Renal involvement in systemic amyloidosis: an Italian collaborative study on survival and renal outcome.

BACKGROUND: Few data are available from large population-based studies on survival and renal outcome of patients with renal involvement and different types of systemic amyloidosis. METHODS: Two hundred and ninety of over 373 patients affected from systemic amyloidosis with renal involvement diagnosed in Italy between January 1995 and December 2000 were followed from diagnosis to death or until the last available clinical control. Eighty-three patients were excluded from analysis either because the amyloid type remained undetermined or they were lost at follow-up. Clinical and laboratory information was collected according to the different types of amyloidosis using a specific form which included renal function with 24 h proteinuria at diagnosis and at the end of follow-up, the type and the date of onset of dialysis and the kind of treatment they underwent. RESULTS: The median time of follow-up was 24 months in primary (AL) amyloidosis (range: 1-88 months), 16 months in AL with associated multiple myeloma (MM + AL: range 1-76 months), 30 months in reactive (AA) amyloidosis (range: 1-99 months) and 52 months in patients with familial forms (AF: range 14-82 months). Patients with AL showed a significantly shorter survival than AA. Despite no significant differences of renal outcome or survival on dialysis being observed between the two groups, a lower renal survival with a higher number of patients who progressed to end-stage renal disease (ESRD) was observed in patients with AA. Overall survival was markedly improved in patients with AL who underwent a specific therapy (conventional chemotherapy or autologous stem cell transplantation (ASCT)) even in the absence of a positive kidney response. Multivariate analysis showed cardiac involvement and specific therapy to significantly influence survival in AL whereas age, serum creatinine (sCr) and heart involvement significantly affected survival in AA. In both groups, sCr and heart involvement were the most relevant predictors for renal outcome, together with urinary protein excretion, in patients with AA. CONCLUSIONS: Our results show a worse survival in AL due to the higher prevalence of heart involvement in this group and emphasize that a specific therapy significantly prolongs survival and slows the progression of renal disease in patients with AL. We suggest that a late nephrological referral is likely the cause of the higher sCr found at presentation in patients with AA and probably accounts for the lower renal survival observed in the short term in these patients. At the time being, renal transplantation and ASCT are still rare therapeutic options for renal patients affected from systemic amyloidosis.     

腹部外科病人术后症状性静脉血栓栓塞症多中心临床流行病学研究

目的探讨腹部外科病人术后症状性静脉血栓栓塞症(VTE)的流行病学特点。方法回顾性分析上海交通大学医学院附属第九人民医院、滁州市第一人民医院、郑州大学第二附属医院、上海市奉贤区奉城医院4家医院自2015-01-01—2019-06-30期间就诊于普通外科,入院后行腹部外科手术的病人共计24336例相关临床资料,并观察术后14 d内发生VTE事件的情况。结果VTE事件发生率为0.89%(216/24336),其中,深静脉血栓形成(DVT)发生率0.75%(183/24336),肺动脉栓塞(PE)发生率0.35%(86/24336)。男性VTE事件发生率为0.85%(123/14443),女性为0.94%(93/9893),男女VTE事件发生率差异无统计学意义(χ^2=2.15,P>0.05)。DVT病人常见的症状是下肢肿胀177例(96.72%),疼痛104例(56.83%),浅静脉曲张36例(19.67%)。PE病人常见的症状是呼吸困难和气促77例(89.53%),胸痛55例(63.95%)。DVT易累及左下肢;混合型最多见,左、右下肢分别为61.11%(88/144)和52.11(37/71)。PE病人最常见低危组病人45例(52.32%)。常见的VTE危险因素包括:年龄≥40岁208例(96.30%),手术时间>45 min 139例(64.35%),恶性肿瘤病史99例(45.83%)。主要的腹部外科手术类型是消化道恶性肿瘤手术105例(48.61%),胆囊切除术73例(33.80%)。腹腔镜手术(1.61%,179/11123)较开放手术(0.28%,37/13213)VTE事件发生率低(χ^2=45.56,P<0.05)。VTE相关病人的病死率为0.10%(25/24336)。结论腹部外科病人术后VTE发生率已经明显降低,医生应当根据其流行病学特点,早期发现,早期诊断和早期预防干预,避免严重不良事件的发生。     

Renal function at the time of renal biopsy as a predictor of prognosis in patients with primary AL-type amyloidosis

Background Amyloid light-chain (AL)-type amyloidosis is a plasma cell disorder with a poor prognosis for survival. Although prognostic factors, such as the number of organs involved and heart function or failure in respond to therapy have been clarified based on studies including a large series of patients, there are large interindividual differences in the prognosis of patients with primary AL-type renal amyloidosis.Methods To clarify the prognostic factors of AL-type renal amyloidosis, we retrospectively investigated the clinical manifestations, histopathological data, and prognosis of 21 patients with amyloidosis, who had been diagnosed by renal biopsy.Results Eleven patients died, at a mean observational time of 21.7 months after renal biopsy, whereas the mean observational time was 51.0 months for the 10 patients who survived. The creatinine clearance rate was significantly higher, and the serum creatinine concentration and the grade of interstitial damage were significantly lower in surviving patients (P < 0.05). The presence of amyloid fibrils in organs other than the kidney did not influence prognosis for survival. However, the intraventricular septum was thinner in surviving patients (P < 0.1). Thirteen patients had undergone melphalan-prednisolone therapy, but it did not affect prognosis for survival. Cox proportional hazard regression analysis revealed that the renal function at the time of diagnosis was a significant and independent prognostic factor for survival.Conclusions Our study demonstrated that renal function at the time of biopsy and renal interstitial damage are the best predictors of survival in AL-type renal amyloidosis.     

Renal histopathology and clinical course in 94 patients with Wegener's granulomatosis.

BACKGROUND: The main purpose of this study was to examine histopathological changes seen in renal biopsies from patients with Wegener's granulomatosis (WG) with varying degrees of renal involvement and to study possible correlations between the morphological variables and the severity of the disease. METHODS: Ninety-four patients with WG and active renal disease were included in this retrospective study. All patients had a percutaneous renal biopsy taken on their first admission to the hospital and 14 patients had a second biopsy. The patients were followed for a median of 42.5 months (range 0.5-184). RESULTS: Segmental necrotizing glomerulonephritis and extracapillary proliferation were present in 85.1 and 91.5% respectively. Of seven patients (7.4%) with normal serum creatinine and urinary protein excretion <0.5 g/day, all had crescents and six had segmental glomerular necrosis. Serum creatinine at biopsy correlated significantly with the percentage of glomeruli with crescents (rho=0.52, P=0.0004), with necrosis (rho=0.36, P=0.002) and with the percentage of normal glomeruli (rho=-0.55, P=0.0003). On a multivariate analysis, only the percentage of normal glomeruli was significantly associated with renal function and development of end-stage renal disease. In 14 second biopsies after a mean of 41.2 (+/-26) months, chronicity scores had increased significantly in 13 biopsies in spite of full immunosuppressive treatment. CONCLUSION: Although renal biopsy is of value in defining renal involvement in WG, it is of limited help in the early stage of the disease in predicting renal outcome for the individual patient. A follow-up biopsy can be useful in revealing the degree of activity and chronicity and hence be of importance for the choice of further therapy.     

A retrospective analysis for aetiology and clinical findings of 287 secondary amyloidosis cases in Turkey.

BACKGROUND: Secondary amyloidosis is the most frequent of the various types of systemic amyloidosis, the epidemiology of which is not yet fully known. The aim of our study was to evaluate retrospectively the collective data for the aetiological distribution, clinical findings and approaches to the management of secondary amyloidosis in Turkey. METHODS: Data from a simple questionnaire addressing aetiology, and demographic and clinical characteristics of patients with biopsy-proven secondary amyloidosis was retrospectively analysed. Eleven nephrology clinics contributed data for this study. RESULTS: The 11 contributing centres provided a total of 287 cases (102 female, 185 male). The aetiological distribution was as follows: familial Mediterranean fever (FMF) 64%, tuberculosis 10%, bronchiectasis and chronic obstructive lung disease 6%, rheumatoid arthritis 4%, spondylarthropathy 3%, chronic osteomyelitis 2%, miscellaneous 4%, unknown 7%. Oedema accompanied by proteinuria was present in 88% of the cases, hepatomegaly in 17%, and splenomegaly in 11%. The mean systolic and diastolic blood pressures were 115+/-26 and 73+/-15 mmHg respectively. The family history was positive in 16%; 73% of the cases were on colchicine treatment when the questionnaire was administered. Thirty-eight per cent of the cases had progressed to ESRD and were on renal replacement therapy. CONCLUSIONS: FMF is the leading cause of secondary amyloidosis in Turkey, followed by tuberculosis. Oedema accompanied by proteinuria is the most prominent presenting finding, and hypotension seems to be common among these patients.     

A prospective study of the use of fine-needle aspiration cytology and core biopsy in the diagnosis of breast cancer

A prospective study was carried out on 143 consecutive patients with palpable lumps larger than 2 cm in size which were clinically suspicious of carcinoma. One hundred and five lumps proved to be malignant and 38 were benign. Of the 105 patients with malignancy, confirmation was made in 95 by fine-needle aspiration cytology (FNAC) with a sensitivity of 90.4% and 100 by core biopsy with a sensitivity of 95.2%. The sensitivity of core biopsies increased with the number of cores taken (one core, 76.2%; two cores, 80.9%, three cores, 89.2%; four cores, 95.2%). The combined sensitivity of FNAC and core biopsies was 100%, and so are complementary in the accurate diagnosis of breast cancer. Patients presenting to the breast clinic with a solid suspicious breast lump larger than 2 cm can benefit from FNAC and a minimum of four core biopsies to improve diagnosis.     

No regression of renal AL amyloid in monoclonal gammopathy after successful autologous blood stem cell transplantation and significant clinical improvement.

BACKGROUND: High-dose chemotherapy followed by autologous blood stem cell transplantation induces remission of plasma cell dyscrasia in patients with AL amyloidosis. The impact of this treatment on the glomerular amyloid mass is still unknown. METHODS: In the present study, the quantity of the renal amyloid mass before and more than 3 years after high-dose melphalan treatment and autologous blood stem cell transplantation was assessed in two patients. At the time of the second renal biopsy, both patients were in complete remission without detectable serum and urinary monoclonal IgA-lambda and a normal percentage of plasma cells in the bone marrow. RESULTS: In both patients with biopsy-proven AL amyloidosis, urinary protein excretion decreased from 7 g/24 h to <2 g/24 h more than 3 years after autologous blood stem cell transplantation. In contrast, glomerular amyloid deposits persisted, as shown in the second biopsy. CONCLUSION: Despite complete remission of the plasma cell dyscrasia and improvement of glomerular permeability, the amount of glomerular amyloid mass did not regress.     

Vascular involvement and cell damage in experimental AA and clinical beta(2)-microglobulin amyloidosis.

BACKGROUND: Amyloidosis is a highly prevalent disease characterized by the deposition of amyloid fibrils. Although several types of amyloidosis can be identified according to their protein constituents and suggest putative aetiological factors, the causes of amyloidosis remain unknown. Furthermore, the cellular participation and the ultrastructural particularities of amyloidosis have received little attention. The aim of our study was to evaluate the vascular participation in amyloidosis and the cellular consequences of this disease. METHODS: Two forms of amyloidosis were studied: experimental amyloid A (AA) and clinical beta(2)-microglobulin amyloidosis. We studied kidney, liver, and spleen in a mouse model, and examined surgically obtained carpal deposits from dialysis patients. We used light and electron microscopy with immunogold labelling for anti-beta(2)-microglobulin and anti-AA protein antibodies. RESULTS: AA amyloid fibril accumulation was associated with membrane lesions in basal, cytoplasmic organelle (endoplasmic reticulum, mitochondria), and nuclear membranes. Amyloid fibrils from beta(2)-microglobulin amyloidosis were also closely associated with elastic fibres and endothelial basement membrane. We observed proliferation of endothelial cells as well as basement membrane enlargement and disruption. CONCLUSIONS: Vascular abnormalities, including endothelial enlargement, basement membrane modifications, and vascular proliferation were associated with amyloidosis. Amyloid fibrils have a high avidity for elastic fibres and are able to contact and damage the basement membrane, the cell and intracellular organelle membranes, as well as the nuclear envelope, suggesting a toxic effect of amyloid fibrils on cells.     

The renal histopathology in systemic vasculitis: an international survey study of inter- and intra-observer agreement

In order to relate histopathological findings of the kidneyin systemic vasculitis to renal outcome, scoring of variousmorphological parameters is necessary. Therefore, we conducteda standardization study for evaluating renal biopsies from patientswith systemic vasculitis. Four experienced renal pathologistsfrom four European centres joined in the study. A scoring protocolwas devised that required the observers to score an extensivenumber of histopathological lesions either quantitatively (asa percentage of the total number of glomeruli) or dichotomously(on a present/absent scale). Twenty renal biopsies were scoredindividually by all the observers, from which the inter-observervariability was analysed. Ten randomly chosen biopsies werescored again, in order to obtain the intra-observer variability.For inter-observer agreement, the evaluation of the quantitativevariables was satisfactory for both rounds (0.55Kendall's W0.95and 0.59W0.96, respectively, with all P<0.05). However, theinter-observer agreement for the dichotomous data was poor (K0.30in more than half of the parameters in both rounds). Also thedata on intra-observer agreement showed more favourable resultsfor the analysis of the quantitative data (Pearson's r>0.45in more than 85% of the variables in both rounds) than for thedichotomous scoring system (K0.30 in more than half of the variables).It is concluded that even between experienced renal pathologistsdiscrepancies occur in scoring kidney biopsies. Inter- and intra-observeragreement is greater if a quantitative method for reviewingthe biopsies is applied that requires the observers to scorethe tissue specimens systematically.     

Renal and systemic effects of continued treatment with renin inhibitor remikiren in hypertensive patients with normal and impaired renal function.

BACKGROUND: Remikiren is an orally active renin inhibitor with established antihypertensive efficacy. As a single dose it induces renal vasodilatation, suggesting specific renal actions. Data on the renal effects of continued treatment by renin inhibition are not available, either in subjects with normal, or in subjects with impaired renal function. METHODS: The effect of 8 days of treatment with remikiren 600 mg o.i.d. on blood pressure, renal haemodynamics, and proteinuria was studied in 14 hypertensive patients with normal or impaired renal function.The study was conducted on an ambulatory in-hospital basis and was designed in a single-blind, longitudinal order. RESULTS: Remikiren induced a significant peak fall in mean arterial pressure of 11.2+/-0.8%, with corresponding trough values of -6+/-0.8%. This fall was somewhat more pronounced in the patients with renal function impairment (-13.3 vs -9.6%; P<0.01). Glomerular filtration rate remained stable, whereas effective renal plasma flow increased from 301+/-35 to 330+/-36 ml/min/1.73 m(2) (P<0.05). Filtration fraction and renal vascular resistance fell by 10+/-2% and 15+/-2% respectively (both P<0.01). Remikiren induced a cumulated sodium loss of -82+/-22 mmol and a positive potassium balance of 49+/-9 mmol (both P<0.01). During remikiren, proteinuria fell by 27% (range -18 to -38%; P<0.01) in the patients with overt proteinuria at onset (n=6). In the remainder of the patients albuminuria fell by 20% (range -1 to -61%, P<0.05). No side-effects were observed. CONCLUSIONS: Continued treatment with remikiren induced a sustained fall in blood pressure, renal vasodilatation, negative sodium balance, and a reduction in glomerular protein leakage. These data are consistent with a renoprotective potential of renin inhibition.     

A retrospective 5-year study in Moldova of acute renal failure due to leptospirosis: 58 cases and a review of the literature.

BACKGROUND: Renal involvement [as acute renal failure (ARF)] is a prominent feature of both mild and severe leptospirosis-a re-emerging infectious disease. Few large series describe in detail clinical and laboratory features of cases with ARF and their outcome. METHODS: We performed a retrospective analysis (1997-2001) of all consecutive, serological confirmed leptospirosis cases with ARF (n=58, 53 male, age 44+/-13 years, rural residents=31%, animal contact=88%. RESULTS: Clinical manifestations (>50% prevalence): oliguria 95%, fever and jaundice 93%, nausea and vomiting 83%, haemorrhagic diathesis 80%, headache, hepatomegaly 76%, myalgias, abdominal pain 70%, hypotension 62%, disturbed consciousness 50%. A pattern of multiple organ failure (MOF) was frequent: ARF together with hepatic failure in 72%, respiratory failure in 38%, circulatory failure in 33%, pancreatitis in 25% and rhabdomyolysis in 5% of cases. Renal dysfunction: 35% of cases had a renal K(+)-wasting defect and 43% a FE(Na)(+)>1% and low-osmolarity urine despite volume depletion. Haematuria was encountered in 12 and mild proteinuria in 10 subjects. Outcome: 26% deaths, 64% normal hepatic and renal function at 90 days from presentation (however 29% maintained the initial tubular defect), 10% persistent mild renal failure. All deceased patients had, beside ARF, at least two other organ failures, affected consciousness, and haemorrhagic diathesis vs a prevalence for the above features of only 34, 33, and 72%, respectively, in the survivors group (P<0.05). CONCLUSIONS: Leptospirosis presenting with ARF is a severe disease, frequently leading to MOF and to death in one-third of the patients. In particular, the haemorrhagic diathesis and cerebral involvement are markers for unfavourable patient and renal outcomes.     

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.     

The impact of social isolation by COVID-19 on the epidemiological and clinical profiles of the burn patients. A retrospective study

BackgroundSocial isolation, imposed by the COVID-19 pandemic, may imply changes in the clinical-demographic and epidemiological profiles of burn trauma victims.ObjectiveEvaluate the changes in the epidemiological profile of patients with burns that resulted in hospitalization during the social isolation period due to the COVID-19 pandemic, comparing with the same period in the previous year.MethodsThe medical records of burn patients who were hospitalized in our Burn Center during the local confinement period (March 18th to August 31st, 2020) and during the same period in 2019 were analyzed. Data on demographic, clinical and hospitalization aspects were studied.Results470 patients were evaluated. In the pediatric population, a significant increase in the number of cases up to 2 years old (P = 0.0003), median of %TBSA (P = 0.037), full-thickness burns (P < 0.0001), involvement of hands (P = 0.024), debridement (P = 0.046) and grafting (P = 0.032) procedures, and higher scores of severity (P < 0.0001) were noted. In the adult population, it was only observed an increase in the burn-hospitalization interval (P = 0.029).ConclusionThe pediatric population was heavily impacted by the imposed period of social isolation, presenting a greater severity of burns. In contrast, the epidemiology of burns for the adult population was slightly altered during the pandemic period.     

Renal cell carcinoma sub-typing by histopathology and fluorescence in situ hybridization on a needle-biopsy specimen

OBJECTIVE: To determine the subtype of renal cell carcinoma (RCC) on needle-core biopsies of renal masses using histopathology and fluorescence in situ hybridization (FISH), and to evaluate the use of interphase FISH to augment the accuracy of needle-core biopsies. PATIENTS AND METHODS: Histology correlates with prognosis in RCC but, historically, biopsies are inaccurate for histological subtype. As histological subtypes of RCC have distinct cytogenetic abnormalities (loss of 3p in clear cell, trisomy 7 or 17 in papillary and widespread chromosomal losses in chromophobe), we hypothesized that FISH would improve the accuracy of biopsies. Forty patients with renal masses underwent nephrectomy, yielding 42 tumours. Needle-core biopsies were taken of the mass immediately after surgery. Interphase FISH was performed on one core for chromosomes 3, 7, 10, 13, 17, and 21 and the locus 3p25-26. Histopathology was performed on a second core. Results were compared in a 'blinded' fashion with final pathology. RESULTS: In all, 36 of 42 masses were RCC or oncocytoma. Histopathology of the biopsy correctly identified the tumour subtype in 27 (75%), while four (11%) were incorrectly classified and five (14%) were inadequate for diagnosis. With the addition of FISH, 31 (86%) were correctly subtyped, while two (6%) were incorrect and three (8%) were inadequate. In cases with adequate tissue, histology alone was 87% accurate, while the combined method was 94% accurate. CONCLUSION: Needle-core biopsy of renal tumours provides adequate material for evaluation of histological subtype. Adding FISH to histopathology might improve the accuracy of kidney tumour biopsies, providing important prognostic information that can guide management decisions.     

MEFV gene mutations in familial Mediterranean fever phenotype II patients with renal amyloidosis in childhood: a retrospective clinicopathological and molecular study.

BACKGROUND: Familial Mediterranean fever (FMF) is an autosomal recessive disease characterized by recurring attacks of fever and serositis. The definition of the mutated gene has allowed molecular diagnosis of the disease. The most important complication of FMF is the development of AA type secondary amyloidosis. In a group of patients clinically designated as phenotype II amyloidosis patients, renal amyloidosis develops without being preceded by typical attacks of the disease. In this study, the mutations of the MEFV gene were analysed in a group of patients clinically recognized as phenotype II. METHODS: DNA samples were obtained from tissue samples of the subjects. PCR-RFLP methods were used to analyse the M694V, M680I, V726A and E148Q mutations that have been previously defined by us to be the most common mutations in our Turkish cohort. RESULTS: The distribution of the four most common mutations among phenotype II patients was 38% for M694V, 8% for M680I, 4% for V726A and 4% for E148Q. CONCLUSIONS: In phenotype II amyloidosis patients, the distribution of the four common MEFV mutations was not significantly different from that found in all FMF patients with typical symptoms who do or do not develop amyloidosis. We therefore suggest that secondary genetic or environmental factors are operative in the development of secondary amyloidosis in patients with FMF.     

Renal epidemiology. The first clinical and epidemiological programme on renal disease in Bolivia: a model for prevention and early diagnosis of renal diseases in the developing countries

Background. The prevalence and incidence of renal diseases in developing countries are not known. This lack of knowledge is an obstacle to the adoption of preventive measures which may be of great value in a social and economic environment where treatment options for end-stage renal failure are simply not available to the vast majority of the population. Urinalysis, a simple and inexpensive test, remains a cornerstone in the evaluation of the kidney and may also be easily employed in mass screening for renal abnormalities in a developing country. Methods. An educational campaign on renal diseases was conducted in three selected areas of Bolivia. Urine samples were collected and sent to one of 21 participating clinical centers. Fresh urine specimens were screened using a dipstick for chemical analysis and by microscopic urinalysis after centrifugation. In those patients in whom urinary abnormalities were found, further investigations were carried out in order to define the diagnosis; these patients were enrolled in a 3-year follow-up program. Results. Apparently healthy subjects (n=14 082) were referred to the First Clinical and Epidemiological Program of Renal Diseases from rural and metropolitan areas in Bolivia. Urinary abnormalities were detected in 4261 subjects at first screening. The most common form of urinary abnormality was hematuria, which was found in 2010 (47% of positively screened subjects). Other renal abnormalities were leukocyturia (41%) and proteinuria (11%). Confirmatory tests and further clinical studies were then carried out in 1019 people. On a second screening 35% of the subjects had no urinary abnormalities; in the remaining people the following diagnosis were made: asymptomatic urinary tract infection (48.4%), isolated benign hematuria (43.9%), chronic renal failure (1.6%), renal tuberculosis (1.6%). Other diagnosis were: renal stones 1.3%, diabetic nephropathy 1% and polycystic kidney diseases 1.9%. Conclusions. This study helped define for the first time the frequency of asymptomatic renal diseases in Bolivia. It shows that it is possible to screen a large population of patients at relatively low cost, providing the framework for further action that may help in the prevention and timely diagnosis of renal diseases. Keywords: Bolivia; developing countries; epidemiology; renal diseases      

Prevalence of co-morbidity in different European RRT populations and its effect on access to renal transplantation.

BACKGROUND: This study compared the prevalence of co-morbidity in patients starting renal replacement therapy (RRT) between European countries and further examined how co-morbidity affects access to transplantation. METHODS: In this ERA-EDTA registry special study, 17907 patients from Austria, Catalonia (Spain), Lombardy (Italy), Norway, and the UK (England/Wales) were included (1994-2001). Co-morbidity was recorded at the start of RRT. RESULTS: The prevalence of co-morbidity was: diabetes mellitus (DM) (primary renal disease and co-morbidity) 28%, ischaemic heart disease (IHD) 23%, peripheral vascular disease (PVD) 24%, cerebrovascular disease (CVD) 14% and malignancy 11%. With exception of malignancy, the prevalence of co-morbidity was highest in Austria, but differences were small among other countries. With exception of DM, males suffered more often from co-morbidity than females. In general, the percentage of haemodialysis was higher in patients with co-morbidity, but treatment modality differed substantially between countries. Using a Cox regression with adjustment for demographics, country, year of start and other co-morbidities, the presence of each of the co-morbid conditions made it less likely [RR; 95%CI] to receive a transplant within 4 years: DM [0.79; 0.70-0.88], IHD [0.59; 0.50-0.70], PVD [0.57; 0.49-0.67], CVD [0.49; 0.39-0.61], and malignancy [0.32; 0.24-0.42]. The age, gender and year of start adjusted relative risk [95%CI] to receive a renal transplant within 4 years ranged from 0.23 [0.19-0.27] for Lombardy (Italy) to 3.86 [3.36-4.45] for Norway (Austria = reference). These international differences existed for patients with and without co-morbidity. CONCLUSIONS: The prevalence of co-morbidity was highest in Austria but differences were small among other countries. The access to a renal graft was most affected by the presence of malignancy and least affected by the presence of DM. International differences in access to transplantation were only partly due to co-morbid variability.