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.     

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.     

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.     

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.     

Outcome in a post-cardiac surgery population with acute renal failure requiring dialysis: does age make a difference?

BACKGROUND: Acute renal failure (ARF), requiring dialysis (ARF-d), develops in 1-5% of patients undergoing cardiac surgery and is associated with higher in-hospital mortality. Age is one of the known risk factors for the development of ARF. As the ageing population is increasing, the nephrologist will be faced with a large population of elderly patients requiring dialysis following cardiac surgery. The aim of our study was to evaluate the influence of age on and the risk factors for in-hospital mortality. METHODS: Eighty-two patients with ARF following cardiac surgery and requiring dialysis between January 1997 and October 2001 were included. Two groups of patients were studied: the younger population (<70 years, 42 patients, mean age 59+/-10) and an elderly population (>/=70 years, 40 patients, mean age 76+/-4). Severity of disease was evaluated using the SAPS (Simplified Acute Physiology Score), the Liano score and the SHARF (Stuivenberg Hospital Acute Renal Failure) score. RESULTS: Overall mortality in the population with ARF-d was 56.1%. No difference in mortality rate was found between the younger (61.9%) and elderly patient group (50.0%). The two groups were very similar in baseline and procedural characteristics with exception of body weight (P=0.02) and preoperative glomerular filtration rate (P=0.0001). No significant difference was found in the scoring systems between the old and the young (SAPS P=0.52; Liano P=0.96; SHARF T0 P=0.06; SHARF T48 P=0.15). Mortality in the elderly was significantly correlated with hypotension before starting renal replacement therapy (RRT) (P=0.002), mechanical ventilation (P=0.002), presence of multiorgan failure (MOF) (P=0.0001) and higher scores in the severity models (SAPS: P=0.01; Liano: P<0.0001 and SHARF: P<0.0001). CONCLUSION: The outcome in the elderly requiring dialysis due to ARF post-cardiac surgery is comparable with the outcome in a younger population. No significant difference was found in severity of disease between the elderly and the younger. Variables predicting mortality in the elderly are the presence of MOF, mechanical ventilation and hypotension 24 h before starting RRT. These findings indicate that at the time the nephrologist is called for an elderly patient requiring dialysis due to ARF following cardiac surgery, age per se is not a reason to withhold RRT.     

Acceptance for chronic dialysis treatment: insufficient and unequal

BACKGROUND.: Evidence suggests that a number of end-stage renal disease (ESRD)patients die without receiving dialysis. We investigated andcompared ESRD patients who died without receiving treatmentand those who were accepted for dialysis. METHODS.: All patients starting chronic dialysis in 1991 in the city ofSão Paulo and prospectively registered in the HealthSecretariat files were studied. From death certificates we obtaineddata from all patients dying with an underlying cause associatedwith chronic renal failure. Medical records from a sample ofpatients who died without receiving dialysis were reviewed. RESULTS.: Of 2127 patients, 1582 (74.4%) received dialysis and 545 (25.6%)did not. The best chance of being dialysed occurred in the 20–29age group. The age groups with the least chance of receivingdialysis were 0–9 years and over 79 years old. The oddsratio (95% Cl) of not receiving dialysis was 12.42 (6.63–23.82)times greater for patients over 60 years old compared to thoseaged 20–29 years. Patients with renal failure due to congenitaldiseases, chronic pyelonephritis, unknown cause, and hypertensionwere less likely to receive dialysis than those with glomerulonephritisor diabetes. CONCLUSIONS.: Our results suggest that many ESRD patients die without receivingdialysis. Age and cause of renal disease influence the chanceof being accepted for treatment. Restrictions of treatment needto be corrected to guarantee that maintenance dialysis willbe accessible to ESRD patients.     

A multicentre study of registration on renal transplantation waiting list of the elderly and patients with type 2 diabetes.

BACKGROUND: Studies in the USA have shown that some patients (African-Americans, women, the elderly and diabetics) were less likely to receive renal transplants. In order to identify patient characteristics modifying the likelihood of being wait-listed, we studied registration on renal transplantation waiting list (WLR) focusing on elderly (age > or =60 years) and on patients with type 2 diabetes (D2) in three departments of nephrology in the Rh?ne-Alpes county in France. METHODS: In a cohort of 549 patients who reached end-stage renal disease (ESRD) between 1995 and 1998 in these units, we analysed the rates of pre-transplant evaluation (PTE), the duration of PTE, the rates of exclusion from transplantation by PTE and the rates of WLR. With Cox regression model, we identified the characteristics that have independent and significant effects on the likelihood of being registered after the first renal replacement therapy (RRT). RESULTS: In this cohort, 185 patients (33.7%) were wait-listed by 31.03.00 and no patient > or =70 years was evaluated or registered. In univariate analysis, PTE and WLR rates were lower in the elderly (21.5 and 20.0%, respectively) than those <60 years (79.1 and 70.2%, P < 0.001) and in D2 (33.0 and 24.2%) than in non-D2 (65.8 and 60.6%, P < 0.001). The duration of PTE was longer in D2 than in non-D2 (12.7 +/- 11.0 vs 7.5 +/- 7.1 months, P < 0.01). Among patients excluded from PTE, more patients without relevant co-morbidities [e.g. rapidly progressive ESRD, cardiovascular disease (CVD), malignancy] were present in the elderly (> or =70 years: 14.8%; 60-69 years: 17.0%; <60 years: 6.4%) and in D2 (18.0%) than in non-D2 (10.9%). The adjusted relative risks (aRR) of being wait-listed after first RRT were significantly lowered by age and D2 (aRR, 95% CI): 60-64 year olds (0.44%: 0.26-0.75), 65-69 year olds (0.07%: 0.03-0.20) and D2 (0.41%: 0.24-0.69). Other conditions associated with a lower aRR were rapidly progressive ESRD (0.21%: 0.08-0.55), CVD (0.59%: 0.36-0.94), malignancy (0.13%: 0.04-0.46) and psychosis (0.05%: 0.01-0.35). CONCLUSION: Advanced age and D2 were associated with low PTE and WLR rates even after adjustment for other patient characteristics.     

Ten-years trends in renal replacement therapy for end-stage renal disease in mainland France: Lessons from the French Renal Epidemiology and Information Network (REIN) registry

BackgroundThe incidence rate of renal replacement therapy (RRT) for end-stage renal disease (ESRD) is decreasing in several countries, but not in France. We studied the RRT trends in mainland France from 2005 to 2014 to understand the reasons for this discrepancy and determine the effects of ESRD management changes.MethodsData were extracted from the French Renal Epidemiology and Information Network registry. Time trends of RRT incidence and prevalence rates, patients’ clinical and treatment characteristics were analysed using the Joinpoint regression program and annual percentage changes. Survival within the first year of RRT was analysed using Kaplan-Meier estimates for 4 periods of time.ResultsThe overall age- and gender-adjusted RRT incidence rate increased from 144 to 159 individuals per million inhabitants (pmi) (+0.8% per year; 95% CI: 0.5–1.2) and the prevalence from 903 to 1141 pmi (+2.4% per year; 95% CI: 2.2–2.7). This increase concerned exclusively ESRD associated with type 2 diabetes (+4.0%; 3.4–4.6) and mostly elderly men. Despite patient aging and increasing comorbidity burden and a persistent 30% rate of emergency dialysis start, the one-year survival rate slightly improved from 82.1% (81.4–82.8) to 83.8% (83.3–84.4). Pre-emptive wait listing for renal transplantation and the percentage of wait-listed patients within one year after dialysis start strongly increased (from 5.6% to 15.5% and from 29% to 39%, respectively).ConclusionKidney transplantation and survival significantly improved despite the heavier patient burden. However, the rise in type 2 diabetes-related ESRD and the stable high rate of emergency dialysis start remain major issues.     

Changing pattern of end-stage renal disease in central and eastern Europe.

BACKGROUND: The epidemiology of end-stage renal disease (ESRD) is changing all over the world. Particularly dramatic changes of the epidemiology of ESRD have occurred in central and eastern Europe (CEE). The aim of the present study was (i) to document the further expansion of renal replacement therapy (RRT) noted in recent years in CEE and (ii) to analyse in some detail treatment modalities and underlying renal conditions. METHODS: Three independent surveys were performed in 1995, 1997 and 1998. Fifteen CEE countries participated. The data were mainly obtained from national registries which are based on centre and patient questionnaires. RESULTS: The data collected from 15 CEE countries document further expansion of RRT in this region. The report includes data on the availability of RRT in Byelorussia, Estonia, and Russia which have become available for the first time. The epidemiology of dialysed patients has changed remarkably. In the majority of countries the number of diabetic patients has increased, most dramatically so in the Czech Republic (31% of all dialysed patients), in the majority of the other countries 10-14%. The number of ESRD patients with the diagnosis of hypertensive nephropathy has also increased and this was accompanied by an increase in proportion of elderly (>65 years) patients, i.e. 46% in the Czech Republic and 12-25% in most other countries. CONCLUSION: Dramatic changes of the availability of RRT treatment have occurred in central and eastern Europe. The proportion of diabetic nephropathy and elderly patients has risen. Large differences in RRT exist between individual CEE countries and this appears mainly dependent on the level of economic development.     

End-stage renal disease and renal replacement therapy in Kuwait--epidemiological proffle over the past 41/2 years

Data on end-stage renal disease (ESRD) patients in Kuwait werecollected retrospectively and prospectively starting in mid-1988.The study period covered 4 years from 1 January 1986 to 30 June1990. Epidemiological characteristics of ESRD patients and theirdisposal by dialysis and transplantation were analysed and comparedwith previous reports from Kuwait, neighbouring countries, Europe,and USA. A total of 647 patients received renal replacementtherapy (RRT) in Kuwait during the study period. This gave anincidence rate of 72 patients per year per million of population.The prevalence rate for patients on maintenance dialysis was80.6 per million population in mid-1988. Nearly one-fifth oftotal patients (19.6%) were older than 60 years of age and one-third(30.8%) were identified as ‘high risk’ category.As for Kuwaiti nationals alone on RRT 29.7% were above 60 yearsof age and 44.2% were high-risk patients. We have noticed asteady decline in the number of patients who accepted continuousambulatory peritonial dialysis (CAPD) for dialytic support. Chronic tubulointerstitial disease resulting from atrophic pyelonephritiswas the leading cause of ESRD amongst both Kuwaiti nationalsand expatriates. Though diabetic nephropathy was only the thirdlead ing cause of ESRD (14.7%) in the total population, it wasmore frequent (21.2%) among Kuwaitis. The gross mortality rateon dialysis was 14.7%. The major causes of death were relatedto cardiovascular diseases (60%) and sepsis (24.2%). Our analysisshowed that age of the patient at admission to dialysis contributedto overall mortality, but it was not an isolated risk factorwhereas diabetic nephropathy (relative risk 1.9) and associatedserious co-morbid illness/es (relative risk 30.3) were. Despitestrict precautionary measures in the dialysis units and earlyuse of erythropoietin, 68 new patients were detected to be HBsAgpositive, 85% of whom remained persistently antigenaemic formore than 6 months. At follow-up 9.8% (4/41) had died of liverfailure. The 50 months patient survival for patients who received unrelatedkidney transplantation (abroad) was lower than in those whoreceived live related kidneys in Kuwait. The most distressingobservation was, however, the very high patient loss associatedwith imported cadaver kidneys transplanted in Kuwait comparedto those who received cadaver kidneys harvested locally (65%versus 94.8% respectively at 16 months).     

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.     

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.     

Analysis of patients dying within one year of starting renal replacement therapy

BACKGROUND: The annual gross mortality of end-stage renal failure patients remains very high (approximately 15-20%) leading some to question the wisdom of accepting patients with limited prognosis for dialysis. We have reviewed the demographic and clinical characteristics of patients who died within a year of commencing renal replacement therapy (RRT) over a 5-year period to establish whether these patients could be identified at the start of therapy. METHODS: Case notes of patients who died within 1 year of commencing RRT between 1st April, 1991 and 31st March, 1996 were reviewed. Comorbidity at the start of dialysis was used to classify patients into high-, medium- and low-risk groups using two published scales to determine whether either graded a high proportion of deaths as high risk. Factors such as age, social circumstances, cause of death, renal diagnosis and mode of dialysis were also analysed. RESULTS: 17.5% of patients commencing RRT died in the first year. Not all of these patients could be identified as high risk by comorbidity assessment at dialysis initiation - 50% of patients who died were classified by one scale as medium risk. Age did not clearly predict outcome, as 42% of patients who died were less than 65 years old. CONCLUSION: These data suggest that it is difficult to use current risk stratifications to accurately predict outcome on RRT.     

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.     

Pediatric dialysis and renal transplantation in Kuwait over the past 11 years

Data on end-stage renal disease (ESRD) patients and their renal replacement therapy (RRT) were collected retrospectively from the three dialysis centers, the pediatric urology unit, and the organ transplant center of Kuwait. The study period was from 1 January 1986 to 31 December 1996. A total of 61 children, 50 of whom were Kuwaiti nationals, required RRT for ESRD during those 11 years. This gave an average annual incidence rate of 18 per million Kuwaiti children. Glomerulonephritis was the most-frequent underlying disease and accounted for 44% of total cases, while pyelonephritis (including urinary tract anomalies and dysplastic kidneys) was responsible for 30%. Multisystem disease was responsible for ESRD in 7 patients (14%), 2 of whom had lupus nephritis, 2 vasculitis, 2 Henoch-Schönlein purpura, and 1 hemolytic uremic syndrome. Continuous ambulatory peritoneal dialysis and home intermittent peritoneal dialysis, using cycler machines, were not favored dialysis techniques by most parents, especially for those <6 years old. The actuarial survival on dialysis was 75%±7% at 12 months. Of the 8 patients who died, 7 were <6 years old. Thirty-eight patients received 46 kidney transplants, 13 of which were performed on a pre-emptive basis. The actuarial patient survivals at 12 months for those receiving first live and cadaveric kidney transplants were 90%±5% and 85%±2%, respectively, while those for grafts were 76%±8% and 66%±2%, respectively. This is the first nationwide long-term study of the incidence and etiology of pediatric ESRD in our area and the RRT in a country with adequate treatment facilities.     

Survival and transplantation outcomes of children less than 2 years of age with end-stage renal disease

Background

Young children with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT) have traditionally experienced high rates of morbidity and mortality; however, detailed long-term follow-up data is limited.

Methods

Using a population-based retrospective cohort with data from a national organ failure registry and administrative data from Canada’s universal health care system, we analysed the outcomes of 87 children starting RRT (before age 2 years) and followed them until death or date of last contact [median follow-up 4.7 years, interquartile range (IQR) 1.4–9.8). We assessed secular trends in survival and the influence of: (1) age at start of RRT and (2) etiology of ESRD with survival and time to transplantation.

Results

Patients were mostly male (69.0 %) with ESRD predominantly due to renal malformations (54.0 %). Peritoneal dialysis was the most common initial RRT (83.9 %). Fifty-seven (65.5 %) children received a renal transplant (median age at first transplant: 2.7 years, IQR 2.0–3.3). During 490 patient-years of follow-up, there were 23 (26.4 %) deaths, of which 22 occurred in patients who had not received a transplant. Mortality was greater for patients commencing dialysis between 1992 and 1999 and among the youngest children starting RRT (0–3 months). Children with ESRD secondary to renal malformations had better survival than those with ESRD due to other causes. Among the transplanted patients, all but one survived to the end of the observation period.

Conclusion

Children who start RRT before 3 months of age have a high risk of mortality. Among our paediatric patient cohort, mortality rates were much lower among children who had received a renal transplant.     

Influence of a pre-dialysis education programme (PDEP) on the mode of renal replacement therapy.

BACKGROUND: The distribution of renal replacement therapy (RRT) modalities among patients varies from country to country, and is often influenced by non-medical factors. In our department, patients progressing towards end-stage renal disease (ESRD) go through a structured Pre-Dialysis Education Programme (PDEP). The goals of the programme, based on both individualized information session(s) given by an experienced nurse to the patient and family and the use of in-house audio-visual tapes, are to inform on all modalities of RRT, in order to decrease anxiety and promote self-care RRT modalities. METHODS: To evaluate the influence of our PDEP on the choice of RRT modalities, we retrospectively reviewed the modalities chosen by all consecutive patients starting a first RRT in our institution between December 1994 and March 2000. RESULTS: Two hundred and forty-two patients started a first RRT during the study period. Fifty-seven patients, median age 66 (24-80) years, were directed towards in-centre haemodialysis (HD) for medical or psycho-social reasons (seven of whom were not involved in the PDEP); the remaining 185 patients, median age 53 (7-81) years, with no major medical complications, went through our PDEP. Eight of them (4%) received a pre-emptive renal transplantation. The therapeutic options of the other 177 patients were as follows: 75 (40%) patients, median age 65 (20-81) years opted for in-centre HD, while 102 patients opted for a self-care modality; 55 (31%) patients, median age 56 (7-77) years, chose peritoneal dialysis, 30 (16%) patients, median age 49 (21-68) years, chose to perform self-care HD in our satellite unit, and 17 (9%) patients, median age 46 (19-70) years, opted for home HD. Interestingly, in the whole cohort of patients, the cause of ESRD was associated with the RRT modality: the proportion of patients with chronic glomerulonephritis or chronic interstitial nephritis on self-care therapy was significantly higher than that of patients with nephrosclerosis, diabetic nephropathy or unknown cause of ESRD. CONCLUSION: In our centre offering all treatment RRT modalities, a high percentage of patients exposed to a structured PDEP start with a self-care RRT modality. This leaves in-centre HD for patients needing medical and nursing care, or for patients refusing to participate in their treatment. Additional large studies, preferably with a randomized design, should delineate the cost-benefit of such a PDEP on the final choice of a RRT modality.     

Renal transplantation outcomes: a comparative analysis between elderly and younger recipients

Renal transplantation is presently the best treatment for end-stage renal disease, although considered contraindicated for elderly patients. However, more investigation is needed due to higher life expectancy rates of the general population and the increasing number of over 60-yr-old patients with chronic renal failure dependent upon dialysis. This study aims to determine graft and patient survival rates of renal transplant patients 60 yr and older compared to a younger group (50-59 yr old). Relevant pre- and post-transplant clinical data related to graft and patient survival in both groups were also investigated. Three-hundred and twenty consecutive renal transplant patients were enrolled in this study and grouped based on age at the time of the transplantation: one-hundred and ten patients at or over 60 yr old (elderly group) and 210 patients ranging from 50 to 59 yr old (younger group). There were no statistical differences in either group regarding clinical characteristics and immunological risk factors. The incidence of acute rejection was higher in the younger group (37.6%) than in the elderly (22.7%) (p = 0.01). Censored to death graft survivals at five yr were respectively 86.7% for patients > or = 60 yr and 82.1% for patients 50-59 yr old (p = 0.49). Patient survival rates at five yr were respectively 76.2% for patients > or = 60 yr and 81.6% for patients 50-59 yr old (p = 0.33). Our data show that renal transplantation for elderly patients has similar results to those found in younger individuals, which does not make age, in and of itself, a contraindication for transplantation.     

APD in the elderly

Few elderly patients with end-stage renal disease (ESRD) are treated with peritoneal dialysis (PD). Among dialysis patients ≥65 years of age reported by the U.S. Renal Data System (USRDS), the percentage treated with chronic peritoneal dialysis (CPD) is lower than in any other age group. To evaluate the effectiveness of automated peritoneal dialysis (APD) in the elderly, we compared several outcome measures in cohorts of different ages maintained on APD. The outcome measures we examined included mortality and technique failure rates, peritonitis rates, outcomes of peritonitis, and quality of life measures. We found that while patients ≥65 years of age have a higher mortality rate than younger patients, technique failure rates, overall peritonitis rates, and most quality of life measures are not different than for younger patients. However, patients ≥65 years of age have higher gram-negative peritonitis rates and lower scores on the physical component score of the SF-36 than younger patients. The present study suggests that APD is a reasonable treatment modality for elderly patients with ESRD and that elderly patients with progressive renal failure should be considered as candidates for APD.     

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.