Losartan reduces the costs of diabetic end-stage renal disease: an Asian perspective

OBJECTIVE: To evaluate losartan and conventional antihypertensive therapy (CT) compared with CT alone on the cost associated with end-stage renal disease (ESRD) in Hong Kong, Japan, Korea, Malaysia, Singapore and Taiwan. METHODS: Reduction of end-points in non-insulin-dependent diabetes mellitus with the angiotensin II antagonist losartan (RENAAL) was a multinational, double-blind, randomized, placebo-controlled trial to evaluate the renal protective effects of losartan on a background of CT in patients with type 2 diabetes and nephropathy. The primary composite end-point was a doubling of serum creatinine, ESRD or death. Data on the duration of ESRD for the Asian subgroup of patients enrolled in RENAAL were used to estimate the economic benefits of slowing the progression of nephropathy. The cost associated with ESRD was estimated by combining the number of days each patient experienced ESRD with the average daily cost of dialysis from the third-party payer perspective in Hong Kong, Japan, Korea, Malaysia, Singapore and Taiwan. Total cost, converted to US dollars, was the sum of ESRD and losartan costs. RESULTS: Losartan plus CT reduced the number of days with ESRD by 37.9 per patient over 3.5 years compared with CT alone. This reduction in ESRD days resulted in a decrease in the cost associated with ESRD, which ranges from $910 to $4346 per patient over 3.5 years across the six countries or regions. After accounting for the cost of losartan, the reduction in ESRD days resulted in net savings in each of the six countries or regions, ranging from $55 to $515 per patient. CONCLUSION: Treatment with losartan in patients with type 2 diabetic nephropathy not only reduced the incidence of ESRD among Asian patients, but resulted in direct medical cost savings in countries or regions representing Asia.     

The epidemiology of end-stage renal disease in Iran in an international perspective.

INTRODUCTION: The epidemiology of end-stage renal disease (ESRD) and renal replacement therapy (RRT) is under continuous evolution all over the world. We report here the epidemiological analysis of ESRD and RRT in Iran and discuss it against the background of the international situation. METHODS: This epidemiological report is based on data from centre questionnaires which were collected in Iran from 1997 onwards, with a response rate of 100%. RESULTS: The prevalence/incidence of RRT patients were 238/49.9 p.m.p. in the year 2000. Haemodialysis and kidney transplantation were the most common RRT modalities, accounting for 53.7% and 45.5% of prevalent RRT patients, respectively. The proportion treated by peritoneal dialysis was very low (<1%). Home haemodialysis was not performed. The majority of haemodialysis centres used synthetic membranes (70%) and 100% of the sessions were performed using acetate as a buffer; 42.5% of haemodialysis patients were treated with a twice-weekly regimen, whilst 49.6% were on the standard thrice-weekly regimen. The majority of RRT patients in Iran were young to middle aged. The great majority of renal allografts came from living donors (mainly unrelated to recipients). The main renal diseases leading to ESRD were diabetes and hypertension. The third most common category was "cause unknown". CONCLUSION: The epidemiology of RRT in Iran is characterized by: (i) young patient age (younger than the international average); (ii) high proportion of patients receiving renal allograft; (iii) use of living-unrelated donors as the major source of renal allografts.     

Epidemiology of Fatal Trauma in Italy in 2002 Using Population-Based Registries

Background:   

Population-based registries have been proposed for epidemiologic studies and quality assessment in trauma care because they consider the entire population of a given geographic area.     

Epidemiology and demographic aspects of treated end-stage renal disease in the elderly

Over the last 10 years an increasing number of patients worldwide have started dialysis or had transplantation. Many are elderly with complex comorbid conditions. Registries across the world all show a rapid and dramatic increase in the number of older patients accepted for renal replacement therapy. In addition, the number of patients who grow old on dialysis is increasing, leading to a marked change in the demographics of the renal population. Changes over time and across registries are discussed with reference to patient characteristics, survival statistics, and the trends seen with transplantation in the elderly.     

Left ventricular geometry and hypotension in end-stage renal disease: a mechanical perspective

Hemodynamic and nonhemodynamic factors are implicated in the maintenance and aggravation of left ventricular (LV) hypertrophy in ESRD. Functional consequences of LV geometry are of substantial importance in patients who undergo dialysis and may contribute to explain the negative outcome related to LV hypertrophy, also in patients without overt coronary heart disease (CHD). Whereas most patients with eccentric LV hypertrophy have systolic dysfunction and the underlying CHD imposes progression of their disease, when overt CHD does not occur to remodel left ventricle, concentric LV geometry is more prevalent in ESRD and functional consequences are different. Concentric LV geometry is very sensitive to abrupt changes of cardiac loading conditions because of increased LV stiffness. Dialysis-related decrease in LV filling pressure reduces Starling forces recruitment and causes a fall in stroke volume as a result of reduced preload. This fall cannot be compensated by increased contractility, as myocardial mechanics is impaired in concentric LV geometry and no functional reserve can be used. When adequate increase in heart rate is not achieved to compensate reduced stroke volume, cardiac output substantially decreases and hypotension occurs. Occurrence of hypotension in the context of concentric LV geometry might contribute to reduce repeatedly coronary blood flow supply in the stiff and thick myocardium and might accelerate myocardial structural deterioration seen in ESRD.     

Sorbent hemoperfusion in end-stage renal disease: an in-depth review

The excessive mortality in dialysis patients has rekindled interest in research of adsorbent removal of nontraditional uremic toxins. Middle-molecular-weight substances, predominantly small proteins, have been correlated with specific uremic syndromes and implicated in the uremic state. New developments in polymer technology and carbon pyrrolization techniques have produced sorbents possessing mesopores of sufficient size to trap middle-molecular-weight substances. Clinical application of hemoperfusion devices containing these sorbents is early in its development. Studies related to hemoperfusion in uremia are discussed in detail.     

Acquired renal cystic disease in end-stage renal disease: an autopsy study of 155 cases

Autopsy reports on 155 successive end-stage renal disease (ESRD) patients and 147 control patients without ESRD, matched for age, race and gender, were collected. Cystic transformation of the kidneys was noted in 58% of the ESRD patients and 13.6% of the control patients. There were 25 ESRD patients with renal adenoma and 3 with renal cell carcinoma. The single best predictor of cystic transformation or tumorous degeneration was patient's age. A statistically significant association between cystic transformation and gender, as well as the cause of ESRD, was also found. In contrast to previous reports we were unable to document a strong association between the incidence of either cystic transformation or tumorous degeneration with the duration of dialysis, nor did these two parameters correlate with mode of dialysis. We suggest that cystic transformation of the kidneys in ESRD is related to age and renal failure per se, is not strongly associated with duration of dialysis and is independent of mode of dialysis. Concomitant tumorous degeneration was frequent, but this was usually an incidental autopsy finding. Renal malignancy was uncommon and metastases were absent.     

Epidemiology of end-stage renal disease in the Ile-de-France area: a prospective study in 1998.

BACKGROUND: The objective of this study was to determine the incidence and prevalence of end-stage renal disease (ESRD) requiring maintenance dialysis in the Ile-de-France district (Paris area), and the characteristics of patients at start of dialysis. METHODS: This is a prospective epidemiological study with the cooperation of all dialysis facilities of the Ile-de-France district (population 10.7 million inhabitants as of March 1999). All consecutive ESRD patients who started dialysis from January 1 to December 31 1998, with demographic and clinical characteristics, and of the total number of patients on dialysis with their distribution according to dialysis modality were recorded. RESULTS: The total number of ESRD patients in 1998 was 1155, including 29 (2.5%) children aged < or =17 years and 86 (7.4%) returns to dialysis following kidney graft failure. Incidence of first-dialysed patients was 100 per million population (p.m.p.) and overall incidence, including returns from transplantation, was 108 p.m.p. The mean age of first-dialysed adult patients was 59.8+/-16.8 years, with 21.6% aged > or =75 years. Patients with vascular renal disease were 22.5% and those with diabetic nephropathy 20.6%. As a whole, 36.5% of patients were referred to the nephrologist < or =6 months before start of dialysis, including 32.2% referred < or =1 month before starting. Prevalence of cardiovascular disease was nearly twice as high in patients referred <6 months of starting dialysis than in those who benefited from effective nephrological care for >3 years in the predialysis period. By multivariate analysis, this difference persisted after adjustment for age and other confounding covariates. The total number of patients on maintenance dialysis increased from 417 to 433 p.m.p. (a yearly 3.8% increase) from the beginning to the end of 1998. CONCLUSION: This recent epidemiological study in a large French urban area indicates an annual incidence of 100 new ESRD patients p. m.p., with a high proportion of older, vascular and diabetic patients. Overall incidence, including returns from transplantation, reached 108 p.m.p. Cardiovascular disease was significantly less frequent in patients who received nephrological care for > or =3 years prior to start of dialysis than in late referred patients, underlining the benefits of early nephrological management of renal patients.     

Refractory hypertension and anemia in end-stage renal disease: an unusual manifestation of Kimura's disease

Hypertension and anemia are common in uremic patients. This article describes a 35-year-old uremic Taiwanese who was admitted to our hospital with refractory hypertension and refractory anemia following chronic hemodialysis for more than two years. He was diagnosed with Kimura's disease finally. Refractory hypertension and refractory anemia were noted over two years before an enlarged inguinal lymph node was observed. The symptoms lead to the diagnosis of Kimura's disease. Unlike most cases, refractory hypertension and refractory anemia were first noted before the inguinal mass and eosinophilia were presented. The inflammatory parameters increased when the disease was active. Steroid treatment was conducted, and the symptoms including hypertension and anemia promptly decreased. To the authors' knowledge, this case is for first one in which Kimura's disease has induced refractory hypertension and anemia in an ESRD patient and in which these symptoms rapidly subsided following steroid treatment. The activity of Kimura's disease is closely related refractory hypertension, suggesting that inflammation may be involved in refractory hypertension and anemia in a dialytic patient with Kimura's disease.     

Inflammation in end-stage renal disease: sources,consequences, and therapy

Cardiovascular disease (CVD) remains the main cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Although traditional risk factors are common in ESRD patients, they alone may not be sufficient to account for the high prevalence of CVD in this condition. Recent evidence demonstrates that chronic inflammation, a nontraditional risk factor which is commonly observed in ESRD patients, may cause malnutrition and progressive atherosclerotic CVD by several pathogenetic mechanisms. The causes of inflammation in ESRD are multifactorial and, while it may reflect underlying CVD, an acute-phase reaction may also be a direct cause of vascular injury by several pathogenetic mechanisms. Available data suggest that proinflammatory cytokines play a central role in the genesis of both malnutrition and CVD in ESRD. Thus it could be speculated that suppression of the vicious cycle of malnutrition, inflammation, and atherosclerosis (MIA syndrome) would improve survival in dialysis patients. Recent evidence has demonstrated strong associations between inflammation and both increased oxidative stress and endothelial dysfunction in ESRD patients. As there is not yet any recognized, or even proposed, treatment for ESRD patients with chronic inflammation, it would be of obvious interest to study the long-term effect of various anti-inflammatory treatment strategies on the nutritional and cardiovascular status as well as outcome in these patients.     

Cardiac troponins: utility in renal insufficiency and end-stage renal disease

Currently available serum markers of cardiac injury in patients with renal insufficiency suffer from impaired sensitivity and specificity. Cardiac troponins (cTnI, cTnT) are relatively new diagnostic markers of myocardial injury and have gained widespread application in the non-renal-failure population to diagnose myocardial infarction. Over the past few years the specificity and sensitivity of cardiac troponins for diagnosing acute myocardial infarction in patients with renal dysfunction have been examined. Most data indicate that cardiac troponin I has an excellent specificity, but until more studies are available this marker should be consdiered a useful but imperfect serum marker of an acute coronary syndrome in patients with underlying renal dysfunction.     

Etiology and treatment of growth retardation in children with chronic kidney disease and end-stage renal disease: a historical perspective

Dramatic changes have occurred in our understanding of the etiology of the growth retardation associated with chronic kidney disease (CKD) and end-stage renal disease (ESRD) during the past 50 years. Significant interest has been focused on preventing and/or correcting the growth retardation because of the emergence of the dual therapeutic modalities of dialysis and renal transplantation to prolong the lives of infants, children, and adolescents afflicted with CKD and ESRD. These efforts have resulted in a significant improvement in the height Z-score over the past two decades of children with CKD and ESRD. This has had a salutary impact on the final adult height of such children which should hopefully lead to an enhanced quality of life in the future. This report addresses the progress that has been made in the management of growth retardation in the pediatric population with CKD and ESRD.     

Disablement and rehabilitation in end-stage renal disease

Patients with end-stage renal disease (ESRD) are encumbered by disabilities in spite of advances in medical treatments. Research shows that exercise training is one way to improve physical work capacity and reduce functional limitations that impede role behaviors, such as shopping, personal care, homemaking, and yard maintenance. However, exercise training does not ameliorate some of the psychosocial and environmental factors that exacerbate disabilities for patients with ESRD. A disability process model described in this review illustrates that disability prevention may be more effective if exercise rehabilitation is integrated with self-management education. Research is needed to delineate which disabilities in patients with ESRD are a product of psychosocial factors and physical environments. Once identified, those disability risk factors that are amenable to change can guide the development of tailored rehabilitation interventions.     

Quality of life for patients in an end-stage renal disease programme

A group of 128 patients in an end-stage renal disease programme in Natal was studied in order to assess the relative success of the different treatment modalities in achieving optimal patient rehabilitation in regard to employability and social, psychological and medical status. Confirmation that successful transplantation achieves the best quality of life was obtained.     

Treatment for end-stage renal disease: an organogenesis/tissue engineering odyssey

The means by which kidney function can be replaced in humans with end-stage renal disease (ESRD) include dialytic therapies and renal allotransplantation. Dialysis, is lifesaving, but often poorly tolerated. Transplantation of human kidneys is limited by the availability of donor organs. During the past decades, several different approaches have been applied towards new means to replace renal function through organogenesis and tissue engineering. These include: (1) incorporation of new nephrons into the kidney; (2) growing new kidneys in situ; (3) use of stem cells; (4) generation of histocompatible tissues using nuclear transplantation; and (5) bioengineering of an artificial kidney. The development of these approaches has depended upon understanding and integrating discoveries made in a diversity of scientific disciplines. The means by which such integration has driven advances in the treatment of ESRD provides a generic roadmap for the successful application of organogenesis and tissue engineering to organ replacement therapy.     

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.