Relationship between night work and health-related quality of life: an analysis based on profiles and cumulative duration of exposure to night work among French workers in the CONSTANCES cohort.

OBJECTIVE: The aim of this study is to estimate the association between night work and health-related quality of life (HRQoL) among French workers. The association between cumulative duration of night work and HRQoL was also investigated. METHODS: Three career-long night work exposure groups were defined at inclusion in the CONSTANCES cohort: permanent night workers, rotating night workers and former night workers. Day workers with no experience of night work were the reference group. HRQoL was assessed using the Short Form Health Survey (SF-12), in particular the physical component summary (PCS) and mental component summary (MCS) scores, with a higher score indicating better HRQoL. Several linear regression models were built to test the association between night work exposure and HRQoL. The relationship between cumulative duration of night work and HRQoL scores was analyzed using generalised additive models. RESULTS: The sample consisted of 10,372 participants. Former night workers had a significantly lower PCS score than day workers (ß [95% CI]: - 1.09 [- 1.73; - 0.45], p = 0.001), whereas permanent night workers had a significantly higher MCS score (ß [95% CI]: 1.19 [0.009; 2.36], p = 0.048). A significant decrease in PCS score from 5 to 20 years of cumulative night work was observed among former night workers. CONCLUSIONS: Former night workers had poorer physical HRQoL in contrast to permanent and rotating night workers who had similar or even better HRQoL than day workers, suggesting the well-known healthy worker survivor effect. Consequently, both current and former night workers require regular and specific follow-up focused on the physical components of their health.

Low Back Pain and Upper-Extremity Musculoskeletal Disorders in French Postal Workers Driving Light-Duty Vehicles for Mail and Parcel Delivery.

Occupational driving of light-duty vehicles (LDVs) became increasingly important in parcel delivery faced with the explosive growth of e-commerce. Since musculoskeletal disorders (MSDs) represent the most reported driving-related health problem, we aimed to analyze the risk of low back pain (LBP) and upper-extremity musculoskeletal disorders (UEMSDs) associated with driving LDVs for parcel delivery. In 306 postal workers exposed to driving and 100 unexposed workers, information on occupational driving, physical/psychosocial constraints, and work organization were collected via a questionnaire. MSDs were assessed using the Nordic Questionnaire, 14 additional questions regarding LBP, and a standardized clinical examination for UEMSDs. Statistical modeling consisted of multivariable logistic regression for UEMSDs and the item response theory approach for LBP. UEMSDs were associated with the distance of rural rounds and inversely associated with urban/mixed delivery rounds. Handling heavy loads was associated with LBP, and high physical demands during delivery rounds were related to MSDs. Karasek dimensions and mobbing actions were associated with MSDs. Work recognition, driving training, using an automatic gearbox, and the utilization of additional staff during peak periods were inversely associated with MSDs. Our results suggest that the distance driven in rural settings and high physical demands were associated with MSDs, while some organizational factors could protect from MSDs.

What do we know about the effect of night-shift work on cardiovascular risk factors? An umbrella review.

Objective: To evaluate the existing evidence on the effect of night-shift work and its subtypes (permanent and rotating) on cardiovascular risk factors: diabetes, lipid disorders, being overweight, hypertension, smoking habits, sedentariness, and occupational psychosocial stressors. Method: A Web of Sciences and Cochrane review library search was conducted to identify systematic reviews with or without meta-analysis dealing with the quantification of the link between night-shift work and the studied cardiovascular risk factors in working populations. We used the AMSTAR 2 to evaluate the quality of each review. The main results of the included systematic reviews were compiled in a summary structured around the different cardiovascular risk factors. Results: After selection, 33 systematic reviews were included: nine for diabetes, four for lipid disorders, nine for being overweight, four for hypertension, two for smoking habits, three for occupational psychosocial stressors and two for sedentariness. The results confirmed an excess risk of diabetes of about 10% regardless of the type of night work. A stated excess risk of being overweight at around 25% was also highlighted for shift workers overall, which could reach 38% among night-shift workers. An increased risk of obesity, estimated at 5% for night-shift workers and at 18% for rotating shift workers, was observed. An excess risk of hypertension was estimated at around 30% when considering the broad definition of shift work and when night periods were included in rotating shifts. The literature provided inconsistent results for the link between lipid disorders and night-shift work. Shift workers appeared to be more likely to smoke. The link between shift work and occupational psychosocial stressors was scarcely explored in the available studies. Sedentariness was scarcely considered in systematic reviews, which prevents any firm conclusions. Conclusion: The consequences of night work in terms of diabetes, being overweight/obesity and hypertension are established. Monitoring of these cardiovascular risk factors for these night-shift workers could be implemented by practitioners. In contrast, the links with lipid disorders, sedentariness, smoking habits, and occupational psychosocial stressors warrant further investigation. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021275212, PROSPERO (ID CRD42021275212).

Co-exposures to physical and psychosocial work factors increase the occurrence of workplace injuries among French care workers.

Objective: The aim of this study was to analyze the effect of co-exposures to physical and psychosocial factors (PSF) regarding the incidence of workplace injuries (WI) among care workers. Additional objective was to identify the work factors associated with the co-exposure combinations leading to the highest rates of WI. Methods: The study sample consisted of 4,418 care workers participating to the French Working Conditions Survey both in 2013 and 2016. WI were assessed during the 4-year follow-up by matching the databases of the National Health Insurance Funds' compensation system. We assessed exposure for physical factors and PSF using factorial analyses and hierarchical clustering. We implemented a Poisson regression model with the WI incidence as the outcome and the clusters as independent variables of interest. Logistic regression model allowed identifying the work factors that predicted co-exposure combinations with a WI rate > 40%. Results: WI were highly related to both physical and psychosocial exposures. With low exposure to one or the other, there was no increased risk of WI. Physical factors and PSF potentiated each other and their co-exposure significantly increased the risk of WI, with model predicted rates per 1,000 persons-year for those most exposed to physical risk of 14.6 [4.5-24.8] with low PSF and 38.0 [29.8-46.3] with high PSF. Work factors that predicted co-exposure combinations with a rate > 40 WI% were: working as nursing assistant or hospital services officer, lack of predictability and flexibility of schedules, overtime, controlled schedules, work-family imbalance and insufficient preventive measures. Conclusions: Our findings highlight the need to take into account psychosocial factors in addition of only considering physical factors when analyzing WI occurrence, as usually done. Prevention actions must be taken to reduce both physical and psychosocial exposure. These results provide keys points for the prevention of WI among care workers.

Effect of Joint Exposure to Psychosocial and Physical Work Factors on the Incidence of Workplace Injuries: Results From a Longitudinal Survey.

OBJECTIVE: To analyze the interaction between physical and psychosocial work factors regarding the workplace injuries incidence among 6900 workers out of a longitudinal survey. METHODS: Based on responses to questionnaires, we obtained exposure groups respectively for physical factors and for psychosocial factors using hierarchical clustering. We performed multiple Poisson regression model with the workplace injuries incidence during 4 years of follow-up as the outcome and the clusters as the independent variables of interest. RESULTS: High psychosocial exposure had a deleterious effect on workplace injuries incidence, which was no longer significant when adjusting for physical factors. The difference in model-based workplace injuries rates between high and low psychosocial exposures seemed to increase (non-significantly) with increasing physical exposure. CONCLUSIONS: The risk of workplace injuries was highest among workers with high physical exposures regardless of the psychosocial exposures.

Do the work unit characteristics directly or indirectly affect psychological distress in female call-handlers?

PURPOSE: This study aimed to test if work unit characteristics (WUCs) reported by call-center managers were directly related to the psychological distress reported by call-handlers or if these associations were mediated by the psychosocial working conditions (PWC). METHODS: Managers of 105 call-centers were interviewed about their call-center's WUCs by occupational physicians. 2719 female call-handlers from these call-centers completed self-reported questionnaires to evaluate PWC (Karasek, Siegrist, and other specific workplace stressors) and psychological distress (GHQ12 score). A two-level analysis tested the relationships between the 14 WUCs and GHQ12 score, with and without adding PWC as confounders. Unchanged coefficients between WUCs and GHQ12 score were assumed to flag a direct association between WUCs and psychological distress. In the case of changed coefficients, the mediated proportion was estimated using multiple mixed models. RESULTS: Five out of fourteen WUCs were related to GHQ12 score: outbound-call type, call-center size, number of activity parameters displayed on the screen, the existence of a fixed break, and the assigned role of the supervisor being the monitoring/supervision of call-handler activities. After adding PWC, the association remained statistically significant only for outbound calls. For the other WUCs, the proportion of mediation by stressor ranged from 56 to 66%. Mediation was mostly through job demand, lack of reward and ethical conflict dimensions. CONCLUSION: The main results were that (1) associations exist between the WUCs reported by managers and the psychological distress reported by call-handlers, and (2) that most of these associations are mediated by psychosocial working conditions.

Is the effect of work-related psychosocial exposure on depressive and anxiety disorders short-term, lagged or cumulative?

PURPOSE: To determine the short-term, lagged, and cumulative effects of psychosocial factors (PSF) on the incidence of depression and anxiety. METHOD: Major depressive disorders (MDD) and generalized anxiety disorders (GAD) were diagnosed in 2006 and 2010 using the Mini International Neuropsychiatric Interview among 5684 workers from the French SIP cohort. The outcome considered here was diagnosis of MDD and/or GAD (MDD/GAD) in 2010. The frequency of 17 PSF, covering labour intensity and working time, emotional demand, autonomy, social relationships, conflict of values, and job insecurity, was self-reported in 2006 and 2010. For each PSF, four groups (A-D) were considered: exposed neither in 2006 nor in 2010 (A as the reference), exposed in 2010 but not in 2006 (B as a short-term association), exposed in 2006 but not in 2010 (C as a lagged association), exposed in both 2006 and 2010 (D as a cumulative association). RESULTS: In men, short-term and cumulative-and to a lesser extent lagged-associations of four labour-intensity factors with MDD/GAD occurrence were observed (high volume of work, pressure at work, high complexity, and long working hours). In women, the short-term and cumulative associations of five PSF were observed, mostly emotional demand factors, lack of reward and work-family imbalance. Job insecurity had strong, short-term, cumulative and lagged associations in both men and women. CONCLUSION: According to PSF and gender, the results suggest that the relationships between PSF exposure and MDD/GAD were mostly short-term and cumulative rather than lagged.

Effect of occupational safety and health education received during schooling on the incidence of workplace injuries in the first 2 years of occupational life: a prospective study.

OBJECTIVES: This study aimed to determine the effect of occupational safety and health (OSH) education during formal schooling on the incidence of workplace injuries (WIs) in young people starting their careers. We hypothesised that young people who had received OSH education during their schooling would have fewer WIs than those who received no OSH education. Secondary objectives focused on the effect of 'first aid at work' training during schooling and the conditions encountered on arrival in the company (occupational hazard information, safety training and job task training) on WI occurrence. DESIGN: Prospective cohort study. PARTICIPANTS: From 2009 to 2012, French apprentices and students at the end of their schooling and starting their careers were included. OUTCOMES: Occurrence of WIs. METHODS: At the time of inclusion, information about school courses and personal characteristics were collected, and subsequent half-yearly contacts gathered information relating to work and personal data. During the 2-year follow-up, WIs were directly reported by participants and were identified by searching the French National Health Insurance Funds' databases listing compulsory WI declarations. RESULTS: 755 participants reported holding 1290 jobs. During follow-up, 158 WIs were identified, corresponding to an incident rate of 0.12 (0.10 to 0.14) WIs per full-time worker. Subjects who reported having received OSH education at school had two times less WIs than those declaring not having received OSH education (incidence rate ratio (IRR) 0.51, 0.00 to 0.98). A lower WI risk was observed for participants who received the 'first aid at work' training (IRR=0.68, 0.00 to 0.98). The conditions on arrival in company were not associated with WIs occurrence. CONCLUSION: In France, the OSH education provided to apprentices and students is mostly broader than the specific risks related to future jobs. Our results highlight the advantages of reinforcing this approach.

Relationships between organizational workplace characteristics and perceived workplace strain in call-centers in France.

BACKGROUND: Our objective was to study the associations between organizational workplace characteristics (OC) reported by call-center (CC) managers and workplace stressors reported by call-handlers. METHODS: The managers of 107 CCs were interviewed by their occupational physicians using a questionnaire designed to specifically explore OC in the CCs. Four thousand two call-handlers from these CCs completed a self-report questionnaire including the Karasek and Siegrist work stressor questionnaires and two specific items on other workplace stressors. RESULTS: Around one-third of the OC examined were associated with the demand/control ratio, the perception of demanding work and ethical conflicts, however, far fewer OC were associated with the effort/reward ratio. Most OC were associated with higher levels of job stressors. Some had strong, systematic negative associations with stressors (e.g., highly formatted instructions for the client relationship). CONCLUSIONS: These findings could help in targeting job stressor prevention and health improvement strategies in CCs.

[The pharmaco-epidemiology to evaluate clinical practices and their impact on health, regarding an example in nephrology: the AVENIR study]. / La pharmaco-épidémiologie pour évaluer les pratiques cliniques et leur impact sur la santé, à propos d'un exemple en néphrologie : l'étude AVENIR.

The AVENIR study is a pharmaco-epidemiological study, lead in Lorraine region (France) between 1st January, 2005 and 31st December, 2006, which aim at: evaluating the quality of therapeutic practices, delivered by nephrologists, for chronic kidney disease patients during the year preceding dialysis onset, assessing the association between quality of predialysis therapeutic practices and survival and hospitalization during the first year of dialysis, and health-related quality of life at dialysis onset. Several data were collected for the AVENIR study: demographic, clinical, biological and therapeutic data before dialysis, morbidity and mortality during dialysis treatment. These data were used for secondary analyses investigating the decline in glomerular filtration rate over the year preceding dialysis, the management of hypertension and proteinuria before dialysis, and characteristics and outcomes of patients with delayed dialysis initiation. Results from the AVENIR study have been published in various international journals. The aim of this manuscript is to present a summary of these results and the lessons we can learn for the nephrological practice.

Impact of predialysis therapeutic practices on patient outcomes during the first year of dialysis: the Pharmacoepidemiologic AVENIR study.

BACKGROUND: Studies evaluating patient outcomes in dialysis as a function of quality of predialysis therapeutic care are lacking. OBJECTIVE: To evaluate the association of quality of predialysis therapeutic practices with survival and hospitalization during the first year of dialysis. RESEARCH DESIGN: The AVantagE de la Néphroprotection dans l'Insuffisance Rénale study was an observational cohort study. Cox models explored the association between quality of therapeutic practices and survival over the first year whereas logistic regression measured the association with total duration of hospitalization (0 to 6 d, ≥7 d) among surviving patients at 1 year. SUBJECTS: All adult patients with chronic kidney disease starting dialysis in Lorraine (France) between 2005 and 2006. MEASURES: The appropriateness of therapeutic practices was evaluated with reference to current guidelines covering 5 aspects of chronic kidney disease: hypertension/proteinuria, anemia, bone disease, metabolic acidosis, and dyslipidemia. Each patient was then assigned a quality of therapeutic practices rating (high, moderate, or poor) depending on the number of aspects appropriately managed. RESULTS: Quality of predialysis therapeutic practices was high in 18.2% of the 566 included patients, moderate in 62.5%, and poor in 19.3%. In multivariate analysis, the higher the quality of practices, the better the survival rate during the first year of dialysis [High: hazard ratio (HR) 1; moderate: HR 1.56, P=0.09; poor: HR 1.95, P=0.02]. Conversely, quality of therapeutic practices was not associated with duration of hospitalization among the 390 surviving patients at 1 year. CONCLUSION: This study suggests that quality of predialysis therapeutic practices is positively associated with survival during the first year of dialysis.

Long-term antioxidant supplementation has no effect on health-related quality of life: the randomized, double-blind, placebo-controlled, primary prevention SU.VI.MAX trial.

BACKGROUND: The effect of antioxidant vitamin and mineral supplementation on health is one of the most controversial issues in human nutrition. Our objective was to investigate the effect of nutritional doses of a combination of antioxidant vitamins and minerals on health-related quality of life (HRQoL) in a sample of healthy French adults. METHODS: SU.VI.MAX is a randomized, double-blind, placebo-controlled, primary prevention trial in which a total of 8112 participants received a single capsule daily containing either placebo or vitamin C 120 mg, vitamin E 30 mg, beta-carotene 6 mg, selenium 100 µg and zinc 20 mg. Participants completed HRQoL questionnaires (SF36 and GHQ12) at baseline and after a mean of 76.0 ± 4.2 months. RESULTS: Scores for physical dimensions tended to decrease over time, whereas those for mental dimensions tended to improve. No differences in changes over time were observed between the supplement and placebo groups. Participants who believed that they received placebo had lower HRQoL scores than did those who thought they had received supplements [SF36 Bodily pain (-3.3), General health (-2.2), Vitality (-1.6) dimensions and physical component summary score (-1.1) in men, and in SF36 Social functioning (-2.3), General health (-1.4) dimensions and physical component summary score (-0.7) in women]. CONCLUSIONS: Long-term supplementation with antioxidant vitamins and minerals had no beneficial effect on HRQoL in this trial. This is contrary to conventional beliefs and claims that such an effect exists. Trial Registration "Primary Prevention Trial of the Health Effects of Antioxidant Vitamins and Minerals." NTC n 00272428 http://www.clinicaltrials.gov.

Off-label use of recombinant activated factor VII in intractable haemorrhage after cardiovascular surgery: an observational study of practices in 23 French cardiac centres (2005-7).

OBJECTIVES: The study aimed to describe French off-label use of rFVIIa for intractable bleeding in major cardiovascular surgery. METHODS: Retrospective observational analysis of data from 2005 to October 2007 (no formal guidelines were available) was employed. The collect request form was elaborated by a multidisciplinary committee. RESULTS: Data on 109 patients--37 mechanical cardiac assist devices--were collected, with repeated injection for 24%. Bleeding stopped, decreased or continued in 43%, 37% and 20% of the cases, respectively. For patients treated in the intensive care unit (ICU), hourly bleeding decreased from 365 ± 212 to 115 ± 106 ml h(-1) (p<0.001). The median number of transfused products was 25 (2-90) before and 6 (0-48) after rFVIIa (p<0.001). Most patients had been well compensated with fibrinogen (>1g.l(-1)) and platelets (>50 G.l(-1)) before rFVIIa. The bleeding outcome (cessation, decrease or no change) was associated with the infused dose (81 ± 31, 71 ± 24, 64 ± 23 µg.kg(-1); p = 0.044) and did not differ whether rFVIIa was administered in the operating room (49%) or ICU (51%). Thrombotic events occurred in 13% of patients without assist devices and in 27% of those with them (but without obvious intra-device clotting). The overall 28-day survival rate was 60% and associated with bleeding outcome (p = 0.002). CONCLUSIONS: rFVIIa rescue therapy was followed by control of bleeding in a substantial number of the patients with seemingly acceptable safety; however, thrombotic risk remains a matter of concern. Our observational study suggests that the dose to be tested prospectively is at least 80 µg.kg(-1).

Predialysis therapeutic care and health-related quality of life at dialysis onset (The pharmacoepidemiologic AVENIR study).

BACKGROUND: To determine the impact of the quality of pre-dialysis nephrological care on health-related quality of life (HRQoL) at dialysis onset, which has not been well evaluated. METHODS: All adults who began a dialysis treatment in the administrative region of Lorraine (France) in 2005 or 2006, were enrolled in this prospective observational study. HRQoL was measured using the Kidney Disease Quality of Life V36 questionnaire, which enables calculation of two generic (physical and mental) and three specific dimensions (Symptoms/problems, Effects and Burden of kidney disease). The specific dimensions were scored from 0 to 100 (worst to best possible functioning). Pre-dialysis nephrological care was measured using three indicators: quality of therapeutic practices (evaluated across five main aspects: hypertension/proteinuria, anemia, bone disease, metabolic acidosis and dyslipidemia), time since referral to a nephrologist and number of nephrology consultations in the year preceding dialysis treatment. RESULTS: Two thousand and eighty-three (67.4%) patients were referred to a nephrologist more than 1 month before dialysis initiation and completed the HRQoL questionnaire. Quality of therapeutic practices was significantly associated with the Mental component. Time since referral to a nephrologist was associated with Symptoms/problems and the Effects of kidney disease dimensions, but no relationship was found between the number of nephrology consultations and HRQoL. CONCLUSIONS: HRQoL at dialysis onset is significantly influenced by the quality of pre-dialysis nephrological care. Therefore, disease management should be emphasized.

Outcomes of patients with delayed dialysis initiation: Results from the AVENIR study.

BACKGROUND: Some patients who reach end-stage renal disease refuse to start dialysis at the time suggested by their nephrologist and delay it. Whether this delay may affect health-related quality of life (HRQoL), clinical and biological parameters at dialysis onset, and then survival and hospitalization during dialysis is unknown. METHODS: We considered all adult patients who began dialysis in Lorraine (France) in 2005-2006 having previously been followed by a nephrologist. Clinical and biological characteristics at dialysis onset were collected from medical records, and nephrologists were interviewed about compliance with the recommended starting date. HRQoL was measured using the French version of the 'Kidney Disease Quality of Life' V36 questionnaire. Mortality and total duration of hospitalization during the first year of dialysis were recorded as part of the end-stage renal disease French registry. The effects of delaying dialysis on survival and on duration of hospitalization were determined using log-rank test and polychotomous logistic regression, respectively. RESULTS: Of 541 patients, 88 (16.3%) declined to initiate dialysis at the time recommended by the nephrologist and delayed it. Compared with patients who were compliant with the advice, noncompliers had more comorbidities, poorer clinical and biological profiles at dialysis start, and a higher risk of beginning dialysis in emergency circumstances with greater decline in the 'burden of kidney disease' dimension of HRQoL. However, there were no differences in survival or duration of hospitalization during dialysis. CONCLUSION: Despite a negative effect on clinical and biological parameters at initiation, delaying dialysis did not impact on survival during treatment.

Factors associated with psychological and behavioral functioning in people with type 2 diabetes living in France.

BACKGROUND: To identify demographic and clinical factors associated with psychological and behavioral functioning (PBF) in people with type 2 diabetes living in France. METHODS: In March 2002, approximately 10,000 adults, who had been reimbursed for at least one hypoglycemic treatment or insulin dose during the last quarter of 2001, received a questionnaire about their health status and PBF (3,646 responders). For this analysis, the 3,090 persons with type 2 diabetes, aged 18-85 years old were selected.PBF was measured with the adapted version of the Diabetes Health Profile for people with type 2 diabetes. This permitted the calculation of three functional scores - psychological distress (PD), barriers to activity (BA), and disinhibited eating (DE) - from 0 (worst) to 100 (best). RESULTS: Major negative associations were observed with PBF for microvascular complications (a difference of 6.7 in the BA score between persons with and without microvascular complications) and severe hypoglycemia (difference of 7.9 in the BA score), insulin treatment (-8.5 & -9.5 in the PD & BA scores respectively, as compared to treatment with oral hypoglycemic agents), non-adherence to treatment (-12.3 in the DE score for persons forgetting their weekly treatment), increasing weight (-8.5 & -9.7 in the PD & DE scores respectively, as compared to stable weight), at least one psychiatrist visit in 2001 (-8.9 in the DE score), and universal medical insurance coverage (-7.9 in the PD score) (due to low income). CONCLUSION: Prevention and management of microvascular complications or adherence to treatment (modifiable factors) could be essential to preserving or improving PBF among people with type 2 diabetes. A specific approach to type 2 diabetes management may be required in groups with a low socioeconomic profile (particularly people with universal medical insurance coverage), or other non modifiable factors.

Chronic kidney disease: appropriateness of therapeutic management and associated factors in the AVENIR study.

RATIONALE, AIMS AND OBJECTIVES: The nephrology literature contains little information about the global patterns of medication used in the management of patients with chronic kidney disease (CKD). This study aims to evaluate the appropriateness of nephrological therapeutic management of CKD patients compared with current guidelines and to investigate associations between patient characteristics and the quality of therapeutic management. METHODS: All adult CKD patients who were starting dialysis in Lorraine (France) between 1 January 2005 and 31 December 2006 and who had been referred to a nephrologist no less than 1 month previously were enrolled. Demographic, clinical, biological and therapeutic data were collected retrospectively from medical records covering the period from the first nephrology consultation to initiation of dialysis. Outcomes of interest were the appropriateness of the therapeutic management of five aspects of CKD: hypertension/proteinuria, anaemia, bone disease, metabolic acidosis and dyslipidemia. Therapeutic care was given a global rating (high, moderate or poor), depending on the number of aspects being managed appropriately. Relationships between the global rating and demographic and clinical characteristics of patients were explored. RESULTS: During predialysis nephrology follow-up, 93.1% of the 420 patients enrolled were receiving antihypertensive therapy; 67.1% were taking a renin-angiotensin system inhibitor. Other prescriptions included: erythropoiesis-stimulating agents (67.4%), iron (48.3%), phosphate binders (38.1%), vitamin D (21.1%), bicarbonates (15.5%) and statins (36.2%). Hypertension/proteinuria was managed appropriately in 72.4% of cases, anaemia in 56.2%, bone disease in 16.7%, metabolic acidosis in 60.2% and dyslipidemia in 61.4%. The global quality of care was high in 22.1% of cases, moderate in 65.7% and poor in 12.2%. After adjustment, the more nephrology consultations a patient had before dialysis, the higher the quality of his or her care. CONCLUSION: The quality of therapeutic care delivered to CKD patients in nephrology setting was suboptimal when assessed in terms of adherence to guidelines.

Patterns and predictors of kidney function decline in the last year prior to dialysis.

BACKGROUND: Establishing a comprehensive characterization of kidney function decline before dialysis is necessary to predict dialysis onset and prepare patients for replacement therapy. AIMS: To investigate kidney function as measured by pattern and rate of decline in glomerular filtration rate (GFR) over the year preceding dialysis and to identify factors associated with a nonlinear GFR decline. METHODS: We enrolled patients beginning dialysis in Lorraine (France) in 2005 and 2006, who were referred to a nephrologist more than 4 months before dialysis and had received more than 3 predialysis serum creatinine tests. From medical records, we retrospectively collected demographic and clinical data, as well as biological data during nephrologist follow-up, limited to 1 year before dialysis. A curve of GFR evolution by time was drawn for each patient and his linearity was evaluated graphically and confirmed by R2 > 0.7. Factors associated with a nonlinear decline in GFR were identified by logistic regression. RESULTS: A total of 342 patients were included; the mean length of predialysis nephrologist care was 10.0 +/- 9.7 months and the median number of serum creatinine tests per patient was 9 . Among these patients, 185 (54.1%) showed a linear decline in GFR and 157 (45.9%) a nonlinear decline. Patients with cardiovascular disease were 2.6 times more likely to show a nonlinear than linear decline in GFR (p < 0.0001). CONCLUSION: For patients with a linear decline in GFR, but not those with a nonlinear decline, date of dialysis onset can be estimated.

Management and control of hypertension and proteinuria in patients with advanced chronic kidney disease under nephrologist care or not: data from the AVENIR study (AVantagE de la Nephroprotection dans l'Insuffisance Renale).

BACKGROUND: Little is known about antihypertensive management and control of blood pressure (BP) and proteinuria in patients with chronic kidney disease (CKD). Data from a large observational study (AVENIR), carried out in Lorraine (France), were used to analyse antihypertensive treatment and control of BP and proteinuria in patients with advanced CKD, under nephrologist care or not. METHODS: All adults with CKD, beginning dialysis in 2005 and 2006, were included and categorized into patients 'under nephrologist care' and 'not under nephrologist care' at the time when treatment, BP and proteinuria results were considered. All data were collected retrospectively from medical records. Demographic and clinical data were from initiation of dialysis. BP, biological and therapeutic data were results obtained at 2.7 months before dialysis for patients under nephrologist care, and results obtained at the first nephrology consultation for those not under such care (2.7 +/- 3.7 months before dialysis). RESULTS: On 566 included patients, the 291 under nephrologist care received more antihypertensive agents (3.1 +/- 1.5 versus 2.2 +/- 1.6) than the 275 not under such care and each antihypertensive class was more often prescribed for these patients, particularly the renin-angiotensin-aldosteron system inhibitors (60.5% versus 36.7%). Nevertheless, BP did not differ between both groups, and proteinuria control was achieved in more patients not under nephrologist care, revealing a likely bias of indication. Whatever the type of care, BP < 130/80 mmHg was achieved in only one quarter of all patients and proteinuria < 0.5 g/day in only 15% of them. CONCLUSION: Understanding the reasons for such a poor level of hypertension and proteinuria control in CKD patients needs to be explored in further investigations.

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.