Chronic kidney disease in Costa Rica

Costa Rica is one of the Central American countries, located between Nicaragua to the north and Panama to the south. Like other Latin American countries, Costa Rica deals with social and economic problems associated with poverty, except for one significant difference-Costa Rica has not had an army since 1948, and so the people and government can spend more money on education and health. For this reason, Costa Rica is very different from other Latin American countries. We do not need weapons, and we have had a democratic tradition for 100 years. Despite our economic and social limitations, Costa Ricans have universal access to a health system that covers 98% of the inhabitants. Renal replacement therapy (RRT) is accessible to all who need it. In the last 5 years, Costa Rica has doubled the number of patients on hemodialysis, and has the highest number of kidney transplants per million population (pmp) in Latin America, with 20.63 transplants pmp in 2000, 27.25 transplants pmp in 2001, and 24.81 transplants pmp in 2002. However, the prevalence of all forms of RRT in Costa Rica is currently 193 pmp. This suggests that end-stage renal disease is underdiagnosed in Costa Rica as it is in many other Latin American countries. Greater research efforts are needed to determine the true extent of renal disease in Costa Rica and to optimize the use of health-sector resources to provide a better and more robust program of RRT for patients with end-stage renal disease.     

Renal replacement therapy in the Canary Islands: demographic and survival analysis

BACKGROUND: The continuous increase in the number of patients on renal replacement therapy (RRT) has heightened the importance of renal patient registries to respond to the demand for data on the state of health, quality and cost of care provided for these patients. Our aim was to analyze the epidemiological profile of this population in the Canary Islands. METHODS: All patients on RRT between January 1999 and December 2003 were considered in this analysis. The information was obtained from the database of the Canary Registry of Renal Patients. RESULTS: We observed a continuous increase in incidence throughout the study period (from 138 per million population (pmp) in 1999 to 160 pmp in 2003), being more evident in patients >65 yrs. Prevalence followed a similar course, increasing from 875 to 972 pmp, being especially evident in the 65-74 yr age group. An alarming finding was the high incidence (43.5%) and prevalence (37.5%) of diabetic nephropathy. While the proportion of hemodialysis (HD) or transplant patients increased, that of peritoneal dialysis (PD) remained low and stable (prevalence of 5% in 2003). Almost half the RRT patients had functioning grafts, with a notably high rate of 58 transplants pmp in 2003, and a prevalence of 425 pmp. Age (hazard ratio (HR) [95% confidence interval (95% CI)] 1.04 [1.03-1.05]; p < 0.001) and diabetic nephropathy (1.47 [1.19-1.82]; p < 0.001) were independently associated with mortality in dialysis patients. Those returning to dialysis after graft loss had a 69% greater risk of death than incident dialysis patients (1.69 [1.06-2.69]; p = 0.026). Cardiovascular events were the main cause of death in all dialysis modalities. Patient death was the main cause of graft loss. CONCLUSIONS: The most outstanding finding was the high incidence and prevalence of patients on RRT, mainly due to diabetic nephropathy. Renal transplant rates were among the highest reported in renal patient registries.     

End-Stage Renal Disease and Its Treatment in Latin America in the Twenty-First Century

The Latin American Society of Nephrology and Arterial Hypertension's Dialysis and Transplant Registry was chartered in 1991. It collects information on ESRD and its treatment in 20 countries of the region. The prevalence of patients on renal replacement therapy (RRT) increased from 129 pmp in 1992 to 447 pmp in 2004; in 2004, 56% of the patients were on hemodialysis, 23% on peritoneal dialysis, and 21% had a functioning kidney graft. The highest rates of prevalence were reported in Puerto Rico (1027 pmp), Chile (686 pmp), and Uruguay (683 pmp). Hemodialysis was widely used, except in El Salvador, Mexico, Guatemala, Nicaragua, and the Dominican Republic, where peritoneal dialysis predominated. Incidence rate increased from 27.8 pmp to 147 pmp in the same period of observation; the lowest rate was reported in Guatemala (11.4 pmp) and the highest in Puerto Rico (337.4 pmp). Diabetes mellitus was the leading cause of renal failure in incident patients; the highest rates were reported in Puerto Rico (62.2%) and Mexico (60%). Forty-four percent of the incident population were older than 65 years. Access to renal replacement therapy was universal in Argentina, Brazil, Chile, Cuba, Puerto Rico, Uruguay, and Venezuela, while was restricted in other countries. Main causes of death in dialysis were cardiovascular (44%) and infectious disease (26%). The rate of renal transplantation increased from 3.7 pmp in 1987 to 14.5 in 2004; fifty-three percent of the organs came from cadavers. Overall, donation rate was 5.9 pmp. In conclusion, the prevalence and incidence rates have increased over the years, and diabetes mellitus has emerged as the leading cause of kidney disease in the region. Although the rate of kidney transplantation has increased, the number remains insufficient to match the growing demand. The implementation of renal health programs in the region is urgently needed.     

End-stage renal disease and its treatment in Latin America in the twenty-first century

The Latin American Society of Nephrology and Arterial Hypertension's Dialysis and Transplant Registry was chartered in 1991. It collects information on ESRD and its treatment in 20 countries of the region. The prevalence of patients on renal replacement therapy (RRT) increased from 129 pmp in 1992 to 447 pmp in 2004; in 2004, 56% of the patients were on hemodialysis, 23% on peritoneal dialysis, and 21% had a functioning kidney graft. The highest rates of prevalence were reported in Puerto Rico (1027 pmp), Chile (686 pmp), and Uruguay (683 pmp). Hemodialysis was widely used, except in El Salvador, Mexico, Guatemala, Nicaragua, and the Dominican Republic, where peritoneal dialysis predominated. Incidence rate increased from 27.8 pmp to 147 pmp in the same period of observation; the lowest rate was reported in Guatemala (11.4 pmp) and the highest in Puerto Rico (337.4 pmp). Diabetes mellitus was the leading cause of renal failure in incident patients; the highest rates were reported in Puerto Rico (62.2%) and Mexico (60%). Forty-four percent of the incident population were older than 65 years. Access to renal replacement therapy was universal in Argentina, Brazil, Chile, Cuba, Puerto Rico, Uruguay, and Venezuela, while was restricted in other countries. Main causes of death in dialysis were cardiovascular (44%) and infectious disease (26%). The rate of renal transplantation increased from 3.7 pmp in 1987 to 14.5 in 2004; fifty-three percent of the organs came from cadavers. Overall, donation rate was 5.9 pmp. In conclusion, the prevalence and incidence rates have increased over the years, and diabetes mellitus has emerged as the leading cause of kidney disease in the region. Although the rate of kidney transplantation has increased, the number remains insufficient to match the growing demand. The implementation of renal health programs in the region is urgently needed.     

1996 Hong Kong Renal Registry Report

Summary: This report was based on the data from the Renal Registry of the Hospital Authority of Hong Kong and accounted for approximately 90-95% of all the patients on Renal replacement therapy (RRT) in Hong Kong. Patients receiving treatment under the private sectors were not included in this report. the data were as of 31 December 1996. There were 15 renal units (2.4 unit per million population [pmp]) and four major renal transplant centres. the number of patients on RRT was 3337 (530 pmp), of which 56% (299 pmp) were on peritoneal dialysis (PD), 15% (79 pmp) on haemodialysis (HD) and 29% (152 pmp) with functioning kidney transplants (TX). the net increase in the number of patients on RRT was +12% from the previous year. the incidence of end stage renal failure was 640 (102 pmp). the median age of patients on RRT was 49 years, of which 27% were above the age of 61 years. For new patients who commenced on RRT during 1996, the median age was 56 years, of which 36% were above the age of 61 years. the causes of renal failure were glomerulonephritis 37%, unknown 30%, diabetes 13%, inherited and congenital 5%, infection/reflux 3%, hypertensive/renal vascular disease 3%, urolithiasis 2%, obstructive 1% and others 5%. For new patients entered into the programme during 1996, 25% were due to diabetic nephropathy. Ten per cent of all the patients on RRT were serologically positive for hepatitis B infection (PD 12%, HD 6%, TX 9%). 5% of all the patients on RRT were positive for hepatitis C infection (PD 3%, HD 12%, TX 7%). Seventy-nine per cent of all the patients on dialysis were on PD (1885 patients, 299 pmp), of which 96% were on CAPD. Thirty-eight per cent of the patients on CAPD were on straight-line systems, 35% on disconnecting systems and 20% on UV flash systems. Four-hundred and ninety-five patients (79 pmp) were on HD, of which 59% were on hospital based HD, 15% on satellite centre based HD, 10% on charitable centre based HD and 5% on home HD. Nine-hundred and fifty-seven patients (152 pmp) had a functioning kidney graft. 542 (57%) were transplanted in Hong Kong, of which 50% were cadaveric kidney transplantations. During 1996, 121 patients (19 pmp) received a kidney transplantation. Eighty-four transplants were performed in Hong Kong, of which 58 were with cadaveric kidneys and 26 with living related kidneys. the annual mortality rate for all RRT was 7.3% (10% for PD, 8% for HD and 1% with TX). the major causes of death were infection (28%), cardiovascular (26%) and cerebral vascular accident (9%). Outcome indicators were on patients entered into the RRT programme during 1995, thus allowing for 1 year of follow up. For CAPD as the first RRT, 1 year patient and technique survival (censored for death and non-technique failure) were 94% and 93%. For living related kidney transplants performed in Hong Kong, 1 year patient and graft survival (censored for death) were both 100%. For cadaveric kidney transplants, 1 year patient and graft survival were 98% and 96%     

The health system in Chile: the nephrologist perspective

Chile is a country with 17 million inhabitants, 13% of them living in rural areas, and with a per capita income of approximately US $14,500. Three percent of national income is assigned to the health budget, with a mixed public and private system, with guaranteed medical benefits from the state to cover chronic kidney disease (CKD) and renal replacement therapy (RRT). Hemodialysis has reached in 2009 a prevalence of 857 patients per million population (pmp). Peritoneal dialysis is less developed, with a prevalence of 40 patients pmp. Both therapies show good quality indexes with a patient mortality rate close to 12% per year. A centralized national renal transplantation program registered 5,949 renal transplants performed up to 2009. Renal survival at 5 years is 86% for living and 76% for cadaveric donor transplants. Organ donation is relatively low with 7.1 cadaveric donors pmp in 2009, despite legal and educational strategies to increase it. Although the country demonstrates one of the highest standards for RRT indexes in Latin America, the proportion of resources invested makes it necessary to improve early diagnosis and renal prevention policies to avoid having the growing incidence of CKD constrain the national health budget.     

Renal replacement therapy among disadvantaged populations in Mexico: a report from the Jalisco Dialysis and Transplant Registry (REDTJAL)

BACKGROUND: End-stage renal disease represents a serious public health problem in Jalisco, Mexico. It is reported among the 10 leading causes of death, with an annual mortality rate of 12 deaths per 100,000 population. The state population is 6.3 million, and more than half do not have medical insurance. In this study, we report the population's access to renal replacement therapy (RRT). METHODS: Patients > or =15 years of age, who started RRT between January 1998 and December 2000 at social security or health secretariat medical facilities, were included. Nine facilities participated in the study. At the start of treatment, the patient's facility, age, gender, cause of renal failure, and initial treatment modality were registered. RESULTS: Within the study period, 2456 started RRT, 1767 (72%) at social security facilities and 687 (28%) at health secretariat facilities, for an annual incidence rate of 195 per million population (pmp). The main cause of renal failure was diabetes mellitus (51% of patients). There were significant differences between the 2 populations. Patients with social security were older (53.1 +/- 17 vs. 45.1 +/- 20 years, P= 0.001) and had more diabetes (54% vs. 42%, P= 0.001) than those without social security. They had higher acceptance (327 pmp vs. 99 pmp, P= 0.001) and prevalence rates (939 pmp vs. 166 pmp, P= 0.001) than patients without medical insurance. Dialysis use was similar in both populations. Eighty-five percent of patients were on continuous ambulatory peritoneal dialysis and 15% on hemodialysis. Kidney transplant rate was higher among insured patients (72 pmp vs. 7.5 pmp, P= 0.001). The number of dialysis programs and nephrologists that offered renal care also differed. There were 10 dialysis programs in social security and 3 in health secretariat facilities. Fourteen nephrologists looked after the insured population, whereas 5 cared for the uninsured (7.7 pmp vs. 2.1 pmp, P= 0.001). The latter had access to 8 hemodialysis stations compared with 34 for the insured population (3.4 pmp vs. 18.8 pmp, P= 0.001). CONCLUSIONS: Access to RRT is unequal in our state. Although it is universal for the insured population, it is severely restricted for the poor. Social and economical factors, as well as the limited number of understaffed, centralized dialysis facilities, could explain these differences.     

Discontinuation of treatment among Italian diabetic patients treated by renal replacement therapy

Death from dialysis termination has been extensively surveyedin Canada, the United States, and Australia. In the US old ageand the presence of diabetes has been associated with treatmentwithdrawal. On the other hand, information for Europe is veryscarce. We addressed the issue of dialysis termination in Italyin both a cohort of diabetic patients starting RRT in 1987,and two age-, sex-, type of RRT, and unit-matched cohorts ofdiabetic and non-diabetic patients alive on RRT treatment on31 December 1987. Follow-up was available till 31 December 1991.Dialysis termination accounted for 1.1% of the known causesof death in the incident diabetic cohort and for only 0.5% and0.9% of the prevalent diabetic and non-diabetic cohorts respectively.In Italy, diabetes is not associated with higher rates of dialysistermination and this cause of death seems uncommon among theoverall Italian RRT population. We cannot, however, excludea predialysis selection against patients presenting with anold age or comorbid conditions.     

The 2008 ERA-EDTA Registry Annual Report-a précis

Background. This study provides a summary of the 2008 ERA-EDTA Registry Report (this report is available at www.era-edta-reg.org).Methods. The data on renal replacement therapy (RRT) were available from 55 national and regional registries in 30 countries in Europe and bordering the Mediterranean Sea. Datasets with individual patient data were received from 36 registries, whereas 19 registries contributed data in aggregated form. We presented incidence and prevalence of RRT, and transplant rates. Survival analysis was solely based on individual patient records.Results. In 2008, the overall incidence rate of RRT for end-stage renal disease (ESRD) among all registries reporting to the ERA-EDTA Registry was 122 per million population (pmp), and the prevalence was 644?pmp. Incidence rates varied from 264?pmp in Turkey to 15?pmp in Ukraine. The mean age of patients starting RRT in 2008 ranged from 69?years in Dutch-speaking Belgium to 44?years in Ukraine. The highest prevalence of RRT for ESRD was reported by Portugal (1408?pmp) and the lowest by Ukraine (89?pmp). The prevalence of haemodialysis on 31 December 2008 ranged from 66?pmp (Ukraine) to 875?pmp (Portugal) and the prevalence of peritoneal dialysis from 8?pmp (Montenegro) to 115?pmp (Denmark). In Norway, 70% of the patients on RRT on 31 December 2008 were living with a functioning graft (572?pmp). In 2008, the number of transplants performed pmp was highest in Spain (Catalonia) (64?pmp), whereas the highest transplant rates with living-donor kidneys were reported from the Netherlands (25?pmp) and Norway (21?pmp). In the cohort 1999-2003, the unadjusted 1-, 2- and 5-year survival of patients on RRT was 80.8% (95% CI: 80.6-81.0), 69.1% (95% CI: 68.9-69.3) and 46.1% (95% CI: 45.9-46.3), respectively.     

Renal replacement therapy for diabetic end-stage renal disease: data from 10 registries in Europe (1991-2000)

BACKGROUND: There is concern about the rising prevalence of type 2 diabetes mellitus and of the resultant nephropathy. This study uses data from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry to provide information on the epidemiology and outcome of renal replacement therapy (RRT) for end-stage renal disease (ESRD) due to diabetic nephropathy (DN). METHODS: Data from the following 10 registries: Austria, French-speaking Belgium, Denmark, Finland, Greece, Norway, Scotland (UK), Catalonia (Spain), Sweden, and The Netherlands were combined. Average annual changes (%) were estimated by Poisson regression. Analyses of mortality were performed by Cox regression. RESULTS: An increase in patients with type 2 DN entering RRT has been observed (+11.9% annually, P < 0.05), while large differences in RRT incidence in this disease continue to exist between countries in Europe. There was a reduction in mortality during the first 2 years on dialysis therapy among patients with type 2 DN (AHR 0.96, 95%CI 0.94-0.97 annually). The mortality among transplant recipients decreased for both type 1 DN and nondiabetic ESRD (non DN) within the 1995-1998 cohort (type 1 DN: AHR 0.49, 95% CI 0.35-0.68; non DN: AHR 0.79, 95% CI 0.69-0.90) compared to the 1991-1994 cohort. CONCLUSION: This report has shown that during the last decade there has been a marked increase in the incidence of RRT for type 2 DN. Survival analysis showed that over the period 1991-1999 the mortality rates of all dialysis patients and of type 1 diabetic and nondiabetic renal transplant recipients have fallen.     

Disparities in end-stage renal disease care in South America

South America is one of the most heterogeneous regions in the world regarding ethnical composition and socioeconomic development level. Our aim was to analyze the status of end-stage renal disease (ESRD) management in the Portuguese-speaking and Spanish-speaking countries of South America. Data were collected using a survey sent to the Society of Nephrology of each country, and complemented with data available in the Latin American Dialysis and Transplant Registry or personal communication with collaborators within the nephrology societies. Most of South America countries have a hybrid of public and private healthcare system. Universal access to renal replacement therapy (RRT) is provided in Argentina, Brazil, Chile, Uruguay and Venezuela which comprise nearly 73% of South America population. The expenditure on health per capita varies from nearly US$ 200 per year in Bolivia to more than US$ 1,600 per year in Argentina. The prevalence of patients on RRT varies from 95 pmp. in Paraguay and 924 pmp in Chile. There is an important association between the prevalence of diabetes and the number of patients on RRT. Older people also are at a higher risk of developing ESRD. The rapid aging of the population and a higher prevalence of diabetes will probably translate into a burden of ESRD in the future. It is to be hoped that political and economical stability in the region can ease the adoption of universal access to ESRD treatment in all South American countries.     

2017 Annual Report Digest of the Renal Epidemiology Information Network (REIN) registry

The French Renal Epidemiology and Information Network (REIN) registry started in 2002 with the goal to provide a tool to evaluate renal replacement therapy (RRT) practices and outcomes, to provide data for research and to support public health decisions related to end‐stage renal disease ESRD. This summary presents the incidence and prevalence of RRT including kidney transplantation and wait‐listing activity in 2017, and patients’ survival and trends over 5 years. In 2017, 11 543 patients started RRT for ESRD, that is, incidence of 172 pmp. Between 2012 and 2017, the incidence of RRT increased by 1% per year [CI 95% (0.0; +2.0)]. On 31 December 2017, 87 275 patients were receiving RRT, that is, prevalence of 1294 pmp, 55% on dialysis, 45% with a functioning transplant. In 2017, 3782 kidney transplantations have been performed including 16% from a living donor, 13% being retransplantations and 15% pre‐emptive transplantations. The median time on the waiting list was 19.7 months when only taking into account active waiting periods on the list. In 2017, 5280 new patients were registered on the renal transplant waiting list (i.e. 78.7 pmp). The number of patients considered as ‘inactive’ represented 45% of the patients on the list.     

Organ donation in Latin America

Recently in Latin America, there has been a strong influence of the "Spanish model" of organ procurement. In 2001, The "Punta Cana Group" was created by Latin American transplantation coordinators with the objective of registering and improving the system of donation and procurement. In many countries there is no universal financial support from the government for medical treatment, including dialysis and transplantation. In other countries there is complete financial support for all of the population, including immunosuppressive drugs. Practically all countries have transplantation laws that follow ethical concepts, such as brain death diagnosis criteria, forms of consent, criteria of allocation, and inhibition of commerce. The rate of potential donors notified in countries that perform transplantations with deceased donors varied from 6 to 47 per million population yearly (pmp/y); The rate of effective donors varied from 1 to 20 pmp. In 2004, the mean rate of effective donors in Latin America was 5.4 pmp. The family refusal rate for the donation of organs varied from 28% in Uruguay to 70% in Peru. In some countries, such as Puerto Rico, Uruguay, and Cuba, it was more than 15 pmp, whereas in others countries deceased donors were practically not used. The number of patients on the waiting list for solid organ transplants in 12 Latin American countries is 55,000. Although the donation rate has increased by 100% during the last 10 years, it is lower than that in Europe (15 pmm/y) or the United States (20 pmp/y).     

Diabetes mellitus and renal replacement therapy in Italy: prevalence, main characteristics and complications

A number of reports on dialysis and transplantation for diabetic patients in the UK and USA are available. The aim of the present survey was to assess the prevalence, main characteristics and complications of diabetic patients treated by dialysis and transplantation in Italy. On 31 December 1987 in Italy, 1605 diabetic patients were being treated by dialysis or transplantation. The prevalence was 28 per million compared with the UK and the USA where the corresponding figures were 17 and 78 per million respectively. The annual incidence in 1987 was 9 per million (UK: 4 per million; USA: 33 per million). The mean age of the Italian diabetic patients was 59 years whereas that for British diabetic patients similarly evaluated was 48 years. Of the Italian diabetic patients 67% had NIDDM (UK: 22%; USA: 50%). Haemodialysis was used in 81% of the Italian patients, peritoneal dialysis in 14%, and only 5% were transplanted. This is in contrast to the UK where only 18% of the patients were treated by haemodialysis and 39% were transplanted. Amongst Italian patients who started RRT in 1987, 9% died within the year, and of the remainder 38% had severe bilateral visual impairment (UK 35%), 3% had had amputations (UK 6%), 7% had suffered from disabling strokes (UK 6%) and 7% had had a myocardial infarction (UK 17%). Before 31 December 1987 another 2.2% developed severe bilateral visual impairment, 0.6% underwent amputations, 1.0% had a disabling stroke and 0.6% suffered from a myocardial infarction. The proportion of diabetic patients treated by RRT in Italy is twice that of the UK but only half that of the USA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Stabilized incidence of diabetic patients referred for renal replacement therapy in Denmark

Despite an improvement in diabetes care during the last 20 years, the number of diabetic patients starting renal replacement therapy (RRT) has continued to increase in the Western world. The aim was to study the incidence of patients starting RRT in Denmark from 1990 to 2004. Data were obtained from The Danish National Registry; Report on Dialysis and Transplantation, where all patients actively treated for end-stage renal disease have been registered since 1990. The incidence of end-stage renal disease increased until 2001. Thereafter the incidence stabilized on 130 per million people (pmp). The number of diabetic patients starting RRT increased steadily from: 52 (number of patients) in 1990, 113 in 1995, 150 in 2000, 168 in 2001, and 183 in 2002. However, during the years 2003 and 2004 this number was significantly reduced by 15% to 156 and 155, respectively. This was mainly due to a 22% reduction in the number of non-insulin- treated (type II) diabetic patients (number of patients): 98, 82, and 76 in 2002, 2003, and 2004, respectively. The mean age in the background population, the mean age in diabetic patients starting RRT and the incidence of type I and type II diabetes increased during the study period. The encouraging stabilization in the incidence of diabetic patients referred for RRT observed in Denmark could be the result of implementation of a multifactorial and more intensive renoprotective intervention in patients with diabetes and chronic progressive renal disease.     

La néphrologie en Tunisie : d’hier à aujourd’hui

Professor Hassouna Ben Ayed is the founder of Tunisian nephrology. He introduced in 1962 the first artificial kidney for the treatment of acute renal failure. In 1963, the first acute peritoneal dialysis was done. Renal biopsy started in 1967 with general pathologists. A special laboratory of renal pathology was set up in 1975 with Pr H. Ben Maïz. Epidemiology of glomerular diseases, when histologically proven, was published [8]. A comprehensive program of chronic hemodialysis was started in 1968 and was developed markedly since 1975 with Pr A. El Matri. An intermittent peritoneal dialysis programme was started in 1982 and CAPD in 1983 by Pr T. Ben Abdallah. The Tunisian renal failure patient association was created in 1982 and the Tunisian society of nephrology in November 1983. A national registry for ESRD treatment is available since 1986. Since this time, the number of patients initiating renal replacement therapy (RRT) for ESRD has increased dramatically due to the extension of acceptance criteria for RRT and the increase of the elderly population. The incidence was 13 pmp in 1986 and 133 pmp in 2008. The prevalence was 48.5 pmp in 1986 and 734 pmp in 2008. From 1971 up to 1986, locally dialysed patients have been transplanted abroad, especially in France. On 4 June 1986, the local transplantation program was started at Charles Nicolle Hospital in Tunis. A national center of organ transplantation was created on 12 June 1995. At the end of 2008, there were106 nephrologists, 26 residents in nephrology and 253 doctors with a training in hemodialysis during 1 year. In university hospitals, the number of nephrology departments is five, with one unit in an army hospital and two units for pediatric nephrology. Five hospitals perform renal transplantation (Tunis: 2 – Sfax: 1 – Sousse: 1 – Monastir: 1). There are 138 centers of hemodialysis: 39 public, 99 private. Seven thousand and eighty patients were treated by HD, 127 patients underwent renal transplantation. The vast majority of these transplants have been performed using living related donors (103/127). The cost of renal replacement therapy (RRT) is taken in charge by the Ministry of Health and the national security boards. Legislation on HD was promulgated by the Tunisian government, setting rigorous and detailed rules for the implementation of new dialysis centers, as well as for the functioning of already active units (4 August 1986 – 4 April 1998). For transplantation, legislation was promulgated on 25 March 1991.     

Parathyroidectomy in patients on renal replacement therapy: an epidemiologic study

Secondary hyperparathyroidism is a frequent complication of long-term dialysis treatment, and despite recent advances in medical therapy, surgical parathyroidectomy (PTx) is necessary in a considerable number of uremic patients. A prevalence of PTx of 22% was reported in Europe in 1988 in patients on dialysis from 10 to 15 yr, but no large-scale epidemiologic study has been published since then. The aim of the study was to evaluate the prevalence, incidence, and risk factors for PTx in patients on renal replacement therapy (RRT) in Lombardy and to determine whether the incidence has changed over time. The study involved 14,180 patients included in the Lombardy Registry of Dialysis and Transplantation who received RRT for end-stage renal disease (ESRD) between 1983 and 1996. Cox-proportional hazards regression models were used to evaluate the risk factors of PTx, the explanatory covariates being age on admission to RRT, gender, underlying renal disease (nondiabetic or diabetic nephropathy), and dialysis modality (peritoneal dialysis or hemodialysis). The prevalence of PTx in the 7371 ERSD patients who were alive on December 31, 1996, was 5.5% and increased with the duration of RRT (9.2% after 10 to 15 yr, 20.8% after 16 to 20 yr). Similarly, the incidence of PTx increased from 3.3 per 1000 patient-years in patients who had been on RRT for <5 yr to 30 per 1000 patient-years in those receiving RRT for >10 yr. The Cox regression models showed that the relative risk for PTx was significantly higher in women and lower in elderly and diabetic patients. The relative risk for PTx (adjusted for gender, age, and nephropathy) was higher in the patients on peritoneal dialysis than in those on hemodialysis and decreased after transplantation. During the course of a follow-up of 7 yr, the incidence of PTx in patients who started RRT between 1990 and 1992 was no different from that observed in patients who started RRT between 1983 and 1985. In conclusion, the prevalence and incidence of PTx in patients receiving RRT in Lombardy is lower than that in Europe and Italy as a whole, as reported by the 1988 European Dialysis and Transplantation Association Registry; its frequency has not changed significantly during the past few years. The need for PTx decreases markedly after successful transplantation. The epidemiologic finding that the rate of PTx is greater in women, young patients, and individuals who do not have diabetes suggests the need for a more aggressive medical treatment of secondary hyperparathyroidism particularly in such patients.     

Paediatric dialysis and renal transplantation in the state of Rio Grande do Sul,Brazil

Renal replacement therapy (RRT) for Brazilian children with uraemia has been utilized since 1970 in the state of Rio Grande do Sul. One hundred and eighty patients receiving this therapy between 1970 and 1988 have been reviewed. The annual acceptance rate of new paediatric patients in this period increased from 0.6 to 6.5 patients per million child population. Glomerulonephritis (36.1%) and pyelonephritis including urological anomalies (31.7%) were the most frequent causes of end-stage renal disease. Outpatient hospital haemodialysis was the primary form of dialytic treatment in patients 5–15 years of age. Continuous ambulatory peritoneal dialysis was more often used in patients less than 5 years of age. The survival after 1 year on dialysis was 79.9% for children aged 5–15 years starting dialysis during the period 1985–1988. Fluid overload with congestive heart failure and infection were the main causes of death in children on dialysis. Eighty-four children received 93 grafts; only 14 (15%) were from cadaveric donors. One-year patient and graft survival of first living-related donor transplants were 92.2% and 78.5% respectively during the period 1985–1988. Infection accounted for 43.5% of deaths after transplantation. We conclude that RRT is becoming increasingly successful for children in our region but that greater emphasis upon patient compliance with all forms of RRT and upon cadaver kidney donation is needed.     

Results of renal replacement therapy in Europe, 1980 to 1987. Registration Committee of the EDTA-ERA

The characteristics of the patient populations accepted for and undergoing renal replacement therapy (RRT) in Europe in 1980 to 1987 are presented. Acceptance rates have increased in most countries reporting to the EDTA Registry and have reached from between 50 to over 80 per million population in the more affluent Western European countries in 1987. Increasing acceptance rates were due to the inclusion of patient groups at a higher risk of dying, such as the elderly and those with diabetic nephropathy. Despite the acceptance of a growing proportion of high-risk patients, no increase in overall mortality was apparent. Gross mortality (some 10% annually) changed little between 1980 and 1987 for patients on hemodialysis, decreased sharply from 1980 to 1984 for patients on continuous ambulatory peritoneal dialysis (CAPD), and improved continuously from 4.2% in 1980 to 2.4% in 1987 for patients with a functioning kidney graft. In order to determine mortality more accurately, actuarial survival rates and annual death rates per thousand patient years at risk were computed according to age groups and to primary renal disease groups, both for the total patient data file and for selected countries. Actuarial 5-year survival on hemodialysis for all patients starting treatment between 1982 and 1987 varied according to age, being 84% in patients age 15 to 24 years and 20% in those age 75 to 84 years. Patients with "standard" primary renal diseases had slightly better survival, while of the group with diabetic nephropathy only 51% age 25 to 34 and no more than 3% of those age 75 to 84 survived the 5-year mark. To recognize trends in the mortality between 1980 and 1987, annual death rates for all patients on record, age 45 to 54 and 55 to 64 at the beginning of 1980, 1983, 1985, and 1987 were computed both for the total Registry and for the FRG. Despite an increasing acceptance rate of patients with diabetic nephropathy, the annual death rates on hemodialysis decreased or remained stable both for the total Registry and for the FRG. Death rates in patients with a functioning graft decreased. It is concluded that, during the last decade, survival on RRT has continued to improve not only because of decreasing mortality after transplantation and on CAPD, but also due to improving survival on hemodialysis. The latter is not readily apparent because of the increasing acceptance rate in older patient groups and a rapidly rising proportion of patients with diabetic nephropathy in most European countries.     

Chronic kidney disease in Cuba: epidemiological studies, integral medical care, and strategies for prevention

The experience of the Republic of Cuba regarding epidemiological studies, integral medical care, and strategies for the prevention of chronic kidney disease is summarized in this report. Cuba has a National Program for Chronic Renal Disease, Dialysis, and Renal Transplantation. There is a national nephrology net, integrated by the Institute of Nephrology as the coordinator center, that has 47 nephrology services with a hemodialysis unit (24 of them with peritoneal dialysis unit), 9 transplantation centers, 33 organ procurement hospitals, and 5 histocompatibility laboratories.In 2004, the incidence rate in dialysis patients was 111 pmp, and the prevalence rate was 149 pmp, demonstrating an increasing mean of 17.0% and 10.0% per year, respectively. Renal transplantation rate was 16.6 pmp. The detection, registration, and follow-up of patients with chronic kidney disease (serum creatinine > or =1.5 mg/dL or glomerular filtration rate <60 mL/min) by family doctors was 9,761 patients, 0.87 patients per 1,000 inhabitants.In the 1980s, three population-based screening studies were performed to define the burden of chronic renal failure in different regions of Cuba. The prevalence rate was 1.1, 3.3, and 3.5 per 1,000 inhabitants, respectively. At present, another three population-based screening studies are ongoing in order to detect the chronic kidney disease in earliest stages.The continuing medical education activities have been very useful in raising the awareness of medical doctors and the basic health staff about the threats posed by and the strategies to prevent, diagnose, and treat chronic kidney disease.