Sahar Bayat

Type 1 and type 2 diabetes and cancer mortality in the 2002-2009 cohort of 39,811 French dialyzed patients.

End-stage renal disease is a chronic and progressive pathology associated with several comorbidities, particularly diabetes. Indeed, diabetes is the first cause of end-stage renal disease and, in France, 42% of incident patients had diabetes in 2012. In the general population, diabetes is associated with increased cancer risk. The aim of this study was to examine the association between risk of cancer death and diabetes in a large French cohort of patients with end-stage renal disease. Data on all patients with end-stage renal disease who initiated dialysis in France between 2002 and 2009 were extracted from the Renal Epidemiology Information Network registry. The risk of dying by cancer was studied using the Fine and Gray model to take into account the competing risk of death by other causes. We analyzed 39 811 patients with end-stage renal disease. Their mean age was 67.7±15 years, 39.4% had diabetes and 55.3% at least one cardiovascular disease. Compared with the non-diabetic group, patients with diabetes were older and had more cardiovascular and respiratory comorbidities when they started dialysis. Conversely, fewer diabetic patients had also a tumor at the beginning of the renal replacement therapy. Cancer was indicated as the cause of death for 6.7% of diabetic and 13.4% of non-diabetic patients. The Fine and Gray multivariate analyses indicated that diabetes (HR=0.72 95% CI: [0.68-0.95], p<0.001) and also female gender, peritoneal dialysis, cardio-vascular disease and kidney transplantation were associated with decreased risk of death by cancer. In this French cohort of patients with end-stage renal disease, diabetes was not associated with a significant increased risk of dying from cancer. Studies on the incidence of cancer in patients with ESRD are now needed to evaluate the potential association between diabetes and specific malignancies in this population.

Deleterious effects of dialysis emergency start, insights from the French REIN registry

BackgroundEmergency start (ES) of dialysis has been associated with worse outcome, but remains poorly documented. This study aims to compare the profile and outcome of a large cohort of patients starting dialysis as an emergency or as a planned step in France.MethodsData on all patients aged 18 years or older who started dialysis in mainland France in 2012 or in 2006 were collected from the Renal Epidemiology and Information Network and compared, depending on the dialysis initiation condition: ES or Planned Start (PS). ES was defined as a first dialysis within 24 h after a nephrology visit due to a life-threatening event. Three-year survival were compared, and a multivariate model was performed after multiple imputation of missing data, to determine the parameters independently associated with three-year survival.ResultsIn 2012, 30.3% of all included patients (n = 8839) had ES. Comorbidities were more frequent in the ES than PS group (≥ 2 cardiovascular diseases: 39.2% vs 28.8%, p < 0.001). ES was independently associated with worse three-year survival (57% vs. 68.2%, p = 0.029, HR 1.10, 95% CI 1.01–1.19) in multivariate analysis. Among ES group, a large part had a consistent previous follow-up: 36.4% of them had ≥3 nephrology consultations in the previous year. This subgroup of patients had a particularly high comorbidity burden. ES rate was stable between 2006 and 2012, but some proactive regions succeeded in reducing markedly the ES rate.ConclusionES remains frequent and is independently associated with worse three-year survival, demonstrating that ES deleterious impact is never overcome. This study shows that a large part of patients with ES had a previous follow-up, but high comorbidity burden that could favor acute decompensation with life-threatening conditions before uremic symptoms appearance. This suggests the need of closer end-stage renal disease follow-up or early dialysis initiation in these high-risk patients.

Prédire l’accès à la liste d’attente de transplantation rénale: comparaison de deux méthodes de fouille de données

The study compares the effectiveness of Bayesian networks versus Decision Trees for predicting access to the renal transplant waiting list in a French healthcare network. The data set consisted in 809 patients starting renal replacement therapy. The data were randomly devised in a training set (90 %) and a validation set (l0 %). Bayesian networks and CART decision tree were built on the training set. Their predictive performances were compared on the validation set. The Age variable was found to be the most important factor for predicting registration on the waiting list in both models. Both models were highly sensitive and specific: sensitivity 90.0 % (95 % CI: 76.8–100), specificity 96.7% (95 % CI: 92.2–100). Moreover, the models were complementary since the Bayesian network provided a global view of the variables’ associations while the decision tree was more easily interpretable by physicians. These approaches provide insights on the current care process. This knowledge could be used for optimizing the healthcare process.

Categorical state sequence analysis and regression tree to identify determinants of care trajectory in chronic disease: Example of end-stage renal disease

Background Patients with chronic diseases, like patients with end-stage renal disease (ESRD), have long history of care driven by multiple determinants (medical, social, economic, etc.). Although in most epidemiological studies, analyses of health care determinants are computed on single health care events using classical multivariate statistical regression methods. Only few studies have integrated the concept of treatment trajectories as a whole and studied their determinants. Methods All 18- to 80-year-old incident ESRD patients who started dialysis in Ile-de-France or Bretagne between 2006 and 2009 and could be followed for a period of 48 months after initiation of a renal replacement therapy were included (nu2009=u20095568). Their care trajectories were defined as categorical state sequences. Associations between patients’ characteristics and care trajectories were assessed using a regression tree model together with a discrepancy analysis. Results On average, each patient experienced 1.56 different renal replacement therapies (minu2009=u20091; maxu2009=u20095) during the 48 months of follow-up. About 55% of patients never changed treatment and only 1% tried three or more renal replacement therapy modalities. Twelve homogeneous care trajectory groups were identified. Covariates explained 12% of the discrepancy between groups, particularly age, regions and initiation of hemodialysis with a catheter. Conclusions Regression tree analysis of categorical state sequence highlighted geographical disparities in the care trajectory of French patients with ESRD that cannot be observed when focusing on a single outcome, such as survival. This method is an original tool to visualize and characterize care trajectories, notably in the context of chronic condition like ESRD.

Sex differences in adherence to antihypertensive treatment in patients aged above 55: The French League Against Hypertension Survey (FLAHS)

Despite the availability of efficient therapies to reduce the risk of cardiovascular complications, poor adherence to antihypertensive (anti‐HTN) drugs is frequent, especially during the first year of treatment and among uncontrolled/resistant hypertensive patients. The aim of the study was to identify factors associated with adherence to anti‐HTN treatment and to examine whether they differ across sex. A total of 2743 treated hypertensive participants to the cross‐sectional Metascope survey (France, 2015) aged 55 years or more were included. The authors measured adherence to anti‐HTN treatment using the 6‐item Girerd compliance test. Variations in adherence were examined using the Rao‐Scott statistics and Poisson regression. Overall, 63.6% of participants were adherent to anti‐HTN treatment. Adherence was more frequent among women than men (69% vs 58%, P < 10−4). For both sexes, level of adherence was positively associated with age (P < 10−4), but inversely associated with number of anti‐HTN tablets, number of tablets taken for metabolic diseases, history of cardiovascular diseases, number of other chronic diseases (all P < 10−4). The inverse relationship between adherence and the number of anti‐HTN tablets significantly differed between sexes (P < 10−4): Adherence decreased sharply when taking two or more anti‐HTN tablets in men, whereas the decrease in women was only observed when taking three or more anti‐HTN tablets. This study suggests that adherence to anti‐HTN treatment is higher among women, decreases with the number of tablets prescribed, and differentially so across sex. Reducing the number of tablets for anti‐HTN treatment may improve adherence, especially among men and patients with multiple comorbidities.

What is the evolution of stroke unit’s accessibility in metropolitan France from 2009 to 2014? A trend analysis of over 600 000 patients using national hospital databases.

Objectives We aimed to study trends in stroke unit (SU) admission during a period of their deployment in France and to assess whether this led to better and more equitable access to this specialised care. Design Analysis of records from the national hospital database. Setting All acute care hospitals in metropolitan France for the period 2009–2014. Participants Over 600 000 patients admitted in acute care with a main diagnosis of stroke. Main outcome measures Admission to a SU. Results Between 2009 and 2014, the number of stroke admissions rose from 93 728 to 109 456, and the proportion of SU admission from 23% to 44%. Overall, characteristics associated with higher probability of SU admission were: male gender, younger age, ischaemic stroke type, medium level of comorbidity and larger size of town of residence. Although likelihood of SU admission increased in all patients’ categories during the study period, we identified steeper positive temporal trends among older patients, those with more comorbidities and those residing in medium or small towns (all p values <0.001), suggesting a ‘catching up’ phenomena. Temporal trends of men and women did not differ however. Conclusions Admission to SU nearly doubled in France between 2009 and 2014. Faster trends observed for patients with lower admission to SU suggest that equity in access has improved over the period.

Correction to: Deleterious effects of dialysis emergency start, insights from the French REIN registry

Following publication of the original article [1], the authors reported that all of the authors’ names were processed incorrectly so that their given and family names were interchanged.

Hilar fat infiltration: A new prognostic factor in metastatic clear cell renal cell carcinoma with first-line sunitinib treatment

INTRODUCTIONnThe selection of patients with metastatic clear cell renal cell carcinoma (ccRCC) who may benefit from targeted tyrosine kinase inhibitors has been a challenge, even more so now with the advent of new therapies. Hilar fat infiltration (HFI) is a validated prognostic factor in nonmetastatic ccRCC (TNM 2009 staging system) but has never been studied in metastatic patients. We aimed to assess its phenotype and prognostic effect in patients with metastatic ccRCC treated with first-line sunitinib.nnnMATERIALS AND METHODSnIn a multicentric study, we retrospectively included 90 patients and studied the corresponding ccRCC at the pathological, immunohistochemical, and molecular levels. Patient and tumor characteristics were compared using univariate and multivariate analysis. All the features were then studied by Cox models for prognostic effect.nnnRESULTSnHFI was found in 42 patients (46.7%), who had worse prognosis (Heng criteria) (P = 0.003), liver metastases (P = 0.036), and progressive diseases at first radiological evaluation (P = 0.024). The corresponding ccRCC was associated with poor pathological prognostic factors that are well known in nonmetastatic ccRCC. For these patients, median progression-free survival was 4 months vs. 13 months (P = 0.02), and median overall survival was 14 months vs. 29 months (P = 0.006). In a multivariate Cox model integrating all the variables, only poor prognosis, according to the Heng criteria and HFI, remained independently associated with both progression-free survival and overall survival.nnnCONCLUSIONnHFI was demonstrated for the first time to be an independent poor prognostic factor. Its potential role in predicting resistance to antiangiogenic therapy warrants further investigation.

Interopérabllité sémantique: comparaison de la représentation du score d’APGAR en HL7V3 et Open EHR

Semantic imeroperabdity. a prerequisite to eHea/th projects, relit’s 011 sharing both information and knowledge models between information systems. Two of the standards of information models are HL7 v3 and the European norm, EN13606/0penEHR. The paper compares both standards on a fr agment of the prenatal medical record, the APGAR score. The HL7v3 perinatology DMIM specification and the OpenEHR APGAR archetype were used. HL7v3 appear, to be more formal than Open EHR and able to represent in an easier way the clinical context. For both standards, the binding to reference terminologies such as LOINC is poor.