Prevalent Dialysis Research Articles

Elevated Plasma Levels of PAI-1 Predict Cardiovascular Events and Cardiovascular Mortality in Prevalent Peritoneal Dialysis Patients

Background. Elevated plasminogen activator inhibitor-1 (PAI-1) levels are associated with increased cardiovascular (CV) risk in the general population. It has been shown that peritoneal dialysis (PD) patients have increased plasma levels of PAI-1. The aim of this study was to investigate whether PAI-1 independently predicted CV outcome in PD patients. Material and Methods. Seventy-two PD patients (53% females, mean age 49.9 ± 16.1 years) were studied. Twelve patients who underwent kidney transplantation and 14 patients who transferred to hemodialysis during follow-up were excluded from the analysis. The remaining 46 patients (54% female, mean age 54 ± 16 years, dialytic age 42 ± 30 months) were followed a mean time of 45.4 ± 19.4 months (range 8–71 months). Baseline PAI-1, clinical, and laboratory parameters were assessed in all patients. Survival analyses were made with Kaplan-Meier and Cox regression analysis, with all-cause mortality and CV mortality and CV events (CVEs) as clinical end points. Results. During the follow-up, 29 patients died (17 from CV causes), and 28 fatal and non-fatal CVEs were recorded. The patients were divided according to plasma PAI-1 levels (i.e., ≤ or >41 ng/mL). The significant independent predictors of all-cause of mortality were age (60 years; p = 0.018), CRP (5 mg/L; p = 0.015), and serum albumin (<3.5 g/L; p = 0.011). Multivariable Cox regression analysis showed that plasma PAI-1 41 ng/mL was independently predictive of higher CV mortality (p = 0.021) and CVEs (p = 0.001). The only other independent predictor of CV mortality was only CRP (5 mg/L; p = 0.008). Conclusions. Plasma levels of PAI-1 41 ng/mL is a significant predictor of CV mortality and CVEs in PD patients.

The ABCs of Cardioprotection in Dialysis Patients: A Systematic Review

Several classes of medications have been shown to decrease all-cause and cardiovascular mortality in the general population. However, dialysis patients have been systematically excluded from these large trials, and the benefits of angiotensin-converting enzyme (ACE) inhibitors, adrenergic beta antagonists (beta-blockers), and calcium channel blockers (CCBs) are uncertain in this population. We performed a systematic review using the MEDLINE database (inception to October 14, 2007) to identify studies. Incident and prevalent dialysis patients. English-language randomized controlled trials (RCTs) and observational studies investigating the use of ACE inhibitors, beta-blockers, and CCBs in humans. ACE-inhibitor, beta-blocker, and CCB administration. Decreases in all-cause and cardiovascular mortality and cardiovascular morbidity. 674 reports yielded 13 suitable reports for ACE inhibitors, 12 for beta-blockers, and 6 for CCBs. Because most studies investigated more than 1 class of drug, there were 17 unique reports; 2 were RCTs, 1 was a "pseudo-RCT," and 14 were observational studies. Meta-analysis was not possible because of the heterogeneity of studies. There is considerable discrepancy in the literature about the utility of these agents. ACE inhibitors have not consistently shown survival benefits in either the single RCT or observational studies. beta-Blockers showed mortality benefit in only 1 large cohort study plus an RCT of patients with congestive heart failure, but results were not duplicated in other studies; the magnitude of beta-blocker benefit after myocardial infarction was similar in dialysis and nondialysis individuals in another study. CCBs show the most consistent benefits, albeit only from observational studies, of the classes examined. Several major limitations were present, including a paucity of RCTs and nonrandom treatment assignment and lack of data for longitudinal medication exposure in observational studies. Despite considerable uncertainty about the benefits and risks in this population, for individuals with well-established traditional indications for these medications, refraining from prescribing them may be imprudent at this time. However, RCTs, as well as well-designed observational studies that adjust for nonrandom treatment assignment and longitudinal drug exposure, are needed.

The Status of, and Obstacles to, Continuous Ambulatory Peritoneal Dialysis in Thailand

The prevalence of dialysis in Thailand is 282 per million population, and utilization of peritoneal dialysis (PD) is only 4.6% of the utilization of hemodialysis (HD). The causes of low PD utilization include a relatively higher cost of PD care, especially from the patient's perspective; less incentive for PD care on the part of health care providers and hospitals; fewer continuing medical and nursing education programs in PD; unavailability of certified PD nurses; lack of confidence in the quality of PD care; fewer offers of PD as a renal replacement therapy option during pre-dialysis counseling; fear of peritonitis on the part of the patient, and also fear of burdening family members; a less stringent government policy regarding the "PD first" strategy. To increase PD utilization. mandatory strategies are lower PD cost, make all PD equipment reimbursable, launch a stringent "PD first" policy, provide incentives to health care providers and hospitals, and improve the quality of PD care.

A Role for the Asian Peritoneal Dialysis Community in Renal Replacement Therapy Worldwide

Prevalence and incidence of peritoneal dialysis (PD) in Asia are both increasing, but the increase is not homogenous. In some countries and regions, PD is not used as one of the standard therapeutic modalities, because of either insufficient medico-economic infrastructure or a lack of clinical experience and knowledge-or sometime both. In the present article, we would like to introduce a little "Asian heat" with regard to PD utilization and academic and scientific contributions to the PD community in the world.

Dialysis After Lung Transplantation: Prevalence, Risk Factors and Outcome

Renal failure requiring dialysis after lung transplantation represents a major source of morbidity for patients and compromises their quality of life. We sought to ascertain the prevalence of dialysis after lung transplantation and to identify risk factors for its occurrence. We also assessed outcomes after institution of dialysis. From our program's inception in February 1990 until January 2005, 425 patients underwent lung transplantation. Data on dialysis occurrence, timing, management and outcome were extracted from the Unified Transplant Database, patient follow-up and medical record review. Thirty-seven patients developed a need for dialysis, a prevalence of 0.6%, 4%, 9%, 13%, 16% and 19%, at 30 days and 1, 3, 5, 7 and 9 years after transplant, respectively. Lower creatinine clearance (p = 0.03) and greater recipient height (p = 0.0002) increased the risk for dialysis, whereas donor blood type O (p = 0.001) and head trauma as donor cause of death (p = 0.01) lowered it. Higher doses of calcineurin inhibitors correlated with the period of highest risk for dialysis. Median survival of patients requiring dialysis was 5 months, considerably lower than expected. Four patients underwent renal transplantation, 3 of whom were still alive 3, 6 and 9 months later. Dialysis after lung transplantation is common and cumulative over time. Risk factors for its development may be modifiable because they appear to be linked to nephrotoxicity secondary to immunosuppression. The low threshold for creatinine clearance appears to be 50 ml/min/1.73 m(2). Survival after institution of dialysis is poor, highlighting the need for prevention. Renal transplantation may be a reasonable therapeutic option.

The organization and financing of dialysis and kidney transplantation services in New Zealand

In New Zealand, patients receive treatment for end-stage renal disease (ESRD) within the tax-funded health system. All hospital and specialist outpatient services are free, while general practitioner consultations and pharmaceuticals prescribed outside of hospitals incur copayments. Total ESRD prevalence is 0.07%, half the U.S. rate, and the prevalence of home-based and self-care dialysis is the highest in the world. Medical staff are not subject to direct financial incentives that could affect treatment choice. Estimated total expenditure per ESRD patient is relatively low. Funding constraints encourage physicians and patients to consider the probable benefit of dialysis for a patient before treatment is prescribed.

Épidémiologie des maladies rénales chroniques

In France, chronic kidney insufficiency is a frequent pathology (3300 cases per million persons, [pmp]). At discovery, a diagnostic procedure is required. The frequency of chronic glomerulonephritis, uropathies, type 1 diabetes is still decreasing. Today, the leading causes are type 2 diabetes and age-related vascular nephropathies. The progression of chronic kidney insufficiency to end-stage renal disease is not inevitable. Treatment to slower progression and preventive attitudes against toxic interventions and cardiovascular risk factors are possible. Moreover, early nephrology referral is associated with better outcomes after initiation of renal replacement therapy, i.e. dialysis or transplantation. In 2003, 7 regions participate to the French registry of end-stage renal diseases. The annual incidence rate was de 122 pmp. Almost 7000 patients per year start dialysis. Before the age of 65, the incidence is constant. Since 1998 in Lorraine, it increases by 3% per year between 65/74 years of age, by 13% per year between 75/84 years of age, by 40% per year between above 85 years. In June 2003, the prevalence of dialysis was 513 pmp. Variations between administrative regions are remarkable. After adjustment, the Nord-Pas-de-Calais region has the highest prevalence. In Martinique and Guadeloupe, the prevalence is higher than in French metropolis. In the Réunion island, the burden of dialysis is as important as in the United-States. From 1992 to 2002, the total prevalence, i.e. dialysis and kidney transplantation, increased by 7.4% per year in Limousin, by 8.8% in Lorraine. The prevalence of patients with a kidney graft doubled in both regions. Almost 45000 French people benefited from dialysis or transplantation. The frequency of type 2 diabetes and cardiovascular diseases in the population seems to be the first factor that impacts the need for kidney replacement therapy. The French registry brings epidemiological data that allowed adapting supply of care to demands.

The Latin American Dialysis and Renal Transplantation Registry Annual Report 2002

Latin America is a conglomerate of adjacent countries having in common a Latin extraction and language (Spanish or Portuguese) and exhibiting extreme variations in socioeconomic status. The Latin American Society of Nephrology and Hypertension Dialysis and Renal Transplantation Registry was created in 1991. Annual data are sent by local societies in 3 forms: patient, center, and country. The prevalence of renal replacement therapy (RRT) (all modalities) increased from 119 patients per million population (pmp) in 1991 to 349 pmp in 2001; the acceptance rate was 91.7 pmp in 2001. Dialysis prevalence was 277 pmp; hemodialysis was the predominant modality, except in Mexico (86% on peritoneal dialysis). The highest dialysis prevalence and acceptance rates were reported by Puerto Rico, Uruguay, and Chile. Among incident patients, diabetic nephropathy (33%) and nephroangioesclerosis (32%) were the primary causes; 38% were older than 65 years old. Renal transplants increased from 3.7 pmp in 1987 to 13.7 pmp in 2001. In 2003, 6357 transplants were performed (55% living donor); the cumulative number performed since 1987 reached 55,947. Prevalence and incidence are low because not all patients with end-stage renal disease have access to RRT because of restricted availability, difficulties in referral, and inequities in coverage. The annual increase in the number of patients on RRT (8%-10%) is higher, proportionally, than the annual growth of the Latin American population in general (1.5%). Efforts must be focused on prevention and treatment of chronic kidney disease, especially in diabetic and older patients, and in implementing better organ donation programs to improve the pool of cadaveric donors.

The Prevalence of ESRD Treated With Renal Dialysis in France in 2003

The prevalence of end-stage renal disease (ESRD) treated with renal dialysis is poorly known in France because there is no national registry of dialysis patients. The specific aims of this study are to determine the total number of patients treated with renal dialysis and their social, demographic, and clinical characteristics, as well as define the overall care they received. We performed a cross-sectional descriptive study from June 2 to June 8, 2003, in all renal dialysis units (including pediatric units) by including all patients residing in France with ESRD who were dialyzed during that week, irrespective of age or the treatment they received. We gathered sociodemographic (age, sex, place of residence, and occupation) and clinical data (year they entered dialysis therapy, initial renal disease, comorbidities, and associated handicaps) and information concerning their overall treatment plan (waiting list for kidney transplant, therapeutic regimen, and dialysis technique used). A total of 30,882 patients residing in France were treated with renal dialysis. The unadjusted prevalence of dialysis was 513.1 patients per million population (pmp); 498.2 pmp in metropolitan France and 1,035.7 pmp in the overseas territories. Clinical and sociodemographic characteristics of patients and their therapeutic regimens were different in metropolitan France and the overseas territories. This study constitutes the first comprehensive inventory of dialysis therapy in France, where the prevalence of ESRD is among the highest in the world.

Addressing the epidemic of chronic kidney disease in Australia

The Australia Diabetes, Obesity and Lifestyle Study (AUSDIAB) study provided, for the first time in Australia, a snapshot of the prevalence of kidney damage, reduced kidney function, hypertension and diabetes in the adult population. With this information, and the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) registry, that has recorded kidney failure statistics for many years, the extent of the chronic kidney disease burden in Australia is being better defined. This burden is even more pronounced in the Indigenous population where the incidence of kidney disease and kidney failure is increased several-fold. Diabetes is the second most common cause of kidney failure among Australians. The number of patients with diabetes accepted to dialysis has doubled in the last 7 years, the mean body weight of patients commencing dialysis has increased 7 kg in the past decade and the mean age at acceptance to dialysis is rising in a linear fashion (presently 60 years). These facts, together with a static transplant rate, all point to the prevalence of dialysis likely staying at or increasing beyond the present yearly growth rate of 6-7%. The evidence shows that a large proportion of chronic kidney disease patients are dying of cardiovascular risk factors before they reach dialysis or transplantation. There are many gaps in delivering appropriate preventative treatment to these patients. A relatively small reduction in the rise in dialysis numbers that might flow from an effective prevention of progression program, could make a significant impact on the spiralling numbers and associated cost of kidney failure treatment in Australia. We now need to develop and implement a national kidney disease strategy designed to address the whole continuum of chronic kidney disease from its earliest stage right through to dialysis and transplantation.

Bring me home: Renal dialysis in the Kimberley

The incidence of end-stage renal failure (ESRF) in the Kimberley region at the top end of Western Australia far exceeds known national rates and trend analysis demonstrates a close parallel to what is occurring in the Northern Territory. Dialysis prevalence in the Kimberley has nearly tripled in the last decade and has increased at a much faster rate than the rest of Western Australia. Almost all of these people with ESRF are Aboriginal Australians living in remote communities. In January 2004, the Western Australia Country Health Service and Kimberley Aboriginal Medical Services' Council, under the auspices of the Kimberley Aboriginal Health Planning Forum, embarked upon a review of renal disease in the Kimberley funded by the Western Australia Department of Health. The main purpose of the review was to identify the scope of the problem and make projections upon which to base programme and service development over the next 10 years. This paper outlines the findings of the Review of Renal Disease in the Kimberley and presents, for the first time, regional data analysis and comparisons. In addition, future projections on the impact of ESRF and recommendations for improving current service delivery are discussed. Given the challenges of remoteness and individuals' desire to return home, this review recommends development of locally-based expertise capable of providing training and support to patients and their families, reinvigoration of community-based dialysis modalities, and the initiation of planning for a second satellite service in the Kimberley.

OPCAB versus early mortality and morbidity: an issue between clinical relevance and statistical significance☆

To evaluate the impact of OPCAB on major postoperative events in a large consecutive cohort of patients, covering the complete spectrum of risk. A consecutive series of 3333 CABG patients operated in a single institution (Jan/97-Jan/03) is analyzed after a complete (98%) midterm reengineering towards off-pump surgery (Oct/99). Patients in cardiogenic shock are excluded. The on- (N=1593) or off-pump (N=1740) datasets are comparable for most demographic and non-cardiac variability. The studied events are early mortality, early stroke, early infarct, early dialysis and hospital stay. Three methods adjust for possible patient selection: similar datasets, forced inclusion of a saturated OPCAB propensity score and finally multivariate correction. Non-risk adjusted. The 3-month survival was 96.7+/-0.4% (OPCAB) and 95.9+/-0.5% (ECC) (P=0.2). The 8-day freedom from stroke was 99.4+/-0.2% (OPCAB) and 98.5+/-0.3% (ECC) (P=0.004). The prevalence of dialysis was 1.67% in OPCAB and 2.27% in ECC (P=0.2). The 8-day freedom from infarct was 98.4+/-0.2% (OPCAB) and 98.3+/-0.2% (ECC) (P=0.7). The freedom from hospital discharge day 15 was 17.6+/-0.9% (OPCAB) and 18.4+/-0.8% (ECC) (P=0.001). Propensity score corrected and adjusted for event-related variability. The survival effect remained non-significant (P=0.3), also for patients with a EuroSCORE>8 (P=0.9). The stroke effect became non-significant (P=0.2), but stayed significant for patients with severe internal carotid artery stenosis (P=0.02). The dialysis-effect remained non-significant (P=0.6), also for patients with an elevated creatinine (P=0.7). The early infarct-effect remained non-significant (P=0.8), also for the female patients (P=0.8). The hospital discharge was significantly influenced by the OPCAB approach for the total group (P=0.02) as well as for the patients with EuroSCORE>8 (P=0.01). The observed 20% reduction of mortality, 60% reduction of stroke and 20% reduction of dialysis were partly neutralized by the adjusting methods and demand, at least, larger datasets to obtain statistical significance. Subdatasets with fewer patients but higher risk identified risk-reducing effects for stroke. Hospital stay was shortened by the OPCAB approach. The interactions between risk, number of patients and the risk-reducing effect are the cornerstones of evidence generation for the OPCAB approach. These results were obtained through a very strict reengineering and cannot be extended to all OPCAB programs.

Natural history of Staphylococcus aureus nasal carriage and its relationship to exit-site infection.

To study the natural history of nasal carriage of Staphylococcus aureus (SA) and its impact on exit-site infection (ESI). A teaching hospital single-center study. A prospective cohort study in prevalent continuous ambulatory peritoneal dialysis (CAPD) patients. 153 patients (76 male, 77 female; mean age 46 years) with a mean duration of CAPD of 2.4 years. Nasal swabs were taken at approximately 2-month intervals over the mean period of follow-up of 22.6 months and cultured for SA. An average of 69% of patients received systemic antibiotics for therapy of ESI, peritonitis, and other infections during the period of the study, but none received local nasal antibiotics. Four groups of patients were identified according to their nasal carriage history: chronic, intermittent, occasional, and noncarriers. The intermittent and chronic carriers had significantly higher SA ESI than the occasional and noncarrier groups. The intermittent group also had the highest percentage of non-SA ES infections. Although this study shows that only half of our CAPD patients with nasal carriage were at risk of developing ESI, we recommend that patients with a positive nasal swab at the start of CAPD therapy should be treated with nasal antibiotics or local antibiotics at the exit site.

Home Dialysis and Dialysis Treatment Modalities in the VA System

A questionnaire was sent to 50 Veterans Administration dialysis centers to inquire about treatment utilization in preparation for a Cooperative Dialysis Study. Thirty-five completed questionnaires in this survey identified a dialysis population of 2,483 patients including 452 contract patients (13.5%). The number of patients treated in-center was 1,101 (48.5%), including 239 on self-care (10.2%), and 930 patients (38.0%) were dialyzed at home. This high utilization rate of home dialysis appears in excess of three times the prevalence of home dialysis experienced overall in non-VA programs. Identification of factors responsible for the present emphasis on home programs in the VA and a corresponding analysis of non-VA programs should provide important information for the planning of future national ESRD policies.

Antibody to hepatitis A and hemodialysis.

Antibody to hepatitis A virus (anti-HAV) was surveyed in 469 patients from 20 of 31 Michigan hemodialysis units, during spring 1978. The mean point prevalence of anti-HAV was 59.5% and within the 20 individual units ranged from zero to 100%. For the entire survey population, the point prevalence of anti-HAV was significantly greater with increasing age, among blacks, and in individuals with hypertension as their underlying renal disease. Anti-HAV was independent of sex, duration of dialysis, or the presence of either hepatitis B surface antigen or its associated antibody. Within individual units, anti-HAV prevalence was associated with a higher mean patient age but not with dialysis unit size, mean duration of dialysis therapy, race, or prevalence of hepatitis B markers among patients or staff. These data support reports that transmission of the hepatitis A virus is neither associated with hemodialysis therapy nor routinely spread by parenteral mechanisms as observed in hepatitis B virus transmission.