Aim. - To describe current practices of glucose-lowering treatments in people with diabetes and chronic kidney disease (CKD), the associated glucose control and hypoglycaemic symptoms, with an emphasis on sex differences. Methods. - Among the 3033 patients with CKD stages 3-5 recruited into the French CKD-REIN study, 645 men and 288 women had type 2 diabetes and were treated by glucose-lowering drugs. Results. - Overall, 31% were treated only with insulin, 28% with combinations of insulin and another drug, 42% with non-insulin glucose-lowering drugs. In CKD stage 3, 40% of patients used metformin, 12% at stages 4&5, similar for men and women; in CKD stage 3, 53% used insulin, similar for men and women, but at stages 4&5, 59% of men and 77% of women used insulin. Patients were reasonably well controlled, with a median HbA1c of 7.1% (54 mmol/mol) in men, 7.4% (57 mmol/mol) in women (P = 0.0003). Hypoglycaemic symptoms were reported by 40% of men and 59% of women; they were not associated with the estimated glomerular filtration rate, nor with albuminuria or with HbA1c in multivariable analyses, but they were more frequent in people treated with insulin, particularly with fast-acting and pre-mixed insulins. Conclusion. - Glucose-lowering treatment, HbA1c and hypoglycaemic symptoms were sex dependent. Metformin use was similar in men and women, but unexpectedly low in CKD stage 3; its use could be encouraged rather than resorting to insulin. Hypoglycaemic symptoms were frequent and need to be more closely monitored, with appropriate patient-education, especially in women. (C) 2018 Elsevier Masson SAS. All rights reserved.

Il est bien établi que les démangeaisons cutanées (prurit), ressenties par les patients hémodialysés, sont associées à une faible qualité de vie et de sommeil, plus de symptômes de dépression et une mortalité accrue, mais il y a peu d’études chez les patients non dialysés. L’objectif était de décrire la sévérité des démangeaisons, les facteurs de risque associés, ainsi que les relations entre le prurit et la santé perçue des patients avec une maladie rénale chronique (MRC) modérée à avancée. Dans une étude menée au Brésil, aux États-Unis et en France, 3780 patients (61 % d’hommes) suivis en néphrologie pour une MRC stades 3–5 non dialysés (DFG moyen de 31,0 ± 12,4 mL/min/1,73 m2), ont complété un auto-questionnaire, permettant d’évaluer le degré de gêne lié aux démangeaisons et plusieurs composantes de la santé perçue. Des ratios de prévalence (PR) ont été calculés pour identifier les facteurs associés à un prurit modéré à extrême, ainsi que pour évaluer les associations entre les différents degrés de prurit, les symptômes de dépression et un sommeil agité. Des régressions linéaires mixtes ont été utilisées pour examiner les associations entre les différents degrés de gêne du prurit et les scores de qualité de vie (physique–PCS et mentale–MCS). Les patients étaient âgés en moyenne de 67,0 ± 12,9 ans et leur répartition selon les stades de MRC 3a, 3b, 4 et 5, étaient respectivement de 14,9 %, 34,0 %, 44,0 %, et 7,2 %. Parmi eux, 24 % ont déclaré avoir un prurit modéré à extrême. Cette prévalence ne différait pas entre pays, entre sexe, ou entre stades, mais était significativement plus fréquente chez les patients les plus âgés, ceux atteints de cirrhose du foie, de maladie pulmonaire, de dépression diagnostiquée par un médecin, ou avec une hémoglobine plus basse ou une phosphorémie plus élevée. Les patients extrêmement gênés par le prurit avaient des scores PCS et MCS de 7,8 points [IC à 95 % = −10,9 ; −4,7] et de 5,0 points [−7,7 ; −2,4] respectivement plus bas que ceux non gênés par ce symptôme. Ces mêmes patients présentaient également une prévalence ajustée encore plus élevée de symptômes de dépression (PR = 2,1 [1,8 ; 2,5]) et de sommeil agité (PR = 1,8 [1,5 ; 2,1]). Cette étude souligne la prévalence élevée de prurit sévère dans la MRC modérée ou avancée et l’importance de son retentissement sur la qualité de vie et de sommeil, et l’humeur des patients.

The increased mortality risk in hemodialysis (HD) patients unable to meet six targets in different areas of HD practice has been reported previously. Using a prevalent cross-sectional sample of Spanish HD patients (n = 613) from the second stage of the Dialysis Outcomes and Practice Patterns Study to determine the percentage with low dialysis dose, hyperphosphatemia, hypercalcemia, hypoalbuminemia, anemia, and catheter use and based on the mortality hazard ratios and the total HD population in Spain, according to the Spanish Society of Nephrology Report, we estimated the number of patient life years that could potentially be gained in our country. These characteristics of HD practice were selected because each is modifiable through changes in practice, each is associated with mortality, and each has a large number of patients outside the target guidelines. The targets that define "within guidelines" are as follows: dialysis dose (single pool Kt/V >1.2), anemia (hemoglobin >110 g/L), albumin after standardization (>40 g/L), serum phosphorus (1.1-1.5 mmol/L), serum calcium (2.1-2.4 mmol/L), and facility catheter use (<10%). Cox proportional hazards regression models were used to calculate the relative risk of mortality for all patients outside each guideline. In all models, calcium values were adjusted for low serum albumin. A separate Cox survival model adjusted for all six HD practices simultaneously to account for correlation that may exist between some facility practices. All models were adjusted for age, sex, race, time on ESRD, and 14 summary comorbid conditions. Patient years attributable to each of the six practice patterns were estimated and are reported here as the potential patient years gained. Comparison of the estimates by individual guideline shows that, in Spain, increasing patient albumin above 40 g/L in all patients would lead to an estimated gain of 9,269 patient years (a 7.9% increase). Additionally, if all facilities could decrease catheter use to less than 10%, 2,842 patient years could be gained (a 2.4% increase). Though it may be an unrealistic goal, if all Spanish patients currently outside the guidelines achieved all six target levels, an estimated 17,300 life years could be gained over the next five years (a 15% increase). A more achievable goal of bringing 50% of patients who are currently outside targets within targets would result in 9,266 life years gained. In conclusion, this analysis suggests large opportunities to improve HD patient care in Spain.

Abstract Background: Various organizations have published clinical practice guidelines for the care of haemodialysis patients. However, it is unknown to what extent improving or even reaching perfect compliance with guidelines would improve the survival of HD patients in Belgium. Methods: Using data from the second phase of the Dialysis Outcomes and Practice Patterns Study (DOPPS), the proportion of haemodialysis patients failing to meet six key practice targets (Kt/V ≥1,2, haemoglobin ≥11 g/dl, phosphate 1,1-1,5 mmol/l, calcium 2,1-2, 4 mmol/l, albumin ≥40 g/l, and facility catheter use ≤10 %) was calculated along with the relative risk of mortality associated with being outside these targets. The life years potentially gained from adherence to the six targets, both separately and all six together were then estimated. Results: The percentage of patients outside the targets were as follows: 30,3%, Kt/V; 33,6%, haemoglobin; 56,2%, phosphate; 58,2%, calcium; 67,1%, albumin; and 91,1%, catheter. Estimated patient life years gained with improved compliance with guidelines was highest for albumin (3.670) and catheter use (2.331) but still substantial for the other four targets (ranging from 551 to 1.258). The total of patient years gained if 100% of patients have all six practices brought within target reaches 7.516 years. A conservative estimate of 50% of patients within all targets still yields an improvement of survival of 3.958 patient years. Conclusion: This analysis suggests large opportunities to improve HD patient care in Belgium. The avoidance of HD catheters, with the use of AV fistulas whenever possible, should be given a high priority. Admittedly, these calculations assume causality or partial causality that has not been definitively proven. Still, if causality is only partial, the results emphasize that the improvement of patient care through adherence to targets of clinical guidelines might be substantial and all Belgian nephrologists and staff members of dialysis units should carefully pursue every potential effort.

Knowing the relative risk (RR) of mortality associated with being outside the guideline targets and the percentage of patients in this situation, it is possible to estimate the number of patient life years that could be gained from adhering to guideline recommendations. We used a prevalent cross-sectional sample of 576 Italian patients from the Dialysis Outcomes and Practices Patterns Study (DOPPS) phase II (2002-2004) to determine the percentage of patients who failed to meet the Italian Society of Nephrology's targets for dialysis dose (spKt/V ≥ 1.3), anemia management (hemoglobin ≥ 11 g/dL), and mineral metabolism (serum calcium and phosphorus: ≤ 2.6 and ≤ 1.8 mmol/L, respectively), and the National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (K/DOQI) targets for nutritional status (serum albumin ≥ 4 g/dL) and vascular access (facility catheter use ≤ 10%). We used a larger random sample of DOPPS patients to establish the adjusted RRs of mortality associated with the 6 examined targets. The percentage of patients outside the targets and the adjusted RRs were 34% and 1.12 for dialysis dose, 37.7% and 1.20 for anemia management, 40.8% and 1.14 for phosphorus, 14.4% and 1.22 for calcium, 62.5% and 1.46 for albumin, and 40.1% and 1.20 for facility catheter use. The adjusted sum of life years potentially gained by complete adherence to all 6 guidelines was 25,156 over a period of 5 years (2006-2010); a more conservative estimate, modeling life years potentially gained by bringing half of all patients outside targets within them, was 13,382. In conclusion, this analysis suggests opportunities to improve hemodialysis patient care in Italy. The magnitude of potential savings in life years should encourage greater adherence to guidelines and practices that are significantly associated with better survival.