Background In France, kidney diseases of undetermined origin account for 5%-20% of all causes of end-stage kidney disease. We investigated the impact of social disadvantage on the lack of aetiological diagnosis of nephropathies. Methods Data from patients who started dialysis in France between 1 January 2017 and 30 June 2018 were extracted from the French Renal Epidemiology and Information Network registry. The social deprivation of each individual was estimated by the European Deprivation Index (EDI) defined by the patient's address. Logistic regression was used to perform mediation analysis to study the potential association between social deprivation and unknown nephropathy. Results Of the 7218 patients included, 1263 (17.5%) had unknown kidney disease. A total of 394 (31.4%) patients in the unknown kidney disease belonged to the most deprived quintile of the EDI [fifth quintile (Q5)], vs 1636 (27.5%) patients in the known kidney disease group. In the multivariate analysis, unknown kidney disease was associated with Q5 (odds ratio 1.40, 95% confidence interval 1.12-1.74, P = .003). Mediation analysis did not identify any variables (e.g. obesity, initiation of dialysis in emergency, number of visits to the general practitioner and nephrologist before initiation of dialysis, date of first nephrology consultation) that mediated the association between social deprivation and nephropathy of unknown origin. Conclusions Our results show that, compared with nondeprived subjects, individuals experiencing social deprivation have a higher risk of unknown nephropathy at dialysis initiation. However, mediation analysis did not identify any variables that explained the association between social deprivation and nephropathy of unknown origin.

Background This study was carried out to evaluate the association between patient sex and the proportion of nurse-assisted peritoneal dialysis (PD) at dialysis initiation and to explore whether sex disparities in nurse-assisted PD utilization was explained by predialysis care and/or by social deprivation using mediation analysis.Methods This was a retrospective study using data from the Renal Epidemiology and Information Network (REIN) registry linked to the French National Healthcare Database (SNDS) of incident patients between 1 January 2017 and 30 June 2018. A regression logistic was used for statistical analysis. A mediation analysis explored the direct effect of sex on nurse-assisted PD proportion and the indirect effect through the European Deprivation Index (EDI), and the number of general practitioner (GP) and nephrologist visits before dialysis initiation.Results Among 1706 patients on PD, there were 637 women (37.3%) and 1069 men (62.7%). Nurse-assisted PD proportion was 332/610 (54.4%) for women vs 464/1036 (44.8%) for men. In the multivariable analysis women were more likely to be treated by nurse-assisted PD {odds ratio (OR) 1.92 [95% confidence interval (CI) 1.46-2.52]}. Nurse-assisted PD was associated with the median number of GP visits [OR 1.44 (95% CI 1.11-1.86)] and with the median number of nephrologist visits [OR 0.59 (95% CI 0.46-0.76)]. The mediation analysis showed a direct effect of sex on nurse-assisted PD [OR 1.90 (95% CI 1.80-2.01)] and an indirect effect through the median number of GP visits [OR 1.05 (95% CI 1.04-1.06], the median number of nephrologist visits [OR 1.02 (95% CI 1.02-1.03)] and quintile 5 of the EDI [OR 1.03 (95% CI 1.02-1.03)].Conclusion Women were more frequently treated by nurse-assisted PD than men. Differences between women and men in predialysis care and social deprivation could explain the greater utilization of nurse-assisted PD among women. Graphical Abstract

Background: Social deprivation is associated with lower peritoneal dialysis (PD) uptake. This study was carried out to evaluate the role of social deprivation on the outcome of PD.Methods: This was a retrospective study of data extracted from the Renal Epidemiology and Information Network registry for patients older than 18 years who started PD in metropolitan France between 1 January 2017 and 30 June 2018. The end of the observation period was 31 December 2020. The exposure was the European Deprivation Index calculated using the patient's address. The events of interest were death, transfer to haemodialysis (HD), transplantation and the composite event of death or transfer to HD. A Cox model and Fine and Gray model were used for the analysis.Results: A total of 1581 patients were included, of whom 418 (26.5%) belonged to Quintile 5 of the European Deprivation Index (the most deprived patients). In the Cox model, the most deprived subjects did not have a greater risk of death (cause-specific hazard ratio (cs-HR): 0.76 [95% confidence interval (CI): 0.53-1.10], transfer to HD (cs-HR 1.37 [95% CI: 0.95-1.98]) or the composite event of death or transfer to HD (cs-HR: 1.08 [95% CI: 0.84-1.38]) or a lower risk of kidney transplantation (cs-HR: 0.73 [95% CI: 0.48-1.10]). In the competing risk analysis, the most deprived subjects had a higher risk of transfer to HD (subdistribution hazard ratio (sd-HR): 1.54 [95% CI: 1.08-2.19]) and lower access to kidney transplantation (sd-HR: 0.68 [0.46-0.99]).Conclusion: In PD patients, social deprivation was not associated with death or the composite event of death or transfer to HD. Socially deprived individuals had a greater risk of transfer to HD and lower access to kidney transplantation in the competing risk analysis.

ABSTRACT Background We aimed to evaluate sex differences in peritoneal dialysis (PD) outcomes and to explore direct and indirect effects of nurse-assisted PD on outcomes. Methods This was a retrospective study using data from the Registre de Dialyse Péritonéale de Langue Française of incident PD patients between 2005 and 2016. Cox proportional hazards modelling was used to analyse transfer to haemodialysis (HD), death, PD failure, peritonitis and renal transplantation. Mediation analyses with a counterfactual approach were carried out to evaluate natural direct and indirect effects of sex on transfer to HD and peritonitis, with nurse-assisted PD as a mediator a priori. Results Of the 14 659 patients included, there were 5970 females (41%) and 8689 males (59%). Women were more frequently treated by nurse-assisted PD than men [2926/5970 (49.1%) versus 3357/8689 (38.7%)]. In the multivariable analysis, women had a lower risk of transfer to HD [cause-specific hazard ratio {cs-HR} 0.82 {95% confidence interval (CI) 0.77–0.88}], death [cs-HR 0.90 (95% CI 0.85–0.95)], peritonitis [cs-HR 0.82 (95% CI 0.78–0.87)], PD failure [cs-HR 0.86 (95% CI 0.83–0.90)] and a lower chance of undergoing transplant [cs-HR 0.83 (95% CI 0.77–0.90)] than men. There was a direct effect of sex on the risk of transfer to HD [cs-HR 0.82 (95% CI 0.82–0.83)], with an indirect effect of nurse-assisted PD [cs-HR 0.97 (95% CI 0.96–0.99)]. Nurse-assisted PD had no indirect effect on the risk of peritonitis. Conclusions Our results suggest that compared with men, women have a lower risk of both transfer to HD and peritonitis. Mediation analysis showed that nurse assistance was a potential mediator in the causal pathway between sex and transfer to HD.

Background: Social deprivation could act as a barrier to peritoneal dialysis (PD). The objective of this study was to assess the association between social deprivation estimated by the European deprivation index (EDI) and PD uptake and to explore the potential mediators of this association. Methods: From the Renal Epidemiology and Information Network registry, patients who started dialysis in 2017 were included. The EDI was calculated based on the patient’s address. The event of interest was the proportion of PD 3 months after dialysis initiation. A mediation analysis with a counterfactual approach was carried out to evaluate the direct and indirect effect of the EDI on the proportion of PD. Results: Among the 9588 patients included, 1116 patients were on PD; 2894 (30.2%) patients belonged to the most deprived quintile (Q5). PD was associated with age >70 years (odds ratio (OR) 0.79 [95% confidence interval (CI): 0.69–0.91]), male gender (0.85 [95% CI: 0.74–0.97]), cardiovascular disease (OR 0.86 [95% CI: 0.86–1.00]), chronic heart failure (OR 1.34 [95% CI: 1.13–1.58]), active cancer (OR 0.67 [95% CI: 0.53–0.85]) and obesity (OR 0.75 [95% CI: 0.63–0.89]). In the mediation analysis, Q5 had a direct effect on PD proportion OR 0.84 [95% CI: 0.73–0.96]. The effect of Q5 on the proportion of PD was mediated by haemoglobin level at dialysis initiation (OR 0.96 [95% CI: 0.94–0.98]) and emergency start (OR 0.98 [95% CI: 0.96–0.99]). Conclusion: Social deprivation, estimated by the EDI, was associated with a lower PD uptake. The effect of social deprivation was mediated by haemoglobin level, a proxy of predialysis care and emergency start.

Les inégalités sociales en santé (ISS) sont responsables de disparités d’accès à la liste d’attente de transplantation rénale (LATR). La perception de ces disparités par le néphrologue impacte l’inscription du patient sur la LATR. Les objectifs de notre étude sont d’évaluer la perception des facteurs d’inégalité d’accès à la LATR par les internes de néphrologie et d’évaluer la qualité du questionnaire. Un questionnaire a été construit afin d’évaluer la perception des déterminants d’inégalités d’accès à la LATR. Les variables quantitatives étaient décrites par leurs médianes, 1er et 3e quartiles, les variables qualitatives par leurs fréquences et pourcentages. Des analyses en composante principale et en cluster ont été réalisées afin d’étudier les corrélations entre les items. Un scree plot et une analyse factorielle ont permis de déterminer les dimensions du questionnaire. La consistance interne du questionnaire a été évaluée par un coefficient de Cronbach. Le taux de réponse était de 98/110 (89 %). Les déterminants des ISS dans l’accès à la LATR n’ayant pas été perçus par les internes étaient le genre féminin, le niveau de revenu et la capacité du centre à adapter l’information (18,3 %, 36,7 %, 47 % respectivement). L’âge, être né à l’étranger, le lieu de résidence, le niveau d’étude, le centre de transplantation et le professionnel de santé étaient des déterminants d’ISS perçus par les internes (85,7 %, 75,5 %, 82,6 %, 78,6 %, 73,5 % et 78,5 % respectivement). Les items liés au centre de transplantation sont corrélés, ainsi que les items « né à l’étranger », « niveau d’étude » et « niveau de revenu ». Deux dimensions sont explorées par le questionnaire. Le coefficient de Cronbach est égal à 0,60. Les ISS sont partiellement perçues par les internes de néphrologie. Un enseignement dédié pourrait réduire l’impact des ISS dans la prise en charge des patients en sensibilisant les néphrologues à cette problématique.

ABSTRACT Background This study was conducted to estimate the direct effect of sex on the proportion of hemodialysis (HD) catheters used at dialysis initiation and to investigate whether predialysis care or socioeconomic status acted as a mediator of the sex effect. Methods Patients who started dialysis between January 1, 2017, and June 30, 2018, in France were included using the data of the Renal Epidemiology and Information Network (REIN) registry. We performed logistic regression to study the association between sex and the proportion of HD catheters used. A mediation analysis with a counterfactual approach was carried out to evaluate whether there was an indirect effect of sex through the proxies of predialysis care {hemoglobin, albumin levels, glomerular filtration rate [GFR] at dialysis initiation} and socioeconomic status. Because an interaction between sex and social deprivation has been identified, we performed a subgroup analysis on deprived and nondeprived patients. Results The study included 16 032 patients, and the sex ratio (male to female) was 10 405:5627. In the multivariable analysis, women were associated with a greater risk of starting dialysis with a catheter {odds ratio [OR], 1.32 [95% confidence interval (CI): 1.23–1.42]}. There was an indirect effect of sex on the proportion of HD catheters through proxies for predialysis care {albuminemia <30 g/L [OR, 1.08 (95% CI: 1.05–1.10)], hemoglobin <11 g/dL [OR, 1.03 (95% CI: 1.02–1.04)], glomerular filtration rate <7 mL/min [OR, 1.05 (95% CI: 1.04–1.07)]}. Among deprived patients, there was no direct effect of sex on catheter proportion. Conclusions Women were associated with a higher risk of starting dialysis through an HD catheter. The effect of sex was mediated by predialysis care, particularly for deprived patients.

Pregnancy with chronic kidney disease is challenging, and patients with diabetic nephropathy are at particular risk of a rapid kidney function decline during pregnancy. While indications for the management of pregnant patients with initial diabetic nephropathy are widely available in the literature, data on patients with severe nephrotic syndrome and kidney function impairment are lacking, and the decision on whether and when dialysis should be initiated is not univocal. We report a type 1 diabetes patient who started pregnancy with a severe nephrotic syndrome and shifted from CKD stage 3b to stage 5 during pregnancy. The management was complicated by a fetal heart malformation and by poorly controlled diabetes. The evidence for and against starting dialysis was carefully evaluated, and the choice of strict nephrological and obstetrical monitoring, nutritional management, and diuretic treatment made it possible to avoid dialysis in pregnancy, after ruling out pre-eclampsia. This experience enables examination of some open issues and contributes to the discussion of when to start dialysis in pregnancy.

BACKGROUND:Social inequalities in health are responsible for disparities in access to the kidney transplant waiting list (KTWL). The perception of disparities by nephrologists has consequences for the registration on the KTWL. The purposes of our study were to assess the perception of the factors implicated in the disparities in access to the KTWL by nephrology trainees and to assess the quality of the questionnaire.METHODS:A questionnaire was developed to assess the perception of the determinants of the inequities in access to waitlisting. Continuous variables were described by median, 1st and 3rd quartiles. Categorical variables were described by frequencies and percentages. A principal component analysis and a hierarchical cluster analysis were performed to approach the correlation between the variables. A scree plot and a factor analysis were performed to determine the dimensions of the questionnaire. The internal consistency was estimated by Cronbach's coefficient.RESULTS:The response rate was 98/110 (89%). The determinants of inequities in the access to KTWL not perceived by the nephrology trainees were "female sex", "income level" and "the centre provision to adapt the information to all of the patients" (18,3%, 36,7, 47% respectively). "Age", "being born abroad", "place of living", "education level", "transplant centre", "the health care provider" were determinants of disparities perceived by most of the trainees (85,7%, 75,5%, 82,6%, 78,6%, 73,5% et 78,5% respectively). Items related to the transplant centre were positively correlated, as well as "being born abroad", "education level" and "income level". The Cronbach's coefficient was 0,60.CONCLUSION:Social inequalities in health are partially perceived by nephrology trainees. A teaching session could raise nephrologists' awareness of this issue and could help reduce the impact of these disparities on the course of ESKD (end-stage kidney disease) patients.

Vascular access is reported to differ among gender groups. Female gender is associated with catheter use in many countries. The objective of this study was to assess the association between gender and vascular access at dialysis initiation and to explore the potential mediators of the pathway. Using the REIN registry, patients who started dialysis between the 1st January 2017 and the 30th June 2018 were included. Logistic regression was used to study factors associated with the use of a catheter. A mediation analysis with a counterfactual approach was carried out to evaluate if hemoglobin and albumin levels, glomerular filtration rate (GFR) at dialysis initiation and social deprivation were mediators of the relation. Among the 16,032 patients included, 5627 were female; 50.9% started dialysis with a catheter. Catheter use was associated with age < 50 and > 80, cardiovascular disease, chronic heart failure, active cancer, chronic respiratory and liver disease. Obesity and polycystic disease were associated with arteriovenous fistula. Female gender was associated with a higher use of catheter (OR: 1.32 [95% CI: 1.23–1.42]) in the multivariate analysis. The association was mediated by albuminemia (OR: 1.07 [95% CI: 1.05–1.09]), hemoglobin level (OR: 1.03 [95% CI: 1.02–1.04]), GFR at dialysis initiation (OR: 1.04 [95% CI: 1.03–1.05]) and social deprivation (OR: 1.00 [95% CI: 1.00–1.01]). Female gender is associated with a higher use of catheter at dialysis initiation in France. The effect was partially mediated by hemoglobin and albuminemia, a proxy of predialysis care, GFR at dialysis initiation and social deprivation. However, a direct effect of gender on catheter use persisted. Further studies would be interesting to identify other mediators.

BACKGROUND Socioeconomic status is associated with dialysis modality in developed countries. The main objective of this study was to investigate whether social deprivation, estimated by the European Deprivation Index (EDI), was associated with self-care dialysis in France. METHODS The EDI was calculated for patients who started dialysis in 2017. The event of interest was self-care dialysis 3 months after dialysis initiation [self-care peritoneal dialysis (PD) or satellite haemodialysis (HD)]. A logistic model was used for the statistical analysis, and a counterfactual approach was used for the causal mediation analysis. RESULTS Among the 9588 patients included, 2894 (30%) were in the most deprived quintile of the EDI. A total of 1402 patients were treated with self-care dialysis. In the multivariable analysis with the EDI in quintiles, there was no association between social deprivation and self-care dialysis. Compared with the other EDI quintiles, patients from Quintile 5 (most deprived quintile) were less likely to be on self-care dialysis (odds ratio 0.81, 95% confidence interval 0.71-0.93). Age, sex, emergency start, cardiovascular disease, chronic respiratory disease, cancer, severe disability, serum albumin and registration on the waiting list were associated with self-care dialysis. The EDI was not associated with self-care dialysis in either the HD or in the PD subgroups. CONCLUSIONS In France, social deprivation estimated by the EDI is associated with self-care dialysis in end-stage renal disease patients undergoing replacement therapy.

Un marin philippin âgé de 56 ans, sans antécédent médical connu, a présenté une insuffisance rénale aiguë fonctionnelle et obstructive aux larges des côtes normandes. La sévérité de l’atteinte rénale compliquée d’une hyperkaliémie et d’une hyperphosphorémie associée à des troubles de la conscience ont justifié une hospitalisation initiale en réanimation. L’imagerie abdominale montrait un rein gauche détruit, une dilatation des cavités pyélocalicielles à droite et de multiples sténoses urétérales typiques d’une tuberculose urinaire. La recherche de bacille acido-alcoolo-résistant urinaire s’est avérée positive confirmant le diagnostic. Le scanner thoracique, l’IRM cérébrale et la ponction lombaire ont mis en évidence une miliaire et une méningoencéphalite tuberculeuse. Une réhydratation intraveineuse et la dérivation des urines par une pose de sonde JJ ont permis une amélioration de la fonction rénale avec persistance d’une insuffisance rénale chronique stade IV. Une quadrithérapie antituberculeuse et une corticothérapie pour l’atteinte neuroméningée ont été débutées. Nous discutons ici de la tuberculose urinaire en reprenant les données de la littérature sur l’épidémiologie, la physiopathologie, le diagnostic et le traitement.

A 56-year-old Philippine seaman without any medical history presented an obstructive and prerenal acute kidney failure near the coasts of Normandy. He was hospitalized in intensive care units because of the seriousness of kidney failure and because of impaired consciousness. Abdominal computed tomography showed a destroyed left kidney, a right hydronephrosis and ureteral strictures, which is typical of urinary tuberculosis. Koch bacillus was positive in urine sample, confirming the diagnosis. Thoracic computed tomography, brain magnetic resonance imaging revealed a tuberculosis miliary with concomitant tuberculous meningitis and intracranial tuberculoma. Intravenous hydration and a double J ureteral catheter improved renal function. Stage 4 chronic kidney disease persisted. A four antituberculous therapy associated with corticotherapy for the meningitis was initiated. We discuss of urinary tuberculosis based on literature data about epidemiology, physiopathology, diagnosis and treatment. (C) 2019 Societe francophone de nephrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.

Les inégalités sociales de santé (ISS) sont associées à la modalité de dialyse au Royaume Uni, en Australie et aux États-Unis. L’objectif de cette étude était d’évaluer si, en France, les ISS estimées par l’European Deprivation Index (EDI) sont associées à la dialyse assistée. Les patients traités par dialyse en 2017 après 3 mois de traitement de suppléance ont été inclus. Un géocodage a été effectué à partir de l’adresse des patients. L’EDI a été calculé à partir de l’IRIS des individus. La dialyse assistée était définie par un traitement en hémodialyse en centre ou en unité de dialyse médicalisée ou par dialyse péritonéale assistée par une infirmière. Un modèle logistique mixte avec le département en effet aléatoire a été utilisé pour l’analyse statistique. Parmi les 9588 patients inclus, 1402 patients étaient autonomes et 8132 étaient assistés. En analyse multivariée, l’EDI n’était pas associé à la dialyse assistée (quintile 2 : OR 0,78 [0,61–1,00], quintile 3 : OR 1,04 [0,81–1,33], quintile 4 : OR 0,97 [0,76–1,23], quintile 5 : OR 1,01 [0,80–1,27]). Un résultat similaire était observé dans le sous-groupe des patients traités par hémodialyse et dans le sous-groupe des patients traités par dialyse péritonéale. L’âge, l’initiation de la dialyse en urgence, la maladie cardiovasculaire, l’insuffisance respiratoire chronique, le cancer, le handicap, l’incapacité totale à la marche, le moyen de transport, l’albuminémie, l’hémoglobine et l’inscription sur liste d’attente de greffe rénale étaient associés à la dialyse assistée. En France, en dialyse, en hémodialyse ou en dialyse péritonéale les ISS estimées par l’EDI ne sont pas associées à la dialyse assistée.

It is estimated that out of the 100,000 or more species of mushrooms worldwide, more than 100 are toxic. In the United States, the National Poison Data System reported 133,700 cases of mushroom exposure from 1999 to 2016, and 6136 cases in 2017.1,2 Identifying the specific mushroom species involved is mandatory because specific treatment exists for some mushroom poisoning. A recent algorithm to group the multiple species and syndromes of mushroom poisoning into 6 presenting syndromes has been proposed by White et al.