Background: Further study is needed on the prognostic impact of cirrhosis on haemodialysis patients.Aim: To evaluate cirrhosis' impact according to severity on survival and to provide therapeutic guidelines for haemodialysis cirrhotic patients. Methods: Patients with end-stage renal failure treated with haemodialysis were included retrospectively from 01/01/2000 to 31/12/2004 and prospectively from 01/01/2005 to 31/12/2014 in our French Region. Clinical data, presence of cirrhosis and its severity were recorded at the beginning of haemodialysis. The primary endpoint was 2-year survival.Results: Seven thousand three hundred and fifty-four patients (96%) without cirrhosis and 304 patients (4%) with cirrhosis were included. Two-year survival in noncirrhotic patients was higher than in cirrhotic patients (71.7% vs 54.4%, P < 0.0001).Patients with decompensated cirrhosis had a worse 2-year outcome (44.1%) as compared to compensated cirrhotic (62.8%, P = 0.002) and noncirrhotic patients (71.7%, P < 0.0001). Compensated and decompensated cirrhosis were independent predictive factors of 2-year mortality. In sensitivity analysis restricted to cirrhotic patients, 2-year survival of Child-Pugh A patients was higher than in Child-Pugh B and C patients (65.5% vs 27.7% vs 0%, P < 0.0001). Development of predictive models based either on severity scores (MELD and Child-Pugh) and extrahepatic comorbidities allowed correct classification of around 70% of patients in terms of mortality and may help to better stratify mortality risk in this population. Conclusions: Cirrhosis is independently associated with mortality in haemodialysis patients. Patients with severe cirrhosis have a poor 2-year outcome. Severity of cirrhosis and presence of extrahepatic comorbidities should be considered when deciding to initiate renal replacement therapy.
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.
Background Systematic reviews have shown a high prevalence of long-term persistent sequelae after COVID-19. The aim of this study was to describe the prevalence and risk factors associated with long‐lasting clinical symptoms (LLCS) in survivors on chronic dialysis at 6 months after the onset of acute COVID-19 infection in the pre-vaccination period. Methods This national cohort study included all French patients on dialysis who had SARS-Cov-2 infection between March and December 2020 and who were alive and still on dialysis 6 months after infection. A form was filled in at 6 months concerning the presence of the following persistent symptoms: extreme fatigue, headache, muscle or weight loss of > 5%, respiratory sequelae, tachycardia, chest pain, joint or muscle pain, persistent anosmia or ageusia, diarrhea, sensory disorders, neuro-cognitive disorders, post-traumatic stress syndrome, depression, and anxiety. Results Complete survey results were available for 1217 patients (25.2% of those included); 216 (17.7%) had some LLCS. Probability of 6-month LLCS was higher in patients who were hospitalized in a medical or intensive care unit: OR 1.64 (95% CI 1.16–2.33) and 5.03 (2.94–8.61), respectively. Younger patients had a lower probability of LLCS. Each year on dialysis, as well as diabetes, overweight or obesity were associated with a higher probability of LLCS by 1.03 (1.01–1.06), 1.53 (1.08–2.17), 1.96 (1.10–3.52) and 2.35 (1.30–4.26), respectively. Conclusions This national study shows that at least one in six patients on dialysis who have COVID-19 will have LLCS. Systematic screening in dialysis patients would allow us to identify those who need more careful prevention and long-term care and to address them towards a rehabilitation pathway.
Background and Aims The great phenotypic heterogeneity in the presentation of kidney diseases makes the diagnostic strategy all the more complex in the elderly. While kidney biopsy should play a pivotal role, its non-negligible risk of bleeding complications (2-5% in the general population) justifies a certain reluctance to its application in the elderly. To date, however, there is little data on the benefit-risk ratio of kidney biopsy in the elderly. Most of these studies have focused on a relatively young population (60-70 years old) and on a limited number of patients. Concerning patients aged 80 years and older, very few studies have described the real therapeutic influence of kidney biopsy findings with regard to the rate of complications. Moreover, none of these studies have evaluated the long-term prognostic impact of therapeutic changes induced by the results of the kidney biopsy. The main objectives of this study are to describe the indications, diagnoses, complication rate, therapeutic influence and the prognostic impact of a change in therapeutic management after native kidney biopsies performed in patients aged 80 years and older. Method The KB-Old study (Kidney Biopsy for Old) is a retrospective multicenter cohort that consecutively included all patients aged 80 years and older who underwent percutaneous native kidney biopsy in 17 centers in the northern region of France, between 2010 and 2020. Clinical, biological and anatomopathological data as well as post-biopsy follow-up (therapeutic strategy, occurrence of complications) were collected from medical records. All pathology examinations were analyzed centrally by a team of experienced nephropathologists. Events of death or kidney failure were identified by specific registry cross-linking. To analyze the prognostic impact of therapeutic management following kidney biopsy (either initiation of a specific treatment or simple nephroprotection) on the risk of kidney failure and death, we performed Cox models weighted by propensity score (Inverse Probability of Treatment Weighting -IPTW-) in the population potentially eligible for treatment (exclusion of diseases without specific treatment). The areas under Kaplan Meier curves were calculated up to 6 years of follow-up (Restricted Mean Survival Time - RMST) and compared according to the initiation of a specific treatment after the kidney biopsy. This study was approved by Institutional Review Board (#AUG-20-707). Results Overall, the cohort included 453 patients (54% men, median age 83 years), half of whom underwent biopsy in the context of acute kidney injury (median serum creatinine level 3.0 mg/dl). The main diagnoses were nephroangiosclerosis (15%), renal involvement of hematological malignancies (13%), acute tubulointerstitial nephritis (12%) and vasculitis (10%). The complication rate was approximately 10%, with only 2.8% of serious complications requiring therapeutic intervention (mostly transfusion). The kidney biopsy identified a disease potentially accessible to a specific treatment in 73% of cases. After exclusion of patients with ineligible diseases, a specific treatment was initiated in about one out of two cases (163/332, 49%). After weighting on propensity score, the two treatment groups were globally balanced. A beneficial effect of treatment on dialysis-free survival was observed (HR = 0.51 [0.28-0.92], p = 0.02), without any major influence on mortality (Figure 1). Over a 6-year follow-up period, there was a gain in dialysis-free survival in the treated group estimated by the delta RMST at +10.46 months [3.39 - 17.54] compared with the untreated group (p = 0.004), with no difference in overall life expectancy. Conclusion To the best of our knowledge, this is the largest multicenter cohort of patients aged 80 years and over who have undergone kidney biopsy. It seems to confirm the interest and safety of this examination for specific indications, and a potentially important benefit on the prognosis when it leads to an adapted therapeutic management.
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