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BACKGROUND AND AIMS Acute interstitial nephritis (AIN) represents an important cause of acute kidney injury. The most common etiology of AIN is drug-induced disease. Definitive diagnosis of AIN requires renal biopsy. Despite this, there is a lack of consensus regarding precise histological diagnostic criteria, and the clinical significance of common histological findings is uncertain. The aim of this study was to explore the histological characteristics of drug-induced AIN and to evaluate their impact on the renal outcome. METHOD We conducted a retrospective study that included patients with biopsy proven drug-induced AIN, followed in the department of nephrology of Charles Nicolle hospital in Tunis during the period between 1990 and 2019. Histological diagnosis of AIN was based on the presence of an interstitial inflammatory cell infiltrate with or without fibrosis. RESULTS During the period of the study, we collected 69 cases of biopsy proven AIN. The diagnosis of drug-induced AIN was performed in 23 patients (33%), with a medium age of 35 years. In eight patients (35%), nonsteroidal anti-inflammatory drugs were the culprit, followed by antibiotics in six patients (26%) and other drugs in three cases (13%). In six patients (26%), no single drug could be identified as the culprit, and these were classified as multidrug causes. The presence of acute kidney disease was the main indication for the kidney biopsy. All cases were characterized by a prominent tubulointerstitial inflammatory cell infiltrate. Interstitial infiltration was mild in three cases (13%), moderate in five cases (17%) and severe in 15 cases (65%). The interstitial infiltrate consisted predominantly of lymphocytes. The presence of eosinophils has been noted in 10 cases (43%). Interstitial granulomas were noted in two patients (8%). Interstitial edema and tubulitis were observed in 13 (56%) and 6 cases (26%), respectively. In seven patients (30%) interstitial fibrosis was present, and four patients (17%) had mild-to-moderate tubular atrophy, whereas tubular necrosis was present in seven cases (30%). After a mean follow up of 24 months, eight patients (35%) progressed to chronic kidney disease. Histological factors associated with poor renal outcome, were interstitial fibrosis (P ˂ 0.001) and tubular atrophy (P = 0.01). Patients with interstitial edema (P ˂ 0.001) or tubulitis (P = 0.005) had a better renal prognosis. CONCLUSION Renal biopsy is required to establish a definitive diagnosis of drug-induced AIN. Nevertheless, it is not carried out in a systematic way. The composition of cells in the interstitial infiltrate may at times be helpful in determining the etiology of AIN. In particular, the presence of a considerable proportion of eosinophils favors a diagnosis of drug-induced AIN. Moreover, during drug-induced AIN, histological data have a great prognostic value. In our study, the main histological prognostic factors were interstitial fibrosis, tubular atrophy, interstitial edema and tubulits. Further studies are needed to validate these results and establish a score based on histological data in order to predict renal outcome during drug-induced AIN.

Background and Aims Acute kidney injury (AKI) is common in the elderly due to physiologic renal aging and underlying pathologies. Few studies focused on AKI in Tunisian elderly. The aim of our study was to highlight the epidemiological, clinical, etiological, therapeutic, and progressive characteristics of AKI in elderly. Method We conducted a descriptive retrospective study of AKI in patients admitted to our department over a period of 04 years from 01/01/2014 to 31/12/2017. Results We collected 40 patients including 25 women and 15 men with a sex ratio of 1.66. The mean age was 74 [65-87] years. We noted the presence of pre-existing chronic kidney disease in 58% of cases, diabetes in 50% of cases and hypertension in 73% of cases. Polypharmacy was found in 40% of cases. AKI was symptomatic in 80% of cases and found on a routine check-up in 20% of cases. Mean creatinine was 612+/-334 µmol/l. AKI was pre-renal in 37% and parenchymal in 63% of cases. Iatrogenic origin was found in 33% of cases. Renal biopsy was performed for diagnostic purposes in 6 cases. Haemodialysis was necessary in 50% of cases. Etiopathogenic treatment was initiated in 73% of cases. Intra-hospital mortality was 10%, recovery of renal function (RF) was partial in 40 % of cases and total in 20 % of cases. Follow-up time was 16 +/- 23.2 months. And at the last news, recovery of renal function (RF) was partial in 7 cases and total in 10 cases, 6 patients kept a chronic renal failure (CRF), among them 3 cases had and end-stage of CRF. Conclusion AKI is a frequent pathology in the elderly and its severity is linked to mortality and the transition to chronicity. Iatrogenic causes are frequent and preventable in this population, hence the major interest of prevention.

We use ambient noise tomography to investigate the crust and the uppermost mantle structure beneath the junction between the Southern Alps, the Dinarides and the Po Plain. We obtained Rayleigh wave empirical Green's functions from cross-correlation of vertical component seismic recordings for three years (2010-2012) using stations from networks in Italy, Slovenia, Austria, Croatia, Serbia and Switzerland. We measure group and phase velocity dispersion curves from the reconstructed Rayleighwaves in the period range 5-30 and 8-37 s, respectively, andwe invert the surfacewave velocities for tomographic images on a grid of 0.1° ×0.1°. After the tomography, the group velocities are then inverted to compute the 3-D shear wave velocity model of the crust and the upper mantle beneath the region. Our shear wave velocity model provides the 3-D image of the structure in the region between Northeastern Italy, Slovenia and Austria. The velocity variations at shallow depths correlate with known geological and tectonic domains. We find low velocities below the Po Plain, the northern tip of the Adriatic and the Pannonian Basin, whereas higher velocities characterize the Alpine chain. The vertical cross-sections reveal a clear northward increase of the crustal thickness with a sharp northward dipping of the Moho that coincides at the surface with the leading edge of the Alpine thrust front adjacent to the Friuli Plain in Northeastern Italy. This geometry of the Moho mimics fairly well the shallow north dipping geometry of the decollement inferred from permanent GPS velocity field where high interseismic coupling is reported. From the northern Adriatic domain up to the Idrija right lateral strike-slip fault system beneath Western Slovenia, the crustal thickness is more uniform. Right across Idrija fault, to the northeast, and along its strike, we report a clear change of the physical properties of the crust up to the uppermost mantle as reflected by the lateral distribution of both group and phase velocity anomalies at relevant periods. Idrija fault is therefore interpreted as a subvertical fault sampling the whole crust. Our 3-D velocity model favours crustal thickening with Adria underthrusting the Alps at a shallow angle north of the Friuli Plain where much of the convergence is absorbed and where the destructive 1976 M s 6.5 thrust Friuli earthquake sequence took place. In Western Slovenia, the deformation is accommodated by strike-slip motion along the Idrija strike-slip fault system where the destructive 1511 M w 6.9 right lateral strike-slip event occurred.

Background and Aims Mesangial deposits Ig A was described the first time in 1968 by Berger and Hinglais. It remains the most common primary glomerulonephritis worldwide. It is often idiopathic but can also be secondary. The aim of our study is to describe the epidemiologic characteristics, the incidence and the anatomopathological features of 501 IgA nephropathy (IgA N) patients. Method It is a retrospective mono-centric study including patients having IgA N in the renal biopsy done in our department among a period of 17 years. Results We analyzed data of 8427 patients who underwent renal biopsy. 81% had glomerular nephropathy with 7.3% (501) IgA N. A male-to-female ratio of 2.27. The average age was 28.7 years. IgA N was primary in 80.2% cases and secondary in 17.8% cases. The most frequent secondary IgA N was rheumatoid purpura (74.8%). There was a male predominance in Berger‘s disease as well as in rheumatoid purpura. Berger’s disease was more common in adults, whereas rheumatoid purpura was more common in children. The main indication of renal biopsy was proteinuria with hematuria in 23.2% of cases and nephrotic syndrome in 23.8%. The association of non-nephrotic proteinuria, hematuria, arterial hypertension and renal injury was found in 9.3% whereas isolated macroscopic hematuria only in 6.4% of cases. According to HAAS classification, HAAS 3 was the most frequent. OXFORD classification used only from 2010, and M1, S1, E0, T0 and M1, S1, E0, T2 were the most frequent. Glomerular lesions were associated to tubulo interstitial and vascular lesions in 48.2% of cases. Conclusion IgA nephropathy is the most common glomerular disease and a frequent cause of end stage renal disease. Because of a clear increase of it’s incidence in our country and the delay in the diagnosis, a systematic screening of urines is needed in our country as it’s done in Singapore and Japan.

Background and Aims The increase in life expectancy has led to increasing numbers of elderly patients in all medical disciplines, particularly in nephrology. Idiopathic membranous nephropathy (IMN) is common in the elderly and can lead to significant morbidity and mortality because of the complication of nephrotic syndrome (NS) and immunosuppressive therapy. The aim of this study is to analyze the diagnostic, therapeutic and evolutionary approach of IMN in elderly patiets. Method We conducted a retrospective descriptive study in the nephrology department at Charles Nicolle hospital over a period of 44 years. All older patients (≥65 years) with histologically proven MN were included in this study. Data collected included demographic, clinical and biological parameters in each patient. Data were entered and analyzed using SPSS software. Results Twenty-eight patients were collected. The mean age was 67.03 years (65-78 years) with a male predominance (sex ratio: 2.3) and low socio-economic level in 82.5% of cases. Sixteen patients were smokers (57.14%), 5 ethyl patients (17.8%), diabetes was present in 3 patients (10.7%) and hypertension in 11 patients (39.28%). Two cases of neoplasm were present, namely one case of prostatic adenocarcinoma and one case of gallbladder adenocarcinoma, all were diagnosed and treated along one year and ten years respectively, before the diagnosis of MN. The circumstances of discovery were dominated by oedema in 27 cases (86.27%), hypertension in 11 cases (39.28%) and elevated creatinine level in 9 cases (32.14%). Deep venous thrombosis was the circumstance of discovery in one case. At the time of diagnosis, the clinico-biological picture was dominated by high systolic blood pressure in 21 cases (75%), anasarca in 7 cases (25%), proteinuria in all cases and hematuria in 20 cases (71.14%). Biology revealed nephrotic syndrome (NS) in all cases, hypercholesterolemia in 23 cases (82.14%), high serum creatinine in 14 cases (50%) with an average creatinine level of 127,95 µmol/l, anemia in 17 cases (60.7%) and anti-neutrophil cytoplasmic antibodies were positive in one case. MN was confirmed by a kidney biopsy in all cases. Symptomatic treatment was indicated in all patients. Immunosuppressive therapy was started early in 12 patients (40%) because of the severe NS and the deterioration of renal function. Eight patients (26.6%) received corticosteroids alone (group 1), three patients received corticosteroid with mycofenolate mofetil (group 2) and one patient received corticosteroid with ciclosporin (group3). Fourteen patients received only symptomatic treatment (group 4). We noted partial remission in group 3, however complete remission in 37.5%, 14.28% and 12.5% from respectively group 1, group 4 and group 2. The side effects of immunosuppressive therapy were infectious complication in 8 patients (28.5%), osteoporosis in 3 patients (10.7%) and Steroid diabetes in one case. The side effects of NS were thrombotic complication in 5 patients (17.85%). Two patients had presented coronary syndrome and two other patients had presented hepatitis C. Two cases of death were noted whose etiology was pulmonary infection in one patient and undeterminate etiology in the other case. Conclusion Treatment of IMN in older patients has unique challenges, reducing the need for renal replacement therapy. Most studies report that the elderly respond to therapy with rates comparable with younger patients but in the other hand elderly are more susceptible to side effects of immunosuppressive therapy.

Background and Aims Hypertension is a common manifestation during systemic lupus erythematosus (SLE). Its mechanism is multifactorial and microthromboses of renal arterioles seem to be the most important mechanism. The objective of our study is to identify the histological and evolutionary characteristics of patients with lupus nephritis (LN) presenting with hypertension. Method A retrospective study of 85 patients followed for LES with lupus nephritis documented by a renal biopsy collected in 17 years and presenting with hypertension. Results Among 174 patients with LN, eighty-five (48.58%) are hypertensive. A sex ratio F / H of 6.08. The mean age of LN diagnosis was 36.4 years old [13 -75 years old]. The average time to onset of hypertension was 25.8 months [0-204 months]. Malignant hypertension was present in 12% of patients. Antiphospholipid Antibody Syndrome (APLS) was found in 35.3% of cases. Renal biopsy showed LN class II in 2 cases, class III in 8 cases, class IV in 43 cases, class V isolated in 8 cases and class VI in 3 cases. Vascular lesions were arteriolosclerosis in 40% of cases and thrombotic microangiopathy (TMA) lesions in 17.6% of cases. The treatment was essentially based on blockers of the renin angiotensin system, either as monotherapy or in combination with calcium channel blockers, beta blockers or central antihypertensives. The evolution was marked by the occurrence of cerebrovascular accidents associated in 7 cases with APLS and coronary artery disease in 2 cases. Renal evolution was marked by total and durable remission in 27.5%, chronic renal disease in 31.7%, and end-stage renal failure in 40.8% of cases. Blood pressure was balanced in 40,5 % of cases and unbalanced in 59,5% of cases. Conclusion In our lupus patients, hypertension was common, associated with severe glomerular and vascular lesions and a rather severe renal prognosis.

Background and Aims The aging of the population and the increase in life expectancy have led to increasing numbers of elderly patients so greater numbers of elderly patients with chronic kidney diseases are surviving longer. Membranous nephropathy (MN) is the most important cause of glomerular disease in older patients (≥65 years). The aim of this study is to describe the epidemiological and clinical profile of elderly patients with MN and to analyze the diagnostic and management approach. Method We conducted a retrospective descriptive study in the nephrology department at Charles Nicolle hospital over a period of 44 years. All older patients (≥65 years) with histologically proven MN were included in this study. Results Thirty patients were collected. The mean age was 69.43 years (65-78 years) with a male predominance (sex ratio: 2.3) and low socio-economic level in 83.3% of cases. Sixteen patients were smokers (55.3%), 5 ethyl patients (16.7%), diabetes was present in 3 patients (10%) and hypertension in 11 patients (36.7%). Two cases of neoplasm were present, namely one case of prostatic adenocarcinoma and one case of gallbladder adenocarcinoma, all were diagnosed and treated along one year and ten years respectively, before the diagnosis of MN. The circumstances of discovery was dominated by oedema in 27 cases (86.27%), hypertension in 11 cases (36.7%) and elevated creatinine level in 9 cases (30%). Deep venous thrombosis was the circumstance of discovery in one case. At the time of diagnosis, the clinico-biological picture was dominated by high systolic blood pressure in 21 cases (67.6%), anasarca in 7 cases (23.3%), proteinuria in all cases and hematuria in 20 cases (66.6%). Biology revealed nephrotic syndrome (NS) in 28 cases (87.11%), hypercholesterolemia in 23 cases (76.6%), high serum creatinine in 14 cases (46.6%) with an average creatinine level of 123,85 µmol/l, anemia in 17 cases (56.6%) and anti-neutrophil cytoplasmic antibodies were positive in one case. MN was confirmed by a kidney biopsy in all cases. Twenty-two patients had idiopathic MN (IMN) and 2 patients had secondary MN. In fact, MN was associated with multiple myeloma in one case and secondary to hepatitis B in other case. Symptomatic treatment was indicated in all patients. Patients with secondary MN received etiopathogenic treatment. For the IMN, immunosuppressive therapy started early for 12 patients (40%) because of the severe NS and the deterioration of renal function. Eight patients (26.6%) received corticosteroids alone, three patients received corticosteroid with mycofenolate mofetil and one patient received corticosteroid with ciclosporin. We noted complete remission in 6 patients and end renal stage disease in 5 patients. Conclusion In studies of glomerular disease in the elderly, MN was the most common cause of NS. The clinical presentation is similar in older and younger patients, but older patients more often present with kidney failure and severe NS.

Background and Aims Idiopathic membranous nephropathy (IMN) is increasingly seen in older patients but little is known about its treatment and outcomes at long term follow up. The objective of this work is to study the renal survival of IMN in elderly as well as prognostic factors. Method We conducted a retrospective descriptive study in the nephrology department at Charles Nicolle hospital over a period of 44 years. All older patients (≥65 years) with histologically proven MN were included in this study. Data collected included demographic, clinical and biological parameters in each patient. Data were entered and analyzed using SPSS software. Chi-squared test with a level of significance of 0.05 was used for the qualitative variables. Results Twenty-eight patients were collected. The mean age was 67.03 years (65-78 years) with a male predominance (sex ratio: 2.3) and low socio-economic level in 82.5% of cases. Sixteen patients were smokers (57.14%), 5 ethyl patients (17.8%), diabetes was present in 3 patients (10.7%) and hypertension in 11 patients (39.28%). The clinico-biological picture was dominated by high systolic blood pressure in 21 cases (75%), anasarca in 7 cases (25%), proteinuria in all cases and hematuria in 20 cases (71.14%). Biology revealed nephrotic syndrome (NS) in all cases, hypercholesterolemia in 23 cases (82.14%), high serum creatinine in 14 cases (50%) with an average creatinine level of 127,95 µmol/l, anemia in 17 cases (60.7%) and anti-neutrophil cytoplasmic antibodies were positive in one case. MN was confirmed by a kidney biopsy in all cases. Symptomatic treatment was indicated in all patients. Immunosuppressive therapy was started early in 12 patients (40%) because of the severe NS and the deterioration of renal function. Eight patients (26.6%) received corticosteroids alone, three patients received corticosteroid with mycofenolate mofetil and one patient received corticosteroid with ciclosporin. Fourteen patients received only symptomatic treatment. We noted complete remission in 6 patients (21.42%) and end renal stage disease in 5 patients (17.85%). Our study showed that treatment with angiotensin receptors blockers was associated with better renal survival with a statistically significant difference, (p = 0.011). A reduced kidney function at presentation, tubule-interstitial disease and interstitial fibrosis and tubular atrophy were associated with poor survival with a statistically significant result (p = 0.012) (p=0,011) respectively. Conclusion IMN is the most common cause of nephrotic syndrome in elderly patients and it has the same risk for progression as in younger individuals. Decrements in glomerular filtration rate, increased risk for comorbidities, vascular disease and change in pharmacokinetics justify special attention to treatment decisions in elderly individuals with IMN.

Background and Aims Systemic Lupus Erythematosus (SLE) is associated with an increased risk of cardiovascular morbidity and cardiovascular mortality. The risk of cardiovascular events is 1.3–2.7 times higher in SLE patients than in the general population, and even higher in patients with lupus nephritis (LN). Traditional risk factors as well as SLE-specific and treatment-related factors all contribute to the increased risk of cardiovascular disease. The primary aim of the present study was to evaluate cardiovascular risk factors, morbidity and mortality in patients with LN. Method This is a retrospective study of patients over the age of 16, with LN proved by kidney biopsy and followed up in our department over a period of 17 years. The diagnosis of lupus was made according to criteria of The American College of Rheumatology revised in 1997. Demographic, clinical and para-clinical data were collected from medical observations. Results We collected 155 women and 19 men with a sex ratio F / H of 8.2. The mean age at the time of the discovery of LN was 32.6 years [15-45 years]. Overall median follow-up time was 81.2 months. Renal symptomatology was dominated by proteinuria noted in all patients with an average proteinuria at 3.3 g / 24h, associated to a nephrotic syndrome in 68% of patients, hematuria was present in 69% of patients and renal failure was present in half of cases with an average serum creatinine of 110 µmol / l. At the time of diagnosis of LN, hypertension was noted in 48.9% of cases, diabetes in 2.8% of cases and obesity in 57.4% of cases with an index average body mass of 28.5 Kg / m2. Smoking was reported in 17.2% of the cases. The average cholesterol level was 5,5±2,1 mmol/l, the average triglycerid level was 2,5±1,1 mmol/. Antiphospholipid syndrome was found in 14.9% of cases. We performed 243 renal biopsies with 174 initial and 69 iterative biopsies. The histological lesions were polymorphic dominated by LN class IV (54.3%), arteriolosclerosis was observed in 47.7% and lesions of thrombotic microangiopathy in 29.8%. Corticosteroid therapy was prescribed in all patients combined with immunosuppressive therapy in 54.6% of cases. The overall survival of the patients at 10 years was 85%. During follow-up, cardiovascular complications found in our series were mainly strokes (6.3%) and coronary insufficiency (5.2%) and transient ischemic attack (6.9%). After a univariate analysis, the additional cardiovascular risk factors identified in our study were antiphospholipid syndrome (p = 0.01), renal failure (p = 0.01), long-term corticosteroid therapy (p = 0.009), the chronicity of the disease (evolution of lupus> 10 years) (p = 0.014), proliferative forms (p=0.001), arteriolosclerosis (p=0.0002) and lesions of thrombotic microangiopathy (p=0.018). Survival in patients without cardiovascular risk factors was better (96% vs 88%). Conclusion In conclusion, in addition to traditional risk factors SLE patients have several disease related risk factors that explain increase cardiovascular disease. A careful control for this risk factors is essential to continuously improve survival in SLE.

Background and Aims Crystal-induced kidney disease refers to kidney injury caused by intratubular crystal deposition. The most common forms of crystalline nephropathy encountered in renal pathology are nephrocalcinosis and oxalate nephropathy. The purpose of our study is to determine the epidemiological and clinical characteristics of hyperoxaluria diagnosed from renal biopsy. Method We retrospectively reviewed all kidney biopsy specimens evaluated at renal pathology laboratory, from 1976 to 2019. The biopsy specimens were received from multiple medical department and medical centers. We studied 8900 biopsy specimens and we were focused on patients whose diagnosis of hyperoxaluria was made from renal biopsy Results We identified 25 cases (15 children and 10 adults) with a sex ratio H / F of 0.9. Mean age at diagnosis was 17.2 years old [4 months-73 years old]. Most patients were offspring of consanguineous mating (14 of 25) with intermarriage of first-degree cousins being the most common pattern. A family history of chronic kidney disease was found in 13 patients: indeterminated nephropathy (n = 6) and renal stone (n = 5) and primary hyperoxaluria (n=2). Among our patients, five had a history of urolithiasis. One patient had a history of chronic diarrhea related to Crohn's disease and one patient had a history of cephalic pancreatectomy and ileal resection. Initial symptoms and signs were dominated by renal failure (n = 25) with mean creatinine of 789.5 μmol / l [306-1832μmol / l], associated with proteinuria in 10 patients and hematuria in 11 patients. Arterial hypertension was present in 4 patients. Oligo anuria was reported in 4 patients without dilation of the urinary excretory pathways. In our patients, the diagnosis of crystalin nephropathy was revealed by renal biopsy. In one case, the diagnosis was made after renal transplant. In 4 cases the diagnosis was made by postmortem kidney biopsy. In all cases, the kidney biopsy specimen showed extensive intratubular crystal deposition and tubulointerstitial mononuclear cell infiltration with features of tubular injury and interstitial fibrosis. Examination of histologic slides showed colorless refractile crystals of polygonal appearance. Multicolored birefringence under polarized light identified these crystals as calcium oxalate. After different investigations (genetic and biological analysis), the diagnosis of hyperoxaluria was confirmed. Hyperoxaluria was primary in 23 patients and secondary in 2 patients. Conclusion Hyperoxaluria is a rare condition, often serious, involving renal prognosis and sometimes life-threatening, especially in early-onset forms. Early diagnosis and treatment should be done as soon as possible to slow the progression to end-stage renal failure. In patients with renal insufficiency, the diagnosis of hyperoxaluria is difficult. Renal biopsy can help when clinical and radiological data are not sufficient.

Slow-slip events (SSEs) are common at subduction zone faults where large mega earthquakes occur. We report here that one of the best-recorded moderate size continental earthquake, the 2009 April 6 moment magnitude (Mw) 6.3 L’Aquila (Italy) earthquake, was preceded by a 5.9 Mw SSE that originated from the decollement beneath the reactivated normal faulting system. The SSE is identified from a rigorous analysis of continuous GPS stations and occurred on the 12 February and lasted for almost two weeks. It coincided with a burst in the foreshock activity with small repeating earthquakes migrating towards the main-shock hypocentre as well as with a change in the elastic properties of rocks in the fault region. The SSE has caused substantial stress loading at seismogenic depths where the magnitude 4.0 foreshock and Mw 6.3 mainshock nucleated.This stress loading is also spatially correlated with the lateral extent of the aftershock sequence.

Background. In the US and Canada, dialysis discontinuation is one of the more frequent causes of death in elderly patients on haemodialysis, particularly after the age of 75. The aim of this study was to analyse the practices of some French nephrologists, 17 of whom (in six nephrology units) were interviewed for this study. Methods. A questionnaire was formulated on the basis of a bibliographical search of the topic. A series of questions, initially open and then more targeted, regarding scientific and non-scientific factors influencing the decision to discontinue or refuse haemodialysis in elderly patients, were put to nephrologists. Results. Psychological and physical deterioration emerged as the principal factors governing decisions to refuse or discontinue treatment. The interviewees felt that severe dementia (15 out of 17 nephrologists), irreversible neurological sequelae of a CVA (11 out of 17) and, paradoxically, patient refusal (10 out of 17) were factors to be taken into account in the decision to discontinue haemodialysis. Although the main reasons for refusing dialysis were cognitive disorders, severe dementia and irreversible neurological conditions, none of these factors where actually found to be in and of themselves decisive. Conclusions. This study has shown that refusing or discontinuing dialysis are practices accepted by the vast majority of nephrologists in one region of France. Patient refusal is not a basis for denial or discontinuation of dialysis in elderly patients. Our investigation has demonstrated a consensus regarding decisions to refuse or discontinue dialysis.

SUMMARY For the central Apennines, peninsular Italy, a series of tectonic mechanisms are reproduced by means of finite-element models, in order to study the effects of active tectonics on the seismic cycle in the Umbria–Marche seismogenic zone. Continental extension and rift push effects induced by small-scale convection are modelled within 2-D viscoelastic models of the crust–lithosphere system, in vertical cross-sections perpendicular to the strike of the major tectonic structures under study, namely the Apennines and the Colfiorito fault zone, where the 1997 seismic sequence took place. With the aim of constraining the active tectonic mechanisms at the regional scale and the behaviour of the fault in the seismogenic zone at the local scale, modelled baseline rate of change are compared with newly acquired GPS data, retrieved from the two permanent GPS receivers of Camerino (CAME) and Elba (ELBA), deliberately installed along the modelled transect. These receivers are located at both edges of the continental extension in the front of the Apennines, close to the Adriatic Plate in the east, and in the rear of the chain, in the Tyrrhenian domain. The deformation pattern inferred from seismicity and from the geodetic data is consistent with small-scale convection in the Tyrrhenian domain, which reproduces extension in the rear of the Apennines and compression in the front of the chain. A convective mechanism, associated with backarc opening and doming of the asthenosphere, provides an extensional rate, along a baseline connecting two sites in the front of the chain (Camerino) and in its rear (Elba), comparable to the observed baseline rate of change. The viscosity of the lower crust plays a fundamental role in determining the style of stress in the crust–lithosphere system. Once constrained by means of the extensional baseline rate inferred from GPS, the modelled slip across the Colfiorito fault and the modelled earthquake recurrence time are consistent with the 1997 normal fault event and with palaeoseismicity, respectively.