How Can Prognosis for Diabetic ESRD Be Improved?

Although the prognosis of patients who have diabetes and are receiving renal replacement therapy has greatly improved, survival and medical rehabilitation rates continue to be significantly worse than those of nondiabetic patients, mainly because of pre‐existing severely compromised cardiovascular conditions. In this scenario, the nephrology community had to do its best in order to offer the best treatment options to these patients using a multifaceted approach. The most common RRT modality in patients with diabetes is still hemodialysis, but it gives rise to a number of clinical problems, in particular difficulties in the management of the vascular access and high frequency of intradialytic hypotension. Recent data suggest that efficient high‐flux treatments have the potential of improving morbidity and mortality of diabetics with ESRD. Sodium profiling during the dialysis session may be also of importance in reducing intradialytic hypotension and helping in achieving the prescribed body weight. Patients who have diabetes and are on peritoneal dialysis have to face a progressive increase in peritoneal permeability, loss of ultrafiltration, and peritoneal fibrosis, all phenomena being accelerated in patients with diabetes and ultimately leading to an increased technique failure. However, the two dialytic modalities are comparable in terms of outcomes in the short term.     

Comorbidities in patients with end-stage renal disease in developing countries

Patients with end-stage renal disease (ESRD) who are on renal replacement therapy (RRT) usually have a certain number of comorbid factors. Cardiovascular diseases are the most common comorbidities and the most common causes of mortality in ESRD patients. Noncardiovascular comorbid factors including nutrition also have impact on survival of ESRD patients on RRT. There are scarce data regarding comorbidity in developing countries. Available data have shown that hypertension, diabetes, and various cardiovascular disorders are the leading comorbidities. Improvement in outcome for ESRD patients would depend on improving quality in RRT as well as a better understanding and management of comorbid conditions.     

Medical and psychosocial rehabilitation of young adults receiving renal replacement therapy since childhood: a single-centre experience

This study reviews medical and psychosocial rehabilitation of children and adolescents with end-stage renal disease (ESRD) and analyses data of young adults with ESRD from a single centre providing renal replacement therapy (RRT) for more than 20 years. Data from 30 patients, aged 25±4 (18-34) years receiving renal replacement therapy (RRT) since childhood were analysed. Medical and psychosocial rehabilitation were assessed by a medical questionnaire and by chart review. The sociological data were compared to an aged-matched control population (n=26) with long-standing diabetes mellitus type I (DM) and to the available national demographic data. Seventeen patients were treated by dialysis (D) and 13 by transplantation (TPL). The duration of RRT was 13 (1-21) years. Growth failure was pronounced in most patients, and a significant number were suffering from hypertension, left ventricular hypertrophy, anaemia, osteodystrophy, hepatitis, and phsical disabilities. Vocational training/school performance, and employment was not markedly different in patients with RRT and controls with DM. However, the type of employment was different with an overrepresentation of lower income jobs in RRT patients. Most patients with RRT were unmarried and one-third was living with their parents. These data, largely reflecting early experience of a paediatric RRT programme, indicate that young adults receiving RRT from childhood have a multitude of medical and psychosocial problems, providing a continuing challenge for centres providing RRT.     

End-stage renal failure and national resources: the Brazilian experience

Brazil is the fifth largest and the fifth most populous nation in the world. Its economy rivals Mexico as the strongest in Latin America and ranks among the 15 largest economies in the world. Despite these achievements, a substantial fraction of the Brazilian population still lives in poverty, and many still have limited access to medical assistance. There are currently about 380 patients on hemodialysis per million populations (pmp), approximately one third of the U.S. prevalence, suggesting that a large fraction of end-stage renal disease (ESRD) patients are not diagnosed and treated properly. In Brazil, access to renal replacement therapy (RRT), including renal transplantation, is universal, and the corresponding costs, including those of medications (immunosuppressors and treatment of ESRD complications), are covered by the Brazilian government. However, given the continuous growth of the ESRD population and of the costs incurred by RRT, the efficacy and reach of this system may be severely limited in years to come. In the current struggle against the ESRD epidemics, the Brazilian medical community and health authorities face a triple challenge: to limit the incidence of renal disease, slow or detain the progression of established chronic nephropathies, and ensure that access to quality RRT remains granted to all those who, despite all efforts, reach ESRD.     

End-Stage Renal Failure and National Resources: The Brazilian Experience

Brazil is the fifth largest and the fifth most populous nation in the world. Its economy rivals Mexico as the strongest in Latin America and ranks among the 15 largest economies in the world. Despite these achievements, a substantial fraction of the Brazilian population still lives in poverty, and many still have limited access to medical assistance. There are currently about 380 patients on hemodialysis per million populations (pmp), approximately one third of the U.S. prevalence, suggesting that a large fraction of end-stage renal disease (ESRD) patients are not diagnosed and treated properly. In Brazil, access to renal replacement therapy (RRT), including renal transplantation, is universal, and the corresponding costs, including those of medications (immunosuppressors and treatment of ESRD complications), are covered by the Brazilian government. However, given the continuous growth of the ESRD population and of the costs incurred by RRT, the efficacy and reach of this system may be severely limited in years to come. In the current struggle against the ESRD epidemics, the Brazilian medical community and health authorities face a triple challenge: to limit the incidence of renal disease, slow or detain the progression of established chronic nephropathies, and ensure that access to quality RRT remains granted to all those who, despite all efforts, reach ESRD.     

Parathyroidectomy in patients on renal replacement therapy: an epidemiologic study

Secondary hyperparathyroidism is a frequent complication of long-term dialysis treatment, and despite recent advances in medical therapy, surgical parathyroidectomy (PTx) is necessary in a considerable number of uremic patients. A prevalence of PTx of 22% was reported in Europe in 1988 in patients on dialysis from 10 to 15 yr, but no large-scale epidemiologic study has been published since then. The aim of the study was to evaluate the prevalence, incidence, and risk factors for PTx in patients on renal replacement therapy (RRT) in Lombardy and to determine whether the incidence has changed over time. The study involved 14,180 patients included in the Lombardy Registry of Dialysis and Transplantation who received RRT for end-stage renal disease (ESRD) between 1983 and 1996. Cox-proportional hazards regression models were used to evaluate the risk factors of PTx, the explanatory covariates being age on admission to RRT, gender, underlying renal disease (nondiabetic or diabetic nephropathy), and dialysis modality (peritoneal dialysis or hemodialysis). The prevalence of PTx in the 7371 ERSD patients who were alive on December 31, 1996, was 5.5% and increased with the duration of RRT (9.2% after 10 to 15 yr, 20.8% after 16 to 20 yr). Similarly, the incidence of PTx increased from 3.3 per 1000 patient-years in patients who had been on RRT for <5 yr to 30 per 1000 patient-years in those receiving RRT for >10 yr. The Cox regression models showed that the relative risk for PTx was significantly higher in women and lower in elderly and diabetic patients. The relative risk for PTx (adjusted for gender, age, and nephropathy) was higher in the patients on peritoneal dialysis than in those on hemodialysis and decreased after transplantation. During the course of a follow-up of 7 yr, the incidence of PTx in patients who started RRT between 1990 and 1992 was no different from that observed in patients who started RRT between 1983 and 1985. In conclusion, the prevalence and incidence of PTx in patients receiving RRT in Lombardy is lower than that in Europe and Italy as a whole, as reported by the 1988 European Dialysis and Transplantation Association Registry; its frequency has not changed significantly during the past few years. The need for PTx decreases markedly after successful transplantation. The epidemiologic finding that the rate of PTx is greater in women, young patients, and individuals who do not have diabetes suggests the need for a more aggressive medical treatment of secondary hyperparathyroidism particularly in such patients.     

Surgical Interventions for Renal Replacement Therapy from the View of Nephrologists

Summary BACKGROUND: The number of patients with end-stage renal disease (ESRD) is increasing worldwide at a rate of approximately 5 % per year. In Austria, 6049 patients were suffering from ESRD in the year 2001, an annual rate of 1093 patients. Higher age of patients and co-morbidities are forcing nephrologists to find the optimal renal replacement therapy (RRT) and access modality for the individual patient. METHODS: For patients with ESRD needing RRT, both nephrologist and surgeon should be consulted to ensure optimal management and treatment including vascular access surgery. Patients planned for peritoneal dialysis (PD) are treated with the cooperation of a visceral surgeon. A catheter is inserted into the pelvic area to enable solution exchange. In patients who are to undergo hemodialysis (HD), nephrologists have to decide whether the cardiac condition is suitable for surgical access creation such as fistula or graft. Otherwise alternative hemodialysis devices such as a central venous catheter (CVC), or subcutaneously implantable ports (Dialock^®), have to be discussed. Access function is routinely monitored during dialysis treatment, but still remains the weak component of extracorporeal RRT responsible for 40 % of hospitalization of HD patients. RESULTS: At the dialysis unit of the University Hospital of Graz, 107 patients were under RRT (70 HD and 37 PD), and 235 patients were hemodialyzed in private units in Graz in 2001. 81 ESRD patients were newly enrolled in the chronic HD program. 131 HD accesses were created in new HD patients and patients under treatment for chronic HD. 36 patients developed HD access complications and in these patients, 181 surgical and/or radiological interventions were performed. CONCLUSIONS: In 12 % of the HD patients in Graz, access problems occurred. These patients have a high frequency of surgical and radiological interventions. Access monitoring and measurement of recirculation may help to reduce the complication rate by 38 %. Before onset of RRT, patients need special management to ensure the best dialysis modality. ESRD patients who are suffering from cardiac diseases, diabetes mellitus, or bad peripheral vascular status need a multidisciplinary approach with nephrologists, cardiologists, surgeons and radiologists working together to find the optimal access for dialysis treatment.     

The impact of severe acute kidney injury requiring renal replacement therapy on survival and renal function of heart transplant recipients – a UK cohort study

Severe acute kidney injury (AKI), defined as requiring renal replacement therapy (RRT), is associated with higher mortality postheart transplantation, but its long-term renal consequences are not known. Anonymized data of 3365 patients, who underwent heart transplantation between 1995 and 2017, were retrieved from the UK Transplant Registry. Multivariable binary logistic regression was performed to identify risk factors for severe AKI requiring RRT, Kaplan–Meier analysis to compare survival and renal function deterioration of the RRT and non-RRT groups, and multivariable Cox regression model to identify predicting factors of mortality and end-stage renal disease (ESRD). 26.0% of heart recipients received RRT post-transplant. The RRT group has lower survival rates at all time points, especially in the immediate post-transplant period. However, conditional on 3 months survival, older age, diabetes and coronary heart disease, but not post-transplant RRT, were the risk factors for long-term survival. The predicting factors for ESRD were insulin-dependent diabetes, renal function at transplantation, eGFR decline in the first 3 months post-transplant, post-transplant severe AKI and transplantation era. Severe AKI requiring RRT post-transplant is associated with worse short-term survival, but has no impact on long-term mortality. It also accelerates recipients’ renal function deterioration in the long term.     

Accelerated lean body mass loss in incident chronic dialysis patients with diabetes mellitus

BACKGROUND: End-stage renal disease (ESRD) patients display a higher incidence of poor nutritional status and are at high risk of hospitalization and death. Patients on renal replacement therapy (RRT) with a primary diagnosis of diabetes mellitus have the lowest survival rates along with highest hospitalization incidence. METHODS: In this study, we examined the importance of diabetes mellitus along with certain demographic and clinical variables in predicting the change in lean body mass (LBM) by dual-energy x-ray absorptiometry (DEXA), as a surrogate marker of somatic protein stores, in 142 incident ESRD patients (91 males, 52.8 +/- 1.0 years, 74.2 +/- 1.2 kg body weight) among which 34 had diabetes mellitus (19 insulin-dependent and 15 noninsulin dependent). RESULTS: Our results show that patients with diabetes mellitus had significantly accelerated loss of LBM compared to nondiabetic patients during the first year of RRT (3.4 +/- 0.6 kg vs. 1.1 +/- 0.2 kg) (P < 0.05). Multivariate linear regression analyses revealed that the presence of diabetes mellitus was the strongest predictor of LBM loss independently of several clinically-relevant variables such as age, gender, serum albumin, presence of malnutrition, presence of inflammation, and RRT modality. CONCLUSION: We conclude that the presence of diabetes mellitus is the most significant independent predictor of LBM loss in renal replacement therapy patients, providing a potential explanation as to why ESRD patients with diabetes mellitus are more prone to muscle wasting.     

The epidemiology of end-stage renal disease in Iran in an international perspective.

INTRODUCTION: The epidemiology of end-stage renal disease (ESRD) and renal replacement therapy (RRT) is under continuous evolution all over the world. We report here the epidemiological analysis of ESRD and RRT in Iran and discuss it against the background of the international situation. METHODS: This epidemiological report is based on data from centre questionnaires which were collected in Iran from 1997 onwards, with a response rate of 100%. RESULTS: The prevalence/incidence of RRT patients were 238/49.9 p.m.p. in the year 2000. Haemodialysis and kidney transplantation were the most common RRT modalities, accounting for 53.7% and 45.5% of prevalent RRT patients, respectively. The proportion treated by peritoneal dialysis was very low (<1%). Home haemodialysis was not performed. The majority of haemodialysis centres used synthetic membranes (70%) and 100% of the sessions were performed using acetate as a buffer; 42.5% of haemodialysis patients were treated with a twice-weekly regimen, whilst 49.6% were on the standard thrice-weekly regimen. The majority of RRT patients in Iran were young to middle aged. The great majority of renal allografts came from living donors (mainly unrelated to recipients). The main renal diseases leading to ESRD were diabetes and hypertension. The third most common category was "cause unknown". CONCLUSION: The epidemiology of RRT in Iran is characterized by: (i) young patient age (younger than the international average); (ii) high proportion of patients receiving renal allograft; (iii) use of living-unrelated donors as the major source of renal allografts.     

Association between attributed cause of end-stage renal disease and risk of death in Brazilian patients receiving renal replacement therapy

BACKGROUND: Studies conducted in several countries have indicated that the survival of patients undergoing renal replacement therapy (RRT) depends on the attributed cause of end-stage renal disease (ESRD). OBJECTIVES: This study was conducted to evaluate the association between attributed cause of ESRD and mortality risk in RRT patients in Brazil. METHODS: We analyzed 88,881 patients from the Brazilian Ministry of Health Registry who were undergoing RRT between April 1997 and July 2000. Cox proportional hazards models were used to estimate the relative risk (RR) of death in patients with ESRD secondary to diabetes mellitus (DM), polycystic kidney disease (PKD), and primary glomerulopathies (GN) compared with a reference group comprised of patients with ESRD caused by hypertensive nephropathy. Patient's age, gender, and length of time (years) in RRT before inclusion in the registry (vintage) were included in the adjusted Cox model. RESULTS: Compared with the reference group, the mortality risk was 27% lower in patients with PKD (RR=0.73, 95% CI: 0.65-0.83, p<0.0001); 29% lower in patients with GN (RR=0.71, 95% CI: 0.68-0.74, p<0.0001); and 100% greater in DM patients (RR=2.00, 95% CI: 1.92-2.10, p<0.0001). These relative risks remained statistically significant after adjustment for age, gender, and length of time in RRT before inclusion in the registry. CONCLUSIONS: Our data indicate that compared with the patients with hypertensive nephrosclerosis as attributed cause of ESRD, patients undergoing RRT in Brazil with idiopathic glomerulopathy and polycystic kidney disease have a lower risk of mortality, and patients with diabetes mellitus have a greater risk of mortality.     

The epidemiology of end-stage renal disease in the Baltic countries: an evolving picture.

INTRODUCTION: The epidemiology of end-stage renal disease (ESRD) and renal replacement therapy (RRT) is under continuous evolution all over the world. Of particular interest is the development of RRT in the countries of the former Soviet bloc which underwent great political and socio-economical changes in the last decade. We report here the epidemiological analysis of ESRD and RRT in the three Baltic countries: Lithuania, Estonia, Latvia. Subjects and methods. This epidemiological report is based on data from centre questionnaires which were collected from 1996 onwards, with a response rate of 98-99%. RESULTS: The prevalence/incidence of RRT patients in 1999 were 213/99.5 p.m.p. in Lithuania, 186/45.5 p.m.p. in Estonia and 172/55.8 p.m.p. in Latvia. Haemodialysis (HD) was the most common RRT modality in Lithuania (60% of prevalent patients), but not in Estonia (29%), while in Latvia it was nearly as common as renal transplantation (45 and 46%, respectively). Home HD was not performed. The proportion treated by peritoneal dialysis (PD) was very low in Lithuania (4% of RRT patients), while the percentage was higher in Latvia (9%) and Estonia (20.4%). The percentage of patients on RRT treated by renal transplantation was high throughout, representing the main modality of treatment in Estonia (50.5% of RRT prevalent patients, 94 p.m.p.) and in Latvia (46%, 79 p.m.p.) and being high in Lithuania (36%, 77 p.m.p.). The main renal diseases leading to ESRD were glomerulonephritis, pyelonephritis and diabetes. CONCLUSION: The epidemiology of RRT in the Baltic countries is undergoing rapid changes. Transplantation has reached an impressive level. A high percentage of RRT patients live with a functioning graft.     

Can we improve early mortality in patients receiving renal replacement therapy?

BACKGROUND: Approximately one in eight patients with end-stage renal disease (ESRD) die within the first three months of starting renal replacement therapy (RRT). We investigated which factors might improve this early mortality. METHODS: We performed a prospective nationwide study of all patients commencing RRT for ESRD in Scotland over one year. Patients were classified according to how they presented to start RRT, their burden of comorbid diseases, access prepared for dialysis, and duration of care by a nephrologist prior to commencing RRT. Those factors most strongly associated with death within 90 days of commencing treatment were determined by logistic regression analysis. RESULTS: Patients with an acute unexpected element to their presentation for RRT had early mortality rates between 6.0 and 8.9 times greater than those who commenced RRT electively after a period of care from a nephrologist. Patients in high and medium comorbidity risk groups had early mortality rates of 4.7 and 2.2 times greater than those in the low-risk group. Low serum albumin had a significant association with early death. Patients who progressed steadily to ESRD, who had a planned start to dialysis, and who had mature access were 3.6 times more likely to survive beyond three months than those with no access; they were, however, also younger with less comorbidity. CONCLUSIONS: The factors principally associated with early mortality are nonelective presentation for RRT, comorbid illness, and low serum albumin. Patients cared for by a nephrologist before requiring RRT who have mature access have better short-term survival than those without access. They are also younger with less comorbidity. It may be possible to improve short-term survival in this "unplanned" group if referred early to facilitate reducing cardiovascular risk factors and preparation for RRT.     

Survival and transplantation outcomes of children less than 2 years of age with end-stage renal disease

Background

Young children with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) have traditionally experienced high rates of morbidity and mortality; however, detailed long-term follow-up data is limited.

Methods

Using a population-based retrospective cohort with data from a national organ failure registry and administrative data from Canada’s universal health care system, we analysed the outcomes of 87 children starting RRT (before age 2 years) and followed them until death or date of last contact [median follow-up 4.7 years, interquartile range (IQR) 1.4–9.8). We assessed secular trends in survival and the influence of: (1) age at start of RRT and (2) etiology of ESRD with survival and time to transplantation.

Results

Patients were mostly male (69.0 %) with ESRD predominantly due to renal malformations (54.0 %). Peritoneal dialysis was the most common initial RRT (83.9 %). Fifty-seven (65.5 %) children received a renal transplant (median age at first transplant: 2.7 years, IQR 2.0–3.3). During 490 patient-years of follow-up, there were 23 (26.4 %) deaths, of which 22 occurred in patients who had not received a transplant. Mortality was greater for patients commencing dialysis between 1992 and 1999 and among the youngest children starting RRT (0–3 months). Children with ESRD secondary to renal malformations had better survival than those with ESRD due to other causes. Among the transplanted patients, all but one survived to the end of the observation period.

Conclusion

Children who start RRT before 3 months of age have a high risk of mortality. Among our paediatric patient cohort, mortality rates were much lower among children who had received a renal transplant.     

Nephrology: main advances in the last 40 years

Modern nephrology has become one of the liveliest and most productive branches of medicine. Once seen as a temporary means of rescue from uremic coma, hemodialysis (HD) has allowed thousands of people with irreversible uremia to survive for many years, and evolving treatment modalities have led to a significant increase in efficacy and tolerability. At the same time, two other forms of renal replacement therapy (RRT) have been developed: peritoneal dialysis (PD) and renal transplantation. The number of end-stage renal disease (ESRD) patients requiring RRT has increased dramatically throughout the world for a number of reasons: the improved survival of patients affected by other diseases, a real increase in the incidence of chronic kidney disease (CKD) mainly due to the burden of 'metabolic syndrome', and the significant broadening of RRT acceptance criteria. This last factor means that RRT has become available to increasing numbers of elderly patients, diabetics and patients with other severe comorbidities, among whom the leading cause of death is cardiovascular disease (CVD). However, nephrology is not just a case of substituting the function of failing kidneys; it also covers the treatment of glomerular diseases, slowing down CKD progression and managing the related comorbidities, all of which have substantially improved over the last 40 yrs.     

Assisted peritoneal dialysis as a method of choice for elderly with end-stage renal disease

In the last two decades, most developed countries have seen a continuous growth in the number of elderly patients with end-stage renal disease commencing renal replacement therapy. Despite the many advantages that peritoneal dialysis (PD) offers to elderly patients with ESRD, it is still underutilized in older patients. Older patients are much more vulnerable to the problems associated with aging, which may affect their level of independence and their long-term prognosis. Those patients have physiological changes related to aging and common health problems such as anxiety, depression, dementia, visual impairment, and cognitive impairment, all of which interfere with self-performing PD. Assistance with home-care nurses and assistance by a family member may overcome this problem. Some old but also more recent literature data justifies the idea that assisted PD may significantly contribute to increase the overall number of elderly patients who can be treated with PD at home. With assisted PD, free choice can be offered to patients with high comorbidity index who cannot perform their peritoneal exchanges by themselves. Automated peritoneal dialysis is the ideal treatment modality for elderly patients with end-stage renal disease who require assistance since this limits home-care nurse visits to only two a day. As expected, the elderly have a higher mortality rate than younger patients treated by assisted PD, but technique failure rate, overall peritonitis rate, and most quality-of-life (QoL) measures are comparable with those of younger patients. Peritoneal dialysis in nursing homes offers treatment for elderly patients without family support. In this regard, automated PD or nightly PD keeps the patient’s daytime free for nursing home activities, increases socialization, and enables better rehabilitation that improves their QoL. Although withdrawal from dialysis is more frequent among nursing-home dialysis patients, this high discontinuation rate is not due to dialysis per se but rather to associated social and medical circumstances. Better communication between nursing staff and renal team is crucial for improving staff confidence and will contribute to higher utilization of PD in nursing homes.     

Renal Replacement Therapy in Patients With HIV Infection in a European Region: Outcomes Following Renal Transplantation

Introduction

The prognosis of HIV infection has improved dramatically in patients with end-stage renal disease (ESRD). Thus, HIV infection is no longer an absolute contraindication for renal transplantation.

Methods

A cross-sectional study was performed to analyze the characteristics of HIV patients receiving renal replacement therapy (RRT) in September 2011, using data from the Registry of Renal Patients in Andalusia. A retrospective cohort study was also carried out, analyzing patients receiving kidney transplants in the era of highly active antiretroviral therapy.

Results

In Andalusia in September 2011, 8744 patients were on RRT; of these, 48 had HIV infection (prevalence 0.54%). The RRT modality was very different between HIV-negative and HIV-positive patients: renal transplantation 49.2% and 16.7%, hemodialysis 46.8% and 81.3%, and peritoneal dialysis 4% and 2%, respectively. The most frequent ESRD etiology was glomerulonephritis (37.5%). Twenty-seven (56.3%) had hepatitis C coinfection. Only three patients (7.5%) were on the waiting list for renal transplantation. From 2001 to September 2011, 10 HIV-infected patients received a renal transplantation (median follow-up 40.5 months). The initial immunosuppressive treatment included tacrolimus and mycophenolate without induction therapy. Only two patients presented acute rejection, both borderline and corticosensitive. All remain alive and the graft survival was 100% in the first and third years posttransplant. We compared demographic and comorbidity variables between patients transplanted or included on the waiting list (n = 12) and patients excluded and never transplanted (n = 36). We found differences only in the ESRD etiology (higher incidence of glomerulonephritis in excluded patients).

Conclusions

Renal transplantation is safe in correctly selected HIV-infected patients. The number of patients on the waiting list is very small. This may reflect the high comorbidity but it is also possible that these patients are still not being assessed systematically for transplant in all centers.     

Outcome of renal replacement therapy in the very elderly.

BACKGROUND: In a retrospective case-note and computer database analysis we assessed the outcome of very elderly patients (> or = 75 years old) with end-stage renal disease (ESRD) on renal replacement therapy (RRT). METHODS: Fifty-eight individuals aged 75 or over (group 1) commenced RRT between 1 January 1991 and 31 December 1995. Comparisons were made with other patients commencing RRT who were divided into two groups: group 2 (201 individuals 65-74 years old) and group 3 (379 patients <65 years old). All subjects were followed up until the point of assessment (30 June 1998), the time of death, or withdrawal from dialysis. Survival rates in the three groups were compared using Kaplan-Meier method. The number of hospital admissions, length of in-patient stay, and complications rate on RRT were assessed for group 1. RESULTS: One-year survival rates in groups 1, 2 and 3 were 53.5, 72.6, and 90.6% respectively and the 5-year survival rates were 2.4, 18.8, and 61.4% respectively. The very elderly spent 20% of their time in hospital, 46% had two co-morbid factors at the outset, and 26% developed multiple complications while on RRT. Withdrawal from dialysis remained the most common cause of death in this group of individuals (38%), followed by cardiovascular causes (24%) and infections (22%). CONCLUSION: Very elderly ESRD patients on RRT have a very poor outcome and, since they are the largest growing group of RRT patients, this has important implications for future health policies.     

Association Between Attributed Cause of End-Stage Renal Disease and Risk of Death in Brazilian Patients Receiving Renal Replacement Therapy

Background. Studies conducted in several countries have indicated that the survival of patients undergoing renal replacement therapy (RRT) depends on the attributed cause of end-stage renal disease (ESRD). Objectives. This study was conducted to evaluate the association between attributed cause of ESRD and mortality risk in RRT patients in Brazil. Methods. We analyzed 88,881 patients from the Brazilian Ministry of Health Registry who were undergoing RRT between April 1997 and July 2000. Cox proportional hazards models were used to estimate the relative risk (RR) of death in patients with ESRD secondary to diabetes mellitus (DM), polycystic kidney disease (PKD), and primary glomerulopathies (GN) compared with a reference group comprised of patients with ESRD caused by hypertensive nephropathy. Patient's age, gender, and length of time (years) in RRT before inclusion in the registry (vintage) were included in the adjusted Cox model. Results. Compared with the reference group, the mortality risk was 27% lower in patients with PKD (RR = 0.73, 95% CI: 0.65–0.83, p< 0.0001); 29% lower in patients with GN (RR = 0.71, 95% CI: 0.68–0.74, p< 0.0001); and 100% greater in DM patients (RR = 2.00, 95% CI: 1.92–2.10, p< 0.0001). These relative risks remained statistically significant after adjustment for age, gender, and length of time in RRT before inclusion in the registry. Conclusions. Our data indicate that compared with the patients with hypertensive nephrosclerosis as attributed cause of ESRD, patients undergoing RRT in Brazil with idiopathic glomerulopathy and polycystic kidney disease have a lower risk of mortality, and patients with diabetes mellitus have a greater risk of mortality.     

Pediatric dialysis and renal transplantation in Kuwait over the past 11 years

Data on end-stage renal disease (ESRD) patients and their renal replacement therapy (RRT) were collected retrospectively from the three dialysis centers, the pediatric urology unit, and the organ transplant center of Kuwait. The study period was from 1 January 1986 to 31 December 1996. A total of 61 children, 50 of whom were Kuwaiti nationals, required RRT for ESRD during those 11 years. This gave an average annual incidence rate of 18 per million Kuwaiti children. Glomerulonephritis was the most-frequent underlying disease and accounted for 44% of total cases, while pyelonephritis (including urinary tract anomalies and dysplastic kidneys) was responsible for 30%. Multisystem disease was responsible for ESRD in 7 patients (14%), 2 of whom had lupus nephritis, 2 vasculitis, 2 Henoch-Schönlein purpura, and 1 hemolytic uremic syndrome. Continuous ambulatory peritoneal dialysis and home intermittent peritoneal dialysis, using cycler machines, were not favored dialysis techniques by most parents, especially for those <6 years old. The actuarial survival on dialysis was 75%±7% at 12 months. Of the 8 patients who died, 7 were <6 years old. Thirty-eight patients received 46 kidney transplants, 13 of which were performed on a pre-emptive basis. The actuarial patient survivals at 12 months for those receiving first live and cadaveric kidney transplants were 90%±5% and 85%±2%, respectively, while those for grafts were 76%±8% and 66%±2%, respectively. This is the first nationwide long-term study of the incidence and etiology of pediatric ESRD in our area and the RRT in a country with adequate treatment facilities.