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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.

International audience; Background and objectives: Epidemiologic studies suggest that higher serum phosphaturic hormone fibroblast growth factor 23 levels are associated with increase morbidity and mortality. The aim of the FGF23 Reduction Efficacy of a New Phosphate Binder in CKD Trial was to evaluate the effect of sevelamer carbonate on serum C-terminal fibroblast growth factor 23 levels in normophosphatemic patients with CKD stage 3b/4. Design, setting, participants, & measurements: Patients with CKD, eGFR between 45 and 15 ml/min per 1.73 m(2), fasting serum phosphate concentration >3.1 mg/dl, and serum C-terminal fibroblast growth factor 23 >80 relative units/ml were included in our double-blind, placebo-controlled, randomized multicenter study. All patients received 100,000 IU cholecalciferol at time of randomization. Participants received either placebo or sevelamer carbonate 4.8 g daily during a 12-week period. Biologic parameters, including serum C-terminal fibroblast growth factor 23, intact fibroblast growth factor 23, and a-klotho, were evaluated at baseline and 12 weeks after inclusion. Results: Of 96 screened patients, 78 (mean +/- SD age: 63 +/- 13 years old; 70% men; mean eGFR: 27 +/- 9 ml/min per 1.73 m(2)) met the inclusion criteria. At baseline, mean eGFR was 27 +/- 9 ml/min per 1.73 m(2), mean serum phosphate level was 3.8 +/- 0.5 mg/dl, and median (interquartile range) serum C-terminal fibroblast growth factor 23 level was 157 (120-241) relative units/ml. After 12 weeks of treatment, urinary phosphate-to-creatinine ratio fell significantly in the sevelamer group. The sevelamer and placebo groups did not differ significantly in terms of median change in serum C-terminal fibroblast growth factor 23 levels: the median (interquartile range) change was 38 (-13-114) relative units/ml in the placebo group and 37 (-1-101) relative units/ml in the sevelamer group (P=0.77). There was no significant difference in serum intact fibroblast growth factor 23, alpha-klotho, or phosphate levels changes between the two groups. Serum total and LDL cholesterol levels fell significantly in the sevelamer group. Conclusions: In our double-blind, placebo-controlled, randomized study performed in normophosphatemic patients with CKD, a 12-week course of sevelamer carbonate significantly reduced phosphaturia without changing serum phosphorus but did not significantly modify serum C-terminal fibroblast growth factor 23 and intact fibroblast growth factor 23 or alpha-klotho levels.

Encapsulating peritoneal sclerosis is a rare but devastating complication of long-term peritoneal dialysis with a high mortality rate. The incidence is between 0.5 and 2.5%, decreasing with time. PSE is defined as a clinical syndrome with signs of gastrointestinal obstruction, inflammation parameters, radiological and macroscopic changes. The duration of treatment and the cessation of peritoneal dialysis are the main risks. About 75% occured in patients on hemodialysis or after kidney transplantation. Morphological alterations are disappearance of mesothelial layer, submesothelial fibrosis, interstitial sclerosis and vasculopathy. Ultrafiltration failure, fast transport status of the peritoneal membrane and loss of sodium sieving, the most powerful predictor, are the functional abnormalities. Biomarkers in peritoneal effluent include cancer antigen 125, interleukin-6. The pathophysiology is probably a consequence of a multiple-hit process in which expression of growth factors and cytokines play a central role. Medical strategies (corticosteroids, tamoxifen) in association with parenteral nutrition and/or surgery (enterolysis) are discussed. Prevention is the use of physiological peritoneal dialysis solutions, icodextrine instead of high glucose concentration solutions and peritoneal lavage after peritoneal dialysis stopping.

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.

International audience

The Kidney Disease Improving Global Outcomes (KDIGO)-2012 on the treatment of anemia emit suggestions (which differ from recommendations) based on a scientific evidence of low level. The first rule is no harm; physicians must take into account the profile of the patient and its associated morbidities and remember on the potential risks to begin a treatment by erythropoiesis stimulating agents (ESA) (thrombosis of arteriovenous fistula, hypertension, stroke). All correctable causes of anemia other than erythropoietin deficiency should be actively sought. It is necessary to individualize the treatment by ESA and assess the clinical improvement expected. The ESA will be used in the following way: initiate at 10 g/dL of hemoglobin level with the aim of 11.5 g/dL, without exceeding 13 g/dL. In case of ESA resistance, it seems suitable to assess the risks and benefits of ESA versus blood transfusion. The ERBP-2013 have endorsed the KDIGO-2012 except the proposals dealing with the treatment by IV iron. The use of intravenous iron must be more cautious in the future taking into account the results of a recent French study published in the American Journal of Medicine showing the high frequency of iron overload at quantitative hepatic MRI among haemodialysis patients receiving iron IV following the current guidelines. It is appropriate to use oral iron in first intention as recommended by the ANSM (French Drug Agency) in a recent information note and respect the dosage regimen of the label. The realization of a quantitative hepatic MRI to evaluate iron overload and monitor the treatment by iron IV must also be considered on a case by case basis.

Resume Introduction En dialyse, une mauvaise evaluation du poids sec peut conduire a une augmentation de la morbi-mortalite. Le but de cette etude transversale, multicentrique, a ete d’evaluer l’association entre la natriurese residuelle et le statut d’hydratation extracellulaire de patients traites par hemodialyse chronique. Patients et methodes Le statut d’hydratation a ete determine par evaluation clinique puis par bio-impedancemetrie (Body Composition Monitor, Fresenius Medical Care) avant une seance de milieu de semaine chez 40 patients ayant une diurese residuelle superieure a 250 mL par jour et traites par hemodialyse chronique dans 4 centres de dialyse. En utilisant l’estimation par bio-impedancemetrie, l’etat d’hydratation a ete defini par comparaison a une population saine de reference et classe en trois categories : deshydratation, normohydratation et hyperhydratation. La diurese, la natriurese et la fonction renale residuelle ont ete mesurees pour tous les patients dans les 30 jours precedant l’estimation de l’etat d’hydratation. Resultats La mediane du volume d’hyperhydratation apres dialyse etait de −0,40 L (IQR : −1,95 a 0,90) et la mediane de natriurese etait de 64 mmol/L (IQR : 46–79). Seize patients etaient normohydrates, 16 etaient deshydrates et 8 etaient hyperhydrates. En regression lineaire, il existait une relation entre l’etat d’hydratation et la natriurese (coefficient : 5,6 ± 1,5 ; p Conclusion Cette etude montre qu’il existe une relation entre la natriurese residuelle et l’etat d’hydratation estime par bio-impedancemetrie.

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.

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.

The optimal method to assess the adequacy of peritoneal dialysis therapies is controversial. Today, the adequacy must not be considered as a number or a concept assessed only by two parameters (total KT/V urea and total solute clearance) but defined by many more items. In the absence of data, based on theoretical considerations, the reanalysis of the CANUSA study showed that renal kidney function, rather than peritoneal clearance, was associated with improved survival. Residual renal function is considered as a major predictor factor of cardiovascular mortality. Results of this reanalysis were supported by the adequacy data in ADEMEX, EAPOS and ANZDATA studies. Therefore, clinical assessment plays a major role in PD adequacy. The management of fluid balance, the regular monitoring of malnutrition, the control of mineral metabolism and particularly the glucose load, considered as the "corner-stone" of the system, are the main points to be considered in the adequacy of PD patients. The essential goal is to minimize glucose load by glucose-sparing strategies in order to reduce the neoangiogenesis of the peritoneal membrane.

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.

SUMMARY Background 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). Review findings 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). Recommendations 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.

Encapsulating peritoneal sclerosis is a rare but devastating complication of long-term peritoneal dialysis with a high mortality rate. The incidence is between 0.5 and 2.5%, decreasing with time. PSE is defined as a clinical syndrome with signs of gastrointestinal obstruction, inflammation parameters, radiological and macroscopic changes. The duration of treatment and the cessation of peritoneal dialysis are the main risks. About 75% occured in patients on hemodialysis or after kidney transplantation. Morphological alterations are disappearance of mesothelial layer, submesothelial fibrosis, interstitial sclerosis and vasculopathy. Ultrafiltration failure, fast transport status of the peritoneal membrane and loss of sodium sieving, the most powerful predictor, are the functional abnormalities. Biomarkers in peritoneal effluent include cancer antigen 125, interleukin-6. The pathophysiology is probably a consequence of a multiple-hit process in which expression of growth factors and cytokines play a central role. Medical strategies (corticosteroids, tamoxifen) in association with parenteral nutrition and/or surgery (enterolysis) are discussed. Prevention is the use of physiological peritoneal dialysis solutions, icodextrine instead of high glucose concentration solutions and peritoneal lavage after peritoneal dialysis stopping.

Resume Les infections du liquide de dialyse peritoneale (DP) restent une complication frequente du traitement par DP. L’objectif de notre etude est de decrire les mecanismes de resistance aux antibiotiques des germes isoles lors des infections du liquide de DP, afin de determiner si l’antibiotherapie proposee par l’ International Society for Peritoneal Dialysis (ISPD) est adaptee aux mecanismes de resistance. Tous les germes responsables d’infection du liquide de DP, survenues chez 106 patients traites par DP et ayant presente 170 episodes d’infections du liquide de DP, pendant la periode du 01/01/2005 au 31/12/2010 ont ete etudies, soit un episode tous les 23 mois-patient. Selon la classification usuelle, douze groupes de bacteries ont ete constitues. Une lecture interpretative des antibiogrammes a ete realisee dans chaque groupe pour identifier les phenotypes de resistance. Les bacteries a gram positif sont les plus frequemment isolees, avec une nette predominance des staphylocoques a coagulase negative ( n = 73) dont 46 ont acquis une PLP2a (proteine liant les penicillines). De nombreuses enterobacteries ont egalement ete isolees ( n = 45), elles sont sensibles aux cephalosporines de troisieme generation a l’exception des enterobacteries produisant une β-lactamase a spectre etendu (BLSE) ou une cephalosporinase. Excepte pour les staphylocoques, l’antibiotherapie probabiliste recommandee par l’ISPD pour traiter les infections du liquide de DP est efficace. En effet, de nombreux staphylocoques produisant une PLP2a (Meti-R), une cephalosporine de premiere generation ne peut pas etre administree dans tous les cas. Il est donc necessaire d’identifier les patients porteurs d’une souche de staphylocoques produisant une PLP2a, qui doivent etre traites par de la vancomycine.

Resume Introduction Le fer dextran de bas poids moleculaire peut etre administre en une perfusion unique d’une dose totale correspondante a la carence en fer. L’objectif de cette etude observationnelle etait de determiner si l’administration unique d’une dose totale de fer dextran permettait de corriger la carence martiale du patient en dialyse peritoneale pendant une duree de quatre mois. Patients et methodes Les patients traites par dialyse peritoneale depuis plus de trois mois et ayant une anemie (hemoglobine Resultats Douze des dix-sept patients inclus terminaient l’etude. La dose totale moyenne administree etait de 742 ± 150 mg sans effet indesirable rapporte. Quatre mois apres l’injection on observait une augmentation significative de la moyenne de l’hemoglobinemie (10,1 ± 0,7 g/dL vs 11,4 ± 1,2 g/dL, p Conclusion Chez le patient traite par dialyse peritoneale, le fer dextran de faible poids moleculaire en injection unique d’une dose totale permet de corriger l’anemie ferriprive pendant une duree de quatre mois.

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.

Gueutin V, Ficheux M, Châtelet V, Lecouf A, Henri P, Hurault de Ligny B, Ryckelynck J-P, Lobbedez T. Hydration status of patients with end-stage renal disease after kidney transplantation. Clin Transplant 2011: 25: E656–E663. © 2011 John Wiley & Sons A/S. Abstract: Background: This study was carried out to estimate the modification of hydration status within the first three months of renal transplantation. Subjects and methods: Fifty patients who underwent a first kidney allograft were prospectively followed for three months after renal transplantation to assess hydration status by bioimpedance spectroscopy. Results: 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; p

Resume On regroupe souvent sous la denomination « dialyse peritoneale » des patients ayant des profils cliniques varies. Afin de quantifier cette « heterogeneite », nous avons analyse les caracteristiques cliniques de 32 975 patients traites par dialyse au 31 decembre 2008 dans les 22 regions participant au registre REIN. Cette etude transversale confirme notre hypothese initiale d’une forte heterogeneite de profils de patients en dialyse peritoneale. A l’image de ce que l’on peut observer en hemodialyse, il existe un gradient entre les modalites : de la DPCA assistee qui prend en charge les patients les plus lourds jusqu’a la DPA non assistee reservee aux patients les moins severement atteints, en passant par la DPA assistee, puis la DPCA non assistee.

Lymphomatoid granulomatosis (LYG) in renal transplant recipients is rare multisystemic angiocentric lymphoproliferative disorder with significant malignant potential. Here, we describe LYG in a 70-year-old renal allograft recipient who, 4 years after transplantation, on tacrolimus and mycophenolate mofetil and prednisone maintenance immunosuppression, complained of low-grade fever, persistent headache and gait disturbance. The MRI of the brain revealed diffuse periventricular cerebral and cerebellar contrast-enhanced lesions. The CT scan of the thorax showed multiple pulmonary nodular opacities in both lung fields. The patient was diagnosed LYG based on the cerebral biopsy showing perivascular infiltration of CD20-positive B-lymphocytes with granulomatous lesions and immunofluorescence staining with anti-EBV antibodies. With careful reduction of the immunossuppression combined with the use of rituximab, our patient showed a complete disappearance of LYG, and she is clinically well more than 4 years after the diagnosis, with good kidney function. No recurrence has been observed by radiological imaging until now. This is the first report of a durable (>4 years) complete remission of LYG after treatment with rituximab in renal transplantation.

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

Lymphocele is a common surgical complication after renal transplantation. The incidence of lymphocele ranges from 0.6% to 18%. The aim of this study was to determine incidence, risk factors and prognosis of complicated lymphocele in the era of modern immunosuppression. We retrospectively reviewed 311 renal transplants from January 2003 to September 2008, we excluding patients who received sirolimus or underwent multiorgan transplantations. A complicated lymphocele was defined by the requirement for a surgical procedure for cure. Of the 311 transplant recipients, we included 269 in the study with 49 (18.9%) presenting a complicated lymphocele after transplantation. Cold ischemia time, waiting time on dialysis, gender, donor source, induction therapy (thymoglobulin vs basiliximab), and dialysis modality were similar between the 2 groups. Mycophenolate mofetil (MMF) doses were higher among the lymphocele than the nonlymphocele group (2.7 ± 0.54 g/d vs 2.36 ± 0.68 g/d; P < .05). However, the areas under the concentration-time curves of mycophenolic acid were not significantly different between the 2 groups (43.7 ± 15.3 h·mg/L vs 48 ± 21 h·mg/L; P = .33). However, a multivariate analysis showed complicated lymphocele to be associated with greater MMF doses (odds ratio [OR] 2.75; P < .01), warm ischemia time (OR 1.035; P < .05), and recipient age (OR 1.04; P < .05). In conclusion, we identified high MMF doses as an independent risk factor for lymphocele formation after renal transplantation.

Resume Bien que les resultats de la greffe renale avec donneur marginal en terme de survie du greffon soient en amelioration, de nombreux greffons juges marginaux sont refuses par les equipes de transplantation. L’objectif principal de notre etude retrospective etait d’evaluer le devenir des greffons renaux refuses a tort et transplantes dans d’autres centres. Dans le notre, l’acceptation ou le refus d’un greffon marginal reposait exclusivement sur le jugement clinique du nephrologue recevant la proposition. Un greffon transplante dans un autre centre etait considere comme refuse a tort si son debit de filtration glomerulaire estime (DFGe) etait superieur ou egal a 60 ml/min/1,73 m 2 un an apres la transplantation renale. Les caracteristiques des greffons et des receveurs etaient compares selon le DFGe a un an : groupe A : DFG ≥ 60 ml/min/1,73 m 2 , groupe B : DFG 2 . A posteriori, il etait calcule pour chaque donneur le score definissant les donneurs a criteres elargis (ECD) et le score Deceased Donor Score (DDS). Parmi les 304 propositions de reins refusees entre le 1 er janvier 2000 et le 31 decembre 2006, 55 reins n’ont pas ete acceptes par le nephrologue de garde car juges de mauvaise qualite sur la base du seul jugement clinique. Seulement 44 reins ont ete acceptes et transplantes dans un autre centre. Deux greffons ont ete perdus dans la premiere annee. A un an postgreffe, 42 greffons renaux etaient fonctionnels : 12 greffons pouvaient etre consideres comme refuses a tort car ayant un DFGe superieur ou egal a 60 ml/min/1,73 m 2 . En utilisant le score DDS, dix greffons sur 12 n’avaient pas les caracteristiques du greffon marginal dans le groupe A et 3 sur 30 dans le groupe B. La survie actuarielle des greffons censuree sur le deces des 42 greffons etait respectivement de 98 et de 93 % a un an et a deux ans. En conclusion, lorsque la decision d’acceptation d’un greffon marginal est basee uniquement sur le jugement clinique, la proportion de refus a tort est elevee. Notre etude montre que l’utilisation d’un score de qualite du greffon disponible au moment de la proposition de greffon comme outil d’aide a la decision medicale est une necessite.

Resume Le retour en dialyse apres echec de transplantation est un probleme emergent dans les centres de dialyse. L’objectif de cette etude est de determiner les conditions de prise en charge initiale en dialyse des patients en echec de greffe et leur devenir a court terme en epuration extrarenale. Patients et methodes Il s’agit d’une etude retrospective portant sur des patients ayant recu une greffe renale dans le centre regional de reference et retournant en dialyse apres plus de six mois en transplantation dans un centre de la region pendant la periode du 31 octobre 1986 au 03 mars 2004. La periode de suivi est de un an pour tous les patients. Resultats Parmi les 600 patients transplantes pendant la periode d’etude, 92 sont retournes en dialyse dont 69 apres une duree en transplantation de plus de six mois. A l’initiation de la dialyse la clairance moyenne de la creatinine etait de 13 ± 5 mL par minute. L’albuminemie moyenne etait de 34 ± 6 g/L et l’hemoglobinemie moyenne etait de 80,7 ± 10,7 g/L. La dialyse a ete debutee dans un contexte d’urgence pour 39 sur 57 (50 %) patients et sur catheter pour 14 sur 58 (25 %) patients. L’hemodialyse etait la methode de choix pour 59 sur 69 (85 %) patients, le retour dans la methode d’origine etait moins frequent chez les patients traites par la dialyse peritoneale que chez les patients traites par hemodialyse (7/13 versus 49/52 ; p Conclusion Malgre un suivi nephrologique regulier les patients en echec de greffe debutent frequemment la dialyse de facon non planifiee et en urgence. Une prise en charge plus precoce en dialyse des patients en echec de greffe est probablement necessaire.

The European patents for epoetin alpha recently expired. Biosimilars (i.e. "a medicine which is similar to a biological medicine that has already been authorized" [EMEA 2007]) of epoetins have thus been released on the market in Europe. Because of the complexity of the processes that are required to produce medicinal products containing biotechnology-derived proteins as active substances and to characterize the physicochemical properties of these compounds, the guidelines that have been developed for generic drugs cannot be used for approval of biosimilar products. The EMEA guidelines do not answer all questions that have been raised for the development of biosimilars, and in some cases, decisions will have to be taken at a national level. This is why the Society of Nephrology (Societe de nephrologie), the French-speaking Society of Dialysis (Societe francophone de dialyse) and the Pediatric Society of Nephrology (Societe de nephrologie pediatrique) established guidelines for the usage of biosimilar epoetins concerning approval, identification, substitution of an innovator drug, post-marketing surveillance, extension of indication and pharmacovigilance plan.

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

Resume La fatigue est un symptome tres frequent chez les patients traites par dialyse. L’objectif de cette etude est d’evaluer l’impact de la modalite de dialyse sur la sensation de fatigue des sujets âges en dialyse. Patients et methodes Il s’agit d’une enquete transversale portant sur des sujets âges de plus de 70 ans traites par dialyse depuis plus de trois mois pendant le mois de juin 2006 dans un centre d’epuration extrarenale. La fatigue a ete evaluee par le questionnaire Multidimensionnal fatigue Inventory (MFI) chez 33 patients dialyses ayant un Mini Mental Status Examination (MMSE) superieur a 22. Un groupe temoin constitue de 21 patients indemnes de maladie chronique, âge de plus de 70 ans, ayant un MMSE superieur a 22 a ete constitue. Resultats Les scores de fatigue des sujets en dialyse etaient significativement plus eleves que ceux des patients du groupe temoin (score de fatigue generale : 14 ± 3 versus 10,8 ± 4, p n = 16) et les patients en hemodialyse ( n = 17) ne differaient pas pour l’âge (77 ± 5 versus 77 ± 5 ans), le score de Charlson modifie (6,3 ± 2,5 versus 6,3 ± 2,4), le MMSE (26 ± 2 versus 25 ± 2), le score d’autonomie Activity of Daily Living (ADL) (5,6 ± 0,8 versus 5,3 ± 1) et le mini Geriatric Depression Scale (GDS) (0.7 ± 0.9 versus 1 ± 1). La duree moyenne en dialyse n’etait pas statiquement differente entre les deux groupes (28 ± 18 versus 49 ± 52 mois). Il n’existait pas de difference significative entre les patients en dialyse peritoneale et ceux en hemodialyse en ce qui concerne l’hemoglobinemie moyenne (12 ± 1 versus 12 ± 1 g/dl), le dosage de la parathormone (227 ± 140 vesus 324 ± 269 ng/l) et le dosage de la C reactive proteine (13 ± 13 versus 10 ± 9 mg/l). L’albuminemie etait plus basse chez les patients en dialyse peritoneale que chez les patients en hemodialyse (32 ± 6 versus 38 ± 8 g/l, p p p p p Conclusion La sensation de fatigue est tres elevee chez les patients en dialyse, la modalite de dialyse pourrait avoir un role sur la fatigue, d’autres facteurs tels que l’inflammation et les comorbidites sont aussi impliques dans la fatigue du dialyse.

Resume L’application de mupirocine ou de gentamicine a l’orifice de sortie du catheter permet de reduire l’incidence des complications infectieuses de la dialyse peritoneale, mais est associee a l’emergence de souches bacteriennes resistantes. Une solution constituee de 600 mg de rifampicine melangee avec 10 mg de protamine pouvant avoir une activite specifique sur le biofilm est utilisee en application locale pour la prevention des infections des catheters d’hemodialyse. La solution rifampicine–sulfate de protamine pourrait constituer une alternative a la mupirocine chez les patients traites par dialyse peritoneale. L’association de ces deux medicaments a un effet synergique in vitro se caracterisant par une denaturation du biofilm facilitant l’acces de l’antibiotique aux bacteries. Une validation pharmaceutique de la solution rifampicine–protamine nous a semble necessaire avant d’envisager son utilisation dans le cadre d’etudes prospectives en dialyse peritoneale et pour permettre une utilisation plus large en hemodialyse. La stabilite de la solution apres conservation pendant 14 jours au congelateur, puis 14 jours au refrigerateur est determinee par trois parametres : le dosage par HPLC de la rifampicine dans la preparation ; l’evaluation de la quantite stable de la protamine par sa capacite a antagoniser l’activite anticoagulante de l’heparine d’un plasma heparine ; la determination de la sterilite de la solution avec une culture sur gelose, apres un test de neutralisation par une culture en bouillon. La stabilite physicochimique de la solution a pu etre demontree par les differents dosages. Les essais de sterilite bien que pouvant etre consideres comme negatifs sont d’interpretation plus difficile du fait d’une interaction entre le bouillon de culture et la solution, alors que la culture sur plaque est restee negative. Ainsi, si la solution est utilisee, il nous semble justifie de fabriquer le melange dans les conditions d’asepsie recommandees pour une preparation extemporanee et en petits conditionnements destines a chaque patient.

The frequency of transfers from peritoneal dialysis to haemodialysis secondary to the catheter-related complications has been estimated between eight to 20% depending the countries. Therefore, it is recommended that the insertion of peritoneal dialysis catheters be made by competent and experienced operators. Indeed, despite the development of new insertion techniques and the availability of new sophisticated catheters, the major prognostic factor remains the quality of the surgical procedure and the postoperative care. As regards the choice between various catheters, there is no consensus for the superiority of one in comparison with others. However it should be noted that a catheter survival rate from 80 to 90% at one year is a recognized index of quality.

Resume Le nombre de patients retournant en dialyse apres transplantation renale est en augmentation constante. Neanmoins il existe peu de donnees disponibles concernant la prise en charge specifique de cette population. Les patients en echec de greffe ont pour particularite d’avoir un suivi nephrologique regulier. Cependant, l’initiation de l’epuration extrarenale intervient souvent tardivement exposant le patient aux complications de l’uremie. Il apparait comme necessaire de preparer le retour en dialyse plus en amont et de debuter le traitement de suppleance plus precocement. La possibilite de beneficier d’une transplantation renale avant le stade de la dialyse doit etre evaluee de facon plus systematique car une proportion importante de patient beneficie d’une reinscription sur liste d’attente apres le retour en dialyse. Il n’existe pas de modalite d’epuration extrarenale preferentielle. La dialyse peritoneale est cependant sous utilisee dans cette population. Les modalites d’arret du traitement immunosuppresseur sont mal codifiees et peu documentees dans la litterature bien qu’elles puissent avoir un impact significatif sur le devenir des patients en dialyse. Le maintien du traitement immunosuppresseur apres le retour en dialyse pourrait permettre de maintenir la fonction residuelle du greffon renale mais est associe a une augmentation du risque infectieux. Des etudes prospectives et retrospectives concernant cette population particuliere sont clairement necessaires.

Background: C.E.R.A., a continuous erythropoietin receptor activator, is in development to provide anemia correction and stable maintenance of hemoglobin (Hb) levels at extended administration intervals in patients with chronic kidney disease (CKD). This study examined its efficacy and safety when administered up to once monthly in patients who have CKD and are on dialysis and randomly convert directly from epoetin α or β one to three times weekly. Design, setting, participants, and measurements: In this three-arm, comparator-controlled, open-label, randomized, parallel-group, Phase III study, 572 dialysis patients (≥18 yr) who were receiving stable subcutaneous epoetin one to three times weekly were randomly assigned (1:1:1) to continue epoetin or to receive subcutaneous C.E.R.A. once monthly or twice monthly for 52 wk. Dosage was adjusted to maintain Hb ±1.0 g/dl of baseline level. Primary end point was mean change in Hb level between baseline and the evaluation period (weeks 29 to 36). Results: Mean Hb levels during the evaluation period were similar between groups (once-monthly C.E.R.A. 11.5 g/dl; twice-monthly C.E.R.A. 11.7 g/dl; epoetin 11.5 g/dl). The difference between C.E.R.A. and epoetin in mean change (97.5% confidence interval) in Hb concentration between baseline and evaluation was −0.022 g/dl (−0.262 to 0.217) for once monthly and 0.141 g/dl (−0.098 to 0.380) for twice monthly. Analysis demonstrated that C.E.R.A. was as effective as epoetin in maintaining Hb and was well tolerated. Conclusions: Subcutaneous C.E.R.A. once or twice monthly successfully maintained tight and stable Hb levels in patients who were on dialysis and randomly converted directly from epoetin one to three times weekly.

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.

Background. In France, 48% of home-based peritoneal dialysis (PD) patients require assistance to perform their exchange and manage their treatment. A total of 7% are aided by their family, and 41% by a private nurse. Of all the continuous ambulatory peritoneal dialysis (CAPD) patients, 61.7%, and among automated peritoneal dialysis (APD) patients 23%, are assisted at home for their bag exchanges and connections. Assisted APD patients (AAPD) are more comorbid and elderly so that a home helper is not always available: this explains why most helpers at home are private visiting nurses paid by the National Social Security. In addition to the home helper (nurse or family), 58% of centres make regular additional home visits to check the respect of procedures previously taught during the initial training of the nurse or the family helper. The aim of this study was to evaluate whether the type of home assistance received by dependent patients had an influence on peritonitis rates, and if home visits done by nurses of training centres may improve results. Methods. Peritonitis rates and the probability of being peritonitis free were analysed for 1624 new APD patients recorded in the French PD Registry (RDPLF) between 2000 and 2004, and followed-up until early 2005. Results. Nurse-assisted APD patients had a peritonitis rate of one episode every 36 months, and familyassisted patients one episode every 45 months; using Poisson analysis this trend was not significant (P ¼ 0.11). However, the probability of being peritonitis free was significantly higher for familyassisted (69.8% at 2 year) compared with home nurse-aided persons (54.4%) after adjustment for age, diabetes and the Charlson comorbidity index. This difference disappeared when nurses from the training centre regularly visited PD patients at their home in the presence of their helper, whichever type of assistance they received. In addition, when the nurses from the training centres visited private nurse-assisted patients, the probability of being peritonitis free was significantly improved in comparison with those persons who did not receive home visits, from 33.9% to 50.8% at 3 years (P ¼ 0.028). Conclusions. APD patients assisted at home by a private nurse have a higher risk of developing peritonitis than family-assisted patients, unless additional regular home visits are organized by the original training centre. Therefore, we recommend that home visits be regularly made for dependent PD patients to optimize the quality of care provided by the helper.

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.

Background The French healthcare system offers the possibility of increasing the use of peritoneal dialysis (PD) by involving in patient care nurses who work in the private system. Objective This study was conducted to evaluate the impact of a private home-nurse network on one dialysis program. Methods This was a retrospective study of 239 dialysis patients who started dialysis in our center between 1 January 1998 and 31 December 2003. Results Of these 239 patients, 142 were treated with hemodialysis and 97 with PD during the study period. Among the PD patients, 36 of 97 were treated with assisted PD and 61 of 97 with self-care PD. Assisted-PD patients were older (74 ± 10 vs 52 ± 18 years, p < 0.001) and presented more comorbidity (Charlson Comorbidity Index 7 ± 2.5 vs 4.3 ± 2.4, p < 0.05) compared with self-care patients. Continuous ambulatory PD was the modality of choice in the assisted group (32/36). Assisted patients were frequently hospitalized (31/36); actuarial survival free of hospitalization at 6 months was 46%. Patients with nurse assistance had a high risk of peritonitis (actuarial survival free of peritonitis: 52% at 1 year). Technique survival was 85% at 6 months and 58% at 1 year. Actuarial patient survival was 90% at 6 months and 83% at 1 year. Conclusion Assisted PD enables increased use of PD in incident dialysis patients. However, in view of the comorbidities of the assisted-PD patients, the need for frequent hospitalization has to be taken into account in such a program.

Peritonitis is still a frequent complication in peritoneal dialysis patients. Medical guidelines have been established to manage this infection. These guidelines do not provide any information regarding the requirement for hospitalization. The main objective of this study was to evaluate the impact of peritonitis episode on the hospitalization rate and on the hospitalization duration in a centre where peritoneal dialysis patients were hospitalized in case of peritonitis. This was a retrospective study of incident peritoneal patients over a six years period. Among 101 peritoneal dialysis patients 65% were hospitalized. Two hundred and twenty hospital stays were registered. The total duration of hospital stays was 2091 days. The hospitalization rate was 2 per patient and per year, the hospital duration was 19 days per patient per year. Of the 220 hospital stays, 67 (30%) were due to a peritoneal infection. Peritonitis episodes represent 581/2091 (28%) days of hospitalization. The mean duration of hospitalization for peritonitis was 8.7+/-7 days. Among the patients hospitalized for a peritonitis episode, 57% were assisted by a nurse at home to perform their peritoneal dialysis exchanges. Of the 67 peritonitis episodes, 91% were discharged from the hospital without any complication. This study emphases the fact that peritonitis has an important impact on the hospitalization rate and on the hospitalization duration in peritoneal dialysis patients. In an attempt to decrease the rate of hospitalization, educational programs are clearly needed in order to treat more peritonitis without any hospitalization requirement.

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.

Peritoneal dialysis patients are frequently transferred from peritoneal dialysis to haemodialysis. In contrary transfer from chronic haemodialysis to peritoneal dialysis is rare. The aim of this study is to describe the main characteristics and the outcome of the dialysis patients transferred from haemodialysis to peritoneal dialysis. We retrospectively analyzed the files of 25 patients treated by haemodialysis for more than 3 months between 1992 and 2002 and subsequently transferred on peritoneal dialysis. Technique survival was 56% at 1 year and 40% at two years in haemodialysis. Technique survival was lower in the group starting haemodialysis in emergency compared with the group of patients who did not need emergent haemodialysis (33 vs 77% at 1 year, P

BACKGROUND The theoretical aim of maintenance cyclosporine monotherapy (mCsA) after kidney transplantation is to reduce the incidence of the metabolic complications of corticosteroids and to minimize the adverse effects of excessive long-term immunosuppression. This study was performed in low-immunological-risk cadaveric kidney transplant recipients to evaluate the risks and benefits of mCsA and the long-term graft survival, and to determine the factors predicting success of this policy. METHODS The multicenter retrospective study was conducted in 329 Caucasian patients receiving mCsA out of 728 first cadaveric kidney transplant recipients. The inclusion criteria were: HLA antibodies < or =25%, serum creatinine

Introduction Mycophenolic acid (MPA) pharmacokinetics exhibit large variability in transplant recipients and may be altered due to concurrent immunosuppressants. Little is known about the influence of sirolimus (SRL) on MPA pharmacokinetics in kidney transplant patients. Methods We studied the areas under concentration-time curves (AUC) for MPA in 15 patients receiving immunosuppression combining SRL with mycophenolate mofetil (MMF). The pharmacokinetic measurements were performed in all patients using three MMF dosing regimens (0.5 g twice a day, 0.75 g twice a day, 1 g twice a day). Similar blood AUC profiles were also sampled from 12 patients treated with a fixed dose of MMF 1 g twice a day and cyclosporine (CsA). MPA was measured using HPLC; the AUC0–12 of MPA was determined by the trapezoidal method using four sampling time points: C0, C1, C3, C5. Results While patients on SRL were receiving 0.75 g MMF twice a day, mean AUC0–12 and C0 values of MPA were comparable to those of patients receiving CsA and 1 g MMF twice a day (54.1 ± 17.6 and 3 ± 1.87 vs 51.7 ± 16.7 mg · h/L and 2.76 ± 1.57 mg/L, respectively). On the other hand, 0.5 g MMF twice a day with SRL therapy resulted in AUC0–12 and C0 values of MPA of 32.3 ± 12.6 mg · h/L and 2.32 ± 1.72 mg/L, respectively, whereas, 1 g MMF twice a day with SRL resulted in AUC0–12 and C0 values of MPA of 70.9 ± 19.3 mg · h/L and 4.7 ± 2.44 mg/L, respectively. Conclusions These findings demonstrate that MPA exposure in the presence of SRL is higher than that with CsA. It appears that the MMF dose should be reduced to 0.75 g twice a day in patients receiving SRL to obtain AUC0–12 of MPA levels comparable to that in patients treated with CsA and MMF 1 g twice a day.

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.

The optimal method to assess the adequacy of peritoneal dialysis therapies is controversial. Today, the adequacy must not be considered as a number or a concept assessed only by two parameters (total KT/V urea and total solute clearance) but defined by many more items. In the absence of data, based on theoretical considerations, the reanalysis of the CANUSA study showed that renal kidney function, rather than peritoneal clearance, was associated with improved survival. Residual renal function is considered as a major predictor factor of cardiovascular mortality. Results of this reanalysis were supported by the adequacy data in ADEMEX, EAPOS and ANZDATA studies. Therefore, clinical assessment plays a major role in PD adequacy. The management of fluid balance, the regular monitoring of malnutrition, the control of mineral metabolism and particularly the glucose load, considered as the "corner-stone" of the system, are the main points to be considered in the adequacy of PD patients. The essential goal is to minimize glucose load by glucose-sparing strategies in order to reduce the neoangiogenesis of the peritoneal membrane.

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