Factors affecting survival in advanced chronic kidney disease patients who choose not to receive dialysis

INTRODUCTION: Non-dialytic treatment (NDT) has become a recognized and important modality of treatment in end stage renal disease (ESRD) in certain groups of chronic kidney disease (CKD) patients. However, little is known about the prognosis of these NDT patients in terms of hospitalization rates and survival. We analyzed our experience in managing these NDT with a multidisciplinary team (MDT) approach over a three-year period. PATIENTS AND METHODS: The Renal Unit at the Royal Liverpool University Hospital set up a dedicated MDT clinic to manage NDT patients in January 2003. Patients approaching end stage chronic kidney disease who chose not to dialyse were recruited from other nephrologists. The study group was classified according to age band (<70 years, 71-80 years, and >80 years), estimated glomerular filtration rate (eGFR) (<10 ml/min, 11-20 ml/min, and >20 ml/min) according to the Modified Diet In Renal Disease formula and Stoke comorbidity grade (SCG). The SCG is a validated scoring system for the survival of patients on renal replacement therapy. We also used the ERA-EDTA primary renal diagnosis codes. As there are no existing standards for NDT patients, we used the U.K. national set for haemodialysis patients as a reference and target for our NDT patients. Data was collected prospectively. RESULTS: The median age was 79 years and the male: female ratio was approximately 1. The most common primary cause of kidney disease in the NDT study population was chronic renal failure of unknown cause n = 22 (31%), but the most common identifiable cause was diabetic nephropathy, n = 20 (28%). The most common comorbidity was ischaemic heart disease n = 25 (34%). Those achieving the standards for anaemia were 78% at referral. Only 30% of the NDT patients achieved the standard for blood pressure (<130/80 mmHg) at referral. Forty-three patients (60%) had no admissions at all. There were a total of 30 patients admitted on 58 occasions. Thirty-one (53%) of these were due to a non-renal cause. The median length of stay for the other NDT patients was 10 days. The median overall survival (life expectancy) was 1.95 years. The one-year overall survival was 65%. SCG was an independent prognostic factor in predicting survival in NDT patients studied (p = 0.005), the hazard ratio being 2.53, for each incremental increase in the SCG. At one year, the survival for comorbidity grade 0, 1 and 2 were 83%, 70% and 56% respectively. Of the 28 patients who died, 20 did so at home (71%). DISCUSSION: The NDT of ESRD has become an important alternative modality in renal replacement therapy. With the emergence of epidemic proportions of CKD, more elderly patients with progressive renal disease will need to make informed decisions regarding renal replacement therapy. There is likely to be increasing number of elderly patients that will tolerate dialysis badly and who will be very dependent on others. We believe that there should be a multidisciplinary approach to assist the ESRD patients in choosing their modality of renal replacement therapy, and with an agreed care plan to support these patients in managing their chosen modality to achieve the best possible quality of life. There should be integrated services with primary care, community nurses, and palliative care teams to enable the majority of the patient's treatment to be carried out at home and to allow a dignified death. However. there was a statistically significant trend for shorter survival among those with greater comorbidities, as determined by the SCG. This is the first report of the potential importance of SCG as an independent prognostic factor in NDT patients. This will help us to counsel our patients in the future about their prognosis if they choose NDT as their modality of renal replacement therapy. CONCLUSION: Our prospective study is the first and currently the largest observational study of a multidisciplinary approach in the management of NDT patients. SCG was an independent prognostic factor in predicting survival. In those patients who chose not to dialyse, SCG provides a potentially useful indication of expected prognosis.     

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.     

Renal replacement therapy in type 2 diabetic patients: 10 years' experience.

The objective of this study was to determine the impact of renal transplantation and hemodialysis treatment on outcome of elderly diabetic patients with end-stage renal disease (ESRD) among other factors related to survival. Results of treatment of ESRD in 78 patients with non-insulin-dependent diabetes mellitus (type 2) showed a survival rate of 58% at 1 year and 14% at 5 years, independent of treatment modality. Patients who received a renal allograft had a higher survival rate as compared with patients on hemodialysis treatment (5-year survival, 59% v 2%; P < 0.005). Diabetic patients with a history of myocardial infarction, stroke, or peripheral gangrene before onset of renal replacement therapy had a worse prognosis in comparison to patients without vascular complications (5-year survival, 2% v 21%; P < 0.05). Analysis of patients who survived less than 6 months and more than 24 months was performed. Long-term survivors were slightly younger, had diabetes for a shorter period, and showed a better metabolic control of diabetes mellitus. Sixteen long-term survivors received a renal allograft. In contrast, only three short-term survivors were transplanted. Furthermore, short-term survivors also had a greater than 70% incidence of severe vascular complications before renal replacement therapy. A history of myocardial infarction, stroke, or peripheral gangrene is an independent predictor of decreased survival, irrespective of whether the patients were transplanted or maintained on chronic hemodialysis treatment. In contrast, renal transplantation improved survival of elderly diabetic patients without vascular complications and should be the treatment of choice in this specific group of patients.     

Does ethnicity influence perceived quality of life of patients on dialysis and following renal transplant?

BACKGROUND: Quality of life (QoL) as perceived by patients with end-stage renal disease (ESRD) is an important measure of patient outcome. There is a high incidence of ESRD in the Indo-Asian population in the UK and a lower rate of transplantation compared with white Europeans. The aim of this study was to determine whether perceived quality of life was influenced by treatment modality and ethnicity. METHODS: Sixty Indo-Asians treated with either peritoneal dialysis (n=20), hospital haemodialysis (n=20) or with a renal transplant (n=20) for >3 months were compared with 60 age-matched white Europeans closely matched for gender, diabetes and duration of renal replacement therapy. QoL was measured using the Kidney Disease and Quality of Life questionnaire (KDQOL-SF). The KDQOL-SF measures four QoL dimensions: physical health (PH), mental health (MH), kidney disease-targeted issues (KDI) and patient satisfaction (PS). Adequacy of treatment was measured by biochemistry, 24 h urine collection and dialysis kinetics. The number of comorbid conditions was scored. Social deprivation was calculated from the patient's postal address using Townsend scoring. RESULTS: QoL was significantly lower in Indo-Asians than white Europeans for PH, MH and KDI. This was not related to treatment adequacy, which was similar in both for each modality. Indo-Asians had a worse index of social deprivation than white Europeans (P=0.008). PH and KDI were related to social deprivation (P=0.007 and P=0.005, respectively). QoL (except PS) was inversely correlated with comorbidity. Dialysis patients had higher comorbidity than transplant patients (P<0.02). Comparing only those dialysis patients considered fit for transplantation (n=51) with transplant patients, comorbidity was similar, but differences in QoL persisted. CONCLUSION: This study demonstrates a lower perceived QoL in Asians compared with white Europeans with ESRD. Analysis of QoL indicates that Asian patients in particular perceive kidney disease as a social burden, even if successfully transplanted.     

Etiology and epidemiology of end-stage renal disease in Dutch children 1987–2001

In this retrospective study 351 children (<16.0 years) with end-stage renal disease (ESRD) accepted for renal replacement therapy (RRT) in the four Dutch pediatric centers were analyzed for the period 1987–2001. The data were compared with a previous study performed in 1979–1986. Eighty patients were of non-Dutch origin. An annual ESRD incidence of 5.8 patients per million of the child population (p.m.c.p.) was calculated, without significant changes with time. The final prevalence in Dutch children under 15 years of ESRD was 38.7 p.m.c.p. The most frequent primary renal disease leading to ESRD was urethral valves, with a significant increase vs. the previous observation period (14% vs. 6%). The distribution of primary renal diseases was similar in patients of non-Dutch origin and in Dutch patients. Peritoneal dialysis was the most frequent dialysis procedure initially applied (62% vs. 26% in the earlier observation period). Thirteen percent of all first transplantations (n=278) were pre-emptive and 19% from living donors. Five-year graft survival after a living-donor and a cadaver graft was 80% and 73%, respectively. Overall patient survival after 10 years on RRT was 94%.     

Renal Replacement Therapy in Patients With HIV Infection in a European Region: Outcomes Following Renal Transplantation

Introduction

The prognosis of HIV infection has improved dramatically in patients with end-stage renal disease (ESRD). Thus, HIV infection is no longer an absolute contraindication for renal transplantation.

Methods

A cross-sectional study was performed to analyze the characteristics of HIV patients receiving renal replacement therapy (RRT) in September 2011, using data from the Registry of Renal Patients in Andalusia. A retrospective cohort study was also carried out, analyzing patients receiving kidney transplants in the era of highly active antiretroviral therapy.

Results

In Andalusia in September 2011, 8744 patients were on RRT; of these, 48 had HIV infection (prevalence 0.54%). The RRT modality was very different between HIV-negative and HIV-positive patients: renal transplantation 49.2% and 16.7%, hemodialysis 46.8% and 81.3%, and peritoneal dialysis 4% and 2%, respectively. The most frequent ESRD etiology was glomerulonephritis (37.5%). Twenty-seven (56.3%) had hepatitis C coinfection. Only three patients (7.5%) were on the waiting list for renal transplantation. From 2001 to September 2011, 10 HIV-infected patients received a renal transplantation (median follow-up 40.5 months). The initial immunosuppressive treatment included tacrolimus and mycophenolate without induction therapy. Only two patients presented acute rejection, both borderline and corticosensitive. All remain alive and the graft survival was 100% in the first and third years posttransplant. We compared demographic and comorbidity variables between patients transplanted or included on the waiting list (n = 12) and patients excluded and never transplanted (n = 36). We found differences only in the ESRD etiology (higher incidence of glomerulonephritis in excluded patients).

Conclusions

Renal transplantation is safe in correctly selected HIV-infected patients. The number of patients on the waiting list is very small. This may reflect the high comorbidity but it is also possible that these patients are still not being assessed systematically for transplant in all centers.     

Survival and morbidity of HIV patients on hemodialysis and peritoneal dialysis: one center’s experience and review of the literature

Background Controversy continues concerning the morbidity and mortality of HIV-infected ESRD patients on the two dialysis options. This article presents our experience with complications and survival rate among our HIV-infected ESRD patients on peritoneal dialysis and hemodialysis. We reviewed the literature on this subject. Methods The charts of seven and eight HIV-infected ESRD patients on peritoneal dialysis and hemodialysis respectively, between January 1989 and November 2004, were reviewed retrospectively for specific clinical and demographic data. Their survival was calculated using the Kaplan-Meier method. Results Total follow-up of HIV-infected PD and HD patients was 248.3 and 207 patient months, respectively. There was no significant difference in hospitalization rate between HIV-infected PD and HD patients (1.01 and 1.39 admission/year, respectively, P = NS). Survival of HIV-infected patients on PD at one, two and three years was 100, 83, and 50%, and for HD patients was 75, 33, and 33%, respectively. HIV-infected patients on HD had more prevalent advanced HIV disease. Two out of seven PD patients were on PD for more than five years and one of the HD patients was on that form of dialysis for more than nine years. Median survival of patients with advanced (Stage IV) AIDS (both HD and PD) was 15.1 months (range 1.6–17.3) while this value for non-advanced (Stage II, III) patients was 61.2 months (range 6.8–116.6). Conclusion Type of renal replacement therapy does not have a significant effect on the morbidity and mortality of HIV-infected ESRD patients. Survival is worse in patients with advanced HIV disease. Both dialysis options provide similar results in HIV patients; hence, the choice of dialysis modality should be based on patient’s preference and social conditions.     

Confounding effect of comorbidity in survival studies in patients on renal replacement therapy.

BACKGROUND: After taking other confounding factors into account, the impact of comorbidity on mortality was investigated when comparing mortality between five European countries, dialysis modalities and renal disease groups. METHODS: The study included 15 571 incident patients on renal replacement therapy (RRT) from five national or regional registries participating in the European Renal Association-European Dialysis and Transplant Association Registry that collect comorbidity data. The presence of diabetes mellitus, ischaemic heart disease, peripheral vascular disease, cerebrovascular disease and malignancy was recorded at the start of RRT. RESULTS: The comorbidities were each independently associated with mortality, with hazard ratios (HRs) ranging from 1.40 (95% CI: 1.30-1.51) for peripheral vascular disease to 1.65 (95% CI: 1.48-1.83) for diabetes. Age, gender, primary renal disease, modality and country together explained 14.4% of the variance in mortality; the comorbidities explained an additional 1.9%. In the comparison of renal vascular disease with glomerulonephritis, the crude HR of 2.40 (95% CI: 2.12-2.72) changed to 1.24 (95% CI: 1.09-1.41) after adjustment for age, gender, primary renal disease, treatment modality and country and to 1.06 (95% CI: 0.93-1.22) after further adjustment for the comorbidities. For the comparison between countries and other patient groups, the change in the survival estimate after adjustment for comorbidity was less. CONCLUSION: Comorbidity is an important predictor for mortality. However, after adjustment for age, gender, primary renal disease, treatment modality and country, when comparing outcomes between patient groups the influence of comorbidity may be less important than expected.     

Predictors of renal and patient outcomes in atheroembolic renal disease: a prospective study

Atheroembolic renal disease (AERD) is part of a multisystemic disease accompanied by high cardiovascular comorbidity and mortality. Interrelationships between traditional risk factors for atherosclerosis, vascular comorbidities, precipitating factors, and markers of clinical severity of the disease in determining outcome remain poorly understood. Patients with AERD presenting to a single center between 1996 and 2002 were followed-up with prospective collection of clinical and biochemical data. The major outcomes included end-stage renal disease (ESRD) and death. Ninety-five patients were identified (81 male). AERD was iatrogenic in 87%. Mean age was 71.4 yr. Twenty-three patients (24%) developed ESRD; 36 patients (37.9%) died. Cox regression analysis showed that significant independent predictors of ESRD were long-standing hypertension (hazard ratio [HR] = 1.1; P < 0.001) and preexisting chronic renal impairment (HR = 2.12; P = 0.02); use of statins was independently associated with decreased risk of ESRD (HR = 0.02; P = 0.003). Age (HR = 1.09; P = 0.009), diabetes (HR = 2.55; P = 0.034), and ESRD (HR = 2.21; P = 0.029) were independent risk factors for patient mortality; male gender was independently associated with decreased risk of death (HR = 0.27; P = 0.007). Cardiovascular comorbidities, precipitating factors, and clinical severity of AERD had no prognostic impact on renal and patient survival. It is concluded that AERD has a strong clinical impact on patient and renal survival. The study clearly shows the importance of preexisting chronic renal impairment in determining both renal and patient outcome, this latter being mediated by the development of ESRD. The protective effect of statins on the development of ESRD should be evaluated in a prospective study.     

Malnutrition–Inflammation–Atherosclerosis (MIA) Syndrome Components in Hemodialysis and Peritoneal Dialysis Patients

Background. Malnutrition, inflammation, and atherosclerosis (MIA syndrome) are common in end-stage renal disease (ESRD) patients. Each component of MIA syndrome is the predictor of outcomes in ESRD patients. In this cross-sectional study, we aimed to compare both dialysis modalities for MIA syndrome components. Material and Methods. Thirty hemodialysis (HD) (mean age 44 ± 11 years, 14 male and 16 female, mean time on dialysis: 31.0 ± 19.0 months) and 30 continuous ambulatory peritoneal dialysis (CAPD) patients (41 ± 9 years, 12 male and 18 female, mean time on dialysis: 25.5 ± 21.5 months) were included. In order to determine malnutrition in ESRD patients, serum albumin level and anthropometric measurements were used. For inflammation, serum C-reactive protein level, erythrocyte sedimentation rate, and fibrinogen levels were measured. Mean-carotid artery intima media thickness (m-CIMT), presence of carotid plaque and serum homocysteine level were used to determine atherosclerosis. Results. Five CAPD patients (16%) and one HD patient (3%) was hypoalbuminemic. HD and CAPD groups were similar for inflammation. Mean-CIMT and serum homocysteine level were higher in HD patients than CAPD patients. There was a positive correlation between homocysteine and m-CIMT. Conclusion. Before choosing renal replacement therapy, malnutrition, inflammation, and atherosclerosis parameters must be investigated in ESRD patients. Hemodialysis seems to be more advantageous for malnutrition components than CAPD. Both dialysis modalities seem to be similar for inflammation, and CAPD modality has superiority for atherosclerosis. Before choosing the type of renal replacement therapy, assessment of MIA syndrome components could be useful for individualization of the decision on which dialytic modality is appropriate in ESRD patients.     

An evaluation of an integrative care approach for end-stage renal disease patients

Studies analyzing the outcome of integrative care of end-stage renal disease (ESRD) patients, whereby patients are transferred from one renal replacement modality to another according to individual needs, are scant. In this study, we analyzed 417 files of 223 hemodialysis (HD) and 194 peritoneal dialysis (PD) patients starting renal replacement therapy between 1979 and 1996, to evaluate the effect of such an approach. Analysis was done for survival of patients on their first modality, for intention-to-treat survival (counting total time on renal replacement therapy, but with exclusion of time on transplantation), and for total survival. Log rank analysis was used and correction for risk factors was performed by Cox proportional hazards regression. Intention-to-treat survival and total survival were not different between PD and HD patients (log rank, P > 0.05). Technique success was higher in HD patients compared to PD patients (log rank, P = 0.01), with a success rate after 3 yr of 61 and 48%, respectively. Thirty-five patients were transferred from HD to PD and 32 from PD to HD. Transfer of PD patients to HD was accompanied by an increase in survival compared to those remaining on PD (log rank, P = 0.001), whereas, in contrast, transfer of patients from HD to PD was not (log rank, P = 0.17). Survival of patients remaining more than 48 mo on their initial modality was lower for PD patients (log rank, P < 0.01). A matched-pair analysis between patients who started on PD and who were transferred to HD later (by definition called integrative care patients), and patients who started and remained on HD, showed a survival advantage for the integrative care patients. These results indicate that patient outcome is not jeopardized by starting patients on PD, at least if patients are transferred in a timely manner to HD when PD-related problems arise.     

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

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

Characteristics of Elderly Patients with Diabetes and End‐Stage Renal Disease

Because of a combination of demographic and social factors, such as the aging of the population in general, increased incidence of diabetes, and more liberal criteria for renal replacement therapy initiation, the proportion of the end‐stage renal disease (ESRD) patients with diabetes who are considered elderly is currently the fastest growing segment of incident ESRD population. Despite the fast growth of this group, it is poorly characterized in current literature. In this review, we attempt to summarize the data available to date regarding demographic composition, outcomes, choice of renal replacement therapy, and other management issues including renal transplantation. There is significant evidence that the elderly diabetic patients might differ from the general dialysis population regarding renal replacement modality, vascular access for dialysis, and that guidelines addressing chronic kidney disease (CKD) issues such as nutrition and blood pressure may need modification in this ESRD subgroup. At the same time, other areas such as anemia and bone mineral metabolism have not been adequately studied. Lastly, despite lower rates of kidney transplantation in this population, it confers significant survival advantages, similar to that seen in younger populations. As the fastest growing group in the incident ESRD population, these patients have issues related to clinical management, which represent very important areas for future research.     

Diabetic end-stage renal disease in the indigenous population of the Commonwealth of the Northern Mariana Islands

The number of cases of treated end-stage renal disease (ESRD) attributable to type 2 diabetes and survival after the onset of renal replacement therapy was examined in the Commonwealth of the Northern Mariana Islands (CNMI). All Chamorros and Carolinians to receive renal replacement therapy for ESRD between January 1982 and December 2002 were identified. Changes in survival over time were examined by dividing the study into three equal periods. Of 180 new cases of ESRD, 137 (76%; 101 Chamorros, 36 Carolinians) were attributed to diabetes. Ninety-nine subjects, 80% of whom had diabetic ESRD, began renal replacement therapy in the last 7 years of the study compared with 81 (72% with diabetic ESRD) in the previous 14 years. All 137 of the diabetic subjects received haemodialysis. During the 21-year study period, 79 of the diabetic subjects receiving dialysis died. The median survival after the onset of haemodialysis was 37 months in the first time period (1982-1988), 47 months in the second period (1989-1995) and 67 months in the third period (1996-2002). The death rate in the first period was 4.3 times (95% CI, 2.1-8.9) as high and the second period was 2.9 times (95% CI, 1.5-5.8) as high as the most recent period, after adjustment for age, sex and ethnicity in a proportional-hazards analysis. The number of diabetic patients in CNMI who are receiving renal replacement therapy is rising rapidly. Considerable improvement in survival after the onset of haemodialysis has occurred over the past 21 years.     

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.     

Ten-years trends in renal replacement therapy for end-stage renal disease in mainland France: Lessons from the French Renal Epidemiology and Information Network (REIN) registry

BackgroundThe incidence rate of renal replacement therapy (RRT) for end-stage renal disease (ESRD) is decreasing in several countries, but not in France. We studied the RRT trends in mainland France from 2005 to 2014 to understand the reasons for this discrepancy and determine the effects of ESRD management changes.MethodsData were extracted from the French Renal Epidemiology and Information Network registry. Time trends of RRT incidence and prevalence rates, patients’ clinical and treatment characteristics were analysed using the Joinpoint regression program and annual percentage changes. Survival within the first year of RRT was analysed using Kaplan-Meier estimates for 4 periods of time.ResultsThe overall age- and gender-adjusted RRT incidence rate increased from 144 to 159 individuals per million inhabitants (pmi) (+0.8% per year; 95% CI: 0.5–1.2) and the prevalence from 903 to 1141 pmi (+2.4% per year; 95% CI: 2.2–2.7). This increase concerned exclusively ESRD associated with type 2 diabetes (+4.0%; 3.4–4.6) and mostly elderly men. Despite patient aging and increasing comorbidity burden and a persistent 30% rate of emergency dialysis start, the one-year survival rate slightly improved from 82.1% (81.4–82.8) to 83.8% (83.3–84.4). Pre-emptive wait listing for renal transplantation and the percentage of wait-listed patients within one year after dialysis start strongly increased (from 5.6% to 15.5% and from 29% to 39%, respectively).ConclusionKidney transplantation and survival significantly improved despite the heavier patient burden. However, the rise in type 2 diabetes-related ESRD and the stable high rate of emergency dialysis start remain major issues.     

The Effect of Dialytic Modalities on Clinical Outcomes in ESRD Patients with Familial Mediterranean Fever

Background. Familial Mediterranean fever (FMF) is an autosomal recessive disease seen primarily in Sephardic Jews, Turks, and Armenians. The disease manifests as recurrent attacks of fever and serositis. The most important complication of FMF is the development of renal failure due to AA type amyloidosis. There has not been extensive experience with renal replacement therapy in FMF amyloidosis. Nevertheless, there may be a concern about the possibility of higher rates of morbidity and mortality in amyloidotic patients maintained on chronic hemodialysis. Moreover, there is not enough experience regarding patients on chronic peritoneal dialysis. As a result, the best treatment modality of end-stage renal disease (ESRD) in these circumstances still remains unclear. This study aimed to compare the effect of hemodialysis and peritoneal dialysis modalities on clinical outcomes in ESRD patients associated with FMF amyloidosis. Methods. Forty FMF patients with ESRD due to amyloidosis were retrospectively analyzed. All 40 patients were on renal replacement therapy, 20 on hemodialysis (HD), 20 on peritoneal dialysis (PD). Peritoneal solute transport rates, weekly mean creatinine clearance, and daily mean ultrafiltration (UF) of the patients on chronic peritoneal dialysis were evaluated. Weekly dialysis durations, dialysis membrane properties, Kt/V values, interdialytic weight gains, and frequency of hypotension during dialysis were evaluated on hemodialysis patients. All of the patients were examined according to their demographic characteristics, laboratory results, duration time on dialysis, erythropoietin requirements, frequencies of infectious complications requiring hospitalization, and the two renal replacement modalities mentioned above were compared in terms of these parameters. Results. Serum albumin levels of the patients with FMF amyloidosis who were maintained on peritoneal dialysis treatment were lower (2.87 vs 3.45) and the frequency of infections of the same group was higher (4.2 vs 0.5) than the patients with ESRD secondary to other diseases in the CAPD group. Conclusions. This retrospective analysis showed that peritoneal dialysis may have some disadvantages in amyloidotic patients. Due to the high frequency of hypoalbuminemia and infectious complications seen in this group, peritoneal dialysis is widely accepted as an alternative choice of treatment when hemodialysis is not appropriate.     

Association Between Attributed Cause of End-Stage Renal Disease and Risk of Death in Brazilian Patients Receiving Renal Replacement Therapy

Background. Studies conducted in several countries have indicated that the survival of patients undergoing renal replacement therapy (RRT) depends on the attributed cause of end-stage renal disease (ESRD). Objectives. This study was conducted to evaluate the association between attributed cause of ESRD and mortality risk in RRT patients in Brazil. Methods. We analyzed 88,881 patients from the Brazilian Ministry of Health Registry who were undergoing RRT between April 1997 and July 2000. Cox proportional hazards models were used to estimate the relative risk (RR) of death in patients with ESRD secondary to diabetes mellitus (DM), polycystic kidney disease (PKD), and primary glomerulopathies (GN) compared with a reference group comprised of patients with ESRD caused by hypertensive nephropathy. Patient's age, gender, and length of time (years) in RRT before inclusion in the registry (vintage) were included in the adjusted Cox model. Results. Compared with the reference group, the mortality risk was 27% lower in patients with PKD (RR = 0.73, 95% CI: 0.65–0.83, p< 0.0001); 29% lower in patients with GN (RR = 0.71, 95% CI: 0.68–0.74, p< 0.0001); and 100% greater in DM patients (RR = 2.00, 95% CI: 1.92–2.10, p< 0.0001). These relative risks remained statistically significant after adjustment for age, gender, and length of time in RRT before inclusion in the registry. Conclusions. Our data indicate that compared with the patients with hypertensive nephrosclerosis as attributed cause of ESRD, patients undergoing RRT in Brazil with idiopathic glomerulopathy and polycystic kidney disease have a lower risk of mortality, and patients with diabetes mellitus have a greater risk of mortality.     

Trends in treatment and outcomes of survival of adolescents initiating end-stage renal disease care in the United States of America

This study characterizes treatment and outcome trends of adolescent patients initiating renal replacement therapy in the USA from 1978 to 2002. This is a retrospective analysis of data from the US Renal Data System (USRDS) of incident end-stage renal disease (ESRD) patients, ages 12 years through 19 years, initiating renal replacement therapy between 1978 and 2002. Survival analyses were conducted from either the first date of kidney failure or date of transplantation until death or 31 December 2002. The ESRD incidence per million adolescents increased from 17.6 in 1978 to 26.0 in 1990, with no change in incidence in the ensuing 12 years. Incidence was slightly higher among males than females and was twice as great in black than in white populations. The major cause of ESRD was glomerulonephritis followed by cystic/congenital diseases and focal segmental glomerulosclerosis (FSGS). Incidence increased with age, from 13.0 per million for children aged 13 years to 32.6 per million for 19 year olds. Three-quarters of all adolescent patients received at least one transplant, and one-fifth of patients received two or more transplants. Ten percent of incident adolescent patients received a preemptive transplant. The 10-year survival rate was lowest in the 1978–1982 incident cohort (77.6%) and improved to approximately 80% for later cohorts. Survival was better for younger adolescents, transplant recipients, preemptive transplant recipients, males, Caucasian, and Asian patients. The primary mode of renal replacement therapy is transplantation in most adolescent ESRD patients. The 80% 10-year survival rate for adolescent-onset ESRD is very good when compared with adult-onset ESRD. However, this represents a 30-fold increase in mortality compared to the general US adolescent population.     

Aggressive surgical strategy should be used for the treatment of thoracic aortic disease in patients with end-stage renal disease

Surgery for disease of the thoracic artery in patients with end-stage renal disease (ESRD) depending on hemodialysis (HD) tends to be avoided because of its high risk. However, considering that the average survival duration after HD induction is increasing, the adequacy of aggressive surgical treatment of thoracic aneurysms was investigated. Seventeen consecutive surgeries for 16 patients with ESRD with disease of the thoracic aorta performed between 1998 and 2008 were analyzed retrospectively. As an intraoperative renal replacement therapy, prior to 2001, HD was performed in six cases and, after 2002, continuous hemodiafiltration (CHDF) was performed in nine cases. In two cases, no renal replacement therapy was performed during surgery. No operative and hospital mortality occurred, despite challenging indications for surgery like emergency setting (52.5%), history of previous aortic surgery (41.2%) and aortic arch surgeries (58.8%). The five-year survival rate was 62.9%. Median follow-up was 38.8 months (1-117.6). According to this excellent outcome, surgical strategy for ESRD patients with disease of the thoracic aorta should be more aggressive than currently indicated because surgery can be safely performed by means of appropriate application of intraoperative HD or CHDF in order to give sufficient amounts of blood products and manage the water and electrolyte balance.