RESUMEN
BACKGROUND: Major inequalities in access to renal transplant waiting lists have been demonstrated among adult patients both in the USA and Europe. In this French nationwide study, we sought to ascertain the influence of patient and centre characteristics. METHODS: We included all children (<18 years) in the French End-Stage Renal Disease National Registry, who started renal replacement therapy (RRT) between 1 January 2002 and 31 December 2011. The primary outcome was the probability of being listed within 6 months after starting RRT. Hierarchical logistic regression models were used to study the association between the patient or the centre characteristics and the outcome. Centre effects were assessed by studying the centre-level residual variance. RESULTS: A total of 614 incident patients treated in 54 centres were included; 421 (68.6%) were listed within 6 months after starting RRT. A higher risk of not being listed was found in patients younger than 2 years or with a renal disease with a high risk of recurrence after transplantation [odds ratio (OR): 2.61; 95% confidence interval (CI): 1.37-4.97]. We found a significant vintage effect: the probability of not being listed decreased over time (OR per 1 year +0.83, 95% CI: 0.74-0.94). Although we found no significant gender effect, a trend towards disfavouring girls persisted over the study period. We found a significant centre effect that remained after adjusting for patient characteristics. However, none of the centre characteristics that we studied (centre size, pre-emptive transplantation program, paediatric versus adult centres and the proportion of patients on the waiting list placed on inactive status during the first month after listing) explained this variability. CONCLUSIONS: Our study confirms inequalities among children in rapid access to the renal transplant waiting list and shows that patient and centre characteristics play a role in these inequalities. Further studies focusing on the organization and practices of the centres are needed to explain the remaining variability.
Asunto(s)
Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/estadística & datos numéricos , Fallo Renal Crónico/cirugía , Trasplante de Riñón , Selección de Paciente , Terapia de Reemplazo Renal , Listas de Espera , Adolescente , Adulto , Niño , Preescolar , Femenino , Francia , Humanos , Lactante , Modelos Logísticos , Masculino , Oportunidad Relativa , Sistema de Registros , Características de la Residencia , Factores de Riesgo , Adulto JovenRESUMEN
Chronic renal disease is a state of microinflammation and insulin resistance. They both impact on the patient's outcome with an increased cardiovascular morbi-mortality and malnutrition. Current evidence suggests that there is a link between these two abnormal conditions. Recent data show a multiple organ regulatory pathway with a key role of bone, adipose tissue, immune system and central nervous system in energy balance control and glucose homeostasis. Thus, in searching for effective therapies, we should use an integrated approach aimed at modifying integrated outcomes rather than targeting single molecules.