Obstructive sleep apnea-hypopnea syndrome (OSAHS) is one of the most common sleep disorders affecting nearly one billion of the global adult population, making it a major public health issue. Even if in-lab polysomnography (PSG) remains the gold standard to diagnose OSAHS, there is a growing interest to develop new solutions with more convenient at home devices enhanced with AI-based algorithms for the detection of sleep apnea. This retrospective study aimed to assess the performances of a new method based on nocturnal long-term electrocardiogram signal to detect apneas and hypopneas, in patients who performed attended in-lab PSG. After assessing the quality of the ECG signal, the new method automatically detected apneas and hypopneas using dedicated machine learning algorithm. The agreement between the new ECG-based detection method and the standard interpretation of PSG by a sleep clinician was determined in a blind manner. Eighty-five exams were included into the study with a mean bias between the proposed method and the scorer of 3.5 apneas-hypopneas/hour (/h) (95% CI -48.1 to 55.1). At a threshold of 15/h, sensibility and specificity were 93.3% and 66.7% respectively, and positive and negative predictive values were 87.5% and 80%, respectively. The proposed method using nocturnal long-term electrocardiogram signals showed very high performances to detect apneas and hypopneas. Its implementation in a simple ECG-based device would offer a promising opportunity for preliminary evaluation of patients suspected or at-risk of OSAHS.

[This corrects the article DOI: 10.1371/journal.pone.0318622.].

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.

ObjectifL’objectif de cette étude était de déterminer la performance d’un algorithme de détection des apnées et hypopnées du sommeil, basé sur la seule utilisation d’un électrocardiogramme (ECG) nocturne.MéthodesLors de cette étude rétrospective, les patients ayant bénéficié d’une polysomnographie (PSG) entre le 01/01/2019 et le 01/07/2020, pour suspicion de syndrome d’apnées du sommeil (SAS) ont été inclus. Le signal ECG, extrait de la PSG, était exploité par l’algorithme préalablement auto-entraîné. Ce dernier effectuait un traitement automatisé de la qualité du signal et d’identification des apnées et hypopnées uniquement à partir du signal ECG. L’index d’apnées-hypopnées (IAH) ainsi estimé était comparé en aveugle à l’IAH obtenu par l’analyse visuelle de la PSG par le clinicien.RésultatsSur 128 patients inclus, 85 examens ont pu être analysés (43 examens exclus pour qualité du signal ECG insuffisante). Le biais moyen de l’étude était de 3,5 apnées-hypopnées/h (/h) avec des limites d’agrément de [−48,1 ; 55,1]/h. Pour un IAH supérieur à 15/h, la sensibilité et la spécificité étaient de 93,3 % et 66,7 % et les valeurs prédictives positive et négative de 87,5 % et 80 % respectivement.ConclusionCette étude a montré que la méthode proposée permet une très bonne estimation de l’IAH depuis la seule analyse automatique de l’ECG nocturne. L’implémentation de l’algorithme dans un dispositif simple de mesure d’ECG nocturne faciliterait l’accès au dépistage rapide du SAS.

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.

We investigated the shape of the relationship between longitudinal uric acid (UA) and the hazard of kidney failure and death in chronic kidney disease (CKD) patients, and attempted to identify thresholds associated with increased hazards. We included CKD stage 3–5 patients from the CKD-REIN cohort with one serum UA measurement at cohort entry. We used cause-specific multivariate Cox models including a spline function of current values of UA (cUA), estimated from a separate linear mixed model. We followed 2781 patients (66% men, median age, 69 years) for a median of 3.2 years with a median of five longitudinal UA measures per patient. The hazard of kidney failure increased with increasing cUA, with a plateau between 6 and 10 mg/dl and a sharp increase above 11 mg/dl. The hazard of death had a U-shape relationship with cUA, with a hazard twice higher for 3 or 11 mg/dl, compared to 5 mg/dl. In CKD patients, our results indicate that UA above 10 mg/dl is a strong risk marker for kidney failure and death and that low UA levels below 5 mg/dl are associated with death before kidney failure.

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.

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). 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. 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]). 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.

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.

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.

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.

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.

Les symptômes rapportés par les patients dialysés sont souvent sous-évalués voire méconnus. La prise en charge des patients et leur qualité de vie peuvent être améliorées par une meilleure prise en compte des symptômes à condition que l’équipe de dialyse en ait connaissance. Comment intégrer la mesure des symptômes faite par les patients dans la prise en charge et la décision thérapeutique ? L’objectif est d’évaluer l’acceptabilité et la faisabilité de l’intégration en routine de mesures électroniques des symptômes perçus par les patients avec un retour à l’équipe de dialyse. Une étude qualitative (focus group professionnels de santé [PS] et patients dialysés) a été menée. Trois centres volontaires participaient (2 centres et 1 association de dialyse), 6 focus group avec des PS et 3 avec des patients, volontaires et > 18 ans, ont été réalisés. Deux grilles d’entretien ont été construites (patients et PS). Les entretiens ont été retranscrits, une grille de codage a été élaborée, stabilisée et validée, l’analyse du contenu a été menée. Trois grands thèmes ont été identifiés. Les freins à la mesure des symptômes étaient une méconnaissance des symptômes par les PS et les patients, le nombre varié et important de symptômes, le défaut de connaissance des prises en charge et un manque de temps des PS. Les leviers évoqués étaient : profiter de la consultation trimestrielle pour mieux identifier les symptômes des patients, améliorer la communication entre patients et PS et favoriser l’interdisciplinarité. Enfin, la fréquence et le moment de la mesure, les participants ont plutôt souligné l’importance de la longueur des questionnaires. L’importance des symptômes et leur méconnaissance ont été soulignés. Des actions visant à améliorer leur repérage et leur prise en charge doivent être proposées. Une mesure faite par les patients, systématique et électronique, avec retour immédiat aux équipes de dialyse est une piste intéressante.

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.

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.

À l’occasion des 20 ans du REIN (Réseau Epidémiologie et Information en Néphrologie), un travail de synthèse sur les apports du registre a été mené. Sur la question de son rôle dans la veille sanitaire, les messages clés suivants ont été retenus.La crise sanitaire récente a permis de montrer l’adaptabilité et l’agilité du registre. Grâce à un réseau humain en place et organisé depuis de nombreuses années et la possibilité de faire évoluer rapidement le système de recueil, le registre a été en mesure de fournir dès le 30 mars 2020 des informations sur le nombre de personnes dialysées infectées par le nouveau SARS-Cov-2.L’utilisation de REIN comme outil de veille sanitaire et d’aide à la décision en ces temps de décisions empiriques est apparue comme un enjeu stratégique.© 2022 Société francophone de néphrologie, dialyse et transplantation. Publié par Elsevier Masson SAS. Tous droits réservés.