Survival on renal replacement therapy in Europe: is there a 'centre effect'?

Religious coping methods predict depression and quality of life among end-stage renal disease patients undergoing hemodialysis: a cross-sectional study

BACKGROUND

Poor quality of life (QOL) and a high prevalence of depression have been identified among end-stage renal disease (ESRD) patients undergoing hemodialysis (HD). We aimed to evaluate the associations between religious/spiritual (R/S) coping methods and both QOL and depression among ESRD patients undergoing hemodialysis (HD).

METHODS

The sample included 161 ESRD patients over 18 years of age who had been undergoing HD for more than 3 months. R/S coping methods were assessed using the Religious Coping Questionnaire (RCOPE). The RCOPE generates scores (from 1 to 5) for positive and negative R/S coping methods. The higher the score, the more frequent the use of that coping method. Depression was evaluated using the 20-item version of the Center for Epidemiologic Studies Depression Scale (CES-D). Scores on the CES-D range from 0 to 60. A cutoff of 18 was used to define depression. QOL was evaluated using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36); this survey was used to generate scores for the eight dimensions of QOL, which can vary from 0 (worst) to 100 (best).

RESULTS

We identified a depression prevalence of 27.3%. Positive R/S coping scores were higher among non-depressed than depressed patients (2.98 vs. 2.77; p = 0.037). Positive R/S coping scores were negatively correlated with depression scores (r = -0.200; p = 0.012) and were an independent protective factor for depression (OR = 0.13; CI 95% = 0.02-0.91; p = 0.039). Regarding QOL, a positive correlation was identified between positive R/S coping scores and scores related to general health (r = 0.171; p = 0.030) and vitality (r = 0.183; p = 0.019), and an inverse correlation was identified between negative R/S coping scores and scores in the social functioning (r = -0.191; p = 0.015) and mental health (r = -0.214; p = 0.006) dimensions. In addition, positive R/S coping scores were an independent predictor of higher scores in the bodily pain (β = 14.401; p = 0.048) and vitality (β = 12.580; p = 0.022) dimensions. In contrast, negative R/S coping scores independently predicted lower social functioning scores (β = -21.158; p = 0.017).

CONCLUSIONS

Our results provide further evidence suggesting that R/S coping methods may be associated with QOL and depression among HD patients. In our opinion, the use of religious resources should be encouraged among HD patients, and psycho-spiritual interventions should be attempted to target religious struggles (negative R/S coping) in patients undergoing HD.

Emotion-oriented coping increases the risk of depression among caregivers of end-stage renal disease patients undergoing hemodialysis

PURPOSE

We investigated the possible association between coping style and depressive feelings among caregivers of end-stage renal disease patients undergoing hemodialysis.

METHODS

We studied 107 main caregivers of hemodialysis patients. Main caregiver was defined as the person on whom the patient counts for daily care or the one the patient calls upon in case of difficulties. Demographic data of caregivers and clinical data of patients were collected. The Jalowiec Coping Scale was applied to score two styles of coping: problem-oriented coping (POC) and emotion-oriented coping (EOC). Depression was screened by the 20-item version of the Center for Epidemiologic Studies Depression Scale (CES-D). A score ≥16 was used to classify depression. Comparisons were made by Student's t and Chi-square tests. The Pearson's test was used to assess correlation between scores. Linear and logistic regressions were used, respectively, to test variables as predictors of the CES-D scores and the presence of depression.

RESULTS

The depression rate among caregivers was 71.9%. In the comparison between depressed and non-depressed caregivers, only EOC score differed, being higher among depressed ones (69.8 vs. 62.4; p < 0.001). EOC score was positively correlated with depression score (r = 0.368; p = <0.001). In the multivariate analysis, EOC independently predicted both the depression score (b = 0.272; p = 0.001) and the presence of depression (OR 1.221; 95% CI 1.123-1.339; p = 0.001).

CONCLUSION

Our results indicate that EOC is associated with and increases the risk of depression among caregivers of HD patients. We propose that strategies aiming to strengthen POC and diminish EOC can be applied to minimize depressive feelings.

Risk factors for in-hospital mortality in patients starting hemodialysis

BACKGROUND

Incident hemodialysis patients have the highest mortality in the first several months after starting dialysis. This study evaluated the in-hospital mortality rate after hemodialysis initiation, as well as related risk factors.

METHODS

We examined in-hospital mortality and related factors in 2,692 patients starting incident hemodialysis. The study population included patients with acute kidney injury, acute exacerbation of chronic kidney disease, and chronic kidney disease. To determine the parameters associated with in-hospital mortality, patients who died in hospital (nonsurvivors) were compared with those who survived (survivors). Risk factors for in-hospital mortality were determined using logistic regression analysis.

RESULTS

Among all patients, 451 (16.8%) died during hospitalization. The highest risk factor for in-hospital mortality was cardiopulmonary resuscitation, followed by pneumonia, arrhythmia, hematologic malignancy, and acute kidney injury after bleeding. Albumin was not a risk factor for in-hospital mortality, whereas C-reactive protein was a risk factor. The use of vancomycin, inotropes, and a ventilator was associated with mortality, whereas elective hemodialysis with chronic kidney disease and statin use were associated with survival. The use of continuous renal replacement therapy was not associated with in-hospital mortality.

CONCLUSION

Incident hemodialysis patients had high in-hospital mortality. Cardiopulmonary resuscitation, infections such as pneumonia, and the use of inotropes and a ventilator was strong risk factors for in-hospital mortality. However, elective hemodialysis for chronic kidney disease was associated with survival.

High cardiovascular event rates occur within the first weeks of starting hemodialysis

Early mortality is high in hemodialysis (HD) patients, but little is known about early cardiovascular event (CVE) rates after HD initiation. To study this we analyzed data in the AROii cohort of incident HD patients from over 300 European Fresenius Medical Care dialysis centers. Weekly rates of a composite of CVEs during the first year and monthly rates of the composite and its constituents (coronary artery, cerebrovascular, peripheral arterial, congestive heart failure, and sudden cardiac death) during the first 2 years after HD initiation were assessed. Of 6308 patients that started dialysis within 7 days, 1449 patients experienced 2405 CVEs over the next 2 years. The first-year CVE rate (30.2/100 person-years; 95% CI, 28.7-31.7) greatly exceeded the second-year rate (19.4/100; 95% CI, 18.1-20.8). Composite CVEs were highest during the first week with increased risk compared with the second year, persisting until the fifth month. Except for sudden cardiac death, temporal patterns of rates for all CVE categories were very similar, with highest rates during the first month and a high-risk period extending to 4 months. Higher or lower cumulative weekly dialysis dose, lower blood flow, and lower net ultrafiltration during dialysis were associated with CVE during the high-risk period, but not during the post high-risk period. Thus, the incidence of CVE in the first weeks after HD initiation is much higher than during subsequent periods which raises concerns that HD initiation may trigger CVEs.

Volaemic status and dyspepsia in end-stage renal disease patients

AIM

Studies in animals show a relationship between extracellular volume and gastrointestinal motility. End-stage renal disease (ESRD) patients present fluid overload and frequent dyspeptic symptoms. We looked for an association between volaemic status and dyspepsia among ESRD patients undergoing haemodialysis (HD).

METHODS

We studied 155 ESRD patients on HD. Their volaemic status was evaluated using bioimpedance analysis. Fluid overload (FO) in litres and relative fluid overload (rFO) in percentage were calculated. rFO > 15% was classified as hypervolaemia. Dyspepsia was assessed through the Porto Alegre Dyspeptic Symptoms Questionnaire (PADYQ). PADYQ scores equal to or greater than 6 classified patients as dyspeptic. Characteristics of patients with and without dyspepsia were compared. Pearson's test was used to test the correlation between continuous variables. Multivariate linear and logistic regressions were performed to test FO as predictor of dyspepsia score and the presence of dyspepsia.

RESULTS

There were 64 (41.2%) patients with dyspepsia. Dyspeptics presented higher FO (2.5 ± 1.8 L vs 1.0 ± 1.8 L; P < 0.001) and higher rFO (16 ± 9.9% vs 4.8 ± 12.0%; P < 0.001). Dyspepsia score was positively correlated with FO (r = 0.300; P < 0.001) and with rFO (r = 0.256; P = 0.001). There were more patients with hypervolaemia among dyspeptics compared to non-dyspeptics (65.6% vs 17.6%; P < 0.001). FO was an independent predictor of dyspepsia score (b = 1.036; P < 0.001) and the presence of dyspepsia (OR = 2.00, 95% CI = 1.55-2.50; P < 0.001).

CONCLUSION

Hypervolaemia is associated with dyspepsia among ESRD patients on HD.

A population approach to renal replacement therapy epidemiology: lessons from the EVEREST study

The marked variation that exists in renal replacement therapy (RRT) epidemiology between countries and within countries requires careful systematic examination if the root causes are to be understood. While individual patient-level studies are undoubtedly important, there is a complementary role for more population-level, area-based studies--an aetiological approach. The EVEREST Study adopted such an approach, bringing RRT incidence rates, survival and modality mix together with macroeconomic factors, general population factors and renal service organizational factors for up to 46 countries. This review considers the background to EVEREST, its key results and then the main methodological lessons and their potential application to ongoing work.

Quality of life in children with end-stage renal disease based on a PedsQL ESRD module

BACKGROUND

Health-related quality of life (HRQOL) is an essential subject for children with end-stage renal disease (ESRD) and their families.

METHODS

We performed a cross-sectional investigation of HRQOL in children undergoing renal replacement therapies, such as dialysis and renal transplantation, using the 34-item Pediatric Quality of Life Inventory 3.0 End-Stage Renal Disease (PedsQL 3.0 ESRD) module. We assessed 92 ESRD patients aged 2-18 from four Korean university hospitals.

RESULTS

The male:female ratio was 44:48, and the most common cause of ESRD was chronic glomerulonephritis. Fifty-five children were treated by dialysis, and 37 received renal transplantation. Transplant patients had better HRQOL than dialysis patients in two domains in parent proxy reports: "About my kidney disease" and "Worry." In child self-reports, transplant patients had better HRQOL than dialysis patients in one domain: Treatment problems. However, there were no significant differences in total QOL scores between peritoneal dialysis (PD) and transplant patients in child self-reports. In addition, there were differences in the ESRD module scores between child self- and parent proxy reports. Children usually reported better QOL than their parents. Child self-reports showed significantly higher QOL scores than parent proxy reports in the domains of General fatigue, Family & peer interaction, and Worry. Children on PD self-reported a significantly higher QOL than children on hemodialysis (HD).

CONCLUSIONS

The PedsQL 3.0 ESRD module may be useful as an ESRD-specific instrument to evaluate HRQOL in children; however, a larger, longitudinal prospective study is warranted.

Distance between residence and the dialysis unit does not impact self-perceived outcomes in hemodialysis patients

Background

Patients have to travel long distances to undergo hemodialysis (HD) in some regions. We aimed to search for an association of the distance between patients’ residence and the dialysis unit with quality of life, depression and coping among end-stage renal disease (ESRD) patients undergoing maintenance HD.

Methods

We studied 161 ESRD patients undergoing HD during April 2009. Quality of life, depression and coping were assessed by the SF-36, the 10-item CES-D and the Jalowiec Coping Scale, respectively. The sample was stratified in three groups: I-patients residing in Sobral (where the dialysis unit is located); II-patients residing in towns up to 100 km from Sobral; and III-patients residing in towns distant greater than 100 km from Sobral. Analysis of variance was used to detect differences in quality of life and coping scores between the groups. Logistic regression was used to test distance as a predictor of depression.

Results

There were 47 (29.2%) patients residing in Sobral, 46 (28.6%) up to 100 km away and 68 (42.2%) greater than 100 km from Sobral. There were no differences related to quality of life and coping scores between the groups. Distance was not a predictor of depression.

Conclusions

Social and cultural factors may explain the lack of differences. Studies from other regions are needed to clarify the distance effects on self-perceived outcomes among HD patients.

Differences in quality of life of hemodialysis patients between dialysis centers

PURPOSE

Hemodialysis patients undergo frequent and long visits to the clinic to receive adequate dialysis treatment, medical guidance, and support. This may affect health-related quality of life (HRQOL). Although HRQOL is a very important management aspect in hemodialysis patients, there is a paucity of information on the differences in HRQOL between centers. We set out to assess the differences in HRQOL of hemodialysis patients between dialysis centers and explore which modifiable center characteristics could explain possible differences.

METHODS

This cross-sectional study evaluated 570 hemodialysis patients from 24 Dutch dialysis centers. HRQOL was measured with the Kidney Disease Quality Of Life-Short Form (KDQOL-SF).

RESULTS

After adjustment for differences in case-mix, three HRQOL domains differed between dialysis centers: the physical composite score (PCS, P = 0.01), quality of social interaction (P = 0.04), and dialysis staff encouragement (P = 0.001). These center differences had a range of 11-21 points on a scale of 0-100, depending on the domain. Two center characteristics showed a clinical relevant relation with patients' HRQOL: dieticians' fulltime-equivalent and the type of dialysis center.

CONCLUSION

This study showed that clinical relevant differences exist between dialysis centers in multiple HRQOL domains. This is especially remarkable as hemodialysis is a highly standardized therapy.

Evaluation of objective and subjective indicators of death in a period of one year in a sample of prevalent patients under regular hemodialysis

Background

To identify objective and subjective indicators of death in prevalent hemodialysis (HD) patients in a follow-up study of 12 months.

Methods

The study included end-stage renal disease patients undergoing HD and analyzed demographic and laboratory data from the dialysis unit's records. Baseline data concerning socioeconomic status, comorbidity, quality of life level, coping style and depression were also assessed. For variables that differed in the comparison between survivors and non-survivors, Cox proportional hazards for death were calculated.

Results

The mortality rate was 13.0%. Non-survivors differed in age, comorbidity, inclusion on the transplant waiting list and physical functioning score. The hazard ratios of death were 8.958 (2.843-28.223; p < 0.001) for comorbidity, 3.992 (1.462-10.902; p = 0.007) for not being on the transplant waiting list, 1.038 (1.012-1.066; p = 0.005) for age, and 0.980 (0.964-0.996; p = 0.014) for physical functioning.

Conclusions

Comorbidity, not being on the transplant waiting list, age and physical functioning, which reflects physical status, must be seen as risk indicators of death among patients undergoing HD.

Depression and quality of life of hemodialysis patients living in a poor region of Brazil

OBJECTIVE: To determine the correlation between depression and quality of life (QOL) of patients in hemodialysis (HD). METHOD: One hundred and sixty six patients over 18 years of age who had been in HD for at least three months and had no history of transplant. QOL was assessed using the SF-36. To categorize depression, a score > 10 was used on the 10-item version of the Center for Epidemiologic Studies Depression Scale (CES-D). Comparisons between depressed and nondepressed patients were performed using the chi-square test, Student's t-test, and Mann-Whitney test. Multiple regression was performed to assess the predictive variables of patients' QOL. RESULTS: Symptoms of depression were found in 13 (7.8%) patients. The only variable that differed among depressed patients was QOL. Depressed patients presented lower scores in vitality (40.7 vs. 57.3; p = 0.010), role-emotional (25.6 vs. 62.5; p = 0.006), and mental health (50.1 vs. 65.4; p = 0.023). Regression analysis demonstrated that depression was a predictor of role-emotional (OR = 0.981, CI = 0.967-0.996; p = 0.010) and mental health (OR = 0.970, CI = 0.946-0.996; p = 0.022). CONCLUSION: Depressed patients experience a poor QOL because, in addition to their chronically affected physical aspects, they also feel limited in the mental dimensions, which usually have the highest score among non-depressed HD patients.

Mortality risk in hemodialysis patients according to anemia control and erythropoietin dosing

There is no consensus about the toxicity of erythropoiesis-stimulating agents among hemodialysis patients. We aimed to calculate the risk of death according to anemia control and erythropoietin (EPO) dosing among end-stage renal disease patients undergoing hemodialysis. We retrospectively studied 156 end-stage renal disease patients on hemodialysis from a single renal unit during 12 months. Participants were classified according to anemia control into four groups: excellent (A), good (B), moderate (C) and bad (D) control. They were also classified according to EPO dosing into two groups: usual and high EPO dosing. The Cox proportional hazards regression model, adjusted for the difference in age, sex, time on dialysis, comorbidity, albumin, and Kt/V index, was performed to calculate the risk of death according to anemia control and EPO dosing profiles. Multivariate analysis by backward stepwise logistic regression was used to calculate the risk of death according to the variables that differed in the comparison between survivors and nonsurvivors. The hazard ratio of death was not significant according to anemia control profile C/D vs. A/B, but hazard ratio was 2.967 (95% confidence interval [CI] = 1.132-7.777; P = 0.027) for high EPO dosing profile patients. The multivariate analysis showed comorbidity (odds ratio [OR] = 8.958; 95% CI = 2.843-26.223; P < 0.001], high EPO dosing profile (OR = 5.172; 95% CI = 1.663-16,081; P = 0.005), age (OR = 1.056; 95% CI = 1.020-1.094; P = 0.002), and mean hemoglobin (OR = 0.435; 95% CI = 0.267-0.709; P = 0.001) to be predictive of death. Even though we cannot conclude that mortality risk is due to EPO toxicity, hemodialysis patients using high EPO dosing must be seen as at risk.

UK Renal Registry 13th Annual Report (December 2010): Chapter 4: comorbidities and current smoking status amongst patients starting renal replacement therapy in England, Wales and Northern Ireland from 2008 to 2009

INTRODUCTION

Comorbidity is an important determinant of survival for renal replacement therapy patients and impacts other care processes such as dialysis access creation and transplant wait-listing. The prevalence of comorbidities in incident patients on renal replacement therapy (RRT) changes with age and varies between ethnic groups. This study describes these associations and the independent effect of comorbidities on outcomes.

METHODS

Incident patients reported to the UK Renal Registry (UKRR) with comorbidity data in 2008 and 2009 (n = 5,617) were included in analyses exploring the association of comorbidity with patient demographics, treatment modality, haemoglobin and renal function at start of RRT. For analyses examining comorbidity and survival, adult patients starting RRT between 2004 and 2009 in centres reporting to the UKRR with comorbidity data (n = 16,527) were included. The relationship between comorbidities and mortality at 90 days and one year after 90 days from start of RRT was explored using Cox regression.

RESULTS

Completeness of comorbidity data was 44.4% in 2009 compared with 52.1% in 2004. Of patients with data, 56.5% had one or more comorbidities. Diabetes mellitus and ischaemic heart disease were the most common conditions seen in 32.9% and 22.5% of patients respectively. Current smoking was recorded for 12.4% of incident RRT patients in the 2-year period. The presence of comorbidities in patients <75 years became more common with increasing age in all ethnic groups. In multivariable survival analysis, malignancy and the presence of ischaemic/neuropathic ulcers were the strongest independent predictors of poor survival at 1 year after 90 days from the start of RRT in patients <65 years.

CONCLUSION

Differences in prevalence rates of comorbid illnesses in incident RRT patients may reflect variation in access to health care or competing risk prior to commencing treatment. The interpretation of analyses continues to be limited by poor data completeness.

Profile of Hospitalisation and Death in the First Year after Diagnosis of End-stage Renal Disease in a Multi-ethnic Asian Population

Introduction: The increasing prevalence of end-stage renal disease (ESRD) is an important public health issue due to the high costs of kidney replacement therapies. We examined the impact of ethnicity and other factors in ESRD management and hospitalisation in a multiracial Asian population in the first year after diagnosis. Materials and Methods: We analysed a prospectively collected database of 168 new ESRD patients from the National University Hospital, Singapore (NUH) in 2005. Univariate and multivariate analyses were performed to assess factors for mortality and hospitalisation. Results: Sixteen patients eventually chose conservative treatment, 102 haemodialysis, 41 peritoneal dialysis and 9 patients underwent kidney transplantation for their long-term treatment. Although more Chinese patients had dialysis plans (56.7% vs 36.8%, P = 0.022), many still required urgent dialysis initiation via catheters (61.3%). These dialysed patients who required urgent treatment had more admissions (3.6 vs 2.6, P = 0.023) and longer length of stay (9.3 days, P = 0.014). Approximately 40 (7.4%) admissions were related to vascular access complications (thromboses, dislodgements and infections), and 15 (2.8%) were for new tunnelled catheter insertions. Deaths were 23.8% in the first year after diagnosis and median survival was 125 days. Age, final treatment modality, type of therapy centre, history of coronary artery disease, left ventricular ejection fraction (LVEF) <50%, and having no plans for dialysis were associated with mortality. Conclusions: The care of ESRD patients requires substantial commitment of healthcare resources particularly in the first year after diagnosis. Steps to reduce urgent initiation of dialysis will help reduce resource utilisation and improve patient outcomes. Key words: Dialysis, Kidney failure, Palliation

Impact of Stratification of Comorbidities on Nutrition Indices and Survival in Patients on Continuous Ambulatory Peritoneal Dialysis

Background

Case-mix comorbidities and malnutrition influence outcome in continuous ambulatory peritoneal dialysis (CAPD) patients. In the present study, we analyzed the influence of stratified comorbidities on nutrition indices and survival in CAPD patients.

Patients and Methods

We categorized 373 CAPD patients (197 with and 176 without diabetes) into three risk groups: low—age under 70 years and no comorbid illness; medium—age 70 – 80 years, or any age with 1 comorbid illness, or age under 70 years with diabetes; high—age over 80 years, or any age with 2 comorbid illnesses. We then compared nutrition indices and malnutrition by subjective global assessment (SGA) between the three groups. Survival was compared using Kaplan–Meier survival analysis.

Results

Mean daily calorie and protein intakes in the low-risk group (21 ± 6.7 Kcal/kg, 0.85 ± 0.28 g/kg) were significantly higher than in the medium- (17.6 ± 5.2 Kcal/kg, 0.79 ± 0.25 g/kg) and high-risk (17.5 ± 6.1 Kcal/kg, 0.78 ± 0.26 g/kg) groups ( p = 0.001 and p = 0.04 respectively). Relative risk (RR) of malnutrition was less in the low-risk group (103/147, 70.06%) than in the medium-risk group [135/162, 83.3%; RR: 2.0; 95% confidence interval (CI): 2.1 to 3.4; p = 0.01] or the high-risk group (54/64, 84.4%; RR: 2.3; 95% CI: 2.1 to 4.9; p = 0.03). Mean survivals of patients in the low-, medium-, and high-risk groups were 51 patient–months (95% CI: 45.6 to 56.4 patient–months), 43.3 patient–months (95% CI: 37.8 to 48.7 patient–months), and 29.7 patient–months (95% CI: 23 to 36.4 patient–months) respectively (log-rank: 35.9 patient–months; p = 0.001). The 1-, 2-, 3-, 4-, and 5-year patient survivals in the low-, medium-, and high-risk groups were 96%, 87%, 79%, 65%, and 56%; 89%, 67%, 54%, 43%, and 34%; and 76%, 48%, 31%, 30%, and 30% respectively.

Conclusions

Intake of calories and protein was significantly lower in the medium-risk and high-risk groups than in the low-risk group. Survival was significantly better in low-risk patients than in medium- and high-risk patients.

Predictors of quality of life among patients on dialysis in southern Brazil

CONTEXT AND OBJECTIVE

Quality of life (QoL) is considered important as an outcome measurement, especially for long-term diseases such as chronic renal failure. The present study searched for predictors of QoL in a sample of patients undergoing dialysis in southern Brazil.

DESIGN AND SETTING

This was a cross-sectional study developed in three southern Brazilian dialysis facilities.

METHODS

Health-related QoL of patients on hemodialysis or peritoneal dialysis was measured using the generic Short Form-36 (SF-36) health survey questionnaire. The results were correlated with sociodemographic, clinical and laboratory variables. The analysis was adjusted through multiple linear regression.

RESULTS

A total of 140 patients were assessed: 94 on hemodialysis and 46 on peritoneal dialysis. The mean age was 54.2 +/- 15.4 years, 48% were men and 76% were white. The predictors of higher (better) physical component summary in SF-36 were: younger age (beta-0.16; 95% confidence interval, CI: -0.27 to -0.05), shorter time on dialysis (beta-0.06; 95% CI: -0.09 to -0.02) and lower Khan comorbidity-age index (beta 5.16; 95% CI: 1.7-8.6). The predictors of higher mental component summary were: being employed (beta 8.4; 95% CI: 1.7-15.1), being married or having a marriage-like relationship (beta 4.56; 95% CI: 0.9-8.2), being on peritoneal dialysis (beta 4.9; 95% CI: 0.9-8.8) and not having high blood pressure (beta 3.9; 95% CI: 0.3-7.6).

CONCLUSIONS

Age, comorbidity and length of time on dialysis were the main predictors of physical QoL, whereas socioeconomic issues especially determined mental QoL.

Risk Stratification of the Peritoneal Dialysis Patient—a Single-Center Experience

⋄ Background

Peritoneal dialysis (PD) patients have many risk factors that may affect their clinical outcomes. Age and diabetes status are unequally distributed in the dialysis population of Singapore. Risk stratification is a means of reducing the effects of case mix such that high-risk groups in the dialysis population can be identified.

⋄ Patients and Methods

Records for 543 patients who started on chronic dialysis during 2002 – 2005 were retrospectively studied for survival in the first year on dialysis. The age, sex, ethnicity, and diabetes status of the patients were noted.

⋄ Results

For patients 60 years of age and older, we observed no differences in the prevalences of diabetes, male sex, or Chinese ethnicity between patients on PD and those on hemodialysis (HD). Patients of Chinese ethnicity on PD were found to have a higher likelihood of survival in the first year as compared with patients on HD. Age, sex, and diabetes status were not associated with survival in the first year.

⋄ Conclusions

In a single PD treatment center, Chinese ethnicity conferred a survival advantage in the first year on dialysis. The reasons for that finding are not clear, but they were not related to age, diabetes status, or sex.

Diabetes, glycaemic control and mortality risk in patients on haemodialysis: the Japan Dialysis Outcomes and Practice Pattern Study

AIMS/HYPOTHESIS

There are few data on the target level of glycaemic control among patients with diabetes on haemodialysis. We investigated the impact of glycaemic control on mortality risk among diabetic patients on haemodialysis.

SUBJECTS AND METHODS

Data were analysed from the Dialysis Outcomes Practice Pattern Study (DOPPS) for randomly selected patients on haemodialysis in Japan. The diagnosis of diabetes at baseline and information on clinical events during follow-up were abstracted from the medical records. A Cox proportional hazards model was used to evaluate the association between presence or absence of diabetes, glycaemic control (HbA(1c) quintiles) and mortality risk.

RESULTS

Data from 1,569 patients with and 3,342 patients without diabetes on haemodialysis were analysed. Among patients on haemodialysis, those with diabetes had a higher mortality risk than those without (multivariable hazard ratio 1.37, 95% CI 1.08-1.74). Compared with those in the bottom quintile of HbA(1c) level, the multivariable-adjusted hazard ratio for mortality was not increased in the bottom second to fourth quintiles of HbA(1c) (HbA(1c) 5.0-5.5% to 6.2-7.2%), but was significantly increased to 2.36 (95% CI 1.02-5.47) in the fifth quintile (HbA(1c) > or = 7.3%). The effect of poor glycaemic control did not statistically correlate with baseline mortality risk (p = 0.27).

CONCLUSIONS/INTERPRETATION

Among dialysis patients, poorer glycaemic control in those with diabetes was associated with higher mortality risk. This suggests a strong effect of poor glycaemic control above an HbA(1c) level of about 7.3% on mortality risk, and that this effect does not appear to be influenced by baseline comorbidity status.

Lack of a centre effect in UK renal units: application of an artificial neural network model

BACKGROUND

Dialysis centre effect has been suggested to influence survival in end-stage renal disease (ESRD) patients. Few studies over the past decade have commented on the existence of the centre effect using logistic regression models.

METHODS

We used high quality prospectively collected data from the UK Renal Registry (UKRR) and created an artificial neural network model to predict mortality within 1 year in this cohort. We used a multitude of demographic variables including co-morbodities as well as relevant laboratory data to create a prognostic model.

RESULTS

A highly efficient model for predicting 1 year mortality was created after restricting the model to use demographic and case-enriched data [area under the receiver operating characteristic curve (AUROC) = 0.974]. The addition of the dialysis centre code and centre size as input variables did not add to the efficiency of the model (AUROC = 0.962). Moreover, dialysis centre code or size alone was not predictive of mortality when applied to an artificial neuronal network architecture (AUROC = 0.649 and 0.628).

CONCLUSION

Residual effects in previous studies may have been due to the non-linear nature of the data and complex intervariable relationships. Centre size and other centre-related factors have no impact on survival on ESRD.

Comparing costing results in across country economic evaluations: the use of technology specific purchasing power parities

The number of economic evaluations conducted on a multinational basis is increasing. Therefore, techniques are required to compare the results of such studies in a meaningful manner. This paper explores different approaches to comparing across country cost data applied to a European study of dialysis therapy for end-stage renal disease. A price and volume index is created at the level of the individual health care technology and compared to an exchange rate conversion and published purchasing power parities (PPPs). Both exchange rate and PPP conversions when published rates are used fail to accurately reflect the true resource use of the applied health care example. These differences can be related to specific issues of input mix and price variation. Alternatively, the use of technology specific PPPs provided a more robust approach for international comparisons and also have the potential for use in multi-centre economic evaluations within the same country.

Octogenarians reaching end-stage renal disease: cohort study of decision-making and clinical outcomes

The fate of octogenarians reaching end-stage renal disease (ESRD) is poorly defined, and implicit dialysis rationing may be practiced in this age group. The main objectives of this study were to analyze the characteristics of pre-ESRD octogenarians offered dialysis or not and to identify factors influencing mortality while on dialysis, to improve prognosis assessment and decision-making. In this single-center cohort, 146 consecutive pre-ESRD octogenarians were referred to a nephrology unit over a 12-yr period (1989 to 2000). Main outcome measures were baseline characteristics of patients offered dialysis and conservative therapy and overall and 1-yr survival according to effective treatment. A therapeutic decision was made for 144 patients. Octogenarians who were not proposed dialysis (n = 37) differed from those who were proposed dialysis (n = 107) mainly in terms of social isolation (43.3% versus 14.7%; P = 0.03), late nephrologic referral (51.4% versus 28.9%; P = 0.01), Karnofsky score (55 +/- 18 versus 63 +/- 20; P = 0.03), and diabetic status (22.2% versus 6.5%, P = 0.008). Six patients refused the dialysis proposal. During the 12-yr observation period, 99 patients died (68.7%). Median survival was 28.9 mo (95% CI, 24 to 38) in patients undergoing dialysis, compared with 8.9 mo (95% CI, 4 to 10) in patients treated conservatively (P < 0.0001). In multivariable piecewise Cox analysis, independent predictors of death within 1 yr on dialysis were poor nutritional status, late referral, and functional dependence. Included in a survivor function, these covariates predict groups with low and high 1-yr mortality risk. Beyond 1 yr on dialysis, the only independent predictor of death was the presence of peripheral vascular disease. It is concluded that beside a patient's individual refusal, late referral, social isolation, low functional capacity, and diabetes may have oriented medical decision toward withholding dialysis in a significant proportion of pre-ESRD octogenarians. Although most patients on dialysis experienced a substantial prolongation of life, identification of mortality predictors in this age group should improve the process of decision-making regarding the expected benefit of renal replacement therapy.

Adjustment for comorbidity in studies on health status in ESRD patients: which comorbidity index to use?

Health status can be an important outcome in studies on patients with end-stage renal disease (ESRD). In these studies, adjustment for prognostic factors, such as comorbidity, often has to be made. None of the comorbidity indices that are commonly used in research on ESRD patients has been validated for studies on health status. This study evaluated three existing indices (Khan, Davies, and Charlson) and four indices specifically developed for use in studies on health status. In a large prospective multi-center study (NECOSAD-2), new ESRD patients were included (n = 1041). Comorbidity was assessed at the start of dialysis. Health status was assessed with the physical and mental component summary score of the SF-36 (PCS and MCS), the symptoms dimension of the KDQOL-SF, and the Karnofsky Scale. Patient data were randomly allocated to a modeling or a testing set. The new indices were developed in the modeling set. The three existing indices explained about the same percentage of variance in the PCS (7 to 8%), MCS (1 to 3%), symptoms (2 to 4%), and Karnofsky (10 to 12%). The new indices performed better than the existing indices in the modeling population (13% PCS, 10% MCS, 10% symptoms, 18% Karnofsky), but not in the testing population (8% PCS, 1% MCS, 3% symptoms, 8% Karnofsky). Individual comorbidities explained more variance in PCS (10 to 15%), MCS (1 to 7%), symptoms (6 to 11%), and Karnofsky (11 to 18%) than comorbidity indices. The Khan, Davies, and the Charlson indices will adjust to the same extent for the potential confounding effect of comorbidity in studies with health status as an outcome. Separate comorbidity diagnoses will adjust best for comorbidity.

Improving survival of octogenarian patients selected for haemodialysis

BACKGROUND

The incidence of end-stage renal disease (ESRD) among patients over the age of 80 has nearly tripled in the last decade, making the 'old-old' the fastest growing ESRD demographic group. Despite this, very little information is available on the characteristics and survival of patients who initiate haemodialysis (HD) after reaching this age.

METHODS

We performed a retrospective study on all patients who entered an outpatient HD programme after the age of 80, from January 1988 to September 1998. A total of 106 charts were reviewed from a single nephrology practice group. Eleven patients were excluded due to incomplete data. The survival probability was calculated using the Kaplan-Meier method.

RESULTS

The characteristics of 95 patients were as follows: mean age at initiation of dialysis, 83.7 years; female, 50.5%; Caucasian, 40.0%, African-American, 30.0%; Hispanic, 10.0%; Asian, 4.3%; polytetrafluorethylene grafts, 80.0%; primary fistulas, 5.6%; tunnelled catheters, 5.6%; mean established Kt/V, 1.68; urea reduction ratio (URR), 0.74; estimated dry weight (EDW), 60.3 kg. ESRD was attributed to hypertension in 37%, diabetes in 22% and analgesic use in 8%. The 1-, 2- and 5-year survival probability of the entire group was 82.6+/-4.0%, 64.0+/-5.6%, and 19.6+/-6.0%, respectively. The median survival was 29 months. When comparing survival probability of patients who were in the highest quartiles of URR and EDW to those in the lowest quartile there was no discernible difference. However, the 2-year survival probability of patients initiated after January 1, 1995 (76.9+/-8.4) was significantly better than those initiated from 1988-1994 (47.8+/-6.5; P<0.05).

CONCLUSIONS

From analysis of this cohort, we conclude that: (i) elderly patients selected for outpatient HD programmes have substantially better survival than previously reported; (ii) Kt/V does not correlate with survival in this demographic group; and (iii) contemporary dialysis practice is associated with better likelihood of survival of elderly patients in outpatient HD programmes.

Evaluation of clinical guidelines for the management of end-stage renal disease in europe: the EU BIOMED 1 study

BACKGROUND

There are wide national and international variations in the management of patients with end-stage renal disease (ESRD). The aim of this study was to develop, harmonize, implement, and evaluate consensus-based clinical guidelines for the management of renal anaemia and renal bone disease in patients with ESRD, and for the prevention and management of cytomegalovirus disease in renal transplant recipients across six renal centres in Europe.

METHODS

The trial was a prospective, multicentre, randomized balanced incomplete block design. Nephrologists from the six European renal units were randomized to develop and implement guidelines for two out of the three conditions and to act as a control for the third condition. Data were collected pre- (1 year) and post- (9 months) intervention on aspects of patient monitoring, management, and outcome.

RESULTS

Eight hundred and twenty-nine dialysis patients from the six European dialysis centres were included in the study. Multivariate analysis (adjusting for case-mix and secular trends) showed a significant increase in the number of monitoring events in the guideline group compared with control group (6%, 95% CI, 1-11%). There was no concomitant increase in either appropriate management or the number of favourable patient outcomes.

CONCLUSIONS

In the first European collaboration on renal guidelines, the introduction of the guidelines improved the monitoring of the patients, but did not improve patient management or outcome. This study suggests the potential for creating clinical guidelines with the aim of standardizing treatment protocols across international boundaries, and improving the quality of the medical care provided.

Using renal transplantation to evaluate a simple approach for predicting the impact of end-stage renal disease therapies on patient survival: observed/expected life span

The effectiveness of therapy for a chronic disease can be assessed by evaluating the length of time that a patient survives after receiving treatment. We used a novel means for measuring the effectiveness of renal replacement therapy for patients with end-stage renal disease (ESRD): the ratio of observed life span divided by expected life span. This ratio incorporated observed life span for patients from the time of ESRD and expected life span based on state-specific life-table analyses. A total of 3,782 individuals with ESRD were analyzed (average follow-up, 14.2 +/- 4.9 years); 3, 192 patients in that group received a kidney transplant at some point during their course of ESRD. For each patient, we determined a curve of observed/expected life span. Separate patient groups were analyzed to determine the median population observed/expected life span or the percentage of patients who reached 0.5 observed/expected life span. Younger transplant recipients (<21 years) had a median observed/expected life span of 67%, significantly greater than the median observed/expected life span for those aged 21 to 40 years (49%; P = 0.01) and 41 to 60 years (47%; P = 0.01). Surprisingly, 57% of the patients aged older than 60 years reached their median observed/expected life span (P = 0.02 versus <21 years; P = not significant against all others). A Cox proportional hazards model identified era of immunosuppression (hazards ratio, 0.32) and atherosclerotic vascular disease-related ESRD (hazards ratio, 2.07) as significant variables influencing patient survival and observed/expected life span. This simple ratio is easy to use and may be a helpful tool for assessing the survival benefits of risk-factor modifications and therapeutic advances in transplantation and ESRD care.

A comparison of the effects of dialysis and renal transplantation on the survival of older uremic patients

BACKGROUND

Patients over age 60 constitute half of all new patients accepted into the renal replacement therapy programs in Australia. However, the optimal treatment of their end-stage renal disease remains controversial. The aim of the present study was to compare survival for dialysis and renal transplantation in older patients who were rigorously screened and considered eligible for transplantation.

METHODS

The study cohort consisted of 174 consecutive patients over 60 who were accepted on to the Queensland cadaveric renal transplant waiting list between January 1, 1993 and December 31, 1997. Follow-up was terminated on October 1, 1998. Data were analyzed on an intention-to-transplant basis using a Cox regression model with time-varying explanatory variables. An alternative survival analysis was also performed, in which patients no longer considered suitable for transplantation were censored at the time of their removal from the waiting list.

RESULTS

There were 67 patients receiving a renal transplant, whereas the other 107 continued to undergo dialysis. These two groups were well matched at baseline with respect to age, gender, body mass index, renal disease etiology, comorbid illnesses, and dialysis duration and modality. The overall mortality rate was 0.096 per patient-year (0.131 for dialysis and 0.029 for transplant, P<0.001). Respective 1-, 3- and 5-year survivals were 92%, 62%, and 27% for the dialysis group and 98%, 95%, and 90% (P<0.01) for the transplant group. Patients in the transplant group had an adjusted hazard ratio 0.16 times that of the dialysis group (95% confidence interval 0.06-0.42). If patients were censored at the time of their withdrawal from the transplant waiting list, the adjusted hazard ratio was 0.24 (95% confidence interval 0.09-0.69).

CONCLUSIONS

Renal transplantation seems to confer a substantial survival advantage over dialysis in patients with end-stage renal failure who are rigorously screened and considered suitable for renal transplantation.

An evaluation of an integrative care approach for end-stage renal disease patients

Studies analyzing the outcome of integrative care of end-stage renal disease (ESRD) patients, whereby patients are transferred from one renal replacement modality to another according to individual needs, are scant. In this study, we analyzed 417 files of 223 hemodialysis (HD) and 194 peritoneal dialysis (PD) patients starting renal replacement therapy between 1979 and 1996, to evaluate the effect of such an approach. Analysis was done for survival of patients on their first modality, for intention-to-treat survival (counting total time on renal replacement therapy, but with exclusion of time on transplantation), and for total survival. Log rank analysis was used and correction for risk factors was performed by Cox proportional hazards regression. Intention-to-treat survival and total survival were not different between PD and HD patients (log rank, P > 0.05). Technique success was higher in HD patients compared to PD patients (log rank, P = 0.01), with a success rate after 3 yr of 61 and 48%, respectively. Thirty-five patients were transferred from HD to PD and 32 from PD to HD. Transfer of PD patients to HD was accompanied by an increase in survival compared to those remaining on PD (log rank, P = 0.001), whereas, in contrast, transfer of patients from HD to PD was not (log rank, P = 0.17). Survival of patients remaining more than 48 mo on their initial modality was lower for PD patients (log rank, P < 0.01). A matched-pair analysis between patients who started on PD and who were transferred to HD later (by definition called integrative care patients), and patients who started and remained on HD, showed a survival advantage for the integrative care patients. These results indicate that patient outcome is not jeopardized by starting patients on PD, at least if patients are transferred in a timely manner to HD when PD-related problems arise.

Predictors of poor outcome in chronic dialysis patients: The Netherlands Cooperative Study on the Adequacy of Dialysis. The NECOSAD Study Group

In a prospective cohort study, we constructed a composite index of poor outcome that incorporates survival, morbidity, and quality of life (QL). We identified baseline patient and treatment characteristics that predicted poor outcome 1 year after the start of chronic dialysis. Outcome was classified as poor if a patient had died or if at least two of the following criteria were present: (1) 30 days or greater of hospitalization per year, (2) serum albumin level of 30 g/L or less or a malnutrition index score of 11 or greater, (3) a 36-item Medical Outcomes Study (MOS)-Short Form Health Survey Questionnaire (SF-36) physical summary QL score of 2 or more SDs less than the general population mean score, and (4) an SF-36 mental summary QL score of 2 or more SDs less than the general population mean score. Multivariate logistic regression analysis was used to identify independent predictors of poor outcome. Of 250 included patients, 189 were assessable with respect to poor outcome. Of these patients, 47 (25%) were classified as poor. A baseline presence of comorbidity, serum albumin level of 30 g/L or less, physical or mental QL score 2 or more SDs less than the general population mean score, and, to a lesser extent, residual glomerular filtration rate of 2.5 mL/min/1.73 m(2) or less were independently associated with a greater risk for poor outcome. A post hoc analysis indicated a mean arterial blood pressure greater than 107 mm Hg was predictive of poor outcome in patients undergoing peritoneal dialysis. In conclusion, our prognostic model provides a useful tool to identify chronic dialysis patients at risk for poor health status. Strategies aimed at preserving residual renal function, controlling blood pressure, monitoring QL, and consequently giving psychosocial support may reduce the risk for poor outcome.

Dialysis in The Netherlands: the clinical condition of new patients put into a European perspective. NECOSAD Study Group. Netherlands Cooperative Study on the Adequacy of Dialysis phase 1

BACKGROUND

The unadjusted annual mortality rate among prevalent Dutch dialysis patients increased from 1981 to 1992. Part of this increase may be attributed to the ageing of the dialysis population, but hardly any data were available on other important prognostic features of new Dutch dialysis patients, such as co-morbidity and other aspects of their clinical condition. The aim of the present study was to obtain these data and to put them into a European perspective.

METHODS

Two hundred and fifty consecutive new patients were included in this prospective multi-centre study. Data were collected 3 months after start of dialysis. Multivariate linear regression analysis was used to explain the variability of parameters of nutritional state and blood pressure.

RESULTS

Mean age was 57 years, co-morbid conditions were present in 51%, diabetes mellitus in 18%, and cardiovascular disease in 28%. Decreased protein intake was related to diminished residual renal function. Our patients did not have more co-morbidity than Dutch patients participating in a European study some years earlier. Comparison with other studies was complicated by the use of different definitions of co-morbidity and of selected patient populations.

CONCLUSIONS

Despite the fact that Dutch dialysis patients have become older and the incidence of diabetic nephropathy has increased, no conclusions could be drawn on a concomitant increase in co-morbidity. This patient group may serve as a reference population to study future changes in patient case-mix within the Netherlands. Furthermore, the use of common international definitions of co-morbidity is needed to be able to make comparisons of survival data.

The effect of age, diabetes, and other comorbidity on the survival of patients on dialysis: a systematic quantitative overview of the literature

BACKGROUND

The UK Renal Registry quotes a 1-year death rate for patients established on dialysis of 19.4 per 100 patient years. Clinical experience, reflected in the UK Renal Association Standards Document (RASD), recognizes qualitatively that age, diabetes, and other comorbidities increase the risk of death. The aim of this paper is to provide quantitative estimates of the relative risk of death associated with particular patient characteristics.

METHODS

Quantitative techniques were used to estimate relative risk of death in the seven studies quoted in the RASD document and 17 other papers identified in a systematic literature search. Relative risk data from each study were pooled using a fixed effects model (f). A random effects model (r) was applied to pool relative risks if heterogeneity was found to exist between studies. A meta-regression analysis was also carried out to investigate whether study covariates substantially explained the heterogeneity between studies.

RESULTS

Pooling the papers identified in the systematic literature search with those from the RASD gave rise to a relative risk of death of 1.029 (95% CI 1.013-1.045) (r) associated with each year's increase in age. The relative risk associated with the presence of diabetes was 1.91 (95% CI 1.67-2.17) (r), whilst that associated with heart disease was 1.59 (95% CI 1.49-1.69) (f), and with peripheral vascular disease 1.58 (95% CI 1.29-1.93) (r). Heterogeneity was found in the estimates of risk associated with age, diabetes, and peripheral vascular disease. Important study covariates included the use of incident or prevalent cases, the use of routine data sources or data collected specifically for a particular study, the country in which the study was located, the use of a P value to infer the standard error of a relative risk estimate in a particular study, and the method of classifying diabetes.

CONCLUSIONS

Published studies can be used to quantify the relative risk of death for dialysis patients with various comorbidities. This information is important if attempts are to be made to set standards for the performance of dialysis units, and to compare the performance of one dialysis unit with that of another.

Quality of life over time in dialysis: the Netherlands Cooperative Study on the Adequacy of Dialysis. NECOSAD Study Group

BACKGROUND

Information on the longitudinal quality of life (QL) of patients treated by different dialysis modalities is lacking. Therefore, we performed a prospective cohort study on the QL over time in hemodialysis (HD) and peritoneal dialysis (PD) patients.

METHODS

New chronic dialysis patients from 13 Dutch dialysis centers were consecutively included. The patients' self-assessment of QL was measured with the SF-36 form at 3, 6, 12, and 18 months after the start of dialysis treatment.

RESULTS

Out of 230 patients who completed the QL questionnaire at least once, 139 patients stayed on their initial dialysis modality, 26 patients switched dialysis modality, 35 patients were transplanted, 28 patients died, and two patients had a recovery of renal function. The QL of patients who died during the study period was considerably worse at baseline and worsened at a faster rate than in the other patient groups. In patients who stayed on their initial dialysis modality, the physical QL decreased over time, whereas the mental QL tended to remain stable. After an adjustment for the initial value of QL and comorbidity, a consistently favorable effect of HD on physical QL over time was found compared with PD, whereas mental QL values remained similar. Parameters of adequacy of dialysis were not associated with QL over time.

CONCLUSION

This prospective cohort study shows that physical QL over time in HD patients is better than in PD patients.

Mortality and technique failure in patients starting chronic peritoneal dialysis: results of The Netherlands Cooperative Study on the Adequacy of Dialysis. NECOSAD Study Group

BACKGROUND

Recent studies have shown an association between small solute clearance and patient survival. Thus far, little attention has been paid to the potential effects of fluid overload. The aim of this study was to determine the relative importance of baseline patient and treatment characteristics to mortality and technique failure in patients starting peritoneal dialysis.

METHODS

One hundred and eighteen consecutive new patients were included in this prospective multicenter cohort study. Cox proportional hazards regression was used to predict mortality and technique failure.

RESULTS

There were 33 deaths and 44 technique failures. The two-year patient survival was 77%, and the two-year technique survival was 64%. Age, systolic blood pressure, and the absolute quantity of small solutes removed at baseline were independent predictors of mortality. A one-year increase in age was associated with a relative risk (RR) of death of 1.05 (95% CI, 1.01 to 1.09) and a 10 mm Hg rise in systolic blood pressure, with a RR of 1.42 (95% CI, 1.17 to 1.73). The removal of 1 mmol/week/1.73 m2 of urinary and dialysate creatinine was associated with a RR of death of 0.95 (95% CI, 0.92 to 0.98) and 0.93 (95% CI, 0.89 to 0.98). The removal of urea had a similar association with the RR of death. Predictors for technique failure were urine volume, peritoneal ultrafiltration, and systolic blood pressure.

CONCLUSIONS

Dialysate solute removal was an independent predictor of mortality. The association between systolic blood pressure and mortality shows that the maintenance of fluid balance and the removal of small solutes deserve equal attention.

Haemodialysis

This paper charts the development of haemodialysis, the cornerstone of renal replacement therapy (RRT). It has enabled patients with end-stage renal failure to survive for years, in many cases with a surprisingly good quality of life. Through technological advances, RRT can be offered to patients who are older and more frail. Many have intercurrent comorbid illness. Such patients can have good quality of life, but their survival is shorter since they are likely to succumb early to comorbid illnesses. The challenge to nephrologists is to provide treatment based on exacting standards for all those patients who can benefit, yet to maintain cost-effectiveness. There is increasing recognition that, however good the technology underpinning dialysis, what justifies the cost and commitment that dialysis entails is the provision for the patient of a satisfactory quality of life.