Rapport REIN 2005 — Synthèse

In 2005, 6,021 patients with end-stage renal disease living in fourteen regions covering 45 millions inhabitants (73% of the French population), started renal replacement therapy (dialysis or preemptive graft): median age was 70 years; 3% had a preemptive graft. The overall crude annual incidence rate of renal replacement therapy for end-stage renal disease was 139 per million population (pmp) in thirteen regions that met exhaustivity, with significant differences in sex and age-adjusted incidence across regions (92 to 171 pmh). At initiation, 48% of the patients had at least one cardiovascular disease and 36% diabetes (89% Type 2 non-insulin-dependent diabetes).On December 31, 2005, 21,813 patients living in these fourteen regions were on dialysis: median age was 69 years. The overall crude prevalence rate of dialysis was 539 pmp in thirteen regions. On December 31, 2005, 19,491 patients were living with a functioning graft : median age was 53 years. The overall crude prevalence rate for these patients was 390 pmp in thirteen regions. The overall crude prevalence rate of renal replacement therapy for end-stage renal disease was 929 pmp in thirteen regions, with significant differences in age-adjusted prevalence across regions (732 to 1009 pmh).In the 2002-05 cohort of 11,632 incident patients, the overall one-year survival rate was 82%, 72% at 2 years and 62% at 3 years. Survival decreased with age, but remained above 50% at 2 years in patients older than 75 at RRT initiation.Among the 5,902 new patients starting dialysis in 2005 in the 14 regions, 7% had a BMI lower than 18,5 kg/m² and 16% a BMI higher than 30. At initiation, 63% had an haemoglobin value lower than 11g/l and 9% an albumin value lower than 25 g/l. The first haemodialysis was started in emergency in 30% of the patients and with a catheter in 46%.On December 31, 2005, 8% treated in the dialysis units of the fourteen regions received peritoneal dialysis, of which 35% were treated with automated peritoneal dialysis. 94% of the patients on haemodialysis had 3 sessions per week, with a median duration of 4 hours.In 2005, 1,911 patients received a renal graft. On December 31, 2005, 4,634 patients were on the waiting list for a renal graft in the transplantation centres of the 14 regions.     

REIN annual report 2005. Renal Epidemiology and Information Network & Agence de la biomédecine

In 2005, 6,021 patients with end-stage renal disease living in fourteen regions covering 45 millions inhabitants (73% of the French population), started renal replacement therapy (dialysis or preemptive graft): median age was 70 years; 3% had a preemptive graft. The overall crude annual incidence rate of renal replacement therapy for end-stage renal disease was 139 per million population (pmp) in thirteen regions that met exhaustivity, with significant differences in sex and age-adjusted incidence across regions (92 to 171 pmh). At initiation, 48% of the patients had at least one cardiovascular disease and 36% diabetes (89% Type 2 non-insulin-dependent diabetes). On December 31, 2005, 21,813 patients living in these fourteen regions were on dialysis: median age was 69 years. The overall crude prevalence rate of dialysis was 539 pmp in thirteen regions. On December 31, 2005, 19,491 patients were living with a functioning graft : median age was 53 years. The overall crude prevalence rate for these patients was 390 pmp in thirteen regions. The overall crude prevalence rate of renal replacement therapy for end-stage renal disease was 929 pmp in thirteen regions, with significant differences in age-adjusted prevalence across regions (732 to 1009 pmh). In the 2002-05 cohort of 11,632 incident patients, the overall one-year survival rate was 82%, 72% at 2 years and 62% at 3 years. Survival decreased with age, but remained above 50% at 2 years in patients older than 75 at RRT initiation. Among the 5,902 new patients starting dialysis in 2005 in the 14 regions, 7% had a BMI lower than 18,5 kg/m2 and 16% a BMI higher than 30. At initiation, 63% had an haemoglobin value lower than 11 g/ l and 9% an albumin value lower than 25 g/l. The first haemodialysis was started in emergency in 30% of the patients and with a catheter in 46%. On December 31, 2005, 8% treated in the dialysis units of the fourteen regions received peritoneal dialysis, of which 35% were treated with automated peritoneal dialysis. 94% of the patients on haemodialysis had 3 sessions per week, with a median duration of 4 hours. In 2005, 1,911 patients received a renal graft. On December 31, 2005, 4,634 patients were on the waiting List for a renal graft in the transplantation centres of the 14 regions.     

Prise en charge des patients avant l’initiation d’un traitement de suppléance de l’insuffisance rénale chronique terminale en 2013 en France

This study evaluated the management of patients with end-stage renal disease prior to initiation of renal replacement therapy. Among the 51 million national health insurance general scheme beneficiaries (77% of the population), persons 18 years and older, starting dialysis or undergoing preemptive renal transplantation in 2013, were included in this study. Data were derived from the French national health insurance system (SNIIRAM). In this population of 6674 patients (median age: 68 years), 88% initiated renal replacement therapy by haemodialysis, 8% by peritoneal dialysis, and 4% by renal transplantation. During the year preceding initiation of dialysis, 76% of patients had been hospitalised with at least one diagnostic code for renal disease in 83% of cases, 16% had not received any reimbursements for serum creatinine assay and 32% had not seen a nephrologist; 87% were taking at least one antihypertensive drug (60% were taking at least a renin-angiotensin system inhibitor) and 30% were taking a combination of 4 or more classes of antihypertensive drugs. For patients initiating haemodialysis in a haemodialysis centre, 39% had undergone a procedure related to arteriovenous fistula and 10% had been admitted to an intensive care unit. This study, based on the available reimbursement data, shows that, despite frequent use of the health care system by this population, there is still room for improvement of screening and management of patients with end-stage renal disease and preparation for renal replacement therapy.     

Chronic renal failure in Sudanese children: aetiology and outcomes

The provision of tertiary paediatric nephrology facilities has led to increasing referrals of children with chronic renal failure (CRF). We report the aetiology and outcomes over 5 years, during which period the improving socio-economic situation has allowed increasing provision of dialysis and transplantation. The records of 205 children (124 male; 60.5%) who were referred to a tertiary paediatric nephrology unit in Khartoum between 2001 and 2006 with a glomerular filtration rate of less than 50 ml/min per 1.73 m² body surface area were reviewed. The mean age at the time of diagnosis with CRF was 9.8 years (range 3 months–17 years). The aetiology was chronic glomerulonephritis in 52 (25.4%), congenital urological malformations in 36 (17.5%), urolithiasis in 19 (9.3%), hereditary nephropathy in 14 (6.8%), multisystem diseases in 4 (2%), and cause unknown in 80 (39.1%). Of the 205 children, 136 (63%) had reached end-stage renal failure, with chronic haemodialysis being undertaken in 48 (35.3%), intermittent peritoneal dialysis in 43 (31.6%), continuous ambulatory peritoneal dialysis in 17 (14.7%), and no treatment in 25 (18.4%). At the end of the study period 53 of the 205 (25.9%) remained on dialysis, 51 (25%) were on conservative treatment, 8 (3.9%) had received transplants, 48 (23.4%) had died, and 45 (22%) had been lost to follow-up. The results illustrate the geographical variations in CRF aetiology in different countries, which may be influenced by current patterns of referral as well as environmental and society factors. The large number with an unknown aetiology for their CRF requires further prospective investigation. We hope the current high mortality rate will improve with earlier referral, improved nutrition, family support, and better access to treatment modalities, especially the provision of kidney transplantation from living related donors.     

Prevention of renal failure: the Malaysian experience

Renal replacement therapy in Malaysia has shown exponential growth since 1990. The dialysis acceptance rate for 2003 was 80 per million population, prevalence 391 per million population. There are now more than 10,000 patients on dialysis. This growth is proportional to the growth in gross domestic product (GDP). Improvement in nephrology and urology services with widespread availability of ultrasonography and renal pathology has improved care of renal patients. Proper management of renal stone disease, lupus nephritis, and acute renal failure has decreased these as causes of end-stage renal disease (ESRD) in younger age groups. Older patients are being accepted for dialysis, and 51% of new patients on dialysis were diabetic in 2003. The prevalence of diabetes is rising in the country (presently 7%); glycemic control of such patients is suboptimal. Thirty-three percent of adult Malaysians are hypertensive and blood pressure control is poor (6%). There is a national coordinating committee to oversee the control of diabetes and hypertension in the country. Primary care clinics have been provided with kits to detect microalbuminuria, and ACE inhibitors for the treatment of hypertension and diabetic nephropathy. Prevention of renal failure workshops targeted at primary care doctors have been launched, opportunistic screening at health clinics is being carried out, and public education targeting high-risk groups is ongoing. The challenge in Malaysia is to stem the rising tide of diabetic ESRD.     

Etiology and outcome of chronic renal failure in Indian children

A prospective analysis of all new pediatric cases of chronic renal failure (CRF) was performed at our hospital over a 1-year period. The diagnosis of CRF was based on serum creatinine >2 mg/dl with supportive clinical, laboratory, and radiological findings. There were a total of 48 patients with CRF with a median age of 13 years (range 10 days to 16 years). The causes of CRF included glomerulonephritis (37.5%), obstruction and interstitial (52%), hereditary (6.3%), and undetermined (4.2%). Patients were symptomatic for a mean of 33.2 months (range 10 days to 11 years) at presentation. Eight patients (16.7%) had acute reversible deterioration of renal function at presentation. This was due to accelerated hypertension in 2, infection in 3, volume depletion in 2, and nonsteroidal antiinflammatory drugs in 1 patient. At presentation, 22 (46%) children had mild to moderate renal failure and 26 (54%) had end-stage renal disease. Twenty-one children (43.7%) had associated illness at presentation. Mean follow-up was 22.9 weeks (range 2–126 weeks). At the end of the study period, 10 (21%) patients were on conservative treatment, 7 (14.6%) on maintenance dialysis, 8 (16.7%) patients had functioning allografts, 4 (8.3%) patients had died, and 19 (39.6%) opted against further therapy. We conclude that CRF in Indian children carries a poor prognosis due to late referral and the limited availability and high cost of renal replacement therapy. Received: 31 July 1998 / Revised: 7 December 1998 / Accepted: 13 December 1998     

Interventional nephrology in a federal hospital: economics of health care

Interventional nephrology is now an accepted subspecialty of nephrology that is revolutionizing the standard of care for renal failure patients. Interventional nephrology deals with the placement of tunneled cuffed catheters (TCCs) and maintenance of permanent vascular accesses, thus assisting in timely care. Prior to 2000 most end-stage renal disease (ESRD) patients from the Overton Brooks Veterans Affairs Medical Center (OBVAMC) were referred to an outlying hospital for TCC placement and endovascular procedures (EVPs) of permanent dialysis access. The referral process was cumbersome for the patients and expensive to the Medicine Service. OBVAMC started an interventional nephrology service in 2000. The current study reports the financial benefits of starting an interventional nephrology service at our institution. All procedures performed during the period from April 2000 to April 2004 were analyzed. The procedures were performed in the cardiac catheterization laboratory. The total payment (physician's and hospital fees) to the referral hospital for procedures prior to April 2000 was used to estimate the average savings to the Medicine Service over the last 4 years. A total of 129 TCCs and 43 EVPs were performed during this period. The estimated expense to OBVAMC would have been US dollars 603,978 for TCCs and US dollars 288,100 for EVPs based on charges prior to April 2000. The actual expense to the hospital, including facility fees and disposables, was US dollars 156,013. The net savings to OBVAMC over the last 4 years was US dollars 736,065. Interventional nephrology provided to a small population of renal failure patients in a tertiary federal health care facility has resulted in huge savings for the hospital. Increasing awareness of this procedural aspect of nephrology benefits not only the patients, but also helps ease the financial burden of ever-escalating health care costs.     

Acquired renal cystic disease in children and young adults on maintenance dialysis

Acquired renal cystic disease (ARCD) is a well-known complication of end-stage renal disease (ESRD). We studied 24 patients, aged 8 – 27 years (mean 19.8±5.3 years), on chronic maintenance dialysis in our service. The duration of dialysis ranged between 13 and 192 months (mean 77.8±44.3 months). High-resolution ultrasonography revealed ARCD in 11 (45.8%) patients. No cysts were seen in 7 (29.1%) patients and solitary cysts in one or both kidneys were seen in 6 (25%) patients. Renal malignancy was diagnosed in 2 patients. One, 15 years old, had renal cell carcinoma after being on dialysis for 6 years. She did well after bilateral nephrectomy, left salpingo-oophorectomy, and regional lymphadenectomy. The second patient, 23 years old, had been on dialysis for 16 years when she developed renal oncocytoma. She died of congestive cardiomyopathy 6 months later. We conclude that ARCD is common in children and young adults with ESRD. Neoplastic transformation, although rare, is a potential complication. Annual follow-up with ultrasonography with selective use of computed tomography or magnetic resonance imaging is advised. Received July 29, 1996; received in revised form and accepted November 15, 1996     

Long-term results of pediatric kidney transplantation at one center in Turkey

Kidney transplantation is considered the treatment of choice for children with end-stage renal disease (ESRD). From November 1975 to June 2004, 80 of a total of 1477 kidney transplantations were performed in 78 pediatric patients. We retrospectively reviewed the records of 42 boys and 36 girls. Patient age ranged from 8 to 16 years (mean, 14.9 +/- 2.2). Sixty-three (78.7) grafts were from living donors and 17 (21.3%) from deceased donors. Two patients (2.6%) underwent preemptive transplantation, while 76 had preoperative renal replacement therapy with either hemodialysis in 62 (79.5%) or peritoneal dialysis in 14 (17.9%). Although the cause of ESRD could not be established in 30 cases, the other 48 showed the most common etiologies to be reflux nephropathy and glomerulonephritis. In conclusion, despite relatively poor socioeconomic conditions and health care problems in our country, the overall outcomes for pediatric patients at our transplantation center are good. We seek to perform more preemptive kidney transplantations in children with ESRD, and to increase our efforts to educate the Turkish public about organ transplantation and donation.     

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

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

Recovery of renal function after long-term dialysis in hemolytic uremic syndrome

Long-lasting recovery of renal function of the native kidneys after prolonged renal replacement therapy is rare. An 8-year-old girl and a 3-year-old boy had suffered from acute atypical and diarrhea-associated hemolytic uremic syndrome (HUS), respectively, with subsequent apparent end-stage renal failure. Both recovered renal function after long-lasting anuria and dialysis of 8 and 16 months, respectively. After prolonged follow-up, i.e., 7 and 5 years after cessation of dialysis, they attained normal or slightly reduced renal function (plasma creatinine 84 and 90 µmol/l, respectively). In addition, growth and cognitive development were normal. We conclude that caution is appropriate before offering early renal transplantation to pediatric patients with presumed end-stage kidney disease secondary to HUS.     

Physician access and early nephrology care in elderly patients with end-stage renal disease

Early nephrology care may improve treatment outcomes of patients with end-stage renal disease. We sought to examine if physician access affects early nephrology care defined as visiting a nephrologist 12 to 4 months before initiating dialysis. The study population consisted of elderly patients starting hemodialysis whose demographic characteristics and initial dialysis therapy were derived from form 2728 files of the Centers for Medicare & Medicaid Services. Early nephrology care, chronic kidney disease and co-morbidities along with access to local non-nephrologist physicians and nephrologists were identified based on Medicare claims and/or United States 2000 Census data. About one-third of elderly patients received early nephrology care prior to initiating dialysis. Patients living in an area with a large number of non-nephrologist physicians or living relatively far away from a nephrologist had a lower likelihood of getting early nephrology care prior to initiating dialysis while those in an area with more practicing nephrologists were more likely to get early nephrology care. The study shows that physician access significantly influences the use of early nephrology care among elderly patients progressing to end-stage renal disease in the United States.     

Épidémiologie de la maladie rénale chronique chez l’enfant

Major advances have been made in the management of children with chronic kidney disease over the past 30 years. However, existing epidemiology data are primarily from kidney replacement therapy registries, and information available at earlier stages of chronic kidney disease is limited. The incidence and prevalence of chronic kidney disease stages 2 to 5 remain poorly understood. However, rare population-based studies suggest that the prevalence of all-stage chronic kidney disease may be as high as 1% of the pediatric population. Congenital disorders including congenital abnormalities of the kidney and urinary tract and hereditary nephropathies account for one-half to two-thirds of pediatric chronic kidney disease cases in middle and high-income countries, whereas acquired nephropathies seem to predominate in low-income countries. The progression of chronic kidney disease is slower in children with congenital disorders than in those with acquired nephropathy, particularly glomerular disease, resulting in a lower proportion of congenital abnormalities of the kidney and urinary tract as a cause of end-stage kidney disease compared to less advanced stages of chronic kidney disease. The incidence of kidney replacement therapy in the pediatric population ranged by country from 1 to 14 per million children of the same age in 2018 (approximately 8 per million children in France) in patients younger than 20 years. The prevalence of kidney replacement therapy in children under 20 years of age in 2018 ranged from 15-30 per million children in some Eastern European and Latin American countries to 100 per million children in Finland and the United States (56 per million children in France). Most children with end-stage kidney disease initiate kidney replacement therapy with dialysis (more frequently hemodialysis than peritoneal dialysis). In about 20% of cases, the initial kidney replacement therapy modality is a pre-emptive kidney transplantation. In high-income countries, 60-80% of prevalent children with end-stage kidney disease live with a functioning transplant (75% in France). While the survival of children with chronic kidney disease has continuously improved over time, mortality remains about 30 times higher than in the general pediatric population.     

Nephrology and renal replacement therapy in Romania

BACKGROUND: In the context of the transformation of the Health Systems of Central and Eastern European countries, the role of professional associations is increasing, especially as regards data collection, analysis, and implementation of programmes for development of nephrology and renal replacement therapy (RRT). METHODS: The Romanian Renal Registry sent questionnaires to the heads of Haemodialysis and Nephrology Centres. The need for renal replacement therapy was deduced from the annual incidence (127 patients p.m.p.) of chronic renal failure. RESULTS: Although the rates of increase in the numbers of Nephrology Departments (+82%), HD Centres (+142%), and total number of patients alive on RRT (+196%) from 1991 to 1995 were higher than the European mean, only 27-30% of the incident patients (459 of 1000-1200 patients) could be provided with RRT. Sixty-two percent of the need for RRT in the age group 25-44 years was met, while only 20% of children (age < 15 years) and people over 55 years requiring RRT received this treatment. Primary renal diseases in patients on RRT were glomerulonephritis (49%) or interstitial nephropathies (23%); diabetic nephropathies, nephroangiosclerosis and systemic diseases were rare (4, 2, and 1% respectively). Most of the CRF patients (88%) were treated by HD. Renal transplantation and peritoneal dialysis were seldom performed (8 and 4%). The cost of HD treatment in Romania (87 USD) is low, even though dialyser reuse is not common practice. CONCLUSIONS: The increase in renal replacement therapy in Romania was mainly due to the expansion of the number of haemodialysis centres. Although a significant progress was realized, only one-third of the patients needing RRT could be treated in Romania in 1995.      

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.     

Patients with Fabry disease on dialysis in the United States.

BACKGROUND.: Fabry disease results from an X-linked deficiency of lysosomal alpha-galactosidase A and is a rare cause of end-stage renal disease. Little is known about the characteristics of patients with Fabry disease that initiate dialysis in the United States, although data from Europe suggests these individuals have a poor survival. METHODS.: Using the United States Renal Disease System database, we first studied in detail 42 Fabry patients who initiated dialysis between April 1995 (following the introduction of the new detailed HCFA 2728 form) and July 1998. To examine crude survival in a larger cohort, 95 Fabry patients were studied who initiated dialysis between 1985 and 1993, similar to the European Registry. Diabetic and non-diabetic controls matched by age, gender, race, year of dialysis initiation, and initial dialysis modality were examined for comparison. RESULTS.: During the years 1995 to 1998, the mean age of Fabry patients that initiated dialysis was 42 years, 83% were Caucasian, and 10% were African American. Despite the X-linked inheritance of Fabry disease, 12% of Fabry patients on dialysis were female. At initiation of dialysis mean serum albumin and creatinine were significantly higher and mean body mass index was significantly lower among Fabry patients, but mean glomerular filtration rate was similar to controls. Fabry patients tended to have a lower three-year survival compared to non-diabetic controls, but the results were not significantly different. In a larger cohort of Fabry patients who initiated dialysis between 1985 and 1993, the three-year survival of Fabry patients was significantly lower than non-diabetic controls: 63% (95% CI, 50 to 75%) versus 74% (95% CI, 67 to 80%; P=0.03). CONCLUSION.: End-stage renal disease is associated with significant morbidity and mortality among patients with Fabry disease. Recent evidence that progression of Fabry disease may be attenuated by enzyme replacement therapy necessitates increased awareness of Fabry disease and its comorbidities.     

Chronic renal failure in pediatrics 1996

 The Nephrology Branch of the Chilean Pediatric Society has greatly influenced the development of government health plans regarding the management and care of patients under 18 years with chronic renal failure (CRF). In order to assess the status of children with CRF in Chile up to 1996, a questionnaire was sent to all pediatric nephrologists in charge of those children. The total sample was of 227 patients under 18 years, giving a national prevalence of 42.5 and an incidence of 5.7 per million inhabitants; of these patients, 50.7% were male, 58.6% over 10 years and 15% younger than 5 years. The most frequent etiologies of CRF were: obstructive uropathy, 18.1%; hypo/dysplasia, 16.7%; reflux nephropathy, 16.7%; and glomerulopathies, 16.3%. Although 48% of patients were on conservative medical treatment, 42.2% of these were in end-stage renal disease, 22.9% were on dialysis, and 29.1% had undergone renal transplantation. Of the dialysis group, 75% were on peritoneal dialysis. Of the transplanted children, 78.8% had normal renal function, but 16.7% returned to dialysis. Three-year graft survival and patient survival were 68% and 94%, respectively. Received: 19 January 1998 / Revised: 6 July 1998 / Accepted: 16 July 1998     

Acute renal failure in the pediatric age group - single center prospective study of 180 cases

Acute renal failure (ARF) is one of the common emergencies in pediatric practice. In the Indian subcontinent, its etiology, clinical features and outcome vary from other parts of the world. We decided to perform a prospective study of ARF in 180 pediatric patients admitted to our institute between August 2006 and March 2008. Our study included children, neonates 7.8%, <1 year 16.7%, 1-5 years 30.5% and >5 years comprised 52.8%. The male:female ratio was 2.3:1. Acute tubular necrosis remains the major cause of ARF; other intrinsic renal disease accounted for almost 30% of the patients. In all patients of ARF who required dialysis, peritoneal dialysis was offered as the first-line management. Six patients were offered hemodialysis. Mortality below one year age was higher compared with those who were more than one year of age (40% vs 11.3%). The overall mortality in the present study was 17.7%. ARF in pediatric nephrology is not uncommon. In our setup, peritoneal dialysis (PD) is an effective and safe modality of renal replacement therapy in most of the cases. Delayed referral, malnutrition, infections, age less than one year and multiorgan involvement were bad prognostic features.     

Renal replacement therapy for end-stage renal failure before 2 years of age.

This report concerns 296 children (67% males and 33% females) from 24 countries who started renal replacement therapy (RRT) for end-stage renal failure between 1969 and 1988. Children under 2 years of age represented 3.6%, 4.4%, and 8.9% of all children under 15 years of age who started RRT in 1978-1982, 1983-1985, and 1986-1988 respectively. During the first 2 years of life, the most frequent causes of end-stage renal failure were renal hypoplasia and dysplasia (24%), and haemolytic-uraemic syndrome (17%). During 1986-1988 the initial therapy for ESRF was continuous ambulatory peritoneal dialysis (CAPD) in 60%, haemodialysis 25%, intermittent peritoneal dialysis 8%, and 7% were transplanted without prior dialysis. Between 1978 and 1988, 139 of these children were grafted; 53 received a graft (39 cadaveric, 10 living donor, 4 donor uncertain) below, and 86 (71 cadaveric, 14 living donor, 1 donor uncertain) above 2 years of age. One-year graft survival was 54% in the 53 children grafted below 2 years of age and 65% in the 86 grafted above 2 years of age. Only two of the 24 living donor grafts were lost during the first year after grafting. These results compare favourably with the 67% 1-year graft survival of all 278 children aged 2 to less than 6 years at grafting in 1978-1988 on the Registry's file. The 3-year survival of all children aged less than 2 years at start of RRT was 65% in 1978-1982 and rose to 78% in 1986-1988. Twenty-three percent of all deaths were caused by infections.(ABSTRACT TRUNCATED AT 250 WORDS)     

End-stage renal disease of the Tunisian child: epidemiology,etiologies, and outcome

From December 1989 to December 1993, 90 children under 15 years were admitted to our department for end-stage renal disease; 9 children were less than 5 years and 28 were aged between 5 and 10 years. The sex ratio (M/F) of the children was 2.1. The estimated incidence of pediatric end-stage renal disease in Tunisia is 7 new cases per year and per million child population under 15 years. The chief etiologies of end-stage renal disease are glomerulonephritis (19%), hereditary nephropathies (29%), and malformative uropathies (13%); 26% of the end-stage renal diseases are of unknown etiologies. Our findings, compared with the European data, show a particularly high frequency of primary hyperoxaluria (13.5%) and an unusual proportion of male subjects. Received April 13, 1995; received in revised form and accepted January 4, 1996