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Launched in 2013 supported by the Program “Cohorts – Investments for the Future”, the CKD-REIN (Chronic Kidney Disease – Renal Epidemiology and Information Network) study is a prospective cohort that included and followed for 5 years more than 3000 patients with moderate or advanced chronic kidney disease (CKD), from 40 nationally representative nephrology clinics. A large amount of data was collected on CKD and its treatments, patient social characteristics and reported outcomes, and nephrology practices and services. A total of 170,000 blood and urine samples were collected and stored in a central biobank. Coordinated with the CKD outcomes and practice pattern study (CKDopps) and collaborating with the international Network of CKD cohorts (iNETCKD), CKD-REIN contributes to the understanding of CKD and the positioning of France with respect to CKD epidemiology and care in the world. This review highlights major findings from the cohort, and their potential implications for clinical practices and the health system, grouped into the following themes: (1) the complexity of patients with CKD; (2) adherence to clinical guidelines; (3) treatment practices and drug risk; (4) acute on chronic kidney disease; (5) CKD metabolic complications; (6) prediction of kidney failure; (7) sex differences in CKD; (8) patient perspective on CKD; (9) transition to kidney failure and replacement therapy; (10) conservative care.

Background: To be able to assess the impact of the bundled payment system on real-life management of patients with chronic kidney disease, an overview of patient-care management before its implementation is needed., Patients and Methods: We describe patterns of nephrology care over 3 years in 2835 patients with moderate to severe chronic kidney disease, who were followed-up from 2013 to 2019 in the CKD-REIN cohort study. Compliance with health authority guidelines during this period is also studied., Results: At baseline, patients' mean age was 67 years, 65% were men, and 43% had chronic kidney disease stage 4 or 5. The mean number of nephrology visits increased from 1.1 to 2.7 per year, from chronic kidney disease stage 3A to stage 5. The minimum number of nephrology visits as recommended by health authorities was achieved in 84%, 63%, and 33% of patients with chronic kidney disease stages 3B, 4, and 5, respectively. In chronic kidney disease stages 4 and 5, only 34% and 40% of patients had seen a dietitian, and 33% and 54% had received information about treatment options, respectively. The average waiting time for a first appointment with a nephrologist was longer, 60 days and its duration shorter, 30 vs 38 to 40 minutes, in university hospitals compared with non-university hospitals and private clinics., Conclusion: The significant gap between received and recommended care reflects human resources and organizational limits in chronic kidney disease management in the nephrology setting. Improvements with bundled payment are expected., (Copyright © 2021 Société francophone de néphrologie, dialyse et transplantation. Published by Elsevier Masson SAS. All rights reserved.)

Introduction: The health crisis linked to the COVID-19 epidemic has required lockdown measures in France and changes in practices in dialysis centers. The objective was to assess the depressive and anxiety symptoms during lockdown in hemodialysis patients and their caregivers., Methods: We sent, during lockdown period, between April and May 2020, self-questionnaires to voluntary subjects (patients and caregivers), treated by hemodialysis or who worked in hemodialysis in one of the 14 participating centers in France. We analyzed their perception of dialysis sessions (beneficial or worrying), their stress level (VAS rated from 0 to 10), their anxiety and depressive symptoms (Hospital anxiety and depression scale). Factors associated with stress, anxiety and depression were analyzed with multiple linear regression models., Results: 669 patients and 325 caregivers agreed to participate. 70 % of participants found it beneficial to come to dialysis during confinement. The proportions of subjects with a stress level ≥ 6 linked to the epidemic, confinement, fear of contracting COVID-19 and fear of infecting a loved one were respectively 23.9%, 26.2%, 33.4% and 42%. 39.2% presented with certain (13.7%) or doubtful (19.2%) anxious symptoms. 21.2% presented a certain (7.9%) or doubtful (13.3%) depressive symptomatology. Age, gender, history of psychological disorders and perception of dialysis sessions were associated with levels of stress, anxiety and depression., Conclusion: During the lockdown period, in France, the majority of hemodialysis patients and caregivers found it beneficial to come to dialysis. One in three subjects had anxiety symptoms and one in five subjects had depressive symptoms., (Copyright © 2021. Published by Elsevier Masson SAS.)

Metabolic complications of chronic kidney disease (CKD) are frequent; the aims of this review are to present a 2018 update for hyperkalemia, hyperphosphatemia and anemia. Hyperkalemia is defined by a plasma level above 5.0 mmol/L, after ruling out pre-analytical problems such as hemolysis. It is frequent in CKD, most often due to drugs and notably renin/ angiotensin blockers. Chronic hyperkalemia is deleterious, with an increased risk of mortality. Therapeutic strategies to decrease the incidence and severity of hyperkalemia are therefore crucial in nephrology: experts recommend to maintain the renin/angiotensin blockers as long as possible, whilst associating diuretics and potassium binders. There are apparent discrepancies between optimal protein intake and decreased phosphate intake in CKD; this is even more important in dialysis since protein decrease is associated with denutrition and subsequent increased risk of mortality. Nutritional phosphate intake from vegetables are less absorbed; in contrast, phosphate additives are almost completely absorbed in the gastro-intestinal tract. These "hidden" intake may increase the total daily phosphate intake by 1 000 mg. As such in addition to optimized dialysis, phosphate binders should be used but compliance may be challenging on the long-term. Educational programs focused on phosphate are also mandatory in CKD patients. "Absolute" iron deficiency is less frequent than "functional" iron deficiency in CKD patients: both require the use of iron supplementation, and the latter may benefit from additional erythropoietin stimulating agents (ESA) when hemoglobin is below 10 g/dL. Intravenous iron is more efficient to correct iron deficiency both in pre-dialysis and dialysis especially in patients with chronic deficiency. Last generation intravenous preparations have largely demonstrated their safety. One indication of iron supplementation one should not forget in nephrology is the patient with moderate CKD and heart failure since the expected benefits are multiple, notably in terms of quality of life, renal function and functional capacity. Cet article fait partie du numéro supplément Innovations en Néphrologie réalisé avec le soutien institutionnel de Vifor Fresenius Medical Care Renal Pharma., (Copyright © 2018 Elsevier Masson SAS. All rights reserved.)

Only limited data is available on the management of the chronic kidney disease-associated bone and mineral metabolism disorder (CKD-MBD) in the pre-dialysis stages of CKD in France. A better knowledge of current management habits could lead to an improvement in the implementation of international recommendations (KDIGO). The 3rd version of the French Phosphorus and Calcium Survey Photo-Graphe (Sanofi) included a cohort of CKD stages 4 and 5 patients, whose aim was to examine the prevalence of CKD-MBD and the quality of its management in patients under the care of 62 nephrologists from over 20 geographical regions in France. The study started in October 2011, i.e. one year after patient enrollment. We examined in particular the percentage of patients presenting with laboratory parameter abnormalities indicative of CKD-MBD who were not receiving adequate treatment. A total of 456 patients with CKD stage 4 and 154 with CKD stage 5 were studied. Their mean age was 72.9±14.2 years, and male/female ratio was 58/42. KDIGO targets of serum PTH for CKD stages 4 and 5 were not achieved in respectively 80 and 84% of the patients, for serum calcium in 8 and 22% and for serum phosphate in 12 and 46%. As a potential explanation, insufficient therapy was estimated to account for respectively 45 and 60% of insufficiently controlled secondary hyperparathyroidism, and for 36% of persistent hyperphosphatemia in stage 5. It should be noted that 55.5 and 57.5% of patients were receiving native vitamin D. In this national observatory, the management of CKD-MBD stages 4 and 5 appears suboptimal, especially as regards the control of secondary hyperparathyroidism, which remained untreated in nearly 50% of the patients. Hyperphosphatemia was also common and inadequately controlled in CKD stage 5. To improve the management of CKD-MBD, nephrologists need to be more aware of the importance of aiming for recommended laboratory targets and how this can be achieved., (Copyright © 2017. Published by Elsevier Masson SAS.)

The nutrition care of patients with chronic kidney disease (CKD) remains a central question which is permanently studied. The benefits of a dietary protein restriction are once again enlightened, either by reducing the urea found to be hyperglycemic, thus improving the peripheric insulin sensitivity, or by decreasing phosphorus and FGF23 hormone, whose reductions are respectively associated with nephroprotection and diminution of cardiovascular events. The numerous researches conducted on the gut microbiota also open promising avenues to better understand the role of this ecosystem in CKD. Finally, the interest in incremental haemodialysis is revived, results show it may be associated with less loss of proteins and preservation of residual kidney function. The development of a nutritional score, informative of survival prediction, also offers the possibility to ensure a better follow-up of patients., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Protein energy wasting (PEW) is an independent factor associated with morbi-mortality in chronic kidney disease. Wasting is particularly common in chronic diseases of organs such as kidney disease with a major impact at the stage of dialysis. It covers 20 to 70% of patients diagnosed with chronic kidney disease according to the degree of evolution of the disease and the diagnostic method used patients. Mechanisms of PEW are based mainly on anorexia and metabolic abnormalities caused by kidney disease. Nutritional treatment differs depending on the stage of the kidney disease acute or chronic treated whether or not by dialysis. Nutritional monitoring should be regular, individualized and collaborative to detect a risk of PEW or treat installed PEW. Refeeding techniques should allow all the nutritional needs. Their indications depend on the clinic, biochemical assessment and nutrient intake., (Copyright © 2016 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Introduction: Chronic kidney disease progressively induces a disorder of mineral and bone metabolism (CKD-MBD) which also leads to cardiovascular abnormalities. Previous studies showed that only few hemodialysis patients had serum calcium, phosphate and parathyroid hormone levels within the K/DOQI (Kidney-Disease Outcomes Quality Initiative) targets of 2003. Our aim was to identify the impact of different therapeutic strategies and that of the KDIGO (Kidney-Disease: Improving Global Outcomes) targets of 2009 on the control of CKD-MBD., Patients and Methods: The French calcium and phosphate observatory monitors the mineral metabolism of patients with CKD at the local, regional and national level every six months. We compared the data recorded in June 2008 (n=1914 patients) with those collected in October 2012 (n=2481) for patients aged 18 years or more, who started hemodialysis therapy within the last 12 months., Results: As compared with 2008, in 2012 fewer patients had hyperphosphatemia (55.1 % versus 64.7 %), hypocalcemia (35.5 % versus 40.3 %) and hyperparathyroidism (9.8 % versus 10.1 %) according to the KDIGO guideline, and more had hypophosphatemia (9.6 % versus 6.5 %), hypercalcemia (3.9 % versus 2.2 %) and hypoparathyroidism (31.5 % versus 25.8 %) (P<0.001, P<0.001 and P=0.002 respectively for differences in serum phosphate, calcium and PTH levels). Mean (± standard deviation [SD]) serum 25 OH vitamin D levels increased by 1.6-fold, from 48.3±42.6 nmol/L in 2008 to 76.6±45.8 nmol/L in 2012. Between 2008 and 2012, the prescription of native vitamin D derivatives and sevelamer (HCl or carbonate) increased whereas that of cinacalcet, lanthanum carbonate, calcium-chelating agents and active vitamin D derivatives decreased., Conclusion: Despite a slight improvement of biochemical CKD-MBD parameters in the observation period only few patients reached the three KDIGO targets (11.5 % in 2012 versus 11.1 % in 2008)., (Copyright © 2015 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Background: Preserving kidney function and improving the transition from chronic kidney disease to end stage is a research and healthcare challenge. The national Chronic Kidney Disease-Renal Epidemiology and Information Network (CKD-REIN) cohort was established to identify the determinants, biomarkers and practice patterns associated with chronic kidney disease outcomes., Methods: The study will include more than 3000 adult patients with moderate to advanced chronic kidney disease from a representative sample of 40 nephrology clinics with respect to regions and legal status, public or private. Patients are recruited during a routine visit and followed for 5 years, before and after starting renal replacement therapy. Patient-level clinical, biological, and lifestyle data are collected annually, as well as provider-level data on clinical practices, coordinated with the International Chronic Kidney Disease Outcomes and Practice Pattern Study. Blood and urine samples are stored in a biobank. Major studied outcomes include survival, patient-reported outcomes, disease progression and hospitalizations., Results: More than 13,000 eligible patients with chronic kidney disease were identified, 60% with stage 3 and 40% with stage 4. Their median age is 72 years [interquartile range, 62-80 years], 60% are men and 38% have diabetes. By the end of December 2015, 2885 patients were included., Conclusion: The CKD-REIN cohort will serve to improve our understanding of chronic kidney disease and provide evidence to improve patient survival and quality of life as well as health care system performances., (Copyright © 2016 Association Société de néphrologie. All rights reserved.)

Often underestimated or misunderstood in chronic renal failure (CRF), muscle wasting is nevertheless common and concerns about 50% of dialysis patients. The consequences of this myopathy on quality of life and outcomes of patients are unfavorable, identical to those observed in sarcopenia in elderly subjects with sarcopenia. The similarities between the two situations also concern the symptoms, the underlying muscle damages and the pathogenic mechanisms and may be partly explained by the frequently high age of ESRD patients. Skeletal muscle involvement should be systematically investigated in the IRC patient as in the elderly with sarcopenia to propose as early as possible a treatment of which physical activity and nutritional interventions are the mainstay., (Copyright © 2015 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Unlabelled: Malnutrition is an independent factor associated with morbi-mortality in chronic kidney disease. It is particularly common and may increase during hospitalization., Objectives: To measure nutritional and physical performance evolution as well as patients' physical autonomy during a hospitalization in a university hospital renal ward. Treatments were adjusted according to different diagnoses (nutritional care, body composition, physical activity) along with a multidisciplinary approach. In this way, it can show the impact of this care on nutritional status of the patient., Design: Regardless of their nutritional status and kidney disease (acute or chronic kidney disease, chronic hemodialysis), patients were included at day 0, within 2 days from admission; nutritional interventions and measurements were assessed on day 7, day 14 and day 21. The study was run from December 2011 till June 2012, and 48 patients were included., Results: On admission, patients had a low energy intake (20.9±8.6 kcal/kg/day). This intake was improved by means of a dietetic intervention (28.1±6.5 kcal/kg/day after two weeks of hospitalization, 29±6.1 kcal/kg/day after three weeks and 29±8.4 kcal/kg/day after four weeks). Seventy-three percent of the hospitalized patients were malnourished, among them 91% had a decreased serum albumin (26.8±6.6 g/L). Weight and muscle mass (measured by impedancemetry) were maintained, prealbumin increased by 16.5 mg/L after two weeks (n=48; P=0.61), 27.8 mg/L after three weeks (n=31; P=0.018), 52.3 mg/L after four weeks (n=13; P=0.002) and albuminemia by 1.8 g/L (n=13 patients monitoring four weeks; P=0.13). Both physical autonomy (assessed with Test moteur minimum) and muscle strength (Hand Grip Test) were significantly improved., Conclusion: A systematic screening of wasting and a multidisciplinary care improved nutritional status and physical ability of patients hospitalized in a renal ward., (Copyright © 2014 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

The changes in eating habits and decreased physical activity have been responsible for part of the high prevalence of chronic diseases such as hypertension or diabetes, currently observed in the so-called civilized societies. These diseases are less prevalent in previous civilizations and several decades of nutrition research have enabled better understanding of the eating habits of our ancestors, and have demonstrated the value of diet called "Mediterranean or Paleolithic". This review provides an update on the latest research. What dietary changes since the Paleolithic period, and finally how can we adapt our current diet? Several animal studies or human clinical demonstrate the value of historical research and nutrition., (Copyright © 2013. Published by Elsevier SAS.)

Finding the optimal dialysate calcium (DCa) in haemodialysis (HD) patients remains a therapeutic challenge. Besides, the Dialysis Outcomes and Practice Pattern Study (DOPPS) has reported a greater mortality rate using higher DCa doses. The objective was to assess the impact of DCa prescription on survival. Baseline DCa prescriptions were recorded using a cross-sectional analysis of HD patients from the regional ARNOS French cohort. A prospective 42-month survival analysis study was performed. In July 2005, 1294 HD patients were included in this study. DCa at doses of 1.25, 1.5, and 1.75 mmol/L was prescribed in 13.6%, 74.1%, and 12.3% patients, respectively. Using a Cox proportional model adjusted for several parameters, DCa was found to be not significantly associated with survival. Patients receiving 1.75 mmol/L DCa were more frequently treated with online haemodiafiltration, cinacalcet, and shorter dialysis sessions; they had a more frequent history of parathyroidectomy and lower calcium levels. The DCa prescription remained stable after 12 months in 80% of cases. This is an observational study; therefore, only baseline data were recorded for analysis. Higher DCa concentration is not associated with mortality, in contrast to the findings by DOPPS. Prescribing DCa on an individual basis according to various mineral metabolism parameters and treatments appears to be safe irrespective of the DCa dosage., (Copyright © 2012 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Unlabelled: In chronic kidney disease patients with secondary hyperparathyroidism (SHPT), the recommended K/DOQI™ target serum levels of parathyroid hormone (PTH), calcium (Ca) and phosphorus (P) are difficult to reach and maintain stable. We present the results of the French cohort from the European study ECHO which investigated the use and effectiveness of cinacalcet in real-world clinical practice., Methods: An observational study of the SHPT management in dialysis patients, partially retrospective (from 6 months prior to cinacalcet initiation) and partially prospective (up to 12 months of cinacalcet treatment)., Results: Four hundred and eighty-five French patients were enrolled from 44 centres. Cinacalcet was given in combination with active vitamin D treatment (39%) and phosphate binders (87%). After 12 months, the proportion of patients reaching recommended K/DOQI™ target levels had increased from 2.5% to 28.8% for PTH, from 46.8% to 50.1% for Ca, from 40.0% to 49.9% for P and 54.8% to 77.7% for the CaxP product. The proportions of patients using active vitamin D and sevelamer decreased by 6% and 20% respectively. Adverse events were reported in 37 (7.6%) patients, mainly nausea (2.1%), vomiting (2.1%) and dyspepsia (1.2%)., Conclusions: The results of this study are consistent with data from controlled and randomized studies showing that cinacalcet increases the proportion of patients achieving the K/DOQI™ targets for PTH, Ca, P and CaxP in real-world clinical practice., (Copyright © 2012 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Unlabelled: The main cause of resistance to erythropoiesis-stimulating agents (ESA) used for treatment of anemia in chronic hemodialysed patients (CHP) is the iron deficiency, absolute or functional. Secondary hyperparathyroidism (SHPT) is a secondary factor of resistance. Indeed, it has been reported in the literature an improvement of anemia parameters after surgical parathyroidectomy (PTX). The objective of this study is to assess in CHP, the impact of the correction of SHPT by a calcimimetic, cinacalcet (CI), (which is considered as a pharmacological PTX) on the response to ESA, measured by the erythropoietin resistance index (ERI). Twenty-two CHP with severe SHPT documented by an intact parathyroid hormone (iPTH) above 800pg/mL were included in this prospective pilot study. Mineral bone metabolism, anemia and nutritional parameters were measured baseline and after 6 months of treatment by CI. The effect on anemia was assessed at the end of study by the ERI, the change in Hb concentration, and the proportion of patients with Hb levels above 11g/dL., Results: At the end of study there was a significant decrease (M6 vs M0) in iPTH (1302 vs 674pg/mL or -48%, p=0.006), serum calcium (2.39 vs 2.15mmol/L or -10%), serum phosphate (2 vs 1.7mmol/L or -15%), serum calcium-phosphorus product (CaxP) (4.8 vs 3.8mmol(2)/L(2) or - 20% (p<0.05), and the number of patients with CaxP>4.4mmol(2)/L(2) (64 vs 32%, p<0.05). The level of bone alkaline phosphatase remained stable during the study (28 vs 27 IU/L). The Hb levels increased from 11 to 11.4g/dL, as did the proportion of patients whose Hb concentration reached 11g/dL or higher (50 vs 70%, p<0.05) without important change of the median weekly ESA dosis in the majority of patients, 18 cases (81%) vs four (19%). Two subgroups were identified from the median decreases in iPTH (delta iPTH) between M0 and M6, Group 1 (delta iPTH≥400pg/mL, n=10) and group 2 (delta iPTH<400pg/mL, n=12): in group 1, we found a correlation between the decrease in iPTH by CI and the stability or decrease in ERI (group 1), at comparable dose of dialysis, nutritional and iron intakes and inflammatory profiles; in group 2 without a significant effect of CI on PTH reduction the levels of ERI and ESA dosis were more elevated., Conclusion: A treatment by calcimimetic improves the control of anemia by ESA in CHP and interferes positively on a cause of secondary resistance to ESA represented by SHPT. The mechanism of these effects could be linked to the decreased of bone marrow fibrosis and inflammation and to the triptych formed by the reduction in iPTH, CaxP and phosphate., (Copyright © 2011 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Introduction: Management of anaemia in chronic renal insufficiency (CRI) represents an important medico-economic challenge because of the great number of patients and the cost of the erythropoiesis-stimulating agent (ESA). The aim of this study was to identify determinants of the costs associated with these treatments in order to choose, with equal efficacy, the most efficient ASE., Method: A bibliographic research was realised by Medline database interrogation., Results: Among the direct medical costs, five studies showed that acquisition of epoetine alfa (EA) compared to darbepoetin alfa (DA) was less expensive. Concerning the costs associated with the route of administration, the subcutaneous injection (SC) of epoetine allowed a gain in costs because of the decrease of doses compared to the intravenous (IV) route. The switch from EA in SC to DA in IV, for hemodialysis patients, was associated with a reduction of the number of injections and with a treatment's cost lower by DA than by EA. Costs related to the regimen of administration, notably those related to nursing, medical and pharmaceutical time, were negligible towards those associated to the acquisition of the ASE. Finally, the costs of the therapeutic follow-up and treatment of the adverse effects of the ASE were similar between the EA and the DA., Conclusion: The costs associated with the prices of acquisition of the ASE, negotiated by the structure of care, represent the most important part of the direct medical costs., (Copyright 2009 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

Introduction: Because of the high associated morbi-mortality, phosphate and calcium disorders remain a major therapeutic challenge for nephrologists. Previous studies showed that only few patients had serum calcium, phosphate and parathyroid hormone within Kidney-Disease Outcomes Quality Initiative (K/DOQI) targets., Patients and Methods: The French calcium and phosphate observatory monitors mineral metabolism at local, regional and national level and its follow-up every six months since 2005. More than 200 nephrologists collected more than 9000 patients' data. We compared the results recorded in June 2005 with those collected in June 2008., Results: As compared with June 2005, in June 2008 fewer patients were hypercalcemic according to the K/DOQI targets (-26.2%, p<0.001) and hyperphosphatemic (-16.5%, p<0.001), more patients were hypocalcemic (+45.5%, p<0.001) and hypophosphatemic (+8.8%, p<0.02). A greater number of patients had elevated serum PTH above 300ng/l (+17.6%, p<0.001) and fewer had a PTH lower than 150ng/l (-25.4%, p<0.001). Serum 25OH vitamin D level was 21.7+/-20.0microg/l in June 2008. Overall, 10.5% of patients met all three K/DOQI targets, an improvement compared with June 2005 (6.8%, p<0.001). Between 2005 and 2008, cinacalcet, lanthane carbonate and native vitamin D derivatives prescription increased whereas calcium-based phosphate binders, sevelamer-HCL and active vitamin D derivatives decreased., Conclusion: Despite a significant improvement between 2005 and 2008, only few patients reach the three K/DOQI targets (10.5%) in 2008. The prospective biannual follow-up during three years will allow us to identify the impact of different treatments on calcium and phosphate metabolic control and patient's survival.

Chronic renal disease is a state of microinflammation and insulin resistance. They both impact on the patient's outcome with an increased cardiovascular morbi-mortality and malnutrition. Current evidence suggests that there is a link between these two abnormal conditions. Recent data show a multiple organ regulatory pathway with a key role of bone, adipose tissue, immune system and central nervous system in energy balance control and glucose homeostasis. Thus, in searching for effective therapies, we should use an integrated approach aimed at modifying integrated outcomes rather than targeting single molecules., (2010 Elsevier Masson SAS. All rights reserved.)

Nutritional guidelines are scarce for patients receiving maintenance hemodialysis. In this review, we address the recent European guidelines released in 2007. They include diagnosis and follow-up criteria for malnutrition to be performed routinely. They provide new values for protein and energy requirements, based on physical activity. Vitamins and trace elements requirements are proposed. The renutrition therapies are addressed, i.e., oral supplement, enteral and intradialytic parenteral nutrition. Finally, androgens, quotidian dialysis and acidosis treatment are also considered., (2010 Elsevier Masson SAS. All rights reserved.)

Insulin resistance (IR) and inflammation are now identified as common features in chronic kidney disease (CKD) patients. These metabolic abnormalities are both predictors of adverse cardiovascular (CV) outcome and are associated with worst nutritional status. Unequivocal experimental, epidemiological and clinical evidence produced during the past decade causally links inflammation to the development of metabolic syndrome or the complications that emerge from these pathologies particularly in the context of obesity or type II diabetes patients. These observations lead to the hypothesis of "meta-inflammation" : metabolically triggered inflammation, with a key role played by adipose tissue. In CKD patients, many other factors related with uremia can be causative but the abnormal cytokine and adipokine concentrations and the cluster of metabolic abnormalities push us to think like other metabolic diseases, that adipose tissue dysfunction may be among the pathways that induce inflammation and IR. Therapeutic approaches of traditional CV risk factors have been inconclusive or failed to improve the outcome of these patients. Further studies assessing the impact of renal failure on adipose tissue function and the pathways that are altered in this disease may allow to have therapeutic approaches targetting adipose tissue dysfunction or inflammation.

Bone damage in patients with chronic kidney disease (CKD), in the spectrum of chronic kidney disease-mineral and bone disorders (CKD-MBD), represents a daily challenge for nephrologists. The impact of CKD on bone health may be immediate (biological equilibrium) or delayed (fractures and vascular calcifications). Histomorphometry remains the gold standard to evaluate bone but it is rarely perfomed in clinical practice. A real measurement of bone mineral density (BMD) by dual X-ray absorptiometry (DXA) is currently performed to evaluate bone mass. However, this technique presents some limitations. In 2000, the National Institute of Health (NIH) defined new "quality" criteria for the diagnosis of osteoporosis in addition to a decreased bone mass. Bone strength actually integrates two concepts: bone density and bone quality (i.e., microarchitectural organization, bone turnover, mineralization and microfractures). These quality criteria cannot be evaluated by DXA. New bone imaging techniques have thus been developed, leading to an improvement in bone evaluation.

The serum parathyroid hormone (PTH) rises in chronic kidney disease (CKD) and induces renal bone disease as well as other organ damage. The bone disease guidelines were released by the K-DOQI in 2003 in order to help physicians to improve bone management at all different CKD stages. However, many different PTH commercial assays are available today and some questions are raised concerning the interpretation, the validity and the practical choice of these different measurements. After reviewing PTH biosynthesis and metabolism, we will describe the regulation of different PTH fragments (particularly 1-84 and 7-84) and the various types of PTH assays. In compromised clinical situations, bone biopsy still remains the golden standard assessment of bone disease, and it will be helpful to clarify the interest of new 3rd generation PTH measurements. At present, we do not dispose of valid therapeutic recommendations using 3rd generation tests, as well as the relevance of the ratio PTH 1-84/7-84.

In France, incidence and prevalence of end-stage renal disease (ESRD) are increasing, requiring a more rational use of available replacement therapies. To help practitioners make their choice between treatment modalities of peritoneal dialysis (PD) and haemodialysis (HD), critical appraisal of relevant literature has been conducted. Although few absolute or relative contraindications for PD and HD exist, arguments in favour of one versus the other dialysis technique can be made. When patients receive adequate and complete information, their preference is neutral between PD and HD. To date, no trial presenting a convincing level of evidence has been published which demonstrates the superiority of one technique compared to the other. Relative to mortality, it appears that no difference can be observed between the two modalities. However, in those instances where patients expect a rapid transplantation, PD is the preferred technique. This analysis suggests that peritoneal dialysis and haemodialysis are not competitive but rather complementary treatments. It is therefore interesting to identify the reasons supporting the various choices between the two different treatment modalities amongst France's regions. Access to transplant, economic or organizational factors must be considered.