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Home dialysis modalities (home hemodialysis [HD] and peritoneal dialysis [PD]) are associated with greater patient autonomy and treatment satisfaction compared with in-center modalities, yet the level of home-dialysis use worldwide is low. Reasons for limited utilization are context-dependent, informed by local resources, dialysis costs, access to healthcare, health system policies, provider bias or preferences, cultural beliefs, individual lifestyle concerns, potential care-partner time, and financial burdens. In May 2021, KDIGO (Kidney Disease: Improving Global Outcomes) convened a controversies conference on home dialysis, focusing on how modality choice and distribution are determined and strategies to expand home-dialysis use. Participants recognized that expanding use of home dialysis within a given health system requires alignment of policy, fiscal resources, organizational structure, provider incentives, and accountability. Clinical outcomes across all dialysis modalities are largely similar, but for specific clinical measures, one modality may have advantages over another. Therefore, choice among available modalities is preference-sensitive, with consideration of quality of life, life goals, clinical characteristics, family or care-partner support, and living environment. Ideally, individuals, their care-partners, and their healthcare teams will employ shared decision-making in assessing initial and subsequent kidney failure treatment options. To meet this goal, iterative, high-quality education and support for healthcare professionals, patients, and care-partners are priorities. Everyone who faces dialysis should have access to home therapy. Facilitating universal access to home dialysis and expanding utilization requires alignment of policy considerations and resources at the dialysis-center level, with clear leadership from informed and motivated clinical teams.

Background This study was conducted to estimate the direct effect of sex on the proportion of hemodialysis (HD) catheters used at dialysis initiation and to investigate whether predialysis care or socioeconomic status acted as a mediator of the sex effect. Methods Patients who started dialysis between January 1, 2017, and June 30, 2018, in France were included using the data of the Renal Epidemiology and Information Network (REIN) registry. We performed logistic regression to study the association between sex and the proportion of HD catheters used. A mediation analysis with a counterfactual approach was carried out to evaluate whether there was an indirect effect of sex through the proxies of predialysis care {hemoglobin, albumin levels, glomerular filtration rate [GFR] at dialysis initiation} and socioeconomic status. Because an interaction between sex and social deprivation has been identified, we performed a subgroup analysis on deprived and nondeprived patients. Results The study included 16 032 patients, and the sex ratio (male to female) was 10 405:5627. In the multivariable analysis, women were associated with a greater risk of starting dialysis with a catheter {odds ratio [OR], 1.32 [95% confidence interval (CI): 1.23–1.42]}. There was an indirect effect of sex on the proportion of HD catheters through proxies for predialysis care {albuminemia Conclusions Women were associated with a higher risk of starting dialysis through an HD catheter. The effect of sex was mediated by predialysis care, particularly for deprived patients.

International audience; IntroductionSocioeconomic status (SES) is recognized as an important determinant of kidney health. We aimed to evaluate the association of social deprivation with different indicators at kidney replacement therapy (KRT) initiation in the French pediatric metropolitan population.MethodsAll patients with end-stage kidney disease (ESKD) who started KRT before 20 years old in France between 2002 and 2015 were included. We investigated different indicators at KRT initiation, which are as follows: KRT modality (dialysis vs. pre-emptive transplantation), late referral to a nephrologist, and dialysis modality (hemodialysis [HD] vs. peritoneal dialysis [PD], urgent vs. planned start of dialysis, use of catheter vs. use of fistula for HD vascular access). An ecological index (European Deprivation Index [EDI]) was used as a proxy for social deprivation.ResultsA total of 1115 patients were included (males 59%, median age at dialysis 14.4 years, glomerular/vascular diseases 36.8%). The most deprived group represented 38.7% of the patients, suggesting pediatric patients with ESKD come from a more socially deprived background. The most deprived group was more likely to initiate KRT with dialysis versus kidney transplantation. Among patients on HD, the odds of starting treatment in emergency with a catheter was >2-fold higher for the most deprived compared with the least deprived children (adjusted odds ratio [aOR] 2.35, 95% CI 1.16–4.78).ConclusionChildren from the most deprived area have lower access to pre-emptive transplantation, have lower access to PD, tend to be late referred to a nephrologist, and have more urgent initiation of HD with a catheter.

International audience; OBJECTIVES: We assessed the direct and indirect effect of social deprivation mediated by modifiable markers of nephrological follow-up on registration on the renal transplantation waiting-list. STUDY DESIGN AND SETTINGS: From the Renal Epidemiology and Information Network, we included French incident dialysis patients eligible for a registration evaluation between January 2017 and June 2018. Mediation analyses were conducted to assess effects of social deprivation estimated by quintile 5 (Q5) of the European Deprivation Index on registration defined as wait-listing at dialysis start or within the first 6 months. RESULTS: Among the 11655 included patients, 2410 were registered. Q5 had a direct effect on registration (OR 0.82 [0.80-0.84]) and an indirect effect mediated by emergency start dialysis (OR 0.97 [0.97-0.98]), hemoglobin < 11 g/dL and/or lack of EPO (OR 0.96 [0.96-0.96]) and albumin < 30 g/L (OR 0.98 [0.98-0.99]). CONCLUSION: Social deprivation was directly associated with a lower registration on the renal transplantation waiting-list but its effect was also mediated by markers of nephrological care, suggesting that improving the follow-up of the most deprived patients should help to reduce disparities in access to transplantation.

Background Access to forms of dialysis, kidney transplantation (Tx) and comprehensive conservative management (CCM) for patients with end-stage kidney disease (ESKD) varies across European countries. Attitudes of nephrologists, information provision and decision-making may influence this access and nephrologists may experience several barriers when providing treatments for ESKD. Methods We surveyed European nephrologists and kidney transplant surgeons treating adults with ESKD about factors influencing modality choice. Descriptive statistics were used to compare the opinions of professionals from European countries with low–, middle– and high–gross domestic product purchasing power parity (GDP PPP). Results In total, 681 professionals from 33 European countries participated. Respondents from all GDP categories indicated that ∼10% of patients received no information before the start of renal replacement therapy (RRT) (P = 0.106). Early information provision and more involvement of patients in decision-making were more frequently reported in middle- and high-GDP countries (P Conclusions Differences in factors influencing modality choice when providing RRT or CCM to adults with ESKD were found among low-, middle- and high-GDP countries in Europe. Therefore a unique pan-European policy to improve access to treatments may be inefficient. Different policies for clusters of countries could be more useful.

International audience; End-stage kidney disease (ESKD) is a major challenge for health care systems around the world because of its ever-rising rates and the ensuing rise in health care costs. In France, the cost of caring for patients with ESKD was estimated at €4.1 billion in 2019, which is 2.5% of the total budget of the health insurance funds that is spent on 1.4% of the general population.Health care systems must attempt to provide appropriate, high-quality, and economically sustainable care that meets the needs and desires of patients with ESKD. Patients aspire to remain independent if at all possible, continuing to have a social life and pursue their profession.1, 2, 3The objective of this study was to compare the cost of 4 dialysis modalities that enable patients to play a substantial role in their own care and have social and professional lives. The dialysis modalities include the following: (i) nonassisted hemodialysis in self-care units (scHD), (ii) nonassisted automated peritoneal dialysis (naAPD), (iii) daily home hemodialysis (dhHD), and (iv) non–facility-based nocturnal extended hours hemodialysis (neHD) (Supplementary Population and Method).(introd.)

Arteriovenous (AV) access choice has sparked controversy with recent evidence suggesting overestimation of benefits associated with AV fistula versus graft in certain populations. We assessed outcomes associated with first-line AV access type in patients who started hemodialysis with a catheter in France, overall and by subgroups of age, sex, and comorbidities. In this retrospective cohort study, we included incident patients who initiated hemodialysis with a catheter from 2010 through 2018, followed by the French REIN Registry. Our main exposure was the first-line (first-created) AV graft versus fistula, ascertained through the linkage with the French national health-administrative database. Outcomes were all-cause and cause-specific hospitalization, and all-cause mortality. We used joint frailty models to deal with recurrent hospitalizations and informative censoring by death, Cox proportional hazard (PH) models, and inverse probability weighting. From the 18,625 patients included (mean age was 68±15 years, 35% were women), 5% had a first-line AV graft. Patients with AV graft had an 11%-higher weighted hazard of all-cause hospitalization (95% CI 1.09 to 1.13), 16% higher weighted hazard of cardiovascular (95% CI 1.05 to 1.29) and infection-related (95% CI 1.01 to 1.33) hospitalization, 34% higher weighted hazard of vascular access-related hospitalization, and a 9%-higher weighted hazard of all-cause death (95% CI 0.97 to 1.23). Results were consistent for most subgroups, except that the highest hazard of hospitalization with AV graft was blunted in patients with comorbidities (i.e. diabetes, weighted HR of all-cause hospitalization 1.03, 95% CI 0.95-1.12).- To conclude, in patients starting hemodialysis with a catheter, first-line AV graft is associated with increased hazard of hospitalization vs. patients with AV fistula. This may, however, not be the case for patients with a poor vascular condition, i.e., those with diabetes, who have a similar hospitalization and mortality rates with either graft or fistula.

International audience; Background and objectives Kidney impairment of ANCA-associated vasculitides can lead to kidney failure. Patients with kidney failure may suffer from vasculitis relapses but are also at high risk of infections and cardiovascular events, which questions the maintenance of immunosuppressive therapy. Design, setting, participants, & measurements Patients with ANCA-associated vasculitides initiating long-term dialysis between 2008 and 2012 in France registered in the national Renal Epidemiology and Information Network registry and paired with the National Health System database were included. We analyzed the proportion of patients in remission off immunosuppression over time and overall and event-free survival on dialysis (considering transplantation as a competing risk). We compared the incidence of vasculitis relapses, serious infections, cardiovascular events, and cancers before and after dialysis initiation. Results In total, 229 patients were included: 142 with granulomatous polyangiitis and 87 with microscopic polyangiitis. Mean follow-up after dialysis initiation was 4.6±2.7 years; 82 patients received a kidney transplant. The proportion of patients in remission off immunosuppression increased from 23% at dialysis initiation to 62% after 5 years. Overall survival rates on dialysis were 86%, 69%, and 62% at 1, 3, and 5 years, respectively. Main causes of death were infections (35%) and cardiovascular events (26%) but not vasculitis flares (6%). The incidence of vasculitis relapses decreased from 57 to seven episodes per 100 person-years before and after dialysis initiation ( P =0.05). Overall, during follow-up, 45% of patients experienced a serious infection and 45% had a cardiovascular event, whereas 13% experienced a vasculitis relapse. Conclusions The proportion of patients with ANCA-associated vasculitis in remission off immunosuppression increases with time spent on dialysis. In this cohort, patients were far less likely to relapse from their vasculitis than to display serious infectious or cardiovascular events. Podcast This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2021_11_08_CJN03190321.mp3

Resume Contexte et objectifs Le registre REIN a pour objectif, depuis 2001, de recenser les patients souffrant d’insuffisance renale chronique terminale et beneficiant d’un traitement de suppleance sur le territoire francais. L’analyse des trajectoires vise a evaluer les flux de patients entre les differentes modalites de traitement afin de mieux connaitre et prevoir leurs parcours. L’objectif de la presente etude etait d’analyser les trajectoires entrantes et sortantes a 1 an des patients prevalents du registre REIN au 31 decembre 2017. Methodes L’analyse des trajectoires a ete effectuee sur les patients prevalents au 31 decembre 2017 en etudiant la modalite de traitement anterieure au 31 decembre 2016 et la modalite ulterieure au 31 decembre 2018, puis en sous-groupe pour chacune des 5 modalites de traitement retenues. Resultats Les analyses ont porte sur un total de 85 472 patients. Plus de 20 % des sujets presentaient une insuffisance renale chronique terminale decouverte dans l’annee. On observait une relative stabilite des flux entrants dans les modalites hemodialyse en centre ou autonome, dialyse peritoneale, et greffe, contrairement a l’hemodialyse en Unite de dialyse medicalisee. Pour les flux sortants, une proportion de deces a un an de 9 % etait constatee. La dialyse peritoneale etait la modalite avec la proportion la plus elevee de patients sortis a 1 an. Conclusion L’analyse des trajectoires des patients montre des profils d’evolution variables, selon les modalites de traitement, et pourrait ainsi constituer un outil precieux dans l’evaluation et l’amelioration de la prise en charge et de l’offre de soins de l’insuffisance renale chronique terminale.

Background Pregnant women with end-stage renal disease on chronic dialysis are at a high risk of maternal and foetal complications. Over the years, the prognosis of their pregnancies has improved with advances in dialysis treatments and maternal and neonatal care. We conducted this systematic review to examine the recent data on maternal and foetal outcomes in pregnant women with end-stage renal failure on chronic dialysis over the last decade. Methods We made a systematic review of studies on pregnant women on chronic dialysis published between 1 January 2010 and 31 December 2020. We searched the following electronic databases: Medline via PubMed, Embase and the Cochrane Library, with search strategies for each database. We checked the titles and abstracts identified by the search equation, and two independent reviewers assessed the articles retrieved. For each study, the two reviewers separately recorded the data from each selected article on a standardized data extraction form. For each article, we recorded relevant general information on the study, patient demographic characteristics, dialysis schedule, pregnancy complications and outcomes, maternal complications, and foetal and neonatal outcomes. Results The literature search yielded 1668 potentially relevant abstracts. After reviewing the titles, abstracts and full text, we identified 14 studies according to the inclusion criteria. All studies were observational, nine of them were retrospective and eight were from a single-centre experience. The total number of women included in these studies was 2364 (range 8–2008) and the total number of pregnancies was 2754 (range 8–2352). The patients’ ages ranged from 15 to 45 years. Obesity was observed in 808 (34.2%) women and ranged from 1 to 778. Haemodialysis was the predominant modality with 2551 (92.6%) pregnancies, and 203 (7.4%) on peritoneal dialysis. Overall, 68 out of 402 (16.9%) spontaneous miscarriages, 21 out of 402 (5.2%) therapeutic abortions and 26 (8.3%) stillbirths among 313 (stillbirths and live births) were recorded. The mean or median gestational age at delivery ranged from 25.2 to 36 weeks. The main maternal complications were preeclampsia 11.9%, hypertension 7.7% and anaemia 3.9%. Live births represented 287 (71.4%) out of 402 pregnancies, birth weight ranged from 590 to 3500 g and preterm birth was the main, most common complication in all studies, ranging from 50% to 100%. Intrauterine growth restriction was present in 5.9% and small-for-gestational-age was reported in 18.9% of neonates. There were 22 (7.6%) neonatal deaths among 287 live births and 48 (15.3%) perinatal deaths among 313 total births (stillbirths and live births). Conclusions Presumably, considering the increase in the number of publications and the total number of pregnancies reported therein, the frequency of pregnancy in patients with end-stage chronic kidney disease treated by chronic dialysis has increased. However, the practice of treating pregnant women on dialysis differs significantly among countries. These findings highlight the need to standardize the definition of outcomes and healthcare for pregnant women on dialysis.

Background: Social deprivation could act as a barrier to peritoneal dialysis (PD). The objective of this study was to assess the association between social deprivation estimated by the European deprivation index (EDI) and PD uptake and to explore the potential mediators of this association. Methods: From the Renal Epidemiology and Information Network registry, patients who started dialysis in 2017 were included. The EDI was calculated based on the patient’s address. The event of interest was the proportion of PD 3 months after dialysis initiation. A mediation analysis with a counterfactual approach was carried out to evaluate the direct and indirect effect of the EDI on the proportion of PD. Results: Among the 9588 patients included, 1116 patients were on PD; 2894 (30.2%) patients belonged to the most deprived quintile (Q5). PD was associated with age >70 years (odds ratio (OR) 0.79 [95% confidence interval (CI): 0.69–0.91]), male gender (0.85 [95% CI: 0.74–0.97]), cardiovascular disease (OR 0.86 [95% CI: 0.86–1.00]), chronic heart failure (OR 1.34 [95% CI: 1.13–1.58]), active cancer (OR 0.67 [95% CI: 0.53–0.85]) and obesity (OR 0.75 [95% CI: 0.63–0.89]). In the mediation analysis, Q5 had a direct effect on PD proportion OR 0.84 [95% CI: 0.73–0.96]. The effect of Q5 on the proportion of PD was mediated by haemoglobin level at dialysis initiation (OR 0.96 [95% CI: 0.94–0.98]) and emergency start (OR 0.98 [95% CI: 0.96–0.99]). Conclusion: Social deprivation, estimated by the EDI, was associated with a lower PD uptake. The effect of social deprivation was mediated by haemoglobin level, a proxy of predialysis care and emergency start.

Background The effect of dialysis dose on mortality remains unsettled. Current guidelines recommend targeting a single-pool Kt/V (spKt/V) at 1.20–1.40 per thrice-weekly dialysis session. However, the optimal dialysis dose remains mostly disputed. Methods In a nationwide registry of all incident patients receiving thrice-weekly haemodialysis, 32 283 patients had available data on dialysis dose, estimated by Kt/V and its variants epuration volume per session (Kt) and Kt indexed to body surface area (Kt/A). Survival was analysed with a multivariate Cox model and a concurrent risk model accounting for renal transplantation. A predictive model of Kt in the upper quartile was developed. Results Regardless of the indicator, a higher dose of dialysis was consistently associated with better survival. The survival differential of Kt was the most discriminating, but marginally, compared with the survival differential according to Kt/V and Kt/A. Patient survival was higher in the upper quartile of Kt (>69 L/session) then deteriorated as the Kt decreased, with a difference in survival between the upper and lower quartile of 23.6% at 5 years. Survival differences across Kt distribution were similar after accounting for kidney transplantation as a competing risk. Predictive factors for Kt in the upper quartile were arteriovenous fistula versus catheters and graft, haemodiafiltration versus haemodialysis, scheduled dialysis start versus emergency start, long weekly dialysis duration and spKt/V measurement versus double-pool equilibrated Kt/V. Conclusions Our data confirm the existence of a relationship between dialysis dose and survival that persisted despite correcting for known confounders. A model for predicting a high dose of dialysis is proposed with practical relevance.

The prevalence of end-stage kidney disease (ESKD) is growing worldwide; the survival of these patients requires renal replacement therapy (RRT, a complex and costly treatment). Over 20% of the patients that start RTT had diabetes. Limited evidence on the effect of comorbidities on the cost of RRT exists. This review summarizes the available evidence on the effect of diabetes mellitus (DM) on the cost of RRT. Electronic databases were searched using key words that combined RRT with DM and cost. References were identified with title, abstract, and full-text screening. The studies included were published in English and presented data on the cost of RRT in ESKD patients with comparison between DM status. Seventeen studies were included in this review. The crude and adjusted cost of care estimates for patients on dialysis was generally higher for DM patients. The cost of care of ESKD patients differed according to various treatment modalities and these differences, mainly driven by inpatient costs. Overall, we found an increased cost of RRT care in patients with DM regardless of the type of treatment. Future analysis of the effects of multiple comorbidities should be considered to better understand the effect of DM on the cost of RRT.

In France, long nocturnal dialyses, eight hours three-times a week, are sparsely proposed. However, numerous studies reported that this specific type of dialysis is associated to better blood pressure control, better cardiac remodeling, better mineral and nutritional balance as well as better life quality and survival rate. MATERIAL AND METHODS: In this study, we aimed at quantifying the benefits, risks and obstacles of developing night dialysis and at describing the results of a program that took place in Rennes from 2002 to 2019. Data were collected between 2008 and 2014 for eighteen case-patients and were compared to thirty-six controls that underwent conventional dialysis. Patients were paired according sex, age and year of dialysis start. RESULTS: The median age for dialysis start was 47.5 years [27-60] with a male prevalence (5/1). After six months, a significant difference was reported for postdialytic, systolic and diastolic pressure (respectively 126±15 vs 139±21 [P=0.04] and 72±9 vs 81±14 [P=0.02]) despite an antihypertensive reduction ranging from 2.4±1.4 to 1.3±0.9 per day at six months and 0.7±0.9 at one year (P=0.02). An increase of nPCR was evidenced at 6 and 9 months (P=0.02). At the end of the study, the phosphate level was maintained for both cohorts at the expense of an increased consumption of phosphate binder for the long nocturnal dialysis group (P=0.025). As a whole, 61% of the patients that pursued long night dialysis maintained a professional activity compared to only 30% for the controls (P=0.04). This highlights the advantages of night dialysis for maintaining employment but also the bias that represents the employment status in observational study on this specific topic.

BACKGROUND: Published algorithms for identifying chronic kidney disease in healthcare claims databases have poor performance except in patients with renal replacement therapy. We propose and describe an algorithm to identify all stage chronic kidney disease in a French healthcare claims databases and assessed its performance by using data from the Renal Epidemiology and Information Network registry and the French Childhood Cancer Survivor Study cohort.METHODS: A group of experts met several times to define a list of items and combinations of items that could be related to chronic kidney disease. For the French Childhood Cancer Survivor Study cohort, information on confirmed chronic kidney disease cases extracted from medical records was considered the gold standard (KDIGO definition). Sensitivity, specificity, and positive and negative predictive value and kappa coefficients were estimated. The contribution of each component of the algorithm was assessed for 1 and 2 years before the start of renal replacement therapy for confirmed end-stage kidney disease in the Renal Epidemiology and Information Network registry.RESULTS: The algorithm’s sensitivity was 78%, specificity 97.4%, negative predictive value 98.4% and positive predictive value 68.7% in French Childhood Cancer Survivor Study cohort and the kappa coefficient was 0.79 for agreement with the gold standard. The algorithm 93.6% and 55.1% of confirmed incident end-stage kidney disease cases from the Renal Epidemiology and Information Network registry when considering 1 year and 2 years, respectively, before renal replacement therapy start.CONCLUSIONS: The algorithm showed good performance among younger patients and those with end-stage kidney disease in the twol last years prior to renal replacement therapy. Future research will address the ability of the algorithm to detect early chronic kidney disease stages and to classify the severity of chronic kidney disease., Contexte: Les algorithmes publiés pour identifier les patients avec une maladie rénale chronique (MRC) dans les bases de données médico-administratives ont de mauvaises performances, sauf chez les patients traités par suppléance. Nous proposons et décrivons un algorithme permettant d’identifier les patients MRC de tout stade dans la base française du Système National de Données de Santé et d’évaluer sa performance en utilisant les données du registre du Réseau d’épidémiologie et d’information rénales (REIN) et de la cohorte Français Childhood Cancer Survivor Study (FCCSS).Méthodes : Un groupe d’experts s’est réuni à plusieurs reprises pour définir une liste de variables et des combinaisons variables qui pourraient être liés à la MRC. Pour la cohorte FCCSS, l’information sur les cas confirmés de MRC extraits des dossiers médicaux a été considérée comme la référen (définition de KDIGO). La sensibilité, la spécificité et les coefficients de prédiction positifs et négatifs (PPV, VAN) et kappa ont été estimés. La contribution de chaque composante de l’algorithme a été évaluée à 1 et 2 ans avant le début de la suppléance à partir du registre REIN.Résultats : La sensibilité de l’algorithme était de 78%, la spécificité de 97,4%, la VPN de 98,4% et la VPP de 68,7% dans la cohorte FCCSS et le coefficient kappa était de 0,79 pour l’accord avec la référence. L’algorithme a permis de détecter 93,6% et 55,1% des cas incidents du registre REIN en considérant 1 an et 2 ans, respectivement, avant le début de la suppléance.Conclusions : L’algorithme a montré de bonnes performances chez les patients plus jeunes et ceux atteints de MRC au cours des deux dernières années précédant la suppléance. Les recherches futures porteront sur la capacité de l’algorithme à détecter les premiers stades de l’IRC et à classer la gravité de l’IRC.

IntroductionSodium polystyrene sulphonate (SPS) and calcium polystyrene sulphonate (CPS) are commonly used cation-exchange resins for the treatment and control of hyperkalaemia. However, their use (particularly SPS) has been limited by reports of adverse gastrointestinal (GI) events. The safety of these compounds in patients undergoing dialysis requires larger investigation.AimsTo study the occurrence of adverse GI events (occlusion, perforation, thrombosis/ischaemia) in the periods of SPS or CPS exposition versus the periods without exposition in dialysis patients.MethodsDialysis patients were extracted from the French National Registry and merged with the French hospital discharge database (between 2006 and 2017). For our primary analysis, we used patients who had any claim of SPS use (n = 43 771). Time-varying Cox models, negative binomial regression and pre- versus post-treatment average treatment effects.ResultsThe mean age was 66 ± 15 years, 37% were female and 92% were undergoing haemodialysis. Over a 1-year follow-up, patients on periods with SPS (on-SPS) did not present an increased risk of adverse GI events versus the periods without SPS (off-SPS): incidence rate (IR) (per 1000 person years) = 7.4 (6.4–8.7) versus 9.5 (8.1–11.0); adjusted hazard ratio (HR) (95% CI) = 0.81 (0.60–1.09), P = 0.17. Patients exposed to SPS did not experience a higher rate of adverse GI events in the year after SPS initiation versus the year before SPS initiation; P-value for parallel trend = 0.87. Patients on-CPS also did not show an increased risk of adverse GI events versus off-CPS: IR (per 1000 py) = 8.6 (5.1–11.9) versus 7.8 (5.1–11.9); adjusted HR (95% CI) = 0.76 (0.31–1.80), P = 0.52. The rates of adverse GI events in the periods on and off exposure were also similar over a follow-up of 5 years.ConclusionOur large, nationwide study shows that the incidence of adverse GI events in patients undergoing dialysis was low and that neither the use of SPS nor CPS was associated with increased GI events risk.

Introduction Emergency dialysis start (EDS) is frequent for patients with chronic kidney disease (CKD). To improve CKD management, new trajectory-based care policies are currently being introduced both in France and in the United States. This study describes the different types of predialysis care trajectories and factors associated with EDS. Methods Adults patients who started dialysis in France in 2015 were included. Individual clinical and health care consumption data were retrieved from the French national end-stage kidney disease (ESKD) registry (Renal Epidemiology and Information Network [REIN]) and the French National Health Data system (SNDS), respectively. Hierarchical Clustering on Principal Component was used to identify groups of patients with the same health care consumption profile during the 2 years before dialysis start. Logistic regression analysis was used to identify factors associated with EDS. Results Among the 8856 patients included in the analysis, 2681 (30.3%) had EDS. The Hierarchical Clustering on Principal Component identified six types of predialysis care trajectories in which EDS rate ranged from 13.8% to 61.8%. After adjustment for the patients’ characteristics, less frequent or lack of follow-up with a nephrologist was associated with higher risk of EDS (odds ratio [OR]: 1.32; 95% confidence interval [CI]: 1.17–1.50 and OR: 1.83; 95% CI: 1.58–2.12), but not follow-up with a general practitioner. Conclusions The care trajectories during the 2 years before dialysis start were heterogeneous and patients with a lesser or lack of follow-up with a nephrologist were more likely to start dialysis in emergency, regardless of the frequency of follow-up by a general practitioner (GP). New CKD policies should include actions to strengthen CKD screening and referral to nephrologists., Graphical abstract

A key component of treatment for all people with advanced kidney disease is supportive care, which aims to improve quality of life and can be provided alongside therapies intended to prolong life, such as dialysis. This article addresses the key considerations of supportive care as part of integrated end-stage kidney disease care, with particular attention paid to programs in low- and middle-income countries. Supportive care should be an integrated component of care for patients with advanced chronic kidney disease, patients receiving kidney replacement therapy (KRT), and patients receiving non-KRT conservative care. Five themes are identified: improving information on prognosis and support, developing context-specific evidence, establishing appropriate metrics for monitoring care, clearly communicating the role of supportive care, and integrating supportive care into existing health care infrastructures. This report explores some general aspects of these 5 domains, before exploring their consequences in 4 health care situations/settings: in people approaching end-stage kidney disease in high-income countries and in low- and middle-income countries, and in people discontinuing KRT in high-income countries and in low- and middle-income countries.

BACKGROUND AND AIMS Although associated with better quality of life and potential economic advantages, home dialysis use varies greatly internationally and appears to be underused in many countries. This study aimed to estimate the dialysis-network variability in home dialysis use and identify factors associated with (i) the uptake in home dialysis, (ii) the proportion of time spent on home dialysis and (iii) home dialysis survival (patient and technique). METHOD All adults ≥18 years old who had dialysis treatment during 2017–9 in mainland France were included. Mixed-effects regression models were built to explore factors including patient characteristics or residence and dialysis network associated with outcomes. RESULTS: During 2017–9, 7728/78 757 (9.8%) patients underwent dialysis at least once at home for a total of 120 594/1 508 000 (8%) months. The heterogeneity in dialysis networks regarding the uptake or total time spent on home dialysis was marginally explained by patient characteristics or residence and dialysis-network factors. Heterogeneity was less for home dialysis survival. These results were similar when the analysis was restricted to home peritoneal dialysis or home hemodialysis. Income inequity and housing were associated with reduced home dialysis uptake and reduced proportion of time on home dialysis. Home dialysis use was not affected by the number of self-care HD units in the administrative district of residence. CONCLUSION Our results suggest that to increase home dialysis use in France, one should focus on home dialysis uptake rather than survival. Financial incentives and a quality improvement program should be implemented at the dialysis-network level to increase home dialysis use.

BACKGROUND AND AIMS Vascular access choice for patients with high risk of arteriovenous (AV) access failure has been sparking growing controversy as recent studies show similar survival and morbidity across patients receiving arteriovenous (AV) fistula or graft. We assessed hospitalization and mortality risks associated with access type in patients who started hemodialysis with a catheter without previous AV access creation in France, overall and by subgroups of age, sex and comorbidities. METHOD Longitudinal study of 18 800 incident hemodialysis patients from 2010 through 2018, based on the linkage of the French REIN registry of kidney replacement therapy (KRT) with the national health administrative database (SNDS). First-line AV access (fistula or graft) was ascertained from SNDS procedures codes. Hospitalizations were also identified through the SNDS, whereas mortality data was obtained from the REIN Registry. We used joint frailty models to estimate hazard ratios (HR) and 95% confidence intervals (CI) of recurrent hospitalization and death associated with AV grafts, compared with AV fistulæ. These models accounted for dependence between hospitalization and death. We further estimated propensity scores for first-line AV graft placement and used inverse probability weighting (IPW) to obtain weighted HR (wHR), accounting for potential indication bias. RESULTS Among studied patients, 35% were women, 45% had diabetes, 26% had history of heart failure and 19% had history of peripheral artery disease. More than half started dialysis urgently (52%). Patients with first-line AV graft (5%) were older than those with AV fistula (72 ± 14 versus 68 ± 15 years, respectively), and required more frequently assistance to walk (29% versus 17%). IPW resulted in covariate balance (absolute standardized difference CONCLUSION In patients starting hemodialysis with a catheter without previous AV access creation, the fistula first approach is associated with similar mortality, but lower risk of hospitalization compared to first-line AV graft. This may, however, not be the case for patients with a poor vascular condition, i.e. those with diabetes or peripheral artery disease, who have a similar hospitalization risk with either graft or fistula.

Heart transplantation (HTX) is a well-established treatment for suitable patients with end-stage heart failure, intended to prolong their survival and improve their health-related quality of life (HR-QoL). No international consensus exists, however, about the preferred patient-reported outcomes (PROs) and their measures (PROMs) for heart transplant recipients. The purpose of this study, the first step in a mixed-method investigation, was to review the PROMs developed and used in this population to identify the instruments for measuring HR-QoL and adherence to immunosuppressive medications most appropriate for heart transplant patients.This systematic search of the literature in the PubMed database focused on the assessment of PROMs for patients after HTX. We analyzed 66 studies with cross-sectional, 28 with longitudinal, and 2 with mixed-methods designs, as well as 6 literature reviews.These 102 articles used 115 different PROMs, which we categorized as generic HR-QoL instruments (n = 19), domain-specific instruments (n = 71), heart disease-specific instruments (n = 9), and heart transplant-specific instruments (n = 16). They cover different dimensions of HR-QoL and of immunosuppressive-drug experience, with diverse numbers of items, types of scales, and psychometric properties.Despite the abundance of instruments, PROMs for HTX can be improved to meet other patient expectations (i.e., by including important issues such as coping strategies, employment, social support, sexual relationships, spirituality, and beliefs), while paying attention to ease of use, reliability, validity, and the contribution of new technologies. A qualitative approach will complete our project of developing a patient-centered instrument for HTX patients.

Introduction: Switch from hemodialysis (HD) to peritoneal dialysis (PD) is unfrequent, but incentive strategies to perform PD can lead to an increase of these transitions. However, data on transitioning from HD to PD are scarce. We hypothesized that time spent on HD before transfer to PD would impact PD outcomes. Methods: This registry-based, nationwide study analyzed patients transferred from HD to PD. Patients who began HD between January 2008 and December 2016 were included. Cox and Fine and Gray regression models were used to explore the relationship between time spent on HD before PD and outcomes in PD: PD cessation for death or retransfer to HD (composite endpoint); for death; and for retransfer to HD. Results: Over the study period, 1,985 of the 77,587 HD starters (3%) were transferred to PD. The median time spent on HD before transfer to PD was 1.94 months (interquartile range [IQR] 1.02–4.01). The median survival time on PD after this transition was 20 months (IQR 18–21). Time spent on HD before PD was associated with increased risk of death or retransfer to HD (cause-specific hazard ratio [cs-HR] 1.01, 95% confidence interval [CI]: 1–1.02 for a 1-month increase) and death (cs-HR 1.02, 95% CI: 1.01–1.03) but not with retransfer to HD censored on death (cs-HR 1.00, 95% CI: 0.99–1.01). The results were similar when considering competing events. Discussion/Conclusion: Switch from HD to PD is rare in France. Time spent on HD before transfer is associated with patient survival but not with retransfer to HD.

The possibility of indirect linkage between data from the French REIN registry and data from the National Health Data System makes it possible to enhance knowledge of the care pathway of patients with severe kidney disease. Taking an interest in hospitalizations makes it possible to understand the burden of this disease, both for patients, in terms of comorbidities, complications and quality of life but also for society in terms of care load, need for organization of the care offer and costs.Patients on dialysis in 2019 were identified from REIN. The information on hospital stays comes from an extraction of the National Health Data System linked with REIN. The hospitalization rate corresponds to the number of hospital stays over the period, relative to the number of people at risk on dialysis over the period.After excluding dialysis sessions, 36,962 patients had a hospital stay in 2019: 36,738 in medicine, surgery, obstetrics, 2863 in rehabilitation, 531 in home hospitalizations and 201 in psychiatry facilities. This represents a total of 146,743 stays, including 140,372 in medicine, surgery, obstetrics. The hospitalization rate in medicine, surgery, obstetrics is 259 stays for 100 person-years. The reasons vary according to age, type of hospitalization (with or without overnight stays) and mode of discharge (home, death or transfer). The median amounts for a stay vary from €7920 in rehabilitation to €719 in medicine, surgery, obstetrics without overnight stay. Due to the volumes, stays for cardiovascular pathology represent a high total amount over the year. Hospitalizations for infection have significant median costs.The results presented in this article confirm the important place of hospitalization in the trajectory of dialysis patients. Hospitalizations in medicine, surgery, obstetrics represent 96% of hospitalizations. For the first time, this study shows the very low place of hospitalizations in psychiatry and rehabilitation facilities.

International audience; Background: The COVID-19 pandemic has resulted in worldwide kidney transplantation (KT) moratoriums. The impacts of these moratoriums on the life expectancy of KT candidates remain unclear.Methods: We simulated the evolution of several French candidate populations for KT using a multistate semi-Markovian approach and according to moratorium durations ranging from 0 to 24 mo. The transition rates were modeled from the 63 927 French patients who began dialysis or were registered on the waiting list for KT between 2011 and 2019.Results: Among the 8350 patients active on the waiting list at the time of the French KT moratorium decided on March 16, 2020, for 2.5 mo, we predicted 4.0 additional months (confidence interval [CI], 2.8-5.0) on the waiting list and 42 additional deaths (CI, -70 to 150) up to March 16, 2030, compared with the scenario without moratorium. In this population, we reported a significant impact for a 9-mo moratorium duration: 135 attributable deaths (CI, 31-257) up to March 16, 2030. Patients who became active on the list after March 2020 were less impacted; there was a significant impact for an 18-mo moratorium (175 additional deaths [CI, 21-359]) in the 10 862 prevalent end-stage renal disease patients on March 16, 2020 and for a 24-mo moratorium (189 additional deaths [CI, 10-367]) in the 16 355 incident end-stage renal disease patients after this date.Conclusion: The temporary moratorium of KT during a COVID-19 peak represents a sustainable decision to free up hospitals' resources if the moratorium does not exceed a prolonged period.