IVF outcomes in patients with a history of bariatric surgery: a multicenter retrospective cohort study.

STUDY QUESTION: How does a history of dramatic weight loss linked to bariatric surgery impact IVF outcomes? SUMMARY ANSWER: Women with a history of bariatric surgery who had undergone IVF had a comparable cumulative live birth rate (CLBR) to non-operated patients of the same BMI after the first IVF cycle. WHAT IS KNOWN ALREADY: In the current context of increasing prevalence of obesity in women of reproductive age, weight loss induced by bariatric surgery has been shown to improve spontaneous fertility in obese women. However, little is known on the clinical benefit of bariatric surgery in obese infertile women undergoing IVF. STUDY DESIGN, SIZE, DURATION: This exploratory retrospective multicenter cohort study was conducted in 10 287 IVF/ICSI cycles performed between 2012 and 2016. We compared the outcome of the first IVF cycle in women with a history of bariatric surgery to two age-matched groups composed of non-operated women matched on the post-operative BMI of cases, and non-operated severely obese women. PARTICIPANTS/MATERIALS, SETTING, METHODS: The three exposure groups of age-matched women undergoing their first IVF cycle were compared: Group 1: 83 women with a history of bariatric surgery (exposure, mean BMI 28.9 kg/m2); Group 2: 166 non-operated women (non-exposed to bariatric surgery, mean BMI = 28.8 kg/m2) with a similar BMI to Group 1 at the time of IVF treatment; and Group 3: 83 non-operated severely obese women (non-exposed to bariatric surgery, mean BMI = 37.7 kg/m2). The main outcome measure was the CLBR. Secondary outcomes were the number of mature oocytes retrieved and embryos obtained, implantation and miscarriage rates, live birth rate per transfer as well as birthweight. MAIN RESULTS AND THE ROLE OF CHANCE: No significant difference in CLBR between the operated Group 1 patients and the two non-operated Groups 2 and 3 was observed (22.9%, 25.9%, and 12.0%, in Groups 1, 2 and 3, respectively). No significant difference in average number of mature oocytes and embryos obtained was observed among the three groups. The implantation rates were not different between Groups 1 and 2 (13.8% versus 13.7%), and although lower (6.9%) in obese women of Group 3, this difference was not statistically significant. Miscarriage rates in Groups 1, 2 and 3 were 38.7%, 35.8% and 56.5%, respectively (P = 0.256). Live birth rate per transfer in obese patients was significantly lower compared to the other two groups (20%, 18%, 9.3%, respectively, in Groups 1, 2 and 3, P = 0.0167). Multivariate analysis revealed that a 1-unit lower BMI increased the chances of live birth by 9%. In operated women, a significantly smaller weight for gestational age was observed in newborns of Group 1 compared to Group 3 (P = 0.04). LIMITATIONS, REASONS FOR CAUTION: This study was conducted in France and nearly all patients were Caucasian, questioning the generalizability of the results in other countries and ethnicities. Moreover, 950 women per group would be needed to achieve a properly powered study in order to detect a significant improvement in live birth rate after bariatric surgery as compared to infertile obese women. WIDER IMPLICATIONS OF THE FINDINGS: These data fuel the debate on the importance of pluridisciplinary care of infertile obese women, and advocate for further discussion on whether bariatric surgery should be proposed in severely obese infertile women before IVF. However, in light of the present results, infertile women with a history of bariatric surgery can be reassured that surgery-induced dramatic weight loss has no significant impact on IVF prognosis. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by unrestricted grants from FINOX-Gédéon Richter and FERRING Pharmaceuticals awarded to the ART center of the Clinique Mathilde to fund the data collection and the statistical analysis. There are no conflicts of interest to declare. TRIAL REGISTRATION NUMBER: NCT02884258.

[The Confusion Assessment Method: Transcultural adaptation of a French version]. / Adaptation transculturelle francophone de la Confusion Assessment Method.

INTRODUCTION: The Confusion Assessment Method (CAM) is a validated key tool in clinical practice and research programs to diagnose delirium and assess its severity. There is no validated French version of the CAM training manual and coding guide (Inouye SK). The aim of this study was to establish a consensual French version of the CAM and its manual. METHODS: Cross-cultural adaptation to achieve equivalence between the original version and a French adapted version of the CAM manual. RESULTS: A rigorous process was conducted including control of cultural adequacy of the tool's components, double forward and back translations, reconciliation, expert committee review (including bilingual translators with different nationalities, a linguist, highly qualified clinicians, methodologists) and pretesting. A consensual French version of the CAM was achieved. CONCLUSION: Implementation of the CAM French version in daily clinical practice will enable optimal diagnosis of delirium diagnosis and enhance communication between health professionals in French speaking countries. Validity and psychometric properties are being tested in a French multicenter cohort, opening up new perspectives for improved quality of care and research programs in French speaking countries.

Simultaneous vitality and DNA-fragmentation measurement in spermatozoa of smokers and non-smokers.

BACKGROUND: Because cigarette smoke is a powerful ROS producer, we hypothesized that the spermatozoa of smokers would be more at risk of having increased DNA fragmentation than spermatozoa of non-smoking men. METHODS: A cross-sectional study was performed on consenting smokers and non-smokers, consulting in an infertility clinic for routine sperm analysis. The application of a novel TUNEL assay coupled to a vitality marker, LIVE/DEAD®, allowed both DNA fragmentation and viability measurement within spermatozoa of participants to be analyzed by flow cytometry. RESULTS: The coupled vitality-DNA fragmentation analysis revealed that non-smokers and smokers, respectively presented medians of 3.6% [0.6-36.8] and 3.3% [0.9-9.6] DNA fragmented spermatozoa among the living spermatozoa population (P > 0.05). CONCLUSION: No deleterious effect of smoking on spermatozoa was found in our study. More studies concerning potential mutagenic capacities of cigarette smoke on spermatozoa are necessary. In addition, the coupled vitality-DNA fragmentation analysis may orient Assisted Reproductive Technology teams when confronted with patients having a high percentage of DNA-fragmented living spermatozoa.

Simultaneous Vitality and DNA-fragmentation measurement in spermatozoa of smokers and non-smokers.

Background: Because cigarette smoke is a powerful ROS producer, we hypothesized that the spermatozoa of smokers would be more at risk of having increased DNA fragmentation than spermatozoa of non-smoking men. Methods: A Cross-Sectional Study was performed on consenting smokers and non-smokers, consulting in an infertility clinic for routine sperm analysis. The application of a novel TUNEL assay coupled to a vitality marker, LIVE/DEAD®, allowed both DNA fragmentation and viability measurement within spermatozoa of participants to be analyzed by flow cytometry. Results: The coupled vitality-DNA fragmentation analysis revealed that non-smokers and smokers respectively presented medians of 3.6% [0.6-36.8] and 3.3% [0.9-9.6] DNA fragmented spermatozoa among the living spermatozoa population (p>0.05). Conclusion: No deleterious effect of smoking on spermatozoa was found in our study. More studies concerning potential mutagenic capacities of cigarette smoke on spermatozoa are necessary. In addition, the coupled vitality-DNA fragmentation analysis may orient Assisted Reproductive Technologies teams when confronted with patients having a high percentage of DNA-fragmented living spermatozoa. © 2014 Clinical Cytometry Society.

[ICU patients and days of intensive care: A mathematical model optimizing the consequences of ICU unit function, intensive care and continual monitoring on incurred supplementary costs]. / Patient de réanimation, journées de réanimation ? Modélisation d'un fonctionnement optimisé des unités de réanimation, de soins intensifs et de surveillance continue et conséquences sur les suppléments tarifaires induits.

INTRODUCTION: "Critical Care Units" are intended to admit patients with multiple organ failure. The severity of patients admitted is variable. The aim of the study was to estimate the number of days that an optimum care organization could release, and therefore the additional admissions that would have been allowed. Estimates of earnings related to the various supplements were carried out jointly. METHODS: Reporting days associated or not with a resuscitation care during the year 2011 in an ICU of a university hospital (16 beds), optimized patient flow simulation, and computation of medical act inducing financial supplements. RESULTS: Six hundred and fifty-seven patients (SAPS II from 0 to 110, 41% ventilated more than 48hours, mortality=26%) were admitted representing 5095days (occupancy rate=87%). Two hundred and twenty-two patients (34%) did not trigger supplement for resuscitation care for 415days in the unit. Four hundred and thirty-five patients have triggered this supplement representing 4680days, including 3035days with resuscitation care and 1645 (35% of days valued resuscitation, 32% of total days) without any. The entire year 2011 has generated earnings of 3,980,192€. Optimization of management would have allowed the admission of additional 235 to 295 patients and potential additional earnings from 524,735€ to 1,063,804€, depending on the occupancy rate chosen (80% or real 2011s) and the severity of discharged patients. CONCLUSION: Optimization of the patients flow between "Critical Care", Intensive Care and Continuous Monitoring Units would increase the number of patients admitted in "Critical Care" Units without any financial loss related to supplements.

Screening for von Willebrand disease: contribution of an automated assay for von Willebrand factor activity.

Measuring von Willebrand factor (VWF) activity is essential to the diagnosis of von Willebrand disease (VWD). The VWF activity is usually assessed based on measurement of the ristocetin cofactor (VWF:RCo). However, that test is technically challenging and has high intra- and inter-assay variabilities. The HemosIL VWF activity (VWF:AC) is a fully automated assay, recently proposed as a good alternative to VWF:RCo for VWD diagnosis. This study was undertaken to assess this new method. First, the analytical performance of VWF:AC on an automated coagulo-meter (ACLTop) was determined, and then this new method was compared with VWF:RCo and the platelet function analyzer (PFA100) for 160 patients referred for VWD screening. The VWF:AC achieved acceptable precision with within-run and between-run coefficients of variation ranging from 2.3% to 14.1%, and linearity from 10% to 100%. Despite some marked differences between VWF:AC and VWF:RCo for 10 plasmas tested, their agreement for VWD diagnosis was good. The VWF:AC had sensitivity similar to that of PFA100 (close to 100%), but better specificity (97.7% vs. 66% or 60%, depending on the cartridge used). The good analytical performance, and the sensitivity and specificity of VWF:AC to detect VWF deficiency renders it a suitable method for VWD screening. Our findings support VWF:AC use for the diagnostic work-up of VWD, paying close attention to concomitant clinical signs and bleeding score, as recommended for VWD.

Hemoglobin level variability in hemodialysis patients treated with epoetin-ß during 1 year.

AIM: This analysis was performed to assess the prevalence and the factors associated with hemoglobin (Hb) variability during treatment with erythropoiesis-stimulating agents (ESA) in France. METHODS: Hb variability was evaluated in a subgroup of hemodialysis (HD) patients of the French cohort DiaNE. Eligible patients had received epoetin-ß at least 6 months before entering DiaNE, 12 months during DiaNE and had no missing monthly Hb measurements. Up and down excursions (Hb variations > 1.5 g/dl with duration > 8 weeks) were assessed. RESULTS: Of the 499 patients evaluated in this analysis, 295 (59%) had Hb levels inside the target range of 11 - 13 g/dl at baseline. The number of patients with constantly stable Hb level inside the target range decreased from baseline to 27.5% at 6 months and 10.8% at 12 months. More than 70% of patients experienced Hb variability. The number of excursions was 1.7 ± 0.8 per patient/year. The amplitude of up excursions was 2.8 ± 1.0 g/ dl with a duration of 14.7 ± 4.7 weeks. The amplitude of down excursions was 2.6 ± 0.9 g/dl with a duration of 14.5 ± 4.6 weeks. The main factors associated with Hb variability were number of epoetin-ß dose changes, adverse events and iron therapy changes. CONCLUSION: Hb variability is frequent in French ESA-treated HD patients and closely related to practices. Further efforts are needed to improve anemia management.

Spectral amplitude and phase measurement of a 40 GHz free-running quantum-dash modelocked laser diode.

We present a linear self-referenced measurement of the spectral amplitude and phase of a free-running quantum-dash modelocked laser diode. The technique is suitable for measuring optical signals with repetition rates up to 100 GHz. In contrast to many other linear techniques it requires no external electronic clock synchronized to the signal under test. Using this method we are able to compensate for the intracavity dispersion of the diode to demonstrate 500 fs pulses at a repetition rate of 39.8 GHz. We also use the technique to characterize the dependence of the diode's intracavity dispersion on the applied current.

Appraising relative and excess mortality in population-based studies of chronic diseases such as end-stage renal disease.

PURPOSE: Modeling excess and relative mortality represents two ways of considering general population mortality rates (ie, background mortality) in cohort studies. Excess mortality is obtained by subtracting the expected mortality from the observed mortality (additive hazard model). Relative mortality is obtained by dividing the observed mortality by the expected mortality (multiplicative hazard model). Our first objective was to compare the results of these two models in a population-based cohort including 5115 dialyzed patients older than 70 years (mean age 79 years, range 70-97 years). Our second objective was to explore an alternative model combining both excess and relative mortality. PATIENTS AND METHODS: Effects of covariates on excess mortality and relative mortality were assessed using a generalized linear model and a Cox model, respectively. The model, combining both excess and relative mortality, is derived from the Aalen model. RESULTS: The effect of age and sex was different according to the additive or multiplicative model used, whereas the effect of the first modality of dialysis or the primary nephropathy was similar. Because there was no evidence of lack of fit, the choice of one of these two models was not obvious. The combined model showed that the two components, additive and multiplicative, had to be kept. In this case, the combined model led to results similar to the pure additive and multiplicative univariate models, except for the method of dialysis, which did not exert an effect on both excess and relative mortality. CONCLUSION: We underlined the complementary interest of modeling excess and relative mortality in looking for factors associated with mortality related to end-stage renal disease. The combined model appeared attractive in offering the possibility of reducing the model to the most appropriate one. When both components have to be retained, it better describes the effect of covariates on excess and relative mortality.

Change in hip fracture incidence over the last 6 years in France.

UNLABELLED: Controversies exist about the change in hip fracture incidence among countries. In France, over the last 6 years, the incidence in people aged 40 years and over of hip fractures decreased in women over 39 years and increased in men; a decrease in the incidence was observed in both genders in the elderly. INTRODUCTION: Controversies exist about the change in hip fracture incidence among countries. The aim of this study was to assess the incidence of hip fractures in men and women aged 40 years and over between 2002 and 2008 in France. METHODS: Data were drawn from the French Hospital National Database. The absolute number of admissions was described and the incidence rates per 1,000,000 adjusted on age (40-59, 60-74; 74-84, and ≥ 85 years), and gender was calculated using the data of the French population. RESULTS: The number of hip fractures increased in men (+13%; from 14,736 in 2002 to 16,611 in 2008) and remained stable in women (+0.2%, 50,910 in 2008). Between 2002 and 2008, the French population increased by 9% in both genders. Incidence over 39 years decreased by 8% in women (3,356 and 3,093 per million in 2002 and 2008, respectively) and increased by 4% in men (1,131 and 1,172 per millions in 2002 and 2008, respectively). An age-specific incidence decrease was found, in particular, in the elderly in both genders (74-84 and ≥ 85 years), most importantly in women. CONCLUSION: Over the last 6 years, the incidence of hip fractures decreased in women aged over 39 years and increased in men aged over 39 years; a decrease in the incidence of these fractures was observed in both genders in the elderly. Such epidemiological data may help policy making, planning resource allocation, and setting up complementary health decisions for the management of osteoporosis.

Hospitalized wrist fractures in France: Incidence and burden trend changes.

INTRODUCTION: The aim of this study was to assess the burden of hospitalized wrist fractures between 2002 and 2006 in France. METHODS: Data were drawn from the French Hospital National Database. The number of admissions and the incidence rates were described as well as the type of entry and discharge from hospital, length of stay, and 2006 in-patients costs. RESULTS: In 2002 and 2006, 38,710 and 38,979 hospitalizations for wrist fractures were registered respectively. The incidence rate of fractures increased with age whatever the year and decreased significantly from 2002 to 2006. Length of stay and mean inpatients costs increased with age. The overall in-patients 2006 costs was 79 millions with an average individual cost of 2100 € per hospitalized wrist fractures. CONCLUSION: The incidence of hospitalizations for wrist fractures decreased in 2006 compared to 2002. The number of hospitalizations increased, as a consequence of ageing, (except for wrist fracture in men), with a subsequent increase in cost related to these fractures. The increase with age outlines the role of underlying osteoporosis and the relevance of appropriate care of patients at risk of for such fractures. LEVEL OF EVIDENCE: IV.

[Methodological and statistical aspects of equivalence and non inferiority trials]. / Aspects méthodologiques et statistiques des essais d'équivalence et de non-infériorité.

BACKGROUND: - The existence of effective reference treatments means that the superior therapeutic efficacy of new treatments is less marked and thus more difficult to demonstrate statistically. Moreover, the potential value of a new treatment is also based on other criteria, such as costs, ease of use, non invasiveness, and immediate or long-term side effects. In this context, methodological issue becomes one of looking for equivalence or non inferiority of the new treatment in comparison with an existing, high-performance reference treatment. METHODS: - In the present work, we reexamine the statistical rational and methodological features of equivalence and non inferiority trials. RESULTS: - We address equivalence margin choice, hypotheses building, and the different approaches for establishing equivalence (hypothesis testing and confidence intervals). We then discuss key aspects of equivalence trial design and the important methodological quality criteria involved in performing such studies: choice of the reference treatment, subject eligibility criteria, primary endpoint, study population and the required sample size. Lastly, we consider the possibility of adopting a new analytical strategy (non inferiority/superiority). CONCLUSION: - A checklist of items to include when reporting the results of randomized controlled trials (Consolidated Standards of Reporting Trials, the CONSORT recommendations) has been adapted for use in non inferiority and equivalence randomized controlled trials.

A prospective study of the evolution of lamivudine resistance mutations in patients with chronic hepatitis B treated with lamivudine.

Lamivudine resistance has been described in subjects with chronic hepatitis B infections, associated with mutations in the viral polymerase gene. The objective of this study was to estimate the emergence rate of lamivudine-resistant viral strains and their consequences over a 2-year period. We evaluated 283 lamivudine-naïve subjects with chronic hepatitis B. Clinical and virological features were assessed at inclusion and every 6 months thereafter. Viral DNA was characterized using polymerase chain reaction (PCR)-based sequencing. Potential risk factors for the emergence of lamivudine resistance mutations were assessed using logistic regression analysis. The annualized incidence rate for viral polymerase mutations was 22%. The only independent risk factor identified was high viral load, at inclusion. Detectable viral DNA and elevated transaminases were more frequent in subjects harbouring mutant viral strains, and these underwent a lower rate of hepatitis B e seroconversion. All subjects responded favourably to treatment, with no difference in symptoms between the two groups. This prospective cohort study identified lamivudine-resistant mutations emerging in 22% of subjects, yearly, which were apparently not associated with clinical aggravation over the study period.

Usefulness of a national hospital database to evaluate the burden of primary joint replacement for coxarthrosis and gonarthrosis in patients aged over 40 years.

OBJECTIVE: To evaluate the 2001 French burden of hospital primary joint replacement (PJR) for coxarthrosis and gonarthrosis. METHODS: Hospital surgical admissions for coxarthrosis and gonarthrosis in people aged over 40 years were selected from the French National Hospital Database. Of the 73,150 and 58,746 admissions for coxarthrosis and gonarthrosis, respectively, only 96 and 73% of them were analysed (exclusion of stays with no respect of coding guidelines). For each, we described the type of osteoarthritis, gender and age group distribution, incidence rate of PJR adjusted on age and gender, the type of joint replacement (total vs partial), the type of hospital (private vs hospital), the mean length of stay (LOS), the percentage of patients transferred to rehabilitation centre and the hospital costs. RESULTS: Whatever the type of osteoarthritis, PJR was mainly performed for primary osteoarthritis, in the 71-80 years' age group, in private hospital, with a total replacement procedure. The mean LOS were 13 and 12 days, and the transfers to a rehabilitation centre were 33 and 44%, for hip and knee, respectively. The incident rate of PJR increased significantly with age. It was higher in the 71-80 years' age group and decreased thereafter, whatever the gender and the type of osteoarthritis. The whole hospital costs were 591 and 411 millions of euros for hip and knee, respectively. CONCLUSION: The French National Hospital Database is a useful tool for assessing the burden of primary PJR for coxarthrosis and gonarthrosis. It might be used for international comparisons.

Dupuytren's disease in France--1831 to 2001--from description to economic burden.

We recorded all elective admissions for Dupuytren's disease from the French National Hospital Database. We used the data from first hospitalizations to calculate the 2001 hospitalization rates for this condition and determine geographical differences between different regions of France. We also calculated the hospital costs of treating admissions with this disease. Fourteen thousand eight hundred and sixty hospitalizations for Dupuytren's disease were reported in France in 2001, of which 93% were for a first treatment. The disease was mostly present in men and was mostly managed by surgical fasciectomy. Most operations were carried out in private hospitals, with a mean stay of 2 days. Geographical differences were found in men only. The total hospital cost for all elective admissions was 14, 179, 998 Euros, indicating the considerable financial burden to the State of treating this condition.

[Knee arthroscopy for gonarthrosis in France in 2001]. / Arthroscopie pour gonarthrose en France en 2001.

PURPOSE OF THE STUDY: The purpose of this study was to describe the number of arthroscopic procedures conducted for gonarthrosis in France in 2001 and to establish the corresponding hospital costs. MATERIAL AND METHODS: The national database of the medicalization program information system (PMSI) which records all public and private hospitalizations was used to identify all arthroscopic procedures performed for gonarthrosis (principal diagnosis=indication for operation). We noted the number of procedures, the type of hospitalization (< 24h vs > or = 24h), hospital sector (private vs public), associated diagnoses involving the knee, interventions, and hospital cost (using the 2004 schedule). We compared these data with hospitalizations for arthroscopy where gonarthrosis was noted as an associated diagnosis (secondary diagnosis). RESULTS: In 2001, a total of 148,870 hospitalizations were recorded (4,059 for gonarthrosis and 5755 with a secondary diagnosis of gonarthrosis). The 9814 arthroscopies performed were mainly in persons aged over 50 years with meniscal lesions, hospitalized for > 24 h, in the private sector, with joint wash-out and meniscectomy and/or removal of a foreign body. Significantly more meniscal conditions and joint wash-out with meniscectomy and/or removal of a foreign body were observed when gonarthrosis was the secondary diagnosis. The mean hospital cost was 1724 +/- 501 euros and 501 +/- 623 euros for gonarthrosis as the primary and secondary diagnosis respectively. The overall hospital cost for all arthroscopic procedures was 15,644,225 euros. CONCLUSION: The national database (PMSI) can be used as a complementary tool to help in the evaluation of arthroscopic procedures associated with gonarthrosis.

Efficacy and tolerability of acetazolamide in migraine prophylaxis: a randomised placebo-controlled trial.

BACKGROUND: Familial hemiplegic migraine and episodic ataxia type 2 (EA2) are allelic disorders with distinct types of mutations in the CACNA1A gene. EA2 attacks are remarkably sensitive to acetazolamide, a carbonic anhydrase inhibitor. The effectiveness of acetazolamide in migraine prophylaxis is unknown. OBJECTIVES: To evaluate the efficacy and the tolerability of acetazolamide in migraine prophylaxis. METHODS: We compared daily oral 500 mg acetazolamide and placebo in patients with migraine in a multicentre, double-blind, randomised trial of 12 weeks duration after a run-in period of 4 weeks without treatment. Frequency of attacks at the last trial period of 4 weeks was the primary efficacy criterion. Secondary efficacy criteria were the frequency of attacks per 4 weeks, the severity and duration of attacks, the number of hours with migraine as well as the number of responders with more than 50% reduction in attack frequency. RESULTS: 53 patients had been enrolled when the study was prematurely stopped because of a high number of withdrawals (34%), primarily linked to acetazolamide related side effects. Considering the primary and secondary efficacy criteria, among the 53 included patients (27 in the placebo group and 26 in the acetazolamide group), no difference between the 2 study groups could be demonstrated. The most frequent adverse events related to acetazolamide were paresthesias and asthenia. CONCLUSIONS: In this trial, migraine sufferers poorly tolerated acetazolamide given in an oral dose of 500 mg daily. No obvious prophylactic beneficial effect of acetazolamide appeared on migraine attacks.

[Epidemiology of care demands]. / Epidémiologie de la demande de soins.

SOME FIGURES: Terminal renal failure (TRF) is a major public health problem in France in view of its increasing incidence (110 pmi/year), prevalence (700 pmi) and the costs of treatments supplied. In France, more than 6,500 new patients started treatment for TRF in 2001; around 42,000 patients with renal failure have been treated. The mean cost of treatment per patient is estimated to be of 350 KF per annum for dialysis, 450 KF for transplantation the first year and 50 KF per annum thereafter. Hence, more than 10 billion francs are spent every year on treating TRF, i.e., 1.5% of the Health Scheme. However, these costs do not include expensive treatments (erythropoietin), transport or hospitalisation. RECENT TENDENCIES: Our information system concerning TRF is fragmented and not coordinated. Identification of the cases is incomplete, their declaration is not always systematic and the quality control of the data has not been formalized. Nonetheless, major tendencies can be identified. The notable facts of the last 10 years are an aging TRF population and an increase in associated comorbidity. The diseases leading to TRF are changing. Vascular nephropathies predominate; ischemic renal diseases have become the first cause of TRF in elderly patients. The incidence of type 2 diabetes is increasing and strangely in the French overseas territories. Glomerular nephropathies are the third cause of TRF, particularly in the young. However, compared with other causes, their prevalence is decreasing. INSUFFICIENCIES: The morbidity and mortality with dialysis is dominated by cardiac and vascular causes. Renal transplantation has stagnated; the waiting lists increase and donations are insufficient. Conversely, transplantation survival is progressing. In a second part, we will examine the elements of health strategy necessary to adapt the supply of care and the organization of preventive measures.