Early Post Transplantation Infections in CAPO Patients

In order to evaluate the risk of infection during the post-transplantation period in CAPD patients, a retrospective multi-center study was performed among six centers: dialysis and transplantation teams differed in size and experience, and geographically were separated so that the group studied can be taken to represent the overall CAPD population. Seventeen CAPD patients were transplanted between 1980 and 1983: no infectious complication related to CAPD was observed, even in patients whose CAPD was continued after the operation. It is concluded that there is no special risk to CAPD patients receiving a kidney transplant and therefore adults waiting for a renal transplant can be safely maintained on CAPD.

Compared to hemodialysis, CAPD is a relatively new treatment and therefore there is no overall agreement about its indications. This is true particularly for ESRD patients younger than 55 years who are waiting for a kidney transplantation; many teams are reluctant to transplant CAPD patients because of a possible high risk for infection due to the presence of an intraperitoneal catheter and a history of previous peritonitis. To evaluate this risk, we have undertaken a multicenter study of CAPD patients transplanted between January 1980 and January 1983.

Variability in Case Mix and Peritoneal Dialysis Selection in Fifty-Nine French Districts

In France, the use of peritoneal dialysis (PD) as the first-choice treatment varies greatly between districts, as it is already known to do between countries. Baseline clinical factors associated with choice of first modality were analyzed in 10815 new end-stage renal disease patients in 59 districts. To describe practices at the district level, we used an agglomerative hierarchical classification, with proximity defined by a likelihood-ratio test that compared multivariate logistic regressions of the following factors: age, gender, diabetes, congestive heart failure, severe behavioral disorders, mobility, and employment. To propose a typology, each cluster of districts was described by a multivariate logistic regression. While populations starting PD in France, as elsewhere, are more likely to be young or employed, they are also more likely to be elderly or have congestive heart failure or severe behavioral disorders. Overall, 14% of patients start with PD, but this rate varies significantly across districts, from 0% to 45%. A specific combination of factors was associated with the first-choice modality in each group of districts. This study highlights the lack of consensual medical criteria for this choice and the likelihood that nonmedical factors may explain the observed differences. The high variability suggests that PD can be used in almost all clinical conditions. Accordingly, patient preference should play a more important role in the decision-making process.

Assisted Peritoneal Dialysis. Experience in a French Renal Department

Background

The French healthcare system offers the possibility of increasing the use of peritoneal dialysis (PD) by involving in patient care nurses who work in the private system.

Objective

This study was conducted to evaluate the impact of a private home-nurse network on one dialysis program.

Methods

This was a retrospective study of 239 dialysis patients who started dialysis in our center between 1 January 1998 and 31 December 2003.

Results

Of these 239 patients, 142 were treated with hemodialysis and 97 with PD during the study period. Among the PD patients, 36 of 97 were treated with assisted PD and 61 of 97 with self-care PD. Assisted-PD patients were older (74 ± 10 vs 52 ± 18 years, p < 0.001) and presented more comorbidity (Charlson Comorbidity Index 7 ± 2.5 vs 4.3 ± 2.4, p < 0.05) compared with self-care patients. Continuous ambulatory PD was the modality of choice in the assisted group (32/36). Assisted patients were frequently hospitalized (31/36); actuarial survival free of hospitalization at 6 months was 46%. Patients with nurse assistance had a high risk of peritonitis (actuarial survival free of peritonitis: 52% at 1 year). Technique survival was 85% at 6 months and 58% at 1 year. Actuarial patient survival was 90% at 6 months and 83% at 1 year.

Conclusion

Assisted PD enables increased use of PD in incident dialysis patients. However, in view of the comorbidities of the assisted-PD patients, the need for frequent hospitalization has to be taken into account in such a program.

[Peritoneal dialysis, a first-line treatment?]

The number of patients heading towards the terminal stage of their chronic kidney disease, for the first time or after the failure of a kidney transplant, is constantly growing, requiring the use of renal replacement therapy. Nowadays, peritoneal dialysis can be given as a first-line treatment for most patients, in the same way as haemodialysis. It allows patients to remain at home or in their care facility, with the help of a private practice nurse when needed. Complications can be quickly detected and resolved. In the event of failure, the switch to haemodialysis is usually possible.

Randomized Clinical Trial of Sevelamer Carbonate on Serum Klotho and Fibroblast Growth Factor 23 in CKD

BACKGROUND AND OBJECTIVES

Epidemiologic studies suggest that higher serum phosphaturic hormone fibroblast growth factor 23 levels are associated with increase morbidity and mortality. The aim of the FGF23 Reduction Efficacy of a New Phosphate Binder in CKD Trial was to evaluate the effect of sevelamer carbonate on serum C-terminal fibroblast growth factor 23 levels in normophosphatemic patients with CKD stage 3b/4.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Patients with CKD, eGFR between 45 and 15 ml/min per 1.73 m2, fasting serum phosphate concentration >3.1 mg/dl, and serum C-terminal fibroblast growth factor 23 >80 relative units/ml were included in our double-blind, placebo-controlled, randomized multicenter study. All patients received 100,000 IU cholecalciferol at time of randomization. Participants received either placebo or sevelamer carbonate 4.8 g daily during a 12-week period. Biologic parameters, including serum C-terminal fibroblast growth factor 23, intact fibroblast growth factor 23, and α-klotho, were evaluated at baseline and 12 weeks after inclusion.

RESULTS

Of 96 screened patients, 78 (mean±SD age: 63±13 years old; 70% men; mean eGFR: 27±9 ml/min per 1.73 m2) met the inclusion criteria. At baseline, mean eGFR was 27±9 ml/min per 1.73 m2, mean serum phosphate level was 3.8±0.5 mg/dl, and median (interquartile range) serum C-terminal fibroblast growth factor 23 level was 157 (120-241) relative units/ml. After 12 weeks of treatment, urinary phosphate-to-creatinine ratio fell significantly in the sevelamer group. The sevelamer and placebo groups did not differ significantly in terms of median change in serum C-terminal fibroblast growth factor 23 levels: the median (interquartile range) change was 38 (-13-114) relative units/ml in the placebo group and 37 (-1-101) relative units/ml in the sevelamer group (P=0.77). There was no significant difference in serum intact fibroblast growth factor 23, α-klotho, or phosphate levels changes between the two groups. Serum total and LDL cholesterol levels fell significantly in the sevelamer group.

CONCLUSIONS

In our double-blind, placebo-controlled, randomized study performed in normophosphatemic patients with CKD, a 12-week course of sevelamer carbonate significantly reduced phosphaturia without changing serum phosphorus but did not significantly modify serum C-terminal fibroblast growth factor 23 and intact fibroblast growth factor 23 or α-klotho levels.

Is Peritonitis Risk Increased in Elderly Patients on Peritoneal Dialysis? Report from the French Language Peritoneal Dialysis Registry (RDPLF)

♦

INTRODUCTION

This study was carried out to examine whether or not elderly patients on peritoneal dialysis (PD) had an increased risk of peritonitis. ♦

METHODS

This was a retrospective cohort study based on data from the French Language Peritoneal Dialysis Registry. We analyzed 8,396 incident patients starting PD between January 2003 and December 2010. The end of the observation period was 31 December 2012. Patients were separated into 2 age groups: up to 75 and over of 75 years old. ♦

RESULTS

Among 8,396 patients starting dialysis there were 3,173 patients older than 75. When using a Cox model, no association was found between age greater than 75 years and increased risk of peritonitis (hazard ratio [HR]: 0.97 [0.88 - 1.07]). Diabetes (HR: 1.14 [1.01 - 1.28] and continuous ambulatory PD (HR: 1.13 [1.04 - 1.23]) were significantly associated with a higher risk of peritoneal infection whereas nurse-assisted PD was associated with a lower risk of peritonitis (HR: 0.85 [0.78 - 0.94]. In the analysis restricted to the 3,840 self-care PD patients, there was no association between age older than 75 years and risk of peritonitis. ♦

CONCLUSION

The risk of peritonitis is not increased in elderly patients on PD in a country where assisted PD is available.

Comparison between on-line high-efficiency hemodiafiltration and conventional high-flux hemodialysis for polyclonal free light chain removal

BACKGROUND

Polyclonal free light chains (FLC) are considered as middle molecular weight uremic toxins in chronic kidney disease. In this study, we investigate polyclonal FLC removal by comparing conventional high-flux hemodialysis (HD) and online high-efficiency hemodiafiltration (ol-HDF) in end-stage renal disease patients.

METHODS

We analyzed 31 chronic dialysis patients who were treated by HD then by postdilution ol-HDF during a prospective study. All patients were anuric and without monoclonal gammopathy. Serum pre- and postdialysis FLC were collected during 4 sessions: 1 HD session and 3 ol-HDF sessions. We calculated the reduction ratio using kinetic modeling.

RESULTS

The κ reduction ratio was higher with ol-HDF than with HD (66 ± 14 vs. 52 ± 13%, p < 0.001). However, the λ reduction ratio was not significantly higher with ol-HDF (37 ± 20 vs. 37 ± 15%, p = 0.67). Furthermore, predialysis κ- and λ-FLC increased with ol-HDF compared with HD (κ 155 ± 82 vs. 87 ± 47 mg/l, p < 0.05; λ 101 ± 46 vs. 72 ± 41 mg/l, p < 0.05). Postdialysis FLC levels were raised only for λ-FLC with ol-HDF (74 ± 39 vs. 53 ± 31 mg/l, p < 0.05) and were not significantly different for κ.

CONCLUSIONS

This study shows that κ-FLC removal is better in ol-HDF compared with HD, whereas there is no difference in λ-FLC removal. Surprisingly, predialysis κ and λ levels are both increased in ol-HDF, which is disturbing since polyclonal excess of λ-FLC is associated with mortality in chronic kidney disease.

Early failure in patients starting peritoneal dialysis: a competing risks approach

BACKGROUND

Technical failure is more likely to occur in the first 6 months of peritoneal dialysis (PD). This study was carried out to identify risk factors for early transfer from PD to haemodialysis (HD) in a country where assisted PD is available.

METHODS

All patients from the French Language Peritoneal Dialysis Registry (RDPLF) who started PD between 1 January 2002 and 31 December 2010 were included. Time to transfer, death and transplantation during the first 6 months on PD were analysed by the multivariate Cox proportional hazard model. The Fine and Gray model was used to examine the occurrence of technical failure by considering death and transplantation as competing events.

RESULTS

Of 9675 patients included, 615 (6.3%) moved to HD during the first 6 months of PD. Cumulative incidence of transfer to HD was 6.6% at 6 months. On multivariate analysis by both the Cox model and the Fine and Gray model, HD prior to PD, allograft failure and early peritonitis were associated with a higher risk of early technical failure, whereas being dialysed in a centre treating more than 20 new patients per year was associated with a lower risk of early transfer to HD.

CONCLUSIONS

Patients treated by HD before PD and failed transplant patients had a higher risk of early PD failure when competing events were considered.

Outcome of the sub-optimal dialysis starter on peritoneal dialysis. Report from the French Language Peritoneal Dialysis Registry (RDPLF)

BACKGROUND

This study was carried out to examine the association of sub-optimal dialysis initiation of peritoneal dialysis (PD) with all the possible outcomes on PD using survival analysis in the presence of competing risks.

METHODS

This was a retrospective cohort study based on the data of the French Language Peritoneal Dialysis Registry. We analysed 8527 incident patients starting PD between January 2002 and December 2010. The end of the observation period was 01 June 2011. Times from the start of PD to death, transplantation, transfer to haemodialysis (HD) and first peritonitis episode were calculated. The sub-optimal dialysis initiation was defined by a period of <30 days on HD before PD initiation.

RESULTS

Among 8527 patients, there were 568 patients who started PD after <30 days on HD. There were 6562 events: 3078 deaths, 2136 transfers to HD, 1348 renal transplantations. When using a Fine and Gray model, sub-optimal dialysis start, early peritonitis and transplant failure were associated with a higher sub-distribution relative hazard of technique failure. There was no association between the sub-optimal dialysis start and the sub-distribution hazard of death or transplantation. In the multivariate analysis using a Fine and Gray regression model, the sub-optimal dialysis start was not associated with a higher sub distribution relative hazard of peritonitis.

CONCLUSIONS

Sub-optimal dialysis initiation is neither associated with a higher risk of death nor with a lower risk of renal transplantation. Sub-optimal PD patients had a higher risk of transfer to HD.

Is assisted peritoneal dialysis associated with technique survival when competing events are considered?

BACKGROUND AND OBJECTIVES

This study assessed whether assisted peritoneal dialysis (PD) was associated with a lower risk for technique failure using methods developed for survival analysis in the presence of competing risks.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This retrospective cohort study, based on data from the French Language Peritoneal Dialysis Registry, analyzed 9822 incident patients starting PD between January 2002 and December 2010. The observation period ended on June 1, 2011. Time to transfer to hemodialysis was compared between patients with assisted PD and those undergoing self-care PD.

RESULTS

There were 5286 patients undergoing assisted PD; 4230 of these were assisted by a community nurse and 1056 by family. Assisted PD patients were older and had a higher Charlson comorbidity index than self-care PD patients. There were 7594 events: 3495 deaths, 2464 transfers to hemodialysis, 1489 renal transplantations, and 146 renal function recoveries. According to a Cox model, assistance and center size were associated with a lower risk for technique failure, whereas hemodialysis before PD, early peritonitis, and transplantation failure were associated with a higher risk for transfer to hemodialysis. A Fine and Gray regression model showed that assisted PD was associated with a lower risk for transfer to hemodialysis.

CONCLUSIONS

Compared with patients undergoing self-care PD, those with assisted PD had a lower risk for transfer to hemodialysis, a higher risk for death, and a lower risk for transplantation.

[Why and how to promote peritoneal dialysis?]

The prevalence of peritoneal dialysis in France remains one of the lowest in Europe in spite of official recommendations in 2008. Progress in peritoneal catheter placement and a good knowledge of the management of catheter complications are essential. A more frequent use of biocompatible solutions should achieve a better preservation of the peritoneal membrane. Such physiological peritoneal fluids seem to decrease morbidity and mortality. Best peritoneal dialysis indications are mainly young patients waiting for a kidney transplantation, old patients without malnutrition and patients with cardiac insufficiency. Objective and complete information dedicated to both peritoneal dialysis and hemodialysis is necessary, even for patients seen in emergency or unplanned or late referral patients. A pre-end-stage renal disease education program has to be mandatory. Non-medical obstacles, mainly financial, are still common so that economic incitations are necessary for the development of peritoneal dialysis. A university formation of nephrologists is now available.

Impact of pre-transplant dialysis modality on post-transplant diabetes mellitus after kidney transplantation

Post-transplant diabetes mellitus (PTDM) is a well-known complication in renal transplant recipients (RTRs). While a number of risk factors for PTDM have been identified, the potential impact of pre-transplant dialysis modality on subsequent development of PTDM has not yet been explored. We performed a multicenter retrospective study on 2010 consecutive RTRs who did not have a history of diabetes prior to renal transplantation. PTDM was defined as a need for anti-diabetic therapy in an RTR without a history of diabetes prior to transplantation. Analysis of the risk factors for development of PTDM was performed with respect to pre-transplant dialysis modality. A total of 137 (6.8%) patients developed PTDM; 7% in the hemodialysis group and 6.5% in the peritoneal dialysis (PD) group (p = 0.85). In the multivariate analysis, age (p < 0.001), body mass index (BMI) (p < 0.001), use of tacrolimus (p = 0.002), and rejection episodes (p < 0.001) were identified as independent risk factors for development of PTDM. Patients in the PD group were younger (p = 0.004), had lower BMI (p = 0.07), and were less likely to have a history of hepatitis C (p = 0.007) and autosomal dominant polycystic kidney disease (p = 0.07). Adjustment for these variables did not modify the results. The results of this study suggest that pre-transplant dialysis modality does not have an impact on the subsequent development of PTDM in RTRs.

Peritoneal dialysis in polycystic kidney disease patients. Report from the French peritoneal dialysis registry (RDPLF)

BACKGROUND

It is commonly believed that polycystic kidney disease (PKD) patients on peritoneal dialysis (PD) are over-exposed to technique failure and peritonitis compared with other patients. This study was carried out to assess whether PKD is associated with technique failure and to evaluate the outcome of PKD patients on PD.

METHODS

This was a retrospective cohort study based on the data of the French Language Peritoneal Dialysis Registry. We analysed 4162 incident non-diabetic patients who started PD between January 2002 and December 2007. The end of the observation period was 31 December 2008.

RESULTS

Among 4162 patients, there were 344 PKD patients and 3818 patients who had another underlying nephropathy. PKD patients were younger, had a lower Charlson comorbidity index, were more frequently treated by automated PD and were less frequently assisted than other patients. For the PKD patients, the main reason for PD cessation was renal transplantation. In the multivariate analysis, comorbidities and centre size were associated with technique survival, and no association between PKD and technique failure was observed. There was no statistically significant association between PKD and peritonitis or between PKD and enteric peritonitis. On multivariate analysis, patient survival was associated with PKD and with patient age, comorbidities and the modality of assistance. Centre size was not associated with patient survival.

CONCLUSION

PD is a suitable method for at least a subgroup of PKD patients reaching end-stage renal disease in a country where renal transplantation is available.

Peritonitis-free survival in peritoneal dialysis: an update taking competing risks into account

BACKGROUND

Peritonitis-free survival is commonly reported in the peritoneal dialysis (PD) literature. The Kaplan-Meier method appears to be the only technique used to date, although it has known limitations for cohorts with multiple outcomes, as in PD. In the presence of these 'competing risks' outcomes, the Kaplan-Meier estimate is interpretable only under restrictive assumptions. In contrast, methods which take competing risks into account provide unbiased estimates of probabilities of outcomes as actually experienced by patients.

METHODS

We analysed peritonitis-free survival in a cohort of 8711 incident patients from the 'Registre de Dialyse Péritonéale de Langue Française' between 1 January 2000 and 31 December 2007 by calculating the cumulative incidence (CI) of the first episode of peritonitis using the Kaplan-Meier method and a method accounting for competing risks. We compared the CI in different patient groups by the log-rank test and a test developed for competing risk data, Gray's test.

RESULTS

After 5 years of PD, the CI of at least one peritonitis episode was 0.4, and the probability of any outcome was 0.96. The Kaplan-Meier method overestimated the CI by a large amount. Compared with the log-rank test, Gray's test led to different conclusions in three out of seven comparisons.

CONCLUSIONS

The competing risk approach shows that the CI of at least one peritonitis episode was lower than reported by the Kaplan-Meier method but that survival peritonitis-free and still on PD was overall low. The competing risk approach provides estimates which have a clearer interpretation than Kaplan-Meier methods and could be more widely used in PD research.

Peritoneal dialysis and renal transplantation

Peritoneal dialysis is commonly used in patients awaiting renal transplantation. The occurrence of delayed graft function is lower in CAPD patients than in hemodialysis patients. This could be explained by the fluid expansion observed in CAPD patients before renal transplantation. Acute allograft rejection incidence is similar in peritoneal dialysis patients and hemodialysis patients. There are controversial data regarding the rate of renovascular thrombosis after renal transplantation in peritoneal dialysis patients. The dialysis modality selected prior to transplantation may explain the rate of renovascular thrombosis in peritoneal dialysis patients. There is an increasing number of patients returning to dialysis after transplantation failure. However, peritoneal dialysis is underused in failed transplant patients. There are few data available regarding the impact of dialysis modality on the outcome of failed transplant patients. Immunosuppression and transplant nephrectomy may affect the outcome of these patients on peritoneal dialysis. The aim of this article is to review the use of peritoneal dialysis in patients awaiting renal transplantation and in failed transplant patients.

[Failed transplant patients: dialysis initiation and short-term outcome]

This study was carried out to evaluate dialysis initiation of failed transplant patient and the short-term outcome of these patients on dialysis.

PATIENTS AND METHOD

We conducted a retrospective study of transplanted patients from one centre returning in dialysis after allograft failure. Those patients were transplanted between 31st October 1986 and 3rd March 2004. Patients who experienced allograft failure after 6 months on transplantation were included in the study.

RESULTS

Among 600 transplanted patients, 92 patients restarted dialysis after allograft failure. Of the 92 failed transplant patients, 69 had a graft survival of more than 6 months. The mean glomerular filtration rate at dialysis initiation was 13+/-5mL per minute. At time of dialysis initiation, patients had mean haemoglobin level at 80.7+/-10.7g/L, and mean serum albumin level at 34+/-6g/L. Urgent dialysis was needed for 39 over 57 patients. Fourteen over 58 patients had no vascular access or peritoneal catheter at dialysis initiation. Fifty-six over 69 patients were treated by haemodialysis. Of the 13 patients treated by peritoneal dialysis 7 were on PD before transplantation whereas 49 over 57 haemodialysis patients were treated by haemodialysis before transplant failure (p<0.05). Immunosuppressive therapy was stopped during the first year following transplantation failure in 52 over 69 patients and 36 over 69 patients underwent transplantectomy. Thirteen over 56 patients presented a least one cardiovascular events after transplantation failure.

CONCLUSION

Unplanned dialysis initiation is frequent in failed transplant patients, in whom an early dialysis start is probably mandatory.

[Position statements regarding usage of biosimilars of Epoetins. Position paper of the Société de néphrologie, Société francophone de dialyse, and Société de néphrologie pédiatrique]

The European patents for epoetin alpha recently expired. Biosimilars (i.e. "a medicine which is similar to a biological medicine that has already been authorized" [EMEA 2007]) of epoetins have thus been released on the market in Europe. Because of the complexity of the processes that are required to produce medicinal products containing biotechnology-derived proteins as active substances and to characterize the physicochemical properties of these compounds, the guidelines that have been developed for generic drugs cannot be used for approval of biosimilar products. The EMEA guidelines do not answer all questions that have been raised for the development of biosimilars, and in some cases, decisions will have to be taken at a national level. This is why the Society of Nephrology (Société de néphrologie), the French-speaking Society of Dialysis (Société francophone de dialyse) and the Pediatric Society of Nephrology (Société de néphrologie pédiatrique) established guidelines for the usage of biosimilar epoetins concerning approval, identification, substitution of an innovator drug, post-marketing surveillance, extension of indication and pharmacovigilance plan.

Regional discrepancies in peritoneal dialysis utilization in France: the role of the nephrologist's opinion about peritoneal dialysis

BACKGROUND

Peritoneal dialysis (PD) is underused in France compared with other countries. In addition, there are tremendous regional discrepancies concerning the utilization rate of PD. This study was carried out to evaluate the opinion of French nephrologists regarding the optimal rate of PD utilization and to determine which factors limit PD development in France.

METHODS

Of the 22 French regions, 2 regions with a high rate of PD utilization (prevalence >15%) and 3 regions with a low rate of PD utilization (prevalence <10%) were selected. In June 2007, nephrologists from the five regions were surveyed by questionnaire. Responses were compared between 'low-prevalence' and 'high-prevalence' groups.

RESULTS

The response rate was 70% and there was no significant difference between the two groups regarding the response rate. In the two groups, a majority of nephrologists were in charge of PD patients (30/34 in 'high-prevalence' group versus 61/80 in 'low-prevalence' group, P = 0.14). Information about PD in the predialysis clinics was provided by nephrologists from high- and low-prevalence regions (32/34 versus 65/80, P = 0.08). Opinions on the optimal rate of PD for prevalent and incident dialysis patients were significantly different between 'high-prevalence' and 'low-prevalence' groups [31 +/- 15% versus 25 +/- 14% (P < 0.03) and 25 +/- 14% versus 19 +/- 9% (P < 0.02)]. There was a significant difference concerning the optimal rate of PD in incident dialysis patients between nephrologists working in public centres (29 +/- 15%), those working in non- profit clinics (27 +/- 12%) and nephrologists working in the private sector (14 +/- 8%). Lack of nurses available for the patient care (48%), low reimbursement of PD (25%), limited training (23%) and hospital care facilities (23%) were the main barriers limiting PD utilization.

CONCLUSIONS

In France, like in other countries, there are factors limiting PD development; however, regional discrepancies regarding PD utilization seem to be linked to the nephrologist's opinion.

Variability in case mix and peritoneal dialysis selection in fifty-nine French districts

In France, the use of peritoneal dialysis (PD) as the first-choice treatment varies greatly between districts, as it is already known to do between countries. Baseline clinical factors associated with choice of first modality were analyzed in 10 815 new end-stage renal disease patients in 59 districts. To describe practices at the district level, we used an agglomerative hierarchical classification, with proximity defined by a likelihood-ratio test that compared multivariate logistic regressions of the following factors: age, gender, diabetes, congestive heart failure, severe behavioral disorders, mobility, and employment. To propose a typology, each cluster of districts was described by a multivariate logistic regression. While populations starting PD in France, as elsewhere, are more likely to be young or employed, they are also more likely to be elderly or have congestive heart failure or severe behavioral disorders. Overall, 14% of patients start with PD, but this rate varies significantly across districts, from 0% to 45%. A specific combination of factors was associated with the first-choice modality in each group of districts. This study highlights the lack of consensual medical criteria for this choice and the likelihood that nonmedical factors may explain the observed differences. The high variability suggests that PD can be used in almost all clinical conditions. Accordingly, patient preference should play a more important role in the decision-making process.

[News in peritoneal dialysis]

Peritoneal dialysis, like hemodialysis, is a first-line therapy for patients with end-stage renal disease. Progress in medical devices and materials has reduced infectious complications such as peritonitis and catheter exit-site infections and thus decreased morbidity. Peritoneal dialysis fluids are increasingly biocompatible, result in fewer glucose degradation products, protect the peritoneal membrane better and thus improve tolerance. The maintenance of residual renal function, together with better comfort and no pain, help control the fluid and sodium balance. Automated peritoneal dialysis can be performed each night, either autonomously or assisted by a visiting nurse twice a day (to prepare, connect, and disconnect the machine). This treatment can thus be provided to most patients, regardless of their age. Peritoneal dialysis is indicated principally for young people waiting for a kidney transplantation (to preserve their vascular network), elderly patients who wish to remain either at home or in an institution, and patients with cardiac insufficiency, because of the better hemodynamic tolerance. Numerous obstacles, mainly nonmedical, still impede the development of peritoneal dialysis. Patients seen in emergencies start hemodialysis without necessarily receiving any information about peritoneal dialysis. Indeed, neither physicians nor patients receive adequate information.

Once-Monthly Subcutaneous C.E.R.A. Maintains Stable Hemoglobin Control in Patients with Chronic Kidney Disease on Dialysis and Converted Directly from Epoetin One to Three Times Weekly

BACKGROUND

C.E.R.A., a continuous erythropoietin receptor activator, is in development to provide anemia correction and stable maintenance of hemoglobin (Hb) levels at extended administration intervals in patients with chronic kidney disease (CKD). This study examined its efficacy and safety when administered up to once monthly in patients who have CKD and are on dialysis and randomly convert directly from epoetin alpha or beta one to three times weekly.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

In this three-arm, comparator-controlled, open-label, randomized, parallel-group, Phase III study, 572 dialysis patients (> or =18 yr) who were receiving stable subcutaneous epoetin one to three times weekly were randomly assigned (1:1:1) to continue epoetin or to receive subcutaneous C.E.R.A. once monthly or twice monthly for 52 wk. Dosage was adjusted to maintain Hb +/-1.0 g/dl of baseline level. Primary end point was mean change in Hb level between baseline and the evaluation period (weeks 29 to 36).

RESULTS

Mean Hb levels during the evaluation period were similar between groups (once-monthly C.E.R.A. 11.5 g/dl; twice-monthly C.E.R.A. 11.7 g/dl; epoetin 11.5 g/dl). The difference between C.E.R.A. and epoetin in mean change (97.5% confidence interval) in Hb concentration between baseline and evaluation was -0.022 g/dl (-0.262 to 0.217) for once monthly and 0.141 g/dl (-0.098 to 0.380) for twice monthly. Analysis demonstrated that C.E.R.A. was as effective as epoetin in maintaining Hb and was well tolerated.

CONCLUSIONS

Subcutaneous C.E.R.A. once or twice monthly successfully maintained tight and stable Hb levels in patients who were on dialysis and randomly converted directly from epoetin one to three times weekly.

The evolution of weight and body composition in renal transplant recipients: Two-year longitudinal study

Previous series have reported weight gain after kidney transplantation. However few studies have investigated the body composition after kidney transplantation, particularly during longitudinal follow-up. In this prospective study, we assessed the changes in body composition after kidney transplantation. We also analyzed the effect of steroid withdrawal from the immunosuppressive regimen on weight gain and body composition.

METHODS

Thirty-eight cadaveric kidney transplant recipients were followed for 2 years posttransplant. Total and segmental body composition were measured by dual energy X-ray absorptiometry (DEXA) at the time of transplantation as well as 3, 6, 12, and 24 months later.

RESULTS

In 28 patients (group A), prednisone was stopped by month 6, whereas, in 10 patients (group B), it was continued throughout the study. In the overall patient group, there were no significant changes in body weight. However, a trend to increased weight was observed in group B. In this group, patients showed an early increase in total body fat with a central accumulation of fat mass that was maintained during the follow-up period. On the other hand, total lean mass increased significantly in group A but did not change significantly in group B.

CONCLUSION

In summary, overall the group showed no major changes in body weight during the 2 years after transplantation. Steroid withdrawal in kidney transplant recipients may have a significant positive effect on body composition.

RDPLF et Rein, deux registres complémentaires: comparaison des données recueillies

The 2 registries RDPLF and Rein are information systems concerning the treatment of end-stage renal disease. The aim of the study was to evaluate the representativeness and exhaustivity of the recorded cases as well as the accuracy of the informations in the 2 registries. Were included 375 adults, who started a first ESRD treatment between 1 January 2003 and 31 December 2003 in 7 French regions and were treated by peritoneal dialysis (PD) on the first day of the 4th month of ESRD treatment. 264 patients were identified found in both registries. Age, body mass index and albuminemia didn't differ significantly. The mean haemoglobin level was higher in RDPLF. There was a good concordance on sex, diabetes status but less so on primary renal disease and PD modalities. There were significant discrepancies between the two registries on the date of the first treatment. The analysis of outcomes (transplantation or death) showed 8 discrepancies related to the lack of recording of the event in one of the 2 registries. The good global agreement observed between Rein and RDPLF for the common data emphasizes the fiability and representativeness of the 2 structures and the synergy of their activities for a best evaluation of the quality of peritoneal dialysis. This study shows the necessity of a common patient identification that will allow us to maintain a good complementarity between the 2 registries and will favour common studies.

Influence of autonomy and type of home assistance on the prevention of peritonitis in assisted automated peritoneal dialysis patients. An analysis of data from the French Language Peritoneal Dialysis Registry

BACKGROUND

In France, 48% of home-based peritoneal dialysis (PD) patients require assistance to perform their exchange and manage their treatment. A total of 7% are aided by their family, and 41% by a private nurse. Of all the continuous ambulatory peritoneal dialysis (CAPD) patients, 61.7%, and among automated peritoneal dialysis (APD) patients 23%, are assisted at home for their bag exchanges and connections. Assisted APD patients (AAPD) are more comorbid and elderly so that a home helper is not always available: this explains why most helpers at home are private visiting nurses paid by the National Social Security. In addition to the home helper (nurse or family), 58% of centres make regular additional home visits to check the respect of procedures previously taught during the initial training of the nurse or the family helper. The aim of this study was to evaluate whether the type of home assistance received by dependent patients had an influence on peritonitis rates, and if home visits done by nurses of training centres may improve results.

METHODS

Peritonitis rates and the probability of being peritonitis free were analysed for 1624 new APD patients recorded in the French PD Registry (RDPLF) between 2000 and 2004, and followed-up until early 2005.

RESULTS

Nurse-assisted APD patients had a peritonitis rate of one episode every 36 months, and family-assisted patients one episode every 45 months; using Poisson analysis this trend was not significant (P=0.11). However, the probability of being peritonitis free was significantly higher for family-assisted (69.8% at 2 year) compared with home nurse-aided persons (54.4%) after adjustment for age, diabetes and the Charlson comorbidity index. This difference disappeared when nurses from the training centre regularly visited PD patients at their home in the presence of their helper, whichever type of assistance they received. In addition, when the nurses from the training centres visited private nurse-assisted patients, the probability of being peritonitis free was significantly improved in comparison with those persons who did not receive home visits, from 33.9% to 50.8% at 3 years (P=0.028).

CONCLUSIONS

APD patients assisted at home by a private nurse have a higher risk of developing peritonitis than family-assisted patients, unless additional regular home visits are organized by the original training centre. Therefore, we recommend that home visits be regularly made for dependent PD patients to optimize the quality of care provided by the helper.

Assisted peritoneal dialysis. Experience in a French renal department

BACKGROUND

The French healthcare system offers the possibility of increasing the use of peritoneal dialysis (PD) by involving in patient care nurses who work in the private system.

OBJECTIVE

This study was conducted to evaluate the impact of a private home-nurse network on one dialysis program.

METHODS

This was a retrospective study of 239 dialysis patients who started dialysis in our center between 1 January 1998 and 31 December 2003.

RESULTS

Of these 239 patients, 142 were treated with hemodialysis and 97 with PD during the study period. Among the PD patients, 36 of 97 were treated with assisted PD and 61 of 97 with self-care PD. Assisted-PD patients were older (74 +/- 10 vs 52 +/- 18 years, p < 0.001) and presented more comorbidity (Charlson Comorbidity Index 7 +/- 2.5 vs 4.3 +/- 2.4, p < 0.05) compared with self-care patients. Continuous ambulatory PD was the modality of choice in the assisted group (32/36). Assisted patients were frequently hospitalized (31/36); actuarial survival free of hospitalization at 6 months was 46%. Patients with nurse assistance had a high risk of peritonitis (actuarial survival free of peritonitis: 52% at 1 year). Technique survival was 85% at 6 months and 58% at 1 year. Actuarial patient survival was 90% at 6 months and 83% at 1 year.

CONCLUSION

Assisted PD enables increased use of PD in incident dialysis patients. However, in view of the comorbidities of the assisted-PD patients, the need for frequent hospitalization has to be taken into account in such a program.

[Hospitalization of peritoneal dialysis patients: the impact of peritonitis episodes on the hospitalization rate]

Peritonitis is still a frequent complication in peritoneal dialysis patients. Medical guidelines have been established to manage this infection. These guidelines do not provide any information regarding the requirement for hospitalization. The main objective of this study was to evaluate the impact of peritonitis episode on the hospitalization rate and on the hospitalization duration in a centre where peritoneal dialysis patients were hospitalized in case of peritonitis. This was a retrospective study of incident peritoneal patients over a six years period. Among 101 peritoneal dialysis patients 65% were hospitalized. Two hundred and twenty hospital stays were registered. The total duration of hospital stays was 2091 days. The hospitalization rate was 2 per patient and per year, the hospital duration was 19 days per patient per year. Of the 220 hospital stays, 67 (30%) were due to a peritoneal infection. Peritonitis episodes represent 581/2091 (28%) days of hospitalization. The mean duration of hospitalization for peritonitis was 8.7+/-7 days. Among the patients hospitalized for a peritonitis episode, 57% were assisted by a nurse at home to perform their peritoneal dialysis exchanges. Of the 67 peritonitis episodes, 91% were discharged from the hospital without any complication. This study emphases the fact that peritonitis has an important impact on the hospitalization rate and on the hospitalization duration in peritoneal dialysis patients. In an attempt to decrease the rate of hospitalization, educational programs are clearly needed in order to treat more peritonitis without any hospitalization requirement.

[Optimal use of peritoneal dialysis fluids in type 2 diabetes mellitus patients]

The glucose side-effects, the main osmotic agent in conventional peritoneal dialysis (PD) solutions, are structural and functional changes of the peritoneal membrane, especially diabetic alterations in the microvasculature. Therefore, hyperpermeability with high small solutes transport and less ultrafiltration necessitates more and more high glucose concentration solutions. Glucose degradation products (PDF) and advanced glycation end-products (AGE) are formed and may induce peritoneal membrane alterations. More biocompatible solutions have to be used with less PDF and physiological pH. Icodextrin containing PD solutions have beneficial effect on sustained ultrafiltration for long dwells in PD, limitating fluid overload common in PD patients above all during peritonitis episodes. Amino acid-based PD solutions contribute to the prevention of malnutrition often observed in the diabetic PD population.

Pharmacokinetics of mycophenolic acid in kidney transplant patients receiving sirolimus versus cyclosporine

INTRODUCTION

Mycophenolic acid (MPA) pharmacokinetics exhibit large variability in transplant recipients and may be altered due to concurrent immunosuppressants. Little is known about the influence of sirolimus (SRL) on MPA pharmacokinetics in kidney transplant patients.

METHODS

We studied the areas under concentration-time curves (AUC) for MPA in 15 patients receiving immunosuppression combining SRL with mycophenolate mofetil (MMF). The pharmacokinetic measurements were performed in all patients using three MMF dosing regimens (0.5 g twice a day, 0.75 g twice a day, 1 g twice a day). Similar blood AUC profiles were also sampled from 12 patients treated with a fixed dose of MMF 1 g twice a day and cyclosporine (CsA). MPA was measured using HPLC; the AUC0-12 of MPA was determined by the trapezoidal method using four sampling time points: C0, C1, C3, C5.

RESULTS

While patients on SRL were receiving 0.75 g MMF twice a day, mean AUC0-12 and C0 values of MPA were comparable to those of patients receiving CsA and 1 g MMF twice a day (54.1 +/- 17.6 and 3 +/- 1.87 vs 51.7 +/- 16.7 mg.h/L and 2.76 +/- 1.57 mg/L, respectively). On the other hand, 0.5 g MMF twice a day with SRL therapy resulted in AUC0-12 and C0 values of MPA of 32.3 +/- 12.6 mg.h/L and 2.32 +/- 1.72 mg/L, respectively, whereas, 1 g MMF twice a day with SRL resulted in AUC0-12 and C0 values of MPA of 70.9 +/- 19.3 mg.h/L and 4.7 +/- 2.44 mg/L, respectively.

CONCLUSIONS

These findings demonstrate that MPA exposure in the presence of SRL is higher than that with CsA. It appears that the MMF dose should be reduced to 0.75 g twice a day in patients receiving SRL to obtain AUC0-12 of MPA levels comparable to that in patients treated with CsA and MMF 1 g twice a day.

Preprocedural creatinine clearance and long term survivalafter successful coronary stenting

AIM

The clinical outcome of patients with severe renal dysfunction undergoing percutaneous coronary intervention (PCI) is poor. However little is known concerning the impact of mild renal insufficiency on long-term clinical outcomes after successful coronary stenting. The present prospective observational study was designed to evaluate long-term clinical outcomes in relation to renal insufficiency after successful coronary stenting.

METHODS AND RESULTS

A consecutive series of 1454 patients were enrolled between January 4th 1997 and January 4th 1999 Demographic and clinical characteristics and long term clinical outcome were compared for patients with normal creatinine clearance (>60 ml/mn), mild renal dysfunction (creatinine clearance rates 30-60 ml/mn) and severe renal dysfunction (creatinine clearance rates <30 ml/mn). Patients with moderate or severe renal dysfunction were older and with more severe coronary artery disease. Beyond conventional risk factors like age (RR = 1.72 [1.10-2.68] 95% CI ; p<0.018), or low left ventricular ejection fraction (RR = 2.60 [1.72-3.94] 95% CI ; p<0.001), severe (creatinine clearance rates < 30 ml/min) and mild (creatinine clearance 30-60 ml/min) renal dysfunction were also identified as strong independent predictors of death after successful coronary stenting (RR = 4.91 [2.63-9.15] 95% CI, p<0.001 and RR = 1.57 [1.03-2.40] 95% CI, p<0.034, respectively).

CONCLUSIONS

In patients with successful coronary stenting, preprocedural creatinine clearance remains an important independent predictor of long term death. These data reinforce the importance of widespread application of prevention strategies especially in patients with coronary artery disease complicated by renal dysfunction.

Access to, and outcome of, renal transplantation according to treatment modality of end-stage renal disease in France

BACKGROUND

Although peritoneal dialysis (PD) is recognized as one of the methods of treatment of end-stage renal disease (ESRD), there have been recurrent concerns about the access of patients treated by this modality to kidney transplantation (KTx), as well as reports showing increased complications of KTx in such patients, such as graft thrombosis and infections.

METHODS

The aim of this study was to provide a comprehensive view of the impact on transplantation of pretransplant modality of treatment of ESRD using a multivariate analysis of the French database. From 1997 to 2000, after exclusion of pediatric patients, multiple transplantations, and living donors, 6420 were patients registered on the waiting list, and 3464 were transplanted.

RESULTS

Using a Cox proportional hazard analysis, we found a shorter waiting time for PD patients (RR 0.71, P < 0.0001), which became equivalent to hemodialysis (HD) patients when taking into account the transplant center as a variable (RR 1.0, P= 0.95). Concerning graft survival, only preemptive transplantation had a significant impact, being associated to a decreased risk of graft failure (RR 0.46, P= 0.005). Conclusion. Our study supports the concept that the choice of any pretransplant dialysis modality does not influence waiting time for transplant or the results of transplantation.

[Transfer from chronic haemodialysis to peritoneal dialysis]

Peritoneal dialysis patients are frequently transferred from peritoneal dialysis to haemodialysis. In contrary transfer from chronic haemodialysis to peritoneal dialysis is rare. The aim of this study is to describe the main characteristics and the outcome of the dialysis patients transferred from haemodialysis to peritoneal dialysis. We retrospectively analyzed the files of 25 patients treated by haemodialysis for more than 3 months between 1992 and 2002 and subsequently transferred on peritoneal dialysis. Technique survival was 56% at 1 year and 40% at two years in haemodialysis. Technique survival was lower in the group starting haemodialysis in emergency compared with the group of patients who did not need emergent haemodialysis (33 vs 77% at 1 year, P<0.05). The reasons for transfer from haemodialysis to peritoneal were vascular access problems (13/25), cardiovascular problems (7/25), and patient's choice (5/25). Automated peritoneal dialysis was used in 9 cases and continuous ambulatory peritoneal dialysis in 16 cases. In 13 cases peritoneal dialysis was performed by a home care nurse. At the initiation of peritoneal dialysis the mean age was 58+/-18 years, the mean Charlson's comorbidity score was 6.1+/-2.5 and 15 patients had a cardiovascular disease. The median time on peritoneal dialysis was 5.2 months. During the time on peritoneal dialysis sixteen patients presented at least one complication related to peritoneal dialysis. In addition fourteen patients were hospitalized for a reason which was not associated with peritoneal dialysis. Survival on peritoneal dialysis was 61% at six months and 35% at one year. In conclusion, in our study, patients transferred from haemodialysis to peritoneal dialysis have had a poor outcome on peritoneal dialysis. However, these patients presented numerous comorbid conditions at peritoneal dialysis initiation which could explain the poor outcome on peritoneal dialysis.

Clinical experience with two physiologic bicarbonate/lactate peritoneal dialysis solutions in automated peritoneal dialysis

Clinical experience with two physiologic bicarbonate/lactate peritoneal dialysis solutions in automated peritoneal dialysis.

BACKGROUND

Patients on automated peritoneal dialysis (APD) usually receive larger volumes of dialysis solution and more frequent, shorter exchanges than patients on continuous ambulatory peritoneal dialysis (CAPD), and therefore are likely to derive greater benefit from more physiologic solutions.

METHODS

Peritoneal dialysis solutions containing 25 mmol/L bicarbonate and either 10 or 15 mmol/L lactate were compared with standard lactate solutions (35 or 40 mmol/L) in two prospective, open-label studies of patients on APD. Each study included a 2-week baseline period (lactate solution), a 6-week treatment period (bicarbonate/lactate solution), and a 2-week follow-up period (same lactate solution as baseline). Biochemical analyses and assessments of vital signs and safety parameters were conducted at baseline, every 2 weeks during treatment, and at the end of the follow-up period. A product use questionnaire was administered in one study at the end of treatment.

RESULTS

A statistically significant rise in plasma bicarbonate (approximately 2 mmol/L) occurred when patients switched from a lactate solution to the bicarbonate/lactate solution with equimolar buffer concentration (P < 0.001 for each solution). Plasma bicarbonate decreased by 1.16 mmol/L after a switch from lactate 40 mmol/L to bicarbonate/lactate 35 mmol/L (P < 0.001). When patients switched to bicarbonate/lactate 35, the majority of individual venous plasma bicarbonate values were in the normal range. A switch from a lower calcium (1.25 mmol/ L) lactate solution to a higher calcium (1.75 mmol/L) lactate/bicarbonate solution resulted in a statistically significant rise in serum calcium (0.06 mmol/L, P < 0.018). The product use questionnaire revealed improvements in symptoms, including reduced pain on infusion.

CONCLUSION

Bicarbonate/lactate solutions may be used safely and effectively in patients on APD. The availability of 2 formulations with different buffer and calcium content provides flexibility for the control of acidosis as well as calcium balance.

Recurrence of ANCA-positive glomerulonephritis immediately after renal transplantation

Recurrence of crescentic necrotizing glomerulonephritis after renal transplantation is rare. Successful renal transplantation in patients with antineutrophil cytoplasmic autoantibody (ANCA) glomerulonephritis has been reported. The presence of ANCA at transplantation does not appear to increase the rate of relapse after kidney allografting. Therapy with cyclophosphamide and corticoids usually is effective. We report a case of recurrent perinuclear ANCA crescentic necrotizing glomerulonephritis immediately after renal transplantation that was treated successfully by cyclophosphamide, plasma exchange, and intravenous polyvalent immunoglobulin.

[Virological, epidemiological and pathogenic aspects of human polyomaviruses]

VIROLOGICAL ASPECTS: Human polyomaviruses (BK virus and JC virus), together with simian polyomaviruses (SV40 virus) share 75% of genomic homology. Their in vivo and in vitro genomes vary. Molecular analyses have identified several genotypes, some of which appear related to the development of viral diseases. Genomic modifications of the regulation area might provide the BKv with a pathogenic aspect thus enhancing the induction of tubulo-interstitial nephropathies in renal transplant recipients.

EPIDEMIOLOGY

Human polyomaviruses are ubiquitous and exhibit a sero-prevalence of 60 to 80% in adults. Following a primary infection via the respiratory tract in childhood, these viruses are diffused in the blood using the B-lymphocytes during their latent stage in the urogenital tract. The reactivation that occurs after several years is asymptomatic and urinary excretion of BKv is observed in 4 to 6% of immunocompetent patients.

PATHOGENIC POTENTIAL

Human polyomaviruses have a cytopathogenic effect on the urothelium and epithelium of renal transplant recipients. Infection by BKv may provoke hemorrhagic cystitis or urethral stenosis. The JCv is the cause of progressive multifocal leuko-encephalitis. The BKv (and less frequently the JCv) is responsible for tubulo-interstitial nephritis possible leading to renal transplant loss. They also have an oncogenic effect and their implication in the origin of tumours is the subject of many studies.

[Therapeutic possibilities for polyomavirus infections in renal transplantation]

TO IMPROVE THERAPEUTIC MANAGEMENT: The aim is the early detection of polyomavirus infection, before the onset of tubulo-interstitial nephritic lesions, and to reduce viral replication. AT THE STAGE OF POLYOMAVIRUS INFECTION: Treatment relies on the reduction of immunosuppression. Efficacy is controlled by monitoring the decoy cells in the urine and the detection and quantification of the DNA of polyomaviruses in the plasma and urine. AT THE STAGE OF POLYOMAVIRUS DISEASE: The aim is to reduce the viral replication by further decreasing immunosuppression to stabilize renal function and avoid graft rejection. When signs of rejection and viral infection co-exist, cidofovir could be a therapeutic alternative. However, the use of cidofovir remains in the field of clinical research and requires the further development of therapeutic protocols.