C. Jacquelinet

Factors associated with health-related quality of life in renal transplant recipients: results of a national survey in France

BackgroundThis study aims to identify factors associated with health related quality of life (HRQOL) through a comprehensive analysis of sociodemographic and clinical variables among a representative sample size of renal transplant recipients (RTR) in France.MethodsA cross-sectional multicenter study was carried out in 2008. All RTR over 18xa0years old with a functioning graft for at least one year were included. Data included socio-demographic, health status, and treatment characteristics. To evaluate HRQOL, the Short Form-36 Health Survey (SF-36) and a HRQOL instrument for RTR (ReTransQol) were administered. Multivariate linear regression models were performed.ResultsA total of 1061 RTR were included, with a return rate of 72.5%. The variance explained in regression models of SF-36 ranges from 20% to 40% and from 9% to 33% for ReTransQol.The variables which decreased scores of both HRQOL questionnaires were: females, unemployment, lower education, living alone, high BMI, diabetes, recent critical illness and hospitalization, non-compliance, a long duration of dialysis and treatment side effects.Specific variables which decreased ReTransQol scores were dismissal and a recent surgery on the graft. These which decreased SF36 scores were being old and a recent infectious disease.The variables the most predictors of worse HRQOL were: side effects, infectious disease, recent hospitalization and female gender.ConclusionsThe originality of our study’s findings was that novel variables, particularly treatment side effects and unemployment, have a negative effect on quality of life of RTR. The French Biomedicine Agency and the National Health Institute for Public Health Surveillance conduct specific actions for professional reintegration and therapeutic education programs in the national plan to improve the HRQOL of people living with chronic diseases.

New primary renal diagnosis codes for the ERA-EDTA

The European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry has produced a new set of primary renal diagnosis (PRD) codes that are intended for use by affiliated registries. It is designed specifically for use in renal centres and registries but is aligned with international coding standards supported by the WHO (International Classification of Diseases) and the International Health Terminology Standards Development Organization (SNOMED Clinical Terms). It is available as supplementary material to this paper and free on the internet for non-commercial, clinical, quality improvement and research use, and by agreement with the ERA-EDTA Registry for use by commercial organizations. Conversion between the old and the new PRD codes is possible. The new codes are very flexible and will be actively managed to keep them up-to-date and to ensure that renal medicine can remain at the forefront of the electronic revolution in medicine, epidemiology research and the use of decision support systems to improve the care of patients.

[Renal Epidemiology and Information Network: 2006 annual report].

In 2007, 7197 patients with end-stage renal disease living in 18 regions ( Auvergne, Basse-Normandie, Bourgogne, Bretagne, Centre, Champagne-Ardenne, Corse, Haute-Normandie, Ile de France, Languedoc-Roussillon, Limousin, Lorraine, Midi-Pyrenees, Nord-Pas de Calais, Picardie, Poitou-Charentes, Provence-Alpes Cote dAzur et Rhone-Alpes) covering 52 million inhabitants (82% of the French population), started renal replacement therapy (dialysis or preemptive graft): median age was 70, 4 years; 3% had preemptive graft. The overall crude annual incidence rate of renal replacement therapy for end-stage renal disease was 139 per million population(pmp), with significant differences in sex and age-adjusted incidence across regions (99 to 168 pmh). At initiation, more than one patient out of the two had at least one cardiovascular disease and 39% diabetes (90% Type 2 non-insulin-dependent diabetes). On December 31, 2007, 31056 patients living in 20 regions( the above region plus Aquitaine and la Reunion) were on dialysis: median age was 69, 8 years. On December 31, 2007, 25699 patients were living with a functioning graft: median age was 53,5 years. In these 20 regions, the overall prevalence of dialysis was 554 pmp, that of renal graft, 459 pmp and the overall rate of renal replacement therapy for end stage renal disease, 1013 pmp with significant differences in age-adjusted prevalence across regions (746 to 2,586 pmh). In the 2003-2007 cohort of 26423 incident patients, the overall one-year survival rate was 83%, 56% at 4 years. Survival decreased with age, but remains above 50% at 2 years in patients older than 75 at RRT initiation. Among the 7195 new patients starting dialysis in 2007 in 19 regions, 7% had a BMI lower than 18,5 kg/m2 and 18% a BMI higher than 30. At initiation, 62% had an haemoglobin value lower than 11 g/l and 10% an albumin value lower than 25 g/l. The first haemodialysis was started in emergency in 32% of the patients and with a catheter in 51%. On December 31, 2007, 8% treated in the dialysis units of the 20 regions received peritoneal dialysis, of which 39% were treated with automated peritoneal dialysis. 95% of the patients on haemodialysis had 3 sessions per week, with a median duration of 4 hours. In the 2002-2007 cohort of incident patients in 11 regions under 60 years, the probability to be at least once on the waiting list for a renal graft is 50% at 18 months. In 2007, 2530 patients received renal graft. On December 31, 2007, 5661 patients were on the waiting list for a renal graft in the transplantation centres of the 20 regions..

Analysis, evaluation and adaptation of the ReTransQoL: a specific quality of life questionnaire for renal transplant recipients

BackgroundEnd stage renal disease (ESRD) profoundly impacts the lives of patients. Kidney transplantation provides the greatest health-related quality of life (HRQOL) improvement. Its measurement has become an important outcome parameter and a very important criterion in the evaluation of any type of medical treatment, especially in the field of renal transplantation.In 2007, a specific self-administered questionnaire for renal transplant recipients was developed in the French language: the ReTransQol (RTQ).After 5 years of use, the properties of the RTQ needed to be re-evaluated in a larger sample.This paper describes the analysis of the ReTransQol and its adaptation to achieve an improved and revised version.MethodsThe study design included three analysis phases for two samples of adult renal transplant recipients which came from two cross-sectional multicenter studies carried out in France in 2007 and 2012. Psychometrics properties like construct validity, acceptability and feasibility, reliability and convergent validity were evaluated and every analysis resulted in a new version of the questionnaire: the RTQ V2. The construct validity of the new RTQ was assessed with a Confirmatory Factor Analysis on a large sample of patients.ResultsThe study samples included 1,059 patients and 1,591 patients, respectively.After a principal component analysis, item reduction was performed and a total of 13 items were deleted. A final version of the RTQ V2 was created and comprised of 32 items describing 5 domains: Physical Health, Social Functioning, Medical Care, Treatment and Fear of Losing Graft.The explained variance between the first and second RTQ versions improved from 46.3% to 53.1%. All psychometric properties of RTQ V2 were satisfactory: IIC >0.4, IDV (%) of 100% and Cronbach’s Alpha >0.7 in every dimension. The confirmatory analysis showed that the overall scalability of the RTQ V2 was satisfactory; all items showed a good fit to the Rasch model within each dimension, and showed INFIT statistics inside the acceptable range.ConclusionsPsychometric properties allow this new version of the questionnaire to be used to assess different specific dimensions for the renal transplant population, more effectively than previously possible.

Accès à la liste d’attente et à la greffe rénale

Resume Ce chapitre fournit un ensemble d’indicateurs concernant l’acces a la greffe renale en France. Il decrit le devenir des patients et les taux d’incidence cumulee d’inscription en liste d’attente et de greffe renale en fonction des grandes caracteristiques de malades et des regions. Le registre du REIN integre les donnees de la greffe renale et de la dialyse. Il permet de fournir aux patients, aux nephrologues et aux autorites sanitaires nationales et regionales une vision large de l’acces a la greffe renale (incluant l’acces a la liste d’attente) a partir de la mise en route d’un traitement de suppleance. L’acces a la liste d’attente est evalue pour 25 regions, sur une cohorte des 51 845 nouveaux patients ayant debute la dialyse entre 2002 et 2011. La probabilite d’etre inscrit pour la premiere fois sur la liste d’attente d’une greffe renale etait, tout âge confondu, de 3,7% au demarrage de la dialyse (malades inscrits en intention de greffe preemptive), 15% a 12 mois, 22% a 36 mois et 24% a 60 mois. La probabilite d’etre inscrit etait fortement liee a l’âge, au diabete et a la region. Les personnes de plus de 60 ans, quel que soit leur statut diabetique ont un acces tres modeste a la liste d’attente. En presence d’un diabete de type 2, chez les patients de 40 a 59 ans, cette probabilite d’etre inscrit pour la premiere fois sur la liste d’attente d’une greffe renale etait beaucoup plus faible, de 36,5% meme a 60 mois. Chez les 13 653 patients moins de 60 ans, la probabilite d’etre inscrit etait de 11% au demarrage de la dialyse, 43% a 12 mois, 62% a 36 mois et 66% a 60 mois ; (duree mediane de dialyse: 16 mois). Pour 17 regions disposant d’un recul de 5 ans, on note une augmentation de 8 a 15% du taux d’inscription preemptive entre 2007 et 2001, sans modification du taux d’inscription a 1 an. L’acces a la greffe renale est evalue pour 25 regions, sur une cohorte de 53 301 malades ayant debute un traitement de suppleance (dialyse ou greffe preemptive) au cours de la periode 2002-2011. La probabilite de beneficier d’une premiere greffe renale etait de 7% a 12 mois, 17% a 36 mois et 21% a 60 mois. 8 633 patients (16,2%) avaient recu une premiere greffe de rein dans un delai median de 14,7 mois ; 1 455 (2,7%) avaient recu une greffe preemptive, en majorite des hommes (58%), avec un âge median de 48,7 ans. La probabilite de beneficier d’une premiere greffe renale pour les 14 770 nouveaux patients de moins de 60 ans etait de 21% a 12 mois, 46% a 36 mois et 58% a 60 mois (duree mediane de dialyse: 42 mois). Si l’on exclut les greffes preemptives, la probabilite d’etre greffe est de 5% a 12 mois, 15% a 36 mois et 19% a 60 mois. Dans la mesure ou la greffe renale est consideree comme le traitement le plus efficient, la problematique de l’acces a la liste d’attente et a la greffe est une question sensible.

Rapport Rein 2011 – Synthèse

Abstract Incident patients In 2011, in France, we estimate that 9 400 patients started a treatment by dialysis (incidence of dialysis: 144 per million inhabitants) and 335 patients with a pre-emptive graft without previous dialysis (incidence of pre-emptive graft: 5 per million inhabitants). As in 2010, incidence rate seems to stabilize. Elders provide the majority of new patients (median age at RRT start: 71 years old). New patients present a high rate of disabilities especially diabetes (41% of the new patients) and cardiovascular disabilities (>50% of the new patients) that increase with age. Considering treatment and follow-up, the first treatment remains centers hemodialysis and we do not notice any progression of self-dialysis. RRT started in emergency in 33% of the patients. This finding contrasts with the fact that 56% of patients started hemodialysis on a catheter. This, together with the major inter-region variability, suggests that different strategies of management exist. Finally, the hemoglobin level at RRT start seems to be an interesting indicator of good management and follow-up since 13% of patients presenting an underprovided follow-up have a hemoglobin level under 10xa0g/dl, whereas only 2.5% of patients with an appropriate follow-up presented such a condition. Prevalent patients On December 31, 2011, in France, we estimate that 70.700 patients were receiving a renal replacement therapy, 39.600 (56%) on dialysis and 31.100 (44%) living with a functional renal transplant. The overall crude prevalence was 1091 per million inhabitants. It was 1.6 higher in males. Download : Download full-size image Renal replacement therapy for End-stage renal disease in 2011 in France Prevalence was subject to regional variations with 5 regions (3 overseas) above the national rate. Renal transplant share varied from 33% in Nord-Pas de Calais to 53% in Pays de Loire, and from 16 to 25% in overseas regions. The study of temporal variations for 18 regions contributing to the registry since 2007 demonstrated a +4% increase in standardized prevalence of ESRD patients with a functional transplant vs. +2% increase for dialysis, resulting in a decreasing gap between dialysis and transplantation prevalence, due to an increase number of renal transplant and a longer survival of transplanted patients. The main dialysis technique was hemodialysis (93.3% of patients). Even if an important inter-region variability remains considering the choices of treatment, more than 50% of the patients are undergoing hemodialysis in a hospital-based incenter unit, and we noticed an increase in hemodialysis in a medical satellite unit with time whereas the rate of self-care hemodialysis decreases. The rate of peritoneal dialysis remains stable. When comparing guidelines to real-life treatments, 77.5% of patients receive adequate dose of treatment (12 H/week, KT/ V>1.2), the rate of patients with a hemoglobin blood-level lower than 10xa0g/dl and without erythropoietin treatment is 1.3%, which confirmed a good management of anemia. On the contrary, 34% of patients have a BMI lower than 23xa0kg/m2 and only 23% have an albumin blood-level over 40xa0g/l, which underlines that nutritional management of ESRD patients can be improved. Mortality Age strongly influences survival on dialysis. Thus, one year survival of patients under age 65 is over 90%. After 5 years, among patients over 85 years, it is more than 15%. The presence of diabetes or one or more cardiovascular comorbidities also significantly worse patient survival. In terms of trend, we do not find significant improvement in the 2-year survival between patients in the cohort 2006–2007 and the 2008–2009 cohort. Cardiovascular diseases account for 27% of causes of death to infectious diseases (12%) and cancer (10%). Life expectancy of patients is highly dependent on their treatment. Thus, a transplant patient aged 30 has a life expectancy of 41 years versus 23 years for a dialysis patient. ESRD pediatric patients In 2011, the incidence and the prevalence of ESRD among patients under 20 years old remained stable at 8 and 53 per million inhabitants respectively. The first causes of ESDR remain uropathies and hypodysplasia followed by glomerulonephritis and genetic diseases. Considering the initial treatment, we found a high rate of hemodialysis and a low rate of peritoneal dialysis that is mainly used in younger children. In 2011, 31 preemptive transplantations were performed accounting for 27.7% of new patients. Finally, survival analysis confirm that younger children (under 4 years old) have the highest risk of death (88% survival rate at 2 years vs. 98% in patients over 4 years old) and that the treatment of choice remains the renal transplantation since it increases the expected remaining lifetime of 20 to 40 years depending on the considered age. Transplantation Access to the waiting list is evaluated on a cohort of 51,846 new patients who started dialysis between 2002 and 2011 in 25 regions. The probability of first wait-listing was of 3.7% at the start of dialysis (pre-emptive registrations), 15% at 12, 22% at 36 and 24% to 60 months. Patient older than 60 had a very poor access to the waiting list, whatever their diabetes status was. Among 13,653 patients less than 60 years old, the probability of being registered was 11% at the start of dialysis, 43% to 12 months, 62% to 36 months and 66% to 60 months (median dialysis duration: 16 months). Seventeen regions with up to 5 years follow-up show an increase of 8 to 15% in pre-emptive registrations between 2007 and 2001, without change at 1 year. Access to kidney transplant is evaluated on a cohort of 53,301 new patients who started a renal replacement therapy (dialysis or pre-emptive renal transplant) between 2002 and 2011 in 25 regions. The probability of first kidney transplant was of 7% at 12, 17% at 36 and 21% at 60 months. 8,633 patients (16,2%) had received a first renal transplant within 14.7 month median time; 1,455 (2.7%) had received a pre-emptive graft. Among the 14.770 new patients less than 60 years old, the probability of being transplanted was of 21% at 12, 46% at 36 and 58% at 60 months (median dialysis duration: 42 months). When pre-emptive graft were excluded, the probability of being transplanted was of 5% at 12, 15% to 36 and 19% to 60 months Flow between treatment modalities 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, out-center 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.

L’incidence de l’IRCT en 2011

This chapter provides a set of indicators on incident patients with renal replacement therapy. In 2011, in 25 French regions (99% population), 9 248 patients started a treatment by dialysis (incidence of dialysis: 149 per million inhabitants) and 334 patients with a pre-emptive graft without previous dialysis (incidence of pre-emptive graft: 5 per million inhabitants). One patient among two are over 70 years old at renal replacement therapy initiation. As in 2010, incidence rate seems to stabilize.This chapter provides a set of indicators on incident patients with renal replacement therapy. In 2011, in 25 French regions (99% population), 9 248 patients started a treatment by dialysis (incidence of dialysis: 149 per million inhabitants) and 334 patients with a pre-emptive graft without previous dialysis (incidence of pre-emptive graft: 5 per million inhabitants). One patient among two are over 70 years old at renal replacement therapy initiation. As in 2010, incidence rate seems to stabilize.

Risk profile, quality of life and care of patients with moderate and advanced CKD : The French CKD-REIN Cohort Study

BackgroundnThe French Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort study was designed to investigate the determinants of prognosis and care of patients referred to nephrologists with moderate and advanced chronic kidney disease (CKD). We examined their baseline risk profile and experience.nnnMethodsnWe collected bioclinical and patient-reported information from 3033 outpatients with CKD and estimated glomerular filtration rates (eGFRs) of 15-60u2009mL/min/1.73u2009m2 treated at 40 nationally representative public and private facilities.nnnResultsnThe patients median age was 69 (60-76)u2009years, 65% were men, their mean eGFR was 33u2009mL/min/1.73u2009m2, 43% had diabetes, 24% had a history of acute kidney injury (AKI) and 57% had uncontrolled blood pressure (BP; >140/90u2009mmHg). Men had worse risk profiles than women and were more likely to be past or current smokers (73% versus 34%) and have cardiovascular disease (59% versus 42%), albuminuria >30u2009mg/mmol (or proteinuria >u200950) (40% versus 30%) (all Pu2009<u20090.001) and a higher median risk of end-stage renal disease within 5u2009years, predicted by the kidney failure risk equation {12% [interquartile range (IQR) 3-37%] versus 9% [3-31%], Pu2009=u20090.008}. During the previous year, 60% of patients reported one-to-two nephrologist visits and four or more general practitioner visits; only 25% saw a dietician and 75% were prescribed five or more medications daily. Physical and mental quality of life (QoL) were poor, with scores <50/100.nnnConclusionsnThe CKD-REIN study highlights high-risk profiles of cohort members and identifies several priorities, including improving BP control and dietary counselling and increasing doctors awareness of AKI, polypharmacy and QoL.nnnTrial registrationnClinicalTrials.gov identifier: NCT03381950.

Évaluation de la prévalence des prescriptions médicamenteuses non adaptées à la fonction rénale selon la prise en compte de la surface corporelle pour estimer le DFG

Introduction Adapter les doses de medicaments au debit de filtration glomerulaire estime (DFGe) par equation est difficile, notamment chez les personnes obeses. Nous avons evalue la prevalence de prescriptions non adaptees chez des patients atteints de maladie renale chronique (MRC), en estimant le DFG par l’equation CKD-EPI, indexee ou non a la surface corporelle (SC). Patients/Materiels et methodes Dans une cohorte incluant 3033xa0patients suivis en nephrologie pour une MRC avec un DFGe entre 15xa0et 60xa0mL/min/1,73xa0m2, nous avons examine les doses journalieres de principe actif prescrites dans les 3xa0mois precedant l’inclusion dans l’etude. Une prescription non adaptee a la fonction renale (fondee sur les recommandations des resumes des caracteristiques des produits) a ete definie comme la prescription declaree d’un medicament contre-indique ou a une dose trop elevee pour le DFGe du patient. Observation/Resultats L’âge median [ecart interquartile] des patients etait de 69 [61–76]xa0ansxa0; 66xa0% etaient des hommes, 43xa0% avaient un diabete et 36xa0%, un indice de masse corporellexa0≥xa030xa0kg/m2. La SC moyenne etait de 1,90xa0±xa00,22xa0m2. Le DFGe moyen etait respectivement de 33xa0mL/min/1,73xa0m2xa0et 36xa0mL/min, selon que l’equation etait indexee ou non a la SC. Le nombre median de medicaments prescrits etait de 8 [5–10] par jour. La proportion de patients avec au moins une prescription non adaptee au DFGe etait de 52xa0% avec, et de 47xa0% sans indexation a la SC. Les hypouricemiants, les antidiabetiques et les medicaments a visee cardiovasculaire etaient les principales classes de medicaments incriminees. Les patients diabetiques avaient avec une SC moyenne de 1,97xa0±xa00,21xa0m2xa0et un DFGe moyen, respectivement, de 33xa0mL/min/1,73xa0m2xa0et 37xa0mL/min avec et sans indexation a la SC. En consequence, chez les 273xa0patients sous metformine (seule ou en association), la prescription etait apparemment contre-indiquee chez 53xa0patients (19xa0%) avec un DFGe indexe a la SCxa0 Discussion/Conclusion La prevalence globale des prescriptions non adaptees a la fonction renale touche pres d’un patient sur deux avec une MRC moderee ou avancee. La prise en compte de la SC pour estimer le DFG induit des variations dans l’evaluation de cette prevalence qui sont d’autant plus importantes que la SC moyenne s’ecarte de la valeur standard de 1,73xa0m2. Il reste cependant a determiner si la desindexation de l’equation CKD-EPI modifie l’estimation de l’effet de ces prescriptions apparemment non adaptees sur les risques d’evenements iatrogenes, d’hospitalisations et de mortalite.

La perte définitive de fonction rénale en greffe : une étiologie croissante de mise en dialyse en France

Introduction En 2012 en France, 11xa0157 patients ont debute un traitement de suppleance par dialyse (patients incidentsxa0+xa0patients apres perte de la fonction de leur greffonxa0+xa0patients en retour de sevrage temporaire pour recuperation de la fonction renale), parmi eux, 969 sont des patients qui debutaient un traitement par dialyse pour perte du greffon, soit 8,7xa0%. Patients et methodes Sur les 20 regions pour lesquelles on dispose de 5xa0ans de recul, le nombre de patients de retour en dialyse apres greffe est passe de 663 en 2008 a 820 en 2012. Resultats La part des retours de greffe parmi les nouveaux patients en dialyse variaient de 5,3 a 12,3xa0% en metropole. L’âge de la moitie des patients etait de 56xa0ans ou plus. La moitie des patients etait greffe depuis plus de 8,9xa0ans. Parmi ces patients, 165 (17xa0%) ont perdu la fonction de leur greffon dans la premiere annee. Probablement, compte-tenu des nombreux facteurs qui fragilisent ces patients, leur prise en charge initiale se fait dans 72xa0% des cas en hemodialyse dans les centres lourds et pour 4,4xa0% en dialyse peritoneale. Discussion et conclusion Au vu du nombre croissant des patients transplantes renaux en France et de l’evolution des caracteristiques des donneurs et receveurs (de plus en plus «xa0limitesxa0»), on peut presumer que le nombre de patients incidents en dialyse «xa0de retour de greffexa0» continuera d’augmenter dans les annees a venir. Une etroite collaboration entre les centres de transplantation et de dialyse est d’autant plus requise qu’il s’agit d’une transition difficile pour ces patients greffes, aux pathologies particulieres liees aux traitements immunosuppresseurs.