Late referral for end-stage renal disease: a region-wide survey in the south west of England.

BACKGROUND: The proportion of patients referred for renal replacement therapy (RRT) at a late stage of disease appears to be similar to that first described nearly 20 years ago. This study investigated the current scale of the problem in a large region in England, identifying the prior health care, patient characteristics, referral pattern, and outcomes of those accepted onto RRT. METHODS: Three hundred and sixty-one (88%) out of 411 patients accepted for RRT in six renal units in the South and West Region of the UK between 1 June 1996 and 31 May 1997 were studied retrospectively. We examined the history of chronic renal failure, referral path to nephrologist, management of chronic renal failure (CRF) and patient outcomes. Patients were categorized as 'late' if they were referred to the renal unit either within 4 months or within 1 month of requiring RRT. RESULTS: One hundred and twenty-four (35%) patients were referred within 4 months of RRT, and 84 (23%) within 1 month. The main differences between patients referred later and other patients was seen for those referred within 1 month. These patients were older and had more co-morbidity, significantly worse laboratory parameters at the start of RRT, were less likely to have received standard treatments for CRF, had less permanent dialysis access in place at the start of RRT (18% vs 47%, P=0.001), and had a significantly longer hospital stay (18 vs 10 days, P=0.001). Seventy-four (19%) patients died in the first 6 months: 27 (32%) in the 1-month group, 46 (16%) in all others (P=0.002). We found no evidence that patients referred late had defaulted from nephrology follow-up or had an excess of rapidly progressive disease. Though data were incomplete, there was evidence of prior CRF of over 1 year in all late referral groups. CONCLUSION: Nearly a quarter of patients are referred for specialist nephrology treatment at a very late stage, within 1 month of RRT. They are less likely to receive interventions that could alter the progression of CRF or reduce its associated co-morbidity, have a worse clinical state at the start of RRT, longer hospitalization and poorer survival. These differences were much less marked for those referred within 1-4 months of starting RRT, although this is an insufficient time to prepare for RRT. Further research is needed to determine the missed opportunities for more proactive diagnosis and management of CRF.     

Comparison of continuous and intermittent renal replacement therapy for acute renal failure.

BACKGROUND: Mortality rates of critically ill patients with acute renal failure (ARF) requiring renal replacement therapy (RRT) are high. Intermittent and continuous RRT are available for these patients on the intensive care units (ICUs). It is unknown which technique is superior with respect to patient outcome. METHODS: We randomized 125 patients to treatment with either continuous venovenous haemodiafiltration (CVVHDF) or intermittent haemodialysis (IHD) from a total of 191 patients with ARF in a tertiary-care university hospital ICU. The primary end-point was ICU and in-hospital mortality, while recovery of renal function and hospital length of stay were secondary end-points. RESULTS: During 30 months, no patient escaped randomization for medical reasons. Sixty-six patients were not randomized for non-medical reasons. Of the 125 randomized patients, 70 were treated with CVVHDF and 55 with IHD. The two groups were comparable at the start of RRT with respect to age (62+/-15 vs 62+/-15 years, CVVHDF vs IHD), gender (66 vs 73% male sex), number of failed organ systems (2.4+/-1.5 vs 2.5+/-1.6), Simplified Acute Physiology Scores (57+/-17 vs 58+/-23), septicaemia (43 vs 51%), shock (59 vs 58%) or previous surgery (53 vs 45%). Mortality rates in the hospital (47 vs 51%, CVVHDF vs IHD, P = 0.72) or in the ICU (34 vs 38%, P = 0.71) were independent of the technique of RRT applied. Hospital length of stay in the survivors was comparable in patients on CVVHDF [median (range) 20 (6-71) days, n = 36] and in those on IHD [30 (2-89) days, n = 27, P = 0.25]. The duration of RRT required was the same in both groups. CONCLUSION: The present investigation provides no evidence for a survival benefit of continuous vs intermittent RRT in ICU patients with ARF.     

Nephrology and renal replacement therapy in Romania--transition still continues (Cinderella story revisited).

INTRODUCTION. This report describes the current status of nephrology and renal replacement therapy (RRT) in Romania, a country with previously limited facilities, highlighting national changes in the European context. METHODS: Trends in RRT development were analysed in 2003, on a national basis, using the same questionnaires as in previous surveys (1991, 1995). Survival data and prognostic risk factors were calculated retrospectively from a large representative sample of 2284 patients starting RRT between January 1, 1995 and December 31, 2001 (44% of the total RRT population investigated). RESULTS: In 2003, RRT incidence [128 per million population (p.m.p.)] and prevalence (250 p.m.p.) were six and five times higher, respectively, than in 1995. The annual rate of increase in the stock of RRT patients (11%) was supported mainly by an exponential development of the continuous ambulatory peritoneal dialysis (CAPD) population (+600%), while the haemodialysis (HD) growth rate was stable (+33%) and renal transplantation made a marginal contribution. Renal care infrastructure followed the same trend: nephrology departments (+100%) and nephrologists (+205%). The characteristics of RRT incident patients changed accordingly to current European epidemiology (increasing age and prevalence of diabetes and nephroangiosclerosis). The estimated overall survival of RRT patients in Romania was 90.6% at 1 year [confidence interval (CI) 89.4-91.8] and 62.2% at 5 years (CI 59.4-65.0). Patients' survival was negatively influenced (Cox regression analysis) by age >65 years (P < 0.001), lack of pre-dialysis monitoring by a nephrologist [P = 0.01, hazards ratio (HR) = 0.8], severe anaemia, lack of erythropoetin treatment (P < 0.001, HR = 0.6), and co-morbidity, e.g. cardiovascular diseases (P < 0.001, HR = 1.8) and diabetes mellitus (P < 0.001, HR = 2.2). CONCLUSIONS: Although the rate of increase in RRT patient stock in 1996-2003 in Romania was the highest in Europe, the prevalence remained below the European mean. As CAPD had the greatest expansion, followed by HD, an effective transplantation programme must be set up to overcome the imbalance. The quality of RRT appears to be good and survival was similar to that in other registries. Further evolution implies strategies of prevention, based on national surveys, supported by the Romanian Renal Registry.     

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.     

Time trend in access to the waiting list and renal transplantation: a comparison of four European countries

Background To examine the time trend and international differences in access to the waiting list and renal transplantation of patients with end-stage kidney disease. Methods We included all patients (n = 30 961) from Austria, Norway, the Netherlands and Scotland who started renal replacement therapy (RRT) between 1995 and 2003 with their kidney transplant waiting list data (until 31 December 2005) and follow-up data on RRT and mortality (until 31 December 2007). The outcome measure was access to the waiting list within 2 years and to a first renal transplant within 4 years from the start of RRT, expressed as incidence per million age-related population (p.m.a.r.p.) per year. To estimate trends over time, mean percentage annual change (MPAC) and 95% confidence interval (CI) were calculated. Results In each country, the number of patients starting RRT > 65 years increased significantly over time, whereas the number of renal transplants did not increase to the same extent. Only in Norway were almost all patients on the waiting list transplanted within 4 years of RRT start if they were < 65 years. In patients who started RRT > 65 years, the access to renal transplantation was high in Norway (49 p.m.a.r.p.) and low in Austria ( < 26 p.m.a.r.p.), the Netherlands and Scotland (both < 10 p.m.a.r.p.) but increased significantly in Austria (MPAC = 9.8%; 95% CI = 3.9-16.9) and the Netherlands (MPAC = 9.0%; 95% CI = 3.2-15.0). Conclusion Only in Norway, virtually all patients on the waiting list < 65 years received a transplant within 4 years after the start of RRT and, remarkably, also most of those > 65 years of age.     

Trends in the use of renal replacement therapy modality in intensive care unit: a 7 year study

Abstract

Background: The use of renal replacement therapy (RRT) modality in the intensive care unit (ICU) depends primarily on provider preference and hospital resource. This study aims to describe the prevalence of RRT use and the trends in RRT modality use in the ICU over the past 7 years. Methods: All ICU admissions, including medical, cardiac, and surgical ICUs from 1 January 2007 to 31 December 2013, were included in this study. RRT use was defined as the use of intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT) within a given ICU day. The RRT use was reported as the proportion of ICU days on each RRT modality divided by the total ICU days with RRT usage. Results: Over the course of this study (72,005 ICU admissions), 272,271 ICU days were generated. RRTs were used in 4110 ICU admissions (5.7%) and on 21,159 ICU days (7.8%). RRT use was 10,402 (49%) for IHD, and 10,954 (52%) for CRRT. The trend of IHD and CRRT use did not change from year 2007 to 2013. On ICU days with RRT, the choice of RRT modality was associated with the number of vasopressor use (p?<?0.001). CRRT was more preferred on the ICU days with the increasing number of vasopressor use. Conclusions: RRTs were used in about 6% of ICU admission. The use of IHD and CRRT was similar and did not change over 7 years. The choice of RRT modality mainly depended on the number of vasopressors used on ICU days with RRT.     

Long-term quality of life and hospital mortality in patients treated with intermittent or continuous hemodialysis for acute renal and respiratory failure

OBJECTIVE: To describe long-term quality of life, intensive care, and hospital mortality in patients with acute renal and respiratory failure treated with one of two methods of renal replacement therapy (RRT). DESIGN: Cross-sectional survey of long-term survivors from a prospective observational study of two methods of RRT. SETTING: A combined surgical and medical intensive care unit in a university hospital. PATIENTS AND PARTICIPANTS: One hundred and twenty-six patients with acute renal and respiratory failure who required treatment with RRT and mechanical ventilation. Interventions. (1) RRT for acute renal failure was with either continuous hemodialysis with ultrafiltration using biocompatible membranes and prostacyclin and heparin anticoagulation (CHDF) or intermittent hemodialysis using cuprophane membranes and heparin anticoagulation (IHD); (2) Health-related quality of life in long-term survivors was assessed with the SF-36 (HRQL) questionnaire. MEASUREMENTS AND MAIN RESULTS: (1) There was no difference in ICU mortality (73.5% [39/53] IHD vs. 71.8% [46/64] CHDF, P = NS) or hospital mortality (83% [44/53] IHD vs. 76.5% [49/64] CHDF, P = NS) between the two RRT treatment groups. By 1999, there were 16 surviving patients; (2) Twelve of these survivors completed SF-36 forms (10 CHDF vs. 2 IHD). The overall physical health summary score and scores for seven of the health domains were significantly reduced. The mental health summary score and the domain mental health score did not differ from the general population. CONCLUSIONS: (1) The method of RRT used in ICU patients with ARF had no influence on survival; (2) The long-term survivors of multi-organ failure have poor physical health.     

Long-Term Quality of Life and Hospital Mortality in Patients Treated with Intermittent or Continuous Hemodialysis for Acute Renal and Respiratory Failure

Objective. To describe long-term quality of life, intensive care, and hospital mortality in patients with acute renal and respiratory failure treated with one of two methods of renal replacement therapy (RRT). Design. Cross-sectional survey of long-term survivors from a prospective observational study of two methods of RRT. Setting. A combined surgical and medical intensive care unit in a university hospital. Patients and participants. One hundred and twenty-six patients with acute renal and respiratory failure who required treatment with RRT and mechanical ventilation. Interventions. 1. RRT for acute renal failure was with either continuous hemodialysis with ultrafiltration using biocompatible membranes and prostacyclin and heparin anticoagulation (CHDF) or intermittent hemodialysis using cuprophane membranes and heparin anticoagulation (IHD); 2. Health-related quality of life in long-term survivors was assessed with the SF-36 (HRQL) questionnaire. Measurements and main results. 1. There was no difference in ICU mortality (73.5%[39/53] IHD vs. 71.8%[46/64] CHDF, P = NS) or hospital mortality (83%[44/53] IHD vs. 76.5% [49/64] CHDF, P = NS) between the two RRT treatment groups. By 1999, there were 16 surviving patients; 2. Twelve of these survivors completed SF-36 forms (10 CHDF vs. 2 IHD). The overall physical health summary score and scores for seven of the health domains were significantly reduced. The mental health summary score and the domain mental health score did not differ from the general population. Conclusions. 1. The method of RRT used in ICU patients with ARF had no influence on survival; 2. The long-term survivors of multi-organ failure have poor physical health.     

Trends in the incidence of renal replacement therapy for end-stage renal disease in Europe, 1990-1999.

BACKGROUND: The epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) varies considerably worldwide, but we have lacked reliable quantitative estimates of trends in the incidence by age, sex and cause in Europe over the last decade. METHODS: We analysed data from nine countries participating in the ERA-EDTA registry: Austria, Belgium, Denmark, Finland, Greece, The Netherlands, Norway, Spain and UK (Scotland). Adjusted incidence rates for age and sex were studied for 2 year periods between 1990 and 1999. Average annual changes (%) were estimated by Poisson regression. RESULTS: The adjusted incidence rate of RRT increased from 79.4 per million population (pmp) (range: 58.4-101.0) in 1990-1991 to 117.1 pmp (91.6-144.8) in 1998-1999, i.e. 4.8% (3.1-6.4%) each year. This increase did not flatten out at the end of the decade, except in The Netherlands, and was greater in men than women, 5.2 vs 4.0%/year. In most countries, the incidence rate remained stable for those younger than 45 years; it rose by 2.2%/year on average in the 45-64 year age group and by 7.0% among those 65-74 years; it tripled over the decade in those 75 years or older, and by 1998-1999 it ranged from 140.9 to 540.4 pmp between countries. The incidence of ESRD due to diabetes, hypertension and renal vascular disease nearly doubled over 10 years; in 1998-1999, it varied between countries from 10.2 to 39.3 pmp for diabetes, from 5.8 to 21.0 for hypertension, and from 1.0 to 15.5 for renal vascular disease. CONCLUSION: RRT incidence continues to rise but at various rates in the European countries studied, tending to widen the gap between them. This mainly results from enlarging differences in incidence in the elderly and, to a lesser extent, in that due to diabetes, hypertension and renal vascular disease.     

Dialysis in Israel, 1989-2005--time trends and international comparisons.

BACKGROUND: A universal increase in the incidence of renal replacement therapy (RRT) was reported in developed countries during the 1990s, especially among the elderly and diabetic patients. We studied trends in RRT incidence and mortality in Israel between 1989 and 2001-2005. METHODS: The end-stage renal disease (ESRD) registry holds data on all RRT patients in Israel. Age-adjusted incidence rate ratios (RRs) were estimated comparing 2001-2005 with 1989. We compared incidence data between Israel and elsewhere using standardized incidence ratios (SIRs). Survival analysis was conducted by the Kaplan-Meier method and Cox's proportional hazards regression was used to compare survival of diabetic with non-diabetic ESRD patients. RESULTS: The mean incidence rates per million population increased from 99 in 1989-1991 to 179 in 2003-2005. In 2000, Israel was the second leading country for incidence of RRT. Age-adjusted incidence rates increased by 67% [95% confidence interval (CI): 49-87%], from 1989 to 2001, but the trend was attenuated between 2002 and 2005. The increase in incidence was positively associated with age, the largest increase being among the elderly aged > or = 75 years (RR: 3.18, 95%CI: 2.72-3.70). Diabetes accounted for 41% of RRT in 2001 vs only 19% in 1989. There was no increase in 1-year survival between the beginning and the end of the study period. Patients with diabetes-associated RRT had 57% increased risk of 1-year mortality (adjusted HR: 1.57 95% CI: 1.51-1.63). CONCLUSIONS: Despite a similar proportion of RRT attributed to diabetes in Israel and other countries, the age-adjusted incidence in Israel is considerably higher than most countries.     

Renal replacement therapy in Europe: the results of a collaborative effort by the ERA-EDTA registry and six national or regional registries.

BACKGROUND: In June 2000 a new ERA-EDTA Registry Office was opened in Amsterdam. This Registry will only collect core data on renal replacement therapy (RRT) through national and regional registries. This paper reports the technical and epidemiological results of a pilot study combining the data from six registries. METHODS: Data from the national renal registries of Austria, Finland, French-Belgium, The Netherlands, Norway, and Scotland were combined. Patients starting RRT between 1980 and 1999 (n=57371) were included in the analyses. Cox proportional hazards regression was used to predict survival. RESULTS: The use of different coding systems for ESRD treatment by the registries made it difficult to merge the data. Incidence and prevalence of RRT showed a continuous increase with a marked variation in rates between countries. The 2-, 5- and 10-year patient survival was 67, 35 and 11% in dialysis patients and 90, 81 and 64% after a first renal allograft. Multivariate analysis showed a slightly better survival on dialysis in the 1990-1994 (RR 0.94, 95% CI 0.90-0.98) and the 1995-1999 cohort (RR 0.88, 95% CI 0.84-0.92) compared to the 1980-1984 cohort. In contrast, there was a much greater improvement in transplant-patient survival, resulting in a 56% reduction in the risk of death within the 1995-1999 cohort (RR 0.44, 95% CI 0.39-0.50) compared to the 1980-1984 cohort. CONCLUSIONS: This study provides support for the feasibility of a "new style" ERA-EDTA registry and the collection of data is now being extended to other countries. The improvement in patient survival over the last two decades has been much greater in transplant recipients than in dialysis patients.     

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     

Regional variability in the incidence of end-stage renal disease: an epidemiological approach.

BACKGROUND: Regional variability in the incidence of end-stage renal disease (ESRD) in Austria is reported. Our aim was to investigate the reason for low rates in the state of Tyrol. METHODS: ESRD incidence data were obtained from the Austrian Dialysis and Transplantation Registry. Additional sources were two health interview surveys, the Hospital Discharge Registry, the Mortality Registry and the Drug Wholesale Registry. RESULTS: Between 1995 and 1999, 4811 new cases of ESRD were recorded; the state of Tyrol (T) had a mean annual, age-adjusted incidence of 97.9/1 000 000 population [95% confidence interval (CI) 86.9-109.1], a number significantly lower than that for the rest of Austria [(RA), 120.9 (95% CI 116.9-124.5); P < 0.001]. This was due mainly to a difference in the incidence of ESRD patients with type 2 diabetes mellitus [(DM-2) T = 12.2 (95% CI 8.2-16.2) vs RA = 28.9 (95% CI 27.2-30.6); P < 0.001]. When these patients were excluded, the difference in the overall ESRD incidence disappeared. When data from various registries were analysed for the prevalence of DM, a highly significant correlation was found between ESRD incidence and DM. CONCLUSION: We conclude that the variability in the ESRD incidence in Austria is explained mainly by regional differences in DM-2. Data from similar studies might be useful for predictions concerning resource allocation for ESRD programmes in the future.     

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.     

The renal epidemiology and information network (REIN): a new registry for end-stage renal disease in France.

The French Renal Epidemiology and Information Network (REIN) registry began in 2002 to provide a tool for public health decision support, evaluation and research related to renal replacement therapies (RRT) for end-stage renal disease (ESRD). It relies on a network of nephrologists, epidemiologists, patients and public health representatives, coordinated regionally and nationally. Continuous registration covers all dialysis and transplanted patients. In 2003, 2070 patients started RRT, 7854 were on dialysis and 7294 lived with a functioning graft in seven regions (with a population of 16.5 million people). The overall crude annual incidence rate of RRT for ESRD was 123 per million population (p.m.p.) with significant differences in age-adjusted rates across regions, from 84 [95% confidence interval (CI): 74-94] to 155 [138-172] p.m.p. The principal causes of ESRD were hypertension (21%) and diabetic (20%) nephropathies. Initial treatment for ESRD was peritoneal dialysis for 15% of patients and a pre-emptive graft for 3%. The one-year survival rate was 81% [79-83] in the cohort of 2002-2003 incident patients. As of December 31, 2003, the overall crude prevalence was 898 [884-913] p.m.p, with 5% of patients receiving peritoneal dialysis, 47% on haemodialysis and 48% with a functioning graft. The experience in these seven regions over these two years clearly shows the feasibility of the REIN registry, which is progressively expanding to cover the entire country.     

Preventing end-stage renal disease: the potential impact of screening and intervention in developing countries.

There are about 1 million people in the world that are alivejust because they have access to one form or another of renalreplacement therapy (RRT) [1]. Ninety percent of them live inthe developed countries, or, as they are defined by the WorldBank (WB), high-income countries, where the average gross incomeis in excess of $10 000 per capita. There is a clear, direct relationship between gross nationalproduct (GNP) and availability of RRT. Dialysis treatment absorbs0.7 to 1.8% of the health care budget in European countries,while the dialysis population represents 0.02 to 0.05% of thewhole population [2]. In the Eastern European countries, theso-called former Soviet block, the prevalence rate of RRT ishalf     

Time trends in initiation and dose of dialysis in end-stage renal disease patients in The Netherlands.

BACKGROUND: The guidelines published by the NKF-Dialysis Outcomes Quality Initiative (DOQI) in 1997 advocate an earlier start of dialysis in ESRD patients and a higher dialysis dose than usual. We studied the possible influence of the increasing emphasis on adequate dialysis on the management of ESRD patients in The Netherlands in 1993-2000. METHODS: The NECOSAD study on the adequacy of dialysis started in 1993. This prospective multi-centre study included ESRD patients older than 18 years who started HD or PD as the first RRT. We analysed the distribution of age, gender, primary renal disease and co-morbidity, the mean residual renal function and the mean dialysis-Kt/V(urea) at 3 months in 1569 consecutive patients by calendar year of initiation dialysis. RESULTS: Age, gender, primary renal disease and number of co-morbid conditions at the start of dialysis remained stable over time between 1993 and 2000. The mean renal Kt/V(urea) at 3 months increased from 0.5 in 1993 to 0.8 per week in 2000 (P<0.01). An upward trend remained after adjustment for patient characteristics and dialysis centre. The total Kt/V(urea) at 3 months increased from 3.3 in 1993 to 3.7 per week in 2000 in HD (P<0.01) and from 2.0 in 1993 to 2.3 per week in 1999 in PD patients (P<0.01). An upward trend in the dialysis-Kt/V(urea) was found after adjustment for renal Kt/V(urea) (HD: +0.3 per week, P=0.06; PD, +0.2 per week, P<0.05). CONCLUSIONS: These results indicate a tendency towards earlier introduction of RRT and higher doses of dialysis in The Netherlands. Possible effects of this development on mortality, morbidity, quality of life and the balance between costs and benefits need further investigation.     

Deaths within 90 days from starting renal replacement therapy in the ERA-EDTA Registry between 1990 and 1992.

BACKGROUND: Patients who die within 90 days of commencing renal replacement therapy (RRT) may be recorded by some centres and not others, and hence data on mortality and survival may not be comparable. However, it is essential to compare like with like when analysing differences between modalities, centres and registries. It was decided, therefore, to look at the incidence of deaths within 90 days in the ERA-EDTA Registry, and to try to define the characteristics of this group of patients. METHODS: Between 1 January 1990 and 31 December 1992, 78 534 new patients started RRT in 28 countries affiliated to the ERA-EDTA Registry. Their mean age was 54 years and 31% were over 65 years old. Eighty-two per cent of the patients received haemodialysis (HD), 16% peritoneal dialysis (PD) and 2% had preemptive transplantation as first mode of treatment. RESULTS: From January 1990 to March 1993 the overall incidence of deaths was 19% and 4% of all patients died within 90 days from the start of RRT. Among those dying within 90 days 59% were over 65 years compared to 53% over 65 years in those dying beyond this time (P<0.0001). The modality of RRT did not influence the distribution of deaths before and after 90 days. Vascular causes and malignancy were more common in those dying after 90 days, while there were more cardiac and social causes among the early deaths. Mortality from social causes was twice as common in the elderly, who had a significantly higher chance of dying from social causes within 90 days compared to those aged under 65 years. The overall incidence of deaths within 90 days was 3.9% but there was a wide variation between countries, from 1.8% to 11.4%. Finally, patient survival at 2 years was markedly influenced in different age groups when deaths within 90 days were taken into account. CONCLUSIONS: The incidence of deaths within 90 days from the start of RRT was 3.9%, with a marked variation between countries ranging from 1.8% to 11.4%, which probably reflects mainly differences in reporting these deaths, although variable selection criteria for RRT may contribute. Deaths within 90 days were significantly more frequent in elderly patients with more early deaths resulting from cardiac and social causes, while vascular causes of death and malignancy were more common in those dying after 90 days. Patient survival analyses should take into account deaths within 90 days from the start of RRT, particularly when comparing results between modalities, countries and registries.     

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

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

Effects of hydroxyethyl starch administration on renal function in critically ill patients

BACKGROUND: The influence of hydroxyethyl starch (HES) solutions on renalfunction is controversial. We investigated the effect of HESadministration on renal function in critically ill patientsenrolled in a large multicentre observational European study. METHODS: All adult patients admitted to the 198 participating intensivecare units (ICUs) during a 15-day period were enrolled. Prospectivelycollected data included daily fluid administration, urine output,sequential organ failure assessment (SOFA) score, serum creatininelevels, and the need for renal replacement therapy (RRT) duringthe ICU stay. RESULTS: Of 3147 patients, 1075 (34%) received HES. Patients who receivedHES were older [mean (SD): 62 (SD 17) vs 60 (18) years,P = 0.022], more likely to be surgical admissions, had a higherincidence of haematological malignancy and heart failure, higherSAPS II [40.0 (17.0) vs 34.7 (16.9), P < 0.001] and SOFA[6.2 (3.7) vs 5.0 (3.9), P < 0.001] scores, and less likelyto be receiving RRT (2 vs 4%, P < 0.001) than those who didnot receive HES. The renal SOFA score increased significantlyover the ICU stay independent of the type of fluid administered.Although more patients who received HES needed RRT than non-HESpatients (11 vs 9%, P = 0.006), HES administration was not associatedwith an increased risk for subsequent RRT in a multivariableanalysis [odds ratio (OR): 0.417, 95% confidence interval (CI):0.05–3.27, P = 0.406]. Sepsis (OR: 2.03, 95% CI: 1.37–3.02,P < 0.001), cardiovascular failure (OR: 6.88, 95% CI: 4.49–10.56,P < 0.001), haematological cancer (OR: 2.83, 95% CI: 1.28–6.25,P = 0.01), and baseline renal SOFA scores > 1 (P < 0.01for renal SOFA 2, 3, and 4 with renal SOFA = 0 as a reference)were all associated with a higher need for RRT. CONCLUSIONS: In this observational study, haematological cancer, the presenceof sepsis, cardiovascular failure, and baseline renal functionas assessed by the SOFA score were independent risk factorsfor the subsequent need for RRT in the ICU. The administrationof HES had no influence on renal function or the need for RRTin the ICU.