Canadian survey of clinical status at dialysis initiation 1998-1999: a multicenter prospective survey

AIMS

The current growth in end-stage kidney disease populations has led to increased efforts to understand the impact of status at dialysis initiation on long-term outcomes. Our main objective was to improve the understanding of current Canadian nephrology practice between October 1998 and December 1999.

METHODS

Fifteen nephrology centers in 7 provinces participated in a prospective data collection survey. The main outcome of interest was the clinical status at dialysis initiation determined by: residual kidney function, preparedness for chronic dialysis as measured by presence or absence of permanent peritoneal or hemodialysis access, hemoglobin and serum albumin. Uremic symptoms at dialysis initiation were also recorded, however, in some cases these symptom data were obtained retrospectively.

RESULTS

Data on 251 patients during 1-month periods were collected. Patients commenced dialysis at mean calculated creatinine clearance levels of approximately 10 ml/min, with an average of 3 symptoms. 35% of patients starting dialysis had been known to nephrologists for less than 3 months. These patients are more likely to commence without permanent access and with lower hemoglobin and albumin levels. Even of those known to nephrologists, only 66% had permanent access in place.

CONCLUSIONS

Patients commencing dialysis in Canada appear to be doing so in relative concordance with published guidelines with respect to timing of initiation. Despite an increased awareness of kidney disease, a substantial number of patients continues to commence dialysis without previous care by a nephrologist. Of those who are seen by nephrologists, clinical and laboratory parameters are suboptimal according to current guidelines. This survey serves as an important baseline for future comparisons after the implementation of educational strategies for referring physicians and nephrologists.

Lack of early acute rejection does not predict safe tapering of immunosuppression

In an effort to reduce long-term complications of immunosuppressive medications, some investigators have devised protocols of reduced dosage [Kupin et al. 1988, Kelly et al. 1989, Reinsmoen et al. 1993] which are intended to maintain the stability of the transplant and at the same time prevent or retard immunosuppressive medication side effects. Implicit in this plan is the assumption that there has been the development of some degree of graft acceptance [Koene 1989] and/or tolerance [Goulmy et al. 1985, Muluk et al. 1991], yet it is also true that drug non-compliance is a common cause of late acute rejection and graft loss in stable kidney recipients [Rao et al. 1988, Didlake et al. 1988, Rao et al. 1989, Hricik et al. 1991]. The latter fact is a warning that immunosuppression should be cautiously and gradually reduced. Patients who reject grafts early tend to require more immunosuppression. It is not known, however, whether patients who do not reject early require less immunosuppression. Herein, we present a case of late acute cellular and vascular rejection that occurred 9 years after stable renal graft function, in the absence of early acute rejection episodes. This case provides evidence to support the notion that lack of early acute rejection may not predict safe reduction of immunosuppression therapy.

Minimal requirements for hematologic cytochemistry in the community hospital laboratory

In the current atmosphere of increasing fiscal awareness, laboratorians are carefully assessing which procedures should be performed in-house and which should be sent to a reference laboratory. Ultimately these decisions are based not only on cost but also on the patient population serviced and on technical and workload considerations in the individual laboratory. A simple rule of thumb is to be able to perform stains that are either needed frequently or are very easy to perform and interpret if needed emergently. In choosing which staining procedure should be sent to a reference laboratory, it is helpful to understand both utility of the procedure and its special handling requirements, such that the best possible information can be obtained for diagnostic purposes.