Initiation Of Maintenance Dialysis Research Articles

Survival Disparity of African American Versus Non–African American Patients With ESRD Due to SLE

A recent study showed an increased risk of death in African Americans compared with whites with end-stage renal disease (ESRD) due to lupus nephritis (LN). We assessed the impact of age stratification, socioeconomic factors, and kidney transplantation on the disparity in patient survival among African American versus non-African American patients with LN-caused ESRD, compared with other causes. Retrospective cohort study. Using the US Renal Data System database, we identified 12,352 patients with LN-caused ESRD among 1,132,202 patients who initiated maintenance dialysis therapy from January 1, 1995, through December 31, 2006, and were followed up until December 31,2010. Baseline demographics and comorbid conditions, Hispanic ethnicity, socioeconomic factors (employment status, Medicare/Medicaid insurance, and area-level median household income based on zip code as obtained from the 2000 US census), and kidney transplantation as a time-dependent variable. All-cause mortality. Multivariable Cox and competing-risk regressions. Mean duration of follow-up in the LN-caused ESRD and other-cause ESRD cohorts were 6.24±4.20 (SD) and 4.06±3.61 years, respectively. 6,106 patients with LN-caused ESRD (49.43%) and 853,762 patients with other-cause ESRD (76.24%) died during the study period (P<0.001). Patients with LN-caused ESRD were significantly younger (mean age, 39.92 years) and more likely women (81.65%) and African American (48.13%) than those with other-cause ESRD. In the fully adjusted multivariable Cox regression model, African American (vs non-African American) patients with LN-caused ESRD had significantly increased risk of death at age 18 to 30 years (adjusted HR, 1.43; 95% CI, 1.24-1.65) and at age 31 to 40 years (adjusted HR, 1.17; 95% CI, 1.02-1.34). Among patients with other-cause ESRD, African Americans were at significantly increased risk at age 18 to 30 years (adjusted HR, 1.17; 95% CI, 1.11-1.22). We used zip code-based median household income as a surrogate for patient income. Residual socioeconomic confounders may exist. African Americans are at significantly increased risk of death compared with non-African Americans with LN-caused ESRD at age 18 to 40 years, a racial disparity risk that is 10 years longer than that in the general ESRD population. Accounting for area-level median household income and transplantation significantly attenuated the disparity in mortality of African American versus non-African American patients with LN-caused ESRD.

Changes over the last decade in carotid atherosclerosis in patients with end-stage kidney disease

ObjectiveTherapies for chronic kidney disease have changed greatly over the last decade. The aim of this study was to examine the changes in the clinical characteristics and carotid atherosclerosis of patients with end-stage kidney disease (ESKD) over the last 9 years. MethodsA cross-sectional study of 150 consecutive patients with ESKD who had initiated maintenance dialysis between January 2005 and December 2013 was conducted. The patients' mean age was 68 ± 13 years. The group comprised 73% men, and 63% of the patients had diabetic nephropathy. The carotid artery-intima media thicknesses and the plaque scores (PS) were measured using carotid artery ultrasonography within 3 months of dialysis initiation. Changes in the patients' carotid atherosclerosis and clinical characteristics over the years were examined by categorizing the patients into 3 groups representing 3-year intervals based on when dialysis was initiated. ResultsThe PS declined from 12.8 to 5.4 (P = 0.001). Low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol levels declined over the 9-year period (P = 0.005 and P = 0.006, respectively), and the ratio of statin users increased markedly from 24% to 54% (P = 0.001). Univariate regression analysis identified a positive correlation between the PS and LDL-C (r = 0.281; P = 0.01), and a strong positive correlation was found between the PS and LDL-C after adjusting for various risk factors for atherosclerosis. ConclusionCarotid atherosclerosis in patients with ESKD has decreased over the past 9 years, which may be a consequence of improvements in dyslipidemia management.

Trends in the Timing and Clinical Context of Maintenance Dialysis Initiation.

Whether secular trends in eGFR at dialysis initiation reflect changes in clinical presentation over time is unknown. We reviewed the medical records of a random sample of patients who initiated maintenance dialysis in the Department of Veterans Affairs (VA) in fiscal years 2000-2009 (n=1691) to characterize trends in clinical presentation in relation to eGFR at initiation. Between fiscal years 2000-2004 and 2005-2009, mean eGFR at initiation increased from 9.8±5.8 to 11.0±5.5 ml/min per 1.73 m(2) (P<0.001), the percentage of patients with an eGFR of 10-15 ml/min per 1.73 m(2) increased from 23.4% to 29.9% (P=0.002), and the percentage of patients with an eGFR>15 ml/min per 1.73 m(2) increased from 12.1% to 16.3% (P=0.01). The proportion of patients who were acutely ill at the time of initiation and the proportion of patients for whom the decision to initiate dialysis was based only on level of kidney function did not change over time. Frequencies of documented clinical signs and/or symptoms were similar during both time periods. The adjusted odds of initiating dialysis at an eGFR of 10-15 or >15 ml/min per 1.73 m(2) (versus <10 ml/min per 1.73 m(2)) during the later versus earlier time period were 1.43 (95% confidence interval [95% CI], 1.13 to 1.81) and 1.46 (95% CI, 1.09 to 1.97), respectively. In conclusion, trends in eGFR at dialysis initiation at VA medical centers do not seem to reflect changes in the clinical context in which dialysis is initiated.

OPTN/SRTR 2013 Annual Data Report: kidney.

A new kidney allocation system, expected to be implemented in late 2014, will characterize donors on a percent scale (0%-100%) using the kidney donor profile index (KDPI). The 20% of deceased donor kidneys with the greatest expected posttransplant longevity will be allocated first to the 20% of candidates with the best expected posttransplant survival; kidneys that are not accepted will then be offered to remaining 80% of candidates. Waiting time will start at the time of maintenance dialysis initiation (even if before listing) or at the time of listing with an estimated glomerular filtration rate of 20 mL/min/1.73 m(2) or less. Under the current system, the number of candidates on the waiting list continues to increase, as each year more candidates are added than are removed. Median waiting times for adults increased from 3 years in 2003 to more than 4.5 years in 2009. Donation rates have not increased. Short-term outcomes continue to improve; death-censored graft survival at 90 days posttransplant was 97% or higher for deceased donor transplants and over 99% for living donor transplants. In 2013, 883 pediatric candidates were added to the waiting list; 65.8% of pediatric candidates on the list in 2013 underwent deceased donor transplant. Five-year graft survival was highest for living donor recipients aged younger than 11 years (89%) and lowest for deceased donor recipients aged 11 to 17 years (68%).

Early mortality in patients starting dialysis appears to go unregistered

Clinical experience suggests a heightened risk associated with the transition to maintenance dialysis but few national studies have systematically examined early mortality trajectories. Here we calculated weekly mortality rates in the first year of treatment for 498,566 adults initiating maintenance dialysis in the United States (2005-2009). Mortality rates were initially unexpectedly low, peaked at 37.0 per 100 person-years in week 6, and declined steadily to 14.8 by week 51. In both early (weeks 7-12) and later (weeks 13-51) time frames, multivariate mortality associations included older age, female, Caucasian, non-Hispanic ethnicity, end-stage renal disease (ESRD) from hypertension and acute tubular necrosis, ischemic heart disease, estimated glomerular filtration rate of 15 ml/min per 1.73 m(2) or more, shorter duration of nephrologist care, and hemodialysis, especially with a catheter. For early mortality risk, adjusted hazard ratios of 2 or more were seen with age over 65 (5.80 vs. under 40 years), hemodialysis with a catheter (2.73 vs. fistula), and age 40-64 (2.33). For later mortality risk, adjusted hazard ratios of 2 or more were seen with age over 65 (4.32 vs. under 40 years), hemodialysis with a catheter (2.10 vs. fistula), and age 40-64 (2.00). Thus, low initial mortality rates question the accuracy of data collected and are consistent with deaths occurring in the early weeks after starting dialysis not being registered with the United States Renal Data System.

Effects of lowering LDL cholesterol on progression of kidney disease.

Lowering LDL cholesterol reduces the risk of developing atherosclerotic events in CKD, but the effects of such treatment on progression of kidney disease remain uncertain. Here, 6245 participants with CKD (not on dialysis) were randomly assigned to simvastatin (20 mg) plus ezetimibe (10 mg) daily or matching placebo. The main prespecified renal outcome was ESRD (defined as the initiation of maintenance dialysis or kidney transplantation). During 4.8 years of follow-up, allocation to simvastatin plus ezetimibe resulted in an average LDL cholesterol difference (SEM) of 0.96 (0.02) mmol/L compared with placebo. There was a nonsignificant 3% reduction in the incidence of ESRD (1057 [33.9%] cases with simvastatin plus ezetimibe versus 1084 [34.6%] cases with placebo; rate ratio, 0.97; 95% confidence interval [95% CI], 0.89 to 1.05; P=0.41). Similarly, allocation to simvastatin plus ezetimibe had no significant effect on the prespecified tertiary outcomes of ESRD or death (1477 [47.4%] events with treatment versus 1513 [48.3%] events with placebo; rate ratio, 0.97; 95% CI, 0.90 to 1.04; P=0.34) or ESRD or doubling of baseline creatinine (1189 [38.2%] events with treatment versus 1257 [40.2%] events with placebo; rate ratio, 0.93; 95% CI, 0.86 to 1.01; P=0.09). Exploratory analyses also showed no significant effect on the rate of change in eGFR. Lowering LDL cholesterol by 1 mmol/L did not slow kidney disease progression within 5 years in a wide range of patients with CKD.

Trends in Anemia Care in Older Patients Approaching End-Stage Renal Disease in the United States (1995-2010)

Anemia is common in patients with advanced chronic kidney disease. Whereas the treatment of anemia in patients with end-stage renal disease (ESRD) has attracted considerable attention, relatively little is known about patterns and trends in the anemia care received by patients before they start maintenance dialysis or undergo preemptive kidney transplantation. To determine the trends in anemia treatment received by Medicare beneficiaries approaching ESRD. Closed cohort study in the United States using national ESRD registry data (US Renal Data System) of patients 67 years or older who initiated maintenance dialysis or underwent preemptive kidney transplantation between 1995 and 2010. All eligible patients had uninterrupted Medicare (A+B) coverage for at least 2 years before ESRD. Time, defined as calendar year of incident ESRD. Use of erythropoiesis-stimulating agents (ESA), intravenous iron supplements, and blood transfusions in the 2 years prior to ESRD; hemoglobin concentration at the time of ESRD. We used multivariable modified Poisson regression to estimate utilization prevalence ratios (PRs). Records of 466,803 patients were analyzed. The proportion of patients with incident ESRD receiving any ESA in the 2 years before increased from 3.2% in 1995 to a peak of 40.8% in 2007; thereafter, ESA use decreased modestly to 35.0% in 2010 (compared with 1995; PR, 9.85 [95% CI, 9.04-10.74]). Among patients who received an ESA, median time from first recorded ESA use to ESRD increased from 120 days in 1995 to 337 days in 2010. Intravenous iron administration increased from 1.2% (1995) to 12.3% (2010; PR, 9.20 [95% CI, 7.97-10.61]). The proportion of patients receiving any blood transfusions increased monotonically from 20.6% (1995) to 40.3% (2010; PR, 1.88 [95% CI, 1.82-1.95]). Mean hemoglobin concentrations were 9.5 g/dL in 1995, increased to a peak of 10.3 g/dL in 2006, and then decreased moderately to 9.9 g/dL in 2010. Between 1995 and 2010, older adults approaching ESRD were increasingly more likely to be treated with ESAs and to receive intravenous iron supplementation, but also more likely to receive blood transfusions.

Provider and Care Characteristics Associated with Timing of Dialysis Initiation

There is a trend in the United States to maintenance dialysis initiation at higher levels of estimated GFR. This study aimed to determine whether provider characteristics and pre-ESRD nephrology care and vascular access are independently associated with higher estimated GFR at initiation. This retrospective cohort study used US Renal Data System data for patients who initiated dialysis in 2006 (n=83,621) and American Medical Association Physician Master File data for provider characteristics. Patient characteristics and estimated GFR were defined, and providers at dialysis initiation were identified. Earlier dialysis initiation was defined as initiation at estimated GFR>10 ml/min per 1.73 m(2). Nephrologist density per 100 ESRD patients was calculated by Health Service Area in 2006. Associations between provider characteristics and estimated GFR were determined using logistic regression and linear regression models, accounting for provider clustering. Of the cohort, 47.8% of patients initiated dialysis at estimated GFR>10 ml/min per 1.73 m(2), and 16.2% of patients initiated dialysis at estimated GFR≥15 ml/min per 1.73 m(2). Predialysis nephrologist care for 0-12 months was associated with greater odds of earlier initiation compared with no care. Patients initiating with an arteriovenous fistula or graft were more likely to initiate earlier than patients initiating with a catheter. Provider sex was not associated with timing of dialysis initiation as measured by estimated GFR. Care by providers who graduated from nondomestic medical schools was associated with greater odds of earlier initiation. Greater provider experience was associated with lower likelihood of earlier initiation. This study supports the hypothesis that provider factors are associated with timing of dialysis initiation in the United States.

Initiation of Dialysis Should be Timely: Neither Early Nor Late

Over the last decade, individuals with end-stage renal disease (ESRD) in the United States are starting maintenance dialysis therapy at progressively higher estimated glomerular filtration rate (eGFR). Moreover, several observational studies have demonstrated an association of a higher risk of death with higher serum creatinine-based estimates of GFR at the time of initiation of dialysis. In contrast, studies in which renal function has been measured by timed urinary collection show either a lower risk of death or no significant association with higher GFR at the time of initiation of dialysis. There are numerous potential sources of bias in such observational studies, particularly in those that use serum creatinine-based eGFR. The only randomized controlled clinical trial to have examined this question did not demonstrate either benefit or harm with initiation of dialysis at higher level of renal function. Thus, the data to date suggest that eGFR should not be the sole consideration when assessing the need for initiating maintenance dialysis in patients with advanced chronic kidney disease. Given the high societal costs of starting renal replacement therapy earlier in the course of the disease, these considerations also suggest that dialysis can be safely be postponed in otherwise asymptomatic individuals with advanced chronic kidney disease. By the same token, dialysis should not be denied to individuals who could clearly benefit from renal replacement therapy simply because the GFR is too high (viz., volume overload, refractory hyperkalemia). Finally, there is a compelling need to reexamine the symptoms that could be attributed to uremia and clearly improve upon initiation of dialysis to better guide clinical decision-making.

Comparison of preemptive kidney transplant recipients with nonpreemptive kidney recipients in single center: 5 years of follow-up

BackgroundFor suitable patients with end-stage renal disease, kidney transplantation (KT) is the best renal replacement therapy, resulting in lower morbidity and mortality rates and improved quality of life. Preemptive kidney transplantation (PKT) is defined as transplantation performed before initiation of maintenance dialysis and reported to be associated with superior outcomes of graft and patient survival. In our study, we aimed to compare the 5-year outcomes of PKT and nonpreemptive kidney transplantation (NPKT) patients who received KT in our center, to define the differences according to complications, comorbidities, adverse effects, clinical symptoms, periodical laboratory parameters, rejection episodes, graft, and patient survival.MethodsOne hundred kidney transplantation (37 PKT, 63 NPKT) recipients were included in our study. All patients were evaluated for adverse effects, complications, comorbidities, clinical symptoms, monthly laboratory parameters, acute rejection episodes, graft, and patient survival.ResultsAcute rejection episodes were found to be significantly correlated with graft loss in both groups (P = 0.02 and P = 0.01, respectively). Hypertension after transplantation was diagnosed by ambulatory blood pressure measurement in 74 of 100 patients. Twenty-five of 37 (67.6%) of Group 1 (PKT) recipients had hypertension while 54 of 63 (85.4%) of Group 2 (NPKT) had hypertension. The incidence of hypertension between two groups was statistically significant (P = 0.03), but this finding was not correlated to graft survival (P = 0.07). Some patients had serious infections, requiring hospitalization, and were treated immediately. Infection rates between the two groups were 10.8% for Group 1 patients and 31.7% for Group 2 patients and were statistically significant (P = 0.02). Infection, requiring hospitalization, was found to be statistically correlated to graft loss in only NPKT patients (P = 0.00).ConclusionWhile the comparison of PKT and graft and patient survival with NPKT is poorer than we expected, lower morbidity rates of hypertension and infection are similar with recent data. Avoidance of dialysis-associated comorbidities, diminished immune response, and cardiovascular complications are the main benefits of PKT.

Magnitude of discordance between registry data and death certificate when evaluating leading causes of death in dialysis patients

BackgroundDiscordance between dialysis registry and death certificate reported death has been demonstrated. Since cause of death is measured using registry data in dialysis patients and death certificate data in the general population, comparisons of cause of death proportions between dialysis patients and the general population may be biased. Our aim was to compare the proportion of deaths attributed to cardiovascular disease (CVD), malignancy, and infections between patients receiving dialysis and the general population using death certificates for both, and to quantify the magnitude of discrepancy between registry and death certificate estimates in dialysis patients.MethodsA retrospective cohort study of 5858 patients initiating maintenance dialysis between 2001 and 2007 was conducted. Cause of death was obtained from both registry and death certificate data for dialysis patients, and from death certificate data for the general population.ResultsCompared to the general population, use of death certificate data in dialysis patients resulted in smaller differences in the proportion of deaths attributed to CVD or infection than that from the registry. In the general population, the proportion of deaths due to CVD is 29.3% for men and 28.2% for women, and the proportion of deaths due to infection is 3.3% for men and 3.6% for women. For men, the proportion of deaths in dialysis patients due to CVD using registry data is 41.5%, compared with a proportion of 32.1% using death certificate data. Similarly for women, the proportion of deaths due to CVD using registry data is 35.2% and that using death certificate data 24.3%. The proportion of deaths due to infection in dialysis patients follows the same pattern: for men, the proportion of deaths due to infection using registry data is 9.9% and that from death certificate data at 5.0%; while for women the proportions are 11.6% and 4.8%, respectively.ConclusionsWhile absolute cause-specific mortality rates did differ, evaluation of causes of death using death certificate in dialysis patients in Quebec revealed that they do not have substantially different proportion of death due to CVD or infections than the general population. Infections appeared to be a frequent complication leading to death, suggesting that infections are an important target to consider for reducing mortality in dialysis populations.

Development of systemic lupus erythematosus in an elderly male hemodialysis patient with pleuritis.

This report describes a 70-year-old man who developed systemic lupus erythematosus (SLE) during treatment with maintenance hemodialysis. At initiation of maintenance dialysis, the etiology of end-stage renal disease (ESRD) was diabetic nephropathy and no clinical symptom or laboratory data suggested SLE. Fever, pleural effusion that did not respond to ultrafiltration, and immunological findings such as low complement and elevated anti-double-strand DNA antibody level appeared 4years after maintenance dialysis initiation. Immunosuppressive therapy with corticosteroids improved these abnormalities remarkably. This case underscores the necessity of considering SLE in the differential diagnosis of pleural effusion with male ESRD patients, even if another etiology of ESRD exists.

Stroke symptoms signal worse outcomes in patients with end-stage renal disease

Individuals with end-stage renal disease (ESRD) or even those with earlier stages of chronic kidney disease have a markedly elevated risk of cardiovascular and cerebrovascular disease. In fact, 20% of individuals with ESRD die within a year of initiating maintenance dialysis, mainly of cardiovascular causes. Although earlier studies in ESRD patients focused on the risk of coronary and related cardiac diseases, more recent studies have indicated that risk of stroke and …

Rural and Micropolitan Residence and Mortality in Patients on Dialysis

Micropolitan and rural patients face challenges when initiating dialysis, including healthcare access. Previous studies have shown little association of nonurban residence with dialysis outcomes but have not examined the association of dialysis modality with residence location. This retrospective cohort study used data from the U.S. Renal Data System. Adults who initiated maintenance dialysis between January 1, 2006, and December 31, 2007, were classified as rural, micropolitan, or urban. Early and long-term mortality and kidney transplantation were examined with Cox regression stratified by dialysis modality. Of 204,463 patients, 80% were urban; 10.2%, micropolitan; and 9.8%, rural. Micropolitan and rural patients were older, were less racially diverse, had more comorbid conditions, and were more likely to start peritoneal dialysis (PD). Median follow-up was 2.0 years. Early mortality or long-term hemodialysis (HD) mortality did not significantly differ by geographic residence. After adjustment, micropolitan and rural PD patients had higher risk for long-term mortality (hazard ratio [HR], 1.21 [95% confidence interval (CI), 1.09-1.35] and 1.12 [95% CI, 1.01-1.24], respectively) than urban PD patients. After adjustment, kidney transplantation was more likely in micropolitan and rural HD patients (HR, 1.19 [95% CI, 1.11-1.28] and 1.30 [CI, 1.21-1.40]) than urban HD patients, and micropolitan PD patients (HR, 1.31 [95%, CI 1.13-1.51]) than urban PD patients. Micropolitan and rural residence is associated with higher mortality in PD patients and similar or higher likelihood of kidney transplantation among HD and PD patients. Studies examining the underlying mechanisms of these associations are warranted.

Low birth weight and end-stage renal disease: demographic analysis by region in Japan

BACKGROUND We have previously shown regional differences in the incidence of end-stage renal disease (ESRD)within Japan, which is ethnically homogenous, suggesting that non-genetic factors may contribute to the differences.We examined regional distribution in the incidence of low birth weight (LBW), a surrogate for low nephron number,in our search for an explanation. Each year, the Ministry of Health, Labour and Welfare of Japan and the Japanese Society for Dialysis Therapy report the number of LBW babies and patients initiating maintenance dialysis in each prefecture of Japan,respectively. In this study, we calculated the annual incidences of LBW and ESRD in 11 regions of Japan over a 24-year period from 1984 to 2007. There were distinct regional differences in the annual incidences of both LBW and ESRD (p<0.0001).These regional distributions persisted despite consistent increases (p<0.0001) in incidences of both LBW and ESRD during the study period. Compared with the reference group consisting of 3 regions with the lowest LBW incidence, the odds ratios for ESRD (95% confidence interval) of the 5 regions with intermediate LBW incidence and the 3 regions with the highest LBW incidence are 1.09(1.05–1.14) and 1.29 (1.22–1.35), respectively. The annual incidence of LBW was positively correlated with annual incidence of ESRD in their regional distribution across 11 regions (r = 0.66, p = 0.03). The present study, relating regional distribution between LBW and ESRD dynamics in a nationwide population of Japan, revealed that the marked regional differences in the incidence of ESRD within Japan could be explained by a similar regional distribution in the incidence of LBW.

Regional Differences in Dialysis Care and Mortality among American Indians and Alaska Natives

American Indians/Alaska Natives (AIANs) compose a heterogeneous population that includes geographically distinct tribal communities, many with high rates of ESRD. Regional features of dialysis care and mortality are unknown in this population. Here, we describe the structure of dialysis care and mortality of adult AIANs who initiated maintenance dialysis during 1995-2008 in different regions of the US. Overall, 13,716 AIANs received dialysis at 2054 facilities. Approximately 10% (n = 197) of these facilities provided care to two-thirds (n = 9011) of AIANs. AIANs from the Southwest and Alaska were concentrated in relatively few dialysis facilities whereas those in the Eastern US and Pacific Coast were distributed more diffusely. Despite comparably high rates of poverty, diabetes, and cardiovascular disease, annual mortality rates were lower in the Southwest (13.9%) compared with the Southern Plains (23.2%), Alaska (21.2%), Eastern US (20.0%), Northern Plains (20.8%), and Pacific Coast (22.0%). These regional differences were consistent over time and persisted after adjusting for sociodemographic and clinical variables and area-based poverty. In conclusion, regional differences in the structure of dialysis care and patient mortality exist among AIANs. Southwestern AIANs experience the highest concentration of dialysis care and the lowest mortality. Our findings suggest that an area-based approach examining the care structure of relatively few dialysis facilities may delineate determinants of these differences and improve the quality of care to many AIAN communities.

Geographic differences in the increasing ESRD rate have disappeared in Japan

We previously showed that there are marked geographic differences in the incidence of end-stage renal disease (ESRD) within Japan. In addition, the use of renin-angiotensin system inhibitors was found to be inversely correlated with the increasing ESRD rate. It was recently demonstrated that the incidence of ESRD due to diabetic nephropathy is declining in both Europe and USA. Therefore, we investigated the increasing ESRD rate and its geographic difference in Japan. Each year, the Japanese Society for Dialysis Therapy reports the numbers of patients initiating maintenance dialysis therapy in each prefecture of Japan. We used old (1984-1991) and recent (2001-2008) data to compare the increasing ESRD rate, which was estimated from the slope of the regression line of the annual incidence corrected for population, between the two periods in 11 regions of Japan. Increasing ESRD rate almost halved, from 11.1±5.6 to 5.4±0.7/million per year from the old to the recent period. Deceleration of the increasing ESRD rate from the old to the recent period was correlated with the incidence in the old period across 11 regions (r=0.81, p<0.003); i.e., the deceleration was greater in the regions where ESRD incidence had been higher. Whereas the increasing ESRD rate was significantly different among regions in the old period, this was not the case in the recent period, resulting in uniformity throughout Japan. The increasing ESRD rate is slowing in Japan, and its geographic differences, previously observed, have disappeared.

A Randomized, Controlled Trial of Early versus Late Initiation of Dialysis

In clinical practice, there is considerable variation in the timing of the initiation of maintenance dialysis for patients with stage V chronic kidney disease, with a worldwide trend toward early initiation. In this study, conducted at 32 centers in Australia and New Zealand, we examined whether the timing of the initiation of maintenance dialysis influenced survival among patients with chronic kidney disease. We randomly assigned patients 18 years of age or older with progressive chronic kidney disease and an estimated glomerular filtration rate (GFR) between 10.0 and 15.0 ml per minute per 1.73 m2 of body-surface area (calculated with the use of the Cockcroft-Gault equation) to planned initiation of dialysis when the estimated GFR was 10.0 to 14.0 ml per minute (early start) or when the estimated GFR was 5.0 to 7.0 ml per minute (late start). The primary outcome was death from any cause. Between July 2000 and November 2008, a total of 828 adults (mean age, 60.4 years; 542 men and 286 women; 355 with diabetes) underwent randomization, with a median time to the initiation of dialysis of 1.80 months (95% confidence interval [CI], 1.60 to 2.23) in the early-start group and 7.40 months (95% CI, 6.23 to 8.27) in the late-start group. A total of 75.9% of the patients in the late-start group initiated dialysis when the estimated GFR was above the target of 7.0 ml per minute, owing to the development of symptoms. During a median follow-up period of 3.59 years, 152 of 404 patients in the early-start group (37.6%) and 155 of 424 in the late-start group (36.6%) died (hazard ratio with early initiation, 1.04; 95% CI, 0.83 to 1.30; P=0.75). There was no significant difference between the groups in the frequency of adverse events (cardiovascular events, infections, or complications of dialysis). In this study, planned early initiation of dialysis in patients with stage V chronic kidney disease was not associated with an improvement in survival or clinical outcomes. (Funded by the National Health and Medical Research Council of Australia and others; Australian New Zealand Clinical Trials Registry number, 12609000266268.)

Preemptive Kidney Transplantation of Living Related or Unrelated Donor–Recipient Combinations

Introduction According to the Japanese renal transplant registry 2005, 834 transplantations were performed using living donors. Among them 112 (13.4%) patients were transplanted from living donors before the initiation of maintenance dialysis. Preemptive kidney transplantation (PreKTx) has been associated with improved allograft and patient survival rates compared to non-PreKTx. This study was designed to summarize our experience with PreKTx. Patients and Methods From April 2003 to July 2007, 44 living kidney transplantations were performed at our institution. We divided these 44 patients into two groups: 5 (11.4%) patients (group 1; G1) who underwent PreKTx and the other 39 patients (group 2; G2) who received kidneys after the institution of maintenance dialysis. Living unrelated donors were mostly spouses. During the induction phase, tacrolimus or cyclosporine, mycophenolate mofetil, and methylprednisolone were used for immunosuppression. In ABO-incompatible cases, plasmapheresis was performed to remove anti-AB antibodies prior to transplantation and splenectomy at the time of or before transplantation. Results Among G1, no patient died. Among G2, two patients died with functioning grafts, one due to a traumatic subdural hematoma and another due to malignant B cell lymphoma. Death-censored graft survival rates were 100% in both groups. The incidence of acute rejection was 20.0% and 20.5% in G1 and G2, respectively. Conclusions Our results demonstrated that PreKTx from a living donor was equivalent to the non-PreKTx. However, there were also potential benefits to PreKTx in the long-term outcome, including avoidance of morbidity associated with dialysis and access procedures, as well as reduced cost. In response to the shortage of deceased donors, PreKTx from living donors will spread in Japan.

Changes in fat mass after initiation of maintenance dialysis is influenced by the uncoupling protein 2 exon 8 insertion/deletion polymorphism

A high body mass index (BMI) has been reported to confer a survival advantage in end-stage renal disease (ESRD) patients. On the other hand, body fat accumulation, especially visceral adipose tissue, is an important risk factor for cardiovascular disease, as well as a clinically important source of adipokines. Uncoupling protein 2 (UCP2) uncouples respiration from ATP synthesis, thus regulating energy expenditure and fat oxidation. In this longitudinal cohort study, we investigated the impact of the UCP2 insertion/deletion (ins/del) polymorphism on body composition changes in ESRD patients starting dialysis. A total of 222 incident Caucasian ESRD patients (mean age 53 +/- 12 years; 60% males) were investigated close to the start of dialysis with peritoneal dialysis (PD; n = 126) or haemodialysis (HD; n = 96), and again after about 1 year (n = 159). Genotyping of the UCP2 ins/del polymorphism was performed in the patients and in 207 healthy controls. Dual-energy X-ray absorptiometry was conducted at baseline and after 1 year to monitor body composition. While HD patients and PD patients with the ins/del genotype did not display any changes in body composition, the 48 PD patients with the del/del genotype that completed follow-up had a significant increase; DeltaBMI (0.7 +/- 1.8 kg/m(2)), Deltabody fat mass (3.5 +/- 3.8 kg) and Deltatruncal fat mass (1.7 +/- 1.2 kg). In a multiple linear regression analysis, the del/del genotype was an independent predictor of the increase in truncal fat mass in PD patients (F-ratio = 7.99, P < 0.05) together with age and diabetes mellitus. PD patients, but not HD patients, with the UCP2 del/del genotype showed a significant increase in total and truncal fat mass during the first year of dialysis therapy, suggesting a possible role for UCP2 in dissipating the excess energy of a high-glucose environment.