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Purpose The new French allocation system (NFAS) based on the candidate risk score has been launched on January 2, 2018. This study aimed to evaluate the effect of implementation of NFAS on newly registered candidates’ profile and their waitlist outcomes. Methods The study included all adults newly registered on the French waiting list for heart transplantation between January and July, 2014-2018 (n=1808). Characteristics and waitlist outcomes of candidates registered during the 7-month period in the 4 years before (n=1401) and the year after (n=407) introduction of NFAS were compared. The access to transplantation was calculated using competing risk estimation and waitlist survival was estimated using the Kaplan-Meier method. Inactive candidates were excluded from those analyses. Results After the new system implementation, new registrations increased by 27% and transplant activity decreased by 14% leading to a rise in organ shortage (candidate per graft ratio: 1.6 vs 1.3). Candidate demographics remained unchanged (75% male, 49±15 years, dilated cardiomyopathy 41%, coronary artery disease 35%). Compared to 2014-2017, the 2018 proportions of new candidates on VA-ECMO (20% vs 17%, p=0.4), long-term MCS (9% vs 8%), mechanical ventilation (13 % vs 11%, p=0.2), inotropic infusion (34% vs 38%, p=0.2) and dialysis (1.8% vs 2.8%, p=0.2) were not significantly different. The proportion of candidates always inactive during their waiting time increased (3% vs 1%, p=0.02). While the 3-month cumulative incidence of transplantation tended to decrease (48% vs 51%, p=0.15), the 3-month waitlist survival remained unchanged (88.5% vs 89.9% respectively in 2018 and 2014-17; p=0.6) (Figure 1). Conclusion The implementation of the new allocation system did not modify candidates’ profile although we observed a significantly higher proportion of candidates always inactive during their waiting time. Despite the increase of organ shortage, waitlist survival did not decrease.

Resume Ce chapitre fournit des informations sur les variations temporelles et geographiques de la prevalence de l’insuffisance renale chronique terminale en France. Cet indicateur mesure les besoins de sante de la population des malades dialyses ou porteurs d’un greffon renal fonctionnel. Il ne mesure pas la place donnee au traitement conservateur. Au 31 decembre 2011, on denombre pour les 25 regions contribuant au registre 70 300 personnes en traitement de suppleance dont 39 200 (56%) en dialyse et 31 100 (44%) porteuses d’un greffon renal fonctionnel. La prevalence brute globale de l’IRTT est de 1091 pmh. Elle est 1,6 fois plus elevee chez les hommes que chez les femmes. Elle connait des variations regionales importantes : 2 regions metropolitaines (Ile-de-France, Nord Pas de Calais) et 3 regions d’outre-mer (Guadeloupe, Guyane et la Reunion) ont une prevalence globale significativement plus elevee que le taux national. La part de la greffe dans le total des patients prevalents varie de 33% dans le Nord-Pas-de-Calais a 53% en Pays de Loire en metropole et de 16% a 25% dans les regions d’outre-mer. Le rapport greffes/dialyses est superieur a 1 en Basse Normandie, Bretagne, Franche Comte, Pays de Loire et Poitou-Charentes. En Alsace, Haute Normandie, Languedoc Roussillon, Nord-Pas-de-Calais, Picardie et PACA, ce rapport est inferieur a 0,7 et il est inferieur a 0,3 dans les regions d’outre-mer. La prevalence globale standardisee sur l’âge et le sexe est de 40 patients par million d’habitants pour la dialyse peritoneale, de 567 pour l’hemodialyse et de 483 pour la greffe. Elle varie fortement d’une region a l’autre. Sur 18 regions contribuant au registre depuis 2007, l’ecart entre les taux de prevalence standardises de l’insuffisance renale terminale traitee par dialyse et par greffe diminue, la prevalence de la greffe augmentant de + 4% contre + 2% pour la dialyse, du fait de l’augmentation du nombre annuel de greffe et de la meilleure survie des greffes. Cette evolution doit conduire la communaute nephrologique et les autorites sanitaires a anticiper des changements dans la maniere de concevoir la prise en charge globale des malades, et a les adapter a des contextes regionaux varies.

This chapter provides a set of indicators related to Renal Transplantation access in France. It describes patient outcomes and reports on cumulative incidence rates of wait-listing and renal transplantation according to main patient of characteristics and regions. The REIN registry integrates kidney transplant and dialysis data. It provides a comprehensive view on waiting list and renal transplantation access to the patients, nephrologists, and national or regional health authorities. Access to the waiting list is evaluated on a cohort of 51,845 new patients who started dialysis between 2002 and 2011 in 25 regions. The probability of first wait-listing was of 3.7% at the start of dialysis (pre-emptive registrations), 15% at 12, 22% at 36 and 24% to 60 months. The probability of being registered was strongly related to age, diabetes and region. Patient older than 60 had a very poor access to the waiting list, whatever their diabetes status was. Probability of first wait-listing was much lower (36.5% at 60 months) in type 2 diabetic-40 to 59 years old patients. Among 13,653 patients less than 60 years old, the probability of being registered was 11% at the start of dialysis, 43% to 12 months, 62% to 36 months and 66% to 60 months (median dialysis duration: 16 months). Seventeen regions with up to 5 years follow-up show an increase of 8 to 15% in pre-emptive registrations between 2007 and 2001, without change at 1 year. Access to kidney transplant is evaluated on a cohort of 53,301 new patients who started a renal replacement therapy (dialysis or pre-emptive renal transplant) between 2002 and 2011 in 25 regions. The probability of first kidney transplant was of 7% at 12, 17% at 36 and 21% at 60 months. 8,633 patients (16,2%) had received a first renal transplant within 14.7 month median time; 1,455 (2.7%) had received a pre-emptive graft [male: 58%, median age: 48.7y]. Among the 14,770 new patients less than 60 years old, the probability of being transplanted was of 21% at 12, 46% at 36 and 58% at 60 months (median dialysis duration: 42 months). When pre-emptive graft were excluded, the probability of being transplanted was of 5% at 12, 15% to 36 and 19% to 60 months Insofar as kidney transplant is regarded as the most efficient treatment, access to the waiting list and renal transplant are sensitive issues.

This chapter provides a set of indicators on incident patients with renal replacement therapy. In 2011, in 25 French regions (99% population), 9 248 patients started a treatment by dialysis (incidence of dialysis: 149 per million inhabitants) and 334 patients with a pre-emptive graft without previous dialysis (incidence of pre-emptive graft: 5 per million inhabitants). One patient among two are over 70 years old at renal replacement therapy initiation. As in 2010, incidence rate seems to stabilize.

Incident patients In 2011, in France, we estimate that 9 400 patients started a treatment by dialysis (incidence of dialysis: 144 per million inhabitants) and 335 patients with a pre-emptive graft without previous dialysis (incidence of pre-emptive graft: 5 per million inhabitants). As in 2010, incidence rate seems to stabilize. Elders provide the majority of new patients (median age at RRT start: 71 years old). New patients present a high rate of disabilities especially diabetes (41% of the new patients) and cardiovascular disabilities (>50% of the new patients) that increase with age. Considering treatment and follow-up, the first treatment remains center's hemodialysis and we do not notice any progression of self-dialysis. RRT started in emergency in 33% of the patients. This finding contrasts with the fact that 56% of patients started hemodialysis on a catheter. This, together with the major inter-region variability, suggests that different strategies of management exist. Finally, the hemoglobin level at RRT start seems to be an interesting indicator of good management and follow-up since 13% of patients presenting an underprovided follow-up have a hemoglobin level under 10 g/dl, whereas only 2.5% of patients with an appropriate follow-up presented such a condition. Prevalent patients On December 31, 2011, in France, we estimate that 70.700 patients were receiving a renal replacement therapy, 39.600 (56%) on dialysis and 31.100 (44%) living with a functional renal transplant. The overall crude prevalence was 1091 per million inhabitants. It was 1.6 higher in males. Download : Download full-size image Renal replacement therapy for End-stage renal disease in 2011 in France Prevalence was subject to regional variations with 5 regions (3 overseas) above the national rate. Renal transplant share varied from 33% in Nord-Pas de Calais to 53% in Pays de Loire, and from 16 to 25% in overseas regions. The study of temporal variations for 18 regions contributing to the registry since 2007 demonstrated a +4% increase in standardized prevalence of ESRD patients with a functional transplant vs. +2% increase for dialysis, resulting in a decreasing gap between dialysis and transplantation prevalence, due to an increase number of renal transplant and a longer survival of transplanted patients. The main dialysis technique was hemodialysis (93.3% of patients). Even if an important inter-region variability remains considering the choices of treatment, more than 50% of the patients are undergoing hemodialysis in a hospital-based incenter unit, and we noticed an increase in hemodialysis in a medical satellite unit with time whereas the rate of self-care hemodialysis decreases. The rate of peritoneal dialysis remains stable. When comparing guidelines to real-life treatments, 77.5% of patients receive adequate dose of treatment (12 H/week, KT/ V>1.2), the rate of patients with a hemoglobin blood-level lower than 10 g/dl and without erythropoietin treatment is 1.3%, which confirmed a good management of anemia. On the contrary, 34% of patients have a BMI lower than 23 kg/m2 and only 23% have an albumin blood-level over 40 g/l, which underlines that nutritional management of ESRD patients can be improved. Mortality Age strongly influences survival on dialysis. Thus, one year survival of patients under age 65 is over 90%. After 5 years, among patients over 85 years, it is more than 15%. The presence of diabetes or one or more cardiovascular comorbidities also significantly worse patient survival. In terms of trend, we do not find significant improvement in the 2-year survival between patients in the cohort 2006–2007 and the 2008–2009 cohort. Cardiovascular diseases account for 27% of causes of death to infectious diseases (12%) and cancer (10%). Life expectancy of patients is highly dependent on their treatment. Thus, a transplant patient aged 30 has a life expectancy of 41 years versus 23 years for a dialysis patient. ESRD pediatric patients In 2011, the incidence and the prevalence of ESRD among patients under 20 years old remained stable at 8 and 53 per million inhabitants respectively. The first causes of ESDR remain uropathies and hypodysplasia followed by glomerulonephritis and genetic diseases. Considering the initial treatment, we found a high rate of hemodialysis and a low rate of peritoneal dialysis that is mainly used in younger children. In 2011, 31 preemptive transplantations were performed accounting for 27.7% of new patients. Finally, survival analysis confirm that younger children (under 4 years old) have the highest risk of death (88% survival rate at 2 years vs. 98% in patients over 4 years old) and that the treatment of choice remains the renal transplantation since it increases the expected remaining lifetime of 20 to 40 years depending on the considered age. Transplantation Access to the waiting list is evaluated on a cohort of 51,846 new patients who started dialysis between 2002 and 2011 in 25 regions. The probability of first wait-listing was of 3.7% at the start of dialysis (pre-emptive registrations), 15% at 12, 22% at 36 and 24% to 60 months. Patient older than 60 had a very poor access to the waiting list, whatever their diabetes status was. Among 13,653 patients less than 60 years old, the probability of being registered was 11% at the start of dialysis, 43% to 12 months, 62% to 36 months and 66% to 60 months (median dialysis duration: 16 months). Seventeen regions with up to 5 years follow-up show an increase of 8 to 15% in pre-emptive registrations between 2007 and 2001, without change at 1 year. Access to kidney transplant is evaluated on a cohort of 53,301 new patients who started a renal replacement therapy (dialysis or pre-emptive renal transplant) between 2002 and 2011 in 25 regions. The probability of first kidney transplant was of 7% at 12, 17% at 36 and 21% at 60 months. 8,633 patients (16,2%) had received a first renal transplant within 14.7 month median time; 1,455 (2.7%) had received a pre-emptive graft. Among the 14.770 new patients less than 60 years old, the probability of being transplanted was of 21% at 12, 46% at 36 and 58% at 60 months (median dialysis duration: 42 months). When pre-emptive graft were excluded, the probability of being transplanted was of 5% at 12, 15% to 36 and 19% to 60 months Flow between treatment modalities Among the 36.849 patients on dialysis at 31/10/2010, 79% were already on RRT at 31/12/2009. Respectively 91%, 85% and 93% of the patients on HD in-center, HD self-care unit and peritoneal dialysis were in the same modality of treatment the year before. Among the 29.758 patients with a functioning graft at 31/12/2010, 98% were already on RRT at 31/12/2009, 95% of them with a functioning graft.72%, 72% and 74% of the patients with in-center HD, out-center HD and self-care unit were in the same modality of treatment at 31/12/2011. But 37% of the patients on PD at 31/12/2010 were not on PD at 31/12/2011. In 2011, new patients represented 89% of the entries in peritoneal dialysis. Renal transplantation represented 10% of the outcomes of the HD patients in self-care unit or at home.

International audience; The analysis of anti-HLA sensitization at the time of and following allograft nephrectomy may help clinicians to define better both the indications for nephrectomy and preventive therapeutic strategies. We carried out a retrospective analysis of anti-HLA antibodies in 63 clinically indicated nephrectomies (baseline and three and 12 months after) according to the time elapsed since transplantation (six months) and clinical background. An intervention study included 10 patients without donor-specific antibodies (DSA) at the time of nephrectomy treated with high-dose intravenous immunoglobulin (IVIG) (1.5 g/kg). Early nephrectomies were performed in 15 patients (24%). Among the late nephrectomies, 14 patients (22%) were asymptomatic and 34 (54%) had graft intolerance syndrome (GIS). At baseline, anti-HLA sensitization was significantly lower in the early and late asymptomatic groups than in the GIS group, but increased considerably within the three months following surgery. In the group of 10 patients treated with IVIG, only the number of class I non-DSA increased in the three months after surgery, whereas in the control group (N = 13), all anti-HLA variables increased significantly. All patients undergoing a clinically indicated allograft nephrectomy become highly sensitized within the 12 months after surgery. In patients without DSA before nephrectomy, high doses of IVIG may prevent anti-HLA sensitization.

Preserving kidney function and improving the transition from chronic kidney disease to end stage is a research and healthcare challenge. The national Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort was established to identify the determinants, biomarkers and practice patterns associated with chronic kidney disease outcomes.The study will include more than 3000 adult patients with moderate to advanced chronic kidney disease from a representative sample of 40 nephrology clinics with respect to regions and legal status, public or private. Patients are recruited during a routine visit and followed for 5 years, before and after starting renal replacement therapy. Patient-level clinical, biological, and lifestyle data are collected annually, as well as provider-level data on clinical practices, coordinated with the International Chronic Kidney Disease Outcomes and Practice Pattern Study. Blood and urine samples are stored in a biobank. Major studied outcomes include survival, patient-reported outcomes, disease progression and hospitalizations.More than 13,000 eligible patients with chronic kidney disease were identified, 60% with stage 3 and 40% with stage 4. Their median age is 72 years [interquartile range, 62-80 years], 60% are men and 38% have diabetes. By the end of December 2015, 2885 patients were included.The CKD-REIN cohort will serve to improve our understanding of chronic kidney disease and provide evidence to improve patient survival and quality of life as well as health care system performances.

Resume Introduction Preserver la fonction renale et ameliorer la transition de la maladie renale chronique vers le stade terminal constituent un defi pour la nephrologie. La cohorte nationale Chronic Kidney Disease–Reseau Epidemiologie et Information en Nephrologie (CKD-REIN) a ete mise en place pour identifier les determinants, les biomarqueurs et les profils de pratiques associes au pronostic de la maladie renale chronique. Methodes L’etude vise a inclure plus de 3000 patients adultes avec une maladie renale chronique moderee ou avancee suivis dans 40 consultations de nephrologie representatives du point de vue des regions et du statut public ou prive des etablissements. Les patients sont inclus a l’occasion d’une consultation de routine et suivis pendant 5 ans, avant et apres l’initiation eventuelle d’un traitement de suppleance renale. Des donnees cliniques, biologiques, sur la sante percue et le mode de vie des patients sont recueillies annuellement, ainsi que sur les pratiques, en coordination avec l’etude internationale Chronic Kidney Disease Outcome and Practice Pattern Study. Une biotheque d’echantillons de sang et d’urine est constituee. Les principaux evenements etudies sont la survie, la qualite de vie, la progression de la maladie et les hospitalisations. Resultats Plus de 13 000 patients eligibles ont ete identifies, 60 % au stade 3 et 40 % au stade 4 de la maladie renale, d’âge median 72 ans [interquartile, 62–80 ans], dont 60 % sont de sexe masculin et 38 % ont un diabete. Fin decembre 2015, 2885 patients etaient inclus. Conclusion La cohorte CKD-REIN servira a mieux connaitre la maladie renale chronique et a apporter des donnees probantes pour ameliorer la sante et la qualite de vie des patients ainsi que les performances du systeme de sante dans ce domaine.

Background Gender inequity in access to renal transplantation waiting lists, in favor of men, has long since been demonstrated in a number of studies. Discrepancies between the results of the available studies might be explained by different analytical approaches or different national contexts. In this study we analyzed French end-stage renal disease registry data using a novel model to determine whether the female gender is associated with a lower probability of being listed on the transplant waiting list or with a longer time from dialysis start until registration, or both. Methods The effect of gender on access to the national renal transplantation waiting list was assessed in 9497 men and 5386 women aged 18 to 74 years who started dialysis between 2002 and 2009. We used a semiparametric regression cure model adjusted for age, work status, and 11 comorbidities or disabilities. Results Women were younger and less likely to work or have associated comorbidities. At the study endpoint, 33.8% of the men and 34.1% of the women were placed on the renal transplantation waiting list. After taking potential confounders into account, our model shows that women demonstrated a lower probability of being registered on the national transplant waiting list (odds ratio=0.69; 95% confidence interval, 0.62-0.78) and a longer time from dialysis start to registration (hazard ratio=0.89; 95% confidence interval, 0.84-0.95) than men. This disparity affects predominantly older women who do not work or have diabetes and is more pronounced in some geographic areas. Conclusions These poorly understood gender-based inequities require further consideration.

Introduction Un nouveau systeme d’attribution des reins a ete introduit en France en fevrier 2015, apres 3 annees de travaux de simulation en interaction avec les equipes de greffe et les associations de patients. Les objectifs etaient d’offrir des strategies d’acces a la greffe differentiees selon l’âge du receveur, en ameliorant l’acces a la greffe et l’appariement donneur-receveur en âge et en HLA pour les jeunes adultes. Patients et methodes En plus des priorites nationales d’attribution pour les urgences (impossibilite de mise en oeuvre de la dialyse), pour les patients hyper-immunises (full match, programme hyperimmunise-antigenes-permis) et les enfants, un nouveau score d’attribution unifie a ete introduit. Ce score prend en compte la duree de dialyse, la duree d’attente sur liste, l’âge du receveur, l’appariement donneur-receveur en âge et en HLA, le nombre potentiel de donneurs ayant au plus 3 mismatches HLA (un indicateur de faible acces a des donneurs bien apparies contrebalancant le poids donne a l’appariement HLA) et le temps de transport entre les lieux de prelevement et de greffe. Resultats Les taux bruts d’acces a la greffe par tranche d’âge ont significativement evolue entre les deux periodes, passant de 23 a 35 %, 23 a 28 %, 24 a 26 %, 23 a 23 %, 26 a 21 % et 32 a 22 % pour respectivement les 18–29, 30–45, 46–55, 56–60, 61–65 et 66–74 ans. Les taux de greffes renales realisees en 0, 1 ou 2 incompatibilites HLA-DR sont passees respectivement de 35 a 59 %, 55 a 39 % et 9 a 2 % entre les deux periodes. Dans le meme temps, les taux de greffes renales realisees en 0, 1 ou 2 incompatibilites HLA-DQ sont passees de 51 a 72 %, 46 a 27 % et 4 a 1 %. Discussion L’amelioration simultanee de l’acces a la greffe et de la qualite de l’appariement en âge et en HLA de classe II chez les jeunes adultes est un resultat majeur et prometteur pour l’avenir. Il contribue a la prevention de l’apparition d’anticorps specifiques du donneur et la preservation d’un acces possibilite a une deuxieme greffe eventuelle sur le long terme. Conclusion Ces resultats sont conformes aux resultats simules et aux objectifs cibles.

Resume Le syndrome hepatopulmonaire est caracterise par une hypertension portale avec ou sans cirrhose, une augmentation du gradient alveolo-arteriel en oxygene en air ambiant superieure ou egale a 15 mmHg, et des dilatations vasculaires intrapulmonaires au niveau des vaisseaux capillaires. Chez les malades cirrhotiques, la prevalence du syndrome hepatopulmonaire est estimee a 20 %. Le diagnostic est fait par l’echographie cardiaque de contraste. La physiopathologie du syndrome hepatopulmonaire ferait intervenir essentiellement une augmentation de la production pulmonaire de monoxyde d’azote. L’hypoxemie s’aggrave progressivement et augmente la mortalite. Une surveillance rapprochee des patients hypoxemiques est necessaire pour envisager une transplantation hepatique dans des conditions optimales. En effet, les principaux facteurs de mortalite postgreffe sont une PaO2 inferieure ou egale a 50 mmHg seule ou associee a un shunt isotopique superieur a 20 %. Nombreux sont les medicaments qui ont ete testes dans le syndrome hepatopulmonaire, mais les resultats probants sont rares : la poudre d’ail et, plus recemment, les aerosols d’iloprost pourraient ameliorer de facon prolongee l’oxygenation des patients avant et apres la transplantation hepatique.

Points essentiels Les regles anterieures de repartition des greffes laissaient une large place a la priorite locale, et la gestion finale a l’equipe, induisant de grandes disparites inter-regionales. Une etude prospective des deces et des retraits de liste d’attente pour aggravation de la maladie initiale (2003–2005) a permis de valider sur les donnees francaises l’utilisation du score MELD (Model for End-stage Liver Disease), qui permet de predire la survie spontanee des cirrhotiques a 3 mois, et qui est utilise aux Etats-Unis pour l’attribution des greffons hepatiques depuis 2002. La reflexion de l’Agence de biomedecine et des equipes de transplantation hepatique a conduit a mettre en place un score d’attribution des greffons hepatiques, a compter du 6 mars 2007. Ce score Foie tient compte du score MELD pour les cirrhoses, de la duree d’attente et du stade TNM pour les cancers, d’un score specifique pour les maladies metaboliques non cirrhotiques ainsi que pour les retransplantations electives, ainsi que d’aspects logistiques comme la distance entre le lieu de prelevement et celui de greffe. Un premier bilan a 5 mois indique que le score Foie permet de diminuer les deces et les retraits de liste pour aggravation, de diminuer le nombre de greffes « prematurees », d’accelerer l’acces a la greffe des malades les plus graves. Plusieurs questions restent en suspens : le score MELD et le score Foie peuvent etre ameliores, la variabilite du MELD liee aux methodes de dosage doit faire l’objet d’une normalisation entre laboratoires.

The provision of care for patients with end-stage chronic renal failure is an important medical and economic challenge for the Health Insurance. Previous studies have shown a lower cost for home dialysis. More recently, studies have confirmed identical short-term survival rates between haemodialysis and peritoneal dialysis. Notwithstanding, home dialysis techniques utilization remains weak in France. This work aims at: determining the average annual cost of dialysis, per patient and per technique of dialysis, and assessing the global annual cost of dialysis in France, from the Health Insurance perspective. Methodologically, this article provides a static estimation of the cost of dialysis. Costs related to co-morbidities of end-stage chronic renal failure have not been considered. Standard patient care schemes have been outlined by a multidisciplinary expert committee, for each dialysis technique, and have been valorised using publicly available data and tariffs recorded in 2005. Our result show that home dialysis techniques are the less costly, with an average annual cost per patient of 49.9, 49.7 and 50.0 k euro respectively for home haemodialysis, automated peritoneal dialysis, and continuous ambulatory peritoneal dialysis. Autodialysis, autonomous in-center haemodialysis and in-center haemodialysis respectively cost 59.5, 62.3 and 81.5 k euro per patient and per annum. The total 2005 cost of dialysis for the Health Insurance is estimated at 2.1 billion euro. Therefore, the development of alternative techniques to in-center haemodialysis, such as home dialysis or autonomous in-center haemodialysis, autodialysis being already well developed, could generate savings for the Health Insurance. From the patient's perspective, it could also allow the enlightened choice of the best customized technique, less guided by local offer than by medical or social criteria, as well as by the patient's own opinion.

International audience; Background Recent randomized trials report that mortality is lower with high-convection-volume hemodiafiltration (HDF) than with hemodialysis (HD). Study Design We used data from the French national Renal Epidemiology and Information Network (REIN) registry to investigate trends in HDF use and its relationship with mortality in the total population of incident dialysis patients. Setting & Participants The study included those who initiated HD therapy from January 1, 2008, through December 31, 2011, and were dialyzed for more than 3 months; follow-up extended to the end of 2012. Factor HDF use at the patient and facility level. Outcomes All-cause and cardiovascular mortality, using Cox models to estimate HRs of HDF as time-dependent covariate at the patient level, with age as time scale and fully adjusted for comorbid conditions and laboratory data at baseline, catheter use, and facility type as time-dependent covariates. Analyses completed by Cox models for HRs of the facility-level exposure to HDF updated yearly. Results Of 28,407 HD patients, 5,526 used HDF for a median of 1.2 (IQR, 0.9-1.9) years; 2,254 of them used HDF exclusively. HRs for all-cause and cardiovascular mortality associated with HDF use were 0.84 (95% CI, 0.77-0.91) and 0.73 (95% CI, 0.61-0.88), respectively. In patients treated exclusively with HDF, these HRs were 0.77 (95% CI, 0.67-0.87) and 0.66 (95% CI, 0.50-0.86). At the facility level, increasing the percentage of patients using HDF from 0% to 100% was associated with HRs for all-cause and cardiovascular mortality of 0.87 (95% CI, 0.77-0.99) and 0.72 (95% CI, 0.54-0.96), respectively. Limitations Observational study. Conclusions Whether analyzed as a patient- or facility-level predictor, HDF treatment was associated with better survival

International audience; The French Renal Epidemiology and Information Network (REIN) registry began in 2002 to provide a tool for public health decision support, evaluation and research related to renal replacement therapies (RRT) for end-stage renal disease (ESRD). It is relying on a network of nephrologists, epidemiologists, patients and public health representatives. Continuous registration covers all dialysis and transplanted patients. In 2012, in France, 10,048 patients started a RRT (154 per million inhabitants). Elders provided majority of new patients (median age at RRT start: 70 years old). New patients had a high and age increasing rate of comorbidities, especially diabetes (42% of the new patients) and cardiovascular comorbidities (>50% of the new patients). Like previous years, incidence is stabilized. On December 31, 2012, 73,491 patients were receiving a RRT in France (1127 per million inhabitants, 56% on dialysis and 44% living with a functional renal transplant). More than 50% of patients were undergoing in-center hemodialysis with significant variations among regions. An increase in medical satellite unit hemodialysis but a decrease in self-care unit hemodialysis rates were noticed across the time, whereas peritoneal dialysis remained stable at 7%. Five years after starting RRT, the overall survival rate was 51% but only 16% among patients over 85 years. Mortality rate was highly dependent on treatment and age; transplanted patients aged 60-69 had a 27/1000 patients-year mortality rate versus 133 for a dialysis patient. Patients who started dialysis had a probability of first wait-listing of 4.8% at the start of dialysis (pre-emptive registrations) and 27% at 72 months. Whatever their diabetes status was, patients older than 60 had poor access to the waiting list. Seventeen percent of the patients received a first renal transplant within 15.4 month median time; 3% had received a pre-emptive graft. Ten years after the start of the French ESRD registry, this report provides a comprehensive and nation-wide overview of dialysis and transplantation cares in France, including overseas.

Background Acetate-free dialysis (AFD) improves haemodynamic stability during dialysis, compared with standard haemodialysis (HD) with a small amount of acetic acid. Using the national REIN registry, we classified 15 160 incident patients who started HD from 2008 to 2010 into three exposure categories according to the type of dialysate used in their dialysis unit: standard dialysate only (reference), both standard and AFD (mixed unit) or HCl dialysate only (100% HCl unit). Methods Cox survival analysis was adjusted for 15 baseline comorbidities, laboratory data and haemodiafiltration (HDF). We took patient clustering within units into account, used age as the time scale and treated patient exposure to AFD and to HDF as time-dependent variables. Results Median age (interquartile range) was 70.5 years (58.1-78.8). Over a median follow-up of 1.8 years (1.2-2.6), 658 patients were dialysed in a 100% HCl unit, 3021 in a mixed unit and 11 481 were never exposed to AFD. The relation between AFD and mortality was not constant with age (Schoenfeld residuals test P = 0.01 for mixed group and P = 0.03 for 100%HCl group). Patients older than 70 years had a significantly lower mortality risk associated with AFD [hazard ratio (HR) = 0.79, 95% confidence interval (CI) = 0.67 to 0.94 for patients exposed in a 100% HCl unit; HR = 0.83, 95% CI = 0.74 to 0.94 for patients exposed in a mixed unit], but no association was found in younger patients. Conclusions AFD was associated with improved survival independent of comorbidities and HDF in patients aged 70 years and older but not in patient younger than 70 years.

International audience; In France, decisions regarding superurgent (SU) liver transplantation (LT) for patients with acute liver failure (ALF) are principally based on the Clichy-Villejuif (CV) criteria. The aims of the present study were to study the outcomes of patients registered for SU LT and the factors that were predictive of spontaneous improvement and to determine the usefulness of the CV criteria. All patients listed in France for SU LT between 1997 and 2010 who were 15 years old or older with ALF were included. In all, 808 patients were listed for SU transplantation: 22% with paracetamol-induced ALF and 78% with non–paracetamol-induced ALF. Of these 808 patients, 112 improved spontaneously, 587 underwent LT, and 109 died or left the waiting list because of a worsening condition. The 1-year survival rate according to an intention-to-treat analysis and the survival after LT were 66.3% [interquartile range (IQR), 62.7%-69.7%] and 74.2% (IQR, 70.5%-77.6%), respectively. The factors that were predictive of a spontaneous recovery with ALF-related paracetamol hepatotoxicity were as follows: hepatic encephalopathy grade 0, 1, or 2 [odds ratio (OR), 4.8; 95% confidence interval (CI), 1.99-11.6]; creatinine clearance ≥ 60 mL/minute/1.73 m2 (OR, 4.77; 95% CI, 1.96-11.63), a bilirubin level \textless 200 µmol/L (OR, 21.64; 95% CI, 1.76-265.7); and a factor V level \textgreater 20% (OR, 5.79; 95% CI, 1.66-20.29). For ALF-related nonparacetamol hepatotoxicity, the factor that was predictive of a spontaneous recovery was a bilirubin level \textless 200 µmol/L (OR, 10.38; 95% CI, 4.71-22.86). The sensitivity, specificity, and positive and negative predictive values for the CV criteria were 75%, 56%, 50%, and 79%, respectively, for ALF due to paracetamol and 69%, 50%, 64%, and 55%, respectively, for ALF not related to paracetamol. The performance of current criteria for SU transplantation could be improved if paracetamol-induced ALF and non–paracetamol-induced ALF were split and 2 other items were included in this model: the bilirubin level and creatinine clearance. Liver Transpl 21:512-523, 2015. © 2015 AASLD.

To assess the usefulness of dialysis with the molecular adsorbent recirculating system (MARS) in patients with acute liver failure who fulfil criteria for liver transplantation. Observational cohort study. ICU at a liver transplantation centre. Twenty-two patients (23 episodes) received MARS dialysis. They were either listed for LT (n = 14), delayed (n = 1), or not listed (contra-indication, n = 7). A total of 56 MARS treatments (median per patient 2; mean duration 7.6 ± 2.6 h) were performed on haemodialysis. Clinical and biological variables were assessed before and 24 h after MARS therapy. The rate of recovery of liver function without transplantation was compared with an expected rate and survival was analysed. Following MARS dialysis, we observed an improvement in the grade of hepatic encephalopathy (P = 0.02) and the Glasgow coma score (P = 0.02), a decrease in conjugated bilirubin (P = 0.05) and INR (P = 0.006), and an increase in prothrombin index (P = 0.005). Overall, liver function improved in seven patients (32%): four listed patients in whom transplantation could be avoided and three patients among those not listed due to contra-indications. The transplant-free recovery rate in listed patients was 29% (vs. expected 9%, P = 0.036). Listed patients (n = 14) had a higher 30-day survival rate [86% (12/14) vs 38% (3/8), P = 0.05] and a higher long-term survival rate (P = 0.02). A statistically significant improvement of liver function was observed after MARS therapy. Transplant-free recovery was more frequent than expected. The apparent benefit of MARS dialysis to treat acute liver failure needs to be confirmed by a controlled study.

In France, incidence and prevalence of end-stage renal disease (ESRD) are increasing, requiring a more rational use of available replacement therapies. To help practitioners make their choice between treatment modalities of peritoneal dialysis (PD) and haemodialysis (HD), critical appraisal of relevant literature has been conducted. Although few absolute or relative contraindications for PD and HD exist, arguments in favour of one versus the other dialysis technique can be made. When patients receive adequate and complete information, their preference is neutral between PD and HD. To date, no trial presenting a convincing level of evidence has been published which demonstrates the superiority of one technique compared to the other. Relative to mortality, it appears that no difference can be observed between the two modalities. However, in those instances where patients expect a rapid transplantation, PD is the preferred technique. This analysis suggests that peritoneal dialysis and haemodialysis are not competitive but rather complementary treatments. It is therefore interesting to identify the reasons supporting the various choices between the two different treatment modalities amongst France's regions. Access to transplant, economic or organizational factors must be considered.

Resume Les regles de repartition des transplants renaux sont regulierement evaluees et modifiees en France, en fonction des avancees scientifiques, de l'evolution de la liste d'attente et des politiques de sante. Des modifications de ces regles ont ete effectuees en 2004 par l'Etablissement francais des Greffes, a l'initiative de la Commission de transplantation 1 de la Societe de Nephrologie, dans le but de diminuer le nombre des patients en attente ayant un acces difficile a la greffe en raison de leur statut immunogenetique (groupe ABO ou HLA rare, immunisation anti-HLA). Elles portent sur quatre points : 1/ une meilleure precision dans la definition de l'hyperimmunisation ; 2/ l'attribution, avec le programme dit « des antigenes permis », et non ; d'une nouvelle priorite aux patients hyperimmunises, pour qui les regles precedentes s'averaient insuffisantes ; 3/ la suppression de la priorite « full-match » aux patients non immunises ; 4/ l'attribution a certains patients immunises (anticorps anti-HLA = 5–80 %) ayant un acces difficile a la greffe, de priorites proches de celles des hyperimmunises. Le but de cet article est de presenter les nouvelles regles de repartition des greffons renaux et les raisons ayant conduit a ces modifications.

UNLABELLED We investigated the long-term efficacy of a 12-month course of interferon (IFN)+ribavirin in chronic hepatitis C relapsers. We randomized 191 relapsers with a 2:1 ratio to receive 3 million units three times a week of interferon alpha (IFN alpha)-2b+ribavirin (1-1.2 g/day) (group A=127 patients) or IFN alpha-2b (group B=60 patients) of same dosage and duration for 1 year. General and hepatitis C data of group A and B patients were similar. The main goal of the study was to determine the rate of sustained virological response evaluated 1 year after treatment. RESULTS Virological sustained response (SR) was 61% and 12% for groups A and B, respectively (P

L'insuffisance renale terminale (IRT) est l'un des domaines de la medecine ou les entrepots de donnees ont un role important a jouer. En effet, la prevalence de l'IRT en France n'est pas connue de facon precise. En consequence, l'offre de soins est inadaptee a la demande. Afin d'ameliorer la connaissance medicale, epidemiologique et organisationnelle de l'IRT, un systeme d'information multisource a ete mis en place a des fins de meilleure apprehension de la situation, a la fois particuliere (suivi du patient) et globale (aux niveaux regional et national), avec une finalite d'aide a la decision sanitaire. Ce systeme est centre patient, fonde sur une organisation regionale, avec un identifiant unique. Il s'appuie sur une architecture de type n-tier et integre un entrepot de donnees. Ce travail est realise dans le cadre du REIN (reseau epidemiologie et information en nephrologie).

In France, the prevalence of End-Stage Renal Disease (ESRD) is not precisely known. The sources of information are scattered and not coordinated. Consequently, care is ill adapted to meet the demand. The Multi-Source Information System is the basis of the Renal Epidemiology and Information Network (REIN). It is dedicated to improve and organise our medical and epidemiological knowledge of ESRD and to aid public health decision-making in this area. The proposed approach is based on the datawarehouses. This model allows a unified vision of scattered data into distinct databases, for a better management, be it particular (patient follow-up) or global (regional follow-up), with a finality of aid in decision-making. Several categories of problems were considered: the global conception of the information system, the organisation of the datawarehouse, which offers different viewpoints of the data, the integration of heterogeneous data coming from different sources, data exchange and definition of a specific ontology.

Introduction A un an des recommandations de la HAS, l’objectif etait de dresser un premier etat des lieux concernant le bilan d’orientation vers la greffe et les motifs de non-inscription en liste d’attente. Patients et methodes Au total, 3324 patients dialyses depuis plus de 1 ans, âges de 67 ± 12 ans ont ete inclus entre le 1er aout 2016 et le 30 novembre 2016 sur l’ensemble du territoire ; les formulaires ont ete remplis avec l’aide du nephrologue dans 82 % des cas. Resultats Soixante-huit pour cent des patients avaient recu une information sur la greffe renale en general et 46 % sur la possibilite d’un recours a un donneur vivant ; 17 % avaient recu cette information dans le cadre d’un programme d’education therapeutique formalise. L’opportunite de demarrer un bilan pre-transplantation avait ete discutee avec l’equipe de greffe dans 28 % des cas. Le bilan pre-transplantation n’etait pas finalise dans 16 % des cas. Au moins un motif de non-inscription figurait dans le dossier dans 78 % des cas et au moins un motif contre-indiquant la greffe renale etait deja present (antecedent, comorbidite, autre) sans qu’il soit necessaire d’engager un bilan specifique dans 67 % des cas. Les motifs de non-inscription associaient a des degres variables au moins une contre-indication pour 77 % des cas, au moins un motif de refus du patient pour 25 % des cas et au moins une autre consideration pour 20 % des cas. Parmi les 3 motifs possibles de contre-indication, etaient mentionnes : l’etat vasculaire (31 %), la co-existence de multiples comorbidites (23 %), l’existence d’un cancer evolutif (12 %), une obesite (11 %), des comorbidites incompatibles avec l’anesthesie generale (10 %), une demence ou des troubles psychiatriques severes (10 %), un autre motif de contre-indication (9 %), un âge trop avance (8 %), une infection active (4 %), une dependance a l’alcool ou addiction aux drogues dures (3 %) et un pronostic vital percu inferieur a 6 mois (2 %). Discussion Notre etude permet de quantifier pour la premiere fois la prevalence des contre-indications medicales, des motifs de refus ou des autres considerations motivant la non-inscription. Conclusion Grâce aux efforts de tous, cette premiere etude ancillaire du REIN se revele un succes en termes d’inclusion, de completude des donnees et de participation des nephrologues. Groupe(s) de travail Groupe REIN – Acces a la liste d’attente.

Determinants of nonfunctional arteriovenous (AV) access, including timing of AV access creation, have not been sufficiently described. We studied 29 945 patients who had predialysis AV access placement and were included in the French REIN registry from 2005 through 2013. AV access was considered nonfunctional when dialysis began with a catheter. We estimated crude and adjusted odds ratio (OR) with 95% confidence intervals (CI) of nonfunctional versus functional AV access associated with case-mix, facility characteristics, and timing of AV access creation. Analyses were stratified by dialysis start condition (planned or as an emergency) and comorbidity profile. Overall, 18% patients had nonfunctional AV access at hemodialysis initiation. In the group with planned dialysis start, female gender (OR 1.43, 95% CI 1.32-1.56), diabetes (OR 1.28, 95% CI 1.15-1.44), and a higher number of cardiovascular comorbidities (OR 1.27, 95% CI 1.09-1.49, and 1.31, 1.05-1.64, for 3 and >3 cardiovascular comorbidities versus none, respectively) were independent predictors of nonfunctional AV access. A higher percentage of AV access creation at the region level was associated with a lower rate of nonfunctional AV access (OR 0.98, 95% CI 0.98-0.99 per 1% increase). The odds of nonfunctional AV access decreased as time from creation to hemodialysis initiation increased up to 3 months in nondiabetic patients with fewer than 2 cardiovascular comorbidities and 6 months in patients with diabetes or 2 or more such comorbidities. In conclusion, both patient characteristics and clinical practices may play a role in successful AV access use at hemodialysis initiation. Adjusting the timing of AV access creation to patients' comorbidity profiles may improve functional AV access rates.

International audience; Background While much has been learned about the epidemiology and treatment of end-stage renal disease (ESRD) in the last 30 years, chronic kidney disease (CKD) before the end-stage has been less investigated. Not enough is known about factors associated with CKD progression and complications, as well as its transition to ESRD. We designed the CKD-renal epidemiology and information network (REIN) cohort to provide a research platform to address these key questions and to assess clinical practices and costs in patients with moderate or advanced CKD. Methods A total of 46 clinic sites and 4 renal care networks participate in the cohort. A stratified selection of clinic sites yields a sample that represents a diversity of settings, e.g. geographic region, and public versus for-profit and non-for-profit private clinics. In each site, 60-90 patients with CKD are enrolled at a routine clinic visit during a 12-month enrolment phase: 3600 total, including 1800 with Stage 3 and 1800 with Stage 4 CKD. Follow-up will continue for 5 years, including after initiation of renal replacement therapy. Data will be collected from medical records at inclusion and at yearly intervals, as well as from self-administered patient questionnaires and provider-level questionnaires. Patients will also be interviewed at baseline, and at 1, 3 and 5 years. Healthcare costs will also be determined. Blood and urine samples will be collected and stored for future studies on all patients at enrolment and at study end, and at 1 and 3 years in a subsample of 1200. Conclusions The CKD-REIN cohort will serve to improve our understanding of the biological, clinical and healthcare system determinants associated with CKD progression and adverse outcomes as well as of international variations in collaboration with the CKD Outcome and Practice Pattern Study (CKDopps). It will foster CKD epidemiology and outcomes research and provide evidence to improve the health and quality of life of patients with CKD and the performances of the healthcare system in this field.

International audience; Data from the national French Renal Epidemiology and Information Network (REIN) registry were used to compare survival between transplant recipients under age 65 who resumed dialysis after graft failure during 2007-2009 and transplant-naïve incident dialysis patients matched for age, gender, diabetes mellitus, and year of starting dialysis. Among 911 transplant patients who returned to dialysis, 103 had died by 1 January 2011. Multivariate analysis showed that age over 48 years, coronary artery disease, peripheral artery disease, and inability to walk unassisted were significant predictors of death. In the case-control analysis, the observed mortality rates in 778 transplant failure and 778 transplant-naïve dialysis patients were 11.8 and 10.8%, respectively. Kaplan-Meier estimates of survival after transplant failure vs. the transplant-naïve controls were 95.2 vs. 94.1% at 1 year, 90.3 vs. 88.8% at 2 years, and 84.2 vs. 80.2% at 3 years (log rank P=0.197 overall). Dialysis in transplant failure vs. transplant-naïve patients was not associated with significantly increased mortality. At the start of dialysis, the serum creatinine levels and the rate of unplanned dialysis were significantly lower in transplant failure patients compared with transplant-naïve controls. Thus, in patients under 65 years of age in France, survival of dialysis patients after graft loss is similar to that of incident dialysis patients who have not undergone transplantation.

The Haute Autorité de santé, in association with the Agence de la biomédecine, realizes, at the request of the Caisse nationale d'assurance maladie des travailleurs salariés and the Direction générale de l'offre de soins, a medical economic evaluation on treatment's alternative of terminal chronic renal insufficiency. To answer at this request, a multiannual working program was set up. A first part of this work concerned specifically the development of the kidney transplant. Indeed, the kidney transplant occupies a particular place among the various modalities of treatment of the terminal chronic renal insufficiency because it is at the same time the most effective on a medical plan and the least expensive, thus the most efficient. However, its development is constraint by the lack of the transplants and the number of patients registered on the national list of wait increases every year. The objective of this article is to present the method of work as well as the main identified axes of development.

Invasive pulmonary aspergillosis (IPA) is an increasing cause of morbidity and mortality in patients with hematologic malignancies. A major program of construction work close to our unit prompted us to evaluate the efficacy of itraconazole prophylaxis in preventing IPA in these patients. During September 1994 to December 1995, 77 patients undergoing 96 neutropenic episodes (mean duration, 19.3 days +/- 9.1) received itraconazole as antifungal prophylaxis. All patients were treated in laminar air flow rooms. Itraconazole was administered at a loading dose of 600mg/d, (day 1 to day 3) and 400mg/d on the following days, in 87 instances. In the remaining episodes, the daily dose was 200 or 400mg. Oral doses were adjusted to reach a plasma itraconazole level (PIL) above 1000ng/l. In cases of inadequate PIL or poor oral intake, IV AmphoB was started at a 20 mg daily dose. Five cases of IPA (proven n = 2, probable n = 3) were observed. This represents an incidence of 5.2% of the total number of episodes. One out of 67 (2%) treatment episodes with adequate PIL were associated with IPA as compared to 4 of 29 (14%) episodes with inadequate PIL, (p0.02). AmphoB was added in 28 cases because of low PIL (n = 25), and/or antibiotic-resistant fever persistent pulmonary infiltrate (n = 8). These results need to be interpreted with caution, because of the absence of randomization or a control group. The efficacy of Itraconazole in neutropenic patients with high risk IPA has to be confirmed on larger and prospective studies.

We studied the activities of the new fluoroquinolones clinafloxacin, levofloxacin, ofloxacin, and sparfloxacin alone or in combination on the intracellular growth of Listeria monocytogenes. Against intracellular growth of the four strains tested, a similar reduction of the bacterial count was obtained with clinafloxacin at the dose of 10 x MIC (delta log10 CFU/ml = -2.19 +/- 0.24), with levofloxacin at 8 x MIC (delta log10 CFU/ml = -2.28 +/- 0.25), and with sparfloxacin at 4 x MIC (delta log10 CFU/ml = -2.16 +/- 0.21) after 24 h of incubation. The combination of the quinolones with trimethoprim-sulfamethoxazole or amoxicillin did not show a substantial increase in activity compared to the fluoroquinolone alone. Antagonism with rifampin was strongly suggested. No modification of the MIC was observed after 20 successive infections of HeLa cells and contact with subinhibitory concentrations of clinafloxacin, levofloxacin, and sparfloxacin for 24 h. We conclude that clinafloxacin, levofloxacin, or sparfloxacin could represent a therapeutic alternative to amoxicillin for the treatment of Listeria infections in adults, especially clinafloxacin, whose MIC is low (0.06 to 0.12 micrograms/ml), and whose best activity against intracellular L. monocytogenes was obtained at a concentration of 1.2 micrograms/ml, which is similar to clinically achievable levels. The results must be confirmed in an experimental model.

BACKGROUND Little is known about the socioprofessional situation of adult-aged kidney-transplanted children. This nationwide French cohort study documented the socioprofessional outcomes of adults who underwent kidney transplantation before age 16 years between 1985 and 2002. METHODS Of 890 patients, 624 were eligible for a questionnaire and 374 completed it (response rate=60%; men=193 and women=181). The data were compared with the French general population using an indirect standardization matched for gender, age, and period. RESULTS The median ages were 27.1 years at survey time and 12.3 years at first transplantation. Of the participants, 31.1% lived with a partner (vs. 52.2%; P

This chapter presents potential uses of information and communication technologies (ICTs) for public health, with a special focus on decision-making and decisional support systems. An overview of public health sub-domains is given as potential functional areas for ICTs and business intelligence. The specifics and principles of decision-making for public health policy are explained. Main methods and observational tools used in epidemiology are overviewed. Relevant decisional support architectures are presented, ranging from data warehouse techniques, geographical information systems and simulation tools. The relevance and reusability of medico-administrative data sources is discussed, and balanced with data from registries and cohort studies in the perspective of evidence-based decisional support systems for public health. Last, public health decisional support systems are discussed as tools for translational research in public health.

International audience; BackgroundEnd stage renal disease (ESRD) profoundly impacts the lives of patients. Kidney transplantation provides the greatest health-related quality of life (HRQOL) improvement. Its measurement has become an important outcome parameter and a very important criterion in the evaluation of any type of medical treatment, especially in the field of renal transplantation.In 2007, a specific self-administered questionnaire for renal transplant recipients was developed in the French language: the ReTransQol (RTQ).After 5 years of use, the properties of the RTQ needed to be re-evaluated in a larger sample.This paper describes the analysis of the ReTransQol and its adaptation to achieve an improved and revised version.MethodsThe study design included three analysis phases for two samples of adult renal transplant recipients which came from two cross-sectional multicenter studies carried out in France in 2007 and 2012. Psychometrics properties like construct validity, acceptability and feasibility, reliability and convergent validity were evaluated and every analysis resulted in a new version of the questionnaire: the RTQ V2. The construct validity of the new RTQ was assessed with a Confirmatory Factor Analysis on a large sample of patients.ResultsThe study samples included 1,059 patients and 1,591 patients, respectively.After a principal component analysis, item reduction was performed and a total of 13 items were deleted. A final version of the RTQ V2 was created and comprised of 32 items describing 5 domains: Physical Health, Social Functioning, Medical Care, Treatment and Fear of Losing Graft.The explained variance between the first and second RTQ versions improved from 46.3% to 53.1%. All psychometric properties of RTQ V2 were satisfactory: IIC >0.4, IDV (%) of 100% and Cronbach’s Alpha >0.7 in every dimension. The confirmatory analysis showed that the overall scalability of the RTQ V2 was satisfactory; all items showed a good fit to the Rasch model within each dimension, and showed INFIT statistics inside the acceptable range.ConclusionsPsychometric properties allow this new version of the questionnaire to be used to assess different specific dimensions for the renal transplant population, more effectively than previously possible.

Apres avoir lu ce chapitre, vous devriez : pouvoir definir la sante et les elements susceptibles d’influencer l’etat de sante des populations et des individus ; connaitre les champs de la sante environnementale, de la sante au travail et de la promotion de la sante, expliquer ce que l’on peut attendre du developpement des systemes d’information geographique pour la sante environnementale ; pouvoir definir les concepts de securite, surveillance, vigilance et alerte sanitaires et les grandes fonctionnalites qui peuvent etre attendues des systemes d’information visant a couvrir ces domaines ; pouvoir decrire les principaux types d’enquetes et d’instruments d’observation epidemiologiques et citer les possibilites d’utilisation des technologies de l’information en epidemiologie ; savoir definir l’incidence et la prevalence d’une maladie ; connaitre les grandes etapes du developpement d’un medicament et l’apport des systemes d’information dans ce contexte ; avoir compris la complexite et la variete des contextes de prise de decision en sante publique, citer les principes qui guident la decision en situation d’incertitude ; connaitre les grandes caracteristiques d’un systeme d’information decisionnel et les elements a prendre en compte pour adapter ce type d’architecture a la sante ; avoir compris l’interet et la place des modeles de simulation ; savoir expliquer comment la mise a disposition d’outil d’aide a la decision en sante publique s’inscrit dans une demarche plus globale de «recherche translationnelle».