection rates rose from 21 to 53%. ECONOMICAL SYNTHESIS: The switch to Reco-Pen of 100 patients in maintenance therapy was associated with a total savings of 22,449 Euro, decomposed as follows: 18,725 Euro corresponding to savings in rHu-EPO, 3,500 Euro corresponding to the non-reimbursed honoraria of the private nurses, and 224 Euro in productivity savings in time spent by the centres' nurses, i.e. an accumulation of 10.4 hours.