Case-mix and treatment in end-stage renal disease: hemodialysis v peritoneal dialysis

The University of Southern California School of Medicine conducted a nationwide survey of 336 nephrologists to obtain demographic and clinical data on 6,411 patients with end-stage renal disease (ESRD). Patient demographic data, along with ESRD etiology and comorbid conditions noted by the physician, were compared across various modalities of dialysis. Characteristics of the treatment provided were differentiated by the mode of dialysis and the location of the patient encounter. Results of the analysis show that patients on peritoneal dialysis are more likely to be female and have higher rates of diabetes compared with hemodialysis (HD) patients. Statistically, patients on intermittent peritoneal dialysis are older, more likely to be black, and have a higher incidence of cardiovascular conditions. Continuous ambulatory peritoneal dialysis patients have greatest problem severity and require more physician time and more complex services, whereas home HD patients require the greatest number of diagnostic tests and therapeutic procedures. Hospital inpatient care shows greater case-mix severity and more intensive treatment, but this does not differ by the mode of dialysis. Finally, patients of freestanding dialysis facilities are more likely to have hypertensive renal disease, whereas patients at hospital-based facilities are older, more likely to be seen in the hospital, have more urgent and severe problems during dialysis rounds, and require more physician time, more complex services, and more diagnostic tests and therapeutic procedures.     

Serum electrolyte patterns in end-stage renal disease

The charts of 70 successive patients presenting for dialysis therapy for end-stage renal disease (ESRD) were evaluated for their serum electrolyte values. The "classical" pattern of low total CO2 (tCO2), elevated anion gap ("delta"), and normal chloride was found in a minority of patients (14 of 70, or 20%). Hyperchloremia was noted in 46%; in 21 patients (30%), this was associated with a normal delta and in 11 (16%), hyperchloremia was accompanied by an elevated delta. Fourteen patients (20%), most with diabetic nephropathy, had normal serum electrolytes. Patients with chronic glomerulonephritis had a hyperchloremic pattern as often as not, and two of four patients with interstitial nephritis demonstrated hyperchloremia without an elevated delta. We conclude that the previously held thesis that hyperchloremia is a rare or absent finding by the time renal failure progresses to ESRD is no longer tenable. Furthermore, a significant minority of ESRD patients may require the initiation of dialysis at a time when their serum electrolytes are still normal.     

Outcomes research in dialysis

Worldwide, the number of patients with end stage renal disease (ESRD) and the number of ESRD patients receiving renal replacement therapy is growing. In the United States the number of patients enrolled in the Medicare-funded ESRD program has grown substantially, from approximately 10000 beneficiaries in 1973 to 340261 as of December 31, 1999. United States has the highest incidence ESRD of 317 per million population. Despite the magnitude of resources committed to the treatment of ESRD and the substantial improvements in the quality of dialysis therapy, these patients continue to experience significant mortality and morbidity, and reduced quality of life. Moreover, 50% of dialysis patients have 3 or more comorbid conditions, the mean number of hospital days per year is approximately 14 per patient, and self reported quality of life is far lower in dialysis patients than in general population. The most desirable interventions are those that specifically target measurable global outcomes such as mortality, morbidity, and health care costs. Nevertheless, patient outcomes that have shown links with these global outcomes may also be appropriate targets for intervention. This article will briefly review the available literature to discuss the role of important clinical indicators on dialysis outcomes and their impact on continuing care of ESRD population.     

Trends in the incidence of treated end-stage renal disease secondary to diabetic nephropathy: 1975-1984

A study of the incidence of treated end-stage renal disease (ESRD) secondary to diabetic nephropathy (DN) in Missouri from 1975 to 1984 documented a relative risk of treated ESRD due to DN 3.7 times higher for blacks than whites. Between 1980 and 1984, the incidence rate for treated ESRD due to DN increased by 150% for white patients and 315% for black patients. Blacks over age 50 have incidence rates of treated ESRD due to DN 4.9 times their white counterparts. Black females have the highest rate of all race/sex groups with DN. The escalating high risk of older blacks for treated ESRD due to DN mandates the development of effective community based identification and referral efforts.     

Peritoneal dialysis in diabetic patients

Diabetes mellitus is the fastest growing cause of end-stage renal disease (ESRD) and has become the leading cause of such ESRD worldwide. In the United States, between 1984 and 1997, the proportion of new patients starting renal replacement therapies whose ESRD was caused by diabetes increased from 27% to 44.4%. Canada saw an increase from 16.5% in 1984 to 28.9% in 1997, and many European countries had similar increases. Among the modes of renal replacement, many clinicians have favored continuous ambulatory peritoneal dialysis (CAPD) for the treatment of diabetic ESRD for several reasons. Many studies have compared clinical outcomes in diabetic patients undergoing CAPD, and nondiabetic patients undergoing CAPD, or diabetic patients undergoing peritoneal dialysis (PD) and those undergoing hemodialysis (HD). However, only a small number of diabetic dialysis patients have been followed up for more than 5 years, largely because of the presence of several comorbid conditions at the start of dialysis and the coexistence of far-advanced target-organ damage at dialysis initiation and its progression during the course of dialysis. Diabetic patients undergoing PD and HD probably have similar survival, and those undergoing CAPD have lower survival and technique success rates than nondiabetic patients of comparable age. This article reviews the literature and our experience with diabetic patients undergoing PD and compares clinical outcomes in diabetic patients undergoing PD and HD.     

End-stage renal disease in India and Pakistan: burden of disease and management issues

In the absence of national registries, no reliable data are available on the incidence and prevalence of end-stage renal disease (ESRD) in India and Pakistan. The incidence of ESRD is likely to be higher than that reported from the developed world, with chronic glomerulonephritis being the most common cause, accounting for more than one third of patients, while diabetic nephropathy accounts for about one fourth of all patients in India. Patients are generally younger (mean age 42 years) at the time of detection of ESRD and two-thirds first see a nephrologist after they have reached end stage. Treatment of ESRD is a low priority for the cash-strapped public hospitals and in the absence of health insurance plans, less than 10% of all patients receive any kind of renal replacement therapy. The vast majority of patients starting hemodialysis die or stop treatment because of cost constraints within the first three months, and less than 2% patients are started on ambulatory peritoneal dialysis. Although renal transplantation is the cheapest option, only about 5% of all patients with ESRD end up having a transplant. Living related donor transplants constitute 30 to 40% of all transplants in India, but there is a conspicuous gender bias with female donors donating kidneys for their male relatives. Cadaveric transplantation has yet to pick up and accounts for less than 2% of all transplants. The enactment of legislation to regulate renal transplantation in India has not been able to prevent unrelated (paid) donor transplants, which constitute 60 to 70% of all renal transplants. Cyclosporine, azathioprine and prednisolone continue to be the backbone of post-transplant immunosuppression, with cyclosporine being stopped in a significant proportion at one year post-transplant to cut down costs. Increasing awareness of renal disease amongst the population and general practitioners could result in early diagnosis of chronic renal failure and give opportunity for preventive strategies to delay the onset of ESRD. Preemptive transplantation and use of generic cyclosporine can help bring down the costs of treatment. Innovative and affordable health insurance policies can also increase the number of patients who receive effective treatment for ESRD in these two countries.     

Renal replacement therapy in Sweden

OBJECTIVE: The Swedish Registry for Active Treatment of Uraemia (SRAU) was founded in 1991 with the objective of documenting demographic data on patients treated for end-stage renal disease (ESRD). The aim of this study was to describe the prevalence, incidence, comorbidity risk factors and survival of patients with ESRD who underwent dialysis treatment and/ or kidney transplantation in Sweden between 1991 and 2002. MATERIAL AND METHODS: All dialysis and transplant units (n = 65) presently report to the SRAU and almost all patients are reported and followed until death. RESULTS: The prevalence of patients on dialysis and transplantation, being approximately 750 per million population (PMP), has increased by 75% in 12 years. The recent annual rise is approximately 3% (200 patients). The incidence has been stable since 1997 at approximately 125 patients PMP. In 2002, there were 1113 new patients, the majority of whom were aged > or =65 years. Their original kidney disease was most often diabetic nephropathy (23.7%), with nephrosclerosis (19.0%) being the second most common disease. The total number of renal transplantations performed has decreased to some extent. The overall 5-year patient survival rate was 23.1% in patients on dialysis and 85.5% after kidney transplantation. The major cause of death was cardiovascular disease (48%) and an increasing frequency of malignancy after transplantation (26%) was noted. CONCLUSION: The prevalence of ESRD has nearly doubled since 1990 and the number of new patients being referred for dialysis has increased. These patients are becoming older, with a large proportion having non-renal complicating diseases. Survival after transplantation was excellent. The shortage of cadaveric donors in Sweden in recent years and increasing mortality from malignant disease after transplantation are issues of great concern.     

End-stage renal disease in the United States: an update from the United States Renal Data System

Patients with ESRD consume a vastly disproportionate amount of financial and human resources. Approximately 0.03% of the US population began renal replacement therapy in 2004, an adjusted incidence rate of 339 per million. Declining incidence rates were observed for most primary causes of ESRD and in most major demographic categories; the worry is that rates of diabetic ESRD continue to rise in younger black adults. Although diabetes and hypertension remain the most commonly reported cause of ESRD, rates of end-stage atherosclerotic renovascular disease seem to be on the rise in older patients. Although clinical care indicators, such as the proportion of hemodialysis patients using fistulas, continue to improve gradually, the proportion of patients overshooting target hemoglobin levels under epoetin therapy may be a source of concern. Survival probabilities have improved steadily in the US ESRD population since the late 1980s, which is remarkable when one considers the ever-expanding burden of comorbidity in incident patients. However, although first-year dialysis mortality rates have clearly improved since 1987, meaningful improvements do not seem to have accrued since 1993, in contrast to steady annual improvements in years 2 through 5. Although most of these findings are grounds for cautious optimism, the same cannot be said for issues of cost; reflecting the growth in the size of the ESRD population, associated costs grew by 57% between 1999 and 2004 and now account for 6.7% of total Medicare expenditures.     

Outcomes of stage 1–5 chronic kidney disease in Mainland China

Objective: This study aims to quantify and compare the risks of death and end stage renal disease (ESRD) in a prospective cohort of patients with chronic kidney disease (CKD) stages 1–5 under renal management clinic at Peking University Third Hospital and to evaluate the risk factors associated with these two outcomes. Method: This was a prospective cohort study. Finally, 1076 patients at CKD stage 1–5 short of dialysis were recruited from renal management clinic. Patients were monitored for up to Dec, 2011 or until ESRD and death. Glomerular filtration rate was estimated (eGFR) according to the using the CKD Epidemiology Collaboration (CKD-EPI) formula. Results: At the end of follow-up, 111 patients (10.1%) developed ESRD (initiated dialysis or kidney transplantation (ESRD)) and 24 patients (2.2%) had died. There were more ESRD occurrence rate in patients with baseline diabetic nephropathy, lower eGFR, hemoglobin <100?g/L and 24?h urinary protein excretion ≥3.0?g. By multivariate Cox regression model, having heavy proteinuria and CKD stage were the risk factors of ESRD. For all-cause mortality, the most common cause was cardiovascular disease, followed by infectious disease and cancer. But we failed to conclude any significant variable as risk factors for mortality in multivariate analysis. Conclusions: Our study indicated that baseline diabetic nephropathy, lower hemoglobin level, lower baseline GFR and heavy proteinuria were the risk factors of ESRD. In this CKD cohort, patients were more likely to develop ESRD than mortality, and cardiovascular mortality was the leading cause of death, and then followed by infectious diseases and cancer in this population.     

End-stage renal disease in US minority groups.

Medicare's End-Stage Renal Disease (ESRD) Program makes renal replacement services accessible for the majority of Americans with renal failure. National data from Medicare demonstrate complex and variable patterns of use of renal replacement services among US racial and ethnic groups. The black population has consistently suffered from a greater than 3.5-fold higher rate of treated ESRD than has the white population. The rates of hypertensive, diabetic, and glomerulopathic ESRD are all substantially greater in blacks than in whites, and hypertension has accounted for a far greater proportion of ESRD in blacks than any other diagnosis. There is a paucity of national data on the occurrence of ESRD in Hispanic Americans. However, data from Texas strongly suggest that the incidence rate of treated ESRD is much higher in Mexican Americans than in non-Hispanic whites. Higher rates are apparent for each of the three most important causes of ESRD: hypertension, diabetes, and glomerulonephritis. Native Americans experience ESRD at a rate intermediate between those of whites and blacks, but their rate of diabetic ESRD is higher than in either blacks or whites. However, considerable diversity exists among Native American tribal groups. Significant barriers to the acquisition of preventive care have been identified, especially for blacks. While these barriers to preventive care are accompanied by a significantly impaired health status of the black American population, a specific causal relationship between impaired access to care for blacks and their predisposition to ESRD has not been established.     

终末期糖尿病肾病患者透析方式的选择

糖尿病肾病(DN)是导致终末期肾脏病的重要病因之一。终末期DN患者可选择的透析方式包括血液透析和腹膜透析,而具体选择何种透析方式,需要综合考虑共存疾病、家庭情况、患者的独立性与积极性、耐受容量转移的能力、血管条件和/或腹部的状态、感染风险及感染史等。     

The Evolution of the End-Stage Renal Disease Program in Australia

Australia was an early pioneer of national integrated programs for the management of end-stage renal disease (ESRD). From being a leader in numbers of patients per population treated, it is now in the top 15. The Australian program has a high proportion of living patients with functioning transplants and a high proportion of out-of-hospital dialysis. The proportion of elderly patients is increasing but lower than expected. A particular problem is the treatment of Aboriginal people. The ANZ Data surveys give accurate complete data for the national program. Unique features of the Australian patients are the high incidence of analgesic nephropathy and the low incidence of primary hypertension as a cause of renal failure. Surveys show that it is possible to improve transplantation rates 2 to 3 times. Analysis of Australian data raises the question of whether dialysis and transplantation should be offered to all potential patients regardless of comorbidity or quality of life when health resources are inevitably finite.     

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.     

Glycemic Control and Burnt‐Out Diabetes in ESRD

Treatment of early diabetes mellitus, the most common cause of chronic kidney disease (CKD), may prevent or slow the progression of diabetic nephropathy and lower mortality and the incidence of cardiovascular disease in the general diabetic population and in patients with early stages of CKD. It is unclear whether glycemic control in patients with advanced CKD, including those with end‐stage renal disease (ESRD) who undergo maintenance dialysis treatment is beneficial. Aside from the uncertain benefits of treatment in ESRD, hypoglycemic interventions in this population are also complicated by the complex changes in glucose homeostasis related to decreased kidney function and to dialytic therapies, occasionally leading to spontaneous resolution of hyperglycemia and normalization of hemoglobin A1c levels, a condition which might be termed “burnt‐out diabetes.” Further difficulties in ESRD are posed by the complicated pharmacokinetics of antidiabetic medications and the serious flaws in our available diagnostic tools used for monitoring long‐term glycemic control. We review the physiology and pathophysiology of glucose homeostasis in advanced CKD and ESRD, the available antidiabetic medications and their specifics related to kidney function, and the diagnostic tools used to monitor the severity of hyperglycemia and the therapeutic effects of available treatments, along with their deficiencies in ESRD. We also review the concept of burnt‐out diabetes and summarize the findings of studies that examined outcomes related to glycemic control in diabetic ESRD patients, and emphasize areas in need of further research.     

Cost-effectiveness of losartan in diabetic nephropathy: a Greek perspective

BACKGROUND: Diabetic nephropathy is the primary cause of end-stage renal disease (ESRD), which involves substantial economic burden. The primary objective of this study was to estimate the potential effect of losartan on the costs associated with ESRD in patients with diabetic nephropathy in a Greek setting. A secondary aim was to approximate the direct health care cost of renal replacement therapy (RRT) in Greece. METHODS: A cost-effectiveness analysis was performed to compare losartan with placebo in patients with type 2 diabetes and nephropathy. Clinical data were derived from the RENAAL study. All costs were calculated from the perspective of the Greek social insurance system, in 2003 euros. Future costs were discounted at 3%. The time horizon was 3.5 years. Extensive sensitivity analyses were performed. RESULTS: The reduction in the number of ESRD days over 3.5 years in patients treated with losartan reduced ESRD-related costs by 3,056.54 euros, resulting in net cost savings of 1,665.43 euros per patient. Net cost savings increase thereafter, increasing to 2,686.48 euros per patient over a period of 4.0 years. The results were robust under a wide range of plausible assumptions. The weighted mean daily cost of RRT was estimated at 90.97 euros per patient. The total economic burden of RRT for the year 2003 has been estimated at 304.773 million euros. CONCLUSIONS: This study demonstrated that treatment of patients with diabetic nephropathy in Greece with losartan is cost-effective, as it leads to important savings for the social insurance system by slowing the progression to ESRD.     

Comparative incidence rates of end-stage renal disease treatment by state

End-stage renal disease (ESRD) treatment rates vary significantly between states in the United States. Much of this variation relates to the much higher rate of ESRD in blacks and the differences in race, age, and sex composition of various states. Even after adjusting for race, age, and sex differences utilizing data from new patients reported to Medicare with ESRD between 1980 and 1983, marked variation in treatment incidence rates per million population were still present. Overall rates varied from 45 in North Dakota to 99 in New Jersey. Regional rate patterns were demonstrated with very high rates in southwestern states (Texas, New Mexico, Arizona, and California: 87-91/million). In contrast, several south-central states had lower rates (Arkansas, Louisiana, Mississippi, Alabama, and Tennessee: 66-75/million). By state the rates for blacks were consistently higher than for whites. After adjustment for sex and age differences, the rates for blacks varied from 125 in Arkansas to 242 in New Jersey. Several north-eastern states (Massachusetts, Connecticut, Rhode Island, New Jersey) had higher rates of ESRD in blacks (197-242 million) as compared with several south-central states (Arkansas, Louisiana, Mississippi, Tennessee, Alabama) where rates varied from 125 to 180 million. ESRD rates by primary etiologies by state showed marked variation of the major primary etiologies of ESRD: diabetic nephropathy rates were most predictive of overall ESRD rates, with much higher rates in the southwestern states (28.1-33.2) as compared with the south-central states (12.8-16.3).(ABSTRACT TRUNCATED AT 250 WORDS)     

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.