[Evaluation of the cost of treatment for terminal chronic renal insufficiency. Thoughts on the value of this type of study and the role of the nephrologist]. / Evaluation du coût du traitement de l'insuffisance rénale chronique terminale. Réflexions sur l'intérêt de ce type d'étude et sur le rôle du néphrologue.

To assess the cost of end stage renal failure treatment was the target of studies we achieved during the last ten years. We showed how much the global cost was favourably influenced by the number of available therapeutic methods. In a recent study, reported here, we followed a new methodology more often used today in our public hospitals. The comparison of analytical accountancy data with computerized medical informations as given by identification of Diagnosis Related Groups probably allows better assessment of "real cost". But is this approach really useful for nephrologists? These frequently asked questions cannot be performed without the participation of physicians. The question remains whether or not these studies will contribute to improve the quality of care and to allow some saving. We also hope sharing with readers of "Nephrologie" these kinds of considerations as well as our opinions and doubts.

More than 17 years of peritoneal dialysis: a case report.

Very few patients have undergone long-term peritoneal dialysis (PD). We report a case of a female patient on PD since 26 May 1979. Suffering from malignant hypertension, she developed renal failure in April 1979. The renal biopsy showed a severe vascular nephropathy. She was 50 years old, her body weight (BW) was 45 kg, and her height was 1.49 m. She refused hemodialysis. A Tenckhoff catheter was installed, and 12-hour intermittent PD (IPD), three times a week, was started in the dialysis center. Ten months later, she began nightly home IPD. In March 1985 she started continuous ambulatory PD (CAPD); she was nearly anuric. During the following years, she developed renal osteodystrophy and suffered from repeated hyperparathyroidism requiring multiple surgical interventions, osteomalacia, pseudotumoral calcinosis, and, finally, adynamic bone disease. She is now 67.5 years old, her BW is 34 kg, and she is still using CAPD. This patient has the same Tenckhoff catheter. She never developed peritonitis or an exit-site or tunnel infection. She used acetate dialysis solution for nearly six years and then lactate solution. Presently her peritoneal permeability is of the high-average type; dialysis adequacy (weekly Kt/V: 2.15, weekly peritoneal clearance: 58 L/1.73 m2) as well as nutritional parameters are satisfactory. She has moderate anemia without erythropoietin treatment. She maintains a good quality of life. Although the patient lost 11 kg in 17 years, she has maintained good nutritional status. Dialysis adequacy could be achieved despite anuria for more than 11 years. Small body size, absence of infection and catheter-related problems, healthy peritoneal membrane, good acceptance of the technique, and vigilance towards dietary habits may be the keys for satisfactory long-term PD.

Subcutaneous versus intravenous administration of erythropoietin improves its efficiency for the treatment of anaemia in haemodialysis patients.

Recombinant human erythropoietin (rHuEpo) seems to be more efficient when given subcutaneously (SC) instead of intravenously (IV) for therapy of anaemia in haemodialysis patients. This was a cross-over study designed to assess the efficiency of rHuEpo when given SC rather than IV in a 1 year follow-up. Sixteen patients received IV rHuEpo for 6 months, then SC rHuEpo for 6 months. They were four males and 12 females with a mean age of 56 years (range 15-82). Haemoglobin concentration ([Hb]) was kept at 10 g/dl and transferrin saturation (TS) at more than 25%. Mean [Hb] was 9.7 +/- 1.0 g/dl with IV rHuEpo and 9.9 +/- 0.9 g/dl with SC rHuEpo (NS). Transferrin saturation was 27% before rHuEpo, 31% with IV rHuEpo and 34% with SC rHuEpo (NS vs IV rHuEpo). Serum ferritin was 691 +/- 113 ng/ml before rHuEpo, 652 +/- 94 ng/ml with IV rHuEpo and 997 +/- 132 ng/ml with SC rHuEpo (P < 0.05 vs IV rHuEpo). Intact parathyroid hormone was 354 +/- 83 pg/ml before rHuEpo, 201 +/- 63 pg/ml with IV rHuEpo and 122 +/- 33 pg/ml with SC rHuEpo (NS vs IV rHuEpo). Doses of IV rHuEpo were 156 +/- 24 U/kg/week and SC rHuEpo 74 +/- 13 U/kg/week (i.e. a saving of 53%; P < 0.001). We conclude that subcutaneous administration of rHuEpo is twice as efficient as IV rHuEpo in patients with good functional iron reserve.

[Assessment of costs of health insurance, substitution therapy in chronic renal insufficiency]. / Evaluation du coût pour l'assurance maladie, des thérapeutiques substitutives de l'insuffisance rénale chronique (IRC).

The authors have studied the cost of the different treatments proposed in ESRD to patients attended by the same nephrologic team. For each patient they have isolated two consecutive periods of treatment, each six months apart. Treatment modifications noted between the two periods allowed the patient to be used as his own control. The results show that the costs are essentially composed of the dialysis sessions, hospitalisations and transport, and that their level and composition differ significantly between the different treatments. They derive a typology composed of three groups of patients, which differ in their treatment, age, duration of ESRD, complications, and total cost of treatment. They conclude that services should be organised in such a way that a range of different treatments can reasonably be provided, according to patient needs.

[A difficult dilemma to resolve: aged patients refused for treatment by iterative hemodialysis. Ethical problem or medical choice? Reflections apropos of a questionnaire-inquiry]. / Un dilemme difficile à résoudre: les malades âgés récusés pour un traitement par hémodialyse itérative. Problèmes éthiques ou choix médical? Réflexions à propos d'un questionnaire-enquête.

An inquiry has been conducted amongst 185 french nephrologists so as to try to determine upon which criteria therapeutic choices for aged patients with chronic renal failure are made: conservative treatment or chronic dialysis? The fear of sharing the responsibility of an injustice towards some patients already handicapped by the disease or by their poor opportunity of social or family rehabilitation, the obsession of passive euthanasia and the refusal of taking into account the economic consequences of their choices, seem to conduct some nephrologists to accept anybody for a dialysis treatment. However, the quality of life enabled by the treatment, the possibility for the patient to enjoy a satisfactory social or family life, the environment of the patient, his degree of autonomy as well as, in some cases, the poor prognosis due to associated diseases, actually constitute the most determining factors of decision. The answer to this inquiry have moreover pointed out the necessity to provide right now for structures fitting the treatment by dialysis of an increasing number of elderly patients.

Late hypertension following renal allotransplantation.

Post-transplant hypertension has been observed in 98 renal allograft recipients who had good renal function and whose follow-up was more than 15 months. The role of the original diseased kidneys as well as the role of the renal pressor system was studied with emphasis on late hypertension. Post-transplant hypertension was found to be a multifactorial phenomenon with frequency decreasing as a function of prolonged graft survival. Renal artery stenosis was an infrequent but significant cause of hypertension and was found in 10 of 29 arteriograms performed. Renin studies performed in 34 hypertensive patients and in a control group of 11 recipients showed that elevation of plasma renin activity and of plasma aldosterone level is frequent but difficult to interpret, particularly when a renal artery stenosis is observed. These investigations may be useful in recognizing the role of retained diseased kidneys in sustaining hypertension. Plasma aldosterone was found elevated in nearly all of the patients. The role of corticosteroids and the similarity of post-transplant hypertension, in some cases, with the one kidney model of experimental hypertension are discussed.