[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.

[Value of the systematic uterine Doppler in the primiparous woman. A series of 315 cases]. / Intérêt du Doppler utérin systématique chez la femme primipare. A propos de 315 cas.

OBJECTIVE: This retrospective study was designed to assess the screening of pre-eclampsia (PE) and intra-uterine growth retardation (IUGR) by uteroplacental doppler scan in a population of primiparous, selected in a hospital having 700 deliveries each year. STUDY DESIGN: We studied, a consecutive series of 315 primiparous women at 19 weeks (gestational age) screened by pulsed Doppler of uterine artery. Group A (normal uterine artery Doppler) was compared with group B (pathological uterine artery Doppler) for pregnancy-induced hypertension, preeclampsia and intra-uterine growth retardation (chi 2 test and Fisher test). RESULTS: Group B included 50 patients (15%). They had more hypertensive pathologies (24%) (p < 0.001) and IUGR (20%) (p < 0.005) were more frequent than the group A (265 patients: 85%) which had only 7.2% and 8.2% respectively. In this study, the sensitivity of uterine artery Doppler was 34.3%, the specificity was 88.5%, the positive predictive value was 42%, the negative predictive value was 84.9% for all hypertensive disorders. CONCLUSION: The contribution of this examination is doubtful in a low risk population where the prevalence of complications is low and the VPP is about 10 to 14% for preeclampsia. On the other hand, test predictivity reaches 50% for all dysgravidic disorders.

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.

[Plea for quality cytological specimens in the screening of cervical cancer]. / Plaidoyer pour la qualité des prélévements cytologiques lors du dépistage du cancer du col.

In the context of a typical false negative cervical cancer test, the authors discuss the value of such screening tests and the various causes of a lack of success. A poor sample is the main cause of false negatives, and therefore involves everyone taking part in the procedures for this screening test.

Efficacy of a therapeutic feeding centre evaluated during hospitalization and a follow-up period, Tahoua, Niger, 1987-1988.

Between 1 February 1987 and 31 May 1988 an evaluation of a nutritional rehabilitation centre in Tahoua, Niger was conducted. Among the 381 children admitted to the centre, 61 (16%) had kwashiorkor and 347 (91.3%) were aged between 6 and 29 months. Recovery and death rates were 46.2% and 14.4%, respectively. The median duration of stay until recovery was 21 days. Sixty-two per cent of deaths occurred during the 1st week of hospitalization. Three risk factors for death were identified by the study: patients with kwashiorkor with a weight/height (W/H) less than -3 SD, those with marasmus with a W/H less than -5 SD, and those dehydrated with marasmus. Among children included in the follow-up study after leaving the centre, the risk of dying during the follow-up period among children who absconded was 7.1 times higher than the risk observed among children who recovered. Among the children who recovered, no relapse was observed 3-18 months after they left the centre. This investigation indicates the importance of intensive therapeutic feeding centres in areas with a high prevalence of malnutrition.

[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.

[Practice of the adaptation of a flexible gas-permeable lens with extended wear in the aphakic patient. Preliminary study]. / Pratique de l'adaptation d'une lentille flexible perméable au gaz, en port prolongé chez l'aphake. Etude préliminaire.

The development of flexible, gas permeable, contact lenses, has permitted their introduction into clinical practice for the long term correction of aphakia. This study groups together the cases reported, by ophthalmologists in the area of Grenoble. Statistical analysis of the results have allowed us to establish a protocol and to define the place of this technique among already existing methods for the correction of the aphakic eye. The follow up was 20 months. There was non preoperative selection in our choice of patients for implantation, which probably explains the 10% failure rate. The protocol is described in detail based on our first 222 results.