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.

[Workload during hemodialysis sessions]. / Description de la charge de soins en séance d'hémodialyse.

In recent years, the population of dialysis patients has become frailer and older. Patients present with more comorbid conditions and experience more complications during their follow-up. The aim of the present study is to describe the workload of the dialysis center during hemodialysis sessions and determine whether comorbidities are associated with increased workload. We conducted a retrospective multicentric study on a sample population of 123 patients selected from a dialysis population within a regional network. We described hospitalizations and HD sessions during a 1-year follow-up. We collected data on 19 prescriptions and events occurring during HD sessions. We described two HD care profiles (easy and difficult) and looked for variables linked with these profiles. We found that age more or equal to 60 years, elevated C-reactive protein and HD catheters are associated with difficult HD care. Surprisingly, apart from heart failure, comorbidities were not linked to greater workload during HD sessions. The development of HD care profiles should be helpful in early detection of frailer patients. This could have concrete applications such as better allocation of human and material resources and better training for the dialysis staff.

[Impact on morbidity and costs of methicillin-resistant Staphylococcus aureus nosocomial pneumonia in intensive care patients]. / Effets sur la morbidité et les coûts des pneumopathies nosocomiales àStaphylococcus aureus résistant à la méthicilline en réanimation.

OBJECTIVES: Prevention of methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections in the intensive care units (ICU) has been recommended for several years. However, the workload and the costs of these programs are to be weighed against the benefit obtained in terms of reduction of morbidity and costs induced by the infection. The purpose of this study was to evaluate the cost and the current morbidity of the infection with MRSA in the ICU. METHODS: In a retrospective case-control study carried out in 2004, all patients of the 6 intensive care units of a teaching hospital having developed a MRSA nosocomial infection were included. They were paired with controls on the following criteria: department, Simplified Acute Physiology Score II (SAPSII), age (+/- 5 years), type of surgery (for the surgical intensive care units). The duration of hospitalization of the paired control had to be at least equal to the time from admission to infection of the infected patient. The costs were evaluated using the following parameters: scores omega 1, 2 and 3, duration of artificial ventilation, hemodialysis, length of ICU stay, radiological procedures, surgical procedures, total antibiotic cost and other expensive drugs. RESULTS: Twenty-one patients with MRSA infection were included. All had nosocomial pneumonia. The 21 paired patients were similar with regard to both initial criteria and sex. Hospital mortality was not different between the 2 groups (cases=8; controls=6; p=0.41), as well as median duration of hospital stay (cases=41 days; controls=43 days; p=0.9). The duration of mechanical ventilation, number of hemodialysis or hemofiltration sessions, number of radiological procedures were similar in both groups. The total omega score was not significantly different between cases (median 435; IQR: 218-579) and controls (median 281, IQR: 231-419; p=0.55). The median duration of isolation was 12 days for cases and 0 day for controls (p=0.0007). The pharmaceutical expenditure was significantly higher in cases (median: 1414euro; IQR: 795-4349), by comparison with the controls (median: 877euro, IQR: 687-2496) (p=0.049). CONCLUSION: In the ICU having set up a policy intended to reduce the risk of MRSA nosocomial infections, MRSA pneumonia does not seem to involve major additional morbidity, as compared to a control population matched for similar severity of illness. It increases modestly the use of the medical resources.

Serum troponin Ic values in organ donors are related to donor myocardial dysfunction but not to graft dysfunction or rejection in the recipients.

BACKGROUND: Increased plasma cardiac troponin I (cTnI) values in heart donors are associated with donor myocardial dysfunction and increased risk of rejection in the recipients. We investigated the association between cTnI values and myocardial dysfunction in potential heart donors and the relationship between donors' cTnI values and recipients' early myocardial function and 1 year survival and risk of rejection. METHODS: cTnI was measured in 159 consecutive potential heart donors. Myocardial function was estimated by the left ventricular ejection fraction (LVEF) and segmental wall motion abnormalities (SWMA). Results are mean+/-SD (range) or median (interquartile range). RESULTS: cTnI values in potential donors were 2.1+/-5 ng/ml (0-40.4 ng/ml); cTnI values were significantly (P<0.001) higher: 4.2+/-5.9 ng/ml (0-30.6 ng/ml) for potential donors with LVEF <50% versus LVEF >50%: 1.7+/-4.7 ng/ml (0-40.4 ng/ml). cTnI values were significantly lower for donors without SWMA. cTnI values were significantly (P<0.001) lower for the 90 donors whose hearts were harvested: 1.1+/-2.3 ng/ml (0-15.6 ng/ml) versus the not harvested: 3.6+/-6.9 ng/ml (0-40.4 ng/ml). There were 87 recipients followed for 1 year. Donors' cTnI values were not associated with early alteration of LVEF, incidence of rejection or 1 year recipients' survival. CONCLUSION: Increased cTnI values in potential heart donors are statistically associated with myocardial dysfunction and could be helpful for organ selection. In contrast, cTnI values in heart donors were not associated with graft dysfunction or recipient survival after transplantation.

[SDIALOR: a dialysis patient satisfaction questionnaire]. / Questionnaire SDIALOR : instrument de mesure de la satisfaction des patients en dialyse.

AIMS: To develop and evaluate the psychometric properties of a dialysis satisfaction questionnaire in the French language. METHODS: Firstly the translation and adaptation to French context in cooperation with dialysis patients and nephrologists. The satisfaction questionnaire was built using items banking, based on the Choice Satisfaction Questionnaire and Satisfaction of Patients in Chronic Dialysis (SEQUS((R))). The tool, named SDIALOR, was comprised of 41 items. Satisfaction scores are standardized from 0 (poor) to 100 (excellent). Secondly, the estimation of the questionnaire's psychometric properties. This work was realized in the Nephrolor network. The sample consisted in all of 1008 adults, prevalent patients, treated in the 12 dialysis structures of the Lorraine region on the 1st February 2004. All of them were mailed a questionnaire. RESULTS: Response rate was 44.3%. Mean age of patients was 65.9 years; 67% were men and 61% retired. Mean length of dialysis was 4.5 years. Women, residents of the Meurthe and Moselle region, patients having a diabetes, having a low haemoglobin level returned the questionnaires less frequently than the other patients (p<0.05). Principal components analysis evidenced seven specific dimensions, in addition to the overall satisfaction dimension. Cronbach's alpha coefficients were greater than 0.73 for five dimensions, but "relation between nephrologist and GP" dimension (0.54). Mean scores of satisfaction varied from 53.9 ("relation between nephrologists and GP") to 74.1 ("overall satisfaction"). Older patients tended to more satisfied than the younger ones. Global satisfaction was significantly higher in peritoneal dialyses (81.7), in hemodialysis at residence (83.1) compared with that in autodialyse (70.9) and in hemodialysis at center (73.3). A significant variability from one care team to another was evidenced. CONCLUSIONS: Our study proves the feasibility of satisfaction measurement at the dialyzed patient. Dialysis Patient Satisfaction Questionnaire in the French version exhibits satisfying psychometric properties. The level of satisfaction is better in peritoneal dialysis and differs according to medical care centers.

Changes in health-related quality of life in patients of self-care vs. in-center dialysis during the first year.

OBJECTIVE: In the Lorraine area (France), dialysis centers propose an educational program to improve patient's ability to perform dialysis by themselves. The objective was to assess changes in health-related quality of life (HRQoL) during the first year of dialysis, comparing independent patients with patients on in-center dialysis. METHOD: All patients aged between 18 and 70 and having started their first dialysis between June 1997 and June 1999 in the Lorraine area were included. Socio-demographic, medical data and HRQoL (KDQoL) were assessed for each patient at enrollment, at 6 and 12 months. RESULTS: At 12 months, 195 patients were in dialysis, 147 were non-autonomous, and 48 were autonomous. Independent patients were younger, were more often in occupational activity, had a lower body mass index and had fewer comorbidities. Several dimensions of the HRQoL were significantly higher in autonomous patients at baseline: physical functioning (60.4 vs. 50.7) and work status (30.9 vs. 18.4); and at 12 months: less burden of kidney disease (51.7 vs. 37.3), fewer effects of kidney disease (65.9 vs. 54.0), cognitive function (72.0 vs. 62.7) and role-emotional (53.0 vs. 34.5). CONCLUSION: These results show improved HRQoL among independent patients. Our regional care network may be a particularly useful model for undertaking actions motivating the healthcare teams and for enhancing the human resources devoted to patient education.

[Measuring quality of life in end-stage renal disease. Transcultural adaptation and validation of the specific Kidney Disease Quality of Life questionnaire]. / Mesure de la qualité de vie dans l'insuffisance rénale chronique terminale. Adaptation transculturelle et validation du questionnaire spécifique Kidney Disease Quality of Life.

End-stage renal disease has an important impact on the patients' daily life, which can be measured by quality of life questionnaires. The objective of this work was to adapt the Kidney Disease Quality of Life questionnaire (KDQoL) into French and to determine its basic psychometric properties, i.e. validity and reliability. The KDQoL consisted of 8 generic dimensions and 11 specific dimensions. The questionnaire was translated several times independently, and then submitted to a committee of professionals. The study of the measurement properties was carried out near 68 dialysis patients. KDQoL is valid and reproducible, and has properties comparable to the original instrument: missing items proportion of 5.5%, limited floor and ceiling effects (except for 4 dimensions), Cronbach alpha coefficient varying from 0.64 to 0.92 (except for 2 dimensions), test-retest coefficient greater than 0.67 (except for 3 dimensions), and the items of KDQoL were better correlated with their dimension than with other dimensions (except for 2 dimensions). Correlations between the generic and the specific scores showed the absence of redundancies between specific and generic dimensions. Thus the French version has comparable properties to the original KDQoL. This questionnaire can be used to measure the quality of life of the dialysis patients. It constitutes a good tool in clinical research, allowing international comparisons.

[Epidemiology of chronic kidney disease in France]. / Epidémiologie de l'insuffisance rénale chronique en France.

End-stage renal failure affects more than 50000 people in France, or nearly 1 per thousand; 60% receive dialysis and 40% have a functioning transplanted kidney. Its incidence is stable, except among those older than 75 years, in whom incidence continues to rise. In nearly half of all cases end-stage renal failure follows hypertension or diabetes, principally type 2 noninsulin-dependent diabetes. About 30% of patients begin dialysis on an emergency basis; this demonstrates the elevated frequency of inadequate predialysis management of chronic kidney disease, from any cause. Since 2002, "chronic kidney disease" has been defined as the persistence for more than 3 months of kidney damage, which is either a laboratory or histologic or morphologic abnormality or a glomerular filtration rate (GFR)<60 mL/min for 1.73 m(2) of body surface, independently of the initial cause. It is classified by stage of severity to facilitate the application of good clinical practice guidelines. Moderate or severe chronic kidney disease, defined by GFR<60 mL/min/1.73 m(2) is approximately 40 times more common than end-stage renal failure. Individuals with chronic kidney disease are much more likely to die of another disease than to progress towards with end-stage renal failure. Diabetes, hypertension, a history of cardiovascular disease, nephrectomy, recurrent urinary infections or kidney failure in the family are all factors that should result in regular check-ups for chronic kidney disease. In two thirds of those older than 70 years, the GFR estimated by laboratories according to Cockcroft and Gault's formula is between 30 and 60 mL/min, but this does not always signal the presence of chronic kidney disease.

[Chronic kidney disease: do generalists and nephrologists differ in their care?]. / Insuffisance rénale chronique: connaissances et perception par les médecins généralistes.

INTRODUCTION: Chronic kidney disease (CKD) is a major public health problem. We report an evaluation of the CKD perception from a French family physician's (FP) point of view. METHODS: A questionnaire was sent to a representative and independently selected sample of 497 FP, i.e. 20% of the FP working in the administrative region Lorraine. There were 214 completed surveys, i.e. response rate: 43%. RESULTS: Age of FP was: < 40 years of age: 13%, 40-50: 40%, > 50: 47%. The geographic working place was urban: 41%, rural: 22%, urban and rural: 37%. Ninety-nine per cent of FP has a nephrologist, devoted to CKD referral. Twenty-one per cent of FP has a comprehensive picture of CKD and 75% thinks that CKD diagnostic is difficult Thirty per cent of FP were aware of CKD guidelines. For FP, risk-factors for CKD were: hypertension: 93%, diabetes: 99%, age over 65: 64%, urinary infection: 34%, hematuria/proteinuria: 78%, anaemia: 43%, therapeutics associated with risk of renal injury: 79%, all of these circumstances: 20%. The referral decision to a nephrologist was done at a mean creatinine clearance of 41+/-12 ml/min. Age over 80, dementia, and cancer were considered to be a contra-indication of renal replacement therapy, for respectively 30%, 69%, and 63% of FP. CME was associated with better awareness of guidelines, and use of clearance rather than serum creatinin. CONCLUSION: From FP point of view, overall awareness of CKD guidelines is low. In the context of the current nephrology services, greater sharing of CKD care with FP is needed.

Impact of first dialysis modality on outcome of patients contraindicated for kidney transplant.

BACKGROUND: We compared, in patients contraindicated for kidney transplant, outcomes between those patients who were only on hemodialysis (HD) and those who were given peritoneal dialysis (PD) as first renal replacement therapy (RRT). DESIGN: Prospective, population-based cohort study of incident cases of end-stage renal disease between June 1997 and June 1999. SETTING: A network of dialysis care: NEPHROLOR, that is, all the renal units in Lorraine, one of the 22 French administrative regions (population over 2.3 million people). PARTICIPANTS: 387 patients were contraindicated for kidney transplant during the first 2 years of RRT: 284 were on HD, 103 on PD. Mean age was 67.6 +/- 11.3 years for HD patients and 70.8 +/- 11.4 years for PD patients (p = 0.015). MAIN OUTCOME MEASURES: Mortality until June 2003, hospitalization over the 2 first years of RRT, and Kidney Disease and Quality of Life Short Form (KDQOL-SF) 6 and 12 months after initiation of RRT. RESULTS: HD patients were more likely to die from cardiac or cerebrovascular causes, PD from cachexia or withdrawal from dialysis. Whatever mode of RRT, the unadjusted 2-year and 5-year survival rates were similar (p = 0.98). The rate of total duration of hospital stay per month of RRT was similarin HD and PD groups: 2.7 +/- 4.5 and 2.9 +/- 4.2 days respectively (p = 0.7). PD was associated with better quality of life than HD. The dimensions Role limitation due to emotional function, Burden of kidney disease, and Role limitation due to physical function ranked first, second, and third for PD. CONCLUSION: In Lorraine, end-stage renal disease patients who were given PD as first-line RRT had no excess of death risk or hospitalizations, and better quality of life the first year of RRT.

In vitro evaluation of microleakage of indirect composite inlays cemented with four luting agents.

STATEMENT OF PROBLEM: Microleakage around dental restorations is implicated in the occurrence of secondary carious lesions, adverse pulpal response, and reduced restoration longevity. PURPOSE: The aim of this in vitro study was to evaluate the microleakage of indirect resin composite inlays cemented with 4 luting agents. MATERIAL AND METHODS: Standardized Class V inlay preparations overlapping the cemento-enamel junction were prepared on the buccal and lingual surfaces of 40 extracted human mandibular third molars. Eighty postpolymerized, heat-treated resin composite inlays (Targis, 72 specimens, 8 controls) were processed in stone replicas and cemented into the preparations using 4 luting agents (n = 18 + 2 controls for each cement group): a resin composite used with a bonding agent (Variolink II/Excite), a resin composite used with a self-etching primer, but without bonding agent (Panavia F/ED Primer), a modified resin composite used with a bonding agent (Resinomer/One Step), and a resin-modified glass-ionomer cement (Fuji Plus). Thirty-six inlays (n = 9 + 1 control) were subjected to thermal cycling (2000 cycles, 5 degrees C/55 degrees C), whereas the other 36 were not. All the teeth were then immersed in 1% methylene blue dye solution for 48 hours. Microleakage score, margin location (enamel/cementum), thermal cycling history, and preparation location (buccal/lingual) were analyzed using a multivariate model (alpha = .05). Multivariate analysis was performed using a polychotomous logistic regression. RESULTS: The preparation location had no significant effect on dye penetration. The margin location (enamel or cementum) and the thermal cycling had a significant effect on microleakage (odds ratios [ORs] = 17.6 and 8.04, respectively). In comparing the 3 resin-based luting agents (Variolink II, Panavia F, and Resinomer) to Fuji Plus, Panavia F exhibited the lowest significant overall microleakage (OR = 0.09), followed by Variolink II (significant OR equal to 0.43), whereas Resinomer demonstrated the greatest significant overall microleakage (OR = 1.35). CONCLUSION: Within the experimental conditions of this in vitro study, thermal cycling significantly increased microleakage (OR = 8.04). The overall microleakage at the enamel margins was significantly lower than the overall microleakage at the cementum margins for the 4 luting agents tested (OR = 17.6).