Use of qualitative methods to optimize collaborative practices by highlighting differences in perceptions between professionals: an example of patient education

Interprofessional working must be approached within health promotion interventions using systematic methods to identify areas of suboptimal collaboration. We designed a qualitative study with a purposive sample of seven French therapeutic patient education programs. Semi-structured individual interviews were conducted with 14 healthcare providers and seven clinician leaders (coordinators) involved in patient education. We used the same interview guide and thematic grid regardless of the professional's profile to compare their perceptions on elements affecting outcome, participation and sustainability of programs. Healthcare providers and coordinators addressed non-convergent issues at both ends of a continuum from a micro-level nested in the program delivery to a macro-level corresponding to the structured implementation and sustainability of the program. Meso-level issues featured convergent perspectives. Our methodology could be used at the level of health services in a health system to provide a complete recovery of stakeholders' perspectives (without "blind spots" from one stakeholder or another). In our study, we focused on patient education in the French health system and pointed out possible considerations to optimize the functioning of programs. Such considerations include specific training plan development, encouraging reflection on the content and use of initial assessment, leading sessions in pairs to save on work time, and communication on the ins and outs of organizational imperatives that require healthcare providers' contributions.

What contextual features affect the outcome and sustainability of therapeutic patient education interventions?

BACKGROUND

Therapeutic patient education interventions are influenced by contextual factors. Therefore, describing the context is crucial to understanding how it can affect therapeutic patient education interventions and contribute to outcomes. We aimed to identify the contextual features that may affect the outcome and sustainability of therapeutic patient education interventions from a healthcare professional perspective.

METHODS

Semi-structured individual interviews were conducted with healthcare professionals involved in 14 therapeutic patient education interventions covering different chronic conditions (e.g., kidney and cardiovascular diseases, chronic pain, diabetes, obesity). Interviews were recorded and fully transcribed. We followed a general inductive approach to identify themes from healthcare professionals' discourse to properly capture their perception.

RESULTS

Saturation was achieved with 28 interviews with 20 nurses, 6 dieticians, one physiotherapist and one psychologist. The average therapeutic patient education experience was 7 years. Identified contextual features clustered in 5 main themes: 1) conditions for the development of the intervention (genesis of the program: Who and what prompted it?; supports; content development; legislative framework); 2) integration of the program (in the healthcare pathway or the environment, relationship with the institution or local environment); 3) teamwork cohesion, interaction and integration with the environment (exchanges, cohesion of the team); 4) sustainability of the program; and 5) patient and healthcare professional contextual factors.

CONCLUSION

New insights into contextual features that may be involved in therapeutic patient education interventions are represented in a framework based on the Medical Research Council evaluation framework. These features need to be addressed in studies of therapeutic patient education interventions and could help healthcare professionals build more effective interventions within the context. However, describing a list of elements of the context is not enough; analyses should also focus on how the contextual elements might affect an intervention and how they interact.

Evolution of HLA-sensitization according to immunosuppressive therapy management among kidney transplant patients returning to dialysis between 2008 and 2019: A French retrospective study

BACKGROUND

The optimal management of immunosuppressive therapy (IT) after kidney allograft failure (KAF) remains controversial. Although maintaining IT may reduce HLA-sensitization and improve access to retransplantation, it may also increase the rate of immunosuppression-related complications. The overall impact on patient mortality is unknown. The main objective of this study was to compare the evolution of HLA-sensitization 6 months after KAF according to IT management.

METHODS

Individual clinical and health care data were extracted from the French national end-stage kidney disease registry (Renal Epidemiology and Information Network [REIN]) and the French National Health Data system (SNDS), respectively. Patients aged > 18 years returning to dialysis after KAF between January 2008 and December 2019 in Lorraine were included. Patients were classified into two groups, IT continuation or IT discontinuation. HLA-sensitization was defined as an increase in incompatible graft rate (IGR) between KAF and 6 months post-KAF (change to a higher predefined category (0%-5%), (5%-20%), (20%-50%), (50%-85%), (85%-95%), (95%-98%), (98%-100%)). Secondary outcome was patient survival according to IT management.

RESULTS

A total of 121 patients were included, 35 (29%) of whom continued IT. HLA-sensitization after KAF tended to be higher in the "IT discontinuation" group (57% vs. 38% in the "IT continuation" group, p = .07). In multivariate analysis, IT continuation was associated with a lower increase in IGR (OR .37, 95% CI [.14; .93]). IT management was not associated with patient mortality.

CONCLUSIONS

Continuation of IT after KAF was associated with less change in IGR and was not associated with excess mortality.

The experience of relatives and friends of patients with moderate to advanced chronic kidney disease: Insights from the CKD-REIN cohort study

OBJECTIVES

The transition from chronic kidney disease (CKD) to kidney failure requiring kidney replacement therapy (KRT; i.e., dialysis or transplantation) to sustain life is a stressful event for patients. Families play a role in patients' treatment decision-making, but little is known about how they are involved. This study aimed to explore the experience of CKD among relatives and friends, their views and involvement in KRT choice.

DESIGN/METHODS

We conducted a qualitative study among 56 relatives or friends of patients with moderate to advanced CKD who were enrolled in the CKD-REIN cohort study. A psychologist conducted semi-structured interviews about their experience with CKD, treatment decision-making and their role in this process. Data were analysed using statistical text analysis.

RESULTS

The mean age of participants was 56.4 ± 14 years; 75% were women, 61% were patients' partners and 48% had a relative or friend with stage G4 CKD. The analysis yielded four lexical classes: listeners with an opinion, coping with CKD on a daily basis, narrating patients' nephrological monitoring and emotions behind facts. Participants reported a listening role in the decision-making period and information needs. Some reported that CKD had no impact on their own daily lives, but others talked about its current and future physical, psychological and social consequences on them, the patients and their relationships.

CONCLUSIONS

Most relatives/friends reported having little influence on KRT decision-making but expressed opinions on these treatments. Including relatives/friends in education on KRT and providing them with decision aids, especially when family members are supportive, may allow for more suitable decisions.

Pre-dialysis care trajectory and post-dialysis survival and transplantation access in patients with end-stage kidney disease

BACKGROUND

The pre-dialysis care trajectory impact on post-dialysis outcomes is poorly known. This study assessed survival, access to kidney transplant waiting list and to transplantation after dialysis initiation by taking into account the patients' pre-dialysis care consumption (inpatient and outpatient) and the conditions of dialysis start: initiation context (emergency or planned) and vascular access type (catheter or fistula).

METHODS

Adults who started dialysis in France in 2015 were included. Clinical data came from the French REIN registry and data on the care trajectory from the French National Health Data system (SNDS). The Cox model was used to assess survival and access to kidney transplantation.

RESULTS

We included 8856 patients with a mean age of 68 years. Survival was shorter in patients with emergency or planned dialysis initiation with a catheter compared to patients with planned dialysis with a fistula. The risk of death was lower in patients who were seen by a nephrologist more than once in the 6 months before dialysis than in those who were seen only once. The rate of kidney transplant at 1 year post-dialysis was lower for patients with emergency or planned dialysis initiation with a catheter (respectively, HR = 0.5 [0.4; 0.8] and HR = 0.7 [0.5; 0.9]) compared to patients with planned dialysis start with a fistula. Patients who were seen by a nephrologist more than three times between 0 and 6 months before dialysis start were more likely to access the waiting list 1 and 3 years after dialysis start (respectively, HR = 1.3 [1.1; 1.5] and HR = 1.2 [1.1; 1.4]).

CONCLUSIONS

Nephrological follow-up in the year before dialysis initiation is associated with better survival and higher probability of access to kidney transplantation. These results emphasize the importance of early patient referral to nephrologists by general practitioners.

The information system of REIN

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of its information system, the following key messages were retained. The REIN information system accompanies the register throughout the life cycle of the data. Two collection tools, one for dialysis, the other for transplantation are accessible via a secure WEB site. Several data quality control tools have been added. Finally, several reporting tools, including a geographic information system completes REIN’s information system.

REIN and international collaboration

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of its international role, the following key messages were retained. Right from its inception, the REIN registry has been integrated into the family of European registries under the direction of the European society ERA and its registry based at the Academic Medical Centre of Amsterdam. In this context, the registry has been a part of numerous international publications and projects financed by the European Commission. The expertise of the Agency of Biomedicine and REIN on the registries has been sought on several occasions in the context of setting up registries of replacement therapies. Several foreign students outside the European Union have also been able to come and work in the REIN national coordination.

REIN: a tool at the service of health monitoring, exemple of the SARS-Cov-2

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of its role in health monitoring, the following key messages were retained. The recent health crisis showed the adaptability and agility of the registry. Thanks to a human network that has been established and organised for many years, and the possibility of rapidly developing the collection system, the registry was able to provide information about the number of dialysis patients infected with the new SARS-Cov-2 from 30 March 2020. The use of REIN as a decision support and health monitoring tool in these times of empirical decisions has emerged as a strategic issue.

REIN: a tool at the service of the patients

On the occasion of the 20th anniversary of the REIN (French Renal Epidemiology and Information Network), a summary work on the contributions of the national French ESKD register was carried out. On the issue of patients’ perspectives, the following key messages were retained. As shown by the SONG (Standardised Outcomes in Nephrology) initiative, the criteria for judging the dialysis treatment that patients and care-givers prefer are not those that are traditionally found in published studies. For example, for haemodialysis, they are fatigue, ability to travel, time without dialysis, impact on family and ability to work. The concern to give the patients a voice has been at the heart of the REIN registry right from the outset. In addition, there are patient representatives in the REIN Scientific Council and the Steering Group. Although mainly focused on quantitative health data collected from professionals, REIN has also supported studies pertaining to data collected directly from patients. These studies enable addressing questions pertaining to the problems faced by patients in their care pathway and their life with the disease. The setting up of a tool for routine and electronic collection of the patients’ point of view in the evaluation of their treatment and the support of patient-initiated research contribute to positioning the REIN as a partner tool at the service of patients, unique in France.

Healthcare providers perception of therapeutic patient education efficacy according to patient and healthcare provider characteristics

OBJECTIVES

Therapeutic patient education improves numerous health and psychological outcomes in patients with chronic diseases. However, little is known about what makes a therapeutic patient education intervention more effective than another one. This study aims to identify in healthcare professionals the perceived determinants of therapeutic patient education efficacy at the individual level.

METHODS

Semi-structured individual interviews have been conducted with healthcare professionals (HCP, n=28, including 20 nurses) involved in therapeutic patient education programs (n=14) covering various chronic conditions (kidney and cardiovascular diseases, chronic pain, diabetes, etc.). A thematic content analysis following an inductive approach was used (Nvivo.11 software).

RESULTS

Five themes were retrieved for patient characteristics: understanding and education, personality, readiness and motivation, social environment, and misinformation and beliefs. Four themes were retrieved for healthcare professionals' characteristics: medical knowledge, appropriate attitude and relational skills, pedagogical skills, and training.

DISCUSSION

Patient personality is rarely discussed in the literature. Patients who are introverted, lack curiosity, or are not compliant might benefit from specific therapeutic patient education practices or formats. All these potential determinants regarding patients and healthcare professionals should be routinely assessed in future studies about therapeutic patient education efficacy to understand precisely what makes an intervention successful.

Cognitive performance is associated with glomerular filtration rate in patients with chronic kidney disease: results from the CKD-REIN cohort

BACKGROUND

Chronic kidney disease (CKD) is associated with cognitive impairment in general population. We assessed the association between kidney and cognitive functions in patients with CKD and the influence of cardiovascular (CV) risk factors, and depression on this association.

METHODS

The CKD-Renal Epidemiology and Information Network cohort included 3033 patients with CKD stages 3-4, followed for 5 years. Cognitive function was assessed with the Mini-Mental State Examination (MMSE) and estimated glomerular filtration rate (eGFR) with the CKD-Epidemiology Collaboration equation-creatinin formula. Evolution of the MMSE score over time and its association with baseline eGFR were investigated with linear mixed models. We assessed the risk of incident cognitive outcome (hospitalisation or death with relevant International Classification of Disease-10 codes), with a Cox proportional hazard model.

RESULTS

The mean age was 66.8, the mean eGFR was 33 mL/min/1.73 m² and 387 patients (13.0%) had an MMSE score below 24 at baseline. A 10 mL/min/1.73 m² decrement of baseline eGFR was associated with a mean MMSE decrease of 0.12 (95% CI 0.04 to 0.19) after adjustment for demographic characteristics, depression, CV risk factors and disease; but baseline eGFR was not associated with MMSE temporal evolution. HR for cognitive outcome during follow-up (median 2.01 years) associated with a 10 mL/min/1.73 m² decrement of baseline eGFR was 1.35 (1.07, 1.70) (p=0.01) after adjustment.

CONCLUSIONS

In patients with CKD, lower eGFR was associated with worse cognitive performance and incident cognitive events, independently of demographics, CV risk factors and depression.

TRIAL REGISTRATION NUMBER

NCT03381950.

Barriers to conservative care from patients' and nephrologists' perspectives: the CKD-REIN study

BACKGROUND

Conservative care is increasingly considered an alternative to kidney replacement therapy for kidney failure management, mostly among the elderly. We investigated its status and the barriers to its implementation from patients' and providers' perspectives.

METHODS

We analysed data from 1204 patients with advanced chronic kidney disease (CKD) [estimated glomerular filtration rate (eGFR) <30 mL/min/1.73 m2] enrolled at 40 nationally representative nephrology clinics (2013-16) who completed a self-administered questionnaire about the information they received and their preferred treatment option, including conservative care, if their kidneys failed. Nephrologists (n = 137) also reported data about their clinics' resources and practices regarding conservative care.

RESULTS

All participating facilities reported they were routinely able to offer conservative care, but only 37% had written protocols and only 5% had a person or team primarily responsible for it. Overall, 6% of patients were estimated to use conservative care. Among nephrologists, 82% reported they were fairly or extremely comfortable discussing conservative care, but only 28% usually or always offered this option for older (>75 years) patients approaching kidney failure. They used various terminology for this care, with conservative management and non-dialysis care mentioned most often. Among patients, 5% of those >75 years reported receiving information about this option and 2% preferring it.

CONCLUSIONS

Although reported by nephrologists to be widely available and easily discussed, conservative care is only occasionally offered to older patients, most of whom report they were not informed of this option. The lack of a person or team responsible for conservative care and unclear information appear to be key barriers to its implementation.

Five-Year Symptom Trajectories in Nondialysis-Dependent CKD Patients

BACKGROUND AND OBJECTIVES

Late stages of CKD are characterized by significant symptom burden. This study aimed to identify subgroups within the 5-year trajectories of symptom evolution in patients with CKD and to describe associated patient characteristics and outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Among 2787 participants (66% men) with eGFR <60 ml/min per 1.73 m2 enrolled in the CKD-Renal Epidemiology and Information Network (CKD-REIN) cohort study from July 2013 to May 2016, we assessed symptoms annually using the Kidney Disease Quality of Life-36 (KDQOL-36) questionnaire until December 2020. A total of 9121 measures were reported over follow-up; all participants had symptoms scored for at least one time point. We used a joint latent class-mixed model to distinguish profiles of symptom trajectories.

RESULTS

Patient mean age (±SD) at baseline was 67±13 years, and mean eGFR was 33±13 ml/min per 1.73 m2. The prevalence of each symptom ranged from 24% (chest pain) to 83% (fatigue), and 98% of participants reported at least one symptom. After a median (interquartile range) follow-up of 5.3 (3.4-6.0) years, 690 participants initiated KRT, and 490 died before KRT. We identified two profiles of symptom trajectories: a "worse symptom score and worsening trajectory" in 31% of participants, characterized by a low initial symptom score that worsened more than ten points over time, and a "better symptom score and stable trajectory" in 69% of participants, characterized by a high initial score that remained stable. Participants in the worse symptom score and worsening trajectory group had more risk factors for CKD progression at baseline, worse quality of life, and a higher risk of KRT and death before KRT than other participants.

CONCLUSIONS

This study highlights a significant worsening of symptoms in about one third of the participants, whereas the majority reported low symptom severity throughout the study.

Lack of Monitoring Is Associated with Risk of Acute Kidney Events among Patients with Inflammatory Bowel Disease

Background: Although the iatrogenic risk of kidney failure is infrequent with treatment for inflammatory bowel disease (IBD), the repercussions for the patient could be major. The aim of this study was to assess the incidence of kidney events in IBD and to examine the protective effect of kidney function monitoring. Methods: In the French National Health Insurance database, 94,363 patients had a diagnosis of IBD between January 2010 and December 2016. By using a survival model with time-dependent covariates, we analyzed the time from inclusion in this IBD cohort to the first hospitalization for acute kidney impairment (AKI) according to patient characteristics, comorbidities, IBD phenotype and presence of monitoring. Results: A total of 693 patients were hospitalized for AKI, with an incidence of 1.36/1000 person−years (95% confidence interval [CI] 1.26−1.47). The incidence of AKI was lower than those without 5-aminosalicylic acid (5-ASA) use. Patients with 5-ASA use rarely had any lack of monitoring as compared with those not under 5-ASA use (3% vs. 17%). On multivariate analysis, lack of monitoring was associated with a substantial risk of AKI (hazard ratio 3.96, 95% CI [3.20−4.90], p < 0.0001). Conclusions: Increased frequency of monitoring is essential to identify nephropathy at an early stage and avoid the progression to chronic kidney disease.

MO503: Cognitive Performance in Patients With Chronic Kidney Disease: Results From the CKD-Rein Cohort Study

BACKGROUND AND AIMS

Chronic kidney disease (CKD) is a risk factor for cognitive impairment. In the general population, many risk factors have been reported in association with incident major neurocognitive disorders. The link between CKD and cognitive dysfunction is not completely understood; it may involve different mechanisms such as vascular dysfunction or uremic toxin toxicity. We aimed to assess the influence of cardiovascular risk factors, cardiovascular disease and depression on the association between kidney function and cognitive function in patients with CKD.

METHOD

We analyzed baseline data from 3033 patients with CKD stage 3–5 included in the Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort between 2013 and 2016. Cognitive function was assessed with the Mini Mental State Examination (MMSE), and the glomerular filtration rate was estimated with the CKD EPI formula. We applied unadjusted and adjusted linear and logistic regression models, with the MMSE score as a continuous or categorical variable (at a cut-off point at 24/30).

RESULTS

The mean patient age was 66.8, the mean estimated glomerular filtration rate (eGFR) was 33 mL/min/1.73 m2 and 393 patients (13.0%) had a MMSE score &lt;24. We observed that, relative to patients with an MMSE score of 24 or more, patients with a score &lt;24 were older and more likely to be female and dependent on activities of daily living (ADL) and/or instrumental ADL. They were taking more medications and they were more affected by depressive symptoms as measured by the CES-D-10 (10 item Centre for Epidemiological Studies-Depression scale). Patients with a score &lt;24 were also more likely to present cardiovascular (CV) risk factors and CV comorbidities. They had a significantly higher parathyroid hormone level, lower haemoglobin, lower albumin and lower eGFR.

The eGFR was positively associated with the MMSE score before and after adjustment for age, sex, education level, cardiovascular risk factors, cardiovascular disease and depression, giving point increases in the MMSE score of 0.24 (0.15–0.33; P &lt; .001) and 0.14 (0.04–0.23; P = .006) for a 10 mL/min/1.73 m2 increment in the eGFR, respectively. Other risk factors significantly associated with a lower MMSE score in multivariate analysis were age, female sex, lower educational level, diabetes, obesity, cerebrovascular disease, atrial fibrillation and CES-D-10 score. The eGFR was associated with a low MMSE score (defined as MMSE score &lt;24/30) with a crude odds ratio (OR) of 0.82 (0.75–0.90), which remained significant at 0.88 (0.78–0.98) after adjustment for age, sex, educational level, cardiovascular risk factors (hypertension, diabetes mellitus, dyslipidaemia, obesity and smoking), cardiovascular comorbidities (cerebrovascular disease, atrial fibrillation and heart failure), history of depression, laboratory parameters (haemoglobin and phosphate) and CES-D score (after imputation of missing values).

CONCLUSION

In a cohort of well-phenotyped patients with CKD, lower eGFR is associated with worse cognitive function, independent of age, sex, educational level, cardiovascular injury and depression.

MO499: Incidence of Cause-Specific Cardiovascular Events in Men and Women With CKD

BACKGROUND AND AIMS

Men are at higher risk of cardiovascular disease (CVD) than women in the general population, and chronic kidney disease (CKD) is a well-established cardiovascular (CV) risk factor [1–4]. However, the incidence of cause-specific CV events in men and women with CKD is poorly documented.

METHOD

All hospitalization and death reports for CV events of the 3033 patients (1983 men and 1050 women) with non-dialysis CKD (stage 3–5) included in the French CKD-REIN Cohort were reviewed and classified by cause using criteria from the Cardiovascular and Stroke Endpoint Definitions for Clinical Trials [5]. Cause-specific Cox proportional hazard models were used to estimate hazard ratios for death and each fatal or nonfatal CV event according to gender.

RESULTS

At baseline, in men (mean age: 68 years; mean eGFR 33 mL/min/1.73 m²), the prevalence of atheromatous CVD was 30% for coronary artery disease, 14% for cerebrovascular disease and 17% for lower limb artery disease, and that of non-atheromatous CVD was 14% for heart failure and 13% for atrial fibrillation. In women (65 years old, 32 mL/min/1.73 m²), these prevalences were 15%, 7%, 9%, 11% and 9%, respectively.

During a median follow-up of 5 (IQR: 3–5) years, 98 men and 43 women died from CVD {i.e. 1.3 [95% confidence interval (95% CI): 1.0–1.5] versus 1.0 (0.7–1.3)/100 person-years}, including 53% versus 46% from heart failure, 31% versus 19% from sudden death, and 16% versus 35% from other cardiovascular causes, respectively.

Crude incidence rates of death or hospitalization for coronary artery disease and lower limb artery disease were higher in men than in women, slightly higher for CV death, cerebrovascular disease and atrial fibrillation, but similar for both genders for heart failure (Fig. 1). History of CVD was strongly associated with subsequent CV events of any type.

In multivariable analyses, gender was no longer associated with any cause-specific CV event, whereas a lower eGFR was significantly associated with an increased risk of coronary artery disease and heart failure, but not with other CV events (Table 1).

CONCLUSION

In patients with moderate or advanced CKD, the burden of atheromatous CVD is higher in men than in women and explained by their higher prevalence of cardiovascular risk factors, but that for heart failure and atrial fibrillation appears to be similar for both genders.

Vaccination and COVID-19 Dynamics in Dialysis Patients

BACKGROUND AND OBJECTIVES

Dialysis patients have a high mortality risk after coronavirus disease 2019 (COVID-19) and an altered immunologic response to vaccines, but vaccine clinical effectiveness remains unknown in this population.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Using Bayesian multivariable spatiotemporal models, we estimated the association between vaccine exposure and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) severe infections (with hospital admission) in dialysis patients from simultaneous incidence in the general population. For dialysis patients, cases were reported within the French end-stage kidney disease REIN registry from March 11, 2020, to April 29, 2021, and vaccine exposure (first dose) was reported in weekly national surveys since January 2021. Cases in the general population were obtained from the national exhaustive inpatient surveillance system (SI-VIC database), and vaccination coverage (first dose) was obtained from the national surveillance system (VAC-SI database).

RESULTS

During the first wave, incidence in dialysis patients was approximately proportional to the general population. However, we showed a lower relative incidence for dialysis patients during the second wave (compared with that observed in nondialysis patients), suggesting an effect of prevention measures. Moreover, from the beginning of the vaccination rollout, incidence in dialysis patients was lower compared with predictions based on the first and second waves. Adding vaccination coverages in dialysis and nondialysis patients as predictors allowed the reported cases to be fit correctly (3685 predicted cases, 95% confidence interval, 3552 to 3816, versus 3620 reported). Incidence rate ratios were 0.37 (95% confidence interval, 0.18 to 0.71) for vaccine exposure in dialysis patients and 0.50 (95% confidence interval, 0.40 to 0.61) per 10% higher in vaccination coverage in the same-age general population, meaning that vaccine exposure in dialysis patients and the general population was independently associated with lower hospitalization rate of dialysis patients.

CONCLUSIONS

Our findings suggest that vaccination may yield a protective effect against severe forms of COVID-19 in dialysis patients, despite altered immunologic vaccine responses.

Effectiveness and Tolerance of Renin-Angiotensin System Inhibitors With Aging in Chronic Kidney Disease

OBJECTIVES

Renin-angiotensin system inhibitors (RASi) are recommended for slowing chronic kidney disease (CKD) progression to kidney failure. Their effectiveness and tolerance as patients age remain uncertain because older patients have often been excluded from clinical trials.

DESIGN

CKD-REIN cohort study.

SETTING AND PARTICIPANTS

We studied 2762 patients with CKD stages 3 and 4 and a clinical indication for RASi enrolled between 2013 and 2016 in 40 nephrology clinics nationally representative in France.

METHODS

The primary outcome was the occurrence of kidney failure or death. The secondary outcomes were the occurrence of cardiovascular events and hospitalizations with acute kidney injury (AKI) or hyperkalemia. A propensity score analysis was performed. We used Cox models to estimate hazard ratios (HRs) for each outcome associated with RASi prescription and tested interactions with age.

RESULTS

Patients' mean age was 67 years, including 841 (30%) aged 75 years and older; 2178 (79%) were prescribed RASi's. During a median follow-up of 4.6 years, 33% of patients reached kidney failure or died. RASi prescription was associated with a lower risk of kidney failure or death (HR 0.79, 95% CI 0.66, 0.95), an association not modified by age (P for interaction = .72). It was not significantly associated with cardiovascular events. During the first 3 years of follow-up, 14% of patients were hospitalized with AKI or hyperkalemia, but risk was not higher among those prescribed RASi's (HR 0.75, 95% CI 0.55-1.02) and age did not modify its effect (P for interaction = .28).

CONCLUSIONS AND IMPLICATIONS

This study shows that aging does not appear to modify either RASi's beneficial effects on major CKD outcomes or their potential adverse effects.

Tailored patient therapeutic educational interventions: A patient-centred communication model

Background

Tailoring therapeutic education consists of adapting the intervention to patients' needs with the expectation that this individualization will improve the results of the intervention. Communication is the basis for any individualization process. To our knowledge, there is no guide or structured advice to help healthcare providers (HCPs) tailor patient education interventions.

Objectives

We used a data‐driven qualitative analysis to (1) investigate the reasons why HCPs tailor their educational interventions and (2) identify how this tailoring is effectively conducted. The perspective aimed to better understand how to individualize therapeutic patient education and to disentangle the different elements to set up studies to investigate the mechanisms and effects of individualization.

Design

Individual semistructured interviews with 28 HCPs involved in patient education were conducted. The present study complied with the COREQ criteria.

Results

Why individualization is necessary: participants outlined that the person must be thought of as unique and that therapeutic education should be adapted to the patient's personality and cognitive abilities. The first step in the individualization process was formalized by an initial patient assessment. Several informal practices were identified: if needed, giving an individual time or involving a specific professional; eliciting individual objectives; reinforcing the relationship by avoiding asymmetrical posture; focusing on patients' concerns; leading sessions in pairs; and making the patient the actor of decisions.

Conclusion

From our thematic data analysis, a model for tailoring patient education interventions based on the Haes and Bensing medical communication framework is proposed. The present work paves the way for evaluation, then generation of recommendations and finally implementation of training for individualization in educational interventions.

Short Informative

Tailoring in therapeutic education consists of an adaptation to patients' needs. Communication is the basis for any individualization process. There is no model of patient‐centred communication in educational interventions. From semistructured interviews with HCPs, we propose a patient‐centred communication model for tailoring patient education intervention.

Effect of age and care organization on sources of variation in kidney transplant waiting list registration

Despite national guidelines, medical practices and kidney transplant waiting list registration policies may differ from one dialysis/transplant unit to another. Benefit risk assessment variations, especially for elderly patients, have also been described. The aim of this study was to identify sources of variation in early kidney transplant waiting list registration in France. Among 16 842 incident patients during the period 2016-2017, 4386 were registered on the kidney transplant waiting list at the start of, or during the first year after starting, dialysis (26%). We developed various log-linear mixed effect regression models on three levels: patients, dialysis networks, and transplant centers. Variability was expressed as variance from the random intercepts (± standard error). Although patient characteristics have an important impact on the likelihood of registration, the overall magnitude of variability in registration was low and shared by dialysis networks and transplant centers. Between-transplant center variability (0.23 ± 0.08) was 1.8 higher than between-dialysis network variability (0.13 ± 0.004). Older age was associated with a lower probability of registration and greater variability between networks (0.04, 0.20, & 0.93 in the 18-64, 65-74, and 75-84 age groups). Targeted interventions should focus on elderly patients and/or certain regions with greater variability in waiting list access.

New Insights into Acute-on-Chronic Kidney Disease in Nephrology Patients: The CKD-REIN Study

BACKGROUND

Acute-on-chronic kidney disease (ACKD) is poorly understood and often overlooked. We studied its incidence, circumstances, determinants, and outcomes in patients with CKD.

METHODS

We used the Kidney Disease Improving Global Outcomes criteria to identify all-stage acute kidney injury (AKI) events in 3033 nephrology outpatients with CKD stage 3-5 participating in the CKD-REIN cohort study (2013-2020), and cause-specific Cox models to estimate hazard ratios (HR, 95% confidence intervals [CI]) of AKI-associated risk factors.

RESULTS

At baseline, 22% of the patients (mean age 67 years, 65% men, mean eGFR 32 ml/min/1.73m2) had a history of AKI. Over a 3-year follow-up, 443 had at least one AKI event: 27% were stage 2 or 3, and 11% required dialysis; 74% involved hospitalization including 47% acquired as hospital inpatients; a third were not reported in hospital discharge reports. Incidence rates were 10.1 and 4.8 per 100 person-years in patients with and without an AKI history, respectively. In 2375 patients without this history, male sex, diabetes, cardiovascular disease, cirrhosis, several drugs, low eGFR, and serum albumin levels were significantly associated with a higher risk of AKI, as were low birth weight (<2500 g) (adjusted HR, 1.98; 95%CI, 1.35 to 2.91) and hemoglobin level (HR 1.21; 1.12 to 1.32 per 1 g/dl decrease). Within one year, only 63% of the patients had recovered their previous kidney function, 13.7% had started kidney replacement therapy, and 12.7% had died.

CONCLUSIONS

The study highlights the high rate of hospital-acquired AKI events in patients with CKD, and their underreporting at hospital discharge. It also reveals low birth weight and anemia as possible new risk factors in CKD patients.

Knowledge of 5-aminosalicylic acid nephrotoxicity and adherence to kidney function monitoring of patients with inflammatory bowel disease

BACKGROUND AND AIM

5-Aminosalicylic acid (5-ASA) nephrotoxicity is a rare and idiosyncratic condition in patients with inflammatory bowel disease (IBD), which may lead to end-stage kidney failure. Kidney function monitoring is recommended in clinical practice to prevent this complication. However, no data is available regarding the knowledge and adherence of patients with IBD to this monitoring.

METHODS

As a part of routine practice, patients with IBD under treatment or previously treated with 5-ASA were systematically interviewed about knowledge of 5-ASA nephrotoxicity and adherence to kidney function monitoring. We reported here the experience among the first 103 consecutive patients seen in a French referral center.

RESULTS

A total of 103 patients (93.2% ulcerative colitis, 5.8% Crohn's disease, and 1% unclassified colitis) were analyzed. Among them, 70% were informed about the need for kidney function monitoring, and in most cases, information was provided by their gastroenterologist (94.4%). The adherence rate to monitoring was very high (84.7%). Monitoring consisted of serum creatinine and estimated glomerular filtration rate in most cases (97.2%), while 24-h proteinuria was less frequently used (69.4%). These tests were performed twice or ≥3 times per year by 44.4 and 41.7% of patients, respectively. One case of isolated elevation of proteinuria related to 5-ASA treatment was observed.

CONCLUSION

We reported for the first time that patients with IBD are well informed and adherent to kidney function monitoring of treatment with 5-ASA. The monitoring performed by their treating physician was generally in accordance with current recommendations.

Consequences of oral antithrombotic use in patients with chronic kidney disease

We assessed the risks of bleeding, acute kidney injury (AKI), and kidney failure associated with the prescription of antithrombotic agents (oral anticoagulants and/or antiplatelet agents) in patients with moderate‐to‐advanced chronic kidney disease (CKD). CKD‐REIN is a prospective cohort of 3022 nephrology outpatients with CKD stages 2–5 at baseline. We used cause‐specific Cox proportional hazard models to estimate hazard ratios (HRs) for bleeding (identified through hospitalizations), AKI, and kidney failure. Prescriptions of oral antithrombotics were treated as time‐dependent variables. At baseline, 339 (11%) patients (65% men; 69 [60–76] years) were prescribed oral anticoagulants only, 1095 (36%) antiplatelets only, and 101 (3%) both type of oral antithrombotics. Over a median (interquartile range [IQR]) follow‐up period of 3.0 (IQR, 2.8–3.1) years, 152 patients experienced a bleeding event, 414 patients experienced an episode of AKI, and 270 experienced kidney failure. The adjusted HRs (95% confidence interval [95% CI]) for bleeding associated with prescriptions of antiplatelets only, oral anticoagulants only, and antiplatelet + oral anticoagulant were, respectively, 0.74 (95% CI, 0.46–1.19), 2.38 (95% CI, 1.45–3.89), and 3.96 (95% CI, 2.20–7.12). An increased risk of AKI risk was associated with the prescription of oral anticoagulants (adjusted HR, 1.90, 95% CI, 1.47–2.45) but not the prescription of antiplatelets (HR, 1.24, 95% CI, 0.98–1.56). Kidney failure was not associated with the prescription of oral antithrombotics of any type. This study confirms the high risk of AKI associated with oral anticoagulants prescription in patients with CKD and also highlights the potential aggravating effect of combining vitamin K antagonist (VKA) and antiplatelets on the risk of bleeding.

Kidney function monitoring to prevent 5-aminosalicylic acid nephrotoxicity: What the gastroenterologist should know

BACKGROUND

The kidney function monitoring is recommended in routine practice to detect 5-aminosalicylic acid (5-ASA) related nephrotoxicity, although is not standardized. The optimal monitoring is unknown, especially the best timing and which tests to perform. We summarized why, how, and when to perform the monitoring for patients treated with 5-ASA and provided an overview of the current guidelines on this topic.

METHOD

Relevant studies on this topic were searched in PubMed, Embase, and Web of Science databases from July to August 2020.

RESULTS

Serum creatinine, the estimated glomerular filtration rate, and 24-h proteinuria are the 3 main tests used for the monitoring in daily practice. Regarding the timing, several monitoring strategies have been proposed and guidelines are available too, but they provide conflicting information. To date, there is no medical evidence-based that one strategy is better than another. Comorbidities, chronic renal disease, use of nephrotoxic drugs or concomitant steroid therapy also impact the nephrotoxicity risk. Based on the literature review we proposed a kidney function monitoring strategy to guide physicians in clinical practice.

CONCLUSION

A baseline assessment should be performed in all patients treated with 5-ASA. The monitoring should be carried out according to the other nephrotoxic factors. A tight monitoring may reduce morbidity and mortality of drug nephrotoxicity.

MO484ADVERSE OUTCOMES ASSOCIATED WITH ORAL ANTITHROMBOTIC USE IN PATIENTS WITH MODERATE-TO-ADVANCED CHRONIC KIDNEY DISEASE*

Background and Aims

The use of oral antithrombotics in patients with chronic kidney disease (CKD) is challenging because of altered pharmacodynamics/pharmacokinetics. Patients prescribed oral anticoagulant are at high risk of bleeding, and possibly also acute kidney injury (AKI) and progression to kidney failure. We assessed bleeding, AKI, and kidney failure risks associated with oral anticoagulant and/or antiplatelet agent prescription in patients with moderate-to-advanced CKD.

Method

CKD-REIN is a prospective cohort of 3022 nephrology outpatients with CKD stages 2-5 at inclusion. Drug prescriptions and their duration were collected prospectively. We used cause-specific Cox proportional hazard models to estimate hazard ratios (HR) for bleeding (identified through hospitalizations), AKI (as defined according to KDIGO 2012), and kidney failure. Prescriptions of oral antithrombotics were treated as a time dependent variable and models were adjusted for baseline comorbidities, laboratory data, and other medications.

Results

At baseline, 339 (11%) patients (65% men; median age 69 [interquartile range (IQR), 60-76] years; median eGFR 32 [IQR, 23-41] were prescribed oral anticoagulants only, 1095 (36%) antiplatelet only, and 101 (3%) both anticoagulant and antiplatelet.

Over a median follow-up of 3 years (IQR, 2.8-3.1), 152 patients experienced a bleeding event requiring hospital visit/stay (crude incidence rate (IR): 1.9% person-years [95%CI,1.6-2.2]), 414 patients experienced AKI (crude IR: 5.4 % person-years [4.9-5.9]), and 270 experienced kidney failure (crude IR: 3.4 % person-years [3.0-3.8]).

A significant interaction was found between oral antithrombotics and eGFR (interaction p=0.03). The adjusted HRs [95%CI] for bleeding associated with prescriptions of antiplatelets only, oral anticoagulants only, and antiplatelet + oral anticoagulant were respectively 0.58 [0.30; 1.11], 2.62 [1.39; 4.93], and 5.76 [2.85; 11.66] in patients with a baseline eGFR &lt; 30 mL/min/1.73m2. In patients with baseline eGFR ≥ 30 mL/min/1.73m2, the adjusted HRs [95%CI] for bleeding associated with prescriptions of antiplatelets only, oral anticoagulants .......only, and antiplatelet + oral anticoagulant were respectively 0.98 [0.48; 1.98], 1.91 [0.87; 4.20], and 1.54 [0.46; 5.12] (Figure 1A).

An increased risk of AKI risk was associated with the prescription of oral anticoagulants (adjusted HR [95%CI]: 1.91[1.48; 2.46]) but not the prescription of antiplatelets (1.24[0.98; 1.56], Figure 1B). No significant interactions were found between oral anticoagulants and eGFR or antiplatelet agents.

Kidney failure was not associated with the prescription of oral antithrombotics of any type (Figure 1C). No significant interactions were found with eGFR and antiplatelet agents.

Conclusion

This study confirms the risk of AKI in CKD patients prescribed oral anticoagulants. It also highlights the potential aggravating effect of combining anticoagulants and antiplatelet on the risk of bleeding in this population.

MO490SYMPTOM BURDEN AND ITS IMPACT ON QUALITY OF LIFE IN PATIENTS WITH MODERATE TO ADVANCED CKD

Background and Aims

It is generally considered that the early stages of CKD are asymptomatic, and that CKD becomes apparent once kidney function is significantly impaired, but large-scale studies in real-world non-dialysis CKD patients under nephrology care are still scarce. We evaluated symptom burden and its impact on quality of life in patients with moderate to advanced CKD.

Method

4423 patients with CKD Stage 3 to 5 from Brazil (N=548), France (N=2691), and the US (N=1184) enrolled in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps) from 2013-2019 completed the Kidney Disease Quality of Life (KDQOL) questionnaire at baseline to assess how much they were bothered by 13 symptoms. Response options ranged from “not at all” to “extremely” bothered. From these Symptoms/Problems of Kidney Disease items, a score was calculated, ranged from 0 to 100, and analyzed in 3 categories: low (≥90), intermediate (66-90), or high symptom burden (&lt;66). Poisson regressions were used to estimate prevalence ratios for each symptom and to study associations between CKD stage and a high symptom burden before and after adjusting for demographics and major comorbidities. Multiple linear regression accounting for clustering at the clinic level was used to examine associations between high symptom burden and physical and mental component summary (PCS and MCS, respectively) scores, with lower scores indicating poorer quality of life.

Results

Patients (mean age 68±13 years, 40% women, mean eGFR at baseline 30.4±12.2 mL/min/1.73m²) were very much to extremely bothered by a number of symptoms, the prevalence of three of which - washed out or drained, nausea or upset stomach, and lack of appetite – significantly increased in more advanced CKD stages before and after adjusting for confounders (Figure). Nearly one in four patients reported a high symptom burden, which was more prevalent in women, those with obesity, anemia, or albumin&lt;3.5 g/dL; it was also more common in France than in the US and Brazil. In adjusted models, as compared to patients with low symptom burden, those with high symptom burden had a worse quality of life with PCS and MCS scores 14.6 (95% confidence interval [95% CI], 15.7 to 13.5) and 7.2 (95% CI, 8.3 to 6.1) points lower, respectively.

Conclusion

Our findings demonstrate a high symptom burden even in nondialysis CKD stages 3-5 with a substantial impact on physical and mental health-related quality of life. Several symptoms, particularly fatigue, and gastrointestinal symptoms, appeared to worsen with increasing CKD stage, independent of patient comorbidities.

[Description of trajectories of patients with end-stage renal disease from the REIN registry]

CONTEXT AND OBJECTIVES

Since 2001, the aim of the REIN registry has been to identify patients suffering from end-stage renal disease and benefiting from replacement therapy in France. The analysis of trajectories aims to evaluate the flow of patients between the different types of treatment in order to better understand and predict patient pathways. The objective of this study was to analyse the incoming and outgoing flows at 1 year of patients prevalent in the REIN registry on 12/31/2017.

METHODS

Flow analysis was carried out on patients prevalent on 12/31/2017 in the REIN registry by studying the before and after treatment modalities on 12/31/2016 and 12/31/2018. This analysis was initially carried out on all patients, then in sub-groups for each of the 5 treatment modalities.

RESULTS

The analyses covered 85,472 patients prevalent on 12/31/2017. The overall analysis showed that more than 20% of patients had been diagnosed with end-stage renal disease the year before. Regarding inflow, there was a relative stability for patients treated with self-care hemodialysis, in-center haemodialysis, peritoneal dialysis, and graft, in contrast to patients treated with hemodialysis in a medical unit. Regarding outgoing flows, proportion of deaths at one year was 9%. Peritoneal dialysis was the modality with the highest outflow proportion at one year.

CONCLUSION

Analysis of patients' trajectories shows variable evolution profiles according to treatment modality and thus could be a valuable tool in the evaluation and improvement of management and care in the field of end-stage renal disease.

Urgent-start dialysis in patients referred early to a nephrologist-the CKD-REIN prospective cohort study

BACKGROUND

The lack of a well-designed prospective study of the determinants of urgent dialysis start led us to investigate its individual- and provider-related factors in patients seeing nephrologists.

METHODS

The Chronic Kidney Disease Renal Epidemiology and Information Network (CKD-REIN) is a prospective cohort study that included 3033 patients with CKD [mean age 67 years, 65% men, mean estimated glomerular filtration rate (eGFR) 32 mL/min/1.73 m2] from 40 nationally representative nephrology clinics from 2013 to 2016 who were followed annually through 2020. Urgent-start dialysis was defined as that 'initiated imminently or <48 hours after presentation to correct life-threatening manifestations' according to the Kidney Disease: Improving Global Outcomes 2018 definition.

RESULTS

Over a 4-year (interquartile range 3.0-4.8) median follow-up, 541 patients initiated dialysis with a known start status and 86 (16%) were identified with urgent starts. The 5-year risks for the competing events of urgent and non-urgent dialysis start, pre-emptive transplantation and death were 4, 17, 3 and 15%, respectively. Fluid overload, electrolytic disorders, acute kidney injury and post-surgery kidney function worsening were the reasons most frequently reported for urgent-start dialysis. Adjusted odds ratios for urgent start were significantly higher in patients living alone {2.14 [95% confidence interval (CI) 1.08-4.25] or with low health literacy [2.22 (95% CI 1.28-3.84)], heart failure [2.60 (95% CI 1.47-4.57)] or hyperpolypharmacy [taking >10 drugs; 2.14 (95% CI 1.17-3.90)], but not with age or lower eGFR at initiation. They were lower in patients with planned dialysis modality [0.46 (95% CI 0.19-1.10)] and more nephrologist visits in the 12 months before dialysis [0.81 (95% CI 0.70-0.94)] for each visit.

CONCLUSIONS

This study highlights several patient- and provider-level factors that are important to address to reduce the burden of urgent-start dialysis.

Serum biomarkers of iron stores are associated with worse physical health-related quality of life (HRQoL) in non-dialysis dependent chronic kidney disease (NDD-CKD) patients with or without anemia

Background

Iron deficiency (ID) is a common condition in nondialysis-dependent chronic kidney disease (NDD-CKD) patients that is associated with poorer clinical outcomes. However, the effect of ID on health-related quality of life (HRQoL) in this population is unknown. We analyzed data from a multinational cohort of NDD-CKD Stages 3–5 patients to test the association between transferrin saturation (TSAT) index and ferritin with HRQoL.

Methods

Patients from Brazil (n = 205), France (n = 2015) and the USA (n = 293) in the Chronic Kidney Disease Outcomes and Practice Patterns Study (CKDopps, 2013–2019) were included. We evaluated the association of TSAT and ferritin (and functional and absolute ID, defined as TSAT ≤20% and ferritin ≥300 or <50 ng/mL) on pre-specified HRQoL measures, including the 36-item Kidney Disease Quality of Life physical component summary (PCS) and mental component summary (MCS) as the primary outcomes. Models were adjusted for confounders including hemoglobin (Hb).

Results

TSAT ≤15% and ferritin <50 ng/mL and ≥300 ng/mL were associated with worse PCS scores, but not with MCS. Patients with composite TSAT ≤20% and ferritin <50 or ≥300 ng/mL had lower functional status and worse PCS scores than those with a TSAT of 20–30% and ferritin 50–299 ng/mL. Patients with a lower TSAT were less likely to perform intense physical activity. Adjustment for Hb only slightly attenuated the observed effects.

Conclusions

Low TSAT levels, as well as both low TSAT with low ferritin and low TSAT with high ferritin, are associated with worse physical HRQoL in NDD-CKD patients, even after accounting for Hb level. Interventional studies of iron therapy on HRQoL among NDD-CKD individuals are needed to confirm these findings.

Low incidence of SARS-CoV-2, risk factors of mortality and the course of illness in the French national cohort of dialysis patients

The aim of this study was to estimate the incidence of COVID-19 disease in the French national population of dialysis patients, their course of illness and to identify the risk factors associated with mortality. Our study included all patients on dialysis recorded in the French REIN Registry in April 2020. Clinical characteristics at last follow-up and the evolution of COVID-19 illness severity over time were recorded for diagnosed cases (either suspicious clinical symptoms, characteristic signs on the chest scan or a positive reverse transcription polymerase chain reaction) for SARS-CoV-2. A total of 1,621 infected patients were reported on the REIN registry from March 16th, 2020 to May 4th, 2020. Of these, 344 died. The prevalence of COVID-19 patients varied from less than 1% to 10% between regions. The probability of being a case was higher in males, patients with diabetes, those in need of assistance for transfer or treated at a self-care unit. Dialysis at home was associated with a lower probability of being infected as was being a smoker, a former smoker, having an active malignancy, or peripheral vascular disease. Mortality in diagnosed cases (21%) was associated with the same causes as in the general population. Higher age, hypoalbuminemia and the presence of an ischemic heart disease were statistically independently associated with a higher risk of death. Being treated at a selfcare unit was associated with a lower risk. Thus, our study showed a relatively low frequency of COVID-19 among dialysis patients contrary to what might have been assumed.

Reliability and validity of the French adaptation of the Family Relationship Index-short form in patients' with chronic kidney disease

The Family Relationship Index (FRI) measures family cohesion, expressiveness and conflict. This study aimed to investigate its reliability and validity in patients with chronic kidney disease (CKD). Confirmatory factor analysis was performed on 1657 patients and on subgroups according to socio-demographics and medical variables. Two items with poor saturation were excluded. The indexes indicated an acceptable fit. Reliability was especially weak for expressiveness. Our results provide partial support for the use of the French-version of the FRI in patients with advanced CKD. The family relationship index should be used with caution, especially in certain subgroups and for the expressiveness subscale.

[Routine collection of perceived health data in the era of payment for quality: Recommendations by the Epidemiology and public health commission of the SFNDT]

In France, the method of financing is mainly based on the quantity of care produced. The fixed-rate financing of patients with chronic kidney disease at stage IV or V introduces the notion of payment to quality. Part of the quality assessment will focus on the patients' feelings about their care. The objective of this paper is to assess these indicators used in nephrology, markers in their own right of the quality of care. The patients reported outcomes measures considering the impact of illness or care and the Patient Reported Experience Measures considering their perception of their experience with the health care system or care pathway, are broader than quality of life. These PROs are measured using standardized and validated questionnaires, generic or specific. The Standardised Outcomes in Nephrology initiative has shown that PROs, too often neglected in favor of biological criteria, are instead favored by patients. In the context of a broad deployment of monitoring the quality of life for the purpose of evaluation of care, outside research protocol, the Commission recommends one of the following 2 tools: EuroQol 5D and 12-Item Short Form Health Survey, a compromise between feasibility and relevance and e-SATIS given its great use in health facilities, with an annual follow-up.

Fine-scale geographic variations of rates of renal replacement therapy in northeastern France: Association with the socioeconomic context and accessibility to care

Background

The strong geographic variations in the incidence rates of renal replacement therapy (RRT) for end-stage renal disease are not solely related to variations in the population's needs, such as the prevalence of diabetes or the deprivation level. Inequitable geographic access to health services has been involved in different countries but never in France, a country with a generous supply of health services and where the effect of the variability of medical practices was highlighted in an analysis conducted at the geographic scale of districts. Our ecological study, performed at the finer scale of townships in a French area of 8,370,616 inhabitants, investigated the association between RRT incidence rates, socioeconomic environment and geographic accessibility to healthcare while adjusting for morbidity level and medical practice patterns.

Methods

Using data from the Renal Epidemiology and Information Network registry, we estimated age-adjusted RRT incidence rates during 2010–2014 for the 282 townships of the area. A hierarchical Bayesian Poisson model was used to examine the association between incidence rates and 18 contextual variables describing population health status, socioeconomic level and health services characteristics. Relative risks (RRs) and 95% credible intervals (95% CrIs) for each variable were estimated for a 1-SD increase in incidence rate.

Results

During 2010–2014, 6,835 new patients ≥18 years old (4231 men, 2604 women) living in the study area started RRT; the RRT incidence rates by townships ranged from 21 to 499 per million inhabitants. In multivariate analysis, rates were related to the prevalence of diabetes [RR (95% CrI): 1.05 (1.04–1.11)], the median estimated glomerular filtration rate at dialysis initiation [1.14 (1.08–1.20)], and the proportion of incident patients ≥ 85 years old [1.08 (1.03–1.14)]. After adjusting for these factors, rates in townships increased with increasing French deprivation index [1.05 (1.01–1.08)] and decreased with increasing mean travel time to reach the closest nephrologist [0.92 (0.89–0.95]).

Conclusion

These data confirm the influence of deprivation level, the prevalence of diabetes and medical practices on RRT incidence rates across a large French area. For the first time, an association was found with the distance to nephrology services. These data suggest possible inequitable geographic access to RRT within the French health system.

Nuclear power plant: state of knowledge of the population living in the area of the Cattenom special intervention plan. A cross-sectional study

In France information campaigns are periodically conducted within a 10 km radius of nuclear power plants on the protective actions to be adopted in the event of a nuclear accident. The aim of this study was to assess the knowledge of the inhabitants of the Cattenom PPI area on the recommended actions to be adopted in the event of a nuclear accident after the information campaign that took place from 2016 to 2017 and compare its results with a similar study carried out before the information campaign. We performed a cross-sectional study in the Cattenom PPI area after the 2016-2017 information campaign. We administered questionnaires in ten municipalities selected by lot. These questionnaires contained queries on the general protective actions and required approach to taking potassium iodide (KI). The results obtained were compared with the results of a study conducted before the information campaign in the same area. Out of 200 questionnaires administered, 122 people responded. Only 40% of respondents remembered the information campaign. Only 16% knew all of the recommended protective actions. 78% of households had KI and only 60% knew the objective of KI intake. Compared to the results of the study before the information campaign, KI coverage was better (69% versus 78%, p = 0.02) and the dosage was better known (16% versus 28%, p = 0.0003). This study provides an overview of the effectiveness of information campaigns on the procedure in the event of a nuclear accident. This study highlights the insufficient knowledge of people living in the Cattenom PPI area.

Intradermal Tests With Drugs: An Approach to Standardization

Background: Intradermal tests (IDTs) are performed and interpreted differently in drug allergy centers making valid comparison of results difficult.

Objective: To reduce method-related and intercenter variability of IDTs by the introduction of a standardized method.

Materials and methods: In 11 centers of the European Network for Drug Allergy, IDTs were prospectively performed with saline and with amoxicillin (20 mg/ml) using (1) the local method and (2) the standardized European Network in Drug Allergy (ENDA) method (0.02 ml). The diameters of the initial injection wheal (Wi) for the different volumes and sites injected obtained from each center were analyzed.

Results: The most reproducible method was to fill a syringe with test solution, then expel the excess fluid to obtain exactly 0.02 ml. The median Wi diameter with 0.02 ml injection using the standardized method was 5 mm [range 2–10 mm; interquartile range (IQR) 5–5 mm; n = 1,096] for saline and 5 mm (range 2–9 mm; IQR = 4.5–5 mm; n = 240) for amoxicillin. IDT injection sites did not affect the Wi diameter. Training improved precision and reduced the variability of Wi diameters.

Conclusion: Using the standardized IDT method described in this multicenter study helped to reduce variability, enabling more reliable comparison of results between individuals and centers.

Risk profile, quality of life and care of patients with moderate and advanced CKD: The French CKD-REIN Cohort Study

Background

The French Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort study was designed to investigate the determinants of prognosis and care of patients referred to nephrologists with moderate and advanced chronic kidney disease (CKD). We examined their baseline risk profile and experience.

Methods

We collected bioclinical and patient-reported information from 3033 outpatients with CKD and estimated glomerular filtration rates (eGFRs) of 15-60 mL/min/1.73 m2 treated at 40 nationally representative public and private facilities.

Results

The patients' median age was 69 (60-76) years, 65% were men, their mean eGFR was 33 mL/min/1.73 m2, 43% had diabetes, 24% had a history of acute kidney injury (AKI) and 57% had uncontrolled blood pressure (BP; >140/90 mmHg). Men had worse risk profiles than women and were more likely to be past or current smokers (73% versus 34%) and have cardiovascular disease (59% versus 42%), albuminuria >30 mg/mmol (or proteinuria > 50) (40% versus 30%) (all P < 0.001) and a higher median risk of end-stage renal disease within 5 years, predicted by the kidney failure risk equation {12% [interquartile range (IQR) 3-37%] versus 9% [3-31%], P = 0.008}. During the previous year, 60% of patients reported one-to-two nephrologist visits and four or more general practitioner visits; only 25% saw a dietician and 75% were prescribed five or more medications daily. Physical and mental quality of life (QoL) were poor, with scores <50/100.

Conclusions

The CKD-REIN study highlights high-risk profiles of cohort members and identifies several priorities, including improving BP control and dietary counselling and increasing doctors' awareness of AKI, polypharmacy and QoL.

Trial registration

ClinicalTrials.gov identifier: NCT03381950.

Perceived health and quality of life in chronic and end-stage kidney disease

Background and objectives

Health-related quality of life (HRQoL) is increasingly considered a major outcome in patients with chronic kidney disease (CKD), but the size of its effect on physical and mental health at different disease stages, compared with the general population, is unclear.

Design, setting, participants, and measurements

We compared HRQoL measures in four groups: 2,687 outpatients with moderate (stage 3, estimated glomerular filtration rate [eGFR] 30-60 mL/min/1.73 m2) or advanced (stage 4-5, eGFR &lt; 30 mL/min/1.73 m2) CKD under nephrology care from 40 nationally representative facilities, 1,658 patients with a functioning graft, 1,251 dialysis patients randomly selected from the national REIN registry, and 20,574 participants in the French Decennial Health Survey, representative of the general population.

Results

Mean age (years) was 67, 69, and 55 in patients with non-end-stage CKD, on dialysis, or with transplants, respectively; 60% were men. Age- and gender-standardized health status was perceived as fair or poor in 27% of those with moderate CKD and more than 40% of those with advanced CKD and those on dialysis, compared with 12% in transplant patients and 3% in the general population. Compared with the general population, HRQoL physical scores adjusted for age, gender, education, obesity, and diabetes, were significantly lower, by a factor of 2.2 among patients with moderate CKD, 4.1 among those with advanced CKD, 10.2 among those on dialysis, and 4.1 among those with transplants. The effect was stronger for those younger than 65 years. The mental score was lower only for dialysis patients.

Conclusions

This study highlights the importance of the physical health effects beginning at the moderate stage of CKD. More attention to patients’ CKD-related perceived health is needed.

Key messages

Physical health declined significantly from moderate through end-stage CKD, with impact greatest among the youngest patients. More attention to CKD’s impact on quality of life is needed.

[Towards an extension of the REIN registry to patients with chronic kidney disease at stage 5 not treated with dialysis or transplantation? A pilot study]

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.

Evaluation of the adequacy of drug prescriptions in patients with chronic kidney disease: results from the CKD-REIN cohort

AIMS

Drug prescription is difficult to manage in patients with chronic kidney disease (CKD). We assessed the prevalence and determinants of inappropriate drug prescriptions (whether contraindications or inappropriately high doses) with regard to kidney function in patients with CKD under nephrology care. We also assessed the impact of the equation used to estimate GFR on the prevalence estimates.

METHODS

The CKD-REIN cohort includes 3033 outpatients with CKD (eGFR between 15 and 60 ml min-1  1.73 m-2 ). We examined the daily doses of pharmacological agents prescribed at study entry. Inappropriate prescription was defined as the reported prescription of either a contraindicated drug or an indicated drug at an inappropriately high dose level with regard to the patient's GFR, as estimated with the CKD-EPI equation, the de-indexed CKD-EPI equation, or the Cockcroft-Gault (CG) equation. Multivariate logistic regression was used to assess the determinants of inappropriate prescription risk.

RESULTS

At baseline, patients' median [interquartile range] number of drugs prescribed per patient was 8 [5-10]. Half of the patients had been prescribed at least one inappropriate drug. Anti-gout, cardiovascular agents and antidiabetic agents accounted for most of the inappropriate prescriptions. The percentage of inappropriate prescriptions varied from one GFR equation to another: 52% when using the CKD-EPI equation, 47% when using the de-indexed CKD-EPI equation and 41% with the CG equation. A multiple logistic regression analysis showed significantly higher odds ratios [95% confidence interval] for inappropriate prescriptions in male patients (1.28 [1.07; 1.53]), patients with diabetes (1.34 [1.06; 1.70]), those with a high BMI (1.58 [1.25; 1.99]), and those with a low GFR (10.2 [6.02; 17.3]). The risk of having at least one inappropriate prescription increased with the number of drugs per patient (P for trend < 0.0001) and therefore the odds ratio was 5.88 [4.17; 8.28] for those who received at least 11 prescribed medications compared to those who received fewer than 5.

CONCLUSION

Our results emphasize the complexity of drug management for CKD patients, for whom inappropriate prescription appears to be common.