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Reliable models of renal failure in large animals are critical to the successful translation of the next generation of renal replacement therapies (RRT) into humans. While models exist for the induction of renal failure, none are optimized for the implantation of devices to the retroperitoneal vasculature. We successfully piloted an embolization-to-implantation protocol enabling the first implant of a silicon nanopore membrane hemodialyzer (SNMHD) in a swine renal failure model. Renal arterial embolization is a non-invasive approach to near-total nephrectomy that preserves retroperitoneal anatomy for device implants. Silicon nanopore membranes (SNM) are efficient blood-compatible membranes that enable novel approaches to RRT. Yucatan minipigs underwent staged bilateral renal arterial embolization to induce renal failure, managed by intermittent hemodialysis. A small-scale arteriovenous SNMHD prototype was implanted into the retroperitoneum. Dialysate catheters were tunneled externally for connection to a dialysate recirculation pump. SNMHD clearance was determined by intermittent sampling of recirculating dialysate. Creatinine and urea clearance through the SNMHD were 76–105 mL/min/m2 and 140–165 mL/min/m2, respectively, without albumin leakage. Normalized creatinine and urea clearance measured in the SNMHD may translate to a fully implantable clinical-scale device. This pilot study establishes a path toward therapeutic testing of the clinical-scale SNMHD and other implantable RRT devices. [ABSTRACT FROM AUTHOR]

To investigate the prevalence of depression and anxiety in patients undergoing maintenance hemodialysis (MHD) in Hohhot, a large city on the northern border of China, and to identify independent risk factors for depression and anxiety in these patients. Patients receiving MHD for >3 months were enrolled in the four largest hemodialysis centers between September 2020 and December 2020. Depression and anxiety were assessed using the Zung self-rated depression scale (SDS) and Zung self-rated anxiety scale (SAS), respectively, with demographic and other data collected for logistic regression analyses. Among 305 MHD patients included in this study, the prevalence of depression was 55.1%, including 27.5%, 21.0%, and 6.6% with mild, moderate and severe cases, respectively. The prevalence of anxiety was 25.9%, with 20.0%, 4.6%, and 1.3% having mild, moderate, and severe cases, respectively. An independent protective factor for depression was family income of ≥1415 US dollars/month relative to <157 US dollars/month (odds ratio [OR] 0.209, 95% confidence interval [CI] 0.065–0.673), and predictors of depression included ≥3 comorbidities (OR 18.527, 95% CI 1.674–205.028) and severe pruritus (OR 15.971, 95% CI 5.173–49.315). Independent predictors of anxiety included infrequent exercise (OR 3.289, 95% CI 1.411–7.664) and severe pruritus (OR 5.912, 95% CI 1.733–20.168). The correlation between depression and anxiety in these patients was significant (rs = 0.775, p < 0.001). MHD patients in Northern China had high prevalence rates of depression (55.1%) and anxiety (25.9%). Lower family income, more comorbidities, and a higher degree of pruritus were predictors of depression, while infrequent exercise and severe pruritus were predictors of anxiety. Depression correlated significantly with anxiety. Attention should be given to family income, comorbidity, exercise, and pruritus severity for improved management of depression and anxiety among MHD patients. [ABSTRACT FROM AUTHOR]

Chronic kidney disease (CKD) is a growing problem among aging population, and the number of individuals at risk of end stage renal disease is rising. Part of the reason lies in incomplete understanding of the pathways underlying renal aging and kidney disease, as well as insufficient delivery of evidence-based treatment to elderly patients with CKD. This review aims to address these unsolved issues by delineating updated mechanisms of renal senescence and summarizing recent findings on key clinical aspects of CKD in the elderly. Challenges and obstacles in caring for older people with CKD are discussed, with an emphasis on modification of risk factors, prevention of acute kidney injury, stabilization of progression and decision on dialysis initiation. [ABSTRACT FROM AUTHOR]

Introduction: Chronic Kidney Disease (CKD) has become a major health issue worldwide. CKD patients require Renal Replacement Therapy (RRT) throughout their life. Haemodialysis is one of the options for RRT. Arterio-Venous Fistula (AVF) creation is required for haemodialysis. The radio cephalic fistula is the initial option for creating vascular access. Fistula can be created by anastomosing cephalic vein to radial artery either by End-To-Side (ETS) or Side-To-Side (STS) techniques. Aim: To compare the efficacy rate of radio cephalic AVF using ETS or STS anastomotic methods. Materials and Methods: This was a retrospective analytical study conducted at SDM college of medical sciences and hospital, Dharwad from March 2017 to February 2020. A total of 43 CKD patients were enlisted for the above duration from the hospital records. These patients were included in the study since they underwent radio cephalic AVF creation. AVF creation at other anatomical sites for rest of the CKD patients was excluded. Out of 43 patients, 24 of them underwent ETS technique and 19 STS technique; 15 patients from the former group and 17 from the latter were followed-up for a period of three months. Eleven patients were lost to follow up. Demographic variables were analysed with frequency, mean and standard deviation. Its association with two different operative techniques was analysed using Fisher’s-exact test. Outcome of the two operative procedures was analysed using Student’s t-test. Results: Effectively 15 patients from ETS group and 17 from STS group were compared. Three (20%) in ETS group and 5 (29.41%) in STS group had primary failure. Mean of maturation time in weeks in ETS group was 4.73±2.73 weeks and in STS group was 5.29±3.75 weeks. Three months patency rate in ETS group was 12 (80%) and in STS group was 12 (70.58%). Student’s t-test was performed comparing the above parameters and no statistical significance was noted. Conclusion: Comparison of two techniques of radio cephalic AVF creation proves that both the techniques are beneficial with no superiority of one over other. [ABSTRACT FROM AUTHOR]

Introduction: Focal segmental glomerulosclerosis (FSGS) accounts for 20% of nephrotic syndromes among children as well as 75% of the steroid resistant nephrotic syndrome (SRNS). The aim of the present study was to evaluate the influence of parental consanguinity on clinical course and outcome of FSGS in children.Methods: This historical cohort was carried out on 69 children affected by steroid resistant FSGS. Patients' data were recorded at the initial and the final analyses and response to therapeutic measures. Subjects were also questioned about the history of parental consanguinity.Results: Forty-four participants (63.8%) were male with a male to female proportion of 1.76:1. Mean baseline age was 5.69 ± 2.39 (range: 1 to 10). Fifty-one patients (73.9%) reported consanguinity. A more significant resistance to cyclosporine A and cyclophosphamide was observed in participants denoting parental consanguinity than those with no kinship. The average renal survival time obtained significantly lower among those reporting consanguinity compared to the others (8.33 vs. 10.44 years, P < .05). According to univariate analysis results, parental consanguinity was a risk factor for developing chronic kidney disease (HR = 4.56, 95% CI: 1.06 to 19.47; P < .05).Conclusion: Patients with FSGS plus parental consanguinity presented less renal survival time with more resistance to cures being more predisposed to the development of CKD. [ABSTRACT FROM AUTHOR]

End Stage Renal Disease (ESRD) patients receiving hemodialysis are at a higher risk of developing dyslipidemia which is undoubtedly a predisposing factor of cardiac related disease in these patients. Objectives: To assess serum lipid profile in subjects having end stage renal disease and receiving maintenance hemodialysis and to compare it with normal healthy controls and also to assess the effects of duration of hemodialysis on the lipid profile. Study Design: Case-control study. Setting: Executed in the Nephrology Department of JPMC. Period: January 2018 to January 2019. Material and Methods: Blood samples were obtained from a total of 90 subjects. Subjects were stratified into 3 groups including cases of ESRD receiving maintenance hemodialysis and matched healthy controls. Analysis for serum triglyceride, serum VLDL, total cholesterol, LDL and HDL was done. Results: A significant rise in serum triglyceride content and total serum cholesterol of hemodialysis patients (p < 0.01) was detected as compared to healthy controls. A statistically significant decrease was found in serum HDL level (p < 0.01) in hemodialysis patients in comparison to healthy controls. The impact of the hemodialysis duration was found to deteriorate the lipid profile of patients having longer duration of hemodialysis. Conclusion: Dyslipidemia was found to be evident in hemodialysis patients. The duration of hemodialysis sessions was found to affect the lipid profile of ESRD patients, which may play a role in higher incidence of atherosclerotic related cardiac events among these patients. [ABSTRACT FROM AUTHOR]

Introduction: Cardiovascular complications are considered as the main cause of mortality in patients with End-Stage Renal Disease (ESRD). Cardiovascular Disease (CVD) includes disorders of the Left Ventricular Hypertrophy (LVH) of the heart which is the most frequent cardiac alteration in ESRD. Galectin-3 (GAL-3), a ß-galactoside-binding protein has been proposed to be a new clinical biomarker that reflects cardiac fibrosis in patients with Heart Failure (HF). Aim: To evaluate the relationship between GAL-3 and biochemical parameters in Peritoneal Dialysis (PD) patients with and without LVH. Materials and Methods: This cross-sectional study enrolled 45 patients (25 women and 20 men) with ESRD who were categorised as having CVD with (n=12) or without (n=33) LVH. Demographic, biochemical and clinical characteristics of 45 patients were analysed. The relationship of plasma GAL-3 levels was analysed with the biochemical parameters for both the groups of patients. For comparison between groups, Student unpaired t-test was used for the data of normal distribution while Mann-Whitney test was used for data of non- Gaussian distribution. Pearson's correlation test was performed to examine various correlations. Results: Significantly high number (83.3%) of female patients were observed in ESRD with LVH. The groups did not differ significantly in their demographic, and biochemical and clinical parameters. There was significant increase in Left Ventricular End-Diastolic Diameters (LVEDD), Left Ventricular (LV) mass and LV mass index in patients with LVH as compared to the patients without LVH. The levels of GAL-3 showed slight increase (91±23.98 ng/mL) levels in LVH patients as compared to the patients without LVH (83.68±32.8 ng/mL). Exponential positive correlation between serum levels of GAL-3 and creatinine in all ESRD patients (r2=0.5488, p=0.0002). GAL-3 also showed positive correlations with urea (r=0.3825, p=0.011) as well as and uric acid (r=0.347, p=0.021) for ESRD patients without LVH. However, GAL-3 showed no association with uric acid and urea (r=0.04487, p=0.896; r=0.2383, p=0.48) in ESRD patients with LVH. Conclusion: GAL-3 positively correlated to the biochemical parameters in ESRD patients. Patients with LVH only showed positive correlation between GAL-3 and creatinine. Moreover, GAL-3 could not be used as the biomarker because it did not correlate with established diagnostic parameter like LV mass and LV mass index. Hence, in this study GAL-3 is not a potential clinical biomarker for the progression of cardiovascular complications in ESRD patients. Overall, these data reflect the need for further investigation of GAL-3 to HF in patients with ESRD. [ABSTRACT FROM AUTHOR]

Chronic Kidney Disease (CKD) is emerging as a major public health priority worldwide. It is a chronic condition influenced by lifestyle and behavior. The risk factors for CKD are highly prevalent among the Indian population, and the number of Indians at risk is increasing. Preventive measures focusing on reducing the prevalence of CKD by limiting exposure to risk factors could be cost effective in a country like India. Kidney diseases disproportionally affect disadvantaged populations and reduce the number of productive years of life. Furthermore, the prospect of financial burden discourages many patients from undergoing treatment, thereby leading to preventable morbidity and death. The management of patients with CKD is focused on early detection or prevention, treatment of the underlying cause (if possible) to curb progression and attention to secondary processes that contribute to ongoing nephron loss. Blood pressure control, inhibition of the renin-angiotensin system and disease-specific interventions are the cornerstones of therapy. Health literacy and self-management are critical to improving the outcomes of chronic conditions such as chronic kidney disease. Primary Care and Family physicians act as a bridge between the nephrologist specialist and the CKD patients; which will help in improving the quality of life, reduce physical and psychologic limitations and complications associated with CRF, and help patients return to their families, jobs, and social lives [ABSTRACT FROM AUTHOR]

Cardiovascular disease is the main cause of morbidity and mortality in end-stage renal disease (ESRD) patients. Recent population based epidemiological studies demonstrated a correlation between reduced renal function and risk for all causes and cardiovascular mortality, 50% of patients dying before the commencement of renal replacement therapy. Vascular calcifications (VC) and arterial stiffness are major contributors to cardiovascular disease and are independent predictors of cardiovascular mortality in ESRD patients. Scarce information is available on the risk factors and prognosis of predialysis patients with VC. The aim of this study was to evaluate the contribution of traditional and uremia related risk factors to abdominal aortic calcification in predialysis patients. A single center, retrospective study was performed on 305 adult patients monitored at the Bucharest University Emergency Hospital for at least 6 months. Our study reports an increased incidence of VC in predialysis chronic kidney disease (CKD) patients, higher in those with advanced age, history of cardiovascular disease, osteoporosis, and declining renal function. [ABSTRACT FROM AUTHOR]

The global prevalence of chronic kidney disease (CKD) is between 11 to 13%. Renal replacement therapies (RRT) – which include dialysis and renal transplantation – consume a significant portion of a country’s health resources even though only 0.1% of all CKD patients are at stage 5, also known as end-stage renal disease (ESRD). The aim of this review was to compare the magnitude of the economic burden of ESRD on national healthcare systems of selected countries with high prevalence of ESRD including Malaysia. The quantity of interest in this review were total ESRD expenditures and its proportions to the national health systems' expenditure. It was identified that total ESRD expenditure contributes between 0.91% to 7.1% of national health system expenditure in countries selected for this review. In Malaysia, the public sector - through its various agencies at the federal and state levels, accounted for almost 70% of dialysis funding; the remaining 30% came from the private sector and out-of-pocket payments. The ESRD expenditures in Malaysia constitutes 4.2% of total health expenditure by the public sector, relatively high compared to other countries. This review will summarise findings of the currently available economic evaluations of RRT in Malaysia. Based on available evidence, estimated weighted cost of treating ESRD patient in Malaysia is MYR39,346 per patient per year (USD26,648, PPP 2016). [ABSTRACT FROM AUTHOR]

Introduction: New diagnostic tools are needed to accurately detect acute myocardial infarction (AMI) in patients with end stage renal disease (ESRD) presenting with ischemic chest pain. We aimed in this study to investigate circulating miR-122, -192 and -499 expression levels in patients with AMI on top of ESRD and evaluate the potential of these miRNAs as blood-based biomarkers for AMI in patients with ESRD.Material and Methods: The study included 80 ESRD patients without AMI, 80 patients with ESRD associated with AMI and 60 healthy subjects. Assessment of microRNAs was done using SYBR Green based real-time PCR.Results: Levels of miR-122 were 28-fold and 20-fold higher in controls than in ESRD patients with or without AMI respectively (p < 0.001), while no differences were detected between the two patient groups (p = 0.9). Levels of miR-192 showed a marked increase in ESRD patients with and without AMI compared to the control group (> 500-fold, > 8000-fold respectively, p ≤ 0.001). Patients who developed AMI had lower expression than ESRD patients without AMI (p < 0.001). Non-significant miR-499 elevation was found in ESRD patients without cardiac disease compared to the control group, while highly significant elevation of miR- 499 was demonstrated in ESRD patients who developed AMI compared to other ESRD patients and the control group (> 100-fold, > 350-fold respectively, p = 0.001).Conclusions: Altered expression of miR-122 and -192 may contribute in pathogenesis of ESRD. MiR-192 and -499 may serve as potential biomarkers for AMI in ESRD. Further studies are needed to correlate these miRNAs with disease progression and outcome. [ABSTRACT FROM AUTHOR]

Context: Turmeric (Curcuma longa) is a wild plant of the ginger family native to tropical South Asia. Evidence Acquisitions: Directory of Open Access Journals (DOAJ), Google Scholar, Pubmed (NLM), LISTA (EBSCO) and Web of Science have been searched. Results: Emerging evidence indicate that turmeric/curcumin inhibits cytokines and TGF-β production. From the various factors involved in the genesis of chronic kidney disease and pathogenesis of primary and secondary glomerulonehritis, TGF-β has emerged as a key factor in the cascade of events. Leading to glomerulosclerosis, tubulointerstitial fibrosis and end-stage renal disease. Conclusions: considering the inhibitory effect of turmeric/curcumin on cytokines and TGF-β, it seems wise to assume that supplementary turmeric/curcumin might be a candidate remedy for chronic kidney disease and possibly prevention of subsequent end stage renal disease. [ABSTRACT FROM AUTHOR]

Background: Focal segmental glomerular sclerosis (FSGS) and necrotizing crescentic glomerulonephritis is a rare combination of diagnoses in the same patient. We report on a patient with FSGS who 10 years later developed anti-neutrophil cytoplasmic antibody (ANCA) associated glomerulonephritis. Case Presentation: Patient is a 60-year-old female with chronic kidney disease stage 3, osteopenia and anemia. In 2007, she was positive for ANCA proteinase-3 antibody, but kidney biopsy revealed FSGS. She was treated with high-dose oral steroids with tapered dose and went into remission. In 2017, she developed acute renal failure with increased proteinuria. Despite prior FSGS diagnosis, her new kidney biopsy revealed pauci-immune necrotizing glomerulonephritis. Patient was treated with methylprednisolone 250 mg IV for three days and high dose oral steroids with tapered dose. She was also started on rituximab 375 mg/m2 IV once weekly for 4 doses. Given the extent of kidney damage, the patient decided to start peritoneal dialysis and she is also on the kidney transplant list. Conclusions: The rare concurrence of FSGS and ANCA associated glomerulonephritis has not yet been reported. The case also emphasizes the significance of screening for ANCA or obtaining kidney biopsy when indicated not only as the gold standard for diagnosis but also as prognostic value. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency and pattern of dyslipidemia in pediatric patients with end stage renal disease presenting in a tertiary care hospital. Study Design: Cross-sectional, observational study. Place and Duration of Study: The Children's hospital and the Institute of Child Health Lahore, from Sep 2016 to Nov 2017. Material and Methods: Children aged 5-15 years, of either gender and diagnosed with end stage renal disease were selected for the study. All the patients were undergoing renal replacement therapy in the form of hemodialysis and/or continuous ambulatory peritoneal dialysis. The serum levels of total cholesterol, triglycerides, high density lipoprotein, low density lipoprotein and very low density lipoprotein were measured. Results: There were 138 patients in the study with mean age 11.24 ± 2.37 years and male to female ratio 2.5:1. The mean ± SD values of total serum cholesterol, triglycerides, and low density lipoprotein were found to be 174.0 ± 54.1, 241.2 ± 142.4 and 95.2 ± 49.0 mg/dl respectively. The frequency of abnormally high levels of total serum cholesterol, triglycerides, and low density lipoprotein were found to be 21.7%, 84.8% and 19.6% respectively. The lipid profile of patients on peritoneal dialysis was markedly elevated as compared to that of patients on maintenance hemodialysis (p-value ≤0.05). Conclusion: Majority of pediatric patients with end stage renal disease had suffered from dyslipidemia especially raised serum triglycerides. Timely identification of abnormal lipid levels and appropriate management is expected to help reduce cardiovascular morbidity and mortality associated with dyslipidemia in these pediatric patients. Moreover, lipid profile of patients on peritoneal dialysis was more deranged than those on hemodialysis. [ABSTRACT FROM AUTHOR]

Background: Calciphylaxis is a potentially fatal condition previously observed in patients with poor renal function. We present a case of atypical presentation in a patient with good renal function after transplantation. Case Presentation: A-68-year old African American female with history of end-stage renal disease (ESRD) secondary to type II diabetes mellitus on hemodialysis for ten years, status post living related donor kidney transplant from her son three years prior to this presentation, parathyroidectomy, and atrial fibrillation on warfarin presented to our institution with progressively worsening, severely tender bilateral thigh lesions that were diagnosed as calciphylaxis. She was treated with sodium thiosulfate infusions for six months and continues to do well. Conclusions: Calciphylaxis, also known as calcific uremic arteriolopathy (CUA), has traditionally been associated with ESRD patients on maintenance dialysis, however several nonuremic cases of CUA have been reported in recent years. Multiple pathophysiologic mechanisms for CUA development have been proposed expanding the scope of known risk factors and possible triggers. CUA can be a life-threatening condition that is important for clinicians to recognize and treat as soon as possible. [ABSTRACT FROM AUTHOR]

Background It is not clear on which level of estimated glomerular filtration rate to start dialysis until now. Objective To compare between patient groups according to estimated glomerular filtration rate at dialysis initiation. Methods Eighty-seven Patients are selected randomly from a list of patients admitted for dialysis (Hemodialysis or Peritoneal dialysis) at Northern General Hospital - Sheffield Kidney Institute from 1st of January to 31st of December 2000. Patients have been categorized into two groups. First group includes 45 patients started dialysis with glomerular filtration rate less than 5 ml/min/1.73m². Second group includes 42 patients started dialysis with glomerular filtration rate from 5-10 ml/min/1.73m². Patients have been followed up for five years retrospectively until 31st December 2005. Results The study showed males are the predominant gender. White Caucasian patients are majority of patients. The mean age is 56 years. About half of patients are middle aged (45-65 years) and are overweight or obese. This study shows no difference between patients who started dialysis early (estimated glomerular filtration rate 5-10 ml/min/1.73m²) versus late (estimated glomerular filtration rate below 5 ml/min/1.73m²) in term of mortality and morbidity throughout five years of follow up. Conclusion This study showed no justification to decide on time to initiate dialysis based solely on estimated glomerular filtration rate level. [ABSTRACT FROM AUTHOR]

[Display omitted] • EDCs are released by medical devices and detected in dialysis fluids. • Patients treated by dialysis are overexposed to seven EDCs. • Strategies to reduce EDCs exposure have been suggested. • Manufacturers must reconsider the conception of medical devices. Endocrine disrupting chemicals (EDCs) were defined as "an exogenous substance or mixture that alters function(s) of the endocrine system and consequently causes adverse health effects". These compounds are mainly eliminated by the renal route. However, patients with end-stage kidney disease treated by dialysis (ESKDD) can no longer eliminate these EDCs efficiently. Furthermore, EDCs exposure could occur via leaching from medical devices used in dialysis therapy. As a result, ESKDD patients are overexposed to EDCs. The aims of this study were to summarize EDCs exposure of ESKDD patients and to evaluate the factors at the origin of this exposure. To handle these objectives, we performed a literature review. An electronic search on PubMed, Embase and Web of science databases was performed. Twenty-six studies were finally included. The EDCs reported in these studies were Bisphenol A (BPA), Bisphenol S (BPS), Bisphenol B (BPB), Nonylphenol, Di(2-ethylhexyl) phthalate (DEHP), Di-n-butyl phthalate (DBP), and Butylbenzyl phthalate (BBP). Regarding the environment of dialysis patients, BPA, BPB, BPS, DEHP, DBP and nonylphenol have been found. Environmental exposure affects EDCs blood levels in ESKDD patients who are overexposed to BPA, BPS, BPB and DEHP. For ESKDD patients, dialyzers with housing in polycarbonate and fibers in polysulfone seem to overexpose them to BPA. Regarding dialysis therapy, peritoneal dialysis seems to decrease patient exposure vs hemodialysis therapy, and hemodiafiltration therapy seems to reduce this exposure vs hemodialysis therapy. Regarding DEHP, levels tend to increase during dialysis and when DEHP plasticizer is used in PVC devices. Finally, in the European Union a regulation on medical devices was adopted on 5 April 2017 and has been applied recently. This regulation will regulate EDCs in medical devices and thereby contribute to reconsideration of their conceptions and, finally, to reduction of ESKDD patients' exposure. [ABSTRACT FROM AUTHOR]

Objective: To perform an assessment of comorbidities of our hemodialysis dependent patients. Material & Methods: This was a cross-sectional descriptive study conducted in the Institute of Kidney Diseases Hayatabad, Peshawar and Khyber Teaching Hospital, Peshawar, Pakistan. The study included 177 patients and the study duration was 04 months (December 2015 to March 2016). ESRD patients on maintenance hemodialysis were asked about their comorbid conditions. This information was recorded on a questionnaire. Results: A total of 177 patients responded to a specially designed questionnaire asking questions about their comorbidity status. Out of these 177 patients 111 (62.7%) were male (M:F 1.7:1). The mean age for male patients was 43.1 years (SD ±14.8 and range from 18 to 70 years). While the mean age for females was 42.3 years (SD ±15.2 and range from 18 to 80 years). About 79% patients were on hemodialysis for duration of less than 03 years. Only 7.3% patients were undergoing hemodialysis at the recommended frequency of 03 or more sessions per week. All but 24.3% patients reported no emergency visits to hospital and all except 33.9% patients had no hospital admission in the previous 06 months. Around 34% patients had more than 5 emergency visits, while 37.8% patients had more than 5 admissions in the previous 06 months. Around 55.3% of patients were taking more than 5 types of drugs in a single day, while 76.7% were taking more than 3 drugs per day. Hypertension was the commonest comorbidity found in about 93.8% of patients. This was followed by cardiac diseases (46.9%) and diabetes (40.6%). Viral hepatitis was found in 21.4% patients, Infections in 12.4%, pulmonary diseases in 9.0%, and strokes were reported by 4.0% patients. Off the male patients, 67.5% (n=75) had two or more co-morbidities while 37.8% (n=42) had both Diabetes and hypertension. Off the female patients 89.3% (n=59) had two or more comorbidities while 45.4% (n=30) had both Diabetes and Hypertension. Conclusion: Comorbidities are common in our ESRD patients. Hypertension is the most common comorbidity followed by Diabetes Mellitus and cardiac diseases. The frequency of these comorbidities is higher in our patients when compared to the international data. This could explain the higher morbidity and mortality of our ESRD patients. [ABSTRACT FROM AUTHOR]

Dialysis remains the mainstay treatment for patients with end stage renal disease. In the UK, there has been a signifi cant decline in home dialysis despite its benefi ts and cost effectiveness. Patients with chronic kidney disease (CKD) are often known to other specialties who they may continue to consult when approaching dialysis. We wished to assess the knowledge of the non-renal multidisciplinary team (MDT) regarding home dialysis and establish whether further education was warranted. This was assessed using an online survey sent to specialties likely to deal with CKD patients. In total, 364 questionnaires were sent out with a 26.4% response rate. According to the survey responses, 81.5% of non-renal MDTs lack confi dence in discussing home dialysis options with patients and 74.55% feel that they need further education about home dialysis. Targeted education may increase home dialysis uptake by multimorbid CKD patients who have a consistent message delivered by all relevant healthcare teams about the benefi ts of home dialysis. [ABSTRACT FROM AUTHOR]

Peritoneal dialysis (PD) offers the healthiest way for starting renal replacement therapy (RRT) in End Stage Renal Disease patients, however exposes long-term PD patients to a dangerous complication named encapsulating peritoneal sclerosis (EPS). In this study, we searched for possible risk factors of EPS. Data were collected from two PD centers covering period 1995–2012 and comprised 464 patients. Control group defined as PD patients stayed on PD >42 month (n = 122), and case group was 12 confirmed EPS patients. Associations were analyzed using linear regression analysis. Prevalence and incidence of EPS were 2.59% and 8.9% with an incidence of 0.7% patient-years, respectively. The age at start of PD in EPS patients (32.75 ± 10.8 year) was significantly lower compared with control group (49.61 ± 16.18 year,p = .0001). The mean duration of PD in EPS and control group were 2494.4 ± 940.9 and 1890.2 ± 598.8 days (p = .002). Control group had 145 episodes of peritonitis during total duration of 7686 patient months (peritonitis rate of 1/53). This was 1/26 with a total 38 episodes of peritonitis during the total duration of 997 patient months (p = .01) for EPS group. In regression analysis, PD duration, age at PD start and duration of Ultrafiltration failure (UFF) were associated with EPS. Longer time being on PD, younger age, and higher UFF duration were the risk factors for EPS development. [ABSTRACT FROM AUTHOR]

Glomerular filtration rate and/or creatinine are not accurate methods for renal failure prediction. This study tested homocysteine (Hcy) as a predictive and prognostic marker for end stage renal disease (ESRD). In total, 176 subjects were recruited and divided into:healthy normal group(108 subjects);mild-to-moderate impaired renal function group(21 patients);severe impaired renal function group(7 patients); andchronic renal failure group(40 patients) who were on regular hemodialysis. Blood samples were collected, and serum was separated for analysis of total Hcy, creatinine, high sensitive C-reactive protein (CRP), serum albumin, and calcium. Data showed that Hcy level was significantly increased from normal-to-mild impairment then significantly decreases from mild impairment until the patient reaches severe impairment while showing significant elevation in the last stage of chronic renal disease. Creatinine level was increased in all stages of kidney impairment in comparison with control. CRP level was showing significant elevation in the last stage. A significant decrease in both albumin and calcium was occurred in all stages of renal impairment. We conclude Hcy in combination with CRP, creatinine, albumin, and calcium can be used as a prognostic marker for ESRD and an early diagnostic marker for the risk of renal failure. [ABSTRACT FROM AUTHOR]

Though renal transplant is preferred mode of renal replacement therapy (RRT), peritoneal dialysis (PD) is an important modality of treatment for children with end stage renal disease (ESRD) but it is underutilized in Pakistan despite several advantages over haemodialysis (HD). The burden of paediatric chronic kidney disease (CKD) and ESRD is under reported, since majority of children (24-63%) present with acute on chronic kidney disease often complicated by multiple co-morbid conditions which may result in death before consideration of long term RRT. In Pakistan, the available care of ESRD/CKD is exclusively hospital based rather than home based dialysis. Manual PD is used as first line option of treatment for acute kidney injury (AKI) or acute on CKD at few centers and long term maintenance PD is not offered at all as first line option of treatment for children with ESRD. Generally, long term PD is less expensive than HD or at least as expensive as HD. This holds true even for most of the developed countries using automated cycler machines but scenario in developing countries like Pakistan is quite different. HD is the only option offered to older children for short period and very few of them become successful to get a renal transplant. Home dialysis or Continuous Ambulatory PD (CAPD) may be the only option to treat young infants to make them free of complications of uraemia and provide adequate nutrition for growth till either HD or transplant become possible. This may be possible once paediatric and adult nephrologists as well as pediatricians recommend and advocate this option for survival of children with ESRD. Furthermore, we need to strengthen the existing RTT facilities and develop more paediatric peritoneal dialysis centers; local production of dialysis fluid and disposables or government should allow free import of PD equipments and solutions. This will not be possible without efforts of all of us including professionals, dialysis nurses or technicians, media persons, pharma industry and community workers as well as parents. [ABSTRACT FROM AUTHOR]

Chronic kidney disease is usually related with anemia and the level of anemia correlates with the severity of renal failure. A chronic kidney disease is complicated by anemia and anemia may contribute to adverse clinical outcomes. No large-scale population data are available for patients with chronic kidney disease regarding prevalence of anemia, subpopulations at risk, and relationships between anemia and renal dysfunctionObjectives:The objective of this study is to determine the frequency of different patterns of anemia in relation to glomerular filtration rate in patients suffering from chronic kidney disease stage II and above patients.Material &Methods:Study Design: Cross sectional study. Setting:Medical and Nephrology wards of Liaquat University Hospital Hyderabad / Jamshoro. Period:20th January 2013 to 19thDecember 2013.Results:During the study period, total 339 patients of chronic kidney disease with stage II and above patients were enrolled. The mean age ± Standard Deviation and range) of patients was 50.65 ± 11.86 (16 to 80 years, n = 339). 211(62.2%) were male and 128(37.8%) were female. (Male to Female Ratio 1:6). Mean Hemoglobin ± SD was 7.16 ± 3.89 (3.0 to 17.0 g/dL). The frequency of anemia was present in 285(84.1%) patients with mean Hb± SD 6.02 ± 2.1 (g/dL). The mean weight ± SD was 56.50 ± 9.84 (40 to 81 kg). The mean serum creatinine ± SD was 5.63 ± 2.48 (0.9 to 12.0 mg/dL) and we observed that most frequent pattern of anemia was normocytic-normochromic anemia in 216(77.0%) patients, hypochromic-microcytic in 61(18.0%) and macroyctic in 17(5.0%) patients. We alsofound that as anemia increased progressively with declining GFR with mean hemoglobin concentration of 11.78 ±2.8 g/dL in CKD stage 2, 10.14 ± 3.6 g/dL in CKD stage 3, 6.8 ± 3.6 g/dL in CKD stage 4, 7.44 ± 4.0 g/dL in CKD stage 5.Conclusion: Frequency of anemia increases with the progression of stage of chronic kidney disease (decreased GFR) and anemia was most common in stage 5 patients of chronic kidney disease.Most frequent pattern of anemia is normocytic normochromic anemia. [ABSTRACT FROM AUTHOR]

Cardiovascular is the major cause of death in chronic kidney disease and end-stage renal disease. The cardiovascular mortality rate of patients with renal impairment is evaluated to be higher than general population. Coronary artery disease seems to be an important type of cardiovascular complication among patients with chronic kidney disease and end-stage renal disease before the renal replacement therapy. Due to the strong association between chronic kidney disease and the incidence of coronary artery disease, accurate screening, diagnosis, and management of cardiovascular complications would be essential in patients at different stages of renal dysfunction. Despite the need for the comprehensive knowledge about different aspects of coronary artery disease in patients with renal failure, there is not sufficient evidence regarding the pathophysiology, ideal diagnosis, and treatment strategies for coronary heart disease in population with chronic kidney disease. In this study, we briefly reviewed the existing literatures about the possible screening, diagnosis, and the treatment approaches of risk of coronary heart disease in patients with kidney dysfunction. [ABSTRACT FROM AUTHOR]

Introduction: The global prevalence of chronic kidney disease (CKD) is estimated to be 8-16%. Studies have shown that the increased mortality in patients with CKD is due to anemia that leads to cardiovascular disease (CVD), also known as "Cardio renal anemia syndrome". The present study was undertaken to look into the laboratory profiles of end stage renal disease (ESRD) patients. Aim: To study the laboratory profiles of End stage renal disease (ESRD) patients coming for hemodialysis. Materials and Methods: The study was a retrospective, crosssectional study done by collecting data from the medical case records of all patients during a period of one year from January 1st 2014 to December 31st 2014. Records of a total of 140 patients who underwent hemodialysis during this period were taken. The laboratory profiles that was recorded included haemoglobin, serum sodium, potassium, chloride, fasting glucose, calcium and phosphorus. Results: The mean age of the subjects was 53.5±14.5 yrs. All the patients had moderate anaemia. There was a significant difference in the mean systolic and diastolic blood pressure, serum creatinine and serum urea values between males and females. The mean serum calcium levels were low. Conclusion: The present study is the first such study in this rural area and shows evidence of a relatively young population with ESRD having moderate anaemia and hypertension. There is evidence of hypocalcaemia and serum phosphorus is on the higher end of the normal range. These findings are usually associated with a higher risk of mortality. With the explosion of diabetes and hypertension in India, chronic kidney disease should be diagnosed and managed as early as possible if not prevented. [ABSTRACT FROM AUTHOR]

Background: Chronic kidney disease is a progressive and irreversible loss of renal function. Anemia is one of the main complications of end-stage renal disease (ESRD) which is linked closely with other complications of the disease. The primary therapy for anemia in these patients is erythropoietin (EPO). The goal of this study was to find the effect of Vitamin D administration in addition to the appropriate dose of EPO in ESRD patients with Vitamin D deficiency. Materials and Methods: This was a double-blind clinical trial on 64 ESRD patients undergoing hemodialysis in Amin and Noor Hospitals of Isfahan, Iran. The patients were divided into two groups of control and intervention. The intervention group was given Vitamin D supplements and the control group received placebo. The required dose of EPO to reach the target hemoglobin (Hb) was measured and statistically analyzed. Results: A total number of 32 females and 32 males were included in this study. All the patients in the treatment group were aged between 18 and 76 and the patients in the control group were aged between 21 and 76 years old. There was a significant statistical relationship between Vitamin D administration and the required dose of EPO in both groups (P = 0.013). However, there was no correlation between the concentration of Hb and serum Vitamin D levels. Conclusion: Based on the main finding of this study, the relationship between Vitamin D administration and required dose of EPO seems that the predicted dose of Vitamin D prescribing strategy in Kidney Disease Outcomes Quality Initiative guidelines is not adequate to achieve normal serum Vitamin D in ESRD patients. [ABSTRACT FROM AUTHOR]

Background: Chronic Kidney Disease (CKD) is a serious disease in which some type of replacement (renal transplant or dialysis) is required. End Stage Renal Disease (ESRD) is the name given to Stage 5 CKD. Various cutaenous manifestations are associated with it which may be due to the disease itself or caused by its treatment. Objectives: This study was conducted to determine the frequency of cutaneous manifestations in patients of end stage renal disease undergoing haemodialysis. Material and Methods: One hundred patients undergoing maintenance haemodialyis in the Department of Nephrology, KEMU / Mayo Hospital, Lahore were examined from January to June, 2011, through specially designed proformas, to determine the presence of cutaneous manifestations in these patients. Results: There were 58 males and 42 females with a mean age of 50 ± 4 years. Overall frequency of cutaneous manifestations was 82%. The commonest findings were xerosis 78% and pruritus 64%. Others were pallor 62%, hyperpigmentation 54%, nail changes 48%, infections 37%, hair changes 35% and mucosal changes 22%. Some rare manifestations seen were arteriovenous shunt dermatitis, acquired perforating disorders, calcification and nephrogenic fibrosing dermatopathy. Conclusion: Cutaneous and mucosal findings are a common problem in patients of ESRD and those undergoing long-term haemodialysis. The commonest are xerosis and pruritus followed by involvement of hair, nails and mucous membranes. [ABSTRACT FROM AUTHOR]

BACKGROUND: End Stage Renal Diseases (ESRD) imposes a huge economic burden on the health system; however, there is a serious lack of data related to ESRD, especially at Sub-national level, in Iran. Calculating the burden of ESRD at National and Sub-national level provides an opportunity to apply cost-effective interventions for the purpose of prevention and treatment. The current study protocol aims to explain the general structure and methods that will be used in the burden of ESRD study in Iran from 1990 to 2013. METHODS: The prevalence, incidence, mortality and geographical and socioeconomic inequality trend of ESRD will be calculated through a comprehensive systematic review of published and unpublished data. Years of Life Lost due to premature mortality, and Years Lived with Disability and Disability-Adjusted Life Years (DALYs) will be quantified for ESRD by gender, age group, and province with their uncertainly intervals. “Spatio-Temporal” and “Bayesian multilevel autoregressive” will be applied to deal with data scarcity and misalignment problem which exist in the data sources. DISCUSSION: The findings of the burden of ESRD study will be useful to organize preventive, treatment also research priorities at national and sub-national levels in Iran. Better understanding of the magnitude of ESRD burden is essential to prevent the progression of chronic kidney diseases to the end stage phase which is considered as a devastating illness. [ABSTRACT FROM AUTHOR]

Despite consensus among nephrologists that exercise is important and probably beneficial for their patients, assessment of physical function or encouragement of physical activity is not a part of the routine management of patients with CKD. In order to plan an useful strategy for exercise training we need to clearly define some questions. First of all, nephrologists need to be aware of physical exercise benefits; lack of motivation and increased perceived risk by health care professionals have been identified as contributing factors to physical inactivity. Moreover, the main elements necessary for sustaining exercise programs in this population have to take in account, such as the requirement of exercise professionals, equipment and space, individual prescription, adequate commitment from dialysis and medical staff. When PA may not be implemented, a comprehensive, individualized occupational therapy program may improve functional independence and activity of daily living. Finally, physical function has to be careful monitored and assesses by medical staff. © 2014 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Despite decades of research, a full understanding of chronic kidney disease (CKD)-end stage renal disease (ESRD) progression remains elusive. The common consensus is a predictable, linear, progressive and time-dependent decline of CKD to ESRD. Acute kidney injury (AKI) on CKD is usually assumed to be transient, with recovery as the expected outcome. AKI-ESRD association in current nephrology literature is blamed on the so-called "residual confounding." We had previously described a relationship between AKI events and rapid onset yet irreversible ESRD happening in a continuum in a high-risk CKD cohort. However, the contribution of the syndrome of rapid onset-ESRD (SORO-ESRD) to incident United States ESRD population remained conjectural. In this retrospective analysis, we analyzed serum creatinine trajectories of the last 100 consecutive ESRD patients in 4 Mayo Clinic chronic hemodialysis units to determine the incidence of SORO-ESRD. Excluding 9 patients, 31 (34%) patients, including two renal transplant recipients, had SORO-ESRD: 18 males and 13 females age 72 (range 50-92) years. Precipitating AKI followed pneumonia (8), acutely decompensated heart failure (7), pyelonephritis (4), post-operative (5), sepsis (3), contrast-induced nephropathy (2), and others (2). Time to dialysis was shortest following surgical procedures. Concurrent renin angiotensin aldosterone system blockade was higher with SORO-ESRD - 23% versus 5%, P = 0.0113. In conclusion, SORO-ESRD is not uncommon among the incident general US ESRD population. The implications for ESRD care planning, AV-fistula-first programs, general CKD care and any associations with renal ageing/senescence warrant further study. [ABSTRACT FROM AUTHOR]

Background: Diabetes mellitus type 2 (DM2) is highly associated with increased risk for chronic kidney disease (CKD), end stage renal disease (ESRD) and cardiovascular morbidity. Epidemiological and genetic studies generate hypotheses for innovative strategies in DM2 management by unravelling novel mechanisms of diabetes complications, which is essential for future intervention trials. We have thus initiated the DIAbetes COhoRtE study (DIACORE). Methods: DIACORE is a prospective cohort study aiming to recruit 6000 patients of self-reported Caucasian ethnicity with prevalent DM2 for at least 10 years of follow-up. Study visits are performed in University-based recruiting clinics in Germany using standard operating procedures. All prevalent DM2 patients in outpatient clinics surrounding the recruiting centers are invited to participate. At baseline and at each 2-year follow-up examination, patients are subjected to a core phenotyping protocol. This includes a standardized online questionnaire and physical examination to determine incident micro- and macrovascular DM2 complications, malignancy and hospitalization, with a primary focus on renal events. Confirmatory outcome information is requested from patient records. Blood samples are obtained for a centrally analyzed standard laboratory panel and for biobanking of aliquots of serum, plasma, urine, mRNA and DNA for future scientific use. A subset of the cohort is subjected to extended phenotyping, e.g. sleep apnea screening, skin autofluorescence measurement, non-mydriatic retinal photography and non-invasive determination of arterial stiffness. Discussion: DIACORE will enable the prospective evaluation of factors involved in DM2 complication pathogenesis using high-throughput technologies in biosamples and genetic epidemiological studies. [ABSTRACT FROM AUTHOR]

Apparent treatment-resistant hypertension (ATRH) is closely related to chronic kidney disease (CKD); however, the long-term outcomes and the effects of improvement in ATRH in patients with CKD are not well understood. We evaluated the relationship between the persistence of ATRH and the progression of CKD. This cohort study enrolled 1921 patients with CKD. ATRH was defined as blood pressure above 140/90 mmHg and intake of three different types of antihypertensive agents, including diuretics, or intake of four or more different types of antihypertensive agents, regardless of blood pressure. We defined ATRH subgroups according to the ATRH status at the index year and two years later. The prevalence of ATRH at baseline was 14.0%. The presence of ATRH at both time points was an independent risk factor for end-point renal outcome (HR, 1.41; 95% CI, 1.04–1.92; p = 0.027). On the other hand, the presence of ATRH at any one of the time points was not statistically significant. In conclusion, persistent ATRH is more important for the prognosis of renal disease than the initial ATRH status. Continuous follow-up and appropriate treatment are important to improve the renal outcomes. [ABSTRACT FROM AUTHOR]

Background: sclerostin, an osteocyte-derived glycoprotein acts as a soluble inhibitor of the Wnt signaling pathway and its physiological role is to reduce bone formation. The serum sclerostin levels increase with the progression of CKD. Aim of the work: in the present study, we investigated the effect of three months thrice weekly hemodiafiltration on serum sclerostin level and bone specific alkaline phosphatase in comparison with high flux dialysis in stable HD patients. Methods: prospective study was concluded upon 32 randomly selected ESRD patients from Dialysis Department in Ain Shams University Hospitals and Maadi Military Hospital. Serum sclerostin and bone specific alkaline phosphatase were measured at the start of the study (Zero months) and after 3 months of HDF dialysis between September 2017 and December 2017. Results: 32 test subjects were randomly selected had mean age 47.38 (± 18.68 years) in HDF group and 55.31 (± 7.40 years) in high flux group. 56.3% were male in HDF group, 81.3% male in high flux group. Patients in HDF group had serum sclerostin reduction ratio with mean 24.72 ± 10.34 pre-3 months and mean 30.34 ± 12.22 in post-3 months. While, serum sclerostin reduction ratio mean was 18.97 ± 7.87 in high flux group. There was a statistically significant difference between HDF group post-3months and high flux group as regard sclerostin reduction ratio (P-value: 0.015). There was no statistically significant difference between group HDF post-3 months and group high flux as regard BS-AP reduction ratio (P-value: 0.212). Conclusion: Sclerostin decreased by HDF. Yet, HDF has no effect on bone specific alkaline phosphatase in comparison to high flux hemodialysis. [ABSTRACT FROM AUTHOR]

Direct-acting antivirals (DAA) have revolutionized the treatment of patients with chronic hepatitis C virus (HCV) infection, possibly leading to HCV elimination by 2030 as endorsed by the World Health Organization (WHO). However, some patients belonging to the so-called unique or special populations are referred to as difficult-to-treat due to unreached sustained virological response, potential drug side effects or interactions or co-morbidities. Several years after the DAA introduction and on the basis of excellent findings in terms of efficacy and safety, some doubts arise around the exact meaning of the special population designation and whether this group of patients actually exists. The aim of this review is to discuss and analyze current evidence on the management and treatment of the so-called "unique populations". We placed particular emphasis on patients with decompensated cirrhosis, chronic kidney disease (CKD), coinfections, rare genotypes, and previous treatment failure, in order to provide physicians with an updated overview of the actual problems and needs in the current scenario. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) and chronic kidney disease (CKD) are strictly related; several independent risk factors of AF are often frequent in CKD patients. AF prevalence is very common among these patients, ranging between 15% and 20% in advanced stages of CKD. Moreover, the results of several studies showed that AF patients with end stage renal disease (ESRD) have a higher mortality rate than patients with preserved renal function due to an increased incidence of stroke and an unpredicted elevated hemorrhagic risk. Direct oral anticoagulants (DOACs) are currently contraindicated in patients with ESRD and vitamin K antagonists (VKAs), remaining the only drugs allowed, although they show numerous critical issues such as a narrow therapeutic window, increased tissue calcification and an unfavorable risk/benefit ratio with low stroke prevention effect and augmented risk of major bleeding. The purpose of this review is to shed light on the applications of DOAC therapy in CKD patients, especially in ESRD patients. [ABSTRACT FROM AUTHOR]

The risk of chronic kidney disease (CKD) following severe acute kidney injury (AKI) in critically ill patients is well documented, but not after less severe AKI. The main objective of this study was to evaluate the long-term incidence of CKD after non-severe AKI in critically ill patients. This prospective single-center observational three-years follow-up study was conducted in the medical intensive care unit in Bordeaux's hospital (France). From 2013 to 2015, all patients with severe (kidney disease improving global outcomes (KDIGO) stage 3) and non-severe AKI (KDIGO stages 1, 2) were enrolled. Patients with prior eGFR < 90 mL/min/1.73 m2 were excluded. Primary outcome was the three-year incidence of CKD stages 3 to 5 in the non-severe AKI group. We enrolled 232 patients. Non-severe AKI was observed in 112 and severe AKI in 120. In the non-severe AKI group, 71 (63%) were male, age was 62 ± 16 years. The reason for admission was sepsis for 56/112 (50%). Sixty-two (55%) patients died and nine (8%) were lost to follow-up. At the end of the follow-up the incidence of CKD was 22% (9/41); Confidence Interval (CI) 95% (9.3–33.60)% in the non-severe AKI group, tending to be significantly lower than in the severe AKI group (44% (14/30); CI 95% (28.8–64.5)%; p = 0.052). The development of CKD three years after non-severe AKI, despite it being lower than after severe AKI, appears to be a frequent event highlighting the need for prolonged follow-up. [ABSTRACT FROM AUTHOR]

A healthy life style is associated with decreased risk of chronic kidney disease (CKD) and mortality in the general population. However, there is no definitive evidence of the benefits of physical activity and other health-related behaviors in the early-stage of CKD. This study aimed to explore the association between health-related behaviors and end-stage renal disease (ESRD) and mortality in the early stages of CKD. The National Health Insurance Service (NHIS) database from 1 January 2009 to 31 December 2016 was used to screen 83,470 subjects with early stage CKD. Cox proportional hazard regression analysis was used to evaluate the association between health-related behaviors and ESRD and death. Kaplan–Meier curves for mortality and ESRD were plotted according to the physical activity, smoking status, and alcohol consumption pattern. Risk of death decreased significantly in subjects who engaged in sufficient physical activity (adjusted Hazard Ratio (HR) 0.73; 95% CI: 0.64–0.83; p < 0.001). Risk of ESRD and death increased significantly in the current smoker with adjusted HR of 1.44 (95% CI: 1.06–1.95; p < 0.02) and 1.61 (95% CI: 1.44–1.80; p < 0.001) respectively. Therefore, systematic interventions to encourage physical activity and smoking cessation need to be actively considered in the early stages of CKD. [ABSTRACT FROM AUTHOR]

In 2005, the incidence of renal replacement therapy (RRT) in the United Kingdom was 110 per million of the population (pmp) using the day 0 definition and 103 pmp using the day 90 definition.Relative to the 42 countries reporting data to the USRDS, the day 0 and day 90 rates for RRT incidence in the UK are the 32nd and 35th lowest, respectively. However, the overall incidence for the UK masks higher rates in Scotland, Wales and Northern Ireland (123, 129 and 140 pmp, respectively).Of the six countries with RRT incidence rates comparable with those in the UK (Australia, Finland, Malaysia, New Zealand, Norway and the Netherlands) three had relatively high rates for the age band 20–44, and two had relatively high rates for the age band 45–60.The proportion of incident patients with diabetes as the cause of established renal failure also varied considerably among these six comparator countries from 16% to 40% but rates of peritoneal dialysis utilization were comparable with that in the UK and generally higher than in countries with higher rates of RRT incidence.When transplantation rates were considered alongside prevalence rates for RRT, the UK position appeared relatively high at 46% (11th out of 37 countries), although still considerably lower than in Norway and the Netherlands (72 and 54%, respectively).Although variation in RRT incidence rate exists within the four countries of the UK, the overall RRT incidence, reported for the first time this year, appears similar to that observed in a number of demographically similar countries around the world.Examining the UK alongside the six comparator countries, different patterns of RRT incidence were observed across the age bands and variation in the RRT incidence secondary to diabetes mellitus raised interesting questions.The higher rates of renal transplantation achieved in several of the comparator countries also justifies further analysis. [ABSTRACT FROM AUTHOR]

Summary data are provided for the whole United Kingdom. There were 41 776 adult patients alive on renal replacement therapy (RRT) in the UK at the end of 2005, a prevalence for adults of 694 pmp. Addition of 748 children under the age of 18 on RRT gives a total prevalence of 706 pmp. The more detailed analysis includes data on 37 534 patients from 65 of the 70 units which returned detailed data to the Registry: all in Northern Ireland, Scotland and Wales, and 45 of the 50 units in England. The annual increase in prevalence in the 38 renal units participating in the Registry since 2000 was 5.0%. There is substantial variation in the crude Local Authority area prevalence from 299 pmp to 1275 pmp.In general, areas with large ethnic minority populations had high standardized prevalence ratios (SPR). Nevertheless several Local Authority areas in South Wales (Methyr Tydfil, Swansea and Rhondda/Cynon/Taff) had a higher SPR than would be predicted from the local ethnic mix. Another group in North West England (Bury, Rochdale, Oldham and Salford), had a lower SPR than expected from the local ethnic mix. The median age of prevalent patients on RRT was 56.6 years, that of patients on HD 64.5 years, PD 59.2 years and transplanted patients 49.7 years. The median vintage of the whole RRT population was 5.1 years: that of transplanted patients was 9.8 years, HD patients 2.8 years and PD patients 2.1 years. The maximal prevalence rate (SPR) occurred in men (2270 pmp) in the 75–79-year age band and women (1144 pmp) in the 65–74-year age band.Of RRT patients in the UK, 45% had a transplant, 41.7% were on centre-based haemodialysis and 12% on peritoneal dialysis. The proportion of patients on home haemodialysis remained very small (1.2%) in spite of the recent NICE guidelines. The haemodialysis population is continuing to expand, mainly through growth in the proportion of patients undergoing dialysis in satellite units. The peritoneal dialysis population is continuing to contract in spite of the small but progressive rise in automated PD.The most common identifiable diagnosis in those under 65 was glomerulonephritis (18.0%) and in those over 65 it was diabetes (13.4%).One-year survival rates of prevalent patients in the different centres contributing to the UK Renal Registry are presented. The centres agreed to remove anonymity. There is no evidence of any significant differences in survival of prevalent patients between UK centres.The one-year survival of prevalent dialysis patients increased significantly from 1998 to 2004 in England (83.3% to 87.1% P = 0.0001 for linear trend), Scotland (84.0% to 87.0% P = 0.023 for linear trend) and Wales (83.4% to 86.1% P = 0.027 for linear trend). The test for non-linearity in this trend (indicating that there has been a large increase which is now tailing off) was significant for England and Wales. [ABSTRACT FROM AUTHOR]

Despite the universal availability of erythropoietin and intravenous iron, 14% of transplant patients and 30% of dialysis patients have a haemoglobin (Hb) <10.5 g/dl. Only 11% of anaemic transplant patients were receiving erythropoietin.There was a linear relationship between estimated glomerular filtration rate (eGFR) and Hb with the risk of anaemia occurring at a much higher eGFR than would be expected in the chronic kidney disease (CKD) population.There was also a significant association between the use of mycophenolate and anaemia. Around 95% of dialysis patients were receiving erythropoietin and 47% intravenous iron.It is speculated that raising the target Hb for this population to 13 g/dl could shift the whole distribution curve to the left, reducing the proportion with anaemia. Doing this would require careful monitoring to steepen the distribution curve and limit the upper tail if complications of high haematocrits are to be avoided. [ABSTRACT FROM AUTHOR]

Short stature is a major problem in paediatric ERF patients with 29% of transplant patients and 41% of dialysis patients below the second percentile for height. Only 6.5% of transplant patients and 15.5% of dialysis patients are receiving rhGH. There is no significant difference in the height distribution of patients commencing RRT and those who have had a functioning allograft for at least 1 year. In patients with at least 2 years between presentation and RRT, there is a significant fall in height Z score. This overall statistic is strongly influenced by the very poor growth of patients with glomerular disease. [ABSTRACT FROM AUTHOR]

The incidence and prevalence of ERF in children in the UK are relatively static at 8.0 and 47.7 per million population under the age of 15 years, respectively.The prevalence of ERF in children from the South Asian community is almost three times that of the White population whilst the incidence is over three times that of the White population and similar to the increase seen in the adult population. The high incidence and prevalence are related to the high incidence of inherited diseases which cause ERF in the South Asian community.ERF in children is more common in males than females (male to female ratio 1.54:1). This is due to a preponderance of males with renal dysplasia and obstructive uropathy causing ERF. For the South Asian patients, the gender ratio is 1:1 as the inherited diseases are mainly autosomal recessive.Renal dysplasia is the single most common cause of ERF in childhood, followed closely by glomerular disorders and then obstructive uropathy.The majority of prevalent paediatric ERF patients (76%) have a renal allograft. Of these, 28% are from living donations.The proportion of patients from ethnic minority groups with a functioning allograft is significantly smaller than that in the White population (P < 0.0001). Despite this, the rate of living related donation is no higher in the ethnic minority population.In prevalent patients PD is twice as commonly used as HD with the majority managed with automated PD. For patients at one year from starting RRT, 49% are on PD, 10% on HD and 41% have a transplant. [ABSTRACT FROM AUTHOR]

This analysis presents the survival of patients starting renal replacement therapy (RRT) in UK renal units (‘centres’), and includes an analysis of survival by centre. Data from 59 of the 70 UK centres are included. This is the first year that UK centre anonymity has been removed from analysis of patient survival by centre. Survival after adjustment for comorbidity is also reported for the first time although this analysis is restricted to those centres returning data on comorbidity in at least 85% of incident patients.The importance of adjusting for comorbidity can be seen in that for one centre, after adjustment of survival for age and diagnosis, the adjusted 1 year after 90 day survival was 84.6%. After adjusting to the average comorbidity present across centres, survival increased to 90.4%. Improved comorbidity data returns by renal units may require investment in informatics staff and creating structural process at renal unit level for clinicians to support these data returns.From the date of first RRT, the 1 year survival of all patients (unadjusted for age) is 79%. From the 90th day of RRT (to allow comparison with other countries’ 1 year survival), the 1 year survival is 83%. The age adjusted (60 years) survival for the 1 year after 90 day period is 86%. There is a high death rate in the first 90 days on RRT (6% of all patients starting RRT), a period not included in reports by many registries and other studies.The 5 year survival (including deaths within the first 90 days) rates are 58, 53, 44, 28, 19 and 12%, respectively for patients aged 18–34, 35–44, 45–54, 55–64, 65–74 and >75 years.The ‘vintage effect’ of increasing hazard of death with length of time on RRT, prominent in data from the US, is only noted in older age groups (65–75 and 75+ years) at 5–6 years after starting RRT.Six centres had a figure for the 1 year after 90 day survival which was outside 2 SDs from the mean for the UK: in three cases this was better survival, and in three, poorer survival, than expected. Poor reporting by renal units of patient comorbidity makes interpretation of these apparent differences in patient survival between centres difficult and a relationship to clinical performance cannot yet be inferred. [ABSTRACT FROM AUTHOR]

The total number of patients active on the transplant waiting list (adult and paediatric) on 31 December 2005 was 5736, an 8% increase from the previous year. On 31 December 2005, 45.7% of prevalent adult RRT patients in the UK, had a functioning renal transplant which equated to 19 074 patients. During 2005, the death rate in prevalent transplant patients was 2.7 per 100 patient years. An additional 3.1% of all prevalent transplants failed with patients returning to dialysis.During 2005, deceased heart beating donor numbers decreased by 18% compared to 2004. In comparison, non-heart beating donors and living kidney donors increased by 35% and 17%, respectively, in 2005. The proportion of renal transplants performed from deceased heart beating donors fell from 68% in 2004 to 60% in 2005. There is wide variation in prevalence per million population (pmp) of transplanted patients resident in each local authority area across the United Kingdom. Total 11.4% of incident transplants in 2005 were due to patients with diabetes. The median eGFR was 46.1 ml/min/1.73 m2, with 18% of prevalent transplant recipients having an eGFR <30 ml/min/1.73 m2. The median Hb in prevalent transplant recipients was 12.9 g/dl, with 10% of patients having an Hb <10 g/dl. The median systolic and diastolic BP was 136 and 79 mmHg, respectively, with only 25% of patients within guidelines.Transplant function analysed by CKD stages 1–2 (eGFR < 60), 3 (eGFR 30–59), 4 (eGFR 15–29) and 5 (eGFR < 15), shows that these categories account for 24%, 59%, 15% and 2.5% of patients, respectively. Haemoglobin values fall with decreasing eGFR such that of the 2.5% of transplant patients with eGFR <15 ml/min, 27% had an Hb <10 g/dl and 51% <11 g/dl. Control of iPTH was poor in transplant recipients in CKD stages 4 and 5, with 22% and 50% of patients, respectively, having a PTH > 32 pmol/l (=300 ng/l). Patients with failing transplants are less likely to achieve RA targets of key biochemical variables when compared to patients on dialysis. There is still wide variability in the completeness of data returns from individual units. [ABSTRACT FROM AUTHOR]

Forty-one percent of UK patients commence RRT with an Hb <10.0 g/dl. The mean Hb at commencement of RRT is 10.3 g/dl. Eighty-five percent of patients on dialysis in the UK have an Hb ≥ 10.0 g/dl by 6 months after commencement of RRT.The median Hb on haemodialysis in the UK is 11.8 g/dl with an IQR of 10.7–12.8 g/dl. Eighty-six percent of haemodialysis patients in the UK have a Hb ≥ 10.0 g/dl. The median Hb on peritoneal dialysis in the UK is 12.0 g/dl with an IQR of 11.0–12.9 g/dl. Ninety percent of peritoneal dialysis patients in the UK have an Hb ≥ 10.0 g/dl.In the UK, 49% of patients on PD and 48% of patients on haemodialysis have an Hb between 10.5–12.5 g/dl.The median ferritin in UK haemodialysis patients is 413 μg/l (IQR 262–623), 95% of UK haemodialysis patients have a ferritin ≥100 μg/l.The median ferritin in UK PD patients is 256 μg/l (IQR 147–421), 86% of UK peritoneal dialysis patients have a ferritin ≥ 100 μg/l.A higher proportion of HD patients than PD patients receive ESA therapy (88% vs 76%). The ESA dose is higher for HD than PD patients (9204 vs 6080 IU/week). [ABSTRACT FROM AUTHOR]

Comorbidity returns have continued to improve, albeit slowly, with centres running Mediqal software having the highest rates of completeness.Diabetes as a primary renal diagnosis accounted for 20% of those starting RRT, but a further 7% had diabetes present as a comorbid condition. The incidence of smoking remained high at 17% of diabetic patients, which was similar to that found in non-diabetics.Twelve percent of the patients starting RRT had a previous myocardial infarction (MI) and 31% of those aged over 65 years starting RRT had ischaemic heart disease (IHD).Patients starting on peritoneal dialysis (PD) were on average 9 years younger than those on haemodialysis (HD) and had fewer comorbidities present.Patients starting RRT without any comorbidity present had a lower median estimated glomerular filtration rate (eGFR) than those with comorbid conditions.Patients with a previous MI or coronary artery bypass grafting (CABG), started RRT with slightly higher mean haemoglobin than those without comorbid conditions or other comorbid conditions.On univariate survival analysis, diabetes was not associated with an increased risk of death amongst patients aged over 65 years, possibly due to its close association with other comorbidities in this age group.In the multivariate survival analysis, the presence of ischaemic/neuropathic ulcers was the predictor of worst survival, followed by malignancy, previous MI and age per 10 year increment.Smoking was less common in both South Asian and black patients than whites (7 vs 17%) starting RRT. Twenty-three percent of both South Asian and white patients started RRT with IHD compared with only 12% of Black patients. [ABSTRACT FROM AUTHOR]

Many renal units still fail to return blood pressure data to the Renal Registry. In England, Northern Ireland and Wales, the percentage of HD patients achieving the combined blood pressure standard (<140/90 pre-dialysis) averages 43% (inter unit range 16–60%) and post-dialysis (<130/80) average 48% (range 22–66%). On average 27% (range 12–48%) of PD patients achieve the standard of <130/80 and 26% of renal transplant patients (range 16–40%).Over the last 8 years there has been no significant change in systolic or diastolic blood pressure achievement.Better comorbidity data returns are required by the Registry to perform blood pressure survival analyses. [ABSTRACT FROM AUTHOR]

In the 2006 Vascular Access Survey, 51% of all patients commenced renal replacement therapy (RRT) using definitive access. Of patients commencing on haemodialysis HD, 37% commenced with definitive access (31% in the 2005 survey).Of those known to the renal units for a year or more, only half started HD with definitive access. Around 4% of patients currently receiving HD were in-patients. Around 30% of staphylococcal line infections were methicillin resistant Staphylococcus aureus (MRSA), which was similar to the 2005 survey.At 6 months after starting RRT, 76% of live patients were using definitive access [defined as the use of peritoneal dialysis (PD), transplant, arteriovenous fistula (AVF) or arteriovenous graft (AVG)] and at 12 months it was 80%.Of the HD patients starting RRT in April 2005, 65% started using venous catheters, at 6 months this had fallen to 35% and at 12 months to 30%. The use of non-tunnelled lines was <1% by 6 months.The proportion on PD had fallen slightly at 12 months (from 20% to 16%) by which time 11% had received a transplant, 1% had recovered and 18% had died.Data returns for the 2006 survey were returned from 37/74 renal units compared with returns from 62 units in the 2005 survey. [ABSTRACT FROM AUTHOR]