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Background and Hypothesis: Young adults starting kidney replacement therapy (KRT) during childhood and reaching their 18th birthday (i.e. adult survivors of childhood KRT) form a challenging population of interest to nephrologists treating adults, as during this period there will be a transition to adult renal centres. Nonetheless, few studies have focused on the epidemiology of KRT in this group. We aimed to provide an update on these patients' characteristics, treatment history, graft and patient survival, to report their 5-year prognosis, and expected remaining lifetime., Methods: Data on KRT patients reaching their 18th birthday in 2008-2019 were collected from 21 European countries/regions providing individual patient data to the European Renal Association (ERA) Registry. Patient characteristics and treatment trajectories were examined before and after turning 18 years. Kaplan-Meier and Cox proportional hazards regression were used for patient and graft survival analyses., Results: In total, 2944 patients were included. The proportion of adult survivors initiating KRT at a very young age (0-4 years), and undergoing pre-emptive kidney transplantation increased. Unadjusted 5-year patient survival was 96.9% (95% CI: 96.2-97.5). Dialysis patients had a higher risk of death than kidney transplant recipients (adjusted hazard ratio 5.44 (95% CI: 3.34-8.86)). Between ages 18 and 23 years, about 21% of the adult survivors lost their kidney transplant and 34% of the dialysis patients continued this treatment. Compared with the general population, life expectancy for eighteen-year-old kidney transplant and dialysis patients was 17 and 40 years shorter, respectively., Conclusion: Life expectancy of 18-year-old kidney transplant recipients was lower compared with the general population. Yet, having a functioning kidney graft at age 18 years resulted in better outcomes than being on dialysis. Nevertheless, between ages 18 and 23 years, about one-fifth of the kidney grafts failed and one-third of the patients remained on dialysis., (© The Author(s) 2024. Published by Oxford University Press on behalf of the ERA.)

Background: Necrotizing myopathies and muscle necrosis can be caused by immune-mediated mechanisms, drugs, ischemia, and infections, and differential diagnosis may be challenging., Case Presentation: We describe a case of diabetic myonecrosis complicated by pyomyositis and abscess caused by Escherichia coli. A white woman in her late forties was admitted to the hospital with a 1.5 week history of bilateral swelling, weakness, and mild pain of the lower extremities and inability to walk. She had a history of type 1 diabetes complicated by diabetic retinopathy, neuropathy, nephropathy, and end-stage renal disease. C-reactive protein was 203 mg/l, while creatinine kinase was only mildly elevated to 700 IU/l. Magnetic resonance imaging of her lower limb muscles showed extensive edema, and muscle biopsy was suggestive of necrotizing myopathy with mild inflammation. No myositis-associated or myositis-specific antibodies were detected. Initially, she was suspected to have seronegative immune-mediated necrotizing myopathy, but later her condition was considered to be explained better by diabetic myonecrosis with multifocal involvement. Her symptoms alleviated without any immunosuppressive treatment. After a month, she developed new-onset and more severe symptoms in her right posterior thigh. She was diagnosed with emphysematous urinary tract infection and emphysematous myositis and abscess of the right hamstring muscle. Bacterial cultures of drained pus from abscess and urine were positive for Escherichia coli. In addition to abscess drainage, she received two 3-4-week courses of intravenous antibiotics. In the discussion, we compare the symptoms and findings typically found in pyomyositis, immune-mediated necrotizing myopathy, and diabetic myonecrosis (spontaneous ischemic necrosis of skeletal muscle among people with diabetes). All of these diseases may cause muscle weakness and pain, muscle edema in imaging, and muscle necrosis. However, many differences exist in their clinical presentation, imaging, histology, and extramuscular symptoms, which can be useful in determining diagnosis. As pyomyositis often occurs in muscles with pre-existing pathologies, the ischemic muscle has likely served as a favorable breeding ground for the E. coli in our case., Conclusions: Identifying the etiology of necrotizing myopathy is a diagnostic challenge and often requires a multidisciplinary assessment of internists, pathologists, and radiologists. Moreover, the presence of two rare conditions concomitantly is possible in cases with atypical features., (© 2024. The Author(s).)

Background: The aim of this study was to provide an overview of age, sex and primary renal disease (PRD) distribution among first kidney transplant recipients across Europe., Method: The European Renal Association (ERA) Registry database was used to obtain data on patients aged 20 years or older receiving their first kidney transplant between 2010 and 2019 from 12 European countries. The numbers and percentages of recipients in each age, sex and PRD group were calculated by country, donor type and year., Results: In total, 99 543 adults received a first kidney transplant. Overall, 23% of the recipients were 65 years or older, 36% were female, and 21% had glomerulonephritis and 15% diabetes mellitus as PRD. Compared with deceased donor kidney transplant recipients, living donor kidney transplant recipients were less often 65 years or older (13% versus 26%), more often had glomerulonephritis (25% versus 20%) and less often diabetes mellitus (8% versus 17%) as PRD. We found large international differences, which were most prominent for age and PRD and less prominent for sex. Over time, the largest change in recipient characteristics was observed for the percentage of recipients aged 65 years or older, increasing from 18% in 2010 to 28% in 2019 for all countries combined with a similar trend in most countries., Conclusion: We observed large differences for age and PRD distribution between recipients of living and deceased donor kidneys and between European countries. Over time, the percentage of older first kidney transplant recipients increased., (© The Author(s) 2023. Published by Oxford University Press on behalf of the ERA.)

Background: Cardiovascular diseases are an important cause of mortality in patients who have undergone kidney transplantation, but the knowledge on trends of cardiovascular mortality and specific causes of cardiovascular death among these patients is scarce., Methods: Our aim was to compare the cardiovascular mortality rates after kidney transplantation in Finland between 1990-1999, 2000-2009, and 2010-2019 using data from the Finnish Registry for Kidney Diseases. We analyzed 1-year and long-term cardiovascular mortality rates as well as the specific causes of cardiovascular death and the trends in them., Results: In total, 4946 patients underwent first kidney transplantation in 1990-2019. During the follow-up time (median 8.3 years, interquartile range 4.0-14.5), there were 1392 deaths, of which 582 were cardiovascular deaths. In an unadjusted Cox regression model, the risk of long-term cardiovascular mortality was similar in the different periods. However, when adjusted for age, sex, duration of dialysis, and cause of kidney disease, the long-term cardiovascular mortality risk was significantly lower in 2000-2009 and 2010-2019 (hazard ratio 0.60 [95% confidence interval, 0.49 to 0.73] and hazard ratio 0.51 [95% confidence interval, 0.39 to 0.66], respectively) compared with 1990-1999. The results were similar regarding 1-year cardiovascular mortality. The distribution of different causes of cardiovascular death remained unchanged during the study period, with coronary artery disease accounting for 47% of deaths. During the first year after transplantation, pulmonary embolisms and arrhythmias were more common than in the long term., Conclusions: Cardiovascular disease remained the most common cause of death in kidney transplant recipients, but adjusted cardiovascular mortality risk has decreased significantly during the past three decades. Coronary artery disease was the most frequent cause of cardiovascular death, and the proportion of coronary artery disease-related cardiovascular deaths increased after the first year after transplantation., (Copyright © 2023 by the American Society of Nephrology.)

Background: The European Renal Association (ERA) Registry collects data on kidney replacement therapy (KRT) in patients with end-stage kidney disease (ESKD). This paper is a summary of the ERA Registry Annual Report 2021, including a comparison across treatment modalities., Methods: Data was collected from 54 national and regional registries from 36 countries, of which 35 registries from 18 countries contributed individual patient data and 19 registries from 19 countries contributed aggregated data. Using this data, incidence and prevalence of KRT, kidney transplantation rates, survival probabilities and expected remaining lifetimes were calculated., Result: In 2021, 533.2 million people in the general population were covered by the ERA Registry. The incidence of KRT was 145 per million population (pmp). In incident patients, 55% were 65 years or older, 64% were male, and the most common primary renal disease (PRD) was diabetes (22%). The prevalence of KRT was 1040 pmp. In prevalent patients, 47% were 65 years or older, 62% were male, and the most common PRDs were diabetes and glomerulonephritis/sclerosis (both 16%). On 31 December 2021, 56% of patients received haemodialysis, 5% received peritoneal dialysis, and 39% were living with a functioning graft. The kidney transplantation rate in 2021 was 37 pmp, a majority coming from deceased donors (66%). For patients initiating KRT between 2012-2016, 5-year survival probability was 52%. Compared to the general population, life expectancy was 65% and 68% shorter for males and females receiving dialysis, and 40% and 43% shorter for males and females living with a functioning graft., Competing Interests: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the ERA.)

Objectives: Infections are the most common non-cardiovascular cause of death among dialysis patients. Earlier studies have shown similar or higher risk of infectious complications in peritoneal dialysis (PD) compared to hemodialysis (HD) patients, but comparisons to home HD patients have been rare. We investigated the risk of severe infections after start of continuous ambulatory PD (CAPD) and automated PD (APD) as compared to home HD., Methods: All adult patients (n = 536), who were on home dialysis at day 90 from starting kidney replacement therapy (KRT) between 2004 and 2017 in Helsinki healthcare district, were included. We defined severe infection as an infection with C-reactive protein of 100 mg/l or higher. Cumulative incidence of first severe infection was assessed considering death as a competing risk. Hazard ratios were estimated using Cox regression with propensity score adjustment., Results: The risk of getting a severe infection during the first year of dialysis was 35% for CAPD, 25% for APD and 11% for home HD patients. During five years of follow-up, the hazard ratio of severe infection was 2.8 [95% CI 1.6-4.8] for CAPD and 2.2 [95% CI 1.4-3.5] for APD in comparison to home HD. Incidence rate of severe infections per 1000 patient-years was 537 for CAPD, 371 for APD, and 197 for home HD patients. When excluding peritonitis, the incidence rate was not higher among PD than home HD patients., Conclusions: CAPD and APD patients had higher risk of severe infections than home HD patients. This was explained by PD-associated peritonitis., Competing Interests: I have read the journal’s policy and the authors of this manuscript have the following competing interests: Dr. Finne has received honoraria for lectures from Baxter, AstraZeneca and Boehringer-Ingelheim, and he is a member in an advisory board of Baxter. Dr. Rauta has received honoraria for lectures from Baxter, Fresenius and AstraZeneca, and research funding (not for this project) from Business Finland; and she is a board member in Finnish Society of Nephrology. Dr. Honkanen has received honoraria for lectures from AstraZeneca and Fresenius Medical Care. The findings, results, and conclusions in this report are those of the authors and are independent from the funding sources., (Copyright: © 2023 Bitar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The aim of this study was to identify trends in total, deceased donor (DD) and living donor (LD) kidney transplantation (KT) rates in European countries., Methods: The European Renal Association (ERA) Registry and the Global Observatory on Donation and Transplantation (GODT) databases were used to obtain the number of KTs in individual European countries between 2010 and 2018. General population counts were obtained from Eurostat or the national bureaus of statistics. The KT rate per million population (p.m.p.) and the average annual percentage change (APC) were calculated., Results: The total KT rate in the 40 participating countries increased with 1.9% annually  [95%  confidence  interval  (CI) 1.5, 2.2] from 29.6 p.m.p. in 2010 to 34.7 p.m.p. in 2018, reflecting an increase of 3.4 p.m.p. in the DD-KT rate (from 21.6 p.m.p. to 25.0 p.m.p.; APC 1.9%; 95% CI 1.3, 2.4) and of 1.5 p.m.p. in the LD-KT rate (from 8.1 p.m.p. to 9.6 p.m.p.; APC 1.6%; 95% CI 1.0, 2.3). The trends in KT rate varied widely across European countries. An East-West gradient was observed for DD-KT rate, with Western European countries performing more KTs. In addition, most countries performed fewer LD-KTs. In 2018, Spain had the highest DD-KT rate (64.6 p.m.p.) and Turkey the highest LD-KT rate (37.0 p.m.p.)., Conclusions: The total KT rate increased due to a rise in the KT rate from DDs and to a lesser extent from LDs, with large differences between individual European countries., (© The Author(s) 2023. Published by Oxford University Press on behalf of the ERA.)

Background: The European Renal Association (ERA) Registry collects data on kidney replacement therapy (KRT) in patients with ESKD. This paper is a summary of the ERA Registry Annual Report 2020, also including comparisons among primary renal disease (PRD) groups., Methods: Data were collected from 52 national and regional registries from 34 European countries and countries bordering the Mediterranean Sea: 35 registries from 18 countries providing individual level data and 17 registries from 17 countries providing aggregated data. Using this data, KRT incidence and prevalence, kidney transplantation rates, expected remaining lifetimes and survival probabilities were calculated., Results: A general population of 654.9 million people was covered by the ERA Registry in 2020. The overall incidence of KRT was 128 per million population (p.m.p.). In incident KRT patients, 54% were older than 65 years, 63% were men and the most common PRD was diabetes mellitus (21%). Regarding initial treatment modality in incident patients, 85% received haemodialysis (HD), 11% received peritoneal dialysis (PD) and 4% received a pre-emptive kidney transplant. On 31 December 2020, the prevalence of KRT was 931 p.m.p. In prevalent patients, 45% were older than 65 years, 60% were men and glomerulonephritis was the most common PRD (18%). Of these patients, 58% were on HD, 5% on PD and 37% were living with a kidney transplant. The overall kidney transplantation rate in 2020 was 28 p.m.p., with a majority of kidney grafts from deceased donors (71%). The unadjusted 5-year survival, based on incident dialysis patient from 2011-15, was 41.8%. For patients having received a deceased donor transplant, the unadjusted 5-year survival probability was 86.2% and for patients having received a living donor transplant it was 94.4%. When comparing data by PRD group, differences were found regarding the distribution of age groups, sex and treatment modality received., Competing Interests: A.O. is the previous Editor-in-Chief of CKJ., (© The Author(s) 2023. Published by Oxford University Press on behalf of the ERA.)

Background: The aim of this study was to describe the trends in the incidence, prevalence and survival of patients on kidney replacement therapy (KRT) for end-stage kidney disease (ESKD) across Europe from 2008 to 2017., Methods: Data from renal registries in 9 countries and 16 regions that provided individual patient data to the ERA Registry from 2008 to 2017 were included. These registries cover 34% of the general population in Europe. Crude and standardized incidence and prevalence per million population (pmp) were determined. Trends over time were studied using Joinpoint regression. Survival probabilities were estimated using Kaplan-Meier analysis and hazard ratios (HRs) using Cox regression analysis., Results: The standardized incidence of KRT was stable [annual percentage change (APC): -1.48 (-3.15; 0.21)] from 2008 (146.0 pmp) to 2011 (141.6 pmp), followed by a slight increase [APC: 1.01 (0.43; 1.60)] to 148.0 pmp in 2017, although trends in incidence varied across countries. This increase was primarily due to a rise in the incidence of KRT in men older than 65 years. Moreover, as a cause of kidney failure, diabetes mellitus is increasing. The standardized prevalence increased from 2008 (990.0 pmp) to 2017 (1166.8 pmp) [APC: 1.82 (1.75; 1.89)]. Patient survival on KRT improved in the time period 2011-13 compared with 2008-[adjusted HR: 0.94 (0.93; 0.95)]., Conclusion: This study showed an overall increase in the incidence and prevalence of KRT for ESKD as well as an increase in the KRT patient survival over the last decade in Europe., (© The Author(s) 2022. Published by Oxford University Press on behalf of the ERA.)

Background: Mortality prediction is critical on long-term kidney replacement therapy (KRT), both for individual treatment decisions and resource planning. Many mortality prediction models already exist, but as a major shortcoming most of them have only been validated internally. This leaves reliability and usefulness of these models in other KRT populations, especially foreign, unknown. Previously two models were constructed for one- and two-year mortality prediction of Finnish patients starting long-term dialysis. These models are here internationally validated in KRT populations of the Dutch NECOSAD Study and the UK Renal Registry (UKRR)., Methods: We validated the models externally on 2051 NECOSAD patients and on two UKRR patient cohorts (5328 and 45493 patients). We performed multiple imputation for missing data, used c-statistic (AUC) to assess discrimination, and evaluated calibration by plotting average estimated probability of death against observed risk of death., Results: Both prediction models performed well in the NECOSAD population (AUC 0.79 for the one-year model and 0.78 for the two-year model). In the UKRR populations, performance was slightly weaker (AUCs: 0.73 and 0.74). These are to be compared to the earlier external validation in a Finnish cohort (AUCs: 0.77 and 0.74). In all tested populations, our models performed better for PD than HD patients. Level of death risk (i.e., calibration) was well estimated by the one-year model in all cohorts but was somewhat overestimated by the two-year model., Conclusions: Our prediction models showed good performance not only in the Finnish but in foreign KRT populations as well. Compared to the other existing models, the current models have equal or better performance and fewer variables, thus increasing models' usability. The models are easily accessible on the web. These results encourage implementing the models into clinical decision-making widely among European KRT populations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Haapio et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Several studies have shown superior survival of patients on home haemodialysis (HD) compared with peritoneal dialysis (PD), but patients on automated PD (APD) and continuous ambulatory PD (CAPD) have not been considered separately. As APD allows larger fluid volumes and may be more efficient than CAPD, we primarily compared patient survival between APD and home HD., Methods: All adult patients who started kidney replacement therapy (KRT) between 2004 and 2017 in the district of Helsinki-Uusimaa in Finland and who were on one of the home dialysis modalities at 90 days from starting KRT were included. We used intention-to-treat analysis. Survival of home HD, APD and CAPD patients was studied using Kaplan-Meier curves and Cox regression with adjustment for propensity scores that were based on extensive data on possible confounding factors., Results: The probability of surviving 5 years was 90% for home HD, 88% for APD and 56% for CAPD patients. After adjustment for propensity scores, the hazard ratio of death was 1.1 [95% confidence interval (CI) 0.52-2.4] for APD and 1.6 (95% CI 0.74-3.6) for CAPD compared with home HD. Censoring at the time of kidney transplantation (KTx) or at transfer to in-centre HD did not change the results. Characteristics of home HD and APD patients at the start of dialysis were similar, whereas patients on CAPD had higher median age and more comorbidities and received KTx less frequently., Conclusions: Home HD and APD patients had comparable characteristics and their survival appeared similar., Competing Interests: P.F. has received honoraria for lectures and membership in advisory board from Baxter. V.R. has received honoraria for lectures from Baxter and Fresenius and research funding (not for this project) from Business Finland. The findings, results and conclusions in this report are those of the authors and are independent from the funding sources., (© The Author(s) 2021. Published by Oxford University Press on behalf of ERA-EDTA.)

Importance: During the past decades, improvements in the prevention and management of myocardial infarction, stroke, and pulmonary embolism have led to a decline in cardiovascular mortality in the general population. However, it is unknown whether patients receiving dialysis have also benefited from these improvements., Objective: To assess the mortality rates for myocardial infarction, stroke, and pulmonary embolism in a large cohort of European patients receiving dialysis compared with the general population., Design, Setting, and Participants: In this cohort study, adult patients who started dialysis between 1998 and 2015 from 11 European countries providing data to the European Renal Association Registry were and followed up for 3 years. Data were analyzed from September 2020 to February 2022., Exposures: Start of dialysis., Main Outcomes and Measures: The age- and sex-standardized mortality rate ratios (SMRs) with 95% CIs were calculated by dividing the mortality rates in patients receiving dialysis by the mortality rates in the general population for 3 equal periods (1998-2003, 2004-2009, and 2010-2015)., Results: In total, 220 467 patients receiving dialysis were included in the study. Their median (IQR) age was 68.2 (56.5-76.4) years, and 82 068 patients (37.2%) were female. During follow-up, 83 912 patients died, of whom 7662 (9.1%) died because of myocardial infarction, 5030 (6.0%) died because of stroke, and 435 (0.5%) died because of pulmonary embolism. Between the periods 1998 to 2003 and 2010 to 2015, the SMR of myocardial infarction decreased from 8.1 (95% CI, 7.8-8.3) to 6.8 (95% CI, 6.5-7.1), the SMR of stroke decreased from 7.3 (95% CI, 7.0-7.6) to 5.8 (95% CI, 5.5-6.2), and the SMR of pulmonary embolism decreased from 8.7 (95% CI, 7.6-10.1) to 5.5 (95% CI, 4.5-6.6)., Conclusions and Relevance: In this cohort study of patients receiving dialysis, mortality rates for myocardial infarction, stroke, and pulmonary embolism decreased more over time than in the general population.

Background: Comorbidities are associated with increased mortality among patients receiving long-term kidney replacement therapy (KRT). However, it is not known whether primary kidney disease modifies the effect of comorbidities on KRT patients' survival., Methods: An incident cohort of all patients (n = 8696) entering chronic KRT in Finland in 2000-2017 was followed until death or end of 2017. All data were obtained from the Finnish Registry for Kidney Diseases. Information on comorbidities (coronary artery disease, peripheral vascular disease, left ventricular hypertrophy, heart failure, cerebrovascular disease, malignancy, obesity, underweight, and hypertension) was collected at the start of KRT. The main outcome measure was relative risk of death according to comorbidities analyzed in six groups of primary kidney disease: type 2 diabetes, type 1 diabetes, glomerulonephritis (GN), polycystic kidney disease (PKD), nephrosclerosis, and other or unknown diagnoses. Kaplan-Meier estimates and Cox regression were used for survival analyses., Results: In the multivariable model, heart failure increased the risk of death threefold among PKD and GN patients, whereas in patients with other kidney diagnoses the increased risk was less than twofold. Obesity was associated with worse survival only among GN patients. Presence of three or more comorbidities increased the age- and sex-adjusted relative risk of death 4.5-fold in GN and PKD patients, but the increase was only 2.5-fold in patients in other diagnosis groups., Conclusions: Primary kidney disease should be considered when assessing the effect of comorbidities on survival of KRT patients as it varies significantly according to type of primary kidney disease., Competing Interests: The authors have declared that no competing interests exist.

The aims of this study were to determine the frequency of dialysis and kidney transplantation and to estimate the regularity of comprehensive conservative management (CCM) for patients with kidney failure in Europe. This study uses data from the ERA-EDTA Registry. Additionally, our study included supplemental data from Armenia, Germany, Hungary, Ireland, Kosovo, Luxembourg, Malta, Moldova, Montenegro, Slovenia and additional data from Israel, Italy, Slovakia using other information sources. Through an online survey, responding nephrologists estimated the frequency of CCM (i.e. planned holistic care instead of kidney replacement therapy) in 33 countries. In 2016, the overall incidence of replacement therapy for kidney failure was 132 per million population (pmp), varying from 29 (Ukraine) to 251 pmp (Greece). On 31 December 2016, the overall prevalence of kidney replacement therapy was 985 pmp, ranging from 188 (Ukraine) to 1906 pmp (Portugal). The prevalence of peritoneal dialysis (114 pmp) and home hemodialysis (28 pmp) was highest in Cyprus and Denmark respectively. The kidney transplantation rate was nearly zero in some countries and highest in Spain (64 pmp). In 28 countries with five or more responding nephrologists, the median percentage of candidates for kidney replacement therapy who were offered CCM in 2018 varied between none (Slovakia and Slovenia) and 20% (Finland) whereas the median prevalence of CCM varied between none (Slovenia) and 15% (Hungary). Thus, the substantial differences across Europe in the frequency of kidney replacement therapy and CCM indicate the need for improvement in access to various treatment options for patients with kidney failure., (Copyright © 2021 International Society of Nephrology. All rights reserved.)

Background: Literature on recovery of kidney function (RKF) in patients with end-stage kidney disease treated with maintenance dialysis (i.e. >90 days) is limited. We assessed the incidence of RKF and its associated characteristics in a European cohort of dialysis patients., Methods: We included adult patients from the European Renal Association-European Dialysis and Transplant Association Registry who started maintenance dialysis in 1997-2016. Sustained RKF was defined as permanent discontinuation of dialysis. Temporary discontinuation of ≥30 days (non-sustained RKF) was also evaluated. Factors associated with RKF adjusted for potential confounders were studied using Cox regression analyses., Results: RKF occurred in 7657 (1.8%) of 440 996 patients, of whom 71% experienced sustained RKF. Approximately 90% of all recoveries occurred within the first 2 years after Day 91 of dialysis. Of patients with non-sustained RKF, 39% restarted kidney replacement therapy within 1 year. Sustained RKF was strongly associated with the following underlying kidney diseases (as registered by the treating physician): tubular necrosis (irreversible) or cortical necrosis {adjusted hazard ratio [aHR] 20.4 [95% confidence interval (CI) 17.9-23.1]}, systemic sclerosis [aHR 18.5 (95% CI 13.8-24.7)] and haemolytic uremic syndrome [aHR 17.3 (95% CI 13.9-21.6)]. Weaker associations were found for haemodialysis as a first dialysis modality [aHR 1.5 (95% CI 1.4-1.6)] and dialysis initiation at an older age [aHR 1.8 (95% CI 1.6-2.0)] or in a more recent time period [aHR 2.4 (95% CI 2.1-2.7)]., Conclusions: Definitive discontinuation of maintenance dialysis is a rare and not necessarily an early event. Certain clinical characteristics, but mostly the type of underlying kidney disease, are associated with a higher likelihood of RKF., (© The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Background: The number of elderly patients on renal replacement therapy (RRT) is increasing. The survival and quality of life of these patients may be lower if they have multiple comorbidities at the onset of RRT. The aim of this study was to explore whether the effect of comorbidities on survival is similar in elderly RRT patients compared with younger ones., Methods: Included were 9333 patients ≥80 years of age and 48 352 patients 20-79 years of age starting RRT between 2010 and 2015 from 15 national or regional registries submitting data to the European Renal Association-European Dialysis and Transplantation Association Registry. Patients were followed until death or the end of 2016. Survival was assessed by Kaplan-Meier curves and the relative risk of death associated with comorbidities was assessed by Cox regression analysis., Results: Patients ≥80 years of age had a greater comorbidity burden than younger patients. However, relative risks of death associated with all studied comorbidities (diabetes, ischaemic heart disease, chronic heart failure, cerebrovascular disease, peripheral vascular disease and malignancy) were significantly lower in elderly patients compared with younger patients. Also, the increase in absolute mortality rates associated with an increasing number of comorbidities was smaller in elderly patients., Conclusions: Comorbidities are common in elderly patients who enter RRT, but the risk of death associated with comorbidities is less than in younger patients. This should be taken into account when assessing the prognosis of elderly RRT patients., (© The Author(s) 2021. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Background: This article presents a summary of the 2017 Annual Report of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) Registry and describes the epidemiology of renal replacement therapy (RRT) for end-stage renal disease (ESRD) in 37 countries., Methods: The ERA-EDTA Registry received individual patient data on patients undergoing RRT for ESRD in 2017 from 32 national or regional renal registries and aggregated data from 21 registries. The incidence and prevalence of RRT, kidney transplantation activity and survival probabilities of these patients were calculated., Results: In 2017, the ERA-EDTA Registry covered a general population of 694 million people. The incidence of RRT for ESRD was 127 per million population (pmp), ranging from 37 pmp in Ukraine to 252 pmp in Greece. A total of 62% of patients were men, 52% were ≥65 years of age and 23% had diabetes mellitus as the primary renal disease. The treatment modality at the onset of RRT was haemodialysis for 85% of patients. On 31 December 2017, the prevalence of RRT was 854 pmp, ranging from 210 pmp in Ukraine to 1965 pmp in Portugal. The transplant rate in 2017 was 33 pmp, ranging from 3 pmp in Ukraine to 103 pmp in the Spanish region of Catalonia. For patients commencing RRT during 2008-12, the unadjusted 5-year patient survival probability for all RRT modalities combined was 50.8%., (© The Author(s) 2020. Published by Oxford University Press on behalf of ERA-EDTA.)

Background: Previous US studies have indicated that haemodialysis with ≥6-h sessions [extended-hours haemodialysis (EHD)] may improve patient survival. However, patient characteristics and treatment practices vary between the USA and Europe. We therefore investigated the effect of EHD three times weekly on survival compared with conventional haemodialysis (CHD) among European patients., Methods: We included patients who were treated with haemodialysis between 2010 and 2017 from eight countries providing data to the European Renal Association-European Dialysis and Transplant Association Registry. Haemodialysis session duration and frequency were recorded once every year or at every change of haemodialysis prescription and were categorized into three groups: CHD (three times weekly, 3.5-4 h/treatment), EHD (three times weekly, ≥6 h/treatment) or other. In the primary analyses we attributed death to the treatment at the time of death and in secondary analyses to EHD if ever initiated. We compared mortality risk for EHD to CHD with causal inference from marginal structural models, using Cox proportional hazards models weighted for the inverse probability of treatment and censoring and adjusted for potential confounders., Results: From a total of 142 460 patients, 1338 patients were ever treated with EHD (three times, 7.1 ± 0.8 h/week) and 89 819 patients were treated exclusively with CHD (three times, 3.9 ± 0.2 h/week). Crude mortality rates were 6.0 and 13.5/100 person-years. In the primary analyses, patients treated with EHD had an adjusted hazard ratio (HR) of 0.73 [95% confidence interval (CI) 0.62-0.85] compared with patients treated with CHD. When we attributed all deaths to EHD after initiation, the HR for EHD was comparable to the primary analyses [HR 0.80 (95% CI 0.71-0.90)]., Conclusions: EHD is associated with better survival in European patients treated with haemodialysis three times weekly., (© The Author(s) 2019. Published by Oxford University Press on behalf of ERA-EDTA.)

Objective: To estimate long-term cumulative risk of end-stage renal disease (ESRD) after diagnosis of type 2 diabetes., Research Design and Methods: This nationwide population-based inception cohort study included 421,429 patients with type 2 diabetes diagnosed in 1990-2011; patients were followed until the end of 2013. Data linkage between several national health care registers in Finland, covering 100% of the population, enabled the inclusion of almost all inhabitants who started taking diabetes medication or were hospitalized for diabetes. Cumulative risk of ESRD and hazard ratios [HR] for ESRD and death were estimated according to age, sex, and time period of diabetes diagnosis., Results: Among 421,429 patients with type 2 diabetes, 1,516 developed ESRD and 150,524 died during 3,458,797 patient-years of follow-up. Cumulative risk of ESRD was 0.29% at 10 years and 0.74% at 20 years from diagnosis of diabetes. Risk was higher among men than among women (HR 1.93 [95% CI 1.72-2.16]), decreased with older age at diagnosis (HR 0.70 [95% CI 0.60-0.81] for age 60-69 vs. 40-49 years), and was lower for those diagnosed in 2000-2011 than in 1990-1994 (HR 0.72 [95% CI 0.63-0.81]). Patients diagnosed with diabetes in 2000-2011 had lower risk of death during follow-up than those diagnosed in 1990-1994 (HR 0.64 [95% CI 0.63-0.65])., Conclusions: Cumulative risk of ESRD is minimal among patients with type 2 diabetes compared with their risk of death. Patients diagnosed with diabetes at an older age have a lower risk of ESRD due to higher competing mortality., (© 2019 by the American Diabetes Association.)

Background: Type 2 diabetic (T2DM) patients on renal replacement therapy (RRT) seldom receive a kidney transplant, which is partly due to age and comorbidities. Adjusting for case mix, we investigated whether T2DM patients have equal opportunity for renal transplantation compared to other patients on dialysis, and whether survival after transplantation is comparable., Methods: Patients who entered RRT in Finland in 2000-2010 (n = 5419) were identified from the Finnish Registry for Kidney Diseases and followed until the end of 2012. Of these, 20% had T2DM, 14% type 1 diabetes (T1DM) and 66% other than diabetes as the cause of ESRD. Uni-/multivariate survival analysis techniques were employed to assess the probability of kidney transplantation after the start of dialysis and survival after transplantation., Results: T2DM patients had a relative probability of renal transplantation of 0.18 (95% CI 0.15-0.22, P<0.001) compared to T1DM patients: this increased to 0.51 (95% CI 0.36-0.72, P<0.001) after adjustment for case mix (age, gender, laboratory values and comorbidities). When T2DM patients were compared to non-diabetic patients, the corresponding relative probabilities were 0.25 (95% CI 0.20-0.30, P<0.001) and 0.59 (95% CI 0.43-0.83, P = 0.002). After renal transplantation when adjusted for age and gender, relative risk of death was 1.25 (95% CI 0.64-2.44, P = 0.518) for T1DM patients and 0.72 (0.43-1.22, P = 0.227) for other patients compared to T2DM patients., Conclusions: T2DM patients had a considerably lower probability of receiving a kidney transplant, which could not be fully explained by differences in the patient characteristics. Survival within 5 years after transplantation is comparably good in T2DM patients., Competing Interests: The authors have declared that no competing interests exit.

Background: The incidence of renal replacement therapy (RRT) in the general population ≥75 years of age varies considerably between countries and regions in Europe. Our aim was to study characteristics and survival of elderly RRT patients and to find explanations for differences in RRT incidence., Methods: Patients ≥75 years of age at the onset of RRT in 2010-2013 from 29 national or regional registries providing data to the European Renal Association-European Dialysis and Transplant Association Registry were included. Chi-square and Mann-Whitney U tests were used to assess variation in patient characteristics and linear regression was used to study the association between RRT incidence and various factors. Kaplan-Meier curves and Cox regression were employed for survival analyses., Results: The mean annual incidence of RRT in the age group ≥75 years of age ranged from 157 to 924 per million age-related population. The median age at the start of RRT was higher and comorbidities were less common in areas with higher RRT incidence, but overall the association between patient characteristics and RRT incidence was weak. The unadjusted survival was lower in high-incidence areas due to an older age at onset of RRT, but the adjusted survival was similar [relative risk 1.00 (95% confidence interval, 0.97-1.03)] in patients from low- and high-incidence areas., Conclusions: Variation in the incidence of RRT among the elderly across European countries and regions is remarkable and could not be explained by the available data. However, the survival of patients in low- and high-incidence areas was remarkably similar.

Objective: To investigate how risk of end-stage renal disease (ESRD) among patients with type 1 diabetes has changed over time and further how the risk is affected by age, sex, and time period of diagnosis of diabetes., Research Design and Methods: A cohort including all patients <30 years old diagnosed with type 1 diabetes in Finland in 1965-2011 was followed until start of renal replacement therapy, death, or end of follow-up at the end of 2013. Altogether, 29,906 patients were included. The main outcome was cumulative risk of ESRD, accounting for death as a competing risk., Results: The patients were followed up for a median of 20 years. During 616,403 patient-years, 1,543 ESRD cases and 4,185 deaths were recorded. The cumulative risk of ESRD was 2.2% after 20 years and 7.0% after 30 years from the diabetes diagnosis. The relative risk of ESRD was 0.13 (95% CI 0.08-0.22) among patients diagnosed in 1995-2011 compared with those diagnosed in 1965-1979. Patients <5 years old at the time of diagnosis had the lowest risk of ESRD after diagnosis. With the cumulative risk of ESRD estimated from time of birth, the patients aged 5-9 years at diabetes diagnosis were at highest risk., Conclusions: The cumulative risk of ESRD has decreased markedly during the past five decades. This highlights the importance of modern treatment of diabetes and diabetic nephropathy., (© 2017 by the American Diabetes Association.)

Introduction: Mortality risk of patients with end-stage renal disease (ESRD) is highly elevated. Methods to estimate individual mortality risk are needed to provide individualized care and manage expanding ESRD populations. Many mortality prediction models exist but have shown deficiencies in model development (data comprehensiveness, validation) and in practicality. Therefore, our aim was to design 2 easy-to-apply prediction models for 1- and 2-year all-cause mortality in patients starting long-term renal replacement therapy (RRT)., Methods: We used data from the Finnish Registry for Kidney Diseases with complete national coverage of RRT patients. Model training group included all incident adult patients who started long-term dialysis in Finland in 2000 to 2008 (n = 4335). The external validation cohort consisted of those who entered dialysis in 2009 to 2012 (n = 1768). Logistic regression with stepwise variable selection was used for model building., Results: We developed 2 prognostic models, both of which only included 6 to 7 variables (age at RRT start, ESRD diagnosis, albumin, phosphorus, C-reactive protein, heart failure, and peripheral vascular disease) and showed sufficient discrimination (c-statistic 0.77 and 0.74 for 1- and 2-year mortality, respectively). Due to a significantly lower mortality in the newer cohort, the models, to a degree, overestimated mortality risk., Discussion: Mortality prediction algorithms could be more widely implemented into management of ESRD patients. The presented models are practical with only a limited number of variables and fairly good performance.

Aims: To examine use and changes of medication in the three years before start of chronic renal replacement therapy (RRT) among patients with type 1 diabetes, and the association between predialytic medication and survival on RRT., Methods: We recorded medication of 496 patients with type 1 diabetes before and after start of RRT in 2000-2006 and followed up until death or end of 2009. Data were retrieved from the Finnish Registry for Kidney Diseases and from the FinDM diabetes database. We evaluated the use of renin-angiotensin system (RAS) blockers, calcium channel blockers, β-blockers, statins, vitamin D, erythropoiesis-stimulating agents, and phosphate binders over three years. The association between predialytic medication and survival was assessed using Cox proportional hazards regression., Results: Medication increased markedly with progressing renal insufficiency. Almost 70% of the patients used calcium channel blockers and β-blockers before initiating RRT. Use of calcium channel blockers (RR 0.72, 95% CI 0.53-0.95) and vitamin D (RR 0.70, 95% CI 0.52-0.94) at start of RRT were associated with better survival when adjusted for age and sex, but after further adjustment the association lost statistical significance., Conclusions: Among type 1 diabetes patients in the predialysis phase, use of medication is abundant. Use of medication appears to keep patients at an equal survival level to those without the same medication. However, due to the observational nature of our study, conclusions regarding the effect of medication on survival must be made with caution., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background/aims: End-stage renal disease (ESRD) is one of the most serious complications of type 1 diabetes, but scarcely studied. Our aim was to estimate the association between biochemical variables and survival among these patients., Methods: This was an incident cohort study of patients with type 1 diabetes entering chronic renal replacement therapy (RRT) in Finland 2000-2011 (n = 834). Biochemical variables were measured before the initiation of RRT. Adjusted relative risk of death according to biochemical variables was estimated by Cox regression., Results: When adjusted for age, sex, comorbidities, and initial treatment modality of RRT, the most important predictors of death were low creatinine and albumin and high C-reactive protein., Conclusion: Among type 1 diabetes patients entering chronic RRT, biochemical variables independently associated with survival are creatinine, albumin and C-reactive protein. They reflect the nutritional status, proteinuria, liver function, and ongoing inflammatory process. Treatment of these might improve survival., (© 2014 S. Karger AG, Basel.)

Background: Studies on dialysis modality and survival have shown conflicting results, mostly due to insufficient and varying control of confounding factors. Using comprehensive data on a well-defined patient cohort, we therefore investigated the association of dialysis modality with survival on chronic renal replacement therapy (RRT) and whether this association varies between subgroups of patients., Methods: Survival analyses included all adult patients entering chronic RRT in Finland between 2000 and 2009 and used information obtained from the Finnish Registry for Kidney Diseases and the Finnish Kidney Transplant Registry. In our primary intention-to-treat (ITT) analysis, we calculated relative risk of death according to dialysis modality on Day 91 from RRT start, comparing peritoneal dialysis (PD) to haemodialysis (HD). Relative risks were adjusted for putative confounders. Interactions between treatment groups and other variables were estimated., Results: Of the total 4463 patients, 42% died during the 10 years of follow-up. Median survival time was 5.2 years. In unadjusted ITT analysis, relative risk of death of PD patients was 0.65 (95% CI 0.58-0.73, P < 0.001) compared with HD patients. With adjustment for 26 variables, the corresponding relative risk of death was 1.07 (95% CI 0.94-1.22, P = 0.33). When censoring at time of kidney transplantation, the result was similar with a relative risk of death of 1.09 (95% CI 0.95-1.25, P = 0.24) on PD compared with HD., Conclusions: PD is associated with several factors generally related to good prognosis. After comprehensive adjustment for putative confounding factors with the ITT analysis approach, we found no significant difference in survival between PD and HD patients.

Background: Estimated glomerular filtration rate (eGFR) is widely used in follow-up and assessment of patients before start of chronic renal replacement therapy (RRT). Reported data on impact of eGFR decline pattern during pre-dialysis phase on consequent survival on RRT are, however, non-existent., Methods: Using the database of the Finnish Registry for Kidney Diseases, we conducted a cohort study of all incident adult patients (n = 457) entering chronic RRT in Finland in 1998, with follow-up until 31 December 2008. We included those (n = 319) with three serum creatinine measurements (at ∼12 and 3 months and 1 to 2 weeks prior to RRT start) and calculated their slopes of eGFR using the modification of diet in renal disease formula. According to eGFR slopes (in mL/min/1.73m(2)/year), patients were divided into tertiles: most rapid (>8.5, n = 107), intermediate (3.4-8.5, n = 107) and slowest decline (<3.4, n = 105)., Results: Median survival time was 5.6 (95% confidence interval 4.2-7.0) years. Compared to the patient group with the slowest eGFR decline, age- and gender-adjusted relative risk of death was 1.1 (0.8-1.5) in the intermediate group and 1.7 (1.2-2.4, P = 0.002) in the most rapid decline group. When further adjusting for kidney disease diagnosis, comorbidities, use of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, body mass index, blood haemoglobin and serum albumin, the association was no longer significant., Conclusions: Rapid decline in eGFR before entering chronic RRT associates with increased mortality on RRT. The elevated mortality appears to be caused by known risk factors for death on RRT.

Aims/hypothesis: Comorbidities are frequent among type 1 diabetes patients on renal replacement therapy, yet the effect of comorbidities on survival is unknown. Our aim was to estimate this effect., Methods: An incident cohort of all patients with type 1 diabetes entering chronic renal replacement therapy (n = 656) in Finland between 2000 and 2008 was followed until death or the end of follow-up on 31 December 2008. All data were obtained from the Finnish Registry for Kidney Diseases, which collects information on comorbidities at the start of renal replacement therapy. The main outcome measure was relative risk of death according to comorbidities., Results: At start of renal replacement therapy, 22% of the patients with type 1 diabetes had coronary artery disease, 19% peripheral vascular disease, 11% cerebrovascular disease, 33% left ventricular hypertrophy and 7% heart failure. All these comorbidities were significant predictors of death in univariate analyses (RR 1.6-4.9). The 5 year survival probability of patients without comorbidities was 74%, while it was 56% and 37%, respectively, for those with one or more than one comorbidity. When the comorbidities were studied in a multivariate model, adjusting for age and sex, peripheral vascular disease (RR 1.9), left ventricular hypertrophy (RR 1.7) and heart failure (RR 2.5) remained independent risk factors for death. Calculations indicated that one-third of deaths in the study population could be attributed to comorbidities., Conclusions/interpretation: Among patients with type 1 diabetes entering renal replacement therapy, comorbidities are common and strong predictors of death. Therefore, it is essential to identify and adequately treat comorbidities.

Objective: Risks of end-stage renal disease and premature death in patients with type 1 diabetes have declined over the past decades. Data on the survival of patients receiving renal replacement therapy (RRT) are, however, limited. We investigated whether survival of patients with type 1 diabetes receiving RRT has improved over time and whether improvement can be attributable to progress in dialysis treatment or diabetes care., Research Design and Methods: An incident cohort of all patients with type 1 diabetes (n = 1,604) starting chronic RRT in Finland between 1980 and 2005 were followed until death or end of follow-up on 31 December 2007. The control group (n = 1,556) consisted of patients with glomerulonephritis who started RRT. All patients were identified from the Finnish Registry for Kidney Diseases., Results: Median survival time of patients with type 1 diabetes increased progressively from 3.60 years during 1980-1984 to >8 years in 2000-2005. In 2000-2005, the unadjusted relative risk of death was 0.55 compared with 1980-1984. After adjustment for the most important variables, the corresponding relative risk of death was only 0.23. For patients with glomerulonephritis, the adjusted relative risk decreased to a lesser extent to 0.30 (P = 0.007)., Conclusions: Survival of patients with type 1 diabetes and end-stage renal disease has improved since the 1980s despite a conspicuous increase in the age of patients who start RRT, suggesting not only true progress in dialysis therapy and overall treatment of patients with end-stage renal disease but possibly also improved management of diabetes.

We studied the in vivo measurements of the autofluorescence of the clear lens in 80 juvenile diabetics and 25 young healthy subjects. When the diabetes was of seven years' duration or more, no overlap with the control subjects was found. The pathologic autofluorescence of the diabetic lens showed a positive correlation with age and the duration of diabetes.

The effects were studied of a standardised general anaesthesia on mean arterial blood pressure, central venous pressure, blood gas values and the course of cataract operations. The material consisted of 20 unselected senile cataract operations, the mean age of the patients being 71.3 years. The arterial blood pressure was continuously checked, using an intra-arterial cannula. In order to avoid vitreous loss, the blood pressure was successfully kept optimally low during the extraction of the lens. No vitreous problems were noted. The oxygenation and ventilation of the patients were sufficient during anaesthesia and immediately postoperatively.