Demographic trends in the Okinawa Dialysis Study (OKIDS) registry (1971-2000)

BACKGROUND: The clinical demographics of chronic dialysis patients are changing worldwide. However, long-term data from regional dialysis registries have not yet been analyzed and reported. METHODS: The Okinawa Dialysis Study (OKIDS) registry included all chronic dialysis patients treated in Okinawa, Japan, since 1971. Data for the years 1971 to 1990 were analyzed to predict trends for 1991 to 2000. The predicted values were then compared to the actual values and analyzed statistically, with particular attention being paid to relative risk of death. Multivariate Cox proportional hazards analysis was done to analyze the time factors of relative risk of death. RESULTS: A total of 5246 patients (2981 men and 2265 women) were registered and the total duration of observation was 28,431 patient-years. The prevalence and incidence of dialysis patients expressed per million population were 2320 and 297, respectively, in 2000, values that were significantly higher (P < 0.02 for both) than the predicted values. The gross mortality rate per 1000 patient-years was 118.4 for 1971 to 1980, 63.3 for 1981 to 1990, and 77.7 for 1991 to 2000. The adjusted hazards ratio (95% confidence interval) for mortality was 0.743 (0.650 to 0.862) for 1981-1990 and 0.721 (0.659 to 0.790) for 1991 to 2000 in comparison to the risk of mortality in 1971 to 1980. The decrease in mortality rate was largely due to the drop in cardiac deaths from 71.0 for 1971 to 1980 to 17.2 for 1991 to 2000. CONCLUSIONS: The incidence and prevalence of chronic dialysis patients increased more than expected over the past decade in Okinawa, Japan. Despite the rapid change in patient demographics, the survival rate did not decrease significantly.     

Improved long-term survival rate of chronic dialysis patients with diabetes mellitus

Background. The survival rate of diabetic dialysis patients has been poor. However, it is uncertain whether the survival rate of these patients has been improving. Methods. Using the Okinawa Dialysis Study (OKIDS) registry, in which the records of all chronic dialysis patients in Okinawa, Japan, are filed, we compared the prognosis of dialysis patients with diabetes mellitus (DM) and that of dialysis patients with chronic glomerulonephritis (CGN). Using Cox proportional hazard analysis, we examined the effect of the start year of dialysis on survival after adjusting for confounding variables such as age, sex, and predialysis comorbid conditions. Results. Between 1976 and 1998, a total of 1256 DM patients and 2101 CGN patients started dialysis. In the DM patients who started dialysis between 1976 and 1990, the survival rate was 80.4% at 12 months and 42.1% at 60 months, and among those who started dialysis between 1991 and 1998, the survival rate was 87.9% at 12 months and 55.8% at 60 months. In both disease groups, the relative risk of death was significantly lower in patients who started dialysis between 1991 and 1998 than in those who started dialysis between 1976 and 1990. The adjusted relative risk (95% confidence interval [CI]) was 0.65 (95% CI 0.54–0.77). The relative risk of death of DM to CGN was 2.23 (95% CI, 1.91–2.60) when comparing those treated between 1976 and 1990, and 2.00 (95% CI, 1.62–2.46) when comparing those treated between 1991 and 1998. Conclusions. While the prognosis of diabetic dialysis patients in both categories improved significantly with time, that of DM patients was still worse than that of CGN patients. Received: December 14, 2000 / Accepted: March 29, 2001     

Diabetes mellitus, hyperhomocystinemia and atherosclerotic vascular disease in Taiwanese chronic hemodialysis patients: a retrospective study

AIM: Diabetic patients with hemodialysis (HD) have a high mortality rate from atherosclerotic vascular disease (ASVD). However, the extent of the role of hyperhomocystinemia as a risk factor of ASVD is uncertain in diabetic HD patients. We investigated whether there was an association with ASVD events in diabetics and non-diabetics where these were chronic hyperhomocystinemia HD patients. METHODS: Two hundred patients undergoing HD were included in the study. About 50% of the patients had diabetes mellitus (DM). They had predialysis blood work performed for total homocysteine. A history of DM was elicited using information from the patients' questionnaires and verified by careful inpatient and outpatient chart review. RESULTS: A total of 196 patients had hyperhomocystinemia and were enrolled this study. Mean homocysteine concentration was 29.7 +/- 6.6 micromol/L overall. DM was present in 50.0% of patients. The mean homocysteine concentration was 29.4 +/- 9.5 micromol/L and 29.9 +/- 9.7 micromol/L in diabetic HD patients (n=98) and non-diabetic HD patients (n=98), respectively (P=0.71). There was no association with hyperhomocystinemia between diabetic and non-diabetic in chronic HD patients. There were significant differences including age, sex, HDL cholesterol, triglycerides, hypertension, smoking, serum creatinine, dialysis duration and glucose intolerance in the two groups (P<0.05). There were also significant differences in ASVD (P=0.0027) and CVD (P=0.0017) between diabetics and non-diabetics in cases of chronic hyperhomocystinemia HD patients. The adjusted odds ratio for ASVD was 3.02 (95%CI, 1.63 to 5.59) for those subjects with a DM in the highest quartile compared with the lowest 3 quartiles. CONCLUSIONS: There were associations with ASVD and CVD in diabetics and non-diabetics in cases of chronic hyperhomocystinemia HD patients. There was no association with hyperhomocystinemia between diabetic and non-diabetic in Taiwanese chronic HD patients. This study found that the presence of DM and advanced age were the major determinants for ASVD events in chronic HD patients, rather than the levels of homocysteine.     

Serum uric acid levels show a 'J-shaped' association with all-cause mortality in haemodialysis patients.

BACKGROUND: Although elevated serum levels of uric acid are common in patients with kidney disease or in those receiving maintenance dialysis therapy, the clinical impact of uric acid on mortality in haemodialysis (HD) patients remains unclear. This work was designed to explore the predictive value of serum uric acid levels on all-cause mortality of HD patients. METHODS: We retrospectively analysed mortality rates in 146 chronic HD patients that were treated with HD three times per week at our HD unit for a period of one full year. The analysed parameters included demographic characteristics, aetiology of end-stage renal disease, co-morbid conditions, duration (at least 1 year) and delivered dose of HD, normalized protein catabolic rate, serum albumin concentration, haematocrit, serum uric acid (UA) levels and other laboratory parameters. A multivariate Cox proportional hazards model, which included adjustment for the above factors, was applied to identify the predictive value of UA levels on patient mortality. RESULTS: A Cox proportional hazards model revealed that decreased serum albumin, underlying diabetic nephropathy (DMN) and UA groups (< or =20th, 20-80th and > or =80th percentiles; P = 0.016) were all significant, independent predictors of all-cause mortality in HD patients. The hazard ratios of death were: serum albumin (per 0.5 g/dl decrease), 3.10 [95% confidence interval (95% CI), 1.80-5.34, P < 0.001]; DMN (vs non-DMN), 3.47 (95% CI, 1.25-9.59, P = 0.017); and UA groups (vs 20th to 80th percentile): < or =20th percentile, 2.98 (95% CI, 0.82-10.90, P = 0.099); > or = 80th percentile, 5.67 (95% CI, 1.71-18.78, P = 0.004). CONCLUSIONS: These preliminary observations suggest that HD patients in the lowest and highest quintiles of UA levels would face higher risk of mortality. Further studies with larger sample sizes will be needed to confirm these findings.     

Low cancer death rate in chronic dialysis patients with diabetes mellitus

Little epidemiological data is available on the association between cancer and secondary hyperparathyroidism. We previously reported that the cancer death rate is significantly higher in chronic dialysis patients who usually have secondary hyperparathyroidism than that of the general population. In diabetic dialysis watients, prevalence of secondary hyperparathyroidism was reported to be less than non-diabetic patients, consequently less renal osteodystrophy. Therefore, we further analyzed whether the diabetic dialysis patients have less cancer death rate than that of the non-diabetic patients by using the Okinawa Dialysis Registry. From the annual report on the cancer death rate in the general population, we calculated the relative risk, observed/expected ratio, in sex and age-class adjusted. The relative risk of cancer death was 4.26 in non-diabetic and 1.64 in diabetic dialysis patients. Our results support the notion that there is a close relation between parathyroid hormone and neoplasia.     

Associations of dialysis modality and infectious mortality in incident dialysis patients in Australia and New Zealand

BACKGROUND: The aim of the present investigation is to compare rates, types, causes, and timing of infectious death in incident peritoneal dialysis (PD) and hemodialysis (HD) patients in Australia and New Zealand. STUDY DESIGN: Observational cohort study using the Australian and New Zealand Dialysis and Transplant Registry data. SETTING & PARTICIPANTS: The study included all patients starting dialysis therapy between April 1, 1995, and December 31, 2005. PREDICTOR: Dialysis modality. OUTCOMES & MEASUREMENTS: Rates of and time to infectious death were compared by using Poisson regression, Kaplan-Meier, and competing risks multivariate Cox proportional hazards model analyses. RESULTS: 21,935 patients started dialysis therapy (first treatment PD, n = 6,020; HD, n = 15,915) during the study period, and 1,163 patients (5.1%) died of infectious causes (PD, 529 patients; 7.6% versus HD, 634 patients; 4.2%). Incidence rates of infectious mortality in PD and HD patients were 2.8 and 1.7/100 patient-years, respectively (incidence rate ratio PD versus HD, 1.66; 95% confidence interval [CI], 1.47 to 1.86). After performing competing risks multivariate Cox analyses allowing for an interaction between time on study and modality because of identified nonproportionality of hazards, PD consistently was associated with increased hazard of death from infection compared with HD after 6 months of treatment (<6 months hazard ratio [HR], 1.08; 95% CI, 0.76 to 1.54; 6 months to 2 years HR, 1.31; 95% CI, 1.09 to 1.59; 2 to 6 years HR, 1.51; 95% CI, 1.26 to 1.80; >6 years HR, 2.76; 95% CI, 1.76 to 4.33). This increased risk of infectious death in PD patients was largely accounted for by an increased risk of death caused by bacterial or fungal peritonitis. LIMITATIONS: Patients were not randomly assigned to their initial dialysis modality. Residual confounding and coding bias could not be excluded. CONCLUSIONS: Dialysis modality selection significantly influences risks, types, causes, and timing of fatal infections experienced by patients with end-stage kidney disease in Australia and New Zealand.     

The differential impact of risk factors on mortality in hemodialysis and peritoneal dialysis

BACKGROUND: While the survival ramifications of dialysis modality selection are still debated, it seems reasonable to postulate that outcome comparisons are not the same for all patients at all times. Trends in available data indicate the relative risk of death with hemodialysis (HD) compared to peritoneal dialysis (PD) varies by time on dialysis and the presence of various risk factors. This study was undertaken to identify key patient characteristics for which the risk of death differs by dialysis modality. METHODS: Analyses utilized incidence data from 398,940 United States Medicare patients initiating dialysis between 1995 and 2000. Proportional hazards regression identified the presence of diabetes, age, and the presence of comorbidity as factors that significantly interact with treatment modality. Stratifying by these factors, proportional and nonproportional hazards models were used to estimate relative risks of death [RR (HD:PD)]. RESULTS: Of the 398,940 patients studied, 11.6% used PD as initial therapy, 45% had diabetes mellitus (DM), 51% were 65 years or older, and 55% had at least one comorbidity. Among the 178,693 (45%) patients with no baseline comorbidity, adjusted mortality rates in nondiabetic (non-DM) patients were significantly higher on HD than on PD [age 18-44: RR (95% CI) = 1.24 (1.07, 1.44); age 45-64: RR = 1.13 (1.02, 1.25); age 65+: RR = 1.13 (1.05, 1.21)]. Among diabetic (DM) patients with no comorbidity, HD was associated with a higher risk of death among younger patients [age 18-44: RR = 1.22(1.05, 1.42)] and a lower risk of death among older patients [age 45-64: RR = 0.92 (0.85, 1.00); age 65+: RR = 0.86 (0.79, 0.93)]. Within the group of 220,247 (55%) patients with baseline comorbidity, adjusted mortality rates were not different between HD and PD among non-DM patients [age 18-44: RR = 1.19 (0.94, 1.50); age 45-64: RR = 1.01 (0.92, 1.11); age 65+: RR = 0.96 (0.91, 1.01)] and younger DM patients [age 18-44: RR = 1.10 (0.92, 1.32)], but were lower with HD among older DM patients with baseline comorbidity [age 45-64: RR = 0.82 (0.77, 0.87); age 65+: RR = 0.80 (0.76, 0.85)]. CONCLUSION: Valid mortality comparisons between HD and PD require patient stratification according to major risk factors known to interact with treatment modality. Survival differences between HD and PD are not constant, but vary substantially according to the underlying cause of ESRD, age, and level of baseline comorbidity. These results may help identify technical advances that will improve outcomes of patients on dialysis.     

Mortality in end-stage renal disease: a reassessment of differences between patients treated with hemodialysis and peritoneal dialysis

Recent registry studies comparing mortality between peritoneal dialysis (PD) and hemodialysis (HD) patients show conflicting results. The purpose of this study is to determine whether previously published results showing higher mortality for patients treated with PD versus HD in the United States continue to hold true over the period 1987-1993. National mortality rates for PD and HD were extracted from the U.S. Renal Data System (USRDS) annual reports for the cohort periods: 1987-1989, 1988-1990, 1989-1991, 1990-1992, and 1991-1993. Using Poisson regression, death rates per 100 patient years were compared between PD and HD for each cohort period controlling for age, gender, race, and cause of end-stage renal disease (diabetes versus nondiabetes). When incident patients and patients with a prior transplant were included in the analysis, starting with the 1989-1991 cohort, we found little or no difference in the relative risk (RR PD:HD) of death between PD and HD (1987-1989: RR = 1.17, P < 0.001; 1988-1990: RR = 1.12, P < 0.001; 1989-1991: RR = 1.06, P = NS; 1990-1992: RR = 1.06, P = NS; 1991-1993: RR = 1.08, P = 0.043). After a test for goodness-of-fit, separate analyses for diabetic patients and nondiabetic patients were done to examine unexplained variation in death rates. For nondiabetic patients, there was less than a 1% difference in the adjusted 1-yr survival between PD and HD from 1989-1993 (1989-1991: RR = 1.05, P = NS; 1990-1992: RR = 1.04, P = NS; 1991-1993: RR = 1.07, P < 0.01). Among diabetic patients, the PD:HD death rate ratio varied significantly according to gender and age. For the average male diabetic patient, there was little or no difference in risk between PD and HD from 1989-1993 (1989-1991: RR = 1.02, P = NS; 1990-1992: RR = 1.05, P = NS; 1991-1993: RR = 1.08, P < 0.01). For diabetic patients under the age of 50, those treated with PD had a significantly lower risk of death than those treated with HD (1989-1993: 0.84 < or = RR < or = 0.89, P < 0.005). Over the same period, female diabetic patients treated with PD had a higher risk, on average, than HD (1.18 < or = RR < or = 1.19, P < 0.001) as did diabetic patients over the age 50 (1.28 < or = RR < or = 1.30, P < 0.001). Unlike previously published results that were restricted to prevalent-only patients, this national study of both prevalent and incident patients found little or no difference in overall mortality between PD and HD. The recent trends in mortality likely reflect the inclusion of incident patients, but they may also reflect changes in case-mix differences and/or improved PD practice. Additional incident-based studies that allow for additional case-mix adjustments are needed to better compare outcomes between HD and PD.     

Survival analysis of pediatric dialysis patients in Taiwan

Aim: The long‐term survival of Taiwanese children with end‐stage renal disease (ESRD) has not been reported before. This study aimed to determine the long‐term survival, mortality hazards and causes of death in paediatric patients receiving dialysis. Methods: Paediatric patients (aged 19 years and younger) with incident ESRD who were reported to the Taiwan Renal Registry from 1995 to 2004 were included. A total of 319 haemodialysis (HD) and 156 peritoneal dialysis (PD) patients formed the database. After stratification by dialysis modality, multivariate Cox proportional‐hazards model was constructed with age, sex and co‐morbidity as predictive variables. Results: The annual paediatric ESRD incidence rate was 8.12 per million of age‐related populations. The overall 1‐, 5‐, and 10‐year survival rates for PD patients were 98.1%, 88.0% and 68.4%, respectively, and were 96.9%, 87.3% and 78.5% for HD patients. The survival analysis showed no significant difference between HD and PD (P = 0.4878). Using ‘15–19 years’ as a reference group, the relative risk (RR) of the youngest group (0–4 years) was 6.60 (95% CI: 2.50–17.38) for HD, and 5.03 (95% CI: 1.23–20.67) for PD. The death rate was 24.66 per 1000 dialysis patient‐years. The three major causes of death were infection (23.4%), cardiovascular disease (13.0%) and cerebrovascular disease (10.4%). Hemorrhagic stroke (87.5%) was the main type of foetal cerebrovascular accident. Conclusion: We conclude that there was no significant difference of paediatric ESRD patient survival between HD and PD treatment in Taiwan. The older paediatric ESRD patients had better survival than younger patients.     

Perceived health-related quality of life and comorbidity in diabetic patients starting dialysis (CALVIDIA study)

BACKGROUND: Diabetes mellitus (DM) is a widespread prevalent illness, currently the main cause of end-stage renal disease (ESRD). MATERIAL AND METHODS: In a longitudinal, prospective study we compared two cohorts of patients starting dialysis therapy, diabetic and non-diabetic ESRD patients. Perceived health was measured by the Medical Outcomes Study Short-Form 36 (SF-36) questionnaire, functional status by the Karnofsky scale and comorbidity by the Charlson age-comorbidity index. A broad spectrum of variables in relation to diabetes, ESRD, comorbidity and renal replacement therapy (RRT) were studied, as well as the distribution of comorbidity frequencies at dialysis start. RESULTS: Thirty-four Spanish centers included 232 diabetic patients, 43 type 1 and 189 type 2, mean diabetes duration 18 +/- 9 yrs, and five centers included 121 non-diabetic patients. Out of the 232 diabetic patients, 187 patients (81%) started hemodialysis (HD) and 45 patients (19%) started peritoneal dialysis (PD) (vs. 82% and 18%, respectively in non-diabetic patients). Transient vascular access (VA) for starting RRT was required in 54% of the diabetic patients vs. 53% in the nondiabetic patients. When both study groups were compared, diabetic patients required antihypertensive drugs more frequently than non-diabetic patients and showed higher systolic blood pressure (BP), as well as higher cardiovascular (CV) complication incidences, poorer SF-36 physical component summary scores and mental component summary scores and worse Karnofsky scale scores, with the Charlson age-comorbidity score being higher. CONCLUSION: Diabetic patients starting dialysis in Spain are more often type 2 diabetics, have worse perceived health-related quality of life (HRQoL) in relation to non-diabetic patients, worse functional status and higher incidences of prognostic mortality markers.     

Late nephrology referral and mortality among patients with end-stage renal disease: a propensity score analysis.

BACKGROUND: Late nephrology referral has been associated with adverse outcomes among patients with end-stage renal disease; however, its relationship to mortality is unclear. We examined the impact of timing of nephrology care relative to initiation of dialysis on mortality after initiation of dialysis. METHODS: Data from the Dialysis Morbidity and Mortality Study - Wave II, a prospective study of incident dialysis patients, were used. Late referral (LR) was defined as first nephrology visit <4 months and early referral (ER) as first nephrology visit >or=4 months prior to initiation of dialysis. Propensity scores (PS) were estimated using logistic regression to predict the probability that a given patient was LR. A Cox proportional hazards model was built to examine the association between timing of nephrology referral and mortality. RESULTS: The cohort was comprised of 2195 patients: 54% were males, 66% were Caucasians, 26% were African-Americans and 33% were referred late. A Cox proportional hazards analysis demonstrated that compared with ER patients, LR patients had a 44% higher risk of death at 1 year after initiation of dialysis [hazards ratio (HR) = 1.44; 95% confidence interval (CI): 1.15-1.80], which remained significant after adjusting for quintiles of PS (HR = 1.42; 95% CI: 1.12-1.80). CONCLUSIONS: Among patients with chronic kidney disease (CKD) who initiated dialysis, LR was associated with higher risk of death at 1 year after initiation of dialysis compared with ER.     

Minor impairment of oral iron absorption in non-diabetic new dialysis patients

BACKGROUND: Iron absorption is impaired in end-stage renal disease (ESRD). ESRD duration and diabetes mellitus (DM) are prominent risk factors in ESRD patients, associated with multi-system complications involving the gastrointestinal tract. Therefore, we suggest that DM and ESRD duration contribute to iron absorption impairment in ESRD. Since we administer oral iron during hemodialysis (HD) sessions, we assessed the relationship of DM and ESRD duration to intradialytic iron absorption. METHODS: A 4-hr intradialytic oral iron absorption test was performed in 22 non-diabetic patients and 21 diabetic chronic HD patients. Elemental iron, 100 mg (iron(III)-hydroxide-polymaltose) was administered at dialysis start. Serum iron levels were measured hourly since iron ingestion, and standardized according to transferrin levels to correct for intradialytic blood volume changes. The primary end point was peak increase in standardized serum iron level (DeltaI). ESRD duration and DM were defined as months on dialysis and the presence of DM before dialysis initiation, respectively. Evaluated confounding factors included age, gender, dry weight (DW), ultrafiltration volume (UF), UF/DW, eKt/V, transferrin saturation (%SAT), ferritin, parathyroid hormone (PTH), C-reactive protein (CRP) and erythropoietin (EPO) dosage. RESULTS: DeltaI was significantly inversely correlated with ESRD duration. DM was significantly associated with lower DeltaI after statistically controlling for ESRD duration. These relationships remained significant after statistically controlling for %SAT, UF and UF/DW. %SAT was significantly inversely correlated with DeltaI, but contributed to lower variability of DeltaI (11%) than DM (15.2%) and ESRD duration (16.5%). CONCLUSIONS: Intradialytic iron absorption was less impaired in non-diabteic patients with shorter ESRD duration. Therefore, intradialytic oral iron therapy could be successful in these patients.     

Clinical and prognostic analysis of pulmonary hypertension in maintenance hemodialysis patients

Objective To investigate the related factors and prognosis of pulmonary hypertension (PAH) in hemodialysis (HD) patients for early diagnosis and intervention of PAH. Methods A retrospective cohort study was conducted in 183 long?term hemodialysis patients with complete follow?up data from January 1, 2010 to December 30, 2015 from the blood purification center of the Third Affiliated Hospital of Sun Yat?sen University. The follow?up deadline was December 30, 2017, and the endpoints were death and cardiovascular events. The clinical data, laboratory examinations, cardiac color Doppler ultrasound parameters and prognosis of patients with and without PAH were compared. Multivariate logistic regression was used to analyze the risk factors for PAH in HD patients. The survival rates were calculated by Kaplan?Meier method, and the survival curves were compared by Log?rank test between the two groups. A multivariate Cox proportional hazard regression model was used to examine the association between PAH and all?cause mortality in HD patients. Results Of the 183 hemodialysis patients, 79(43.2%) were female, 104(56.8%) were male, and the age was (56.1±16.9) years, of which 72(39.3%) were complicated with PAH. Compared with the non?PAH group, patients in the PAH group was older and had a longer duration of dialysis (both P＜0.05). The left atrial diameter (P=0.002) and the proportion of valvular calcification (P=0.004) were significantly higher in the PAH group than that in the non?PAH group. Logistic regression analysis showed increased age (OR=1.027, 95% CI 1.001-1.053, P=0.041) and increased duration of dialysis (OR=1.129, 95% CI 1.004-1.269, P=0.042) were risk factors for PAH in HD patients. After a median follow?up of 27.8 months, Kaplan?Meier survival analysis showed that all?cause mortality was higher in the PAH group than that in the non?PAH group (χ2=5.636, P=0.018). The main cause of death in two groups was cardiovascular event. After adjusting for age, diabetes mellitus, duration of dialysis, valvular calcification, and hypertension, Cox regression showed that PAH increased the risk of all?cause mortality in HD patients (HR=1.894, 95% CI 1.083-3.313, P=0.025). Conclusions HD patients complicated with PAH are more common and the prognosis is poor. Increased age and increased duration of dialysis may be risk factors for PAH in HD patients. Regular color Doppler echocardiography is helpful for early detection and diagnosis of PAH.     

Mortality differences by dialysis modality among incident ESRD patients with and without coronary artery disease

It is unclear whether peritoneal dialysis (PD) compared with hemodialysis (HD) confers a survival advantage in end-stage renal disease (ESRD) patients with coronary artery disease (CAD). This hypothesis was tested in a national cohort of 107,922 patients starting dialysis therapy between May 1, 1995, and July 31, 1997. Data on patient characteristics were obtained from the Center for Medicare and Medicaid Services Medical Evidence Form (CMS) and linked to mortality data from the United States Renal Data System (USRDS). Patients were classified on the basis of CAD presence and followed until death or the end of 2 yr. Nonproportional Cox regression models estimated the relative risk (RR) of death for patients with and without CAD by dialysis modality using primarily the intent-to-treat but also the as-treated approach. Diabetic patients (DM) and nondiabetic patients (non-DM) were analyzed separately. Among DM, patients with CAD treated with PD had a 23% higher RR (95% CI, 1.12 to 1.34) compared with similar HD patients, whereas patients without CAD receiving PD had a 17% higher RR (CI, 1.08 to 1.26) compared with HD. Among non-DM, patients with CAD treated with PD had a 20% higher RR (CI. 1.10 to 1.32) compared with HD patients, whereas patients without CAD had similar survival on PD or HD (RR = 0.99; CI, 0.93 to 1.05). The mortality risk for new ESRD patients with CAD differed by treatment modality. In both DM and non-DM, patients with CAD treated with PD had significantly poorer survival compared with HD. Whether differences in solute clearance and/or cardiac risk profiles between PD and HD may explain these findings deserves further investigation.     

The impact of diabetes on patients' survival in dialysis patients with non-diabetic renal disease and in patients who develop diabetes during chronic dialysis

BACKGROUND.: It is well known that dialysis patients with diabetic nephropathyhave a poor prognosis, but data concerning the survival of dialysispatients with diabetes plus a non-diabetic primary nephropathyor the survival of patients who develop diabetes after the startof regular dialysis are scarce. AIM AND METHODS.: We reviewed the survival of two cohorts of dialysis patientsin whom diabetes mellitus was associated with non-diabetic primarynephropathy. In the first cohort (18 patients with a primarydiagnosis of APKD) diabetes mellitus preceded hyperazotaemia,whilst the second cohort of 34 patients developed diabetes afterthe start of regular dialysis. We compared the survival of eachgroup of patients to the survival of a group of dialysis patientswith a primary diagnosis of diabetic nephropathy, and to thesurvival of a control group of non-diabetic dialysis patients.Within each case series, groups were similar according to age,sex, age at start of RRT, and place of treatment. All patientswere selected among those alive on treatment at 31 December1987 and were followed up to 31 December 1991. RESULTS.: In both case series the survival of patients with diabetes wassimilar irrespective of the primary diagnosis (Lee—Desustatistics: first cohort P=0.43; second cohort, P=0.08). Moreover,the survival of patients either with diabetic nephropathy orwith diabetes in association with non-diabetic primary nephropathywas significantly worse compared to the survival of the non-diabeticpatients (Lee—Desu statistics: first case series P=0.02and P<0.01; second case series P<0.05 andP<0.01). Logisticregression showed that survival was negatively associated todiabetes and age but not to sex, duration of diabetes and diagnosisof diabetic nephropathy. CONCLUSIONS.: Our limited data show that the survival of diabetic patientson regular dialysis is poor, irrespective of the primary causeof renal failure and of the duration of diabetes. These dataneed confirmation and further study.     

Angiotensin-converting enzyme (ACE) insertion/deletion polymorphism and survival in a cohort of chronic hemodialysis patients

BACKGROUND: There are conflicting reports regarding the relationship between the angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism and the initiation and progression of cardiovascular disease. Moreover, there is no report regarding the relationship between the ACE I/D polymorphism and the prognosis of chronic dialysis patients. METHODS: We examined the frequency of the ACE I/D polymorphism in 727 chronic hemodialysis patients in Okinawa, Japan, and observed the prognosis over 2 years in 407 men and 320 women with mean age (SD) of 55.5 (13.9) years with a mean duration of dialysis of 84.3 (66.6) months. RESULTS: Genotype frequencies were 42.1% for II, 43.2% for ID, and 14.7% for DD. The relative risks of death were examined by Cox-proportional hazards analysis after adjusting for age, sex, age at the start of dialysis, presence of diabetes mellitus and hypertension and total cholesterol and serum albumin levels. The adjusted hazard ratio (95% confidence interval) was 1.03 (0.38 - 2.85) for DD genotype and 1.50 (0.83 - 2.70) for DD+ID genotype when compared to II genotype. CONCLUSION: ACE I/D polymorphism appears to have no relation to the short-term prognosis in chronic hemodialysis patients.     

Geriatric comorbidities, such as falls, confer an independent mortality risk to elderly dialysis patients.

BACKGROUND: As the number of patients aged >/=65 years starting haemodialysis (HD) continues to increase, more patients are at risk of falls, functional decline and cognitive impairment. In an earlier prospective cohort study, we showed that 44% of elderly HD patients had more than one fall within a 1-year period. The objective of this study was to assess whether falls remained predictive of increased mortality risk even after controlling for age, comorbidity, dialysis vintage and laboratory variables. METHODS: Using a prospective, cohort study design, patients aged >/=65 years and on chronic HD during the period April 2002-2003 were recruited. Patients were followed biweekly, and falls occurring within the first year were recorded. Outcome data were collected until death, study end (30 December 2006), transplantation or transfer to another dialysis centre. RESULTS: A total of 162 patients were followed for a median of 32.7 months (quartiles 14-57). In a univariate Cox model with a time-dependent variable for falls status, survival was worse amongst fallers compared to non-fallers (HR 2.13, 95% CI 1.32-3.45; P = 0.002). After adjustment for age, dialysis vintage, comorbidity and laboratory variables, falls were a significant predictor of mortality (HR 1.78, 95% CI 1.07-2.98, P = 0.03). Exclusion of falls associated with concurrent illnesses did not alter the results (HR 1.63, CI 1.02-2.28 P = 0.05). CONCLUSIONS: We conclude that the occurrence of more than one accidental fall in a community-dwelling HD patient aged >/=65 years is associated with an independent increased risk of death. As fall interventions are effective, screening HD patients for falls may be a simple measure of clinical importance.     

Patient and technique survival of diabetics on peritoneal dialysis: one-center's experience and review of the literature

BACKGROUND: Diabetes is the leading cause of end-stage renal disease (ESRD). This retrospective study investigated the long-term patient and technique survival and sought to identify the predictors of mortality in diabetic patients receiving PD. METHODS: Patients, aged 17 years or more who commenced home PD between January 31, 1994, and December 31, 2001 were included. Clinical data were available for 358 patients out of 418 total patients who started PD during this period. They were followed until cessation of PD, death, or to January 31, 2003. Survival probabilities were generated according to the Kaplan-Meier method, and multivariate Cox proportional hazards models were used to assess predictors of survival. RESULTS: A total of 358 patients were enrolled in the study. Among them, 139 patients (38.8%) were diabetics. The 1-, 2-, 3- and 5-year patient survival rates were 91%, 76%, 66% and 47% in diabetics and 94%, 89%, 84% and 69% in non-diabetics, respectively. Median actuarial patient survival for diabetic patients (51.8 months; 95% CI 36.0 a 67.5 months) was significantly shorter than that of non-diabetic patients (log rank 14.117, p < 0.001). Death-censored technique survival rates at 1-, 2-, 3- and 5-year were 90%, 83%, 67% and 58% in diabetic, and 94%, 87%, 77% and 70% in non-diabetic patients, respectively. Similar to patient survival, the median technique survival time was significantly shorter for diabetic patients (63.9 months; 95% CI 35.7 - 92.2 months) than that of non-diabetic patients (log rank 4.884, p = 0.027). Multivariate Cox regression analysis showed that advancing age was the only independent predictor of death in the diabetic patients, whereas higher age and wider pulse pressure were associated with mortality in non-diabetic patients. CONCLUSION: Long-term patient and technique survival for diabetic patients on PD seem to be improved compared to our previous report and other studies. The mortality of diabetic patients was predicted predominantly by advancing age. PD remains a viable form of long-term renal replacement therapy for diabetic patients with ESRD.     

Relationship of body size and initial dialysis modality on subsequent transplantation, mortality and weight gain of ESRD patients

Background Whether peritoneal dialysis (PD) treatment leads to greater weight gain than with hemodialysis (HD) and if this limits access of obese end-stage renal disease patients to renal transplantation has not been examined. We undertook this study to determine the interrelationship between body size and initial dialysis modality on transplantation, mortality and weight gain. Methods Time to transplantation, time to death and weight gain were estimated in a 1:1 propensity score-matched cohort of incident HD and PD patients treated in facilities owned by DaVita Inc. between 1 July 2001 through 30 June 2006 followed through 30 June 2007 (4008 pairs) in four strata of body mass index (BMI) (<18.5, 18.5-24.99, 25.00-29.99 and ≥30 kg/m(2)). Results Transplantation was significantly more likely in PD patients [adjusted hazards ratio (aHR) 1.48, 95% confidence interval (95% CI) 1.29-1.70]; the probability of receiving a kidney transplant was significantly higher in each strata of BMI >18.5 kg/m(2), including with BMI ≥30 kg/m(2) (aHR 1.45, 95% CI 1.11-1.89). PD patients had significantly lower all-cause mortality for patients with BMI 18.50-29.99 kg/m(2). Both these findings were confirmed on analyses of the entire unmatched incident cohort (PD 4008; HD 58 471). The effect of dialysis modality on weight gain was tested in 687 propensity score-matched pairs; the odds of >2, >5 or >10% weight gain were significantly lower in PD patients. Conclusion Treatment with PD is less likely to be associated with a significant weight gain and does not limit the access of obese patients to renal transplantation.