Percentage Of End-stage Renal Disease Patients Research Articles

Prostate cancer outcomes by ESRD status.

e17513 Background: Persons with end-stage renal disease (ESRD) comprise a vulnerable subgroup of the population. Yet, rarely have studies on cancer disparities accounted for ESRD status. We sought to compare prostate cancer stage at diagnosis, treatment, and outcomes among men with and without ESRD. Methods: Utilizing SEER-Medicare database between years 2000-2016, we retrieved sociodemographic variables, including age (40-54, 55-64, 65-74, and 75+), race (African American vs. all others), marital status (married/partnered vs. all others), residence in a census tract with poverty rate > 20%; cancer stage at diagnosis (local, regional, distant, and unknown); treatment (surgery and radiation therapy); and overall and cancer specific survival (OS and CSS) from the SEER, and ESRD status preceding prostate cancer diagnosis from the Medicare portion of the file. In addition to descriptive analysis, multivariable survival analysis was utilized to evaluate the association of ESRD status with OS and CSS after adjusting for patient covariates. Results: Our study population included 2,922 ESRD and 600,848 non-ESRD men diagnosed with incident prostate cancer during the study period. A disproportionately higher percentage of ESRD patients were in the 40-54 age group compared to non-ESRD (9.7 vs 3.6%). Similarly, the percentage of prostate cancer patients who were African American was 41.5% among ESRD patients, compared with 14.4% in their non-ESRD counterparts. In addition, more ESRD than non-ESRD patients lived in census tracts with poverty rates greater than 20% (31.2% vs. 18.0%). With regard to stage, 10.6% of ESRD patients but only 4.5% of non-ESRD patients were diagnosed with distant-stage disease; and while only 24.8% of ESRD patients underwent surgery, 36.9% of non-ESRD patients did so. The rate of radiation therapy was similar across the two groups. Multivariable survival models showed that, adjusting for patient covariates, ESRD status was associated with unfavorable OS and CSS (adjusted hazard ratio (AHR): 4.00 (95% confidence interval: 3.82, 4.18), and AHR: 1.54 (1.37, 1.73), respectively). Median follow up was 3.35 and 7.13 years between the ESRD and non-ESRD cohorts. Conclusions: ESRD status in prostate cancer patients is associated with marked sociodemographic and economic disparities. Compared to their non-ESRD counterparts, more ESRD patients are diagnosed with advanced-stage disease, are less likely to undergo surgery, and experience shorter overall and cancer-specific survival. Future studies should be directed to gain insight into factors contributing to unfavorable cancer-specific outcomes.

Comorbidity burden in prostate cancer patients by ESRD status.

e17510 Background: The co-occurrence of cancer and end-stage-renal disease (ESRD) may pose significant challenge in the management of both diseases. Further complicating clinical decisions is our limited understanding of the comorbidity burden (CB), which also affects their outcomes to a considerable extent. The purpose of this study is to characterize the CB in prostate cancer patients, with and without ESRD. Methods: Using SEER-Medicare database between years 2000-2016, we retrieved sociodemographic variables, including age (40-54, 55-64, 65-74, and 75+), race (African American vs. all others), marital status (married/partnered vs. all others), residence in a census tract with poverty rate > 20%, and dual Medicare-Medicaid enrollment status; chronic conditions identified in the year of cancer diagnosis; and ESRD status preceding prostate cancer diagnosis. We limited our study population to cancer patients enrolled in Medicare at the time of cancer diagnosis, and were receiving their care through the fee-for-service system. In this descriptive analysis, we compared the prevalence of these conditions between prostate cancer patients by ESRD status. Results: Our study population included 2,046 ESRD and 302,136 non-ESRD men diagnosed with incident prostate cancer during the study period. Compared to non-ESRD patients, a disproportionately higher percentage of ESRD patients were in the 40-54 and 55-64 age groups compared to non-ESRD (11.0 vs 0.95% and 32.2% vs. 8.51%, respectively). Similarly, the percentage of prostate cancer patients who were African American was 44.1% among ESRD patients, compared with 13.6% in their non-ESRD counterparts. With regard to comorbidities, several conditions were significantly higher in ESRD than non-ESRD patients, including: anemia (65.4% vs. 15.3%), congestive heart failure (31.1% vs. 8.9%), ischemic heart disease (38.9% vs. 25.2%), diabetes (40.7% vs. 17.0%), hypertension (68.0% vs. 42.6%), hypothyroidism (4.6% vs. 2.9%), hyperlipidemia (43.1% vs. 35.1%), and stroke (3.7% vs. 2.5%). Conclusions: Compared to their non-ESRD counterparts, ESRD patients present with high CB, severely compromising their physiologic reserve and tolerance for various cancer treatment modalities, and affecting outcomes. Future studies should compare the prevalence of specific combinations of conditions constituting multimorbidity between ESRD and non-ESRD patients, and identify multimorbidity profiles associated with a lower likelihood to receive standard treatment. Such detailed analysis will be foundational to clinical management and outcome studies.

Renal replacement therapies in the elderly: Part II. Renal transplantation.

The United States end-stage renal disease (ESRD) population is growing progressively older. As a percentage of the overall ESRD population, the number of patients 65 years of age and older approached 40% by 1989. However, the percentage of ESRD patients with a functioning transplant was only 2.7% in this age group. Success of transplantation in geriatric ESRD patients over the last decade is due to improved patient selection as well as the use of cyclosporine A and lower doses of corticosteroids, with the achievement of 1-year patient and graft survival rates of 85% and 75%, respectively. For patients older than 60 or 65 years, the 5-year "functional" graft survival is 55% to 60%. Although overall results are excellent, the management of transplantation in the elderly requires an understanding of pharmacology, immunology, and physiology peculiar to this age group. Since the elderly have a degree of immune incompetence, they require less aggressive immunotherapy. Elderly patients have decreased hepatic enzyme activity, especially the P450 system, and therefore require a lower cyclosporine dose. Although elderly patients experience less rejection episodes than younger patients, graft loss in the elderly transplant recipient is due mainly to patient death. Most common causes of death in the elderly transplant recipient are cardiovascular disease and infection related to peaks of immunosuppression. Shortage of cadaver kidneys and limited life expectancy of the geriatric ESRD patient make allocation of cadaver kidneys to patients over 70 years (and even 65 years) a controversial issue and an ethical dilemma. Use of elderly cadaver donors (over 55 to 60 years) is associated with inferior success rates and is not an optimal solution to shortage of cadaver kidneys.

Hemodialysis in the diabetic patient with end-stage renal disease.

Diabetes mellitus is now the most common cause of end-stage renal disease (ESRD) in the U.S., and the percentage of ESRD patients with diabetes is increasing yearly. One-year survival in such patients is poorer than in those with other etiologies of ESRD but has improved from 64% to 74% over the past decade. However, overall 5-year survival on dialysis is still less than 20% in this population. It is controversial whether hemodialysis or peritoneal dialysis (CAPD, CCPD) is the best choice. Advantages of hemodialysis include its ready availability and convenience for patients, who are frequently incapacitated by blindness, cerebrovascular disease, and/or amputations. However, patients may tolerate dialytic ultrafiltration poorly due to autonomic neuropathy. Maintenance of vascular access is difficult, which may contribute to inadequate dialysis in some patients. Cardiovascular disease remains the most common cause of death. Management of coronary artery disease is difficult because of the high prevalence of silent ischemia. Control of blood pressure is of paramount importance in preventing cardiovascular complications. Improved survival in diabetics who were dialyzed in a more intensive than usual fashion has been reported recently. In addition, much of the difference in survival rates between diabetics and nondiabetics can be accounted for by the poorer nutritional status in the former group. Thus attention to the dose of dialysis administered and assurance of adequate nutrition should result in improved survival of the diabetic patient on hemodialysis.

ASSESSMENT OF RESOURCES FOR RENAL TRANSPLANTATION IN THE UNITED KINGDOM

Statistics on treatment rates for patients with end stage renal disease (ESRD) show that the number of ESRD patients per million population in the United Kingdom has increased slowly in recent years. The British Transplantation Society issued questionnaires in 1983 and 1984 to determine the number of patients transplanted, the number of suitable patients, and the facilities needed to enable all suitable patients to receive treatment. While there is a high transplant rate, the percentage of ESRD patients on dialysis is low, and there is a "socially unacceptable deficit" with respect to treatment of diabetics and the elderly.