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International audience; Objectives: Pneumococcal immunization is recommended in dialysis patients. We aimed to estimate pneumococcal vaccination coverage among patients who initiate dialysis in France, and its association with mortality. Methods: Data were extracted from two prospective national databases, merged using a deterministic linkage method: renal epidemiology and information network (REIN) registry, which includes all patients on dialysis and kidney transplants recipients in France, and the national health insurance information system (SNIIRAM) which collects individual data on health expenditure reimbursement, including vaccines. We enrolled all patients who initiated chronic dialysis in 2015. Data on health status at dialysis initiation, dialysis modalities, and pneumococcal vaccine prescribed from 2 years before to 1 year after dialysis start were collected. Univariate and multivariate Cox proportional hazard models were used to assess one-year all-cause mortality. Results: Among the 8,294 incident patients included, 1,849 (22.3 %) received at least one pneumococcal vaccine before (n = 542, 6.5 %), or after (n = 1,307, 15.8 %) dialysis start, as follows: 13-valent pneumococcal conjugated vaccine (PCV13) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23), n = 938 (50.7 %); only PPSV23, n = 650 (35.1 %); or only PCV13, n = 261 (14.1 %). Vaccinated patients were younger (mean, 66.5 ± 14.8 years vs. 69.0 ± 14.9 years, P ≤ 0.001), more likely to suffer from glomerulonephritis (17.0 % vs. 11.0 %, P ≤ 0.001), and less likely to start dialysis in emergency (27.2 % vs. 31.1 %, P = 0.001). On multivariate analysis, patients who received PCV13 and PPSV23, or only PCV13 were less likely to die (respectively, HR = 0.37; 95 %CI 0.28–0.51, and HR = 0.35; 95 %CI 0.19–0.65). Conclusions: Pneumococcal immunization with PCV13 followed by PPSV23, or with PCV13 alone, but not with PPSV23 alone, is independently associated with decreased one year-mortality in patients who start dialysis.

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.

International audience; Background: Recently, many research groups have tried to develop emergency department triage decision support systems based on big volumes of historical clinical data to differentiate and prioritize patients. Machine learning models might improve the predictive capacity of emergency department triage systems. The aim of this review was to assess the performance of recently described machine learning models for patient triage in emergency departments, and to identify future challenges.Methods: Four databases (ScienceDirect, PubMed, Google Scholar and Springer) were searched using key words identified in the research questions. To focus on the latest studies on the subject, the most cited papers between 2018 and October 2021 were selected. Only works with hospital admission and critical illness as outcomes were included in the analysis.Results: Eleven articles concerned the two outcomes (hospital admission and critical illness) and developed 55 predictive models. Random Forest and Logistic Regression were the most commonly used prediction algorithms, and the receiver operating characteristic-area under the curve (ROC-AUC) the most frequently used metric to assess the algorithm prediction performance. Random Forest and Logistic Regression were the most discriminant models according to the selected studies.Conclusions: Machine learning-based triage systems could improve decision-making in emergency departments, thus leading to better patients’ outcomes. However, there is still scope for improvement concerning the prediction performance and explicability of ML models.

International audience; Background: Recently, many research groups have tried to develop emergency department triage decision support systems based on big volumes of historical clinical data to differentiate and prioritize patients. Machine learning models might improve the predictive capacity of emergency department triage systems. The aim of this review was to assess the performance of recently described machine learning models for patient triage in emergency departments, and to identify future challenges.Methods: Four databases (ScienceDirect, PubMed, Google Scholar and Springer) were searched using key words identified in the research questions. To focus on the latest studies on the subject, the most cited papers between 2018 and October 2021 were selected. Only works with hospital admission and critical illness as outcomes were included in the analysis.Results: Twenty-one articles concerned the two outcomes (hospital admission and critical illness) and developed 75 predictive models. Random Forest and Logistic Regression were the most commonly used prediction algorithms, and the receiver operating characteristic-area under the curve (ROC-AUC) the most frequently used metric to assess the algorithm prediction performance. Boosting, Random Forest and Logistic Regression were the most discriminant models according to the selected studies.Conclusions: Machine learning-based triage systems could improve decision-making in emergency departments, thus leading to better patients’ outcomes. However, there is still scope for improvement concerning the prediction performance and explicability of ML models.

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.

International audience; The study objective was to estimate the effect of social deprivation estimated by the European Deprivation Index (EDI) on the risk of death and graft failure on renal transplantation in France. EDI was calculated for 8701 of 9205 patients receiving a first renal transplantation between 2010 and 2014. Patients were separated in EDI quintiles of the general population. A Cox model (cs-HR cause-specific hazard ratio of death or graft failure) and a Fine and Gray model (sd-HR subdistribution hazard ratio of death and graft failure) were used for the analysis. The 5th quintile group (most deprived) accounted for 32% of patients [2818 of 8701]. In the multivariate analysis, compared with quintile 1, the risk of death was higher for the 5 quintile group in the complete cohort [cs-HR 1.31, 95% CI (1.01-1.70), sd-HR 1.29, 95% CI (1.00-1.68)], in the deceased donor group [cs-HR 1.31, 95% CI (1.00-1.71), sd-HR 1.30, 95% CI (1.00-1.70)] but not in living donor transplant patients. There was no association between the EDI groups and the risk of transplant failure. Social deprivation estimated by the EDI is associated with an increased risk of death in transplantation in France but not with the chance of allograft loss.

Resume Objectif Il s’agit de mesurer la surveillance et l’incidence des effets indesirables renovasculaires des anti-angiogeniques en population reelle. Methode Sont inclus dans cette etude de pratique descriptive, retrospective, monocentrique, les patients âges d’au moins 18 ans, traites oralement par anti-angiogeniques et suivis en consultation par les infirmieres cliniciennes. La variable d’interet principale est l’incidence de l’hypertension arterielle (HTA) a trois mois de traitement. Resultats Du 1er janvier 2011 au 31 juillet 2014, 324 patients ont ete inclus, dont 53 % d’hommes. L’âge moyen est de 62 ± 13 ans. Les antecedents sont : 37 % d’HTA, 17 % d’insuffisance renale chronique, 21 % de nephrectomie, 13 % de diabete. Les cancers les plus frequents sont : rein (31 %), foie (23 %), sein (16 %). Les molecules le plus utilisees sont le sorafenib (30 %), le sunitinib (23 %) et l’everolimus (16 %). La pression arterielle a ete mesuree a l’initiation du traitement chez 157 patients (48 %). Parmi eux, 55 (35 %) vont presenter une HTA selon la definition « oncologique » au cours des trois premiers mois de traitement, contre 59 (38 %) selon la definition classique ; 30 patients (19 %) ne repondent qu’a une seule definition. En analyse multivariee, les variables significativement associees a la survenue d’une HTA sont l’âge (OR = 1,04 ; IC 95 % 1,02–1,08 ; p Conclusion Dans notre cohorte, seuls 48 % des patients ont eu une mesure de la pression arterielle avant traitement. L’HTA sous anti-angiogeniques est probablement sous-estimee car non systematiquement recherchee. L’âge et l’antecedent de nephrectomie semblent etre correles a la survenue d’une HTA.

Studies at the population level must take into account the effect of social insecurity and socioeconomic inequalities on the patient outcomes. Socioeconomic inequalities depend on many determinants that are socially determined. In renal transplantation, these social determinants are not registered in the databases. The European Deprivation Index (EDI) is a composite index of social vulnerability with a French version. The EDI is an ecological measure of deprivation including the individual perception of basic needs for daily life that is called "subjective poverty". The Townsend index, Carstairs index and the Index of Multiple Deprivation are other ecological index available. It has been demonstrated in the United States that socioeconomic indicators of deprivation were associated with both the access to the waiting list for renal transplantation and transplantation failure. In France, socioeconomic deprivation may also affect the access to the waiting list and outcome of transplantation. This article is a review about deprivation and renal transplantation.

Resume But de l’etude Le parcours de soins coordonne implique que les patients doivent etre adresses aux specialistes, par exemple les nephrologues, par un autre medecin. Il n’existe cependant pas de liste des motifs justifiant le recours a un nephrologue, ni de donnees sur les motifs effectivement rencontres par ces specialistes en consultation. Notre etude a pour objectif principal de decrire les motifs de primo-consultations en nephrologie dans le territoire de sante 5 de Bretagne. Methode Nous avons recueilli retrospectivement les courriers issus des primo-consultations realisees par les 17 nephrologues du territoire de sante, dans 4 centres, pendant l’annee 2014. Dans ces courriers, nous avons releve le motif de consultation, la specialite du medecin adressant le patient, ainsi que les principales caracteristiques des patients. Resultats Nous avons inclus 662 primo-consultations. Le principal motif de consultation etait la maladie renale chronique (68,7 %), dont l’insuffisance renale chronique (56,9 %), la proteinurie (7,3 %), l’hematurie microscopique (3,3 %) et la recherche d’une maladie renale chronique en presence de facteur de risque (1,2 %). Les autres motifs frequents etaient la consultation de controle au decours d’une grossesse compliquee de pre-eclampsie (9,5 %), la maladie lithiasique (5,7 %), l’hypertension arterielle (3,8 %) et les troubles hydro-electrolytiques (3,5 %). Les motifs ne relevant pas de la nephrologie representaient 3,2 % des primo-consultations. Les patients ont ete adresses par un medecin (99,7 %), et principalement un medecin generaliste (71,9 %). Conclusion Les primo-consultations de nephrologie sont realisees dans le respect du parcours de soins puisqu’elles font quasiment toutes suite a la demande d’un autre medecin. Les motifs sont appropries a la specialite. Le plus frequent est la maladie renale chronique, souvent associe a une insuffisance renale chronique.

Introduction Les donnees sont limitees sur la couverture vaccinale antipneumococcique et l’impact de cette immunisation parmi les patients dialyses. Methodes Cette etude observationnelle, retrospective, nationale, avait pour objectifs d’estimer la couverture vaccinale selon les differents schemas vaccinaux chez les patients qui demarraient la dialyse chronique en France en 2015, et l’impact de cette vaccination sur la mortalite, selon les caracteristiques des patients et le schema vaccinal. Les donnees ont ete extraites de deux bases de donnees nationales, selon un rapprochement indirect par une methode de regroupement deterministe : le Reseau Epidemiologique et Information en Nephrologie (REIN), et le Systeme National d’Information Inter-Regime de l’Assistance Maladie (SNIIRAM). Les caracteristiques a l’initiation de la dialyse et la vaccination antipneumococcique prescrite 2 ans avant et 1 an apres l’initiation de la dialyse, ont ete collectees. Des analyses de Cox univariees et multivariees ont permis d’evaluer la mortalite toute cause a 1 an. Resultats obtenus ou attendus Parmi les 8294 patients inclus, 1849 (22,3 %) patients ont recu une vaccination antipneumococcique. Parmi ces patients, 35,1 % ont recu le Vaccin Pneumococcique Polyosidique 23 valences (VPP23) seul, 50,7 % le Vaccin Pneumococcique Polyosidique Conjugue 13 valences (VPC13) suivi du VPP23, et 14,1 % seulement le VPC13. Les patients vaccines etaient plus jeunes, ayant plus d’antecedents de glomerulonephrite, et demarrant la dialyse en programme. Apres ajustement sur les donnees clinico-biologiques et le contexte de demarrage de la dialyse, les patients ayant recu le VPC13 seul ou associe au VPP23, avaient moins de risque de deceder (respectivement, HR = 0,35 ; IC95 % : 0,19–0,65, et HR = 0,37 ; IC95 % : 0,28–0,51) ( Fig. 1 ). Conclusion La vaccination antipneumococcique par le VPC13 associe ou non au VPP23, mais pas par le VPP23 seul, est associee a une diminution de la mortalite a 1 an chez les patients demarrant la dialyse. Les patients demarrant la dialyse devraient recevoir une vaccination contre le pneumocoque par le VPC13.

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.

Introduction En France comme ailleurs dans le monde, l’acces a la transplantation a partir de donneurs decedes est largement limite par la penurie de greffons et partout on constate un allongement du temps d’attente pour les candidats a la transplantation. Afin d’apporter de nouveaux elements susceptibles d’optimiser l’allocation des greffons, nous avons cherche a identifier les facteurs de risque de mortalite des patients insuffisants renaux dialyses apres leur inscription sur liste d’attente, en prenant en compte la competition pour ces patients entre le deces et la transplantation. Methodes Pour repondre a cet objectif, nous nous sommes appuyes sur le registre national REIN (Reseau epidemiologie et information en nephrologie) pour les donnees des patients dialyses et sur le registre national Cristal pour les dates d’inscription sur liste d’attente de transplantation. Nous avons estime un modele original de melange pour prendre en compte les risques competitifs. Il possede la particularite de distinguer les facteurs associes a la probabilite de deceder plutot que d’etre transplante et les facteurs associes a la vitesse d’apparition de chacun des evenements, ce qui n’est pas le cas des modeles plus classiques. Resultats Au total, 9852 patients dialyses inscrits sur liste d’attente pour la premiere fois ont ete inclus. Nous avons montre que l’âge a l’inscription superieur a 40 ans, les comorbidites (diabete, antecedents cardiovasculaire ou de neoplasie), le groupe sanguin O ou B, la maigreur, une duree prolongee de dialyse avant inscription sur liste et une immunisation anti-HLA de classe I en pre-transplantation etaient fortement associes a la probabilite de deceder avant d’etre transplante apres avoir ete inscrit sur liste d’attente. Nous avons de plus mis en evidence une survenue retardee de la transplantation pour les patients transplantes de plus de 50 ans, de groupe sanguin O ou B, obeses ou immunises. Conclusion Dans cette etude, grâce a une methodologie adaptee, nous avons identifie certains facteurs de risque de mortalite des candidats a la transplantation qui pourraient etre pris en compte pour l’adaptation du systeme francais d’allocation des greffons. Ces resultats sont originaux grâce au modele utilise.

Hypertension is a leading risk factor for cardiovascular diseases. It affects nearly one out of three adults worldwide and ranks first in terms of disability-adjusted life years in women, and second in men behind smoking. However, hypertension prevalence varies between geographical regions and socioeconomic groups, and these variations are still poorly understood. Few studies have addressed these inequalities in France. In addition, little attention has been paid to social inequalities in hypertension incidence. In this context, the main objective of this thesis is to estimate and explain geographical and social inequalities in hypertension using data from two cohorts: the French CONSTANCES cohort which includes adults aged 18 to 69 years and recruited since 2012 (n=63,000) and the American HRS cohort which includes participants aged 50 and older followed since the 90s (n=17,000). This work highlights both strong geographical and socioeconomic disparities in the prevalence of hypertension in France. Marked socioeconomic inequalities also exist in the incidence of hypertension in the United States. However, behavioral and anthropometric determinants included in the analyses only partially explain the observed inequalities. Furthermore, the magnitude of inequalities and the associations between socioeconomic status, behavioral and anthropometric factors, and hypertension differ between men and women. This work provides new elements for a better identification of the most vulnerable populations and effective levers of action for prevention and reduction of inequalities in hypertension.; L’hypertension artérielle (HTA) est l’un des principaux facteurs de risque de maladies cardiovasculaires. Elle touche près d’un adulte sur trois dans le monde et occupe la première place en termes d’années de vie en bonne santé perdues chez les femmes, et la deuxième chez les hommes derrière le tabagisme. La prévalence de l’HTA, comme l’incidence, varient entre différentes zones géographiques mais également selon le statut socioéconomique. Ces inégalités territoriales et socioéconomiques sont cependant encore mal comprises. Or, peu de travaux se sont penchés sur ces inégalités en France et les études d’incidence de l’HTA restent rares. Dans ce contexte, l’objectif principal de cette thèse est d’estimer et d’expliquer les inégalités territoriales et sociales dans l’HTA. Les données de deux cohortes ont été exploitées : la cohorte française CONSTANCES qui regroupe des individus âgés de 18 à 69 ans et recrutés depuis 2012 (n=63 000) et la cohorte américaine HRS qui inclut des adultes de plus de 50 ans suivi depuis le début des années 90 (n=17 000). Ce travail met en évidence l’existence d’une part, de fortes disparités territoriales et d’autre part, d’inégalités sociales marquées de prévalence de l’HTA en France. Des inégalités sociales importantes sont également observées dans l’incidence de l’HTA aux Etats-Unis. Cependant, les déterminants comportementaux et anthropométrique pris en compte n’expliquent que partiellement les inégalités observées. Par ailleurs, l’ampleur des inégalités et la forme des associations entre statut socioéconomique, facteurs comportementaux et anthropométrique, et HTA diffèrent entre les hommes et les femmes. Ces travaux apportent de nouveaux éléments pour une meilleure identification des populations les plus vulnérables et des leviers d’action efficaces pour la prévention de l’HTA et la réduction des inégalités dans l’HTA.