[REIN Report 2011--summary].Nephrol Ther. 2013 Sep; 9 Suppl 1:S3-6.NT
In 2011, in France, we estimate that 9 400 patients started a treatment by dialysis (incidence of dialysis: 144 per million inhabitants) and 335 patients with a pre-emptive graft without previous dialysis (incidence of pre-emptive graft: 5 per million inhabitants). As in 2010, incidence rate seems to stabilize. Elders provide the majority of new patients (median age at RRT start: 71 years old). New patients present a high rate of disabilities especially diabetes (41% of the new patients) and cardiovascular disabilities (>50% of the new patients) that increase with age. Considering treatment and follow-up, the first treatment remains center's hemodialysis and we do not notice any progression of self-dialysis. RRT started in emergency in 33% of the patients. This finding contrasts with the fact that 56% of patients started hemodialysis on a catheter. This, together with the major inter-region variability, suggests that different strategies of management exist. Finally, the hemoglobin level at RRT start seems to be an interesting indicator of good management and follow-up since 13% of patients presenting an underprovided follow-up have a hemoglobin level under 10g/dl, whereas only 2.5% of patients with an appropriate follow-up presented such a condition.
On December 31, 2011, in France, we estimate that 70.700 patients were receiving a renal replacement therapy, 39.600 (56%) on dialysis and 31.100 (44%) living with a functional renal transplant. The overall crude prevalence was 1091 per million inhabitants. It was 1.6 higher in males. Prevalence was subject to regional variations with 5 regions (3 overseas) above the national rate. Renal transplant share varied from 33% in Nord-Pas de Calais to 53% in Pays de Loire, and from 16 to 25% in overseas regions. The study of temporal variations for 18 regions contributing to the registry since 2007 demonstrated a +4% increase in standardized prevalence of ESRD patients with a functional transplant vs. +2% increase for dialysis, resulting in a decreasing gap between dialysis and transplantation prevalence, due to an increase number of renal transplant and a longer survival of transplanted patients. The main dialysis technique was hemodialysis (93.3% of patients). Even if an important inter-region variability remains considering the choices of treatment, more than 50% of the patients are undergoing hemodialysis in a hospital-based incenter unit, and we noticed an increase in hemodialysis in a medical satellite unit with time whereas the rate of self-care hemodialysis decreases. The rate of peritoneal dialysis remains stable. When comparing guidelines to real-life treatments, 77.5% of patients receive adequate dose of treatment (12 H/week, KT/ V>1.2), the rate of patients with a hemoglobin blood-level lower than 10g/dl and without erythropoietin treatment is 1.3%, which confirmed a good management of anemia. On the contrary, 34% of patients have a BMI lower than 23kg/m(2) and only 23% have an albumin blood-level over 40g/l, which underlines that nutritional management of ESRD patients can be improved.
Age strongly influences survival on dialysis. Thus, one year survival of patients under age 65 is over 90%. After 5 years, among patients over 85 years, it is more than 15%. The presence of diabetes or one or more cardiovascular comorbidities also significantly worse patient survival. In terms of trend, we do not find significant improvement in the 2-year survival between patients in the cohort 2006-2007 and the 2008-2009 cohort. Cardiovascular diseases account for 27% of causes of death to infectious diseases (12%) and cancer (10%). Life expectancy of patients is highly dependent on their treatment. Thus, a transplant patient aged 30 has a life expectancy of 41 years versus 23 years for a dialysis patient.
ESRD PEDIATRIC PATIENTS
In 2011, the incidence and the prevalence of ESRD among patients under 20 years old remained stable at 8 and 53 per million inhabitants respectively. The first causes of ESDR remain uropathies and hypodysplasia followed by glomerulonephritis and genetic diseases. Considering the initial treatment, we found a high rate of hemodialysis and a low rate of peritoneal dialysis that is mainly used in younger children. In 2011, 31 preemptive transplantations were performed accounting for 27.7% of new patients. Finally, survival analysis confirm that younger children (under 4 years old) have the highest risk of death (88% survival rate at 2 years vs. 98% in patients over 4 years old) and that the treatment of choice remains the renal transplantation since it increases the expected remaining lifetime of 20 to 40 years depending on the considered age.
Access to the waiting list is evaluated on a cohort of 51,846 new patients who started dialysis between 2002 and 2011 in 25 regions. The probability of first wait-listing was of 3.7% at the start of dialysis (pre-emptive registrations), 15% at 12, 22% at 36 and 24% to 60 months. Patient older than 60 had a very poor access to the waiting list, whatever their diabetes status was. Among 13,653 patients less than 60 years old, the probability of being registered was 11% at the start of dialysis, 43% to 12 months, 62% to 36 months and 66% to 60 months (median dialysis duration: 16 months). Seventeen regions with up to 5 years follow-up show an increase of 8 to 15% in pre-emptive registrations between 2007 and 2001, without change at 1 year. Access to kidney transplant is evaluated on a cohort of 53,301 new patients who started a renal replacement therapy (dialysis or pre-emptive renal transplant) between 2002 and 2011 in 25 regions. The probability of first kidney transplant was of 7% at 12, 17% at 36 and 21% at 60 months. 8,633 patients (16,2%) had received a first renal transplant within 14.7 month median time; 1,455 (2.7%) had received a pre-emptive graft. Among the 14.770 new patients less than 60 years old, the probability of being transplanted was of 21% at 12, 46% at 36 and 58% at 60 months (median dialysis duration: 42 months). When pre-emptive graft were excluded, the probability of being transplanted was of 5% at 12, 15% to 36 and 19% to 60 months FLOW BETWEEN TREATMENT MODALITIES: Among the 36.849 patients on dialysis at 31/10/2010, 79% were already on RRT at 31/12/2009. Respectively 91%, 85% and 93% of the patients on HD in-center, HD self-care unit and peritoneal dialysis were in the same modality of treatment the year before. Among the 29.758 patients with a functioning graft at 31/12/2010, 98% were already on RRT at 31/12/2009, 95% of them with a functioning graft.72%, 72% and 74% of the patients with in-center HD, out-center HD and self-care unit were in the same modality of treatment at 31/12/2011. But 37% of the patients on PD at 31/12/2010 were not on PD at 31/12/2011. In 2011, new patients represented 89% of the entries in peritoneal dialysis. Renal transplantation represented 10% of the outcomes of the HD patients in self-care unit or at home.