Economic impact of a modification of the treatment trajectories of patients with end-stage renal disease

Outcomes and Cost Comparison of 3 Different Laparoscopic Approach for Living Donor Nephrectomy: A Retrospective, Single-Center, Inverse Probability of Treatment Weighting Analysis of 551 Cases

BACKGROUND

At our institution, we switched from hand-assisted retroperitoneal laparoscopic donor nephrectomy (HRN) to hand-assisted transperitoneal laparoscopic donor nephrectomy (HTN); we later switched to standard retroperitoneal laparoscopic donor nephrectomy (SRN). This study was performed to evaluate outcomes and hospital costs among the 3 techniques.

METHODS

This retrospective, observational, single-center, inverse probability of treatment weighting analysis study compared the outcomes among 551 cases of living donor kidney transplantation between 2014 and 2022.

RESULTS

After the inverse probability of treatment weighting analysis, there were 114 cases in the HRN group, 204 cases in the HTN group, and 213 cases in the SRN group. Donor complication rates were lowest in the SRN group but did not differ between the HRN and HTN groups (1.1 vs 4.4 and 5.9%, P = .021). Donors in the SRN group had the lowest serum C-reactive protein concentrations on postoperative day 1 (4.3 vs 10.5 and 7.8 mg/dL, P < .001) and the shortest postoperative stay (4.3 vs 7.4 and 8.4 days, P < .001). Donors in the SRN group had the lowest total cost among the 3 groups (8868 vs 9709 and 10,592 USD, P < .0001). Donors in the SRN group also had the lowest costs in terms of "basic medical fees," "medication and injection fees," "Intraoperative drug and material costs," and "testing fees." Furthermore, the presence of complications was significantly correlated with higher total hospital costs (P < .001).

CONCLUSION

SRN appeared to have the least invasive and complication, and a potential cost savings compared with the HRN and HTN.

Twenty years of the French Renal Epidemiology and Information Network

Background

The French Renal Epidemiology and Information Network (REIN) is 20 years old. It is not just a national data registry, but rather an epidemiological and informational network serving patients with chronic kidney disease, nephrology teams and health services.

Methods

The past 10-year trends of the incidence and prevalence of renal replacement therapy by dialysis or kidney transplantation and waitlist activity are presented. To detect potential significant changes in trends from 2012 and 2021, a Joinpoint regression model was used.

Results

The overall incidence of treated end-stage kidney disease (ESKD) was 169 per million population (pmp) in 2021. It was stable despite an increase in the incidence of diabetes. We found a decreasing trend in the proportion of patients starting dialysis in an emergency but an increase in those starting haemodialysis (HD) with a temporary catheter. Peritoneal dialysis decreased by 1.7% each year, whereas home HD, although involving only 1% of dialysis patients, increased by 10% each year. For patients not treated at home, the median time to drive from the patient's home to the dialysis unit was 17 min. The proportion of patients on the transplantation waitlist at the start of dialysis increased from 7% to 12%. Among the 111 263 new ESKD patients from 2012 to 2021, 8% received a first transplant at 1 year and 20% at 5 years. Among kidney transplant recipients, the mean time on the waitlist increased from 13.8 to 22.6 months. Living donor transplants increased in frequency, representing 15% of kidney transplants.

Conclusions

Data from the REIN registry allow for the evaluation of needs and provide a planning tool for French authorities. The progressive implementation of automatic data retrieval from dialysis informatics charts might alleviate the burden of data collection. Furthermore, the research activity the REIN engenders, resulting in renewed confidence by health authorities in the dynamism of French nephrology, allows for an optimistic outlook for the REIN.

[REIN: a tool at the service of health authorities]

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of its link with health authorities, the following key messages were retained. One of the purposes of REIN is to contribute to a better understanding about patient management and its evolution, and thus to be called upon to develop health strategies aimed at improving the prevention and treatment of chronic renal failure. Indeed, the planning of the supply and the evaluation of the treatment are important issues for the public health decision-makers who must have the relevant indicators and tools to help them in their decision-making and follow-up processes. REIN is clearly identified as a source of information by institutional partners, as is shown by the various requests made by the Regional health agencies (ARS), the French National Authority for Health (HAS) and the General Directorate for Healthcare Services (DGOS), as well as other health authorities. It allows estimating the needs of the population within the framework of decree nos. 2002-1197 and 2002-1198 of September 2002 relating to the treatment of chronic renal failure by renal dialysis. The recent possibility of probabilistic matching of REIN data with the data from the National Healthcare Data System (SNDS) for a pseudonymised individual allows for more detailed studies on the different care pathways, as well as evaluating the impact of the different actions or experiments that are set up, with the help of detailed clinical information from the REIN and, among other things, the expenses reimbursed by the Health Insurance.

[REIN: a tool for the benefit of renal transplantation]

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of access to renal transplantation for ESKD patients, the following key messages were retained. The registry of the REIN includes data about kidney transplant and dialysis. It thus allows evaluating the access to kidney transplant in France based on the needs of the population with stage 5 CKD treated by renal replacement therapy. The data produced by the registry is complementary to the data in the report of the Agence de la biomédecine (Agency of Biomedicine) based on the activity of the transplant centres and the population of registered patients waiting for a transplant. The proportion of preemptive transplant (transplant without prior recourse to dialysis) as well as that of preemptive registration (before starting dialysis) have increased since 2012 but remain low. The proportion of preemptive transplant as the first replacement therapy remains low and stable over time at around 3 to 4%. The access to the waiting list and the transplant varies depending on the age and co-morbidities of the patients (diabetes, obesity) as well as on the region. The rates of registration on the kidney transplant waiting list at the time of initiation of dialysis and at 1 year from the start have been increasing since 2012, irrespective of the patients’ characteristics, though it remains low in elderly, diabetic and severely obese patients. This is partly the result related to the publication of the HAS (French National Authority for Health) recommendations in 2015 and the publications on the disparities in access to transplants established thanks to the REIN registry. The causes of non-registration at the time of initiation of dialysis have changed over time with some patients not registering for contraindication steadily decreasing since 2012. Thanks to several studies conducted using data from the registry, the variations in access to the list could be explained, partly, by the health condition of the dialysis population as well as by the socio-economic context and differences in practices according to dialysis networks. The median waiting time for a kidney transplant has been gradually increasing since 2012, with a delta of about 8 months between 2012 and 2020. However, the waiting time between the initiation of dialysis and the transplant has increased less significantly. The probability of receiving a first kidney transplant depends on the age, diabetic status and obesity of the patient, and has remained stable over time.

[Treatment trajectories of patients with End Stage Kidney Disease]

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of trajectory of ESKD patients, the following key messages were retained. Apart from a few rare, absolute or relative contraindications, till date, there is no medical consensus on the indications of one treatment modality as compared to another, and therefore, no recommendations allowing defining criteria for guiding patients, based on their characteristics, to a technique/treatment modality. In addition, the patients’ choices and their changing needs over time must be taken into account. Thus, due to the limitations of each of these modalities, a good number of patients with stage 5 renal failure treated with kidney replacement therapy will move between these different modalities. For many years, the REIN registry has endeavoured to represent the patient flows between the different treatment modalities. In order to better understand and then optimise the trajectories followed by patients who have reached stage 5 of their chronic renal failure, it was necessary to develop tools to model these complex trajectories where the treatment modalities are considered as complementary.

What does the French REIN registry tell us about Stage 4-5 CKD care in older adults?

The aim of this paper is to illustrate all the clinical epidemiology searches made within the French network REIN to improve CKD stage 4-5 care in older adults. We summarize various studies describing clinical practice, care organization, prognosis and health economics evaluation in order to develop personalized care plans and decision-making tools. In France, for 20 years now, various databases have been mobilized including the national REIN registry which includes all patients receiving dialysis or transplantation. REIN data are indirectly linked to the French administrative healthcare database. They are also pooled with data from the PSPA cohort, a multicenter prospective cohort study of patients aged 75 or over with advanced CKD, monitored for 5 years, and the CKD-REIN clinical-based prospective cohort which included 3033 patients with CKD stage 3-4 from 2013 to 2016. During our various research work, we identified heterogeneous trajectories specific to this growing older population, raising ethical, organizational and economic issues. Renal registries will help clinicians, health providers and policy-makers if suitable decision- making tools are developed and validated.

Similar survival on home hemodialysis and automated peritoneal dialysis: an inception cohort study

BACKGROUND

Several studies have shown superior survival of patients on home hemodialysis (HD) compared to peritoneal dialysis (PD), but patients on automated PD (APD) and continuous ambulatory PD (CAPD) have not been considered separately. As APD allows larger fluid volumes and may be more efficient than CAPD, we primarily compared patient survival between APD and home HD.

METHODS

All adult patients who started kidney replacement therapy (KRT) between 2004 and 2017 in the district of Helsinki-Uusimaa in Finland, and who were on one of the home dialysis modalities at 90 days from starting KRT, were included. We used intention-to-treat analysis.Survival of home HD, APD and CAPD patients was studied using Kaplan-Meier curves and Cox regression with adjustment for propensity scores that were based on extensive data on possible confounding factors.

RESULTS

The probability of surviving 5 years was 90% for home HD, 88% for APD and 56% for CAPD patients. After adjustment for propensity score, the hazard ratio of death was 1.1 [95% CI 0.52-2.4] for APD and 1.6 [95% CI 0.74-3.6] for CAPD in comparison to home HD. Censoring at the time of kidney transplantation or at transfer to in-center hemodialysis did not change the results. Characteristics of home HD and APD patients at the start of dialysis were similar, whereas patients on CAPD had higher median age and more comorbidities, and received kidney transplantation less frequently.

CONCLUSIONS

Home HD and APD patients had comparable characteristics and their survival appeared similar.

The role of kidney registries in expediting large-scale collection of patient-reported outcome measures for people with chronic kidney disease

In this issue of Clinical Kidney Journal, Van der Willik et al. report findings from a pilot study where they introduced collection of patient-reported outcome measures (PROMs) into routine kidney care in Dutch dialysis centres. It is comparable to a registry-led PROMs initiative in Sweden, published in Clinical Kidney Journal in 2020. Both studies reported low average PROMs response rates with substantial between-centre variation, and both identified suboptimal patient and staff engagement as a key barrier to implementing PROMs in routine care for people with chronic kidney disease (CKD). This suggests that national kidney registries could be well placed to facilitate large-scale collection of PROMs data, but that they may require additional guidance on how to do this successfully. In this editorial, we discuss the current state-of-play of PROMs collection by kidney registries and provide an overview of what is (un)known about the feasibility and effectiveness of PROMs in CKD and other conditions. We anticipate that the fast-growing evidence base on whether, and how, PROMs can be of value in CKD settings will expedite registry-based PROMs collection, which will ultimately lead to more valuable and person-centred services and to enhanced health and well-being of people with CKD.

Cost-effectiveness of four living-donor nephrectomy techniques from a hospital perspective

BACKGROUND

In Europe, transplantation centres use different nephrectomy techniques: open surgery, and standard, hand-assisted and robot-assisted laparoscopies. Few studies have analysed the disparity in costs and clinical outcomes between techniques. Since donors are healthy patients expecting minimum pain and fast recovery, this study aimed to compare the cost-effectiveness of four nephrectomy techniques focusing on early surgical outcomes, an essential in the donation act.

METHODS

A micro-costing approach was used to estimate the cost of implementation from a hospital perspective. Estimates took into account sterilization costs for multiple-use equipment, costs for purchasing single-use equipment, staff and analgesics. The study recruited donors in 20 centres in France. Quality of life by EuroQol-5D was assessed preoperatively, and 4 and 90 days post-operatively. Two effectiveness indicators were built: quality-of-life recovery and post-operative pain days averted (PPDA). The study was registered at ClinicalTrials.gov NCT02830568, on 10 June 2010.

RESULTS

A total of 264 donors were included; they underwent open surgery (n = 65), and standard (n = 65), hand-assisted (n = 65) and robot-assisted laparoscopies (n = 69). Use of the nephrectomy techniques differed greatly in cost of implementation and immediate post-operative outcomes but not in clinical outcomes at 90 days. At 4 days, hand-assisted laparoscopy provided the lowest cost per quality-of-life recovery unit of effectiveness (%) and PPDA (days) (€2056/40.1%/2.3 days, respectively). Robot-assisted laparoscopy was associated with the best post-operative outcomes but with the highest cost (€3430/59.1%/2.6 days).

CONCLUSION

Hand-assisted, standard and robot-assisted laparoscopies are cost-effective techniques compared with open surgery. Hand-assisted surgery is the most cost-effective procedure. Robot-assisted surgery requires more healthcare resource use but enables the best clinical outcome.

Health claims databases used for kidney research around the world

Health claims databases offer opportunities for studies on large populations of patients with kidney disease and health outcomes in a non-experimental setting. Among others, their unique features enable studies on healthcare costs or on longitudinal, epidemiological data with nationwide coverage. However, health claims databases also have several limitations. Because clinical data and information on renal function are often lacking, the identification of patients with kidney disease depends on the actual presence of diagnosis codes only. Investigating the validity of these data is therefore crucial to assess whether outcomes derived from health claims data are truly meaningful. Also, one should take into account the coverage and content of a health claims database, especially when making international comparisons. In this article, an overview is provided of international health claims databases and their main publications in the area of nephrology. The structure and contents of the Dutch health claims database will be described, as well as an initiative to use the outcomes for research and the development of the Dutch Kidney Atlas. Finally, we will discuss to what extent one might be able to identify patients with kidney disease using health claims databases, as well as their strengths and limitations.

The impact of chronic kidney disease on developed countries from a health economics perspective: A systematic scoping review

Chronic kidney disease (CKD) affects over 10% of the global population and poses significant challenges for societies and health care systems worldwide. To illustrate these challenges and inform cost-effectiveness analyses, we undertook a comprehensive systematic scoping review that explored costs, health-related quality of life (HRQoL) and life expectancy (LE) amongst individuals with CKD. Costs were examined from a health system and societal perspective, and HRQoL was assessed from a societal and patient perspective. Papers published in English from 2015 onward found through a systematic search strategy formed the basis of the review. All costs were adjusted for inflation and expressed in US$ after correcting for purchasing power parity. From the health system perspective, progression from CKD stages 1-2 to CKD stages 3a-3b was associated with a 1.1-1.7 fold increase in per patient mean annual health care cost. The progression from CKD stage 3 to CKD stages 4-5 was associated with a 1.3-4.2 fold increase in costs, with the highest costs associated with end-stage renal disease at $20,110 to $100,593 per patient. Mean EuroQol-5D index scores ranged from 0.80 to 0.86 for CKD stages 1-3, and decreased to 0.73-0.79 for CKD stages 4-5. For treatment with renal replacement therapy, transplant recipients incurred lower costs and demonstrated higher HRQoL scores with longer LE compared to dialysis patients. The study has provided a comprehensive updated overview of the burden associated with different CKD stages and renal replacement therapy modalities across developed countries. These data will be useful for the assessment of new renal services/therapies in terms of cost-effectiveness.

[What do registries compared to clinical trials tell us?]

The objective of this review is to illustrate the interests of registries in terms of clinical research, using practical examples from the French REIN registry. In addition to their interest in terms of observation and decision-making for public health, registries may also be used to compare structures, and to evaluate causality in clinical research. Indeed, even though randomized controlled trials are the gold standard to assess causality, they may be difficult to perform, with an applicability in daily life that remains to be demonstrated since patients are highly selected patients with a very close follow-up. In contrast, observational studies from registries have other advantages, and notably high number of patients, low cost, relatively rapid research, focus on specific sub-groups. In the future, data mining with an implementation of a huge number of data for patients (hospitalization data, genetics, ambulatory care, etc.) will dramatically improve the databases. We may even imagine running RCTs directly in registries, with lower costs and patients closer to reality. However, many challenges remain to be solved, and notably the ethical issues of confidentiality and protection of patients in these "mega-databases". Cet article fait partie du numéro supplément Innovations en Néphrologie réalisé avec le soutien institutionnel de Vifor Fresenius Medical Care Renal Pharma.

THE EFFECT OF EXERCISE ON INTERFERON GAMMA, BODY FAT AND BMI OF KIDNEY TRANSPLANT PATIENTS

ABSTRACT Introduction: Poor physical function and obesity are well documented in kidney transplant patients. Significant health benefits result from regular physical activity, many of which are important for kidney transplant patients. Objective: The aim of this study was to investigate the effects of 10-week combined exercises on Interferon Gamma (IFNγ), body fat percentage (BF%) and body mass index (BMI) in kidney transplant patients. Method: In a randomized controlled experimental design, 44 kidney transplant patients aged 20-50 years were randomly divided into two groups of exercise (n=23) and control (n=21). The exercise group participated in a cumulative training program for 10 weeks, three days a week, 60–90 minutes per day at 40-65% of predicted maximal heart rate reserve. A 5 ml venous blood sample and anthropometric parameters were taken from the subjects at baseline and after 10 weeks. Results: The exercise group showed an improvement in BF% (from 31.80±5.64 to 28.86 ± 5.82, p =0.001) and BMI (from 26.23 ± 1.81 to 25.45 ± 2.11, p = 0.001), but there was no significant change in the IFNγ level (from 0.06 ± 0.02 to 0.06 ± 0.02, p = 0.829). There was a significant difference between the control and exercise groups for BF% (p = 0.001) and BMI (p = 0.001). Conclusion: As a take-home message, it should be mentioned that combined exercise intervention is inexpensive and portable and can be performed at home or health centers for kidney transplant patients to reduce their weight and BF%. Evidence Level I; High quality randomized trial with or without statistically significant difference, but with narrow confidence intervals.

Two-year management after renal transplantation in 2013 in France: Input from the French national health system database

The objective of this study was to describe the management of patients undergoing renal transplantation in 2013 and over the following two years on the basis of healthcare consumption data. The National Health Insurance Information System was used to identify 1876 general scheme beneficiaries undergoing a first isolated renal transplantation (median age: 53 years; men 63%). Overall, 1.2% of patients died during the transplantation hospital stay (>65 years 3.3%) and 87% of patients had a functional graft at 2 years. Thirty-three percent of patients were readmitted to hospital for 1 day or longer during the first month, 73% the first year and 55% the second year. At least 10% of patients were hospitalised for antirejection treatment during the first quarter after renal transplantation, 16% the first year and 9% the second year. The first year, 32% of patients were hospitalised for renal disease (12% the second year), 14% were hospitalised for cardiovascular disease (9% the second year), 13% for infectious disease (5% the second year) and 2% for a malignant tumour (2% the second year). Almost 80% of patients consulted their general practitioner each year (almost 50% consulted every quarter). During the second year, 83% of patients were taking antihypertensives, 45% lipid-lowering drugs, 26% antidiabetic drugs, 77% tacrolimus, 18% ciclosporin, 88% mycophenolic acid and 69% corticosteroids. This study highlights the important contribution of healthcare consumption data to a better understanding of the modalities of management of renal transplant recipients in France, allowing improvement of this management in line with guidelines.

Patient healthcare trajectory. An essential monitoring tool: a systematic review

BACKGROUND

Patient healthcare trajectory is a recent emergent topic in the literature, encompassing broad concepts. However, the rationale for studying patients' trajectories, and how this trajectory concept is defined remains a public health challenge. Our research was focused on patients' trajectories based on disease management and care, while also considering medico-economic aspects of the associated management. We illustrated this concept with an example: a myocardial infarction (MI) occurring in a patient's hospital trajectory of care. The patient follow-up was traced via the prospective payment system. We applied a semi-automatic text mining process to conduct a comprehensive review of patient healthcare trajectory studies. This review investigated how the concept of trajectory is defined, studied and what it achieves.

METHODS

We performed a PubMed search to identify reports that had been published in peer-reviewed journals between January 1, 2000 and October 31, 2015. Fourteen search questions were formulated to guide our review. A semi-automatic text mining process based on a semantic approach was performed to conduct a comprehensive review of patient healthcare trajectory studies. Text mining techniques were used to explore the corpus in a semantic perspective in order to answer non-a priori questions. Complementary review methods on a selected subset were used to answer a priori questions.

RESULTS

Among the 33,514 publications initially selected for analysis, only 70 relevant articles were semi-automatically extracted and thoroughly analysed. Oncology is particularly prevalent due to its already well-established processes of care. For the trajectory thema, 80% of articles were distributed in 11 clusters. These clusters contain distinct semantic information, for example health outcomes (29%), care process (26%) and administrative and financial aspects (16%).

CONCLUSION

This literature review highlights the recent interest in the trajectory concept. The approach is also gradually being used to monitor trajectories of care for chronic diseases such as diabetes, organ failure or coronary artery and MI trajectory of care, to improve care and reduce costs. Patient trajectory is undoubtedly an essential approach to be further explored in order to improve healthcare monitoring.

[Outcome of living kidney donors for transplantation]

Nowadays, several treatments exist to treat terminal chronic renal failure. Best results for the recipients are obtained with kidney transplantation concerning mortality and quality of life. Transplantation is also the cheaper option for society. Living kidney donation raises the issue of the becoming of the donor, an absolutely healthy subject who gets to a surgical procedure. The becoming of living kidney donors has been compared with the one of controls subjects in several studies. The evaluations focused on the complications of nephrectomy in the short and long-term: kidney failure, hypertension, proteinuria, possibility of pregnancy, quality of life, and mortality. The first results did not show any risk linked to kidney donation, compared to general population. However, since 2013, kidney donors were found at higher risk for kidney failure and even for mortality, compared with controls selected like donor candidates. The risk of kidney donation is nevertheless acceptable and minimal, on the condition of rigorous selection of candidates and regular follow-up.

A comprehensive approach to assess the costs of renal replacement therapy for end-stage renal disease in France: the importance of age, diabetes status, and clinical events

OBJECTIVES

In the current pressured economic context, and to continue to treat the growing number of patients with high-quality standards, the first step is to have a better understanding of the costs related to end-stage renal disease (ESRD) treatment according to various renal replacement therapy, age, diabetes status, and clinical events.

METHODS

In order to estimate the direct costs of all adult ESRD patients, according to (RRT) modality, patient condition, and clinical events, data from the French national health insurance funds were used.

RESULTS

The mean monthly costs for the 47,862 stable prevalent patients (73 % of the population) varied substantially according to treatment modality (from 7300€ for in-center hemodialysis to 1100€ for a functioning renal graft) and to clinical event (8300€ for the first month of dialysis, 11,000€ for the last month before death, 22,800€ for the first month after renal transplantation). Mean monthly costs varied according to diabetic status and to age to a lesser extent.

CONCLUSIONS

These results demonstrate, for the first time in France and in Europe, the importance of a dynamic view of renal care and the bias likely when comparing treatments in cross-sectional studies.

Facilitating access to the renal transplant waiting list does not increase the number of transplantations: comparative study of two French regions

BACKGROUND

In France, there are important regional disparities of access to the renal transplant waiting list and transplantation. Our objectives were to compare the characteristics of patients with end-stage renal disease (ESRD) of two French regions (Ile-de-France and Bretagne) and to identify determinants of access to the waiting list and subsequent transplantation, with a focus on temporary inactive status (TIS) periods.

METHODS

All 18-80-year-old incident patients who started dialysis in Ile-de-France or Bretagne between 2006 and 2009 were included (n = 6160). Associations between patients' characteristics and placement on the waiting list or transplantation were assessed using a Fine and Gray model to take into account the competing risk of death and living donor transplantation.

RESULTS

At the end of the follow-up (31 December 2013), more patients had undergone transplantation in Bretagne than in Ile-de-France (30 versus 27%), although the percentage of waitlisted patients was higher in Ile-de-France than in Bretagne (47 versus 33%). More patients were on TIS and with a longer median TIS duration in Ile-de-France. Independent of age and clinical characteristics, patients in Bretagne were less likely to be waitlisted than those in Ile-de-France [subdistribution hazard ratio 0.77 (95% confidence interval 0.7-0.9)]. After waitlisting, patients in Bretagne were four times more likely to be transplanted.

CONCLUSIONS

Our study highlights clinical practice differences in Bretagne and Ile-de-France and shows that facilitating access to the waiting list is not sufficient to improve access to renal transplantation, which also depends on organ availability.

[Chronic kidney disease and kidney transplantation]

OBJECTIVES

To report epidemiology and characteristics of end-stage renal disease (ESRD) patients and renal transplant candidates, and to evaluate access to waiting list and results of renal transplantation.

MATERIAL AND METHODS

An exhaustive systematic review of the scientific literature was performed in the Medline database (http://www.ncbi.nlm.nih.gov) and Embase (http://www.embase.com) using different associations of the following keywords: "chronic kidney disease, epidemiology, kidney transplantation, cost, survival, graft, brain death, cardiac arrest, access, allocation". French legal documents have been reviewed using the government portal (http://www.legifrance.gouv.fr). Articles were selected according to methods, language of publication and relevance. The reference lists were used to identify additional historical studies of interest. Both prospective and retrospective series, in French and English, as well as review articles and recommendations were selected. In addition, French national transplant and health agencies (http://www.agence-biomedecine.fr and http://www.has-sante.fr) databases were screened using identical keywords. A total of 3234 articles, 6 official reports and 3 newspaper articles were identified; after careful selection 99 publications were eligible for our review.

RESULTS

The increasing prevalence of chronic kidney disease (CKD) leads to worsen organ shortage. Renal transplantation remains the best treatment option for ESRD, providing recipients with an increased survival and quality of life, at lower costs than other renal replacement therapies. The never-ending lengthening of the waiting list raises issues regarding treatment strategies and candidates' selection, and underlines the limits of organ sharing without additional source of kidneys available for transplantation.

CONCLUSION

Allocation policies aim to reduce medical or geographical disparities regarding enrollment on a waiting list or access to an allotransplant.

French patients on daily hemodialysis: clinical characteristics and treatment trajectories

BACKGROUND

Increasing the weekly frequency of hemodialysis sessions has positive effects, on the control of several biological data of patients. However, knowledge about Daily HemoDialysis (DHD) practices is limited in France. The aim of the present study was to describe the characteristics and treatment trajectories of all French patients undergoing DHD.

METHODS

All patients older than 18 years who started DHD between 2003 and 2012 in France were included and followed until December 31, 2013. The patients' demographic and clinical characteristics and treatment modalities were extracted from the French Renal Epidemiological and Information Network (REIN) registry.

RESULTS

During the inclusion period, 753 patients started DHD in France. Based on their median age (64 years), patients were classified in two groups: "old" group (≥64 years) and "young" group (<64 years). Patients in the old group had more comorbidities than in the young group: 48 % had diabetes (vs 29 % in the young group), 17 % an active malignancy (vs 10 %) and 80 % ≥1 cardiovascular disease (vs 41 %). Concerning patients' treatment trajectories, 496 (66 %) patients started with another dialysis before switching to DHD and 257 (34 %) directly with DHD. At the end of the follow-up, 69 % of patients in the old group were dead (27.4 % in the young group) and kidney transplantation was more frequent in the young group (30.4 % vs 0.5 %).

CONCLUSION

In France, DHD is proposed not only to young in rather good clinical conditions and waiting for kidney transplantation, but also to old and frail patients with higher mortality.

Spatial Analysis of Case-Mix and Dialysis Modality Associations

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BACKGROUND

Health-care systems must attempt to provide appropriate, high-quality, and economically sustainable care that meets the needs and choices of patients with end-stage renal disease (ESRD). France offers 9 different modalities of dialysis, each characterized by dialysis technique, the extent of professional assistance, and the treatment site. The aim of this study was 1) to describe the various dialysis modalities in France and the patient characteristics associated with each of them, and 2) to analyze their regional patterns to identify possible unexpected associations between case-mixes and dialysis modalities. ♦

METHODS

The clinical characteristics of the 37,421 adult patients treated by dialysis were described according to their treatment modality. Agglomerative hierarchical cluster analysis was used to aggregate the regions into clusters according to their use of these modalities and the characteristics of their patients. ♦

RESULT

The gradient of patient characteristics was similar from home hemodialyis (HD) to in-center HD and from non-assisted automated peritoneal dialysis (APD) to assisted continuous ambulatory peritoneal dialysis (CAPD). Analyzing their spatial distribution, we found differences in the patient case-mix on dialysis across regions but also differences in the health-care provided for them. The classification of the regions into 6 different clusters allowed us to detect some unexpected associations between case-mixes and treatment modalities. ♦

CONCLUSIONS

The 9 modalities of treatment available make it theoretically possible to adapt treatment to patients' clinical characteristics and abilities. However, although we found an overall appropriate association of dialysis modalities to the case-mix, major inter-region heterogeneity and the low rate of peritoneal dialysis (PD) and home HD suggest that factors besides patients' clinical conditions impact the choice of dialysis modality. The French organization should now be evaluated in terms of patients' quality of life, satisfaction, survival, and global efficiency.