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The spectrum of polycystic kidney disease (PKD) comprises a family of inherited syndromes defined by renal cyst formation and growth, progressive renal function loss and variable extrarenal manifestations. The most common form, autosomal-dominant PKD is caused by mutations in one of two genes, PKD1 or PKD2. Recent developments in genomic and proteomic medicine have resulted in the discovery of novel genes implicated in the wide variety of less frequent, recessive PKD syndromes. Cysts are the disease, and overall cystic burden, measured by MRI as total kidney volume, is being established as the best available biomarker of disease progression. Current state-of-the-art therapy is aimed at quality treatment for chronic renal insufficiency and cyst-related complications. Recent therapeutic studies have focused on mechanisms reducing intracellular cyclic AMP levels, blocking the renin-angiotensin-aldosterone system and inhibiting the mTOR-signaling pathway. PKD therapies with vasopressin antagonists and somatostatin analogues result in the reduction of intracellular cAMP levels and have shown limited clinical success, but side effects are prominent. Similarly, mTOR pathway inhibition has not shown significant therapeutic benefits. While the HALT-PKD study will answer questions by the end of 2014 about the utility of renin-angiotensin-aldosterone system blockade and aggressive blood pressure control, the next generation of PKD therapy studies targeting proliferative mechanisms of cyst expansion are already under way. Advances in research on the molecular mechanisms of cystogenesis will help design novel targeted PKD therapies in the future.

Background/Aims: Systemic thrombolysis for acute ischaemic stroke is the standard of care in the UK. In the absence of trial data on the safety and efficacy of this treatment in patients with end-stage renal disease, we captured the views of UK nephrologists to highlight health care policy and research objectives. Methods: Consultant nephrologists participated in an internet-based questionnaire. Respondents were asked about their involvement in thrombolysis decisions, safety concerns in dialysis patients, views on stroke rehabilitation and opinions on antiplatelet and warfarin use for stroke prevention. Results: 122/433 (28%) clinicians responded. 75% wanted involvement in thrombolysis decisions although just 10% gave input in practice. 64% expressed a high degree of concern (≥7/10) regarding intracranial bleeding risk in haemodialysis (HD). Overall risks of intra- and extracranial bleeding were rated lower in peritoneal dialysis (PD; p < 0.001). 85% felt the HD schedule impacted negatively on rehabilitation, whereas 63% felt this was the case in the context of PD (p = 0.001). More clinicians favoured warfarin for stroke prevention in PD patients with atrial fibrillation in comparison with HD patients (79 vs. 66%, p = 0.04). Conclusion: The majority of nephrologists want involvement in thrombolysis decisions relevant to their patients. Concerns about bleeding risks with thrombolysis are high and we identify a vital need to improve access to stroke rehabilitation in the UK, especially in HD patients.

To describe the demographics of the paediatric RRT population under the age of 16 years in the UK and to analyse changes in demography with time.Data were collected from all 13 paediatric renal centres within the UK. A series of cross-sectional and longitudinal analyses were performed to describe the demographics of paediatric RRT patients.A total of 856 children and young people under 18 with ERF were receiving treatment at paediatric nephrology centres in 2011. At the census date, 80.1% had a functioning transplant, 10.5% were receiving peritoneal dialysis (PD) and 9.4% were receiving haemodialysis (HD). In patients aged16 years the prevalence of ERF was 56.8 pmarp and the incidence 8.3 pmarp. Analysis of trends over the last 15 years shows that both incidence and prevalence are increasing. A third of the prevalent patients had one or more reported comorbidities. At transfer to adult services, 86% of patients had a functioning renal transplant. Pre-emptive transplantation was seen to occur in 31% of children starting RRT under 16 years, with lower rates seen in girls and ethnic minorities. Survival in childhood amongst children starting RRT was the lowest in those aged less than 2 years.The data provided in this report show increasing trends over 15 years in the incidence and prevalence of established renal failure. This is important for the planning of the provision of care for children needing renal replacement therapy. Further research is required to understand the gender and ethnic differences in pre-emptive transplantation rates and the reduced survival amongst children aged less than 2 years.

To describe the demographics of the paediatric renal replacement therapy (RRT) population under the age of 18 years in the UK and to analyse changes in demography with time.Data were collected from all 13 paediatric renal centres within the UK. A series of crosssectional and longitudinal analyses were performed to describe the demographics of paediatric RRT patients.A total of 861 children and young people under 18 with established renal failure (ERF) were receiving treatment at paediatric nephrology centres in 2012. At the census date, 80.2% had a functioning transplant, 10.6% were receiving haemodialysis (HD) and 9.2% were receiving peritoneal dialysis (PD). In patients aged16 years the prevalence of ERF was 56.7 pmarp and the incidence 9.0 pmarp. A third of the prevalent patients had one or more reported comorbidities. At transfer to adult services, 81.5% of patients had a functioning renal transplant. Preemptive transplantation was seen to occur in a third of children starting RRT under 16 years, with lower rates seen in girls and ethnic minorities. Over the past 15 years for those referred early, there has been a rise in pre-emptive transplantation rates, rising from 26.2% in 1998-2002 to 36.3% in 2008-2012. Over the same period there has also been an increase in living donation from 7.1% to 18%. Survival in childhood amongst children starting RRT was the lowest in those aged less than two years.The findings of this report are similar to last year with continued improvement in data quality and electronic submission of data returns. The data provided in this report show slowly increasing trends of incidence and prevalence in children with established renal failure.

This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT) in the UK in 2010 and the incidence rates for RRT in Primary Care Trusts and Health Boards (PCT/HBs) in the UK.The basic demographics and clinical characteristics are reported on patients starting RRT from all UK renal centres. Presentation time, defined as time between first being seen by a nephrologist and start of RRT, was also studied. Age and gender standardised ratios for incidence rates in PCT/HBs were also calculated.In 2010, the incidence rates in the UK and England were similar to 2009 at 107 per million population (pmp). The incidence rate fell in Scotland (from 104 pmp to 95 pmp), increased in Northern Ireland (from 88 pmp to 101 pmp) and Wales (from 120 pmp to 128 pmp). There were wide variations between PCT/HBs in standardised incidence ratios. The median age of all incident patients was 64.9 years (IQR 51.0, 75.2). For transplant centres this was 63.1 years (IQR 49.7, 74.2) and for non-transplanting centres 66.5 years (IQR 52.9, 76.0). The median age for non-Whites was 57.1 years. Diabetic renal disease remained the single most common cause of renal failure (24%). By 90 days, 68.3% of patients were on haemodialysis, 18.1% on peritoneal dialysis, 7.7% had had a transplant and 5.9% had died or stopped treatment. The mean eGFR at the start of RRT was 8.7 ml/ min/1.73 m(2) which was similar to the previous three years. Late presentation (90 days) fell from 28.2% in 2005 to 20.6% in 2010. There was no relationship between social deprivation and presentation pattern.Incidence rates have plateaued in England over the last five years. They have fallen in Scotland and fallen and then risen again in Northern Ireland and Wales. Wales continued to have the highest incidence rate of the countries making up the UK.

Background: The UK Renal Association (RA) and National Institute for Health and Clinical Excellence (NICE) have published clinical practice guidelines which include recommendations for management of anaemia in established renal failure. Aim: To determine the extent to which the guidelines for anaemia management are met in the UK. Methods: Quarterly data were obtained regarding haemoglobin (Hb) and factors that influence Hb from renal centres in England, Wales, Northern Ireland (EWNI) and the Scottish Renal Registry for the incident and prevalent renal replacement therapy (RRT) cohorts for 2010. Results: In the UK, in 2010 53.6% of patients commenced dialysis therapy with Hb ≥10.0 g/dl (median Hb 10.1 g/dl). The median Hb of haemodialysis (HD) patients was 11.5 g/dl with an interquartile range (IQR) of 10.5–12.3 g/dl. Of HD patients 84.6% had Hb ≥10.0 g/dl. The median Hb of peritoneal dialysis (PD) patients in the UK was 11.6 g/dl (IQR 10.6–12.5 g/dl). Of UK PD patients, 87.2% had Hb ≥10.0 g/dl. The median ferritin in HD patients in EWNI was 444 µg/L (IQR 299–635) and 96% of HD patients had a ferritin ≥100 µg/L. The median ferritin in PD patients was 264 µg/L (IQR 148–426) with 86% of PD patients having a ferritin ≥100 µg/L. In EWNI the mean Erythropoietin Stimulating Agent (ESA) dose was higher for HD than PD patients (9,020 vs. 6,202 IU/week). Conclusions: Of prevalent HD patients, 52.7% had Hb ≥10 and ≤12 g/dl. Of prevalent PD patients, 54.3% had Hb 10.5–12.5 g/dl.

Background and Aims: Cardiovascular disease is the leading cause of death among end-stage renal disease (ESRD) patients with hypercholesterolemia as a major cause. A few studies have demonstrated counter-intuitive findings known as reverse epidemiology where normal levels of cholesterol are associated with higher levels of mortality. The purpose of this study was to determine if there are reverse epidemiological associations between lipid risk factors and mortality in ESRD patients. Methods: ESRD (n = 438) patients were recruited from 4 outpatient dialysis units. Patients were tracked for 36 months until study completion or death with mortality status as the outcome measure. Results: Analysis of covariance revealed significant differences at posttest and reverse epidemiological effects for total cholesterol (p = 0.0001), low-density lipoprotein cholesterol (LDL) (p = 0.023), LDL particle number (p = 0.0001), LDL size (p = 0.009), triglycerides (p = 0.0001), and very low-density lipoprotein cholesterol (p = 0.036). A step-wise linear regression revealed weak, but significant predictors of mortality with total cholesterol (β = 0.263, p = 0.017) and LDL (β = –0.177, p = 0.045). A Cox death hazard ratio revealed LDL size as a significant predictor of mortality in this study. Conclusions: Our study discovered reverse epidemiology in a number of lipid variables. Additionally regression revealed that LDL and total cholesterol were predictors of mortality with lower levels being more predictive of death.

Excellent results of transplantation in elderly recipients, together with regulatory requirements encourage continued consideration of this modality. The organ shortage compels the use of deceased-donor kidneys and may be a suboptimal therapy. However, the elderly patient may not tolerate the prolonged wait for an optimal organ. While individual comorbidities can be evaluated, patient selection requires the transplantation team to render a judgment based on the candidate’s overall condition, which is best correlated with the ability to accomplish activities of daily living and to perform moderate exercise. Psychosocial considerations are complex in the elderly patient because of frequent dementia, absence of a sufficient support mechanism and the need for more resources than those required by younger patients. After transplantation, appropriate management of immunosuppression typically entails lower doses in elderly patients, a logical consequence of immunosenescence. Transplantation should not be considered an acceptable exercise in futility when the ability to offer this life-saving therapy to other patients will be adversely affected by doing so.

Background: There is no clinical classification of immunoglobulin A nephropathy (IgAN) in clinical practice. In this study, we used receiver-operating characteristic (ROC) analysis to create accurate clinical grades based on clinical parameters associated with the development of end-stage renal disease (ESRD) in IgAN patients. Methods: We performed a retrospective analysis of 116 patients with IgAN. The association between clinical variables and progression to ESRD was examined. Results: Logistic regression analysis indicated that 24-hour urinary protein excretion (UPE) and the estimated glomerular filtration rate (eGFR) at the time of renal biopsy (RBx) were independently associated with the development of ESRD. When combining UPE and eGFR, the areas under the curve were superior to those for UPE or eGFR alone. Moreover, two-graph ROC analysis indicated that the threshold values for UPE and eGFR in predicting future ESRD were 1.0 g/day and 64.0 ml/min/1.73 m2, respectively. Of note, the patients were classified into 4 grades by levels of UPE and/or eGFR, and the OR for risk of ESRD rose significantly from grade I to grade IV. Conclusion: The combination of UPE and eGFR at the time of RBx can improve the predictive accuracy of risk for subsequent ESRD in IgAN patients.

The composite of end stage renal disease (ESRD), doubling of serum creatinine and (renal) death, is a frequently used endpoint in randomized clinical trials in nephrology. Doubling of serum creatinine is a well-accepted part of this endpoint because a doubling of serum creatinine reflects a large sustained change in glomerular filtration rate (GFR) and predicts the development of ESRD. Although doubling of serum creatinine is frequently used, the validity of using this outcome as part of a composite endpoint is hampered by various factors. Firstly, serum creatinine may reflect changes in muscle mass unrelated to true GFR changes. Secondly, changes in serum creatinine may reflect hemodynamic changes in renal perfusion and not a structural effect on renal function. Finally, doubling of serum creatinine is an arbitrary choice and different proportional changes may represent a better indicator for ESRD. In this minireview, each of these factors will be discussed and recommendations are made for interpretation of clinical trials using doubling of serum creatinine as a composite endpoint in nephrology trials. Copyright (C) 2011 S. Karger AG, Basel

Aims: To describe the demographics of the paediatric RRT population under the age of 16 years in the UK and to analyse changes in demography with time. Methods: Extraction and analysis of data from the UK Renal Registry (UKRR). Results: There were 751 children Conclusions: The paediatric ERF population continued to expand with a slow increase in both incidence and prevalence rates. The high incidence in patients from ethnic minority groups will lead to a greater proportion of the population being from these groups in time. To maintain the high proportion of engrafted patients it will be necessary to encourage living donation in the ethnic minority population.

Introduction: RRT incidence rates and the proportion of patients using a home dialysis modality (peritoneal or home haemodialysis) varies widely between centres and persists even after area differences in age, ethnicity and social deprivation structure are taken into account. A nationwide survey was undertaken to identify possible drivers of this variation. Methods: A systematic literature review followed by a two-stage Delphi consensus technique was employed to identify renal centre characteristics and practice patterns that may be important in determining either RRT incidence or home modality usage. Results: All 72 (100%) of UK adult renal centres responded. Questions about staffing numbers, interface with primary care, interface with other secondary care sites, capacity within the HD programme, constituents of pre-dialysis education programmes, conservative management programmes, range of treatments available, dialysis access and training and physician attitudes to home modalities were included. Conclusions: There was wide variation in practice patterns and centre characteristics across the UK. Overall, physician enthusiasm for home dialysis modalities was greater than the actual usage of home dialysis.

Background: Renal transplantation is recognised as being the optimal treatment modality for many patients with end stage renal disease. This analysis aimed to explore the equity of

Background: The UK Renal Association (RA) and National Institute for Health and Clinical Excellence (NICE) have published Clinical Practice Guidelines which include recommendations

Introduction: This chapter describes the characteristics of adult patients on renal replacement therapy (RRT) in the UK in 2009. The prevalence rates per million population (pmp) we

Chronic inflammation is closely linked to several complications of chronic kidney disease (CKD), such as vascular calcification, accelerated atherosclerosis, loss of appetite, insulin resistance, increased muscle catabolism and anemia. As a consequence, inflammation is a predictor of mortality in this group of patients. Specific causes of the activation of the immune system in CKD are largely unknown. Endotoxin (ET) release to the circulation represents a potentially important target for interventions aiming to reduce mortality in CKD patients. In this minireview, we propose that there are several potential sources of endotoxemia in CKD and that gut translocation, leading to the generation of ligands of the innate immune response, represents a potentially reversible cause. Prevention of endotoxemia, through treating foci of ET (periodontal disease, catheters, vascular access) or reducing translocation from the gut, will potentially reduce the inflammatory response.

Autosomal dominant polycystic kidney disease (ADPKD) is the most common mendelian disorder of the kidney and accounts for ∼5% of end-stage renal disease in North America. It is characterized by focal development of renal cysts which increase in number and size with age. Mutations of PKD1 and PKD2 account for most cases. Although the clinical manifestations of both gene types overlap completely, PKD1 is associated with more severe disease than PKD2, with larger kidneys and earlier onset of end-stage renal disease. Furthermore, marked within-family renal disease variability is well documented in ADPKD and suggests a strong modifier effect from as yet unknown genetic and environmental factors. In turn, the significant inter- and intra-familial renal disease variability poses a challenge for diagnosis and genetic counseling. In general, renal ultrasonography is commonly used for the diagnosis, and age-dependent criteria have been defined for subjects at risk of PKD1. However, the utility of the PKD1 ultrasound criteria in the clinical setting is unclear since their performance characteristics have not been defined for the milder PKD2 and the gene type for most test subjects is unknown. Recently, highly predictive ultrasound diagnostic criteria have been derived for at-risk subjects of unknown gene type. Additionally, both DNA linkage and gene-based direct sequencing are available for the diagnosis of ADPKD, especially in subjects with equivocal imaging results, a negative or indeterminate family history, or in younger at-risk individuals being evaluated as potential living related kidney donor. This review will highlight the utility and limitations of clinical predictors of gene types, imaging- and molecular-based diagnostic tests, and present an integrated approach for evaluating individuals suspected to have ADPKD.

The current review collates what is already known of the genetics of chronic kidney disease (CKD), and focuses on new trends in genome-wide assessment of the inherited component of susceptibility to this condition. Early efforts to identify kidney disease susceptibility genetic loci using linkage and candidate gene strategies proved disappointing. More recently, genome-wide association studies have yielded highly promising results suggesting a number of potential candidate genes and genomic regions that may contribute to the pathogenesis of CKD. Renal failure susceptibility genes identified by these methods, such as MYH9, have yielded novel insights into the pathogenesis of CKD. Genome-wide association studies of CKD are beginning to define the genomic architecture of kidney disease and will impact our understanding of how genetic variation influences susceptibility to this condition.

The worldwide high prevalence of chronic kidney disease (CKD) and the increasing number of patients reaching end-stage renal disease (ESRD) are a matter of major concern. The most widely accepted classification system of CKD is that proposed by the Kidney Disease Outcomes Quality Initiative (KDOQI) in 2002. When applying this system, it has become apparent that the prevalence of CKD is particularly high in elderly subjects. The fact that this system is mainly based on estimated glomerular filtration rate (eGFR), subdividing the severity of CKD into five stages, is a matter of debate. A main issue is that although a reduced eGFR is often encountered in elderly subjects, most of these subjects do not have a renal disease leading to an increased risk of ESRD, i.e. the predictive power of ESRD is unsatisfactory. Recent advances have been put forward to improve (1) estimation of GFR and (2) prediction of ESRD. In this review, we discuss the currently available data with a focus on the elderly and propose an improved classification system of CKD which is characterized by a substantially better diagnostic accuracy for progression to ESRD. This is simply and cost-effectively accomplished by subdividing stage 3 CKD into two groups (eGFR 30–44 and 45–59 ml/min/1.73 m2) and by complementing all levels of eGFR with information about urinary albumin excretion, i.e. whether normoalbuminuria, microalbuminuria, or macroalbuminuria is present. The consequence should be a revision of the 2002 KDOQI CKD classification system according to these findings, which would be a significant step forward, particularly for elderly CKD patients.

Background: First-degree relatives (FDRs) of chronic kidney disease (CKD) patients have a high prevalence of CKD and its risk factors. We evaluated adult FDRs of end-stage renal disease (ESRD) patients for the prevalence of CKD and its risk factors. Methods: Adult FDRs of ESRD patients were screened. Patients Results: 606 FDRs of 145 index patients were screened; mean age was 39.8 years and 53.3% were male, 26 obese and 122 overweight. 29.7% had hypertension and 3.6% diabetes mellitus. Screening identified new cases of hypertension (21.5%), diabetes mellitus (2.0%), impaired fasting glucose (22.4%) and hypercholesterolemia (18.8%). 5.9% had proteinuria (≧1+). 61.2% of FDRs had eGFR in stage 1, 34.7% in stage 2, 3.6% in stage 3, and 0.5% in stage 4–5. 8.6% had CKD (88.5% were unaware). On multivariate analysis, older age, female sex, proteinuria and uncontrolled blood pressure had a significant association with eGFR 2. Conclusion: In India, CKD and its risk factors show a familial clustering, and screening of FDRs of ESRD patients will be a viable option for a CKD preventive program.

Background: International comparisons between renal registries are important to highlight epidemiological and practice differences in RRT provision between countries. This report aims to compare the rates of RRT incidence and prevalence in the UK with a number of different countries. Methods: Data from 19 countries or regions between 2003 and 2007 from four international renal registries were analysed. Rates of RRT incidence, prevalence, transplantation and dialysis modality were compared. A crude mortality rate for each country was calculated. Results: Despite continued growth, the UK ranked 16th highest in incidence rate and 15th in prevalence rate in 2007. This may partly be related to successful primary care preventing stage 5 CKD. The UK had the 8th fastest rate of increase in RRT prevalence of 18 countries (4.2%/ year). The age profile of UK RRT patients was comparable with other countries. The UK had the 6th highest use of home dialysis therapies. The UK has the 8th highest incidence and 9th highest prevalence rate of kidney transplantation of 16 countries. Conclusion: Meeting the growing demand for RRT is a problem for all countries that choose to offer it. The UK continues to provide for growth in demand for RRT.

Aims: To describe the demographics of the paediatric RRT population in the UK and analyse changes in demographics with time. Methods: Extraction and analysis of data from the UK Paediatric Renal Registry and the UK Renal Registry (UKRR). Results: The UK paediatric established renal failure (ERF) population in December 2008 was 905 patients. The prevalence under the age of 16 years was 56 per million age related population (pmarp) and the incidence 7.4 pmarp. The incidence and prevalence for South Asian patients was much higher than that of the White and Black populations. Renal dysplasia was the most common cause of ERF accounting for 33% of prevalent cases. Diseases with autosomal recessive inheritance were a common cause of ERF in all ethnic groups, 23.5% of prevalent and 18% of incident cases. Whilst the incidence and prevalence of diseases with autosomal recessive inheritance in the South Asian population was 3 times that of the white population, this was not the sole reason for the increased proportion of South Asian patients with ERF, as diseases with no defined inheritance were twice as common in this ethnic group than in White patients. Prevalent mortality stood at 9.4%. Most deaths were in patients presenting with ERF early in life and mortality varied markedly according to the aetiology of ERF. The proportion with new grafts from living donors has steadily risen to 54%. Children from ethnic minority groups were less likely to have an allograft and living donation was less frequent in this population. For those on dialysis, 56% were receiving peritoneal dialysis. This was the main treatment modality for patients under 4 years of age. Conclusions: The paediatric ERF population continued to expand slowly. Incidence and prevalence rates were stable and similar to other developed nations. The high incidence in patients from ethnic minority groups will lead to a greater proportion of the population being from these groups in time. To maintain the high proportion of engrafted patients it will be necessary to encourage living donation in the ethnic minority population. Case note analysis of the factors involved in mortality would be valuable.

Background: A preliminary review of the UK Renal Registry (UKRR) pre-RRT study data revealed results suggesting that, for some patients, the date of start of renal replacement thera

Introduction: This chapter describes the characteristics of adult patients on renal replacement therapy (RRT) in the UK in 2008 and the prevalence rate per million population (pmp) in Primary Care Trusts and local authorities (Council Areas or District Councils) (PCT/LAs) were calculated. Methods: Complete data were electronically collected from all 72 renal centres within the UK. A series of cross-sectional and longitudinal analyses were performed to describe the demographics of prevalent RRT patients in 2008 at centre and national level in the UK. Age and gender standardised ratios of actual to expected for prevalence rates in PCT/LAs were calculated. Results: There were 47,525 adult patients receiving RRT in the UK on 31/12/2008, equating to a UK prevalence of 774 pmp. This represents an annual increase in prevalence of approximately 4.4% although there was significant variation between PCT/LA areas. The pmp growth rate from 2007 to 2008 for prevalent patients by treatment modality in the UK was 5.9% for haemodialysis (HD), a fall of 9.2% for peritoneal dialysis (PD) and growth of 4.6% with a functioning transplant. Over the long term (1982–2007), the steady growth in transplant prevalent numbers was maintained at 4%. There was a slow but steady decline in PD patient numbers from 1999 onwards. Median RRT vintage was 5.3 years. The median age of prevalent patients was 57.3 years (HD 65.5 years, PD 61.0 years and transplant 50.4 years). For all ages, prevalence rates in males exceeded those in females peaking in the 75–79 years age group at 2,582 pmp for males and 70–74 years age group at 1,408 pmp for females. The most common identifiable renal diagnosis was biopsy-proven glomerulonephritis (16.0%), followed by diabetes (14.1%). Transplantation was the most common treatment modality (47%) followed closely by HD (43%). However, HD was increasingly common with increasing older age at the expense of transplantation. Conclusions: The HD and transplant population continued to expand whilst the PD population contracted. There was national, regional and dialysis centre level variation in prevalence rates. This has implications for service planning and ensuring equity of care for RRT patients.

Background: The UK Renal Association (RA) and National Institute for Health and Clinical Excellence (NICE) have published Clinical Practice Guidelines which include recommendations for management of anaemia in established renal failure. Aims: To determine the extent to which the guidelines for anaemia management are met in the UK. Methods: Quarterly data (haemoglobin (Hb) and factors that influence Hb) extracts from renal centres in England, Wales, Northern Ireland (EWNI), and annual data from the Scottish Renal Registry for incident and prevalent renal replacement therapy (RRT) cohorts for 2008 were analysed by the UK Renal Registry (UKRR). Results: In the UK, in 2008 57% of patients commenced dialysis therapy with Hb ≥ 10.0 g/dl (median Hb 10.2 g/dl). For incident patients the Hb at 3 and 6 months of dialysis treatment was 11.4 and 11.7 g/dl respectively. The median Hb of haemodialysis (HD) patients was 11.6 g/dl with an interquartile range (IQR) of 10.6–12.5 g/dl. Of HD patients 85% had a Hb ≥ 10.0 g/dl. The median Hb of peritoneal dialysis (PD) patients in the UK was 11.7 g/dl (IQR 10.8–12.6 g/dl). Of UK PD patients 89% had a Hb ≥ 10.0 g/dl. The median ferritin in HD patients in EWNI was 436 mg/L (IQR 289–622) and 95% of HD patients had a ferritin ≥ 100 mg/L. The median ferritin in PD patients was 246 mg/L (IQR 141–399) with 84% of PD patients having a ferritin ≥ 100 mg/L. In EWNI the mean ESA dose was higher for HD than PD patients (9,166 vs. 6,302 IU/week). Conclusions: Last year for the flrst time a small fall (from 85.9% in 2006 to 85.6% in 2007) in the % of HD patients with a Hb of ≥ 10 g/dl which was thought to be related to the implementation of the new Hb Standard which has a target range of 10.5–12.5 g/dl was seen. This year attainment of Hb ≥ 10 g/dl in HD patients fell again slightly to 85.3%. In HD patients, 54% of patients had a Hb ≥ 10.5 and ≤ 12.5 g/dl compared with 53% in the 2008 Report.

Background/Aims: Inpatient initiation of chronic hemodialysis is considered undesirable because of cost and possible harms of hospitalization. We examined the patient characteristics and outcomes associated with inpatient initiation. Methods: In a prospective cohort study of incident dialysis patients, the independent association of inpatient hemodialysis initiation with patient outcomes was assessed in multivariable analyses with adjustment for patient characteristics and propensity for inpatient initiation. Results: A total of 410 of 652 (63%) hemodialysis patients began as inpatients; uremia and volume overload were the most commonly documented reasons. Compared to outpatients, inpatients were more likely to be unmarried, report less social support, have multiple comorbidities and be referred to a nephrologist 4 months or less prior to initiation. Inpatient initiation was protective for subsequent all-cause hospitalization (incidence rate ratio (IRR) = 0.92, confidence interval (CI) 0.89–0.94); this was most pronounced among those who had the highest propensity for inpatient initiation (IRR = 0.66, CI 0.56–0.78), including those referred late to nephrology. Similar results were found for infectious hospitalization. Mortality [hazard ratio = 1.03, CI 0.82–1.30] and cardiovascular events were not significantly different for inpatients versus outpatients. Conclusion: Inpatient hemodialysis initiation has a protective association with hospitalization among those patients referred late to nephrology, with multiple comorbidities and/or little social support.

Background: Since their introduction, the use of drug-eluting stents (DES) has increasingly become standard practice due to their decreased rates of in-stent restenosis and target lesion revascularization (TLR) rates in comparison to bare metal stents (BMS). However, these benefits have not been reproduced in patients with severe renal disease (SRD). This study compared TLR rates in patients with severe renal insufficiency treated with DES vs. BMS. Methods: Between 2003 and 2006, we collected data on 6,220 consecutive patients receiving either DES or BMS. Both groups were similar in angiographic and clinical variables. TLR rates at 270 days and 1 year were then compared between patients receiving DES or BMS with varying creatinine clearance (CrCl). Results: At 1 year after PCI, TLR rates were significantly lower for DES in patients with CrCl >60 (5 vs. 9.3%; p < 0.0001). However, in patients with CrCl Conclusion: While DES showed improved clinical outcomes in patients with normal and mildly impaired renal function, they showed no benefit over BMS in patients with moderate to severe renal insufficiency. Coupled with the possibly increased risk of late stent thrombosis with DES, BMS may be a more appropriate and safer stent in this population.

Background/Aims: In diabetics with end-stage renal disease (ESRD), risk of death has been reported to be non-constant after the first dialysis, and different outcomes have been observed between genders. We assessed the impact of type 2 diabetes (T2DM) on mortality in dialysis regarding its differential effect by gender using time-dependent analyses. Methods: All T2DM and non-diabetic (no-DM) patients who started dialysis in two renal units in Lyon, France, between January 1, 1995, and December 31, 2007, were included. In multivariate analyses, the Cox model and Shoenfeld residual approach were used to assess the effect of T2DM on dialysis mortality by gender. Results: We included 235 T2DM (males: 57.9%) and 480 no-DM (males: 65.6%) patients. In males, the adjusted hazard ratio (aHR) for death in T2DM versus no-DM was 0.83 (p = 0.20) and was constant over time after the first renal replacement therapy (RRT) (p = 0.88). In females, aHR for death in T2DM versus no-DM patients was not constant over time (p = 0.002). It was 0.64 (p = 0.13) within the first year after the first RRT and 2.10 (p = 0.002) after the first year. Evolutions with time of these aHR by gender were significantly different (p = 0.009). Conclusions: T2DM was associated with death only in females. This association was not constant over time after the first dialysis.

Background: Patients with end-stage renal disease receiving renal replacement therapy are at higher risk of infection with hepatitis B, C and HIV viruses as compared to the general population. Early screening, education and vaccination potentially reduce the risk of acquiring these viruses and therefore future morbidity and mortality. We have sought to establish the opinions, perceptions and understanding of patients regarding the routine testing for blood-borne viruses (BBV) to help improve testing strategies. Methods: An anonymised survey was conducted in all local dialysis patients that asked their understanding, knowledge and opinions on BBV screening and counselling. Results: 55.3% (167/302) of all local dialysis patients responded to the survey. 55.1% of these patients knew that they had been screened for BBV and only 12.6% indicated that they had received any counselling prior to testing. However, 74.3% answered that they would be happy to be tested without consent or counselling. Conclusion: The majority of the patients had not received adequate information regarding BBV screening, but most were content with regular viral screening after initial counselling and consent. Information during pre-dialysis sessions may be an appropriate way of educating patients about the importance of BBV.

These analyses examine survival from the start of renal replacement therapy (RRT), based on the total incident UK dialysis population reported to the Registry, including the 21% who started on PD and the 5% who received a pre-emptive transplant. Survival of prevalent patients and changes in survival between 1997-2006 are reported. The article includes a discussion on the technical definition for the date of start of both PD and HD.Survival was calculated for both incident and prevalent patients on RRT and compared between the UK countries after adjustment for age. Survival of incident patients (starting during 2006) was calculated with and without a 90 day RRT start cut off. Survival of incident patients is shown with and without censoring at transplantation. Both the Kaplan-Meier and Cox adjusted models were used to calculate survival. Causes of death were analysed for both groups. Relative risk of death was calculated compared with the general UK population.The 2006 unadjusted 1 year after 90 day survival for patients starting RRT was 86%. In incident 18-64 year olds the unadjusted 1 year survival had risen from 85.9% in 1997 to 91.5% in 2006 and for those agedor = 65 it had risen from 63.8% to 72.9%. The age adjusted survival of prevalent dialysis patients rose from 85% in 2000 to 89% in 2007. Diabetic patient survival rose from 76.6% in 2000 to 84.0% in 2007. The relative risk of death on RRT compared with the general population was 30 at age 30 years compared with 3 at age 80 years. In the prevalent RRT dialysis population, cardiovascular disease accounted for 34% of deaths, infection 20% and treatment withdrawal 14%.Incident and prevalent patient survival on RRT in all the UK countries for all age ranges and also for patients with diabetes continued to improve. The relative risk of death on RRT compared with the general population has fallen since 2001. Death rates on dialysis in the UK remained lower than when compared with a similar aged population on dialysis in the USA.

This chapter describes the characteristics of adult patients starting renal replacement therapy (RRT) in the UK in 2007 and the acceptance rate for RRT in Primary Care Trusts (PCT) or equivalent Health Authority (HA) areas in the UK.The basic demographics are reported for all UK centres and clinical characteristics of patients starting RRT from all except 1 centre in the UK. Late presentation, defined as time between first being seen by a nephrologist and start of RRT being90 days was also studied. Age and gender standardised ratios for acceptance rate in PCTs or equivalent HAs were calculated.In 2007, the acceptance rate in the UK was 109 per million population (pmp) compared to 111 pmp in 2006. Acceptance rates in England (107 pmp), Scotland (108 pmp) and Northern Ireland (105 pmp) have fallen slightly, whilst that in Wales (140 pmp) has risen. There were wide variations between PCTs/HAs with respect to the standardised ratios which were lower in more PCTs in the North West and South East of England and higher in London, the West Midlands and Wales. The median age of all incident patients was 64.1 years and for non-Whites 57.1 years. There was an excess of males in all age groups starting RRT and nearly 80% of patients were reported to be White. Diabetic renal disease remained the single most common cause of renal failure (21.9%). By 90 days, 67.4% of patients were on haemodialysis, 21.3% on peritoneal dialysis, 5.2% had had a transplant and 6.1% had died or had stopped treatment. The incidence of late presentation in those centres supplying adequate data was 21%.The acceptance rate has fallen in England, Northern Ireland and Scotland but continues to rise in Wales with wide variations in acceptance rate between PCTs/HAs.