Adequacy of dialysis in acute renal failure

Renal replacement therapy (RRT) is currently the mainstay of management for patients with acute renal failure (ARF). Adequacy of dialysis in the setting of renal failure is defined poorly and encompasses multiple domains of clinical and biochemical outcomes. Multiple operational factors influence the delivery of adequate dialysis. No current standards exist for RRT for ARF; current RRT practices for ARF generally have been extrapolated from end-stage renal disease (ESRD) literature. The heterogeneity of patient population, variation in RRT practices, and differences in outcomes studied have made it difficult to define or study adequate dialysis in ARF or its impact on clinical outcomes.     

Gastric emptying in patients on renal replacement therapy

In addition to gastrointestinal tract symptoms such as nausea, vomiting, and loss of appetite, impaired gastric emptying time (GET) may be related to nutritional parameters and nutritional status of patients on renal replacement therapy (RRT). Patients on RRT are affected by several factors such as uremic toxins, the presence of dialysate in the peritoneal cavity, and the drugs used against renal allograft rejection. In this study, we investigated the gastric emptying time and its relationship with biochemical and nutritional parameters in patients on RRT: those on hemodialysis and peritoneal dialysis, and renal transplantation patients. Seventy-five patients, 44 on hemodialysis, 16 on peritoneal dialysis, and 15 renal transplant patients, were included in the study. They were examined for gastric emptying time using a radioisotopic method. The results were compared with the GET of healthy subjects. Each group of patients was evaluated in terms of hemoglobin, hematocrit, blood urea nitrogen (BUN), creatinine, blood glucose, total protein, albumin, serum lipids, parathyroid hormone (PTH) and body mass index and biceps and triceps skinfold. The mean GET of patients on RRT was significantly longer than the mean GET of healthy subjects (87.8 +/- 23.4 vs. 55 +/- 18 min, p<0.05). The mean GET of each therapy subgroups was significantly longer than the healthy subjects (the mean GET was 85.1 +/- 22.4 min for hemodialysis, 87.7+/-31.8 min for peritoneal dialysis, and 94.6+/-16.7 min for renal transplant patients, respectively, p<0.05). On the other hand, the differences in the mean GET between the three therapy subgroups were not statistically significant (p>0.05). In addition, time on replacement therapy inversely and blood glucose positively correlated with GET in renal transplant patients. In conclusion, GET was longer in patients on all three RRT modalities than in healthy subjects. GET was not significantly different in dialysis patients and renal transplant patients.     

Why do patients known to renal services still undergo urgent dialysis initiation? A cross-sectional survey.

BACKGROUND: Unplanned, urgent initiation of renal replacement therapy (RRT) is associated with poorer outcomes than planned initiation. However, in many services worldwide, substantial numbers of patients still do not begin treatment electively. The aim of this study was to identify numbers of and possible risk factors for, patients starting unplanned RRT despite being known to renal services for > or =4 months. METHODS: A retrospective survey of electronic and medical records was conducted of patients starting RRT in a large regional UK renal network in 2003. Data extracted included information on demographic, biochemical and treatment factors. Patients were classified as known acute (starting dialysis urgently yet known to renal services > or =4 months) or elective (starting RRT in a planned manner with a fistula or peritoneal dialysis catheter). Urgent dialysis was defined as starting either with a haemodialysis catheter or as an inpatient. Logistic regression was used to identify factors predicting an urgent dialysis start. RESULTS: Data from 109 of the 126 eligible patients were included; 60 elective, 49 known acute. Reasons for presenting as known acute were illness (21), service (24) and patient related (17). More than one reason was identified for 11 patients. The known acute group had more severe anaemia and lower glomerular filtration rates. Fewer known acute patients had attended dedicated predialysis clinics (90% increased odds of known acute start for non-attendance, P = 0.001) and patient dialysis information sessions (P = 0.020). Dialysis counselling had begun sooner in elective patients (P = 0.003). Odds of an urgent dialysis start increased by 4% with each year of age (P = 0.024). CONCLUSIONS: Early dialysis education and predialysis clinic attendance were associated with greater likelihood of elective dialysis initiation. Further studies are required to determine the cost effectiveness of these interventions, but services that initiate RRT urgently in a high proportion of patients should consider improving predialysis clinic attendance and early dialysis education.     

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.     

Renal cell carcinoma co-existent with other renal disease: clinico-pathological features in pre-dialysis patients and those receiving dialysis or renal transplantation.

BACKGROUND: Patients on chronic dialysis are prone to developing acquired cystic kidney disease (ACKD), which may lead to the development of renal cell carcinoma (RCC). The risk factors for the development of RCC so far have not been determined in pre-dialysis patients with co-existent renal disease. The aim of this study was to evaluate the clinico-pathological features of RCC in pre-dialysis patients with associated renal diseases or in those undergoing chronic dialysis and renal transplantation. METHODS: We studied 32 kidneys from 31 patients with RCC and associated renal diseases. Of those, 18 kidneys were from 17 patients not on renal replacement therapy (RRT) when diagnosed with RCC; 14 patients received dialysis or dialysis followed by renal transplantation. Several clinico-pathological features were analysed and compared between the two groups. RESULTS: Overall, there was a preponderance of males (75%); nephrosclerosis was the predominant co-existent disease (31%). The median intervals from renal disease to RCC in the dialysis and transplanted groups were significantly longer than in the pre-dialysis group (15.8+/-1.1 vs 2.4+/-0.7 years, P<0.0001). In contrast to pre-dialysis RCC, the dialysis and transplant RCC groups had greater frequency of ACKD (100 vs 28%, P<0.0001), papillary type RCC (43 vs 11%, P<0.05) and multifocal tumours (43 vs 5%, P<0.05). At the end of the study, 71% of dialysis and transplanted patients and 72% of pre-dialysis patients were alive. CONCLUSIONS: ACKD develops in dialysis patients, as it does in those with renal disease prior to RRT. The duration of renal disease, rather than the dialysis procedure itself, appears to be the main determinant of ACKD and RCC. The RCC occurring in patients with ACKD and prolonged RRT is more frequently of the papillary type and multifocal than the RCC occurring in patients with no or few acquired cysts and a short history of renal disease. Long-term outcomes did not differ between the two groups.     

The impact of major perioperative renal insult on long-term renal function and survival after cardiac surgery

Temporary renal replacement therapy (RRT) facilitates recovery from a major perioperative renal injury and, although RRT can improve the hospital outcome, it is not known as to whether it mitigates long-term renal sequelae. Therefore, we investigated the risk of long-term dialysis after RRT post-cardiac surgery. We analysed prospectively the data collected for all hospital survivors who received RRT following cardiac surgery between March 1996 and July 2010, excluding those on dialysis preoperatively or with a functioning renal transplant. The follow-up data were obtained for all surviving patients. The mean age of the 82 patients was 68.6 ± 9.9 years, and 60 (73%) were male. Severe pre-existing renal dysfunction with a serum creatinine level of >200 μmol/l was present in 15 (18%) patients and diabetes in 31 (38%) patients. Operative procedures included redo surgery (n = 11, 13%) and thoracic aortic surgery (n = 9, 11%). During a 13.4-year follow-up, there were 38 late deaths. Only three patients with severe preoperative renal dysfunction received dialysis. The Kaplan-Meier 5- and 7-year survival rates for this patient cohort were 54% and 38%, respectively. In conclusion, a major renal insult requiring temporary RRT after cardiac surgery does not increase the risk for renal dialysis in the long term for patients with normal renal function preoperatively.     

Agalsidase therapy in patients with Fabry disease on renal replacement therapy: a nationwide study in Italy.

BACKGROUND: In Fabry disease, end-stage renal disease (ESRD) and severe neurologic and cardiac complications represent the leading causes of late morbidity and mortality. A comprehensive Italian nationwide survey study was conducted to explore changes in cardiac status and renal allograft function in Fabry patients on renal replacement therapy (RRT) and enzyme replacement therapy (ERT). METHODS: This study was designed as a cross-sectional survey study with prospective follow-up. Of the 34 patients identified via searches in registries, 31 males and 2 females who received RRT and ERT (agalsidase beta in 30 patients, agalsidase alpha in 3) were included. Left ventricular mass index (LVMI), interventricular septal thickness at end diastole (IVSD), left ventricular posterior wall thickness (LVPWT) and renal allograft function were assessed at ERT baseline and subsequently at yearly intervals. RESULTS: The patients in the dialysis and transplant groups had been started on dialysis at age 42.0 and 37.1 years (mean), respectively, and patients in the transplant group received their renal allograft at age 39.8 years (mean). The mean age at the start of ERT was similar, 44.1 and 44.6 years, respectively. The mean RRT follow-up was 61.1 and 110.6 months for dialysis and transplant patients, respectively, whereas the ERT duration was 45.1 and 48.4 months, respectively. Cardiac parameters increased in dialysis patients. In transplant patients, mean LVMI seemed to plateau during agalsidase therapy at a lower level as compared to baseline. Decline in renal allograft function was relatively mild (-1.92 ml/min/year). Agalsidase therapy was well tolerated. Serious ERT-unrelated events occurred more often in the dialysis group. CONCLUSIONS: Kidney transplantation should be the standard of care for Fabry patients progressing towards ESRD. Transplanted Fabry patients on ERT may do better than patients remaining on maintenance dialysis. Larger, controlled studies in Fabry patients with ESRD will have to demonstrate if ERT is able to change the trajectory of cardiac disease and can preserve graft renal function.     

Gastric Emptying in Patients on Renal Replacement Therapy

In addition to gastrointestinal tract symptoms such as nausea, vomiting, and loss of appetite, impaired gastric emptying time (GET) may be related to nutritional parameters and nutritional status of patients on renal replacement therapy (RRT). Patients on RRT are affected by several factors such as uremic toxins, the presence of dialysate in the peritoneal cavity, and the drugs used against renal allograft rejection. In this study, we investigated the gastric emptying time and its relationship with biochemical and nutritional parameters in patients on RRT: those on hemodialysis and peritoneal dialysis, and renal transplantation patients. Seventy‐five patients, 44 on hemodialysis, 16 on peritoneal dialysis, and 15 renal transplant patients, were included in the study. They were examined for gastric emptying time using a radioisotopic method. The results were compared with the GET of healthy subjects. Each group of patients was evaluated in terms of hemoglobin, hematocrit, blood urea nitrogen (BUN), creatinine, blood glucose, total protein, albumin, serum lipids, parathyroid hormone (PTH) and body mass index and biceps and triceps skinfold. The mean GET of patients on RRT was significantly longer than the mean GET of healthy subjects (87.8 ± 23.4 vs. 55 ± 18 min, p < 0.05). The mean GET of each therapy subgroups was significantly longer than the healthy subjects (the mean GET was 85.1 ± 22.4 min for hemodialysis, 87.7 ± 31.8 min for peritoneal dialysis, and 94.6 ± 16.7 min for renal transplant patients, respectively, p < 0.05). On the other hand, the differences in the mean GET between the three therapy subgroups were not statistically significant (p > 0.05). In addition, time on replacement therapy inversely and blood glucose positively correlated with GET in renal transplant patients. In conclusion, GET was longer in patients on all three RRT modalities than in healthy subjects. GET was not significantly different in dialysis patients and renal transplant patients.     

The epidemiology of end-stage renal disease in the Baltic countries: an evolving picture.

INTRODUCTION: The epidemiology of end-stage renal disease (ESRD) and renal replacement therapy (RRT) is under continuous evolution all over the world. Of particular interest is the development of RRT in the countries of the former Soviet bloc which underwent great political and socio-economical changes in the last decade. We report here the epidemiological analysis of ESRD and RRT in the three Baltic countries: Lithuania, Estonia, Latvia. Subjects and methods. This epidemiological report is based on data from centre questionnaires which were collected from 1996 onwards, with a response rate of 98-99%. RESULTS: The prevalence/incidence of RRT patients in 1999 were 213/99.5 p.m.p. in Lithuania, 186/45.5 p.m.p. in Estonia and 172/55.8 p.m.p. in Latvia. Haemodialysis (HD) was the most common RRT modality in Lithuania (60% of prevalent patients), but not in Estonia (29%), while in Latvia it was nearly as common as renal transplantation (45 and 46%, respectively). Home HD was not performed. The proportion treated by peritoneal dialysis (PD) was very low in Lithuania (4% of RRT patients), while the percentage was higher in Latvia (9%) and Estonia (20.4%). The percentage of patients on RRT treated by renal transplantation was high throughout, representing the main modality of treatment in Estonia (50.5% of RRT prevalent patients, 94 p.m.p.) and in Latvia (46%, 79 p.m.p.) and being high in Lithuania (36%, 77 p.m.p.). The main renal diseases leading to ESRD were glomerulonephritis, pyelonephritis and diabetes. CONCLUSION: The epidemiology of RRT in the Baltic countries is undergoing rapid changes. Transplantation has reached an impressive level. A high percentage of RRT patients live with a functioning graft.     

Temporal association between the incidence of foot ulceration and the start of dialysis in diabetes mellitus.

BACKGROUND: The aim of this study was to seek a temporal association between the start of renal replacement therapy (RRT) and the first recorded foot ulcer in diabetes. METHODS: Details of all patients with diabetes who had received RRT were extracted from the renal database and were cross-checked with the database held in the specialist foot clinic. The date of onset of first registered foot ulcer was taken and compared with the date of onset of RRT. The self-controlled case-series method was used to establish any significant temporal association between the start of RRT and first recorded foot ulcer in diabetes. RESULTS: Of 466 patients with diabetes dialysed at our hospital since 1976, 94 (20.2%) were recorded as having at least one foot ulcer, with 15 of these undergoing major amputation. Incidence ratios (IRs) were calculated for 90 patients in whom complete data were available. A close temporal association was observed between the start of RRT and the first recorded foot ulceration: IR (95% CI) in the first and between the second and fifth years of dialysis were 3.35 (95% CI: 1.59-7.04), and 4.56 (2.19-9.50), respectively, relative to the time before dialysis. The IR for major amputation was 31.98 (2.09-490.3) in the first year and 34.01 (1.74-666.2) in the second to fifth years. CONCLUSION: These results reveal a close relationship between the onset of RRT in diabetes and the onset of foot ulceration, and confirm the high incidence of amputation in those on dialysis. Urgent steps should be taken to coordinate all aspects of diabetes foot care before and after the start of RRT.     

Impact of graft failure on patient survival on dialysis: a comparison of transplant-naive and post-graft failure mortality rates.

BACKGROUND: While the number of patients returning to dialysis after graft failure (GF) is increasing steadily, the impact of a failed kidney transplant on mortality among dialysis patients has not been studied well. METHODS: Data from the Canadian Organ Replacement Register were utilized to examine the outcomes of an incident cohort of patients (n = 25,632) initiating renal replacement therapy (RRT) between 1990 and 1998. Cox regression was used to compare covariate-adjusted mortality among five RRT categories: transplant-naive dialysis, cadaveric primary renal transplant, living-donor primary renal transplant, post-GF dialysis and retransplant. RRT category-specific hazard ratios (HR) were estimated using Cox regression and adjusting for age, sex, race, calendar period, primary renal diagnosis and comorbid conditions. RESULTS: Mortality among post-GF dialysis patients was approximately equal to that of transplant-naive patients (HR = 0.90; P = 0.30) while the HR for retransplanted patients was significantly decreased, relative to the transplant-naive group (HR = 0.35; P<0.01). Diabetes was found to be a significantly (P<0.01) stronger mortality risk factor among post-GF dialysis patients (HR = 3.71) compared with the transplant-naive group (HR = 1.73). In the post-GF group, cardiovascular disease (HR = 1.66) and 'other serious illness' (HR = 2.07) were found to be much stronger risk factors for mortality than in the transplant-naive group (HR = 1.33 and 1.43, respectively), although the differences failed to reach statistical significance. CONCLUSIONS: These results suggest that transplant-naive and post-GF dialysis patients have equivalent mortality risk and that mortality is significantly reduced upon retransplantation. In addition, the results highlight the importance of diabetes and, possibly, comorbid conditions as potential modifiable risk factors in the management of post-GF dialysis patients.     

Residual renal function in dialysis patients

Residual renal function (RRF) contributes to the achievement of treatment adequacy in CKD-5 patients. It may facilitate patients' acceptance of renal replacement therapy (RRT) in minimizing dietary and fluid restriction. It has been confirmed to improve dialysis patient outcomes. Attempts to preserve RKF in incident CKD-5 patients are still subject to controversies. In this review we analyze the role of RRT in dialysis patient. What are the positive and the beneficial effects of maintaining RRF? What are the negative and the risks of maintaining a RRF? At what expense the maintenance of RRF is achieved? Preservation of RRF is undoubtedly an interesting means to enhance the efficacy of renal replacement therapy and reduce dietary fluid restriction. However, maintainance of RRF should not be considered as a goal of dialysis adequacy in dialysis patients but rather a means of optimizing RRT. Further, preservation of RRF should be considered as a permanent trade-off between patient comfort and chronic fluid volume overload with its deleterious effects.     

Acute kidney injury: Epidemiology,outcomes, complications,and therapeutic strategies

Acute kidney injury (AKI) is one of the most common serious complications for all hospital admissions, with its incidence increasing among hospitalized patients, particularly those in the intensive care unit. Despite significant improvements in critical care and dialysis technology, AKI is associated with an increased risk of short‐ and long‐term mortality, prolonged hospital stays, and dialysis dependence. These risks are particularly relevant for critically ill patients with AKI severe enough to require renal replacement therapy (RRT). No specific pharmacologic treatment has been established to treat AKI. Hence, the mainstay treatment for patients with AKI is RRT even though there are still several problematic issues regarding its use including RRT modality, dose, and timing. Recently, the impact of AKI on an increased risk of progression to chronic kidney disease (CKD) and end‐stage renal disease requiring dialysis or transplantation is attracting increased attention.     

Inequality of renal replacement therapy in the low-income countries.

Sir, As Grassmann and associates [1] have shown, chronic renal failure(CRF) patients treated by renal replacement therapy (RRT) worldwideare increasing rapidly. The cost of RRT, especially the cost of dialysis, has been growingrapidly with an increasing numbers of RRT patients [2], becominga financial problem even in Euro–American countries andJapan. More seriously, developing countries have been struckby a surge in the RRT population and a sharp rise in reimbursementcosts for RRT. Although     

We Offer Renal Replacement Therapy to Patients Who Are Not Benefitted by It

Nephrologists offer renal replacement therapy (RRT) to patients who are unlikely to benefit in part because of our discomfort discussing goals of care in the setting of an uncertain prognosis for a given individual. Permanent neurological impairment, terminal illness (life expectancy <6 months), medical conditions precluding the safe delivery of dialysis, elderly patients with poor prognosis, and those who begin “early” RRT are categories of patients for whom dialysis may not be beneficial. Successful use of time‐limited trials of dialysis may reduce the number of patients who are started on RRT without significant benefit. However, clear achievable milestones and goals need to be incorporated into plans for time‐limited trials to ensure that continuing RRT beyond the trial period is appropriate. The lack of information on outcomes and symptom management using a “palliative approach” to dialysis suggests this should not be a clinical option until additional study is done and efficacy data available. Clinical practice guidelines are available to assist nephrologists in the appropriate withholding of RRT.     

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.     

Mortality trends in pediatric patients with chronic renal failure

Mortality trends were analyzed in 441 children and adolescents with chronic renal failure (CRF) observed over a 24-year period before and after institution of renal replacement therapy (RRT). A total of 93 patients died. Overall mortality rate (MR) per 100 patient years decreased from 6.6 in 1969–1978 to 2.5 in 1979–1988 and increased slightly to 2.9 in 1989–1992. The fall involved all four modes of treatment: conservative hemodialysis (HD), continuous peritoneal dialysis (CPD), and transplantation (TX). From 1979–1988 to 1989–1992 MR on conservative and on dialysis treatment changed only slightly and was similar on HD and CPD. An alarming rise in MR was noted after TX in 1989–1992, mainly due to malignant tumors. In 44 patients who died on conservative treatment, the reasons for non-acceptance for RRT were analyzed: in 22 multi-morbidity was the main reason, usually because of a congenital neurological disorder. Some patients died from advanced uremia or unexpected events after the decision to institute RRT. Our experience demonstrates a persistent mortality in pediatric patients with CRF, which in recent years is primarily ascribed to congenital multi-morbid conditions which make RRT unfeasible, infections on dialysis treatment, and malignancies after TX.     

Surgical Interventions for Renal Replacement Therapy from the View of Nephrologists

Summary BACKGROUND: The number of patients with end-stage renal disease (ESRD) is increasing worldwide at a rate of approximately 5 % per year. In Austria, 6049 patients were suffering from ESRD in the year 2001, an annual rate of 1093 patients. Higher age of patients and co-morbidities are forcing nephrologists to find the optimal renal replacement therapy (RRT) and access modality for the individual patient. METHODS: For patients with ESRD needing RRT, both nephrologist and surgeon should be consulted to ensure optimal management and treatment including vascular access surgery. Patients planned for peritoneal dialysis (PD) are treated with the cooperation of a visceral surgeon. A catheter is inserted into the pelvic area to enable solution exchange. In patients who are to undergo hemodialysis (HD), nephrologists have to decide whether the cardiac condition is suitable for surgical access creation such as fistula or graft. Otherwise alternative hemodialysis devices such as a central venous catheter (CVC), or subcutaneously implantable ports (Dialock^®), have to be discussed. Access function is routinely monitored during dialysis treatment, but still remains the weak component of extracorporeal RRT responsible for 40 % of hospitalization of HD patients. RESULTS: At the dialysis unit of the University Hospital of Graz, 107 patients were under RRT (70 HD and 37 PD), and 235 patients were hemodialyzed in private units in Graz in 2001. 81 ESRD patients were newly enrolled in the chronic HD program. 131 HD accesses were created in new HD patients and patients under treatment for chronic HD. 36 patients developed HD access complications and in these patients, 181 surgical and/or radiological interventions were performed. CONCLUSIONS: In 12 % of the HD patients in Graz, access problems occurred. These patients have a high frequency of surgical and radiological interventions. Access monitoring and measurement of recirculation may help to reduce the complication rate by 38 %. Before onset of RRT, patients need special management to ensure the best dialysis modality. ESRD patients who are suffering from cardiac diseases, diabetes mellitus, or bad peripheral vascular status need a multidisciplinary approach with nephrologists, cardiologists, surgeons and radiologists working together to find the optimal access for dialysis treatment.     

Effect of having a functioning cadaveric renal transplant on cardiovascular mortality risk in patients on renal replacement therapy

Our aim was to estimate the effect of having a functioning cadavericrenal transplant on the risk of cardiovascular and total mortalityin patients on renal replacement therapy (RRT). We retrospectivelystudied (by the Cox proportional hazards regression model) 195subjects who began RRT with maintenance dialysis in our centrefrom 1 January 1978 to 31 December 1991. Out of this number,76 patients received a cadaveric kidney transplant. Cardiovascular abnormalities at the onset of RRT were the principalindependent determinant of both total and cardiovascular mortalityrisk. As compared to patients on dialysis with the same durationof RRT, patients with a functioning renal transplant for morethan 1 year had a significantly lower total mortality risk (meanrelative risk (RR): 0.48 (0.25–0.91) (95% confidence limitsin parentheses), P=0.03), an effect whose significance disappearedafter adjustment for pretreatment conditions (RR=0.62 (0.30–1.30),P>0.3). However, the beneficial effect of a functioning renaltransplant for more than 1 year on cardiovascular mortalityrisk was significant, both before (RR=0.21 (0.06–0.74),P=0.02) and after the adjustment for pretreatment conditions(RR=0.32 (0.11–0.90), P=0.035). During the first yearafter a successful transplantation the beneficial effect ofhaving a functioning transplant on cardiovascular mortalityrisk was only weakly attenuated. During RRT a functioning cadaveric renal transplant decreasescardiovascular mortality risk partially independently of thebetter pretreatment status of the patients selected for transplantation.     

Cost of renal replacement therapy in Turkey

BACKGROUND AND RESULTS: By the end 2000, 22224 patients were on renal replacement therapy (RRT) in Turkey. We investigated the cost of RRT in three medical faculties and one private dialysis centre. Yearly expenses were US dollars 22759 for haemodialysis (HD), US dollars 22350 for continuous ambulatory peritoneal dialysis (CAPD), and US dollars 23393 and US dollars 10028, respectively, for the first and second years of transplantation (Tx). In the first year, renal Tx was significantly more expensive than CAPD. However, after the first year of renal transplantation, Tx became significantly more economical than both CAPD and HD. The sum of all yearly RRT expenses for the country was US dollars 488958709, which corresponds to nearly 5.5% of Turkey's total health expenditure. CONCLUSION: Measures such as early construction of vascular access, promoting home dialysis and the reuse of the dialysers, strict control of the use of some expensive drugs like erythropoietin and active vitamin D, and also increasing the number of transplantations, especially if pre-emptive transplantation is possible, should be taken into account in order to reduce these expenses.