Perception of social inequities in the access to the kidney transplant waiting list by nephrology trainees: a national survey.

BACKGROUND: Social inequalities in health are responsible for disparities in access to the kidney transplant waiting list (KTWL). The perception of disparities by nephrologists has consequences for the registration on the KTWL. The purposes of our study were to assess the perception of the factors implicated in the disparities in access to the KTWL by nephrology trainees and to assess the quality of the questionnaire. METHODS: A questionnaire was developed to assess the perception of the determinants of the inequities in access to waitlisting. Continuous variables were described by median, 1st and 3rd quartiles. Categorical variables were described by frequencies and percentages. A principal component analysis and a hierarchical cluster analysis were performed to approach the correlation between the variables. A scree plot and a factor analysis were performed to determine the dimensions of the questionnaire. The internal consistency was estimated by Cronbach's coefficient. RESULTS: The response rate was 98/110 (89%). The determinants of inequities in the access to KTWL not perceived by the nephrology trainees were "female sex", "income level" and "the centre provision to adapt the information to all of the patients" (18,3%, 36,7, 47% respectively). "Age", "being born abroad", "place of living", "education level", "transplant centre", "the health care provider" were determinants of disparities perceived by most of the trainees (85,7%, 75,5%, 82,6%, 78,6%, 73,5% et 78,5% respectively). Items related to the transplant centre were positively correlated, as well as "being born abroad", "education level" and "income level". The Cronbach's coefficient was 0,60. CONCLUSION: Social inequalities in health are partially perceived by nephrology trainees. A teaching session could raise nephrologists' awareness of this issue and could help reduce the impact of these disparities on the course of ESKD (end-stage kidney disease) patients.

Mycobacterium genavense Infections in Immunocompromised Patients Without HIV: Case Series of Solid Organ Transplant Patients and Literature Review.

Background: Mycobacterium genavense infection is rare and can occur in immunocompromised patients without human immunodeficiency virus (HIV). Methods: We describe 2 cases of M genavense infection in solid organ transplant (SOT) recipients, and we performed a literature review of immunocompromised patients without HIV. Results: Fifty-two cases are reported. Predisposing factors were receipt of SOT (40.4%) and autoimmune disease (36.5%). Infection was disseminated in 86.5% of cases. Organs involved were lymph nodes (72.3%), gastrointestinal tract (56.5%), lung (35.5%), and bone marrow (28.8%). Most patients were treated with at least 3 antimycobacterial agents (98%), with a clinical cure achieved in 54.9%. In multivariate analysis, lack for cure was associated with age of the time infection (odds ratio [OR], 15.81 [95% confidence interval {CI}, 2.92-152.93]; P = .011) and positive bone marrow culture (OR, 1.05 [95% CI, 1.01-1.12]; P = .042). Conclusions: Mycobacterium genavense infection is a rare and generally disseminated disease with a poor prognosis. Optimal treatment regimen and its duration remain to be defined.

Paternity in male kidney transplant recipients: a French national survey, the PATeRNAL study.

BACKGROUND: There is concern about the impact of immunosuppressive agents taken by male kidney transplant (KT) recipients on the risk of foetal malformations. The aim of our survey was to estimate the paternity rate and the outcomes of pregnancies fathered by kidney transplanted males. METHODS: This survey analysed 1332 male KT recipients older than 18 years, followed in 13 centres in France. A self-reported questionnaire was used to collect data on the patients, treatments at the time of conception and the pregnancy outcomes. RESULTS: The study included data on 349 children from 404 pregnancies fathered by 232 male KT recipients. The paternity rate was 17% (95% CI [15-20]). There were 37 (9%, 95% CI [7-12]) spontaneous abortions, 12 (3%, 95% CI [2-5]) therapeutic abortions, 2 (0.5%, 95% CI [0.1-1]) still births, and 13 (4%, 95% CI [2-6]) malformations reported. Compared to the general population, there was no difference in the proportion of congenital malformations nor unwanted outcomes whether the father was exposed or not to immunosuppressive agents. CONCLUSIONS: This survey does not provide any warning signal that pregnancies fathered by male patients exposed to immunosuppressive agents, notably the debated MMF/MPA, have more complications than pregnancies in the general population.

[Ericksonian hypnosis and mindfulness meditation: Towards a behavioral medicine in nephrology]. / L'hypnose Ericksonienne et la méditation pleine conscience : vers une médecine comportementale en néphrologie.

The utilization of behavioral medicine, like Ericksonian hypnosis and mindfulness meditation, in the patient care is increasing. Psychological disorders associated with chronic renal failure are similar to the post-traumatic stress disorder and need a continuous personnel adjustment. Preventing depression, managing stress, pain and emotions, like anger, guiltiness and shame, is of importance in individual who suffer of chronic kidney disease, but also in their family caregivers and in health-care workers. The objective of this report is to describe how Ericksonian hypnosis, mindfulness meditation and compassion meditation could support chronic kidney disease patients, their caregivers and the health-care professional.

[Descriptive study of practices with patients in conservative care practices in a French district, the Normandy]. / Étude descriptive des pratiques normandes dans la prise en charge des patients en traitement conservateur.

INTRODUCTION: Renal replacement therapy and renal transplantation can't be considered as the only way to treat old end-stage renal disease patients. Nowadays conservative management has to be considered and proposed as a treatment option to patients with a chronic kidney disease. The aim of this study was to describe nephrologists' practices concerning conservative management care in a French department. MATERIAL AND METHOD: A cross-sectional practices survey has been conducted in 2015. A survey was sent to 66 nephrologists in 14 treatment centers in the Normandy region. RESULTS: 49 of the 66 nephrologists responded to the questionnaire. Among the 48 nephrologists who responded to the questionnaire, 38 out of 48 (79.2%) did not use decision support tools to implement conservative treatment. In all, 42/48 (87.5%) nephrologists did not discuss with their colleagues before providing conservative treatment. Meeting dedicated to the decision of conservative treatment did not exist in any center surveyed in this study. When conservative management was chosen, 34/48 nephrologists (70.8%) discussed end-of-life. And 31/48 nephrologists (64.6%) used the term "death". CONCLUSION: The results of this study show that the course of the patients in conservative treatment is heterogeneous and is not formalized. Improvements are needed to integrate conservative treatment for patients with chronic kidney disease.

Improved Detection and Evaluation of Depression in Patients with Chronic Kidney Disease: Validity and Reliability of Screening (PHQ-2) and Diagnostic (BDI-FS-Fr) Tests of Depression in Chronic Kidney Disease.

OBJECTIVE: Depression is underdiagnosed and thus undertreated. This study aimed to validate the French version of the PHQ-2 (Patient Health Questionnaire-2) and BDF-FS-Fr (Beck Depression Inventory-Fast Screen-France) on patients with chronic kidney disease (CKD) living in France. METHOD: A cross-sectional study was conducted on 109 patients of the Centre universitaire de maladies rénales, Centre Hospi-talier Universitaire (CHU) de Caen (37 patients with CKD on pre-dialysis and grafting stage, 36 grafted patients, and 36 dialyzed patients). STATISTICAL APPROACH: Test parameters and statistical aspects of assessing diagnostic and screening tests were used, including knowledge of and ability to calculate, sensitivity, specificity, positive and negative predictive values, diagnostic odds ratios, and the use of ROC (receiver operating characteristic) curves. RESULTS: PHQ-2 and BDI-FS-Fr statistical parameters for depression tested very positively and had a satisfactory AUC (area under the curve). The PHQ-2 had a satisfactory AUC > 0.70, sensitivity > 0.60, and specificity > 0.80. The BDI-FS-Fr had a satisfactory area under the curve (0.859) with sensitivity (83%) and specificity (0.859); and internal consistency (α = 0.668). The PHQ-2 and BDI-FS-Fr showed good internal and external validity of structure, construct validity, criterion validity, discriminant validity, internal consistency, and factorial validity. CONCLUSION: The French versions of the PHQ-2 and BDI-FS have highly favorable psychometric properties. These instruments are valid self-assessment tools for screening and evaluating depression, its intensity, and its evolution. The PHQ-2 and BDI-FS-Fr thus have very good psychometric properties and are useful tools for researchers and practitioners. Regarding clinical practice in the hospital, clinicians and nurses can use the PHQ-2 to screen quickly for depression during routine consultations, during hospitalization, and in dialysis centers. The 7 items of the BDI-FS-Fr enable us to assess the depressive state, thereby avoiding a false diagnosis of depression among CKD patients in a clinical setting.

[Outcome of living kidney donors for transplantation]. / Devenir des donneurs vivants de rein pour la 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 new paradigm: home therapy for patients who start dialysis in an unplanned way.

BACKGROUND: Starting dialysis in a non-planned manner or in a 'suboptimal' manner is a frequent situation in dialysis centres, even for patients with a regular nephrology follow-up. Unplanned dialysis initiation can be defined as a patient beginning dialysis with no functional vascular access or peritoneal dialysis catheter. These patients start haemodialysis with a temporary catheter, frequently converted to a tunnelled catheter pending native fistula creation or whilst waiting for fistula maturation. In this case, conventional in-centre haemodialysis (ICH) is more frequently used than peritoneal dialysis (PD) or home haemodialysis (HHD). REVIEW FINDINGS: This review found that patients who start dialysis in an unplanned way are significantly older and have more heart and peripheral vascular diseases. Home-based dialysis therapies showed better outcomes than ICH (PD for the first two to three years and HHD for the long-term). RECOMMENDATIONS: This review proposes a paradigm shift in the initial form of dialysis offered to new patients starting dialysis in an unplanned way. Even if they require a temporary catheter, it is possible for them to receive a pre-dialysis education programme (PDEP). The PDEP should be based on both individualised information session(s) given by an experienced nurse to the patient and family and therapeutic education (educative diagnosis, individualised and group session(s)) in order to relieve anxiety and promote home modalities.

Hydration status of patients with end-stage renal disease after kidney transplantation.

BACKGROUND: This study was carried out to estimate the modification of hydration status within the first three months of renal transplantation. SUBJECTS AND METHODS: Fifty patients who underwent a first kidney allograft were prospectively followed for three months after renal transplantation to assess hydration status by bioimpedance spectroscopy. RESULTS: Two hours before the transplant procedure, 10/42 (23.8%) patients were overhydrated. Two days after surgery, 32/40 (80.0%) patients were overhydrated and at three months, 14/27 (51.9%) patients remained fluid-overloaded. Peritoneal dialysis (PD) patients had a lower hydration status (-0.60 L) than hemodialysis (HD) patients (0.70 L; p < 0.05) and better residual diuresis (41.7 vs. 8.3 mL/h for HD patients, p < 0.01). Compared with patients who had a delayed graft function (DGF) or a slow graft function (SGF), the immediate graft function (IGF) group had a better hydration status before transplantation (p = 0.031). At three months, 12/14 of the overhydrated patients had a creatinine clearance between 30 and 60 mL/min/1.73 m(2) . CONCLUSION: Patients receiving a first kidney transplant frequently have a hydration disorder. Transplantation is associated with increased hydration status, which seems to persist if DGF or SGF occurs.

[Treatment of iron deficiency by a bolus intravenous iron dextran in peritoneal dialysis]. / Traitement de la carence martiale par injection d'une dose totale de fer dextran en dialyse péritonéale.

INTRODUCTION: The main objective of this study is to determine whether a single dose of iron dextran can correct iron deficiency during a period of four months in peritoneal dialysis patients. METHOD: This was a prospective observational study in peritoneal dialysis patients who had anemia (hemoglobin<11g/dL) and iron deficiency (ferritin<100µg/L and/or transferrin saturation<20%). Patients who were resistant to oral iron or who could not tolerate oral iron were included in the study. At baseline, based on the iron deficiency estimation, a single dose of iron dextran was infused over four hours. RESULTS: Of 17 patients included, 12 completed the study. The mean iron dose infused was 742±150mg. No clinically significant adverse event was reported during the infusion. Four months after the iron dextran infusion there was a significant increase of the mean hemoglobin level (10.1±0.7g/dl vs 11.4±1.2g/dL, P<0.05), the mean blood ferritin level (66±46mg/L vs 212±121mg/L, P<0.05) and the mean transferrin saturation (14±5% vs 23±8, P<0.05). Four months after the iron infusion 10 patients had a blood ferritin level higher than 100µg/L and a transferrin saturation higher than 20%. There was no significant modification of the erythropoietin dose during the four months period. CONCLUSION: In patients treated by peritoneal dialysis, the anemia due to iron deficiency can be treated by a single infusion of iron dextran for a period of four months.

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.

Is rapid initiation of peritoneal dialysis feasible in unplanned dialysis patients? A single-centre experience.

BACKGROUND: Starting dialysis in an unplanned manner is a frequent situation in a dialysis centre even for patients with a regular nephrology follow-up. For no clear reason, chronic haemodialysis (HD) is more frequently used than peritoneal dialysis for unplanned dialysis patients. OBJECTIVE: The purpose of this study was to evaluate the results of a dialysis policy dedicated to unplanned dialysis patients. The aim of this policy was to increase the use of peritoneal dialysis (PD) in an attempt to reduce the need for tunnelled catheter. METHODS: One hundred seventy-one patients from a single centre, who started dialysis between 1 January 2004 and 31 December 2006, were prospectively followed until 31 December 2006. Unplanned dialysis patients were defined as patients entering in dialysis with no vascular access or peritoneal dialysis catheter. PD was presented as a modality of choice for renal replacement therapy to avoid the need for a tunnelled HD catheter. RESULTS: There were 60 unplanned dialysis patients during the study period. Among these patients, 34 agreed to be treated by PD. Compared with unplanned peritoneal dialysis patients, unplanned haemodialysis patients had a greater modified Charlson's comorbidity index (5.9 +/- 2.4 versus 4.4 +/- 1.9, P < 0.05). The mean duration of the temporary catheter period was 32 +/- 29 days (median: 24 days) for haemodialysis patients compared with 26 +/- 21 days (median: 25 days) for peritoneal dialysis patients (P = NS). The initial hospitalization duration was similar in haemodialysis patients and peritoneal dialysis patients (24 +/- 28 versus 30 +/- 33 days; median value: 17 versus 20 days, P = NS). PD was started 8.6 +/- 10 days (median: 4 days) after catheter insertion. A tunnelled catheter was used only in three patients until peritoneal dialysis was initiated. Acute automated peritoneal dialysis was used in 19 patients. Among 26 haemodialysis patients, 23 were dialyzed through a tunnelled catheter. Of these 23 patients, 15 were successfully converted to fistula. Median time for fistula creation was 2.6 months after dialysis initiation; median time for fistula utilization was 4.4 months. Actuarial patients survival at 1 year was 79% on haemodialysis compared with 83% on peritoneal dialysis (P = NS). After adjustment of the initial modified Charlson's comorbidity index, dialysis modality had no impact on patient's survival. There was no significant difference between haemodialysis patients and peritoneal dialysis patients regarding survival free of re-hospitalization. Actuarial survival free of peritonitis was 73% at 6 months and 58% at 1 year. CONCLUSION: Peritoneal dialysis is a safe and efficient alternative to haemodialysis for unplanned dialysis patients. Peritoneal dialysis offers the advantage of reducing the need for tunnelled catheter in unplanned dialysis patients.