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Patients with chronic renal failure on periodical dialysis frequently are hypertensive. This frequency has increased in relation to the liberalization of diet and to short dialysis with a high sodium concentration in the dialysate. Although various factors influence the pathogenesis of this type of hypertension, volume overload is the most significant. The achievement of an optimal dry weight is still one of the most difficult and important tasks of a dialysis clinic. The reduction in extracellular volume in haemodialysis implies an improvement in dialysis tolerance. The time factor is one of the principal elements in this control, but it is possible, using other elements, to improve tolerance in 4-5 h sessions and to achieve the proper dry weight associated with normotension in most patients.

Background. Hypertension (HTN) is very frequent in patients with renal disease and its prevalence increases as renal failure progresses. Methods. We studied the prevalence of HTN in 1921 patients with different nephropathies. Patients on dialysis and renal transplant patients were not included in the study. HTN was defined as SBP > 140 and/ or DBP > 90 mmHg, or requiring antihypertensive therapy. Results. The prevalence of HTN in the total group of patients with renal diseases was 60.5%, but this prevalence varied widely depending upon the type of underlying nephropathy. The prevalence of HTN was practically universal in patients with renal vascular disease (93%) and in patients with established diabetic nephropathy (87%), and 74% of the patients with polycystic kidney disease, 63% of the patients with chronic pyelonephritis and 54% of the patients diagnosed with glomerulonephritis were hypertensive. The prevalence of HTN in patients with renal insufficiency (80%) is significantly higher than that in patients without renal insufficiency (43% P < 0.001). In a multiple logistic regression analysis, the independent risk factors defining HTN in renal patients were: renal failure, age, the presence of diabetes, hypertriglyceridaemia and proteinuria. Antihypertensive treatment consisted of diet alone in 4% of the patients, one drug in 45%, two drugs in 36%, three medications in 13% and more than three drugs in 2.5%. The angiotensin-converting enzyme (ACE) inhibitors were the most frequently prescribed drug (39% of the patients treated in monotherapy) followed by calcium channel blockers (27%), diuretics (18%) and β-blockers (9%). The most common combined therapy was a diuretic plus an ACE inhibitor. The percentage of patients with BP controlled according to current recommendations for renal patients (BP < 130/85) was very low; SBP in only 49% and DBP in 24%. Control of both was only achieved in 10% of the patients. Conclusions. There is a high prevalence of HTN in renal patients, which depends on the type of nephropathy and the degree of renal failure. Other independent risk factors for HTN in patients with renal disease are: advanced age, the presence of diabetes, hypertriglyceridaemia and the severity of proteinuria. BP control in renal patients is quite poor and should be improved to reduce progression of the renal disease.

(n=370), comparative analyses would be inappropriResults ate. For the group of ‘high-dose’ patients, only 31.4% had haemoglobin levels of 11.0 g/dl; 29.7% had levels Key points from the EBPG between 10.0 and 10.9 g/dl, 21.1% between 9.0 and 9.9 g/dl, and the remaining 17.8% below 9.0 g/dl $ A need for >300 IU/kg/weekly epoetin defines an (Figure 39). The mean serum ferritin level was inadequate response (‘resistance’). 481.2 mg/l (SD=472.9) and the mean transferrin $ Iron deficiency (absolute or functional ) is the most saturation (TSAT) was 25.1% (SD=13.2). Of 313 common cause of an inadequate response to patients for whom serum ferritin values were available, epoetin although patients must be screened for 36 (11.5%) had levels

Locatelli: There has been a striking increase in the and anaemia) and to prepare patients for RRT. incidence of end-stage renal disease ( ESRD) over the Cambi: Our main goal is to keep the patient’s metabolic last 30 years world-wide [1]. The growing proportion state as near to normal as possible. This means checkof elderly patients mainly accounts for the total ing blood pressure, acid-base balance and nutrition, increase in the number of these patients admitted to waiting until these are satisfactory; ensuring correct renal replacement therapy ( RRT ), with a dramatically iron status and avoiding secondary hyperparathyroidhigh morbidity and mortality rate [1–3]. ism. Anaemia will come later and at that point it A number of physiological and metabolic changes should be corrected. The majority of patients are old may contribute not only towards progressive loss of (the mean age of patients starting dialysis is 70 years) renal function but also to increased mortality observed and most of them do not need immediate dialysis thereafter, during the dialytic phase. The detection and treatment if metabolic conditions are stable. correction of these events may slow the progression of Hoenich: In the United Kingdom ( UK ) blood pressure chronic renal insufficiency (CRI ) and delay the need control, nutrition and acid-base control provide the for dialysis. Thus the question of whether therapeutic framework for pre-dialysis patient monitoring. interventions may retard the progression of CRI in Erythropoietin ( EPO) treatment is not widely used in man is extremely important not only clinically, but pre-dialysis patients due to its cost. also in terms of patient suffering and the social and Bommer :E ffective antihypertensive therapy, timely economic impact of regular RRT [4]. installation of vascular access, and appropriate start of dialysis are the targets in treating preuraemic patients. Pre-dialysis—overall objectives

$ 5.3% of the population experienced a vascular access thrombosis. The greatest incidence occurred occurred in the cohort of patients with a synthetic A–V graft (14.5% experiencing thrombosis during the in the cohort of patients with a synthetic A–V graft. A relationship with the haemoglobin levels 5-month period). Those with catheter access had a rate of thrombosis of 5.5%, while only 4.4% of patients has not been shown. $ Nearly 50% of all deaths during the study period with a native AVF had documented thrombosis. Overall, AVF thrombosis rates by achieved haemowere related to cardiovascular causes.

and 26.4% of peritoneal dialysis patients. Table 11 Results summarizes the results by country, and some betweencountry variation is observed. Figure 3 presents aggregKey points from the EBPG ate findings for both cohorts of patients. In 35.1% of patients, the start of dialysis and initiation of epoetin $ Evaluate anaemia in chronic renal failure therapy were simultaneous. Only 7.9% of patients were (CRF ) patients when haemoglobin (Hb) is started on epoetin in the 6 months preceding dialysis, 6 months before’ and ‘>6 months Hb is consistently 25% of haemodialysis patients and >30% of peritoneal dialysis patients started epoetin therapy with haeAs EBPG 1–3 are narrative guidelines for which no moglobin levels between 8 and 8.9 g/dl, and >25% of empirical support is available, the data reported here dialysis patients started treatment below 8 g/dl. These pertain mainly to EBPG 4 [1]. They are complemented starting haemoglobin levels were consistent regardless with additional results that support the main issues in of the relationship between start of dialysis and initithis cluster of guidelines. ation of epoetin therapy for both haemodialysis and The relationship between the start of dialysis and peritoneal dialysis patients (Figure 5). Some variability initiation of epoetin treatment was examined. As shown between Western European countries was observed in Figure 2, the patterns are different for haemodialysis

Quality of life for patient groups. Along with survival and other types of clinical outcome, patients' quality of life is an important indicator of the effectiveness of the medical care that they receive. Quality of life in patients with end-stage renal disease (ESRD) is influenced by the disease itself and by the type of renal replacement therapy. Numerous studies have enabled the identification of the effects of factors such as anemia, age, comorbidity, depression, etc. on quality of life. It is possible to counteract many of these effects, and the earlier this is done, the more effective the results will be. Among replacement therapies, transplantation appears to be the one that gives the best quality of life results for very large groups of patients. In the case of elderly patients or patients with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all the possible factors into account.

Renal artery stenosis after kidney transplantation: Diagnostic and therapeutic approach. Transplant renal artery stenosis (TRAS) is a common complication after transplantation and an important cause of graft dysfunction. Many factors have been implicated as possible causes of TRAS, such as damage from trauma and atherosclerosis. We reviewed all 286 patients transplanted in our unit from January 1990 to July 1997 to study the prevalence, clinical features, and diagnostic and therapeutic approach. Thirteen patients with TRAS were identified, and their mean age was 40 6 15 years. The detected incidence was 4.5%. They were treated with triple therapy (prednisone, azathioprine and cyclosporine A). The mean age of the donors was 28 6 27 years. TRAS was diagnosed within nine months after transplant. All patients were studied with Doppler ultrasound, renography with captopril and angiography. The preferred initial therapy was percutaneous transluminal balloon renal angioplasty. Angioplasty was performed in four patients with good results. Two patients underwent surgery because angioplasty was not possible. Blood pressure control could be achieved with less antihypertensive medication after angioplasty. Transplantectomy was performed in one patient because of surgical complications. In conclusion, most patients with TRAS can be treated successfully with percutaneous transluminal angioplasty as the initial interventional treatment of choice for high-grade renal artery stenosis, and surgical revascularization is indicated when percutaneous transluminal angioplasty cannot be done or is unsuccessful.

The incidence and prevalence of end-stage renal failure in London, with permanent staV. This oYce is run by a ( ESRF ) continue to increase despite the many Managing Director and should issue and collect all Centre advancements achieved in general nephrology. This and Patient Questionnaires, in order to establish the situation is due mainly to ageing of the general popula- European data. There is a Scientific Advisory Board (SAB) composed of expert colleagues from various fields (nephrolo

Background. In endemic areas, visceral leishmaniasis has been identified as an opportunistic infection in patients with derangements in their cellular immune system. Methods. We report a renal transplant patient with visceral leishmaniasis. We also reviewed the previously published cases of 17 organ transplant recipients with this parasitic disease. Results. Visceral leishmaniasis occurred a median time of 8 months after transplantation, and the clinical picture was characterized by fever, splenomegaly, and blood cytopenias. Leishmaniae were detected in bone marrow in 16 of 18 patients and diagnostic serology results were found in 8 of 10 tested patients. Pentavalent antimonials were used to treat 16 patients, five of which developed pancreatitis. Five of 18 patients died, including two untreated patients. Relapses of visceral leishmaniasis occurred in 4 of 13 survivors. Conclusions. In endemic areas, visceral leishmaniasis may complicate the clinical course of organ transplantation and can have fatal consequences, particularly when untreated.

The proportion of centres returning the ERA-EDTA Registry questionnaires has decreased considerably in recent years. Demographic information, based on the response rate of centres in 1994 (44%), does not allow reasonable projections for management of renal failure in Europe. To encourage the participation of non-responding centres, the timing was right to show the powerful impact of the ERA-EDTA Registry as a supra-national registry, by studying patients in renal replacement therapy (RRT) suffering from rare diseases. Four such diseases, Fabry's disease, nephropathy due to cyclosporin (CsA), nephropathy due to cisplatin and scleroderma, were studied using the records of 440665 patients on file up to 31 December 1993. There were 83 patients with Fabry's disease (0.0188%), 85 patients with CsA nephropathy (0.0193%), 120 patients with cisplatin nephropathy (0.0272%) and 625 patients with scleroderma (0.142%). Scleroderma was introduced as a primary renal disease (PRD) in the ERA-EDTA Registry in 1977. Seven patients were accepted for RRT in that year, whereas the number increased to over 50 new patients per year after 1986. More than half of the patients were aged over 55 years, and 68% of them were women. Survival rate of dialysis patients suffering from scleroderma was 22% at 5 years, compared to 51% in patients with standard primary renal diseases. The main causes of death were cardiovascular complications (41%), cachexia (15%) and infection (10%). Survival of first graft in a small number of 28 patients was 44% at 3 years, compared to 60% in standard PRD. Patient survival after first transplant, however, was higher by 32% at 3 years compared to that of dialysis patients. Cisplatin nephropathy was introduced as a PRD in the ERA-EDTA Registry in 1985, and since then six to 19 new patients have been accepted for RRT each year. The main reason for undergoing cisplatin treatment was ovarian (32%) and testicular cancer (21%), and the mean interval from treatment to RRT was 21.5 months, ranging widely from 0.1 to 131 months. Patient survival on dialysis was 22% at 5 years, compared to 51% in patients with standard PRD. Malignancy and cachexia accounted for over 60% of the total number of deaths. CsA nephropathy was introduced as a PRD in the ERA-EDTA Registry in 1985 and, despite its rarity, is of particular interest as a new iatrogenic entity resulting from CsA administration, mainly in solid organ transplantation. In 1985, two new patients commenced RRT in Europe, and the number increased to 59 in 1991-93. The main reason for undergoing CsA treatment was heart (68%) and liver transplant (22%), and the mean interval from treatment to RRT was 50.2 months, ranging from 5 to 90 months. Patient survival on dialysis was 46% at 4 years, compared to 58% in patients with standard primary nephropathies. Cardiovascular causes (48%) and infection (17%) were the main causes of death. Fabry's disease was introduced as a PRD in the ERA-EDTA Registry in 1985, and since the four to 13 new patients per year have commenced RRT in Europe. It is a sex-linked recessive disorder primarily affecting males (87%), and the mean age at start of RRT was 38 years. Proteinuria, skin lesions and painful paresthesiae were the most common presenting symptoms, and over 70% of the patients were hypertensive and had significant cardiovascular problems at RRT. Patient survival on dialysis was 41% at 5 years, compared to 68% in patients with standard primary nephropathies. Cardiovascular complications (48%) and cachexia (17%) were the main causes of death. Graft survival at 3 years in 33 patients was not inferior to that of patients with standard nephropathies (72% vs 69%), and patient survival after transplantation was comparable to that of patients under 55 years of age with standard PRD. (ABSTRACT TRUNCATED)

The aim of this study was to evaluate the quality of life in patients on chronic dialysis and to research the influence of various factors related to treatment and ESRD on quality of life. The cross-sectional study was carried out nationally and 1013 randomly selected stable patients on dialysis were evaluated. The evaluation of quality of life was by the Karnofsky Scale ( KS ) and the Sickness Impact Profile (SIP). Both questionnaires were self-reported. Co-morbidity was evaluated according to the Friedman Comorbidity Index. Adjusted quality of life scores for case-mix differences of several groups of patients were compared. Twenty-six per cent of the patients showed severe quality of life restriction on the Global Score of SIP (score ≥20) and 31% on the KS (score ≤60). The partial categories of the SIP that were more affected were work, recreation and pastimes, home management, and sleep and rest. No significant differences were found relating to dialysis technique, dialysis solution, or dialyser membrane. Greater haemoglobin concentrations were related to better quality of life scores on Physical Dimension and Global Score of SIP. Advanced age and Comorbidity Index were related to worse quality of life scores. We conclude that 25% of the patients showed an important effect of the disease on their quality of life. An increase in haemoglobin was related to better quality of life in dialysis patients. Advanced age and co-morbidity both adversely affected quality of life.

The XXV Report of the EDTA-ERA Registry includes data up to 31 December, 1994 as given on the Centre Questionnaire. This form, which was sent to 2,942 units known in the 34 countries reporting to the Registry, requested summary information on new patients accepted for treatment during the year, patients alive on different forms of therapy on 31 December, kidney transplants performed, and patients who died during the year. The Centre Questionnaire also provided summary data on the number of patients on home versus centre haemodialysis and on special forms of blood purification-haemofiltration, haemodiafiltration, bicarbonate haemodialysis, IPD, CAPD, and CCPD. The Centre Questionnaire also examined the incidence of hepatitis C and its relation to previous blood transfusions in haemodialysis patients, the use of certain treatments in dialysis patients, the incidence of parathyroidectomies, and the use of urea kinetic modelling for haemodialysis prescription. Data provided by the Centre Questionnaires is very up-to-date and gives a panoramic view of policies and practices as well as the incidence and the prevalence of patients and specific problems. However, the most interesting analyses carried out by the Registry require the detailed information that is provided on the individual Patient Questionnaire. The EDTA-ERA Registry contains data up to 31 December 1993 on 466,711 individually reported patients. The number of patients recorded as being alive at the end of 1993 was 117,423. Information derived from this source is given on IgA nephropathy as primary renal disease (PRD). The increasing frequency of older age new patients— the median age of new adult patients starting renal replacement therapy (RRT) in 1992 was 60 years— prompted a study of the survival of patients aged more than 60 years. The progressive tendency to decrease hours of haemodialysis per week has been previously studied [1]. It was decided to examine any relationship between hours of haemodialysis treatment per week and mortality in Europe, as previously reported in the US. The last topic studied in the Patient Questionnaire database has been the re-use of dialysers, hi an attempt to discover the current tendency in Europe of this practice.

BACKGROUND The PRE-dialysis survey on anaemia management (PRESAM) was designed to assess the care given to pre-dialysis patients in the 12 months before haemodialysis or peritoneal dialysis, with emphasis on anaemia management. METHODS For this epidemiological study, a retrospective chart review was conducted for patients who started haemodialysis or peritoneal dialysis between 1 August, 1999 and 6 April, 2000. All adult patients who entered one of the 779 participating centres in 21 European countries, Israel or South Africa were included, except for patients who underwent dialysis only during an acute episode. In addition to demographic characteristics, the study examined the prevalence of anaemia, anaemia management including the use of iron supplementation and epoetin, source of referral to the dialysis centre, comorbidities and major clinical events. RESULTS A total of 4333 new dialysis patients were included in the survey. At the first visit to the dialysis centre, 68% of the patients had a haemoglobin (Hb) concentration < or = 11.0 g/dl; Hb concentration was positively correlated with creatinine clearance rate (r = 0.43, P < 0.01). Patients who received epoetin had a mean Hb concentration of 8.8 g/dl at the start of epoetin treatment, and 96% of these patients had an Hb concentration < or = 11.0 g/dl. Only 26.5% of the patients received epoetin before dialysis. The length of time under the care of a nephrologist was associated with meeting the European Best Practice Guidelines (EBPG) target Hb concentration, as well as receiving epoetin. CONCLUSIONS Few pre-dialysis patients met the EBPG target for Hb concentration, despite regular nephrology care.

This paper describes three recent, related surveys of anaemia management practice in patients with chronic kidney disease, with particular emphasis on initiation of epoetin therapy. It also compares current practice with the European Best Practice Guidelines (EBPG) for anaemia management. The European Survey of Anaemia Management (ESAM) was a 6 month, longitudinal prospective survey of anaemia management in dialysis patients. Although most survey data concerned patients already on dialysis, some retrospective data concerned initiation of dialysis and epoetin therapy. These findings led to the Predialysis Survey of Anaemia Management (PRESAM), a cross-sectional, retrospective survey of patients beginning dialysis, focusing on referral to renal centres and anaemia management in the year preceding dialysis. The Early Renal Insufficiency Referral Survey (ERIRS) is a further cross-sectional survey currently in progress, investigating referral practices during pre-dialysis care. Collectively, these three surveys provide a wealth of data about pre-dialysis anaemia management. ESAM included data from 14527 patients, PRESAM from 4333 patients, and data from 724 patients enrolled in ERIRS have been analysed. The evidence indicates that, at the time of referral to a renal centre, most patients have haemoglobin concentrations well below the levels recommended by the EBPG. Haemoglobin concentrations are lowest in patients referred within the month prior to the initiation of dialysis. Most patients do not start epoetin treatment until dialysis is initiated, despite having haemoglobin concentrations below the level recommended by the EBPG for the initiation of epoetin. Patients who are referred earlier (i.e. those under the care of the renal centre nephrologist for more than a month before the initiation of dialysis) tend to have higher haemoglobin concentrations and are more likely to be receiving epoetin therapy. Such patients are in the minority, however, indicating that pre-dialysis anaemia management practices continue to fall short of the recommendations of the EBPG.

Background. Recent data have suggested the existence of a relationship between the use of synthetic vascular accesses and increased erythropoietin (Epo) requirements. The present study aimed to evaluate the possible role of the type of vascular access in both Epo and intravenous (i.v.) iron requirements. Methods. One-hundred-and-seven individuals without recognized causes of Epo resistance, 62 of them undergoing chronic haemodialysis through native arteriovenous fistulae (AVF) and 45 through PTFE grafts, were retrospectively studied (one-year follow-up). Sixtynine patients, i.e. all but three with a PTFE graft and 27 with native AVF, were taking anti-platelet agents. Doses of i.v. iron and Epo and laboratory parameters were recorded. Results. Erythropoietin and i.v. iron requirements were higher in the patients dialysed through PTFE grafts compared with those with native AVF (Epo: 103.8"58.4 vs 81.0"44.5 Uukguweek, Ps0.025; i.v. iron: 178.9"111 vs 125.9"96 mgumonth, Ps0.01). On a yearly basis, the difference in Epo dose represented a total of 94 582"16 789 U Epoupatientuyear. Moreover, the patients with PTFE grafts received more red blood cell transfusions than patients with native AVF (Ps0.021). No differences between laboratory, dialysis kinetics, demographic or comorbidity parameters were found. The type of vascular access was the best predictor of the requirement of P150 Uukguweek Epo (Ps0.03). Even though the patients who received anti-platelet therapy required more i.v. iron (167.5"103.6 vs 114.5"101.4 mgumonth, Ps0.008) but not more Epo (PsNS), the possibility of an accessory role of anti-platelet agents in the increased Epo requirements with PTFE grafts cannot be ruled out. Conclusions. The use of a PTFE graft and anti-platelet drugs represents a previously undescribed association related to higher Epo and i.v. iron requirements. The association described herein adds new arguments to the debate concerning the choice of vascular access in chronic haemodialysis patients.

Health-related quality of life (QOL) refers to the measure of a patient's functioning, well-being, and general health perception in each of three domains: physical, psychological, and social. Along with survival and other types of clinical outcomes, patient QOL is an important indicator of the effectiveness of the medical care they receive. QOL of patients with end-stage renal disease is influenced by the disease itself and by the type of replacement therapy. Numerous studies have identified the effect of such factors as anemia, age, comorbidity, and depression on QOL. Most of these factors appear during the predialysis period, and the adequate management of some of them could influence patient outcomes. Among replacement therapies, transplantation appears to give the best QOL for large groups of patients. No conclusive data exist to prove differences in QOL between hemodialysis patients and peritoneal dialysis patients. In the case of elderly patients or those with a high degree of comorbidity, the best treatment option should be assessed in each individual case, taking all possible factors into account. Finally, it has been proven that physical and mental function are inversely correlated with the risk for hospitalization and mortality.

Background. The severity of proteinuria is the main predictive factor in the progression of renal failure in chronic nephropathies. Therefore, action aimed at reducing proteinuria should be a priority in the treatment of these patients. Various antihypertensive drugs, in particular the angiotensin-converting enzyme inhibitors (ACEIs), have a greater antiproteinuric effect, although it is difficult to establish whether this is due only to their effect on arterial blood pressure (BP) or to other mechanisms associated with blockade of the renin-angiotensin system (RAS). Methods. The evolution of proteinuria after two successive treatment periods was studied prospectively for 2 years in 22 patients with chronic glomerulonephritis. In period I, which lasted for 12 months, BP was strictly controlled (< 125/75 mmHg) and the patients received random and double-blind treatment with a β-blocker (βB), atenolol; a non-dihydropyridine calcium channel blocker (CCB), verapamil; an ACEI, trandolapril; or a fixed combination of the latter two. In period II, all of the patients received treatment openly for an additional 12 months with a fixed combination of verapamil + trandolapril at half the dose of the preceding period, to obtain conventional control of BP at < 140/90 mmHg. Results. The mean level for basal SBP/DBP was 136 ± 14/86 ± 7 mmHg, which decreased in period I to 121 ± 15/76 ± 8 mmHg (P=0.01) and to 124 ± 5/78 ± 8 mmHg (P < 0.05) at 6 and 12 months of treatment, respectively. There were no differences in the BP reached in the four therapy groups; however, proteinuria only decreased in the patients treated with trandolapril alone or in combination with verapamil. In period II, BP levels rose to 134 ± 10/84 ± 8 mmHg (P < 0.05); this increase in BP was accompanied by an increase in proteinuria in those patients who had received the ACEI alone or in combination in the previous period, while in patients previously treated with a βB or a CCB, proteinuria decreased, in spite of the increase in BP. Conclusions. With equal BP control, treatment with the ACEI trandolapril alone, or in combination with a CCB, has a greater antiproteinuric effect than that obtained with other antihypertensive drugs, but this effect is attenuated if BP is not strictly controlled.

Objective: To study the incidence, prevalence, treatment modalities and prognosis of diabetic patients on renal replacement therapy. Material: We studied all end-stage renal failure (ESRF) diabetic patients on renal replacement therapy in "Area Sanitaria 1" in Madrid from 1978 to 1998. Results: Diabetes mellitus has become the leading cause of ESRF in our health area of Madrid, 30% of all causes of ESRF. Incidence of diabe tics beginning RRT was 33,3 per million population (pmp) in 1998, while in 1993-94 diabetes was 15 % and 21 pmp, respectively, table 1. The propor tion of diabetics on RRT has increased from 7,4 % 1986 to 12,7 % 1998. The prevalence of diabetics on RRT in 1998 was 135 pmp, with an overall prevalence of 1054 pmp. At the mean time, the proportion between incident diabetics type 2/ diabetics on RRT has increased from 15 % in 1987-88, to 54 % in 1993-94 and to 81% in 1997-98, consequently, mean age of diabe tic patients at beginning RRT has increased from 47 years before 1988, 58 in 1989-90, 61 in 1993-94, 62 in 1995-96 and 63 in 1997-98 (Table I). We studied 182 diabetics admitted for renal replacement therapy, 106 males and 76 females, 105 were diabetics type 1 and 77 type 2. Their mean age at RRT beginning was 57 12 years (SD). Hemodialysis (HD) was the first modality of treatment for 128 (70%) diabetics and CAPD for 54. Seventy out of 128 patients on HD were dialyzed in the Hospital Unit, 40% on AFB (acetate free biofiltration) and 58 in two Satellite Units, that means a higher proportion of diabetics on CAPD and on HD in Hospital Unit. Diabetics allocated to CAPD were 5 years, as mean, younger than patients allocated to HD (p

on the correction of anaemia with epoetin [3], iron Results deficiency, whether absolute or functional, was clearly implicated as the major factor responsible for a subKey points from the EBPG optimal response to epoetin therapy [4]. Conversely, inadequate iron stores may result in higher dose $ All chronic renal failure patients must be iron requirements of epoetin as physicians strive to achieve replete to achieve and maintain the target the target haemoglobin. haemoglobin (Hb). Although no definitive test is available, iron $ Adequate iron status is defined as: serum ferritin deficiency or iron overload commonly are measured 100 mg/l, hypochromic red cells 20%]. To achieve these as an index of iron stores, and/or the percentage of targets, the population medians will be: serum hypochromic red cells in circulation (as an index of ferritin 200–500 mg/l and hypochromic red cells the availability of these stores) [1]. Since the required 20%). iron deficiency. Optimal levels are defined as: serum ferritin of $ 41% of patients receiving epoetin in the correction 200–500 mg/l with hypochromic red cells

In evaluating outcomes in end-stage renal disease (ESRD), quality of life has become as important as morbidity and mortality. Various instruments are available to analyse patients' perceptions of the physical, psychological and social domains of health. Non-specific instruments, such as the Sickness Impact Profile, the Karnofsky Scale, and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), have been widely used in evaluating quality of life in various chronic diseases including ESRD. The Kidney Disease Quality of Life (KDQOL) questionnaire and other scales have also have been developed specifically for ESRD patients. Several studies have demonstrated a significant improvement in quality of life after initiation of epoetin treatment in both dialysis patients and those with early renal failure. Quality-of-life scores show a strong positive correlation with haemoglobin concentration. Other factors associated with better quality of life are higher socio-economic level and level of education. However, older age, comorbidity, diabetes, female sex, and unemployment have a negative influence on quality of life. In patients not yet on dialysis, quality of life deteriorates as the glomerular filtration rate decreases. The later the patient is referred to a nephrologist, the worse the quality of life. Recent studies show that quality of life is a prognostic factor for survival. Early and effective treatment of anaemia in ESRD patients is essential in maintaining quality of life both before and after initiation of dialysis.

The objective of this study was to evaluate the modifications that renal transplantation produces on the quality of life (QOL) of patients with chronic renal failure (CRF) previously undergoing hemodialysis (HD) and to analyze the possible factors implicated. A multicenter study of QOL was performed on 1,023 patients undergoing dialysis, using as QOL indicators the Karnofsky Scale (KS) and the Sickness Impact Profile (SIP). Among this group, 93 patients received a renal transplant and QOL was re-studied in them; each subject, therefore, was his own control. In the 88 patients with a functioning graft, an improvement in QOL indices was globally observed; this improvement was much more marked in men than in women, for unclear reasons. Older age and greater prior comorbidity diminished the beneficial effects of transplantation. (Am J Kidney Dis 1998 Jul;32(1):93-100)