Current trends in European renal epidemiology

Investigation of Factors Affecting Clinical Outcome of Peritoneal Dialysis Patients

Background

End-stage kidney disease (ESKD) is a global issue. Although the use of kidney replacement therapy measures has improved outcomes for patients with ESKD, the mortality rate remains significant. Identifying modifiable factors that affect patient outcomes can help improve their survival. The aim of this study was to investigate the factors affecting the clinical outcome of peritoneal dialysis patients.

Methods

This prospective cohort study was conducted between 2018 and 2021.Participants: Patients aged between 18 and 75 years with a history of peritoneal dialysis (PD) for at least six months were included. Demographic data, kt/v ratio, medical history, serum levels of albumin, creatinine, triglycerides, total cholesterol, calcium, phosphorus, parathyroid hormone, hemoglobin, and ferritin were recorded before starting PD and during the follow-up period, along with clinical outcomes. To describe the data, the central index of mean, frequency, and relative frequency was used, and for analytical statistics, Chi-square test, analysis of variance, and Kruskal-Wallis were used.

Results

A total of 64 patients with a mean age of 51.78 ± 15.31 years were included. Of these, 27 (42.18%) had a history of diabetes mellitus, and 38 (59.37%) had a history of hypertension (HTN). 48 (75%) patients survived until the end of the study, while 47 (73.4%) participants experienced peritonitis. Our findings indicate that variables such as sex, marital status, weight, history of HTN, and serum levels of hemoglobin and ferritin significantly affect outcomes.

Conclusion

We found that factors including sex, marriage, normal weight, HTN, normal hemoglobin, and ferritin can lead to better survival in PD patients. Recurrent peritonitis was the most crucial cause of PD to HD shifts.

Comparison of Clinical Performance Between Two Types of Symmetric-Tip Hemodialysis Catheters: A Single-Centre, Randomized Trial

PURPOSE

To compare the clinical performance of a newly designed, symmetric-tip Arrow-Clark™ VectorFlow® tunnelled haemodialysis catheter, with a Glidepath™, symmetric-tip tunnelled haemodialysis catheter.

MATERIAL AND METHODS

From November 2018 to October 2020, patients with End-Stage Renal Disease requiring a de novo tunnelled catheter for hemodialysis, were randomized to Vectorflow® (n = 50) or to Glidepath™ catheter (n = 48). The primary outcome was catheter patency at one year following catheter insertion. Catheter failure was defined as the removal of the catheter due to infectious complications, or low blood flow rate by intraluminal thrombosis or fibrin sheath occlusion. Secondary outcomes were blood flow rate, fractional urea clearance and urea reduction ratio during dialysis.

RESULTS

Demographic characteristics were not different between the two groups. At three months and on the one-year endpoint the patency rates with the Vectorflow® catheter were 95.83% and 83.33% respectively, compared to 93.02% at both endpoints with the Glidepath™ catheter (P = 0.27). Catheter failure to infectious complications or low blood flow rate was similar in both groups. Catheter blood flow rate reached the threshold of 300 ml/min at all time points for both catheters. All patients had a high mean fractional urea clearance (1.6-1.7).

CONCLUSIONS

The catheter patency rate was not significantly different in patients with a VectorFlow® or a Glidepath™ catheter. Both catheters presented satisfactory dialysis adequacy over one year.

Novel strategies in nephrology: what to expect from the future?

Chronic kidney disease (CKD) will become the fifth global case of death by 2040. Its largest impact is on premature mortality but the number of persons with kidney failure requiring renal replacement therapy (RRT) is also increasing dramatically. Current RRT is suboptimal due to the shortage of kidney donors and dismal outcomes associated with both hemodialysis and peritoneal dialysis. Kidney care needs a revolution. In this review, we provide an update on emerging knowledge and technologies that will allow an earlier diagnosis of CKD, addressing the current so-called blind spot (e.g. imaging and biomarkers), and improve renal replacement therapies (wearable artificial kidneys, xenotransplantation, stem cell-derived therapies, bioengineered and bio-artificial kidneys).

Impact of high, low, and non-optimum temperatures on chronic kidney disease in a changing climate, 1990-2019: A global analysis

BACKGROUND

Although a few studies have reported the relationship between high and low temperatures and chronic kidney disease (CKD), the global burden of CKD attributable to extreme heat and cold in recent decades remains unknown.

METHODS

Based on the Global Burden of Disease Study (GBD) 2019, we obtained data on age-standardized mortality rates (ASMR) and age-standardized rates of disability-adjusted life years (ASDR) per 100 000 population of the CKD attributable to non-optimum temperatures from 1990 to 2019. The annual mean temperature of each country was used to divide each country into five climate zones (tropical, subtropical, warm-temperate, cool-temperate, and boreal). The locally weighted regression model was used to estimate the burden for different climate zones and Socio-demographic index (SDI) regions.

RESULTS

In 1990, the ASMR and ASDR due to high temperature estimated -0.01 (95% UI, -0.74 to 0.44) and -0.32 (-21.66 to 12.66) per 100 000 population, respectively. In 2019, the ASMR and ASDR reached 0.10 (-0.28 to 0.38) and 2.71 (-8.07 to 10.46), respectively. The high-temperature burden increased most rapidly in tropical and low SDI regions. There were 0.99 (0.59 to 1.39) ASMR attributable to low-temperature in 1990, which increased to 1.05 (0.61-1.49) in 2019. While the ASDR due to low temperature declined from 22.03 (12.66 to 30.64) in 1990 to 20.43 (11.30 to 29.26) in 2019. Overall, the burden of CKD attributable to non-optimal temperatures has increased from 1990 to 2019. CKD due to hypertension and diabetes mellitus were the primary causes of CKD death attributable to non-optimum temperatures in 2019 with males and older adults being more susceptible to these temperatures.

CONCLUSIONS

The CKD burden due to high, low, and non-optimum temperatures varies considerably by regions and countries. The burden of CKD attributable to high temperature has been increasing since 1990.

First-year mortality in incident dialysis patients: results of the Peridialysis study

Background

Controversy surrounds which factors are important for predicting early mortality after dialysis initiation (DI). We investigated associations of predialysis course and circumstances affecting planning and execution of DI with mortality following DI.

Methods

Among 1580 patients participating in the Peridialysis study, a study of causes and timing of DI, we registered features of predialysis course, clinical and biochemical data at DI, incidence of unplanned suboptimal DI, contraindications to peritoneal dialysis (PD) or hemodialysis (HD), and modality preference, actual choice, and cause of modality choice. Patients were followed for 12 months or until transplantation. A flexible parametric model was used to identify independent factors associated with all-cause mortality.

Results

First-year mortality was 19.33%. Independent factors predicting death were high age, comorbidity, clinical contraindications to PD or HD, suboptimal DI, high eGFR, low serum albumin, hyperphosphatemia, high C-reactive protein, signs of overhydration and cerebral symptoms at DI. Among 1061 (67.2%) patients who could select dialysis modality based on personal choice, 654 (61.6%) chose PD, 368 (34.7%) center HD and 39 (3.7%) home HD. The 12-months survival did not differ significantly between patients receiving PD and in-center HD.

Conclusions

First-year mortality in incident dialysis patients was in addition to high age and comorbidity, associated with clinical contraindications to PD or HD, clinical symptoms, hyperphosphatemia, inflammation, and suboptimal DI. In patients with a “free” choice of dialysis modality based on their personal preferences, PD and in-center HD led to broadly similar short-term outcomes.

Risk of Intradialytic Hypotension by Day of the Week in Maintenance Hemodialysis

Intradialytic hypotension (IDH) is a common complication of hemodialysis (HD) and is associated with a higher risk of cardiovascular (CV) events and mortality. CV events are more common on the days of HD, especially following the longer interdialytic interval. We investigated the risk of IDH according to day of HD in adults undergoing in-center, thrice-weekly HD in the Hemodialysis (HEMO) Study (N = 1,837 patients; n = 64,474 sessions), and the DaVita Clinical Research biorepository [BioReG]) (N = 952 patients; n = 61,197 sessions). Random effects logistic regression models assessed the risk of IDH (defined as nadir intra-HD systolic blood pressure [SBP] <90 mm Hg if pre-HD SBP <160 mm Hg, or <100 mm Hg if pre-HD SBP ≥160 mm Hg [Nadir90/100 definition]) according to HD day (Mon/Tue [HD1]; Wed/Thu [HD2]; Fri/Sat [HD3]). Alternative definitions of IDH were explored. Nadir90/100 occurred in 14% of HEMO and 18% of BioReG sessions. A monotonic increase in the risk of IDH was observed for HD2 and HD3, compared with HD1, for all IDH definitions in both cohorts. Compared with HD1, HD2 was associated with a 10% higher risk of Nadir90/100 (adjusted odds ratio, 1.10; 95% CI, 1.03-1.17) and HD3 was associated with a 31% higher risk (adjusted odds ratio, 1.31; 95% CI, 1.19-1.45) in HEMO, with consistent results in BioReG. We observed a monotonic increased risk of IDH with later days of the dialytic week in two separate cohorts. Further research to determine the underlying mechanisms is necessary to guide strategies for IDH prevention.

Quality indicators in hemodialysis: A 5-year experience of national campaigns in France

BACKGROUND

End stage kidney disease (ESKD) is associated with increased morbidity and mortality. Hemodialysis (HD) is the main technique used for kidney replacement therapy. Dialyzed patients are expected to live less than one half as long as their counterparts without ESKD. Improving quality of care may help to improve mortality in this population.

METHODS

The French National Authority for Health has carried out three consecutive national campaigns over 5 years for the assessment of quality indicators (QCI) during HD. QCI included anemia management, iron status evaluation, nutritional status assessment, and annual transplantation access.

RESULTS

From 2013 to 2017, 227 health facilities participated, and 33,319 files were analyzed. Median age was 72 years old (IQR_25-75  = 61-81), and 58.25% of patients were men. Median time in HD was 39.4 months (IQR_25-75  = 20.7-72.7). Most of the patients underwent in-center HD (85.41%). Overweight and obese patients accounted, respectively, for 28.39% and 21.32%, and malnutrition was present in 38.61%. A contra-indication for renal transplantation was found in 68.3% of patients. All QCI improved over 5 years.

CONCLUSION

Developing QCI based on guidelines is crucial to assure appropriate care of HD patients. Repeating campaigns over 5 years in France improves the quality of care among physicians.

Incidence and risk factors of chronic kidney disease: results of a nationwide study in Iceland

Background

Information on the incidence of chronic kidney disease (CKD) in the general population is scarce. This study examined the incidence and risk factors of CKD stages 1–5 in Iceland, based on multiple markers of kidney damage.

Methods

All SCr values, urine protein measurements and diagnosis codes for kidney diseases and comorbid conditions for people aged ≥ 18 years were obtained from electronic medical records of all healthcare institutions in Iceland in 2008–2016. CKD was defined according to the KDIGO criteria as evidence for kidney damage and/or eGFR &lt; 60 mL/min/1.73 m2 for &gt; 3 months. Alternatively, CKD was defined using age-adapted eGFR thresholds. Mean annual age-standardized incidence of CKD was calculated for persons without CKD at study entry. Risk factor assessment was based on ICD diagnosis codes. Incidence was reported per 100 000 population.

Results

We retrieved 1 820 990 SCr values for 206 727 persons. Median age was 45 years (range, 18–106) and 47% were men. Mean annual age-standardized incidence of CKD per 100 000 was 649 in men and 694 in women, and 480 in men and 522 in women using age-adapted eGFR thresholds. The incidence reached over 3000 in men and women aged &gt; 75 years. Traditional CKD risk factors, such as acute kidney injury, diabetes, hypertension and cardiovascular disease, as well as less well characterized risk factors, including chronic lung disease, malignancy and major psychiatric illness were associated with increased risk of CKD, and the same was true for obesity and sleep apnea in women.

Conclusion

The annual incidence of CKD, with strict adherence to the KDIGO criteria, was &lt; 0.7% but markedly lower using age-adapted eGFR thresholds. Apart from acute kidney injury, the observed risk factors comprised chronic and potentially modifiable disorders.

Medium Cut-Off Versus High-Flux Hemodialysis Membranes and Clinical Outcomes: A Cohort Study Using Inverse Probability Treatment Weighting

Rationale & Objective

This study investigated the effects on patients’ outcomes of using medium cutoff (MCO) versus high-flux (HF) dialysis membranes.

Study Design

A retrospective, observational, multicenter, cohort study.

Setting & Participants

Patients aged greater than 18 years receiving hemodialysis at the Baxter Renal Care Services dialysis network in Colombia. The inception of the cohort occurred from September 1, 2017, to November 30, 2017, with follow-up to November 30, 2019.

Exposure

The patients were divided into 2 cohorts according to the dialyzer used at the inception: (1) MCO membrane or (2) HF membrane.

Outcomes

Primary outcomes were the hospitalization rate from any cause and hospitalization days per patient-year. Secondary outcomes were acute cardiovascular events and mortality rates from any cause and secondary to cardiovascular causes. Laboratory parameters were assessed throughout the 2-year follow-up period.

Analytical Approach

Descriptive statistics were used to report population characteristics. Inverse probability of treatment weighting was applied to each group before analysis. All categorical variables were compared using Pearson’s χ² test, and continuous variables were analyzed with the t test. Baseline differences between groups with a value of >10% were considered clinically meaningful. Laboratory variables were measured at 5 consecutive time points. A between-patient effect was analyzed using a split-plot factorial analysis of variance.

Results

The analysis included 1,098 patients, of whom 564 (51.3%) were dialyzed with MCO membranes and 534 (48.7%) with HF membranes. Patients receiving hemodialysis with MCO membranes had a lower all-cause hospitalization incidence rate (IR) per patient-year (IR = 0.93; 95% CI, 0.82-1.03) than those receiving hemodialysis with HF membranes (IR = 1.13; 95% CI, 0.96-1.30), corresponding to a significant incident rate ratio (MCO/HF) of 0.82 (95% CI, 0.68-0.99; P = 0.04). The frequency of nonfatal cardiovascular events showed statistical significance, with a lower incidence in the MCO group (incident rate ratio = 0.66; 95% CI, 0.46-0.96; P = 0.03). No statistically significant differences in all-cause time until death were observed (P = 0.48). Albumin levels were similar between the 2 dialyzer cohorts.

Limitations

Despite the robust statistical analysis, there remains the possibility that unmeasured variables may still generate residual imbalance and, therefore, skew the results.

Conclusions

The incidences of hospitalization and cardiovascular events in patients receiving hemodialysis were lower when dialyzed with MCO membranes than HF membranes. A randomized controlled trial would be desirable to confirm these results.

Trial Registration

Clinical Trials.gov, ISRCTN12403265.

Evaluation of PROMIS Preference Scoring System (PROPr) in Patients Undergoing Hemodialysis or Kidney Transplant

BACKGROUND AND OBJECTIVES

A preference-based health utility score (PROPr) can be calculated using Patient-Reported Outcomes Measurement Information System domain scores. We assessed the construct validity of PROPr among patients treated with KRT (hemodialysis or kidney transplant).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed a secondary analysis of data collected in multicenter, cross-sectional studies of adults treated with KRT, recruited between April 2016 to March 2020 in Toronto, Canada. All participants provided informed consent. The outcome was the PROPr score. Coadministered outcome variables included the Short-Form Six-Domain (SF-6D) and EuroQol Five-Domain Five-Level (EQ-5D-5L) scores. Socioeconomic and clinical variables included age, sex, diabetes, eGFR, serum albumin, hemoglobin, KRT, and Charlson Comorbidity Index. Construct validity was assessed through correlations between PROPr and SF-6D or EQ-5D-5L, and associations between PROPr and other exposure variables. Health-condition impact estimates (coefficients for health conditions compared with a referent category, e.g., dialysis versus kidney transplant) were calculated using multivariable linear regression.

RESULTS

The mean (SD) age of the 524 participants was 57 (17) years, 58% were male, and 45% were White. Median (interquartile range) score was 0.39 (0.24-0.58) for PROPr, 0.69 (0.58-0.86) for SF-6D, and 0.85 (0.70-0.91) for EQ-5D-5L. Large correlations were observed between PROPr versus SF-6D (0.79; 95% confidence interval [95% CI], 0.76 to 0.82) and EQ-5D-5L (0.71; 95% CI, 0.66 to 0.75). Both PROPr and the other utility indices demonstrated health-condition impact in the expected direction. For example, the estimate for PROPr was -0.17 (95% CI, -0.13 to -0.21) for dialysis (versus kidney transplant), -0.05 (95% CI, -0.11 to 0.01; P=0.08) for kidney transplant recipients with an eGFR of <45 versus ≥45 ml/min per 1.73 m², and -0.28 (95% CI, -0.22 to -0.33) for moderate/severe versus no/mild depressive symptoms.

CONCLUSIONS

Our results support the validity of PROPr among patients treated with KRT.

Projecting the Incidence of Type 2 Diabetes-Related End-Stage Kidney Disease Until 2040: A Comparison Between the Effects of Diabetes Prevention and the Effects of Diabetes Treatment

OBJECTIVE

This study sought to examine the effects of two diabetes prevention approaches and of widespread use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) among people with diabetes on the future incidence of diabetes-related end-stage kidney disease (ESKD-D).

RESEARCH DESIGN AND METHODS

We developed a life table model to project the incidence of ESKD-D for type 2 diabetes in Australia until 2040. We projected incident ESKD-D under three separate scenarios: a large-scale lifestyle modification program for diabetes prevention; a population-wide sugar-sweetened beverage tax for diabetes prevention; and widespread use of SGLT2is among people with diabetes.

RESULTS

Assuming current trends, we projected that the annual incidence of ESKD-D will increase from 3.7 per 100,000 of the general population in 2014 to 5.7 by 2040. Incorporating the diabetes prevention approaches, we projected that the annual incidence of ESKD-D will be between 5.2 and 5.5 per 100,000 by 2040. When we modeled scenarios in which 50% and 70% of eligible people with diabetes were prescribed an SGLT2i, the annual incidence of ESKD-D by 2040 was projected to be 4.7 and 4.3 per 100,000, respectively. SGLT2is were projected to reduce the total number of incident ESKD-D cases between 2020 and 2040 by 12-21% compared with current trends, whereas diabetes prevention reduced cases by 1-3%.

CONCLUSIONS

It is likely that the number of people developing ESKD-D will increase over the coming decades, although widespread SGLT2i use will be effective at limiting this increase. Diabetes prevention will be crucial to prevent an ever-increasing burden of diabetes complications.

International Society of Nephrology Global Kidney Health Atlas: structures, organization, and services for the management of kidney failure in Western Europe

Populations in the high-income countries of Western Europe are aging due to increased life expectancy. As the prevalence of diabetes and obesity has increased, so has the burden of kidney failure. To determine the global capacity for kidney replacement therapy and conservative kidney management, the International Society of Nephrology conducted multinational, cross-sectional surveys and published the findings in the International Society of Nephrology Global Kidney Health Atlas. In the second iteration of the International Society of Nephrology Global Kidney Health Atlas, we aimed to describe the availability, accessibility, quality, and affordability of kidney failure care in Western Europe. Among the 29 countries in Western Europe, 21 (72.4%) responded, representing 99% of the region's population. The burden of kidney failure prevalence varied widely, ranging from 760 per million population (pmp) in Iceland to 1612 pmp in Portugal. Coverage of kidney replacement therapy from public funding was nearly universal, with the exceptions of Germany and Liechtenstein where part of the costs was covered by mandatory insurance. Fourteen (67%) of 21 countries charged no fees at the point of care delivery, but in 5 countries (24%), patients do pay some out-of-pocket costs. Long-term dialysis services (both hemodialysis and peritoneal dialysis) were available in all countries in the region, and kidney transplantation services were available in 19 (90%) countries. The incidence of kidney transplantation varied widely between countries from 12 pmp in Luxembourg to 70.45 pmp in Spain. Conservative kidney care was available in 18 (90%) of 21 countries. The median number of nephrologists was 22.9 pmp (range: 9.47-55.75 pmp). These data highlight the uniform capacity of Western Europe to provide kidney failure care, but also the scope for improvement in disease prevention and management, as exemplified by the variability in disease burden and transplantation rates.

Two Faces of Vitamin C in Hemodialysis Patients: Relation to Oxidative Stress and Inflammation

Hemodialysis (HD) is the most common method of renal replacement therapy. Besides toxins, it eliminates nutrients from the circulation, such as ascorbic acid (AA). HD-patients present AA deficiency more often than representatives of the general population, also due to dietary restrictions. This condition aggravates oxidative stress and inflammation related to uremia and extracorporeal circulation and increases cardiovascular risk followed by mortality. Supplementation of AA seems to be a promising approach in the treatment of hemodialysis patients. Many successful interventions restored plasma AA concentration in HD patients by enteral or intravenous supplementation, concomitantly inhibiting oxidative stress and inflammation. A significant number of studies reported opposite, serious pro-oxidant effects of AA. In this narrative review, we present studies, commenting on their limitations; on AA plasma or serum concentration and the influence of its supplementation on protein and lipid peroxidation, DNA damage, reactive oxygen species generation, paraoxonase activity, advanced glycation endproducts, and C-reactive protein (CRP) concentration. Moreover, in terms of safety, the possible development of oxalosis in HD patients regarding the intravenous or enteral route of AA administration is discussed. Unequivocal clinical results of recent studies on hemodialysis patients are displayed.

End-stage renal disease reduces the expression of drug-metabolizing cytochrome P450s

BACKGROUND

End-stage renal disease is an irreversible status of kidney dysfunction that reduces both renal and non-renal drug clearance. Accumulation of uremic toxins seems to modify the activities of drug-metabolizing cytochrome P450 (CYP) enzymes. The aim of the present work was to refine gene expression analysis for efficient and accurate quantification of CYP mRNAs in patients' leukocytes.

METHODS

We compared six liquid-liquid extraction reagents for RNA isolation and five reverse transcriptase kits for RNA-to-cDNA conversion, and developed quantitative polymerase chain reaction methods for duplex measurements of CYP target genes and the reference gene. The expression of CYP1A2, CYP2C9, CYP2C19 and CYP3A4 in patients with end-stage kidney disease (N = 105) and in organ donors with healthy kidney function (N = 110) was compared.

RESULTS

Regarding the RNA yield and purity, TRIzol, Trizolate and TRI reagents were equal; however, TRI reagent was the most advantageous in terms of financial cost. Reverse transcription using Maxima First Strand cDNA Synthesis kit appeared to be the most efficient with the widest range for quantification of the target transcript. The refined method with the detection of various CYPs and the reference gene in duplex PCR efficiently quantified even the low-level CYP expression. In leukocytes of patients with end-stage renal disease, all four CYPs were expressed at significantly lower level than in organ donors with normal kidney function (p < 0.0001).

CONCLUSIONS

Reduced CYP expression was a direct evidence of transcriptional down-regulation of CYP genes in patients with impaired kidney function.

Health Policy for Dialysis Care in Canada and the United States

Contemporary dialysis treatment for chronic kidney failure is complex, is associated with poor clinical outcomes, and leads to high health costs, all of which pose substantial policy challenges. Despite similar policy goals and universal access for their kidney failure programs, the United States and Canada have taken very different approaches to dealing with these challenges. While US dialysis care is primarily government funded and delivered predominantly by private for-profit providers, Canadian dialysis care is also government funded but delivered almost exclusively in public facilities. Differences also exist for regulatory mechanisms and the policy incentives that may influence the behavior of providers and facilities. These differences in health policy are associated with significant variation in clinical outcomes: mortality among patients on dialysis is consistently lower in Canada than in the United States, although the gap has narrowed in recent years. The observed heterogeneity in policy and outcomes offers important potential opportunities for each health system to learn from the other. This article compares and contrasts transnational dialysis-related health policies, focusing on key levers including payment, finance, regulation, and organization. We also describe how policy levers can incentivize favorable practice patterns to support high-quality/high-value, person-centered care and to catalyze the emergence of transformative technologies for alternative kidney replacement strategies.

Increased incidence and improved prognosis of glomerulonephritis: a national 30-year study

Background

While there are many cross-sectional studies of glomerulonephritis (GN) incidence, changes in incidence over time, particularly in the 21st century have received less attention. Similarly, little is known about temporal changes in GN prognosis. The presence in Denmark of comprehensive registries for renal biopsy results, end-stage renal disease (ESRD), comorbidity and mortality permit these questions to be addressed.

Methods

Data for all renal biopsies in Denmark between 1985 and 2014 were extracted from the Danish Renal Biopsy Registry and Patobank registries. The date of first dialysis or transplantation was extracted from the Danish Nephrology Registry for those patients developing ESRD. Dates of death and presence of chronic comorbid conditions at date of biopsy were extracted from the National Patient Registry. The incidence of GN, adjusted to the 2013 European standard population, was calculated. ESRD incidence and mortality were calculated, both in absolute terms and after correction for age, comorbidity and presence of renal tubulointerstitial fibrosis.

Results

The incidence rose from 33.3 patients per million (ppm)/year in 1985–94 to 46.5 ppm in 2005–14. The increase could in part be related to changes in renal biopsy policy. Large increases in Anti-neutropil cytoplasmic antibody (ANCA) vasculitis (ANCAV) (3.1–7.7 ppm/year) and focal segmental glomerulosclerosis (FSGS) (1.5–5.7 ppm/year) incidence were noted. The biopsy-proven prevalence of GN in 2014 was 748 ppm of which 155 ppm were being treated with dialysis or transplantation. Adjusted ESRD incidence fell by 25% during the study period, mortality by 62% and combined ESRD/mortality by 46%. The fall in ESRD incidence was limited to minimal change GN, FSGS, membranous GN and lupus nephritis, while reductions in mortality, and the combination of ESRD and/or death, were seen for nearly all GN diagnoses.

Conclusions

This study suggests that the incidence of GN has generally increased between 1985 and 2014, but some of the increase may be related to changes in renal biopsy policy. Major increases in FSGS and ANCAV incidence have occurred. The prognosis of GN, both as regards ESRD and mortality, has improved.

The Effects of Chronic Dialysis on Physical Status, Quality of Life, and Arterial Stiffness: A Longitudinal Study in Prevalent Dialysis Patients

INTRODUCTION

It is widely known that dialysis patients have significantly impaired functional outcomes and arterial stiffness, but still few studies have investigated the effects of dialysis longitudinally by a multidimensional approach. We aimed to assess longitudinal patterns of physical activity (PA), physical functioning (PF), health-related quality of life (HrQoL), body composition (BC), and arterial stiffness in prevalent dialysis patients.

MATERIALS AND METHODS

Thirty-nine prevalent dialysis patients (23 conventional hemodialysis [CHD] and 16 peritoneal dialysis) with a mean vintage of 25.7 (±22.1) months were included in this observational prospective study with a 2-year follow-up, and at baseline 20 healthy controls were included. Measurements were performed every 6 months. HrQoL was assessed using the Short Form-36 (SF-36) questionnaire. PA was assessed using the SenseWear™ Pro3 accelerometer. PF was assessed by walking speed, the PF subscale of the SF-36, and handgrip strength (HGS). BC was assessed using the Body Composition Monitor® and arterial stiffness by measuring carotid-femoral pulse wave velocity (PWV). The longitudinal trend was assessed using linear mixed models, correcting for sex, age, and dialysis vintage. For PWV, the trend was additionally corrected for diabetes and systolic blood pressure.

RESULTS

After correction, no statistically significant changes over time were observed for the parameters of PA, PF, HrQoL, and BC. In the combined group and in the group of CHD patients only, a significant change was observed for PWV (overall trend: p = 0.007 and p = 0.008, respectively). A statistically significant difference at baseline was observed between dialysis patients and healthy controls in all parameters, except for HGS and PWV.

DISCUSSION/CONCLUSION

We observed no statistically significant changes in functional outcomes during a 2-year follow-up period, but a significant increase was observed for arterial stiffness. These results might suggest that after a certain period in time, a relatively stable course is present in functional outcomes, but an ongoing deterioration in arterial stiffness occurs, which might increase the risk of cardiovascular disease and all-cause mortality in these patients.

Peridialytic serum cytokine levels and their relationship with postdialysis fatigue and recovery in patients on chronic haemodialysis - A preliminary study

BACKGROUND

The aetiology of postdialysis fatigue (PDF), an intermittent but debilitating fatigue occurring after haemodialysis (HD) treatment, is still unclear. In other inflammatory diseases, increasing evidence points toward the involvement of the immune system in the onset of fatigue symptoms. Altered serum levels of inflammatory cytokines have also been shown in HD patients. Therefore, we investigated whether pre- and postdialysis serum levels of pro- and anti-inflammatory cytokines (i.e. IL-1β, IL-6, TNF-α and IL-10) or their intradialytic changes (if any) were related to PDF or the time HD patients reported needing to recover from HD treatment (TIRD).

METHODS

Serum levels of IL-1β, IL-6, TNF-α and IL-10 were measured immediately before and after HD in 45 patients using commercially available kits on an ELLA™ automated immunoassay system. The presence and severity of PDF as well as TIRD duration were assessed by self-report measures.

KEY RESULTS

Seventy-four percent of patients reported PDF, with a median PDF severity index of 3.30 [IQR: 3.00-4.30] on a scale from 1 to 5. Median TIRD was 120 min [IQR: 60-480]. PDF severity correlated strongly with TIRD, r_s = 0.85, p < 0.001. Only predialysis levels of IL-10 significantly and positively correlated with PDF severity (r_s = 0.43, p = 0.003).

CONCLUSION

Findings of the present study do not support the involvement of the immune system in the onset of PDF or the time patients needed to recover from HD treatment. A positive, but counterintuitive relationship was found between predialysis levels of anti-inflammatory IL-10 and PDF severity, which warrants further research.

Incidence, prevalence and crude survival of patients starting dialysis in Portugal (2010-16): analysis of the National Health System individual registry

Background

The Portuguese Society of Nephrology (PSN) reported that Portugal has one of the highest incidences of dialysis in Europe. However, this claim was based on aggregated data supplied by dialysis providers, hampering comparisons between countries. In 2009, an individual registry of patients starting dialysis was set up by the Portuguese Ministry of Health. We analysed individual data of patients starting dialysis from January 2010 until December 2016.

Methods

Demography, starting treatment day, modality, regional distribution and outcomes, such as death, recovery of renal function, transfer to renal transplantation, peritoneal dialysis or conservative management, were extracted. Incidence, prevalence and survival analysis were calculated and compared with the PSN registry.

Results

Out of 19 190 registrations, 16 775 were incident patients (61.8% men). Yearly incidence of renal replacement therapy was 250, 248, 229, 239, 230, 231 and 244 per million population (p.m.p.) for 2010 to 2016, compared with 235, 224, 218, 230, 234, 225 and 239 p.m.p. reported by the PSN registry. On the other hand, prevalence increased from 998 p.m.p. in 2010 to 1286 p.m.p. in 2016, compared with 1010 p.m.p. in 2010 increasing to 1203 p.m.p. in 2016 from the PSN registry. The regions of Alentejo (122.9 p.m.p.) and the the Centre (160.8 p.m.p.) had the lowest regional incidence, while Lisbon had the highest (386 p.m.p. in 2016). Unadjusted survival analysis revealed that 93.5% of the patients were alive on the 91st day, whereas 85.2 and 78.3% were alive at 1 and 2 years, respectively. Crude survival at 7 years was 40%.

Conclusions

For the first time, an individual registry of patients starting dialysis in Portugal was subject to analysis and added new information about long-term survival and regional differences in the incidence and prevalence of renal replacement therapy. We were able to confirm that Portugal has one of the world's highest incidences and prevalences of dialysis. We also demonstrate, for the first time, a striking regional difference in the incidence of dialysis and an excellent early and long-term survival of patients on dialysis. These results compare well with other European countries in terms of the dialysis efficiency.

Data from the ERA-EDTA Registry were examined for trends in excess mortality in European adults on kidney replacement therapy

The objective of this study was to investigate whether the improvement in survival seen in patients on kidney replacement therapy reflects the enhanced survival of the general population. Patient and general population statistics were obtained from the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry and the World Health Organization databases, respectively. Relative survival models were composed to examine trends over time in all-cause and cause-specific excess mortality, stratified by age and modality of kidney replacement therapy, and adjusted for sex, primary kidney disease and country. In total, 280,075 adult patients started kidney replacement therapy between 2002 and 2015. The excess mortality risk in these patients decreased by 16% per five years (relative excess mortality risk (RER) 0.84; 95% confidence interval 0.83-0.84). This reflected a 14% risk reduction in dialysis patients (RER 0.86; 0.85-0.86), and a 16% increase in kidney transplant recipients (RER 1.16; 1.07-1.26). Patients on dialysis showed a decrease in excess mortality risk of 28% per five years for atheromatous cardiovascular disease as the cause of death (RER 0.72; 0.70-0.74), 10% for non-atheromatous cardiovascular disease (RER 0.90; 0.88-0.92) and 10% for infections (RER 0.90; 0.87-0.92). Kidney transplant recipients showed stable excess mortality risks for most causes of death, although it did worsen in some subgroups. Thus, the increase in survival in patients on kidney replacement therapy is not only due to enhanced survival in the general population, but also due to improved survival in the patient population, primarily in dialysis patients.

Present and future of kidney replacement therapy in Italy: the perspective from Italian Dialysis and Transplantation Registry (IDTR)

Incidence of kidney replacement therapy (KRT) stabilizes or declines both in Europe and in the US; however, it is predictable that global prevalence of KRT will double by 2030. In this paper, we focus on the patterns of incidence, mortality, and prevalence of KRT in Italy, and we compare, when possible, the findings with other countries. The Italian Dialysis and Transplantation Registry (IDTR) currently collects aggregate data from regional registries. In Italy, KRT yearly incidence is around 160 patients per million population (pmp). This incidence showed an increasing trend up until 2011 with an average annual percentage change (AAPC) of 1.8%, after which it stabilized. Older age is an important determinant for KRT incidence, and it is strongly associated with the variability between Italian regions. Incidence is very stable within patients less than 50 years old; however, it greatly differs between regions for patients over 75 years old, ranging from 400 to 900 pmp. Moreover, the incidence for patients over 50 years old declined from 366 pmp in 2011 to 285 in 2017. An age-period-cohort (APC) model showed a very strong cohort effect, which shows the decline in incidence seems mainly due to the better health conditions of people born after 1940. Mortality rate in KRT patients was 109 per 1000 patient-year (py) between 2011 and 2017 with great differences among treatment modalities: 162 per 1000 py in haemodialysis, 117 per 1000 py in peritoneal dialysis, and 16 per 1000 py in kidney transplantation. Premature death is better detected by the standard expected years of life lost (YLL). The distribution of YLL rate per age shows a sharp increase between 40 and 70 years old both in haemodialysis and peritoneal dialysis patients with an AAPC of 5.2% and 4.1% respectively. Transplanted patients experience a very low YLL rate at any age. KRT prevalence was 1118 pmp in 2017 and it should be close to 1175 pmp by 2025 with a projected increase of transplanted patients' prevalence to 500 pmp, and a decrease of dialysis patients from 714 to 680 pmp. The proportion of patients treated with one of the three modalities strictly depends on age, with a sharp increase of haemodialysis after the age of 50. All data suggests the necessity to improve the care of middle and older age patients who experience the higher incidence of disease and mortality.

Exploring the Diurnal Course of Fatigue in Patients on Hemodialysis Treatment and Its Relation With Depressive Symptoms and Classical Conditioning

CONTEXT

Fatigue is one of the most prevalent symptoms among hemodialysis (HD) patients. To design effective treatments, it is crucial to understand the diurnal pattern of fatigue in this population.

OBJECTIVES

The objectives of this study were to assess diurnal changes in fatigue in patients undergoing hemodialysis and their relation with depressive symptoms and to explore whether fatigue may become a classically conditioned response to the hospital environment.

METHODS

A prospective, observational study was conducted in 51 HD patients. Subjects repeatedly rated their current fatigue on three different days during one week of hemodialysis treatment to capture changes in momentary fatigue. First, on an HD treatment day, fatigue was measured one hour before and immediately before dialysis, as well as immediately after dialysis and again at 22:00 pm Second, on the postdialysis day and on the seventh weekday (when patients had not received treatment on the previous day), fatigue was measured at the same moments in time as the two measurements before dialysis on the treatment day. Beck Depression Inventory-II and Fatigue Severity Scale were administered to evaluate depressive mood and fatigue severity in daily life.

RESULTS

Fatigue increased as a result of hemodialysis treatment over the entire sample. However, diurnal fatigue patterns differed significantly between individuals high and low in depressive symptoms, with the former being fatigued more constantly throughout the day, and the latter experiencing increases in fatigue due to treatment. Pretreatment fatigue experienced in the hospital environment followed a pattern consistent with the development of a classically conditioned response.

CONCLUSION

Diurnal fatigue patterns during hemodialysis treatment are associated with depressive symptoms, and classical conditioning may play a role in the experience of pretreatment fatigue.

Associations between plasma lysophospholipids concentrations, chronic kidney disease and the type of renal replacement therapy

BACKGROUND

Lysophosphatidic acid (LPA) and lysophosphatidylcholine (LPC) are bioactive lysophospholipids involved in the pathogenesis of renal diseases, especially the renal fibrosis. Plasma LPC concentrations in chronic kidney disease (CKD) patients are lower or similar to those observed in control groups, but less is known about the LPA concentrations. The main aim of the study was the analysis of associations of chronic kidney disease and renal replacement therapy with the plasma LPA concentrations. We have also analyzed the relationship between the plasma concentrations of LPA and LPC.

MATERIAL AND METHODS

Study group consisted of 110 patients with CKD in stages G3-G5 according to the KDIGO guidelines and was divided into four subgroups: treated conservatively (CT, 30 patients), on hemodialysis (HD, 30 patients), on peritoneal dialysis (PD, 30 patients) and renal transplant recipients (RT, 20 patients). In HD the blood was collected immediately before (HD D1) and after the dialysis (HD D2). In RT the blood was collected immediately before (RT D1) and 3-14 days after the transplantation (RT D2). The control group (Con) consisted of 50 healthy volunteers. Plasma concentrations of LPA and LPC were measured using enzyme-linked immunosorbent assays.

RESULTS

In CT, PD and RT D2 plasma concentrations of LPA were significantly higher, compared to Con. In HD, LPA levels did not differ compared to Con and they were significantly lower compared to PD (HD D1 and HD D2), RT D2 (HD D1 and HD D2) and CT (HD D1). However, in most of patients concentrations of LPA were within the range of reference values established in healthy volunteers. Concentrations of LPC were significantly lower in almost all patients subgroups, compared to Con, except in PD. There were no significant correlations between plasma concentrations of LPA and LPC in any of patients subgroups.

CONCLUSIONS

Presence of CKD is associated with increased plasma LPA levels and the hemodialysis therapy reduces this influence. However, only in a small percentage of patients with CKD, LPA concentrations are out of the reference range, which makes LPA not useful as a diagnostic marker for CKD. Further studies are needed to confirm and explain observed relationships.

End-stage renal disease treated in Provence-Alpes Côte d'Azur: 12-years follow-up and forecast to the year 2030

BACKGROUND

This study describes the time trend of renal replacement therapy for end-stage renal disease (ESRD) in the Provence-Alpes Côte d'Azur region (PACA) between 2004 and 2015, and forecasts up to 2030.

METHODS

A longitudinal study was conducted on all ESRD patients treated in PACA and recorded in the French Renal Epidemiology and Information Network (REIN) during this period. Time trends and forecasts to 2030 were analyzed using Poisson regression models.

RESULTS

Since 2004, the number of new patients has steadily increased by 3.4% per year (95% CI, 2.8-3.9, p < 0.001) and the number of patients receiving RRT has increased by 3.7% per year (RR 1.037, 95% CI: 1.034-1.039, p < 0.001). If these trends continue, the PACA region will be face with 7371 patients on dialysis and 3891 with a functional renal transplant who will need to be managed in 2030. The two most significant growth rates were the percentage of obese people (RR 1.140, 95% CI: 1.131-1.149, p < 0.001) and those with diabetes (RR 1.070, 95% CI; 1.064-1.075, p < 0.001).

CONCLUSION

This study highlights the increase in the number of ESRD patients over 12 years, with no prospect of stabilization. These findings allow us to anticipate the quality and quantity of care offered and to propose more preventive measures to combat obesity and diabetes.

Rate of bacteremia in the hemodialysis patient presenting to the emergency department with fever: a retrospective chart review

BACKGROUND

Infectious disease is the second most common cause of death in patients receiving hemodialysis (HD). When presenting to the emergency department (ED) with fever, it remains a diagnostic challenge to distinguish patients with potentially life-threatening bacterial infections from those with less significant causes of fever. The primary goal of this study was to determine the rate of bacteremia in HD patients presenting to the ED with fever. The secondary goal of this study was to identify any independent risk factors associated with bacteremia in the febrile HD patient.

METHODS

This is a retrospective medical record review of all HD patients who presented to the ED with either subjective fever as primary complaint or with a documented triage temperature of 38 °C or higher during the 3-year period between September 1, 2014, and September 1, 2017. Patient visits were included in the study if blood cultures were ordered in the ED. Data related to demographic information, clinical parameters, diagnostic test results in the ER, final diagnosis, and results of microbiology cultures were collected from each patient encounter. Univariate analysis was performed to identify risk factors associated with bacteremia.

RESULTS

We identified 353 patient visits from 138 unique patients that met inclusion criteria. Fifty-eight percent of these were women, and the average age was 54.6 years. The rate of bacteremia was 31.7%, and the main microorganisms isolated in blood culture were non-MRSA Staphylococcus aureus (40.7%), MRSA (13.3%), Pseudomonas aeruginosa (11.5%), and Enterobacter spp. (11.5%). Independent prognostic factors associated with bacteremia were use of dialysis catheter, prior history of bacteremia, and > 5% neutrophilic band cells (OR 6.55 [95% CI 3.96-10.8; p < 0.0001]; OR 8.87 [95% CI 5.32-14.8; p < 0.0001]; OR 3.32 [95% CI 1.90-5.80; p < 0.0001] respectively).

CONCLUSION

HD patients presenting to the ED with fever have high rates of bacteremia, with a significantly higher rate in patients using dialysis catheters or those with a history of bacteremia. Other clinical data available in the ED is minimally useful in predicting bacteremia.

Soluble Urokinase Plasminogen Activator Receptor (suPAR) and All-Cause and Cardiovascular Mortality in Diverse Hemodialysis Patients

Introduction

The soluble receptor of urokinase plasminogen activator (suPAR) is an innate immunity/inflammation biomarker predicting cardiovascular (CV) and non-CV events in various conditions, including type 2 diabetic patients on dialysis. However, the relationship between suPAR and clinical outcomes in the hemodialysis population at large has not been tested.

Methods

We measured plasma suPAR levels (R&D enzyme-linked immunosorbent assay [ELISA]) in 1038 hemodialysis patients with a follow-up of 2.9 years (interquartile range = 1.7−4.2) who were enrolled in the PROGREDIRE study, a cohort study involving 35 dialysis units in 2 regions in Southern Italy.

Results

suPAR was strongly (P < 0.001) and independently related to female gender (β = −0.160), age (β = 0.216), dialysis vintage (β = 0.264), CV comorbidities (β = 0.105), alkaline phosphatase (β = 0.136), albumin (β = −0.147), and body mass index (BMI; β = 0.174) (all P < 0.006). In fully adjusted analyses, suPAR tertiles predicted the risk of all-cause mortality (third tertile vs. first tertile hazard ratio (HR) = 1.91, 95% confidence interval (CI) = 1.47 – 2.48, P < 0.001), CV mortality (HR = 1.47, 95% CI = 1.03–2.09, P = 0.03), and non-CV mortality (HR = 1.94, 95% CI = 1.28–2.93, P = 0.002); these relationships were not modified by diabetes or other risk factors. suPAR added only modest prognostic risk discrimination and reclassification power for these outcomes to parsimonious models based on simple clinical variables.

Conclusion

In conclusion, suPAR robustly predicted all-cause and both CV and non-CV mortality in a large unselected hemodialysis population. Intervention studies are needed to definitively test the hypothesis that suPAR is causally implicated in clinical outcomes in this population.