[Flows between modalities in the treatment of ESRD]. / Flux entre modalités de traitement de l'IRCT.

This chapter provides indicators to describe the outcome of prevalent and incident patients in the various modalities of treatment. Among the 36 849 patients on dialysis at 31/10/2010, 79% were already on RRT at 31/12/2009. Respectively 91%, 85% and 93% of the patients on HD in-center, HD self-care unit and peritoneal dialysis were in the same modality of treatment the year before. Among the 29 758 patients with a functioning graft at 31/12/2010, 98% were already on RRT at 31/12/2009, 95% of them with a functioning graft. 72%, 72% and 74% of the patients with in-center HD, outcenter HD and self-care unit were in the same modality of treatment at 31/12/2011. But 37% of the patients on PD at 31/12/2010 were not on PD at 31/12/2011. In 2011, new patients represented 89% of the entries in peritoneal dialysis. Renal transplantation represented 10% of the outcomes of the HD patients in self-care unit or at home.

[Granulomatous interstitial nephritis: A retrospective study of 44 cases]. / Granulomatoses rénales : étude rétrospective de 44 observations.

PURPOSE: Granulomatous interstitial nephritis (GIN) are identified in 0.5 to 1,3% of all renal biopsies. Renal outcome and treatment modalities are not clearly established in the literature. METHODS: We retrospectively analyzed a case series of 44 GIN identified among all renal biopsies performed between 1984 and 2005 in the Rhône-Alpes area. RESULTS: The study population included 25 men and 19 women with a mean age of 56 years, and mean diagnostic delay was 11 months. Renal function was severely impaired (mean creatinine clearance 24mL/min). Proteinuria was observed in 77% (mean value 0,9 g/24h) of the patients and associated with microscopic hematuria and leukocyturia in 30% and 25%, respectively. The most common diagnosis was sarcoidosis (25%, n = 11), followed by drug-induced GIN (9%, n = 4), tuberculosis (6,8%, n=3), hemopathy-related paraneoplastic GIN (6,8%, n = 3), HIV infection (n = 1) and chronic renal allograft rejection (n = 1). In other patients, no aetiology was found (48%, n = 21). Severity of renal failure justified hemodialysis in 34% (n = 15) of the patients. Three patients underwent renal transplantation. Nonetheless, renal outcome was generally favorable: renal function improved in 41% (n = 18) and stabilized in 34% (n = 15) of patients. CONCLUSIONS: Sarcoidosis, drug-induced and infections represent the main causes of GIN. Histologic features are not specific enough to determine the aetiology. Corticosteroids is the gold standard in sarcoidosis, drug-induced, and idiopathic GIN. Treatment is etiologic in the other cases.

The Impact of type 2 diabetes on mortality in end-stage renal disease patients differs between genders.

BACKGROUND/AIMS: In diabetics with end-stage renal disease (ESRD), risk of death has been reported to be non-constant after the first dialysis, and different outcomes have been observed between genders. We assessed the impact of type 2 diabetes (T2DM) on mortality in dialysis regarding its differential effect by gender using time-dependent analyses. METHODS: All T2DM and non-diabetic (no-DM) patients who started dialysis in two renal units in Lyon, France, between January 1, 1995, and December 31, 2007, were included. In multivariate analyses, the Cox model and Shoenfeld residual approach were used to assess the effect of T2DM on dialysis mortality by gender. RESULTS: We included 235 T2DM (males: 57.9%) and 480 no-DM (males: 65.6%) patients. In males, the adjusted hazard ratio (aHR) for death in T2DM versus no-DM was 0.83 (p = 0.20) and was constant over time after the first renal replacement therapy (RRT) (p = 0.88). In females, aHR for death in T2DM versus no-DM patients was not constant over time (p = 0.002). It was 0.64 (p = 0.13) within the first year after the first RRT and 2.10 (p = 0.002) after the first year. Evolutions with time of these aHR by gender were significantly different (p = 0.009). CONCLUSIONS: T2DM was associated with death only in females. This association was not constant over time after the first dialysis.

[Evaluation of the needs of a population of hemodialysis patients in Rhône-Alpes]. / Evaluation des besoins en soins d'une population de patients hémodialysés en Rhône-Alpes.

The evaluation of the needs of patients with terminal renal insufficiency is necessary to determine the appropriate care programme. An evaluation of the medical and nursing needs, as well as those related to handicap (a total of 47 items) was undertaken on all hemodialysis patients in the Rhône-Alpes region. Only 34.4% were free of co-morbidity and 35.7% of significant handicap, 63.7% needed no other nursing care than that related to supervision of the dialysis and 16.9% were free of all the conditions studied. The patients treated in the centre required care needs than those treated in all other structures. The autodialysis population differs from that treated at home by a greater need for care due to handicaps, and from that treated in a dialysis centre by a lesser degree of handicap and less need for medical treatment. A level of theoretical unsuitability (needs incompatible with the statutory provisions for each type of treatment) was defined: it concerns 5% of the population in a dialysis centre and to 33% of the population on home dialysis. The needs evaluation grid could be used to quantify the requirements of a dialysis population and to arrange for the necessary resources.

[A tool to predict the resources necessary for the whole hemodialysis population]. / Un outil de prédiction des moyens requis pour l'hémodialyse à l'échelon d'une population.

Predicting the resources necessary for the treatment of terminal renal insufficiency requires an understanding of the needs of the whole dialysis population. This study evaluates the advantages of a complete evaluation grid for care needs (CG, 47 items) compared with a simplified version (SG) and with the data obtained from REIN (R) as a tool for predicting the required resources. Compared to CG, the two other classifications under-estimate the level of care needed and the prevalence of patients who have at least one condition resulting in an 'excess' of needs. In a system with three types of structures, the theoretical distribution of patients according to the CG is: in structure A (permanent medical presence): 43.4% (vs 39 for SG and 21% for R); in structure B (intermediate): 34% (vs 31.5 and 24.7% respectively); and in structure C (independent): 22.3% (vs 29.5 and 53.5%) of patients. The care needs scores of populations assigned by R to home dialysis are incompatible with the resources allocated to it. With a certain number of adjustments and qualifications, a population study using a simplified needs grid could enable a prediction of the resources which need to be provided. The patients' records which take precedence in the future REIN should be modified in order to make possible a regular evaluation of the appropriateness of the resources allocated.

[Compensatory hyperfunction in living kidney donors]. / Hyperfonction compensatrice chez les donneurs vivants de rein.

Renal transplantation using living donors still remains of interest, given the shortage of cadaveric donors. Using reference methods for measuring kidney function, we studied the adaptation to nephrectomy in 99 living donors. The glomerular filtration rate and renal plasma flow showed long lasting increase (by 40 and 33% respectively). Age and the glomerular filtration rate at surgery had a clear-cut effect on these changes. The spontaneous changes in protein intake further influence the value of post-nephrectomy glomerular filtration rate. The analysis of serial changes in serum creatinine or creatinine clearance would falsely have suggested a late increase in renal function. Microalbuminuria increased in few patients, pointing to the need for careful long term follow-up of such donors.

[Treatment of end stage renal failure by dialysis in Rhône-Alpes: changes over the period 1993-1999]. / Traitement de l'insuffisance rénale terminale par dialyse en Rhône-Alpes: évolution sur la période 1993-1999.

Over a seven years period, the prevalence of end stage renal failure patients requiring dialysis in a French area of 5.6 10(6) inhabitants was determined by yearly studies. The number increased from 1693 to 2296 (+ 35.6%), a 5% annual increase in the prevalence rate from 311 to 407. No tendency toward a plateau was evident. The main observed changes in the prevalent population were an increasing age (59.4 to 63), mainly for in-center patients, and male/female ratio, the rising of vascular or diabetic nephropathies (de 26.4 to 31.7%), and a decrease in the percentage of in-center dialysis patients (64 to 57%).

[Which method of dialysis for the type 2 diabetic?]. / Quelle méthode de dialyse chez le diabétique de type 2?

Type 2 diabetes is becoming a major cause of chronic renal failure leading to health care problem. Literature data do not allow to choose between hemodialysis or peritoneal dialysis as the treatment of choice of end stage renal failure in type II diabetic patients according to their co-morbidities. A retrospective study was performed in 28 type II diabetic patients, either 11% of the total population, who started dialysis in our center between 1994 and 1997. Fourteen patients had chosen peritoneal dialysis and 14 hemodialysis. The 2 groups were not different for their initial neurological, cardiovascular, ophthalmological complications and for their metabolic control. After a mean follow-up of 14 months on dialysis a significant higher number of infections (9 versus 4), of hospitalisation days (34 +/- 19 versus 6.5 +/- 5.5), of technical transfers (6 versus 0) and of deaths (5 versus 0) were recorded in patients on peritoneal dialysis, without any difference in the metabolic control. A prospective, multicenter study is required to identify the best dialysis technique in type 2 diabetic patients, according to their co-morbidities and the dialysis dose.

Screening early renal failure: cut-off values for serum creatinine as an indicator of renal impairment.

BACKGROUND: The aim of this study was to define cut-off values for serum creatinine as an indicator of several levels of renal impairment. METHODS: To identify the suitable values, receiver operating characteristic curves were constructed based on the data of 984 laboratory assessments of renal function. The glomerular filtration rate was measured with inulin clearance. Three levels of renal impairment were analyzed. An index that gave the same weight to false positive and false negative results was used to determine the thresholds. Robustness of the results was tested using a "bootstrap" technique. RESULTS: Considering an inulin clearance of less than 80 ml/min/1.73 m2, the cut-off value for serum creatinine was 11.5 mumol/liter for men and 90 mumol/liter for women. The cut-off value for a clearance of less than 60 ml/min/1.73 m2 was 137 mumol/liter for men and 104 mumol/liter for women. For a clearance of less than 30 ml/min/1.73 m2, the cut-off value was 177 mumol/liter for men and 146 mumol/liter for women. CONCLUSION: This method is useful to determine a cut-off value for serum creatinine in epidemiological studies concerning early chronic renal failure screening. The value of the glomerular filtration rate of reference and the weight of false positive and false negative results have to be adapted to the aim of the individual study design.

[National study of screening practices for hepatitis C among hemodialysis patients. Hepatitis Group]. / Etude nationale des pratiques de dépistage de l'hépatite C chez les patients hémodialysés. Hepatitis Group.

French and American consensus conferences on hepatitis C confirmed the burden of that disease, especially in high risk populations. In France, the seroprevalence of HCV is about 20% among haemodialysed patients. This study aimed at describing the French screening practices in haemodialysed patients. In 1995, 1213 self-administered questionnaires were sent to nephrologists working in 715 dialysis units. The response rate was 48% (585/1213) and 485 questionnaires were analysed. In 98% of questionnaires nephrologists answered that they prescribed screening test. Routine screening with alanine amino-transferase (ALT) was reported in 98% of questionnaires, usually once a month (57%) or four times a year (23%). Routine anti-HCV serology was reported by 96%, usually once (28%) or twice (46%) a year. The two main annual strategies combining ALT and anti-HCV serology were 12 ALT and 2 serologies (21%), or 12 ALT and 1 serology (14%) per year. HCV RNA detection was reported mainly in the case of positive anti-HCV serology (70%). The study suggested heterogeneity in screening practices and revealed the need to determine the cost-effectiveness ratios of the various strategies.

[Evaluation of information for renal insufficiency patients before dialysis]. / Evaluation de l'information aux patients insuffisants rénaux avant dialyse.

The aim of this audit was to assess the quality of information given to patients before dialysis and to improve the use of this information on the acceptability of the treatment. Methods were those used in medical audit: retrospective data collection in a sample of patients, comparison to a set of standards given by professionals and recommendations disseminated in the group of professionals. Results showed that patients received a partial information on the various techniques used in dialysis. More complete information is needed. Recommendations consisted in a specialised team giving a detailed information on the disease and the techniques used in dialysis, with a psychological assistance. After implementation of this team, re-assessment showed a consistent benefit of structured information and entailed the necessity to improve the process of information delivery by general practitioners and specialists.

Transplant renal artery stenosis. Evaluation of diagnosis with magnetic resonance angiography compared with color duplex sonography and arteriography.

The goal of this study was to assess the value of a three-dimensional phase contrast magnetic resonance angiography (3D PC MRA) for diagnosing transplant renal artery stenosis (TRAS). Twelve consecutive patients clinically suspected of having TRAS were prospectively enrolled during a period of 18 months. Delays from transplantation varied from 3 months to 4 years (mean: 18.3 months). Patients first had color Doppler sonography, then MRA-and, on the following day, intraarterial digital subtraction angiography (IADSA). The site of the maximum peak systolic velocity was noted when doing the report of each color Doppler sonogram. On MRA images, any signal cutoff or any vascular narrowing of more than 50% of the diameter of the vessel was considered to be a significant stenosis. Eight patients were considered to have TRAS on MRA, but only two stenoses were noted on IADSA. The six false-positive results of MRA (due to major intravoxel phase dispersion) were observed when elevated peak systolic velocities were noted on doppler sonograms (mean: 214 cm/sec). These elevated peak systolic velocities were noted in the proximal part of the renal artery when there was a tortuous vessel or a sharp angle between the renal artery and the parent vessel. It is our opinion that 3D PC MRA is of limited value for the diagnosis of renal transplant artery stenosis because of a high number of false-positive results.

MR angiography of renal artery stenosis: value of the combination of three-dimensional time-of-flight and three-dimensional phase-contrast MR angiography sequences.

OBJECTIVE: It has been reported and also has been our preliminary experience that many false ostial stenoses are attributable to a loss of signal intensity at the origin of the renal arteries when three-dimensional (3D) phase-contrast MR angiography is used. Our objective was to add a 3D time-of-flight MR angiography sequence to the 3D phase-contrast MR angiography sequence to better analyze the origin of the main renal arteries. We assessed the value of the combination of these two MR angiography sequences for the depiction of renal artery stenosis. SUBJECTS AND METHODS: Forty-six patients suspected of having renal artery stenosis on the basis of clinical history, physical examination, and laboratory data were prospectively enrolled. Intraarterial digital subtraction angiography findings were available for all patients. Using intraarterial digital subtraction angiography, we considered stenosis to be significant when the vessel was narrowed more than 50%. During MR angiography, half of the data were reconstructed by interpolation to avoid long acquisition times. Total acquisition times were less than 15 min. MR angiography findings were interpreted independently by two radiologists who were unaware of the findings of intraarterial digital subtraction angiography. With 3D phase-contrast MR angiography, any cutoff in signal intensity or any narrowing of the vessel diameter of more than 50% from the renal ostium to the renal hilum was considered to represent significant stenosis. With 3D time-of-flight MR angiography, our image analysis was focused on the origin of the arteries. Any cutoff in signal intensity in the first centimeter of the renal artery was considered to represent significant stenosis. RESULTS: Intraarterial digital subtraction angiography showed 105 renal arteries, including 15 supernumerary renal arteries. Eleven stenoses were localized to the main hilar renal arteries. Using time-of-flight MR angiography, we found that polar supernumerary renal arteries of small caliber and intrarenal branches of renal arteries were not adequately displayed. Using phase-contrast MR angiography to evaluate only whether the main hilar renal arteries were stenotic, we calculated the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy to be 100%, 65%, 28%, 100%, and 69%, respectively. Using a combination of the two imaging sequences, we found that the specificity, positive predictive value, and accuracy were increased to 90%, 58%, and 92%, respectively. CONCLUSION: For detecting stenoses of the main renal arteries but not for visualizing small accessory renal arteries or distal branches, our results support the use of a combination of the two MR angiography sequences. For now, this combination of sequences should be viewed primarily as a technique for screening patients.

[Renal biopsy in the elderly]. / La biopsie rénale chez le sujet âgé.

Fifty years after the first percutaneous needle biopsies of the kidney, enough results have been obtained to evaluate indications in elderly patients, a population group we define as over 75 years of age. In approximately 50% of the patients in this group, the indication for renal biposy is a nephrotic syndrome. The lesions usually observed involve extramembranous glomerulonephritis or minimal change glomerulopathy. The biopsy may also reveal amylosis. Chronic renal failure is the predominant reason for nephrology consultation in the elderly. Although all of these patients do not undergo biopsy, in our experience, results show chronic glomerulopathies, mainly IgA, in about half of the case as well as chronic interstitial nephritis and nephroangiosclerosis. The aging process also leads to acute renal failure in many patients. Biopsy would not be indicated in case of shock, drug toxicity or obstruction but in approximately 10% of the cases histology can reveal a specific parenchymal lesion. The technique for renal biopsy is the same in elderly patients as in younger adults. Renal biopsy can be considered as a safe diagnostic tool of considerable importance when ordered by a nephrologist, performed by an experienced operator and read by a well-trained pathologist. In many cases it is essential to in order to provide patients over 75 with the same quality care as younger adults.