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Background Short leukocyte telomere length (TL) is associated with atherosclerotic cardiovascular disease. Endothelial repair plays a key role in the development of atherosclerosis. The objective was to examine associations between TL and proliferative dynamics of endothelial colony‐forming cells (ECFCs), which behave as progenitor cells displaying endothelial repair activity. Methods and Results To isolate ECFCs, we performed a clonogenic assay on blood samples from 116 participants (aged 24–94 years) in the TELARTA (Telomere in Arterial Aging) cohort study. We detected no ECFC clones in 29 (group 1), clones with no replating capacity in other 29 (group 2), and clones with replating capacity in the additional 58 (group 3). Leukocyte TL was measured by Southern blotting and ECFCs (ECFC‐TL). Age‐ and sex‐adjusted leukocyte TL (mean±SEM) was the shortest in group 1 (6.51±0.13 kb), longer in group 2 (6.69±0.13 kb), and the longest in group 3 (6.78±0.09 kb) ( P P P r =0.82; P Conclusions Individuals with longer telomeres display a higher number of self‐renewing ECFCs. Our results also indicate that leukocyte TL, as a proxy of TL dynamics in ECFCs, could be used as a surrogate marker of endothelial repair capacity in clinical and laboratory practice because of easy accessibility of leukocytes. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02176941.

To date, it is important to know more about the population of CKD stage 5 patients in order to better understand the practices of access to renal replacement therapy (RRT) or conservative treatment and to anticipate future needs. In April 2015, at the instigation of the Scientific Committee of REIN, a working group was formed to reflect on the opportunity and feasibility of a data collection on these patients. Between September 2017 and March 2018, 21 participating centers included 390 patients over a period of at least one month. The data collected included the patient's living conditions, level of study, mode of referral, clinical data and the therapeutic project. The median age at baseline was 71.4years (IQR: 58.4-80.4), 39.9% were diabetic. The median eGFR was 12mL/min/1.73m2 (IQR: 9-14). At inclusion, 77% of the patients were already followed in nephrology, 11% had been referred by a general practitioner. For the majority of patients included (81%), there was a RRT project. In 10% of cases, there was a project of conservative care, in 5% of cases the project was not yet decided and in 7% the project had not been yet discussed. At the latest news (median time 4.0months), 35% of patients were dialyzed, 9 (2%) have been pre-emptively transplanted, 25 (6%) died, 210 (54%) were still with a CKD stage 5. Our pilot study has shown the feasibility and interest of setting up such a data collection. Such a registry will provide important public health information regarding the demographic of nephrologists and advanced practices nurses. At the local level, this information will help the department to organize themselves to set-up pre-RRT information, implementation of care pathway nurses and multidisciplinary meetings for difficult cases. However, our pilot study shows that to ensure the completeness of the collection, the tracking upstream or downstream of nephrology consultations for eligible patients is essential and therefore requires dedicated human time on site.

Background Cervical artery dissection (CeAD) is a frequent manifestation of fibromuscular dysplasia (FMD). However, risk factors for CeAD are unknown. We investigated factors associated with CeAD in the ARCADIA (Assessment of Renal and Cervical Artery Dysplasia) registry. Methods and Results The ARCADIA registry includes women or men aged ≥18 years, with a diagnosis of renal, cervical, or intracranial artery FMD, who were prospectively recruited at 16 university hospitals in France and Belgium. Diagnosis of acute or past CeAD at inclusion was established on imaging according to standard diagnostic criteria. Associations between potential determinants and CeAD were assessed by logistic regression analyses. Among 469 patients (75 men) with FMD, 65 (13.9%) had CeAD. Patients with CeAD were younger, more likely to be men, have a history of migraine, and less likely to have a history of hypertension than patients without CeAD. In the multivariable analysis, male sex (odds ratio [OR], 2.66; 95% CI, 1.34–5.25), history of migraine (OR, 1.90; 95% CI, 1.06–3.39), age ≥50 years (OR, 0.41; 95% CI, 0.23–0.73), history of hypertension (OR, 0.35; 95% CI, 0.20–0.64), and involvement of ≥3 vascular beds (OR, 2.49; 95% CI, 1.15–5.40) were significantly associated with CeAD. To validate the association between CeAD and sex, we performed a systematic review. We collected additional data on sex from 2 published studies and unpublished data from the US Registry for Fibromuscular Dysplasia and the European/International FMD Registry. In the pooled analysis (289 CeAD, 1933 patients), male sex was significantly associated with CeAD (OR, 2.04; 95% CI, 1.41–2.95; I 2 =0%). Conclusions In patients with FMD, male sex and multisite involvement are associated with CeAD, in addition to other previously known risk factors. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02884141.

Background The estimated glomerular filtration rate (eGFR) measured at 1 year is the usual benchmark applied in kidney transplantation (KT). However, acting on earlier eGFR values could help in managing KT during the first post-operative year. We aimed to assess the prognostic value for long-term graft survival of the early (3 months) quantification of eGFR and proteinuria following KT. Methods The 3-, 6- and 12-month eGFR using the Modified Diet in Renal Disease equation (eGFRMDRD) was determined and proteinuria was measured in 754 patients who underwent their first KT between 2000 and 2010 (with a mean follow-up of 8.3 years) in our centre. Adjusted associations with graft survival were estimated using a multivariable Cox model. The predictive accuracy was estimated using the C-index and net reclassification index. These same analyses were measured in a multicentre validation cohort of 1936 patients. Results Both 3-month eGFRMDRD and proteinuria were independent predictors of return to dialysis (all P Conclusion The 3-month eGFR was a valuable predictor of the long-term return to dialysis whose predictive accuracy was not significantly less than that of the 12-month eGFR in multicentre cohorts totalling >2500 patients. Three-month outcomes may be useful in randomized controlled trials targeting early therapeutic interventions.

Recommendations on the glomerular filtration rate (GFR) threshold compatible with living kidney donation are not agreed upon. The recent KDIGO guidelines suggested a reset of the conventional cutoff value of 80 to 90 mL/min/1.73 m2. While GFR physiologically declines with age, it is unclear whether and how age should be taken into account for selecting acceptable pre-donation GFR. In this multicenter retrospective study encompassing 2007 kidney donors in France, we evaluated the impact of age using two threshold measured GFR (mGFR)s (80 and 90 mL/min/1.73 m2). Three groups of donors were defined according to baseline mGFR: below 80, 80-89.9 and 90 mL/min/1.73 m2 or more. Thirty-two percent of donors were selected despite an mGFR below 90 mL/min/1.73 m2. Donors with the lowest mGFR were significantly older (60 ± 9 vs. 47 ± 11 years) and this applied to both male and female donors. The lifetime-standardized renal reserve, defined as the pre-donation mGFR value divided by the expected number of remaining years of life, was similar irrespective of baseline mGFR groups. Similar results were obtained when eGFR was used instead of mGFR. Finally, in a subgroup of 132 donors with repeated mGFR five years after donation, the magnitude of mGFR decrease was similar in all groups (-34.3%, -33.9%, and -34.9% respectively). Thus, the decision to accept individuals with mGFR lower than 90 mL/min/1.73 m2 for kidney donation is highly dependent on the age of the candidate. Hence, threshold values lower than 90 mL/min/1.73 m2 are reasonable for older donors. Age-calibrated mGFR may improve efficiency of the selection process.

International audience

Introduction Plusieurs etudes ont montre que le syndrome de fragilite et les troubles neurocognitifs (TN) etaient frequents chez les patients hemodialyses (HD) âges mais le bilan geriatrique n’est actuellement pas systematique dans les unites de dialyse. Description Grâce au soutien d’un reseau de sante, un service de nephrologie et un service de geriatrie ont mis en place une evaluation geriatrique standardisee (EGS) systematisee chez tous les patients de plus de 70 ans en HD-centre, avec pour objectif d’ameliorer leur prise en charge et de leur offrir une education therapeutique (ETP) adaptee. Methodes Dans un 1er temps, depistage de la fragilite (SEGA) chez tous les patients HD (≥ 70 ans) par des infirmier(e)s de dialyse (IDE-D) forme(e)s. Les patients depistes fragiles beneficiaient alors d’une EGS par l’equipe de geriatrie. Ensuite, EGS, par l’equipe de geriatrie, de tout nouveaux patients (≥ 70 ans) mis en HD. Une reevaluation entre 6 et 12 mois etait realisee. Resultats Vingt-sept patients ont ete evalues (âge median : 79 ans, 18 hommes) : 7 sans TN, 17 avec TN averes, 3 avec TN severes. Cinquante-huit pour cent des patients etaient dependants (IADL ≥ 2), 44 % etaient consideres comme tres fragiles. Chez 51 %, un risque d’iatrogenie a ete identifie, justifiant une modification du traitement. Seize patients ont ete reevalues : 9 etaient stables (dont 4 sans TN), 5 ont aggrave leurs TN, 2 ont developpe des TN. Vingt-deux patients pouvaient suivre un parcours ETP : standard pour 6, adapte pour 12 et propose a leurs aidants pour 4. Conclusion Cette etude confirme la grande frequence du syndrome de fragilite, des TN et du risque iatrogenique chez des patients âges hemodialyses en centre. La collaboration geronto-nephrologique a permis d’adapter et de centrer notre programme d’ETP sur les savoirs utiles. Nous envisageons d’etendre cette collaboration pour une meilleure prise en charge des patients en pre-suppleance.

Purpose Transplant recipients who develop cutaneous squamous cell carcinomas are at high risk for multiple subsequent skin cancers. Sirolimus has been shown to reduce the occurrence of secondary skin cancers, but no study included a follow-up exceeding 2 years. We extended at 5 years the TUMORAPA randomized trial of sirolimus-based immunosuppressive regimen versus calcineurin inhibitor–based immunosuppression. Methods Kidney transplant recipients receiving calcineurin inhibitors who had at least one cutaneous squamous cell carcinoma were randomly assigned to receive sirolimus as a substitute for calcineurin inhibitors (n = 64) or to maintain their initial treatment (n = 56). The primary end point was survival free of squamous cell carcinoma at 5 years. Secondary end points included the occurrence of other skin cancers, renal function, patient and graft survival, and treatment tolerance. Results Survival free of cutaneous squamous cell carcinoma was significantly longer in the sirolimus group than in the calcineurin inhibitor group ( P = .007). In the sirolimus group, the number of patients with new skin cancers was significantly lower compared with the calcineurin inhibitor group: 22% versus 59% for squamous cell carcinomas ( P < .001), 34% versus 66% for other skin cancers ( P < .001), and 20% versus 37.5% for basal cell carcinomas ( P < .05). Kidney graft function, patients, and graft survival were similar in both groups. In the sirolimus group, the mean number of serious adverse effects per patient decreased from 1.16 during the first 2 years, to 0.83 between years 2 and 5. Conclusion In kidney transplant recipients with previous cutaneous squamous cell carcinomas, the antitumoral effect of conversion from calcineurin inhibitors to sirolimus was maintained at 5 years, and sirolimus tolerance was satisfactory.

Background Assessment of human leukocyte antigen (HLA) matching by using high-resolution allele typing and knowledge of HLA molecule structure may lead to better prediction of de novo donor-specific antibody (dnDSA) development. Methods We conducted a single-center cohort study among 150 non-sensitized first kidney transplant recipients to compare the association between antigenic (Ag), allelic (Al), eplet (Ep), amino acid (AAMS) HLA matching and electrostatic (EMS) and hydrophobic (HMS) mismatch scores, and the development of dnDSA. Results After a mean follow-up time of 49.3 ± 17.7 months, 18 patients (12%) developed dnDSA. The number of HLA mismatches (MM) was significantly associated with the development of dnDSA. The optimal threshold, determined by Harrell's C-index, varied according to the method (5 MM for Ag, P = 0.006; 6 for Al, P = 0.009; 22 for Ep, P = 0.005; 42 for AAMS, P = 0.0007; 45 for EMS, P = 0.009 and 44 for HMS, P = 0.026). C-indices were similar for all matching approaches, suggesting a similar prediction of dnDSA development. Conclusion In this cohort of low immunological risk transplant patients, the use of Al or Ep matching did not improve the prediction of dnDSA development in comparison with the traditional approach.

International audience; The impact of preemptive second kidney transplantation (2KT) on graft and patient survival is poorly established. The association between preemptive 2KT (p2KT, N = 93) and outcomes was estimated in a multicenter French cohort of 2KT (N = 1314) recipients using propensity score methods. During the follow-up, there were 274 returns to dialysis and 134 deaths. p2KT was associated with lower death-censored graft loss (HR = 0.39 [0.18-0.88], P = 0.024) and graft failure from any cause including death (HR = 0.42 [0.22-0.80], P = 0.008). Similar associations were observed for death with a functioning graft, although not reaching statistical significance (HR = 0.47 [0.17-1.26], P = 0.13). There was a significant interaction between donor type and p2KT (P for interaction = 0.016). Indeed, p2KT was not significantly associated with the risk of graft failure from any cause including death in living donor 2KT (P = 0.39), whereas the association was substantial in the deceased donor subset (HR = 0.30 [0.14-0.64], P = 0.002). Of note, the adjusted graft survival of p2KT with deceased donor paralleled that of 2KT with living donor, either preemptive or not (93.8% vs. 88.6% at 4 years and 76.1% vs. 70.5% at 8 years, P = 0.13). This large French multicenter study analyzed using propensity scores suggests that p2KT is associated with better graft prognosis.

Supplemental digital content is available in the text., Background End-stage renal failure occurs in a substantial number of patients having received a nonrenal transplantation (NRT), for whom a kidney transplantation is needed. The medical strategy regarding the use of immunosuppression (IS) for a kidney graft in patients after an NRT is not well established. The prekidney grafts long-term IS advocates for a mild induction, such as using anti-IL-2R antibodies, whereas addition of new incompatibilities and anti-HLA preimmunization may suggest using stronger IS such as induction by polyclonal antithymocyte globulins (ATG). Methods We performed Cox multivariate and propensity score analysis of our validated transplant database to study the impact of the type of induction therapy on kidney graft survival of recipients of a kidney graft after NRT. Results We report here that kidney transplantation after NRT treated with an ATG induction has a poorer outcome (kidney and recipient survival) than that with an anti–IL-2R induction. After accounting for potential baseline differences with a multivariate Cox model, or by adjusting on a propensity score, we found that despite patients having received ATG cumulate more risk factors, ATG appears independently involved. As animal-derived biotherapeutics induce antiglycan antibodies and particularly anti–N-glycolylneuraminic acid (Neu5Gc) IgGs which may activate endothelial cells in patients and grafts, we also investigated the magnitude and the nature of the anti-Neu5Gc elicited by the induction and showed that induction was associated with a shift in anti-Neu5Gc IgG repertoire. Possible reasons and mechanisms of a deleterious ATG usage in these patients are discussed. Conclusions Our study suggests that ATG induction after a kidney transplantation in recipients already under maintenance IS for a NRT should be used cautiously.

International audience; BACKGROUND:In low-immunological risk kidney transplant recipients (KTRs), reduced exposure to calcineurin inhibitor (CNI) appears particularly attractive for avoiding adverse events, but may increase the risk of developing de novo Donor Specific Antibodies (dnDSA).METHODS:CNI exposure was retrospectively analyzed in 247 non-HLA immunized first KTRs by taking into account trough levels (C0) collected during follow-up. Reduced exposure to CNI was defined as follows: C0 less than the lower limit of the international targets for ≥50% of follow-up.RESULTS:During a mean follow-up of 5.0 ± 2.0 years, 39 patients (15.8%) developed dnDSA (MFI ≥1000). Patients with DSA were significantly younger (46.6 ± 13.8 vs. 51.7 ± 14.0 years, p = 0.039), received more frequently poorly-matched grafts (59% with 6-8 A-B-DR-DQ HLA mismatches vs. 34.6%, p = 0.016) and had more frequently a reduced exposure to CNI (92.3% vs. 62.0%, p = 0.0002). Reduced exposure to CNI was associated with an increased risk of dnDSA (multivariable HR = 9.77, p = 0.002). Reduced exposure to CNI had no effect on patient survival, graft loss from any cause including death, or post-transplant cancer.CONCLUSIONS:Even in a low-immunological risk population, reduced exposure to CNI is associated with increased risk of dnDSA. Benefits and risks of under-immunosuppression must be carefully evaluated before deciding on CNI minimization.

Appropriate anticoagulation for hemodialysis (HD) requires a subtle balance between under- and over-heparinization to prevent extracorporeal circuit (ECC) clotting and bleeding, respectively. We discuss five key issues relating to anticoagulation therapy for chronic HD in adults following a review of relevant literature published since 2002: (i) options for standardization of anticoagulation in HD settings. The major nephrology societies have issued low evidence level recommendations on this subject. Interventional studies have generally investigated novel low-molecular weight heparins and provided data on safety of dosing regimens that cannot readily be extrapolated to clinical practice; (ii) identification of clinical and biological parameters to aid individualization of anticoagulation treatment. We find that use of clinical and biological monitoring of anticoagulation during HD sessions is currently not clearly defined in routine clinical practice; (iii) role of ECC elements (dialysis membrane and blood lines), dialysis modalities, and blood flow in clotting development; (iv) options to reduce or suppress systemic heparinization during HD sessions. Alternative strategies have been investigated, especially when the routine mode of anticoagulation was not suitable in patients at high risk of bleeding or was contraindicated; (v) optimization of anticoagulation therapy for the individual patient. We conclude by proposing a standardized approach to deliver anticoagulation treatment for HD based on an individualized prescription prepared according to the patient's profile and needs.

Several studies have investigated geographical variations in access to renal transplant waiting lists, but none has assessed the impact on these variations of factors at both the patient and geographic levels. The objective of our study was to identify medical and non-medical factors at both these levels associated with these geographical variations in waiting-list placement in France. We included all incident patients aged 18-80 years in 11 French regions who started dialysis between January 1, 2006, and December 31, 2008. Both a multilevel Cox model with shared frailty and a competing risks model were used for the analyses. At the patient level, old age, comorbidities, diabetic nephropathy, non-autonomous first dialysis, and female gender were the major determinants of a lower probability of being waitlisted. At the regional level, the only factor associated with this probability was an increase in the number of patients on the waiting list from 2005 to 2009. This finding supports a slight but significant impact of a regional organ shortage on waitlisting practices. Our findings demonstrate that patients' age has a major impact on waitlisting practices, even for patients with no comorbidity or disability, whose survival would likely be improved by transplantation compared with dialysis.

Resume Introduction L’evolution de la glomerulonephrite extramembraneuse idiopathique (GEMi) est variable ; le traitement est debattu. Notre travail avait pour objectif principal d’evaluer les resultats d’une strategie standardisee de prise en charge proposee en 2006 en Lorraine par le reseau Nephrolor. L’objectif secondaire etait d’evaluer les pratiques professionnelles. Patients et methodes Cette etude comparait l’evolution des GEMi incidentes entre 2002 et 2005 (Avant), puis entre 2007 et 2010 (Apres) : dates de point respectives au 31/12/2006 et au 31/12/2011. Chez les patients nephrotiques sans insuffisance renale, l’appreciation du risque devolution vers l’insuffisance renale chronique terminale reposait sur le debit urinaire de β2-microglobuline (uβ2 m, seuil a 0,5 μg/min). Les patients a haut risque devaient recevoir un traitement immunosuppresseur. Resultats Soixante-quatorze GEMi etaient diagnostiquees par biopsie renale, dont 50 nephrotiques (22 Avant et 28 Apres) parmi lesquels 20 avaient une fonction renale normale. Chez ces nephrotiques, il n’y avait pas de difference significative concernant la probabilite et le delai moyen de survenue d’une remission entre les deux groupes (p = 0,26). Le dosage de uβ2 m etait realise dans 35 % des cas. Cinquante pour cent etaient traites par IS en accord avec la strategie. Conclusion Malgre des ecarts entre la strategie et les pratiques, pouvant expliquer les resultats non significatifs, nous avons observe des changements dans la reflexion et l’attitude therapeutique du clinicien. La strategie tend a standardiser et ameliorer les pratiques concernant la GEMi en Lorraine, ce qui semble ameliorer les resultats en matiere de remission. Nous incitons donc a generaliser l’application de cette strategie et a poursuivre le suivi de cette cohorte.

International audience; When a patient is registered on renal transplant waiting list, she/he expects a clear information on the likelihood of being transplanted. Nevertheless, this event is in competition with death and usual models for competing events are difficult to interpret for non-specialists. We used a horizontal mixture model. Data were extracted from two French dialysis and transplantation registries. The ''Ile-de-France'' region was used for external validation. The other patients were randomly divided for training and internal validation. Seven variables were associated with decreased long-term probability of transplantation: age over 40 years, comorbidities (diabetes, cardiovascular disease, malig-nancy), dialysis longer than 1 year before registration and blood groups O or B. We additionally demonstrated longer mean time-to-transplantation for recipients under the age of 50, overweight recipients, recipients with blood group O or B and with pre-transplantation anti-HLA class I or II immunization. Our model can be used to predict the long-term probability of transplantation and the time in dialysis among transplanted patients, two easily interpretable parts. Discriminative capacities were validated on both the internal and external (AUC at 5 years = 0.72, 95% CI from 0.68 to 0.76) validation samples. However, calibration issues were highlighted and illustrated the importance of complete re-estimation of the model for other countries. We illustrated the ease of interpretation of horizontal modelling, which constitutes an alternative to sub-hazard or cause-specific approaches. Nevertheless, it would be useful to test this in practice, for instance by questioning both the physicians and the patients. We believe that this model should also be used in other chronic diseases, for both etiologic and prognostic studies.

Objective The goal of this study is to compare patient-reported quality of life (PRQOL) evolution between two groups of end-stage renal disease patients with secondary hyperparathyroidism (SHPT). The first with a cinacalcet prescription within 3 months after a diagnosis of SHPT (early group) and a second group of patients with a later or no cinacalcet prescription (nonearly group). Patients and methods From 2009 to 2012, we conducted a multicenter pharmaco-epidemiologic study in Lorraine region (France) including all consecutive patients on maintenance dialysis for at least 3 months with a diagnosis of SHPT (PTH > 500 pg/ml or first cinacalcet prescription). PRQOL was estimated using the Kidney Disease Quality Of Life-Short Form questionnaire, at baseline and at 6 and 12 months follow-up. Change in PRQOL was compared between the groups and adjusted with a propensity score. Results We included 124 patients: 44 in the early group and 80 in the nonearly group. The mental component summary score was lower in the early group, at baseline (43.6 ± 6.6 vs 46.6 ± 7.6; p = 0.030), and at the follow-up assessment (42.6 ± 6.9 vs 45.7 ± 7.9; p = 0.033). We found no difference between the groups in change in PRQOL, for all dimensions, even after adjustment with the propensity score. Mean serum alkaline phosphatase levels were normal in both groups at baseline (80.9 ± 32.5 vs 95.1 ± 39.6; p = 0.41). Conclusion Cinacalcet prescription immediately following diagnosis of SHPT does not seem to be associated with better PRQOL evolution at 1 year. Mean serum alkaline phosphatase levels suggest that physicians should consider waiting for another PTH assay result before starting cinacalcet in case of a PTH rise. Copyright © 2014 John Wiley & Sons, Ltd.

The kidney transplant recipient is faced not only with the perspective of taking immunosuppressive drugs lifelong, but also the possibility of other long-term treatments prescribed for preexisting conditions, complications, or side effects. Proper management, and most importantly patient adherence, can become a complex challenge. Here we recall current definitions and describe methods for measuring treatment adherence, followed by a discussion on the prevalence of non-adherence in kidney transplant recipients, its effect on graft survival, and factors predictive of non-adherence. Ways of improving adherence are examined, leading to the conviction that helping patients take their medications regularly would probably have a greater impact on graft survival than marketing a new immunosuppressive agent.

Introduction Au total, 80 % des programmes d’education therapeutique du patient (ETP) dans notre region sont portes par des etablissements hospitaliers. Toutefois, la plupart des malades chroniques sont suivies en ville ou en ambulatoire, ce qui est le cas des patients atteints de maladie renale polykystique hereditaire (PKR). L’objectif est de decrire la demarche de construction d’un programme avec un parcours mixte ville-hopital. Methodes La construction du programme s’est basee sur les besoins des patients (focus group). Un comite de pilotage compose de professionnels de sante et de patients a construit le programme a partir des besoins exprimes. Ce comite s’est reuni plusieurs fois afin de determiner les objectifs pedagogiques et le contenu des seances, d’elaborer les outils et de reflechir a la mise en œuvre d’un parcours mixte. Resultats obtenus ou attendus Les patients PKR ont surtout exprime le besoin de pouvoir suivre leur parcours d’ETP en ville, seuls les ateliers specifiques restant a l’hopital. Le programme se compose de 4 ateliers (connaissance de la maladie et heredite ; symptomes et complications ; adaptation therapeutique et dietetique ; vivre avec sa PKR) et de 3 seances individuelles, dont une dedie au traitement par tolvaptan. Les seances specifiques aux aspects genetiques et therapeutiques se derouleront a l’hopital, les autres au sein d’un reseau de sante territorial. Des seances de formation au programme sont organisees de facon commune pour les professionnels de sante de l’hopital, du reseau territorial et les patients-ressources. Les avantages esperes sont nombreux : eviter l’abandon des patients grâce a un parcours integre dans leur parcours de soins et de vie ou avoir une expertise nephrologique pour certains ateliers. Conclusion Les programmes d’ETP ont ete crees pour repondre aux besoins des patients atteints de maladie chronique. Des relais entre les programmes et un lien ville-hopital doivent etre developpes pour accroitre l’efficacite de la demarche educative.

The AVENIR study is a pharmaco-epidemiological study, lead in Lorraine region (France) between 1st January, 2005 and 31st December, 2006, which aim at: evaluating the quality of therapeutic practices, delivered by nephrologists, for chronic kidney disease patients during the year preceding dialysis onset, assessing the association between quality of predialysis therapeutic practices and survival and hospitalization during the first year of dialysis, and health-related quality of life at dialysis onset. Several data were collected for the AVENIR study: demographic, clinical, biological and therapeutic data before dialysis, morbidity and mortality during dialysis treatment. These data were used for secondary analyses investigating the decline in glomerular filtration rate over the year preceding dialysis, the management of hypertension and proteinuria before dialysis, and characteristics and outcomes of patients with delayed dialysis initiation. Results from the AVENIR study have been published in various international journals. The aim of this manuscript is to present a summary of these results and the lessons we can learn for the nephrological practice.

The objective was to take into consideration patient concerns for an original qualitative approach to the elaboration of three therapeutic education programs (TEP) designed for chronic renal failure patients, transplantation recipients, and dialysis patients. Four discussion groups involved patients with non-terminal chronic renal failure (one group), transplantation recipients (one group), and dialysis patients (two groups). Topics discussed were patients' knowledge of the TEP and their disease and treatment, patients' expectations concerning the educative content and the organisation of the TEP. For all levels of chronic renal failure, patient expectations focused on nutrition, treatments, and the social and occupational supportive network. Patients with non-terminal renal failure also expressed their expectations concerning the comprehension of laboratory tests and the course of their renal disease. Transplantation recipients wanted to strengthen their knowledge about graft evolution and immunosuppression. Dialysis patients expressed their concerns about disease announcement and the decision for dialysis. While certain topics were common, patients were preoccupied by different problems depending on their degree of renal insufficiency. Nephrolor thus integrated these different levels of concern into the elaboration of E'Dire programs designed for non-terminal renal failure patients and EDUGREFFE for transplant recipients. The third program designed for dialysis patients is currently in the development phase.

Medical advances which have marked the history of transplantation include the work of Jean Dausset on the HLA system from 1952, brain death described in 1959 and prolonged organ preservation. This article looks back at the major turning points.

Background There are discrepancies regarding the impact of preemptive 2nd kidney transplantation (PSKT) on graft survival. The present study aimed to determine whether the association between PSKT and outcome varies over time and whether this association is era dependent. Methods A total of 266 patients underwent SKT (244 non-PSKT, 22 PSKT) in our center from 1985 to 2015. Association between PSKT and graft survival (allograft failure from any cause including death) was assessed with the use of Cox models. Results During a median follow-up of 6.7 years, 116 events were recorded: 72 returns to dialysis and 44 deaths before return to dialysis. Survival curves diverged up to 5 years (5-year survivals: PSKT, 94.1 ± 5.7%; non-PSKT, 76.8 ± 2.9%) but they converged thereafter (12-year survivals: PSKT, 50.9 ± 15.2%; non-PSKT, 55.5 ± 3.9%). After adjustment for age and living-donor status, PSKT tended to be associated with better graft survival (hazard ratio [HR], 0.18; 95% confidence interval [CI], 0.02–1.27; P = .08) within the first 5 years of SKT but tended to be associated with worse outcome thereafter (HR, 2.36; 95% CI, 0.97–5.72; P = .06; P for interaction with time = .04). In addition, a significant interaction was identified between PSKT and SKT year ( P for interaction = .04). In the multivariable model, the estimated HR for PSKT was 2.54 (95% CI, 0.88–7.35; P = .08) in 1990 as opposed to 0.16 (95% CI, 0.02–1.17; P = .07) in 2012. Conclusions The effect of PSKT on graft survival varies over time and according to year of the procedure. Although the benefit observed within the first 5 years of SKT appears to fade over time, overall graft survival seemingly improved in more recent years.

Adherence to immunosuppressive treatments is a major concern in transplanted patients.This 6-month French observational, longitudinal, prospective study aimed to assess patient adherence to and acceptance of once-daily tacrolimus (Advagraf) initiation in kidney and liver transplant recipients. Data from 1106 patients initiating once-daily tacrolimus during posttransplant follow-up were analyzed. Adherence and acceptance were assessed using self-administered questionnaires at inclusion and at 3 and 6 months.Mean age was 52.4 ± 13.2 years, 61.5% were men. For 94.9% of patients, once-daily tacrolimus was prescribed after switching from twice-daily tacrolimus. At inclusion, 20.9% of patients reported good treatment adherence, 72.0% minor nonadherence, and 7.1% were nonadherent. Mean general acceptance score (range, 0-100) was 77.7 (±24.7). At 3 months, adherence was improved in 21.1%, unchanged in 69.2%, and worsened in 9.7% of patients. Mean general acceptance score was 75.4 (±26.5). General acceptance score was improved in 28.0%, unchanged in 39.4%, and worsened in 32.7% of patients. At 6 months, similar changes in adherence and acceptance were observed. Higher general acceptance score at month 3 was significantly associated with better adherence at month 6.Conversion to once-daily tacrolimus led to an improved rate of adherence at month 3 in more than 20% of patients and a worsened rate of adherence in less than 10% of patients.

International audience; After the first year post transplantation, prognostic mortality scores in kidney transplant recipients can be useful for personalizing medical management. We developed a new prognostic score based on 5 parameters and computable at 1-year post transplantation. The outcome was the time between the first anniversary of the transplantation and the patient's death with a functioning graft. Afterwards, we appraised the prognostic capacities of this score by estimating time-dependent Receiver Operating Characteristic (ROC) curves from two prospective and multicentric European cohorts: the DIVAT (Données Informatisées et VAlidées en Transplantation) cohort composed of patients transplanted between 2000 and 2012 in 6 French centers; and the STCS (Swiss Transplant Cohort Study) cohort composed of patients transplanted between 2008 and 2012 in 6 Swiss centers. We also compared the results with those of two existing scoring systems: one from Spain (Hernandez et al.) and one from the United States (the Recipient Risk Score, RRS, Baskin-Bey et al.). From the DIVAT validation cohort and for a prognostic time at 10 years, the new prognostic score (AUC = 0.78, 95%CI = [0.69, 0.85]) seemed to present significantly higher prognostic capacities than the scoring system proposed by Hernandez et al. (p = 0.04) and tended to perform better than the initial RRS (p = 0.10). By using the Swiss cohort, the RRS and the the new prognostic score had comparable prognostic capacities at 4 years (AUC = 0.77 and 0.76 respectively, p = 0.31). In addition to the current available scores related to the risk to return in dialysis, we recommend to further study the use of the score we propose or the RRS for a more efficient personalized follow-up of kidney transplant recipients.

Background Although chronic kidney disease (CKD) affects a growing number of people, epidemiologic data on incident CKD in the general population are scarce. Screening strategies to increase early CKD detection have been developed. Methods From a community-based sample of 4,409 individuals residing in a well-defined geographical area, we determined the number of patients having a first serum creatinine value ≥1.7 mg/dL and present for at least 3 months that allowed us to calculate an annual incidence rate of CKD (stages 3 to 5). CKD (stages 3 to 5) was defined by estimated glomerular filtration rate (eGFR)

Changing trends concerning the incidence, sociodemographic features, and comorbidities observed among patients, starting their first renal replacement therapy by dialysis were studied in nine geographic regions in France participating in the REIN registry from 2004 to 2009. The standardized incidence of patients on dialysis remained stable while patient age tended to increase. After adjustment for age, the overall number of comorbid conditions remained unchanged, with a decrease in the number of patients with cardiovascular disease. These results, together with trends in laboratory results, suggest that the general health status of the patient population remains unchanged despite increasing age and that care for chronic renal failure has improved, generating an environment of prudent optimism for the future.

This prospective, multicenter, proof-of-concept study aimed to evaluate the possibility to reduce the ordinary heparin dose and the systemic anti-Xa activity during hemodialysis (HD) sessions using a new heparin-grafted HD membrane. In 45 stable HD patients, the use of a heparin-grafted membrane with the ordinary heparin dose was followed by a stepwise weekly reduction of dose. Reduction was stopped when early signs of clotting (venous pressure, quality of rinse-back) occurred during two out of three weekly HD sessions. Heparin dose was decreased for 67% of patients resulting in the lowering of these patients' anti-Xa activity by 50%. Dose reductions were achieved with both types of heparin (low-molecular-weight heparin: 64 ± 14 to 35 ± 12 IU/kg, P0.0001; unfractionated heparin: 82 ± 18 to 46 ± 13 IU/kg, P0.0001) resulting in a decrease of anti-Xa activity at dialysis session end (low-molecular-weight heparin: 0.51 ± 0.25 to 0.25 ± 0.11 IU/mL, P0.0001; unfractionated heparin: 0.28 ± 0.23 to 0.13 ± 0.07 IU/mL, P0.0001). Failure to further decrease heparin dose was related to signs of clotting in blood lines (57% of sessions), in dialyzer (9%), or both (34%). Significant reduction of heparin dose and anti-Xa activity at the end of HD sessions was possible in stable HD patients using heparin-grafted membrane. HD patients who require low anti-Xa activity at the end of HD sessions might benefit from a heparin-grafted membrane to reduce bleeding risk and other heparin adverse events.

Background. Short-term intensified dosing using enteric-coated mycophenolate sodium (EC-MPS) reduces rejection after kidney transplantation without compromising safety and may facilitate steroid avoidance. Methods. In a 6-month, multicentre open-label trial, 222 de novo kidney transplant recipients at low-immunological risk were randomized to steroid avoidance or maintenance steroids with interleukin (IL)-2 receptor antibody (IL-2RA) induction, EC-MPS (2160 mg/day to Week 6, 1440 mg/day thereafter) and cyclosporine. Results. The primary end point; treatment failure at Month 6 [biopsy-proven acute rejection (BPAR), graft loss, death or loss to follow-up], occurred in 17.9% (20/ 112) of steroid-avoidance patients and 14.5% (16/110) of controls (difference 3.4%, 95% confidence interval -6.3 to 13.1, P = 0.47 for superiority testing). BPAR occurred in 11.6 and 7.3% of patients in the steroid-avoidance and control arms, respectively (P = 0.27). Creatinine clearance was similar at Month 6 (steroid-avoidance 56 ± 18 mL/ min/1.73m 2 , controls 60 ± 22 mL/min/1.73m 2 , P = 0.34). Cytomegalovirus infection, as reported by investigators, occurred in 12.5% of steroid-avoidance patients and 22.7% of controls (P = 0.045). Conclusions. A regimen of early intensified EC-MPS dosing with calcineurin inhibitor and IL-2RA induction permits oral steroid avoidance in adult kidney transplant patients at low-immunological risk without compromising efficacy at 6 months' follow-up.

Resume Face a la penurie de greffons renaux, l’alternative de la greffe a partir de donneur vivant est debattue. Le but de ce travail est de comparer, dans 16 pays europeens et d’Amerique du Nord ayant une activite consequente, les niveaux d’activite, leur historique et leur eventuel impact sur la penurie, rapportes jusqu’alors de facon parcellaire et ponctuelle. En 2009 et malgre une legere croissance, le taux francais de 3,5 greffes a partir de donneur vivant par million d’habitants (pmh) etait l’un des plus faibles devant l’Italie et la Finlande. De nombreux pays depassaient le taux de 14 pmh. D’autres comme l’Espagne et le Portugal connaissent une croissance reguliere alors que leur activite de greffe est basee sur le donneur decede. Cette croissance est aussi observee en Allemagne et en Autriche. La France malgre une activite globale de greffe en augmentation a un niveau de penurie important (2,7 inscrits en 2009 pour une greffe) avant l’Italie, qui a une tres faible activite de greffe a partir de donneur vivant, le Portugal, dont l’activite est moins ancienne, mais aussi les Etats-Unis avec une incidence importante de l’insuffisance renale terminale et le Royaume-Uni qui a un faible taux de prelevement de donneurs decedes. Pour ces derniers, la France a un des taux les plus eleves mais il semble plafonner depuis trois ans. Ce constat devrait induire une veritable politique de la greffe a partir de donneur vivant avec un soutien aux professionnels de sante, l’information du grand public, des patients et de leur famille.

Aim This analysis was performed to assess the prevalence and the factors associated with hemoglobin (Hb) variability during treatment with erythropoiesis-stimulating agents (ESA) in France. Methods Hb variability was evaluated in a subgroup of hemodialysis (HD) patients of the French cohort DiaNE. Eligible patients had received epoetin-β at least 6 months before entering DiaNE, 12 months during DiaNE and had no missing monthly Hb measurements. Up and down excursions (Hb variations > 1.5 g/dl with duration > 8 weeks) were assessed. Results Of the 499 patients evaluated in this analysis, 295 (59%) had Hb levels inside the target range of 11 - 13 g/dl at baseline. The number of patients with constantly stable Hb level inside the target range decreased from baseline to 27.5% at 6 months and 10.8% at 12 months. More than 70% of patients experienced Hb variability. The number of excursions was 1.7 ± 0.8 per patient/year. The amplitude of up excursions was 2.8 ± 1.0 g/ dl with a duration of 14.7 ± 4.7 weeks. The amplitude of down excursions was 2.6 ± 0.9 g/dl with a duration of 14.5 ± 4.6 weeks. The main factors associated with Hb variability were number of epoetin-β dose changes, adverse events and iron therapy changes. Conclusion Hb variability is frequent in French ESA-treated HD patients and closely related to practices. Further efforts are needed to improve anemia management.

Resume L’etude observationnelle DiaNE dresse un etat des lieux, sur trois ans, de la prise en charge de l’anemie par Epoetine beta chez les patients hemodialyses en France au regard des recommandations europeennes. Les patients en cours de traitement par Epoetine beta 12 mois apres leur inclusion dans DiaNE etaient eligibles pour une phase d’extension de vingt-quatre mois intitulee « DiaNE 2 ». Les donnees concernant 439 patients suivis pendant trois ans, de M0 a M36, ont ete analysees. Le taux d’hemoglobine (Hb) de la cohorte est reste en moyenne au-dessus de la valeur cible de 11 g/dL durant l’etude (M0 : 11,3 ± 1,2 g/dL ; M36 : 11,8 ± 1,3 g/dL). La prise en charge de l’anemie a evolue avec les differentes mises a jour des recommandations europeennes et a ete conforme chez un patient sur trois au regard de l’intervalle cible recemment preconise (11–12 g/dL). Au cours du suivi, la majorite des patients (97 %) a eu au moins une modification du traitement par Epoetine beta (changement du rythme des injections, ajustement des doses) principalement justifiee par un taux d’Hb non conforme a la cible. Toutefois, la dose mediane d’Epoetine beta a peu varie. La proportion de patients ayant recu un traitement martial est restee stable (60 %). Malgre les efforts entrepris, la prise en charge de l’anemie des patients hemodialyses doit encore etre optimisee en France afin de maintenir la stabilite du taux d’Hb dans l’intervalle cible recommande.

Background. Increased arterial stiffness (AS) is a major determinant of cardiovascular complications in end-stage renal disease (ESRD) patients. Little is known about AS evolution after kidney transplantation. The aim of the study was to characterize the evolution of AS after kidney transplantation in a population of ESRD patients, in comparison to those remaining in dialysis. Methods. Eighty-eight patients (age between 35 and 65) were recruited from the waiting list for kidney transplantation of the University Hospital of Nancy. Two vascular evaluations were performed at a 1-year interval. During this interval, 39 patients were transplanted and 49 remained in dialysis. Results. At inclusion, median pulse-wave velocity (PWV) was similar in transplanted patients and transplantationpending patients, respectively, 9.2 (7.9–11.9) and 9.8 (7.7–12.1) m/s. No difference between the two groups was found at the 1-year interval. Median of time after transplantation was 6.3 (3.8–10.1) months. Median of blood pressure (MBP) decreased only in the transplanted patients [99 (93–112) versus 96 (90–101) mmHg, P < 0.01] Multivariate analysis showed that PWV changes depend on changes in MBP and baseline PWV. Conclusion. Although no difference in the 1-year PWV evolution was found, the low MBP value in transplanted patients allow to expect a better long-term evolution of AS and a better cardiovascular prognosis after kidney transplantation than in transplantation-pending patients.

Renal transplantation in patients with autosomal dominant polycystic kidney disease (ADPKD) is a medical and surgical challenge. Detailed longitudinal epidemiological studies on large populations are lacking and it is mandatory to care better for these patients. The success of such a project requires the development of a validated epidemiological database. Herein, we present the results of the largest longitudinal study to date on renal transplant in patients with ADPKD. The 15-year outcomes following renal transplantation of 534 ADPKD patients were compared with 4779 non-ADPKD patients. This comprehensive, longitudinal, multicenter French study was performed using the validated database, DIVAT (Donnees Informatisees et VAlidees en Transplantaion). We demonstrate that renal transplantation in ADPKD is associated with better graft survival, more thromboembolic complications, more metabolic complications, and increased incidence of hypertension, whereas the prevalence of infections is not increased. This study provides important new insights that could lead to a better care for renal transplant patients with ADPKD.

Resume La dialyse peritoneale (DP) est un traitement de l’insuffisance renale terminale dont les resultats sont au moins aussi bons sinon meilleurs que ceux de l’hemodialyse (HD) en termes de morbidite et mortalite, et meilleurs en termes de qualite de vie, en particulier quand le malade est traite sequentiellement par DP puis HD. De plus, le cout genere par un malade traite par DP est inferieur a celui du meme malade traite par HD, du moins dans les pays developpes. Or on constate dans la majorite des pays une stagnation ou une diminution de l’utilisation de la DP, dont on peut penser qu’elle n’a pas de raison medicale, mais peut-etre une cause economique. Les aspects economiques multiples et les divers postes de depense de la DP sont passes en revue, et les resultats des amenagements financiers pris dans tel ou tel pays sont analyses, en gardant comme reference le systeme francais de remboursement. En conclusion, des incitations economiques pourraient favoriser le developpement de la DP, a condition qu’elles ne portent aucun prejudice a certains intervenants (assurance maladie, etablissements, medecins ou malades), et qu’elles s’accompagnent d’une meilleure formation et information des medecins et des malades.

Large analyses have demonstrated that pre-emptive kidney transplantation (PKT) leads to significant improvements in patient and graft survival when compared with transplantation performed after a period of dialysis. We analysed 1585 patients who received a first renal transplantation from a deceased donor between 2000 and 2004 in four French transplantation centres. The objective was to compare the characteristics of the deceased donor transplantations with or without previous dialysis and to evaluate the impact of PKT and length of dialysis on patient and graft outcomes. Mean age of recipients was 48.1 ± 13.4 years, 62% were men, and 118 (7.4%) of them received a pre-emptive transplantation. For the nonpre-emptive patients, mean time on pretransplant dialysis was 3.4 ± 3.2 years. Pretransplant factors independently related to pre-emptive transplantation were year of transplantation, centre and recipients characteristics: gender, diabetes history, blood group and donor age. Patients with pretransplant dialysis were three times more likely to have delayed graft function than pre-emptive transplant patients, and were 10 times more likely to receive post-transplant dialysis. Five-year patient survival was 92.9%. Five-year graft survival was 89.0%. Neither pre-emptive transplantation nor time on dialysis was significantly associated with patient and/or graft survival.

Resume La Segmental arterial mediolysis (SAM) est une pathologie vasculaire rare non inflammatoire, non atheromateuse, d’etiologie indeterminee, a l’origine de complications ischemiques ou hemorragiques realisant typiquement un tableau d’hemorragie intra-abdominale engageant le pronostic vital. La maladie evolue classiquement sur un mode aigu avec mediolyse segmentaire des arteres de moyens calibres, puis laisse place a des lesions vasculaires chroniques. Le diagnostic de certitude est histologique mais rarement realisable en pratique en l’absence de complication chirurgicale. La prise en charge therapeutique et le suivi de la maladie au long court est affaire d’equipe en l’absence de recommandation existant a notre connaissance sur le sujet. Chez notre patiente l’interet est double : d’une part, le mode de presentation atypique avec un tableau d’hypertension arterielle renovasculaire et, d’autre part, la decouverte lors du bilan de la coexistence de lesions vasculaires aigues et de lesions dysplasiques d’allure chronique laissant entrevoir la possibilite de recurrence dans l’evolution naturelle de la maladie. Nous decrivons aussi le lien existant entre infarctus renal et SAM et la similitude existant entre les lesions vasculaires chroniques de SAM et les lesions de dysplasie fibromusculaire, faisant discuter le cadre nosologique de ces atteintes, l’une n’etant peut-etre qu’une forme evolutive de l’autre.

In recent years, the population of dialysis patients has become frailer and older. Patients present with more comorbid conditions and experience more complications during their follow-up. The aim of the present study is to describe the workload of the dialysis center during hemodialysis sessions and determine whether comorbidities are associated with increased workload. We conducted a retrospective multicentric study on a sample population of 123 patients selected from a dialysis population within a regional network. We described hospitalizations and HD sessions during a 1-year follow-up. We collected data on 19 prescriptions and events occurring during HD sessions. We described two HD care profiles (easy and difficult) and looked for variables linked with these profiles. We found that age more or equal to 60 years, elevated C-reactive protein and HD catheters are associated with difficult HD care. Surprisingly, apart from heart failure, comorbidities were not linked to greater workload during HD sessions. The development of HD care profiles should be helpful in early detection of frailer patients. This could have concrete applications such as better allocation of human and material resources and better training for the dialysis staff.

Resume Le taux de donneurs en etat de mort encephalique (EME) par million d’habitants sert a suivre et a comparer l’activite relative au don d’organes mais il ne permet pas d’estimer le potentiel de donneurs en EME. La comparaison des chiffres fournis par les statistiques des causes de deces, les etudes specifiques sur le potentiel et le programme de medicalisation des systemes d’information (PMSI) permettent d’etablir une fourchette de 3500 a 4000 deces avec EME en France. En 2007, 3147 donneurs en EME ont ete effectivement recenses et 9691 malades toujours inscrits debut 2007 ou nouvellement inscrits en 2007 sur liste d’attente de greffe de rein. La comparaison des statistiques de deces est en faveur d’un potentiel d’EME similaire entre la France et l’Espagne, pays qui affiche le taux de donneurs preleves le plus eleve et qui represente la reference a atteindre. Le meilleur taux observe en Espagne est lie a l’opposition au don plus faible (15 % versus 30 % en France), mais son benefice est diminue par un nombre important de greffons preleves et non greffes (28 % versus 13 % en France). La baisse du niveau d’opposition et l’augmentation des niveaux d’activite de certaines regions sont des actions a promouvoir mais difficiles a atteindre et leur impact sur l’activite de greffe est limite. Le developpement du prelevement chez le donneur vivant et le donneur a cœur arrete, existant ou en cours de mise en place dans de nombreux pays, doit etre pris en compte face a un niveau de penurie en 2007 de 3,7 malades en attente pour un greffon renal preleve chez un donneur en EME et greffe, et de 3,3 pour tous types de donneurs.

Resume Introduction La transplantation renale a partir d’un donneur vivant est une methode de choix pour pallier le deficit d’organes. La nephrectomie laparoscopique grâce a ses avantages en termes de morbidite s’est developpee dans ce sens. La securite du geste peut etre amelioree par une assistance robotique. Methode Nous rapportons les 35 premiers prelevements assistes par robot utilises par notre centre. Resultats Apres des explorations anatomiques et fonctionnelles precises, tous les donneurs ont choisi l’option du prelevement par cœliochirurgie assistee par robot. La duree moyenne d’hospitalisation a ete de 5,5 jours. La creatininemie moyenne a un, deux, trois et quatre ans a ete respectivement de 107, 104, 91 et 71 μmol/l. Concernant les receveurs, aucune dialyse n’a ete necessaire apres la greffe. Aucune complication vasculaire n’a ete observee. Les complications urologiques ont ete : six lymphoceles, une stenose ureterale et une necrose ureterale. Dix patients (29 %) ont presente 16 rejets prouves par biopsie. Apres un suivi moyen de 3,8 ± 1 ans, la survie des donneurs et des receveurs est de 100 % a quatre ans et 34 greffons sont fonctionnels avec une creatininemie moyenne de 107, 124, 125 μmol/l respectivement a un, deux, trois et quatre ans. Conclusions Au vu de la tres faible morbidite et des bons resultats a long terme concernant donneurs et receveurs, la laparoscopie robot-assistee semble etre une technique sure et efficace. En offrant des conditions optimales au chirurgien preleveur, elle pourrait contribuer a l’augmentation du nombre de greffes realisees avec donneur vivant en France.

Objectifs - Estimer l'incidence de l'insuffisance renale chronique en population generale et decrire les caracteristiques des patients incidents. Methodes - Entre le 1 er avril 2004 et le 30 juin 2006 tous les nouveaux cas d'insuffisance renale chronique dans l'agglomeration nanceienne ont ete recenses de facon prospective. Tous les dosages de creatininemie ≥ 150 μmol/l (ou seuils pediatriques equivalents) ont ete declares par tous les laboratoires de biologie medicale de l'agglomeration. Les criteres d'inclusion etaient: avoir un premier dosage posterieur au 1 er avril 2004, avoir au moins un dosage avec les memes criteres sur une periode de trois mois et resider dans l'agglomeration nanceienne. Resultots - Pres de 50 000 dosages de creatinine ont ete declares, pour plus de 4 400 patients. Parmi eux, seulement 631 etaient des patients incidents. L'incidence annuelle de l'insuffisance renale chronique en population a ete estimee a 1 ‰ habitants (1,3 ‰ chez les hommes et 0,7‰ chez les femmes). Les patients sont tres âges (77 ans en moyenne), atteints de multiples pathologies (diabete: 34 %, insuffisance cardiaque: 23 %) et plus de 30 % sont diagnostiques a un stade severe de l'insuffisance renale (< 30 ml/min/1,73 m 2 ). Conclusion - L'incidence de l'insuffisance renale chronique est environ 10 fois plus elevee que celle de l'insuffisance renale terminale en France. Un nombre important de patients sont diagnostiques a un stade avance alors qu'ils pourraient etre identifies plus precocement et beneficier d'une prise en charge anticipee, pluridisciplinaire et adaptee.

Resume Depuis fin 2004, la Lorraine est confrontee a une epidemie de colonisation digestive a enterocoques resistants aux glycopeptides (ERG). Elle a debute au centre hospitalier universitaire de Nancy ou elle a evolue en deux phases successives : une premiere bouffee a ete maitrisee en 2005 grâce a un renforcement de l’hygiene des mains et a des mesures de regroupement. Puis, apres une accalmie d’un an, seules des mesures de promotion exclusive de desinfection des mains par friction avec des produits hydro-alcooliques et de cohorting ont lentement permis de contenir cette seconde bouffee epidemique a la mi-2008. Mais l’epidemie a diffuse a partir de 2007 a d’autres etablissements de la region. Une mission regionale, diligentee par l’agence regionale d’hospitalisation, a alors edicte, sur la base des recommandations nationales, mais en tenant compte du caractere deja installe de l’epidemie et de la specificite de chaque etablissement confronte, une serie de procedures destinees a guider les soignants dans leurs prises en charge. Ainsi, une liste des services concernes par l’ERG est diffusee de facon hebdomadaire afin d’optimiser la politique de depistage et d’isolement probabiliste lors des transferts dans la region et une conduite a tenir pour la prise en charge specifique des patients colonises par l’ERG en service d’hemodialyse a ete proposee. L’ensemble de ces mesures a donne lieu a la creation d’un guide pratique pour la prise en charge d’une epidemie a ERG. Au total, plus de 900 cas de colonisations a ERG ont ete recenses en Lorraine entre 2004 et 2008. L’application des mesures decrites ci-dessus, au niveau du CHU mais aussi de la region, semble avoir permis le controle de l’epidemie.