Rethinking secularism, World affairs:

The new faces of the European far-right posted by Nilüfer Göle Two hitherto marginal but rising forces proved pivotal in the 2009 European elections: a burgeoning Green movement and a renascent far-right. On one hand, the British National Party won its first entry to the European Parliament, while in the Netherlands a rich multicultural heritage has been challenged by the electoral victories of the nativist Party for Freedom (PVV). On the other hand, the breakthrough of environmental groups on the political scene was celebrated everywhere in Europe. In Germany, where there was already a strong Green tradition, and in France, they outstripped the center parties in unprecedented fashion. But since the election, the actions of the Greens have remained virtually invisible, while the far-right never ceases to occupy the public stage, shaping societal debate across Europe and positioning itself as a viable alternative political force.

Republicanist France, which believed itself immune to the ominous rise of far-right political parties, is no exception. With the ascent of Marine Le Pen to the head of the National Front and her growing popularity in the polls, France joins the surge of nationalist parties that is sweeping over all of Europe. We must understand the new dynamics that underlie this relapse toward a continent-wide far-right movement: in its latest change of face, the far-right misappropriates the legacy of 1968 at the same time that it targets Islam under the guise of defending national values, just as its leaders claim to embody the value of personal liberty all the while asserting their belonging to the "land" of popular imagination, thus forging a new rhetorical repertoire and introducing it into European political culture. The movement is garnering newfound legitimacy by taking up themes of identity that have, for a decade, continued to gain purchase in European public debates. The far-right parties" entrance into these debates procures, in particular, an audience for their spokespeople, who stand out in these arenas through their combativeness toward Islam and through their irreverence, which breaks down former taboos surrounding multiculturalism.

The new faces of the far-right have gained power in their political parties by virtue of their capacity to make a place for themselves in debate-in other words, by manufacturing public personalities-as well as by stirring up controversies over the presence of Islam in Europe. They take great care over their self-presentation, which is given precedence over their political representation and their function in the party. We are witnessing a process whereby the presence of actors in the public sphere and the media determines the place they occupy in the political arena. However, public popularity and political engagement do not always follow the same logic, and, indeed, they sometimes come into tension with each other. There are those among the French public, for instance, who declare the National Front an obstacle to the popularity of Marine Le Pen.

Hence, we face a movement that has been revived politically by its entry to the public sphere, through which it acquires legitimacy for its ideas and puts an end to the stigma of the farright. These parties are no longer at the end of the political spectrum but seek their political legitimacy at the center of public opinion, and they do so in large part by making Islam a common enemy. Thinkers from the republican right and intellectuals from the left both express perplexity over the rise of right-wing movements that do not hesitate to endorse egalitarian, feminist, and secular ideas. They have been dispossessed of the ideas that previously guaranteed the far-right"s restriction to the margins of the political system.

The rising stars of the European far-right, such as Marine Le Pen in France, in fact scramble the divide between right and left, thus distinguishing themselves from the preceding generation of conservatives. They sometimes display a habitus evocative of European counter-culture-something completely out of step with the style of their predecessors. The leader of the far-right Freedom Party of Austria, Heinz-Christian Strache, who often sports a tee-shirt emblazoned with an effigy of Che, and the Swiss politician Oskar Freysinger, who wears his long hair in a ponytail, do not hesitate to borrow the emblems of cultural revolt. In choosing Islam as a target, they make themselves out to be defenders of sexual equality, feminism, and freedom of expression, as well as supporters of the fight against homophobia and anti-Semitism. Hijacking the cultural legacy of the left, they promote those values to which the preceding, patriarchal, xenophobic, and anti-Semitic far-right was hostile.

Similarly, Marine Le Pen, while profiting from her lineage, aims for political renewal by breaking away from her father"s tradition and its representation of the "real" (i.e., Catholic and working-class) France. If the father made himself spokesman for the "little people," in opposition to the established elites associated with the Grand Écoles education system, the daughter, a lawyer and Member of the European Parliament, does not oppose the Republic"s elite but, on the contrary, claims to be a defender of its values. She even goes so far as to claim to embody those values; she emblazons herself in republican ideals, defending secularism and adopting a feminist stance. She does not hesitate to endorse ideas that were introduced by a specific, and influential, form of feminism in support of her fight against the Islamic veil and the perceived threat of Muslim communitarianism.

Marine Le Pen has established herself through her declarations on controversies surrounding Islam. She attracted public attention by comparing Friday prayers on rue de la Myrha in the 18 th arrondissement of Paris, which is home to a significant number of Muslims, to the German occupation. This comparison earned her a complaint for inciting racial hatred but also assured her a bill of entry to the public arena. She denounces the burkha and then demands even more comprehensive laws, setting herself up against "mosque-cathedrals," polygamy, and the proscription of pork from public cafeterias. In her eyes, all Muslim religious practices constitute an instrumentalization of religion for political purposes. And according to her, any tolerance of Muslims or minority rights leads to discrimination against those of "French" descent.

It was likewise by arousing a sensitive debate around the construction of minarets in Switzerland that Oscar Freysinger, hitherto a relative unknown in the political landscape, won popularity on a European scale. Moreover, Switzerland, a neutral, non-EU country that willingly places itself at Europe"s margins, also made an entrance into European politics through this debate. The Swiss referendum became a major reference point and moved to the center of European public discourse. A Swiss poster opposing the construction of Minarets that was used during the referendum, and which depicts the Swiss flag pierced by minarets in the shape of bullets and overlaid by a woman wearing a burkha, has been appropriated and used by almost all the other European far-right parties. Its graphics communicate a feeling of invasion and menace to the nation posed by foreign forces-a representation of Islam that is far from the realities of Muslims in Europe, a dehumanized version of Islam, faceless and faithless.

In the Netherlands, a short film titled Fitna (an Arabic word that signifies social disorder or chaos), produced by Geert Wilders, current leader of the Party for Freedom (PVV), in 2008, takes up the theme of the purported Islamic menace in terms of the question of women in Islam. In this film, images of Islamic terrorism and stoning are intermingled with images of women in burkhas. Wilders explicitly invites Europeans to "defend their freedom by halting Islamization." In order to do so, he suggests a ban on the sale of the Qur"an, which he compares to Mein Kampf.

Thus, like Marine Le Pen, the other leaders of Europe"s far-right parties have constructed their careers and redefined the political agenda on the basis of controversies over Islam. The Austrian Freedom Party organizes anti-mosque campaigns; the Lega Nord in Italy initiates "pig parades" to desecrate land reserved for the construction of mosques; in France, the Riposte Laïque makes appeals for people to rally around an "apéritif saucisson pinard" for the celebration of June 18, the anniversary of de Gaulle"s famous speech to the people of occupied France. In other words, we see a repertoire of action that takes its inspiration and draws its references entirely from a battle against Islam. National values are thus defined in opposition to Islamic culture; accordingly, these movements valorize emblems of local French cuisine such as cochon (pork) and pinard (cheap wine), both of which are haram.

Indeed, the rise of neo-populist movements illustrates well the concern over a sense of national identity and belonging, that is, the concern over a conception of identity that posits the national community as a homogeneous group of white Christians that is thus incompatible with Islam. Meanwhile, the difficulty in naming these movements indicates a change in the rhetorical register of the far-right. We can no longer trace a direct evolution of xenophobic and anti-immigration policies to the 1970s. Today, the category of race assumes religious overtones. Patriarchal conservatism and anti-Semitism have been overshadowed in favor of the so-called national (i.e., supposedly, not universal) values of personal liberty, freedom of expression, and sexual liberty.

These movements converge at the European level, yet the themes vary according to national context. Nordic countries, which are more concerned with sexual liberties, highlight the fight against homophobia, whereas France, with its attachment to its secular heritage, defends republican education. Muslims are under pressure to prove their national loyalty by demonstrably subscribing to these values; sometimes they are put to the test by demands of feminism, sometimes by tolerance of homosexuality. European democracy, as Eric Fassin has written, is becoming a "sexual democracy," where questions of gender and sexuality provoke and promote numerous public controversies.

The term populist is no longer suitable for grasping the significance of these movements. As Jacques Rancière states, racism today is not a "popular passion" but simply a "racist passion on high." This logic of the state, he writes, will be "supported primarily not by what we know as backwards social groups but by a large section of the intellectual elite [. . .], by an intelligentsia that is known as a leftist, republican, and secular intelligentsia." The intellectuals of this line submitted to the logic of the state and wound up accomplices in the narrowing of public space and the legitimization of prohibition and exclusion. An entire intellectual and political arsenal for thinking about the relationship between the public and cultural and religious difference is falling into disuse. The principles that guarantee democratic pluralism and allow new social groups to integrate as citizens are criticized and even attacked head-on. Thus, ideals such as religious minority rights, freedom of worship, and multiculturalism are no longer used to think about difference. Muslim citizens suffer the loss of a viable political language and access to the public sphere. They are not invited to participate, except for those who attempt to adhere in mimetic fashion to the ideas of the secular, republican, and feminist intelligentsia, and thus turn away from Islam.

Muslims are issuing forth from their immigrant status and seeking, in this post-migratory phase, to establish the conditions of their citizenship by making their religious signs visible in public space. Presenting themselves as guardians of this public space, new faces have emerged on the far-right to bar entry to these new citizens. And any talk that calls into question the use of the term "Islamophobia" only contributes to the ascendancy of the new figures of nationalism and nativism in the public arena. We could soon see the sign "No Entry to Muslims" on the doors of the European public sphere.

Tags: Europe, Islam, laïcité, nationalism, Rethinking secularism, world affairs http://blogs.ssrc.org/tif/2011/05/11/the-european-far-right


Nilüfer Göle

Politics of Islamic Praying in European Publics

Covering and praying, two Islamic prescriptions ,bring religion into public life and debate in Europe. Praying in Europe where Muslims are in minority becomes a public issue. From the perspective of the liberal discourse on religious freedom and the freedom to exercise one's faith requires a place for worship. The author selects three different practices of praying that have provoked a public debate to illustrate the specificity of contesting religious practices in a European context. Confrontation with Islam carries also European citizens and countries that were considered to be in the periphery of Europe to the Center. Switzerland, a non-EU member, becomes European, enters into the center of European debates by the Islamic door.

Covering and praying

Islamic covering is adopted by some young group of women who turns towards Islamic faith and at the same time they express their ambitions to pursue their educational and professional trajectories in Europe. Total veiling on the other hand is adopted only by a minority of women, following a more fundamentalist and ascetic interpretation of Islam. Among them there are also converts, hence "native" citizens of Europe. Covering and praying, two Islamic prescriptions ,bring religion into public life and debate in Europe. Although Islamic covering of women is a source of theological debate among Muslims as well, praying is considered as a major religious ritual shared by all the faithful. Praying is an obligation for every pious person, a shared expression of faith by majority of Muslims. Praying in Europe where Muslims are in minority becomes a public issue. From the perspective of the liberal discourse on religious freedom and the freedom to exercise one's faith requires a place for worship. In that respect, claim for praying rooms and construction of mosques for Muslims living in Europe can be approached as a right for religious freedom. However, such liberal discourses of religious freedom fall short of framing the religious claims. Covering and praying, as new forms of Islamic visibility in Europe provoke a series of reactions and debates on secular norms and European values, calling in some cases for prohibitive legislations against such visibilities across Europe. The referendum that banned the minaret construction in Switzerland follows and illustrates these dynamics at work. (1)

Contesting religious practices

Islam in a migrant, secular European context acquires different meanings and forms. The context of immigration requires an effort for Muslims to re-learn and practice their religion. Muslims have to struggle and search for ways of being a "good Muslim" in a multi-religious secular European context. Therefore religious faith is not a fixed, given, opaque category but un-stabilized by migrant dislocations and subject to reinterpretation in the European context. Chains of transmission of religious knowledge are broken, intergenerational transmission and learning in the family, as well as faith community in the countries of origin are not sufficient (linguistic and environmental differences) to provide a guidance for young generations. In a secular and multi-religious environment, faith is constantly subject to learning and supervision leading to a more rigorous search for piousness and higher awareness of one's faith. I'll select three different practices of praying that have provoked a public debate to illustrate the specificity of contesting religious practices in a European context. a) Muslim prayer in a Berlin high-school. In Berlin's Wedding district, a 16 year old Berlin boy called Yunus was the first student in Germany to demand the right to conduct his prayers at school. Following a religious obligation to pray five times a day at set times creates tensions in an environment of a high school regulated with secular norms. He had been praying during class breaks, by kneeling on his jacked, laid out in a school hallway. The court first said that to ban the student from praying at school would violate his right for religious freedom and agreed for a requirement to have a prayer room. But others argued that school is a neutral space, condition to allow plurality of beliefs. Some others put under suspicion Yunus's religious convictions, interpreting the praying practice as a political act. At the end a Berlin court 27.5.2010 ruled that praying at school could cause conflict and disturb peace in school. Not the end of the dispute; there is an appeal at a higher Court, Federal Court. b) In front of the Dome cathedral in Milan a public prayer took place in January 2009 after a manifestation organized by leftist and pacifist associations against Israeli occupation of Gaza. The public debate that followed revolved around several arguments: the public praying has shown the lack of a mosque in the eyes of Muslims, whereas Catholics have expressed their feeling of being invaded by a foreign religion; some have put the emphasis on the political feature of the praying and questioned the intentionality of the religious practice, and others have questioned the loyalty of Muslims citizens to Italy as they have manifested for Palestine. c) The third example concerns Cordoba mosque-cathedral, Mezquito and the praying of a revert citizen in front of it. It is the most well known heritage of Muslim Spain and the Reconquista period, witnessing the presence of Muslims in Spain from the VIII to XV century most accomplished moment of the Umayyad period in Cordoba. In 786 the Umayyad bought the land of St.Vincent church and constituted a mosque. It was transformed into a church after the Reconquista and then into a cathedral. Mansur Escudero (passed away in October 2010 at the age of 63), President of the Islamic Council, himself convert, a "revert" Muslim, demanded the right for Muslim praying in the Mezquito. He wished to transform the cathedral into a multi-faith centre that includes a mosque. He prayed in front of the Mezquito (2007) to make his claim public and said he was looking to "soften the heart of the bishop".

All uncanny examples of praying of Muslims, diasporas, reverts, immigrants in Europe where religious faith, culture and rituals are manifested in an environment in which Muslims are not a majority. They bring into the public agenda a series of novel issues, such as lack of praying rooms, and mosques in the center of cities. Praying which is common to all monotheistic religions becomes divisive and controversial, becomes a site of public debate; whether it is an expression of faith, cultural identity, or political instrumentalization. The rights of Muslim minorities for citizenship are debated also in relation to questions of loyalty, whether they have different loyalties such as to their countries of origin, to Palestinian cause, to global Islamic networks that funds mosques and train imams.

These three distinct examples illustrate well the different faces of European Islam, the way Islamic religion is interpreted, manifested by European citizens of different origins. The Muslim past in Cordoba, and the issue of conversion (reversion) to Islam, Muslim immigration and transnational loyalties (Palestine cause), young school boy in Berlin and integration all witness the different faces of European Islam. Each case brings forth different forms of praying, and the changing frontiers between private religion and public visibility, personal piousness and public perceptions, between faith and politics; collective praying and political manifestation, student praying in a public school, convert praying as a protest. Each of these performances bring forth the question of space and its neutrality, whether secularism is a condition for pluralism or a hindrance of multi-religious, multi-cultural society is tested in each of these cases. (Public school in Berlin, public space in front of the Cathedral in Milan, Mezquito in Cordoba all in different ways reveals the tensions between secular and religious, as well as between different religions).

The issue of space, citizenship and State authority are closely related with each other. These cases reveal the ways in which religious identities change and contest politics of secularity and neutrality. Politics of praying reveal the question of ownership and exclusion in space, the norms that organize a space and the imprint of State authority that defines and controls the frontiers between private and public distinctions, religious and sacred norms, established citizens and "strangers".

Mosque itself is an interface between Muslim and non-Muslim inhabitants. Which forms, spaces, and concepts to accord to a mosque? Does a mosque always have a dome and a minaret? Can we have a mosque that would not be identifiable as such? Can we separate the minarets from the mosques? Can we replace the word "mosque," a word that some fear, with "place of prayer"? In Europe, minarets and mosques face "existential" problems; the minarets are always mute without the muezzins' call to prayer, and the mosques acquire new architectural forms in response to the landscape and the heritage of their surroundings. How can the mosque rally different ethnic communities? Do, for example, Turks frequent the mosques of Pakistanis in Birmingham? Are the Turkish mosques of Berlin also frequented by North Africans and other Muslim minorities? How to choose the language of the sermon? How might one rethink the space of the mosque for women, for the youth, and as the site of diverse activities? All of these questions are important in light of the real lives and daily experiences of Muslims in Europe. The mosque is an interface between the urban environment, Muslim citizens, and religious pluralism. Accepting its visibility leads to a series of negotiations and regulations-aesthetic, religious, financial, architectural, and spatial in nature-in the process of making it an object of a common heritage in-becoming. (2) Islamic religion enters into a phase of interpretation and change, becoming "indigenous" and European, meaning personal practices of piousness but also collective social experimentation and negotiation. Prohibitive legislations that exclude Muslim participation in public life ends this process by exclusionary politics, they put a halt to the process of interaction and mutual borrowings. Democracy is a place of negotiable, whereas the public opinions and politics claiming for the non-negotiable can betray the democratic ideal.

New transnational european populist right and islamophobia

Confrontation with Islam carries also European citizens and countries that were considered to be in the periphery of Europe to the Center. Switzerland, a non-EU member, becomes European, enters into the center of European debates by the Islamic door. Other European countries start discussing the Swiss referendum intensively, either as an error to be avoided or as an act of public courage expressing what people think in private. The Swiss anti-minaret poster is reproduced in other European countries by similar movements such as Pro-Koln movement in Germany, The Northern League in Italy, British Nationalist Party in England. Anti-Islam mouvement instigates a transnational European dynamics. Marginal political figures-such as Oscar Freysinger in Switzerland, Geert Wilders in the Netherlands, and Philippe de Villiers and Marine Le Pen-become popular public figures for the mainstream politics. They operate a change of discourse and political agenda in shifting from antiimmigration issues to anti-Islam politics. Actors who choose to confront Islam, either by putting the emphasis on religion or gender issues become audible and popular in European publics. Ex-progressiste actors of post-68 movement join these populist trends. The discourse of freedom of expression, gender equality, secularism are mobilized in counter-distinction with European muslims. Islam becomes an active force in the Europeanization of public sphere. But the question remains if this Europe is not turning against its democratic ideals by means of politics of fear, dressing new cultural frontiers, engaging politics of exclusion. Politics of praying becomes a challenge in redefining European public life and cultural pluralism.

Notes:

1) The referendum was held on 29 November 2009 in Switzerland. The initiative for the referendum was taken not by the State, but by the "Egerkinger Committee", composed of two right-wing populist parties: the Swiss People's Party and the Federal Democratic Union. 57 percent of voters approved a legislation to be included in the Constitution to ban minaret constructions.

2) See my articles where I elaborate this topic more in detail. Nilüfer Göle, "Les minarets, symboles muets de l'Islam et leur résonance dans l'espace public européen", RESET-DOC; and "Mute Symbols of Islam", The Immanent Frame.


Mute symbols of Islam

by Nilüfer Göle Each time I cross the Galata bridge, I never tire of contemplating with wonder the panorama of Istanbul in which emerge, like drawings, the silhouettes of its longilineal minarets. Unlike the Eiffel Tower, the minarets, multiple and discreet, are not erected as symbols of the city of Istanbul. Nevertheless, Istanbul, without its slender minarets, which symbolize the spiritual elevation of man towards God, would lose a part of its soul. The minarets, in the eyes of the inhabitants-pious and secular, Muslim and non-Muslim-are part of the familiar landscape, of the common heritage. Certainly, many regret that the new mosques built in contemporary Turkey are far from equaling those of the great architect Mimar Sinan (d. 1588 CE), who worked during the glorious days of the Ottoman Empire. The contemporary mosques, for the most part, lack architectural innovation, fineness, and proportion between the dome and the minarets. Likewise, the calls to prayer, since the adoption of cassettes and loudspeakers, have become the source of an ongoing public debate over whether they constitute a nuisance to the sound environment. But public debate does not confine itself to these subjects. The projects of re-opening Hagia Sophia as a place of prayer for Muslims and of constructing a new mosque at Taksim Square in the heart of Istanbul have given rise for two decades to a lively and passionate controversy, a controversy which divides citizens who position themselves against signs of Islamization from those who would like to mark the social rise of Islam by making a religious imprint on Turkey's public spaces. The split between those who declare themselves, respectively, defenders of secularism and the religious, and who both claim to adhere to the freedom of conscience, runs through the current public life of Turkey. The confrontation became more intense when minarets were compared to bayonets and mosques to barracks in a poem recited in public by Recep Tayyip Erdoğan on the occasion of his electoral victory in 1997. Erdoğan, the current prime minister of Turkey, was sentenced and jailed for "incitement to religious hatred" for having recited these verses, which are attributed to one of the nationalist poets who wrote in the context of the war for national independence.

It is amazing that in a country with a Muslim majority like Turkey, the historic and cultural symbols of Islam can cease to be parts of the field of a familiar, peaceful, and immutable heritage, and begin to develop a new visibility in the public field and to awaken religious and political divisions. One wonders when and how a symbol, or an object, which is to us so familiar as to have become imperceptible, becomes one day "visible"-nay, ostentatious and disturbing to the eyes of a public. The Swiss referendum which enacted, by a popular majority vote, the ban on constructing minarets reveals to us this new, disturbing visibility of Islam in the eyes of the European public. But at the same time, this quarrel confirms the transformation of the terms of the debate on Islam in Europe.

In the first place, the public visibility of religious and cultural signs of Islam expresses the presence of Muslim actors in European countries. The minarets-as, in other respects the veils, the other mute symbol-reveal the Muslim actor-as pious, as feminine-in public life. This visibility attests to the presence of Muslims in European societies, their desire to stay there, their claim to the freedom of conscience, and their right to worship and dress according to their personal interpretation of their religion. Islam, in a paradoxical way, has become a political and cultural resource for the singularization of immigrants, for their quest for recognition, and so it indicates in turn their particular citizenship in the public space of Europe. This new visibility marks the end of a stage in the migratory phenomenon and in the integration, lived experience, and modes of appropriation of public space in Europe. What hides behind the controversies around Islam is the difficulty of recognizing this passage from the stranger to the citizen. So, the debates on the minarets and their ban bear witness to the difficulty in Swiss society of recognizing the presence of newly settled Muslims, and of making a place for them in public life. The sentiment that Islam is invading their territory, the fear of losing one's "home," has fed these debates. In speeches, Muslims have been asked to install their minarets "back home;" in posters they have been compared to dangerous "black sheep;" they are considered "strangers" and are thus symbolically expelled. All the semantics of the debate lead us to think that the recognition of Islam and Muslims within Swiss society has been refused.

The leitmotiv of the debate, to protect oneself and one's home from this conquering religion, hides as well the reluctance to renounce the monopoly of Swiss-born citizens on their public space. The undemocratic character of this vote resides in its expression of a desire to contain and fix public space in strict equivalence with an essentialist conception of the nation, without opening it to the plurality of citizens. In another respect, Muslims, with their multiple attachments-to languages, ethnic groups, religion, and the ummah-disrupt the national definition of citizenship and arouse suspicion of their loyalty. The definition of a public space which is identified with a pre-established national community can only create tensions and exclusions in a world traversed by migratory and transnational dynamics, be they religious, economic, or cultural.

In the second place, this passage of Islam to the West confronts Muslims with a series of novel questions, which lend European Islam its distinctive traits. A Europeanized Islam exacerbates the paradox of visibility and invisibility. Here, unlike in Muslim countries, the minarets are mute, the mosques are discreet. Some European democracies, however, with a view to both security and openness, have sought to increase the visibility of places of worship, inviting them to come out of their caves and garages and to appear in daylight.

Nevertheless, the significance of allowing the mosque its visibility is not self-evident; which forms, which spaces, and which concepts can one accord it? Does a mosque always have a dome and a minaret? Can we have a mosque that would not be identifiable as such? Can we separate, as the Swiss want, the minarets from the mosques? Can we replace the word "mosque," a word that some fear, with "place of prayer"? In Europe, minarets and mosques face "existential" problems; the minarets are always mute without the muezzins' call to prayer, and the mosques acquire new architectural forms in response to the landscape and the heritage of their surroundings. How can the mosque rally different ethnic communities? Do, for example, Turks frequent the mosques of Pakistanis in Birmingham? Are the Turkish mosques of Berlin also frequented by North Africans and other Muslim minorities? How are we to arrange things so that the mosques are recognized as both public and religious spaces of European Muslims? By which criterion should one decide the language of the sermon? How might one rethink the space of the mosque for women, for youth, and as the site of diverse activities? All of these questions are important in light of the real lives and daily experiences of Muslims in Europe. The mosque is an interface between the urban environment, Muslim citizens, and religious pluralism. Accepting its visibility leads to a series of negotiations and regulations-aesthetic, religious, financial, architectural, and spatial in nature-in the process of making it an object of a common heritage in-becoming. But this Swiss referendum has imposed the non-negotiable; it is in this sense as well that this vote signifies an undemocratic attitude, as it puts a brake on the processes of evolution, exchange, and cultural mixture.

* * *

The referendum, far from staying confined to the Swiss context, has resonated in other national contexts and has given a transnational, European dynamic to the debate. Some deplore the Swiss error as one not to be repeated; others have applauded the courage to have said out loud what everybody thinks in a whisper. Polls conducted in France have revealed a favorable opinion of the limitation on the construction of mosques. The British National Party (BNP) has appropriated the "anti-minarets" poster used by its Swiss counterpart (UDC). This poster shows the national flag (Swiss or British, respectively) pierced by minarets represented as guns. There appears as well a woman in full veil. In the English versions, the verses recited by Tayyip Erdoğan (quoted above) are included. In public debates throughout Europe, these same verses have incessantly been taken out of context. One sees how the debate on the minarets in particular, and the visibility of Islam in general, generates transnational dynamics and assemblages of disparate elements. One notices that even insular England and Switzerland, isolated from Europe, enter the European public field. The fear of Islam is instrumentalized by different populist parties and "anti-Islamization politics" finds resonance within the silent majority. Marginal political figures-such as Oscar Freysinger in Switzerland, Gert Wilders in the Netherlands, and Philippe de Villiers in France-have contributed to the transformation of national political agendas across Europe and have won popularity in their fight against the Islamic presence in Europe.

It is around the theme of Islamic visibility, in large part, that collective passions and public debates are mobilized today. The headscarf at school, the burka in the street, the mosque in the city, and the minarets in the landscape indicate the presence of Muslim actors in daily life (sometimes with an Islamicity that is exacerbated and in a state of rupture), but also place on the public agenda the debate over the secular norms of common space. These questions put public space to the test of democratic debate and one risks inflaming such public debate by promoting a politics of fear.

By appealing to personal sentiments and eliciting the visceral and the emotional, one makes of public space a place plagued by prejudices. European democracies have developed by making a distinction between opinion and truth, by advocating the use of reason in public debate. The current political populism threatens this European tradition of the "enlightened public." The public sphere is at risk of losing its role as the ideal expression of democracy and becoming a place of common sense, of the sacralization of public opinion, and of the contagion of the sensational and scandalous. It is by this regression of public debate towards the irrational and the emotional that the Swiss vote betrays the democratic ideal.

Translated from the French by Lena Royant.


The silent symbols of Islam and their importance in the European public sphere

Nilüfer Göle

Islam becomes a political and cultural source for identifying immigrants, their quest for acknowledgment. They in turn manifest their particular citizenship within the European public arena. This visibility marks the end of a stage in the migratory phenomenon, that of integration, as well as experiences and ways of appropriating the public sphere in Europe. It is the difficulty in acknowledging this passage from foreigner to citizen that lies beneath the controversies surrounding Islam. The concept of acknowledging Islam and Muslims as a phenomenon endogenous to Swiss society has been rejected.

Nilüfer Göle is Director of studies at the Ecole des Hautes Etudes en Sciences Sociales in

Paris and the author of "Interpénétrations: l'Islam et l 'Europe", published by Galaade éditions, 2005. Every time I cross the Galata Bridge I never tire of gazing in amazement at the view of Istanbul where the silhouettes of its tall minarets stand out like drawings. Unlike the Eiffel Tower, the many discreet minarets are not erected as symbols of the city of Istanbul. And yet, without its slim minarets symbolising man's spiritual elevation towards God, Istanbul would lose part of its soul. In the eyes of both its pious and secular inhabitants, Muslims and non-Muslims, the minarets are part of the familiar landscape of a shared legacy. Of course many regret that new mosques built in contemporary Turkey are far from a match for those of the great architect Mimar Sinan, created in the glorious age of the Ottoman Empire. Most contemporary mosques lack any architectural innovation, any finesse or proportion between the domes and the minarets. Even the calls to prayer, after the adoption of loudspeakers and recordings have become a constant source of public debate addressing the nuisance caused by the noise. Public debate, however, is not restricted to these subjects. Projects to reopen Saint Sophia as a place of worship for Muslims and the building of a new mosque in the heart of Istanbul have for decades caused lively and passionate controversy. A controversy that divides citizens into those objecting to signs of islamisation and those who wish to mark its social rise with religious symbols in the public sphere. This gap between those defining themselves as defenders of secularism and the more religious who demand freedom of conscience, is one that currently affects all political life in Turkey. The conflict has intensified since minarets were compared to bayonets and mosques to barracks, in a poem recited in public by Recep Tayyip Erdogan after he won the 1997 elections. Turkey's current prime minister was sentenced and imprisoned for "inciting religious hatred" after reciting these verses attributed to a nationalist poet, expressing himself about the national war of independence.

One is entitled to be astonished that in a country like Turkey with its Muslim majority, Islam's historical and cultural symbols are no longer part of the unchangeable and peaceful familiar legacy and have assumed a new public visibility and reawakened religious and political differences. One could ask oneself when and how a symbol, or an object, familiar and imperceptible to us should one day become "visible" and therefore ostentatious and upsetting in the eyes of the public? The Swiss referendum, that with a popular and majority vote decided to ban the building of minarets, has revealed that Islam's visibility is distressing in the eyes of Europeans. Simultaneously this conflict confirms the transformation of the terms of the debate on Islam in Europe.

First of all the public visibility of Islam's religious and cultural symbols marks the presence of Muslims in Europe. Just like the other silent symbol, the veil, minarets reveal the presence of Muslims both pious and female in public life. This visibility certifies the presence of Muslims in European society and their desire to remain there, demanding freedom of conscience, freedom to practice their religion and also the freedom to dress according to their personal interpretation of their religion. Paradoxically, Islam becomes a political and cultural source for identifying immigrants, their quest for acknowledgment. They in turn manifest their particular citizenship within the European public arena. This visibility marks the end of a stage in the migratory phenomenon, that of integration, as well as experiences and ways of appropriating the public sphere in Europe. It is the difficulty in acknowledging this passage from foreigner to citizen that lies beneath the controversies surrounding Islam.

The debates on minarets and on the ban to build them have born witness to Swiss society's problems in acknowledging the presence of Muslims who are establishing their roots and their place in public life. Debates have been feeding on the feeling that Islam is invading their territories and the fear of losing one's "home". Speeches include demands for Muslims to build their minarets "in their own countries," posters compared them to dangerous "black sheep" hence as "foreign" and symbolically expelled. All the semantics of the debate seem to indicate that the concept of acknowledging Islam and Muslims as a phenomenon endogenous to Swiss society has been rejected. The debate's leitmotiv, to protect oneself in one's own country from this conquering religion, also conceals a reticence experienced by Swiss citizens in renouncing a monopoly over their public sphere. The non-democratic aspect of this referendum lies in its intention to contain and freeze the public arena in its strict adaptation to the nation, refusing to open it to a plurality of citizens. On one hand, Muslims, with their multiple attachments, including languages, ethnic groups, religions and oumma, disturb the national definition of citizenship awakening suspicion regarding their loyalty. The definition of a public sphere identifying with a pre-established national community can only create tension and exclusion in a world filled with migratory and transnational dynamics, be these religious, economic or cultural.

Secondly, Islam's passage to the West causes Muslims to address a series of new issues that characterise Islam in Europe in a particular manner. Islam that has become European, exacerbates the paradox of visibility and invisibility. Unlike what happens in Muslim countries, here the minarets are silent and the mosques are discreet. Concerned with security and transparency, European democracies have encouraged the visibility of places of worship, inviting them to abandon cellars and garages and show themselves. Nonetheless, it is not that simple to provide a mosque with visibility. What form should it have, what space should it occupy, what ideas should be attributed to it? Does a mosque always have a dome and a minaret? Is it possible to create a mosque that is not identifiable? Is it possible to separate mosques from minarets as the Swiss hope? Is it possible to replace the word "mosque" which frightens some people with "place of worship"? In Europe, minarets and mosques face "existential" problems.

Minarets are always silent, without the muezzins calling people to prayers; mosques have begun to acquire new architectural characteristics respecting the landscape and the environment. How can mosques assemble together different ethnic communities? Do, for example, the Turks in England attend Pakistani mosques in Birmingham? Are the Turkish mosques in Berlin attended by citizens of the Maghreb and by other Muslim minorities? How can one ensure that mosques are acknowledged as the public and religious space of European Muslims? According to what criteria should one decide what language should be used for preaching? How should one rethink the mosque area for women, for the young and for various activities? These are all questions that become more important when considering the experiences and daily lives of Muslims in Europe. Mosques act as an interface between the urban environment, Muslim citizens and religious pluralism. Accepting their visibility involves a series of negotiations and rules that involve aesthetics, worship, finance, architecture and space, so as to create objects of a future shared legacy. The Swiss referendum has now imposed non-negotiability and it is also in this sense that this referendum indicates a non-democratic attitude, because it involves stopping the process of evolution, exchange and cultural mixing.

The sensation caused by the minarets: Islam obliges Europe to go public

Far from being restricted to the Swiss context, this referendum caused a sensation in other countries and set off a transnational European debate. Some deplored the Swiss mistake saying it should not be repeated, others applauded the courage of having said what everyone thinks. Surveys in France have revealed that most people are in favour of restricting the building of mosques. The BNP in the UK has copied the "anti-minaret" poster used by the Swiss populist party (UDC). The poster depicts the national flag (Swiss, British) pierced by minarets shaped like guns. There is also an image of a woman wearing a burqa. In the British version there are also the verses recited by Tayyip Erdogan (see above). In public debates in Europe, these same verses alluding to the "bayonets" of the minarets are continuously repeated out of context. One can see how the debate on minarets in particular, and Islam's visibility in general, results in transnational dynamics and gatherings of diverse elements. One sees that even Europe's insular Great Britain and isolated Switzerland are part of the European public sphere. Fear of Islam is exploited by the various populist political parties and the "politics of anti-islamisation" also resonates within the silent majority. Marginal political figures such as Oscar Freysinger in Switzerland, Gert Wilders in Holland or Philippe de Villiers in France, have contributed to changing national political agendas and gained popularity with their battle against an Islamic presence in Europe.

It is around the themes addressing Islamic visibility that collective passions and public debates mobilise. Veils at schools, burqas in the streets, mosques in cities and minarets visible in the landscape make manifest the presence of Muslim players in daily life (at times with an exacerbated and fragmented Islamism) but also introduce to the public agenda and debate the secular rules to be applied in the public sphere. These subjects oblige the public sphere to endure the test of a public debate than runs the risk of being poisoned by the politics of fear. When personal feelings are touched, and visceral and emotional elements are emphasised, the public sphere becomes a place of prejudice. European democracies developed by distinguishing between opinions and truth, by ensuring the use of reason within the public debate. Current political populism is mobilised against this European tradition of an "enlightened public". The public sphere risks losing its role as the ideal expression of democracy and becomes the place of shared awareness, rendering sacred public opinion, and contaminating all that is sensational and scandalous. It is because of this regression experienced by the public debate, now inclined towards the irrational and the emotional, that the Swiss referendum betrays the democratic ideal.

Translated by Francesca Simmons


Benedicte Stengel
email: benedicte.stengel@inserm.fr

M Metzger

M Froissart

M Rainfray

C Berr

C Tzourio

C Helmer

Epidemiology and prognosis significance of chronic kidney disease in the elderly -The Three-City prospective cohort study

Keywords: chronic kidney disease, glomerular filtration rate, elderly, mortality, proteinuriaanaemia

Background.

Little is known about normal kidney function level and the prognosissignificance of low estimated glomerular filtration rate(eGFR) in the elderly.

Methods

. We determined age and sex distribution of eGFR with both the Modification of Diet in Renal Disease (MDRD) study and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations in 8705 community-dwelling elderly aged ≥ 65 years and studied its relation to 6-year mortality. In a subsample of 1298 examined at 4 yrs, we assessed annual eGFR decline and clinically relevant markers including microalbuminuria (3-30 mg/mmolcreatinine) with diabetes, proteinuria ≥50 mg/mmol, haemoglobin<11 g/L, or resistant hypertension despite 3 drugs.

Results. Median (interquartile range) MDRD eGFR was 78 (68-89)mL/min/1.73m 2 in men and 74 (65-83)in women; there were 79 (68-87) and 77 (67-85) for CKD-EPI eGFR, respectively. Prevalence of MDRD eGFR< 60mL/min/1.73m 2 was13.7%, and of CKD-EPI eGFR, 12.9%. After adjustment for several confounders, only those with an eGFR<45 mL/min/1.73 m 2 had significantly higher all-cause and cardiovascular mortality than thosewith an eGFR of 75 to 89 mL/min/1.73 m 2 whatever the equation. In subsample men and women with MDRD eGFR of 45-59 mL/min/1.73m 2 , 15% and 13% had at least one clinical marker, and 15% and 3% had microalbuminuria without diabetes, respectively; these percentages were 41% and 21%, and 23% and 10%, in men and women with eGFR<45, respectively. Mean MDRD eGFR decline rate was steeper in men than women, 1.75 vs 1.41 mL/min/1.73m 2 per year.

Conclusion.

Moderately decreased eGFR is more often associated with clinical markers in men than women. In both sexes, eGFR< 45 mL/min/1.73m 2 is related to poor outcomes. The CKD-EPI and the MDRD equations provide very similar prevalence and long-term risk estimates in this elderly population.

Introduction

Chronic kidney disease (CKD) as defined by the Kidney Disease Outcome Quality Initiative (K/DOQI) is increasingly recognized as a public health priority and targeted in prevention programs. [START_REF] Levey | Chronic kidney disease as a global public health problem: approaches and initiatives -a position statement from Kidney Disease Improving Global Outcomes[END_REF][START_REF] Stenvinkel | Chronic kidney disease: a public health priority and harbinger of premature cardiovascular disease[END_REF][3] Routine reporting of estimated glomerular filtration rate (eGFR) has led to label up to nearly half of the elderly as having CKD [START_REF] Hallan | Screening strategies for chronic kidney disease in the general population: follow-up of cross sectional health survey[END_REF][START_REF] Coresh | Prevalence of chronic kidney disease in the United States[END_REF][START_REF] Campbell | Kidney disease in the elderly: update on recent literature[END_REF][START_REF] Zhang | Prevalence of chronic kidney disease in population-based studies: systematic review[END_REF] and increased referrals to nephrologists. [START_REF] Hemmelgarn | Nephrology visits and health care resource use before and after reporting estimated glomerular filtration rate[END_REF][START_REF] Kagoma | Impact of Estimated GFR Reporting on Patients, Clinicians, and Health-Care Systems: A Systematic Review[END_REF] Because CKD diagnosis in many of these subjects is based only on either microalbuminuria or moderately decreased eGFR (i.e., 30-59 mL/min/1.73 m 2 ),controversy exists about its clinical relevance, [START_REF] Clase | Classifying kidney problems: can we avoid framing risks as diseases?[END_REF][START_REF] Glassock | Screening for CKD with eGFR: doubts and dangers[END_REF][START_REF] Coresh | Chronic kidney disease is common: what do we do next?[END_REF][START_REF] Stevens | CKD in the elderly--old questions and new challenges: World Kidney Day 2008[END_REF][START_REF] Hare | The management of older adults with a low eGFR: moving toward an individualized approach[END_REF][START_REF] Poggio | A critical evaluation of chronic kidney disease--should isolated reduced estimated glomerular filtration rate be considered a 'disease'?[END_REF][START_REF] Glassock | Referrals for chronic kidney disease: real problem or nuisance?[END_REF][START_REF] Mangione | The epidemic of chronic kidney disease: looking at ageing and cardiovascular disease through kidney-shaped lenses[END_REF] especially given how little is known about normal kidney function level [START_REF] Wetzels | Age-and gender-specific reference values of estimated GFR in Caucasians: the Nijmegen Biomedical Study[END_REF][START_REF] Esposito | Renal function and functional reserve in healthy elderly individuals[END_REF] and the epidemiology of CKD in the elderly. [START_REF] Anderson | Prediction, progression, and outcomes of chronic kidney disease in older adults[END_REF][START_REF] Roderick | Detecting chronic kidney disease in older people; what are the implications?[END_REF] More information is needed about the prevalence of clinically significant kidney markers such as clinical proteinuria, [START_REF] Crowe | Early identification and management of chronic kidney disease: summary of NICE guidance[END_REF] resistant hypertension, [START_REF]DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease[END_REF] or anaemia [START_REF]KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target[END_REF] in the older people. [START_REF] Roderick | Detecting chronic kidney disease in older people; what are the implications?[END_REF][START_REF] Ferrari | Estimation of glomerular filtration rate: does haemoglobin discriminate between ageing and true CKD?[END_REF] Data on eGFR change over time is also needed to better define rapid decline in this population. [START_REF] Lindeman | Longitudinal studies on the rate of decline in renal function with age[END_REF][START_REF] Hemmelgarn | Progression of kidney dysfunction in the community-dwelling elderly[END_REF][START_REF] Rifkin | Rapid kidney function decline and mortality risk in older adults[END_REF] Moreover, although several studies have shown increased mortality risk with decreasing eGFR, [START_REF] Fried | Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study[END_REF][START_REF] Go | Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization[END_REF][START_REF] Shlipak | Cystatin C and the risk of death and cardiovascular events among elderly persons[END_REF][START_REF] Hwang | Increased risk of mortality in the elderly population with late-stage chronic kidney disease: a cohort study in Taiwan[END_REF][START_REF] Roderick | CKD and mortality risk in older people: a community-based population study in the United Kingdom[END_REF] others suggest age attenuates these associations. [START_REF] Eriksen | The progression of chronic kidney disease: a 10-year population-based study of the effects of gender and age[END_REF][START_REF] O'hare | Age affects outcomes in chronic kidney disease[END_REF][START_REF] Hallan | Association of kidney function and albuminuria with cardiovascular mortality in older vs younger individuals: The HUNT II Study[END_REF][START_REF] Raymond | Elevated relative mortality risk with mildto-moderate chronic kidney disease decreases with age[END_REF][START_REF] Matsushita | Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis[END_REF] Finally, use of creatinine enzymatic assay and development of new equations improved eGFR assessment, but while the CKD Epidemiology Collaboration (CKD-EPI) [START_REF] Levey | A new equation to estimate glomerular filtration rate[END_REF] equation has shown to better categorized middle-aged individuals with respect to long-term outcomes compared with the Modification of Diet in Renal Disease (MDRD) Study equation, [START_REF] Levey | Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate[END_REF] distribution of eGFR values according to one another and risk implications in the oldest are unknown. [START_REF] Matsushita | Risk implications of the new CKD Epidemiology Collaboration (CKD-EPI) equation compared with the MDRD Study equation for estimated GFR: the Atherosclerosis Risk in Communities (ARIC) Study[END_REF] We therefore determined age-and sex-specificeGFR using both the MDRD and CKD-EPI equations in community-dwelling people aged 65 years and older participating in the Three-City (3C) cohort study and studied their relations to 6-year all-cause and cardiovascular mortality risks. In a subsample, we also assessed eGFR decline at 4 years and CKD markers.

Subjects and Methods

Study design and participants

The 3C study is a community-based, prospective cohort that included non-institutionalized individuals aged 65 years or older randomly selected from the electoral rolls of Bordeaux, Dijon, and Montpellier (France) from March 1999 through March 2001. The acceptance rate of 37% yielded a sample of 9294 participants. Details of the study design are reported elsewhere. [START_REF]Vascular factors and risk of dementia: design of the Three-City Study and baseline characteristics of the study population[END_REF] Here, we studied 8705 participants with baseline serum creatinine and mortality data for 6 years; a subsample of 1298 from Bordeauxwas also seen at four years, to assess eGFR decline and CKD markers (Figure 1).

Information

Baseline data came from face-to-face interviews and physical examination. Cardiovascular diseases and cardiorenal risk factors were recorded in detail. Open questions about surgery, hospitalization, treatment, and 100% health insurance benefits for severe illness in the last 2 years provided a history of kidney diseases and nephrectomy. At both baseline and 4 years, medication use was recorded and coded according to the WHO's Anatomical Therapeutical Chemical classification; [START_REF] Atc/Ddd | WHO Collaborating Centre for Drug Statistics Methodology[END_REF] height and weight were measured and body mass index (BMI) was calculated; seated blood pressure (BP) was measured twice after 5 minutes rest and averaged. Hypertension was defined by a mean systolic BP ≥140 or diastolic BP ≥90 mm Hg, [START_REF] Chobanian | The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report[END_REF] or by the use of antihypertensive drugs. Resistant hypertension was defined as a mean systolic BP ≥ 140 or diastolic BP ≥ 90 mm Hg despite the use of at least three antihypertensive drugs for all participants except those with diabetes or CKD as defined below; thresholds for them were ≥130 or 80 mm Hg. [START_REF]DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease[END_REF]. Diabetes was either self-reported or defined as fasting glucose ≥ 7 mmol/L or non-fasting ≥ 11 mmol/L (in 1% of the participants) or antidiabetic drug treatment. Fasting plasma cholesterol was also measured.

Assessment of kidney function and CKD markers

Serum creatinine was measured with the Jaffe method in a single laboratory at baseline and in a different one at 4 years. In order to standardize creatinine values, 1720 frozen serum samples at baseline and 325 at 4 years wereremeasured in a single laboratory with an isotope dilution mass spectrometry (IDMS) traceable enzymatic assay previously shown to provide very reliable eGFR compared to measured GFR. [START_REF] Moranne | Timing of onset of CKD-related metabolic complications[END_REF] We then developed equations relating the Jaffe and IDMS traceable creatinine and standardized all baseline (1) and follow-up [START_REF] Stenvinkel | Chronic kidney disease: a public health priority and harbinger of premature cardiovascular disease[END_REF] values as follows: (1)S crIDMS = 0.86 x S crJaffe + 4.40; (2) S crIDMS = 0.87 x S crJaffe + 7.85.

We calculated eGFR in mL/min/1.73 m 2 with both the MDRD and the CKD-EPI equations without correction for ethnicity (which was unavailable). [START_REF] Levey | A new equation to estimate glomerular filtration rate[END_REF][START_REF] Levey | Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate[END_REF] At the 4-year follow-up, blood and urine were collected in 1298 participants and analyzed for haemoglobin (Hb), urinary protein:creatinine ratio (PCR), and albumin:creatinine ratio (ACR) when proteinuria was < 300 mg/L. Dipstick haematuria and leukocyturia were recorded. Anaemia was defined as Hb< 11 g/dL. [START_REF]KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target[END_REF] Clinical proteinuria was defined as a PCR> 50 mg/mmol and microalbuminuria as an ACR of 3-30 mg/mmol. These data were missing for 40 participants.

In the sub-sample, we used the UK National Institute for Health and Clinical Excellence (NICE) [START_REF] Crowe | Early identification and management of chronic kidney disease: summary of NICE guidance[END_REF] and 2009 KDIGO Controversies Conference [START_REF] Levey | The definition, classification and prognosis of chronic kidney disease: a KDIGO Controversies Conference report[END_REF] recommended modifications to define CKD stages and the mean of baseline and 4-year eGFR values to classify individuals. CKD stage 1-2 was defined as a mean eGFR ≥ 60 mL/min/1.73 m 2 with ACR≥ 3 mg/mmolor clinical proteinuria; stage 3A, as an eGFR of 45-59, and 3B or higher, as eGFR< 45.

Mortality

Six-year mortality was assessed by active follow-up of all participants. It remained unknown for only 8 participants. Causes of deathwereascertained by an adjudication committeeusing all availablemedical data fromhospitals, familyphysicians or specialists, and proxy interviews as

reportedearlier[Ref]

Statistical analysis

We compared baseline characteristics between the participants with and without (n=589)creatinine values, with and without the 4-year follow-up, and with and without CKD risk factors -obesity, BP ≥ 160/100, diabetes, history of cardiovascular disease -or selfreportedkidney disease. Subjects without creatinine values were older than those with (76.6 versus 74.2 years), had significantly more cardiovascular diseases, but did not differ for other CKD risk factors after adjustment for age (data not shown). We calculated mean, median,interquartile range, and 5 th percentile for both MDRD and CKD-EPI eGFR, by sex and 5-year age group, in all participants, and in those with and without CKD or risk factors.

Distribution by eGFR stratum was compared between the two equations. We also provided these values for serum creatinine. Adjusted all-cause and cardiovascular mortality hazard ratios (HR) associated with MDRD-and CKD-EPI-eGFR per 15 mL/min/1.73 m 2 stratum were then estimated in the overall population and by sex with Cox models and eGFR of 75 to 89 as the reference category. The 8 participants who were lost to follow-up were excluded.

Proportional hazard assumption was checked by examining Cox model residuals. An annual eGFR slope in mL/min/1.73 m 2 /year was calculated for each participant as the difference between baseline and 4-year values divided by exact follow-up time. We used a general linear model to estimate adjusted eGFR slopes (SAS GLM procedure, lsmeans statement with obsmargins option) and 95% confidence intervals, by sex, age, hypertension and diabetes status, and mean eGFRvalues. The percentages of participants with eGFR decline rate >4ml/min/1.73m 2 are alsoshownaccording to thesefactors. [Ref 3]Finally, we studied the prevalence of each kidney markers according to meanMDRD-eGFR at 4 years. We also evaluated the prevalence of CKD stages at 4 yrs by sex and diabetes status, as well as the distribution of at least one clinical marker (among microalbuminuria associated with diabetes, clinical proteinuria, resistant hypertension or anemia), isolated microalbuminuria, and low eGFR alone, by CKD stage. Statistical analyses were performed with SAS 9.2 (SAS Institute, Cary, NC) and R 2.8.1 (R Development Core Team, 2009).

Results

Baseline characteristics

More than 80% of the participants had at least one CKD risk factor, but fewer than 1% reported kidney disease (Table 1). They were older, more often men, and had lower eGFR with either equation than their counterparts without CKD risk factors or kidney disease (all pvalues <0.0001). Baseline eGFRs and BMI were higher in participants with than without the 4-year follow-up (p<0.001); they were also more often women and had less stage 2 hypertension (p<0.05), but other characteristics were similar.

Age-and sex-specific serum creatinine and eGFR values

MDRD eGFRs ranged from 17 to 176 mL/min/1.73 m 2 and CKD-EPI eGFRs from 16 to 109, for serum creatinine values from 32 to 322 µmol/L (Table 2 and Supp Table ). Gradient for age was steeper with the CKD-EPI than the MDRD equation. Mean eGFR was higher in men than women using either equation, but differences between sexes were attenuated with the CKD-EPI equation. All eGFR values were lower in participants with than without CKD risk factors. The CKD-EPI equation reclassified 117 participants (9.8%) with MDRD eGFR< 60 mL/min/1.73 m 2 upward to an eGFR ≥ 60 and 49 (<1%) with MDRD eGFR ≥60 downward to an eGFR<60; 49.3% of those with MDRD eGFR ≥ 90 were reclassified downward(Table 3).

Hazard ratios for 6-year mortality related to baseline eGFR

After adjustment for several confounders, only those with an eGFR<45 mL/min/1.73m 2 had significantly higher all-cause mortality than those with an eGFR of 75 to 89, in both men and women and with either equation. (Table 3) Cardiovascular mortality significantly exceeded that of the reference group foreGFRs<60 mL/min/1.73 m 2 in the overall population, but for each sex taken separately, it significantly exceeded only for eGFR<45 mL/min/1.73 m 2 .

Estimated GFR decline according to participant baseline characteristics and mean eGFR

In the 1298 participants with a 4-year follow-up, the MDRD eGFR decreased in nearly four out of ten by > 2 mL/min/1.73 m 2 /yr, one out of six by > 4, and in 10% by > 5 mL/min/1.73 m 2 /yr. The adjusted mean annual decline was significantly steeper in men than women and in those with than without diabetes at baseline, but was not related to age and individual mean MDRD eGFR. There was a nonsignificant trend towards steeper decline with increasing blood pressure in those with hypertension. Mean CKD-EPI eGFR decline was 1.53±2.35 mL/min/1.73 m 2 /yr, and was similarly related with studied factors (data not shown).

Prevalence of kidney damage markers according to mean MDRD eGFR level

In the sub sample, as MDRD eGFR decreased from ≥75 to <45 mL/min/1.73 m 2 , the prevalence of microalbuminuria increased from 7.4% to 25.6%, that of microalbuminuria associated with diabetes from 2.8% to 9.8%, clinical proteinuria from 0.6% to 14.0%, resistant hypertension from 3.3% to 15.7%, and of anaemia from 1.5% to 7.5% (Figure 2). Haematuria without leukocyturia did not increase with decreasing MDRD eGFR.

Prevalence of CKD stages and percentage of kidney damage markers by stage

In the sub sample,the prevalence of CKD using MDRD eGFR was 27.9%; it was 7.0% for stages 1-2, 16.7% for 3A, and 4.2% for 3B or higher. (Figure 3) More men than women had CKD stages 1-2, but more women than men had stage 3. Nearly half of both men and women at stages 1-2 had at least one clinically relevant marker and the other half microalbuminuria alone. In men and women with stage 3A, 30% and 16% had markers of kidney damage, and with stage 3B or higher, 64% and 31%, respectively. The prevalence of CKD stages 1-2 was three times higher in those with than without diabetes, 15.7% vs 5.7%;it was closer for other stages: 15.1 vs 16.9% for stage 3A, and 5.7% vs 3.9% for stage 3B or higher. Using CKD-EPI, the overall prevalence was also 27.9%; it was 7.2% for stages 1-2, 15.4% for 3A, and 5.3% for 3B or higher.

Discussion

Knowledge of the specific aspects of CKD epidemiology in the elderly is essential to implement appropriate management. The determination of eGFR distribution for old and very old people, based on IDMS traceable serum creatinine and appropriate equations, is thus an important step forward. This study showed that impaired kidney function was associated with excess mortality with very similar risk estimates using the MDRD or the CKD-EPI equations.

Moreover, more than one out of six individuals in this population had fast eGFR decline rate, > 4 mL/min/1.73 m2. The most original findings indicate that only a fraction of those with decreased eGFR have markers of kidney damage and that others than proteinuria should be considered to assess its clinical significance in the elderly.

The large sample size of this population and the low number of participants lost to follow-up (8 out of 8,705 at six years) are major strengths of this study. Other strengths include the use of standardized measures of creatinine over 4 years which reduced systematic bias in the estimate of eGFR decline. This study also has limitations. First, the participation rate was low, and those who participated differedsomewhat in age and sex distribution as comparedwith the general population aged 65 years and over in the threetowns. [START_REF]Vascular factors and risk of dementia: design of the Three-City Study and baseline characteristics of the study population[END_REF]Moreover, the recruitmentprocedureled to the selection of urban participants only, whoalsohada higher socioeconomic levels than the overall French population. Although this might have led to underestimate CKD prevalence, it should not have biased the relations between eGFRlevel and the studied markers and outcomes. Second, data on ethnicity were not available to calculate eGFR. Because elderly people selected from these cities' electoral rolls are unlikely to be of African origin, this factor should have minimal impact on eGFR estimates, but our reference values are only generalizable to European or North African elderly. Third, baseline data on ACR/PCR would have been valuable to assess the independent impact on decline and mortality and to assessrisk stratification usingeGFR and ACR. Fourth, 26% of Bordeaux participants alive at 4 years declined the follow-up study. They differ slightly from those included with respect to age and sex, but were highly comparable for the other baseline data including eGFR. This may have decreased study power, particularly in the subgroup analyses,but is unlikely to have systematically biased our estimates of eGFR decline. In contrast, the 137 participants who died within 4 years are likely to be those with more rapid decline, [START_REF] Rifkin | Rapid kidney function decline and mortality risk in older adults[END_REF] and this may have underestimated the observed rate. Finally, eGFR decline rate was assessed based on only two creatinine measurements which may have reduced the accuracy of estimates, but other sources of inaccuracy were well controlled: creatinine measurements were standardized over the study period, and adjustment for individual mean eGFR should have reduced regression to the mean. [START_REF] Bland | Regression towards the mean[END_REF][START_REF] Barnett | Regression to the mean: what it is and how to deal with it[END_REF] It is well established that kidney function decreases with age, but the magnitude of normal decline, measured by a reference method, is unknown in the oldest groups. Our ageand sex-specific mean MDRD eGFR values in participants without CKD risk factors were 7-12 mL/min/1.73 m 2 higher than those provided in 869 Dutch subjects aged 65 years or older, free from kidney or cardiovascular disease, hypertension, and diabetes. [START_REF] Wetzels | Age-and gender-specific reference values of estimated GFR in Caucasians: the Nijmegen Biomedical Study[END_REF]This is likely to be due to the use of non IDMS traceable creatinine and early MDRD equation in the Dutch study, [START_REF] Wetzels | Age-and gender-specific reference values of estimated GFR in Caucasians: the Nijmegen Biomedical Study[END_REF] which underestimates true GFR at higher levels. [START_REF] Levey | A new equation to estimate glomerular filtration rate[END_REF] Another likely explanation may be a healthier profile in the 3C population. As expected, eGFR values with either equation were lower in those with than without CKD risk factors, and differences tended to widen with age and in men compared with women. In contrast with what was observed in the middle-aged population of the Atherosclerosis Risk in Communities (ARIC) study, the CKD-EPI equation reclassified upward less than 10% of the 3C participants with MDRD eGFR less than 60 mL/min/1.73 m 2 versus about 45% in ARIC participants, [START_REF] Matsushita | Risk implications of the new CKD Epidemiology Collaboration (CKD-EPI) equation compared with the MDRD Study equation for estimated GFR: the Atherosclerosis Risk in Communities (ARIC) Study[END_REF] resulting in little impact on the prevalence of CKD stage 3 or higher, 12.9 vs 13.7%. On the opposite side, while only those with MDRD eGFR> 120 mL/min/1.73 m 2 were reclassified downward with the CKD-EPI equation in the ARIC study, this was observed in nearly 50% of the 3C participants with MDRD eGFR> 90, resulting in lesser discrimination in the upper range of eGFR values. As previously noticed from the properties of the CKD-EPI equation compared with the MDRD equation, the gradient with age was steeper, and differences between men and women at each age were smaller. [START_REF] Levey | A new equation to estimate glomerular filtration rate[END_REF] Few population-based studies have investigated eGFR changes over time. [START_REF] Lindeman | Longitudinal studies on the rate of decline in renal function with age[END_REF][START_REF] Hemmelgarn | Progression of kidney dysfunction in the community-dwelling elderly[END_REF][START_REF] Rifkin | Rapid kidney function decline and mortality risk in older adults[END_REF] Our annual rates of eGFR decline, 1.46 mL/min/1.73 m 2 per year with the MDRD equation and 1.53 with CKD-EPI, compared with the 1.49 mL/min per year based on creatinine clearance in the 70-79 year-olds from The Longitudinal Aging Study, [START_REF] Lindeman | Longitudinal studies on the rate of decline in renal function with age[END_REF] but was greater than in the Cardiovascular Health Study (CHS) elderly population, 0.4 mL/min/1.73 m 2 per year. [START_REF] Rifkin | Rapid kidney function decline and mortality risk in older adults[END_REF] Differences in creatinine assays and eGFR equations between studies probably explain this discrepancy. As in another community-dwelling elderly cohort, [START_REF] Hemmelgarn | Progression of kidney dysfunction in the community-dwelling elderly[END_REF]eGFR declined faster in men than women, in those with than without diabetes, but no trend appeared as individual mean eGFR decreased. Although there was a trend toward steeper decline in those with poorer BP control, the association was nonsignificant in this population. The K/DOQI [START_REF]DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification[END_REF] defines decline rates higher than 4 mL/min/1.73 m 2 per year as "fast", as individuals with eGFR<60 mL/min/1.73 m 2 might reach end-stage kidney disease within 10 years. This was found in 17% of the 3C participants. In contrast, the UK NICE defines progression as a decline >5 mL/min/1.73 m 2 within one year or >10 mL/min/1.73 m 2 within 5 years. [START_REF] Crowe | Early identification and management of chronic kidney disease: summary of NICE guidance[END_REF] More than a third of 3C participants had an annual decline >2 mL/min/1.73 m 2 , i.e., 10 in 5 years, but 9.9% > 5 mL/min/1.73 m 2 , which is slightly higher than the 6.8% observed in the UK East Kent population aged 70 to 80 years old. [START_REF] John | Unreferred chronic kidney disease: a longitudinal study[END_REF] Although it is well-known that mortality risk outweighs that of end-stage kidney disease, [START_REF] Eriksen | The progression of chronic kidney disease: a 10-year population-based study of the effects of gender and age[END_REF][START_REF] O'hare | Age affects outcomes in chronic kidney disease[END_REF][START_REF] Shlipak | Rapid decline of kidney function increases cardiovascular risk in the elderly[END_REF] this percentage may more closely assess the fraction of the elderly population with significant CKD progression to be targeted for management.

Several studies have shown that the mortality risk associated with a given eGFR level is attenuated in the elderly. [START_REF] Hare | The management of older adults with a low eGFR: moving toward an individualized approach[END_REF][START_REF] Roderick | CKD and mortality risk in older people: a community-based population study in the United Kingdom[END_REF][START_REF] Raymond | Elevated relative mortality risk with mildto-moderate chronic kidney disease decreases with age[END_REF][START_REF] Matsushita | Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis[END_REF][START_REF] O'hare | Mortality risk stratification in chronic kidney disease: one size for all ages?[END_REF] In younger individuals, mortality risk exceeds that of their reference category at an eGFR of 60 mL/min/1.73 m 2 , 21 but in those older than 75, the relevant eGFR would be closer to 45 mL/min/1.73 m 2 . 23 [START_REF] Raymond | Elevated relative mortality risk with mildto-moderate chronic kidney disease decreases with age[END_REF] Our results are consistent with these studies when using the MDRD equation to estimate GFR. Using the CKD-EPI equation provided very similar hazard ratio estimates, but in women, that for cardiovascular mortality in those with an eGFR of 45 to 60 mL/min/1.73 m 2 was of borderline significance.

This study assessed the severity of kidney damage, based on current recommended criteria for specialist referral and available evidence that treatment can improve patient outcomes. [START_REF]DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification[END_REF][START_REF] Crowe | Early identification and management of chronic kidney disease: summary of NICE guidance[END_REF][START_REF]DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease[END_REF][START_REF]KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target[END_REF] As previously observed, [START_REF] Coresh | Prevalence of chronic kidney disease in the United States[END_REF]microalbuminuria was common, but was associated with diabetes in only one third of cases. Although microalbuminuria is a wellestablished risk factor of both end-stage kidney disease and death, [START_REF] Hallan | Association of kidney function and albuminuria with cardiovascular mortality in older vs younger individuals: The HUNT II Study[END_REF][START_REF] Matsushita | Association of estimated glomerular filtration rate and albuminuria with all-cause and cardiovascular mortality in general population cohorts: a collaborative meta-analysis[END_REF][START_REF] Brantsma | Cardiovascular and renal outcome in subjects with K/DOQI stage 1-3 chronic kidney disease: the importance of urinary albumin excretion[END_REF][START_REF] Hemmelgarn | Relation between kidney function, proteinuria, and adverse outcomes[END_REF] only in this latter case is it targeted by therapeutic guidelines. [START_REF]DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification[END_REF][START_REF] Crowe | Early identification and management of chronic kidney disease: summary of NICE guidance[END_REF][START_REF]KDOQI Clinical Practice Guidelines and Clinical Practice Recommendations for Diabetes and Chronic Kidney Disease[END_REF][START_REF] O'hare | Current guidelines for using angiotensin-converting enzyme inhibitors and angiotensin II-receptor antagonists in chronic kidney disease: is the evidence base relevant to older adults?[END_REF] In contrast, clinical proteinuria, a modifiable risk factor for CKD progression, [START_REF] Crowe | Early identification and management of chronic kidney disease: summary of NICE guidance[END_REF] was uncommon above an eGFR of 45 mL/min/1.73 m 2 , which is consistent with findings for older adults in the US. [START_REF] O'hare | Current guidelines for using angiotensin-converting enzyme inhibitors and angiotensin II-receptor antagonists in chronic kidney disease: is the evidence base relevant to older adults?[END_REF] Another sign of disease severity requiring specialist referral is resistant hypertension, defined by the 2004 K/DOQI as poor BP control despite the use of at least three antihypertensive drugs. [START_REF]DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease[END_REF][START_REF] Castro | CKD surveillance using laboratory data from the populationbased National Health and Nutrition Examination Survey (NHANES)[END_REF] Whereas several studies have shown a high prevalence of uncontrolled BP among those with CKD, [START_REF] Tonelli | Barriers to blood pressure control and angiotensin enzyme inhibitor use in Canadian patients with chronic renal insufficiency[END_REF][START_REF] Sarafidis | Hypertension awareness, treatment, and control in chronic kidney disease[END_REF][START_REF] Plantinga | Blood pressure control among persons without and with chronic kidney disease: US trends and risk factors 1999-2006[END_REF] that of resistant hypertension has not been specifically assessed. Here, it affected 6% of those at CKD stage 3A and 16%, at stage 3B or higher. K/DOQI defined anaemia [START_REF]KDOQI Clinical Practice Guideline and Clinical Practice Recommendations for anemia in chronic kidney disease: 2007 update of hemoglobin target[END_REF] is also an early and severe CKD complication. [START_REF] Moranne | Timing of onset of CKD-related metabolic complications[END_REF][START_REF] Ferrari | Estimation of glomerular filtration rate: does haemoglobin discriminate between ageing and true CKD?[END_REF] Though less common than resistant hypertension, anaemia may help identify elderly people with true, but poorly proteinuric CKD. Finally, disproportionately high rates of CKD stage 3 as compared with stages 1-2 were often observed in the elderly, e.g., 38% vs 10% in NHANES, 3 an odd finding which nourished the controversies about its clinical significance. [START_REF] O'hare | Current guidelines for using angiotensin-converting enzyme inhibitors and angiotensin II-receptor antagonists in chronic kidney disease: is the evidence base relevant to older adults?[END_REF] Although such disproportion was not seen in the 3C study with either equation, it is clear that kidney markers together with eGFR level provided a more relevant distribution for disease severity stages than previoulsy observed in the older population.

In conclusion, we have shown that the CKD-EPI equation may not improve categorization of elderly people with respect to CKD and long-term mortality risk compared with the MDRD equation. Only a fraction of those with impaired function, higher in men than women, have markers of kidney damagewho might deserve specialist assessment and appropriate care.This study provides evidence that markers other than proteinuriaare needed to distinguish aging kidneys from true CKD and avoid unnecessary referrals in the elderly with moderately decreased eGFR, particularly in women. [START_REF] Khwaja | A critique of the UK NICE guidance for the detection and management of individuals with chronic kidney disease[END_REF][START_REF] Eckardt | Definition and classification of CKD: the debate should be about patient prognosis--a position statement from KDOQI and KDIGO[END_REF][START_REF] James | Early recognition and prevention of chronic kidney disease[END_REF] CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate †Diabetes was either self-reported or defined as fasting glycemia ≥ 7 mmol/L or nonfastingglycemia ≥ 11 mmol/L orantidiabetic drug treatment. ‡Hypertension defined as blood pressure ≥140/90 mm Hg or antihypertensive drug treatment (stage 2 defined as blood pressure ≥ 160 /100 mm Hg with or without antihypertensive drug treatment) [START_REF] Chobanian | The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report[END_REF] Microalbuminuria defined as an albumin:creatinine ratio ≥ 3 [START_REF] Fried | Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study[END_REF] and <30 (300) mg/mmol (mg/g) and clinical proteinuria as a protein:creatinine ratio ≥ 50 mg/mmol (≥500 mg/g).

Resistant hypertension defined as a blood pressure ≥ 130/80 mmHg for those with either an eGFR<60 mL/min/1.73 m², diabetes, proteinuria ≥ 50 mg/mmol or albuminuria ≥ 30 mg/mmol, otherwise the threshold was 140/90 mmHg. Anemia defined as an hemoglobin <11 g/dL Microalbuminuria defined as an albumin:creatinine ratio ≥ 3 [START_REF] Fried | Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study[END_REF] and <30 (300) mg/mmol (mg/g); clinically relevant markers include microalbuminuria with diabetes, clinical proteinuria defined as a protein:creatinine ratio ≥ 50 mg/mmol (≥500 mg/g), anaemia defined as an hemoglobin <11 g/dL, and resistant hypertension defined as a blood pressure ≥ 130/80 mmHg for those with either an eGFR<60 mL/min/1.73 m², diabetes, proteinuria ≥ 50 mg/mmol or albuminuria ≥ 30 mg/mmol, otherwise the threshold was 140/90 mmHg.

  age, sex, city, annual income, smoking, history of cardiovascular disease, body mass index, hypertension, diabetes, hypercholesterolemia, and use of reninangiotensin system inhibitors. eGFR : glomerular filtration rate estimated with both the Modification of Diet in Renal Disease (MDRD) Study and the Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equations

Figure legends Figure 1 -Figure 2 -

 legends12 Figure legends

Figure 3 -

 3 Figure 3 -Prevalence of CKD stages and distribution of isolated low eGFR, microalbuminuria without diabetes, and at least one clinically relevant marker by CKD stage and sexMicroalbuminuria defined as an albumin:creatinine ratio ≥ 3[START_REF] Fried | Risk factors for 5-year mortality in older adults: the Cardiovascular Health Study[END_REF] and <30 (300) mg/mmol (mg/g); clinically relevant markers include microalbuminuria with diabetes, clinical proteinuria defined as a protein:creatinine ratio ≥ 50 mg/mmol (≥500 mg/g), anaemia defined as an hemoglobin <11 g/dL, and resistant hypertension defined as a blood pressure ≥ 130/80 mmHg for those with either an eGFR<60 mL/min/1.73 m², diabetes, proteinuria ≥ 50 mg/mmol or albuminuria ≥ 30 mg/mmol, otherwise the threshold was 140/90 mmHg.

Figure 3

 3 Figure 3

Table 1 . Baseline characteristics of the Three-City study participants.

 1

			CKD risk factors or known	Subsample
		Overall	kidney disease	with 4-year
	(N)	(8,705)	No (3,768)	Yes (4,937)	follow-up (1,298)
	Age in years	74.3 ± 5.5	73.3±5.2	75.1±5.7	74.3 ± 4.9
	Women	60.5	67.8	54.9	63.5
	Income (€/month)
	<760	5.3	4.7	5.7	8.2
	760-1499	28.8	27.5	29.7	35.0
	1499-2299	26.8	27.1	26.5	23.0
	>2300	33.1	34.5	32.1	28.2
	no response	6.0	6.1	6.0	5.6
	School education < 9 years	63.1	60.8	64.7	60.2
	Smoking
	No	61.2	65.6	57.8	64.8
	Yes, past	33.2	28.0	37.3	29.8
	Yes, present	5.6	6.4	4.9	5.3
	Hypercholesterolemia
	No	43.4	43.8	43.1	42.4
	Yes,≥6.2 mmol/L not treated	26.5	30.5	23.5	26.1
	Yes, treated	30.1	25.8	33.4	31.4
	Diabetes †	9.7	-	17.1	9.7
	Hypertension ‡	77.3	61.3	89.6	77.8
	Blood pressure ≥ 160/100	26.3	-	46.4	23.7
	Body mass index > 30 kg/m 2	13.2	-	23.3	17.4
	History of cardiovascular disease	29.6	-	52.1	29.0
	Known kidney disease	0.7	-	1.3	0.7
	Use of reninangiotensin system inhibitor	22.9	13.9	29.7	22.6
	Serum creatinine (micromol/L)	76.4±18.2	73.6±14.4	78.5±20.4	73.8 ± 17.3
	MDRD eGFR in mL/min/1.73m²	76.0±15.6	76.9±14.5	75.2±16.4	78.3±16.3
	≥ 90	16.7	16.9	16.6	20.7
	60-89	69.6	73.2	66.8	67.6
	30-59	13.4	9.8	16.2	11.4
	<30	0.3	0.1	0.4	0.2
	CKDEPI

eGFR in mL/min/1.73m²

		75.4±13.2	76.9±11.9	74.3±14.0	77.2±12.9
	≥ 90	10.2	11.4	9.3	12.9
	60-89	76.9	79.9	74.6	76.9
	30-59	12.6	8.6	15.6	9.9
	<30	0.3	0.1	0.5	0.4
	Values are means ± sd or percent.

Table 2 . Age-and sex-specific eGFR values in ml/min/1.73m² calculated with the MDRD and CKD-EPI equations in all participants, and by sub-group

 2

			All 3C participants		Participants without CKD risk factors* or known kidney disease		Participants with CKD risk factors* or known kidney disease
	Age	N Mean ± Std Median (Min-Max) P5 Q1-Q3	N Mean ± Std Median (Min-Max) P5 Q1-Q3	N Mean ± Std Median (Min-Max) P5 Q1-Q3
	eGFR MDRD
	All 65 -69 2277	79±15	78	(17-168) 58 69-88 1217	79±14	78	(30-168) 58 69-87 1060	79±15	78	(17-132) 57 70-89
	70 -74 2808	77±15	77	(25-176) 53 68-86 1248	78±14	77	(30-154) 56 69-86 1560	77±16	77	(25-176) 51 68-86
	75 -79 2307	74±15	73	(20-135) 51 64-84	902	75±14	74	(30-132) 53 65-84 1405	74±16	73	(20-135) 49 63-84
	80 -84 884	71±17	71	(18-130) 45 61-82	287	74±16	73	(28-120) 51 63-83	597	70±17	69	(18-130) 43 59-82
	85 -89 356	68±17	68	(18-121) 40 57-80	97	72±16	71	(37-121) 46 59-82	259	67±17	67	(18-116) 37 56-77
	≥ 90	73	65±16	66	(26-101) 40 51-76	17	69±14	69	(44-97) 44 60-78	56	64±17	63	(26-101) 39 51-75
	all 8705	76±16	75	(17-176) 51 66-85 3768	77±15	76	(28-168) 54 67-85 4937	75±16	75	(17-176) 49 65-85
	Men 65 -69 900	83±15	81	(17-137) 60 73-92	399	84±15	82	(44-137) 62 73-93	501	82±16	81	(17-130) 59 72-90
	70 -74 1170	80±16	80	(28-154) 53 70-89	416	82±15	81	(45-154) 61 71-89	754	79±16	80	(28-129) 51 69-89
	75 -79 857	76±17	75	(20-135) 50 65-87	269	77±15	77	(37-132) 55 68-86	588	75±17	74	(20-135) 48 63-87
	80 -84 339	75±18	75	(19-130) 46 62-87	90	79±17	78	(35-120) 50 68-88	249	73±18	73	(19-130) 43 60-87
	85 -89 152	70±18	69	(18-116) 41 59-81	34	74±15	72	(48-112) 51 63-82	118	69±19	68	(18-116) 35 57-81
	≥ 90	23	64±15	63	(41-101) 43 51-73	4	64±5	64	(59-69) 59 60-69	19	64±16	63	(41-101) 41 51-74
	all 3441	78±17	78	(17-154) 51 68-89 1212	81±15	80	(35-154) 57 71-90 2229	77±17	77	(17-135) 49 67-88
	Women 65 -69 1377	77±14	76	(30-168) 57 68-85	818	76±13	75	(30-168) 57 68-84	559	77±15	76	(31-132) 55 67-87
	70 -74 1638	76±14	75	(25-176) 53 67-84	832	76±14	75	(30-125) 54 67-83	806	76±15	76	(25-176) 52 67-84
	75 -79 1450	73±14	72	(26-133) 51 64-82	633	74±14	73	(30-123) 53 64-82	817	73±15	72	(26-133) 49 63-82
	80 -84 545	70±16	68	(18-122) 44 59-79	197	71±15	71	(28-117) 51 62-81	348	68±16	67	(18-122) 43 58-78
	85 -89 204	67±17	67	(27-121) 40 56-79	63	71±17	69	(37-121) 44 57-83	141	66±16	66	(27-106) 38 55-76
	≥ 90	50	66±17	68	(26-97) 39 51-78	13	71±16	72	(44-97) 44 66-78	37	64±18	64	(26-95) 39 50-76
	all 5264	74±15	74	(18-176) 51 65-83 2556	75±14	74	(28-168) 53 66-83 2708	74±16	73	(18-176) 48 64-83

Table 3 .

 3 Number of participants (%) reclassified into upper or lower eGFR categories using CKD-EPI-versus MDRD study equation.

				CKD-EPI eGFR (mL/min/1.73m²)
			<30	30 -44	45-59	60-89	>90	Total
			25	0	0	0	0	25
		<30
			(0.3)	0	0	0	0
			5	171	6	0	0	182
		30-44
			(0.1)	(2.0)	(0.1)	0	0
	MDRD eGFR (mL/min/1.73m²)	45-59	0 0	18 (0.2)	849 (9.8)	117 (1.3)	0 0	984
			0	0	49	5,914	93	6,056
		60-89
			0	0	(0.6)	(67.9)	(1.1)
			0	0	0	663	795	1,458
		>90
			0	0	0	(7.6)	(9.1)
		Total	30	189	904	6,694	888	8,705

Note: In theupper diagonal, eGFR CKD-EPI underestimates eGFR compared to MDRD study equation whereas it overestimates into the lower diagonal

Abbreviations: eGFR, estimated glomerular filtration rate with the CKD-EPI, Chronic Kidney Disease Epidemiology Collaboration and the MDRD, Modification of Diet in Renal Disease study equations

Table 4 . Adjusted hazard ratios for 6-year all-cause and cardiovascular mortality related to baselineeGFR using either the MDRD or CKD-EPI equation, overall and by sex.

 4

				eGFR in ml/min/1.73m²
		≥90	75-89	60-74	45-59	30-44	<30
	All participants
	MDRD	1458	3018	3032	982	182	25
	CKD EPI	888	4075	2612	903	189	30
	All-cause mortality
	MDRD	1.1(0.9-1.4)	1(ref)	1.0(0.8-1.2) 1.1(0.9-1.4) 2.2(1.6-3.0)	3.4(2.0-5.9)
	CKD EPI	1.2(0.9-1.6)	1(ref)	0.9(0.8-1.1) 1.1(0.9-1.3) 2.0(1.5-2.7)	3.3(2.0-5.5)
	Cardiovascular mortality
	MDRD	1.4(0.9-2.1)	1(ref)	1.0(0.7-1.4) 1.7(1.1-2.5) 3.7(2.2-6.2) 3.5(1.2-10.0)
	CKD EPI	1.5(0.9-2.6)	1(ref)	0.9(0.6-1.3) 1.6(1.1-2.3) 3.1(1.8-5.0) 4.3(1.8-10.2)
	No of men
	MDRD	773	1240	1008	337	64	14
	CKD EPI	417	1664	918	350	70	17
	All-cause mortality

Acknowledgements

We also thank Jo Ann Cahn for the English revision of this manuscript.

Transparency declarations

The authors declare that they have no competing financial interest