Phenotypes influencing low physical activity in maintenance dialysis.

OBJECTIVE: The "Pas à Pas" initiative aimed at evaluating the weekly physical activity (PA) and its determinants in a large cohort of dialysis patients. SETTING: Physical inactivity is a risk factor for mortality in maintenance dialysis patients and is still poorly documented in this population. DESIGN: A prospective national epidemiological study was performed. SUBJECTS: A total of 1,163 patients on maintenance dialysis (hemodialysis and peritoneal dialysis) were included. INTERVENTION AND MAIN OUTCOME MEASURE: PA was recorded during seven consecutive days using a pedometer to measure daily step numbers. RESULTS: Median age was 63 years (Q1 51-Q3 75). Sixty-three percent were sedentary (<5000 steps/day) with a median of 3,688 steps/day (1,866-6,271)]. PA level was similar between hemodialysis patients and those on peritoneal dialysis (3,693 steps [1,896-6,307] vs. 3,320 [1,478-5,926], P = .33). In hemodialysis patients, PA was lower on dialysis days compared with nondialysis days (2,912 [1,439-5,232] vs. 4,054 [2,136-7,108], respectively, P < .01). PA gradually decreased with age, 57% being sedentary between 50 and 65 years and 83% of patients after 80 years. Beyond this age effect, we identified, for the first time, specific phenotypes of patients with lower PA, such as inflammation, cardiovascular disease, protein energy wasting, obesity, and diabetes. By contrast, previous kidney transplantation and a higher muscle mass were associated with higher PA. CONCLUSIONS: Dialysis patients present a very low level of PA with high sedentary. Acting on patient's modifiable phenotypes may help to increase PA to improve morbidity, mortality, and quality of life.

Aortic stiffness of kidney transplant recipients correlates with donor age.

Increased aortic stiffness is a major factor responsible for the high cardiovascular mortality in patients with end-stage renal disease, but the impact of kidney transplantation on recipient aortic stiffness remains poorly defined. The use of expanded-criteria kidney donors is associated with decreased recipient survival compared with the use of standard-criteria donors, although the underlying mechanisms are incompletely understood. It was hypothesized that donor characteristics may affect recipient aortic stiffness, which may contribute to cardiovascular mortality in these patients. Aortic stiffness was evaluated by measurement of carotid-femoral pulse wave velocity in 74 cadaveric kidney recipients at 3 and 12 mo after transplantation. At 3 mo, aortic stiffness was associated exclusively with recipient-related factors: Age, gender, and mean BP. At 12 mo, age of the donor kidney emerged as an additional determinant. The change in aortic stiffness between 3 and 12 mo strongly correlated with donor age; stiffness improved in recipients of young kidneys (first tertile of donor age) and worsened in recipients of older kidneys (upper tertile of donor age). At 12 mo, the carotid-femoral pulse wave velocity was >1 m/s higher in recipients of the oldest kidneys than in the recipients of younger kidneys. The association between donor age and aortic stiffness was independent of recipient age, gender, mean BP, pretransplantation dialysis duration, conventional cardiovascular risk factors, medication, posttransplantation events, and GFR. These results demonstrate that the impact of kidney transplantation on recipient aortic stiffness is dependent on donor age and suggest that ongoing damage to large arteries might contribute to the mechanism underlying the association of old-donor kidneys and increased cardiovascular mortality.

[When to place a patient on the kidney transplantation waiting list?]. / Quand faut-il inscrire un patient sur la liste d'attente de transplantation rénale?

Practices for enrollment on kidney transplantation waiting lists are variable between geographical areas and centers. Early referral of patients with chronic renal failure (CRF) to a nephrologist, particularly one practicing in a transplantation center, is a prerequisite to early enrollment. Despite improved survival in elderly transplant recipients, being aged over 65 years is still a barrier against enrollment. Furthermore certain comorbid conditions such as diabetes mellitus are often wrongly considered as contraindications for transplantation. If nephrological management is initiated early, enrollment could (should?) be considered before the terminal phase of CRF, with the hope of preemptive transplantation with the known advantages not only for the individual recipient but also for the community in general. Glomerular filtration rate below 20 ml/minute could be a reasonable cutoff for enrollment. Patients referred late to a nephrologist will require dialysis. Dialysis center staff should be well trained in delivering appropriate information on kidney transplantation and initiating evaluation. A consultation with a transplantation specialist should be rapidly scheduled.

[Physical activity in dialysis population: how and why to assess and establish a program?]. / Activité physique chez les patients dialysés: comment et pourquoi l'évaluer et mettre en place un programme?

The studies that evaluated physical activity in dialysis patients show a significant inactivity. This inactivity is associated with increased mortality. In contrast, the benefits in terms of morbidity and mortality of physical activity in this population are numerous. Recommendations exist for these patients: those set out for the general elderly adult population. However, few centers are implementing training programs in dialysis patients. There are many reasons, among which the lack of knowledge of the medical staff. The purpose of this article is to clarify the assessment of physical activity in dialysis patients and implementation program for the fight against inactivity. The initial assessment by simple means is essential. It ideally requires the intervention of a specialist in physical activity. The main types of exercise are presented as well as the different types of program and their results. It is important to note that no serious adverse events were reported in the different programs and their feasibility has been demonstrated. The fight against the sedentary patients undergoing dialysis should be a goal of health care teams, as well as the fight against the other cardiovascular risk factors.

[Description of characteristics, therapy and outcome of patients older than 75 years presenting with severe renal insufficiency (eGFR below 20 mL/min/1.73 m(2): pilot study]. / Description des caractéristiques, des projets de soins et du devenir des patients de plus 75ans présentant une insuffisance rénale sévère (DFGe≤20mL/min/1,73m(2)) : phase pilote du projet PSPA.

In France, the incidence of dialysis patients is increasing in people over 75 years and represents 40% of incident patients. In these elderly patients with many comorbidities, the benefit of dialysis in terms of survival and quality of life remains controversial. Using data from REIN, determinants of early mortality were identified and a prognostic score was provided. This approach must now be adapted to elderly with end stage renal failure (ESRF) not on dialysis for which we have little data on their clinical characteristics, therapeutic projects and outcome. We report the results of a pilot study and the prospective study protocol that resulted. In four French nephrology department, 76 patients were studied with a mean age of 83 ± 5 years, with a MDRD estimated GFR (abbreviated MDRD) of 16 ± 4 mL/min/1.73 m(2). These patients were different from the population on dialysis recorded in REIN. This pilot study has shown the feasibility of a prospective study on a larger scale, which aims to build a valuable tool for decision making in elderly patients with ESRF not yet on dialysis.