Showing papers by "Cécile Couchoud published in 2018"

Changes in co-morbidity pattern in patients starting renal replacement therapy in Europe-data from the ERA-EDTA Registry.

Abstract: Background Patients starting renal replacement therapy (RRT) for end-stage renal disease often present with one or more co-morbidities. This study explored the prevalence of co-morbidities in patients who started RRT in Europe during the period from 2005 to 2014. Methods Using data from patients aged 20 years or older from all 11 national or regional registries providing co-morbidity data to the European Renal Association - European Dialysis and Transplant Association Registry, we examined the prevalence of the following co-morbidities: diabetes mellitus (DM) (primary renal disease and/or co-morbidity), ischaemic heart disease (IHD), congestive heart failure (CHF), peripheral vascular disease (PVD), cerebrovascular disease (CVD) and malignancy. Results Overall, 70% of 7578 patients who initiated RRT in 2014 presented with at least one co-morbidity: 39.0% presented with DM, 25.0% with IHD, 22.3% with CHF, 17.7% with PVD, 16.4% with malignancy and 15.5% with CVD. These percentages differed substantially between countries. Co-morbidities were more common in men than in women, in older patients than in younger patients, and in patients on haemodialysis at Day 91 when compared with patients on peritoneal dialysis. Between 2005 and 2014 the prevalence of DM and malignancy increased over time, whereas the prevalence of IHD and PVD declined. Conclusions More than two-thirds of patients initiating RRT in Europe have at least one co-morbidity. With the rising age at the start of RRT over the last decade, there have been changes in the co-morbidity pattern: the prevalence of cardiovascular co-morbidities decreased, while the prevalence of DM and malignancy increased.

Deleterious effects of dialysis emergency start, insights from the French REIN registry

Abstract: Emergency start (ES) of dialysis has been associated with worse outcome, but remains poorly documented. This study aims to compare the profile and outcome of a large cohort of patients starting dialysis as an emergency or as a planned step in France. Data on all patients aged 18 years or older who started dialysis in mainland France in 2012 or in 2006 were collected from the Renal Epidemiology and Information Network and compared, depending on the dialysis initiation condition: ES or Planned Start (PS). ES was defined as a first dialysis within 24 h after a nephrology visit due to a life-threatening event. Three-year survival were compared, and a multivariate model was performed after multiple imputation of missing data, to determine the parameters independently associated with three-year survival. In 2012, 30.3% of all included patients (n = 8839) had ES. Comorbidities were more frequent in the ES than PS group (≥ 2 cardiovascular diseases: 39.2% vs 28.8%, p < 0.001). ES was independently associated with worse three-year survival (57% vs. 68.2%, p = 0.029, HR 1.10, 95% CI 1.01–1.19) in multivariate analysis. Among ES group, a large part had a consistent previous follow-up: 36.4% of them had ≥3 nephrology consultations in the previous year. This subgroup of patients had a particularly high comorbidity burden. ES rate was stable between 2006 and 2012, but some proactive regions succeeded in reducing markedly the ES rate. ES remains frequent and is independently associated with worse three-year survival, demonstrating that ES deleterious impact is never overcome. This study shows that a large part of patients with ES had a previous follow-up, but high comorbidity burden that could favor acute decompensation with life-threatening conditions before uremic symptoms appearance. This suggests the need of closer end-stage renal disease follow-up or early dialysis initiation in these high-risk patients.

Access to kidney transplantation in European adults aged 75-84 years and related outcomes: an analysis of the European Renal Association-European Dialysis and Transplant Association Registry.

Abstract: To what extent access to, and allocation of kidney transplants and survival outcomes in patients aged ≥75 years have changed over time in Europe is unclear. We included patients aged ≥75-84 years (termed older adults) receiving renal replacement therapy in thirteen European countries between 2005-2014. Country differences and time trends in access to, and allocation of kidney transplants were examined. Survival outcomes were determined by Cox regression analyses. Between 2005-2014, 1,392 older adult patients received 1,406 transplants. Access to kidney transplantation varied from ~0% (Slovenia, Greece and Denmark) to ~4% (Norway and various Spanish regions) of all older adult dialysis patients, and overall increased from 0.3% (2005) to 0.9% (2014). Allocation of kidney transplants to older adults overall increased from 0.8% (2005) to 3.2% (2014). Seven-year unadjusted patient and graft survival probabilities were 49.1% (95% confidence interval, 95%CI: 43.6; 54.4) and 41.7% (95%CI: 36.5; 46.8) respectively, with a temporal trend towards improved survival outcomes. In conclusion, in the European dialysis population aged ≥75-84 years access to kidney transplantation is low, and allocation of kidney transplants remains a rare event. Though both are increasing with time and vary considerably between countries. The trend towards improved survival outcomes is encouraging. This information can aid informed decision-making regarding treatment options. This article is protected by copyright. All rights reserved

Survival advantage of planned haemodialysis over peritoneal dialysis: a cohort study.

Abstract: Background Previous studies comparing the outcomes in haemodialysis (HD) with those in peritoneal dialysis (PD) have yielded conflicting results. Methods The aim of the study was to compare the survival of planned HD versus PD patients in a cohort of adult incident patients who started renal replacement therapy (RRT) between 2006 and 2008 in the nationwide REIN registry (Reseau Epidemiologie et Information en Nephrologie). Patients who started RRT in emergency or stopped RRT within 2 months were excluded. Adjusted Cox models, propensity score matching and marginal structural models (MSMs) were used to compensate for the lack of randomization and provide causal inference from longitudinal data with time-dependent treatments and confounders including transplant censorship, modality change over time and time-varying covariates. Results Among a total of 13 767 dialysis patients, 13% were on PD at initiation of RRT and 87% were on HD. The median survival times were 53.5 months or 4.45 years and 38.6 months or 3.21 years for patients starting on HD and PD, respectively. Regardless of the model used, there was a consistent advantage in terms of survival for HD patients: hazard ratio (HR) 0.76 [95% confidence interval (95% CI) 0.69-0.84] with the Cox model using propensity score; HR 0.67 (95% CI 0.62-0.73) in the Cox model with censorship for each treatment change; and HR 0.82 (95% CI 0.69-0.97) with MSMs. However, MSMs tended to reduce the survival gap between PD and HD patients. Conclusion This large cohort study using various statistical methods to minimize the bias appears to demonstrate a better survival in planned HD than in PD.

The effect of differing kidney disease treatment modalities and organ donation and transplantation practices on health expenditure and patient outcomes

Abstract: The Effect of Differing Kidney Disease Treatment Modalities and Organ Donation and Transplantation Practices on Health Expenditure and Patient Outcomes (EDITH) aims to obtain information on long-term kidney transplant outcomes, long-term health outcomes of living kidney donors and detailed outcomes and costs related to the different treatment modalities of end-stage kidney disease. Nine partners from seven European Union countries will participate in this project.

Patient and transplant outcome in infants starting renal replacement therapy before 2 years of age.

Abstract: Background Despite major technical improvements in the care of children requiring renal replacement therapy (RRT) before 2 years of age, the management of those patients remains challenging and transplantation is generally delayed until the child weighs 10 kg or is 2 years old. In this national cohort study, we studied patient and graft survival in children starting RRT before 2 years of age to help clinicians and parents when deciding on RRT initiation and transplantation management. Methods All children starting RRT before 24 months of age between 1992 and 2012 in France were included through the national Renal Epidemiology and Information Network (REIN) registry. The primary endpoints were patient survival on dialysis and 10-year graft survival. Results A total of 224 patients were included {62% boys, median age 10.5 months [interquartile range (IQR) 5.8-15.6]}. The 10-year survival rate was 84% (IQR 77-89). Suffering from extrarenal comorbidities was the only factor significantly associated with both an increased risk of death on dialysis [hazard ratio 5.9 (95% confidence interval 1.8-19.3)] and a decreased probability of being transplanted. During follow-up, 174 renal transplantations were performed in 171 patients [median age at first transplantation 30.2 (IQR 21.8-40.7) months]. The 10-year graft survival was 74% (IQR 67-81). Factors associated with graft loss in multivariate analysis were the time spent on dialysis before transplantation, donor/recipient height ratio with an increased risk for both small and tall donors and presenting two human leucocyte antigen-antigen D-related mismatches. Conclusions This study confirms the good outcome of children starting RRT before 2 years of age. The main question remains when and how to transplant those children. Our study provides data on the optimal morphological and immunological matching in order to help clinicians in their decisions.

Outcome of autosomal dominant polycystic kidney disease patients on peritoneal dialysis: a national retrospective study based on two French registries (the French Language Peritoneal Dialysis Registry and the French Renal Epidemiology and Information Network).

Abstract: Background Pathological features of autosomal dominant polycystic kidney disease (ADPKD) include enlarged kidney volume, higher frequency of digestive diverticulitis and abdominal wall hernias. Therefore, many nephrologists have concerns about the use of peritoneal dialysis (PD) in ADPKD patients. We aimed to analyse survival and technique failure in ADPKD patients treated with PD. Methods We conducted two retrospective studies on patients starting dialysis between 2000 and 2010. We used two French registries: the French Renal Epidemiology and Information Network (REIN) and the French language Peritoneal Dialysis Registry (RDPLF). Using the REIN registry, we compared the clinical features and outcomes of ADPKD patients on PD (n = 638) with those of ADPKD patients on haemodialysis (HD) (n = 4653); with the RDPLF registry, those same parameters were determined for ADPKD patients on PD (n = 797) and compared with those of non-ADPKD patients on PD (n = 12 059). Results A total of 5291 ADPKD patients and 12 059 non-ADPKD patients were included. Analysis of the REIN registry found that ADPKD patients treated with PD represented 10.91% of the ADPKD population. During the study period, PD was used for 11.2% of the non-ADPKD population. Compared with ADPKD patients on HD, ADPKD patients on PD had higher serum albumin levels (38.8 ± 5.3 versus 36.8 ± 5.7 g/dL, P < 0.0001) and were less frequently diabetic (5.31 versus 7.71%, P < 0.03). The use of PD in ADPKD patients was positively associated with the occurrence of a kidney transplantation but not with death [hazard ratio 1.15 (95% confidence interval 0.84-1.58)]. Analysis of the RDPLF registry found that compared with non-ADPKD patients on PD, ADPKD patients on PD were younger and had fewer comorbidities and better survival. ADPKD status was not associated with an increased risk of technique failure or an increased risk of peritonitis. Conclusions According to our results, PD is proposed to a selected population of ADPKD patients, PD does not have a negative impact on ADPKD patients' overall survival and PD technique failure is not influenced by ADPKD status. Therefore PD is a reasonable option for ADPKD patients.

Outcomes of acute kidney injury depend on initial clinical features: a national French cohort study

Abstract: Background Acute kidney injury (AKI) is a common condition that is associated with poor short- and long-term outcomes. The aim of this nationwide cohort study was to profile the long-term outcome of patients admitted for AKI in France. Methods Based on the comprehensive French hospital discharge database, all hospitalizations for an AKI episode were categorized in four groups according to the presence of at least one dialysis session [renal replacement therapy (RRT)] and according to the coding of AKI as the principal or associated diagnosis (PRINC_DIAG or ASS_DIAG). Results In this nationwide cohort of 989 974 patients (median age 77 years) hospitalized with AKI during the 2009-16 period, 422 739 (43%) patients died (235 572 during the first hospitalization) and 40 015 (4%) patients reached end-stage renal disease (ESRD) (5962 during first hospitalization) up to 31 December 2016. Patients without RRT and discharged from hospital had a cumulative incidence of ESRD that ranged from 5.3% (5.2-5.4) in the ASS_DIAG group to 28.7% (27.9-29.5) in the RRT-PRINC_DIAG group at 60 months. The cumulative incidence of death ranged from 31.0% (30.2-32.2) in the RRT-ASS_DIAG group to 45.5% (45.3-45.7) in the ASS_DIAG group. Initial clinical features were associated with outcome independent of comorbidities and age. Conclusions The death penalty of AKI is abysmal and AKI was an important predisposing factor to chronic ESRD. Our study strengthens the current recommendations for long-term follow-up of patients with AKI. The novelty of this study is to propose a clinical classification of AKI episodes that is easy to detect in administrative medical databases and that is strongly associated with immediate and long-term outcomes.

Factors associating with differences in the incidence of renal replacement therapy among elderly: data from the ERA-EDTA Registry.

Abstract: Background. The incidence of renal replacement therapy (RRT) in the general population 75 years of age varies considerably between countries and regions in Europe. Our aim was to study characteristics and survival of elderly RRT patients and to find explanations for differences in RRT incidence. Methods. Patients 75 years of age at the onset of RRT in 2010-2013 from 29 national or regional registries providing data to the European Renal Association-European Dialysis and Transplant Association Registry were included. Chi-square and Mann-Whitney U tests were used to assess variation in patient characteristics and linear regression was used to study the association between RRT incidence and various factors. Kaplan-Meier curves and Cox regression were employed for survival analyses. Results. The mean annual incidence of RRT in the age group 75 years of age ranged from 157 to 924 per million age-related population. The median age at the start of RRT was higher and comorbidities were less common in areas with higher RRT incidence, but overall the association between patient characteristics and RRT incidence was weak. The unadjusted survival was lower in high-incidence areas due to an older age at onset of RRT, but the adjusted survival was similar [relative risk 1.00 (95% confidence interval, 0.97-1.03)] in patients from low- and high-incidence areas. Conclusions. Variation in the incidence of RRT among the elderly across European countries and regions is remarkable and could not be explained by the available data. However, the survival of patients in low- and high-incidence areas was remarkably similar.

Performance of an easy-to-use prediction model for renal patient survival: an external validation study using data from the ERA-EDTA Registry

Abstract: Background An easy-to-use prediction model for long-term renal patient survival based on only four predictors [age, primary renal disease, sex and therapy at 90 days after the start of renal replacement therapy (RRT)] has been developed in The Netherlands. To assess the usability of this model for use in Europe, we externally validated the model in 10 European countries. Methods Data from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry were used. Ten countries that reported individual patient data to the registry on patients starting RRT in the period 1995-2005 were included. Patients <16 years of age and/or with missing predictor variable data were excluded. The external validation of the prediction model was evaluated for the 10- (primary endpoint), 5- and 3-year survival predictions by assessing the calibration and discrimination outcomes. Results We used a data set of 136 304 patients from 10 countries. The calibration in the large and calibration plots for 10 deciles of predicted survival probabilities showed average differences of 1.5, 3.2 and 3.4% in observed versus predicted 10-, 5- and 3-year survival, with some small variation on the country level. The concordance index, indicating the discriminatory power of the model, was 0.71 in the complete ERA-EDTA Registry cohort and varied according to country level between 0.70 and 0.75. Conclusions A prediction model for long-term renal patient survival developed in a single country, based on only four easily available variables, has a comparably adequate performance in a wide range of other European countries.

Association between daily haemodialysis, access to renal transplantation and patients' survival in France

Abstract: AIM Daily haemodialysis improves patients' quality of life and blood purification, but its effect on survival remains controversial. The aim of this study was to analyze the association between daily haemodialysis and renal transplantation and survival in France. METHODS This was an observational cohort study based on the French REIN registry. All incident patients ≥18 years old who started daily haemodialysis in France between 2003 and 2012 were included. Using a propensity score, 575 patients on daily haemodialysis were matched with 1696 patients receiving thrice-weekly haemodialysis. Survival analysis was performed using the Cox model. Access to the renal transplant waiting list and renal transplantation were analyzed using the Fine and Gray model. RESULTS Daily haemodialysis was not independently associated with reduced access to transplant waiting list, whereas, major comorbidities remained associated with restricted waitlisting after multivariate analysis adjusted for confounding factors. After being waitlisted, the cumulative incidence of renal transplantation was lower for the daily haemodialysis than for the thrice-weekly haemodialysis group (SHR = 0.72, 95%CI: 0.56-0.91). The risk of death was significantly higher in the daily haemodialysis group (HRadjusted = 1.58, 95%CI: 1.4-1.8). Major comorbidities were associated with higher risk of death and lower likelihood of receiving a renal transplant during the follow-up period. CONCLUSION Our study showed that in France, the likelihood of undergoing renal transplantation after being waitlisted was lower for patients on daily haemodialysis than those on thrice-weekly haemodialysis. Moreover, daily haemodialysis was associated with higher risk of death, even after taking into account age and all major comorbidities.

Description des traitements immunosuppresseurs d’entretien post-greffe rénale à travers le système national de l’Assurance maladie

Abstract: Resume L’objectif de la presente etude etait de decrire la delivrance medicamenteuse des traitements immunosuppresseurs d’entretien, sur l’annee 2014, des patients ayant recu une transplantation renale en 2012, a partir des donnees du Systeme national des donnees de sante (SNDS) et de comparer ces resultats aux informations declarees dans la base nationale Cristal de suivi des receveurs. Pour chaque patient, etaient considerees toutes les delivrances pharmaceutiques d’immunosuppresseurs avec la date de delivrance, la substance active (principe actif) et sa presentation (nombre de comprimes, dosage). Parmi les 2463 patients adultes greffes en 2012 et toujours porteurs d’un greffon en 2014, 73 % avaient au moins une delivrance de tacrolimus monohydrate (TAC), 59 % de mycophenolate mofetil (MMF), 54 % de prednisone et 20 % de ciclosporine (CSA) en 2014. Les doses journalieres, mais non le nombre de comprimes par jour, diminuaient avec l’âge. L’association la plus frequente etait tacrolimus monohydrate-mycophenolate mofetil-corticoides dans 34 % des cas. L’utilisation d’inhibiteurs mTOR, rare dans l’ensemble (7 %) en 2014, etait plus frequente chez les 66–85 ans. Les associations ne differaient pas de facon importante selon le statut diabetique, pour les patients avec un rein de donneur de plus de 70 ans ou selon le nombre de mismatch. Par rapport a la declaration dans Cristal, les doses journalieres delivrees en pharmacie etaient respectivement similaires (tacrolimus), sous-estimees (mycophenolate) ou surestimees (ciclosporine). Cette etude confirme la difficulte d’apprehender la consommation medicamenteuse et ses variations sur la seule delivrance pharmaceutique ou sur une declaration ponctuelle, meme si cela permet d’avoir une vue assez globale sur les pratiques francaises.

End stage renal disease as a symptom of health inequalities in French Guiana

Abstract: Objectives: French Guiana attracts numerous migrants in search of a better life. They often live in very poor conditions, and may thus have difficulties in accessing care. The objective of the study was to look at differences between French and non-French ESRD patients in French Guiana. Material and methods: Data from REIN registry in French Guiana was used between 1 January 2011 and 31 December 2016. Data from the population census was used to compare the prevalence of ESRD between French and foreign citizens. Longitudinal data was analyzed using survival analysis. Cox proportional hazards modelling was used. Results: Half of patients on dialysis were of foreign origin. The odds ratio of ESRD was 2.2 (95% CI = 1.8-2.8, p < 0.0001) for foreigners relative to French citizens. When looking at adults only, immigrants were still more likely to have ESRD OR = 1.45 (95% CI = 1.2-1.7), p < 0.001. There was a significant age difference between foreign patients with ESRD and French patients with ESRD, 58.9 years (SD = 13.79) vs. 62.2 years (SD = 16.03), respectively, p = 0.02. No significant difference was found between French citizens and migrants regarding the underlying nephropathy, or mortality. However, when adjusting for age and looking at specific nationalities, patients from Guyana, Brazil, and the Dominican Republic, had a greater mortality. Conclusions: Although there was no difference in prevalence between migrants and French citizens, the age at diagnosis of ESRD was lower in immigrants from neighboring countries Guyana, Suriname, and Brazil. Age-adjusted mortality was higher in some immigrant groups relative to French patients. Earlier detection of socially vulnerable patients with renal failure or with risk factors for renal failure should be a priority in French Guiana.

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

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

Outcomes of acute kidney injury depend on initial clinical features: A national French cohort study

Abstract: Background Acute kidney injury (AKI) is a common condition that is associated with poor short- and long-term outcomes. The aim of this nationwide cohort study was to profile the long-term outcome of patients admitted for AKI in France. Methods Based on the comprehensive French hospital discharge database, all hospitalizations for an AKI episode were categorized in four groups according to the presence of at least one dialysis session (RRT) and according to the coding of AKI as the principal or associated diagnosis (PRINC_DIAG or ASS_DIAG). The cumulative incidences of death and ESRD in each group were analyzed with a subdistribution hazard (Fine and Gray) model to take into account the competing risks between those two outcomes. A subgroup analysis was done for patients who were alive and not on RRT at hospital discharge. The effect of the initial clinical feature on death or ESRD was analyzed with an adjusted cause-specific Cox proportional hazard regression censored at other outcomes. All the models were adjusted for age, gender and comorbidities. Results In this nationwide cohort of 989,974 patients (median age 77 years) hospitalized with AKI during the 2009–2016 period, 422,739 (43%) patients died (235,572 during the first hospitalization) and 40,015 (4%) patients reached ESRD (5962 during first hospitalization) up to 31 December 2016. Former cardiovascular disease and CKD were diagnosed in 40% and 16% of patients, respectively. Patients without RRT and discharged from hospital had a cumulative incidence of ESRD which ranged from 5.3% [5.2–5.4] in the ASS_DIAG group to 28.7% [27.9–29.5] in the RRT-PRINC_DIAG group at 60 months. The cumulative incidence of death ranged from 31.0% [30.2–32.2] in the RRT-ASS_DIAG group to 45.5% [45.3–45.7] in the ASS_DIAG group. Initial clinical features were associated with outcome independent of comorbidities and age. Compared to RRT-PRINC_DIAG, PRINC_DIAG (HR: 0.4, 95% CI: 0.4–0.4), ASS_DIAG patients (HR: 0.1, 95% CI: 0.1–0.2) and RRT-ASS_DIAG (HR: 0.4, 95% CI: 0.4–0.5) patients were at lower risk of reaching ESRD. Results were similar in each age group and whether or not patients had a previous diagnosis related to urinary tract or kidney disease. RRT-ASS_DIAG patients had a higher risk of death (HR: 1.9, 95% CI: 1.9–2.0) as compared to RRT-PRINC_DIAG, while patients with AKI as principal diagnosis (PRINC_DIAG) or associated diagnosis (ASS_DIAG) not requiring dialysis had a lower risk (HR: 0.7, 95% CI: 0.6–0.7 and HR: 0.9, 95% CI: 0.9–0.9, respectively). Conclusions The major strength of our observational study was the national coverage obtained from the comprehensive French hospital discharge database and a long follow-up over seven years. Our study strengthens the current recommendations for long-term follow-up of patients with AKI. The novelty of this study is to propose a clinical classification of AKI episodes that is easy to detect in administrative medical databases and that is strongly associated with immediate and long-term outcomes. This novel classification is based on the perceived primacy of AKI as a driver of the illness that brought the patient to the hospital and the need of RRT. Further studies are now warranted to compare the performance of our classification to predict long-term outcome to other classifications, including the KDIGO, AKIN or RIFLE.

Correction to: Deleterious effects of dialysis emergency start, insights from the French REIN registry

Abstract: Following publication of the original article [1], the authors reported that all of the authors’ names were processed incorrectly so that their given and family names were interchanged.