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The number of patients heading towards the terminal stage of their chronic kidney disease, for the first time or after the failure of a kidney transplant, is constantly growing, requiring the use of renal replacement therapy. Nowadays, peritoneal dialysis can be given as a first-line treatment for most patients, in the same way as haemodialysis. It allows patients to remain at home or in their care facility, with the help of a private practice nurse when needed. Complications can be quickly detected and resolved. In the event of failure, the switch to haemodialysis is usually possible.

Background: Polyclonal free light chains (FLC) are considered as middle molecular weight uremic toxins in chronic kidney disease. In this study, we investigate polyclonal FLC removal by comparing conventional high-flux hemodialysis (HD) and online high-efficiency hemodiafiltration (ol-HDF) in end-stage renal disease patients. Methods: We analyzed 31 chronic dialysis patients who were treated by HD then by postdilution ol-HDF during a prospective study. All patients were anuric and without monoclonal gammopathy. Serum pre- and postdialysis FLC were collected during 4 sessions: 1 HD session and 3 ol-HDF sessions. We calculated the reduction ratio using kinetic modeling. Results: The κ reduction ratio was higher with ol-HDF than with HD (66 ± 14 vs. 52 ± 13%, p < 0.001). However, the λ reduction ratio was not significantly higher with ol-HDF (37 ± 20 vs. 37 ± 15%, p = 0.67). Furthermore, predialysis κ- and λ-FLC increased with ol-HDF compared with HD (κ 155 ± 82 vs. 87 ± 47 mg/l, p < 0.05; λ 101 ± 46 vs. 72 ± 41 mg/l, p < 0.05). Postdialysis FLC levels were raised only for λ-FLC with ol-HDF (74 ± 39 vs. 53 ± 31 mg/l, p < 0.05) and were not significantly different for κ. Conclusions: This study shows that κ-FLC removal is better in ol-HDF compared with HD, whereas there is no difference in λ-FLC removal. Surprisingly, predialysis κ and λ levels are both increased in ol-HDF, which is disturbing since polyclonal excess of λ-FLC is associated with mortality in chronic kidney disease.

Background Technical failure is more likely to occur in the first 6 months of peritoneal dialysis (PD). This study was carried out to identify risk factors for early transfer from PD to haemodialysis (HD) in a country where assisted PD is available. Methods All patients from the French Language Peritoneal Dialysis Registry (RDPLF) who started PD between 1 January 2002 and 31 December 2010 were included. Time to transfer, death and transplantation during the first 6 months on PD were analysed by the multivariate Cox proportional hazard model. The Fine and Gray model was used to examine the occurrence of technical failure by considering death and transplantation as competing events. Results Of 9675 patients included, 615 (6.3%) moved to HD during the first 6 months of PD. Cumulative incidence of transfer to HD was 6.6% at 6 months. On multivariate analysis by both the Cox model and the Fine and Gray model, HD prior to PD, allograft failure and early peritonitis were associated with a higher risk of early technical failure, whereas being dialysed in a centre treating more than 20 new patients per year was associated with a lower risk of early transfer to HD. Conclusions Patients treated by HD before PD and failed transplant patients had a higher risk of early PD failure when competing events were considered.

BACKGROUND Peritoneal dialysis (PD) is underused in France compared with other countries. In addition, there are tremendous regional discrepancies concerning the utilization rate of PD. This study was carried out to evaluate the opinion of French nephrologists regarding the optimal rate of PD utilization and to determine which factors limit PD development in France. METHODS Of the 22 French regions, 2 regions with a high rate of PD utilization (prevalence >15%) and 3 regions with a low rate of PD utilization (prevalence

The Registre de Dialyse Péritonéale de Langue Française (RDPLF Registry) is a non-profit association that has been set up to assist physicians and nurses in evaluating their practical experience and results regarding peritoneal dialysis (PD). Five French-speaking and two Spanish-speaking countries have participated in this initiative (which includes 21 000 patients). In France, 82% of all PD patients are included in the registry and the main results for the period from 1995 to January 2006 form the basis of this report: of 11 744 incident patients with a median age of 71 years, 21.5% were over 80 years of age and 56% were not able to perform PD treatment at home without assistance. Eighty-six percent of the latter group received external assistance from a private nurse and 14% were aided by their family. The overall average rate of peritonitis was one episode every 29 months. The probability of being peritonitis-free appeared to be better for patients on automated PD (59.4% at 2 year) than for those on continuous ambulatory PD (55.3%), but this finding requires further validation. The average waiting time before transplantation was about 2 years. In patients who had undergone transplantation, the peritonitis rate was one episode per 42 months before transplantation compared to one episode per 29 months for patients who had not received a transplant. Eighty-three percent of patients had a hemoglobin level greater than 11 g%. Catheter survival was 92% at 2 years post-insertion and 85% at 5 years, with 94% being implanted by experienced surgeons. In conclusion, the RDPLF results demonstrate that PD may be successfully prescribed for older patients who receive assistance either from their family or from a nurse. Further, a larger number of younger patients should also be prescribed this technique in France. Patients eligible for transplantation and on short-term PD have the lowest risk of developing peritonitis; PD before transplantation may help prolong residual renal function, and initial treatment by PD may also help to preserve vascular access for the future.

Access to, and outcome of, renal transplantation according to treatment modality of end-stage renal disease in France.BackgroundAlthough peritoneal dialysis (PD) is recognized as one of the methods of treatment of end-stage renal disease (ESRD), there have been recurrent concerns about the access of patients treated by this modality to kidney transplantation (KTx), as well as reports showing increased complications of KTx in such patients, such as graft thrombosis and infections.MethodsThe aim of this study was to provide a comprehensive view of the impact on transplantation of pretransplant modality of treatment of ESRD using a multivariate analysis of the French database. From 1997 to 2000, after exclusion of pediatric patients, multiple transplantations, and living donors, 6420 were patients registered on the waiting list, and 3464 were transplanted.ResultsUsing a Cox proportional hazard analysis, we found a shorter waiting time for PD patients (RR 0.71, P < 0.0001), which became equivalent to hemodialysis (HD) patients when taking into account the transplant center as a variable (RR 1.0, P = 0.95). Concerning graft survival, only preemptive transplantation had a significant impact, being associated to a decreased risk of graft failure (RR 0.46, P = 0.005).ConclusionOur study supports the concept that the choice of any pretransplant dialysis modality does not influence waiting time for transplant or the results of transplantation.

In dialysis patients, a misevaluation of dry weight may lead to an increased morbidity and mortality. The aim of this cross-sectional multicenter study was to evaluate the association between residual urinary sodium excretion and extracellular volume status in chronically treated hemodialysis patients.Dry weight was determined clinically and by whole-body bioimpedance spectroscopy (Body Composition Monitor, Fresenius Medical Care) prior to a mid-week session in 40 chronic hemodialysis patients with significant residual diuresis (more than 250 mL per day) and receiving treatment in four dialysis centers. Regarding their hydration status assessed by the Body Composition Monitor and in comparison to a healthy reference population, patients were assigned to 1 of the 3 categories: overhydrated, normohydrated and dehydrated. Urine output, urinary sodium excretion and residual renal function were measured for all patients within 30 days before dry weight assessment.The median post-HD session FO was of-0.40 L (IQR: from-1.95 to+0.90) and the median residual urinary sodium excretion was of 64 mmol/L (IQR: 46-79). Among these patients, 16 were normohydated, 16 were dehydrated and 8 were overhydrated. There was a linear relationship between the hydration status after HD session and the urinary sodium excretion (estimate: 5.6±1.5; p0.001). Compared with normohydrated patients, overhydrated patients had a higher residual urinary sodium excretion (estimate: 26±10; p0.01).In this study, urinary sodium excretion is associated with the hydration status evaluated by whole-body bioimpedance spectroscopy.

There are evidences supporting a positive impact of renal residual function (RRF) on survival and quality of life of dialysis patients. Many strategies are available in clinical practices to maintain RRF. Hemodiafiltration seems to be better that conventional hemodialysis and similar to peritoneal dialysis. Arterial hypotension in hemodialysis or dehydration in peritoneal dialysis are deleterious in terms of preservation of RRF. Loop diuretics increase urine volume and natriuresis, not RRF. Radiocontrast and aminoglycosides may be used safely. The benefits of ACE inhibitors and angiotensin II receptor blockers are debated but have positive effect on blood pressure control and cardiac function. Neither biocompatible solutions nor the modality of peritoneal dialysis have demonstrated benefits on RRF.

Background. This study was carried out to examine the association of sub-optimal dialysis initiation of peritoneal dialysis (PD) with all the possible outcomes on PD using survival analysis in the presence of competing risks. Methods. This was a retrospective cohort study based on the data of the French Language Peritoneal Dialysis Registry. We analysed 8527 incident patients starting PD between January 2002 and December 2010. The end of the observation period was 01 June 2011. Times from the start of PD to death, transplantation, transfer to haemodialysis (HD) and first peritonitis episode were calculated. The sub-optimal dialysis initiation was defined by a period of

Starting dialysis in a non-planned manner or in a 'suboptimal' manner is a frequent situation in dialysis centres, even for patients with a regular nephrology follow-up. Unplanned dialysis initiation can be defined as a patient beginning dialysis with no functional vascular access or peritoneal dialysis catheter. These patients start haemodialysis with a temporary catheter, frequently converted to a tunnelled catheter pending native fistula creation or whilst waiting for fistula maturation. In this case, conventional in-centre haemodialysis (ICH) is more frequently used than peritoneal dialysis (PD) or home haemodialysis (HHD).This review found that patients who start dialysis in an unplanned way are significantly older and have more heart and peripheral vascular diseases. Home-based dialysis therapies showed better outcomes than ICH (PD for the first two to three years and HHD for the long-term).This review proposes a paradigm shift in the initial form of dialysis offered to new patients starting dialysis in an unplanned way. Even if they require a temporary catheter, it is possible for them to receive a pre-dialysis education programme (PDEP). The PDEP should be based on both individualised information session(s) given by an experienced nurse to the patient and family and therapeutic education (educative diagnosis, individualised and group session(s)) in order to relieve anxiety and promote home modalities.

The pharmacokinetics of rilmenidine (1 mg orally) was studied in 3 groups of patients with stable chronic renal insufficiency. This was an open, single-blind study following a single administration, and after 15 days of treatment. Group 1 included 11 patients with a creatinine clearance between 15 and 80 mL/min. Group 2 included 17 patients with a creatinine clearance < 15 mL/min. Group III included 10 hemodialysis patients. In patients with chronic renal failure, total plasma clearance and renal clearance of rilmenidine decreased; terminal half-life was 30-42 hours, which is clearly longer than previous values achieved in healthy volunteers. After repeated administration (1 mg daily in group 1, 1 mg every other day in group 2, 1 mg at the end of each dialysis session in group 3), the area under the curve was significantly increased, corresponding to drug accumulation. The steady state was reached after 6 days in patients in group 1 and after 8 days in patients in group 2. The pharmacokinetics of rilmenidine was linear since the terminal elimination half-life and renal clearance were not significantly different after single and repeated administration of rilmenidine. A positive correlation was found between rilmenidine total plasma clearance and creatinine clearance, and between rilmenidine renal clearance and creatinine clearance. Mean rilmenidine hemodialysance was 85 mL/min, that is, 26% of the rilmenidine renal clearance value achieved in healthy volunteers (330 mL/min). Thus, the following dosage schedule can be proposed. In patients whose creatinine clearance ranges between 15 and 80 mL/min, a 1 mg dose every day can be recommended.(ABSTRACT TRUNCATED AT 250 WORDS)

This study was carried out to estimate the modification of hydration status within the first three months of renal transplantation.Fifty patients who underwent a first kidney allograft were prospectively followed for three months after renal transplantation to assess hydration status by bioimpedance spectroscopy.Two hours before the transplant procedure, 10/42 (23.8%) patients were overhydrated. Two days after surgery, 32/40 (80.0%) patients were overhydrated and at three months, 14/27 (51.9%) patients remained fluid-overloaded. Peritoneal dialysis (PD) patients had a lower hydration status (-0.60 L) than hemodialysis (HD) patients (0.70 L; p0.05) and better residual diuresis (41.7 vs. 8.3 mL/h for HD patients, p0.01). Compared with patients who had a delayed graft function (DGF) or a slow graft function (SGF), the immediate graft function (IGF) group had a better hydration status before transplantation (p = 0.031). At three months, 12/14 of the overhydrated patients had a creatinine clearance between 30 and 60 mL/min/1.73 m(2) .Patients receiving a first kidney transplant frequently have a hydration disorder. Transplantation is associated with increased hydration status, which seems to persist if DGF or SGF occurs.

The prevalence of peritoneal dialysis in France remains one of the lowest in Europe in spite of official recommendations in 2008. Progress in peritoneal catheter placement and a good knowledge of the management of catheter complications are essential. A more frequent use of biocompatible solutions should achieve a better preservation of the peritoneal membrane. Such physiological peritoneal fluids seem to decrease morbidity and mortality. Best peritoneal dialysis indications are mainly young patients waiting for a kidney transplantation, old patients without malnutrition and patients with cardiac insufficiency. Objective and complete information dedicated to both peritoneal dialysis and hemodialysis is necessary, even for patients seen in emergency or unplanned or late referral patients. A pre-end-stage renal disease education program has to be mandatory. Non-medical obstacles, mainly financial, are still common so that economic incitations are necessary for the development of peritoneal dialysis. A university formation of nephrologists is now available.

Post-transplant diabetes mellitus (PTDM) is a well-known complication in renal transplant recipients (RTRs). While a number of risk factors for PTDM have been identified, the potential impact of pre-transplant dialysis modality on subsequent development of PTDM has not yet been explored. We performed a multicenter retrospective study on 2010 consecutive RTRs who did not have a history of diabetes prior to renal transplantation. PTDM was defined as a need for anti-diabetic therapy in an RTR without a history of diabetes prior to transplantation. Analysis of the risk factors for development of PTDM was performed with respect to pre-transplant dialysis modality. A total of 137 (6.8%) patients developed PTDM; 7% in the hemodialysis group and 6.5% in the peritoneal dialysis (PD) group (p = 0.85). In the multivariate analysis, age (p 0.001), body mass index (BMI) (p 0.001), use of tacrolimus (p = 0.002), and rejection episodes (p 0.001) were identified as independent risk factors for development of PTDM. Patients in the PD group were younger (p = 0.004), had lower BMI (p = 0.07), and were less likely to have a history of hepatitis C (p = 0.007) and autosomal dominant polycystic kidney disease (p = 0.07). Adjustment for these variables did not modify the results. The results of this study suggest that pre-transplant dialysis modality does not have an impact on the subsequent development of PTDM in RTRs.

Often, one gathers together under the denomination "peritoneal dialysis" patients with various clinical profiles. To quantify this "heterogeneity" we analysed the clinical characteristics of 32,975 patients treated by dialysis at 31 December 2008 in 22 French regions, participating to the REIN registry. This cross-sectional study confirms our initial hypothesis of a great heterogeneity of patients' profiles in peritoneal dialysis. As in hemodialysis, there is a gradation between modalities: from assisted continuous ambulatory peritoneal dialysis which concerns the frailty patients to autonomous automated peritoneal dialysis for more healthy patients, through assisted automated peritoneal dialysis and autonomous continuous ambulatory peritoneal dialysis.

The main objective of this study is to determine whether a single dose of iron dextran can correct iron deficiency during a period of four months in peritoneal dialysis patients.This was a prospective observational study in peritoneal dialysis patients who had anemia (hemoglobin11g/dL) and iron deficiency (ferritin100μg/L and/or transferrin saturation20%). Patients who were resistant to oral iron or who could not tolerate oral iron were included in the study. At baseline, based on the iron deficiency estimation, a single dose of iron dextran was infused over four hours.Of 17 patients included, 12 completed the study. The mean iron dose infused was 742±150mg. No clinically significant adverse event was reported during the infusion. Four months after the iron dextran infusion there was a significant increase of the mean hemoglobin level (10.1±0.7g/dl vs 11.4±1.2g/dL, P0.05), the mean blood ferritin level (66±46mg/L vs 212±121mg/L, P0.05) and the mean transferrin saturation (14±5% vs 23±8, P0.05). Four months after the iron infusion 10 patients had a blood ferritin level higher than 100μg/L and a transferrin saturation higher than 20%. There was no significant modification of the erythropoietin dose during the four months period.In patients treated by peritoneal dialysis, the anemia due to iron deficiency can be treated by a single infusion of iron dextran for a period of four months.

Background. The number of elderly patients starting dialysis is increasing in developed countries. Older age is frequently associated with contraindication of peritoneal dialysis (PD). The aim of this study was to report the outcome of elderly patients on PD in a country where assisted PD is available. Methods. This was a retrospective study based on the data of the French Language Peritoneal Dialysis Registry (RDPLF). We retrospectively analysed 1613 patients older than 75 years who started PD between January 2000 and December 2005. The end of the observation period was 31 December 2007. Results. The mean age at dialysis initiation was 81.9 years; 545 patients had a Charlson comorbidity index (CCI) >9. Of these 1613 patients, 1435 were treated by continuous ambulatory peritoneal dialysis (CAPD) and 1232 were on assisted PD. The median patient survival was 27.1 months. In the multivariate analysis, patient survival was associated with sex, age, modified CCI, method of assistance and underlying nephropathy. The median pure technique survival was 21.4 months. In the Cox model, technique survival was associated with the modified CCI, but the association did not remain significant after adjustment for the centre size. The median survival free of peritonitis was 32.1 months. Neither the modality of assistance nor the centre size was associated with peritonitis risk. Conclusion. PD is a suitable method for elderly patients. In order to increase the rate of PD utilization in elderly patients, the need for the funding of assisted peritoneal dialysis has to be taken into account.

Peritoneal dialysis is commonly used in patients awaiting renal transplantation. The occurrence of delayed graft function is lower in CAPD patients than in hemodialysis patients. This could be explained by the fluid expansion observed in CAPD patients before renal transplantation. Acute allograft rejection incidence is similar in peritoneal dialysis patients and hemodialysis patients. There are controversial data regarding the rate of renovascular thrombosis after renal transplantation in peritoneal dialysis patients. The dialysis modality selected prior to transplantation may explain the rate of renovascular thrombosis in peritoneal dialysis patients. There is an increasing number of patients returning to dialysis after transplantation failure. However, peritoneal dialysis is underused in failed transplant patients. There are few data available regarding the impact of dialysis modality on the outcome of failed transplant patients. Immunosuppression and transplant nephrectomy may affect the outcome of these patients on peritoneal dialysis. The aim of this article is to review the use of peritoneal dialysis in patients awaiting renal transplantation and in failed transplant patients.

Starting dialysis in an unplanned manner is a frequent situation in a dialysis centre even for patients with a regular nephrology follow-up. For no clear reason, chronic haemodialysis (HD) is more frequently used than peritoneal dialysis for unplanned dialysis patients.The purpose of this study was to evaluate the results of a dialysis policy dedicated to unplanned dialysis patients. The aim of this policy was to increase the use of peritoneal dialysis (PD) in an attempt to reduce the need for tunnelled catheter.One hundred seventy-one patients from a single centre, who started dialysis between 1 January 2004 and 31 December 2006, were prospectively followed until 31 December 2006. Unplanned dialysis patients were defined as patients entering in dialysis with no vascular access or peritoneal dialysis catheter. PD was presented as a modality of choice for renal replacement therapy to avoid the need for a tunnelled HD catheter.There were 60 unplanned dialysis patients during the study period. Among these patients, 34 agreed to be treated by PD. Compared with unplanned peritoneal dialysis patients, unplanned haemodialysis patients had a greater modified Charlson's comorbidity index (5.9 +/- 2.4 versus 4.4 +/- 1.9, P0.05). The mean duration of the temporary catheter period was 32 +/- 29 days (median: 24 days) for haemodialysis patients compared with 26 +/- 21 days (median: 25 days) for peritoneal dialysis patients (P = NS). The initial hospitalization duration was similar in haemodialysis patients and peritoneal dialysis patients (24 +/- 28 versus 30 +/- 33 days; median value: 17 versus 20 days, P = NS). PD was started 8.6 +/- 10 days (median: 4 days) after catheter insertion. A tunnelled catheter was used only in three patients until peritoneal dialysis was initiated. Acute automated peritoneal dialysis was used in 19 patients. Among 26 haemodialysis patients, 23 were dialyzed through a tunnelled catheter. Of these 23 patients, 15 were successfully converted to fistula. Median time for fistula creation was 2.6 months after dialysis initiation; median time for fistula utilization was 4.4 months. Actuarial patients survival at 1 year was 79% on haemodialysis compared with 83% on peritoneal dialysis (P = NS). After adjustment of the initial modified Charlson's comorbidity index, dialysis modality had no impact on patient's survival. There was no significant difference between haemodialysis patients and peritoneal dialysis patients regarding survival free of re-hospitalization. Actuarial survival free of peritonitis was 73% at 6 months and 58% at 1 year.Peritoneal dialysis is a safe and efficient alternative to haemodialysis for unplanned dialysis patients. Peritoneal dialysis offers the advantage of reducing the need for tunnelled catheter in unplanned dialysis patients.

Peritoneal dialysis, like hemodialysis, is a first-line therapy for patients with end-stage renal disease. Progress in medical devices and materials has reduced infectious complications such as peritonitis and catheter exit-site infections and thus decreased morbidity. Peritoneal dialysis fluids are increasingly biocompatible, result in fewer glucose degradation products, protect the peritoneal membrane better and thus improve tolerance. The maintenance of residual renal function, together with better comfort and no pain, help control the fluid and sodium balance. Automated peritoneal dialysis can be performed each night, either autonomously or assisted by a visiting nurse twice a day (to prepare, connect, and disconnect the machine). This treatment can thus be provided to most patients, regardless of their age. Peritoneal dialysis is indicated principally for young people waiting for a kidney transplantation (to preserve their vascular network), elderly patients who wish to remain either at home or in an institution, and patients with cardiac insufficiency, because of the better hemodynamic tolerance. Numerous obstacles, mainly nonmedical, still impede the development of peritoneal dialysis. Patients seen in emergencies start hemodialysis without necessarily receiving any information about peritoneal dialysis. Indeed, neither physicians nor patients receive adequate information.

The 2 registries RDPLF and Rein are information systems concerning the treatment of end-stage renal disease. The aim of the study was to evaluate the representativeness and exhaustivity of the recorded cases as well as the accuracy of the informations in the 2 registries. Were included 375 adults, who started a first ESRD treatment between 1 January 2003 and 31 December 2003 in 7 French regions and were treated by peritoneal dialysis (PD) on the first day of the 4th month of ESRD treatment. 264 patients were identified found in both registries. Age, body mass index and albuminemia didn't differ significantly. The mean haemoglobin level was higher in RDPLF. There was a good concordance on sex, diabetes status but less so on primary renal disease and PD modalities. There were significant discrepancies between the two registries on the date of the first treatment. The analysis of outcomes (transplantation or death) showed 8 discrepancies related to the lack of recording of the event in one of the 2 registries. The good global agreement observed between Rein and RDPLF for the common data emphasizes the fiability and representativeness of the 2 structures and the synergy of their activities for a best evaluation of the quality of peritoneal dialysis. This study shows the necessity of a common patient identification that will allow us to maintain a good complementarity between the 2 registries and will favour common studies.

Early loss of renal grafts is generally caused by vascular or immunologic complications. We describe two patients who received a kidney transplant from the same donor and lost their grafts during the first posttransplant week. Both cases presented necrotizing graft vasculopathy without inflammatory element. The donor was a 21-year-old woman who regularly used "ecstasy" over a 2-year period. After an extensive work-up to investigate the potential causes of graft loss, we considered the possibility of ecstasy being the cause of these two renal-graft losses.

The pharmacokinetics of fluconazole given orally (100 mg) or intraperitoneally (50 and 150 mg) were determined in 15 patients with chronic renal failure who were undergoing continuous ambulatory peritoneal dialysis. The half-life (72 to 85 hours) was intermediate between values obtained in healthy volunteers and in patients with renal insufficiency studied during an interhaemodialysis period. The peritoneal clearance, 0.26 to 0.33 L/h, led to an 18% recovery of administered drug in the dialysates after 48 hours. The peritoneal absorption was slow (time to peak plasma concentration 7 hours) but the peritoneal bioavailability was excellent at 87 +/- 5%. The mean concentrations of fluconazole up to 24 hours were 770 and 1900 micrograms/L after single intraperitoneal doses of 50 and 150 mg, respectively. The volume of distribution (40 to 60 L) did not differ from that determined in patients with normal renal function. In the case of fungal peritonitis essentially attributed to Candida spp., a 6-hour intraperitoneal infusion of fluconazole 150 mg every 2 days appears to be a good regimen to rapidly exceed minimum inhibitory concentrations and treat infection without risk of systemic dissemination of fungi or toxicity.

Recurrence of crescentic necrotizing glomerulonephritis after renal transplantation is rare. Successful renal transplantation in patients with antineutrophil cytoplasmic autoantibody (ANCA) glomerulonephritis has been reported. The presence of ANCA at transplantation does not appear to increase the rate of relapse after kidney allografting. Therapy with cyclophosphamide and corticoids usually is effective. We report a case of recurrent perinuclear ANCA crescentic necrotizing glomerulonephritis immediately after renal transplantation that was treated successfully by cyclophosphamide, plasma exchange, and intravenous polyvalent immunoglobulin.

A 72-year-old woman presented with rapidly progressive renal failure and multiple myeloma. The patient died 6 months later of severe hepatic insufficiency. The light-microscopic, immunological and ultrastructural findings showed widespread kappa-light-chain deposits including the kidneys, liver, spleen, heart, lungs, tongue, ovary, pancreas and bone marrow associated with massive AL amyloid deposits in the same organs and in the thyroid gland. The concurrent presence of two different deposits is very unusual and the possible mechanisms for such an association are discussed.

In France, the use of peritoneal dialysis (PD) as the first-choice treatment varies greatly between districts, as it is already known to do between countries. Baseline clinical factors associated with choice of first modality were analyzed in 10815 new end-stage renal disease patients in 59 districts. To describe practices at the district level, we used an agglomerative hierarchical classification, with proximity defined by a likelihood-ratio test that compared multivariate logistic regressions of the following factors: age, gender, diabetes, congestive heart failure, severe behavioral disorders, mobility, and employment. To propose a typology, each cluster of districts was described by a multivariate logistic regression. While populations starting PD in France, as elsewhere, are more likely to be young or employed, they are also more likely to be elderly or have congestive heart failure or severe behavioral disorders. Overall, 14% of patients start with PD, but this rate varies significantly across districts, from 0% to 45%. A specific combination of factors was associated with the first-choice modality in each group of districts. This study highlights the lack of consensual medical criteria for this choice and the likelihood that nonmedical factors may explain the observed differences. The high variability suggests that PD can be used in almost all clinical conditions. Accordingly, patient preference should play a more important role in the decision-making process.