Global Dialysis Perspective: France

CKD Management

CKD management relies exclusively on the referent nephrologist in collaboration with primary care physicians and other specialists (e.g., diabetologist, cardiologist). Patient care is on the basis of outpatient clinics in an ambulatory mode, with periodical consultations, clinical assessments, laboratory tests, or imaging monitoring with medicine prescription. From CKD stages 3–5, including RRT, all costs related to patient monitoring and treatment are covered by the universal social security insurance system, under the regime of long-lasting or chronic disease (Affection Longue Durée, list of 30 pathologies covered) (1).

Patients with CKD may benefit from dialysis care when necessary. It is at the discretion of the nephrologist to decide when and how to start RRT. For all patients, the nephrologist must follow the recommendations and implement best clinical practices developed by professional experts of the Haute Autorité de Santé (HAS) (2). The referent practitioner must present and explain all therapeutic modalities (e.g., RRT on the basis of facility, preemptive transplant), with their benefits and risks. The treatment modality choice must be shared with the patient and/or relatives, and noted in the medical file. When RRT is indicated, the patient is then referred to the care-provider partner of the network habilitated to provide the adequate therapeutic option. More information on CKD management in France can be found in a recent review of Nephrology in France (3), as part of a Worldwide Nephrology Project (4).

RRT: Legal Framework

Dialysis facilities are part of the national health service network serving the whole population under authority of the Ministry of Solidarity and Health, represented regionally by Regional Health Agencies (ARS). Renal care providers operate under three legal entities, namely public hospitals including academic hospitals, private for-profit (e.g., privately owned clinics or part of a chain) and private not-for-profit (e.g., associations). Total dialysis stations are provided through 891 facilities shared by 433 private not-for-profit entities (49%), 216 private for-profit entities (24%), 102 public hospitals (11%), 58 academic public hospitals (7%), and 82 mixed public-private entities (9%). Creation and distribution of dialysis units through various legal entities is established regionally every 5 years by ARS, according to the population’s needs defined by Réseau Epidémiologie et Information en Néphrologie registry. Legal entities then contract with ARS to provide the care service for the number of patients defined. Dialysis units belong to the health care facilities network, which is subject to regular certification (5 years) by the HAS. Nephrologists serving in these dialysis facilities must be certified, registered to French National Medical Council, and periodically accredited by a national organization (SIAM, HAS) that checks the acquisition of continuous medical education credits.

Dialysis-related costs are fully covered by the National Health Insurance Fund (Caisse Nationale Assurance Maladie) as part of the French Social Security System, no matter who the care provider is (public, private for-profit, or private not-for-profit), according to a yearly tariff established on the basis of facility, not modality. This is discussed later in the Funding of RRT section.

The technical operating conditions of dialysis units have been revised by law and what are known as “2002 September decrees” (5,6). They apply to all renal care providers. These decrees specify the technical platforms and quotas of minimum caregivers to ensure safety and care quality for patients: (1) the in-center hemodialysis (CHD) facility mainly supports patients whose health conditions (e.g., comorbidity, disabilities) require the permanent presence of doctor. It also specifies the number of patients per nephrologist and the number of nurses and/or caregivers per series of patients treated. The center must be located geographically within a health care facility, with full hospital beds, and emergency and continuous care services. The HD center has, on its own or by agreement, the services of a laboratory and imaging unit. The number of patients treated per day and per dialysis station is limited to three. The certified nurse to patient ratio is 1:4. (2) Satellite in-center HD units, namely medicalized dialysis units, do not require a continuous medical presence during the session. However, without being physically present, the medical team must be able to intervene during the session, while maintaining security. The nephrologist visit is carried out one to three times a week. Up to three patients can be treated per machine, per day. The certified nurse to patient ratio is 1:4 with a care helper. (3) Self-care HD (SCHD) units offer unassisted or nurse-assisted HD. (3a) Unassisted SCHD is intended for patients who are autonomous, and can provide their own treatment themselves. The permanent presence of a certified nurse is necessary to help patients when needed. The certified nurse to patient ratio is 1:6, with care helpers. A personal and not sharable dialysis machine is assigned to each patient to provide more flexibility and a wide range of treatment time schedules. (3b) Assisted SCHD is offered to patients who are semiautonomous and require the assistance of a certified nurse to perform certain actions (for example, arteriovenous fistula puncture). The maximum number of patients treated in this case is two per shift, per day. The unit has a permanent nurse. The certified nurse to patient ratio is 1:6 optionally with a care helper. The visit of the nephrologist, during the session, is provided at least once a quarter in simple SCHD, and at least once a month in assisted SCHD. In addition, an external consultation must be carried out at least once a quarter. (4) Home therapy relies on HD and home peritoneal dialysis (PD). Home HD is offered to patients who are autonomous and capable of performing all of the necessary actions for their treatment, in the presence of a person who can assist them. PD is provided under two options (unassisted or assisted) for patients able to treat themselves at home. For unassisted PD, patients receive a monthly allowance for costs related to treatment (such as electricity, water, media) and loss of financial resources. In assisted PD, the patient does not receive this allowance, but private nurse care fees for patients are paid for by the social security system. For home-based therapy, the care provider is responsible for training, monitoring, logistical support, and repatriation to the clinic if there are issues. A specialized coordinating nurse must be able to provide 24-hour and 7-day operational support. In all cases, so-called “out-of-center” dialysis units and the unit care providers must have, on their own or by convention, fallback protocols with specialized care structures capable of ensuring immediate care if there are complications and/or medical emergencies. (5) Training and repatriation units are intended to teach, train, and install equipment for patients at home when they are ready to perform their own treatment, and to ensure repatriation and continuity of care in case there are technical or medical issues. For serious medical issues, the patient should be referred to a secondary-level hospital or clinic.

Epidemiology of RRT: Updated End 2019

Epidemiologic data on RRT in France including overseas territories are captured, monitored, and analyzed via the national Réseau Epidémiologie et Information en Néphrologie registry on behalf of the Biomedical Agency, established in 2002 (7,8).

Global RRT: Overview

On December 31, 2019, 91,875 patients were receiving a RRT in France, 55% on dialysis and 45% living with a functional renal transplant as presented in Figure 1 (9). The overall standardized prevalence was 1355 per million population (pmp). It was 1.7-fold higher in males. Prevalence was subject to regional variations with seven regions (five overseas) above and seven below the national rate, as presented in Figure 2. The renal transplant share varied from <40% in three regions to >50% in five regions, and from 15% to 32% in overseas regions. The overall sex and age standardized prevalences were 44,700 and 610 pmp, respectively, for PD, HD, and transplantation, with marked regional variations. Trends in incidence and prevalent standardized rates of patients with ESKD treated in France through 2012–2019 are presented in Figure 3.

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Figure 1.

Incoming/outgoing patients with ESKD flows in 2019. Patient flows were aligned on December 31, 2019. pmp, per million population; pmi, per million inhabitants; PD, peritoneal dialysis; LRD, living related donor.

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Figure 2.

Territorial organization and standardized prevalence rate (pmp) of patients treated for ESKD heat map color. pmp, per million population.

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Figure 3.

Trend in incidence and prevalent rates of patients treated for ESKD (2012–2019). pmp, per million population.

In 2019, 11,437 new patients with ESKD started RRT. The overall incidence of RRT was 169 pmp (dialysis, 162 pmp; preemptive transplantation, 7 pmp). The median age at RRT initiation was 71 years. Those patients present a higher rate of comorbidities, especially diabetes (48% of new patients) and cardiovascular diseases (57% of new patients), which increases with age. The first treatment option remains in-center HD. RRT started as an emergency in 30% of patients. The hemoglobin level at the start of RRT offers an interesting proxy indicator of timely appropriate CKD management before dialysis initiation. As indicated, 67% of patients presenting an underprovided follow-up during advanced CKD management have a hemoglobin level <10 g/dl, whereas only 48% of patients on HD and 27% patients on PD with an appropriate follow-up presented such a condition.

On December 31, 2019, 50,337 patients with prevalent ESKD, including in overseas territories, were maintained on dialysis (HD 47,324 and PD 2999). Interestingly, the prevalence of patients on dialysis in overseas territories is almost twice that of mainland France (1355 pmp versus 2677 pmp). It is interesting to note patients aged >65 years account for 55% of the patients undergoing dialysis (median age 71 years, stable since 2012). These patients present a high rate of comorbidity, especially diabetes (44% of patients, increasing since 2012) and cardiovascular comorbidities (59% of patients), which increases with the patient’s age.

HD Prescription

PD Prescription

PD is performed exclusively at home on a daily basis, either with support of a cycler as automated PD (APD) or manually as CAPD with a bag and transfer set systems. APD is the most used modality, with 59% of patients. Unassisted accounts for 51% of patients on PD, whereas assisted modality accounted for 44% and is mostly used in patients on CAPD; 5% had information missing, as shown on Table 5. PD solutions are multiple and prescription relies on various associations (dextrose 1%, 2%, and 4%) with biocompatible solutions, including bicarbonate-buffered and low glucose degradation product solutions, and icodextrin-based solution for long-dwell exchange in almost 80% of patients. Median exchange volume in CAPD is 6.2 L/day (0.5–12) and in APD is 10.1 L/day (1.0–18.0). The type of PD solutions and daily exchange volume are tailored to the peritoneum membrane permeability test and residual kidney function to fit the patient’s needs. Support may be given to PD care givers by the Francophone PD registry (Registre de Dialyse Péritonéale de Langue Française), which that captures data and provides feedback support to PD centers (13) on a voluntary basis.

Funding of RRT

Kidney disease and chronic renal failure are listed as 19th out of the 30 recognized chronic diseases (Affection Longue Durée, list of 30 pathologies covered). CKD is considered an “exonerating” disease totally covered by the universal national health insurance system (Caisse Nationale Assurance Maladie and regional branches Caisse Régionale Assurance Maladie [CRAM]) (2,3). As soon as a patient is diagnosed with kidney disease, their general practitioner and referent nephrologist must document the clinical case to the CRAM medical office. After this, CKD is recognized and covered by the social security system. All rights will appear on the patient’s electronic card (Vital Card) and open the rights for the patient to be treated with all costs related to kidney disease fully covered. Thanks to its personal electronic card (Vital Card), each patient may benefit from health insurance funding for CKD care. A patient with CKD has no out-of-pocket expenses for their renal care. Full coverage of renal care remains true across all kidney disease stages, including dialysis and transplantation.

Reimbursement Policy and Tariff

During RRT, the cost of treatment includes dialysis reimbursement fees, use of disposable material, intradialytic medications (e.g., erythropoetin stimulating agent, iron), and physician fees (private for-profit), but also during the interdialytic period, medicine prescription, specialized consultations, laboratory tests, and imaging tests when needed. Renal replacement fees are on the basis of the facility (CHD, self-care HD, home HD and PD, training centers), and not on the modality itself. Reimbursement tariffs are presented in Table 5. In other words, HD or hemodiafiltration receive the same reimbursement fees. It is of interest to note transportation to the dialysis unit benefits from an additional specific reimbursement by the CRAM (4).

Disclosures

B. Canaud reports having consultancy agreements with Fresenius Medical Care as Senior Chief Scientist; and reports having patents and inventions for an implantable vascular access port. The remaining author has nothing to disclose.

Funding

None.

Author Contributions

B. Canaud and C. Couchoud conceptualized the study; C. Couchoud was responsible for the data curation; and B. Canaud wrote the original draft, and reviewed and edited the manuscript.