Individual and regional factors of access to the renal transplant waiting list in france in a cohort of dialyzed patients.

Several studies have investigated geographical variations in access to renal transplant waiting lists, but none has assessed the impact on these variations of factors at both the patient and geographic levels. The objective of our study was to identify medical and non-medical factors at both these levels associated with these geographical variations in waiting-list placement in France. We included all incident patients aged 18-80 years in 11 French regions who started dialysis between January 1, 2006, and December 31, 2008. Both a multilevel Cox model with shared frailty and a competing risks model were used for the analyses. At the patient level, old age, comorbidities, diabetic nephropathy, non-autonomous first dialysis, and female gender were the major determinants of a lower probability of being waitlisted. At the regional level, the only factor associated with this probability was an increase in the number of patients on the waiting list from 2005 to 2009. This finding supports a slight but significant impact of a regional organ shortage on waitlisting practices. Our findings demonstrate that patients' age has a major impact on waitlisting practices, even for patients with no comorbidity or disability, whose survival would likely be improved by transplantation compared with dialysis.

Optimized convective transport with automated pressure control in on-line postdilution hemodiafiltration.

PURPOSE: In a stable patient population we evaluated on-line postdilution hemodiafiltration (HDF) on the incremental improvement in blood purification versus high-flux HD, using the same dialyzer and blood flow rate. For HDF we used a new way of controlling HDF treatments based on the concept of constant pressure control where the trans-membrane pressure is automatically set by the machine using a feedback loop on the achieved filtration (HDF UC). METHODS: We enrolled 20 patients on on-line HDF treatment and during a 4-week study period recorded key treatment parameters in HDF UC. For one mid-week study treatment performed in HD and one midweek HDF UC treatment we sampled blood and spent dialysate to evaluate the removal of small- and middle-sized solutes. RESULTS: We achieved 18+/-3 liters of ultrafiltration in four-hour HDF UC treatments, corresponding to 27+/-3% of the treated blood volume. That percentage varied by patient hematocrit level. The ultrafiltration amounted to 49+/-4% of the estimated plasma water volume treated. We noted few machine alarms. For beta2m and factor D the effective reduction in plasma level by HDF (76+/-6% and 43+/-9%, respectively) was significantly greater than in HD, and a similar relation was seen in mass recovered in spent dialysate. Small solute removal was similar in HDF and HD. Albumin loss was low. CONCLUSION: The additional convective transport provided by on-line HDF significantly improved the removal of middle molecules when all other treatment settings were equal. Using the automated pressure control mode in HDF, the convective volume depended on the blood volume processed and the patient hematocrit level.

[Spontaneous skin necrosis from acquired protein S deficiency in a renal transplant recipient]. / Nécrose cutanée spontanée par déficit auto-immun en protéine S chez un transplanté rénal.

INTRODUCTION: Spontaneous skin necrosis revealed acquired protein S deficiency due to isotype G autoantibodies. CASE: This 31-year-old male renal transplant recipient, receiving immunosuppressive treatment, was hospitalized for necrotic purpural lesions. We were not able to detect any triggering factor. Sustained anticoagulant therapy remained essential to prevent new skin lesions and perhaps more thrombotic events. COMMENTS: This condition is rare in adulthood, but is well described in children's purpura fulminans, especially the post-varicella form. Its mechanism remains unclear.

[Natural history of vascular ports for hemodialysis after renal transplantation]. / Histoire naturelle des abords vasculaires pour l'hémodialyse après transplantation rénale.

INTRODUCTION: The objective of this study was to assess the long-term outcome of AV shunts in renal transplant recipients, to discuss mechanisms affecting their functioning and the surgical strategy designed to optimally preserve the venous capital in the hypothesis of a return to dialysis. MATERIALS AND METHODS: 160 renal transplant recipients, with a mean age of 47 years, were reviewed. AV shunts were performed at the wrist in 95% of cases and in the cubital fossa in 13% of cases. The AV shunt had been performed an average of 29 months before renal transplantation. RESULTS: 62% of AV shunts were considered to be functional with a mean follow-up of 69 months after transplantation and 95 months after creation. The intraoperative and early and late postoperative thrombosis rates were 6%, 7.5% and 17%, respectively. The AV shunt was subsequently closed in 12 patients (7.5%). CONCLUSION: Native distal AV shunts, although not used after renal transplantation, have a prolonged survival. The main risk is thrombosis which can be prevented intraoperative and perioperatively. These results encourage a conservative attitude to all well tolerated AV shunts.

[Central venous access for hemodialysis. Dysfunctions: role of the nephrologist]. / Accès veineux centraux pour hémodialyse. Dysfonctionnements: rôle du néphrologue.

Central venous catheter for chronic hemodialysis can present primary or secondary dysfunctions. The first are related to malpositions or kinking, diagnosis is radiological. A postoperative chest radiography has to be done, but during the first session an initial evaluation of the catheter functioning is useful: a 'pressions test' (recording of arterial depression and venous counter-pression for progressively increasing blood flow) and recirculating test have to be performed. Later, clotting or thrombosis of catheter are often involved, detection and management are different according to the type of manifestations and to the moment of occurrence (when aspiration of residual heparin or when initiating dialysis). Fibrinolytics are often used. Catheter fissuration and leak are also frequent, often on the external extremity of adaptator, occasionally on the proximal extremity, exceptionally on the catheter itself. management is according to location of the fissuration, but there are always infectious and hemorrhagic risks during manipulations and changing of the external adaptor. Prevention of these dysfunctions is imperative, it depends on a strict follow-up and good practices.

[Improvement of hemorheologic parameters in hemodialyzed patients treated with human recombinant erythropoietin]. / Amélioration des paramètres hémorhéologiques chez les patients hémodialysés traités par érythropoiétine humaine recombinante.

Recombinant human erythropoietin (rhu EPO) is the choice treatment of dialytic anemia; however, this therapy has side effects due to the increased number of blood components involved. It seemed to us worth assessing, by hemorheological study, the impact of such a treatment on blood flow properties, already impaired in this type of patients. This study was designed to measure the evolution of hemorheological parameters in 16 hemodialysed patients before and after 2.3 and 6 months of treatment with rhu EPO. Hemorheological work-ups included: erythrocyte filtration with a hemorheometer; blood and plasma viscosities (LS30), ATP and 2.3 DPG, RBC aggregation (Sefam erythroaggregameter), RBC morphology under a scanning electron microscope; blood counts and full biochemical work-ups were performed to explore renal function. The results showed, besides a significant increase in hemoglobin: normalized rigidity index, reflecting the better deformability of erythrocytes; a moderate increase in blood viscosity with uncorrected hematocrit, becoming significant after 6 months of treatment. This increase however did not reach the values that could be expected with the increased hematocrit (it was probably balanced by improved erythrocyte deformability, which is confirmed by the fact that with corrected hematocrit, blood viscosity decreases during treatment). Studying erythrocyte aggregation in hemodialysed patients reveals, in the absence of any treatment, a decrease in aggregation time and a higher dissociation threshold, which reflects a tendency to erythrocyte hyperaggregation enhanced by erythropoietin.(ABSTRACT TRUNCATED AT 250 WORDS)