Early identification of risk factors for refractory secondary hyperparathyroidism in patients with long-term renal replacement therapy.

BACKGROUND: Secondary hyperparathyroidism can complicate renal replacement therapy (RRT) in patients with end-stage renal disease. Current medical therapies often result in hypercalcaemia and fail to correct hyperparathyroidism, but might be more effective at an early stage of disease. The aim of this study was to identify prognostic factors at the start and during the first year of RRT for refractory secondary hyperparathyroidism needing parathyroidectomy (PTx) during long-term follow-up. METHODS: A total of 202 consecutive patients starting RRT between August 1988 and August 1996 at our centre with at least 1 year of follow-up were included. Biochemical and treatment data at the start and during the first year of RRT were collected. Univariate and multivariate analyses were used to identify risk factors for PTx during follow-up. RESULTS: Thirty-three patients (16%) needed PTx after 52+/-23 months of RRT. Need for PTx was not different between patients undergoing haemodialysis and peritoneal dialysis, but was associated with parameters reflecting calcium and phosphate control at start and after 1 year of RRT. In a Cox multivariate model, serum parathyroid hormone [relative risk (RR): 1.02 per pmol/l; P<0.001], phosphate (RR: 1.107 per 0.1 mmol/l; P = 0.002) and alkaline phosphatase (RR: 1.004 per U/l; P = 0.049) after 1 year of RRT were independently associated with increased risk for PTx. CONCLUSIONS: Failure of control of calcium-phosphate metabolism at the start of and early during RRT is strongly associated with PTx during long-term follow-up. Given the high prevalence of insufficient phosphate control, patients may benefit from aggressive correction of serum phosphate in the pre-dialysis and early dialysis period.     

Survival and development of cardiovascular disease by modality of treatment in patients with end-stage renal disease.

Patients undergoing dialysis are at high risk for cardiovascular disease (CVD). The aim of this study was to evaluate the influence of hemodialysis (HD) versus peritoneal dialysis (PD) on survival and the risk of developing de novo CVD. Of the 4191 patients with end-stage renal disease (ESRD) who started renal replacement treatment (RRT) in Lombardy between 1994 and 1997, 4064 (who were on dialysis 30 d after the start of RRT) were considered for survival analysis: 2772 were on HD (mean age 60.9 yr; 21.2% diabetic) and 1292 on PD (mean age 63.6 yr; 16% diabetic). The 3120 patients who were free of CVD at the start of RRT were included in the analysis of the risk of developing de novo CVD. HD and PD were compared by use of a Cox-regression proportional hazard model, stratified by diabetic status; the explanatory covariates were age and gender. The death rate was 13.3 per 100 patient-years (13.0 on HD and 13.9 on PD); 197 (6.3%) of the 3120 patients included in the CVD analysis developed de novo CVD (128 on HD and 69 on PD). After adjustment for age, gender, and established CVD and stratification by diabetic status, there was no significant between-treatment difference in 4-yr survival (relative risk [RR], 0.91; 95% confidence interval [CI], 0.79 to 1.06). The risk of de novo CVD did not differ significantly by treatment modality (RR, 1.06; 95% CI, 0.79 to 1.43). The risk of mortality and de novo CVD for new patients with ESRD assigned to HD or PD was similar in Lombardy in the period 1994 through 1997.     

Epidemiology of end-stage renal disease in an interregional perspective: Registries of Puglia and Basilicata, southern Italy

BACKGROUND: This report on the 1994-1998 Dialysis and Transplantation Registry (DTR) of Puglia and Basilicata provides the first epidemiological profile of ESRD in southern Italy. METHODS: Frequency measures of patients in renal replacement therapy (RRT) were computed for Puglia and Basilicata (inhabitants: 4,086,422 and 610,000 respectively). Hazard ratios (HR) of death in relation to sex, age, educational level, primary nephropathies, and modality of dialysis, were estimated by applying the Cox model to patients starting dialysis as first RRT in 1994-1998 in Puglia. RESULTS: The prevalence of treated ESRD in Puglia was 881 per million population (p.m.p.) (dialysis: 721 p.m.p.) in 1998, 713 p.m.p. (dialysis: 617 p.m.p.) in 1994. In Basilicata the prevalence of ESRD was 795 p.m.p. (dialysis: 669 p.m.p.) in 1998, 636 p.m.p. (dialysis: 575 p.m.p.) in 1994. Mean age at start of dialysis of incident cases of Puglia was 60 yr (median: 64 yr). Figures of diabetes, vascular diseases, and glomerulonephritis, were: 16%, 21%, 17%. Out of 2,152 incident patients on dialysis for at least one month, 293 started with peritoneal dialysis (PD). A 60-70% higher risk of death was observed for diabetic nephropathy and PD. In the Puglia/Basilicata DTR pooled analysis, lower educational level was associated with a 60% increased mortality risk. CONCLUSIONS: The associations of PD and low education with the risk of death are very likely to be due to comorbid conditions, unavailable in these databases as in most regional and national DTR. By looking at variations of rates and outcomes among areas, potential improvements of local DTR for planning and research uses are discussed.     

Low cancer death rate in chronic dialysis patients with diabetes mellitus

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

The Latin American Dialysis and Renal Transplantation Registry Annual Report 2002

Latin America is a conglomerate of adjacent countries having in common a Latin extraction and language (Spanish or Portuguese) and exhibiting extreme variations in socioeconomic status. The Latin American Society of Nephrology and Hypertension Dialysis and Renal Transplantation Registry was created in 1991. Annual data are sent by local societies in 3 forms: patient, center, and country. The prevalence of renal replacement therapy (RRT) (all modalities) increased from 119 patients per million population (pmp) in 1991 to 349 pmp in 2001; the acceptance rate was 91.7 pmp in 2001. Dialysis prevalence was 277 pmp; hemodialysis was the predominant modality, except in Mexico (86% on peritoneal dialysis). The highest dialysis prevalence and acceptance rates were reported by Puerto Rico, Uruguay, and Chile. Among incident patients, diabetic nephropathy (33%) and nephroangioesclerosis (32%) were the primary causes; 38% were older than 65 years old. Renal transplants increased from 3.7 pmp in 1987 to 13.7 pmp in 2001. In 2003, 6357 transplants were performed (55% living donor); the cumulative number performed since 1987 reached 55,947. Prevalence and incidence are low because not all patients with end-stage renal disease have access to RRT because of restricted availability, difficulties in referral, and inequities in coverage. The annual increase in the number of patients on RRT (8%-10%) is higher, proportionally, than the annual growth of the Latin American population in general (1.5%). Efforts must be focused on prevention and treatment of chronic kidney disease, especially in diabetic and older patients, and in implementing better organ donation programs to improve the pool of cadaveric donors.     

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 in Brunei Darussalam – report from the first Brunei Dialysis Transplant Registry (BDTR)

Abstract

The Brunei Dialysis and Transplant Registry (BDTR) was established in 2011 to collect data from patients undergoing renal replacement therapy (RRT) in Brunei Darussalam. The chief aims of the registry are to obtain general demographic data for RRT patients and to determine disease burden attributable to End Stage Renal Disease (ESRD). The registry population comprises of all ESRD patients treated in Brunei Darussalam. Data domains include general demographic data, medical history, ESRD etiological causes, laboratory investigations, dialysis treatment and outcomes. There were 545 prevalent RRT patients in Brunei at the end of 2011. The incidence and prevalence of ESRD were 265 and 1250 per million population. Hemodialysis (HD), Peritoneal Dialysis (PD) and Transplant comprised of 83%, 11% and 6% of the RRT population, respectively. Diabetes mellitus accounted for 57% of all new incident cases. The mean serum hemoglobin, phosphate, calcium and iPTH were 11.0?±?1.6?g/dL, 1.9?±?0.5?mmol/L, 2.3?±?0.2?mmol/L and 202.5?±?323.4?ng/mL. Dialysis adequacy for HD and PD were 65.1 (urea reduction ratio) and 2.0?±?0.3 (Kt/v). 71 % of all prevalent HD had functioning AV fistulae and the peritonitis incidence was one in 24.5 patient-month/episode. The first BDTR has identified some deficiencies in the renal services in Brunei. However, it signals an important milestone for the establishment of benchmarked renal practice in the country. We hoped to maintain and improve our registry for years to come and will strive to align our standards to acceptable international practice.     

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.     

Vascular access for chronic haemodialysis in elderly patients: the Lombardy experience

The growing proportion of elderly patients largely accounts for the striking increase in number of patients admitted to renal replacement treatment (RRT) in recent years. Most of them are treated with haemodialysis, which involves various problems connected with vascular access. A survey was therefore conducted amongst the Dialysis Units of Lombardy. The aim was to evaluate how vascular access surgery for elderly patients is or-ganized, and which techniques are used to monitor surgical access as well as the central catheters (CVCs). A questionnaire was sent to the 43 Lombardy Units, 79.1% of which replied. The results of a previous study analyzing the same topics in all patients on RRT in Lombardy were considered as 'controls'. In this way it was possible to compare the strategy used for elderly patients with that of the general dialysis population. Forty-one percent (41%) of elderly patients in Lombardy were started on RRT using acute CVCs. This percentage is quite similar to that documented (39%) in the general dialysis population. The distribution is quite dif-ferent when we consider the patients alive on RRT at 31 December 1999, when a permanent vascular access (distal AVF, proximal AVF or AV graft) was used in about 70% of cases. For elderly patients, as for the general RRT population, first choice access is mainly (79%) distal arterio-venous fistula (AVF) with end-to-end, side-to-side with distal ligature of the vein or side-to-end anastomosis. As a second choice, proximal AVF is more widely used than AV grafts, which are implanted only when all native vessels and related surgical procedures are exhausted. CVCs are valid solutions not only as temporary access, but also as an alternative permanent solution to the problems related to elderly dialysis patients. In the elderly, the jugular vein is the most frequent site of inser-tion for chronic tunnelled devices (91%) and the femoral vein for acute CVCs (40%). Despite the documented incidence of related episodes of stenosis/obstruction, the subclavian vein is used as a temporary access in quite a high percentage of cases (22% in the elderly and 32% in the general RRT population). Only in selected cases diagnostic procedures (mainly Venography and Doppler studies) are performed prior to permanent access choice. Similarly, vascular access is monitored mainly using a recirculation test, albeit not routinely. As in the general dialysis population, in the cases of vascular access thrombosis and stenosis, surgical re-vision is the most common approach.     

The epidemic of aging in renal replacement therapy: an update on elderly patients and their outcomes

BACKGROUND: In the past 2 decades, a rapid growth has occurred in the number of patients over 65 years of age accepted for renal replacement therapy (RRT) with an increasing need for dialysis resources as a consequence. The aim of this study is to describe the trends in incidence, treatment and outcome of RRT of these elderly patients included in the new ERA-EDTA Registry database. METHODS: Data from 6 national renal registries have been included for the period 1985 - 1999, comprising data of 18,920 elderly patients starting RRT. We used Cox-proportional hazards regression to predict patient and technique survival. RESULTS: The incidence and prevalence of RRT showed a 4- to 5-fold increase over the period, resulting in 48% of the new patients being older than 65 years in 1999. However, the rates varied considerably between countries. The 2-year patient survival was 51% in dialysis patients. Mortality due to social causes increased with age. Multivariate analysis showed no change with time in patient survival on dialysis, but the risk of death following a first renal allograft between 1995 and 1999 was reduced by 31%, compared with the 1985 - 1989 time period (RR 0.69; 95% CI: 0.54 - 0.90). The relative risk of peritoneal dialysis technique failure was more than doubled in the 1995 - 1999 cohort compared to the 1985 - 1989 cohort (RR 2.38; 95% CI: 1.89 - 3.01), with the highest technique failure rate in the first 2 years of the 1995 - 1999 cohort. CONCLUSIONS: The number of elderly patients receiving RRT is rising rapidly. Patient survival on dialysis has been stable over the last 15 years, whereas transplant outcome has improved. The increased peritoneal dialysis technique failure and the high mortality due to social causes in the elderly age groups require further investigation. The challenge of the years ahead is to provide this life-prolonging therapy to all patients who need it in such a way that it improves quality of life and at a cost that a society can afford.     

Recruiting the community for supporting end-stage renal disease management in the developing world

Although the incidence of new end-stage renal disease (ESRD) patients in Pakistan is estimated at 100 patients per million (ppm), the prevalence of those alive on renal replacement therapy (RRT) is around 40 ppm, reflecting the severe shortage of facilities. A national program was launched in 1998 to provide free RRT, but the funds were extremely limited, leading to the flourishing of suboptimal treatment in private dialysis and transplant centers. The Sindh Institute of Urology and Transplantation (SIUT), started as a small unit in 1975, took the lead in recruiting nongovernmental funds for RRT. Through the devotion of several groups, it was possible to raise funds from individuals, pharmaceutical firms, and other organizations, which permitted the development of SIUT into an independent, large, and fully equipped institution that provides free RRT including dialysis and transplantation to many thousands of patients. This prompted the government to increase its contributions to encourage SIUT to pursue its unique path.     

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.     

Technical-economic management models in dialytic treatment: an evolving reality. The Italian experience

Health care organisations and financial factors (particularly treatment reimbursement rates) may influence the management of ESRD. We analysed the organisation of renal replacement therapy (RRT) in Italy, focusing on RRT population trends, patient distribution by treatment modality and provision, reimbursement rates, accreditation and quality control. Data from the Italian Dialysis and Transplant Registry and market research studies indicate that Italy has one of the highest dialysis and treatment acceptance rates in Europe. There is a high rate of hemodialysis (HD) and good use of peritoneal dialysis (PD), whereas the prevalence of transplanted patients is lower than the European mean. Dialytic treatment in private centers is limited by law to HD (mainly in Central-Southern Italy) and covers nearly 25-30% of the demand for RRT which means that, although Italy has a public national health care system, the provision of RRT is based on a "mixed" model. Regions with a higher prevalence of "private" dialysis have more dialysis centers, but a lower prevalence of PD since it is not permitted in private facilities, and fewer transplanted patients. The "public" system is not an automatic guarantee of quality and efficacy, and the "private" system is not necessarily a synonym of poor quality treatment due to its need to make a profit. The coexistence of private and public facilities (if well balanced and integrated) may in fact help overcoming bureaucracy in the public administration in relation to the demand for innovation and improving performances by means of fair competition.     

Renal replacement therapy in children: data from 12 registries in Europe

In June 2000 the ERA-EDTA Registry office moved to Amsterdam and started collecting core data on renal replacement therapy (RRT) entirely through national and regional registries. This paper reports the pediatric data from 12 registries. The analysis comprised 3,184 patients aged less than 20 years and starting RRT between 1980 and the end of 2000. The incidence of RRT rose from 7.1 per million of age-related population (pmarp) in the 1980–1984 cohort to 9.9 pmarp in the 1985–1989 cohort, and remained stable thereafter. The prevalence increased from 22.9 pmarp in 1980 to 62.1 in 2000. Hemodialysis was the commonest form of treatment at the start of dialysis, but peritoneal dialysis gained popularity during the late 1980s. Pre-emptive transplantation accounted for 18% of the first treatment modality in the 1995–2000 cohort. The relative risk of death of patients starting dialysis in the period 1995–2000 was reduced by 36% {adjusted hazard ratio (AHR) 0.64 [95% confidence interval (CI) 0.41–1.00]} and that of those receiving a first allograft by 42% [AHR 0.58 (95% CI 0.34–1.00)], compared with patients in the period 1980–1984. The prevalence of RRT in children has continued to rise, while its incidence has been stable for about 15 years. Patient survival has improved in both dialysis patients and transplant recipients. The development of this pediatric registry will form the basis for more-detailed and focused studies in the future.     

The use of continuous peritoneal dialysis in Europe for the treatment of children with end-stage renal failure: data from the EDTA Registry

The demographic data on the use of continuous peritoneal dialysis in Europe for children starting renal replacement therapy under the age of 15 years was obtained from data collected by the Registry of the European Dialysis and Transplant Association--European Renal Association (EDTA Registry) on individual patient questionnaires 1980-1986. Continuous ambulatory peritoneal dialysis (CAPD) and its variants appeared to be increasingly utilised as treatment for children with end-stage renal failure (ESRF) and accounted for approximately 25% of all renal replacement therapy (RRT). Important differences in its use in various European countries are demonstrated. The proportional contribution of CAPD to treatment was higher during the first year of RRT and gradually decreased thereafter. No significant sex differences existed in the use of this treatment. Approximately 70% of all patients on CAPD were older than 6 years of age, but it is in those under 6 years that the highest proportion are put on CAPD as first method of treatment for end-stage renal failure. The most common cause of abandonment of this treatment was peritonitis, which contributed 50% of the drop-out rate.     

Calciphylaxis: A Rare Complication of Patients Who Required Parathyroidectomy for Advanced Renal Hyperparathyroidism

Calciphylaxis is a relatively rare but life-threatening complication in uremic patients. Clinical findings and prognosis were evaluated in six patients who developed calciphylaxis from a group of 1499 patients who underwent parathyroidectomy (PTx) for advanced renal hyperparathyroidism (HPT) in our department from July 1972 to July 2003. The frequency of calciphylaxis was 0.40% (6/1499). Two patients were women and four were men. The mean age was 50.5 years, and the mean duration of hemodialysis (HD) treatment was 14.0 years. In five of six patients, calciphylaxis was classified as distal type; in one case, as proximal type. In three patients, calciphylaxis was diagnosed at the time for PTx. In two patients, calciphylaxis was identified after PTx, although the serum parathyroid hormone (PTH) level was within the appropriate range for dialysis patients. In two patients, calciphylaxis improved after PTx, but two patients required leg and toe amputations after PTx. In one patient with the proximal type of calciphylaxis, the condition occurred when a high PTH level recurred after the initial PTx. The patient died as a result of a serious infection due to uncontrollable skin ulcers. Calciphylaxis is a rare complication in patients who require PTx for renal HPT. Especially the proximal type has a poor prognosis. High levels of the Ca × P product and/or PTH are risk factors. Therefore, this syndrome should be kept in mind and attention should be paid to reduce risk factors. It is important that PTx being performed at the right time in patients with advanced renal HPT refractory to medical treatment.     

Current incidence, treatment patterns and outcome of end-stage renal disease among indigenous groups in Australia and New Zealand

SUMMARY: The changes in rates of treated end-stage renal disease (ESRD) among indigenous populations have profound consequences for those individuals affected and for health-care providers. By using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, we examined the current incidence, treatment and outcomes of ESRD among indigenous groups in Australia and New Zealand. All patients who began renal replacement therapy (RRT) in Australia or New Zealand between October 1991 and September 2000 were included. Rates of ESRD, RRT modalities, renal transplantation and mortality were the outcomes examined. End-stage renal disease rates among indigenous groups in Australia and New Zealand exceeded non-indigenous rates up to eightfold. The median age of indigenous ESRD patients was younger (51 vs 60 years, P  < 0.0001), and there was an excess of comorbidities, particularly diabetes. For Australian Aboriginal and Torres Strait Islanders, and New Zealand Maori patients, mortality rates across all modalities of RRT were 70% higher than non-indigenous rates. Indigenous people were less likely to receive a renal transplant prior to dialysis treatment, less likely to be accepted onto the cadaveric transplant waiting list, and less likely to receive a well-matched transplant. The poorer outcomes among Australian Aboriginal and Torres Strait Islanders, and New Zealand Maori patients did not appear to be explained by the different comorbid conditions or age. Whether the outcomes reflect unmeasured differences in disease burden or treatment differences is not known. Tackling this problem will involve a spectrum of people and approaches, from tertiary care providers and RRT to local staff and preventative programs.     

Increases in renal replacement therapy in Australia and New Zealand: understanding trends in diabetic nephropathy

Aim: The incidence of end‐stage kidney disease (ESKD) has been increasing worldwide, with increasing numbers of older people, people with diabetic nephropathy and indigenous people. We investigated the incidence of renal replacement therapy (RRT) in Australia and New Zealand (NZ) to better understand the causes of these effects. Methods: Data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA)registry and relevant population data were used to investigate the incidence of RRT in five demographic groups: Indigenous and non‐indigenous Australians, Māori, Pacific Islanders and other New Zealanders, as well as differences between genders and age groups. Results: The numbers of patients commencing RRT each year increased by 321% between 1990 and 2009. This increase was largely driven by increases in patients with diabetic nephropathy. In 2009 35% of new patients had ESKD resulting from diabetic nephropathy 92% of which were type 2. Indigenous Australians, and Māori and Pacific people of NZ have elevated risks of commencing RRT due to diabetic nephropathy, although the risks compared with non‐indigenous Australians have decreased over time. A small element of lead time bias also contributed to this increase. Males are more likely to commence RRT due to diabetes than females, except among Australian Aborigines, where females are more at risk. There is a marked increase in older, more comorbid patients. Conclusions: Patterns of incident renal replacement therapy strongly reflect the prevalence of diabetes within these groups. In addition, other factors such as reduced risk of dying before reaching ESKD, and increased acceptance of older and sicker patients are also contributing to increases in incidence of RRT.     

Nephrology, dialysis and transplantation in Turkey.

The establishment of the Turkish Society of Nephrology (TSN) in 1970 coincided with that of many western European nephrology societies. The TSN organized the 15th ERA-EDTA Congress in Istanbul in 1978, earlier than many European Countries, and currently has 286 active members. At present, Turkey has 161 nephrologists, which equals 2.5 nephrologists per million population (p.m.p.). The number of original articles submitted by Turkish authors to the journal Nephrology Dialysis Transplantation ranks 7th-8th amongst total submissions to the journal. Turkey also ranks 2nd-4th in the number of abstracts submitted to recent ERA-EDTA Congresses. With 18 063 patients undergoing intermittent haemodialysis treatment in 348 dialysis centres, Turkey has the 5th largest chronic haemodialysis patient population among European countries. In addition, 1903 patients are currently undergoing continuous ambulatory peritoneal dialysis. However, with a total of 4693 renal transplants since 1975, of which only 21.3% were of cadaveric origin, Turkey lags considerably behind other European countries in renal transplantation. In Turkey, the prevalence and incidence of renal replacement therapy (RRT) are at present 358 and 52 p.m.p. respectively, and the expansion rate of the RRT stock is 17% (HD 18.5%, CAPD 6%, and transplantation 1.7%). The yearly gross mortality rate of the total RRT population is 9.4%. The present priorities of the Turkish nephrological community include high-standard research activity and long-term, prospective clinical and epidemiological studies, an increase in the total number and percentage of cadaveric transplants, further improvement of the quality and cost-effectiveness of RRT, and finally the further development of scientific and educational collaboration with the world nephrological community.     

Is abdominal surgery still a contraindication for peritoneal dialysis?

Peritoneal Dialysis (PD) is considered an underutilized modalityof renal replacement treatment (RRT) in our media if we comparewith other countries as Canada [1], with an incidence that hasreached a plateau in the last years (Figure 1). In the 2005Spanish Registry only 14% started RRT with PD,