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Several sociodemographic and clinical variables are known to influence the health-related quality of life (HRQOL) of patients with kidney disease, yet the relationship between psychological factors and the HRQOL measured by the Kidney Disease Quality of Life Short-Form (KDQOL-SF) is incompletely understood. The objective of this study was to examine the relationship between psychosocial status (depressive symptoms, trait anxiety, and social support) and KDQOL-SF scales in hemodialysis (HD) patients by controlling the effects of sociodemographic and clinical variables. The HRQOL of 194 patients from 43 dialysis centers in Spain was assessed by completing the KDQOL-SF, and evaluating depressive Symptoms (Cognitive Depression Index), trait anxiety (Trait Anxiety Inventory) and degree of social support (Scale of Perceived Social Support). We also recorded several sociodemographic and clinical variables. Two regression models were estimated for each of the 19 scales in the KDQOL-SF. In the first model, we only included sociodemographic and clinical-factors, while the second model also took into consideration psychosocial variables. These last factors (trait anxiety and depressive symptoms, not social support) were found to increase the proportion of explained variability, with highest standardized regression coefficients observed for most KDQOL-SF scales. Depressive symptoms were related to a poor HRQOL when there was a strong physical component, while trait anxiety was mainly related to emotional upset and social relationships. We were able to conclude that trait anxiety and depressive symptoms are strongly associated with the HRQOL assessed by the KDQOL-SF in HD patients. The effects of these factors should therefore be considered when evaluating the quality of life of this type of patient.

The Predialysis Survey on Anemia Management was designed to assess the care given to predialysis patients within 3 months of the start of hemodialysis or peritoneal dialysis (PD) therapy. In this presentation, we focus on demographic data and patient referral practices of patients who enter kidney centers.We conducted a retrospective chart review of patients who had started hemodialysis or PD therapy between August 1999 and April 2000. All patients (age, 16 to 99 years) who entered 1 of the 779 centers in 21 European countries, Israel, or South Africa were included, except those for whom dialysis therapy was only started during an acute episode. Demographic characteristics, referral to kidney centers, comorbidities, drug treatments, major clinical events, and use of epoetin were documented.Mean creatinine clearance rate at the first visit to the kidney center was 18.2 mL/min (0.303 mL/s). Of all patients, greater than 35% had a creatinine clearance less than 10.0 mL/min (0.167 mL/s) at their first visit. Overall, 87% of patients were initiated on hemodialysis therapy, and 13% were started on PD therapy. PD was used more often the longer a patient was under the care of a nephrologist. Of 4,333 new dialysis patients, 68% had a hemoglobin concentration of 11.0 g/dL or less (or =110 g/L) at the first visit.The majority of patients in the survey had been under the care of a nephrologist for more than 12 months before the start of dialysis therapy. Nevertheless, most of these patients were anemic, and only a minority were on epoetin treatment.

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

The content of this Supplement issue reflects our personal experiences during 40 years of dialysis treatment in a remarkable way. We have witnessed tremendous progress in the treatment of end-stage renal disease (ESRD). However, uremia remains a constellation of signs and symptoms that, in large part, await definitive elucidation. There is growing awareness that it is the entire spectrum of accumulated products that play a pathophysiological role, rather than an as yet unknown "uremic toxin." It is not surprising that the question of what actually constitutes adequate dialysis for ESRD patients is still a controversial and debated issue within the dialysis community. The term "adequate" may, in fact, refer not only to the "dose," but also to the "systems' biocompatibility," the reduction of cardiovascular and atherosclerotic risk factors, and the minimization of chronic inflammation. The previously mentioned attributes of dialysis adequacy have developed during the last decade as fast-evolving areas of pathophysiological research in dialysis, and this issue contains contributions from different individuals who have actively participated in their development. We, as Guest Editors, avoided giving practical guidelines, but felt we should highlight whatever consensus could be found in the dialysis community. When this was not possible, we felt that both sides of the ongoing controversies should be presented, with the aim of leaving the reader to make a final conclusion. We were motivated by the fact that at the turn of the new millennium, we all are facing a new era of clinical medicine that whenever new, more sophisticated investigations become available, less and less space will remain for simplistic empiricism. The clinical practice of hemodialysis is no exception to this trend. The still unacceptably high mortality/morbidity rates in ESRD patients and the high cost of ESRD management are imperatives for the dialysis community to direct all efforts toward a more comprehensive understanding of the underlying mechanisms and for possible corrective measures.

Target hematocrit/hemoglobin values in dialysis patients are still controversial. The Spanish Cooperative Renal Patients Quality of Life Study Group (including 34 hemodialysis units) conducted a prospective, 6-mo study of the effect on patient functional status and quality of life of using epoetin to achieve normal hematocrit in hemodialysis patients with anemia. The possible adverse effects of increased hematocrit, patient hospitalization, and epoetin requirements were also studied. The study included 156 patients (age range, 18 to 65 yr). Given the minimal experience in the safety of increasing hematocrit in dialysis patients to normal levels with epoetin, stable patients on hemodialysis who had received epoetin treatment for at least 3 mo and had a stable hemoglobin level of > or = 9 g/dl were included in the study. Patients with antecedents of congestive cardiac failure, ischemic cardiopathy, diabetes mellitus, uncontrolled hypertension, cerebrovascular accident or seizures, malfunction of the vascular access or severe comorbidity (defined by a comorbidity index), and those over 65 yr of age were excluded from the study. Quality of life was measured with the Sickness Impact Profile (SIP) and Karnofsky scale. Patients completed questionnaires at home at onset and conclusion of the 6-mo study. Mean hematocrit increased from 30.9 to 38.4% and hemoglobin from 10.2 to 12.5 g/dl during the study. Health indicator scores improved significantly: mean Physical Dimension (SIP) from 5.38 to 4.1 (P < 0.005); mean Psychosocial Dimension from 9.2 to 7 (P < 0.001); mean global SIP from 8.9 to 7.25 (P < 0.001); mean Karnofsky scale score from 75.6 to 78.4 (P < 0.01). (SIP is scaled so that lower scores represent better functional status, and vice versa for the Karnofsky scale). Therefore, functional status and quality of life improved with increased hematocrit. No deaths occurred. Three patients (2%) were censored for hypertension and nine (5.7%) for thrombosis of the vascular access. The cumulative probability of thrombosis of the vascular access was 0.067. The average epoetin dose rose from 93 +/- 62 U/kg per wk at onset to 141 +/- 80 U/kg per wk at conclusion, a 51% increase. The number of patients hospitalized decreased and hospital lengths of stay were shorter during the study period than in the same patients in the 6-mo period preceding the study (P < 0.05). Nine patients (5.7%) had thrombosis of the vascular access. There were no changes in the prevalence of arterial hypertension, but three patients (2%) showed hypertension that was difficult to control. It is concluded that normalization of hematocrit in selected hemodialysis patients, i.e., nondiabetic patients without severe cardiovascular or cerebrovascular comorbidities, improves quality of life and decreases morbidity without significant adverse effects.

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.

Hypertension as cause of end-stage renal disease: Lessons from international registries. The incidence of hypertension as cause of ESRD has doubled in the ERA-EDTA Registry in the past two decades, going from 7 to 13%. It is very possible that this is not a real increase in the incidence of hypertension as cause of ESRD, but rather a consequence of greater acceptance of older patients, a phenomenon that has simultaneously occurred. There are geographic differences in the incidence of hypertension as cause of ESRD, from 6% in Japan to 28.5% in the U.S., and 13% in Europe. With the present data, it is impossible to know if these differences are real. The diagnostic criteria used are not uniform and a consensus would be necessary to establish uniform diagnostic criteria for nephrosclerosis or ischemic nephropathy. The percentage of patients starting renal replacement therapy (RRT) with unknown primary renal disease is very different in the U.S. and Europe. This could be a critical factor in explaining these differences. Survival of patients at 5 and 10 years with renal vascular disease did not improve from 1977 to 1989. The same occurs with survival of patients with standard primary renal disease, although this is better than that of patients with renal vascular disease. To interpret this lack of improvement in survival of patients over a decade, we must take into account that at the same time there has been a significant increase in the age of patients starting RRT. Therefore, when the population of patitents of under 55 is analyzed, there is evidence that those starting treatment in the 80’s have much better survival than those starting in the 70’s. However, survival of patients with renal vascular disease continues to be poorer than that of patients with standard primary renal disease. This lower survival of patients with renal vascular disease seems to be related to higher cardiac mortality, which is in alignment with the diagnosis of hypertension as cause of renal failure.

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.

Effects of erythropoietin on left ventricular hypertrophy in adults with severe chronic renal failure and hemoglobin 130 g/m2 in men and >100 g/m2 in women), hemoglobin levels, creatinine clearance, blood pressure, medications, and medical history were obtained. Forty anemic and 61 nonanemic control subjects were enrolled.ResultsOverall, the prevalence of LVH was 68.3% (95% CI 58.3-77.2), and entry hemoglobin level was the only significant predictor of baseline LVH (adjusted OR 0.69 per g/dL increase in hemoglobin, 95% CI 0.50-0.94). After 6 months, LVMI decreased in anemic patients receiving rhEPO (142 ± 56 vs. 157 ± 56 g/m2) (P = 0.007), with an increase in hemoglobin (11.3 ± 1.9 vs. 9.1 ± 0.7 g/dL) (P = 0.001). There were no changes in LVMI or hemoglobin level among controls. After adjusting for confounders and change in hemoglobin, receipt of rhEPO was associated with a significant reduction in LVMI (P = 0.01).ConclusionTreatment with rhEPO was not independently associated with significant changes in blood pressure or renal function. LVH is a common finding in chronic renal insufficiency and is associated with lower hemoglobin levels. Treatment with rhEPO may decrease LVH in patients with severe renal insufficiency and anemia.

The current predominance of older patients, diabetic patients and high-comorbidity patients among the hemodialysis (HD) population has probably influenced the definition of the effects of renal disease on health-related quality of life (HRQOL), and these effects can be different in the patient subgroup without these characteristics. This multicenter study aimed to assess HRQOL in non-diabetic HD patients, aged65 yrs and with low comorbidity, and to study the effects of the demographic, clinical and psychosocial characteristics on their HRQOL.117 patients from 43 Spanish HD centers participated in the study. Patients completed the Kidney Disease Quality of Life Short-Form questionnaire (KDQOL-SF) and screening for depressive symptoms, anxiety symptoms and social support. Various sociodemographic and clinical variables were also recorded.HD patients' HRQOL showed a profile similar to that of the general HD population, with low physical health scores, but normal mental health scores. Multivariate analysis demonstrated that gender, older age, non-working status, low social support and low levels of hemoglobin (Hb), Kt/V or protein catabolic rate (PCR), had a negative effects, but these effects were of relatively small magnitude and appeared only in some scales. The most important independent predictors of HRQOL were anxiety state and depressive symptoms.In non-diabetic HD patients, agedor = 65 yrs and with low comorbidity, psychological factors (anxiety state and depressive symptoms) are crucial HRQOL determinants. These variables should be considered when assessing HRQOL in HD patients with these demographic and clinical characteristics.

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.

Target hematocrit/hemoglobin values in dialysis patients are still controversial. The Spanish Cooperative Renal Patients Quality of Life Study Group (including 34 hemodialysis units) conducted a prospective, 6-mo study of the effect on patient functional status and quality of life of using epoetin to achieve normal hematocrit in hemodialysis patients with anemia. The possible adverse effects of increased hematocrit, patient hospitalization, and epoetin requirements were also studied. The study included 156 patients (age range, 18 to 65 yr). Given the minimal experience in the safety of increasing hematocrit in dialysis patients to normal levels with epoetin, stable patients on hemodialysis who had received epoetin treatment for at least 3 mo and had a stable hemoglobin level ofor = 9 g/dl were included in the study. Patients with antecedents of congestive cardiac failure, ischemic cardiopathy, diabetes mellitus, uncontrolled hypertension, cerebrovascular accident or seizures, malfunction of the vascular access or severe comorbidity (defined by a comorbidity index), and those over 65 yr of age were excluded from the study. Quality of life was measured with the Sickness Impact Profile (SIP) and Karnofsky scale. Patients completed questionnaires at home at onset and conclusion of the 6-mo study. Mean hematocrit increased from 30.9 to 38.4% and hemoglobin from 10.2 to 12.5 g/dl during the study. Health indicator scores improved significantly: mean Physical Dimension (SIP) from 5.38 to 4.1 (P0.005); mean Psychosocial Dimension from 9.2 to 7 (P0.001); mean global SIP from 8.9 to 7.25 (P0.001); mean Karnofsky scale score from 75.6 to 78.4 (P0.01). (SIP is scaled so that lower scores represent better functional status, and vice versa for the Karnofsky scale). Therefore, functional status and quality of life improved with increased hematocrit. No deaths occurred. Three patients (2%) were censored for hypertension and nine (5.7%) for thrombosis of the vascular access. The cumulative probability of thrombosis of the vascular access was 0.067. The average epoetin dose rose from 93 +/- 62 U/kg per wk at onset to 141 +/- 80 U/kg per wk at conclusion, a 51% increase. The number of patients hospitalized decreased and hospital lengths of stay were shorter during the study period than in the same patients in the 6-mo period preceding the study (P0.05). Nine patients (5.7%) had thrombosis of the vascular access. There were no changes in the prevalence of arterial hypertension, but three patients (2%) showed hypertension that was difficult to control. It is concluded that normalization of hematocrit in selected hemodialysis patients, i.e., nondiabetic patients without severe cardiovascular or cerebrovascular comorbidities, improves quality of life and decreases morbidity without significant adverse effects.

Renal vascular disease in the elderly. The aging of Western societies is causing a progressive increase in the number of patients over 65 starting dialysis. The EDTA Registry shows that in 1995 this section of the population represented nearly 45% of patients under dialysis, and the percentage is even higher in the USRDS at 48%, 20% of whom are over 75. These changes have not only been quantitative, but have also modified the causes of end-stage renal disease (ESRD). Diabetic nephropathy (DN) and renal vascular disease (RVD) account for more than 50% of all these causes, reaching 66% according to the latest USRDS calculations. According to these numbers, RVD represents 29% of all causes, the incidence varying with the age group, and has become the main cause of ESRD in the elderly (38% of all cases). Until a few years ago, RVD was synonymous with hypertension, but as the population ages, the range of diseases in this group is increasing. The main RVDs that cause ESRD in the elderly are: hypertensive RVD (nephrosclerosis), atheromatous RVD (either as ischemic atherosclerotic nephropathy or as atheroembolism), and acute occlusion of renal arteries (either bilateral or unilateral in single-kidney patients). The diagnosis of nephrosclerosis in the absence of histological confirmation is a presumed clinical diagnosis, made in most cases by exclusion, and is therefore clearly overestimated. On the other hand, atheromatous RVD is an underdiagnosed disease that is often overlooked. The prevalence, natural history, diagnosis and prognosis are discussed in this report.

Effects of antihypertensive therapy on progression of diabetic nephropathy. There is a clear relationship between hypertension and the microvascular complications of diabetes. Genetic predisposition to hypertension has been correlated to the risk of diabetic nephropathy in type I diabetes, and hypertension is a well known risk factor for developing nephropathy in patients with type II diabetes. Multiple studies have emphasized the importance of hypertension on renal disease progression, and blood pressure control with conventional antihypertensive drugs slows the rate of renal function loss in diabetic nephropathy. Furthermore, evidence of the role of renin-angiotensin system (RAS) on progression of renal damage has focused much interest on the therapeutic action of the RAS blockade. In patients with type I diabetes, blocking the RAS with angiotensin converting enzyme (ACE) inhibitors prevents progression from microalbuminuria to overt nephropathy, and in overt nephropathy decreases the gradual loss of renal function beyond its blood pressure lowering effect. Less clinical information is available in type II diabetic nephropathy, but our experience and some recent studies suggest that ACE inhibitors also have a renoprotective action in type II diabetes. The role of calcium channel blockers in diabetic nephropathy is not clear. Several short-term studies with the first generation dihydropyridine calcium antagonists showed a lower effect on urinary albumin excretion and a more rapid progression to renal failure than with ACE inhibitors. However, other calcium channel blockers, particularly of the non-dihydropyridine type, have been shown to have a beneficial effect on diabetic nephropathy, decreasing proteinuria and slowing progression.

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)

In cases with severe hyperparathyroidism, anaemia improves after parathyroidectomy. The objective of this study was to investigate the influence of treatment with intravenous calcitriol on anaemia in 28 haemodialysis patients. The patients showed moderate to severe hyperparathyroidism (mean parathyroid hormone level 811.6 ± 327 pg/ml) and were treated with calcitriol (2 µg i.v.) after haemodialysis. The follow-up period was 12 months. 21 out of the 28 patients had been receiving erythropoietin (EPO) prior to calcitriol administration; the remaining 7 did not receive EPO. 24 patients received oral or intravenous iron. The doses of EPO and iron were modified throughout the study period to maintain a haematocrit equal to or higher than 30% and ferritin levels above 150 ng/ml, respectively. EPO needs were evaluated according to the relation EPO dose/haematocrit. We found a significant rise in haematocrit and haemoglobin at 3 and 12 months on calcitriol therapy, with no modification of the EPO dose nor ferritin levels. This improvement in anaemia was observed both in those patients who received EPO initially (p < 0.01) and in those who did not (p < 0.05). Upon dividing the patients according to the response of hyperparathyroidism to the intravenous calcitriol treatment, we observed in the responding patients (n = 19) significant increases in haematocrit (from 31.7 ± 4.2 to 36.3 ± 4.9%) and haemoglobin (from 10.6 ± 1.5 to 12.2 ± 1.5 g/dl; p < 0.001) at 12 months on intravenous calcitriol therapy, while this was not true of the non-responding patients. The EPO needs diminished in the group of responding patients and increased in the non-responders, although these changes were not statistically significant. We found no direct correlation between the decrease of parathyroid hormone and EPO needs in the group of responding patients. However, an inverse correlation between parathyroid hormone levels and EPO needs (r = –0.799, p < 0.05) was seen in the group of non-responding patients. Treatment with intravenous calcitriol in patients on haemodialysis controls secondary hyperparathyroidism, improves anaemia, and decreases the need for EPO. Studies including a larger number of patients are necessary to clarify the mechanisms underlying the improvement of anaemia upon control of secondary hyperparathyroidism with intravenous calcitriol treatment and to confirm our findings.

Despite the long experience in erythropoietin (EPO) treatment in end-stage renal disease (ESRD)-related anemia, controversy remains as to whether EPO treatment of anemia can improve the quality of life (QL) in elderly ESRD patients, as it does in younger ones. We conducted a prospective study of 57 stable patients on hemodialysis who started on EPO treatment. A control group of 29 hemodialysis patients not requiring EPO was simultaneously studied. Diabetic patients and patients with severe comorbidity were excluded. Quality of life was assessed at baseline before EPO treatment and after 3 and 6 months of follow-up, using the Karnofsky scale (KS) and the Sickness Impact Profile (SIP) questionnaire. A high KS score and a low SIP score indicate better QL. Erythropoietin patients were stratified into two age groups: or = 60 years (n = 23). In the EPO group mean hematocrit values improved from 21 percent at baseline to 29 percent at the sixth month; mean KS scores increased from 68 +/- 1.8 to 81 +/- 1.5 (P < 0.0001) and the mean global score of SIP decreased from 19.8 +/- 1.6 to 13.5 +/- 1.2 (P < 0.0001). No significant changes were observed in the control group. Elderly patients in the EPO group showed improved KS scores, from 61 +/- 1.5 to 75 +/- 2.5 (P < 0.0001), and the global score of SIP decreased from 27.7 +/- 2.1 to 20 +/- 1.8 (P < 0.001). Younger patients had improvement of their KS scores, from 73 +/- 2.5 to 85 +/- 1.5 (P < 0.0001), and the global score of SIP decreased from 14.5 +/- 1.9 to 9.1 +/- 1.2 (P < 0.001). No relationship was found between age groups and improvement in QL indicator scores. On regression analysis, a poor basal QL score was related to higher QL improvement under EPO treatment, and final hematocrit was positively related to global SIP improvement. Treatment of ESRD-related anemia with EPO significantly improved the QL of hemodialysis patients. Quality of life in elderly patients improved as much as in younger patients, thereby fully justifying the use of EPO for the elderly.