Current incidence, treatment patterns and outcome of end-stage renal disease among indigenous groups in Australia and New Zealand

SUMMARY: The changes in rates of treated end-stage renal disease (ESRD) among indigenous populations have profound consequences for those individuals affected and for health-care providers. By using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, we examined the current incidence, treatment and outcomes of ESRD among indigenous groups in Australia and New Zealand. All patients who began renal replacement therapy (RRT) in Australia or New Zealand between October 1991 and September 2000 were included. Rates of ESRD, RRT modalities, renal transplantation and mortality were the outcomes examined. End-stage renal disease rates among indigenous groups in Australia and New Zealand exceeded non-indigenous rates up to eightfold. The median age of indigenous ESRD patients was younger (51 vs 60 years, P  < 0.0001), and there was an excess of comorbidities, particularly diabetes. For Australian Aboriginal and Torres Strait Islanders, and New Zealand Maori patients, mortality rates across all modalities of RRT were 70% higher than non-indigenous rates. Indigenous people were less likely to receive a renal transplant prior to dialysis treatment, less likely to be accepted onto the cadaveric transplant waiting list, and less likely to receive a well-matched transplant. The poorer outcomes among Australian Aboriginal and Torres Strait Islanders, and New Zealand Maori patients did not appear to be explained by the different comorbid conditions or age. Whether the outcomes reflect unmeasured differences in disease burden or treatment differences is not known. Tackling this problem will involve a spectrum of people and approaches, from tertiary care providers and RRT to local staff and preventative programs.     

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.     

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.     

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.     

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.     

End-stage renal disease in Scotland: outcomes and standards of care

BACKGROUND: The number of patients starting renal replacement therapy (RRT) for end-stage renal disease (ESRD) in the United Kingdom rises annually. Patients are increasingly elderly with a greater prevalence of comorbid illness. Unadjusted survival, from the time of starting RRT, is not improving. The United Kingdom Renal Association has published recommended standards of treatment, which all United Kingdom nephrologists strive to attain. This study was devised to define the impact of attaining recommended treatment standards, adjusting for patient age and comorbid illnesses, upon survival on RRT in the United Kingdom population. METHODS: A prospective, registry based, observational study of all patients starting RRT in Scotland over a 1-year period, followed for the first 2 years of RRT. RESULTS: Of the 523 patients who were studied, 217 (41.5%) had died by 2 years of follow-up, 32% excluding deaths within the first 90 days. Age, comorbidity, weight when starting RRT, and attaining the recommended standards for albumin and hemoglobin had a significant impact upon survival. CONCLUSION: This study has emphasized the very high mortality of patients starting RRT in Scotland. By paying close attention to the attainment of recommended standards of care for patients with ESRD, it may be possible to improve upon current mortality figures. The monitoring of such success is only possible if correction is made for age and comorbidity.     

Renal replacement therapy in patients with diabetes and end-stage renal disease

The number of patients who have diabetes and ESRD and are being admitted to renal replacement treatment (RRT) is increasing dramatically worldwide, and in many countries, diabetes has become the single most frequent cause of ESRD. Although the prognosis of patients who have diabetes and are receiving RRT has greatly improved, survival and medical rehabilitation rates continue to be significantly worse than those of nondiabetic patients, mainly because of preexisting severely compromised cardiovascular conditions. 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. However, 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. The results of observational studies and national registries, although conflicting, suggest that these two dialytic modalities are somehow comparable in terms of outcomes, whereas accumulating evidence shows that both survival and medical rehabilitation of patients with diabetes are significantly better after renal transplantation, which should be the first-choice option for patients who have diabetes and reach ESRD but unfortunately still accounts for only a limited proportion of RRT treatments in these patients.     

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.     

Renal replacement therapy options from an Indian perspective: dialysis versus transplantation

In developing countries such as India, the management of end-stage renal disease (ESRD) is largely guided by economic considerations. In the absence of health insurance plans, fewer than 10% of all patients receive renal replacement therapy (RRT). Hemodialysis (HD) is mainly a short-term measure to support ESRD patients prior to transplant. Infections are common in dialysis patients. The majority of patients starting HD die or are forced to abandon treatment because of cost constraints within the first 3 months. The cost of peritoneal dialysis (PD) is two times higher than that of HD, fewer than 2% of patients are started on PD. Among the three RRT options available, renal transplant is the preferred mode, as it is most cost-effective and provides a better quality of life. But due to financial constraints and nonavailability of organs, only about 5% of ESRD patients undergo transplant surgery. Though the removal of organs from brain-dead patients has been legalized, the concept of donation of organs from deceased donors has not received adequate social sanction. Only 2% of all transplants are performed from deceased donors. Due to limited access to RRT, the ideal approach should be to reduce the incidence of ESRD and attempt preventive measures. Preemptive transplant, reducing the duration of dialysis prior to transplant, use of immunosuppression for only up to 1 year, and availability of more deceased donor organs may be helpful to make RRT options within the reach of the common man.     

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.     

Changing pattern of end-stage renal disease in central and eastern Europe.

BACKGROUND: The epidemiology of end-stage renal disease (ESRD) is changing all over the world. Particularly dramatic changes of the epidemiology of ESRD have occurred in central and eastern Europe (CEE). The aim of the present study was (i) to document the further expansion of renal replacement therapy (RRT) noted in recent years in CEE and (ii) to analyse in some detail treatment modalities and underlying renal conditions. METHODS: Three independent surveys were performed in 1995, 1997 and 1998. Fifteen CEE countries participated. The data were mainly obtained from national registries which are based on centre and patient questionnaires. RESULTS: The data collected from 15 CEE countries document further expansion of RRT in this region. The report includes data on the availability of RRT in Byelorussia, Estonia, and Russia which have become available for the first time. The epidemiology of dialysed patients has changed remarkably. In the majority of countries the number of diabetic patients has increased, most dramatically so in the Czech Republic (31% of all dialysed patients), in the majority of the other countries 10-14%. The number of ESRD patients with the diagnosis of hypertensive nephropathy has also increased and this was accompanied by an increase in proportion of elderly (>65 years) patients, i.e. 46% in the Czech Republic and 12-25% in most other countries. CONCLUSION: Dramatic changes of the availability of RRT treatment have occurred in central and eastern Europe. The proportion of diabetic nephropathy and elderly patients has risen. Large differences in RRT exist between individual CEE countries and this appears mainly dependent on the level of economic development.     

Management of the dialysis patient in general intensive care

The incidence of end-stage renal disease (ESRD) is rising and represents an important group of patients admitted to intensive care units (ICU). ESRD patients have significant co-morbidities and specific medical requirements. Renal replacement therapy (RRT), cardiovascular disease, disorders of electrolytes, drug metabolism, and sepsis are discussed. This review provides a practical approach to problems specific to the ESRD patient and common problems on ICU that require special consideration in ESRD patients. ESRD patients are at risk of hyperkalaemia. I.V. insulin and nebulized salbutamol lower serum potassium until definitive treatment with RRT is instituted. ESRD patients are prone to hypocalcaemia, which requires i.v. replacement if associated with complications. Midazolam has delayed metabolism and elimination in renal impairment and should be avoided. Morphine and its derivatives accumulate in renal failure and shorter-acting opiates are preferable. The use of diuretics is limited to patients with residual urine output. When required, therapeutic systemic anticoagulation should be achieved with unfractionated heparin as it is reversible and its metabolism and clearance are independent of renal function. The risk of sepsis is higher among ESRD patients when compared with patients with normal renal function. Empiric treatment should include both Gram-positive and Gram-negative cover, and methicillin-resistant Staphylococcus aureus cover if the patient has a dialysis catheter. Cardiovascular events account for the majority of deaths among ESRD patients. Troponin-I and CK-MB in combination should be used as markers of acute myocardial damage in the appropriate context, whereas B-type natriuretic peptide and troponin-T values are of less value.     

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.     

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.     

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.     

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.     

Risk factors for renal replacement therapy in the Early Treatment Diabetic Retinopathy Study (ETDRS), Early Treatment Diabetic Retinopathy Study Report No. 26

BACKGROUND: Diabetes is a leading cause of end-stage renal disease (ESRD). The purpose of this study is to assess the risk factors for renal replacement therapy (RRT) in the Early Treatment Diabetic Retinopathy Study (ETDRS). METHODS: We examined demographic, clinical, and laboratory characteristics of the 2226 subjects with complete laboratory data enrolled in the ETDRS. The primary renal variable evaluated was the time to development of renal replacement therapy, defined as the need for dialysis or transplantation. Multivariable Cox proportional hazards regression was used to assess risk factors for type 1 and type 2 diabetes separately. RESULTS: The 5-year estimated incidence of RRT in the entire ETDRS population was 10.2% and 9.8% for patients with type 1 and type 2 diabetes, respectively. Of those patients with complete data, 127 of 934 (14%) of patients with type 1 diabetes, and 150 of 1292 (12%) patients with type 2 diabetes required RRT during the study. Baseline risk factors common to type 1 and type 2 diabetes included elevated total cholesterol, and serum creatinine; and low serum albumin and anemia. Other risk factors significant in type 1 diabetes included body mass index (BMI), shorter duration of diabetes, elevated hemoglobin A(1c) (HbA(1c)), elevated systolic blood pressure, and the development of proliferative diabetic retinopathy. Risk factors significant in type 2 diabetes, but not type 1 diabetes, included younger age, proteinuria, and elevated triglycerides. CONCLUSION: In this study, major modifiable risk factors such as hypertension, dyslipidemia, and hyperglycemia were found to be predictive of RRT. Other predictors were markers of vascular pathology and inflammation, proteinuria, hypoalbuminemia, and increased serum creatinine. Controlled clinical trials with treatment strategies that improve serum lipid levels, systemic blood pressure, glycemic control, and markers of inflammation may be important in furthering our knowledge on the pathogenesis of diabetic complications such as nephropathy and 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.     

Adequacy of dialysis in acute renal failure

Renal replacement therapy (RRT) is currently the mainstay of management for patients with acute renal failure (ARF). Adequacy of dialysis in the setting of renal failure is defined poorly and encompasses multiple domains of clinical and biochemical outcomes. Multiple operational factors influence the delivery of adequate dialysis. No current standards exist for RRT for ARF; current RRT practices for ARF generally have been extrapolated from end-stage renal disease (ESRD) literature. The heterogeneity of patient population, variation in RRT practices, and differences in outcomes studied have made it difficult to define or study adequate dialysis in ARF or its impact on clinical outcomes.     

The epidemiology of end-stage renal disease in Nigeria: the way forward

The incidence of CKD (Chronic kidney disease) in Nigeria has been shown by various studies to range between 1.6 and 12.4%. We have shown that the burden of renal disease in Nigeria is probably significantly higher than any previous study on end-stage renal disease (ESRD) has documented, as most studies are hospital-based and fail to include the many patients who do not have access to hospital care. The increased prevalence of ESRD among blacks in the United States and South Africa compared with other races also suggests that ESRD may be more prevalent in Africa than in the United States and other developed nations. Common causes of CKD in Nigerian adults are glomerulonephritis and hypertension, while common causes in children are glomerulonephritis and posterior urethral valves. In the United States, diabetes and hypertension are the commonest causes of CKD and glomerulonephritis plays a less important role. Access to renal replacement therapy (RRT) in Nigeria is limited, and mortality rates are very high, ranging between 40 and 50%. Important steps towards improving the situation are the development of prevention programmes and increased funding to ensure increased availability of RRT. To achieve this, health policies concerning CKD must be formulated, and the lack of a renal registry makes it difficult for this to be done. There is need for the development of a functional organizational structure for the reporting of CKD in Nigeria, the Nigerian Renal Registry.