Evolution of renal replacement therapy in East Germany from 1989 to 1992

Diminished availability of facilities for renal replacementtherapy is known to cause spuriously low acceptance and treatmentrates. In this context the evolution of renal replacement therapyin the former German Democratic Republic is a useful model tostudy and to quantify some of the relevant factors. We performed a survey in all dialysis units for adults in EastGermany (excluding East Berlin) by questionnaire, achievinga response rate of 97%. From December 1989 to December 1992the number of dialysis centres increased from 53 to 96 (+81%),reaching 6.7 centres p.m.p. Of these facilities, 45% were hospitalunits, 29% private units, and 26% dialysis units run by non-profithealth care organizations. The number of dialysis stations forregular dialysis treatment increased from 602 to 1276 (+112%),i.e. 89 stations p.m.p. In parallel, the number of chronic dialysispatients increased from 2127 to 3848 (+81%), i.e. 267 patientsp.m.p. A more detailed survey was carried out in Thüringen andpart of Sachsen, in a region covering 5 million inhabitants.The acceptance rate for chronic dialysis treatment has increasedfrom 49 to 107 patients p.m.p. (+115%). The average age of newpatients increased from 49 to 59 years, the proportion of patientsaged 65 years increased from 16 to 42% and the proportion ofdiabetics from 13 to 35%. Introduction of alternative treatmentmodalities became possible, with 2.3% of the patients receivinghaemofiltrations and 3% CAPD. The proportion of HBs-antigen-positivepatients decreased from 14.2% to 5%. At the end of 1989 in the former GDR (excluding East Berlin),773 patients and, at the end of 1992, 1153 patients were alivewith functioning renal transplants (+49%). The annual rate oftransplantations was 254 in 1989, and 283 in 1992 (+11%), i.e.18 transplantations p.m.p. (including East Berlin). At the end of 1989 2900 patients (193 p.m.p.), and at the endof 1992 5001 patients (347 p.m.p.), werealive on renal replacementtherapy (dialysis or functioning renal transplant) in East Germany,excluding East Berlin; this represents a 72% increase. The figures in East Germany are now almost equivalent to thosein West Germany regarding the number of admissions (incidence),whereas the number of patients on renal replacement therapyis still lower (prevalence).     

A systematic review of continuous renal replacement therapy and intermittent haemodialysis in management of patients with acute renal failure

Background: Acute renal failure (ARF) still bears a poor prognosis with mortality rates up to 70% and the ideal form of renal replacement therapy (RRT) remains controversial. The purpose of this study was to conduct a systematic review and meta-analysis of all randomized controlled trials (RCT) to examine the effect of dialysis modality (IHD: Intermittent haemodialysis; CRRT: continuous renal replacement therapy) on survival of patients with ARF and to also study the effect of each modality on dialysis dependence (DD). Methods: Using and combining two comprehensive search themes (ARF and RRT), we searched electronic databases from 1969 through September of 2007, supplemented by a manual review of abstracts from nephrology meetings and reference lists of review articles. All RCT comparing IHD with CRRT in adult patients with ARF and with explicit reporting of mortality were included. The primary outcome was the pooled estimate of the odds ratio (OR) of mortality for patients with ARF treated with CRRT versus IHD. The secondary outcome was OR of DD at time of discharge for surviving patients. Results: A total of 587 studies were identified, 554 of which were excluded on initial screening. Analysis of the nine RCT (1635 patients) showed an OR of 0.89 (0.63–1.24) for survival in patients on CRRT. Limiting the analysis to the seven RCT published after the year 2000, revealed an OR of 0.72 (0.58–0.90). The OR of all the studies before 2000 was 1.06 (95% CI 0.67–1.68), as compared with OR of 0.61 (95% CI 0.50–0.74) for studies post-2000. Four studies showed a significantly lower risk of DD among the CRRT group and none showed higher OR for DD. When analysis was limited to the RCT, the OR for DD was 1.07 (0.47–2.39), suggesting no difference in DD between the modalities. Conclusions: Similar to previously reported meta-analyses, we did not find a significant effect of CRRT on the OR of survival. The progressive reduction in the OR of survival with CRRT relative to IHD might reflect progressive improvements in IHD. The OR of DD was not affected by mode of RRT. In conclusion, compared with IHD, CRRT does not offer an advantage with regards to survival or DD in ARF. Considering its cost and potential disadvantages, it is imperative to identify the subset of patients with ARF that would potentially derive maximum benefit from CRRT. This will require large, adequately powered studies with sufficient follow-up.     

Comparison of outcomes of peritoneal dialysis between patients after failed kidney transplant and transplant-naïve patients: a meta-analysis of observational studies

PurposeThe influence of prior failed kidney transplants on outcomes of peritoneal dialysis (PD) is unclear. Thus, we conducted a systematic review and meta-analysis to compare the outcomes of patients initiating PD after a failed kidney transplant with those initiating PD without a prior history of kidney transplantation.MethodsWe searched PubMed, Embase, CENTRAL, and Google Scholar databases from inception until 25 November 2020. Our meta-analysis considered the absolute number of events of mortality, technical failures, and patients with peritonitis, and we also pooled multi-variable adjusted hazard ratios (HR).ResultsWe included 12 retrospective studies. For absolute number of events, our analysis indicated no statistically significant difference in technique failure [RR, 1.14; 95% CI, 0.80–1.61; I²=52%; p = 0.48], number of patients with peritonitis [RR, 1.13; 95% CI, 0.97–1.32; I²=5%; p = 0.11] and mortality [RR, 1.00; 95% CI, 0.67–1.50; I²=63%; p = 0.99] between the study groups. The pooled analysis of adjusted HRs indicated no statistically significant difference in the risk of technique failure [HR, 1.25; 95% CI, 0.88–1.78; I²=79%; p = 0.22], peritonitis [HR, 1.04; 95% CI, 0.72–1.50; I²=76%; p = 0.85] and mortality [HR, 1.24; 95% CI, 0.77–2.00; I²=66%; p = 0.38] between the study groups.ConclusionPatients with kidney transplant failure initiating PD do not have an increased risk of mortality, technique failure, or peritonitis as compared to transplant-naïve patients initiating PD. Further studies are needed to evaluate the impact of prior and ongoing immunosuppression on PD outcomes.     

连续性肾脏替代治疗剂量对急性肾衰竭患者预后影响的荟萃分析

目的 通过荟萃分析评价连续性肾脏替代治疗（CRRT）剂量对急性肾衰竭（ARF）患者预后的影响。 方法 制定原始文献的纳入标准和检索策略,在Medline、EMBASE及Cochrane 图书馆内进行相关的检索。比较标准剂量和低剂量CRRT对ARF患者预后影响的随机对照试验（RCT）纳入分析。应用随机或固定效应模型处理预后指标的相对危险度（RR）。 结果 6项研究符合纳入标准。与低剂量比较,标准剂量CRRT未能降低病死率（RR 0.87,95%CI 0.70~1.07,P = 0.19）和联合终点事件（死亡和依赖透析）的发生率（RR 0.87,95%CI 0.69~1.09,P = 0.21）,但有增加依赖透析率的趋势（RR 1.43,95%CI 0.94~2.18,P = 0.09）。由于研究间存在异质性,亚组分析显示,实际治疗剂量达标（标准剂量>35 ml&#8226;kg-1&#8226;min-1）、治疗模式以连续性静脉-静脉血液滤过（CVVH）为主（置换液量大于透析液量）、非脓毒症为ARF主要原因（脓毒血症发病率<50%）的研究中,经标准剂量CRRT后病死率显著下降（P < 0.01）。 结论 尽管标准剂量CRRT未能降低ARF患者的病死率、依赖透析率和联合终点事件的发生率,但可改善实际治疗剂量达标、治疗模式以CVVH为主及非脓毒症ARF患者的存活率。     

Report of renal failure treatment in Australia and New Zealand from the dialysis and transplant registry (ANZDATA)

Summary: The Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) has recorded 15675 patients resident in Australia and 2909 patients in New Zealand who have been treated by dialysis and transplantation for end-stage renal failure. the majority of patients have a functioning transplant (51% Australia, 50% New Zealand). Cadaveric organs have been the mainstay of the transplant programme from 1963 to 1993 (91% Australia, 87% New Zealand). In recent years the early graft survival has dramatically improved; the 12 month graft survivals were 74 and 87% in Australia, and 68 and 78% in New Zealand in 1983 and 1992, respectively. A large majority of patients have dialysed at home (49% Australia, 84% New Zealand) or with low level assistance in facilities remote from tertiary level hospital renal units (21% Australia). While most patients use haemodialysis (64% Australia, 41% New Zealand), continuous ambulatory peritoneal dialysis is the predominant form of dialysis in the home (63% Australia, 70% New Zealand). the demographic analysis displays a slight predominance of males (55.5% Australia, 50.4% New Zealand), and a steadily increasing number of patients over 65 years old (31% Australia, 15% New Zealand), and of diabetics (16% Australia, 31% New Zealand). Aborigines, Maoris and Pacific Islanders have a strikingly higher rate of renal failure per million population than the Caucasoid/Europid population. Certain causes of renal failure such as excess analgesic ingestion and malignant hypertension have declined. Glomerulonephritis has been the most common cause of renal failure in Australia (33%), diabetic nephropathy the most common in New Zealand (31%).     

Agalsidase therapy in patients with Fabry disease on renal replacement therapy: a nationwide study in Italy.

BACKGROUND: In Fabry disease, end-stage renal disease (ESRD) and severe neurologic and cardiac complications represent the leading causes of late morbidity and mortality. A comprehensive Italian nationwide survey study was conducted to explore changes in cardiac status and renal allograft function in Fabry patients on renal replacement therapy (RRT) and enzyme replacement therapy (ERT). METHODS: This study was designed as a cross-sectional survey study with prospective follow-up. Of the 34 patients identified via searches in registries, 31 males and 2 females who received RRT and ERT (agalsidase beta in 30 patients, agalsidase alpha in 3) were included. Left ventricular mass index (LVMI), interventricular septal thickness at end diastole (IVSD), left ventricular posterior wall thickness (LVPWT) and renal allograft function were assessed at ERT baseline and subsequently at yearly intervals. RESULTS: The patients in the dialysis and transplant groups had been started on dialysis at age 42.0 and 37.1 years (mean), respectively, and patients in the transplant group received their renal allograft at age 39.8 years (mean). The mean age at the start of ERT was similar, 44.1 and 44.6 years, respectively. The mean RRT follow-up was 61.1 and 110.6 months for dialysis and transplant patients, respectively, whereas the ERT duration was 45.1 and 48.4 months, respectively. Cardiac parameters increased in dialysis patients. In transplant patients, mean LVMI seemed to plateau during agalsidase therapy at a lower level as compared to baseline. Decline in renal allograft function was relatively mild (-1.92 ml/min/year). Agalsidase therapy was well tolerated. Serious ERT-unrelated events occurred more often in the dialysis group. CONCLUSIONS: Kidney transplantation should be the standard of care for Fabry patients progressing towards ESRD. Transplanted Fabry patients on ERT may do better than patients remaining on maintenance dialysis. Larger, controlled studies in Fabry patients with ESRD will have to demonstrate if ERT is able to change the trajectory of cardiac disease and can preserve graft renal function.     

Fluid overload and acute renal failure in pediatric stem cell transplant patients

Acute renal failure (ARF) with fluid overload (FO) occurs often in stem cell transplant (SCT) recipients. We have previously demonstrated that an increased percentage of FO prior to the initiation of continuous renal replacement therapy (CRRT) is associated with mortality in children with ARF. Based on these data, we devised a protocol for the prevention of FO in SCT patients with ARF. SCT patients with ARF and 5% FO were started on furosemide and low-dose dopamine. To allow for nutrition, medication, and blood product administration, RRT was initiated for patients with 10% FO. There were 272 patients who received allogeneic SCT from 1999 to 2002. Of these, medical records of 26 SCT patients with a first episode of oliguric ARF were reviewed. The mean patient age was 13±5 years (range 2–23.5 years). Mean days to ARF after SCT were 28±29 days (range 2–90 days). Of the 26 patients, 11 (42%) survived an initial ARF episode. All 11 survivors either maintained <10% FO during their course or re-attained <10% FO with RRT treatment. Of the 15 non-survivors, 6 had <10% FO at the time of death. Of 14 patients who received RRT, 4 (29%) survived. Mechanical ventilation and pediatric risk of mortality score 10 at the time of admission to the intensive care unit were associated with lower survival (P<0.05). The use of one or more pressors, the presence of graft-versus-host disease, and septic shock were not correlated with survival. Our data demonstrate that maintenance of euvolemia (<10% FO) is critical but not sufficient for survival in SCT patients with ARF, as all non-euvolemic patients died. We suggest that aggressive use of diuretics and early initiation of RRT to prevent worsening of FO may improve the survival of SCT patients.     

间断性肾脏替代治疗重症急性胰腺炎的临床观察

目的：探讨间断血液滤过治疗对重症急性胰腺炎（SAP）的临床疗效。方法：分析我科自2008 年10月～2011 年11月21例SAP患者行间断血液滤过治疗的疗效。观察治疗前后患者的体温、心率、呼吸、血压,检测肝肾功能、氧合指数(PO2／FiO2)、电解质、葡萄糖、血常规,并行APACHEⅡ评分。结果：21例SAP患者存活18例,死亡3例;经IRRT治疗后APACHEⅡ评分明显下降（P＜0.05）,生命体征明显好转;生化指标明显改善（P＜0.05）。结论：常规综合治疗SAP同时,早期合理应用IRRT可以清除炎症介质,维持内环境稳定,改善脏器功能,提高疗效,为临床治疗SAP 提供一种重要辅助手段。     

Cost of renal replacement therapy in Turkey

BACKGROUND AND RESULTS: By the end 2000, 22224 patients were on renal replacement therapy (RRT) in Turkey. We investigated the cost of RRT in three medical faculties and one private dialysis centre. Yearly expenses were US dollars 22759 for haemodialysis (HD), US dollars 22350 for continuous ambulatory peritoneal dialysis (CAPD), and US dollars 23393 and US dollars 10028, respectively, for the first and second years of transplantation (Tx). In the first year, renal Tx was significantly more expensive than CAPD. However, after the first year of renal transplantation, Tx became significantly more economical than both CAPD and HD. The sum of all yearly RRT expenses for the country was US dollars 488958709, which corresponds to nearly 5.5% of Turkey's total health expenditure. CONCLUSION: Measures such as early construction of vascular access, promoting home dialysis and the reuse of the dialysers, strict control of the use of some expensive drugs like erythropoietin and active vitamin D, and also increasing the number of transplantations, especially if pre-emptive transplantation is possible, should be taken into account in order to reduce these expenses.     

Increased erythropoietin requirements in patients with failed renal transplants returning to a dialysis programme

The response to erythropoietin (Epo) is dose dependent but,for various poorly understood reasons, variable. In a cross-sectionalstudy we determined the Epo requirement of 60 patients in adialysis population to identify those patients requiring a highdose of Epo, and ascertained the reasons for higher requirements,paying particular attention to the effect of previous transplantation.All 289 patients attending a single centre were surveyed. Ofthese, 164 were receiving renal replacement therapy by continuousambulatory peritoneal dialysis (CAPD) and 125 were on haemodia-lysis(HD). Patients on HD needed more Epo than those on CAPD (129.0±14.9U/kg/week versus 86.9±10.7 U/kg/week, P<0.05). However,this difference was accounted for by a subgroup of patientswho had a previously failed transplant. The Epo requirementin those patients on HD with a failed transplant was significantlygreater than those on HD who had never been transplanted (164.0±24.5 U/kg/week versus 96.6 ± 11.9 U/kg/week, P<0.05).The seven patients who retain their transplanted kidney hadthe highest Epo requirement of all (213.4±46.6 U/kg/week).These studies have shown that previous transplantation is asignificant determinant of Epo requirement upon return to dialysis.They also show that it is necessary to ‘correct’for the effect of previous transplantation when investigatinggenerally accepted determinants of Epo need. Interpretationof previously published studies needs to take account of this.     

The incidence of thrombocytopenia associated with continuous renal replacement therapy in critically ill patients

Abstract

Introduction: Thrombocytopenia in the intensive care unit (ICU) is a commonly experienced complication; the pathology is not always easily understood. Continuous renal replacement therapy (CRRT) provides a method to dialyze unstable critically ill patients. We hypothesized that CRRT may precipitate a form of thrombocytopenia. In trials thrombocytopenia occurred at rates as high as 70%. The etiology remains unknown and results in additional diagnostic workup, as well as possible drug therapy. The extent, duration and temporal relation of thrombocytopenia remain to be determined. Objectives: Identify a pattern in platelet fluctuations after the initiation of CRRT and its impact on health care. Methods: A retrospective study was conducted in patients receiving CRRT for >24?h with no pre-existing thrombocytopenia. Patients initiated on CRRT had daily platelet counts monitored, and CRRT attributes and therapeutic interventions were collected. Platelets were assessed for time to nadir, degree of decline and time to return to baseline after discontinuation of CRRT. Results: Forty-nine patients met inclusion criteria. Thirty-seven percent of patients receiving heparinoids were tested for heparin-induced thrombocytopenia (HIT), during CRRT, with 39% of these patients having therapy changed to non-heparinoid agents due to suspected HIT; no HIT antibodies were positive. Eleven patients (22%) receiving anticoagulants, prophylactically or therapeutically had them held for a drop in platelets. There was a mean decline in platelets of 48% with a mean of 4.6 days to the nadir. An average 2.48 days were observed until rebound to >150?×?10³/mm³. Statistical analysis failed to identify any patient attributes that correlated with the probability of thrombocytopenia. Conclusion: CRRT appears to be associated with a drop in platelets within the first 5 days of therapy with an average decline of 48%. However, platelets appear to return to >150?×?10³/mm³ after cessation of CRRT. This fluctuation should be considered in the setting of patients developing thrombocytopenia after initiation of CRRT.     

持续肾替代治疗在肝移植术后急性肾损伤的应用

目的 探讨持续肾替代治疗(CRRT)对肝移植术后急性肾损伤的治疗效果.方法 回顾性分析82例肝移植围手术期应用CRRT患者的肾功能情况,对其治疗前后的主要指标进行检测.结果 与治疗前比较,治疗后患者丙氨酸氨基转移酶(ALT)、总胆红素(TBil)、血尿素氮(BUN)、肌酐(Cr)、肌酸磷酸激酶(CPK)、C反应蛋白(CPR)、肌酐下降,差异均有统计学意义(P＜0.05).与治疗前比较,CRRT治疗后患者血K+、Na+、Cl-、HCO3-、中心静脉压(CVP)显著好转,差异亦具有统计学意义(P＜0.05).其他生化指标与治疗前比较变化不大,差异无统计学意义(P＞0.05).对开始血滤治疗的时机进行研究显示,在急性肾损伤RIFLE分级Ⅰ级开始血滤治疗的患者肾功能恢复的比例明显高于在F级开始血滤治疗的患者(P＜0.05).结论 CRRT治疗能明显改善肝移植术后急性肾损伤患者的预后.     

Poor prognosis of heart transplant patients with end-stage renal failure.

BACKGROUND: Chronic kidney disease (CKD) and end-stage renal failure (ESRF) are major complications after a heart transplant. The aim of this study is to compare survival in heart transplant (HT) vs non-heart transplant (non-HT) patients starting dialysis. METHODS: Survival was studied among the 539 newly dialysed patients between 1 January 1995 and 31 December 2005 in our Department. All patients were prospectively followed from the date of first dialysis up to death or 31 December 2005. Multivariate survival analysis adjusted on baseline characteristics was performed with the Cox model. RESULTS: There were 21 HT patients and they were younger than non-HT patients at first dialysis: 58.6+/-11.6 vs 63.0+/-16.2 years (P=0.09). Calcineurin inhibitor nephrotoxicity was the main cause of ESRF in HT patients (47.6%). Crude 1, 3 and 5-year survival rates in HT and in non-HT patients were as follows: 76.2%, 57.1%, 28.6% and 79.1%, 58.7%, 46.7% (P=0.2). The adjusted hazard ratio of death in HT vs non-HT patients was 2.27 [1.33-3.87], P=0.003. Sudden death was the main cause of death in HT patients, in 33.3% vs 10.4% in non-HT patients (P=0.01). Five HT patients benefited from renal transplant. They were all alive at the end of the study period, while one patient among the 16 remaining on dialysis survived. CONCLUSION: HT patients with CKD who reached ESRF have a poor outcome after starting dialysis in comparison with other ESRF patients. Improvement in renal function management in the case of CKD is needed in these patients and non-nephrotoxic immunosuppressive regimens have to be evaluated. Renal transplant should be the ESRF treatment of choice in HT 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.     

Problems and advantages of continuous renal replacement therapy*

SUMMARY: The continuous replacement of renal function must facilitate fluid and solute homeostasis, nutrition and vital organ function, and, where possible, hasten the recovery of renal function. Difficulties with anticoagulation, biocompatibility, mobility and cost remain obstacles to be overcome. the use of continuous renal replacement therapy (CRRT) to remove systemic inflammatory mediators is yet to be confirmed. Although survival benefits of CRRT over intermittent dialysis remain controversial, the slow continuous removal of fluid, acid and solute has a number of advantages, especially where patients are haemodynamically unstable.     

Trends in the use of renal replacement therapy modality in intensive care unit: a 7 year study

Abstract

Background: The use of renal replacement therapy (RRT) modality in the intensive care unit (ICU) depends primarily on provider preference and hospital resource. This study aims to describe the prevalence of RRT use and the trends in RRT modality use in the ICU over the past 7 years. Methods: All ICU admissions, including medical, cardiac, and surgical ICUs from 1 January 2007 to 31 December 2013, were included in this study. RRT use was defined as the use of intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT) within a given ICU day. The RRT use was reported as the proportion of ICU days on each RRT modality divided by the total ICU days with RRT usage. Results: Over the course of this study (72,005 ICU admissions), 272,271 ICU days were generated. RRTs were used in 4110 ICU admissions (5.7%) and on 21,159 ICU days (7.8%). RRT use was 10,402 (49%) for IHD, and 10,954 (52%) for CRRT. The trend of IHD and CRRT use did not change from year 2007 to 2013. On ICU days with RRT, the choice of RRT modality was associated with the number of vasopressor use (p?<?0.001). CRRT was more preferred on the ICU days with the increasing number of vasopressor use. Conclusions: RRTs were used in about 6% of ICU admission. The use of IHD and CRRT was similar and did not change over 7 years. The choice of RRT modality mainly depended on the number of vasopressors used on ICU days with RRT.